Long-Term Care Financing: What’s Fair and Sustainable?
Frances Woolley
On November 4-5, 2013, the Institute for Research on Public Policy hosted a symposium on creating age-friendly communities, in collaboration with the Government of Ontario, the Association of Municipalities of Ontario and the City of Toronto. The symposium brought together key academic researchers, decision-makers and a broad range of stakeholders. Participants discussed all aspects of age-friendly communities – healthy aging, housing, transportation and mobility, and social participation and recreation.
On November 4-5, 2013, the Institute for Research on Public Policy held a -two-day symposium, “Age-Friendly Communities in Ontario: Multi-Level Governance, Coordination Challenges and Policy Implications,” in Toronto. This event was organized in collaboration with the Association of Municipalities of Ontario and the City of Toronto, and made possible with the support of the Government of Ontario.2 The event’s goals were to identify what works best in Ontario in terms of moving communities along the path of age-friendliness, and to stimulate debate on the policy changes that might further that goal.
The first part of the event was an invitational, research-focused round table attended by 50 participants from across Ontario. It brought researchers together with decision-makers and stakeholders to discuss the state of research on the critical issues facing governments and what it might mean for the future course of public policy. The second part of the event was a public symposium with open registration that featured 23 guest speakers and was attended by 125 people from every corner of the province. The symposium consisted of -panels, break-out sessions and keynote addresses. It examined how, in this process of creating age-friendly communities, large-scale macro issues cascade down to the local level; the impact on large urban areas, suburbs, mid-size cities, smaller and remote communities; as well as possible policy solutions that can be adopted to improve the communities’ governance.
The program, presentations and list of participants are available here. This report will summarize the discussions held over the two days of meetings, focusing on those observations that are most relevant to policy-makers. Please note that while the content of the round table is reflected in this report, no specific attribution or quotations have been included, as the event was held under the Chatham House rule.
Because the population of older adults is growing, developing age-friendly -communities will be increasingly important to help meet the challenges faced by the elderly. An age-friendly community is one that recognizes the great diversity of the elderly population, promotes their inclusion in all areas of community life, respects their decisions and lifestyle choices, and anticipates and responds flexibly to their age- related needs. But are communities truly embracing all these principles in their efforts to become age friendly?
In the discussion, it was noted that more must be done to empower older people and include them more directly in decision-making; that officials need to be sensitized further to the particular needs and limitations of older adults; and that older people should be seen as a resource or an opportunity, rather than a burden.
The age-friendly community concept is not well known in the general public and is therefore not considered a priority. In that context, proponents of age-friendly initiatives must be stealthy and strategic about advancing policy strategies in order to gain political support and ensure that age-friendly initiatives are supported and maintained.
The World Health Organization’s concepts of “active communities” and “age-friendly communities” are part of a broader trend in Ontario and elsewhere. This trend is known as “new localism,” whereby municipalities are increasingly responsible for service delivery and are getting involved in a broader range of policy issues. Because municipalities are on the front line of contact with the population, they are increasingly expected to employ an age-friendly lens in policy design, urban planning and service delivery; to play a key role in policy planning; and to develop a capacity for research. However, shifting the responsibility for services from the provincial government to the municipalities without providing adequate resources and support can leave municipal governments ill equipped to implement age-friendly initiatives.
Participants also noted that the widely used concepts of “active aging” and “productive aging” can be problematic. These concepts, which are central to the age-friendly-community model, imply that older adults should be working, contributing to society and taking care of themselves, to avoid becoming dependent. We need to consider that older adults encounter barriers (such as ageism in the job market) while trying to remain active. In addition, seniors’ societal contributions (such as care-giving and volunteering) should be better recognized.
In fact, a successful approach to “age friendliness” should recognize that seniors are not a homogeneous group, participants noted. For instance, there are two broad age groups among seniors, with different realities. The 55 to 74 age group is, by and large, made up of active adults who have higher disposable income and generally prefer ground-level housing. The 75 and over group, in contrast, needs affordable, adapted housing that ranges from assisted living to long-term-care homes. Policy-makers also need to pay attention to issues such as economic situation, culture and gender, which translate into important structural differences among seniors. Too often, not considering this diversity leads to policy gaps, where public policy is designed to meet the needs of older adults as a homogeneous group and fails to address their particular needs.
Municipalities need to consider all dimensions of diversity in the aging population, as they will need varied strategies depending on demographics, location, region and socio-economic differences. For example, aging residents in one municipality who are financially secure will tend to stay in their own homes, and the municipal government will have the challenge of helping them age in place. By contrast, if a municipality is smaller and suffers a loss of economic activity, young people are likely to leave the region, leaving older family members behind, and the incomes of senior residents might be limited. If so, the municipality will be directly affected by the restricted financial means of seniors and by gaps in informal care available to help them cope with long-term disabilities. There will be pressure on formal services and higher demand for long-term-care homes. In planning a seniors’ strategy, municipalities need to make long-term plans by looking at the entire demographic situation and projections.
It was also suggested that using a longitudinal, life-course approach to policy design, as opposed to orienting it around chronological age, would improve the -quality of decisions. A longitudinal, life-course model takes a long-term view of an individual’s characteristics and his or her trajectory. It accounts for not only chronological age but also how relationships, life transitions and social changes impact life.
In Ontario, a total of 12 communities have become age friendly according to the WHO age-friendly-community guidelines, and another 27 are in the process of joining the movement. The symposium offered insights into successful governing models and lessons learned from those experiences in implementing age-friendly policies. Having studied age-friendly communities across Ontario, Margaret Denton shared her observations on their success, while Cheryl Hitchen (Kingston), Josh Matlow and Wayne Chu (Toronto), Clara Freire (Ottawa) and Debbie Amoroso (Sault St. Marie) shared their “on the ground” experiences in their communities. Below is a synthesis of their observations.
Ontario’s population is aging, and the growth rate of the 65 and over -population is 3.5 times higher than that of the rest of the population. However, the growth rates of the various age groups is not the same in all areas. In fact, as urban areas are growing faster than smaller municipalities, smaller municipalities are growing older faster than large cities. We need to consider the fiscal impacts of population aging in different municipalities according to whether it is a slow-growth or a fast-growth municipality. For instance, slow-growth municipalities will have aging municipal infrastructure spread out over large areas, modest growth in property taxes and uncertainty regarding government funding for age-friendly initiatives due to changing demographics. Fast-growth municipalities will experience extensive capital costs to accommodate new growth in suburban areas as well as a backlog in asset management (such as in replacing existing infrastructure). These long-term scenarios must be taken into account when developing policy.
Municipal finances differ significantly from provincial and federal finances, in that municipalities have stringent debt restrictions and are required to balance annual budgets. Even though age-friendly initiatives have been successfully implemented in several Ontario communities, there have been obstacles to funding these initiatives. The major challenge stems from the increase in municipal spending responsibilities, including the increasing involvement of municipalities in the provision of social services. In particular, seniors’ housing facilities are only partially cost-shared with the province, and they are very costly to administer. Municipalities are well positioned to offer many services to their citizens, but participants questioned whether it was right that they be responsible for larger cost areas such as transit or road infrastructure.
The dependence of Ontario’s municipalities on property taxes is a major concern. Municipalities simply do not have adequate financial resources for the responsibilities they have. Moreover, the added funding they can obtain through grants or cost–sharing is complicated and does not offer viable, long-term solutions.
The federal and provincial governments have not yet undertaken a revision of the overall system of revenues and expenditures. Many participants noted that, over the longer term, pressure on federal and provincial governments should be intensified to communicate concerns over the increasing responsibilities at the local level.
The amount of municipal and provincial funding that goes to age-friendly initiatives is largely unknown, and there is a need for clearer information about governments’ budgets for seniors’ services.
Many seniors are property rich but income poor. As such, they are more concerned with the level of taxes than the level of services. Seniors may want community services to be more adapted to their needs, but they will often vote thinking of their tax bills. Consequently, municipal governments may be left with insufficient resources to finance their age-friendly initiatives.
Keynote speaker Stephen M. Golant, gerontologist and geographer at University of Florida, offered an insightful presentation on the feasibility of achieving all aspects of an age-friendly community. Today’s seniors are faced with the social expectation of having to take care of themselves for as long as possible. Society tells them to “eat well,” “volunteer,” “exercise” and “work part-time.” However, in order to be able to do these things, the right conditions must be in place. Older people with mobility problems would be able to stay in their homes longer if they did not have accessibility barriers, could count on a grocery store nearby, and had access to adequate home support services. Golant argued that in their attempts to resolve these issues, age-friendly-community initiatives lack focus, and their goals often overlap those of other policy initiatives such as Walkable Communities, Universal Design or Universal Accessibility. He said that these initiatives should come together to avoid duplication and make the best use of resources. He further suggested that age-friendly–community initiatives should focus on ensuring that all older people have adequate, affordable housing and services that facilitate their everyday lives. There is a need to plan for long-term solutions, to support caregivers and to provide appropriate home-care services. Without a clearer focus, there is no consistency in age-friendly initiatives across communities, leaving older people in some communities with unmet needs, and some with no services at all.
The six breakout sessions during the symposium allowed participants to explore more deeply specific policy areas that are core to the local governance of aging communities in Ontario. They are summarized below.
The panellists emphasized the inadequacy of housing for Ontario’s aging population. Steve Pomeroy noted that by 2036, one-third of all households will consist of seniors. Currently, one in five senior renters is vulnerable – most are single women or immigrants waiting for social housing.
The principal housing problem is affordability. As older adults age, they often cannot find appropriate housing and find themselves in care placements that are very expensive. Pomeroy proposed that the health care and housing departments should work together and share resources to reduce inefficiencies. Another problem is that social housing developers buy property in isolated, less sought after locations, often far away from where older adults live, and older adults are often reluctant to move away from their social networks.
Margie Carlson examined housing affordability and the effects of shifts in government responsibility in this area. The federal government transferred operating authority for many services to the provinces and territories in the 1990s, which in Ontario provoked a downloading of some services from the province to municipalities. The municipalities therefore had to reorganize their housing services.
Lynn McDonald studied housing stability and evictions among older adults and outlined the lack of coordination among housing service agencies. The unin-tended consequences of downloading housing services is that when various aspects of housing become the responsibility of different levels of government there is a lack of coordination.
In discussing possible solutions, all panellists said it was important to focus on practicality. For example, it makes more sense financially to support independent living than to build new long-term-care units. Another suggestion was to build low income housing next to long-term-care units: seniors who only need occasional assistance could take advantage of long-term care that is offered nearby, while remaining in their homes. The panel also discussed the links between housing and health care, and how the living conditions and housing support of an older person can affect their health. There was consensus that the housing and health departments need to col-laborate on finding housing-based solutions to health care problems. One suggestion was to redirect money from seniors’ income tax credits to fund adequate and affordable housing. Ultimately, the panel recognized that for significant change to occur, there needs to be a concerted, strategic approach when addressing policy-makers.
The silo system is in the way of providing appropriate long-term care for seniors.
Graham W. S. Scott, Chair, IRPP, and President, Graham Scott Strategies Inc.
Graham W. S. Scott argued that long-term care in Ontario suffers from an administrative system organized in silos, which results in a lack of collaboration between long-term-care institutions and the health care system. He observed that the industry is heavily regulated and administrative burdens are reducing efficiency. For example, the goal of Health Links is to follow individuals through different points of care, but the program does not engage with retirement or long-term-care homes. Moreover, there is no comprehensive vision in long-term-care planning, so the various stakeholders (the provincial government, private developers, nonprofit organizations and municipalities) are all operating independently. Scott said that a task force should be created to improve efficiency and collaboration among the various stakeholders.
Monika Turner noted that while municipalities are discussing different options to provide and sustain long-term care, there is a lack of strategies. Long-term care is costly, and municipalities currently receive inadequate financing from the provincial government to sustain the needs. An important point of discussion among symposium participants was how far municipalities should even be involved in providing or administering long-term care. Turner examined a range of alternatives and degrees of municipal involvement, but noted that the most important thing was for municipal and provincial governments to maintain open communications in addressing this issue.
Some participants argued Ontario should follow Alberta, which eliminated its -Local Health Networks. Others disagreed, saying that doing this in Ontario would place greater reliance on the nonprofit and for-profit sectors. Participants agreed that innovative solutions are available and should be explored. Since long-term-care providers cannot financially compete for land with condo developers, various options could be considered for providing more affordable seniors’ housing. For example, municipalities could offer land or properties such as old schools, or empty retirement home beds could be offered. Participants expressed the importance of gaining political support for the issue by involving the whole community in long-term-care planning and educating the public and politicians about this issue.
We’ve got to fix what we have been doing for the last 60 years: the scale of population aging will magnify the problems we have built through our reliance on commuting and the car.
Glenn R. Miller, Vice-President, Education and Research, Canadian Urban Institute
Mobility is a key aspect of a good quality of life. In his presentation, Christian E. -Fisker shared a pressing concern regarding people in suburbs and their reliance on driving, which could leave them isolated if they become unable to drive. Without accessible transportation, older adults are heavily reliant on family members to conduct their daily activities. Fisker explained that in living environments such as suburbs, facilities are often far from residential areas, making older people entirely dependent on the car. But another major challenge is the lack of municipal capacity to provide more services, particularly transportation, which is very costly.
Glenn R. Miller offered specific suggestions on how to adapt public transit to older people. He recommended focusing on certain key areas or destinations of seniors, such as libraries, banks, malls or medical clinics. Miller explained that the journey must be physically feasible, easily achievable and desirable for seniors. There must be enough information for older people to make decisions about where to go, and the journey must be affordable.
There was consensus on the need to introduce financing schemes to make transportation affordable for seniors. Harry Kitchen suggested charging for parking based on the time of day and the length of stay, to increase municipal revenues. More sophisticated pricing systems might nudge everybody to change their transportation habits. He argued that transportation costs should also reflect the distance travelled. -Currently, shorter-distance travellers subsidize those travelling long distances. He suggested that older people should pay full fares if they have the resources to do so: fares should be adjusted to income rather than age.
Getting to medical appointments is often a pressing problem for older people with chronic illnesses, and there is a need for more accessible taxis. Some participants suggested that private businesses and tax incentives could be used to offer accessible taxi services. One suggested that technology could be used to reduce transportation needs; for example, to offer medical appointments and checkups remotely, which would also reduce the number of medical visits. Another proposed there should be tax incentives for family members and caregivers to take time off work or use their own resources to care for older people.
It is no longer acceptable to think of seniors as one large age cohort.
Howie Dayton, Director, Recreation Services, City of Mississauga
This session examined the challenges of helping older adults to stay healthy and engaged through recreation. Howie Dayton outlined Mississauga’s Older Adult Plan from the perspective of recreation services. Due to the diversity of the older population, services for them cannot be geared only to one group. Older people need specialized services and dedicated spaces within community centres. For instance, therapeutic pools help condition muscles, increase range of motion and improve mobility. Dayton pointed to some successful programs in Mississauga’s Older Adult Plan: intergenerational programs, information technology for older adults, and partnerships between older adult volunteers and community centres. He stressed that there must be a sustainable funding strategy, even if this means phasing out discounts for seniors and moving to a needs-based model.
Jacqueline Powell’s presentation offered an interesting perspective, that of a funding agency. The Ontario Trillium Foundation funds many nonprofits and -charity groups for recreation programs such as ecology centres, good neighbourhood clubs, and health and community services. The challenge for the funding agency is how to measure the impact of the grants, because there are no centralized indicators. Powell proposed using the Canadian Wellbeing index to measure the programs’ real effectiveness and benefits.
The principal challenges raised in the presentations and discussion in this session were the lack of municipal funding to achieve the desired changes, and the difficulties in gaining political buy-in and commitment to long-term goals. Caroline Andrew suggested increasing lobbying of federal and provincial governments to ease the burden on municipalities and decrease their reliance on property taxes. She said one way to increase political will would be to inform seniors about where their tax money goes and help them understand the challenges of long-term planning. Andrew also proposed involving seniors in a formal collaborative governance process in which diverse groups are represented.
In the discussion participants focused on the lack of funding, and there was support for the creation of a central group that would facilitate the coordination of efforts.
Large urban areas, suburbs and midsize cities face particular challenges when adapting to their growing aging populations. Pierre Filion explained the problem of urban dispersion and the elderly. Urban centres are not adapted to the needs of older people. Large roads divide neighbourhoods and people are therefore obliged to drive between each activity. Fillion argued the solution is to create superblocks, concentrated areas where all facilities would be close together. For example, schools could be used as service and activity centres for older people, since they are already strategically placed in dispersed environments.
Presenters Wayne Chu, Clara Freire and Cheryl Hitchen outlined the development and implementation of the Toronto, Ottawa and Kingston seniors’ strategies, respectively. They noted that they first had to identify the most pressing needs and priorities to determine the most achievable solutions. In all cases, the initiatives began in areas of exclusive municipal jurisdiction, where it is easier to implement changes. The presenters emphasized the importance of getting the support of the mayor and the council. The main challenges in the three cities were the need to prioritize, break down the silos and find resources to implement the changes.
In midsized to large cities the main challenge is the diversity of the population, which means there have to be neighbourhood-based approaches to address the differences. Public transportation poses a significant challenge because it is often geared toward a work-commuting population rather than toward older people. As people age, their transportation needs change; for example, they need to go to medical appointments, they typically travel shorter distances and they travel outside peak hours. The transportation system is not yet adapted to their needs, and this affects their mobility and quality of life. Another problem presenters mentioned is the possibility that the visions of seniors’ strategies and private city developers might conflict. For example, developers typically want to build very tall condo buildings, while an age-friendly neighbourhood would involve smaller buildings, and more open and green spaces.
An example of a successful seniors’ residence is the Manulife Centre residence in Toronto. This residence is centrally located on two subway lines connected to the underground pathway system, which links it to a shopping mall with various retail outlets, businesses and services. Participants suggested that housing units should be built in major centres where services already exist. To deal with diverse populations, translating documents is important, but more should be done; for example, authorities should collaborate with local organizations that cater to different populations, and they should take into consideration the nuances of diverse cultures when developing policy.
Rural aging populations are increasingly relying on volunteers, but volunteers themselves are aging.
Mark Skinner, Department of Geography, Associate Professor, Director,
Trent Centre for Aging and Society
The smaller populations and slower economic growth in some rural communities severely affects the implementation of seniors’ policies, and the challenges they face are different from those faced by large urban areas. Paul Rosebush outlined the operational challenges of providing services to a small community. A particular problem is the lack of home-care services and insufficient resources to support seniors in their own homes. Due to limited health services in rural communities, older people typically do not get assistance until their need is urgent. Therefore they rely heavily on hospitals. One major obstacle to accessible health services is inadequate transportation, given the frequently large distances between the residences and the health-care facilities. There is also a lack of continuity and coordination in the health services offered across the various rural communities. Among the initiatives presenters proposed are 1) linking primary caregivers to patients; 2) improving coordination and transitions between levels of care and services; and 3) increasing home supports by breaking down the silos between the various service providers.
The key role played by volunteers and the challenges of sustaining continuity of care in rural communities was the focus of Mark Skinner’s presentation. Volunteerism is essential in rural areas, and policy-makers often rely on volunteers to offer services in remote communities. However, Skinner pointed out, there is an assumption that those volunteers will always be there to fill in the gaps. He noted that we tend to overlook the fact that most volunteers are older people themselves, and there is always uncertainty as to how long this valuable resource will be there. Furthermore, often we neglect to fully recognize services offered by older people, such as providing care, helping with transportation, cooking, cleaning and shopping. Skinner urged that when developing policy for rural communities we should be cautious and consider the limits of volunteerism.
Elaine Wiersma also emphasized the importance of informal volunteers and social networks, and rural communities’ reliance on them. She argued that the culture of caring in rural communities is a strength, and having a sense of family enables strong social networks that are positive for older adults and indeed the whole community. However, Wiersma pointed out, there can be a lack of continuity of care when communities rely on informal support networks, especially when caregivers become patients themselves. Therefore, even though a culture of caring can greatly improve the quality of life of community members, the system must recognize that it is difficult to maintain over the longer term.
All in all, participants widely acknowledged the resilience of rural communities, but also noted that policy-makers must be aware of its limitations. Furthermore, participants emphasized that it will be important to break down silos and connect rural communities within a region. Community Care Access Centres (CCACs), hospitals, and community care providers must develop mutual trust to be able to continue along the path of becoming age friendly.
Below are some of the main ideas identified by participants throughout the two days.
This well-attended event offered a rare forum of exchange between researchers from a variety of disciplines and decision-makers. The discussion yielded high-quality content that will inform the IRPP’s research agenda going forward. In terms of the next steps, we are currently in the process of receiving proposals from researchers and commissioning commentaries and studies on some of the central issues addressed during the symposium. Rigorous studies will examine those issues in more detail and propose ideas that will stimulate the public policy debate on age-friendly communities. We expect to start releasing these publications over the next months.
The policy environment in Ontario is a particularly propitious place to begin constructive deliberations, research and analysis on these crucial challenges. But these issues are to varying degrees being debated in all provinces. Therefore, the symposium and the resulting publications will not only advance the debate in Ontario, they will also serve as a launching point for similar discussions across the country. It is our hope that the experiences shared and the lessons learned during this event will lead to similar discussions of the challenges faced by communities across Canada on the path to becoming age friendly.
