One million people; two billion dollars. Those are the numbers Quebec faces as it confronts an aging population. Its dilemma is shared by every province.
By about 2030, Quebec will have another one million seniors. Providing them with home care and long-term care will cost about $2-billion. Where will the money come from?
That's the pertinent and brave question being asked by Parti Québécois Health Minister Réjean Hébert, himself a physician. A variation of that question should be asked all across Canada.
Mr. Hébert's government has published a white paper on the creation of what it calls "autonomy insurance." The idea is to create, soon, a special fund taxpayers will start contributing to so that more money will be available when the costs hit.
Quebec's demographic challenge is more acute than most. The share of its population over 65 will double in the next 30 years, compared to 51 years for the rest of Canada. But it's a challenge that all Canadian provinces will eventually face.
Other countries (whose health-care systems generally perform better in international comparative studies) have already begun addressing this long-term challenge posed by aging.
Sweden and Denmark began preparing through the tax system more than two decades ago, although Sweden does require some payments from the elderly, based on income. Germany, Japan and the Netherlands all have compulsory contributions for everyone in the work force.
Today, providing or preparing to provide more seniors' care out of hospital is all the rage in health care, and properly so. In acute-care hospitals across Canada, 10 to 15 per cent of beds are occupied by the frail elderly, many of whom wait days, even many weeks, for space in nursing homes or long-term-care facilities. Some would be better off at home.
Home care and institutionalized care outside hospitals is obviously desirable for some seniors, and cheaper than hospital beds. Despite much pontificating about the need for more long-term care outside hospitals, Canada remains below the OECD average for the share of health-care spending devoted to long-term care – and way, way behind the Netherlands, France, Sweden and Denmark.
Long-term care outside hospitals is obviously cheaper than the status quo, but it will still cost more money to build facilities for institutionalized care and train staff for institutionalized and home care. Where's that money going to come from?
If the answer is "just wait until tomorrow," as has often been the case in the past, then the costs will fall on the next generation. This would be unfair, the Quebec white paper correctly notes, because it would offend "inter-generational equity."
Here is a concept foreign to Canadian public health care. Canadians guard as a bedrock social value the idea that equity of access should prevail within a generation, regardless of income or circumstance. That worked fine, financially speaking, when the population was spread roughly equally among age groups.
But when additional seniors arrive in large numbers, requiring more health-care spending, then the tax burden for those costs will fall on the next generation. Hence "inter-generational equity" becomes a new and difficult way of thinking about the value of "equity" within health care.
That is why other countries, and now Quebec, think about using social insurance – payments now for paying possible needs later – as a way of preparing for the future that we know will be demographically quite different from the past and present.
So, who should pay? Should personal taxes be raised and, if so, by how much and on whom? Should employers pay? Should the payments be related to age – should people 50 to 65, who might need this long-term care sooner, pay more? How should the need for long-term care be evaluated? It's impressive that Quebec is asking these questions.
The principle is sound, but the details are politically charged and difficult to get right. Since drugs are a more prevalent need than institutionalized care or home care for seniors, drugs would be a better place to start thinking about social insurance to pay for what we know will be higher costs.