A few years ago, almost three years to the day, in fact, long before the pandemic, I had a grim thought. The then-Liberal government had announced that it was reopening two hospitals it had mothballed in Toronto but not yet sold off as real estate. They were needed as overflow facilities to cope with particularly acute overcrowding in GTA hospitals ahead of the flu season. That year, Ontario had spent 38 cents out of every provincial dollar on health care. We had run an almost $4 billion deficit.
Those three data points swirled around in my mind for a minute before clicking into a coherent if unpleasant realization: health care was already, by far, the province’s largest expenditure. We clearly weren’t spending enough on it, else we wouldn’t have needed the overflow facilities to cope with a seasonal event. And we still couldn’t balance the budget.
In other words, we couldn’t afford even the objectively inadequate system we had.
Three weeks ago, the provincial NDP put forward a plan to radically overhaul long-term care in this province. The party is proposing billions in new capital spending to create tens of thousands of new beds in smaller, modern LTC facilities, and an additional $3 billion a year — every year — to fund them. Within eight years, the NDP claims, it would erase the wait-list of Ontarians needing a bed (which is nearing 40,000); it also pledges to phase out the for-profit system and make LTC in Ontario entirely publicly funded.
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The NDP isn’t wrong that something needs to be done. As noted here previously, LTC has been a shambles in Ontario for many years, with chronic staffing problems and long wait-lists. The backlog of cases in our LTC system, indeed, contributes to dysfunction elsewhere in the health-care system; in a 2019 series for TVO.org, I explored the root causes of chronic dysfunction in our emergency rooms and discovered that a major challenge is that hospitals are often unable to discharge patients who are no longer in danger but have nowhere to go. Not all patients can simply return to their normal lives after an illness or injury. Some can go home with support, but our community-care system is overloaded. Some will be able to return to independent living but need a spell of full-time rehabilitation first, yet the rebab hospitals are slammed. Some, sadly, will no longer be able to live independently and will require a bed in a LTC home. Until such a space (within reasonable geographic proximity) becomes available, that patient will remain in the hospital, taking up a bed that’s needed for a new arrival in the emergency room … which has nowhere to send the new patient.
We’ve known all this for years. We didn’t do anything. And then the pandemic hit. And something interesting happened.
Ontario’s LTC system is heavily privatized — three-fifths of the beds are private. During the first wave of the pandemic, privately operated facilities were not any more likely than public ones to experience an outbreak; the primary contributor to outbreaks in any given home was, naturally enough, the prevalence of COVID-19 in the broader community. LTC homes in hot spots had more outbreaks than did homes in areas with low levels of the virus in the community. But when Ontario LTC homes did experience outbreaks, those in private facilities were larger and resulted in more deaths. A report in the Canadian Medical Association Journal found that much of the difference could likely be attributed to the fact that older facilities proved more vulnerable to COVID-19 — and many of the privately owned facilities are indeed of an older vintage. Ownership by a chain was also a risk factor.
This seems to be a slamdunk case against privately run LTC homes, and the NDP can tell you what the problem is: the profit motive. For-profit homes divert some money to executive compensation and shareholder dividends. That’s money not spent on patients and staff and more modern facilities, and that explains the deaths. Easy peasy.
But it’s not quite that easy. As journalist Peter Shawn Taylor notes in C2C Magazine, the experience of different provinces, which have different rates of private ownership, has muddied the water. Ontario’s experience doesn’t neatly align with that of other provinces, raising questions about the real cause — if private ownership indeed contributes, how much does it contribute, and would mandating staffing levels and facility upgrades be a cheaper way of addressing it than taking the entire system public?
Because as fashionable as it is, mid-emergency, to simply say that this is no time to worry about money and that we can’t put a dollar value on lives, the case for the publicly funded system has one gigantic problem: the state of the publicly funded system. A backlog of almost 40,000 people waiting for an LTC bed isn’t the private sector’s fault. Rushing to reopen mothballed hospitals to cope with seasonal-flu surges isn’t the private sector’s fault. The well-established and chronic issues in our publicly funded health-care system aren’t the private sector’s fault.
It may well be true that the public LTC homes fared better during this pandemic than the private ones, but the entire system is dysfunctional, and long has been, and that includes the publicly owned facilities. Simply phasing out the for-profit homes won’t fix the fundamental problem that lies at the heart of all our health-care woes: the Canadian public does not want to pay the true price of the kind of health-care system we feel we are owed. There is an obvious problem with this kind of thinking that no politician has a ready answer for.
We can build new LTC homes. We’re already doing that. We can establish a new model of public-only LTC care in Ontario, if the NDP convinces the voters and sees it through. But until we have a reckoning — until the public makes up its mind about what it’s willing to spend money on and what it is willing to do without — we can’t solve the real problem. The problem is us.