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BETTER WITH AGE:
Health Systems Planning for the Aging Population
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A BACKGROUNDER
Rising healthcare costs and population aging have fuelled debate about the financial sustainability of Canada’s
healthcare systems. Many Canadians are concerned that the situation may impact their ability to access the health
services they need, when they need them. Without question, Canada’s population, as elsewhere, is aging. By 2015,
Canada will have more people aged 65 and older than people aged 15 and younger. Further, by 2050, the proportion
of the elderly will be one in four.i; ii What is questionable is the evidence base that suggests this demographic shift
will overwhelm Canadian Medicare, ultimately threatening its financial sustainability. This argument—long debunked
in health services and policy research circlesiii; iv—continues to surface in popular press and public discourse.
This focus on Medicare’s sustainability threatens meaningful and productive discussions related to delivering
high-quality healthcare to seniors. There is no shortage of pressing issues that demand the attention of health
system managers and planners in this area. To help raise and address these issues, the Canadian Health Services
Research Foundation (CHSRF) has invited, from across Canada, health system policy- and decision-makers to
engage in a dialogue with invited experts about healthcare planning for an aging population. Through October
and November 2010, CHSRF is hosting five regional roundtables and one national roundtable as part of its
series, “Better with Age: Health Systems Planning for the Aging Population.” The roundtable series aims to
bring clarity to the impact of population aging on the financial sustainability of Medicare; raise the profile of
the most pressing policy- and decision-making challenges and research gaps; and offer ideas and strategies for
delivering high-quality care to seniors.
Following each roundtable, CHSRF will publish a roundtable report. At the end of the series, CHSRF will produce a
synthesis report, which will inform CHSRF’s continued work in this area.
Relevant references are provided for more information at the end of this document.
Myth: The aging population will overwhelm the healthcare system
There is a general perception that Medicare as we know it is financially unsustainable.v In addition, many
Canadians worry that as they age they will increasingly have to reach into their own pockets to pay for the
services they need. According to a 2010 Canadian Medical Association (CMA) poll that surveyed nearly 3,500
Canadians:vi
80% believe the quality of healthcare will decrease as a result of increased demands from
baby boomers
72% believe they will not have the funds required to maintain their health as they age
Over 70% believe the health system must change to accommodate the needs of the
aging population.
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Fears that the aging population willAlignement
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the demise of the public healthcare system stem from real facts. For
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instance, population aging is associated with an aging workforce. Coupled with Canadians retiring earlier today
than they did in the past, this means fewer tax dollars for public healthcare funding.i Additionally, both the cost
of acute care and the prevalence of chronic illness (which requires expensive hospital-delivered diagnosis and
treatment) increase with age.vii; viii There is some evidence that suggests seniors are aging healthier (for example,
reduced rates of cardiovascular disease, arthritis/rheumatism, hypertension, and bronchitis/emphysema).ix However,
higher rates of diabetes, asthma, respiratory diseases, and obesity among seniors threaten to offset any projected
savings. An older population also means increased end-of-life health services, which are substantially higher cost
than those provided to other patients.i; vii; ix; x Seniors are also more likely to have co-occurring conditions that
require complex, more time-consuming medical attention and tend to remain in hospital for treatment longer
than younger individuals.i
Although use of health services rises with age, there is much data to refute the myth that the demographic shift
will bankrupt the health system.iii; xi; xii; xiii Holding factors like inflation constant, population aging is projected
to cause Canadian healthcare costs to increase by an average of about 1% per year between 2010 and 2036.xi; xii
These increases are small compared to the cost pressures from other factors (non-aging and often non-Medicare).
Prescription drug spending is a key cost driver, with drugs having more than tripled their share of the Gross
Domestic Product (GDP) over the last two decades. Medicare-related costs have consumed a relatively steady share
(around 10%) of the nation’s GDP for the last 20 years. Another cost driver is increasingly expensive diagnostics
and treatments that have coincided with technological advancements.
The question that needs to be addressed is this: why are healthy elderly people, in particular, receiving more
intensified care? The trend toward providing more treatment to seniors (compared to what they used to receive)
is more striking when compared to the healthcare use of other age groups.iii This is especially concerning because
when it comes to invasive procedures, and even diagnostic testing, less may be more.xiv In fact, compared to
patients in regions that spend less, patients in high-spending regions are no more satisfied with their care, and
actually experience a greater risk of harm and possibly even death.xiv
Is the current structure of Canadian healthcare equipped to manage the
influx of seniors?
It is a widely held belief that the healthcare system in Canada—driven by a common set of values, democratic
principles and tax-based funding—provides Canadians with equal access to a range of healthcare services, free
from direct, out-of-pocket costs. In reality, though, healthcare in Canada is fragmented: access is inconsistent,
services are limited, and out-of-pocket costs are endemic and varied. Canadians value their public healthcare,
but they have good reason to wonder if it is keeping pace with their health needs. This is especially relevant for
Canadian seniors and their caregivers. Provinces and territories have covered non-Medicare services demonstrated
to be effective in the management, treatment and prevention of illness in the elderly in at least some jurisdictions1
For example, in the 2004 Health Accord, provincial and territorial leaders agreed to fund certain services not required by the Canada Health Act,
such as two weeks of home care after hospital discharge, some mental health community services and two weeks of palliative care in the home.
1
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since the late 1970s. However, the Alignement
need to àimprove
the access and integration of services in order to provide highgauche/
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quality care for the growing aging population remains. While the Canada Health Act covers medical and hospital
services, provinces have typically provided a wider range of service, including a range of support and health
services for the elderly.iv; xv
Arguably, changes to the current healthcare system will only take us so far toward one that meets expected needs
and helps ensure healthy aging for all Canadians. A more comprehensive response requires the development of
integrated/coordinated systems of care delivery,xvi and partnerships across government sectors. This would allow
housing and income support issues, as examples, to be addressed in tandem with health services issues. Particular
attention must be paid to improving access to culturally appropriate and technologically advanced care for people
of First Nations, Inuit and Métis decent as well as northern, rural and remote populations. Further, the unique
challenges of certain marginalized populations (for example, Canadian immigrants and seniors living in their
own homes) must also be better understood and addressed. Finally, the contribution of family and other unpaid
caregivers needs to be recognized.viii; x; xvi
Key policy- and decision-making issues for consideration
Health services and associated policies will need to adapt to address the needs of Canada’s aging population. But
what needs to change? When? How? Among the top issues for consideration are:
Funding (for example, hospitals, home care or services for special populations such as First Nations, Inuit,
Métis as well as northern, rural and remote populations)
Health human resources (for example, recruitment, retention, mix of workers, wage equity
and adequacy of workforce)
Unpaid and informal caregivers/volunteers (for example, recruitment, training, compensation
and respite care)
Re-focus of home support services (for example, including non-professional or lay worker care
as part of the care delivery system)
Drug and health supplies coverage (for example, seniors rationing their medications to make prescriptions
last longer, lack of awareness of drug coverage and health supplies entitlements)
Technological innovation (for example, telemedicine including tele-home care and information
communication technologies that make use of the Internet)
Integration of service delivery (for example, care coordination/navigation, transitions between services,
drawing from a single-funding envelope, reduction of “bed blockers” and other system stovepipes and
delivering patient-centered, seamless care)
Special topics (for example, chronic disease management including chronic mental health management for
the elderly).
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Conclusion and next steps
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Canada’s population is aging, but it is unclear what impact this will have on individuals, our society and the
social and health services on which we depend. Realizing improvements in health services and associated policies
for seniors’ care will entail moving past the rhetoric to a focus on what needs to change and how to manage
that change. There are a number of reports that provide evidence-driven recommendations for action to guide
health system transformation.xviii; xix; viii The 2009 Special Senate Committee on Aging’s report, “Canada’s Aging
Population: Seizing the opportunity,” in particular, makes a number of recommendations for embracing the
challenges of an aging population and turning these into healthy public policy. As a signatory to the Madrid
International Plan of Action on Ageingxx (tabled at the 2002 United Nations Second World Assembly on Aging),
Canada committed “to help ensure that people everywhere can age with security and dignity, and continue to
participate in their societies as citizens with full rights”.xx Now, eight years later, the promise remains unfulfilled.
CHSRF’s roundtable series on health services and systems planning for the aging population provides an
opportunity to confront the challenges that population aging presents for Canadian health system managers and
planners. More importantly, these roundtables create the space for managers and planners to liaise with experts to
discuss strategies for realizing improvements. For CHSRF, it also serves to inform our continued work in this area,
and in so doing make Canada’s healthcare system better.
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References
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i.
Thompson, V. (2010). Health and health care delivery in Canada. Toronto, ON: Elsevier Canada.
ii.
McDaniel, S. A. (2009). The conundrum of demographic aging and policy challenges: A comparative case study of Canada, Japan,
and Korea. Canadian Studies in Population, 36, 37-62.
iii. Canadian Health Services Research Foundation. (2002). Myth: The aging population will overwhelm the healthcare system.
Retrieved September 24, 2010, from http://www.chsrf.ca/mythbusters/html/myth5_e.php
iv.
Federal/Provincial/Territorial Subcommittee on Continuing Care. (1992). Future Directions in Continuing Care. Ottawa: Health and
Welfare Canada.
v.
Soroka, S. (In press). Public perceptions & media coverage of the Canadian health care system: A report to the Canadian Health
Services Research Foundation.
vi.
Canadian Medical Association. (2010). 10th annual national report card on health care. Ottawa, ON: Ipsos Reid. Retrieved
September 24, 2010, from http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Media_Release/2010/
report_card/2010-National-Report-Card_en.pdf
vii. McGrail, K., Green, B., Barer, M. L., Evans, R. G., & Hertzman, C. (2009). Age, costs of acute and long-term care and proximity to
death: Evidence for 1987-88 and 1994-95 in British Columbia. Age and Ageing 2000, 29, 249-253.
viii. Chappell, N. L. (2010). Policy challenges and issues in caring for older adults. Institute for Research on Public Policy.
ix.
Johnson, D., & Yong, J. (2006). Costly ageing or costly deaths? Understanding health care expenditure using Australian medicare
payment data. Australian Economic Papers, 45, 57-74.
x.
Hollander, M. J., Liu, G., & Chappell, N. L. (2009). Who cares and how much? The imputed economic contribution to the
Canadian healthcare system of middle-aged and older unpaid caregivers providing care to the elderly. Healthcare Quarterly, 12(2),
42-49.
xi.
Mackenzie, H. & Rachlis, M. (2010). The Sustainability of Medicare. Ottawa, ON: Canadian Federation of Nurses Unions.
xii. Evans, R. G. (2010). Sustainability of Health Care: Myths and Facts. Retrieved September 15, 2010, from http://medicare.ca/main/
the-facts/9-sustainability-of-health-care/langswitch_lang/en
xiii. Barer, M. L. et al., (1995). Avalanche or glacier? Health care and the demographic rhetoric. Canadian Journal on aging, 14(2),
193-224.
xiv. Canadian Health Services Research Foundation. (2008). Myth: In healthcare, more is always better. Retrieved September 24, 2010,
from http://www.chsrf.ca/mythbusters/html/myth30_e.php
xv. Canadian Nurses Association (2000). A National Approach to Home and Community Care: Through the Canada Health Act Lens.
Ottawa: Canadian Nurses Association.
xvi. Hollander, M. J., Chappell, N. L., Prince, M. J., & Shapiro, E. (2007). Providing care and support for an aging population: Briefing
notes on key policy issues. Healthcare Quarterly, 10, 34-45.
xvii. Hollander, M. J. (2009). Costs of end-of-life care: Findings from the province of Saskatchewan. Healthcare Quarterly, 12(3), 48-56.
xviii.Hollander, M. J. (2007). Thematic scan of Canadian and international literature on health system responses to aging populations.
Victoria, BC: Hollander Analytical Services Ltd.
xix. Special Senate Committee on Aging. (2009). Canada’s Aging Population: Seizing the Opportunity. Retrieved September 24, 2010,
from http://www.parl.gc.ca/40/2/parlbus/commbus/senate/com-e/agei-e/rep-e/AgingFinalReport-e.pdf
xx. Government of Canada. (2007). Addressing the challenges and opportunities of ageing in Canada. Retrieved September 24, 2010,
from http://www.hrsdc.gc.ca/eng/publications_resources/research/categories/population_aging_e/madrid/madride.pdf
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Additional References
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Canadian Health Services Research Foundation. 2007. Myth: Canada’s system of healthcare financing is unsustainable. Retrieved
September 24, 2010, from http://www.chsrf.ca/mythbusters/html/myth28_e.php
Canadian Home Care Association. (2008). Home care: The next essential service meeting the needs of an aging population. Retrieved
September 21, 2010, from http://www.cdnhomecare.ca/media.php?mid=1914
Canadian Institute for Health Information. (2009). Alternate level of care in Canada: Analysis in brief. Retrieved Sept 13 2010, from
http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=PG_1751_E&cw_topic=1751&cw_rel=AR_2610_E#full.
Canadian Medical Association. (2010). Health care transformation in Canada: Change that works. Care that lasts. Retrieved
September 20, 2010, from http://www.newswire.ca/en/releases/archive/August2010/03/c7852.html
Canadian Mental Health Association. (2004). Caregiver support and mental health. Retrieved September 20, 2010, from
http://www.cmha.ca/data/1/rec_docs/194_caregiver_2.pdf
Coyte, P., & McKeever, P. (2001). Home care in Canada: Passing the buck. Canadian Journal of Nursing Research, 33, 11-25.
Dormont, B., Grignon, M., & Huber, H. (2006). Health expenditure growth: reassessing the threat of ageing. Health Economics, 15(9),
947-963.
Hogan, S. (2001). Aging and financial pressures on the health care system. Retrieved September 15, 2010, from http://www.hc-sc.
gc.ca/sr-sr/pubs/hpr-rpms/bull/2001-1-aging-veillissement/intro-eng.php
Hollander, M.J. & Prince, M.J. (2007). Organizing Healthcare Delivery Systems for Persons with Ongoing Care Needs and Their Families:
A Best Practices Framework. Health Quarterly, 11, 42-52.
Johri, M., Beland, F., & Bergman, H. (2003). International experiments in integrated care for the elderly: a synthesis of the evidence.
International Journal of Geriatric Psychiatry, 18, 222-235.
Keefe, J., Rajnovich, B. (2007). To pay or not to pay: Examining underlying principles in the debate on financial support for family
caregivers. Canadian Journal on Aging, 26 (S1), S77-90.
MacAdam, M., Hollander, M.J., Miller, JA., Chappell, N. & Pedlar, D. (2009). Increasing value for money in the Canadian healthcare
system: New findings and the case for integrated care for seniors. Healthcare Quarterly, 12, 38-47.
MacAdam, M. (2008). Frameworks of integrated care for the elderly: A systematic review. Retrieved September 24, 2010, from
https://www.cssnetwork.ca/Resources%20and%20Publications/MacAdam-Frameworks%20for%20Integrated%20Care%20for%20
the%20Frail%20Elderly.pdf
MacAdam, M. (2009). Moving toward health service integration: Provincial progress in system change for seniors. Retrieved
September 24, 2010, from http://www.cprn.org/documents/51302_EN.pdf
Martin-Matthews, A., Tamblyn, R., Keefe, J., & Gillis, M. (2009). Bridging policy and research on aging in Canada: Recognizing an
anniversary, realizing an opportunity. Canadian Journal on Aging, 28, 185-193.
Motiwala, S. S., Flood, C. M., Coyte, P. C., Laporte, A. (2005). The first Ministers’ accord on health renewal and the future of home care
in Canada. Longwoods Review, 2, 2-10.
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