Just before the Quebec National Assembly adjourned for the holidays, Health Minister Réjean Hébert tabled Bill 67, the proposed "autonomy insurance" law.
On the surface, the legislation would provide an additional $100-million a year for home care and home support services for seniors. Given that Quebec already spends $4.3-billion annually on long-term care for seniors, the new monies are modest, not nearly enough to keep pace with burgeoning demand.
But the move is important – and will be watched closely by other provinces – because, more than anything, it represents a philosophical shift.
Hébert, a well-respected physician specializing in geriatric care before he made the jump to politics, has been outspoken about the need to slow the stampede of seniors into institutional care and instead provide support for them to continue living in the community.
Spending on home care has risen tremendously in recent years, but the investment has largely been to get people out of acute-care hospitals more quickly, principally post-surgery. There have not been serious or sustained efforts to offer home care and home support to people with chronic conditions, most of whom are frail seniors.
(The distinction is that home care is the provision of medical care, by nurses, physicians and other health professionals; home support is the term used to describe ancillary services such as cooking, housecleaning, bathing, transporting and so on. What is rarely acknowledged is that, for people with chronic conditions, the support is just as important as the medical care.)
Medicare covers hospital care and physician services. It does not systematically cover essential services such as home care, home support, rehabilitation and long-term care outside hospitals (such as in nursing homes). There are different programs in each province, but who and what they cover varies considerably.
In Quebec, about 85 per cent of home care, home support and long-term care is paid out-of-pocket. A lot of people can't afford to pay for these services; generally speaking, those without means end up in publicly funded nursing homes. The absurdity of this approach is that it costs more than twice as much to provide comparable care in a nursing home as in a person's home.
Hébert said the purpose of autonomy insurance is to give people more choice by bringing out-of-pocket costs down to about 60 per cent. In essence, the minister wants to make it more affordable for people to continue living in the community and in their homes – an option most people prefer.
The proposed legislation, while popular with consumer groups and patients, has nonetheless had more than its share of controversy, most of it revolving around financing. The current plan is to create a large capital pool to fund future needs of the aging population – essentially a parallel public insurance program for home care.
Opponents, including Claude Castonguay, who is known as the Father of Medicare in Quebec, argue that creating a separate fund for needs of the frail elderly undermines the principle of universality. Others, like the Quebec Council for the Status of Women, fear that shifting more care into the home will place greater physical and financial burdens on women (who tend to be caregivers).
Quebec's Ombudsperson, Raymonde Saint-Germain, got in on the act, recommending that citizens pay premiums into the autonomy insurance plan and that rates vary by age. In short, she suggested that baby boomers, who will benefit most from the new plan, pay more than younger people, an approach she argued was necessary to ensure "inter-generational equity."
That was similar to the initial approach of the Parti Québécois government, which wanted to impose autonomy insurance premiums on taxpayers beginning at age 50. The government later backed away from that proposal, saying funding should come from general tax revenues and that subsidies for services will be income-based.
The Health Minister has said that a broad range of services will be subsidized, including domestic help, bathing, cooking, nursing, rehab, psychological support, equipment, and respite care for family members. Under the plan, most of these services will be delivered by private providers, and that has drawn criticism from public-sector unions.
But the precise amount of subsidies and the eligibility criteria have still not been hashed out, which has rankled opposition parties. Those details will be made public in the spring, when a second round of public hearings will be staged. The law itself is not supposed to take effect until April, 2015.
In a minority-government situation, that is a long way away, and the debate will likely shift from the National Assembly to the campaign trail.
But at least Quebec is having the long-overdue and very public discussion about how to best provide care to the aging population, something other provinces are avoiding, to their detriment.
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