The Four Lenses of Population Aging: Planning for the Future in Canada’s Provinces 9781442699816

Citation preview

THE FOUR LENSES OF POPULATION AGING Planning for the Future in Canada’s Provinces

With its implications for health care, the economy, and an assortment of other policy areas, population aging is one of the most pressing issues facing governments and society today, and confronting its complex reality is becoming increasingly urgent, particularly in the age of COVID-19. In The Four Lenses of Population Aging, Patrik Marier looks at how Canada’s ten provinces are preparing for an aging society. Focusing on a wide range of administrative and policy challenges, this analysis explores multiple actions from the development of strategic plans to the expansion of long-term care capacity. To enhance this analysis, Marier adopts four lenses: the intergenerational, the medical, the social gerontological, and the organizational. By comparing the unique insights and contributions of each lens, Marier draws attention to the vital lessons and possible solutions to the challenges of an aging society. Drawing on over a hundred interviews with senior civil servants and thousands of policy documents, The Four Lenses of Population Aging is a significant contribution to public administration, provincial politics, and comparative public policy literatures, and a timely resource for policymakers and general readers seeking an informed perspective on a timely and important issue. (IPAC Series in Public Management and Governance) PATRIK MARIER is a professor in the Department of Political Science at Concordia University.

The Institute of Public Administration of Canada Series in Public Management and Governance Editors: Peter Aucoin, 2001–2 Donald Savoie, 2003–7 Luc Bernier, 2007–9 Patrice Dutil, 2010–18 Luc Juillet, 2018– This series is sponsored by the Institute of Public Administration of Canada as part of its commitment to encourage research on issues in Canadian public administration, public sector management, and public policy. It also seeks to foster wider knowledge and understanding among practitioners, academics, and the general public. For a list of books published in the series, see page 361.

The Four Lenses of Population Aging Planning for the Future in Canada’s Provinces

PATRIK MARIER

UNIVERSITY OF TORONTO PRESS Toronto Buffalo London

© University of Toronto Press 2021 Toronto Buffalo London utorontopress.com Printed in the U.S.A. ISBN 978-1-4426-4439-7 (cloth) ISBN 978-1-4426-9982-3 (EPUB) ISBN 978-1-4426-1263-1 (paper) ISBN 978-1-4426-9981-6 (PDF)

Library and Archives Canada Cataloguing in Publication Title: The four lenses of population aging : planning for the future in Canada’s provinces / Patrik Marier Names: Marier, Patrik, author. Series: Institute of Public Administration of Canada series in public management and governance. Description: Series statement: Institute of Public Administration of Canada series in public management and governance | Includes bibliographical references and index. Identifiers: Canadiana (print) 20200410970 | Canadiana (ebook) 20200410989 | ISBN 9781442644397 (cloth) | ISBN 9781442612631 (paper) | ISBN 9781442699816 (PDF) | ISBN 9781442699823 (EPUB) Subjects: LCSH: Population aging – Canada – Provinces. | LCSH: Older people – Government policy – Canada – Provinces. Classification: LCC HQ1064.C3 M32 2021 | DDC 305.260971–dc23 This book has been published with the help of a grant from the Federation for the Humanities and Social Sciences, through the Awards to Scholarly Publications Program, using funds provided by the Social Sciences and Humanities Research Council of Canada. University of Toronto Press acknowledges the financial assistance to its publishing program of the Canada Council for the Arts and the Ontario Arts Council, an agency of the Government of Ontario.

Funded by the Financé par le Government gouvernement du Canada of Canada

To Marlene

This page intentionally left blank

Contents

List of Tables and Figures xi Foreword by Luc Juillet xiii Acknowledgments xvii List of Acronyms xix Introduction 3 Facing the Consequences of an Aging Population 5 Purpose of This Book 8 Methods 12 Content 13 Theoretical Underpinning 1 The Lenses of Population Aging 21 The Intergenerational Lens 24 The Medical Lens 34 The Social Gerontology Lens 41 The Organizational Lens 46 Conclusion: Policy Lenses in Public Administration 49 2 Population Aging as Policy Problems 51 Introduction 51 Linking Policy Problems with Population Aging Lenses 51 Solutions to Policy Problems 63 Interactions between the Lenses: Coexistence, Complementarity, and Competition 69 Conclusion 73

viii

Contents

3 The Politics of the Long View 75 Introduction 75 The Rise and Fall of Planning 77 Thinking and Acting with a Long View in the Public Sector 82 What Facilitates or Impedes the Long View in Canadian Provinces? 90 Conclusion 95 Public Policy and Population Aging 4 Pension Policies 101 Introduction 101 Historical Overview and Current Structure of Canada’s Pension Policy 103 What Solution for Pensions? 107 The Harper Years: Lack of Consensus Led to Multiple Provincial Initiatives 109 The Liberal Years: Improving the CPP, Occupational Pension Plans, and New Alternatives 122 A Lens Analysis of the Pension Debates 125 Conclusion 129 5 Health and Residential Care 132 Introduction 132 Health Care Expenditure 133 Long-Term Care: Residential Care 143 Analysing the Four Lenses in Health Policy 152 COVID-19 and the Long-Term Care Crisis of 2020 157 Conclusion 159 6 Home Care Services and Caregiving 163 Introduction 163 Home Care Services in Canadian Provinces 165 Caregiving 182 Home Care as a Universal Solution for Population Aging? 187 Conclusion 195 Public Administration and Population Aging 7 Central Agencies and Inter-ministerial Coordination 199 Introduction 199 The Organizational Lens and Policy Problems 201 Central Agencies 202 Inter-ministerial Coordination 216 Conclusion 220

Contents

8 Offces for Seniors 223 Introduction 223 The Creation (and Expansion) of Offces for Seniors 224 What Do Offces for Seniors Do? 234 The Tension between the Social Gerontological and Medical Lenses 239 Long-Term View 244 A Third Wave of Offces for Seniors? Seniors’ Advocate Offces 247 Conclusion: Divergent Path for Seniors’ Offces? 249 Conclusion 252 Revisiting the Four Lenses of Population Aging 253 Revisiting the Long-View Theoretical Expectations 262 Federalism, Population Aging, and Policy Diffusion and Learning 268 Continuing Marginalization of Social Policies and Its Consequences in the Context of an Aging Population and the Challenges of COVID-19 271 Notes 275 Index 347

ix

This page intentionally left blank

Tables and Figures

Tables 2.1 2.2 4.1 6.1 6.2 8.1

Core population aging problem defnitions across the four lenses 53 Core population aging problem solutions across the four lenses 54 Comparison between the 2016 CPP reform and the ORPP 123 Inquiries into home care since 2000 (excluding follow-up reports) 165 Publicly funded home care models in Canada 174 Responsibilities for seniors in Canadian provinces, 2010– 2018 227

Figures 1.1 5.1 5.2 5.3 5.4 5.5 9.1

Policy issues associated with population aging in the Globe and Mail and La Presse, 2013–2018 4 Total provincial government health expenditure as a proportion of total provincial programs in 2016 135 Public health expenditure as a percentage of GDP, per capita in 2016 135 Estimate of total per capita governmental health expenditures by age group in Canada, 2016 136 Comparative estimates of total per capita health expenditures in Alberta and Nova Scotia, 2016 137 Long-term care beds in institutions, 2015 (or nearest year) per 1,000 population aged 65 years old or over 144 Policy coordination scale 260

This page intentionally left blank

Foreword

Canada is undergoing a fundamental demographic shift. According to Statistics Canada and the Canadian Institute for Health Information, its seniors population – those age 65 and older – tripled in size over the last 40 years. The result is a progressive but significant change in the country’s age distribution. In 2016, for the first time in its history, seniors outnumbered children (aged 14 and under). Moreover, the number of seniors is expected to grow again by 68% over the next 20 years, while the population of older seniors – those age 75 and older – will grow even faster, doubling in size over the same period. As a result, by 2037, more than 10 million Canadians will be 65 and older and, by 2048, seniors should constitute about a quarter of Canada’s population. Such significant demographic change necessarily represents an important challenge for government. An older population will increase or lessen the demand for some public services, but it may also require fundamentally rethinking some policies, especially since the living conditions, needs, and expectations of future seniors will differ from those of past generations. For this reason, a good understanding of the policy implications of population aging and the choices faced by governments as they attempt to respond to it is increasingly important to anyone interested in the ability of Canadian governments to effectively contribute to the well-being of their citizens in the coming decades. The inescapable policy challenges – but also possible opportunities – of population aging make The Four Lenses of Population Aging: Planning for the Future in Canada’s Provinces a much-needed contribution to policy scholarship. Drawing on comparisons across Canadian provinces, including their individual relationships with the federal government, Patrik Marier’s book provides an insightful overview of recent policy debates and developments in some of the areas most impacted by aging, namely pensions, health, and social care. Its readers – practitioners as

xiv

Foreword

much as scholars – will greatly benefit from its discerning survey of the main contemporary debates about how Canadian governments have so far responded to population aging. However, while readers will undoubtedly benefit from this analysis of recent debates, it may not be the most important and lasting contribution of the book. As he takes us through these arguments, Marier does not only seek to provide us with a compelling analysis of what has been said and done across the provinces; he also provides us with the interpretative tools needed to understand and critically assess future debates about aging, even beyond the policy areas discussed in the book. Firmly rooted in a “problem definition” perspective, he shows us how policy arguments and prescriptions about aging are partly shaped by how governments, advocates, and analysts think about the “problem” of population aging. As such, the four “lenses” – competing problem definitions – that he identifies and uses throughout the book will help readers think about the policy and organizational challenges of an older population long after they finish reading. The Four Lenses of Population Aging is not a polemic or a call to action. Its analysis is nuanced and it mostly reveals the complexity of the issues. It is not an argument about impending doom and Marier largely eschews specific policy prescriptions. Still, its reading suggests that Canada needs to do a lot better to help its growing number of older citizens. For example, despite some recent successes in protecting the future of public pensions, serious concerns remain about the financial security of a large number of seniors. Moreover, notwithstanding the official priority afforded to home care across the provinces as a cheaper and preferred option for most seniors, public budgets are still mostly devoted to residential care facilities. Insufficient attention is also being paid to some of the social problems faced by seniors, including ageism and marginalization, especially of underprivileged older adults. In order to do better, governments would do well to tackle two important and inter-related challenges that stand out from Marier’s analysis. First, an overwhelming tendency to define population aging as a medical challenge – how to help the growing number of citizens with declining physical and cognitive abilities – is impoverishing policy debates about population aging and curtailing our policy imagination. On this score, Marier tells us that social gerontology would have much to offer to apprehend more fully the realities of aging citizens. Second, population aging should be better acknowledged as an important social change with implications for the whole of government. In fact, an important contribution of the book is its examination of how provincial governments have organized themselves to ensure

Foreword

xv

that the long-term implications of population aging are considered in policymaking across policy areas as well as to bolster the effectiveness of policy interventions through better inter-ministerial coordination. Unfortunately, on this score, the verdict is rather sobering. Despite some interesting innovations, such as the creation of centralized offices for seniors and the appointment of dedicated ministers, much could still be done by all provinces to adopt a coherent and coordinated approach to population aging. Population aging is still mostly seen as a problem for the Department of Health and, by failing to craft a coherent long-term and government-wide vision for how to deal with population aging, many governments seem to condemn themselves to a sector-by-sector incremental response that may not deliver the best results. In sum, we are pleased to publish The Four Lenses of Population Aging as part of the IPAC Series in Public Management and Governance because, through the remarkable breadth of its coverage and the multiple perspectives that it brings to its analysis, the book will help practitioners, scholars, and students grapple more fully with one of the most pressing issues currently facing governments and society. If we are to adequately address the challenges of this on-going demographic shift, it is imperative that we first appreciate its multi-faceted complexities and the diversity of provincial responses that it has so far elicited. To do so, readers could hardly do better than to start with this book. Luc Juillet, PhD University of Ottawa Editor, IPAC Series in Public Management and Governance

This page intentionally left blank

Acknowledgments

This book has been in the making for over a decade. My nomination as scientific director at the Centre for Research and Expertise in Social Gerontology (CREGÉS) in 2013 has altered this project considerably, as I ventured into the universe of research and practice within a local community service centre. The transition from the comfortable world of pensions and finance into the underappreciated universe of aging studies and long-term care is at the origin of the conceptualization of the four lenses in this book. This project benefited from the input and encouragements of many individuals. First and foremost, this book features valuable content from 125 individuals (mostly senior civil servants) who patiently answered my questions and shared their knowledge and experience. They went the extra mile – sometime literally – to ensure that I captured the essence of their work and their province. Special thanks to Ken Rasmussen and the late Christopher Dunn who put me in touch with some senior civil servants in their respective province. I would like to thank the many research assistants who provided all kinds of help – big and small – throughout this project. Among them, I would like to mention Nika Deslauriers, Yoana Garcia-Poulin, Mahsa Hedayati, and Mark Frimpong. Earlier versions of the chapters have been presented at conferences and seminars. I would like to thank discussants (Vandna Bhatia, Sonja Blum, Cherryl Collier, B. Guy Peters, Donley Studlar, and Sara Marie Wiebe) and participants who made comments and suggestions. Some public forums with a large and diverse audience helped tremendously to better conceptualize core ideas and to organize the findings of the book. For instance, the presentation of the four lenses during the Forum Vieillir et vivre ensemble, organised by the Secrétariat des aînés in 2017, led to a wide range of input and comments from civil servants, policy

xviii Acknowledgments

actors, elected officials, volunteers, and professionals involved in nonprofit organizations, health and social services professionals, and older adults. Thanks to Shari Brotman, Patrick Durivage, Raquel Fonseca, Zelda Freitas, and Cindy Starnino, who provided comments and feedback on some chapters in this volume. Portions of the research material was explored further with a few colleagues, resulting in complementary – and more timely – contributions in academic journals, which crystalized some of the key concepts and ideas in this book. Thanks to Chris Cooper, Ali Halawi, Stephanie Paterson, and Isabelle Van Pevenage. Many colleagues have been encouraging me in the pursuit of this project and provided feedback along the way: Daniel Béland, Jonathan Craft, Suzanne Dupuis-Blanchard, Bryan Evans, Meghan Joy, John Hoornbeek, Michael Howlett, Rachel Laforest, Poland Lai, André Lecours, David McGrane, Éric Montpetit, Brenda O’Neill, Mireille Paquet, Amy Poteete, Anthony Sayers, David Stewart, and Russ Williams. While far removed from my graduate days, B. Guy Peters continues to be a source of inspiration and an excellent critique. The completion of this book would not have been possible while juggling the responsibilities of a research chair, CREGÉS, and VIES without the contributions of key individuals. My colleague Anne-Marie Séguin recruited me to embark into the CREGÉS/VIES journey, and we worked closely and collaboratively until her recent retirement. Shannon Hebblethwaite served as associate scientific director for a few years at CREGÉS. There are also many individuals working in the shadows supporting these research infrastructures. I would like to thank, most notably, Véronique Billette, Maya Cerda, Michèle Modin, and Virginie Tuboeuf, with whom I have had the pleasure to work over many years. At both ends of this book project, I benefited from the hospitality of wonderful hosts during two sabbatical leaves. Chad Damro and the Europa Institute at the University of Edinburgh provided all that was needed to engage deeply in a novel research project. My recent stay at INED in Paris allowed me to wrap up this research project. Many thanks to Loïc Trabut and Alexandra Garabige for their hospitality at INED. Special thanks to the Bibliothèque historique de la ville de Paris and its personnel, who contribute to make this place so inspiring. I would also like to thank the entire team at UTP, and especially Daniel Quinlan, for being so supportive and patient throughout this entire process. Thanks to both reviewers who provided generous comments and suggestions to improve the manuscript. In closing, this book would have never seen the light of day without the love and support of Marlene, to whom I dedicate this book.

Acronyms

AARP ADL ADM ALC ALMP AoA APPF CA CAQ CARP CBO CCAC CCF CEASR CHA CHSLD CIHI CISSS CIUSS CLSC CMA CPP CSPP DB DC DM EHPAD

(formerly) American Association of Retired Persons activities of daily living assistant/associate deputy minister alternate level of care active labour market policies Administration on Aging Aging Population Policy Framework Community Accounts Coalition Avenir Québec (formerly) Canadian Association of Retired Persons Congressional Budget Office Community Care Access Centres Cooperative Commonwealth Federation Comité d’expert sur l’avenir du système de retraite Canada Health Act Centres d’hébergement de soins de longue durée Canadian Institute for Health Information Integrated Health and Social Services Centres Integrated University Health and Social Services Centres Local Community Service Centre Canadian Medical Association Canada Pension Plan Canadian Supplementary Pension Plan defined-benefit defined-contribution deputy minister Établissement d’hébergement pour personnes âgées dépendantes

xx Acronyms

EÉSAD FADOQ FPT GIS GSS ICT ISO-SMAF ISQ JEPPS LHIN LPN LTC MADA MITI MLA NSPRP OAA OAS OECD OECP OPS ORPP PEFSAD PPBS PQ PRPP QPP RH RHA RPP RRQ RRSP SHARE SHAS TFSA TTD VON VRSP WHO WITB

Entreprises d’économie sociale en aide à domicile (formerly) Fédération de l’âge d’or du Québec federal/provincial/territorial Guaranteed Income Supplement General Social Survey Information and Communication Technology Système de mesure de l’autonomie fonctionnelle Institut québécois de la statistique Joint Expert Panel on Pension Standards Local Health Integrated Networks Licensed Practical Nurses Long-Term Care Municipalités amies des aînés Ministry of International Trade and Industry (Japan) Member of the Legislative Assembly Nova Scotia Pension Review Panel Older Americans Act Old Age Security Organisation for Economic Co-operation and Development Ontario Expert Commissions on Pensions Ontario Public Service Ontario Retirement Pension Plan Programme d’exonération financière pour les services d’aide domestique Planning, Program, and Budgeting System Parti Québécois Pooled Registered Pension Plans Quebec Pension Plan Retirement Housing Regional Health Authorities Registered Pension Plans Régie des rentes du Québec Registered Retirement Savings Plans Survey of Health, Ageing and Retirement in Europe Seniors and Healthy Aging Secretariat Tax-Free Savings Accounts time to death Victorian Order of Nurses Voluntary Retirement Savings Plan World Health Organization Working Income Tax Benefit

THE FOUR LENSES OF POPULATION AGING

This page intentionally left blank

Introduction

Population aging, defined in its most basic form as the increasing share of individuals above the age of 65, represents a gradual change in the demographic structure of most societies in industrialized countries. In multiple jurisdictions, such as Spain and Italy, this gradual change has led to a substantial alteration of their demographic profile, and an older population is already a reality. These trends are seen in Canada as well, where the number of individuals aged 65 and over reached 17.2% of the population in 2018, and this proportion is expected to reach 24% by 2048 and 25.7% in 2068.1 Barring major unforeseen circumstances, there is a consensus that this demographic shift is unavoidable. In sharp contrast, there is a wide range of opinions and prognostics concerning the socio-economic consequences related to population aging. A quick survey of newspaper headlines illustrates well the diverse and eclectic views on the matter. Population aging represents a “potential health-care time bomb,”2 it “spells trouble for federal finances,”3 and it “emphasizes our heavy dependence on government.”4 Our future is also at stake, since an aging population “will kill the American Dream”5 and “sideswipe Canada’s small businesses.”6 It already creates “boomerangst”7 and “could lead to Greek-style debt crisis in Canada.”8 For readers seeking immediate causes for concerns, our aging population “doesn’t mean we’re safer,”9 and it already “fuels [the] retirement home boom.”10 Those expecting two solitudes on this matter will be utterly disappointed. Although press coverage in the province of Quebec is less alarmist, population aging is still “l’enjeu de l’heure” (the pressing issue) according to La Presse11 or un “péril vieux” (the jeopardy of aging) according to Les Affaires, which featured a drawing of an aging and bending fleur-de-lys using a cane on its front page.12 Beyond sensational headlines, a search for articles featuring population aging in the Globe and Mail and La Presse during 2013–18 reveals

50 45 40 35 30 25 20 15 10 5 0

-

Percentage of articles per policy issue associated with population aging

Figure 1.1 Policy issues associated with population aging in the Globe and Mail and La Presse, 2013–2018

Globe and Mail

La Presse

Introduction 5

that multiple policy consequences are being discussed. While more than a third of the coverage on aging populations involves health policy, with budgetary concerns not far behind, there is a wealth of other policy issues such as long-term care, labour, immigration, and pensions (see figure 1.1). Similar debates are prevailing in academic and policy circles. This is a very eclectic landscape with many political and socio-economic consequences attributed to population aging echoing newspaper reports. There is even a debate on the potential development of gerontocracies due to the current and future electoral strength of older adults resulting in policy preferences aligned with their interests.13 Still, most debates are geared primarily towards the extent to which population aging will trigger a reappraisal, or even sweeping reforms, of current (and future) policies. There remains a perceived gap between the socio-economic consequences of population aging and proposed policy reforms. At one end of the spectrum, the American Kotlikoff alludes to a generational storm and fiscal child abuse.14 At the other end of the spectrum, policy reforms to address these consequences are seen to be within reach and do not necessitate alarmist discourse. As stated eloquently by Chappell and Hollander in their analysis of aging within the context of health and social services in Canada, “While the analysis of the problem is usually competent, many authors propose excessively dismal solutions, such as dismantling medicare. Such solutions typically fail to consider alternative ways to organize the overall system of care delivery to increase value for money.”15 Facing the Consequences of an Aging Population In the best-selling Boom, Bust and Echo, David Foot famously claimed that demographic change explains two-thirds of everything.16 Yet, twentyfive years later, with the baby boomers entering retirement, population aging remains an ubiquitous concern affecting countless policies and programs in Canada as well as other industrialized countries. Complicating matters further is the competing ways in which population aging is treated across social and health sciences and, as importantly, within the civil service. Provinces encounter multiple obstacles when seeking to address the challenges and opportunities of an aging population. First, it affects many aspects of life and spans a wide range of policies and programs well beyond those targeting seniors. For instance, family relationships have been altered significantly; having great-grandparents is now far more common. Healthier grandparents are increasingly able to enjoy

6

The Four Lenses of Population Aging

meaningful and sustained interactions with their grandchildren. As illustrated by research on the sandwich generation, this can represent a mixed blessing, however.17 With family structures in flux, grandparents are often expected to play a key role in the upbringing of grandchildren, including providing child care to compensate for day care policies that are often at odds with the necessity to have parents actively engaged in the labour market. When combined with rising demands to provide assistance to their own parents and life partner, the experiences of many recent retirees – most notably women – tend to be far removed from the leisure-filled life often portrayed in commercials and the media. As an illustration of the reach of demographic change on programs and policies, social services programs are increasingly placing children with older foster parents, necessitating new ideas about placement strategies and public interventions needed to support hosting families and children.18 Each provincial department analyses and treats population aging differently according to their respective mandate, which can accentuate the risk of elaborating contradictory responses by public authorities. To illustrate succinctly, caregivers have become an essential partner of health authorities to address the care needs of older adults. Women represent the majority of caregivers and they typically perform time-consuming assignments. With pressures to limit the growth of health care budgets and the expectation to facilitate aging at home, there is a risk of instrumentalizing caregivers further by offering training and requiring a higher level of care from them. However, this is in direct contradiction to the mandates of labour departments, which are increasingly pressed to secure a higher participation rate in the labour force and bridge the income gap between men and women. Reducing the number of hours worked – or worse, leaving the labour market altogether – also has important financial consequences in the long run, most notably on retirement income. Women’s agencies, concerned with the heightened expectations placed upon caregivers, have been vocal in their criticism that current practices encourage a return to traditional gender roles and the disappearance of avenues to seek better socio-economic opportunities. They have also been highly concerned with the low wages and the precarious working conditions of women providing long-term services in the formal sector.19 To tackle horizontal challenges, such as caregiving, no province has sought to create a new office or administrative unit with the specific mandate of ensuring that policy decisions consider the ongoing demographic shift. Still, there is increasing awareness of the facets associated with an aging population, and provinces have initiated diverse measures and strategies to enhance the opportunities and address challenges.

Introduction 7

Second, population aging is a demographic transition that cannot be avoided. There is a consensus in Canada that population aging is a fait accompli. Contrary to a popular belief that still permeates the civil service, albeit to a far lesser extent than a decade ago, immigration has a narrow impact.20 Interprovincial migration has played a role in accentuating (in Eastern Canada) or decreasing (Alberta) the combined impacts of lower birth rates and increased life expectancy.21 Governmental authorities have limited capacities to address this kind of challenge and can only mitigate its effects. The literature on the welfare state is clear that this is an era of retrenchment, or at best stasis, in social policy developments.22 However, citizens’ expectations continue to exceed the scope of public intervention, and, as illustrated in this book, policy expansion now involves community groups, non-profit organizations, and the private sector. In addition and contrary to sudden and unexpected crises that prompted large-scale policy responses, such as the oil crisis of the 1970s,23 population aging remains slow and gradual, with ad hoc measures prevailing. There is a real danger of falling into an incrementalist trap wherein policy issues are dealt with as they arise, avoiding a longer-term vision that would tackle challenges and embrace the opportunities presented by an aging population. Third, and accentuating the fear of a piecemeal approach to population aging, governments are increasingly embracing a shorter time horizon in the age of Twitter and 24-hour news cycles. Recent developments in public administration point in the same direction, with the electoral calendar gaining prominence amidst growing input from key Cabinet figures and political appointees. Akin to development at the federal level, provinces have been accentuating the power of central agencies.24 In addition, they have been increasingly relying on political appointees to do their work, leading to a new dynamic where political appointees and career civil servants frequently cooperate.25 Finally, population aging has an uneven impact, not only across provinces, with the socio-economic and demographic of Atlantic Canada being very different from Alberta and Saskatchewan, for instance, but also within them. The proportion of older adults is highest in rural areas and urbanization continues, even from recent migrants.26 This threatens the future of some communities and the ability to provide (or maintain) basic socio-health services. As a case in point, there is an increasing number of rural regions with staff shortages, which have had negative impacts on the quality and quantity of long-term care services offered.

8

The Four Lenses of Population Aging

Purpose of This Book This book offers a comprehensive analysis of how Canadian provinces are preparing to withstand the challenges and embrace the opportunities resulting from population aging. A unique feature of this book is its dual focus on developments in public policy and public administration and the relationship between them. Concretely, it provides a detailed account of initiatives to alter programs and policies closely identified with an aging population and proposals to introduce new ones. It also tackles the difficulties for governments and senior civil servants within central agencies and line departments to plan for the long term, to enhance horizontal coordination, and to alter administrative entities to respond to population aging. In terms of analysis, the book relies upon two approaches. First, embedded within the public policy literature on policy problems27 and inspired by Lakatos’s characterization of research programs,28 this book introduces four lenses of population aging (intergenerational, medical, social gerontology, and organizational). The construction of these lenses originates from the academic literature and from within policy debates. These lenses have core characteristics that can coexist, complement, and compete with one another, depending on the policy area under discussion. As such, this differs from other approaches that present a dominant paradigm29 or social construction30 as the key force that formulates policy problems. In a nutshell, the book studies not only the political dimensions of the administrative and policy responses in the 10 provinces, involving not only partisan politics, the centralization of power, and the politicization of the civil service, but also the ubiquity of actors embracing divergent problem definitions across the four lenses of population aging. Second, the subject of demographic change raises important questions of long-term planning within public administration. More recently, there has been renewed interest in both long-term policymaking and the analysis of the temporal dimensions of public programs.31 However, civil servants, who commonly have tenure and a longer time horizon in public policy,32 are surprisingly absent from these new studies.33 The book contributes to this literature by studying how civil servants seek to enhance a long-term view at a time when short-term pressures are omnipresent. It also analyses the mechanisms deployed by public authorities to enact long-term plans. Interestingly, the four lenses of population aging also display very different time horizons, with the intergenerational lens revealing a much longer time view than the social gerontological lens, for instance. This contributes to their divergence in breadth and urgency of actions promulgated.

Introduction 9

As this book was in the final stages of production, COVID-19 spread across the country, resulting in the introduction of exceptional policy measures. As the COVID-19 situation continues to evolve, the longterm impacts remain very much in question. So far, as of July 2020, Canada stands amongst the worst countries in its handling of the crisis in residential care facilities (i.e., nursing homes), with 81% of all COVID-19 deaths.34 This national figure masks starkly different realities as provincial responses to contain the virus in residential care facilities have diverged noticeably, eliciting praise in British Columbia and condemnation in both Ontario and Quebec. Conditions have been so bad in the latter two cases, the Canadian Armed Forces have been called in to intervene. This crisis has become a focusing event that has put longterm care atop the provincial policy agenda and even led to the launch of an inquiry in Ontario.35 In response to the magnitude of these developments, there is an additional section related to COVID-19 in chapter 5 (“Health and Residential Care”) and some reflections on its potential impact in the conclusion. Why Focus on Canadian Provinces? Canada is a federal country, but most comparative policy analyses treat it as a unitary state.36 This is quickly changing, however, with the publication of studies such as Haddow’s application of the power resource theory across the provinces,37 Paquet’s work on immigration,38 and Wood’s study on the devolution of employment services.39 This recent shift is aligned with current realities: “The simple fact is that in substantive terms, the largest proportion of policy development, adaptation, and change is concentrated in the provincial sector.”40 Hence, to comprehend how public authorities are responding to the challenges and opportunities of population aging, provincial capitals are the proper places to concentrate this inquiry, rather than Ottawa. To facilitate identification of developments across the country, this book focuses on all 10 provinces, allowing us to assess whether the actions of a province are unique or part of a cross-country trend. A case in point is the provision of home care in New Brunswick and Nova Scotia, which are at opposite ends of the spectrum in access and generosity, in spite of the similarity of their population profiles.41 New Brunswick is unique in Canada in that long-term care is under the responsibility of a social department, as opposed to health in the other nine provinces (see chapters 5 and 6). The selection of a sample of specific cases would have potentially led to understating (or the opposite) the uniqueness and relative importance of administrative and/or policy reforms.

10

The Four Lenses of Population Aging

Provinces with a relatively small population provide the most puzzling cases, with population aging having a more pronounced effect. Demographic changes have historically been an important political focus for these governments. To illustrate, population growth has regularly featured as part of the premier’s assessment in Saskatchewan. Smaller provinces also lack many of the resources available to larger provinces, forcing them to collaborate with other jurisdictions (federal and provincial) to enhance their policy capacities and to be more creative in their approaches. This interprovincial collaboration has been particularly visible in the development and functioning of offices for seniors (chapter 8). The Maritimes are cornerstone cases, since they are experiencing lower economic growth combined with the highest percentage of older adults in the country. Population decline is also clearly on the horizon, with New Brunswick already experiencing population decline on the basis of the 2016 census.42 Population aging has also received increasing attention from the four most populous provinces (Alberta, British Columbia, Ontario, and Quebec), most notably British Columbia and Quebec where reports from the auditor general and the ombudsperson have revealed issues related to population aging (see chapters 5, 6, and 7). Ontario almost introduced its own earnings-related pension plan to raise the replacement rate of its citizens (chapter 4). Interestingly, the “youngest” province, Alberta, has been one of the most active and explicit in the study and analysis of the broader socio-economic consequences of an aging population (see chapter 7). Why Focus on Civil Servants? Unlike journalists and researchers, policymakers are expected to enact measures to confront the opportunities and challenges related to population aging. They are the ones who must decide how to identify and address policy problems related to this demographic phenomenon. Policy problems and their potential solutions operate in highly contested terrains along different dimensions.43 Multiple contributions stress the strong linkage between solutions and policy problems,44 such as Wildavsky’s famous claim that policymakers are unlikely to tackle a problem if there is no solution already formulated.45 Following decades of increased politicization and welfare state retrenchments, bureaucrats have disappeared as important actors in policymaking.46 This book joins a growing literature that argues to the contrary.47 Four key reasons support this assertion. First, as illustrated in Savoie’s Governing from the Centre and Bogdanor’s Join-Up Government,

Introduction

11

the centre tends to concentrate its energy on only a few policy issues, leaving others in the hands of career civil servants.48 In addition, governing from the centre does not imply that civil servants disappear, but rather that those operating in central agencies have gained influence at the expense of those working in line departments. Thus, even in policy areas where the centre has engaged itself, these still require collaboration between civil servants and elected officials. Second, ministers rarely occupy their posts long enough to see a project through from beginning to end. The presence of a new minister is the rule rather than the exception within parliamentary democracies.49 For example, the average tenure for a minister in the United Kingdom, the source of the Westminster system, is 26.9 months.50 Under these circumstances, it is rather difficult to conceptualize a minister making thorough costs/benefits evaluations and engaging in broad consultations with other political actors and interest groups when there is a strong likelihood that these efforts will have no benefit. Third, New Public Management has also accentuated the powers of civil servants by granting more flexibility and power to managers operating in public agencies.51 As I will demonstrate in the chapter on the rise and expansion of offices for seniors (chapter 8), civil servants are increasingly involved in complex networks involving stakeholder groups, academics, public employees from other governments (municipal, provincial, and federal), and even private sector representatives. In line with these changing modes of governance, the role of bureaucrats is as important as ever, since they now have the twin role of managing networks while contributing to the actual enactment of policies.52 This is all the more important at a time when process affects the level of trust towards civil servants even more than policy outcomes.53 Fourth, recent evidence suggests that elected officials still predominantly turn to the civil service when they are unsure of what course of action to take. Swedish politicians, for instance, turned to civil servants to prepare and enact proposals to rescue the country from its economic crisis in the early 1990s.54 Finally, civil servants are also engaged in multiple phases of the policy process. This goes beyond supporting governments to introduce new policies and programs, which is the primary focus of most studies in political science and policy studies, and overseeing public policies and programs. For instance, they are highly involved in the investigation of policy issues, such as inquiries and consultations, and lead offices that independently research the operations of government and report to the legislature. This is the case notably of the Office of the Auditor General

12

The Four Lenses of Population Aging

and the Ombud Office. Increasingly, audit reports have become quasievaluations of public programs.55 As such, they provide tremendous feedback on the policy process. The focus on provincial civil servants also contributes to our understanding of Canadian public administration, where the primary focus is on the federal government. The findings put forward in this book corroborate recent studies stressing that one cannot infer from national studies the behaviour and activities of provincial civil servants.56 Methods This study employs a comparative case analysis method within the tradition of historical institutionalism57 by seeking to portray the evolution of administrative offices and policy decisions over time and across multiple jurisdictions. Beyond policy legacies, it pays particularly close attention to the importance of formal bureaucratic structures58 and the ways in which they shape policy responses across the four lenses of population aging mentioned earlier. It also focuses on the types of arguments developed to identify and justify courses of action by civil servants within their respective administrative units. This emphasis is warranted, given the importance of the way in which policy actors frame policy problems, a crucial element to understanding responses to population aging as a result of its polysomic nature. With a focus on present and ongoing provincial plans to address the challenges and opportunities of population aging, the primary method of inquiry chosen for this study consisted of individual interviews with senior civil servants in all Canadian provinces complemented by a thorough analysis of public documents pertaining to population aging. In the investigation, the research team employed the same recruitment strategy for each province and targeted deputy ministers, directors, and senior policy analysts in the following agencies/departments: executive council (and/or cabinet office), finance, labour, social affairs, seniors, pensions, women’s office, health, social services, and community affairs. In addition, a few interviews with officials in departments unlikely to consider population aging as a major issue, such as transport, were also conducted. These interviews, alongside those performed in women’s offices, were utilized to assess the scope and depth of coordination in each province. To ensure homogeneity in the treatment and conduct of interviews, I performed all interviews mostly over a five-year period (2009–14), but with additional interviews in 2015–19 to complement earlier findings and/ or account for new developments. A total of 125 individuals participated

Introduction

13

in interviews in the 10 Canadian provinces. In a few cases, there was more than one person for an interview, but each was coded individually. The province featuring the highest number of interviews was Alberta, while the least occurred in Newfoundland and Labrador. Questionnaires were open-ended and, beyond broad administrative and policy questions, included specific questions on the four lenses and the long-term view. Following standard practice in public administration research, the anonymity of all interviewees is essential, and editorial decisions have been taken accordingly. As such, a randomly generated number was assigned to each individual interviewed, and the content throughout the book has been presented in such a way as to ensure anonymity. This explains why the specific position of a civil servant or province is not given when a citation or material obtained from an interview is provided. With regard to public documents, members of the research team targeted annual reports, action/strategic plans, policy frameworks, discussion papers, audits, and reports from inquiries published between 2006 and 2018. This involved the analysis of over a thousand documents. Content analyses related to population aging are provided throughout the book. Content This book was written with both academic researchers and practitioners in mind. In its structure, it seeks to appeal to both audiences, and substantial efforts were made to consider input from all provinces, with an emphasis on the provinces that best illustrate specific actions to improve the coordination of actions and address specific policy challenges. It includes four specific sections: Theoretical Underpinning, Public Policy and Population Aging, Public Administration and Population Aging, and the Conclusion. To ensure accessibility to readers who are interested only in specific chapters, the analysis related to the theoretical material is presented separately and typically in a separate section before the conclusion in each chapter, with the exception of the first and fourth section. The first section features the theoretical discussions engaging academic research, most notably with regard to policy problems and long-term planning. It introduces the four lenses of population aging (chapter 1), it presents policy problem characteristics associated with each lens along with how lenses interact with one another (chapter 2), and it discusses the challenges of planning for the long term (chapter 3). The second section consists of traditional policy analyses with different expectations concerning the power of each lens. The intergenerational lens in pension policies (chapter 4) and the medical lens in the

14

The Four Lenses of Population Aging

field of health care (chapter 5) are dominant. However, the medical and social gerontology lenses are clearly at odds in the field of home care policies, with recent developments accentuating the importance of the medical lens (chapter 6). The third section is anchored in public administration and devoted to the organizational lens. It analyses the development of action plans or strategies and the creation and/or reform of administrative units (chapters 7 and 8). These two sections include valuable insights into innovative approaches undertaken by Canadian provinces to face the upcoming challenges and opportunities of population aging. Finally, the conclusion features comparisons between Canadian provinces and some industrialized countries, along with a review of key findings in this book rooted in theoretical expectations from the first section. Drawing from the literature on policy problems, chapter 1 presents the main analytical tools employed throughout the study. It proposes four distinct lenses to analyse the policy consequences of population aging: intergenerational, medical, social gerontological, and organizational. These lenses refer to competing problem definitions related to population aging. Each lens is composed of theoretical and/or practical approaches that adhere to key underlying assumptions to conceptualize and analyse population aging and its consequences on public policies. This matters greatly, since these lenses result in multiple “problem representations” based on different understandings of policy problems and solutions.59 The intergenerational lens highlights that population aging represents a new societal cleavage between seniors and younger populations, which has important economic, social, and political consequences. The cleavage can take multiple forms, such as age groups, cohorts, generations, or even the age of the median voter.60 The focal point is the (potential) age-related conflict within the population and the long-term consequences of current policy choices. Policy actors engaged with the medical lens embrace the notion that aging is akin to an inevitable illness that must be treated with biomedical policy tools. Population aging matters, since it increases the number of individuals living to old age. Most studies aim to develop interventions and preventative measures to increase the well-being and control of aging citizens; this involves – often implicitly – extending life expectancy even further. Research employing the medical lens focuses broadly on losses in both cognitive and physical abilities over time. Social gerontology “focuses on the social as opposed to the physical or biological aspects of aging.”61 The raison d’être of social gerontology is to challenge the dominance of biomedical approaches in aging studies. This lens focuses on the importance of social interactions and

Introduction

15

the continued presence of socio-economic factors amongst seniors. Contrary to the intergenerational lens, it emphasizes the contributions of seniors in society, the complexity of social relations and current (as opposed to future) policy issues. As such, users of this lens typically object to the construction of “dependency ratios” as well as its use to steer policy debates.62 Finally, the public administration literature on challenges to fostering coordination across government is at the origin of the organizational lens. Population aging creates a host of multifaceted policy problems, and potential opportunities, where the construction of an overarching approach faces daunting obstacles. Proposed policy responses will be quite different if an analyst begins with the view that population aging triggers an intergenerational conflict requiring first and foremost policies to attenuate it, as opposed to one considering population aging mostly as a biomedical challenge due to the rising number of seniors living with chronic conditions and various forms of dementia. Chapter 2 provides an overview of the complexity and difficulty of attaching problem definitions on population aging. As such, this chapter justifies the use of a policy problem theoretical framework to study the consequences of population aging and explores the unique characteristics of population aging as a policy problem. Building upon earlier works on policy problems,63 it presents problem characteristics across all four lenses used throughout the book. This involves an in-depth analysis of seven core characteristics associated with the identification of policy problems (definition, causality, severity, novelty, proximity, complexity, and problem population) and four associated with potential solutions to policy problems (solvability, monetarization, capacity, and interdependencies). It concludes with a discussion of the coexistence and interaction of the lenses. Chapter 3 tackles the ongoing challenges faced by governmental authorities – and their civil servants – who have shown a desire to plan. Population aging has been expected for years, and critics often lament the lack of organized plans to tackle current and future policy issues. Yet the situation requires forward thinking, often in the face of multiple parameters and unknown factors. This chapter presents a historical review of long-term planning and introduces the variables that enhance (or impede) the implementation of long-term visions in Canadian provinces. It also features theoretical expectations for the subsequent chapters. Chapter 4 addresses the ongoing challenges related to pension policies from a provincial perspective. The intergenerational lens remains highly influential in current pension debates, especially since it draws

16

The Four Lenses of Population Aging

attention to conflicts between workers and retirees. Although the federal government shoulders most of the responsibility for basic programs such as the Guaranteed Income Supplement, Old Age Security, and the Canada Pension Plan (CPP) (Quebec being an exception with the QPP), provinces are responsible for the regulatory frameworks surrounding occupational pensions and have a veto on CPP reform. In addition, many provinces provide additional assistance to poor retirees and, as illustrated vividly by the proposal to create an Ontario Retirement Pension Plan, have tools to assume a larger role in pension policies. This chapter reviews the role of provinces in the latest pension debates and how it prompted an expansion of the Canada Pension Plan. Chapter 5 analyses health care policies where a medical lens is increasingly confronted with the realities of limited public resources. The first portion of this chapter closely examines the relationship between population aging and health care expenditure, its impact across the 10 provinces, and how this relationship is framed in policy debates in aging societies. The second portion studies developments in residential care facilities, which operate at the margins of health care in provincial systems. These establishments face important challenges, especially in rural and remote areas, and have negative reputations. Despite policy objectives clearly aligned towards home care, residential care facilities account for more than 80% of all spending in long-term care in Canada. There are important provincial differences, most notably in the types of operators (public, private, not for profit) and waiting times to access them. Chapter 6 tackles home care services and caregiving. At a time of budgetary constraints, how to improve the quality and quantity of services is a major concern for provincial policymakers. Home care is a policy priority in all Canadian provinces. Yet there is a wide gap between policy intentions and current services, as illustrated by public reports in multiple provinces. The total amount of public funding for home care represents only 4.1% of public health care expenditure in Canada.64 The second portion of this chapter studies the primordial role played by informal caregivers and emerging policy issues to facilitate caregiving and support caregivers. This chapter highlights the tensions between the medical and social gerontological lenses, with home care services under the responsibility of health departments (with the noticeable exception of New Brunswick), and caregivers who face other personal and professional engagements beyond caring for an older adult. This chapter also illustrates how the organizational lens and gender permeate policy considerations, since the vast majority of formal workers in home care and informal caregivers are women.

Introduction

17

The following two chapters are rooted in public administration where the organizational lens is at the forefront. Chapter 7 focuses mostly on how central agencies, such as finance departments and executive councils (or cabinet offices) analyse policy problems related to population aging and, subsequently, coordinate public actions. As a result of their horizontal mandate, central agencies employ the organizational lens in their approach to population aging and deploy strategic plans and long-term visions. The intergenerational lens is also present in finance departments, since generational accounting emerged as a potential tool to address the long-term future of public finances. This chapter also features discussions on the role of independent agencies, such as auditors’ offices, that have (mostly) criticized governmental authorities for their inappropriate actions, or lack thereof, to address concerns about population aging. Chapter 8 studies the rising importance of another horizontal actor: offices for seniors. This includes, for example, secretariats and aging/ seniors’ departments. Akin to central agencies, they aim to resolve horizontal policy issues, but do so with a specific population in mind. Offices for seniors also provide a point of entry where seniors can interact with public officials to address ongoing policy problems. Most of these offices were originally established outside health departments and, as a result, this is also where the social gerontology lens is prominent within most provincial administrations. Offices for seniors also face the task of promoting this social perspective to other departments, albeit with very limited resources. In addition, this chapter discusses the creation and/or growth of these small governmental offices at a time when reduction in the number of civil servants is the norm. The conclusion presents a summary of the findings, revisits the theoretical expectations from the first section, and studies the relevance of the four lenses to our understanding of population aging in public administration and public policy. Where pertinent, international comparisons are used to shed light on the Canadian context, followed by a succinct analysis of federalism and its importance in encouraging learning and policy diffusion. It ends with a discussion of the continuing marginalization of the social aspects of aging and its long-term consequences.

This page intentionally left blank

1 The Lenses of Population Aging

After watching countless episodes of the Republic of Doyle, you decide to visit Newfoundland and Labrador and climb the famous Gros Morne Mountain. While its height (806 metres) does not compare to the previous climbs you made in other national parks, the shale rocks filling the ascent and the 16-kilometre path compel you to bring provisions for a long day of hiking. This trek likewise presents a fantastic photographic opportunity. Unfortunately, by the time you are done packing the essentials, you realize that you have room for only one photographic lens. You have a detailed map with you, but you are unsure of exactly what you will see along the way. Thus, you have a difficult decision to make. Do you bring the telephoto zoom lens, hoping to catch a rock ptarmigan in the distance? While there are many on top of the mountain, you are unsure about the odds of seeing one. Perhaps you should instead focus on capturing the superb landscape of the tablelands, and bring a wide-angle lens? This seems like a safe strategy, although the weather can change rapidly, and with fog being a common occurrence on the mountaintop, this could obscure the picturesque scenery surrounding Gros Morne. As an alternative, do you play it safe and just bring your everyday mid-range lens? Yet if you were to see arctic hares, ptarmigans, and/or wonderful landscapes, you would be ill equipped to capture the perfect shot. In order to select an appropriate lens, you must consider which specific photographic subject(s) you want to focus your attention on – a decision that largely affects how you will handle other elements such as lighting, composition, depth of field, and exposure. The decision about your photographic lens parallels the approaches used in this book to study the consequences of population aging and its impact on public policies. Depending on your lens selection, you will have a different focal point and zoom across diverse time horizons, which shape the strategy you plan to deploy.

22

Theoretical Underpinning

In public policy, the word “lens” has multiple meanings, although most scholars imply that the use of lenses concerns different ways of analysing, conceptualizing, and studying an issue. In Theories of the Policy Process, a prominent textbook in public policy, Sabatier refers to lenses to discuss the added value of analysing public policies using rival theoretical approaches and frameworks, such as rational choice and the advocacy coalition theory.1 For example, lenses can refer to those experiential and theoretical frameworks that enrich explanations of complex issues such as the Cuban Missile Crisis. In his seminal article, Allison employs three competing explanatory scenarios, which lead to three different understandings of the events surrounding this international crisis.2 In the academic literature, the word “lens” also relates to the ways one understands a policy problem, which consequently influence the solutions proposed (and enacted) to resolve policy issues.3 The way in which policy actors frame problems is important, as it emphasizes the discourse attached to a policy issue. This, in turn, reinforces the connection between the way in which a problem is constructed and the range of potential solutions that accompany it. Discourse is significant, because it can misrepresent or marginalize specific groups and inevitably produce policies that may be discriminatory and/or burdensome. Conversely, discourse may be overtly favourable for certain segments of the population, who benefit from the perpetuation of a positive image in the media and among policymakers.4 For policymakers, the word “lens” often stresses a population, region, or even an economic sector that requires special attention within the policy process. Typically, this results in the creation of practices or offices with a horizontal mandate to ensure that the consequences of current and future policies do not disproportionally affect the groups or populations covered by the lenses. For example, Newfoundland and Labrador explicitly refers to lenses to describe its efforts to incorporate gender, persons with disabilities, and rural regions in its policy analysis.5 Similar usage is present in Ontario with the OPS Inclusion Lens, which targets seventeen dimensions of diversity, including age, gender, race, and religion.6 For the purposes of this book, lenses are understood as competing problem definitions related to population aging. This involves different ways to conceptualize and analyse policy problems, which result in distinctive causal mechanisms consisting of diverse factors and elements. This understanding of lenses is akin to Lakatos’s explanation of research programs.7 Each research program rests on core assumptions – a hard core – that is complemented by supporting theories and

The Lenses of Population Aging

23

hypotheses. Research programs are extremely difficult to eradicate and therefore rarely disappear. When some elements are challenged by competing explanations, researchers seek to alter theories to explain anomalies, rather than embark on wholesale changes.8 Thus, multiple research programs compete with one another, each making a distinctive contribution to advancing knowledge without necessarily eliminating alternatives. This is an understanding different from what Kuhn presents in The Structure of Scientific Revolutions and its application to policy studies among scholars who emphasize the role of policy ideas.9 The notion of policy paradigms assumes the presence of a hegemonic set of ideas, which comprise a single dominant paradigm. Other paradigms, which have varying understandings of the policy environment, compete with the dominant paradigm with the aim of eventually replacing it. The key to this transformation becomes explaining the conditions that trigger a paradigm shift, a third order change, which is reflected in radical changes in policy. For instance, in his highly influential article on social learning, Hall analyses the shift from Keynesian economic policies to monetarist policies in Britain.10 Lakatos’s description of research programs is a far better representation of competing problem definitions relating to population aging, with the four lenses shaping and influencing public policy in multiple areas. In addition, different departments or ministries have marked preferences for particular lenses. Hence, some lenses are more powerful than others, but there is no single dominant lens similar to a paradigm when addressing the breadth of policy issues surrounding population aging, albeit some are clearly dominant in specific sectors, such as the medical lens in health care. Akin to a research program, each lens comprises theoretical and/or practical approaches that adhere to underlying assumptions in order to conceptualize. To pursue the photographic metaphor, these approaches are similar to using camera lenses, which provide different focal ranges and depth of field possibilities. Each lens conflates population aging and its consequences for public policies differently. This is significant, as these lenses result in multiple “problem representations” based on different understandings of policy problems and solutions.11 The core of each lens features the basic issue at heart with an aging population such as inequality across generations, discrimination, or institutional legacies. Each of these cores provides a distinct understanding of what the problem is, with specific problem characteristics and proposed solutions. The use of these lenses, and its prevalence within a unit or even a policy sector, depends strongly on multiple factors, such

24

Theoretical Underpinning

as professional training, organizational culture, and policy legacies. As such, policy actors, including civil servants, are more tenacious with their population aging lens than photographers. Even animal photographers, for instance, will engage in creative projects with other lenses than their favourite telephoto zoom lens, which is rarely the case for most policy actors analysed in this volume. This book focuses on four key lenses: the intergenerational lens, the medical lens, the social gerontology lens, and the organizational lens. The Intergenerational Lens In essence, the intergenerational lens reveals that population aging is a new societal cleavage between seniors and younger populations, which has important economic, social, and political consequences. This cleavage can take multiple forms such as age groups, cohorts, generations, or even the age of the median voter.12 This inevitably raises the question of the ability of public policies to tackle age-related risks equitably.13 The focal point is the potential for age-related conflict within the population, as aging represents a type of social stratification.14 Many of the approaches discussed below stipulate that generations are engaged in competition or conflict between one another. This assumes that belonging in a generation or a cohort coexists with other traditional cleavages such as class and religion. For the most part, there is a strong emphasis on the long-term consequences of population aging and growing inequities (real or perceived) between cohorts. As a result, the primary empirical material consists of comparing (past, current, and future) costs and benefits of public programs across cohorts. In a nutshell, population aging raises significant issues in generational equity, which (often) underscore the necessity for governmental authorities to take action to restore an intergenerational equilibrium or balance. There is no uniform or standard understanding of how authors conceptualize age groups, cohorts, and generations. Sociologists and social workers often prefer to employ the term “generation” to emphasize common experiences and values resulting in a cohesion that goes beyond growing up at the same time.15 In contrast, these factors are insignificant for economists studying generational accounting16 and in studies focused on how demographics affect economic growth and public finances,17 since birthdates form the basis of each generation. These distinctions explain, in part, the variance in the approaches developed within the intergenerational lens. Critics dismiss the very existence of intergenerational conflicts. They point to the power of political groups that aim to accentuate intergenerational angst to justify reductions in

The Lenses of Population Aging

25

social programs, while also rejecting the necessity to analyse policies with such a view of population aging.18 Four popular approaches fall under the broader intergenerational lens: generational accounting, dependency ratio, Musgrave rule, and generational politics. Despite their differences, they all share the underlying assumption that an aging population requires a better understanding of generational dynamics, as these matter in all aspects of the policy process. As such, they represent filters that emphasize the importance of different generational mechanisms. Generational Accounting Generational accounting originates from a critique of the short-term view utilized by governments when preparing their annual budgets. The traditional budgetary process concentrates on the upcoming year and rarely extends beyond a few years into the future. Thus, fiscal imbalance resulting from demographic shifts is not captured by traditional fiscal planning measures. Advocates of generational accounting stress that this exercise should have a much longer time horizon to comprehend fully how programmatic commitments influence costs and revenues in the future, and how governments redistribute resources across generations.19 As such, generational accounting focuses on the sustainability of current fiscal policies, as well as the amount each generation pays in net taxes and how much they receive back in benefits.20 In this context, a fair society would provide a similar balance between net taxes and benefits over time. Proponents of generational accounting call for increased efforts to integrate this dimension into the budgetary process. With generational accounts currently favouring older citizens, policy options available to alter public benefits and tax liabilities to restore a generational balance include raising taxes, cutting debt, and reforming pension policies.21 In a nutshell, generational accounts are measured by calculating the governmental revenues and expenditures of each generation throughout their lifetime. This includes the share of debt and liabilities, which may be passed on from one generation to the next.22 Analyses employing generational accounting paint a very negative picture of the future wherein younger generations are expected to face a much higher tax burden primarily because of the liabilities of current public programs such as pension and health. As an illustration, in their 2012 book, Kotlikoff and Burns argue that “the United States is bankrupt,” since its real debt is not $11 trillion, but rather $211 trillion because of large unfunded spending commitments. The American generational accounts may be

26

Theoretical Underpinning

even worse than those of countries such as Greece and Italy.23 In addition, Kotlikoff and Burns accuse the US government of committing “fiscal child abuse” by ignoring the growing fiscal gap (the difference between current and future fiscal revenues and liabilities). To use the photography metaphor, generational accounting adds a grey filter to the American intergenerational lens, resulting in a sombre picture of the future unless important actions favouring younger generations are undertaken. Can similar conclusions be applied to Canada? The United States is somewhat of a unusual case with its two major social programs (Social Security and Medicare) being targeted at seniors. In fact, comparative studies demonstrate that the United States has a biased welfare state24 and inequitable social spending benefiting older adults.25 In contrast, the Canadian welfare state ranks slightly above average on most indicators in these studies. The health care system is universal in providing similar coverage from “womb to tomb,” with the last major pension reform in 1997 serving as a source of financing for future liabilities.26 The cost of population aging remains a topic of debate within academic and professional circles (see chapters 5 and 7). As a result, generational accounting exercises have demonstrated a degree of intergenerational inequity, albeit far less than in the United States. The Canadian intergenerational lens has a far more neutral filter. For example, Oreopoulos and Vaillancourt’s 1998 study indicates that current policies are sustainable if ongoing surpluses are utilized to reduce the debt. Interestingly, the expected difference in the net income tax rate for someone born in 1940 was only 6 percentage points lower than a child born in 1995 (32% vs. 38%).27 Beyond the academic sphere, generational accounts first appeared as an appendix in the 1993 US budget, which garnered significant media coverage. It also became a powerful tool for politicians seeking to reform Social Security.28 This addition to the budget prompted closer scrutiny of whether this method ought to be employed in standard budgetary analysis. To this effect, the US Congressional Budget Office (CBO) prepared a lengthy study on the merits of generational accounting to determine whether generational accounts could become a standard tool within the budgetary outlooks performed by the CBO. The report stated that the inclusion of generational accounts “depends on calculations that are not only empirically uncertain but theoretically ambiguous,” leading to the conclusion that they “should not become part of the regular budgetary outlook. They lie in the realm of analysis, not accounting.”29 This report led to its eventual demise as a governmental analytical tool in the US federal bureaucracy.

The Lenses of Population Aging

27

Statistics Canada published an edited volume on generational accounting following a conference on the topic that involved Kotlikoff.30 Canada does not publish budget documents that incorporate intergenerational equity. Indeed, while the Public Accounts Committee recommended that the Treasury Board and Department of Finance examine the use of generational accounting to assess the sustainability of health care and pension spending, the government responded in favour of the status quo. The government argued that generational accounting entertains a great deal of uncertainty because it is based on projections that must be revised often.31 The same conclusions apply to the provinces. Questions to officials who have potentially been exposed to generational accounting all featured negative responses, and none claimed to have participated or known of an exercise akin to the review performed by the American CBO within their province. Generational accounting is now a “global idea” that has attracted significant attention within epistemic communities, and has extended its reach to international organizations and across multiple states.32 As a result, it has faced strong scrutiny and sustained criticism beyond the governmental critiques discussed above. An exhaustive review goes well beyond the scope of this chapter; however, three key points are worth mentioning. First, accountants and economists have challenged the underlying assumptions made to project generational accounts. According to Haveman, generational accounts “inevitably rest on a set of particular views and assumptions regarding both private and governmental behavior, many of them without any especially clear basis.”33 For instance, the focus of generational accounting is limited to fiscal policy and does not necessarily take into account the overall effects on social welfare.34 It treats all spending, whether on infrastructure, health care, or education, as consumption spending, which overlooks the notion that such spending may be considered an investment for future generations, through increased life expectancy, human capital, or productivity.35 Second, as financial departments around the world continuously fail to accurately predict the evolution of their own economy annually, the prospect of making decisions on the basis of fiscal projections over a fifty-year period raises significant questions.36 Finally, from a policy development perspective, generational accounting may be limited by the fact that although it may be able to indicate that there is an imbalance, it cannot prescribe specifically which fiscal tools should be implemented, how quickly they must be implemented, or the length of their duration.37 In sum, generational accounting remains quite popular, despite its demise as a new budgetary tool for the US government. In fact,

28

Theoretical Underpinning

Kotlikoff is often portrayed as a key figure of the “gloom and doom” scenario on population aging.38 He even featured prominently in a BBC program “If … the Generations Fall Out,” which included some dramatic futuristic scenes with young people demonstrating against rising pension and health care cuts in 2024.39 These images are reminiscent of the protests depicted in the novel Boomsday by Christopher Buckley, where the youth disturb seniors at golf clubs and retirement resorts!40 In Kotlikoff’s latest push to capture the attention of policymakers and the public on the looming importance of population aging, he ran for US president as a write-in candidate in 2016. Dependency Ratio The OECD and the World Bank have played an important role in advancing the use of dependency ratio as a tool to analyse policy areas including pensions, health care, and the labour market.41 The appeal of dependency ratios stems from the fact that they are easy to calculate and interpret. Two types of dependency ratios are most common. First, the traditional dependency ratio simply calculates the number of individuals aged 0–20 and those aged 65 and above, divided by the number of working-age individuals (above age 15 or 20 to 64 years old). Second, an old-age dependency ratio focuses on the number of individuals aged 65 and above, divided by the working age population (individuals aged 15 to 64) multiplied by 100. For example, a ratio of 50 implies that there are two working-age individuals per retired person. Within the context of an aging population, what is the impact of having a rising old-age dependency ratio? This remains one of the most hotly contested issues. Early comparative welfare state studies stressed early on that the age structure of the population was a very important – if not the most important – factor in the rise in social welfare spending.42 As a result, the dependency ratio measure is often employed as a proxy to project the costs or “burden” generated by population aging. For the purposes of this book, the old-age dependency ratio is critically analysed as an approach, since many studies assume that this measure represents concepts in public policy debates, such as overpopulation43 or the burden of old age care.44 For example, Galasso claims that the old-age dependency ratio represents a crucial feature of the social security debate.45 It often serves to validate or propose cuts to social benefits and services, especially in health care and pensions.46 The use of dependency ratio features an underlying assumption that an increasingly large senior population has dire consequences for the economy and public finances. A declining dependency ratio – i.e., a

The Lenses of Population Aging

29

higher number of working-age citizens – is associated with higher economic growth. A lower dependency ratio has largely contributed to the East Asian economic miracle,47 and also explains divergent growth paths from countries benefiting from similar socio-economic conditions.48 In the opposite direction, rising dependency ratios are seen as an important cause of (potential) decline in growth rates in industrialized countries, thus resulting in pressures to reform public programs.49 On the basis of 2010 population data, Canada has an old-age dependency ratio of 20, compared with an average of 24 for industrialized countries. However, by 2035, Canada is expected to have a ratio of 33, which is the expected average for industrialized countries.50 This signifies a gradual shift from five individuals of working age (15–64) for everyone aged 65 and above, to having three for every citizen aged 65 and above. Despite this noticeable transformation in the age structure of the population, it is important to stress that Canada fares much better than other industrialized countries such as Japan (36 in 2010 and 58 in 2035) and Germany (32 in 2010 and 55 in 2035).51 The use of dependency ratios in policy analysis faces two major criticisms. First, many authors have contested the simplicity and inaccuracies of this measure. Most often, studies divide dependents and non-dependents along strict age lines (0–14 and 65+ for the dependent, and 15–64 to represent the working population). It assumes that older citizens do not participate in the labour force52 and that they are dependent on economically active individuals.53 These assumptions run against current trends that demonstrate both increasing participation rates in the labour market by older citizens and declining unemployment rates.54 Both phenomena currently apply to Canada with employment rates amongst the 65–9 cohorts reaching 25.3% in 2018 and higher than 10% among men aged 70 and over.55 As a result, the use of old-age dependency ratios can result in a dubious logic where a 65-year-old millionaire is a dependent while the opposite status applies for an individual aged 64 in the midst of a lengthy unemployment period.56 Simply put, dependency ratios create false dichotomies between dependent and active populations.57 Second, the concept of dependency and, consequently, over-reliance on social programs is a subject of contention in and of itself. Critical gerontologists have often attacked the very notion of dependence to portray older citizens. The social construction of a dependent population is often employed by politicians to devise policy tools that are difficult to access in order to exclude particular groups or populations.58 In the specific case of old-age dependency, older citizens are not considered

30

Theoretical Underpinning

active economically, either as workers or consumers.59 In addition, the notion of dependency undervalues activities outside of the labour market, which includes caregiving and volunteering.60 Also, it implies that retirees have not saved or taken actions to provide for themselves throughout their working years.61 In the Canadian context, retirement savings contribute to minimizing the fiscal impact of population aging, since retirees pay taxes on sources of retirement income originating from public (CPP) and private programs (RRSP and company pension plans).62 Third, the literature assumes that older adults deploy their wealth strictly for their own benefit, ignoring potential transfers within families. On the basis of the Survey of Health, Ageing and Retirement in Europe (SHARE), Martin concludes that there is a net transfer of both financial transfers and social support from retired parents to adult children.63 Similar conclusions apply to the United States.64 Interestingly, many policy proposals insist on the imperative of spending more, not less, on “dependent” populations in order to sustain a good rate of economic growth among industrialized societies with aging populations. This includes investing more in children and young adults to enhance their educational achievements and develop skills to generate higher productivity rates.65 In the same vein, potential investments specifically target older citizens. For example, active aging programs have the potential to reduce health-related costs and sustained participation in the labour market.66 Thus, what is key is not spending on various age cohorts per se, but targeted spending across different sectors. The analytical use of dependency ratios remains far more common than generational accounting.67 Nonetheless, illustrations of population pyramids and references to the percentage of individuals aged 65 and over remain far more conventional in public documents, presumably because they are less controversial than dependency ratios. Many of the senior civil servants interviewed for this book, especially those dealing with financial matters (the so-called revenue departments) referred to measures associated with dependency ratios. Inspection of old-age dependency ratios across Canadian provinces reveals considerable disparities. This divergence in dependency ratios does not have an impact on federal programs such as the Canada Pension Plan, but health care is a different story. For instance, Atlantic provinces have pressured the federal government to consider the age structure of the population when calculating federal transfers in health (see chapter 5). Population aging is already having a far more salient economic impact in eastern provinces.68

The Lenses of Population Aging

31

The Musgrave Rule The Musgrave rule pays significant attention to intergenerational equity, but represents a counter approach to generational accounting. Its main concern with population aging is the maintenance of broadbased support for social programs in the face of changing demographic conditions. In its most basic form, Musgrave puts forth a model of pension reform that strives to achieve social solidarity. Advocates of this approach suggest that its normative foundation may be applied within the context of all social programming.69 It rests on the assumption that the survival of the social system depends on the extent to which costs are shared equally between generations (or cohorts). As Musgrave argues, it is important to draw attention to who benefits on the one hand, and those who are paying on the other. This approach is similar to generational accounting in that both are concerned with government expenditure and revenue. Contrary to generational accounting, however, overall program costs are not as significant as opposed to how they are distributed in relation to the advantages each group receives. Moreover, while generational accounting articulates the problem of population aging as one of fiscal sustainability, the Musgrave rule focuses on maintaining political support to sustain governmental spending. Thus it is concerned primarily with the survival of public social programs (and pensions in particular) rather than embarking on retrenchment. The Musgrave rule’s solution to population aging is to strengthen the bonds between generations by ensuring effective risk and burdensharing within the welfare state. This requires that the added costs of supporting a disproportionate number of older people are shared between those contributing to, and those collecting benefits from the system. A constant ratio must be maintained between the per capita earnings of the working population and the per capita benefits of retirees. This “fixed relative proportion” model70 therefore implies that any increases in the tax rate must be offset by decreases in benefits, so that both the working and the retired populations experience the same relative loss. The Musgrave rule is thus inherently conservative, since it seeks primarily to evaluate potential reforms on the basis of current programs. Thus, it ignores redistributive functions within cohorts and other elements such as gender. Moreover, it assumes that the status quo represents an optimal intergenerational contract. The main critique of Musgrave’s approach is fairness. In particular, equity is not based on sharing the burden, but on assigning responsibility for the need for reform. According to Sinn, this is achieved when generations invest in either real or human capital. Since the baby boomer

32

Theoretical Underpinning

generation had fewer children (human capital) to support them, they must invest in real capital (private savings).71 This position has been criticized on the basis that collectivities (generations or cohorts) are not moral agents and, as a result, they cannot be held responsible.72 Moreover, human capital can be defined in various ways. The boomer generation could have conceivably countered low fertility with higher levels of education for their children.73 A second criticism challenges the likelihood of achieving genuine dialogue across generations (cohorts) when introducing social policy reforms. The political science literature is adamant that older adults have a disproportionate political advantage over younger cohorts for various reasons, such as the presence of powerful old-age interest groups and a positive social construction. Moreover, younger cohorts tend to underestimate policies (and their consequences) that do not immediately affect them, such as pensions.74 Therefore, politicians are far more likely to introduce reforms that protect older voters, albeit at the expense of younger cohorts. The Musgrave rule is not a prominent approach employed in policy circles. Opportunities to both better understand the risks faced by each generation, and employ consensual mechanisms to address them, remain rare. In many cases, tools developed that would favour something akin to the Musgrave rule are either narrow in scope or have a short time life. For example, intergenerational exchanges promoted by community groups and seniors’ secretariats consist mostly of encouraging schools to welcome seniors to discuss their experience or read for them in class.75 Generational Politics The last prominent approach that relies on intergenerational lenses implies that politics is increasingly structured along age, cohort, or generational lines, which coexists with or even replaces traditional cleavages such as religion, class, or ethnicity. Population aging has fostered a wealth of studies on the topic of generational policies.76 Political scientists have brought forward two broad arguments to stress the idea that the power of senior citizens, often referred to bluntly as grey power, is on the rise. Broadly speaking, electoral considerations and policy legacies accentuate the political power of older citizens beyond their relative weight within the population, which translates into more generous and targeted policies that work to their advantage. First, speaking directly to popular theories emerging from the field of social gerontology, early studies focusing on voting behaviour

The Lenses of Population Aging

33

demonstrated that aging did not result in voters shifting towards conservative parties, nor did voters become disengaged politically as they aged.77 On the contrary, the increasing number of older citizens and their higher propensity to vote has led to fears of industrialized countries becoming gerontocracies.78 Inspired by Anthony Downs’s work on the median voter,79 population aging implies that as the age of the median voter rises, electoral competitions should feature more proposals, and eventually policies, that are primarily targeting older voters.80 Studies have already linked increases in spending on senior-friendly programs to population aging.81 The second “grey power” argument involves senior-based groups, which have evolved as a result of policy feedback, such as the creation and maturation of public pension systems.82 This explains, for example, the active and potent role attributed to the AARP in the United States.83 European studies argue that labour unions play a similar role because they are associated with the development of social insurance benefits.84 This policy feedback has even resulted in the creation of pensioners’ parties, which have been most successful at the regional level, particularly in jurisdictions where important social and health services are provided to older citizens.85 Along similar lines, Lynch emphasizes the importance of institutional legacies, which have reproduced age biases in certain welfare states such as the United States, where universal social programs target older citizens.86 Interestingly, Birnbaum et al. argue that many industrialized countries exhibit a pro-old orientation (Australia, Canada, Ireland, Italy, New Zealand, United Kingdom, and the United States). Contrary to Lynch, however, this study focuses exclusively on income replacement and ignores, for instance, public services. The classification of Canada is quite puzzling, since it exhibits the characteristics of a balanced generational welfare contract, but was included in the pro-old category as a result of its modest generosity.87 Critics who point out the rising predominance of older voters emphasize the continued importance of traditional cleavages and the range of barriers that prevent the direct translation of electoral votes into policy action.88 In The Welfare Generational Contract, the authors demonstrate that the presence of left-wing governments correlates with welfare states that offer balanced income replacements for children, workingage individuals, and retirees.89 Other survey-based research has called for a more nuanced approach wherein the salience of age has a differentiated impact based on the policy in question and the country of respondents.90 In terms of policy feedback, both expected outcomes and the strength of senior-based groups have sustained their fair share of criticisms.

34

Theoretical Underpinning

to reduce the size and scope of welfare states across industrialized countries. This is particularly evident in pensions, with Pierson’s case par excellence for the status quo as a result of the strength and power of AARP.91 While Social Security has escaped major reforms, despite reform proposals, this is clearly not the case in other jurisdictions around the world.92 There have also been questions raised about the strength and representativeness of age-based groups. For example, to what extent is the AARP capable of counteracting groups within strong institutionalized power such as business interests or fiscal conservatives? Guillemard’s study of French old-age policies and Ginn’s studies of the British and American landscapes stress that class remains a key factor even in retirement, and that age-based groups are not necessarily representative of retirees.93 The Medical Lens At its core, the medical lens involves the understanding and analysis of human conditions as medical problems, which can potentially be treated.94 It examines how human problems become medicalized and how this process represents a tool of social control, wherein the medical profession exerts paramount influence by organizing and delivering treatments, thereby defining the process known as medicalization95 or biomedicalization.96 The gradual societal shift towards medicalization and its ubiquitous presence has not escaped aging.97 The notion of maintaining or even prolonging autonomy, which is defined in functional and cognitive terms and measured via indices surrounding activities of daily living, continues to steer research and practice.98 Specific conditions associated with aging are predominant in the study of geriatrics, such as dementia,99 and are also highly medicalized. My aim here is not to enter into a debate about whether or not specific problems or conditions ought to be medicalized and to what extent but, in line with other lenses, discuss the ways in which the medical lens reflects specific policy consequences of population aging. Contrary to the intergenerational lens, which features various age cohorts competing for policy attention, the core challenges of an aging population are policy issues surrounding the growing number of older individuals and how to meet their (health care) needs. The macro perspective involves analyses of the number of individuals living with a specific condition, as well as the probabilities that some at-risk populations will require medical interventions or treatments. Population aging is considered problematic because it involves an increasing number of individuals, i.e., seniors, at risk. The issue of how to meet the health care

The Lenses of Population Aging

35

needs of a growing senior population continues to dominate in the literature because of the financial resources this may potentially require. As illustrated in the introduction, a review of health care policy issues in Canadian newspapers reveals that close to 25% of all articles published between 2009 and 2014 equated population aging with (potential) rising costs for health care, followed by potential solutions to alleviate or curb costs, such as privatizing or reorganizing service delivery. This focus on costs is hardly surprising, since rising expenditures combined with potential shortages of medical professionals threatens the ability to fulfil these needs. The medical lens involves a close relationship between research and practice, which explains why Estes and Binney also stress the practice of aging as a medical problem in their seminal article on the biomedicalization of aging. It features four key dimensions that are interrelated and reinforce each other: the scientific, the professional, the policy arena, and the lay or public perceptions, as well as their consequences.100 First, medical lens users share a deep commitment to science and its development. This association with science has generated trust and acceptance of this framework in comprehending problems involving everyday life.101 Medical research involves a strong commitment to reducing analysis to the smallest unit possible; hence it maintains a strong focus on individuals living with specific diseases or conditions rather than in the social environment.102 Originally, the medical field had a broader understanding of human conditions and aging. For example, according to a historical study by Achenbaum on the field of gerontology, the development of geriatrics is geared toward the study of frailty and diseases associated with aging, which represents a break from previous methods of inquiry focusing on the behavioural and social aspects of aging.103 An extensive review of the medical and biomedical research on aging would require a thorough analysis of chronic conditions, diseases, illnesses, and other factors influencing longevity and good health, which is beyond the scope of this book. Nonetheless, it is worth stating that research debates in the biomedical field have moved beyond simply studying elements favouring longevity – such as genetics accounting for 25% of one’s life expectancy – 104 to complementary issues such as whether longevity involves postponing functional and cognitive limitations105 and how this is associated with an increase in the quality of the years added to life expectancy.106 This research implies that population aging may not necessarily equate higher spending on health care, since gains in longevity simply postpones medical conditions prevalent with older individuals. The relationship between longevity and health care spending is actually analysed in depth in chapter 5.

36

Theoretical Underpinning

The second dimension of the medical lens involves the power of health care professionals, who determine the (medical) needs of an aging population and decide on the appropriate response.107 The professionalization of medicine, nursing, and other health professionals has influenced how problems are defined and studied, as well as which interventions are deemed appropriate. Scientific advances are responsible for the increasing scope of medicine and its subsequent specializations, often at the expense of generalists.108 This trend also has a profound impact on the organization of health services, which are now organized by specialties. In the realm of politics, medical professionals benefit from a very positive social construction and they possess the power and capacity to self-regulate.109 Simply put, medical professions have a quasimonopoly on all matters of health or illness,110 including the capacity to act as a gatekeeper by preventing other professions from obtaining formal recognition, or even by making some interventions illegal. Thus, the medicalization of aging concerns both the process and outcome by which problems that are common among older populations enter into the jurisdiction of the medical profession. It should be noted, however, that this (medical) authority is facing challenges from competing actors such as social movements, consumers, and corporations.111 The third dimension of the medical lens focuses on policy. Estes and Binney focus on health policy, research policies, and professional training to highlight the potency of the biomedical model of aging. The professional status of medicine confers a privileged space within the policy process to medical personnel who are the recognized experts.112 They demonstrate that major investments to service the senior population directed towards Medicare, which is primarily an acute-care program, as opposed to community and social services such as home care and homemaker services.113 Estes and Binney also point out that research money on aging and funding for training are allocated almost exclusively to health.114 In Canada, health spending is by far the largest government expenditure in the provinces, with expenditure growth being the source of multiple concerns, particularly in an era with slower economic growth and diminishing federal transfers.115 Seniors face challenges akin to their American counterparts, since there is no continuum of health services, partly because they were originally conceived within an institutionalized (i.e., hospital centric) framework.116 Some of these issues are well documented, as some seniors spend too much time in hospital following their acute care stay.117 Yet, despite these shortcomings, seniors’ issues have long been considered the domain of health departments, as

The Lenses of Population Aging

37

evidenced by the presence of seniors’ offices within health ministries. This association has been challenged and, in many provinces, has led to the creation and expansion of offices for seniors (see chapter 8). Mirroring the United States, Canada’s Institute of Aging is located within the Canadian Institute of Health Research, which has a mandate that is closely aligned with the medical lens: “to support research, to promote healthy aging and to address causes, prevention, screening, diagnosis, treatment, support systems, and palliation for a wide range of conditions associated with aging.”118 Only 6% of its funding is allocated to social science research.119 The Institute of Aging is “unique within Canada as the sole national funder of strategic research that specifically targets aging,” and it works collaboratively with senior officials within the federal government and in departments such as Human Resources and Skills Development Canada and the Public Health Agency of Canada.120 Finally, the fourth dimension relates to public perception of aging. Simply put, the medical lens is dominant in discussion on seniors and aging populations.121 As highlighted in the introduction of this book, there is no suggestion that the Canadian case is vastly different from that of the United States, since most media coverage of aging populations relates, first and foremost, to health care policy. A longitudinal analysis of science news coverage in Britain confirms the dominance of biomedical news typically featuring alarming case scenarios, personal stories, and expert statements that effectively reaffirm the authority attached to scientific findings.122 The medical lens broadly focuses on the challenges that result from losses in both cognitive and physical abilities over time, and on preventive measures to age successfully. The medical lens, in this book, focuses more specifically on three general approaches concerning the following policy issues: the senior population, geriatrics, and health promotion. Population Aging: A Rising Number of Seniors with Special Needs Standard textbooks in gerontology and geriatrics often begin with a sentence to the effect that there is a higher proportion of individuals aged 65 and above suffering from medical conditions and/or functional problems than any other age cohort. Although very few gerontologists would agree with the claim that aging is a disease, the medical lens points out the fact that aging represents a stage in life where individuals are more susceptible to acute and chronic conditions. The primary issue surrounding an aging population in the medical field is the increasing number of seniors, who represent a vulnerable

38

Theoretical Underpinning

population, therefore more at risk of needing medical interventions and follow-up. Although researchers and professional associations, such as the Canadian Medical Association, are quick to point out that aging does not necessarily equate living with medical issues, the probability of experiencing disabilities and chronic conditions increases significantly with age. Hence, the focus remains on how to prevent and treat an increasingly large senior population experiencing these conditions. Within the context of Canadian health care, this raises the issue of identifying and meeting medical and health needs for seniors and the population in general. In part as the result of improvements in public health and public safety, chronic diseases have increasingly become leading causes of death. Comorbidity of multiple chronic diseases, which is far more frequent in older adults, necessitates a different kind of medical care that involves more frequent visits, better monitoring practices, and a stronger focus on home care. In addition, medical standards have also risen.123 Equally important, however, are the technoscientific improvements that have pushed the age boundaries for surgical interventions. For instance, Kaufman, Shim, and Russ demonstrate that life-extending interventions are increasingly routine and often encouraged by medical professionals for older patients.124 Cognitive and physical functions constitute the core features of health assessments for aging patients in Canadian provinces (e.g., InterRAI and ISO-SMAF). These assessments aim to evaluate restrictions in the activities of daily living (ADL). Assessment of individuals’ autonomy indicates to health professionals whether services (if any) should be provided at a home or a long-term care facility. This raises the issue of developing a continuum of care for older adults. This includes a strengthening of long-term care to ensure that seniors can have the proper level of services at home or in a residential care facility and avoid the use of acute care beds by seniors. There also important cost implications (see chapters 5 and 6).125 In most, if not all policy discussions linked to health care needs of older adults, the costs of an aging population inevitably arises. Geriatrics: A Marginalized Specialty in Medicine One would suspect the present period to be the golden age of geriatrics. Adding to this appeal, geriatricians, with a far more holistic approach to medicine and interventions in general, have been early advocates for better long-term care infrastructure, which aligns with policy priorities in all provinces. Sorbero et al. also demonstrate that patients admitted to a hospital overseen by a geriatrician, as opposed to other

The Lenses of Population Aging

39

physicians, experience shorter length of stay and lower costs per admission.126 Hence, this is clearly the specialty and approach within medicine expected to thrive. Surprisingly, this is hardly so, as geriatrics continues to be a very marginal specialty. It remains a “medical discipline with little prestige, low scientific interest, and bad pay.”127 Multiple factors contribute to this status, including early ambivalence about embracing the specialization movement, the awkwardness of fitting a specialization based primarily on age within an organ centred on the organizational structure of medical specialties, opposition from other established fields of specialisation, and ageism.128 The acceptance of geriatrics as a specialization in medicine is telling: geriatrics came to existence in large part because it was able to identify specific diseases common in old age, which contribute to a distinct physiological stage of life.129 The State of Seniors Health Care in Canada, a report produced by the Canadian Medical Association, exemplifies this marginalization clearly by omitting geriatrics and geriatricians in it.130 This is quite surprising, considering the breadth of health care issues raised by the report, including access to primary care, the development of home care and long-term care facilities, improving palliative care, and caregiver support.131 This state of affairs goes well beyond the medical community. No one interviewed for this book made reference to this specialization, let alone the need to hire more of these practitioners. There are only 304 geriatricians in Canada (and 40% are 55 years of age and above), which represents an average of 0.8 per 100,000; British Columbia and Nova Scotia are the only provinces with a ratio of 1:100,000.132 There are no universal standards on the ideal ratio of geriatricians per population, but a task force in New South Wales (Australia) suggested a requirement of 4:25,000.133 Also revealing of a side-lined specialization, there are nearly 10 times more paediatricians (2,887) than geriatricians (304) in Canada.134 Recruitment remains challenging. In the United States, a study of students who completed four years of medical study with geriatric activities illustrates the challenges ahead. Transcripts from focus groups revealed a lack of appropriate engagement with geriatrics, the low prestige of the profession, the non-curative nature of interventions, and the higher time demands of older patients.135 Despite growing needs in this specialty, students still prefer to work with young patients and acute somatic diseases that can be cured.136 Debates continue on the best way to train future medical professionals to cater to the needs of seniors beyond geriatrics onto general training in medicine.137 Unfortunately, gerontology content remains marginal in Canada, as evidenced by a survey of medical schools where

40

Theoretical Underpinning

the exposure to geriatrics content average 82 hours in undergraduate curricula, but with a median of 37. In addition, only 7 medical schools out of 14 included a mandatory clerkship of one week in geriatric medicine.138 It is important to note that this marginalization of training in gerontology/geriatrics is also prevalent in the training of other professionals, including nursing.139 A study of gerontology content within departments of nursing and social work reveals that only 6% of faculty members have a specialization in gerontology, which is likely one of the many factors resulting in only 6% of graduates opting to work in a gerontological setting.140 Health Promotion or How to Age Successfully From the early days of modern gerontology, medical research has made the distinction between “normal” aging, which implies healthy living with a slow and continuous decline associated with aging, and pathological aging, in an effort to identify and document various diseases and conditions. In medical research, normal aging frequently acts as a benchmark by which various ailments, conditions, and treatments are compared. An underlying feature of aging research is that genes are only one of many factors that contribute to a lengthier life. This has prompted an ongoing debate between researchers who advocate for better lifestyle choices – which implies that aging successfully is an individual responsibility or undertaking – and those focusing on the social environment to enhance the longevity and quality of life of (older) adults. A wealth of literature stresses the need for individuals to embrace specific behaviours and practices in order to “age successfully.”141 The research within this domain embraces a more positive view of aging, akin to the “new” and “positive gerontology” in social gerontology, which allows seniors to avoid or delay hospitalization. Emphasis is placed on the fact that aging does not necessarily equate with sickness and that individuals can achieve a status beyond normal aging by embracing better lifestyle choices and prolonging the number of normal aging years.142 It is considered a biomedical approach, since it equates physical and medical functioning to successful aging.143 In Canada, the successful aging movement has been a driving force behind initiatives such as Healthy Aging Strategies, which in some provinces led to the creation of Healthy Aging Secretariat (Manitoba) or Seniors’ Health Promotion Directorate (British Columbia).144 Compared to offices for seniors, these were more integrated within formal ministries of health

The Lenses of Population Aging

41

and social services, indicating that precedence is given to preventive medical approaches to aging over social ones. This approach to aging has faced criticism. First, the meaning of “aging successfully” has been highly debated. Bowling, for example, claims that seniors and the medical community view this process very differently; in fact many seniors consider themselves to be aging successfully, even if their medical conditions suggest otherwise.145 Second, advocates of successful aging often invoke the image of old-aged marathon runners or entrepreneurs to highlight that aging should not be associated too strongly with decline and sickness. Critical gerontologists have emphasized that the promotion and celebration of these exceptional cases stigmatizes individuals with limited to no capacities to attain these lofty goals for various reasons, such as poor health or disability.146 Many studies also point towards the importance of social stratification and health outcomes.147 This positive understanding of aging, albeit rooted in a biomedical perspective for the most part, promotes the concept of resilience, or developing individuals’ capacity to reduce the impact of their sickness or disability on their lives.148 Finally, increasing emphasis on social determinants of health and aging also challenges the traditional medical lens and its focus on prevention.149 Recent studies demonstrate that spending on social policies improves health outcomes as much as, if not more than, health spending,150 in addition to increasing the likelihood of becoming a centenarian.151 However, one should not confuse these campaigns – and successful aging – with social approaches to aging, since the former represent instruments to improve health and not necessarily a desired outcome in itself. For example, reducing inequality is not promoted strictly because it is considered a desirable societal goal but also because it generates better health outcomes. The Social Gerontology Lens Social gerontology “focuses on the social as opposed to the physical or biological aspects of aging.”152 Within the context of population aging, social gerontology accentuates the importance of social needs for older adults. The raison d’être of social gerontology is to challenge the influence of biomedical approaches in aging studies, and in particular its focus on losses of physical and cognitive abilities. This is hardly a new debate. There are strong reasons to assume that aging, and old age in general, does not equate with an extended period of cognitive and physical decline and illness. Based on a composite indicator including eight factors, the 2009 Canadian Community Health Survey indicates

42

Theoretical Underpinning

that 56% of individuals aged 65 and above reported good health, compared to 76% for Canadians in midlife. Older citizens actually reported positive health outcomes in more than four areas, compared to younger Canadians (95% vs. 84%).153 Even individuals who suffer from chronic ailments are still capable of maintaining active lives.154 Yet aging continues to be perceived and treated primarily as a biomedical issue, with aging studied as a pathology.155 Early studies in social gerontology painted a bleak picture of the aging process as theories tended to focus on older citizens’ loss of capacity and their gradual withdrawal from societal activities.156 Moreover, socio-economic conditions clearly aligned with the status of dependence portrayed in the media, as well as in many studies employing the intergenerational lens.157 These original contributions to social gerontology anchored an understanding of aging and old age that falls along a spectrum of rising social problems among aging populations. These conclusions imply that there is a large cohort of socially and politically passive citizens in an aging population. In response to these early theories, recent social gerontology research presents a far more dynamic picture of the aging process and the older population in general. For the purpose of this book, three contemporary approaches in social gerontology are relevant and feature strongly within policy circles: the “new” or “positive” gerontology, critical gerontology, and political economy. The “New” or “Positive” Gerontology As the use of the words “new” and “positive” suggest, this theoretical perspective breaks away from the bleak picture offered by early social gerontological studies.158 It challenges the dichotomy endorsed by many proponents of the intergenerational lens, which characterizes younger citizens as working individuals and seniors as dependents. In this framework, aging is reconceptualized as active rather than passive, with citizens encouraged to take measures to ensure a successful transition to their older years. Governmental authorities are expected to embrace policies promoting active aging or aging well, and retiring old gerontological policies geared towards “taking charge of seniors,” moving away from the social construction of older adults as patients. In positive gerontology, aging and old age present new opportunities for individuals to achieve a greater range of personal goals and objectives, as opposed to being limited by experiences of decline and loss of capacity.159 This approach assumes that older citizens can lead enjoyable and fulfilling lives and therefore should be empowered by governmental authorities to maximize their potential and further contribute to

The Lenses of Population Aging

43

their communities.160 This necessarily entails developing good healthrelated and social behaviours at an earlier age. Many research programs are centred on aging well, such as Successful Aging,161 Healthy Aging,162 and Active Aging.163 A key difference with the revival of an aging-well research agenda is the priority given to social elements such as active engagement in life164 and community involvement. Thus, the new and positive theoretical approach focuses on the important contributions of seniors to society. This new and positive gerontology has also had a noticeable impact on policy, as recent initiatives are clearly aligned with its core aims and objectives. This includes the United Nations’ campaign to mainstream aging and increase the social and political participation of seniors within their communities,165 and the World Health Organization’s (WHO) push for Active Aging166 and Aging Friendly Cities167 to ensure, among many goals, that senior citizens benefit from municipal infrastructure and services. At a 2018 WHO technical meeting on facilitating aging, a technical opinion sought to encourage the development of “engagement mechanisms [to] represent the diversity of the aging population.”168 At the provincial level, the lobbying efforts of advocacy groups have challenged previous organizational and policy legacies where older citizens are perceived as dependent, and aging issues are treated as illnesses and are therefore confined to health departments. The impact is clearly visible across Canada, as evidenced by the creation of horizontal offices such as seniors’ secretariats and the adoption of overarching strategies such as Alberta’s Aging Population Policy Framework.169 Aging well programs present a prescription for how to age successfully. They assume a fit, healthy individual – with good genes – who is also well engaged within the community. These programs provide tools for individuals with the capacity (intellectual, physical, and financial) to enact changes in their lifestyle. However, critics mention that this represents an ideal that is out of reach for many senior citizens. The senior population is extremely heterogeneous, and the glorified image of aging portrayed by aging well programs does not fit individuals suffering from high levels of poverty, disability, and/or poor health. Interestingly, by focusing so strongly on developing individual abilities and ignoring the barriers that prevent successful aging, these programs run the risk of further marginalizing the most vulnerable seniors.170 In addition, critics argue that the discourse on individuals in control of their own aging runs counter to the collective fabric of risk-sharing that is present in welfare states. Thus, aging well measures can be interpreted as being aligned with current strategies to reduce the scope and size of welfare states.

44

Theoretical Underpinning

Critical Gerontology Critical gerontology has distinguished itself with its commitment to emancipate older people from “all forms of domination,” as well as its opposition to positivism and empiricism, which prevail in biomedical approaches.171 Baar even refers to the latter as “dust-bowl empiricism” and claims that theories of aging need to more closely reflect the actual aging experience.172 Critical gerontologists maintain that ageism and social problems such as exclusion remain at the forefront of issues faced by seniors173 and, as a result, they draw attention to the diversity of aging paths based on different life cycles, gender, race, social classes, and family relationships. They also stress the disconnection between the realities of aging and its socio-cultural construction based on societal norms, culture, and policies, to name a few.174 Multiple contributions in this field demonstrate how individual aging experiences do not conform to established norms and policies, and discuss how this disparity affects the aging experience. For instance, recent works have criticized initiatives emanating from the “new” gerontology such as positive aging and aging well for further marginalizing vulnerable populations who do not have the ability or capacity to reach the idealized stereotypes promoted in these initiatives.175 To illustrate, the aging experiences of individuals who are HIV-positive clearly do not fit with the aging well model.176 According to critical gerontologists, researchers should not be passive but rather should be engaged in advocacy and inquiry.177 Thus, they should participate alongside their research participants to alter current social constructions of aging. The critical approach is highly interdisciplinary, involving researchers and students from the humanities and social sciences. It also employs a breadth of methods and tools such as discourse analysis, life course, and literary evidence. With a strong focus on marginalized groups, critical gerontologists best exemplify the shortcomings of universal approaches that are developed primarily to serve the middle class. Beyond the danger of “microfication,”178 this conclusion presents a major headache for policymakers: research demonstrates that targeting policies tend to reinforce marginalization and are less sustainable politically than universal policies.179 For example, individuals living with chronic disabilities have a favourable social construction even amongst political actors, who employ a strict dichotomy on who qualify as the deserving’ ”poor. Still, this is a group of citizens that has been affected by continuous reforms, simply because they are not large enough to sustain significant opposition.180 As a result, individuals living with a disability must rely on informal

The Lenses of Population Aging

45

care networks, since public services fail to address their needs. Even in countries known to have a generous welfare state, such as Sweden, informal care remains the norm.181 Political Economy The political-economy approach is rooted in the vast literature on comparative welfare state analyses. It valorizes the role of socio-economic structures, including most notably the state, political power, and the impact of policy legacies to explain inequities within the older population and vis-à-vis other groups of citizens. As such, this approach speaks directly to the Generational Politics framework described above but also features different mechanisms to explain socio-economic outcomes of older citizens and pays closer attention to variations within older populations. The first wave of political economy studies sought to explain the precarious socio-economic conditions of older citizens, whose withdrawal from the labour force was often accompanied by long spells of poverty and a “structured dependency” on the state.182 The policy structure of aging facilitates “social control” in terms of a “loss of autonomy, power, influence and authority” for seniors, resulting in a lower quality of life.183 Many contemporary studies point out that this bleak portrait for seniors has not changed drastically despite rising retirement income, caused by the maturation of public retirement programs, for the middle class. Older citizens still face barriers to remain active in the labour market and continue to face numerous obstacles associated with structured dependency.184 With population aging resulting in a rise in the median age and an increasing number of citizens in retirement, recent contributions highlight the growing political and economic strength of older citizens. As stated earlier, the presence of aged-based organizations is often mentioned as playing an important role in preventing a retrenchment of the welfare state.185 On the economic side, rising retirement income for the middle class is slowly eroding the association between poverty and old age, although poverty continues to affect many segments of the retiree population, with, for instance, Quebec retirees aged 75 and above living with an average net income of $23,400 for women and $26,500 for men.186 Also, social stratification tends to be reinforced in old age since those with better socio-economic status tend to benefit from better retirement income plans.187 Comparative studies argue that the presence of left-wing governments remains the best predictor of social rights for retirees.188

46

Theoretical Underpinning

The Organizational Lens Inspired by the public administration literature, this book suggests that a key difficulty with identifying challenges and opportunities arising from an aging population is the horizontal nature of this policy issue, which tends to be ubiquitous and interdependent. This occurs within an environment already filled with well-known difficulties to facilitate policy coordination.189 The organizational lens shines a light on the importance of the bureaucratic structure in policymaking.190 For instance, the predominance of a medical lens in Canada can be attributed partly to the importance of health ministries across the 10 provinces and the early allocation of responsibility for seniors. The organizational lens emphasizes the problems faced by governments to ensure that horizontal policy issues and large-scale problems are addressed appropriately,191 and it assumes that bureaucrats play a key political role in defining policy problems and in proposing solutions to tackle them.192 In line with the literature on public administration and policy instruments, organizations have specific preferences that are often difficult to alter. The literature on organizational learning actually stresses that organizations are more likely to learn how to improve their knowledge of preexisting instruments or practices rather than learning from elsewhere.193 For instance, finance departments, which are highly familiar with the budgetary process and fiscal policies, have a bias towards the use of fiscal credit to achieve social objectives. These biases can also have broader societal roots. For example, contrary to most other welfare states, the United States has routinely favoured fiscal credits to achieve social policy aims.194 More statist countries, such as Germany and the Scandinavian countries, are inclined to embrace more intrusive policy instruments to tackle problems.195 Two types of organizational response to population aging matter, especially in developing strategies for an aging population. By “strategies” I refer to the adoption of mechanisms to implement policy and programs with a long-term perspective in order to tackle what are perceived as policy problems. First, the enhancement of horizontal coordination across departments and agencies generates the development of a broad and comprehensive aging strategy. The point of departure to favour such an organizational response is that population aging is an inherently complex and interdependent policy problem that requires strong collaboration across departments and agencies that otherwise have diverse and sometimes even conflicting mandates. Population aging can be considered both a large-scale problem196 and one that is ubiquitous, like gender. Research in both the private and public sectors has emphasized the importance of maintaining some link between vertical organizations.197

The Lenses of Population Aging

47

This is exacerbated by the legacy of New Public Management, which has produced further decentralization and fiscal realities that constantly require that more be done with less.198 The lack of coordination can have disastrous consequences within the context of population aging. For instance, particularly in rural areas, it is imperative to ensure that infrastructure decisions be coordinated so that if health authorities decide to centralize services into one municipality, the transport ministry should take this into serious consideration when deciding which roads to improve and maintain. Two of the most important proponents to enhance horizontal coordination internationally are the United Nations and the OECD. The UN has opted to focus on the lack of representation of seniors within policy debates by introducing aging mainstreaming, which targets developing countries primarily. This may seem surprising, since the political science literature has emphasized the political power of seniors199 and seniors-based groups.200 However, these conclusions are based almost entirely on industrialized countries. So far, the implementation of aging mainstreaming has been difficult because it lacks a strong monitoring and evaluation system.201 Aging mainstreaming has not been put in place anywhere in Canada. The OECD has been advocating adoption of national strategic frameworks to coordinate aging-related reforms.202 The objective is to reinforce policy coherence, improve horizontal specialization, and build better public understanding of the issue. Although not stated as eloquently in its documentation, the key issue for the OECD is to avoid the development of policies that generate contradictory incentives, such as having a department of labour increasing penalties for not joining the labour market while a department of social affairs introduces subsidies or tax credits to encourage women to engage further into informal old age and/or child care. In a subsequent publication, the OECD presents concrete examples to illustrate good practices. For example, Japan adopted a law on aging society and created the Aged Society Policy Council, chaired by the prime minister, which presents an annual report to parliament.203 With a broad and comprehensive scope that encompasses elements such as health, learning, promotion of research, and work, this strategic framework clearly represents the outcome depicted by the first hypothesis. The danger with such an approach is that centralization of power within a central agency can further enhance the power of political executives, who can then use this as a means to better control various departments, rather than providing a cohesive vision to enhance policy coordination.204

48

Theoretical Underpinning

A second response involves the creation of a seniors’ department or ministry, which is likely to generate a narrow focus on issues related to population aging because it devotes its energy to a specific clientele. The creation of a similar organization within an existing department or ministry is likely to produce policies and programs similar to those elaborated within the host department. The creation of a line department devoted primarily to servicing the needs of seniors has at least two broad implications. First, this organizational structure focuses on a specific clientele rather than on the problems caused by population aging. This could create other long-term issues, because organization by clientele may result in an “organization for clientele” where the clients (in this case, seniors’ groups) “capture” the organization in ways similar to farmers’ interests and departments of agriculture.205 Second, the vertical integration of aging, as opposed to the horizontal strategy described above, is more likely to present a narrow definition of the policy problems associated with population aging. The departmentalization of a policy issue tends to result in less political control from above and is therefore likely to have stark preferences for the types of issues to engage and which to exclude.206 Rather than cooperating with other departments and agencies to introduce broad measures to deal with the consequences of population aging, the creation of a department is not likely to be welcomed by other governmental organizations, because it results in a potential loss of responsibilities for some departments while heightening competition for resources. It is important to emphasize that in Canada, which features a highly centralized budgetary process and strong, well-established departments such as finance, health, and education, it is extremely difficult for a new department to grow, especially if it fails to receive a strong commitment from the premier and/or the finance minister. Another major issue concerns the professionalization within a seniors’ department. Depending on the primary issue identified with seniors, the department risks developing a bias in its focus on aging. This is of particular concern for secretariats and offices, which are usually integrated within a specific department. Thus, the development of a senior office within a health ministry is likely to result in a stronger focus on health issues than warranted, because it will be embedded within the activities of the department. Moreover, the office or secretariat is likely to adopt similar kinds of instruments. For instance, if located within a finance ministry, tax credits are likely to be favoured over the development of governmental services.

The Lenses of Population Aging

49

Conclusion: Policy Lenses in Public Administration This chapter introduced four distinct lenses, which reveal competing problem definitions vying for policy attention within public administrations and the political arena to address the challenges and opportunities triggered by population aging. The intergenerational lens zooms in on current policy practices accentuate inequities across generations and that governmental authorities need to embrace a longer time perspective by focusing on the redistributive impact of policies across cohorts. The medical lens focuses on the consequences of having a large cohort of seniors, who are framed as a vulnerable population, on current interventions and practices. It also promotes healthier lifestyle choices and an active role for family members to reduce the likelihood of diseases and chronic conditions into old age. The social gerontology lens examines those socio-economic conditions, as opposed to medical conditions, that prevail among seniors and other societal groups. This results in a problem definition that rejects the polarizing vision of aging in which seniors are perceived as either frail or superhuman, while challenging the societal cleavage portrayed in the intergenerational lens. The organizational lens illuminates the fact that population aging represents a horizontal challenge akin to gender, since it concerns departments that operate interdependently, as responses in one department can have negative consequences for another. Hence, governmental authorities must develop tools and strategies to ensure a coherent and coordinated policy response. In the construction of these lenses, other alternatives were considered. For instance, life as a continuum could have been the object of its own lens (as opposed to being integrated within social gerontology). It assumes that both age discrimination and a general lack of consideration for life cycles are largely responsible for many of the policy and political conflicts related to population aging. In turn, this results in the promotion of universal policies that eliminate, or at the very least downplay, age-based criteria. While sharing these concerns, these four lenses present sufficient variation as frameworks for analysing and regrouping specific communalities, while also making it easier to analyse the broad diversity of policy problems associated with aging. Rooted in the policy problems literature, the following chapter goes into more depth about the distinctive features of each lens, and discusses how the four lenses produce significant biases within the policymaking process. Not only do these lenses emphasize different elements in an aging population, they tend to favour different policy instruments and mechanisms to alleviate related policy problems. This highlights the

50

Theoretical Underpinning

difficulties associated with developing cohesive strategies to tackle the challenges, and seize the opportunities, related to an aging population. The second section of the book presents different policy problems associated with population aging and analyses how the prevalence of the four lenses varies strongly across ministries and policy problems. The intergenerational and organizational lenses find strong credence in finance ministries and central agencies, who play a significant role when population aging is conceptualized as a horizontal problem (chapter 7). While public authorities in Canada have not explicitly embraced intergenerational tools such as generational accounting, it has nonetheless influenced public administrations to develop a more long-term overview of the economy and public finances. This has led to the development of broad strategies such as Alberta’s Aging Population Policy Framework and tools such as Newfoundland and Labrador’s Community Accounts. The intergenerational lens is also instrumental in analysing population aging as a pension (chapter 4) and features in health care debates (chapter 5). The medical lens features prominently when population aging is studied as a health problem. Thus this lens dominates health ministries and agencies, including health care, long-term care, home care, and community services to seniors (chapters 5 and 6). Provinces have deployed a host of measures that are rooted in medical lenses, such as emphasizing home care and aging in place, and building stronger relationships with private organizations. Finally, the social gerontology lens is firmly anchored in newly created seniors’ secretariats (chapter 8). This assumes that population aging most greatly affects seniors, and that the current governmental and administrative structures neglect their unique needs and concerns.

2 Population Aging as Policy Problems

Introduction As discussed in the introduction, the media have been quick to predict a wide range of policy and socio-economic outcomes as a result of population aging. Scholarly debates are not very different. Within the social sciences, population aging raises the potential for gerontocracies in Western societies,1 the possibility of smaller welfare states,2 and even bankruptcies.3 Two geographers even argue that the changing demographic landscape in Canada will have a greater impact than political and economic factors, which concerns not only population aging but also changes in household composition and the highly selective nature of immigration.4 In opposition to these claims, a group of Canadian researchers have challenged these “apocalyptic demography” scenarios and the extent to which public policies require drastic changes.5 The primary objective of this chapter is to discuss the relationship between population aging and the multiple policy issues associated with it. The first section analyses the characteristics of policy problems that underpin the four lenses of population aging. Population aging triggers specific policy problems, which are analysed in depth in subsequent chapters. This chapter aims to provide a big picture of how each individual lens results in very different ways to analyse and tackle policy problems in population aging. The second section discusses the characteristics associated with solutions, while the third section analyses the interaction between the lenses. Linking Policy Problems with Population Aging Lenses Policymakers face important challenges daily, but rather than facing dilemmas with the selection of lenses to analyse a policy issue, they must make decisions about how to identify and address policy problems.

52

Theoretical Underpinning

Unfortunately for policymakers, there is no standing operating manual to guide them, since policy problems and their potential solutions operate in highly contested terrains along different dimensions.6 Multiple contributions stress the strong linkage between solutions and policy problems,7 since policymakers are unlikely to tackle a problem if no solution has been previously formulated.8 One of the most famous approaches, the multiple streams framework, assumes that opportunistic policy entrepreneurs have solutions prepared well in advance, and they simply wait for the right problem to come along.9 It is, however, easier analytically to separate problems from solutions, especially with a macro issue such as population aging, which is frequently associated with a wide variety of policies. In this vein, this chapter follows in the footsteps of Peters, whose contribution distinguishes between identifying policy problems (stage 1) and framing solutions to resolve them (stage 2).10 Drawing from the work of Rochefort and Cobb, and Peters and their categorization of policy problems, there are seven core characteristics associated with policy problems and four key variables related to policy solutions.11 With regards to policy problems, the core characteristics are definition, causality, severity, novelty, proximity, complexity, and problem population (table 2.1). For solutions, the variables are solvability, monetarization, capacity, and interdependencies (table 2.2). The ensuing analysis represents a broad picture of population aging as policy problems and should not be considered an exhaustive account of the policy issues associated with this demographic phenomenon across the four lenses. Defining the Problem The first and most basic, yet fundamental characteristic associated with any policy problem is establishing what the problem is.12 We can employ the analogy of a leaking roof to illustrate that an individual can no longer wait to pay attention to a specific problem. However, social realities are far more difficult to recognize and understand. Policymakers do not have obvious signs such as water dripping over their heads to signal that they need to act and, equally important, how to act. Many problems are in fact “squishy, messy, or ill-structured” without any clear delimitations, let alone solutions.13 To be acknowledged by governmental authorities, a policy problem must first and foremost make it onto the public agenda. This usually implies that a problem must (1) garner significant attention, (2) be understood to require some sort of action, and (3) be on the radar of

Population Aging as Policy Problems

53

Table 2.1 Core population aging problem definitions across the four lenses Intergenerational

Medical

Social

Organizational

What is the problem?

Inequity across cohorts and ongoing debt to future generations

Number of older adults living longer, and resources

Traditional socio-economic issues, ageism, medicalization of aging, apocalyptic aging

Traditional crossdepartmental issues and regional coordination

Causality

Policy design and Increasing Framing of well-entrenched reliance on health seniors as either programs dependent system by a or selfish, higher number discriminatory of older adults, structure of CHA, nature of current policies and medical profession

Nature of specific issues and maturity of current programs

Severity

High to moderate High

Moderate

Moderate

Novelty

No

No

No

No

Proximity

Current – late

Current

Current

Current

Complexity

Moderate to high – mostly an issue of political leadership

Political – high (need to increase spending in health). Programmatic – moderate – coordination of services

High both politically and programmatically due to grip of medical model

Political – easier due to concentration of power. Programmatic – high with multiple matured policies

Problem population

Seniors, mostly baby boomers

Seniors

Society

Diverse

governmental officials.14 As a result, much attention is placed upon the politics of problem definition,15 since there is a multitude of competing problems and solutions. How issues make it onto the public agenda, as well as who has control or influence over it, are featured prominently in academic debates.16 Identifying population aging as a potential source of policy problems, or as a contributor to existing problems, is significant because it shapes the eventual solutions proposed to address these problems. The point of departure for this book is that civil servants are not bystanders in this process. They can simplify complex policy realities for their

54

Theoretical Underpinning

Table 2.2 Core population aging problem solutions across the four lenses Intergenerational

Medical

Social

Organizational

Solvability

Yes – long-term planning and reformed policies

Yes – transformation of health care system

Yes – prioritize social policies

No – can improve actions

Monetarization

Yes – costs and benefits of public programs

Yes – costs of health care needs

No, although certain aspects can be (i.e., caregiving contributions)

No

Governmental capacity

Stretched to the limit

Issue linked to the ability to find additional resources

Primarily a question of political priorities, not capacity

Issue mostly with coordinations and long-term actions

Interdependen- Yes – emphasis cies on cohort dynamics, which require more visibility

Yes – challenge is mostly vertical coordination within health system

Yes – but social Yes – issues are rarely ubiquitous. Raison d’être of acknowledged the lens

political superiors while providing solutions to tackle issues such as economic crises17 and pension reforms.18 Civil servants can assume these functions because they possess many attributes that cannot be easily replaced, even in highly politicized environments, such as information, organizational and technical knowledge, and experience with aspects of policies under scrutiny.19 Equally important, where civil servants are situated in the bureaucratic structure provides a delimitation or boundary for potential problem identification. Do public authorities view population aging as a health problem, a coordination problem, a financial problem, a pension problem, or even a transportation problem? Answers to these questions will vary significantly, depending on whether this question is put to a deputy minister for health services or a senior economist in a ministry of finance. Each of the four lenses introduced in the previous chapter represents a different perspective on how population aging creates or accentuates policy problems. The intergenerational lens emphasizes

Population Aging as Policy Problems

55

the fact that population aging results in socio-economic inequities that currently disadvantage younger generations. In generational accounting, it takes the form of an uneven distribution of public resources across generations, which is caused by ill-designed programs and the actions of elected officials who choose to ignore the long-term consequences of their fiscal decisions.20 The dependency ratio approach, promulgated and diffused widely by many international organizations, simply claims that there are too many dependents (defined simply as individuals aged 65 and over), creating an unsustainable burden on public programs.21 The Musgrave rule acknowledges financial difficulties with some public programs, but emphasizes the lack of political mechanisms to ensure against demographic risks as the most pressing issue. The medical lens conflates population aging mostly with a growing number of older adults living longer22 and the additional resources this will require.23 As such, it prioritizes the increasingly complex needs of older patients, who suffer from chronic conditions beyond the traditional health risks associated with aging.24 As its name indicates, the social gerontology lens focuses on the social elements associated with population aging, including ageism, the challenges related to caregiving, economic precarity, and access to social services. As such, users of this lens challenge the medicalization of human conditions related to aging and the subsequent choice of solutions, which tackles aging as a pathology. In the medical universe, social activities are reduced to a determinant or an instrument of well-being, as opposed to being ends in themselves. Critics also target preventive strategies such as successful aging, healthy aging, and productive aging because they further exclude marginalized groups such as individuals living with disabilities. Finally, the organizational lens zooms in on the lack of horizontal coordination across the public sector (and beyond) to tackle the ubiquitous policy issues related to an aging population. The danger is that individual departments continue to function semi-autonomously without serious consideration for the way their actions affect other departments, policies, and programs. In the context of population aging, a unilateral course of action by a department can potentially create unexpected policy responses that are impossible to enact for many sub-populations. For example, there is strong evidence that health departments are increasingly offloading responsibilities to caregivers in order to alleviate costs, thereby cutting the number of measures imposed by governments.25 From a health ministry perspective, this makes sense, given that caregivers already

56

Theoretical Underpinning

offer multiple “free” social services and could potentially do more if provided the necessary support. However, this approach fails to consider the enormous pressure caregivers are under to remain actively engaged in the labour force. Employment and retirement reforms are being redesigned to prevent withdrawals from the labour market. With women still performing the majority of caregiving duties, these individual departmental policy choices also accentuate gender disparities in income and leisure time. What to coordinate is another important question within provincial jurisdictions, and it flows from identifying what the problem is. This rather simple question steers resources and focus in very diverse directions. Should the focus be on older adults, a specific strategy like healthy aging, a general administrative approach akin to “aging mainstreaming,” or a more holistic understanding of population aging and its consequences? Causality Closely related to problem identification is the issue of causality, since defining a problem “invariably entails some statement about its origins.”26 The linkage between problems and solutions also requires some understanding of causality between the solution chosen and the problem at hand. This ultimately leads to a discussion about who or what is responsible, with the media in particular playing a key role in promulgating the connection between cause and effect. The political leanings of policy actors come to light when analysing the cause of a given policy problem.27 Right-wing parties tend to focus on individual responsibilities, while left-wing parties give greater consideration to societal factors. In Canadian pension debates, for example, conservatives typically attribute the lack of pension savings to individual behaviours, while parties on the left stress gaps in the current retirement system. Interestingly, there is a consensus on the demographic change currently happening in Canada, as all lenses recognize that population aging presents new kinds of policy problems and policy opportunities. There are noticeable differences, however, in how population aging interacts with other factors such as public programs, economic policies, and politics to create policy problems. This implies competing interpretations of who or what is responsible for the issues related to population aging. With demographic change being a fairly impersonal and inadvertent cause, public debates tend to quickly shift focus onto the factors complementing population aging, and those actors responsible for their management. Within a broader agenda to scale back the welfare state,

Population Aging as Policy Problems

57

this can occur as part of broader exercise of assigning blame for the enactment of policy reforms.28 For the intergenerational lens, the primary issue is how population aging interacts with two important elements. First, the policy design of many public programs and procedures are short-sighted and therefore create or contribute to intergenerational inequities. For instance, the generational accounting literature is highly critical of budgetary institutions organized along a yearly cycle, instead stressing the importance of long-term financial commitments.29 Policies do not seek to attenuate the impact of demographic shifts to achieve a similar cost/benefit ratio over time for citizens, because addressing intergenerational equity has, at least until recently, not been considered an important goal in policy development. As a result, policies are ill-suited to secure a similar mix of tax levels and benefits across generations. Second, building on recurring arguments in the literature on policy feedbacks,30 public institutions continue to highlight the difficulties of adapting to an aging population. Both generational accounting and generational politics emphasize the role of political institutions and how they accentuate or diffuse intergenerational cleavages. This conservative bias, combined with the rising median age of the electorate and the emergence of interest groups concerned with specific programs such as pensions, are often cited as major obstacles to reforming the welfare state, which is regarded as an “immovable object.”31 Albeit with a different objective in mind, the Musgrave rule echoes this sentiment by stressing the need for better political institutions that could facilitate exchanges and compromises across generational boundaries.32 With respect to the medical lens, population aging implies a growing number of older adults, especially above 75 years of age, resulting in increased reliance, or even dependence, on the health care system. In turn, this necessitates additional resources and new ways of delivering health care to ensure that the system can satisfy the (medical) needs of this specific population while maintaining adequate services for the rest of Canadians. As with the intergenerational lens, program structure plays an important role, although the dynamic differs significantly. With a near monopoly on defining what constitutes a medical condition, governmental authorities are expected to ensure the best care possible for all its citizens. The Canada Health Act, with its hospital-based framework, is often criticized for marginalizing the treatment of older adults and the practice of gerontology more generally, with home care and related social services falling short of the expectations of older adults.33 This creates a strain on already scarce resources, which is a cause for concern

58

Theoretical Underpinning

within geriatric medical communities. Population aging also sheds light on the behaviour of citizens and their usage of the health care system. This focus coincides with most medical practices that prioritize individual responsibilities over broader societal or systemic trends.34 The social gerontology lens accentuates the fact that ageism is omnipresent within aging societies. Far from presenting population aging as a societal issue, many actors with important policy influence such as the media, politicians, and the medical profession paint an alarmist and ageist vision of the challenges ahead by portraying older adults in a negative light. Stereotypes are continually reproduced, despite research demonstrating the heterogeneous nature of aging.35 The social gerontology lens also highlights the fact that current policies and practices neglect the social dimensions of aging. This is in part a response to the predominance of health care institutions and the medicalization of aging,36 which can likewise result in a medicalization of social services.37 Despite the increasing importance of social determinants of health, these are still presented as instruments to enhance healthier lifestyles.38 In the case of the organizational lens, the discussion surrounding problems related to population aging tends to focus closely on the nature of the problems themselves and their place within the broader state machinery. Population aging is a classic transversal issue, since it affects multiple programs and policies that are housed in various ministries.39 Each of these ministries possesses a different agenda, organizational culture, and understanding of the policy issues surrounding population aging. This requires active coordination amongst actors whose main priorities lie elsewhere. These efforts are also undermined by a tendency to equate population aging with aging, resulting in a much narrower understanding of the demographic phenomenon and its impact on policies. Complicating matters further, the policy space is now crowded with mature public programs, thus making important policy change more difficult to enact.40 This is particularly the case with many of the programs that are cited in conjunction with population aging, such as the Canada Pension Plan, universal health care, and employment insurance. In addition, population aging, like climate change, demands a longterm policy outlook, which is difficult to maintain. The dismantlement of long-term policy agencies, which were highly popular in the 1970s and 1980s,41 and the increasing politicization of civil services, have contributed to cementing a shorter time horizon for the policy agenda.42 In fact, strategic plans in Canadian provinces tend to coincide with respective electoral mandates.43

Population Aging as Policy Problems

59

Severity The four underlying perspectives notably diverge on the severity of problems associated with an aging population, or what is considered the third characteristic of policy problems. The intergenerational lens, with the exception of the more moderate Musgrave rule, reveals the most colourful and pessimistic language when discussing population aging, invoking the imagery of storms, crises, and even tsunamis. Canada has been “awakening to the intergenerational equity debate,”44 but studies45 and media representations46 indicate that mentions of a severe crisis remain rare. This outcome is not surprising, since a comparative analysis of the age orientation of welfare states suggests that Canada ranks amongst the least “elderly biased” among industrialized countries, while the United States is ranked at the top.47 The severity of a given policy problem tends to be more prominent and polarizing when analysed through the medical lens. There are concerns to address specificities associated with an older population, since they require a more complex type of care.48 The lack of financial tools for individuals to obtain long-term care and home services49 and the slow development of public alternatives are becoming increasingly problematic. Future projections paint a worrisome picture, especially for those providing informal care.50 Interestingly, and in spite of the difficulties to recruit in gerontology, studies on the potential shortages of medical professionals are nearly unanimous in concluding that this does not present a major challenge.51 Within social gerontology, studies reject the severe crisis scenarios portrayed by generational accountants such as Kotlikoff, which accentuate ageism. For social gerontologists, ageism presents a far more pressing and severe policy problem. As stated earlier, aging is a highly heterogeneous experience that is well documented in life course and longitudinal studies. Yet, despite the steady removal of barriers that discriminate on the basis of age, such as mandatory retirement, older adults continue to face ageist attitudes and policies. Ageism entrenches practices and policies remotely connected to the actual aging experience (as illustrated by critical gerontologists). It also fails to acknowledge that traditional socioeconomic cleavages remain present in old age. Another severe problem within the social gerontology lens is the continuous marginalization of social services, which often occurs at the expense of medical care (see chapter 6). Provincial authorities cover only 8–10% of caregiving needs for older adults,52 who consequently have to rely on informal caregivers and third parties to deliver services geared towards an older population.

60

Theoretical Underpinning

Lastly, with regards to the organizational lens, there is no indication that population aging is a severe policy problem. Rather, this perspective recognizes that new strategies or approaches are needed to tackle this demographic phenomenon. It assumes that the generational storm highlighted by the intergenerational lens is not construed as governmental incapacity (as opposed to unwillingness) to enact a large-scale budgetary and programmatic reform agenda. Novelty In terms of novelty, population aging is clearly not a new or a surprising policy problem, since this demographic trend has been anticipated for decades in policy documents and academic research.53 Action by provincial governments, albeit limited, was already underway in the 1990s on the potential impact(s) of population aging. Serious pan-Canadian awakenings to the growing importance of population aging occurred in the late 1990s and early 2000s with, for example, the publication of Principles of the National Framework on Aging: A Policy Guide54 in the lead up to the International Year of Older Persons in 1999. Other Canadian initiatives followed broader developments at the international level, such as the OECD’s work on prosperity in aging societies55 and the WHO’s push for the development of active aging strategies.56 Canadians played an role in both of these international undertakings. Beyond their participation via the federal/provincial/territorial forum, provinces enhanced their knowledge through the creation of commissions and study groups.57 Proximity In general, there is a growing sense that policy issues resulting from population aging are far more proximate than they used to be, especially with the first wave of baby boomers retiring. However, the proximity of specific policy problems is closely related to the type of public programs under study. For example, finding ways to keep baby boomers in the labour market past retirement age is a far more proximate policy issue in time than enhancing the capacity to welcome older adults in long-term care institutions where demand is expected to peak in 2050 if current mortality rates remain constant.58 With each lens emphasizing different public programs and divergent understandings of the consequences associated with population aging, this results in a variation in proximity as well. The intergenerational lens, with its heavy reliance on measures such as dependency ratios, reveals that policy problems are prevalent, as

Population Aging as Policy Problems

61

the dependency ratio is expected to steadily double over the course of the next 20 years. This temporal disconnect can be attributed to the design of popular programs such as pay-as-you-go pension systems and universal health care financed through general taxation revenues. Hence, there is a shift from employing metaphors such as the upcoming generational storm to “saving ourselves” from the current clash of generations.59 Other studies focusing on intergenerational issues are far more nuanced on proximity. Studies modelling voters’ preference, for example, associate a rising median age with potential increases in contribution rates that are often in line with dependency ratios.60 In all these scenarios, the key issue is not the rise in contribution rates in itself, but the timing of this occurrence, since it alters the dynamic of redistribution across generations. As for the medical lens, the most proximate issues relate to human resources, since many professionals are baby boomers who are expected to retire in the near future and the lack of proper facilities and services to cater to the needs of an older population. At the same time, informal caregivers are subject to increasing pressures to remain active in the labour market while simultaneously providing care. There is also a great sense of urgency about implementing healthy aging practices, reducing the expected use of long-term care facilities in the next 20–30 years, and developing strategies to tackle the expected increase in the number of patients with complex needs, especially dementia. For social gerontologists, policy and institutional legacies play a key role in structuring the proximity of policy problems, albeit for reasons entirely different from those of the previous two lenses. The focus, rather, is on the discriminatory nature of policies and institutions, as well as the prevalence of ageism in societies.61 This includes, for example, the paternalistic attitudes within the health care system and ageist practices in the workplace. There is thus a variation in proximity according to the program or policy in question. For the organizational lens, proximity is not an issue in itself, since it assumes that population aging is an ongoing issue. Complexity Complexity, the sixth characteristic of policy problems, can be best understood in terms of political and programmatic complexity.62 Every lens illustrates that population aging is highly complex in a political sense. This is hardly surprising for political scientists, since so many welfare state theories emphasize factors favouring the status quo and the lack of reforms or an arduous reform process for politicians brave enough

62

Theoretical Underpinning

to embrace significant policy change.63 More specific to social gerontology, the political and programmatic complexities lie in the institutional strength of the medical model and its deep historical association with aging.64 When it comes to the medical lens, the primary issue is not with the system itself, but rather with the growing gap between future needs and financial commitments provided to meet them.65 The understanding of complexity resulting from the use of the organizational lens may represent an exception, since political power is increasingly centralized within the hands of premiers in Canadian provinces, which can facilitate the execution of broad strategies or important reforms as long as these feature highly on the list of priorities of new governments.66 However, this comes at the cost of continuity in government actions. Programmatic complexities are broad and varied. Despite the primary focus on health and pension policies within the intergenerational lens, the approach is programmatically weak, since a host of measures and actions could arguably produce more equitable outcomes along generational lines. The major obstacle is political. With the use of the medical lens, there is an increased risk of conflicting perspectives on how to best treat patients. The complexities also occur in the forms of coordinating forms of health care delivery, which may have different priorities in what should be enacted to improve the well-being of older adults. The organizational lens illuminates similar issues but at a macro level. It also operates within a broader policy environment, resulting in an additional layer of difficulties. In addition, the number of public policies and programs has grown significantly over the years, making it difficult to alter one without affecting another. Thus, there has been little to no attempt to recreate the kind of planning exercises that were prevalent in the 1970s. Problem Population The various lenses filter very different understandings of the problem population. Although population aging is a complex societal demographic transformation, it often becomes entangled with the individual experiences of aging and the aged. The attention is often geared towards existing older adults and, most specifically, baby boomers. They represent the aging population or, if you have a flair for the dramatic, the “silver tsunami.”67 Baby boomers are frequently and explicitly identified as culprits in intergenerational and medical approaches. Each lens features a noticeable exception. The Musgrave rule within the intergenerational lens insists on the necessity of a consensus across generations to alter policy as problems arise. Successful aging presumes

Population Aging as Policy Problems

63

that even younger members of society should embrace healthy habits as they age. The social gerontology lens reflects the fact that population aging affects everyone and vehemently rejects claims that define or label older adults as a problem population. On the contrary, most specifically within the new gerontology approach, older adults are part of the solution to tackle ongoing changes triggered by population aging. This competing definition of a problem population among these three lenses is clearly visible in the organizational lens. On one hand, the expansion of seniors’ secretariats reflects a desire to strengthen collaboration and improve services and programs for older adults; however, this also tends to diffuse the message that population aging is strictly a seniors problem. On the other hand, attempts to establish a broader view of the problem population to encompass all generations runs the risk of being too complex to succeed and concentrates only on a few facets of policy problems generated by population aging. Solutions to Policy Problems This leads to the second set of characteristics, which concern the dual task of devising and enacting solutions to policy problems. Again inspired by Rochefort and Cobb, as well as Peters,68 there are four core characteristics: solvability, monetarization, governmental capacity, and interdependencies. Solvability First and foremost, can the problem be solved? The question of solvability is quite problematic in population aging, since the first obvious avenue is to seek solutions that alter the composition of a given population, which is considered the root cause of policy problems. As discussed in the introduction, it would take changes in immigration patterns and birth rates not experienced since the Second World War. Life expectancies are unlikely to decline unless a country experiences a major shift in political or economic regimes, as seen in some former European communist countries. Thus, demographic solutions are unlikely to yield a sufficiently large impact to truly affect the policy problems engendered by an aging population. With this in mind, population aging creates not a specific policy problem but rather a countless number of policy issues that could be analysed individually as policy problems. In terms of responses, most issues related to population aging cannot be solved, only attenuated. It is interesting to consider the notable differences across the lenses. In the

64

Theoretical Underpinning

intergenerational lens, the generational accounting and the dependency ratio approaches assume that policy dynamics are geared towards the status quo, suggesting that a major event – or the emergence of one – is likely needed to enact the changes necessary to embrace policies aligned with socio-demographic realities. The prescription involves long-term budgetary planning and mechanisms to ensure that politicians adhere to it. This perspective is shared, albeit far less dramatically and more specifically in terms of policy instruments, by the generational politics approach. However, the Musgrave rule assumes a more pragmatic approach to identifying policy challenges, such as establishing forums to facilitate discussions across the generational divide, which is considered key for developing long-term solutions.69 Users of the medical lens advocate for the transformations of health delivery (albeit without questioning the primary role played by medical professionals), as well as stronger investment in health prevention and research to combat diseases associated with aging, such as Alzheimer’s. Thus, this response to an aging population could lead to longer but healthier lives. The medical profession also stresses individual, as opposed to environmental, factors. As a result, citizens are said to play a major role in providing solutions to improve the health status of (future) older adults. Citizens are expected to embrace healthy lifestyles to diminish their risk of chronic conditions and aging-related disease, which in the long term reduces their potential utilization of the health care system. This is often presented as a win-win solution, as better health behaviours can increase life expectancy and decrease morbidity rates while reducing the costs of the health care system. These objectives are clearly present in recent healthy aging/positive aging initiatives undertaken across the country. Use of the social gerontology lens challenges this biomedical understanding of aging. Many of the policy problems are deemed social and can be resolved with proper political and financial investments alongside changes to existing policies to tackle specific policy problems such as ageism and elder abuse. Hence, governmental authorities should prioritize solutions that improve the socio-economic conditions of every citizen, including older adults. The solutions involve development of more inclusive societies, where older adults are not marginalized. It could be akin to the aging-friendly cities program to improve living environments, which ensures, for example, that public infrastructure planning does not ignore older adults. Better policies are also prescribed to tackle traditional socio-economic issues such as poverty, which most notably affects women living past the age of 75.

Population Aging as Policy Problems

65

For the organizational lens, coordination issues are omnipresent; they can be alleviated to some degree but they are not solvable in themselves. Solutions tend to be strongly embedded with the ministry or agencies within which civil servants operate. For example, civil servants working in a finance department are far more likely to be influenced by approaches such as generational accounting than social gerontology. Monetarization Monetarization is a crucial consideration in the policymaking environment, since it is virtually impossible to launch a public initiative without being able to present a dollar amount for it. The projection of future costs remains highly contested, since changes to multiple variables (such as economic growth, interest rates, mortality, actual retirement age, the size of federal transfers, and stock market performances) can have a tremendous impact on the costs of public programs, and equally importantly, on the financial capacity of governments to pay for them. Within the intergenerational lens, the ability to monetarize benefits and costs represents a core feature of the generational accounting approach. Analyses usually employ dollar amounts to describe the extent to which public programs are not equitable across generations, and to illustrate the costs of inaction of governmental authorities. For example, a recent study claims that as a result of the nature of Canada’s pay-as-you-go financing within the health care system, individuals born prior to 1990 “will not have paid their full resource cost of healthcare spending,” thereby underscoring the need to enact reforms promptly.70 Interestingly, other approaches within the intergenerational lens are rather vague on monetarization. Generational politics, for example, is more concerned with the link between public policy change and how it relates to specific age groups. Monetarization is also an integral part of the medical lens and is subject to multiple contributions in public policy,71 primarily as a result of the universal and public structure of Canadian health care and its dominant place in provincial budgets. Each of the three approaches associated with the medical lens has made monetary claims. For example, the Canadian Medical Association commissioned a study from the Conference Board of Canada, which concludes that aging will add $93 billion in spending over the next 10 years, and the report criticizes the long-term negative impact of declining federal transfers when needs are rising.72 A recent study on informal caregivers claims that their unpaid contributions to older adults in need amounts to $25 billion per

66

Theoretical Underpinning

year.73 Finally, a big driver behind initiatives such as healthy aging and positive aging is the potential savings this could generate for publicly funded health care systems. Monetarization is less prominent as a policy problem characteristic for the social gerontology and the organizational lenses, even though inter-ministerial cooperation inevitably prompts discussions about costs and financing in order to determine which ministry is expected to foot the bill. In some cases, such as Quebec’s aging action plans, the list of proposed measures features clear indications of which ministry will be responsible for financing and implementing specific initiatives. Governmental Capacity Population aging raises a number of important questions about governments’ capacity to tackle policy challenges that arise from this demographic change. This goes beyond the capacity to finance new public initiatives, to include the extent to which governments can resolve policy problems. Consistent with findings suggesting that states suffer from declining capacity to analyse policy, a study on the policy capacity of the federal and provincial governments in Canada denotes that more deputy ministers experienced an erosion of policy capacity than improvements in the provinces, but the opposite occurred at the federal level.74 Another contribution stresses that provincial civil servants are more likely to engage in “firefighting” exercises rather than focusing on more long-term issues like their federal counterparts.75 These findings give credence to earlier research on provincial public administrations, most notably in smaller provinces, since they feature small bureaucracies with close proximity between analysts and decision makers.76 The notion of capacity also implicitly refers to the nature of the policy problem, particularly in terms of scale. In his seminal work, Schulman describes the complexities surrounding large-scale policy problems such as poverty and the mission to land a man on the moon.77 These undertakings require tremendous (public) resources and unprecedented political and organizational mobilization, especially in the initial stages.78 Hence, the demands of large-scale policymaking may be unattainable for many provincial jurisdictions, even with the support of federal authorities. This leads to the question of whether or not population aging constitutes a large-scale policy problem. As discussed above, population aging is not a problem in itself. Rather, it is the scale of the demographic shift and its multiple socio-economic impacts that are raising critical debates across the country. For Schulman, the key attribute for the classification of a problem as large-scale is

Population Aging as Policy Problems

67

first and foremost its indivisibility, since the ability to divide a problem into smaller pieces would remove many of the specificities related to scale. For example, in his book he argues that the Kennedy administration in the United States did not seek to go halfway to the moon, in the same way that a war on cancer cannot be won until the disease is completely eliminated.79 At first glance, this does not seem to apply to population aging, because there are many policy challenges with varying levels of prioritization based on the strength of policy lenses, which could be tackled somewhat autonomously. For instance, enhancing training opportunities for older workers and pursuing policies to promote retirement at a later age do not necessarily have to be implemented together, although the lack of employment opportunities for older workers would prevent training policies from yielding the desired policy outcomes. However, for Schulman, the source of indivisibility goes beyond the intrinsic qualities of a particular problem. It features the psychological conditions that prompt an entire population to rally behind a specific issue, as well as political factors that refine policy problems and affect the ability to stretch the limits of political feasibility. There are indications across the four lenses that population aging could be treated as a large-scale policy problem. Approaches within the intergenerational lens (with the exception of the Musgrave rule) assume that current policies are not only inequitable across generations, but are also unsustainable. In general, population aging is regarded as a large-scale issue, comparable to a tsunami or a generational storm, which leads to concerns that governments do not have the financial capacity to maintain current policies.80 There is at least a strong fear that this capacity is lacking.81 As a result, users of the intergenerational lens typically prescribe a withdrawal of the public sector from addressing policy problems related to population aging, which leaves greater room for individuals and actors in the private sector. This is particularly the case in the United States, although recent Canadian studies have drawn similar conclusions.82 Use of the medical lens presumes that the rising number of older adults will challenge health services and test the capacity of the current system to satisfy demands. In this lens, the challenge lies in the fiscal and the human resources required to continue down the current path. With a general shift towards the social dimensions of health, proponents of the medical lens explicitly state that individuals have responsibilities to maintain good health and family obligations towards seniors in order to delay (or even avoid) hospitalizations. This represents not only an acknowledgment of the limits of the curative-based model, but

68

Theoretical Underpinning

it also indicates the limited capacity of provincial governments to sustain such a model.83 Social gerontologists rarely consider capacity to be an issue, preferring to focus on shifting political priorities. The first wave of studies in political economy claimed that governments were using their resources to restrict older adults from actively participating in social, political, and economic activities, namely by building institutions that accentuate their withdrawal from society.84 However, the recent focus on the heterogeneity of aging and the necessity of considering the life course instead of age85 raise important challenges about the development of policies that can respond to an eclectic target population across time and the resources to implement interventions and tools that are individualized. Governmental capacity is also of central importance within the organizational lens. In a complex policy environment, where policy inheritance86 and succession87 represent the norm rather than the exception, it becomes extremely difficult for governmental authorities to resolve coordination issues and tackle “new” policy problems that are horizontal. In theory, the increasing politicization of the civil service and its stronger reliance on central agencies should strengthen capacity for coordination. However, studies demonstrate that elected officials tend to focus on a few highly visible issues with a short time horizon.88 Thus, population aging ought to be considered a political priority in order to benefit from additional resources that could be used to support a longterm plan or strategy to addresses the complexity surrounding an aging population and its impact on public policies. Interdependencies The last characteristic to consider when elaborating a solution to a policy problem is the extent to which the problem and solution are interdependent. Population aging is clearly not confined to a single policy domain, as it requires the involvement of many public organizations across various levels of government, from municipalities to international organizations. It features all of the challenging elements enumerated by Peters in his discussion on interdependencies:89 policy issues arising from population aging involve many policy instruments and tend to concern a large coalition of actors. They are also highly contested in framing (making them more contentious), while many issues, such as pensions, are solidly anchored in long-standing departments or agencies. All of these issues are clearly present within each of the competing lenses. First, interdependencies represent the raison d’être of the

Population Aging as Policy Problems

69

organizational lens, with population aging requiring stronger and better coordination from governmental authorities. This involves, for example, mitigating traditional “turf wars” between competing governmental organizations and dissociating the near monopoly held by health ministries over older adults as a target population. For the intergenerational lens, interdependencies represent a compelling rationale to enact policy reforms that will restore equity across generations and, equally important, generate public savings to invest in more youth-oriented programs. In this context, the focus is much more on the political will to act than on the horizontal capacity of public authorities to alleviate interdependencies and enact reforms. As for the medical lens, interdependencies are seen as a prominent feature of the Canadian health care system. As such, proponents aim to enhance inter-professional collaboration – a key issue when dealing with increasingly complex older patients – and improving and extending care beyond the confines of hospitals. Environmental and social factors also garner attention in the literature, even though they are emerging issues rather than established practices. While many policy documents consider these factors as health priorities for the future, many hurdles – such as the current financing formula employed by the federal government to support health services and the lack of public infrastructure – prevent provinces from deviating radically from the curative-based model. Interdependencies are also featured strongly in social gerontological approaches wherein interdependencies are identified as a cause for some of the discriminatory practices of governments. This is particularly evident in the case of caregivers, namely women, who struggle to combine their familial and professional responsibilities while having to assume an active role in providing care to older adults. Interactions between the Lenses: Coexistence, Complementarity, and Competition This section analyses the ways in which the four lenses coexist, compete, or complement one another. To facilitate the discussion and avoid repetition from the prior sections on the characteristics of policy problems, these are presented in pairs, starting with the intergenerational lens. In addition, the focus is mostly on the specific elements that complement or compete within each pair, along with an indication of the chapter(s) in which they are most prominent.

70

Theoretical Underpinning

Intergenerational and Medical Lenses The relationship between the intergenerational and medical lenses rests primarily upon the expected impact of having a higher number of older adults in the health care systems and the extent to which this fosters intergenerational inequities. In the United States, the structure of Medicare, with coverage restricted to seniors, is at the source of its old-aged biased welfare state,90 makes it an easy target to raise issues of intergenerational equity. In Canada, it relates to beliefs that population aging will increase health care costs, and that the current health infrastructure is ill-equipped to tackle the needs of an increasing number of older adults. The causal relationship between aging and health care costs remains contentious and omnipresent, as illustrated by the high volume of health care articles written on this topic, which is analysed in depth in chapter 5. Most analysts claim that the growth of older adults will result in a 1% increase in expenditure per year.91 It is not simply aging that has pushed health care costs higher, but also factors such as technological advances, a greater number of procedures and treatments, and an enhanced ability to live longer with chronic conditions. In addition, beyond techno-scientific advances, the discovery of new diseases and treatments means that more and more human conditions are becoming medicalized. Nonetheless, even in Canada there remains a strong perception in the media and among many policy analysts that population aging will drive up health care costs and crowd out other policy areas.92 Hence, this results in the search for ways to alter the cost structure of the universal health system and its overwhelming importance in provincial budgets. As illustrated clearly in chapters 5 and 6, policy feedback has made it extremely difficult to alter the health policy landscape to embrace cheaper and more effective ways to address the diverse care needs of older adults. Evidence shows that, despite the quasi-universal appeal of home care, priorities remain firmly entrenched in curative interventions, with long-term care needs confined to the family and the private sector. Intergenerational and Social Gerontology Lenses The primary contention between the intergenerational and social gerontology lenses is the divergent views on the consequences of an aging population for public programs. The former tends to emphasize the long-lasting financial and programmatic consequences of this demographic shift (see chapters 4 and 7). While acknowledging that there

Population Aging as Policy Problems

71

are generational issues, use of the social gerontology lens stands in strong opposition to any problem definition that assumes dramatic or catastrophic scenarios as a result of demographic change.93 It takes particular aim at the generational accounting approach and the dependency ratio, most notably for the simple manner in which the concept of dependence englobes adults aged above 65. This position is particularly prevalent in offices for seniors (chapter 8). The social gerontology lens also points towards a distinctive form of ageism associated with the diffusion of analysis and ideas rooted within the intergenerational lens and its instrumentalization by right-wing politicians to justify cuts to public programs. This features, for instance, portrayals of older adults as selfish or as “greedy geezers” to justify scaling back the size of the welfare state.94 While few researchers deny that population aging will lead to increasing public expenditures, social gerontologists reject anticipated “tsunami” scenarios and the “apocalyptic demography”95 depicted by “merchants of doom.”96 In fact, political science research has given credence to the notion of older adults as highly powerful political actors who can withstand the assaults of neoconservative forces.97 However, recent studies present a more nuanced picture, as emphasizing the marginalization of underprivileged older adults, such as women and minorities, within senior organizations,98 and have challenged their decision to abort retrenchment.99 There are certain elements where the social gerontology and intergenerational lenses complement each other. There is an acknowledgment within social gerontology that there is a growing generational divide and that the participation of older adults remains essential, even more so in an aging society. Accentuating intergenerational exchanges across generations in various forms, such as engaging seniors to participate in school activities, is valorized, since it helps to alleviate the generational divide and promote a more inclusive society across all ages (see chapter 8). This is clearly within the spirit of the Musgrave rule, where a consensual approach is sought to alleviate the consequences of an aging population. Intergenerational and Organizational Lenses The overlap between the international and organizational lenses occurs most visibly in the importance of planning for the long term to tackle the consequences of an aging population. The key differences, however, are in the urgency, severity, proximity, and underlying reasons for the lack of substantial changes in public policy. In the case of the intergenerational lens, inequities across generations are growing every year and are

72

Theoretical Underpinning

substantial; this requires immediate and swift actions to remedy to this situation, and a lack of political will largely explains the modest changes that are being undertaken. The Musgrave rule, one of the four approaches embedded within this lens, is more oriented to favour the development of a consensus across generations and downplays the severity of the policy challenges. As such, it has more in common with the ways in which the organizational lens depicts population aging, which represents a new element, among many, to consider while seeking to coordinate across departments and jurisdictions. The lack of substantial change in policies stems from long-established policies and administrative structures alongside a lack of political will. In this book, the interaction of these two lenses is most prominent in chapter 7 on central agencies. Medical and Social Gerontology Lenses The medical and social gerontology lenses are competing with one another, and the curative biases of the Canada Health Act (CHA) accentuate this divide. From the perspective of the medical lens, social elements are determinants of health, which have garnered increasing attention most notably in public health. Hence, they are encouraged, but not prioritized in programs and policy, as they belong “outside” the curative world. The field of social gerontology defines itself in contrast, not to say opposition, to the medical lens. To state it bluntly from the perspective of the social gerontology lens, a social intervention or policy should not require a health outcome to make it a priority. There are two chapters where these tensions are highly potent and visible. In both cases, the predominance of the medical lens is ubiquitous. The chapter on home care policies and caregiving (chapter 6) demonstrates that the place of residential care facilities (i.e., nursing homes) remains predominant in long-term care, despite policy shifts favouring home care services. Budgetary constraints and policy feedback with a strong curative bias have made it extremely challenging to alter the current residential care/home care ratio in long-term care. Chapter 8 focuses on the development, expansion, and reform of offices of seniors and, among key findings, demonstrates a shift from socially oriented interventions towards a public health understanding of aging, with explicit references to the social determinants of health. Medical and Organizational Lenses Canadian health systems are integrated and even include social services in nine of the 10 provinces, so there is a priori limited overlap

Population Aging as Policy Problems

73

between the medical and organizational lenses. In many provinces with a relatively young population profile, such as Alberta and Saskatchewan, population aging is frequently mentioned as a health care issue among civil servants from non-health organizations. As discussed in depth in chapter 5, the consequence of an aging population on health expenditures is part of ongoing debates among academics and practitioners. It is within this context that the use of these two lenses competes, since the budgetary space occupied by health care has been a source of concern in some provinces, regardless of the consequences of an aging population. As a result, the development of long-term strategies across multiple ministries and their viability inevitably cannot be separated from health care developments. This is also leading governmental authorities to push onto other departments and actors (such as families and the private sector) some care responsibilities in order to prioritize other policy areas (see chapter 6). Social Gerontology and Organizational Lenses There is a strong complementarity between the social gerontology and organizational lenses, albeit in a more limited scope for the former. The problematization of population aging focused on the social issues affecting older adults does not have a strong anchoring within a governmental department. Consequently, the development of social policies and programs targeting seniors typically involves crossdepartmental actions. It is within that context that most provinces have established offices for seniors (chapter 8), which have been an important conduit for older adults’ concern within government and at the origin of cross-departmental initiatives. These offices have played a key role in communicating information on programs and services offered to older adults. However, with limited governmental capacities to initiate policy actions, most offices for seniors have actually faced tremendous challenges to sustain their collaborations and even, in some cases, their existence. Conclusion The analysis of policy problem characteristics across the four lenses reveals the breadth and depth upon which population aging triggers multiple types of policy issues. More importantly, it demonstrates the limitations of each lens in framing policy problems and, subsequently, proposing the necessary reforms.

74

Theoretical Underpinning

Interestingly, this chapter reveals some strong common points. Two are noteworthy. First, no one contests the assertion that population aging can be reversed or altered significantly, nor is it novel. The ongoing debates across the lenses are primarily about its impact on the current policy landscape and the type, breadth, and depth of policy reforms needed. Second, each lens indicates that population aging has a proximate impact, although most approaches embedded within the intergenerational lens would argue that it is already too late. The focus on problem characteristics also reveals important divergence that alters their formulation and their solvability across the lenses. First, the problem population includes cohorts (intergenerational), seniors (medical), society (social gerontology), and essentially actors involved in public policies and programs (organizational), but older adults play a key role as culprit (intergenerational) or target of discrimination (social gerontology). Second, there is an important dissonance in the governmental financial capacity and political will. The latter re-occur frequently in the case of the intergenerational and medical lenses, while the former is frequently stated by approaches attached to the social gerontology lens. In the case of the organizational lens, the concentration of power at the centre facilitates the launch of new initiatives, but limits the capacity to sustain them in the long term. This chapter also identifies when lenses are more likely to complement or compete with one another. This has important impacts on the ability to build a large coalition of actors behind specific framing of policy problems and vice versa. For instance, there is strong opposition between the medical and social gerontology lenses, which marginalizes the latter. At the other end, there is complementarity between the intergenerational and organizational lenses where both stress the need to enact long-term decision-making mechanisms to tackle the consequences of population aging.

3 The Politics of the Long View

Introduction The degree to which public authorities should prepare for future events has been the subject of debate for centuries. In the twenty-fifth chapter of The Prince, Machiavelli talks about two kinds of planners. The first thinks it is impossible to predict the future and that no planning can prevent future events from occurring. The second type acknowledges that not everything can be predicted, but believes that contingency planning (the construction of a canal, for example) can help mitigate the risks. Albeit in a different form, this debate remains as important today as it was 500 years ago. Canadian provinces face the challenges of population aging, and opinions vary strongly on whether public authorities should be planning. On one hand, there are senior civil servants who explicitly embrace the non-planning perspective, or consider planning only with a very short time horizon. A clear expression of this perspective comes from a deputy minister in a western province who stated bluntly that the government is not looking for policy problems that do not exist yet.1 Many politicians and planning critics would endorse this view, although they would likely support some action geared towards the future if this required a small investment on their part. On the other hand, public organizations have better tools to address long-term challenges. When the Canada Pension Plan (CPP) and the Quebec Pension Plan (QPP) were created in the 1960s, only Ontario, Quebec, and the federal government had actuaries to evaluate the long-term consequences of the main proposals under study.2 Today it is impossible to conceive of provincial administrations without professionals such as actuaries to assess the potential impact and consequences of policy propositions. In spite of a professionalization of the

76

Theoretical Underpinning

civil service, there is a wide gap between earlier expectations and present development of a professional capacity to chart future scenarios and plan consequently. In the United States, early planners envisioned planning as an impartial “fourth power” of government protecting the public interest against the short-sighted views of political actors.3 Professional planners embedded within the civil service could alleviate political and economic risks in the development of public policies. With politicians focused primarily on seeking re-election, the presence of planners was considered critical to promote and protect long-term goals. American planners never achieved “fourth power” status, but their argument on the merit of having a professionalized body focused on long-term objectives to counteract the short-term myopia of elected officials deserves closer scrutiny. This, in essence, is an important focus of this book. Interestingly, current work on the long view also presents a mixed message, despite being one area where civil servants would be expected to have a strong input as a result of their expertise, tenure, prior experiences, non-partisan status, and interactions with stakeholder groups. On one hand, there is strong evidence to suggest that having a professional civil service results in better socio-economic outcomes in the long term, with tenure and a merit system mentioned as key variables.4 In Preparing the Future, the lack of politicization within the US Air Force ensured that the development of a strategic vision was insulated from political pressures.5 On the other hand, recent contributions with a strong analytical focus on long-term considerations by Jacobs6 and Ascher7 simply ignore civil servants. This chapter has three key objectives. First, it presents a brief history of planning within a comparative perspective. The past fifty years have been turbulent for planners. Once considered essential for policymaking, planning bureaus became marginalized (and in many cases eliminated) in central agencies by the end of the 1980s. Recently, however, there has been a planning revival to address long-term challenges such as the future of the military,8 developing countries,9 and climate change.10 Second, this chapter defines the key concepts related to the long view that are employed throughout this study. What is and what is not thinking and acting with the long view in mind are part of contentious debates in the literature, and any study involving long-term strategies must address this point. Third, it reviews the key factors that facilitate (and impede) thinking and acting in the long view in Canadian provinces. These elements feature prominently in the remaining chapters of this book, as they explain the kinds of planning undertaken in the provinces and the

The Politics of the Long View

77

extent to which provinces have established strong long-view practices across multiple ministries. The Rise and Fall of Planning In the aftermath of the Second World War, the love affair with planning spread quickly across the world, regardless of ideological preferences. In France, de Gaulle created the Commissariat général du Plan in 1946, whose goal was to develop five-year social and economic plans. Reporting directly to the head of government, Jean Monnet (later be closely involved in creating the predecessor to the European Union) was its first Commissaire. The plan played a crucial role in developing strategies and policies to reconstruct the country. It was also utilized to develop and expand social policies.11 One of the most popular accounts of Japan’s phenomenal economic growth after 1945, MITI and the Japanese Miracle argues that the longterm planning of the Ministry of International Trade and Industry (MITI) is largely responsible for this outcome.12 The Swedes went further than most countries by creating a Secretariat for Future Studies in 1973, following the recommendations of an influential parliamentary commission. Beyond its planning activities, the secretariat legitimized future studies as an important element of policy sciences.13 States without planning agencies were soon criticized for this oversight. For example, following a thorough investigation of the UK civil service, the Fuller Report advocated more policy planning within its activities.14 Developing countries were urged to embrace planning as a means to foster economic development.15 Beyond defining broad macroeconomic objectives, planning exercises were strongly embraced in budgetary and defence departments. Public organizations adopted planning exercises originating from defence. For instance, the Planning, Program, and Budgeting System (PPBS), which has had a long-lasting influence in budgetary policymaking across industrialized countries, was first devised and implemented in the US Department of Defense. Canada did not escape these trends. For example, the establishment of the Economic Advisory and Planning Board in 1945 was a key element of the “administrative revolution”16 performed by the Cooperative Commonwealth Federation (CCF) in Saskatchewan.17 While planning has often been associated with the CCF (and now the New Democratic Party), the love affair with planning was not confined to left-wing governments. Ontario’s Conservative governments invested strongly in planning in the 1960s,18 and British Columbia, under the

78

Theoretical Underpinning

right-wing government of W.R. Bennett, adopted a centralized planning structure to achieve better fiscal control.19 The influence of PPBS was strong in other Canadian provinces and at the federal level as well. It was even utilized (successfully) to woo the electorate! Robert Bourassa’s public speeches during the 1970 electoral campaign included references to PPBS and its potential benefits to Quebec.20 As stated by one of Bourassa’s political organizers, “I remember that he used to talk about PPBS, which was highly fashionable at the time. No one understood what this meant, but he came from Harvard. These were new economic theories. Thus, this inspired confidence.”21 Interestingly, planning also became highly popular in the private sector, with companies such as General Electric (GE) and Texas Instruments embracing formalized planning exercises developed in partnership with American business schools. Prior to its recent difficulties, GE became the face of strategic planning, establishing semi-independent strategic business units responsible for developing and implementing long-term strategies.22 The Fall As planning’s influence and status spread across industrialized countries, its usefulness became increasingly questioned in the literature and by policymakers engaged with planners and planning. First, in line with ongoing debates on whether or not to engage in planning in the first place, many began to question the wisdom and the validity of the claims about the future made by planners.23 Projections and forecasts were unable to cope with the strong variations in socio-economic conditions following the oil crisis, which perturbed the more stable environment of the 1960s. This resulted in rising discrepancies between economic projections and actual outcomes. In a highly critical review, Wildavsky went so far as to claim that planning should be a field reserved for theologians.24 Second, and related to the previous argument, critics questioned the actual efficacy of planning. Pitfalls or “planning disasters” began to emerge, which cast doubts on the ability of planning offices to generate a road map for public authorities or even provide reliable information.25 In the field of budgetary policy, a consensus emerged on the inability of PPBS to improve fiscal performance, let alone facilitate program planning.26 Contributions in the field of implementation studies emphasize that changes in key variables such as economic conditions, priorities, or simply taste can send the bestlaid plan into disarray.27

The Politics of the Long View

79

Third, planning became increasingly synonymous with formalized planning. Planning became very rigid, as it involved planning units reporting to the apex of organizations, creating timetables and complex organizational flow charts to name but a few elements. Some critics linked these exercises with the central planning activities undertaken in the Soviet Union, given the strong emphasis on control.28 Formalized planning was even described as “dehumanizing social engineering exercises.”29 Fourth, planning became strongly associated with an expanding role for the government. With a declining faith in the ability and capacity of governments to manage or even steer the economy, a stronger role was granted to the private sector.30 The election of Conservative governments in the United States, Canada, and the United Kingdom in the 1980s led to a reorientation of governmental goals and objectives, and the public administration became a target for reform.31 Planning units, via their involvement in designing and implementing formalized plans to control the economy, represented what was wrong with public administration and its inability to develop policies that stimulate economic growth. While the introduction of administrative reforms in the spirit of New Public Management proved to be difficult in many countries,32 targeting planning units did not represent an imposing challenge, since their activities and status had already been strongly criticized for a decade. Already in 1980, a Canadian contribution advocated that the survival of policy planning and research units in the federal government depended on their ability to adopt a more modest role and profile.33 In light of mounting criticism, planning units began to reorient their mandate and functions in Canada and abroad. Today, famous planning offices have been either eliminated or replaced with far less ambitious organizations. The Swedish Secretariat is now a research institute operating at arm’s-length from government (Future Studies Institute), the French Commissariat du Plan has been replaced by a forecasting office (centre d’analyse stratégique), and the recent economic problems plaguing Japan have diminished the appeal and strength of MITI, which was reformed in 2001. A similar dissociation with formalized planning occurred in the private sector. Strategic planning has replaced formalized planning in the private sector in multiple firms. The evidence on whether or not the adoption of strategic planning resulted in improved firm performance is mixed, however. On one hand, evidence suggests that firms embracing and enacting strategic planning have had more success than those that have shied away from these practices. This positive impact occurs

80

Theoretical Underpinning

regardless of firm size.34 A review of the literature in the early 1980s suggests that formal planning was more successful than alternative processes to help firms tackle large changes.35 On the other hand, critics have pointed out that anecdotal evidence, such as featured stories in Business Week and descriptive accounts in academic journals, suggest that planning has been a failure and abandoned by leading proponents such as GE and Texas Instruments.36 In addition, methodological issues have cast doubt on the validity of findings that support the positive effects associated with strategic planning. According to Mintzberg, these studies have relied strongly on mail-in surveys with a low response rate and answered primarily by planners themselves.37 The Revival: Old Wines in New Bottles? Ironically, while planning became increasingly marginalized in public administrations, the private sector remained committed to it, albeit in forms vastly different from those reminiscent of formalized planning; the time horizon has been shortened, the planning process is now more open-ended and less formalized, and a stronger emphasis has been placed on involving individuals throughout organizations. It is the transformation of these planning practices in the private sector and the push to embrace private business practices that led to the revival of planning in the public sector. In spite of GE’s strong dissent in the 1980s, the company has continued to invest heavily in planning.38 The value to think and plan for the long term also gained further prominence after the highly popularized performance of Shell during the 1970s oil crisis.39 Two features distinguish these planning efforts from their predecessors. First, expectations are far more modest. Stronger value has been placed on generating information that can guide the development of strategies rather than developing models in which the organization assumes that the environment is stable or controllable. Learning is also a crucial component of the planning exercise. Second, the role of the planner has also been altered. Emphasis has been placed on involving individuals throughout the firm rather than a select group of individuals in a corner office. This change has occurred in line with the process of planning, which is now more open-ended and less formalized.40 The public sector has not been immune to these developments either. The development of a new strategic vision in the US Air Force, for instance, illustrates the new perspective on planning quite well.41 While the leadership of senior officers was key, the involvement of personnel

The Politics of the Long View

81

throughout the Air Force facilitated the adoption and implementation of a new long-term strategic vision. Rather than adopting the traditional top-down approach, the strategic planning exercise resulted in a change of culture within the organization and included a “commitment to vision-based organizational entrepreneurship.”42 In addition, emphasis on developing a strategic vision meant considering sectors and elements outside the realm of the Air Force, which would not have occurred with prior planning processes that involved highly technical data generated by the Air Force on the basis of its ongoing activities, with relatively little place for analyses that took into account norms, values, and human knowledge. In a more constrained fashion than the previous example, strategic planning has been embraced by many public organizations with a proliferation of strategic and business plans often as part of ongoing reforms associated with New Public Management.43 This proliferation has been well documented at various levels in the United States.44 A national survey in the early 1990s claimed that 60% of agencies employed strategic planning within their offices.45 These American studies point to noticeable differences between the strategic plans adopted in the public sector and those elaborated in the private sector. First, and most important for this book, public sector strategic plans have a much shorter time horizon. This is a direct consequence for the political environment within which these are embedded. Strategic plans are indicative of not only the goals and objectives of a public organization, but also of its government. No government wants to be associated with the priorities of its predecessor. Thus, strategic plans are most likely to be introduced shortly after an election46 with a time frame coinciding strongly with the electoral mandate. There is also an administrative reason behind the adoption of shortterm strategic plans. Public organizations are highly dependent on the resources provided to them by the budget, and have thus sought to align their activity with the budgetary cycle. This is why 27% of US agencies have adopted plans with a one- to two-year time framework, and 75% of all agencies with a strategic plan have tied in their planning process with the budgetary process.47 Second, the content of the strategic plans have had to be adapted to reflect the realities of the public sector. Goals and objectives have become more vague and have been replaced with mission statements or values guiding the actions of the organization. For example, dealing with citizens equitably is more important than dealing with them efficiently.48 Third, public managers operate in a very complex and rigid organizational environment, and multiple characteristics, beyond the

82

Theoretical Underpinning

political ones cited above, constrain leaders’ ability to pursue their preferences independently. Decision making involves far more actors from more diverse backgrounds than is found in the private sector. As a result, consultations are “necessary and cumbersome,”49 and with an increasing number of actors, strategic planning becomes far more difficult.50 The rising influence of strategic planning in public organizations has also spread to Canada. In most provinces, ministerial mandates are now accompanied by short-term plans. As in the United States, these are often introduced following the election of a new government and, in most cases, have a short time horizon. As such, they rarely include a road map that extends beyond electoral mandates. The content of these plans (often called strategic/business plans, framework, or even policy) usually includes a mission statement and a description of the managerial style for the department, an account of the activities performed by the department, policy goals and objectives related to governmental action in the domain of activity, and measures to address the goals, objectives, and priorities of the current government. Beyond providing a quick overview of the ongoing activities of governmental departments, there is little evidence to suggest that the elaboration and implementation of these plans has done little to improve the long-term vision of public organizations. A recent survey of Canadian deputy ministers and assistant deputy ministers mentions that longterm planning is a greater concern, with only 30% agreeing that the government does well with medium- to long-term planning.51 Thinking and Acting with a Long View in the Public Sector With formalized planning confined to the dustbin and strategic planning operating on a much shorter time frame, how are public authorities tackling long-term challenges that require farsightedness? The long view need not necessarily produce a plan within a formalized planning environment. Nonetheless, the development and nurturing of a long-term perspective should be given room lest organizations adopt strategies or actions that have narrow, short-term goals and objectives without being able to address the kinds of (potential) policy problems that require a long time horizon. To illustrate this point, the ongoing difficulties with reintegrating older individuals in most provincial labour markets are the result of having had a short-term focus resulting in the adoption of short-term fixes. The civil servants interviewed on this subject have all claimed that their respective departments have followed the baby-boomer cohorts for

The Politics of the Long View

83

the past decade and attempt to ensure that they remain in the labour market. The famous active labour market policies (ALMP) developed in Scandinavian countries are always promoted as a potential remedy, although Canada has always ranked in the bottom among industrialized countries for its spending efforts in ALMP. The problem is that ALMPs would have had to be implemented 20 to 30 years ago in order to function well today. The key behind the high participation rates among older workers in Scandinavia is that they have benefited from incentives to participate in retraining programs for a long time, resulting in a skilled workforce across all ages.52 The focus of Canadian authorities has been geared primarily to maintaining employment by generating incentives for the employer rather than investing in its workforce. This legacy is extremely difficult to overcome, as it would have required the enactment of long view policies when the symptoms first became apparent. Why do short-term solutions predominate over long-term ones? The political and, consequently, public administration environments are not typically conducive to thinking and acting in the long view. First, the political science literature has emphasized elements that prevent the realization of long-term objectives: (1) the short-term horizon of politicians; (2) ideological preferences; (3) agenda setting and media; and (4) interest group pressure. Politicians have a short-term horizon with strong pressures to demonstrate accomplishments prior to the end of their mandate in order to facilitate their re-election.53 This results in preferences for measures that can generate (perceived) results in the short term and, at the other end, the avoidance of options that require substantial investment in the present with expected benefits beyond electoral mandates.54 With mounting evidence that political executives have stronger input within the decision-making process and tend to zoom onto specific projects,55 long-term considerations take a back seat. There is also an ideological gap in thinking about the long view. On one hand, left-wing parties have long been associated with the development of long-term governmental objectives, which have often featured prominently in planning. In Canada, the NDP (and its precursor, the CCF) has long been associated with development of long-term objectives. On the other hand, right-wing parties have tended to favour a more limited role for governments, with the private sector being responsible for long-term growth. However, it is more appropriate to analyse this gap in terms of the long-term objectives each party prioritizes, as opposed to whether or not a particular party favours long-term objectives more than the others. As stated above, right-wing parties have employed planning exercises and institutions to control expenses,

84

Theoretical Underpinning

which represented a key objective for them. Left-wing parties are more likely to favour the use of public institutions and instruments to plan for broader socio-economic objectives. The literature on agendas and public policy presents interesting findings on why politicians place a strong emphasis on short-term issues. Although this body of work fails to specify what measures will be introduced by a government, it does suggest that a policy issue featuring prominently in the media is more likely to result in governmental action.56 This suggests that the presence of a crisis or failure given prominence in the media prompts governments to respond with immediate action. This has two major consequences for the place occupied by the long view in governmental agendas. It is difficult for governments to prioritize policies for the long view since they are unlikely to bring the kinds of media coverage associated with immediate action to resolve the issue of the moment. Governments are also more inclined to prioritize policy issues that can easily capture the headlines. These usually involve a cause-and-effect relationship that can be established easily by the reporter and generate a strong reaction from citizens. Thus, the need to cut waiting time in emergency rooms or mistreatment in nursing homes – where shortcomings can result in premature deaths – receives far more attention than alleviating poverty and home support services with a long-term impact that is far more abstract, although it too can result in premature deaths. Institutions can also facilitate or impede governments’ inter-temporal policy choices.57 The achievement of long-term objectives is best served when short-term costs are minimized. For instance, in the field of pension politics, when seniors’ groups occupy a privileged position in policymaking, they are more conducive to transferring the costs of adjustments to younger generations while maintaining the current level of benefits for retired individuals.58 Second, the public administration literature provides important insights into why civil servants, who have a longer time perspective than politicians as a result of their tenure, are also hindered in the pursuit of the long view. These include (1) inherent hurdles to foster longterm thinking within public organizations; (2) changes in executive positions; and (3) difficulties associated with coordination. Civil servants operate in a highly regulated environment that is hierarchical and circumscribed. In addition, policy objectives are not clearly enunciated and policies are sometimes in conflict. With this in mind, policymaking is often described as something civil servants “muddle through”59 or a process whereby bureaucrats seek to improve on preexisting procedures often at the cost of more efficient alternatives.60

The Politics of the Long View

85

These writings suggest that public administrations are concerned almost exclusively with current policy problems and fine-tuning existing policies and procedures when they confront new challenges. Thus, they are engaged primarily in “firefighting.” Another element disrupting the ability and willingness of civil servants to engage in long view activities, including analysis and planning, is the frequent changes in senior positions. Policy analysts and managers are often encouraged to gain experience in various departments to enhance their skills. In many jurisdictions, such as the United States and Belgium, a change in government also results in the appointment of new officials in key positions. Why does this matter? As reported in a national survey on strategic planning in the United States61 and a review of strategic planning in Canada and Quebec,62 the presence of a new head, such as a manager in an agency or a deputy minister in a line department, is the primary reason behind the launch of a strategic plan. Thus, civil servants do not have strong incentives to adopt long view goals when they are threatened by the likelihood of having to change or adapt them once a new leader is appointed. Policy coordination remains a constant challenge for any government.63 With an increasing number of policy problems requiring cooperation across departments and agencies (not to say countries), this is an issue that is likely to rise in importance. The development of long-term strategies requires a high level of coordination in order to be successful. However, as evidenced by planning accounts, this is very difficult to achieve, since this is often perceived as an exercise of control by central agencies responsible for monitoring and enforcing cooperation, if needed, across organizations. In fact, many strategic planning exercises discussed above represent a form of fiscal management by the finance department and emerged as a result of the failure of PPBS. Third, beyond political and administrative reasons, thinking and acting with the long view is often perceived as counterintuitive. An increasing number of contributions have stressed the short-term cognitive biases of individuals and policymakers.64 In a nutshell, individuals are impatient and tend to discount the value of future benefits.65 This was in fact a key argument behind the expansion of public pension systems.66 Finally, any long-term discussions involve a high level of uncertainty. Multiple elements can change radically, altering expected benefits from any action taken with the long view in mind. As a result, it is far easier for authorities to justify short-term measures and to be more proactive in the present rather than introducing investment measures with the potential to be beneficial in the long term. For any long-term investment

86

Theoretical Underpinning

to receive serious consideration, decision makers must have strong beliefs in the solutions they advocate.67 As a result of their expertise, skills, and previous policy experience, civil servants play a key role in reducing uncertainty in policymaking. What Is the Long View? In this study, the long view represents any period where the potential return on the policy investment will, at a minimum, exceed 5 years, which implies governmental action beyond an electoral mandate.68 This timeline also encompasses some of the earlier formalized planning tradition such as France’s five-year plans. The literature often discusses a horizon varying from 10 to 25 years69 (although several contributions do not mention how long the long term is).70 For example, the long-range plan for the US Air Force strategic vision had a 25-year time horizon to reorient its activities.71 On the basis of interviews conducted for this project, it is safe to conclude that any analysis beyond 20 years receives little attention within the civil service, even though it is frequent within statistical, pension, and demographic bureaus. This does not necessarily imply that individuals operating within these offices do not have a longer time frame in mind. For instance, the lack of pension coverage among an increasing number of private sector workers in countries with limited earnings-related public pension schemes has been a source of worry among pension professionals who foresee an increasing risk of poverty in old age 30 years from now. In Canada, this concern led to a flurry of provincial investigations seeking solutions to alleviate pension coverage, and it was a strong impetus behind the reform of the Canada Pension Plan in 2018. The time horizon for the long view also varies according to the policy sector under study. Even though chronological time remains the same, its impact can be felt differently across policies. For example, in pension policy, 10 years is rather immediate, since pension outcomes are determined on the basis of a working career comprising 35 to 45 years. A 10-year horizon in a labour market department, however, is considered to be an extremely long period because its activities are geared mainly toward tackling challenges that affect those currently unemployed, as opposed to those who may be unemployed in the future. How Is the Long View Promoted within the Public Sector? In spite of hurdles that favour short-term considerations, this book claims that there are four principal approaches to increase the

The Politics of the Long View

87

importance of the long view within policymaking. Together, they represent a move away from previous planning efforts, which are far less structured, more flexible, involve more individuals, utilize a broader diversity of information and data, and employ a variety of mechanisms to consider the long view. This shift is actually comparable to ongoing developments in policymaking analysis where the old technocratic view of policymaking has been replaced by other approaches, such as evidence-based policymaking.72 First, public organizations can seek to enhance learning opportunities in relation to long-term challenges. This requires an accentuation of exchange across ministries or departments and occasions to discuss and exchange on what exactly the upcoming challenges are. The primary aim here is to increase awareness within the civil service to ensure that its members pay more attention to the long view. As I will show throughout this study, this avenue has been embraced in most Canadian provinces. In many cases, a specific civil servant was mentioned by his or her first name as being highly active to improve knowledge on the potential challenges arising from an aging population. This has been notable in small provinces where leading figures in ministries of finance and offices for seniors (such as seniors’ secretariats) are frequently mentioned. This approach is widely popular, as it does not require substantial resources and has the positive side effect of strengthening cross-ministerial cooperation. The use of learning institutions such as commissions can also be utilized to raise awareness of long-term policy issues. For example, the Swedish government instituted a parliamentary commission to study what could be done to adapt public programs and policies in an aging society, and the commission presented a document mentioning 100 steps for the years 2010 to 2020.73 In Canada, a similar exercise was undertaken by a Senate committee whose report is well known in aging circles.74 These learning opportunities can also arise from intergovernmental exchanges with counterparts in other Canadian provinces. These have been acknowledged in the literature for being highly conducive to the implementation of innovative practices.75 The political salience of health policy has hindered cooperation, but it has been crucial in expanding the capacity of offices for seniors across the country. What are the drawbacks to enhancing learning opportunities? Learning about the challenges of a long-term phenomenon, such as an aging population, does not necessarily imply that civil servants will either internalize or strongly consider this newly acquired knowledge in their day-to-day activities. In addition, this solution does not formally replace

88

Theoretical Underpinning

pre-existing practices, nor will it necessarily result in acceptance of this new knowledge. For instance, if those responsible for raising awareness originate from a finance department, “spending” departments are likely to welcome them with scepticism. The second approach to improving long-view considerations within the public service is the creation of new procedures when introducing, reforming, or even assessing policies. This approach can be akin to gender mainstreaming, where new proposals must demonstrate that gender considerations featured in the elaboration of a new policy. These can also be more formal and include such provisions as a budgetary requirement for all new proposals that include long-term cost projections. The main advantage of this approach is that actors throughout the civil service are constrained to demonstrate that the long view was taken into account in devising or reforming a policy. In addition, in the case of budgetary instruments, finance departments are quite powerful and have the means to enforce such mechanisms. Ultimately, they decide which department obtains what resources. That being said, it is important to stress that popular long-view instruments such as generational accounting have failed to secure the endorsement needed to emerge. Other attempts, such as fostering consideration for seniors in day-to-day policy considerations at both provincial and municipal levels have had limited success beyond the confines of public organizations involved in policies and programs targeting seniors. The creation of new procedures also has negative consequences. It is unlikely to be welcomed in most public organizations, since it would add to an already cumbersome policy process and could accentuate the difficulties of obtaining a political compromise. Moreover, the literature rings alarm bells on their efficacy. As demonstrated by the growing literature on the impact of gender mainstreaming, many organizations have failed to implement it properly and in some cases have included a gender assessment after policy decisions were already made.76 A third way to improve the long-view capacity of governments is to introduce or strengthen the role of gatekeepers. There are already actors and organizations throughout the public sector that, as part of their mandate, protect citizens’ long-term interests. In the context of an aging population, a considerable number of interlocutors mentioned the role of their finance ministry in preventing organizations throughout the civil service from enacting solutions that could have long-term negative fiscal consequences. This occurs without having necessarily created new procedures to achieve this objective.

The Politics of the Long View

89

As part of their mandate to oversee governmental programs and activities, the Auditor General and Ombud Office can play an important role in ensuring that governments follow their own long-term initiatives. For example, Quebec’s auditor general (Vérificateur général) presented a strong critique of the incompatibility of its sustainable strategy with ongoing long-term planning. Provincial audits have been particularly adept at stressing the need to prepare for the large cohort of baby boomers and their impact on the health system, while reports from ombud offices have documented the lack of proper planning and resources for the growing number of beneficiaries, which has had important consequences on the quantity and quality of health and social services. For instance, strong critique emanating from the 2015 Manitoba auditor general77 prompted the Ministry of Health to commission a study on long-term care needs in the province. Governments have also created new senior positions specifically tasked to think and act with the long view in mind. For a time, Quebec and Ontario appointed deputy ministers reporting to their respective executive councils to ensure that current policies and programs were consistent with a longer time frame. New institutions have also been created with long-term issues related to population aging. For instance, both New Brunswick and Prince Edward Island established population secretariats to increase their interprovincial and international migration. The fourth approach to improving capacity for the long view within the public sector is the development of strategies. This is the modern version of formalized plans, with the key difference being that strategies are less focused on the process and the use of formal models. As such, they are more flexible, with a strong emphasis on missions or visions; they rely strongly on cross-ministerial cooperation and stakeholder participation; they have long-term objectives; they mobilize new resources; and they may even specify policy instruments to be employed. Alberta’s Aging Population Policy Framework (APPF) provides a good illustration of this approach. Launched in 2010, APPF identifies core challenges for subsequent decades; provides the context for future coordination; introduces guidelines for future funding priorities, and principles to follow within the decision-making process; and states the general orientation the government should take to address issues related to an aging population. What sets Alberta’s strategy apart from others across the country is a section in which governmental, individual, and private sector (including non-profit) responsibilities are clearly enunciated. Although it is not a necessary condition, the vast majority of provincial strategies involve cross-ministerial work. This reflects the

90

Theoretical Underpinning

increasing complexity of policy problems but also a way to avoid the creation of new organizations. A key element behind the development of strategies is the strong support received by political executives and civil servants in central agencies. Distinguishing further the development of strategies from earlier formalized plans, the origin of these strategies is mixed. Some occur from similar experiences in other provinces, some from elected officials, while others emerge from within the civil service. This approach is increasingly popular because it specifies a set of concrete measures and a hierarchy of goals and objectives to tackle broad policy problems. Also, in placing them in a broad network of actors working to implement strategies, it gives civil servants a more dynamic role. In addition, there have been some early successes with these strategies that further encourage their development in other domains. For example, poverty strategies have been considered quite successful in Quebec and Newfoundland and Labrador.78 These four approaches will be analysed throughout this book and assessed for their ability to enhance the long view. It is important to note that these four approaches coexist with one another and are sometime interdependent. What Facilitates or Impedes the Long View in Canadian Provinces? This section focuses on the elements that facilitate or impede approaches that enhance long-term considerations within public administration and policymaking, drawing upon the rich literature on the construction of successful planning. On their own, these factors explain a lot of the variation associated with planning outcomes, but they are not entirely independent. Some factors are stimulated by others. To facilitate the discussion, I present each factor independently, followed by expected outcomes that will be revisited in both public administration chapters (chapters 7 and 8) and, more systematically, in the conclusion. Politicization of the Civil Service The politicization of the civil service is an important development within public administration in the last 30 years. Inspired by the public choice literature, many countries with strong independent civil services have introduced reforms to enhance the power of politicians at the expense of career civil servants.79 This has taken multiple forms such as centralizing the decision and policy making process within the office of the prime minister,80 increasing the number of political

The Politics of the Long View

91

appointees throughout the civil service, and accentuating the input of consultants.81 Across Canadian provinces, very few (Ontario, Alberta, and British Columbia) have experienced a noticeable centralization of decision making. Factors such as the relatively small size of the civil service and strongly institutionalized practices explain this outcome.82 It is difficult to make the case for centralization in smaller provinces; senior civil servants already have a close cross-departmental working relationship, which is facilitated by working in the same (or very nearby) building. As a result, there is “a high degree of personal engagement between the political executive and those with policy knowledge.”83 In the course of the research, many interviewees stressed that coordination problems are often resolved informally by simply crossing the hall or discussing it over lunch in the cafeteria. Interestingly, in spite of a similar Westminster heritage, there is significant variation in the input of political appointees within the civil service. For instance, Saskatchewan has had a long history of replacing a substantial number of deputy ministers (DMs) and assistant/associate deputy ministers (ADMs) following a change in government. Some authors even claim that Saskatchewan is sliding towards a US-style appointment system, which permeates the entire federal civil service.84 Patronage is still rampant in Nova Scotia, and efforts to professionalize its bureaucracy have failed.85 These two cases are in stark contrast to New Brunswick and Manitoba, which continue to maintain a strong independent civil service86 and have historically experienced the least turnover among deputy ministers.87 Political appointees, even those highly qualified and familiar with the civil service, are unlikely to prioritize the long view. Their main objectives are to implement the government’s agenda, confer with political actors, and liaise with the bureaucracy. As such, political appointees have a much shorter time horizon, coinciding with the electoral calendar, than do career civil servants. They are far more preoccupied with current events and ensuring continued support for the government than with the long-term consequences of their actions.88 A rise in the number of political appointees in the upper echelons of the civil service can radically transform the environment of those working with a long view perspective, as it significantly curbs their ability to develop long-term plans and strategies. In the United States, research findings clearly demonstrate that long-term initiatives have been far more successful where civil servants possessed substantial autonomy with a marginalized role for political appointees.89 A recent contribution

92

Theoretical Underpinning

comparing the development of home care in New Brunswick and Nova Scotia shared similar conclusions.90 For all these reasons, we would expect that provinces with a highly politicized civil service are less successful in fostering long-view approaches than provinces relying strongly on career public officials. There is no classification of politicization for Canadian provinces. However, there has been a clear identification of outliers in public administration research, which can lead to clear expectations. More traditional Weberian bureaucracies such as those in New Brunswick and Manitoba should be more likely to embrace a longer view than provinces with a highly politicized bureaucracy such as Nova Scotia and Saskatchewan, where we would expect the opposite outcome. A short time horizon is also likely in British Columbia, the sole province with a turnover rate above 40% in the 2000s and the highest predicted turnover probability with Saskatchewan for the period 1980–2013.91 In Alberta, Ontario, and Quebec the lengthy tenure of the Conservatives (Alberta) and Liberals (Quebec and Ontario) in government from the early 2000s mitigates the potential impact of a politicization. Leadership In both private and public sectors, successful long-view actions require strong leadership with long-term vision, strong communication skills, and guidance. The development of long-term strategies is unlikely to succeed if those leading an organization do not, at the very least, support the activity. This is particularly true within the provincial public sector, where the organizational structure is more hierarchical and formalized than in the private sector, with frequent contacts between elected officials and senior officials. Still, it is possible to develop a working environment in which thinking about long-term issues is not enforced in a hierarchical manner within provincial administrations, and leaders are given space to develop innovative approaches without having to be head of a department. The literature has also stressed the importance of generating a learning environment that is conducive to planning.92 For instance, in scenario planning, leaders must ensure that there is not a loss of potential creativity and that long-term plans are strongly embedded within the organization.93 Leaders need to build an organizational capacity that will allow them to change course rapidly to achieve its goals when circumstances dictate or when the planning exercise reveals important lacunae. This skill set corresponds nicely to the qualities required for ADMs and DMs to be successful in today’s environment, with policy

The Politics of the Long View

93

problems affecting a wide range of ministries. These are the kinds of qualities that are increasingly emphasized throughout Canada.94 Reminiscent of Kingdon’s policy entrepreneur,95 a successful longview leader should be able to identify which strategies are most likely to succeed and introduce them promptly when there is an opportunity. Leadership is likely to operate differently depending on the level of politicization within the civil service. In traditional Westminster settings, the degree of autonomy granted to the civil service allows leaders to emerge and emphasizes the need to develop long-term strategies. Having a more politicized civil service does not necessarily imply that long-term thinking does not occur, but it is more likely to originate from other sources such as political appointees and elected officials. Hence, long-term initiatives are likely to be improved with the presence of a strong leader. Policy Capacity within the Civil Service The increasing complexities of policy problems, stronger emphasis on engaging stakeholder groups, and declining resources have led to increasing studies on the policy capacity of Canadian public authorities.96 As discussed, there are noticeable differences between the policy capacity of provinces and the federal government.97 A recent survey of DMs and ADMs suggests that policy capacity has improved in Ottawa but has declined in the provinces.98 This trend is unlikely to change in the near future, as many cost-cutting measures involve not filling positions vacated by retiring civil servants. How does policy capacity affect the study and implementation of long-view approaches? The first important, and the most basic variable to discuss is the wide diversity in the size of Canadian provinces. Large provinces like Quebec and Ontario tend to have a civil service that can rival many of the departments and ministries in Ottawa. It is an entirely different story for the smaller provinces. For example, a Prince Edward Island senior civil servant stated that there were 20 individuals in Quebec City doing the same task he performed for the government. What’s worse, the task in question was one of four in his mandate! Small provinces also tend to be the ones for whom population aging is a more pressing problem. They are well aware of the situation but tend to tackle these challenges informally, while large provinces have more flexibility and resources to improve their long-view policy capacity. Second, provincial civil servants are also more likely to be engaged in program activities and immediate actions than their federal counterparts. This difference has important consequences, since it implies that they have less time to work on long-view and other analytical projects.99

94

Theoretical Underpinning

In smaller provinces, not only do civil servants need to deal with more firefighting issues, these issues span a wider range of programs and policies, making it very difficult to find the expertise needed to handle them day-to-day basis and compounding the difficulty of thinking and acting with the long view.100 Third, the renewal of the civil service is a clear and immediate challenge to maintain (let alone develop) a better long-view perspective. Many provincial civil servants were hired in the 1970s, and large senior civil servant cohorts are departing together. This is particularly problematic for small provinces, which often have only a handful of individuals performing a specific function. This creates a real challenge, because the long view tends to be considered more informally than in large provinces. On this basis, smaller provinces are more likely to focus on enhancing learning and will struggle with the long view – even though this affects them most – while larger provinces will embrace a wider range of approaches.101 Professionalization of the Long View While there is increasing evidence in Canada to suggest that technical skills are falling out of favour and are being replaced by broader generalist skill sets, many routine activities focused on the long view remain strongly professionalized. Long-term analyses are produced predominantly by actuaries, economists, demographers, and urban planners. The first three groups of professionals often interact with each other (at least informally) and often cooperate when developing forecasts or projections. This strong professionalization has important consequences when considered in the context of the four approaches discussed above. When it comes to enhancing learning, these professionals must ensure that their analyses are accessible to a general audience, and they must find a way to incorporate data that may not be traditionally employed within their profession to remain relevant. Otherwise, they will fall into the same trap associated with formal planners. They will be relegated to a corner office and their analyses may simply be ignored. This represents an important challenge. As illustrated by a survey of the environmental sector in Canada, Howlett and Joshi-Koop demonstrate that civil servants are unlikely to utilize information obtained from outside their working environment.102 In addition, professionals are not receptive to requests that deviate from their standard practices. Yet these civil servants have developed a longview mindset that places them apart from others and possess a highly valuable perspective that is often ignored.

The Politics of the Long View

95

We can conclude that the presence of professionals trained with a longview perspective can accentuate learning opportunities on the long view, as long as they are integrated into broader networks. Institutional Mechanisms The literature on neo-institutionalism identifies a diversity of mechanisms with multiple consequences for policymaking.103 In this study, few mechanisms are particularly potent to favour the anchoring of policy decisions in the long term. First, the literature has been adamant that constitutional structures can result in additional veto points in policymaking.104 In turn, this makes substantial policy reforms more difficult, favouring policy stability over the long term. The Canadian federal system involves a sharing of responsibilities between provinces and the federal government that is often enshrined in binding agreements with long-term implications. This is particularly the case in the Canada Pension Plan, which requires the approval of the federal government and the support of at least seven provinces representing more than 50% of the population. Consequently, substantial pension reforms tend to occur rarely, since they require sustained mobilization of provincial and federal policy actors during the reform process.105 In the field of health care policies, provinces must abide by the Canada Health Act (CHA) to benefit from federal funding. With the federal government providing a more modest share of health care costs, provinces face an additional hurdle in their attempt to “bend the health care cost curve.”106 Second, the literature on policy feedback provides valuable insights on how a policy design can facilitate the entrenchment of policy/program107 or accentuate its demise.108 The emergence of new policies and programs to alleviate population aging issues occurs within a crowded policy space where well-established policies and programs are more likely to receive attention from policymakers than the development of novelties. Policy feedback also has implications for public administrations as it affects organizational capacity, structures, and authorities.109 Consequently, policies and strategies featuring positive feedback mechanisms or constructed within such a policy framework are likely to be more potent in the long run than the alternatives. One would expect similar outcomes in the introduction of new administrative structures. Conclusion Thinking and acting with the long view has been profoundly transformed in the past 40 years. In addition, formalized planning became

96

Theoretical Underpinning

increasingly associated with big government, which made it a primary target for neoconservative parties once in power. Ironically, planning remained an important element of private sector practices, and the infusion of New Public Management made it easier to embrace new approaches to address longer-term considerations within government. This chapter introduced four approaches to thinking and acting with the long view. Enhancing learning opportunities involves non-binding actions by government and instead seeks to promote the acquisition of knowledge to ensure that civil servants consider the long view in their analyses. This can take multiple forms, such as the creation of a broad consultation within the civil service, a commission, and mechanisms to accentuate interprovincial exchanges. The creation of new procedures implies an additional step within the decision-making process where those involved must ensure that a new proposal or a reform meets new standards. This would be akin to gender mainstreaming or adding a new requirement from a department as part of the budgetary cycle. The introduction of gatekeepers is another approach that has been utilized in Canadian provinces. It can consist of the appointment of individuals reporting directly to the Executive Council. These individuals have the mandate to oversee the (planned) activities of departments and agencies to ensure that none of their proposed measures have negative consequences in the long term. Gatekeepers can also be found in other institutions such as the Auditor General’s Office and the Ministry of Finance. In such instances, public authorities can strengthen their current mandate. Finally, the development of strategies seeks to address complex policy problems that require coordination of public organizations. Contrary to private sector practices, public strategies are geared more towards presenting broad orientations and missions. They can represent a framework guiding future action, as underlined by the Alberta example. Five key variables have a strong influence on the use of approaches to tackle long-term challenges and on which of the four approaches introduced in this chapter is likely to be preferred. These are the politicization of the civil service, leadership, policy capacity, professionalization of the long view, and institutional mechanisms. An assessment of these elements features in the conclusion of this book. In closing, it is important to observe that the four lenses of population aging introduced in chapter 1 have different relationships with the long view. The intergenerational lens focuses primarily on the longterm consequences of population aging and accentuate considerations for the long view in current policy debates and evaluations. Within the medical lens, day-to-day concerns with the accessibility and generosity

The Politics of the Long View

97

of the health care system dominate. Still, there is a growing engagement with approaches, mostly in preventive health care, that have long-term visions and a rising awareness of the recruitment challenges posed by an aging workforce of health care professionals. The social gerontological lens and the organizational are relatively well-anchored in the present. The former tends to blur the reliability of long-term projections by giving more credence to ongoing policy issues such as ageism and caregiving. The latter focuses primarily on current horizontal issues facing public administration, but also stresses the need to enact and implement action plans or strategies to tackle the challenges and opportunities from population aging.

This page intentionally left blank

4 Pension Policies

We do not see pensions as a population aging issue, but rather as a funding issue. – Manager from a Ministry of Finance

Introduction In this chapter, I focus on pension policies from the perspective of the provinces. At first that approach may seem surprising, considering the structure of the Canadian pension system. Originally, the Constitution provided provinces with jurisdiction over most matters related to pension policies. As part of a strategy to become a core facilitator of income redistribution, the federal government has pursued an increasing role in pensions since 1927.1 The federal government plays a substantial role in pension policies, since it is responsible for multiple programs such as the Old Age Security (OAS), the Guaranteed Income Supplement (GIS), and the Retirement Registered Saving Plan (RRSP). In addition, it manages the Canada Pension Plan (CPP), regulates the pension plans for workers operating in employment sectors covered by the federal government (such as telecommunication), and provides a pension to its employees. Despite these devolutions of powers to the federal government, Canadian provinces continue to play an important role within the Canadian retirement income system. First, they complement federal basic income (OAS) and poverty relief programs (GIS) by providing income supplements. Second, provinces maintain a strong input within the CPP, since seven provinces representing more than 50% of the population must assent to any modification of this program. This input does not prevent them from pursuing their own earnings-related pension scheme, such

102

Public Policy and Population Aging

as with the Quebec Pension Plan (QPP) and the proposed (and then abandoned) Ontario Retirement Pension Plan (ORPP). Third, they regulate occupational pension plans within their territory, with the noticeable exception of employees operating within a federal sector such as banking and communications. Finally, provinces provide occupational pension plans for their own employees. As a result, pension policies remain a multi-legged stool with multiple programs and regulations. Two pension experts from different provincial public administrations indicated that this is an important obstacle when tackling pension issues and building a consensus on problem definitions. One noted that “everybody talks about pensions, but it means something different for everyone,”2 while the other claimed that many discussions feel “like talking about apples and oranges.”3 With a recent contribution analysing the role of provinces in the provision of social assistance to older adults,4 this chapter focuses primarily on the regulation of occupational pensions and efforts to improve the CPP, including provincial efforts to construct complementary regimes. Going back to the lenses analysed in this book, the intergenerational lens is expected to have the strongest influence on pension policies as a result of the long time horizons involved and the structures of programs, which alter costs/benefits for each cohort across time, and the simple fact that we are referring to a cash transfer program. As such, it features predominantly across all four approaches associated with it: generational accounting,5 dependency ratio,6 Musgrave rule,7 and generational politics.8 In addition, contrary to the European Union, where federal meetings and discussions on pension policies grant an important place to social ministries, the Canadian institutional structure strongly favours the finance ministries.9 They are the ones who meet to discuss potential changes and adjustments to the Canadian pension plan. The intergenerational lens is most likely to prevail in finance ministries, which matters when defining policy problems in pensions. The social gerontology lens also plays an important role, since retirement income is a key element to enhance the well-being of older adults. An analysis from the horizontal lens shifts the focus to ongoing issues in labour market policies and the desire to keep older workers in the labour market as long as possible. Of the 125 individuals who participated in interviews for this book, 34 referred directly to pension policies. They include individuals from departments who work closely and regularly on pension-related matters such as finance (11, including three deputy ministers), labour (7), but also other organizations such as seniors’ secretariats/ministries (7), and central agencies (5). There were also four other senior civil

Pension Policies

103

servants from the Office of the Auditor General, Council on the Status of Women, Intergovernmental Affairs, and Social Services). All interviews occurred at a time when the Conservative Party formed the government in Ottawa, which was a formative moment for the provinces that explored a wide range of alternatives, some of which collectively addressed the shortcomings of the Canadian retirement income system. These developments and exchanges across provinces set the stage for quick adoption of a Canada Pension Plan (CPP) reform following the election of the Liberal Party in 2015. This chapter is divided into three core sections. First, it provides a historical overview of the Canadian retirement income system and a brief description of its policy structure. The second section analyses the search for a solution to enhance pensions with the gradual loss of coverage of company pension plans and the surrounding debates on the improvement of the CPP and provincial initiatives to counter the federal inertia on this issue. The third section features an assessment of these debates via the four lenses structuring this book (intergenerational, medical, social gerontology, and organizational). The conclusion summarizes the findings and discusses the specifics of pensions vis-àvis other policy areas within the context of population aging. Historical Overview and Current Structure of Canada’s Pension Policy Canada’s retirement income system features all three basic philosophies pertinent to pensions. It is a system based on citizenship, need, and individual contributions (i.e., earned benefits).10 First, Old Age Security (OAS), a quasi-universal program, provides benefits on the basis of citizenship. Second, the Guaranteed Income Supplement (GIS), the Spouse Allowance, and the Survivor Allowance provide a supplement to the OAS, depending on one’s income and relationship status. These programs are financed and administered by the federal government and represent 14% of all yearly federal spending.11 Third, the introduction of the Canada and Quebec Pension Plan (CPP/QPP) in 1965 brought the concept of earned benefits into the field of pensions. In addition, Canada has a well-developed private pillar because contributions for the CPP are collected on income ranging from $3,500 to $58,700 (2020 figures). The replacement rate is roughly 25% for those at average salary, which is rather low by international standards.12 To secure a higher replacement rate, individuals must turn to other instruments to bolster their retirement income. The federal government encourages this endeavour through Registered Pension

104

Public Policy and Population Aging

Plans (RPPs), Registered Retirement Savings Plans (RRSPs), and the Tax-Free Savings Accounts (TFSAs), which provide tax benefits to establish private savings that can also be deployed to complement retirement income. CPP/QPP In light of the Canadian Constitution, the federal role in pension policies is surprising. The Supreme Court of Canada shut down early attempts by the federal government to intervene in the field of income replacement in 1936 when it ruled against the creation of an unemployment insurance scheme. This closed the door for the elaboration of a similar insurance scheme for pensions, as other national contribution pension plans were being developed (such as Social Security in the United States). Surprisingly, however, the provinces agreed to reform the Constitution in 1951 and 1964 to allow federal government intervention in providing pensions.13 The 1964 compromise leading to the creation of the CPP/QPP resulted in a provincial veto. The federal government needs the support of two-thirds of the Canadian provinces, representing two-thirds of the Canadian population, to legislate change in the CPP. As a result of its population size, Ontario has a de facto veto over reform. The promarket Conservative governments there have deployed this veto to thwart any attempts to expand the scope of the CPP.14 Further, the inclusion of an opt-out clause allows individual provinces to set up their own schemes without losing their voting rights on changes to the CPP, which Quebec did when the CPP was established in 1966. By creating a parallel system, Quebec has increased its power in this process, since the federal scheme must be similar enough to ensure, for example, free labour movement. There is an administrative agreement between Quebec and Ottawa to coordinate their benefits in the event of a move from Quebec to another province (and vice versa). Reforming the CPP “require[s] an elaborate process of federal-provincial bargaining and a high level of consensus before action is taken.”15 Nonetheless, the federal government has acquired substantial rights in this field by creating and managing the actual pension systems for the citizens of most provinces. With pension liabilities considered to be as high as the public debt and with the erosion of assets beginning in 1993, the Chrétien government saw pension system reform as an urgent task. Ottawa reached an agreement with eight of the 10 provinces in 1997 and the Quebec government agreed to reform its system along similar lines.16 Benefits

Pension Policies

105

were untouched by the new reforms, even though their costs for individual contributors increased. The main features of this legislation (Bill C-2, 1998) include an increase in the contribution rate, the creation of an investment board, a freeze on the contribution floor, and the introduction of a tri-annual review by the provinces and Ottawa. First, contribution rates were gradually increased by 70% to reach 9.9% in 2003. Despite the magnitude of the raise, the government was able to sell this measure by claiming that rates would go up by a far greater amount without proper action. Further, by scheduling the first raise in 1998, the government ensured that citizens would feel the effect of the reform after the election. This increase in contributions was largely compensated for by the reduction of the payroll tax for unemployment insurance, which was running high surpluses.17 Second, the new bill instituted the CPP Investment Board: an independent agency to invest excess contributions into the stock market. Third, it established a freeze on the first $3,500 earned, so that it would not be subject to contributions. This measure was put in place to lower the tax burden on poor workers. However, in no longer adjusting this amount for inflation, the government ensured that it obtained supplementary contributions. Finally, a tri-annual meeting between the provinces and Ottawa was institutionalized to make necessary adjustments to the CPP according to evaluations made in actuarial reports. Occupational Pensions Contrary to the OAS and the CPP/QPP, occupational pension plans provide uneven and unequal coverage. They are (mostly) voluntary, they operate under various rules, and they generate a wide range of benefits. Yet, because of the limited replacement rate offered by C/QPP (25%), they play a crucial role in ensuring a replacement income for Canadian retirees. Occupational pension plans fall into two broad categories: definedbenefit (DB) pension schemes and defined-contribution (DC) pension schemes.18 DB plans offer benefits on a formula usually including the number of years of contributions, best or last annual earnings, and age. In brief, the amount of the benefit is predetermined and the plan sponsor (i.e., the employer) is mostly responsible to ensure its financial security. The majority of workers (56.2%) covered by an occupational plan have a DB plan.19 DC plans do not guarantee any retirement income, which is based on the investment decisions and returns accumulated in an individual pension account. The commitment of the employer resides in granting a contribution to workers’ accounts, and the financial risks are

106

Public Policy and Population Aging

borne primarily by the employee. More than a third of workers (38%) who are covered by an occupational plan have a DC plan in 2019.20 Provinces retain most regulatory responsibilities for occupational pension plans. With many companies operating in more than one province, provincial authorities have had to cooperate to alleviate the issues generated by different rules. Most notable in these efforts is the 1968 memorandum of reciprocal agreement, involving all provinces except PEI, which established the convention that “whichever province is the place of work of a plurality of active plan members has jurisdiction to regulate the plan for all of those members and for almost all purposes.”21 As a result of this agreement, Ontario quickly became the most important and influential provincial player, as it regulates almost 40% of all registered pension plans in Canada. To illustrate the gap with the other provinces, Ontario regulates 7.8 times more plans than Quebec.22 Accentuating the importance of Ontario further, senior officials from the Ministry of Finance in two Western Canadian provinces pointed out that Ontario has the reputation of having a balanced approach in regulations governing employers and plan members as well as from an intergenerational perspective.23 The regulatory powers of provincial governments are far from absolute. The Office of the Superintendent of Financial Institutions Canada regulates private pension plans covering employees operating within a federally regulated area, such as banking and telecommunications (representing roughly 6% of private sector pension plans in Canada).24 In addition, as illustrated nicely in the 2008 report of the Expert Commission in Ontario, federal statutes such as the Income Tax Act and the Bankruptcy and Insolvency Act matter greatly, since they limit reform options of any province seeking to improve its pension system. Thus, the Canadian occupational pension policy landscape is highly fragmented with multiple types of pension plans and many regulators role, resulting in differences in rules across the country. This policy environment is complex and difficult to administer.25 Private Alternatives Voluntary savings play a perceptible role in the current pension infrastructure in Canada as a result of the declining coverage (and generosity) of occupational pension schemes and the limited retirement income offered by public pension programs (GIS, OAS, and CPP/QPP).26 Two federal instruments, the Registered Retirement Savings Plan (RRSP) and the Tax-Free Savings Account (TFSA), complement public and occupational pension schemes. The creation of the RRSP dates back to

Pension Policies

107

1957, as a means to provide additional retirement protection for a small portion of the population, and, to stimulate contributions, it features a tax deferral. RRSPs have grown in importance in recent decades. Albeit not conceived explicitly as a pension savings tool, the TFSA, introduced in 2009, can appeal to lower-income Canadians, since it operates in the reverse manner of RRSPs by sheltering withdrawal from taxation while contributions do not benefit from tax exemptions. However, so far this has not been the case, with only a few low-income individuals taking advantage of this tool.27 Both federal programs, RRSPs and TFSAs, play a role in the ways in which provinces consider pension alternatives. What Solution for Pensions? The gradual decline in pension coverage and generosity offered by occupational pension plans in the private sector brought the CPP back to centre stage. The findings from many provincial commissions on occupational pensions clearly indicated that important modifications were needed to safeguard the replacement rate of future cohorts of retirees. The ensuing pan-Canadian debate resulted in a flurry of analysis, proposals, and innovations embedded within a conflict on two broad proposals: (1) an expansion in the coverage (by raising the income ceiling) and replacement rate targets of the CPP, and (2) modifications to the current occupational pension plan infrastructure to facilitate higher retirement income and coverage. The result is a combination of both features: a modest improvement of the CPP and the introduction of pooled registered pension plans (PRPPs) alongside new regulatory measures to solidify existing occupational pension schemes. From a provincial perspective, this was a highly interesting period in Canadian pension politics. Despite a quasi-consensus among the provinces on the need to expand the CPP, the federal government under Harper sought instead to increase the appeal of private alternatives. As stated bluntly by a senior civil servant within a Ministry of Finance, the federal government represented “a key barrier to progress.”28 With Quebec’s pension plan experiencing a less favourable outlook financially, its policy preferences had far more in common with the positions of the federal government than with those advocated by its provincial counterparts. This resulted in some provinces scrambling for ways to bolster the pension income of their residents on their own. In Alberta and British Columbia, the proposal to create a joint defined contribution benefits pension plan eventually lost momentum, but not before attracting interest from both Manitoba and Saskatchewan while briefly

108

Public Policy and Population Aging

considering a Western pension plan. Nova Scotia also had internal discussions to create a pension plan along similar lines, which was abandoned when expansion of the CPP returned to the policy agenda. In Ontario, the government pursued the creation of the Ontario earnings-related pension plan (ORPP), which became a key platform in the provincial election of 2014. Its adoption, overturned with the CPP agreement of 2016, would have represented a major departure from the current pension system. Interestingly, this latest pension debate featured two very separate tracks of discussions on intergenerational equity and redistribution across cohorts. Traditional social policy issues on the role of government in the provision of public pensions and the effect of the latest reform on poorer cohorts dominated the CPP debate, while intergenerational equity was never a salient theme throughout these discussions. This can be explained partly by a clause in the 1997 reform. It states that any improvement to the CPP ought to be fully funded, which implies that future reforms would not feature redistributive transfers across cohorts within the public scheme akin to a traditional pay-as-you-go scheme. Hence, this restricts CPP discussions to solutions involving a stronger relationship between contributions and benefits, which were not present in the 1997 reform. Occupational pension plans, however, operate under a very different dynamic. DB pension schemes are facing strong reform pressures without jeopardizing past commitments, and solutions such as closing these plans for new members inevitably trigger intergenerational equity debates. What Is Wrong with the Canadian Pension System? With the Canadian pension system performing comparatively well in poverty alleviation and the future of the CPP/QPP secured, most attention has been directed to the declining coverage of occupational pensions in the private sector. Although current shifts in the pension plans offered by employers, affecting mostly private sector workers, are likely to have a long-term impact on the generosity of retirement benefits, the key missing piece remains that more than 60% of Canadian paid workers are currently not covered by an RPP.29 The lack of extensive occupational coverage in the private sector means that many workers need to establish their own pension plan; otherwise they will receive a low replacement rate by relying simply on the CPP/QPP, OAS, and, potentially, GIS. The Registered Retirement Savings Plan was originally created in 1957 to compensate for the lack of employer-sponsored pension plans for a segment of the labour

Pension Policies

109

force. Its status within the Canadian pension system was solidified in 1984 when the government explicitly stated that the CPP/QPP would not be expanded and that private pensions would provide additional resources for retirement. Despite the presence of RRSPs, multiple hurdles contribute to a generally lower pension for individuals who are not covered by an employersponsored pension plan. First, administrative costs are higher for individuals than group pension plans. Second, occupational pension plans offer the opportunity to pool pension risks, thus increasing the likelihood of higher returns and retirement income. Third, individual pension plans assume that individuals have a good knowledge of the risks and uncertainties associated with retirement. Unfortunately, the literature is almost unanimous on the fact that individuals, regardless of their income and for a variety of reasons, underestimate the costs of retirement. They also do not know how to deal with the uncertainties associated with private investments, they have difficulties finding the proper information, and they do not make the right investment decisions. Individual private pension coverage and benefits are deficient for many middle- to high-income earners, resulting in noticeable (forthcoming) lower replacement rates. More than 25% of Canadians do not have RRSPs or RPPs,30 and 50% of all workers did not contribute to a RRSP or RPP in 2008.31 However, it is also an important issue for low- to middle-income earners, most notably as a policy objective is to “ensure that the working poor do not become the pension poor.”32 This is due in large part to the fact that company pension plans are rarely available to those fulfilling a precarious, temporary, or low-skilled position. They are also the individuals with limited financial capacity to contribute regularly to a RRSP. The Harper Years: Lack of Consensus Led to Multiple Provincial Initiatives The 2008 economic crisis brought the issue of securing a higher replacement rate for future retirees back to the forefront of political debate. Despite a host of potential solutions to achieve this policy objective, the debate quickly turned into a battle between an expansion of the CPP and the pursuit of private solutions. While most provinces, with Ontario leading the charge, clearly favoured the former, the federal government preferred the latter option, and it received support most notably from Quebec and Alberta. This stalemate was at the origin of highly interesting pension debates in multiple forums culminating with

110

Public Policy and Population Aging

the (failed) introduction of the ORPP and a proposal to create a rente de longévité (longevity pension) in Quebec. At the heart of these debates is the classic question of whether pension solutions should be mandatory or voluntary. In 2008/9 alone, three provincial inquiries released their findings: the Joint Expert Panel on Pension Standards (JEPPS) (Alberta and British Columbia), the Nova Scotia Pension Review Panel (NSPRP), and the Ontario Expert Commission on Pensions (OECP). The last, established in 2006 to study DB plans, generated a wealth of commissioned research papers on a wide range of issues, such as incentives to develop occupational pensions, tax policy, the coverage and funding of defined benefits pension plans, and income security. In addition, Quebec’s retirement agency released a consultation document proposing proposals to alter its own pension regime (QPP).33 The federal government quickly followed suit by establishing a working group led by Jack Mintz, which led to a report published in 2009 ahead of a federal/ provincial/territorial (FPT) meeting on retirement income adequacy. With the pension dynamic very different between the public and private sectors, the former was notoriously absent in the mandates provided to these commissions.34 A summary of these reports is beyond the scope of this chapter.35 However, they can be grouped into three distinct categories based on their mandate and the object of their inquiries. The Ontario, Alberta– British Columbia, and Nova Scotia commissions tackled private sector occupational pension plans. A second wave of reports addressed similar issues with an eye on the enactment of specific solutions; it features Quebec’s comité d’experts sur l’avenir du système de retraite (CEASR) in 2012–13 and Ontario’s consultations to establish the Ontario Retirement Pension Plan. Quebec also held consultations in 2008 to reform the QPP. Contrary to the Canada Pension Plan, the 1997 reform did not sufficiently alleviate the long-term financial viability of the regime. Finally, the Mintz report (2009) analyses these issues from the point of view of the federal government. Provincial Commissions on Occupational Pension Plans Prior to the economic crisis, many jurisdictions launched consultations and special committees to improve the legislative and regulatory frameworks of occupational pensions with their focus almost exclusively on the private sector.36 In provinces such as Nova Scotia and Ontario, the last comprehensive reviews occurred in the 1980s and resulted in legislative changes. The OECP stressed multiple changes since then,

Pension Policies

111

resulting in controversies with occupational pensions. These included changes in public and private sectors, turbulence in financial markets, mergers and acquisitions, insolvencies, and even the province’s own legal-regulatory framework.37 The governments of British Columbia and Alberta also jumped into the fray by establishing the JEPPS in October 2007. Quebec would eventually conduct its own formal review with the creation of the CEASR in 2012. These provincial inquiries identified many challenges with occupational pension plans in the private sector and provided plenty of recommendations. The OECP, for example, featured 142 recommendations, including specific elements related to coverage, governance, and plan design, to name a few. For the purpose of this chapter, I focus on three broad conclusions shared by these reports. First, the overall policy landscape of occupational pension plans came under intense scrutiny. The legal-regulatory framework is complex, as it involves, for example, diverse pension plans and multiple rules in different jurisdictions. Yet the space remains voluntary, since employers are not obligated to provide a pension scheme to their employees. Thus, the emphasis on creating a better environment for occupational pensions came as no surprise when commission reports were released. For instance, the OECP advocated for “a focus on creating a positive environment,”38 while the NSPRP claimed that a key mandate for them was the creation of “an environment where pension promises will be fulfilled.”39 To make strides towards this objective, the commissions made many recommendations, such as a shift towards principles instead of rules to simplify the regulatory environment (JEPPS and OECP), a list of what legislation and regulations should avoid (NSPRP), more clarity on the financial pictures to achieve something akin to a truth about costs (CEASR, but also JEPPS, OECP and NSPRP), and the creation of a “pension advocate” (JEPPS) or a “pension champion” (OECP) to promote pension coverage and facilitate leading policy development. Interestingly, as highlighted by Baldwin,40 these committees devoted relatively little time and effort to DC plans, despite their growing importance.41 The simplification of rules also resides beyond provincial borders. The Canadian regulatory landscape remains highly fragmented, with the cohabitation of different provincial and federal regulations.42 The Canadian Association of Pension Supervisory Authorities has criticized this state of affairs more than once.43 Hence commission reports stressed the need for better exchanges across provinces and with the federal government to alleviate the multiple coordination issues occupying the occupational policy space. For example, the OECP emphasized that the current provincial arrangement granting regulatory responsibility

112

Public Policy and Population Aging

to the province with a plurality of active plan members was “less than satisfactory.”44 It also stressed the need to organize federal-provincial meetings to investigate further provincial divergence and to enact several changes to federal legislation, related mostly to contribution limits and treatment of plan members under bankruptcy and insolvency legislation.45 Interestingly, however, reports pointed to opposite solutions. While the JEPPS and the OECP called for more harmonization,46 the NSPRP stressed these benefits, but mentioned that this diverse universe allows for the introduction of innovations.47 Second, a significant portion of the work performed by the provincial inquiries focused on improving funding rules to ensure the sustainability of pension promises underpinning DB plans. Ensuring adequate funding has been seen as a key goal to restore faith within this policy space in all provinces. The vast majority of senior civil servants interviewed in finance departments and pension agencies also brought up this point when discussing pension policies in their province. The need to act “to ensure that previous promises are met”48 was a common theme across all provinces. As succinctly put by a senior official in a Ministry of Finance, “We do not see this [DB pension problems] as a population aging issue, but rather as a funding issue.”49 New actuarial standards by the Canadian Institute of Actuaries also accentuated liabilities at a time when many plans are already struggling, resulting in a “perfect storm.”50 The proposed solutions in Nova Scotia included better rules on minimum funding requirements, such as tests of funding adequacy for all promises made, and actuarial valuations every three years.51 Protecting the financial security of pension plans was a core principle in the Ontario report, which implies at its core that secured entitlements should correspond to the promises made.52 As part of measures to promote confidence in the pension system, the JEPPS recommended the creation of a governance policy for each plan that would be available to all plan members. This governance policy should also include a funding policy. The joint panel also stressed the need to create minimum funding standards set up to respond to the kind of “pension deal” in place.53 This focus on clarity and funding was far more prominent in Quebec’s inquiry, which was set up after the 2008 economic crisis. The 2013 report indicated that 72% of DB pension schemes had a degree of solvency below 80%.54 Fifteen of its 21 recommendations focused on occupational pension schemes. Among them, Quebec’s expert committee proposed an “enhanced funding” method (recommendation 4),55 and it suggested a five-year period to engage in negotiations to restructure pension plans so that employees and employers could agree on measures to eliminate

Pension Policies

113

plan deficits, which would also allow reformulation of vesting rights (recommendation 14).56 It also went as far as to advocate identical funding rules for all schemes supervised by Retraite Québec (which also has a mandate to oversee occupational pensions) independent of the labour market sector to provide clarity on their costs (recommendation 3). This measure targeted public sector regimes primarily57 and led to important reforms for regimes covered by Retraite Québec. Contrary to the other provincial commissions, the focus here was more on ensuring the viabilities of current DB schemes rather than seeking or hoping for a reversal of fortune via the creation of new DB schemes. Third, the focus quickly turned to the deployment of new pension tools to bolster coverage alongside measures to sustain current DB plans after the economic crisis. In this vein, the NSPRP and the JEPPS recommended the creation of a DC pension plan (NS and a joint Alberta/ British Columbia Plan respectively) that would be easily accessible with low administrative costs. Both panels recommended an auto-enrolment plan that would require “a conscious choice to either participate or opt out,”58 but the JEPPS advocated mandatory participation for “employees of employers who participate in the plan.”59 The NSPRP even went as far to allow “individuals to transfer the commuted value of their pension plans to the new province wide plan.”60 The limits of its mandate prevented the OECPP from venturing into such recommendations. Proposals to develop provincial DC plans raised a host of important questions. Interviews with pension experts within ministries of finance and pension offices throughout Canada revealed serious questions about the consequences of going alone, such as “what happens if you leave to work in another province?” and “could such a plan easily be created at the national level?” The provincial commissions have stimulated debates about pension issues such as adequacy, coverage, and harmonization. As for regulations to occupational pension plans, the impetus provided by these inquiries led to the enactment of changes within this space in many provinces. For example, Ontario enacted modifications to the Pension Benefits Act. This included the introduction of Bill 236 and Bill 120 in 2010. The former featured the addition of conditions – activating event – to access early retirement benefits and expanded rights to immediate vesting and locking in of pension benefits. The latter, Bill 120, included new rules for payment of surplus to an employer. In 2014 the government enacted an amendment to facilitate mergers of singleemploy pension plans with jointly sponsored pension plans. Efforts to increase coordination and harmonization of occupational pension plans across the province continue. British Columbia, Nova

114

Public Policy and Population Aging

Scotia, Ontario, Quebec, and Saskatchewan ratified a new agreement in 2016 on multi-jurisdictional pension plans. The Canadian Association of Pension Supervisory Authorities, which consist of the regulatory authorities of each Canadian province and the federal level (except PEI), is working to enhance this agreement with amendments to “address the issue of changing funding regimes across jurisdictions.”61 It is still worth pointing out, however, that none of these measures addressed the increasing lack of pension coverage for private sector workers. The following two subsections tackle two reform paths: the creation of DC plans sponsored by provincial authorities and the potential expansion of the CPP (or creation of a national supplementary pension plan). Pooled Registered Pension Plans and Quebec’s Voluntary Registered Savings Program In the aftermath of the provincial inquiries and the economic crisis of 2008, pension reform was clearly on the policy agenda. The discussion quickly turned into a national debate and the pressure was on the federal government to take some initiative. By 2010 Canada was “on an irrevocable path to improving its retirement income system.”62 This section discusses the evolution of the voluntary path, where most federal efforts were directed during the Harper years, while the subsequent section focuses on the events resulting from the expansion of the Canadian Pension Plan in 2016 under the Liberal government. The Harper government signalled clearly and early its preferences for the pursuit of voluntary and minimalist intervention in the pension debate. First, it appointed Jack Mintz, a noted critic of governmental involvement in the creation of pension funds63 who would eventually be a staunch opponent to the ORPP and CPP expansion, to lead a Research Working Group on Pension Coverage and Retirement Incomes following the FPT meeting of ministers of finance in May 2009. The summary report of the research group, published ahead of a FPT meeting of finance ministers in December 2009, shied away from proposing substantial measures and concluded that the current system was “performing well” and that “some Canadians do not have sufficient replacement income.”64 The conclusions of this report were contradicted a month later by the minister of finance in British Columbia, Colin Hansen, who chaired the provincial-territorial Steering Committee of Ministers on Pension Coverage and Retirement Income Adequacy. He released what was originally a confidential report from the steering committee.65 Contrary to

Pension Policies

115

the Mintz report, it painted a more pessimistic picture of the retirement system by emphasizing that future generations of retirees are likely to experience difficulties because of serious gaps in coverage. The Hansen report offered two distinct proposals, which could also be pursued jointly: the creation of a Canadian Supplementary Pension Plan (CSPP) and a CPP expansion. The CSPP, which would be a voluntary DC scheme, would act as a new tier in the Canadian retirement income system. It follows from the proposed DC schemes in the British Columbia/Alberta and Nova Scotia inquiries and a proposal from Keith Ambachtsheer inspired by the Dutch multisectorial pension funds.66 The CSPP would operate at arm’s length from the government, provide a low-cost option, feature automatic enrolment, and target individuals earning $30,000–$100,000.67 Three Western premiers (British Columbia, Alberta, and Saskatchewan) openly called for such a solution and even pledged that they would enact a common DC regional pension plan if Ottawa failed to act at a joint meeting in September 2009.68 The federal government, led by the Conservatives, also had a clear preference for this option over an expansion of the CPP, as it favoured regulatory tools to enhance private savings. The creation and expansion of the Tax-Free Savings Account, which is now considered part of the policy landscape in the field of pensions, is a case in point. Initially, federal Finance Minister Jim Flaherty indicated that the federal government would support a modest increase of the CPP and avoid voluntary options.69 This position soon changed. At a meeting of finance ministers in December 2010, Flaherty announced its intention to introduce a Pooled Registered Pension Plan (PRPP). Federal-provincial discussions ensued in 2011. A speech by Ted Menzies, the federal Minister of State for Finance, in the summer featured references to the Mintz report along with the conclusion that “some modes and middle-income individuals may be achieving a lower overall income replacement rate.”70 The Pooled Registered Pension Plans Act (Bill C-25) was introduced in November 2011. As its name indicates, PRPPs facilitate the creation of pooled pension plans for employers and employees. These are DC schemes with members originating from a wide range of employers, leading to potential savings in management costs, making them more appealing than RRSPs. Inspired by the Kiwi-Saver experience in New Zealand, it includes an auto-enrolment mechanism. Rather than having to opt in, employees must actually opt out of a PRPP within 60 days after they join a firm (or when the employer opts to join one). It also has the benefit of lowering administrative costs for employers, which could facilitate participation

116

Public Policy and Population Aging

of smaller employers who cannot benefit from the economy of scale. The legal and regulatory structure established by the federal government ensures that members benefit from the same tax credit as other registered accounts such as RRSPs and occupational pension plans. However, PRPPs remain voluntary and employers do not have to provide a contribution. In addition, provinces can override any portion of this bill and must introduce enabling legislation to cover employees governed by provincial law.71 As such, this bill has represented a platform to favour the growth of broad DC plans in the private sector by provincial authorities rather than a broad supplementary pension plan that would be easily portable. This initiative gathered solid support in the provinces that had been advocating creation of DC provincial plans in recent inquiries (Alberta, British Columbia, and Nova Scotia), in Quebec and in Saskatchewan, but failed to pick up steam in the other five. By then, many provinces had already been very vocal in their desire to pursue expansion of the CPP as the favoured solution, with six provinces (BC, PEI, Nova Scotia, New Brunswick, Manitoba, and Ontario) issuing a joint statement to this effect at the December 2010 meeting of finance ministers. British Columbia and Nova Scotia consistently pursued both alternatives. The enthusiasm for PRPPs rapidly waned after final adoption of the federal bill in 2012, and even the most enthusiastic provinces moved slowly to enact PRPPs.72 As of 2020, four provinces (British Columbia, Nova Scotia, Ontario, and Saskatchewan) have an agreement with the federal government making PRPPs available to employees in their respective province. Employees operating within a federal jurisdiction, such as banking, can also join a PRPP, regardless of the province. The supervision of PRPPs falls under the responsibility of the Office of the Superintendent of Financial Institutions. Quebec remains the only province to have pursued and implemented a PRPP. The 2011 budget featured the introduction of the Voluntary Retirement Savings Plan (VRSP). It includes an auto-enrolment mechanism; employees are automatically enrolled in the plan offered by the employer and they can withdraw only if they do so in writing. The default contribution rate is set at 4% for 2019, but starting at 2% and rising gradually over three years to reach its target. Employees can ask in writing for a lower contribution rate. Implementation of the VRSP began in 2015 and was gradually phased in to offer employers with few employees a longer transition period. As a result, there has been a steady increase from the number of employees covered by the VRSP and employers offering the VRSP. As of 2019, 12,368 employers put in place a VRSP with 102,033 employees contributing to them.73

Pension Policies

117

In many ways, the PRPP remains a poor replacement for alternative pension plans. First, employers are not obliged to contribute into the employees’ pension plan, even though employers have the responsibility to select the plan provider. Hence, this is a poor alternative to DC plans with active (financial) contributions from employers. As such, it cements the voluntary nature of employers’ participation in the provision of retirement income. Second, the administration fee of these plans, hovering around 1% to 1.25%, is lower than traditional mutual funds, but still much higher than indexed funds that can be purchased individually. It comes as no surprise, therefore, that PRPPs have faced criticism from a wide range of pension experts across the country. For example, according to John Myles, PRSPs are a “minimalist response to the national problem faced by today’s workers and future retirees.”74 Early indications in Quebec, a province that embraced the VRSP, suggest that employers contribute slightly more than one dollar for every four dollars invested by employees.75 Provincial Earnings-Related Pension Schemes: The Longevity Pension and the ORPP The 2008 economic crisis had a profound impact on the occupational pension landscape. It eliminated hopes to restore the popularity of defined benefit plans. With the federal government under Harper signalling its intent to embrace only minor modifications to the actual retirement income system, such as the introduction of PRPPs, and unwilling to improve CPP benefits, alternative solutions quickly appeared, most notably in Ontario and Quebec. the longevity pension Quebec is in a unique position on public pensions within a provincial setting. Contrary to the other provinces, it administers and manages its own earnings-related pension plan (QPP) and can modify it without having to negotiate with the federal government. It is important to point out that its room to navigate is constrained by commitments to ensure the portability of the CPP-QPP across Canada. Originally confined to analysing private sector pensions, the comité d’experts sur l’avenir du système de retraite québécois sought and obtained a broader mandate to study the entire pension system with a 30–40-year time horizon. Starting with the objective of achieving a replacement rate oscillating between 50% and 70%, the committee quickly concluded that Quebecers were saving insufficiently. Among the most compelling statistics provided at the time, the committee stated

118

Public Policy and Population Aging

that only 35% of Quebec workers benefited from a DB plan, while 47% did not participate in any group plan (DB, DC, etc.).76 In addition, citing a Régie des rentes du Québec (now Retraite Québec) study, the report also indicated that 45% of Quebec households with an income between $38,000 and $67,000 did not save enough to achieve a 60% replacement rate at age 65.77 Acknowledging difficulties to re-establish the pre-eminence of DB plans, already facing “significant pressures”78 in the aftermath of the 2008 financial crisis, the comité d’experts sur l’avenir du système de retraite québécois proposed the creation of a longevity pension accessible at age 75 (recommendation 1).79 This plan would be fully independent from the QPP and feature a contribution rate estimated at 3.3% in the report, to be shared equally between employers and employees. Contrary to the QPP, this scheme would be fully capitalized, cover workers aged 18–74 years old, and, as a result, discourage early retirement. No pension rights would be credited for periods where contributions are not provided. Contributions would be collected on the same range of revenues as the QPP and benefit from the same fiscal advantages. The commission estimated that someone working between 18 and 74 would receive a pension at age 75 corresponding to a replacement rate of 28.5% up to the level of the contribution ceiling ($51,100 in 2013). This would be in addition to revenues gathered from other sources such as the GIS, OAS, QPP, and private pension income. Contrary to the debate surrounding the ORPP, the Quebec debate on the longevity pension did not result in a legislative proposal. Originally created by the Liberal government, the Expert Committee submitted its report to a PQ minority government in 2013. The longevity pension was the subject of a special Parliamentary Public Finance Commission80 in August, and widespread opposition surfaced from diverse actors such as the Fédération des chambres de commerce du Québec and the Canadian Union of Public Employees. On the right side of the political spectrum, employer groups opposed the creation of new contributions, claiming the additional labour costs would affect their competitiveness vis-à-vis other provinces and the United States. On the left side, groups such as the Fédération des travailleurs du Québec proposed to bolster the QPP. In addition, the introduction of the longevity pension would result in a decrease in the GIS for low-income earners, which would reduce the contribution from Ottawa at the expense of workers and employers. As stated by the PQ Minister Maltais, “On soulage le fédéral et on charge les employeurs et les employés.”81 FADOQ, a Quebec-based organization representing older adults over the age of 50 with a membership exceeding

Pension Policies

119

550,000 members, expressed reservations that the longevity pension becomes a disguised tool to encourage workers to remain in the labour market until 75, which would cause problems for many older workers. Hence its support would be contingent on ensuring adequate protection for retirees aged between 65 and 75.82 What makes the work of this expert committee so interesting is the presence of proposals that would have definitively made it more difficult to maintain the current harmonized structure between the CPP and the QPP. Eventually, the Quebec government first opted to sustain the long-term financial viability of the QPP by announcing a progressive increase in contribution rates. The government stated that the longevity pension announced would be part of discussions with other provincial and federal counterparts alongside discussions to enhance the CPP/ QPP in a strategic plan in late 2013.83 With a polarized opposition in the province and a lack of serious considerations from other provinces and the federal government, the longevity pension proposal vanished from policy debates. the ontario retirement pension plan Ontario also flirted with provincial innovations, but committed itself far more than Quebec did. With an election scheduled less than a year away, the Ontario government proposed the creation of an Ontario Retirement Pension Plan (ORPP) in its 2014 budget84 and established the ORPP Implementation Secretariat to facilitate the legislative process and oversee its implementation. Pointing to the diminishing number of workplace pensions, the failure of voluntary private options to fill the gap, and the federal government’s position favouring the status quo with regards to the CPP, the ORPP targeted workers without a company pension plan. Financed by a contribution rate of 3.8%, split evenly between employers and workers, the original plan aimed to provide a replacement rate of 15% of an individual’s earnings up to $90,000 (the contribution ceiling). The earnings threshold would increase each year, as with the CPP income threshold ($55,900 in 2018). Replacement rates – including the CPP – for someone earning $52,500 would reach 40% of pre-retirement income and 30% for individuals earning $90,000 – an increase of 60% and nearly 50%, respectively, compared to the stand-alone CPP benefit.85 Other features included the creation of an arm’s-length agency to manage the ORPP, benefits tied to contribution, and a low-income threshold to be determined at a later date. In addition, the government announced that Ontario would be willing to consider expansion into other provinces.86

120

Public Policy and Population Aging

The ORPP proposals quickly became a contentious point of debate at the provincial and federal levels. The ORPP was a core policy issue introduced by the Liberal Party during the provincial election of 2014. The Liberals stressed the need for higher retirement savings and criticized the federal government for refusing to expand the CPP. On the opening day of the electoral campaign, the ORPP was front and centre. “The first choice would have been to have an improvement and enhancement to the Canada Pension Plan, but the federal government is not interested in doing that… So quite frankly I think that if Prime Minister Harper isn’t interested in partnering with us then he should move out of the way.”87 The provincial Conservatives referred to the ORPP as a “job-killing payroll tax”88 and they embraced the development of PRPPs, making them clearly aligned with their federal counterpart. They further argued that implementation of the ORPP would result in the loss of 150,000 jobs.89 Following the re-election of the Liberal Party, consultations began in earnest with a consultation document and the introduction of the Ontario Retirement Pension Plan Act in December 2014.90 It focused on three key elements: what constitutes a comparable workplace pension plan, a crucial issue since workers covered by a comparable pension plan are not enrolled in the ORPP; the minimum earnings threshold; and the participation of self-employed individuals. In the rationale for action, the consultation paper emphasized the decline of workplace pension plan coverage, the lack of savings for retirement, and longer life expectancy. It also stressed the similarities with the CPP and how it can assist those at risk of under-saving.91 In the spring of 2015, the government revealed its intention to implement the ORPP as early as 2017.92 This next step towards adoption of the ORPP led to highly publicized confrontations between Premier Wynne and the Canadian prime minister, Stephen Harper.93 The federal government refused to co-operate with the province as it moved forward with the legislation. As a result, the Ontario government could not use the collection set-up deployed by the Canada Pension Plan (CPP), have the ORPP treated like the CPP for tax purposes, or even integrate the ORPP as part of RRSP contribution limits, resulting in considerable administrative hurdles and additional costs to implement the ORPP.94 Other critics quickly emerged against the ORPP and reiterated positions that are traditionally voiced in opposition to an expansion of the CPP. During a consultation of the Standing Committee on Social Policy on the legislative proposal, the Ontario division of the Canadian

Pension Policies

121

Manufacturers and Exporters Association, the Ontario Restaurant Hotel and Motel Association, and the Ontario Convenience Stores Association raised the potential impact on the ORPP on small businesses and ways to offset the additional cost, which could lead to reduced employee benefits elsewhere.95 The Portfolio Management Association of Canada argued that DC plans should be made comparable and that the government should favour PRPPs.96 In addition, the Ontario Chamber of Commerce and other large employers pressured the government to expand its definition of comparable plans to include defined contribution (DC plans) and to consider more carefully the ORPP’s impact on the economy.97 Actors who supported the creation of the ORPP had traditionally been advocates of a CPP expansion such as unions and CARP. However, the ORPP was clearly presented as a less-valuable alternative. For example, the International Association of Machinists and Aerospace Workers emphasized that there are no real comparable alternatives to a plan like a compulsory earnings-related pension plan, criticized the opt-out provision, and expressed concerns at the hurdles introduced by the federal government.98 With the federal government pursing the status quo with the CPP and opposed to facilitating implementation of the ORPP, pension policies became an important issue during the federal election of 2015, most notably in Ontario. Contrary to the provincial election, Prime Minister Harper voiced his criticism of the ORPP far more openly. He criticized it as a “Justin-Wynne Payroll Tax Hike” and harmful to the economy.99 Kathleen Wynne expressed open support for the federal Liberal Party and its promise to expand the CPP. The expansion of the CPP was also an important electoral promise made by the NDP. The election of the Liberal Party in Ottawa altered the policy landscape. However, initially this election did not signal the end of the ORPP. The CPP requires support from seven provinces with at least 50% of the population and, consequently, the federal government sought broader support to amend the CPP. Hence, the Wynne government continued in its implementation of the ORPP. The new federal government quickly agreed with Ontario to remove the administrative barriers to make the ORPP compatible and complementary to the CPP. In December 2015, the Ontario government announced the creation of the Ontario Retirement Pension Plan Administration Corporation, set up at arm’s length from government primarily to administer the ORPP, and it appointed the first three board members. In the 2016 budget, the government indicated that all eligible Ontario workers would be covered by the ORPP or a comparable plan by 2020. The government also clearly stated its

122

Public Policy and Population Aging

preference for a national pension solution, consisting of an expansion of the CPP that would “provide a level of adequacy and targeted coverage that is consistent with the ORPP.”100 Such an outcome, at least in the eyes of the government, was achieved with an intergovernmental agreement to enhance the CPP on 20 June 2016. The speed with which the ORPP was being introduced led to important political pressure to act quickly at the national level, even though there was already substantial support across the country for such a solution, with the noticeable exception of Quebec. The Liberal Years: Improving the CPP, Occupational Pension Plans, and New Alternatives The election of the federal Liberal Party in 2015 brought Canada Pension Plan reform back to the policy agenda. Scheduled implementation of the ORPP also lurked in the background. A functioning ORPP would have led to a profound transformation of the Canadian retirement income system, with the remaining provinces having to establish similar alternatives or a new kind of federal-provincial agreement. However, as expected, the federal government, with the support of eight provinces (Manitoba and Quebec being the two exceptions), agreed to expand the coverage and increase the generosity of the CPP in June 2016. Alberta, which had supported the status quo of the Conservative government in Ottawa, changed its stance with the election of the NDP in 2015, and pushed for a later phase-in date.101 The new reform has the twin objective of increasing the targeted replacement rate from 25% to 33.33% for the average worker retiring at 65 with a full working career (i.e., 40 years of contributions) and expanding its coverage by raising the contribution and benefit ceiling by 14%. These changes are introduced in two distinct phases, with contribution rates for both employers and employees slowly increasing to reach one percentage basis point, from 4.95% to 5.95% (for a total of 11.90%), between 2019 and 2023, while the contribution ceiling will increase gradually by 14% in 2024 and 2025. The income between the first and second ceiling faces a lower contribution rate of 8%, to be divided equally between employers and employees.102 Following the announcement of this agreement, the Ontario government quickly cancelled its plan for the ORPP. Table 4.1 demonstrates that the expansion of the CPP is consistent with the objectives of the ORPP, but it is noticeably less generous. It requires contribution rates and an income ceiling that are below that of the ORPP (with a lengthier transition period), which results in additional replacement of 8%

Pension Policies

123

Table 4.1 Comparison between the 2016 CPP reform and the ORPP CPP

ORPP

Contribution rates

An additional 2% to the current scheme divided equally between employees and employers up to the first income ceiling (from 9.95% to 11.95%) ($54,900 in 2016); creation of a second income ceiling (approx. $62,600 in 2016 dollars) with 8% contribution rate also divided equally

3.8% to be divided equally between employees and employers. Like the CPP, the first $3,500 is exempt

Income ceiling

$82,700 in 2025 (rising gradually from $62,600 in 2016)

$90,000 in 2017 dollars

Replacement rates

Additional 8.3% basis points for the average worker with a full career (40 years)

Additional 15% basis points for wages up to the ceiling for a full career (40 years)

Exemptions

No exemption

Exemption for employers sponsoring “comparable workplace pension plans”

Sources: Service Canada website and 2016 Ontario Budget

instead of the 15% proposed by the ORPP. Hence, the CPP represents only 53% of the targeted replacement rate of the ORPP. However, contrary to the ORPP, employers sponsoring a comparable pension plan will not be able to withdraw from the modifications to the new CPP. Manitoba and Quebec did not support the new agreement on the CPP. The newly elected government of Manitoba originally abstained, but threw its support behind the agreement a few weeks later after securing a commitment by the federal government to closely study additional changes to the CPP such as indexation of the death benefit and elimination of the GIS clawback for widowed seniors’ CPP survivor benefits.103 The government of Quebec sought to secure a freeze on contribution rates for individuals earning less than $25,000 (50% of the earnings ceiling), arguing that the net additional gains for this contribution would be cancelled by a reduction in the Guaranteed Income Supplement (GIS), but faced opposition from the federal and Ontario governments.104 As a response to this issue, the CPP agreement features federal engagement to improve the Working Income Tax Benefit (WITB), which mitigates some of the replacement effect denounced by Quebec.105 This failed to satisfy Quebec. Adoption of the CPP reform triggered a debate on whether to reform the QPP along similar lines. The Quebec government launched a consultation in the winter, offering three potential scenarios: the status quo,

124

Public Policy and Population Aging

CPP reform, and a proposal akin to the one proposed to provincial and federal financial ministers in June. It also proposed modifications to the indexation of pensions and retirement age.106 Officially, the Quebec minister of finance did not embrace a specific option, but his preference for the third option was clearly spelled out during negotiations to reform the CPP. This scenario, which was frequently referred to as the RRQ (the acronym for the pension agency at the time) scenario, was elaborated further in the consultation document and included measures to freeze contribution rates for individuals earning less than 50% of the earnings ceiling, while increasing the contributions rates and the income ceiling akin to the federal option for other income levels.107 The government faced strong criticism by limiting consultations to a few groups and providing them with only a month to react, in stark contrast with previous negotiations to reform the QPP even when it involved alignment with the CPP. During the work of the parliamentary commission to study the three options in January 2017,108 it emerged quickly that the RRQ scenario had negligible support. In fact, it was no one’s first choice. The vast majority of actors, such as trade unions, the invited youth group (Force Jeunesse), seniors’ associations, the Canadian Institute of Actuaries, the Fédération des femmes du Québec, and former members of the comité d’experts sur l’avenir du système de retraite (CEASR) expressed a clear preference for the CPP option. Business groups supported the status quo, stressing the difference in population structure and the higher taxes on labour between Quebec and the other nine provinces, but stated a preference for the QPP option over the CPP option. Comparison with the CPP was ubiquitous. Multiple actors pointed out the dangers of deviating too far from the CPP and the unacceptability of endorsing a proposal that would result in Quebec pensioners receiving less than the rest of the country. Under the QPP proposal, the maximum replacement rate would be 29.6%, compared with 33.3% with the CPP reform, because there is no contribution for revenues below 50% of the earnings ceiling. The presentation from CEASR members was probably most damaging for the government. Beyond illustrating that Quebec pensioners would receive lower retirement income and that reliance on the GIS had important limitations, it indicated that employers would only face an increase of two cents per hour for minimum-wage workers with the CPP option and that the Régie des rentes du Québec (now Retraite Québec) would confront administrative challenges by freezing the contribution rates for lower-wage workers, such as how to determine employer contribution rates for individuals with two part-time jobs.109 Eventually the government announced that it would essentially

Pension Policies

125

introduce a mirror copy of the CPP, moving rapidly on its adoption to ensure the same implementation dates and phases as the CPP. Béland and Weaver argue that feedback mechanisms made the CPP reform act as a collusive benchmark prompting the Quebec government to enact QPP adjustments along the same line.110 A Lens Analysis of the Pension Debates This brief section revisits pension developments via the perspective of the four lenses deployed in this book. In this policy area, each of the lenses has relevance with the exception of the medical lens. The intergenerational lens is the most potent when it comes to the field of pensions, but there are noticeable differences across the provinces both concerning its presence in policy debates and, albeit less divergent, on how intergenerational equity is defined and used. Alberta and Quebec are the two provinces where intergenerational issues have been expressed most explicitly when it comes to pension reform and, coincidentally, they have been articulated in a similar manner. The first principle enunciated in the Aging Population Policy Framework (APPF) is “fair and equitable to future generation,”111 which implies that addressing the needs and priorities of an aging population “should not place a disproportionate tax burden on future generations.”112 It is therefore not surprising that the intergenerational issues were brought up by six senior civil servants from four different administrative units when discussing pensions. Prior to the election of the NDP, this had been articulated at the political level with an opposition to increasing CPP contribution rates focusing instead on developing private solutions and improving financial literacy. While these priorities shifted with the election of the NDP, it is worth pointing out that the APPF remained on the governmental website albeit not in a prominent fashion. In Quebec, intergenerational equity has been front and centre in recent pension debates. Concretely, it expresses itself as moving away from the pay-as-you-go funding model, replacing it with funded benefits, meaning that all contributions are invested in the financial market and nothing is redistributed to current retirees. In fact, with the title Consolider le Régime pour renforcer l’équité intergénérationnelle the government indicates clearly that the primary aim of the reform is intergenerational equity. In the words of the government, the first principle is “to preserve intergenerational equity.”113 This is not defined anywhere, but it slowly becomes evident that the government expressed it as ceasing to offer benefits involving intergenerational transfers. The document

126

Public Policy and Population Aging

stresses the accelerated increase in contribution rates from the 1997 CPP/QPP reform to reduce intergenerational transfers and that the new reform proposal maintains this equity by ensuring new contributions will finance their eventual benefit as much as possible.114 A similar argument was given to justify introduction of a longevity indexation.115 Intergenerational equity was the first value for the CEASR, which they define as involving considerations for retirees whose employers (public and private) face financial difficulties, workers currently contributing to the pension system, and youth entering the labour market.116 They expressed clearly that this implies that fully funded pension schemes are preferable to pay-as-you-go schemes.117 In Ontario, the ORPP debate heard traditional pension arguments such as lack of coverage and insufficient savings. It was surprisingly silent on intergenerational issues, except for mention in the 2016 budget that the ORPP would “require benefits to be earned as contributions are made to ensure plan sustainability and intergenerational equity.”118 This is the same argument as the ones used in Quebec in their pension debates. The ways in which intergenerational equity has been conceptualized to define pension problems has roots in two approaches in the intergenerational lens. The focus on intergenerational transfers and rates of return per cohort, which was explicit in Quebec, is associated with the generational accounting approach. Contrary to the conflictual ways intergenerational issues have been deployed in the United States, intergenerational equity has not been a key argument in provincial and Canadian debates to undermine the public regimes. On the contrary, the Canadian way is more reminiscent of the spirit of the Musgrave rule, in which the narrative has been to find mechanisms to secure current schemes and reassure younger cohorts that additional contributions would benefit them first and foremost. It is important to stress, however, that these debates occurred in the aftermath of the previous grand pension debates of the late 1990s, which solidified the future of the CPP and the QPP, although the latter required further adjustments. This allowed policymakers to offer proposals to tackle the adequacy and coverage of the pension system with an eye to the future. However, the situation is far more complex when discussing occupational pension plans, most notably DB pension plans. The issue of intergenerational equity is forced upon policymakers by the challenges of revisiting earlier promises, or entitlements, even though some were never financed properly. This issue came up most frequently while interviewing senior civil servants in pension offices overseeing private sector occupational plans. The CEASR also raised this issue of

Pension Policies

127

intergenerational transfers with DB schemes and pointed out that one should not be surprised to see younger workers reticent to embrace these schemes, knowing full well that part of their contributions alleviate deficits to provide current benefits.119 Higher contributions should generate some forms of higher benefits to be equitable.120 The committee also stressed the tendency to replace DB schemes with DC schemes, which provide less financial security for younger workers than older colleagues in the same enterprise. With population aging a fait accompli and continuing in Atlantic Canada, one would expect intergenerational debates on pensions to dominate there. To use the colourful language of the generational accountant, this is where the generational storm should be at full force. This has not been the case. Federalization of pension alleviates some of the pressure, since Atlantic Canada benefits from an enlarged pool risk, alleviating by the same token the need to raise contribution rates. One would suspect a very different dynamic in private occupational pension schemes. However, there is also a federalizing force for occupational pension schemes, because the reciprocal agreement on occupational pension plans provides jurisdiction to the province with a plurality of members when a plan is active in more than one province. For smaller provinces, this substantially reduces the number of plans overseen by provincial pension authorities. Still, while the Nova Scotia Pension Review Panel raised issues similar to those discussed in investigations in Ontario and Quebec, the matter of intergenerational equity was not raised anywhere in their final document.121 As in Ontario, the panel defined the ongoing financial difficulties of these schemes as a funding issue. Analysis of population aging with a social gerontology lens in the field of pensions involves prioritization of intragenerational issues and a broader understanding of intergenerational issues. Traditional social issues surrounding the adequacy and coverage of the pension system – most likely as a result of the diminishing role played by occupation plans in the private sector – played a large role in promoting the need to enact reforms. As such, this problem definition is within the traditional scope of political-economy issues analysed in social gerontology. Population aging remained omnipresent in the formulation of pension problems, leading to the adoption of a policy design rooted in generational transfers in the case of the CPP/QPP reforms. The new reforms involve a close relationship between contributions and benefits that is fully capitalized, meaning a lengthy transition with continuous contributions will be needed to profit fully from the latest reforms. While these developments still run counter to reform trends in OECD

128

Public Policy and Population Aging

countries, where retrenchment has been the norm, the CPP/QPP still remain in the lower tier of public earnings schemes in its generosity and replacement rates.122 While the gap between those benefiting from an occupational pension plan and those without them will be shrinking, it is likely to remain substantial. In addition, these reforms fail to address inequities and redistribution within the CPP/QPP and their potential reproduction. A prime example is the gap between the retirement income of men and women. As discussed earlier, women experience a higher likelihood of career interruptions and are at greater risk of poverty in retirement. The vast majority of pension reform proposals mention these gaps, but most fail to provide a gender-based analysis, or at the very least considerations, on the potential impact of proposed reforms. For example, the Fédération des femmes du Québec strongly objected to the proposal to push forward the retirement age, citing the fact that some women leave the market in their 50s or early 60s to care for a parent or their partner.123 The two core documents on the consultations and discussions on the ORPP featured a long list of reasons why the plan was needed, but nothing on gender differences in the labour market and in retirement.124 Beyond interviewees from women’s offices, only two senior civil servants raised gender distinctions, one mentioning important differences in asset accumulation between men and women,125 while another indicated that the occupational pension coverage of women was improving relative to men as a result of their higher participation in the public sector.126 Interviews with senior civil servants in the provinces reveal a strong awareness of coordination issues. The organizational lens was actually at the forefront of many discussions, with those working in labour agencies/departments preoccupied with sustaining (or alleviating the decline of) the size of the labour market in an aging society, especially in Atlantic Canada. Alleviating unemployment among older adults and keeping them active longer in the labour market are two important objectives. A deputy minister pointed out that a lot of resources have been deployed in her department since 2000 to follow the babyboomer cohort.127 Pension systems inevitability appear when engaging in participation of older adults in the labour market. In most cases, conversations centred on the maturity of occupational pension plans and professionals continuing to retire early, accentuating labour shortages.128 As a senior civil servant put it when discussing stumbling blocks to increase the labour participation of older adults, “There is a lot of legacy problems that we cannot as a government get rid of. Lots of people are taking early retirement. Even if you decided that it is not desirable,

Pension Policies

129

you cannot retroactively take these commitments away. It is an entitlement issue.”129 In other cases, criticism was directed at the lack of efforts by pension offices and the Ministry of Finance to consider instruments other than raising the retirement age or eliminating early retirement to enhance the labour participation of older adults. For example, a senior official in an employment agency mentioned that specific measures must be introduced to assist older adults with disabilities.130 Interestingly, very few of these issues were brought up after the election of Justin Trudeau and ensuing reform discussions with the provinces, with the focus being squarely on improving the replacement and increasing the earnings ceiling. Quebec was a noticeable exception, since the discussion documents from the government in 2016–17 brought up issues such as altering the indexation, increasing the retirement age, and strengthening the link between contributions and benefits. However, none of these elements featured in the final reform, which was a mirror image of the CPP reform. Conclusion The launch of multiple pension inquiries in the late 2000s led to a flurry of adjustments in the regulation of occupation pension plans and a reform to the Canada Pension Plan in 2016 (and the QPP in 2017). At first glance, the outcome is not particularly surprising, considering the strength of institutional legacy in public pension schemes. In a recent article, Béland and Weaver argue that construction of the Canadian pension system with the twin CPP/QPP schemes and the intergovernmental nature of pension policy facilitated the creation of a race to the top, which led to the recent reforms of the CPP and QPP.131 Beyond the actual reforms, some of the material gathered throughout these interviews supports these findings. Many provinces clearly indicated in their policy documents, and confirmed in the interviews, that a panCanadian solution was the preferred option. Indicative of this stance, the creation of a western-based pension scheme never really led to the elaboration of a serious proposal. In the interviews across the four western provinces, only a deputy minister for intergovernmental affairs mentioned the possibility of a Western Canadian Pension Plan.132 Nonetheless, a strong theoretical focus on policy feedback and federalism shadows important ongoing developments. First, the ORPP episode revealed a willingness to move away from the CPP arrangement in the case of failed federal leadership to address pension problems. Had the Conservative government won the 2015 election, there could have been a new public pension scheme implemented in Canada, and other

130

Public Policy and Population Aging

provinces would have been left scrambling for alternatives to tackle similar problems. Ironically, while Wynne and Trudeau campaigned together on the importance of improving the CPP, the ORPP would have left Ontarians with a broader and more generous coverage, consigning occupational pension plans and private retirement savings to a lesser role in the pension system. While the 2016 reform will improve the pension outcomes of retirees in a generation, it fails to address the broader systemic issues with the declining coverage of pension plans and the individualization of risks with the proliferation of DC schemes. A 33% replacement rate is still well below international standards. Second, while the latest QPP reform followed in the footsteps of the CPP reform, most proposals to reform the QPP have involved a dissociation from the CPP. While there was some criticism to this effect when the CEASR proposed the longevity pensions, the critiques resonated strongly in 2016 only when the government proposed something less generous than the CPP reform. When it comes to analysis of the lenses, the surprise comes with the relative strength of the social gerontological lens vis-à-vis the intergenerational one. The interaction between both lenses results in important constraints on pension reform debates. Social considerations related to both adequacy of retirement income and the declining coverage of private sector occupational pensions schemes dominated the problem definition. Other social issues, however, were noticeably absent. There were, for example, no serious proposals to consider redistributive functions and the impact of divergent employment trajectories on current and future pension income. This limited attention to social policy issues is due in part to the consultation structure of the Canada Pension Plan. As mentioned in the introduction, the routine evaluation of the CPP and reform discussion occur among finance ministers and, contrary to the European Union, socially minded ministries do not have a forum on pensions.133 To employ the words of a senior pension policy analyst interviewed for this book, “There are no natural forums for pensions”134 because of this institutional structure. This partly explains the gap between the coordination concerns raised by civil servants operating in labour ministries, and the lack of discussion of these issues at the federal level within the context of pension reform. The intergenerational lens has not been deployed strongly in this round of pension reform debates. However, it has played a role in shaping the acceptable parameters of CPP/QPP expansion by enforcing a close relationship between contributions and benefits while at the same time committing to a fully capitalized structure to finance these benefits. The latter element has been in place

Pension Policies

131

since the 1997 CPP reform, which calls for prefunded models for any benefit expansion. Consequently, intra- and intergenerational solidarity are quite marginal. In addition, future pensions from CPP/QPP will depend even more on capital markets to fund pension commitments. This strong coupling between contributions, benefits, and capital returns opens the door to a different notion of risk sharing, which could involve a reduction in pension income, if investment returns do not meet expectations because of the emphasis on funded public schemes. The extension of the CPP/QPP relieves provinces from handling an important component of pension risk (with the exception of Quebec), notwithstanding regulation of private occupational schemes and management of public sector occupational pensions. Consequently, intergenerational concerns are displaced onto other policy areas that have a more substantial impact on the fiscal health of public budget. In this vein, an assistant deputy minister in finance mentioned that the real policy where intergenerational issues warrant discussion is not pension policies, but rather health care.135

5 Health and Residential Care

Everything begins and ends with health care. – Clerk of an executive council in an Atlantic province

Introduction Health care is the most frequent policy mentioned among the challenges and opportunities of population aging in the media. As illustrated in the introduction, an analysis of newspaper articles devoted to the policy problem of an aging population reveals that health policy was the most frequently discussed policy area, featuring in 38% of all articles in the Globe and Mail between 2013 and 2018, and 44% in La Presse during the same period. This emphasis on health policy is hardly surprising; universal and free access to health care facilities continue to represent a common value amongst Canadians. Survey data are unequivocal on Canadians’ support of the health care system, which even includes a willingness to pay more to sustain it.1 Worries about the consequences of an aging population for provincial health care systems are also very common. Analysis of 167 health policy documents2 published between 2006 and 2014, as part of this research project, revealed that 57.5% discussed upcoming challenges and opportunities explicitly for population aging. Typically, and aligned with the medical lens, population aging is frequently a prelude to state that the increasing number of older adults will trigger higher support and service demands in health and long-term care. In addition, as will be explored in a section of this chapter, this demographic shift features strongly in reform narratives of health care policies that represent very divergent points of view, ranging from pressuring the federal government to augment its financial contribution3 to encouraging more privatization.4

Health and Residential Care

133

Beyond policy documents and studies on health care policy and aging, this chapter relies primarily on interviews with 23 senior civil servants involved in health care policies among eight provinces.5 These individuals were mostly directors, policy analysts, and deputy ministers in health ministries, community/social services ministries, and senior officials in regional health agencies. Health care was also central among the policy concerns of senior officials in other departments as a key issue when discussing the policy challenges of an aging population. It was, in fact, the policy sector most frequently mentioned after the policies overseen by their own department/agency. Stating that population aging is mostly a problem for the Health Ministry was a popular refrain among officials in provinces west of Quebec. An exhaustive analysis of health care in the context of population aging could easily stretch beyond a volume, let alone a chapter. To ensure a cohesive and succinct treatment of the interplay between health care and population aging, this chapter focuses on two prevalent core issues during the interviews and explored in policy discussions: health care expenditure and residential care.6 The focus on health care expenditure implies considerations on the long-term sustainability of the publicly funded system in an aging society, most notably in the Atlantic provinces. Long-term care involves services within a residential care facility and home care. In this chapter, the focus is on residential care policies, with home care analysed in chapter 6. This is followed by an analysis featuring the four lenses of this book: intergenerational, medical, social gerontology, and organizational. The next section represents a late addition to the manuscript in light of the spread of COVID-19 in residential care facilities and the dire consequences that ensued. The section seeks to analyse, in a succinct way, some provincial responses and the impact of this crisis on policy debates to improve long-term care. The conclusion revisits the health care expenditure debates in relation to population aging by exploring prior projections and discusses the root of the residential care bias in long-term care. Health Care Expenditure The current and future cost of health care frequently ranks among the most important policy concerns in all 10 provinces. There is clear awareness that provincial health care systems must adapt to provide different and sufficient care to baby boomers soon. Although this features broad policy discussions including, for example, how and where care is provided and better patient engagement,7 first and foremost it involves a discussion about how these health care services will be financed.

134

Public Policy and Population Aging

Some provinces have gone beyond stating that population aging creates pressure to transform or reinvent health care, often valorizing aging at home as an innovative solution, by making explicit statements in governmental action plans/strategies that slowing the growth of health care expenditure in an aging society is now a priority. These go beyond publications from the Ministry of Finance. For example, British Columbia’s Strategic Plan from the Liberal government for 2014–18 states, “As our population continues to age, controlling the growth of health-care spending will be a critical component to ensuring successive balanced budgets.”8 This section first presents an overview of health care expenditure in Canadian provinces, relying primarily on data from the Canadian Institute for Health Information (CIHI). The second section discusses the link between health care costs and population aging and the last section brings up key policy debates on how to tackle these financial challenges. Overview of Health Care Expenditure in Canadian Provinces Canadian health care expenditure amounted to $253.5 billion in 2018, which represents 10.9% of GDP or $6,839 per Canadian.9 Health care expenditure has been an omnipresent concern in Canadian provinces, even more so since the mid- to late 1990s when federal transfer payments started to decline substantially to less than 15% of health expenditures, far from the time when this contribution represented over 35% in the mid-1970s.10 In 2018, provinces accounted for 64.2% of all health care expenditure, including private and public spending.11 Health care is the most important budgetary item in the provinces and represented around 37% of all program expenditures in 2016.12 While provinces must adhere to guidelines in the Canada Health Act, there are notable provincial differences in the allocation of resources, both vis-à-vis other public programs and across health programs, and overall financial commitments. This reflects the simple fact that health spending remains first and foremost a provincial prerogative. Figure 5.1 shows that the relative share of health care expenditure, as a percentage of all program expenditure in the 10 provinces, ranges from 32.8% in Alberta to 39.2% in Prince Edward Island. Provincial differences are also substantial once we consider the relative financial health care expenditure in each province. As figure 5.2 indicates, public health care expenditure amounts to more than 10% of GDP in Nova Scotia and Prince Edward Island, and slightly more than 6% in Alberta.

Health and Residential Care

135

Percentage of provincial public programs expenditure

Figure 5.1 Total provincial government health expenditure as a proportion of total provincial programs in 2016 40 39 38 37 36 35 34 33 32 31 30 29

BC

AB

SASK MAN

ON

QC

NB

PEI

NS

NL

Source: CIHI F-Series, 2018

Figure 5.2 Public health expenditure as a percentage of GDP, per capita in 2016 12

Percentage of GDP

10 8 6 4 2 0

BC

AB

SASK MAN

Source: CIHI F-Series, 2018

ON

QC

NB

PEI

NS

NL

136

Public Policy and Population Aging

Figure 5.3 Estimate of total per capita governmental health expenditures by age group in Canada, 2016 35,000 30,000

Dollars

25,000 20,000 15,000 10,000 5,000

90+

85–89

80–84

75–79

70–74

65–69

60–64

55–59

50–54

45–49

40–44

35–39

30–34

25–29

20–24

15–19

5–9

10–14

hospital is a long

Health and Residential Care

149

way from the current repartition of public health expenditures. A very approximate picture, using different data sources, suggests that hospitals make up 28.3% of all health care spending, ahead of drugs (15.7%) and physicians (15.1%),98 while residential care and home care represent 11.5% and 2.5% of public health expenditure, respectively.99 More realistically, one would suspect the share of home care expenditure to rise as a proportion of health care expenditure. However, as illustrated in chapter 6, there is little evidence suggesting that this is so. Senior civil servants in health organizations indicated that the increasing number of seniors occupying acute care beds in hospitals is a strong impetus to improve long-term care. As a way to illustrate that this issue has become critical, one senior civil servant stated bluntly, “You cannot train surgeons if your beds are clogged up.”100 These hospital patients, regardless of their age, are typically referred to as “ALC patients” because they await transfers to an alternative level of care environment.101 A 2009 CIHI study revealed that the percentage of hospital beds occupied by ALC patients oscillated between 2% (Saskatchewan and PEI) and 7% (Ontario and Newfoundland and Labrador), and residential care facilities received 43% of the discharged patients.102 A recent study indicates that there might be up to 14% of ALC patients in Ontario hospitals.103 The BC seniors’ advocate reported that ALC days represented 15.6% and 25.7% of total inpatient days for the 65–84 and 85+ age categories respectively for 2016–17.104 Developing more places in residential care – along with better home care services – is the most popular solution to reduce the number of beds used by ALC patients. In one interview, a manager responsible for planning in the health ministry mentioned that there were increasing pressures on policy planning within the health care system, but ultimately this issue rests on the number of available beds in residential care.105 A recent case study of ALC patients in six hospitals in British Columbia and Ontario identified stumbling blocks to resolve this issue: lack of proper home and community supports prior to hospitalization; underestimation of patients’ potential for independence (meaning they could have been cared for at home while awaiting residential care placement); general deconditioning of patients while in hospital; and lack of knowledge of home and community care resources by hospital staff.106 Few senior civil servants raised the issue of home care disincentives, which may encourage individuals to seek premature placement in residential care. One civil servant in a women’s agency indicated that home care is expensive, particularly for the oldest women, which is one factor prompting an earlier consideration for residential care than should be

150

Public Policy and Population Aging

necessary.107 Few others, in different provinces, also mentioned this perverse effect, since home care results in higher out-of-pocket expenses, most notably relating to drug coverage in most provinces. Both interviewees mentioned that it has been very difficult to develop proposals aligning policies across home and residential care.108 Geopolitical and Economic Realities of Residential Care Population aging has been far more pronounced in rural areas throughout the country and continues to be accentuated by urbanization trends.109 This results in challenges for decision-makers when allocating resources. In rural areas, a hospital, or at least access to one nearby, is a key infrastructure that comes with jobs and prestige, making it easier to attract prospective employers. This, in turn, makes it easier to retain younger populations.110 Concerns with service inequities between urban and rural regions and the fear that rural services will be reduced substantially or disappear altogether have been recurrent themes in provincial consultations with seniors.111 Provinces have invested in their projection capabilities, but knowing that public investments should be diverted from a specific region in favour of another, as a result of the changing demographic landscape, is only the first step in altering regional allocation of resources. Closure of a hospital or its transformation into a residential care facility is a highly difficult proposition to endorse for any politician, especially since home care services already tend to be less generous relative to those in cities, accentuating the importance of regional health centres (including hospitals) for older adults. These geopolitical issues were raised in interviews with senior civil servants, mostly in Saskatchewan, Manitoba, and the Atlantic provinces. In Saskatchewan, the transformation of many hospitals into primary care health centres in rural areas in the 1990s looms large in these debates, even though, in line with the literature, affected communities did not experience lower health status as a result.112 Interviews revealed awareness of the difficult nature of these decisions and why politicians tend to avoid them. With experience similar to that in Saskatchewan experience, three senior civil servants from the Atlantic provinces addressed this policy issue. First, a senior policy analyst in the Department of Health said that it would be sensible to transform some community hospitals, which are at the point of saturation, into residential care facilities. However, “if we were to do that, there would be significant opposition … this requires a lot of political will.”113 Another senior

Health and Residential Care

151

policy analyst in a different province and department said, “This is a very difficult conversation for a politician. Nobody wants nursing home beds. They all want hospitals.”114 A previous director in a rural administrative office expressed the same dilemma: “No politician wants to go out and tell rural residents that we will not renovate side roads and move some of their services out of town.”115 For the policy problem characteristics reviewed in chapter 3, this represents a prime example of a complex political problem. In the Prairies, formulation of these problems had much more to do with where investments were made. A former deputy minister for health said, “We continue to build at the wrong place.” Construction of a residential facility in a small community is always very popular with politicians, even though it is not a good long-term choice, because these communities are experiencing depopulation and it is extremely difficult to recruit staff.116 According to a senior civil servant in a ministry of health in another province, a major stumbling block in planning for an aging population is that the assessment of needs at the departmental level collides with politicians’ needs. She referred to a recent experience with a politician who insisted on having more beds, even though there was a surplus in the region.117 Ironically, these decisions are probably even more difficult to make with the popularized push to age at home and make cities and communities age-friendly, raising awareness of the importance of health and social infrastructure to achieve goals enshrined in these policy initiatives. According to Menec et al., community experts on aging in rural and remote communities who participated in age-friendly efforts stressed the lack of infrastructure and limited access to health and social services.118 Human Resources Senior care services is an employment sector expecting substantial growth in the near future.119 As with home care, retention and recruitment of personnel in residential care facilities is a challenge120 and expected to worsen. This situation is particularly acute in Atlantic Canada. Representing 48% of the health professional workforce, nurses receive the bulk of attention from policymakers and play an essential role in residential care. In Canada, 32.3% of licensed practical nurses (LPNs) work in long-term care.121 A recent survey of nursing homes in New Brunswick revealed that the turnover rate is 27% among registered nurses and, on the basis of the numbers provided by nursing homes that responded, a vacancy rate of 6.2%.122

152

Public Policy and Population Aging

These issues are not confined only to Atlantic Canada. In Quebec, a recent report of the Protecteur du citoyen mentioned the lack of sufficient personnel in residential care facilities and under-staffed care teams, which has led to an increase of absenteeism, high resident/staff ratio, and high personnel turnover.123 In Quebec City, the regional health authority recently authorized creation of a shortened training program for personal care workers who can receive their accreditation in five weeks, to alleviate vacant positions in their 30 residential care facilities.124 A systematic review of articles spanning over 25 years revealed a strong relationship between the quality of care in residential care facilities and staff levels. In addition, a high turnover ratio is a contributor to poor resident outcomes.125 The average age of nurses, and their eventual departure from the labour market, and ongoing vacancy rates were among core issues identified in long-term care.126 Manitoba even launched a recruitment and retention strategy over 10 years ago with some elements still in place today, with up to $5,000 in relocation assistance and $2,000 in grant money specifically for those who elect to work in residential care facilities.127 Other provinces have similar programs. In New Brunswick, residential care facilities spend the equivalent of $26.17 per bed on recruitment alone.128 This issue is particularly difficult in rural areas, an important recruitment barrier for operators129 and one that partly explains the lengthier wait-times. In early 2018, the BC auditor general issued a special report that rang alarm bells by reporting vacancy rates of 15% for registered nurse positions in the Northern Health Regional Authority, resulting in challenges to offer the mandated number of hours for long-term care patients.130 In fact, linking this with the previous section on the geopolitical dimensions of care infrastructure, one interviewee claimed that new health infrastructure should be constructed where the labour force is.131 However, this observation raises a significant political question about the planning and longterm viability of rural and remote communities in the context of an aging population. Analysing the Four Lenses in Health Policy To what extent do policy documents and senior policymakers consider health policy through one or multiple lenses? This question matters a great deal, since it will most likely steer government efforts to reorient health policy to tackle the challenges and opportunities presented by population aging.

Health and Residential Care

153

Intergenerational Lens Embedded within the Definition of Crowding Out As mentioned, scholars have criticized the apocalyptic scenarios in population aging, and the future of health care has been front and centre in these debates.132 As a result, one would have expected, at the very least, some references to the sustainability of the health care system, along with the need to introduce reform to safeguard its universality for future generations. But the interviews revealed a very marginal treatment of intergenerational issues in health care, and they have not featured noticeably in policy documents. A key exception was Alberta, where policies, programs, and services were expected to be “fair and equitable to all generations” in its Aging Population Policy Framework (APPF).133 Still, health care was a marginal reference, with pension policies being mentioned more than twice as frequently in response to the question of intergenerational issues and planning in the province. It is important to stress that the APPF call for intergenerational fairness is more along the lines of the search for a consensus à la Musgrave than the crisis narrative deployed by advocates of generational accounting (see chapter 1). For example, there were no references to health as a broken pay-as-you-go or an unsustainable system, as introduced in a policy paper by economists from the University of Calgary.134 This is consistent with how the media have portrayed rising health care expenditures in Canada and the United Kingdom, where the crowding-out effect perspective prevails, contrary to the United States, where intergenerational equity dominates.135 Actually, the intergenerational issue in Alberta has been deployed within this crowding-out narrative. Discussing the APPF in greater depth and the notion of intergenerational equity, a senior civil servant stated that health competes with education and environment.136 The primary issue in the conceptualization of health care as a policy problem remains its crowding effect vis-à-vis other programs throughout the provinces, which population aging exacerbates. In the Atlantic provinces, this issue and its consequences are prominent now. Still, the envisioned health care reforms tend to be much more in line with the growing consensus to move, albeit slowly, towards more long-term care and social/health prevention approaches, which have been proven to cost less while providing better health outcomes in the long run. However, cost-sharing has been a subject of increasing discussion at the federal level, since Ottawa refuses to consider the proportion of senior citizens in the transfer formula. This has been the subject of numerous complaints from provinces with a higher proportion of seniors, such as British Columbia.137 Nova Scotia has been advocating

154

Public Policy and Population Aging

for this change to the funding formula for a long time, as evidenced by its submission138 to the Senate for its work on Canada’s Aging Population, which led to the 2009 report.139 Otherwise, intergenerational issues in health care have tended to mention the importance of the life course, as opposed to focusing on chronological age, to emphasize the need for health prevention measures.140 As alluded to earlier, the recruitment of young nurses poses a significant intergenerational challenge, with younger generations having different expectations in the labour market.141 Others stressed the development of intergenerational tools to engage younger caregivers, who are also more likely to embrace technology.142 With caregivers being increasingly instrumentalized within health care systems, important upcoming intergenerational tensions are likely to arise. In addition to being fewer, future caregivers will be more likely to have a stronger attachment to the labour market and to provide care at both ends of the age spectrum.143 These considerations also intersect strongly with gender, with women continuing to occupy a predominant space in caregiving. Dominance of the Medical Lens and Marginalization of the Social Gerontology Lens With the medical lens being powerful in aging, its strength and ubiquity in health care are highly visible and show no signs of weakening. The emphasis is on where public authorities deliver health care to older adults, but not necessarily how. Policy positions from most advocacy groups tend to highlight the precarious nature of residential care facilities within the current health care system and propose the extension of publicly funded universal care. The Canadian Healthcare Association, for example, proposes that medicare should cover the continuum of care – adding residential care facilities within the parameters of the CHA144 – but stops short of embracing the same remedy for home care, recommending only stronger federal leadership.145 Long-term care is often construed as a top-up, albeit an important one, to primary care. More telling is the position of the Canadian Medical Association (CMA) for the development of a seniors care strategy. It fully embraces the narrative that population aging represents a substantial budgetary challenge and strongly criticizes the limited growth of federal health transfers to the provinces.146 It advocates the creation of a national seniors strategy that would include: development of innovative models to facilitate the transition along the continuum of care (with ALC patients identified as a major issue later on in the document);

Health and Residential Care

155

evidence-based hospital practices; tools and resources to help primary care physicians provide better care for seniors living in the community; a national approach to reduce poly-pharmacy; and additional support for caregivers.147 On the specific issue of residential care facilities, the CMA focuses on inequitable access to facilities and calls for “new approaches to funding and delivery arrangements that will reduce the inequities while sustaining the LTC [i.e., residential care] system.”148 Hence, this politico-institutional context strongly favours cost containment measures that continue to prioritize medical services – a priority reinforced by the policy feedback of the CHA. This was very apparent when health and non-health actors portrayed policy problems. The former emphasized the importance of residential care to address ongoing problems with ALC beds and future needs of seniors, referencing chronic medical conditions. Non-health actors embraced a broader cost perspective (rooted in the crowding-out perspective) while suggesting, sometimes stating, that health care decision makers need to rethink, broadly and beyond delivery systems, how to reform the health sector to reduce the growth of health care expenditures with an aging population. The emphasis on sustainability and cost containment, combined with the continuous valorization of acute care, dims the prospects of relative growth of long-term care or growth in long-term care at the expense of other health care priorities. There is still a wide gap between the rhetorical commitment to long-term care (including both residential care and home care) and the actual actions of provincial governments. Despite recognition of the need to shift towards a new delivery of care and public assessments indicating ongoing issues, non-long-term care spending continues to grow faster than long-term care spending. Using the estimated data from Grignon and Spencer for the period 1975–2013, long-term care spending was at its peak (15%) in 1997 and 1999, and has fallen two percentage basis points since. At the same time, the private proportion of expenditure on long-term care has risen four basis points.149 However, this is a Canadian average and not the case for all provinces. Atlantic provinces, most notably, are facing strong budgetary constraints for their public programs and demand pressures for residential care. For example, New Brunswick’s budget for residential care rose 185% in 2001–16, outpacing the growth in public health care expenditure (98%), although a policy change eliminating an asset test in 2006 is partly responsible for this increase.150 This generates a potentially vicious policy circle, where underfunding throughout early stages of the continuum of care (i.e., home and residential care) and the ability to increase the life expectancy

156

Public Policy and Population Aging

of individuals with chronic conditions and/or dementia generates admission delays. This, in turn, leads to the admission of individuals with more complex needs,151 accentuating pressures to expand care services more in line with those offered in acute care to avoid adding to the number of ALC beds in hospitals. If the BC seniors’ advocate findings that private operators tend to send their residents more frequently and for longer periods to hospitals is accurate, the pressures to transform residential care practices and services will only increase with the rising proportion of private residential care facilities. With these ongoing transformations, it is difficult to subscribe to the valorization of social elements such as ensuring that residential care facilities should be more akin to a home or residence. For example, Quebec’s Ministry of Health and Social Services organized a highly publicized forum on best practices in residential care facilities (CHSLD) in 2018, five months prior to the fall elections. As part of this event, presidents and managing directors of residential care facilities pledged to enhance the quality of CHSLDs. Among them, many targeted residents’ living environment. They committed to provide more personalized services, including better consideration for hygiene and dietary preferences. They also committed to take into account residents’ lifestyles, which includes social and leisure activities adapted to their preferences. If enacted, these changes would substantially improve residents’ social environment and make them feel at home. However, none of these commitments featured a time table or ways to follow their progress. Demonstrating the lesser importance of these social elements, the minister of health and social services also made promises, which by the simple virtue of coming from the minister just before an election, overshadowed those of administrators. These included additional funds, a provincial strategy to attract and retain personal care workers, a greater number of specialized nurses, and a follow-up on the pledges of presidents and managing directors.152 In other provinces there is a strong push to embrace Inter-RAI assessment tools to standardize performance evaluation and provide comparable data across residential care facilities within Canada and abroad. Quality reviews in Ontario, for example, utilized several core indicators: wait-time to admission, use of antipsychotic medications, daily physical restraints, daily moderate or any severe pain, falls among residents, worsened symptoms of depression, and new or worsened pressure ulcers.153 The quality measure indicators tackle narrow outcomes, and none focus on the living and social environment of residents beyond continuous care needs.

Health and Residential Care

157

Organizational Lens: Expanding the Health Perspective into Other Bureaus Among Canadian provinces, with the exception of New Brunswick, health ministries have the primary responsibility for older adults across the continuum. As a result, coordination tends to be vertical. “Better integration” was a frequent buzzword of many civil servants in health organizations. The professional organization of the health care sector features a rigid division of labour that makes coordination difficult. A document on inter-professional coordination in residential care facilities in Quebec features 14 professional orders! Other occupations, such as leisure and music therapists, are considering or seeking the creation of a professional order. Many categories of workers are also seeking greater recognition such as personal care workers. With a constant deficit of specialized professionals, health workers must routinely intervene and perform tasks that are not part of their training and sometimes even proscribed by their professional order. This is especially – though not exclusively – the case for residential care facilities operating in rural and remote areas. Beyond the health ministry, few governmental organizations are involved in health and long-term care with an eye on the impact of population aging. Most notably, seniors’ secretariats have been developing health promotion tools under the umbrella of Healthy Aging and in encouraging local governments and municipalities to adapt their practices and infrastructures to accommodate the increasing number of older adults. They have also been key in campaigns against ageism and elder abuse. Many of the actions of the secretariats involve nonrecurrent budgets and complex partnerships with public, not-for-profit organizations and private actors. Civil servants in these secretariats become de facto policy coordinators for these health initiatives. With a broader understanding of the implications of an aging population upon health and long-term care, women’s agencies have voiced increasing concerns about the long-term consequences for caregivers to their health, quality of life, and labour market opportunities. These issues are discussed in greater detail in the following chapter. COVID-19 and the Long-Term Care Crisis of 2020 As the COVID-19 pandemic is still ongoing, it is far too early to draw definitive conclusions about provincial responses, but the high number of fatalities in residential care facilities has fostered a wave of popular

158

Public Policy and Population Aging

appeals to address the underlying issues discussed in this chapter. This section presents a summary of the impact of COVID-19 in residential care facilities and its potential repercussions in long-term care policies amidst recent commitments to do better amongst premiers and the federal prime minister. As of 17 October 2020, 9,746 deaths have been classified as COVID19 deaths in Canada, with the vast majority originating from Quebec (62%) and Ontario (31%).154 COVID-19 has had a major impact on older adults, and most noticeably on individuals living in residential care facilities. Based on the 27 October data from the Institut national de santé publique – Québec, 61.3% of all deaths were individuals who lived in residential care (CHSLD), while another 17% lived in seniors’ housing.155 Ontario exhibits nearly identical figures, with 64.7% of COVID-19 deaths found among residents of long-term care homes as of 17 October.156 Both provinces struggled to contain the spread of the virus, exposing the weaknesses discussed throughout this chapter, including notably staff shortages, and eventually had to rely on the Canadian Armed Forces. There have been intervention challenges with vulnerable populations during COVID-19, a virus that is extremely difficult to contain in residential care facilities,157 and both premiers were quick to mention that other jurisdictions had similar issues. Still, there are clear signs that Canada – Quebec and Ontario specifically – fared worse than most industrialized countries in handling the spreading of the coronavirus in residential care facilities. In a long-term care report, for instance, a Working Group on the Future of Long-Term Care, featuring leading Canadian experts in this field, illustrates that Canada has been among the worst countries. They argue that the COVID-19 episode reveals “deep operational cracks” linked to 13 failures, including limited funding, lack of support for care workers, poor regulatory framework, and lack of input from residents and caregivers.158 Early signs indicate that public administration and politics matter in the deployment and success of strategies to contain the spread of COVID-19 in residential care facilities. This is notable when comparing British Columbia, the province with the first known outbreak of coronavirus in Canada, and Quebec, which became the province with the most cases and fatalities. British Columbia was very proactive in securing additional personal protective equipment (PPE) to alleviate shortages and a measure forbidding care workers from working at more than one location, while enacting measures to ensure that they would not suffer financially. This involved the negotiation of collective agreements and arrangements with private

Health and Residential Care

159

sector providers. Reports in Quebec denote a slow reaction to the pandemic and a strategy focused on hospitals, which failed to tackle pre-existing issues in residential care facilities (CHSLD) that facilitated the spread of the virus. For instance, while the government recommended that care workers operate at a single site, media accounts reveal that this has clearly not happened in practice. In the midst of extraordinary working conditions, including the lack of PPE, rates of absenteeism soared in the province, compounding an already fragile situation. The shortages were so severe that the government had to launch calls to volunteers, medical specialists, health professionals, recently retired nurses, and the federal government to send the Canadian Armed Forces. There were even accounts of sick workers being pressured to continue to work at multiple locations, despite protocols forbidding it.159 This tragedy represents a “focusing event,” as it opens a rare policy window to enact meaningful LTC reforms.160 Ontario has announced an independent commission on the nursing home industry. In Quebec, the government has accentuated its efforts to deploy its Maison des aînés (residential care infrastructure with a design providing more spaces for residents and an experience closer to living in an apartment than a CHSLD), although the number of expected new places will still fail to catch up with the size of the waiting lists. The government also launched an aggressive campaign to train and recruit orderlies promising an annual salary of $49,000. Private sector operators have also come under the microscope. In Quebec, the CHSLD Hérron is undergoing a criminal investigation in the wake of 31 deaths among its 150 residents in less than one month in the early days of the pandemic.161 This cast a light on private facilities, especially those operating without a long-standing agreement with the province operating with the same guidelines as public facilities (i.e., non conventionnés), such as CHSLD Herron. The government is now studying the possibility of ensuring that all private operators become conventionnés. The role and importance of private providers has also been at the centre of policy debates in Ontario, where they occupy a far more prominent space than in Quebec. Conclusion This chapter analysed debates on the relationship between population aging and health care expenditures, referring to academic articles, policy papers, and the content of interviews with senior civil servants in all 10 provinces. In addition, we discussed current and future policy issues

160

Public Policy and Population Aging

in residential care facilities, with special attention to the continuum of care, geopolitical and economic realities, and human resources. While studies demonstrate that population aging is a contributing factor to increasing health care costs, this particular cost factor continues to attract significant attention. Policy documents and interview content reveal a widely held position that population aging is inevitably leading to higher health care expenditure. This is in contrast to the academic literature and its ongoing debates on time of death and duration of morbidity periods. Senior civil servants also raised mitigating factors such as better health status for baby boomers and higher income. Still, in line with studies projecting financial capacity for the health care system as a result of the twin impact of population aging via health care cost pressure and a smaller labour market, Atlantic provinces are currently facing this difficult policy environment. Policy documents and senior civil servants did not make alarmist calls to overhaul the health care system, but population aging is accentuating worries that health care is crowding out other public programs, particularly in Atlantic Canada, where health care expenditure accounts for 10% of the GDP (see figure 5.2). Still, New Brunswick devotes the least on health care as a proportion of its budget, coincidentally the province with the most generous home care program, and Nova Scotia is not far behind (see figure 5.1). This suggests some space to absorb an increasing share of health care expenditure relative to other programs, especially when one considers that citizens in Atlantic Canada are well versed in the realities of population aging, making it less difficult politically to justify such decisions. One must also consider the capacity of provinces to adapt their programs, even if this implies a reduction and transformation in services over time. The Conference Board of Canada, with a strong reputation among senior civil servants in finance ministries for delivering balanced analyses, projected in a 2000 paper that health care costs would represent 10.2% of GDP per capita and reach 42% of program expenditure in Canadian provinces by 2020.162 The 5.2% yearly average growth in health care expenditure simply did not occur, as the provinces adjusted their spending in line with reduced federal dollars and their economic realities. This also indicates the reality, stated on countless occasions by auditors general and ombudspersons, that budgetary envelops and not health/long-term care needs determine the access and quality of services. As we also saw, residential care facilities play a crucial role in the continuum of care and are by far the most important budget item, capturing over 80% of long-term care budgets.163 As a result of its

Health and Residential Care

161

status as an “extended service” in the Canada Health Act, the provinces have benefited from more policy discretion in the transformation and development of residential care facilities, but this status also contributes to the marginalization of long-term care in health care. Provincial divergences are most visible in the type of ownership, with Ontario and British Columbia, for example, relying far more on the private sector and large-scale operators than in other provinces. Nonetheless, other provinces are increasingly relying on the private sector to increase their capacity. With a steady and sometimes rising number of “alternative level of care” patients in hospital, provincial authorities will continue to experience pressure to secure beds in residential care facilities and develop services to handle residents with more complex care needs. This would require a reversal of priorities up to now, since, in most provinces, health care costs have grown at a faster rate than long-term care expenditures. Access to long-term care facilities is a major issue in Quebec, where the average waiting time is 9.9 months.164 The interviews also indicated that the ability to deliver residential care, most notably in rural and remote communities, is a challenge likely to worsen. This issue involves a high level of political complexity, as decision makers must grapple with the realities of having to re-scale services and make geographical allocation decisions that ultimately affect the existence and economic prospects of communities. The transformation of a community hospital into a residential care facility, for example, is a losing proposition for any deputy to endorse, even if this decision is solidly supported. Another key challenge lies in the recruitment and retention of staff in residential care facilities, which is also more difficult in rural and remote communities. The ongoing COVID-19 episode has had tragic consequences in residential care facilities and laid bare long-standing issues in the sector. Unfortunately a crisis often precedes policy change; COVID-19 has provided the cataclysm to propel the lack of resources and supports in long-term care policies to the top of governmental agendas. Early political discussions across Canada point towards a closer investigation of the private services providers and ways to make them comparable to public residential care. There are accentuated pressures for the federal government to dedicate funding to long-term care to compel provinces to dedicate more health dollars in this area, but Ottawa is already facing opposition from some provinces since LTC is a provincial jurisdiction. There is also a growing momentum to provide better working conditions for residential care workers. As mentioned, Quebec has already promised an annual salary of $49,000 to orderly trainees. There is also

162

Public Policy and Population Aging

mounting pressure on the BC government to retain the improved wage conditions offered to care workers during the pandemic. In closing, the analysis of the four lenses points towards a strong endorsement of Estes and Binney’s conclusions that the biomedical model overshadows everything else, even though there is mounting evidence stressing “the importance of social and behavioural factors in explaining health and aging.”165 This illustrates nicely the challenges of policymakers when deploying the argument of the crowding-out effect in health care to curb spending in this policy area in favour of another. The medical lens remains a hegemonic force on how individuals and decision-makers conceptualize challenges and opportunities when analysing population aging.166 Thus, the extensive media coverage on this issue is as much a reflection of the privileged position of the medical lens as its importance on the values underlying the Canadian health care system. The intergenerational lens, which highlights growing expenditure linked to population aging, actually solidifies a narrower focus on curative interventions as provinces strive to address the crowding-out effect of health expenditures.

6 Home Care Services and Caregiving

Home care is the catch phrase for everything these days.1 Toute politique ministérielle, aussi pertinente soit-elle, prend sa valeur dans son application.2

Introduction In the context of an aging population, few policy options could claim to benefit from a widespread endorsement like home care. The development of home care services has been a quasi-universal policy recommendation in public inquiries,3 from international organizations, and from a wide range of experts. There are three core reasons why home care benefits from such widespread support. First, it simply costs less than developing long-term care facilities.4 A Canadian study by Chappell et al. concludes that “costs were significantly lower” for home care recipients than facility residents.5 In fact, this has been a very popular argument throughout industrialized countries for many years.6 Comparisons between the daily costs of staying in hospital versus receiving home care are omnipresent in governmental publications. Home care also has the potential to reduce demand on other health services.7 Second, for the most part, older adults prefer to age at home. This preference coincides with a broader movement favouring the de-institutionalization of individuals living with chronic conditions and mental illnesses. Third, a Canadian study indicates improvement in self-reported health outcomes with increased availability of publicly financed home care.8 Finally, socio-economic and demographic trends are resulting in fewer family caregivers capable of providing informal care, necessitating a formal home care response.9

164

Public Policy and Population Aging

Therefore, it comes as no surprise that improving home care is a ubiquitous priority in Canadian provinces that features predominantly in their strategies. During the 2011–13 alone, nine jurisdictions announced their intent to shift the emphasis of care to home and communities.10 In Quebec, the primary policy document for home care is entitled “Chez soi, le premier choix,” leaving no doubt about where older adults should be receiving care.11 New Brunswick’s latest strategy for seniors, entitled Home First, follows in these footsteps.12 Senior civil servants interviewed for this book were unanimous that home care must be expanded and revisited. Interestingly, similar observations came from senior civil servants in organizations beyond health care and social services, such as the Department of Finance, the Executive Council, and women’s offices or agencies. This shift is apparent as the number of individuals (with older adults representing 61% of recipients in Canada) benefiting from home care is growing rapidly, rising by 55% during the period 2008–11 alone.13 Based on the 2012 General Social Survey (GSS), 45% of older adults aged 85 and over receive home care.14 Yet home care remains, for the most part, an elusive policy goal in all provinces. There is a wide gap between the ambitious policy objectives of provincial governments and the means deployed to achieve them. This is well documented, with over 12 provincial inquiries (and followups) from auditors general (BC, Alberta, Manitoba, Ontario, Quebec, and Nova Scotia) and ombudspersons (BC and Quebec) since 2000 (see table 6.1). These inquiries have prompted quick, albeit mitigated, government responses. For example, the comprehensive multi-year (multi-volume) investigation The Best of Care,15 by the BC ombudsperson played a key role in the creation of a seniors’ advocate office in 2014. Similar offices now exist in Alberta (2014), and Newfoundland and Labrador (2017), while the Nova Scotia Office of the Ombudsman has some representatives dedicated to seniors’ issues. As part of their mandate, these offices have since produced home care related reports (see table 6.1). Canada’s long-term care spending remains heavily concentrated in facilities and not in home services (see chapter 5). As reported in the latest OECD figures, Canadian provinces devote 87% of long-term care spending to residential care facilities and less than 13% on home care, in sharp contrast with Finland, where 70% of its long-term care budget goes to home care services. The average OECD country devotes 30% of its long-term care budget, in the form of compulsory insurance or governmental spending, to home care.16 Despite a policy emphasis on moving away from the institutionalization of individuals, public health care funding attributed to home care averages only 4.1% in Canada.17

Home Care Services and Caregiving

165

Table 6.1 Inquiries into home care since 2000 (excluding follow-up reports) Year

Office

Title

2001

Vérificateur général, QC

Services à domicile relevant du réseau de la santé et des services sociaux

2002

Auditor General, NS

2008* Auditor General, BC

Health: Home Care Home and Community Care Services: Meeting Needs and Preparing for the Future

2008

Auditor General, NS

Health: Home Care

2012

Ombudsperson, BC

Best of Care: Getting It Right for Seniors in British Columbia (part 2, vol. 1)

2012

Protecteur du citoyen, QC

Chez soi: Toujours le premier choix?

2013

Vérificateur général, QC

Services à domicile

2015

Auditor General, ON

Community Care Access Centres: Financial Operations and Service Delivery

2015

Auditor General, ON

CCAC – Community Care Access Centre – Home Care Program

2015* Seniors’ Advocate, BC

Monitoring Seniors’ Services

2015

Auditor General, MB

Home Care Program

2017

Seniors’ Advocate, BC

2017* Seniors’ Advocate, AB

Caregivers in Distress Building a Strong Foundation

* A yearly report that began in 2015 (BC) and 2017 (AB)

This chapter presents an overview of home care services in Canada and summarizes the ongoing challenges in this complex policy area. The following section discusses the important role of informal caregivers, who continue to be the primary care providers. The third section analyses home care and caregiving across the four lenses (intergenerational, medical, social, and organizational) while the conclusion summarizes the core points and discusses the particularity of home care in relation to both pensions and health care. Home Care Services in Canadian Provinces

What Is Home Care? Prior to describing the underlying policy environment in Canada, it is imperative to define what home care refers to. The range and scope of interventions is the primary differentiating element.18 The Canadian Home Care Association defines home care as “an array of services for people of all ages, provided in the home and community setting, that encompasses health promotion and teaching, rehabilitation, support

166

Public Policy and Population Aging

and maintenance, social adaptation and integration, end-of-life care and support for family caregivers.”19 This encompassing definition includes two components. First, it involves health care at home; this health component is sometimes referred to as home health or home health care. This features medical visits at home and other professional services, such as rehabilitation services typically provided by health care professionals like nurses and occupational therapists. Frequently labelled home support or social care, the second component is eclectic and is best described by what it does not include, namely health care. It is also described as non-medical support. This component typically features personal assistance/care (hygiene), home assistance/ domestic help (meal preparation, cleaning), and civic support (administrating a budget). In some cases, it also includes services for caregivers and day programs. It is important to note that case management is a function carried out mostly by social workers and nurses who plan and coordinate both aspects of home care services. What is actually covered by home care remains an open question, even within public authorities, especially in the social care realm. For example, as pointed out by the Manitoba auditor general, the Department of Health does not describe precisely which services regional health authorities (RHAs) must provide, since the home care guidelines refer to the principles of comprehensiveness, coverage throughout the province, and universality. This results in services such as housekeeping, laundry, and safety check not being available everywhere.20 In this chapter, the focus is solely on services targeting older adults and their caregivers. Still, the reader should keep in mind that population aging is a growing preoccupation for social service departments, despite their traditional focus on a younger clientele. For example, individuals with developmental disabilities have also experienced a noticeable increase in their life expectancy. Few interviewees mentioned that the parents of these individuals are getting older, raising multiple problems in ensuring that sufficient support is available to avoid institutionalization.21 The Canadian Context of Home Care: Common Challenges The Canada Health Act (CHA) covers primarily hospital care and necessary medical treatments. This policy structure and approach to health care is ill equipped to tackle long-term home care for older adults due to its non-curative nature. It necessitates interventions in a population that is losing its physical and cognitive ability, as part of what is

Home Care Services and Caregiving

167

commonly referred to as normal aging in health sciences, and/or experiencing multiple chronic conditions.22 Accordingly, a senior manager in a regional health authority in a western province claimed that the major problem with Canada’s health care system was adoption of an institutional as opposed to a service-based model of care.23 This opposition in modes of intervention and financing has had dire consequences for the development of home care policies in Canada. Home care is an “extended health service” under the CHA, meaning there are no governmental obligations to offer minimum services.24 Still, the federal government does not relinquish its role in steering health care spending towards specific priorities, and home care has recently appeared on the agenda. In 2017 the FPT ministers of health concluded an agreement with 11 billion federal dollars earmarked for mental health and addiction services and home and community care. This institutional environment has pushed home care to the margins of the health care system,25 with private spending on home care exceeding public expenditure.26 Home care – for all ages – represents only 2% to 7% of public health care spending in Canadian provinces.27 As a direct consequence of the low level of public funding in home care, the public sector covers a small fraction of older adults’ needs. A Quebec study of local health and social services concludes that their services cover only 8% of older adults’ comprehensive care needs.28 Consequently, the informal sector plays a vital role, and there are multiple purveyors of services involved in this field. As briefly mentioned in an ombudsperson’s report in British Columbia, “Home and community care … is a complex and interconnected system involving a number of provincial government authorities as well as private service providers (both forprofit and non-profit).”29 Public sector involvement in home care is also quite complex. Without a federal framework comparable to the CHA, there are no minimum requirements across the country. Provinces have considerable flexibility in setting their intervention priorities and admissibility criteria, though recent federal involvement in home care indicates that this may be slowly changing. Theoretically, this institutional arrangement should result in a stronger focus on local adaptability instead of harmonization, as prescribed, for example, by the CHA in health care. In Scandinavian countries, municipalities manage home care services with a local adaptability approach, resulting in “unequal, but equitable” services.30 However, this tension is rarely discussed, at least explicitly, with harmonization being the overwhelming element targeted and evaluated within provinces, despite multiple factors warranting local adaptability, such as

168

Public Policy and Population Aging

service delivery in territories with low socio-economic status and/or a predominantly rural environment. There are few reasons why provinces have actually opted to harmonize public services, as opposed to embrace local adaptability. Provinces prioritize medical services. In all provinces, with the noticeable exception of New Brunswick, it is the ministry/department of health (and its agencies), and not social service departments or municipal departments, that has the primary responsibility to deliver and regulate home care. As a result, policy goals mirror the goals of health services. That is, they seek to offer similar services across the territory and use an assessment tool (most provinces use InterRai Home Care), which focuses narrowly on the ability to perform activities of daily living.31 This results in a policy objective requiring that assessment scores result in similar services across a province, a powerful instrument to encourage harmonization. Provinces are also increasingly centralizing their health services, adding another element pushing for harmonization. With the federal government adding home care conditions in the latest round of health care transfer agreements, the role of health care in home care will likely remain predominant. As such, the Canadian approach to home care resembles that of the United States, with its biomedicalized approach to social services for seniors.32 The fragmented landscape of home care makes governance an ongoing issue with organizations, workers, caregivers, and older adults needing assistance, all having different objectives and approaches to home care. This makes it very difficult to coordinate a coherent plan of action for older adults who require home care. Adding to this difficulty, provincial governments also deploy programs to bolster home care, targeting service providers (public, private, and nonprofit), older adults, and caregivers and utilize different instruments, such as regulations, tax credits/subsidies, and co-funding programs for specific initiatives. Indicative of how easily one can get lost in this maze of actors and programs, the Canadian Institute for Health Information struggles to obtain a clear and accurate picture of the field.33 Moreover, the lack of proper measures (i.e., indicators) for multiple aspects of home care has been a constant and continuous criticism of Auditor General and Ombud Offices in the five provinces that conducted inquiries on home care (British Columbia, Manitoba, Ontario, Quebec, and Nova Scotia). For example, the 2008 Nova Scotia audit states that “performance and statistical information [are] inadequate,”34 and the 2015 Manitoba audit reports issues with a wide range of performance statistics including service volume, service quality, and client outcomes.35

Home Care Services and Caregiving

169

This also raises issues with compliance in the enactment of governmental policies by third parties. Audits question whether compliance systems actually exist. In 2008, the Nova Scotia auditor general was far more explicit than others when he revealed that there is simply no compliance system.36 There are mechanisms to ensure compliant behaviour: incentives and sanctions, monitoring, enforcement, information requirements, attitudes and beliefs, peer effects, target resources, and autonomy issues.37 Most of these barriers are present in some form in the current governance infrastructure in home care across Canada. For example, monitoring is one of the most important contributing elements to facilitate compliance.38 This is actually a core critique of many audits. The 2017 report of the Nova Scotia auditor general indicates that there is no comprehensive monitoring of home support providers;39 this is also not done consistently in Ontario40 or in Quebec.41 Compliance issues are not only confined to non-governmental actors. In 2015, the auditor general of Manitoba reported that the Department of Health, Healthy Living and Seniors fails to monitor the compliance of its own home care standards by Regional Health Authorities.42 Similar issues are reported in audits from BC,43 Quebec,44 and Ontario.45 Governance issues are particularly noticeable from the perspective of users and caregivers.46 Even within formal health care provision, the continuous specialization of medicine creates a fragmentation in delivery of care in multiple settings. For older adults and their caregivers, this cocktail produces an extremely complex field to navigate, to the point where system navigation to ensure proper care and treatment for older adults and their caregivers is an emerging field.47 As discussed previously in the seniors’ secretariat chapter, the first major request of older adults across the country has been clarity about services offered in the form of a seniors’ guide or handbook. These complaints are also omnipresent in reports from ombudspersons and seniors’ advocates. Finally, home care remains a gendered profession, with women occupying the vast majority of jobs in the formal sectors and providing the most informal care. According to the 2011 National Household Survey, women represent 77% of all social and community service workers, 86% of all nurse aides, orderlies, and patient service associates, and 93% of all registered nurses and registered psychiatric nurses.48 In the non-profit sector, a Quebec study of social economy enterprises in home support indicates that 93% of their workers are women and are mostly aged between 46 and 55.49 Women working in the non-profit sector also tend to earn a wage slightly above the minimum wage with few social benefits, in contrast with social services workers in the public sector.

170

Public Policy and Population Aging

While acknowledging an aging population and seniors who prefer to age at home, a senior policy analyst in an Atlantic province quickly identified labour market challenges as a major hurdle to successful home care. The analyst emphasized that this is a predominantly female labour force that is also aging. Ongoing recruitment is very difficult for multiple reasons, such as the low interest from younger workers to opt for this profession, the rising complexity of care, the low pay, and labour shortages in other sectors.50 This is clearly in line with the conclusion of a study of Ontario home support workers who operate in the unregulated end of the home care continuum under poor working conditions and with minimal training whose labour remains “largely invisible in the context of public discourse about home care.”51 Classifying Home Care Models in Canada By virtue of being an “extended health service,” provinces have had far more flexibility in the development of their policy preferences, especially in comparison to retirement and health policies, as we saw in chapters 4 and 5. Early on, provinces sought to provide home care on a basis consistent with the CHA, meaning the development of public programs with access to those who qualify. This includes, for example, the establishment of a home care program in Ontario in 1970 and Manitoba’s coordinated continuing care program in 1974.52 Manitoba remains entrenched within a public service provision model, while Quebec’s soins à domicile program has progressively delegated home support functions to third parties, mostly social economy enterprises. Multiple jurisdictions embraced New Public Management practices in the 1980s, and this has had strong repercussions on home care policies in provinces such as Alberta, British Columbia, and Ontario, where right-wing governments pushed for the introduction of market mechanisms. This foray into the private sector has been possible in home care because of its status outside the CHA. The influence of New Public Management, both as a modus operandi within the delivery of services in the public sector and in relationship to the creation of quasi-markets involving non-profit and for-profit organizations is highly visible.53 This has also occurred within a broader health care organizational restructuring where Canadian provinces established semi-independent regional health authorities (RHAs) to deliver health care, including home care (with the noticeable exceptions of New Brunswick and Ontario). Ontario established Community Care Access Centres (CCACs) specifically to tender contracts to deliver home care services. It is worth noting

Home Care Services and Caregiving

171

that the emerging trend has been to reduce the number of RHAs. For example, Manitoba established 13 RHAs in 1997 and the number gradually diminished to 5 following the 2012 reform. Alberta and Saskatchewan recently integrated all of their RHAs into a province-wide entity (Alberta Health Services and Saskatchewan Health Authority). Quebec went from 146 Local Community Services Centres (CLSCs) in the late 1990s, to 95 Health and Social Services Centres (integrating some hospitals and public long-term care facilities) in 2004, to 22 Integrated Health and Social Services Centres (CISSS)/Integrated University Health and Social Services Centres (CIUSSS). The purveyors of services include private sector companies and an eclectic collection of voluntary/non-profit organizations. Private operators vary significantly in size, ranging from small local initiatives to large corporations listed on the Toronto Stock Exchange. Large corporations, or at the very least their investors, prefer to invest in the development of retirement housing (RH), where retirees can select services à la carte. Profit margins in this area are higher than in the operation of long-term care facilities and home care services.54 Voluntary and non-profit organizations are very eclectic, and provinces rely on them – formally and informally – to extend the coverage of social services. They include, for example, the Victorian Order of Nurses (VON), a non-profit charitable organization active in Nova Scotia and Ontario that provides a wide range of services such as caregiving support, adult and Alzheimer’s day programs, homemaking, and personal services.55 It is, in fact, the primary provider of professional nursing care services in Nova Scotia with $37.1 million received in payment in 2007–8.56 An analysis of welfare markets illustrates nicely the contribution of the private sector in home care across Canada. In her comparative analysis, Gingrich identifies six types of markets in the welfare state along two dimensions: allocation and production.57 The allocation dimension refers to the interplay between the price and selection of services, which has consequences for who is primarily responsible to access services. When the government enters into a contract with service providers, the primary objective is to seek the lowest cost possible, with bidders vying for the contract. If the primary aim of the welfare market is to enhance choice and allow for a greater variety of services, the responsibility to access the services falls to individuals. The production dimension focuses on the extent to which the competitive environment in the market favours the state, beneficiaries, or the service providers. The state targets value for money, beneficiaries prefer high quality while paying indirectly via taxation, and providers seek profit.58

172

Public Policy and Population Aging

In Canada, among the six types of markets identified by Gingrich along the allocation (collective or individual) and production (state, users, producers) dimensions,59 two types of home care markets are present. First, there is a managed market, where the state has substantial control over production by fostering competition among providers (private and not-for-profit) to capture delivery contracts within specific territories and\or services. In addition, it is the state – and not potential beneficiaries – that selects which providers operate within a territory. Contrary to other types of markets, providers cannot push costs onto customers, and efficiency gains are needed to remain competitive and secure future contracts by offering the lowest costs.60 In most cases, regional health authorities enter into contracts with service providers and are responsible for monitoring their performance. Services are typically provided free of charge or are income-tested following an assessment performed by a public employee from the RHA or CCAC (Ontario). Second, ceilings for the type and amount of services provided allow private sector actors to enter the home care market by providing additional and/or complementary services. This results in a private power market, which is at the other extremity of the ideal types Gingrich constructed, since this is a very producer-driven market, with providers able to supply a wide range of services while having a great deal of power to set prices. Individual users can select and pay for the services they want to access, and they bear the costs of these services (although some tax credits may be available). Private operators can even develop their own assessment tool to guide customers to select the best range of services offered. The role of the state is minimal.61 The coexistence of these two specific markets in home care is sometimes quite visible. The care options and cost website from the Ministry of Health in British Columbia clearly indicates the underlying conditions within which potential beneficiaries can access these two markets. In the state-driven managed market, potential beneficiaries can approach health authorities to receive subsidized services. Potential beneficiaries must undergo an assessment performed by the health authority to evaluate their needs and eligibility. The site clearly states that subsidies originate from the Ministry of Health, while services are “administered and delivered by the health authority and contracted providers.”62 More importantly, the site stresses that individuals have very limited options in which types of services they receive, since these decisions are made on the basis of the formal assessment. When accessing the producer-driven private power

Home Care Services and Caregiving

173

market, the website emphasizes that individuals can shop for services, which are negotiated between providers and users, and that the government does not provide financial assistance to individuals or service providers.63 Beyond the accessibility and generosity of publicly funded options in home care, an important element to consider when analysing the increasing role of private providers in the private power market dynamic is the ability of older adults to pay. With home care/longterm insurance playing a marginal role – a situation unlikely to change in the near future, with 74% of Canadians not including this kind of provision in their retirement plans64 – current income plays an important role in staying in one’s home. The median income of unattached retirees is $26,100 and it declines as they advance in age. As a result, low income is still prevalent for many older adults, most notably widows who relied strongly on their husband’s income.65 As mentioned by a senior civil servant coordinating care responses in her province, public authorities are faced with a conundrum: “Most seniors tend to be quite poor…. Still, from a critical point of view, we need the private sector to increase our capacity.”66 When discussing the role of the private sector in home care, a senior official in a regional health authority raised the same issue: “They [private sector providers] are very interested in middle- to high-income earners. The problem is that most sick elderly tend to be poorer, and it is difficult to find partners for those who are really in need.”67 Indicative of this environment, 71% of BC seniors qualify for subsidized home support services, making them eligible to receive these services free of charge.68 Hence, unless public authorities increase the range and depth of their home care services substantially, the presence of non-profit and voluntary organizations remains essential to expand the coverage and affordability of public and private services. With these elements in mind, there are four delivery models of publicly funded home care in Canada (see table 6.2). It should be noted that these should be interpreted as ideal types because there is a wide range of policy tools deployed in this sector; even public models rely on private sector agents to fulfil some of their needs, and this varies even within provinces. In addition, it is important to stress that these policy mixes do not necessarily correlate with generosity and accessibility of home care. New Brunswick and Manitoba are leaders in this regard but rely on a different delivery model. To simplify the analysis, the development of home care in a representative province follows the description of each model.

174

Public Policy and Population Aging

Table 6.2 Publicly funded home care models in Canada

Public delivery home health care

Public delivery home support

Mixed delivery home support

Private delivery home support

Public service model MB, PEI, SK

Mixed public managed market QC*

Mixed managed market NB, NL, BC

Mixed delivery home health care

Semi-comprehensive managed market AB, NS, ON

* Carried out mostly by EÉSAD; contracting out

The first model consists of a public system where home health care and home support are provided primarily by the public sector.69 This public service model is present in Manitoba, PEI, and Saskatchewan. Manitoba has the oldest publicly funded province-wide home care program70 and one of the most generous in Canada. Instituted in 1974, through a provincial Order in Council, it provides universal coverage – albeit with a resource test – with one objective being to delay (or even to prevent) institutionalized care. It covers all ages, with seniors comprising 71% of beneficiaries.71 The Department of Health, Seniors and Active Living sets the standards for the home care program, and the five regional health authorities independently manage and deliver home care services. In the Winnipeg area, the scope of home care infrastructure “is about the size of two-and-a-half hospitals.”72 Its budget grew from $252 million in 2007/873 to $359 million in 2016/1774 – an increase of 42%. The Portraits of Home Care 2013 reveals that Manitoba spends substantially more per capita ($241) than the Canadian average ($150).75 Similar results occur when analysing the share of home care spending out of total health spending, with Manitoba being one of two provinces to devote more than 5% of its health expenditure to home care (5.8%).76 Manitoba has been the sole province to stay clear of market-based principles and the development of quasi-markets. After a one-year flirtation with private service provisions, the province performed a reversal amidst rising costs and a much higher personnel turnover rate.77 Other provinces rely to varying degrees on the services of providers from the private/non-profit sector. The second model consists of a mixed public managed market where home health care is provided by regional health authorities and home support by a domestic help social economy (entreprises d’économie sociale en aide à domicile – EÉSAD). Quebec is the sole province with

Home Care Services and Caregiving

175

such a model. Established in the mid-1990s under a PQ government, EÉSADs offer a wide range of home support services, in effect gradually replacing some of what was historically offered by local health and social services (CLSCs) and providing services beyond them. The provincial government encouraged the development of these entities, since services cost much less than those offered formally by local health and social services centres. Consequently, this allows the coverage of a higher number of older adults. There are 100 EÉSAD across Quebec offering more than seven million hours of services to 100,000 users.78 EÉSADs rely strongly on the programme d’exonération financière pour les services d’aide domestique (PEFSAD), which provides users with a fixed subsidy amounting to $4 per hour (tax credit) and a variable subsidy per hour of up to $11.44, for a maximum total of $15.44 based on a need assessment conducted by the RHA and revenues. In addition, the PEFSAD program provides a compensatory allocation directly to EÉSADs to facilitate their operation. In 2017–18, $60.09 million were given to qualified users and $21.15 million to EÉSAD.79 The gap between the subsidy and the hourly rate has been steadily rising, in part as the result of poor indexation by governmental authorities and wage pressures. For example, it costs $22.45 per hour for cleaning services with Répit-Ressource de l’Est de Montréal, which operates in a poor region of Montreal.80 This figure is quite considerable, considering that 45% of the individuals benefiting from PEFSAD are over 75 years old and 71% are women,81 two categories of people more likely to live in poverty. In the third model, home health care is provided mostly by public employees, while home support is delivered by private agencies, with the province offering subsidies to cover the cost. This mixed managed market is present in British Columbia, New Brunswick, and Newfoundland and Labrador. On the basis of two key metrics, spending per capita ($249) and the percentage of health care expenditure devoted to home care (6.4%), New Brunswick ranks first in Canada.82 New Brunswick’s home care policy grew substantially from its modest origin in 1972 with the implementation of the Extra-Mural Hospital Program in 1981, also known as “hospitals without walls.”83 Interestingly, an interdepartmental committee composed of senior civil servants and politicians proposed the idea to tackle upcoming challenges from an aging population, to reduce health care costs, and to favour non-institutional approaches. Despite strong opposition from the medical community and the initial costs to set up the program, the professional civil service convinced the government to move ahead with this plan.84 This stood

176

Public Policy and Population Aging

in stark contrast to Nova Scotia, which has faced similar demographic challenges, who could not move past the opposition from the medical association, resulting in the adoption of small ad hoc measures.85 Still today, New Brunswick is the only province where home care responsibilities are shared by the Department of Social Development and the Department of Health. The latter oversees the Extra-Mural Program, implemented by both regional health authorities. The program is financed and managed by the public sector. The Department of Social Development has the mandate for home support services. The department subcontracts these services to different types of private service providers. Indicative of an eclectic landscape, the New Brunswick Home Support Association comprises 45 service providers.86 This division of labour has also fostered stronger emphasis on the social dimensions of care, relative to other Canadian provinces, with Social Development having its own budget to manage home support services, which represents 60% of home care expenditure.87 As mentioned by a former deputy minister, the “seniors file is wrapped up totally with social services.”88 Home support has had an easier time flourishing within its own department, while coordination is facilitated by the smaller size of the New Brunswick civil service. The money allocated per capita to home support in New Brunswick ($151) is slightly above the Canadian average for all home care expenditure per capita of $150.89 Fourth, some home health care functions are performed by both public and non-public organizations, and home support is contracted out. Hence, it represents a semi-comprehensive managed market, since it encompasses both core dimensions of home care, albeit a partial home health care managed market. This is the case in Alberta, Nova Scotia, and Ontario. In Ontario, the current infrastructure originates from the 1996 reform, which instituted a comprehensive managed market for both home health care and home support. The government created Community Care Access Centres (CCACs), not-for-profit public organizations, to manage the assessment, coordination, and procurement of both home health care and home support.90 Following a reform in 2017, CCACs transitioned into the Local Health Integrated Networks (LHINs), which now fulfil these responsibilities and report to the Ministry of Health. There are 160 private service providers throughout the province.91 Care coordinators, who are health professionals employed by the 14 LHINs, play a crucial role by conducting individual assessments and facilitating the liaison between care providers, health services, and

Home Care Services and Caregiving

177

community organisations, which offer complementary benefits and services. Recently, the government mandated the then-CCACs to expand their role in direct patient services in three areas: rapid-response nurse program, mental health and addictions nurse program, and palliative care nurse practitioner program.92 As a result, wages now represent 27% of the former CCACs’ expenditure, while the amount granted to health services providers continue to constitute the most important portion of expenses at 62%.93 These models provide a snapshot of the diversity of arrangements throughout Canada. These models have some limitations, since they do not reveal the extent of privately funded home care efforts in each province and the depth of the public coverage (both in the number of services offered and their intensity). One would suspect, for example, stronger reliance on private and informal channels in Saskatchewan, where 3.8% of the health budget is devoted to home care,94 than in Manitoba, with its more substantial commitment to publicly funded home care (5.8%).95 In addition, the models also conceal similarities and convergence. All provinces rely to some extent on nursing services that are contracted out, assessments are made by public employees, and home health care tends to be free of charge, while home support is mostly means-tested.96 In terms of convergence, it is worth noting, on one hand, that both Manitoba and Quebec have granted contracts to private sector firms to complement the services of their public agencies.97 Recently, the Laval regional health authority in Quebec awarded a contract to a private firm instead of its local EÉSAD.98 A news report from Radio-Canada reveals that private firms provide more than 50% of home support services in three regional health authorities in Montreal,99 suggesting a trend towards a mixed managed market. Meanwhile, in Manitoba, the Winnipeg Regional Authority awarded a $15.7 million contract to two private providers to provide intensive home care following hospital release.100 In response to criticism raised by this contract, the Manitoba premier signalled that the private sector is likely to play a larger role in the province: “We are looking for major change to happen within our system and we are being attacked for trying to improve a system that is the worst in Canada.”101 At the other end, provinces relying strongly on the private sector have made adjustments to scale back some of the negative impacts of past reforms. This includes, for example, suspensions of competitive bidding in Ontario for a wide range of reasons, such as lack of consistency in services, turnover of support workers due to a change in service providers, lower quality of care, and less cooperation among providers.102

178

Public Policy and Population Aging

Regardless of the regulatory environment in place and, consequently, the type of actor operating in the home care space, a Quebec-Ontario study stresses that the infrastructures in place aim primarily to organize the supply of services rather than service demands.103 For the most part, provinces continue to attribute funding on the basis of historic budgets. The Role of Partisan Politics With home care being far less institutionalized than other policy sectors, such as health care and pensions, provinces have had far more flexibility to embrace policy options closer to the political preferences of government. In the welfare state literature, partisan politics has traditionally played an important role in the development of social policies, with left-wing parties favouring public alternatives to tackle social risks in an encompassing manner.104 Some support for this theoretical position also prevails within Canadian provinces, at least in income inequalities among working age populations.105 Evidence of a left-wing partisan legacy can be found in Manitoba, Saskatchewan, and Quebec, where NDP and PQ governments embrace a public service approach to home care. In recent decades, however, the literature has focused more on the capacity to withstand welfare state retrenchment106 and the extent to which New Public Management has been embraced by public authorities.107 As a result of its weak institutionalization and the absence of a strong beneficiary group, which are key ingredients to prevent the retrenchment of the welfare state, home care has been far more vulnerable to the flux of partisan politics. Partisan politics plays an important role in the choice of market mechanisms embraced by government. Typically, right-wing parties favour market tools that increase the number of service providers and reduce the size and influence of the state. In Ontario, the Conservatives under Mike Harris advocated the proliferation of “producers,” which is a preference aligned with right-wing parties. Recent decisions to enlarge the number of service providers in Quebec and Manitoba, both under right-wing governments, follow a similar logic. There is also emphasis on individual and familial responsibility, typically associated with right-wing parties, in Alberta’s policy initiatives, constructed by previous conservative governments, with clear and explicit references to the role that must be played by families in care. The 2010 Aging Population Policy Framework is very explicit: “Individuals have primary responsibility for preparing for their senior years. This includes meeting their own basic needs, and securing the resources they will require

Home Care Services and Caregiving

179

for the lifestyle they choose as they age.”108 Interestingly, this has the clear advantage of encouraging explicit discussion on what the role of individuals and families should be. During an interview, a senior civil servant stated that determining “what families are expected to be doing” is a key stumbling block.109 Also, maintaining a low ceiling on the quantity of services provided encourages the participation of private actors by increasing the space of additional services one can seek. This is clearly evident in British Columbia, for example, where the commitment to home support has virtually vanished in recent years.110 However, it was an NDP government in the 1990s that eliminated meal preparation, transportation, and housekeeping from the home care program while also restricting the circumstances within which support is offered.111 Left-wing parties seek the opposite, mainly to enhance the efficiency and legitimacy of the welfare state and its popularity with the middle class. As such, it favours market tools that exercise strong control on costs and delivery.112 The creation and expansion of the EÉSAD in Quebec under a PQ government is clearly aligned with this theoretical perspective. In closing, New Brunswick stands out as a very interesting case, since it has clearly been a leader in the field of home care. However, this has occurred primarily under the conservative government of Hatfield. As part of a comparative analysis of home care development, which occurred under conservative governments in both Nova Scotia and New Brunswick, an article stresses the strength and importance of the meritocratic bureaucracy and its ability to plan for the future in the latter jurisdiction.113 Home Care as a Policy Failure? There are multiple obstacles and challenges in the field of home care policy. As a result, and in spite of the unequivocal public support for its expansion, home care faces hurdles to facilitate its expansion and continues to operate at the margins. Ombudspersons and Auditor General Offices across the country have concluded that there is a wide gap between policy intentions, as frequently presented in strategic/action plans, and the actual delivery of home care services. Quebec’s Protecteur du citoyen was very explicit on the importance of this gap in its 2012 report: “Nous assistons actuellement à une répartition des ressources et à un discours justificatif qui donnent l’illusion d’une accessibilité équitable pour tous, mais qui, en réalité, répondent bien peu aux besoins adéquatement évalués des personnes visées.”114 Its most recent

180

Public Policy and Population Aging

report in 2018 claims the situation has actually worsened and that the government is well behind its coverage targets.115 Five provinces have been conducting either audits or investigations from the ombudsperson since 2000 (see table 6.1). By far the most extensive evaluation of home care services occurred in British Columbia with an investigation initiated by the Office of the Ombudsperson. Following complaints about seniors’ care, the office conducted the “longest systemic investigation … and the most comprehensive report” in its history.116 The three-volume report featured an analysis of residential care (parts 1 and 2) and home and community care, home support, and assisted living (part 2), resulting in 143 findings and 176 recommendations! There is some evidence of a substantial retrenchment, which most likely contributed to a rising number of complaints to the ombudsperson. A longitudinal study of older adults aged 65 and above indicates that continuing care costs, which include both long-term and home care, experienced a decline between 15% and 25% for individuals who had more than one year to live, depending on the age cohort, between 1996 and 2001.117 It is worth stressing that no systematic overview on home care policies has been conducted in five Canadian provinces: Alberta, New Brunswick, Newfoundland and Labrador, Prince Edward Island, and Saskatchewan. Interestingly, the Alberta auditor general conducted a review of seniors’ care and programs in 2005 but did not analyse home care services. The report focused on long-term care facilities, the Seniors Lodge Program, and the Alberta Seniors Benefit Program.118 In New Brunswick, the Office of the Ombudsman faced a lengthy political battle to obtain an expansion of its statutory mandate to include a wide range of programs and services affecting older adults, such as home care services, finally gaining approval from the legislature to do so in 2014. The recent creation of seniors’ advocates has already led to the production of yearly reports in Alberta and British Columbia. As a result, home care will likely be more in the public eye in the future. However, these offices have a twin advocacy and monitoring role (albeit not at the individual level, like the ombudsperson), which is producing very different political interactions. In BC, for example, the seniors’ advocate is already pushing for a national strategy on home care with federal standards, stressing the inequities resulting from having to pay for home care in BC while seniors in other provinces do not.119 The office has already had encounters with the BC Care Providers Association, not only on the positions taken by its office, but also on the findings of reports.

Home Care Services and Caregiving

181

The conclusions of these multiple reports are eerily similar. Among the ongoing issues, three broad issues stand out. First, they typically stress that services fail to address current needs, and budgetary allocation is typically disconnected from program needs. In BC, the 2008 audit concludes, “The Ministry of Health Services is not adequately fulfilling its stewardship role in helping to ensure that the home and community care system has the capacity to meet the needs of the population.”120 In the 2015 annual report, the auditor general of Ontario mentioned that funding for Community Care Access Centres (CCACs), the governmental organizations responsible for helping people access home care, is still determined largely by the amount received in the years prior “rather than on actual client needs and priorities.”121 In Quebec, the Vérificateur général reported in 2013 that historical budgets remain the primary tool to allocate funding and that financial needs are not costed.122 Second, in accordance with academic research,123 most reports indicate (or suggest) that access, generosity, and quality of home care services have been declining, despite a growing senior population, most notably in British Columbia124 and Quebec.125 The sustained efforts from their respective ombudspersons have been crucial in bringing these changes to light, and it remains an open question as to what the outcome would be if similar inquiries were undertaken in other provinces. The ombudspersons in both Quebec and British Columbia identify tools to contain costs and retrench services in their respective investigations: a more restrictive use of the assessment tool by regional health authorities and deployment of other exclusionary mechanisms,126 increasing reliance on wait times for assessment and delivery of services,127 a lengthy and confusing system to voice complaints,128 diminution and cancellation of some services,129 failure to communicate the presence of additional programs,130 and consideration of caregivers’ availability in the assessment procedure (which runs counter to the official provincial policy in both cases).131 The BC report Best of Care actually includes a section on the historical development of home care services in the past decades to highlight the declining ambitions in the field, despite a discourse that suggests the contrary.132 Third, recruitment in gerontology is a constant challenge, and the field of home care is not different. The recruitment and retentions of health professionals (nurses, occupational therapists, etc.) and home support workers (including personal care workers) are major concerns across the province. A survey of service providers in Nova Scotia conducted by the auditor general in 2008 is particularly revealing on the scope and depth of current (and future) problems. Among service providers, 20%

182

Public Policy and Population Aging

stated that they did not have sufficient staff to meet current demands, 44% mentioned that current shortages had an impact on how they meet demands, 52% indicated that they have difficulties recruiting and retaining staff, and 44% believed that they would not be able to meet future demands for services. In the same vein, a 2017 survey from SafeCare BC found that 87% of home care workers claimed that their organization is understaffed, most notably among home support workers and care aides.133 In 2011, Manitoba took the unprecedented step of transforming the status of many casual workers into full-time positions. By 2015, 50% of its workforce had achieved full-time status, falling slightly under the initial objective of 60%.134 In spite of these efforts, recruitment and retention remain important challenges, with vacancy rates still oscillating between 8% and 10%.135 Ironically, while auditors and ombud offices point to the lack of proper measures to assess the quality and performance of home care programs, home care professionals have stressed the negative consequences of New Public Management, most notably the paperwork associated with evaluation, and the consequences for their practice.136 A case in point, the Vérificateur général in Quebec strongly criticized the lack of time in clients’ home, with data indicating that home care nurses in the three regional health authorities studied spent only 17% to 43% in clients’ homes in 2011–12.137 Caregiving Most provincial policies state clearly that family members are responsible to provide care to seniors.138 Caregivers play an essential role in the life of older adults with care needs. They provide personal and medical care, facilitate transportation, perform tasks within and outside the residence, and assist with administrative tasks such as care management, budget making, and income tax filings. Caregivers are typically women and most frequently a partner, friend, daughter, or daughter-inlaw.139 Caregivers offer instrumental and emotional support, although the type of assistance offered by men is mostly confined to instrumental support, such as facilitating home repairs.140 Hollander et al. analysed the importance of caregiving provided to older adults. They estimated its 2009 value at $25–6 billion in Canada, which only included caregivers aged 45 and over.141 As a comparative measure, the Canadian Home Care Association estimated that all public expenditures on home care amounted to $5.9 billion in 2010. This includes expenditure from both levels of governments (provincial/territorial and federal).142 With older adults accounting for 61% of home

Home Care Services and Caregiving

183

care beneficiaries,143 total home care public expenditures for older adults is $3.6 billion, which is only 14.4% of the amount of support offered by caregivers. Caregivers could in fact be fulfilling more than 80% of all care needs for older adults.144 Increasingly, provinces have explicitly recognized the contributions of caregivers in policy documents, but measures to support them remain fairly marginal. Indicative of the marginal status of caregiving, a myriad of policy actors from many departments were quick to mention home care as a core issue within aging societies across Canada, but few brought up caregiving and those who did came from health care, community care, and women’s agencies. A De-familializing Model? Welfare state typologies factoring caregiving roles typically focus on the extent to which caregiving functions are assumed by the family, the private sector, or the government. Studies of this kind are prevalent within the comparative welfare state literature. At the micro level, these studies analyse caregivers’ motivations and roles and the impact of caregiving on caregivers. This also includes the interactions between older adults in need of care and caregivers. In the comparative welfare state literature, the marginal treatment of women and the absence of care activities in early typologies have led to stark critiques.145 The role of the family and its interactions with care provision and the labour market within the welfare state has since been the object of multiple studies. But in care provision, far less attention has been paid to caregiving for seniors than child care.146 Succinctly, countries can be classified as familialistic if policies reinforce the caring role, usually resulting in much lower labour force participation for women, and de-familializing when the state or the market alleviates caring functions.147 Canada represents a case of defamilializing by the market.148 Governments play a marginal role in care provisions for older adults, and additional services can be purchased on the market. This assumes fairly accessible services, but that is not necessarily the case, as lower-income older adults rely on private services much less than others, as discussed above. An Ontario-based study of home-based care recipients split evenly between short-term and long-term users revealed that the average costs of care for a fourweek period was $7,670 in 2004. Private expenditures accounted for 85% of these costs, and variables associated with higher needs (such as having four or more chronic conditions) are key determinants of private expenditures.149

184

Public Policy and Population Aging

This state of affairs encourages a distinct labour market trajectory, with women occupying part-time positions while fulfilling caregiving activities and men working full-time150 unless both are high income earners. The lack of formal services results in the assumption that a large supply of (free) caregiving is available, unless one can purchase it. This was stated succinctly in an interview with a senior civil servant working in community care who said, “It is clear that women with a good professional income are not going to be a caregiver.”151 This dual caregiving path is further illuminated when caregiving and labour market participation in Canada is compared to other industrialized nations, most notably Denmark, where need assessments do not consider family members and/or friends care providers.152 Hence, at best, home care services aim to supplement the assistance provided by informal caregivers. This is explicit in many Canadian provinces. The New Brunswick standard document for home support states clearly that home support services aim to “complement rather than replace the informal support network.” Similar statements are included in manuals from most provinces. Moreover, assessing what is available in family resources has proven difficult. In Manitoba, for example, the auditor general stated that determining family resources resembles a negotiation more than an assessment.153 At first glance, Quebec has embraced a Scandinavian approach by stressing that the availability of informal help should not matter in need assessment, which individualizes services for older adults in need. However, there have been reports that regional health authorities have frequently violated this policy directive.154 Caregiving Policies across Canada and Recent Developments Although the vital importance of caregivers is frequently mentioned in governmental strategies and policy documents throughout the 10 provinces, they do not benefit from strong governmental programs to support them, with government authorities relying on a wide range of ad hoc measures instead. Throughout Canada, 38% of caregivers providing more than 10 hours of caregiving weekly report that their needs are not met.155 Most recent assessments denote a reduction in the support offered to caregivers, especially in respite services. If one were to assess a hierarchy of governmental actions and priorities on the basis of the policy tools deployed, caregivers would be far behind home health care and home support. Government actions have focused primarily on specific policy tools such as information

Home Care Services and Caregiving

185

campaigns, change in regulations, targeted fiscal benefits, and project funding, often requiring co-funding from a third party. In 2011, Manitoba proclaimed the Caregiver Recognition Act to bolster awareness of caregiving issues while promising better support and a mandatory progress report every two years. The first of these reports, published in 2015, stressed the creation a caregiver recognition day (1 April), an increase to the Primary Caregiver Tax Credit, and consultations with stakeholders.156 While the measures were minimal, the progress report was quite positive as the result of ongoing consultations. However, the second report, due in 2017, is still missing and there is no indication of any new measures. Elsewhere in Canada, recognition such as caregiver awards and celebrations during the carer’s day/week are now ubiquitous. Information campaigns, which represent a similar policy instrument, include the diffusion of knowledge and tools to provide better care, available services, and information on how to access home care (and residential) options available for older adults. Nova Scotia’s Positive Aging Strategy devotes considerable attention and focus on caregivers throughout. Among the objectives related to caregivers, the strategy aims explicitly to enhance a better use of their output and facilitate their inclusion in health care plans.157 Measures also seek to increase the disposable income of caregivers and offer better employment protection. In a program originally launched in 2009, caregivers in Nova Scotia providing more than 20 hours of care per week are eligible to receive the Caregiver Benefit, an allowance of up to $400 per month, depending on the revenues and health assessments of the care recipients.158 Along similar lines, New Brunswick introduced the Primary Informal Care Benefit in 2018, which can amount to $106.25 per month. Ontario introduced work-leave protection and a tax credit.159 Québec offers a tax credit for caregivers and introduced work-leave measures in 2018.160 Beyond the proliferation and diffusion of these policy instruments, there are indications that publicly funded support for caregivers has been heading in the opposite direction in the past decade. In Ontario, the 2015 report from the auditor general mentions that supports to caregivers are limited and not consistently available. Out of the three Community Care Access Centres evaluated, only one distinguished between caregiver aid and services provided to care recipients, and in the span of three years “the number of caregiver respite hours decreased 16-fold” in large part as the result of a program modification that omitted caregiver respite care.161 Quebec’s ombudsperson reached similar conclusions through a comprehensive analysis of home care policy. The report

186

Public Policy and Population Aging

states that services put in place in the provincial policy for home care for caregivers are rarely accessible, have lengthy waiting lists, and are sometimes non-existent.162 In BC, the seniors’ advocate noted marginal improvement in the number of residential care respite beds (albeit with shorter stay), but a decline in home support hours and access to adult day programs.163 New governmental strategies and actions indicate that the primary source of support for caregivers is and will likely remain in the not-forprofit sector. Newfoundland and Labrador’s update on the Provincial Healthy Aging Policy Framework highlights financial support for a seniors resources centre.164 It can also result in new forms of not-forprofit partnership such as the development of L’Appui pour les proches aidants d’aînés in Quebec, which supports a wide range of local initiatives devoted to caregivers, co-financed by the provincial government and the Chagnon Family Foundation. Impact on Health Status, Labour Market, and Retirement Income The continuous reliance on caregiving has noticeable socio-economic and health consequences that are well documented in social sciences and in the gerontology literature. These consequences deserve attention in planning for an aging society, as they feature significant interdependencies with other important policy issues, such as health, retirement, the status of women, and labour market participation, to name a few. First, caregiving can be rewarding and it can provide a source of satisfaction and enjoyment.165 In fact, many caregivers prefer to provide care rather than having a third party offer services at their home, and both caregivers and care beneficiaries value caregiving.166 This may change with baby boomers who expect to benefit from public services rather than perform and receive caregiving from family members.167 There are, however, ongoing debates on the health impact of caregiving on caregivers.168 The literature on caregiver burden mentions gender, financial stress, social isolation, higher number of hours spent caregiving, and lack of choice in being a caregiver as key factors.169 It is not caregiving in itself that is a burden, but the unrealistic expectations placed upon many caregivers.170 A recent report from the BC seniors’ advocate indicates that 31% of primary caregivers are in distress, which is defined as feeling unable to continue as a caregiver and “expressing feelings of distress, anger, or depression.”171 A Canadian study, using data over a six-year period in the 1990s, indicates a correlation between increased availability of publicly financed home care and improvement in selfreported health status.172

Home Care Services and Caregiving

187

Second, limited provision of home care services has negative consequences for the retention of women in the labour market.173 In Canada, 35% of individuals employed in the labour market provide informal care,174 and 15% of them have had to cut their number of work hours, while 10% refused a promotion or a better position elsewhere.175 There are no meaningful differences in the labour market participation between caregivers and non-caregivers. However, when caregiving intensity is considered, results are very different. Both men and women who are primary caregivers are significantly less likely to be in the labour market, but this status has surprisingly limited impact on wages and on the number of hours for those employed.176 Third, as a result of a more precarious attachment to the labour market, caregivers have a higher risk of relying on a reduced pensionable income. Partly as a result of caregiving activities, women are far more likely than men to depend on the Guaranteed Income Supplement,177 and high-intensity caregiving strongly correlates with early retirement for both men and women.178 There is also a strong gender dynamic at play in retirement timing. US data suggest that while wives caring for their husbands are five times more likely to retire early, compared to non-caregivers, husbands caring for their wives are slower to retire, compared to men who are not caregivers.179 Home Care as a Universal Solution for Population Aging? Throughout this book, competing lenses define policy problems in distinctive manners to tackle the challenges of an aging population. In most cases, this results in policy prescriptions that are distinctive, or even opposed to one another. In home care, it represents – a priori – a policy objective that resonates with all four lenses, and it is an appealing and ubiquitous solution in all provinces. However, the means to expand it substantially to facilitate a shift away from hospital-based health care and to account for an increasing number of individuals requiring assistance are sorely lacking and trigger very different types of responses from the perspective of each lens. The Intergenerational Lens The intergenerational lens focuses on the impact of policy choices across generations, with analysis relying heavily on the costs and benefits of programs per cohort. As discussed in the previous two chapters, cost projections for pensions and health care are frequently utilized to justify reforms to ensure a better equilibrium across generations. Thus, a

188

Public Policy and Population Aging

strategy that proposes long-term cost reductions, which could take the form of expending home care, is bound to be widely popular among decision-makers. With such a focus on costs over the long term, home care delivers health care services that cost far less. The narrative on home care being less expensive than long-term care and hospital care is used frequently and plays an important role in the justification for an expansion of its services. For example, a magazine article celebrating the 40th anniversary of home care in Manitoba states that home care costs $200 per day, as opposed to $800 for an average stay in a hospital ($2,000 in intensive care).180 In Ontario, the home care services webpage on facts and figures includes a table with an average per diem cost comparing hospital bed ($842), long-term care bed ($126), and care at home ($42).181 As such, it delivers a powerful argument and narrative on how to contain health care costs amidst an aging population. At the root of generational accounting is a lack of transparency on long-term expenditures, which mask the consequence of (previous) policy decisions and potential intergenerational transfers. In the case of home care policies, however, long-term projections and forecasting could well illustrate the positive impacts of investing more in home care. However, long-term planning is notoriously absent. Provinces still function with historic budgets, and financial adjustment to home care budgets have been widely irregular. Long-term evaluations of needs and their costs are lacking. In light of her investigation and the previous report from the auditor general, the BC ombudsperson concludes that challenges in home care would be very difficult to resolve without a “clear process for forecasting needs, a plan for the resources required to meet those needs, tracking of the funding assigned to home and community care service delivery, and evaluation and reporting of the results that funding produces.”182 This case illustrates home care planning quite well in Canadian provinces. The result is that many, if not most, provinces have experienced a relative decline in the quality and quantity of services offered due to the increasing number of older adults requiring services, which can be partly explained by the fact that budget increases in home care have remained below expenditure growth in other areas of health care. This is at odds with the increasing number of strategic/action plans put in place in many provinces on home care. However, the vast majority of these plans consist of specific measures and policy intentions, usually with a very short-term horizon. Quebec’s action plan on aging released a few months prior to the 2018 elections illustrates this very well. It consists of 85 measures ranging from commitments such as

Home Care Services and Caregiving

189

supporting more research in aging in partnerships, granting a tax credit for grandparents hosting their grandchildren during their studies, and many other measures where the government seeks to promote activities or to sensitize the population on specific realities of aging.183 This makes it relatively easy for governments to keep track of commitments and set themselves up to receive a high score on their engagements. However, this falls short of an actual long-term plan that considers future needs and challenges. Manitoba conducted the most exhaustive review of home care policy in 2016 with the objective of developing a comprehensive long-term plan.184 The structure of its program, being a public provider without strong reliance on the private sector, helps to provide a clearer picture of future needs. It involved consultations with all stakeholders, demographic and clinical data, and the use of internal documents. In long-term needs and challenges, the three scenarios – based primarily on different expenditure growth rates – estimate home care expenditures to reach between $648 and $897 million by 2037, which is more than double current costs ($324 million). Equally important, however, is the human resources need estimated at requiring an addition 90 to 100 full-time equivalent workers per year until 2037 – a daunting challenge, considering the current vacancy rate of 8–10% and millennials with work expectations very different from those of current workers.185 An important element often neglected in intergenerational discussions is the long-term financial consequences of relying strongly on informal (and unpaid) means to provide home care. Reducing the costs of formal home care simply transfers the intergenerational issue elsewhere and accentuates gender differences. There are many hidden costs associated with caregiving, such as foregone employment opportunities, worker productivity, out-of-pocket expenditures, and social wellbeing costs.186 As discussed in the section on caregiving, these labour market impacts eventually feed into retirement contributions and result in lower levels of generosity. The most prominent intergenerational issues in home care/caregiving policy debates and analyses have a micro foundation. They tackle intergenerational exchanges and different expectations of old age. First, caregiving is de facto a continuous and dynamic intergenerational exchange across generations featuring at least six dimensions of solidarity.187 Much is said about the sandwich generation, which provides care to both children and seniors, but the fact that older adults also provide care to their children, grandchildren, and their partners is often overlooked.188

190

Public Policy and Population Aging

Second, increasing attention is being given to the impact of the baby boomer cohort shifting from being primarily a group that provides caregiving to one receiving care. This will result in additional strain on future caregivers, who will be far fewer.189 In addition, there is interesting literature that stresses baby boomers expect a high level of services for their parents and reject the notion of caregiving as being natural and the only source of their identity.190 There is already clearly a gap between these expectations and the realities in the field, where caregivers continue to assume the primary role. As part of a 2017 survey with FADOQ members, 22% of respondents expect their local health and social services centre to be the primary care providers, when this is, in fact, the case for only 5.6% of older adults with care needs.191 This conclusion is consistent with the recent developments in home care described in this chapter. Medical Lens Home care represents an integral part of the wider biomedicalization of aging, which extends the domain of application beyond hospitals. In their studies on the evolution of home health agencies in the United States, Binney et al. argue that three main factors indicate the extent to which this process is ongoing: an increasing offering of medical services (some of which are highly technical), the transformation of social problems into medical issues, and the institutionalization of medical doctors as gatekeepers.192 An assessment of the content of this chapter along these three factors points toward a medicalization of home care policies in Canadian provinces. Cost containment in health care and pressure to bring services closer to home are key factors responsible for moving home care atop policy priorities.193 However, this could not have occurred without noticeable improvements in the ability to perform same-day surgeries and interventions. Aligned with findings on the medicalization of home care services in Canada and the United States,194 a 2016 Manitoba report indicates that strong pressure to discharge hospital patients rapidly is pushing home care increasingly in a medical direction.195 As illustrated throughout this chapter, home care operates on a dual track: home health care and home support. The extension of services has clearly benefited the former, while home support has seen a continuous disengagement from the provinces. Other social services, such as respite for caregivers and seniors’ accompaniment, occupy a marginal space within the Canadian approach to home care, while training caregivers to offer complex and technical care is prioritized by health

Home Care Services and Caregiving

191

authorities. In Quebec, this even led to a change in the professional code to allow caregivers to perform tasks in the exclusive domain of health professionals.196 Many provinces are increasingly recognizing caregivers as health care partners, but Canada continues to follow a “carer blind” approach with need assessments and supports targeting the older adults’ needs (almost) exclusively.197 Access to respite remains difficult and it is not available in certain regions. Caregivers must typically justify the need for respite, often via a physician recommendation, suggesting that caregivers must be ill to warrant support.198 Along these lines, the literature in gerontology has produced an impressive number of studies on caregiver burden and its consequences.199 This “carer blind” approach also manifests in debates on the use of technology to offer more care at home. The Canadian Healthcare Association published a position document encouraging policymakers to ensure that home care evolves from the margins to the mainstream, providing a nice illustration.200 While it recognized the key role played by informal caregivers – even stating that more respite, financial support, and recognition are needed – caregivers are absent in the deployment of technology. The document stresses that information and communication technology (ICT) offers valuable opportunities for home care, since it can ease self-monitoring, reduce the number of hospital visits, and provide more peace of mind for care recipients. ICT also offers advantages for service providers. In this analysis, the role of caregivers in the utilization of these tools and their impact on caregiving are simply missing. From an institutional point of view, this absence is somewhat surprising. US studies are quick to point out that Medicare covers home health services, which creates a powerful incentive to develop reimbursable services at the expense of social and community care. In fact, homemaker services were removed from the final bill, since they threatened physicians’ autonomy and did not feel appropriate as part of a medical package. Consequently, in terms of public policy, home care represents an extension of acute medical care in the United States.201 As an extended service in Canada, home care does not benefit from a similar institutional arrangement, and, until recently, the federal government has not provided substantial incentives to develop home care. Yet similar trends are at play. With the federal contribution to health care noticeably lower than in the past, provinces face pressures to contain health care costs. The potential savings offered by home care represent a potent tool to achieve this financial objective, and its deployment may compensate for the lack of incentives akin to Medicare. However, this home care shift occurs within the confines of public expectations

192

Public Policy and Population Aging

aligned with the universality of the CHA. Consequently, home care policies aim – at least in communicating intentions – to extend acute medical care into the home. It is along these standards that home care policies have actually been assessed and evaluated by public bodies. With limited investment in home care, provinces have fallen well short of the standards of the CHA. This also partly explains the increasing similarity of practices across the country and the strong emphasis on harmonization, which makes a lot more sense within a hospital setting than in community care settings. Social Gerontology Lens The social gerontology lens highlights the limitations of the medical lens in home care by stressing a different set of policy problems. A policy approach insisting on providing home care in a harmonized fashion on an assessment tool centred strongly on the loss of physical abilities and cognitive functions is ill-equipped to deal with social issues such as changing family dynamics, gender equity, and poverty. Still, the primary issue with an increasing medicalization of home care is that these efforts tend to replace rather than complement social initiatives targeting older adults and their caregivers.202 This “crowding out” effect spills over onto partner organizations, such as non-profit service providers, which must tailor their activities to secure the necessary funding to pursue their operation and better align the services being offered. While home health care continues to benefit from well-preserved budgetary envelops, albeit still insufficient to address current demands, home support increasingly relies on non-profit associations and private providers to complement the help given by caregivers. The jurisdiction with the most substantial budget for home support is New Brunswick, which has preserved this important home care policy domain away from regional health authorities. The primary instrument deployed nowadays to bolster home support, when it is not offered (or contracted out) by regional health authorities, consists of tax benefits, and many are means-tested. The government also relies increasingly upon project funding to kick-start initiatives involving mostly non-profit organizations with the hope that these will self-finance in the future and tackle some of the current social needs such as isolation and other non-medical tasks such as transportation. In sum, the instruments deployed in the social realm pale in comparison to the efforts devoted to cover medical needs, despite many studies stressing that social efforts have a similar, if not more positive impact on well-being than medical interventions.

Home Care Services and Caregiving

193

The expansion of a medicalized home care has delegated more care responsibilities to families.203 As pointed out by critical gerontologists, aging is very heterogeneous and this extends to care networks. Compared with the previous cohort, baby boomers have fewer children with higher rates of divorce/separation. A genuine partnership with caregivers necessitates a strong awareness of the social environment of both care beneficiary and caregiver with the tools to tackle social problems. For multiple reasons, ranging from familial conflict to migration, informal support can also be limited and represent a contributing factor to the isolation experienced by many seniors. Yet home care policies continue to assume, often implicitly, the presence of family members nearby who are willing and eager to offer assistance, while care coordinators must contend with quite different realities. Policy documents frequently mention that most caregivers are women, but measures to address socio-economic consequences are rare. As part of ongoing efforts to raise awareness of the gendered dimension of care and its consequences, Quebec’s Conseil du statut de la femme recently published a lengthy report. Amongst its key findings, the office indicates that 17.1% of women providing care have had financial difficulties as a result of providing informal care.204 Tax benefits are frequently used to support caregivers financially. Still, as a result of the multiple accessibility criteria, few actually benefit from these measures and the levels of compensation remain marginal. For example, Quebec offers a universal tax credit to caregivers who reside with the senior receiving care. In 2015, 53,485 individuals (54% women) received $1,152 on average. In March 2018 the government expanded this benefit to cover caregivers who do not reside with the person receiving assistance. However, in this case, the benefit is means-tested on the revenues of the care beneficiary. A beneficiary earning $27,000 generates a $5 benefit to the caregiver!205 The social consequences of home care policy development also extend to the working conditions of the formal caregivers composed nearly exclusively of women. Home care workers, most notably those involved in home support, typically earn less and have worse working conditions when they work for the non-profit and private sectors. The precarious nature of the work atop the ongoing recruitment challenge in gerontology is partly responsible for labour shortages accentuating difficulties in offering continuous services to older adults in need. It will be interesting to study the long-term impact of the Manitoba decision to improve the working status of a large portion of its workforce.

194

Public Policy and Population Aging

Organizational Lens The organizational lens focuses on the importance of horizontal coordination to tackle the challenges and opportunities of an aging population. In the case of home care policies, however, vertical coordination represents a far more pressing challenge, as a result of policy reforms made recently in health and policy choices to deliver home care. Most notably, home support and social services directed at older adults and caregivers is rapidly evolving into a complex web of actors, instruments, and objectives. The level of coordination difficulty relates to the publicly funded models of home care. As a result of its integrated structure (covering home care and home support while relying predominantly on workers and services provided by health authorities), the public service model (Manitoba) faces far fewer vertical barriers than the semi-comprehensive managed market model (Ontario). It is not just a coincidence that Manitoba alone has prepared a long-term assessment of home care in response to criticism from the auditor general. In other jurisdictions, as clearly illustrated in provincial reports, the high number of actors and the prevalence of formal contracts with third parties generate important challenges to present an accurate global portrait of home care, let alone long-term projections. Regardless of the province, the complexity of home care makes it very difficult to deviate from historic budgets, despite mechanisms established to either encourage market principles or address needs revealed from individual assessments. With this caveat in mind, few horizontal challenges are receiving substantial attention. First, the limits of the Canadian de-familializing model are evident. The use of medical lens prompts policy analysts to focus mainly on policy problems in training, caregiving burden, and monetary compensation to raise their standard of living. This understanding of policy problems in home care understates ongoing transformations with new cohorts of caregivers who are, for example, less likely to identify as caregivers and more likely to have better work opportunities in a labour market beginning to experience shortages. Second, with revenues an integral part of the welfare state, increasing the participation of women into the labour force is offered both as a gender equality issue and one necessary to sustain economic growth.206 Consequently, maintaining caregivers active in the labour force will soon become a priority. So far, measures to facilitate caregiving and continuous participation in the labour market have been tenuous. Recent measures under study or, in some provinces, legislated provide better work protection for caregivers, although few include paid

Home Care Services and Caregiving

195

compensation. With these two elements in mind, one should expect pressure to provide more home care services while most indications point in the opposite direction. Conclusion As indicated, home care has become a very popular policy solution to address complementary concerns, such as rising costs in health care and the negative impact of institutionalizing older adults in poor health, and these coincide with preferences of most seniors to age at home. It is therefore not surprising to discover that expanding home care provision is a ubiquitous policy goal in all Canadian provinces. In stark contrast with pensions (chapter 4) and health care (chapter 5), provinces have had a lot of freedom to enact their policy preferences in home care. Operating at the margins of the Canada Health Act, the role of the federal government is less predominant, and home care has become far less institutionalized. This results in four models of publicly funded home care (public service, mixed public managed market, mixed managed market, and semi-comprehensive managed market), depending on the role played by the public sector and the depth of private sector involvement. Political preferences of sitting governments have had a noticeable influence on the construction of these models with an NDP government in Manitoba (public service model), and a PQ government (Quebec) behind predominantly public models, while the Ontario Conservatives initiated a deep foray of the private sector into home care (semi-comprehensive managed market model). With a more recent history, home care policies have been less entrenched and far more vulnerable to sudden shifts in orientations, as in Ontario, where successive NDP, Conservative, and Liberal governments introduce reforms with different delivery models.207 Also, as a result of its functioning within the health care system, the restructuring of regional health authorities has had repercussions for the delivery of home care services. Henceforth, vertical coordination problems foreshadow any attempt to tackle horizontal coordination seriously. In spite of these provincial differences, there are important similarities in the approaches taken by the provinces, suggesting that political differences, at least in the long run, will have much more to do with how many publicly funded home care services the state will provide and by whom, rather than how. The first lies with the prioritization of home health care at the expense of home support services, consistent with a medical lens. The former benefits from strong recurrent public budget and practices aligned closely with other health care services within

196

Public Policy and Population Aging

regional health authorities. The recent federal agreement on health care financing, featuring commitments in home care and shortened hospital stays will likely cement this alignment. Home support, with few exceptions, has been delegated to third party actors, and community/volunteer groups have been called upon to assume a greater role. As a consequence of these developments and consistent with a market-based de-familialization model, the second commonality is the important role played by caregivers, most notably among lower income earners who can ill-afford to secure services in the private sector. As demonstrated in this chapter, few Canadians have long-term care insurance, and the proportion of older adults in need who have the financial resources to purchase services is very limited. Caregivers are thus called upon frequently to address the shortcomings of home care. Tackling social problems in this context is quite difficult, and governments offer few tools to do so. The current structure in home care is facing headwinds against planning for an aging population. The supply of caregivers will decline, and they will likely face stronger pressures to remain in the labour market. Among retirees, who represent 25% of caregivers, studies indicate that baby boomers have different values and expectations of home care, consisting of a broader understanding of autonomy than the current generation. Recruitment and retention of personnel are major challenges in home care, and these issues are expected to worsen, even with an increasing number of migrants. Lowering qualification standards to enlarge the pool of applicants collides with the push to medicalize homes to sustain aging at home. In a context of low economic growth and a policy landscape consisting of numerous well-established programs, it is difficult to envision the kind of expansion that would address most of the issues identified in this chapter.

7 Central Agencies and Inter-ministerial Coordination

Population aging issues are a tough sale. They are not fully recognized by the public. – Senior civil servant from an executive council

Introduction This is the first of two chapters focusing on population aging as a horizontal problem. Population aging results in inherent, complex, and interdependent policy problems that benefit from strong collaboration across departments and agencies that have diverse and sometimes conflicting mandates. As a result, international organizations, such as the Organisation for Economic Co-operation and Development (OECD), have long been advocating for the adoption of national strategic frameworks to co-ordinate aging-related reforms.1 The aims are to reinforce policy coherence, improve horizontal specialization, and build better public understanding of the issue. A key objective is to avoid the development of policies that generate contradictory incentives such as having a department of labour increase penalties for not joining the labour market while a department of social affairs introduces subsidies or tax credits to encourage women to perform senior and/or child care. The OECD presents concrete examples to illustrate good practices. For instance, Japan adopted a law on ageing society and created the Aged Society Policy Council chaired by the prime minister, which presents a report to parliament every year.2 It features a broad and comprehensive scope that includes elements such as health, learning, promotion of research, and work. Central agencies represent the most common venues and tools to foster coordination.3 While many indications suggest that provinces are

200

Public Administration and Population Aging

more centralized than the federal government,4 this has not resulted in the development of comprehensive strategies to tackle the challenges of an aging population. Nonetheless, horizontal initiatives fulfilling some of the objectives discussed in OECD reports have clearly been enacted, such as Alberta’s Aging Population Policy Framework and Newfoundland and Labrador’s Community Accounts. This chapter relies primarily on interviews with senior civil servants in the central agencies of all 10 provinces, and policy documents. It also draws upon responses from interviews with senior civil servants in other departments in all 10 provinces, since the questionnaire included a specific question on horizontal coordination. Horizontal actions that specifically target seniors are the subject of chapter 8. The focus is on executive councils (also known as cabinet offices in some provinces), ministries of finance, and cross-ministerial initiatives. This was necessary to ensure the coverage of all 10 provinces. There are multiple reasons behind this choice. First, Treasury Board secretariats are also important central agencies, but they were ignored since they are concerned mostly with implementation of the budget and overseeing managerial matters. In contrast, the Ministry of Finance has a much broader and active role in policymaking and a longer-term vision concerning the power of the purse. It also oversees many of the forecasting units where population aging is an important factor in analyses. Second, the Office of the Premier is clearly partisan, and one core objective of this book was to focus on the civil service and move beyond partisan considerations, which tend to have a shorter time horizon. It is important to note, however, that not all provinces clearly distinguish between the Office of the Premier and the Executive Council. In such cases, interviews were conducted with individuals in these offices. Beyond policy documents and secondary literature, interviews were conducted with 33 senior officials within the Executive Council and Ministry of Finance across all 10 provinces. This includes four clerks of the Executive Council, four deputy ministers of finance, associate deputy ministers, senior policy analysts, and directors in the executive council and in the Ministry of Finance. In light of strong interest in demographic change in the report of the Auditor General’s Office in Quebec, two interviews were conducted with senior officials in these offices in two provinces. In one case, the interview was actually with the auditor general. In addition, content from interviews with civil servants in other organizations complements this research material. I begin with a summary of the organizational lens and how it filters the conceptualization of policy problems linked to population aging, as discussed in chapters 1 and 2. Second, I look at how provincial central

Central Agencies and Inter-ministerial Coordination

201

agencies (executive council and ministry of finance) have prepared responses to facilitate a cohesive approach to the interdependencies associated with population aging across public organizations. Third, I present recent initiatives to foster a broader horizontal understanding of its issues. The Organizational Lens and Policy Problems The organizational lens concentrates on policy problems that originate in coordinating government action across public organizations with different mandates and organizational cultures, and that value specific expertise. This somewhat eclectic landscape creates silos that can easily lead to disparate and uncoordinated responses without preventive and remedial action. Public administrations have developed a host of responses to address these issues such as the creation of central agencies, the development of strategic plans, and formal and informal mechanisms to strengthen communication across ministries. On the last point, the vast majority of senior civil servants interviewed across all 10 provinces have emphasized the rapid rise of (formal and informal) cross-ministerial exchanges in the past 10 years. It is, in many ways, the new normal within civil services where senior civil servants can spend up to twice as much time with their peers in other ministries as those within their own department.5 In the case of population aging, uncoordinated actions can have dire consequences. For instance, public policies can create unresolvable dilemmas for informal caregivers if health authorities encourage increased participation in caregiving while employment agencies adopt a more punishing stance on gradual withdrawals from the labour market.6 In the case of health departments, this strategy reflects the desire to delay the institutionalization of older adults, release patients quickly from hospitals, reduce costs, and shift more responsibilities to family caregivers. For employment departments, the focus remains on accentuating the labour-market participation of as many citizens as possible. As such, labour market units have paid increasing attention to workers aged 55 and above, often facing important societal and institutional barriers, which also happen to be a core group of family caregivers. Resolving these interdependencies for a horizontal problem such as population aging is highly complex. As succinctly put during an interview with a senior civil servant in a central agency, the problem is that “ministries are organized by programs, not issues or outcomes.”7 In line with the multiple characteristics of policy problems illustrated in chapter 2, population aging represents horizontal issues for central

202

Public Administration and Population Aging

agencies that have consequences on state machinery, especially in human resources and public programs and policies. Regarding agenda setting, the primary focus is the causal mechanism behind these difficulties and the ensuing complexities in resolving them. It is worth stressing that governmental capacity and interdependencies predominate in policy problem characteristics in search of solutions. Central Agencies Central agencies take different shapes and forms across the 10 provinces. An in-depth analysis of these structures goes beyond the aims of this book, but the underlying organizational features are similar to those found in Ottawa (Privy Council Office, Prime Minister’s Office, Ministry of Finance, and Treasury Board Secretariat). An important distinction across the 10 provinces is the extent to which executive councils or cabinet offices, akin to the Privy Council Office in Ottawa, remain separate from the Office of the Premier.8 For example, Quebec has two distinct organizations, the Ministry of the Executive Council and the Office of the Premier, while British Columbia does not have a formalized structure akin to an executive council ministry. Also, in most provinces, Treasury Board functions are hosted within the Finance Ministry, often as a separate secretariat or branch (Ontario, Quebec, and New Brunswick are the exception). Earlier findings suggest that provinces have historically utilized and benefited from the creation and expansion of central agencies to enact broad strategies. The most famous case is probably the CCF in Saskatchewan, where the Economic Advisory and Planning Board played a key role in the implementation of its broad socio-economic agenda.9 Similar structures also benefited right-wing governments, such as the Social Credit in British Columbia, which strengthened its centre in its attempts to maintain better control of public expenditure.10 The concentration of power within a central agency can further enhance executive power by using it to control better departments,11 but it can also facilitate adoption of horizontal strategies to cope with the challenges of an aging population. The degree of politicization of the civil service also plays an important role within this dimension. As argued throughout this book, the development of long-term approaches to population aging is more likely to be sustainable in civil services that grant important leadership roles to career civil servants, as opposed to political appointees. This section reviews the role of both executive councils and finance ministries to accentuate coordination and facilitate long-term

Central Agencies and Inter-ministerial Coordination

203

considerations related to population aging. In addition, it features an in-depth analysis of the continuous work performed by Quebec’s Conseil exécutif to monitor how population aging affects public policies and programs, and the One Nova Scotia Coalition, initiated by the Commission on Building Our New Economy.12 Executive Council Delegation of responsibilities for population aging to an executive council has advantages. It signals that this issue is a core priority for governments and ensures stronger collaboration from deputy ministers across the civil service. This has been a solution encouraged by international organizations such as the OECD. No province has created a coordination structure linked to an executive council or a Cabinet office devoted to population aging although Quebec introduced a monitoring tool. In one province, a very small unit aimed to facilitate development of capacities in long-term planning and one of the first issues it tackled was the consequences of an aging population. However, this unit was short-lived. A noteworthy finding on the role of central agencies in population aging is the importance of premiers. In Cabinets and First Ministers, Graham White demonstrates that premiers have tremendous power over the policy agenda and can push their priorities efficiently as a result of the strong policy capacity and strength of their office. In the absence of a priority signal from the premier, individual ministries tend to conduct business as usual with a more collaborative approach in Cabinet.13 Throughout the interviews across the country, policy initiatives strongly endorsed by the Premier’s Office were easily identifiable by the visibility of the actions, but also by the allotted resources. Over the past 20 years, premiers have seldom made population aging a priority. Perhaps the most notable is Ed Stelmach in Alberta. Originating from a rural area, he was highly concerned with the impact of changing demographics in his community. This eventually led to the adoption of the Aging Population Policy Framework.14 In Atlantic provinces, few premiers stressed the importance of population growth and launched a strategy to this effect, the latest being Paul Davis in Newfoundland and Labrador. Most striking, however, provincial initiatives tend to suffer from benign neglect with a change in leadership. Still, there are no permanent senior officials or formal mechanisms – with the noticeable monitoring performed in Quebec – to oversee the impact of population aging on public policies. The absence of a senior official mandated to monitor broad policy issues related to

204

Public Administration and Population Aging

demographic change within an executive council does not signal lack of concern. Respondents were quick to stress that demographic change is clearly amongst the most important policy issues discussed in deputy ministers’ meetings and in policy groups – such as strategic or priority units – attached to the executive. This is especially the case for the five eastern provinces. It is ubiquitous in Atlantic Canada, while the sense of urgency with this preoccupation in Quebec has been sporadic. For example, a senior official in a central agency in Atlantic Canada was quick to state that “population aging is an underlying theme for all the things we do and it is clearly there within the four core priorities.”15 A clerk of the Executive Council in another Atlantic province was quick to cite David Foot by claiming that two-thirds of policy issues in his province are related to population aging. Simply put, “this is not a broad issue where we woke up one morning and realized that we need to do something about this.”16 Another clerk discussed this issue in a similar way, emphasizing that population aging is hardly a surprise. He also compared potential policy approaches to population aging to those that can be used to alleviate climate change, since “you cannot do a lot to change it, but you seek to reduce its impact.”17 Some specific horizontal issues have prompted provinces to enact or expand specific bureaus with well-constricted mandates. This includes senior secretariats with mandates focused primarily on seniors and their well-being (see chapter 8). Seeking to address a shrinking labour force and labour shortages, Prince Edward Island and New Brunswick also established a Population Growth Secretariat in the late 2000s to facilitate the recruitment of migrants. In both cases, they quickly amalgamated within traditional ministries. In Prince Edward Island, it was folded into the Department of Innovation in 2012. In New Brunswick, following the election of the Progressive Conservatives in 2010, an organizational reform led to the transformation of the secretariat into a division within the Ministry of Post-Secondary Education, Training and Labour and an assigned assistant deputy minister. The division led to the development of the Population Growth Strategy in 2013, which aimed to “attract, retain and repatriate more people” to the province at a time when vacancies were already widespread in many sectors of the labour force.18 Similar to New Brunswick, Newfoundland and Labrador also instituted a population growth strategy led by the Ministry of Advanced Education and Skills just prior to the 2015 election.19 Following the election of the Liberals, the strategy remains on the government website, but the focus is clearly on the new government’s plan to bolster immigration within the overarching Way Forward Plan.20

Central Agencies and Inter-ministerial Coordination

205

Monitoring the Consequences of Population Aging in Quebec Across Canada, as illustrated by the examples above on the development of population growth strategies, the lack of a specialized office has not prevented development of horizontal responses from provincial authorities to tackle the challenges and opportunities of population aging. Still, while it is still common to identify population aging as part of the broader context of specific public policy reforms, it is rarer to denote a sustained effort with resources to analyse horizontally how it matters. Since the 1990s, Quebec has been the only province with a consistent track record of addressing the horizontal challenges triggered by an aging population within central agencies formally and in a routinized manner, but results have been limited. Alberta has also had a strong record on the socio-economic challenges of demographic change, but these actions are discussed in the next section, since the Executive Council did not constantly lead these efforts. Quebec’s Conseil exécutif has worked on the socio-economic consequences of an aging population for close to two decades. The Vérificateur général (auditor general) actually played a key role in this development. Following considerable media attention on the consequences of an aging population and fuelled by alarming projections published by the Institut québécois de la statistique (ISQ) in 1999 forecasting population decline by 2026, and rising interest within the civil service, the management of risk related to demographic changes was a core element of the 2000–1 report of the auditor general.21 The aim of the audit was to obtain assurance that Quebec’s public administration had identified the most important risks pertaining to an aging population, assessed them, and developed a strategic plan to make enlightened decisions when needed.22 Its assessment was extremely critical of what had been done. The report highlighted the use of very different long-term models using various underlying hypotheses, which also meant that financial projections were not comparable across ministries. Similar complaints were raised about human resource challenges across the civil service. Finally, the report indicated some positive ministerial initiatives, but emphasized that the government did not have a global vision to tackle the challenges of an aging population and, as a result, did not have a common strategy to ensure that individual initiatives were coherent.23 The report of the Vérificateur général had a tremendous impact within government and the civil service. One month following its publication, the PQ government opted to give a mandate to the Ministère du Conseil exécutif in January 2002. The election of the Liberal Party in the spring of 2003 did not alter these ongoing activities and the new

206

Public Administration and Population Aging

government actually embraced efforts to bolster analytic capacities. The Secrétariat aux priorités et aux projets stratégiques has since been responsible for coordinating strategic thinking on the issues occasioned by demographic changes.24 Interestingly, there is no timetable on the frequency or the process within which the Conseil exécutif exercises these functions. Three major reports (2003, 2009, and 2016) have been written and their conclusions were presented to Cabinet. It is important to note that the reports represent first and foremost a picture of what is being done across ministries and few recommendations about what ought to improve. As such, there is no attempt to create an overall strategy or framework spearheaded by the Conseil exécutif or the government. The first report built upon the Vérificateur général 2001 evaluation and involved consultation with 17 ministries and public agencies.25 Based on these consultations, two major conclusions featured prominently. There is a focus – analytically and programmatically – on the needs of the aging population, but not on how population aging affects the population in general. Also, cross-ministerial and multidisciplinary reflections on the issues related to an aging population need to be improved significantly. The report listed phased retirement and family support as two key policy issues that would greatly benefit from crossministerial discussions.26 This report provided much of the background work deployed during the 2004 Forum des générations. This highly publicized three-day event, featuring Premier Charest, many members of his Cabinet, and other local and provincial politicians aimed to foster discussions on the twin challenges that represent an aging population and the state of public finance.27 A broad range of stakeholder groups representing older adults, students, and community groups attended the event, but many social partners chose to boycott it.28 The material handed to conference participants began with a clear reference to the report from the Vérificateur général, the work essentially performed by the Ministère du Conseil exécutif, and a broad consultation with more than 2,500 regional elected representatives, leaders, and citizens. The participant handbook stated three core objectives: (1) form a common understanding of the challenges surrounding the state of public finance and changing demographics; (2) foster participant engagement to collectively tackle the challenges facing Quebecers; (3) agree on initiatives to follow up on the development of a strategy of actions to undertake.29 In addition, it featured a 14-page summary of the fiscal, social, and economic challenges, stressing the already precarious status of public finance, which was expected to worsen with an aging population. For instance, it stressed that the health budget could represent 85% of program expenditure

Central Agencies and Inter-ministerial Coordination

207

within 30 years based on current trends, that migration is insufficient to sustain population growth, and that a reduction of the labour force would lead to lower economic growth.30 The forum did not result in an ensuing cohesive policy/strategy, but paved the way for measures such as the Fonds des générations in 2006 to build a financial reserve to reduce the size of the debt. Rather surprisingly, however, the Quebec government made responding to demographic changes one of its nine strategic directions in its 2008 sustainable development strategy.31 It included specific objectives such as “improving the demographic profile of Quebec and its regions” and “keep public finances healthy for the generations to come.”32 Interestingly, the number of strategic directions shrank to eight in the 2015 Sustainable Development Strategic Plan, with the removal of the demographic strategic direction.33 The sense of urgency to tackle the broader socio-economic challenges of an aging population in Quebec started to subside after the mid-2000s. A key contributing factor has been the improving demographic scenarios forecasted by the ISQ. While the 1999, 2004, and 2009 demographic projections alluded to a decline in population in 2026, 2031, and 2056 respectively, no population decline is expected in the 2014 projection up to year 2061.34 Most notable among the socio-demographic factors alleviating these concerns is the fact that the birth rate rose by 12.3% between 2000 and 2009, peaking in 2008 at the same level as in 1976 (1.73).35 Still, in the last two decades, the Conseil exécutif has pursued its work and produced far more exhaustive assessments of what is being done throughout Quebec’s public administration. In 2009, it included a synthesis covering more than 60 ministries and public organizations.36 As in 2003, this document represents a smorgasbord of initiatives rather than a coherent and well-orchestrated vision to tackle the challenges related to population aging. Nonetheless, the Conseil exécutif went further than 2003 by introducing 10 specific recommendations, such as putting more emphasis on economic productivity, increasing the labour participation rates of individuals aged 55 and above, targeting an improvement in interprovincial migration, and attracting international students to entice them to remain in Quebec after their studies.37 It is important to stress that these recommendations were discussed with elected officials, including Cabinet, after its publication in 2009. The 2016 version of the report did not feature such recommendations, but otherwise followed the previous template.38 It remains to be seen whether these efforts will be pursued or not by the Coalition Avenir Québec, following their election in 2018.

208

Public Administration and Population Aging

The continuous work performed by Quebec’s Conseil exécutif has no equivalent in other Canadian provinces but still has serious shortcomings. The reports provide readers with an excellent picture of measures and actions undertaken by ministries and public organizations to tackle the consequences of an aging population. Nonetheless, contrary to the work of central planning offices in a previous era, its involvement is extremely limited in promoting, let alone enacting horizontal initiatives that could be implemented by senior officials across ministries. In fact, the lack of global vision or ligne directrice with specific goals and objectives remained a criticism from the 2009–10 report of the Vérificateur général: “une structure de coordination permettant de gérer efficacement les changements démographiques au sein de l’appareil administratif n’a pas été instaurée.”39 The creation of a coordination structure within the executive council has been reflected upon in a few Canadian provinces, such as Newfoundland and Labrador, which eventually settled on the creation of a secretariat housed within the Health and Community Affairs Department (see chapter 8).40 In other cases, there have been one-off efforts, not specifically related to population aging, where demographic changes are omnipresent in the analyses. For example, spearheaded by the clerk of the Executive Council Office, New Brunswick performed a longterm review of its upcoming challenges in the fall of 2010. The new premier, David Alward, embraced it upon taking office, and it became widely diffused throughout the civil service and was frequently mentioned during interviews with senior civil servants in the province. A large portion of the analyses and information in the document concerned the impact of the demographic shift on governmental policies and programs. Population aging played a predominant role in all four challenges identified by the executive council: the deficit, health and services, the size and quality of human resources, and economic development. It is important to note that this document assessed current and future challenges, but it did not provide explicit recommendations or potential solutions. In this case, this was hardly surprising, since the aim was to present a broad portrait for an incoming government while it prioritized its agenda. Albeit with far fewer details and less depth in the analysis, this document is similar in spirit to what has been done by the Conseil exécutif in Quebec. Interestingly, no other provincial auditing office conducted assessments akin to those performed by Quebec’s Vérificateur général, who engaged in extensive comparative research on horizontal coordination, starting with recent documents from the OECD. It is worth pointing out that few provinces have the capabilities to enact such broad studies, and

Central Agencies and Inter-ministerial Coordination

209

auditing offices prefer to focus on evaluations with more traditional accounting tools. Thus, the emphasis remains on more targeted assessments of specific programs.41 A Unique Initiative Spearheaded by a Central Agency in Nova Scotia Most initiatives undertaken by premiers to tackle the consequences of population aging tend to thrive alongside the success of their government. The current work undertaken by the One Nova Scotia Coalition represents a surprising exception in the approach undertaken and the multi-partisan participation in the coalition so far. In 2012, the NDP government under Darrell Dexter established an external independent commission on building the new economy. This was a core priority for the government, and the commission had the full support of the now defunct Office of Policy and Priority connected closely to the Executive Council. The mandate included, for instance, the engagement and mobilization of communities, local governments, and business and labour leaders to foster economic growth and led to 35 public meetings across the province.42 Early on, the commission obtained explicit support from both opposition leaders. As a result of the multi-partisan support, the election of the Liberal Party in 2013 did not affect the work of the commission. That hands-off approach was unique in a province as highly politicized as Nova Scotia, and proved essential to build the basis for a 10-year horizon action plan, an explicit objective for the commissioners.43 Commission findings, commonly referred to as the Ivany report after the commission chair, were released in February 2014. The relation between demographic change and economic growth was front and centre, with a core message stating, “Nova Scotia is today in the early stages of what may be a prolonged period of accelerating population loss and economic decline.”44 The findings reaffirmed the conclusions from a recent external audit by Deloitte, the findings of the Economic Advisory Panel,45 and a commissioned report from Donald Savoie.46 Consequently, it made it easier for the commissioner to steer discussions and debates quickly onto what actions should be taken. The commission pressed upon the need to change “attitudes and understandings” to foster economic growth and targeted three areas aiming to (1) strengthen business and community leadership; (2) bolster the rates of international and inter-provincial immigration; and (3) improve “performance in the areas of productivity, trade, innovation and valued-added production.”47 These formed the basis of the 19 goals regrouped under population, economic development, and governance

210

Public Administration and Population Aging

and fiscal goals. These included, for example, averaging net gains in inter-provincial migration, raising the labour force participation rate in line with the Canadian average, equalling or surpassing the national youth employment rate, and developing “a province-wide plan to achieve Nova Scotia’s new goals for sustainable economic growth and population renewal.”48 In the aftermath of the Ivany report, the government requested and facilitated the development of the One Nova Scotia Coalition, which undertook the mandate to develop a 10-year plan based on the 19 goals. Strongly anchored in a result-based management framework, this coalition developed targets with multiple indicators to follow the progress of the action plan.49 Interestingly, in the spirit of the Ivany report and contrary to similar exercises conducted by government plans, responsibility to achieve these targets is collective. While this commission and the work of the One Nova Scotia Coalition have attracted further attention to long-term socio-economic challenges in an aging population, they have done so by moving away from political leadership. They continue to attract sustained interest in business circles, especially within the sectors prioritized in the Ivany report, but the political attention and the commitment to work collaboratively across parties has waned.50 There was, for instance, no multiparty province-wide plan enacted by the end of 2015 to achieve core economic growth and population renewal by 2024, although this was categorized as an achieved objective with a link to the playbook constructed by the One Nova Scotia Coalition,51 and the report did not feature prominently in the 2017 elections. Finance Ministries The influence and importance of finance ministries have been growing across industrialized countries in the past 30 years, even in the field of social policy.52 In Canada, the federal Department of Finance not only continues to set fiscal parameters for policy action, but has also become the policy designer of new initiatives.53 Similar conclusions apply to the provinces. In interviews with senior civil servants in the provinces, the Ministry of Finance has been consistently mentioned as one of the most important organizations, along with the Office of the Premier, in tackling policy issues related to an aging population. However, one should not confuse its ubiquity within the policy process and its powerful position as holder of the purse with the capacity, not to say willingness, to entrench a long-term policy vision within government.

Central Agencies and Inter-ministerial Coordination

211

The very first interview with a deputy minister (DM) of finance was with a recent retiree who had had a lengthy tenure in this position. Upon hearing a brief summary of this research project before moving into specific questions, the former DM quickly interjected: “Almost 0% of my time was actually devoted to population aging.”54 Expecting the worst after this initial statement, triggering even a moment of self-doubt in the pursuit of this project, the DM promptly followed up by stating that it did not get the attention it deserved and identified a significant number of ongoing long-term financial issues covering a wide range of governmental programs. The DM concluded on the need “to look at intergenerational issues from a finance perspective.”55 Each province has statistical offices and units within finance ministries to analyse the evolution of many socio-economic indicators such as demography, labour market fluctuations, and migration. Demands for specific regional data have risen continuously, reflecting the territorial dimension of population aging and its variations.56 As pointed out by a senior researcher within one of these units, this has implied, for instance, improving older econometric models to consider demography more seriously.57 Interviews also indicated that many departments of finance perform forecasts specific to policy issues sensitive to population aging, but few of them are publicly available. For instance, beyond the standard evaluation of proposed changes to fiscal measures, it has been common to project how a tax credit or a new tax adopted in one province would fare in the province conducting the analysis. In fact, few provinces emphasized closer inspection of the impact of population aging not only on revenues, but also on the actual efficiency of tax systems. The frequency of these analyses depends on factors such as the availability of expertise necessary to do it. Increasingly, detailed analyses are being performed on contract basis with external researchers; university professors were mentioned most frequently, even in large provinces. Analysis of recent public documents such as budgets, fiscal plans, governmental annual reports, and economic reviews in all 10 provinces reveals that basic descriptions of the latest demographic data, including labour market trends, migration figures, and population change are now standard across the provinces. Beyond the presentation of these snapshots, documents denote mostly the impact of population aging on labour market participation and its potential economic consequences, albeit briefly, within a yearly progression status framework, and typically without follow-up measures. This connection is explicit in only some cases and notably in Ontario’s Plan for the People: Economic Outlook and Fiscal Review covering the period 2018–21. Confined within two

212

Public Administration and Population Aging

pages on long-term challenges in a document of 174 pages, the review states, Demographic change has a signifcant impact on Ontario’s long-term economic and fscal outlook. While the provincial population is projected to continue growing at a steady pace, sustained by immigration, the average age will continue to rise. Over the next 15 years, baby boomers will retire. As a result of these large cohorts leaving the provincial workforce, growth in the working age group (15–64) will slow down signifcantly. A slower growing labour force may restrain future economic growth, unless productivity accelerates. Population aging … is projected to accelerate as the baby boomers become seniors. Over the next two decades, the number of seniors in the province will nearly double, putting pressure on government’s capacity to deliver appropriate services and programs to this fast-growing age group. Long-term population growth and aging will also affect government spending, on infrastructure, as well as on transfer programs and services for seniors.58

It is important to note that Ontario is the only province with the mandate and resources to create long-term reports, which partly explains the inclusion of this section in this economic review. In New Brunswick, the 2017–18 economic outlook included a brief section to denote that population decline “continue[s] to influence economic growth.”59 The decline in the size of the labour force is common in the other Atlantic provinces and in Quebec. Quebec’s 2018 economic update even explicitly states that “demographics stopped contributing to real GDP growth in 2014” and stresses the need to increase productivity.60 Another common theme, as we saw in chapter 5, is the need to invest more resources in health and seniors’ care, as a result of rising demands caused by an aging and growing population. This typically features a funding announcement, such as British Columbia’s $5 million additional funding to train and graduate more health care professionals.61 Comparisons with other provinces are made most often when the resulting analysis sheds a positive light on the report’s respective province. For instance, in recent budgets, Manitoba actually discussed population aging and its labour market outlook in relation to other provinces to highlight a decline in the median age of its population (falling from 37.8 in 2013 to 37.4 years in 2017)62 – the positive impact of its immigration policy. This policy contributed to “a remarkable gain in population”63 and “the fastest population growth rates among provinces in the last three years” in 2018,64 which were referenced as key elements

Central Agencies and Inter-ministerial Coordination

213

to account for more favourable labour market situations than in other provinces. This sporadic effort to engage population aging occurs because few provinces have a special mechanism to prioritize this demographic shift and the tools necessary to foster long-term perspectives beyond a two- to four-year horizon. Although forecasting is a continuous and essential part of the budgetary process,65 it remains strongly anchored in a yearly perspective, which frames these analyses and reports. Lawmakers rarely have information on the long-term sustainability and viability of budgetary actions, and such discussions are rarely allowed in parliamentary debates.66 This short-term horizon transcends the civil service with very few exceptions, such as actuarial reports in pension policy. The deputy minister of finance in a large province stated, for instance, that he does not have specific measures to assess the impact of demographic change beyond relying on the data with the primary focus being on the ability to raise taxes and manage costs. On the question of major stumbling blocks to developing a strategy to face the upcoming aging of the population, this DM saw population aging as inevitable and “as a progressing part of the day-to-day operations.”67 Throughout this interview, while the DM was clearly aware of the long-term consequences for public finance within the province, population aging was viewed more as something to keep an eye on rather than requiring development of long-term perspective tools. Perhaps the strongest critique of this approach to population aging, which is prevalent across Canada, came from the auditor general of Alberta, who recently published a special commentary on the need to put the “financial future in focus.”68 Echoing many of the reasons listed in chapter 3 that prevent development of the long-term view within government, the auditor general mentioned that politicians focus on “short-term politics, election cycles, isolated controversies and lobbying for local interest” and that “the electorate is satisfied with this state of affairs.”69 A cocktail of foreseeable long-term risks includes demographic change, aging within the labour force, a rise in the number of individuals with chronic diseases, climate change, and the shift from fossil fuels to renewables. The auditor general prescribes the adoption of long-term reporting and analysis to ensure that citizens are informed of the interplay between today’s decisions and their future impacts. Interestingly, the auditor general also evokes the intergenerational lens as part of what long-term analyses can reveal.70 Ontario is the only province that is mandated to publish a longterm report following the adoption of the Fiscal Transparency and Accountability Act in 2004 and represents, at least at the time of its

214

Public Administration and Population Aging

adoption, the only initiative of this kind by a subnational government in the world.71 The legislation mandates the government to perform analyses anticipating demographic and economic changes in the economy over the next 20 years, assessing potential impacts on the public sector and fiscal policy, and exploring fiscal issues that could affect the long-term sustainability of the economy and public sector. Four reports have been published so far in 2005, 2010, 2014, and 2017. The latest, Ontario’s Long-Term Report on the Economy, includes a full chapter on demographic change, revealing a slower rate of population growth, population growth concentrated in the Greater Toronto Area, and consequently slower economic growth in certain regions of the province, for example.72 Akin to the 2009 report from Quebec’s report from the Executive Council,73 it included, albeit broadly and succinctly, policy suggestions to address population aging such as “encouraging underrepresented groups to participate in the labour market, modernizing and improving the delivery of quality health care for seniors … and improving the economic conditions of all regions of the province.”74 For instance, the report stated the importance of removing “gender equity barriers” to bolster the participation rates of women in the labour market and as a means to reduce the gap between men and women.75 Ontario’s public report has no equivalent elsewhere in Canada.76 Despite the uniqueness and added value of this tool, this would most likely still fall short of what the auditor general in Alberta recommended, primarily because it involves a shorter time horizon (20 years as opposed to 30–75 stated in the report)77 and a broader framework of analysis. The unit responsible for preparation of the long-term reports in Ontario, labour market and demographics, has also been quite present within the civil service, making presentations in other ministries and providing input on issues touching education, post-secondary education, health care, and income. They also present their forecasts to deputy ministers meetings and at Cabinet. Following the election of the Conservative government in 2018, it remains to be seen whether the government will continue the practice of employing these forecasting tools. In the course of interviews with civil servants working in statistical, demography, and finance units, other projects and initiatives have been mentioned and discussed, albeit most of them for internal use only and for a specific one-off purpose. One noteworthy exception that clearly stood out is the development of Community Accounts (CA) led by the Economics and Statistics Branch of the Department

Central Agencies and Inter-ministerial Coordination

215

of Finance in Newfoundland and Labrador. Aiming to assist policymakers at all levels of government and raise awareness within the general public, CA is an open access tool that allows users to zero in on a specific region or town and access long-term projections. Faced with the historical legacy of resettlement, the developers took the extraordinary step of visiting small communities throughout Newfoundland and Labrador to complement the demographic statistics from Statistics Canada and secure the best estimates. This tool has the potential, at least in theory, to increase the knowledge base upon which public authorities can make better decisions on where public investment should be targeted. This does not remove politics from these decisions but can assist policymakers at all levels. This initiative even won a prize from the Institute of Public Administration of Canada and has been followed (and even adapted) in other Atlantic provinces. Adding credence to the overwhelming presence and strength of finance ministries in the policy process, there are also multiple examples of initiatives led by finance departments to address the consequences of population aging. However, one quickly discovers a highly visible departmental bias towards fiscal instruments. For instance, the Quebec Finance Ministry played a key role in the prelude to the first aging policy put in place in 2012 by the Seniors’ Secretariat (see chapter 8). As part of the 2007–8 budget speech, the government revealed its Stratégie d’action en faveur des aînés.78 As part of this strategic plan, the government announced four key objectives: raise the disposable income of seniors, encourage aging at home, adapt services and infrastructures to the needs of older adults, and strengthen the place of seniors within Quebec society. Despite its name, the 44-page document represents in fact a series of targeted measures, valued at $238 million per year, rather than a new approach or strategy to tackle the issues related to older adults and population aging. The policy tools deployed included a series of financial commitments for the next five years, including, first and foremost, fiscal measures and tax credits (targeting the income of older adults, caregivers, home care services, and facilitating a progressive retirement) representing a total of $228 million per year.79 As another example, Manitoba innovated with the first caregiver policy in 2011, which aims to increase support for and enhance recognition of caregivers. The key financial measure has consisted of the Primary Caregiver Tax Credit, with eligible caregivers able to claim $1,400 for up to three recipients of care, for a maximum tax credit of $4,200 since 2015.80

216

Public Administration and Population Aging

Inter-ministerial Coordination Another horizontal approach utilized in some Canadian provinces is the adoption of strategic policy frameworks directly related to population aging. Studies indicate that inter-ministerial actions are on the rise, with tales of deputy ministers being frequently engaged in crossdepartmental meetings.81 The extent to which this indicates declining policy capacity at the expense of central agencies82 or the interdependence of policy problems83 remains a source of constant debate in public administration and public policy. Civil servants in all 10 provinces were quick to mention engagement in some form of inter-ministerial coordination on policy issues related to aging. An exhaustive review of these efforts is outside the scope of this section but I will analyse how Alberta, a province with one of the most sustained track records on reflecting on population aging, has been formally coordinating cross-departmental action to think analytically and strategically about the impact of population aging. Alberta’s Approach to Population Aging Considering its demographic profile and the fact that it has one of the highest median ages of retirement in Canada,84 it is somewhat surprising that Alberta has devoted a lot of attention and energy to addressing the policy impact of population aging globally. As in Quebec, the civil service began to devote particular attention to this issue in the 1990s, culminating with the release of Alberta for All Ages: Directions for the Future.85 After a brief hiatus, this issue was revisited with the creation of the Demographic Planning Commission in May 2008, which eventually led to the development of the Aging Population Policy Framework (APPF). The then ministry responsible for community affairs, which also had the portfolio for seniors until 2012,86 led these efforts. Alberta’s involvement occurred in two distinctive periods. First, coinciding with the International Year of Older Persons in 1999, the Ministry of Community Development launched a government-wide study on the impact of population aging, followed by an Alberta-wide consultation, which led to the report entitled Alberta for All Ages in 2000.87 Planning was a central theme in it. To prepare for the consultation, the civil service conducted a thorough review of government programs and services, which became known as Report A. The primary objectives were to present a portrait of older Albertans alongside recommendations to the minister on short-term issues. Within government, Community

Central Agencies and Inter-ministerial Coordination

217

Development, Municipal Affairs, Health, Family and Social Services, and Intergovernmental Affairs and Aboriginal Affairs made presentations and prepared written documents for the committee. Interestingly, there are no indications that the Ministry of Finance played an important role in the making of this report. The committee identified 11 short-term issues with recommendations on how to tackle them. These include the complexity of programs and services, income shortages, the need for coordinated health services, and the need to improve access to various services.88 The committee encouraged the creation of an “Interdepartmental Standing Committee for Seniors Programs and Services.”89 Following the publication of this report, four members of the now defunct Seniors’ Advisory Council joined the Steering Committee and participated in the public consultations, involving focus groups, a survey, and a three-day symposium in Edmonton in November 1999, where participants were asked to envision Alberta in 2020 featuring many seniors in communities across the province.90 These representatives from the Seniors’ Advisory Council were also involved in the making of Alberta for All Ages.91 Recommendations centred on eight themes: (1) healthy aging; (2) financial security; (3) flexible retirement; (4) housing; (5) supportive communities; (6) caregivers and volunteers; (7) workforce; and (8) educational opportunities. Interestingly, within the context of this book, a core finding from the 17 focus groups conducted across the province revealed that “people are looking for long-range planning,”92 including better coordination and partnerships across governments and with private and community actors. Second, the most recent plan is the Aging Population Policy Framework (APPF), which, contrary to the previous effort, has resulted in a more comprehensive approach to address policy issues surrounding population aging. However, this came at the cost of being less ambitious, since the creation of a framework to guide policymakers does not require the same commitments and resources to develop concrete longterm plans. The data and information built upon earlier inquiries performed in the province, most notably the findings of the Demographic Planning Commission. The creation of this commission featured in the mandate letter given to new minister of seniors and community supports following the appointment of Ed Stelmach as premier in December 2006. Minister Jablonski appointed members of the commission in 2008 and appointed MLA George VanderBurg to chair the proceedings. Contrary to previous efforts, its composition was far more expertdriven, including four members originating from universities (geriatric medicine, social work, sociology, and business). The other members

218

Public Administration and Population Aging

consisted of individuals who have (or had) a leadership position with the Alberta Non-Profit/Voluntary Sector Initiative, the Alberta Association on Gerontology, and the Alberta Motor Association. At the onset, the aim was clear and consisted of helping the government to develop the APPF. The commission focused on the issues facing current and future seniors, responsibilities to tackle these issues, and how programs and services ought to be adapted to be sustainable over the long term. The commission held five consultations with 100 stakeholder groups involved primarily in the delivery of programs and services to older adults across the province.93 In addition, it conducted a survey of 10,170 citizens, 9,520 of whom completed it online. Survey results were featured consistently throughout the document, despite its obvious limitations in reaching out to older adults and poorer residents; only 16.8% of the respondents were seniors – a figure that is somewhat surprising for a consultation focused on seniors’ programs and services – and only 15.4% had income below $40,000.94 Still, despite working with a sample of wealthier individuals, 85% of respondents claimed that “being able to afford the cost of living” was an issue facing current and future seniors, making it the most important issue in this consultation.95 It is worth stressing that, until recently, Alberta offered the most generous GIS top-up in Canada, which could reach up to $280 per month.96 The emphasis on healthy aging, present in Alberta for All Ages, gave way to themes focusing more upon providing programs and services for older adults to age in their own home within their community. Among survey respondents, 90% expressed a clear desire to age in their own home,97 and participants and survey respondents emphasized the challenges to receiving proper services in rural communities.98 The commission also stressed the importance of building a workforce to offer services to older adults, better coordination of services, infrastructure investment to make the living environment more senior friendly, and ensuring that health needs of seniors could be met throughout the province (including rural areas). The publication of the Findings Report led to cross-ministerial collaborations to elaborate the Aging Population Policy Framework (APPF) in 2008–10.99 Conceptually and analytically, the APPF focuses more on the older population and less on broader socio-economic impacts resulting from an aging population than the initiatives taken by Quebec’s Conseil exécutif. This is hardly surprising, considering the demographic makeup of Alberta, which also explains why the mandate of creating this framework fell upon Alberta Seniors and Community Supports and not a central agency. Despite these limitations, this document is clearly

Central Agencies and Inter-ministerial Coordination

219

forward looking and involves a host of clear guidelines with the aim of providing future policy directions, improving collaboration among individuals, communities, and government, and providing supports and services to seniors. Efforts were made to ensure the production of a vision that was not rooted in current programs, and the APPF also features core principles for government decision-making, such as respecting individual choices, collaborating with communities, and being fair and equitable to future generations.100 In providing policy directions, the APPF focuses on the following areas: financial security and income, housing, and aging in the right place; continuing care; healthy aging and health care; transportation and mobility; safety and security; supportive communities; and access to government. Questions surround the extent to which the APPF has been discussed or fully utilized while making policy decisions and measurement issues related to the desired outcomes. While still officially on the departmental website, its prominence declined following the departure of Ed Stelmach. Nonetheless, the APPF has prompted the Alberta government to state what is being done to address the challenges of an aging population coherently and comprehensively. It also entrenches a broader and deeper appreciation and understanding of the policy challenges associated with an aging population throughout the civil service. This clearly stood out in the interviews, especially when Alberta is compared to provinces experiencing a similar demographic shift. Alberta distinguishes itself from other provinces by the clear references to the role of government and principles within which public action should be expected. Even in 1999, Report A emphasized the importance of individual responsibility for basic needs, communities to facilitate participation and inclusion of older adults, and government to “provide adequate support to those unable to provide for their own basic needs.”101 This emphasis on roles and responsibilities also comes to the fore in the 2008 consultations of the Demographic Planning Commission and in 2010 in the APPF. This time, however, governmental responsibilities come first and involve providing policy directions for seniors and population aging, facilitating coordination between actors, and providing programs and services that “are effective, efficient and affordable.”102 Informal Channels Finally, the most common vehicle utilized to discuss population aging across departments remains informal communications among public officials, for smaller jurisdictions in particular, where external demands

220

Public Administration and Population Aging

often require extensive collaboration. In the 1970s, a large cohort of civil servants were hired across Canadian jurisdictions, causing a major challenge to renewing the civil service today. However, this provides an advantage when establishing informal lines of communication because senior civil servants know each other very well. Moreover, they are likely to have had to cooperate on previous projects. This facilitates the utilization of expertise and input from an “external” department. In some cases, civil servants working on issues related to population aging acknowledged that they spend more time working with civil servants outside their department than with professionals within their department. In the small provinces, many political appointees and members of the civil service questioned the potential value of a central agency devoted to aging, arguing that informal relationships within the civil service achieve a similar result. For instance, many senior civil servants in Prince Edward Island stated that coordination can be quite easy by simply crossing the hallway. Conclusion Recent efforts to build horizontal policy capacities remain fairly marginal across Canadian provinces. There are no comprehensive provincial strategies akin to what has been advocated by the OECD. This should not be equated with a lack of action to address upcoming issues related to an aging population. Most provinces have developed new tools and institutions to service the growing number of older adults, abolished mandatory retirement, and, as illustrated by the development of Community Accounts in Newfoundland and Labrador and Ontario’s mandated long-term reports, improved the quality of demographic projections and forecasts. In addition, provincial authorities are aware that they are operating within the context of an aging population. This is especially true in eastern provinces, where population aging is a current (as opposed to upcoming) issue. For instance, the population of New Brunswick experienced a slight decline in population between 2011 and 2016.103 Many, not to say most, policies/strategies deployed by provincial governments are either abandoned or eliminated following the election of another political party in government, however. Hence, sustaining a horizontal course of action and capacity is an important hurdle for public administrations and policymakers seeking to enact a long-term perspective. Only two provinces, Quebec and Alberta, have sustained specific resources to improve their analytical and policy capacity to deal horizontally with broader socio-economic issues related to population

Central Agencies and Inter-ministerial Coordination

221

aging, which should not be confused with specific action plans targeting seniors where many provinces undertook initiatives. It is important to note that these two provinces have been governed by the same party almost continuously from 2000 to 2018. In Quebec, the Liberal government was in power from 2003 to 2018 with a brief interruption between 2012 and 2014 when the Parti Québecois led a minority government. In Alberta, the Conservatives experienced their first defeat in a generation in 2015, but returned to power in 2019. Nothing substantial has been produced akin to the APPF in the past decade, and its status is unclear. Still, in both cases, there are important deficiencies. Quebec’s efforts mostly involve a gathering of information across all ministries, and the Conseil exécutif has not assumed leadership to entrench or develop horizontal approaches, preferring to leave the responsibility of dealing with the consequences of an aging population to individual ministries. The novelty of the APPF lay in the extent to which it addressed some of the criticism formulated by Quebec’s Vérificateur général towards the approach taken by the Conseil exécutif. First, there are clear guidelines being developed with specific outcomes to reach. How to measure these outcomes is still nebulous, but nonetheless there was directionality in the APPF. Second, Alberta developed principles, which were expected to be embedded within the policymaking process. Finally, Seniors Alberta was mandated to follow up on and implement the APPF, while there is no comparable mandate given in Quebec. On the negative side, the approach undertaken by the Alberta government took less into account the broader socio-economic opportunities and challenges resulting from an aging population than Quebec’s initiatives, and the latter was already criticized for not discussing how an aging population affects all age groups. What explains the absence of better horizontal efforts? The biggest challenge is to move away from the conception of population aging as an issue concerned primarily with how to serve a growing senior population. As indicated in the Vérificateur général’s finding for Quebec, which also applies to other provinces, population aging has much broader consequences – positive and negative on public policies. A common theme throughout the interviews has been to “download” any issue related to aging to senior secretariats. These newly created offices have made significant headway in facilitating and disseminating information to improve the well-being of their target population, but they do not have the resources and vision to tackle other horizontal issues, as we shall see in the next chapter. Interest groups representing older individuals, such as FADOQ, are increasingly demanding a broader

222

Public Administration and Population Aging

approach and understanding of the challenges and opportunities arising from an aging population. Second, there is no appetite to alter governmental structures to analyse policy issues differently, especially for an issue as (potentially) explosive as population aging. Even in Quebec, where the civil service has played a more predominant role in public policy in general, there is no indication that the Conseil exécutif will increase its efforts to enact the core recommendations of the Vérificateur général. This is somewhat surprising, considering the time invested in gathering valuable information on the state of activities performed across ministries and other public organizations. Hence, the Alberta model has had a better chance of succeeding, assuming that it improves on the point stated above. The Seniors’ Department, which has the mandate to implement and assess progression on the APPF, requires considerable authority and resources to fulfil its obligations. Finally, and complementary to the previous point, the increasing politicization of the civil service accentuates the need to focus on shortterm issues. The most politicized provinces have the weakest strategies/infrastructure to tackle horizontal issues related to population aging. The ongoing work in Nova Scotia to elaborate a comprehensive 10-year plan to foster economic development and population renewal illustrates these difficulties well. The entire process has occurred with external reporters, commissioners, and consultants with the support of civil servants. While external actors can mobilize resources and produce reports within a specific mandate and time, it is extremely difficult to sustain the momentum of an initiative such as the One Nova Scotia Coalition away from government. Despite an initial multi-party endorsement for the work of the Ivany commission undertaken by the NDP government in 2012, it slowly eroded as the requirements for political parties required a “new form of politics,” which is still awaited.

8 Offices for Seniors

Coordination is the way of life for us. – Executive offcer from an offce for seniors

Introduction The previous chapter focused on traditional central agencies that tackle horizontal challenges routinely, including those occurring as a result of an aging population. An alternative method to foster horizontal coordination is to focus on a specific client group.1 This chapter analyses the creation (or expansion) of administrative offices devoted to seniors. Most public policies and programs were not originally designed with a large segment of the population being older, and the same applies for governmental institutions. In light of the growing number of older adults and their rising political importance, provincial authorities have developed administrative offices to address the concerns of senior citizens specifically. This phenomenon is hardly unique to Canadian provinces. In the United States, albeit at the federal level, the Administration on Aging (AoA) has fulfilled this role for decades following the adoption of the Older Americans Act (OAA) in 1965. The OAA is responsible for multiple joint programs with states and local governments. In Sweden, corporatist structures have been adapted to include a senior representation.2 Following in the footsteps of organizations devoted to specific populations such as women and youth, Canadian provinces (with the noticeable exception of Saskatchewan3) have all engaged in creating and/or expanding offices for seniors. Regardless of their appellation (secretariat, department, division, office, and advocate), these bureaus are rarely involved in the management of public programs. Rather, they tend to

224

Public Administration and Population Aging

focus on coordination and act as an advocacy group within provincial public administrations to ensure that seniors’ concerns are not marginalized in the policy process. This involves, for example, ensuring that new public parks, designed primarily with young families in mind, are also senior friendly. As part of the research for this book, senior civil servants and even ministers involved in offices for seniors from all 10 jurisdictions participated in interviews. This chapter aims, first, to present a brief historical review that led to the creation (or expansion) of these offices. This is essentially the first wave of development. This is followed by a discussion of what offices for seniors primarily do within the policy and administrative sphere. The third section analyses the tension between the social gerontological lens and the medical lens, which led to a second provincial wave of creation or transformation for offices for seniors, with a growing focus on healthy aging. The fourth section discusses the long view, with enhancing learning on aging and seniors a key contribution from these offices. However, they face obstacles in their promotion of action to establish a long-term perspective, with their administrative instability being the most noticeable. The fifth presents the creation of seniors’ advocate offices in British Columbia, Alberta, Newfoundland and Labrador, and New Brunswick, which represent a third wave of seniors’ offices. The conclusion discusses key challenges moving forward for these seniors’ offices. The Creation (and Expansion) of Offices for Seniors A key reason behind the development of offices for seniors across Canadian provinces is the absence of institutions to facilitate the input of older adults and seniors’ organizations within the policy process. With disparate voices representing seniors, these offices organize the voice of seniors within the policy process and aim to ensure that governmental organizations consider the impact of their decisions on older adults. As stated eloquently by an executive director, “Our perspective is to work across all departments to ensure that aging population lenses are there … as a secretariat we work across departments and with seniors’ groups.”4 Historically, offices for seniors were integrated within health departments, since most non-financial programs targeting seniors have been related primarily to health, as has been established in research on the biomedicalization of aging. The subject of aging and seniors as a group were primarily grouped under the banner of health. This health-based perspective on aging has been vehemently contested by seniors’ groups,

Offces for Seniors

225

stressing that aging is not a sickness (or a disease) and that intervention should go well beyond determinants of health. As stated by a civil servant when discussing the motivations behind the organizational setting of her office, “Seniors did not feel that they belonged in a health ministry, since they are not sick.”5 Aging remains a very heterogeneous experience, with a large cohort of seniors living long and healthy lives. As a result, there has been a strong push to move seniors’ offices within provincial public administrations at arm’s-length from health ministries. The first wave of offices for seniors occurred in the 1980s, as few provinces created secretariats with a horizontal mandate. Nova Scotia was the first in 1980, followed by Ontario (1982) and Manitoba (1988). In the case of Manitoba, the Seniors Directorate reported directly to the Executive Council up until its transformation into a seniors and healthy living secretariat in 2004. In these days, resources were extremely limited and consisted of a few civil servants (and still does for smaller provinces). In the past 20 years, three different and complementary factors in government have compelled provincial authorities to strengthen (or create) secretariats (or similar offices with a horizontal mandate) devoted to seniors: lack of policy input from seniors across government, growing discontent with the omnipresence of the medical lens and the predominant understanding of aging as a health problem, and the growing political importance of seniors’ groups. First, the United Nations embraced aging mainstreaming in its Madrid International Plan of Action on Ageing.6 This document stresses the importance of granting a more important role to seniors in the development of public policies and the need to emphasize the positive contributions made by older individuals in society. The UN document argues that the needs and concerns of older persons should be considered at all levels of decision-making.7 Subsequently, public inquiries across Canada confirmed the prevalence of similar issues, as clearly highlighted in the publication of reports such as Manitoba’s Advancing Age: Promoting Older Manitobans8 and Quebec’s Une pleine participation des aînés au développement du Québec.9 Second, provincially and federally, seniors-based associations have denounced the underlying message that aging is a sickness by leaving seniors’ issues within health departments. A core request was the creation of a secretariat or independent public organization devoted to seniors, which would be at arm’s-length from health organizations. As part of public consultations on the seniors issue in the 2000s, the need to de-link seniors’ issues from the health department was frequent. In a few cases, final reports featured an explicit recommendation to create an independent organization with a cross-departmental function. For

226

Public Administration and Population Aging

example, one of the five major recommendations in British Columbia’s Ageing Well in BC10 was the creation of a secretariat to be located outside the health department. Third, with an increasing number of senior voters, politicians have been keen to join this broader debate by proposing to create an actual ministerial portfolio for seniors and a secretariat or department. In Newfoundland and Labrador, the Conservative Blue Book in 2003 included a promise to create a secretariat devoted to healthy aging. The Conservative government eventually created a small division on aging and seniors within the Department of Health and Community Services in 2007. During the 2003 Quebec election, Jean Charest promised a minister for seniors. Contrary to his expectations, however, this was actually opposed by the main seniors’ association (FADOQ), who feared a loss of influence in other ministries.11 These worries subsided when the secretariat was integrated within the Ministère de la famille, as had been previously advocated by the FADOQ. A Diversity of Organizational Settings In light of these pressures, provinces have been creating (or expanding) offices devoted to seniors and have been eager to reform them. Many have also appointed a minister responsible for seniors (see table 8.1). The majority of these assignments are granted as an additional responsibility to a more pronounced portfolio such as Labour or Health. An increasing number of provinces, however, have had a Cabinet minister whose primary responsibility involves the seniors’ portfolio. Interestingly, despite having fairly similar mandates and objectives, provinces have opted for very diverse organizational structures in their seniors’ office. There are secretariats, offices of aging, divisions within departments, and departments of seniors. Complicating matters further, all provinces have made changes to these structures at least once. Fortunately, during interviews conducted across Canada, five people interviewed had been closely involved in the creation or restructuration of their office of aging. Two of them were ministers. On the basis of these interviews and policy documents, we can identify three key factors explaining their configuration. First, the creation of any governmental unit at a time when departments are frequently asked to reduce the number of employees requires careful planning to ensure its survival. These relatively new units involve very few employees who could be dismissed easily by a subsequent government. Many of these issues have been considered with the creation of new offices, but also in reforming existing ones. In

Offces for Seniors

227

Table 8.1 Responsibilities for seniors in Canadian provinces, 2010–2018 Year BC

AB

Seniors’ office

Host ministry seniors

Minister for seniors (Y/N)

2010 Seniors’ Healthy Living Secretariat 2011 Seniors’ Directorate (Seniors’ Action Plan Team) 2011 Seniors’ Health Promotion Team 2012

Ministry of Healthy Living and Sport

N: Ida Chung (minister of healthy living and sport)

Ministry of Health

N: Margaret MacDiarmid (parliamentary secretary of health for seniors)

Ministry of Health

2013

Ministry of Health

2014

Ministry of Health

2015

Ministry of Health

2017

Ministry of Health

2010 Seniors Policy and Plan

Ministry of Seniors and Community Support Ministry of Seniors

N: Ron Cantelon (parliamentary secretary of health for seniors) Y Ralph Sultan (minister of state for seniors) N: Linda Larson (parliamentary secretary to the minister of health for seniors) N: Michelle Stilwell (parliamentary secretary for healthy living and seniors) N: Darryl Plecas (parliamentary secretary for the minister of health for seniors) N: Anne Kang (parliamentary secretary for the minister of health for seniors) Y: Mary Ann Jablonski (minister of seniors and community support)

2011

SK

Ministry of Health

2012 Department for Seniors

Ministry of Health

2014

Ministry of Seniors

2015

Ministry of Seniors

2016

Ministry of Seniors and Housing N/A

N/A

Y: George VanderBurg (minister of seniors and community support) Y: George VanderBurg (associate minister, reports to Health) Y: Jeffrey David Johnson (minister of seniors) Y: Sarah Hoffman (minister of health and seniors) Y: Lori Sigurdson (minister of seniors and housing) N (Continued)

228

Public Administration and Population Aging

Table 8.1 (Continued ) Year

Seniors’ office

MB 2010 Seniors’ and Healthy Aging Secretariat (SHAS) 2012 SHAS

2013 SHAS 2016 Seniors and Health Aging (Branch) 2018 Seniors and Healthy Aging (Branch) ON 2010 Seniors’ Secretariat 2010 Seniors’ Secretariat

Host ministry seniors

Minister for seniors (Y/N)

Department of Healthy Living, Youth, and Seniors

Y: Jim Rondeau (minister of healthy living, youth and seniors)

Department of Healthy Living, Seniors and Consumer Affairs Department of Health Department of Health, Seniors and Active Living Department of Health, Seniors and Active Living Ministry of Tourism, Culture and Sport

Y: Jim Rondeau (minister of healthy living, seniors and consumer affairs)

Ministry of Tourism, Culture and Sport

2011 Seniors’ Secretariat 2013 Seniors’ Secretariat

2016 Seniors’ Secretariat

2017 2018

QC 2010 Secrétariat aux aînés 2012 Secrétariat aux aînés

Ministry of Citizenship, Immigration and International Trade Ministry of Citizenship, Immigration and International Trade Ministry of Seniors’ Affairs Ministry of Seniors and Accessibility Ministère de la famille et des aînés Ministère de la santé et des services sociaux

Y: Sharon Blady (minister of healthy living and seniors) Y: Kelvin Goertzen (minister of health, seniors and active living) Y: Cameron Friesen (minister of health, seniors and active living) Y: Aileen Carrol (minister of culture and minister responsible for seniors) Y: Sophia Aggelonitis (minister of revenue and minister responsible for seniors) Y: Linda Jeffrey (minister of labour and minister responsible for seniors) Y: Mario Sergio (minister responsible for seniors’ affairs)

Y: Dipika Damerla (minister responsible for seniors’ affairs)

Y: Dipika Damerla (minister for seniors’ affairs) Y: Raymond Cho (minister responsible for seniors and accessibility) Y: Marguerite Blais (ministre responsable des aînés) Y: Réjean Hébert (ministre de la santé et des services sociaux et ministre responsable des aînés)

Offces for Seniors Year

NB

Seniors’ office

229

Host ministry seniors

Minister for seniors (Y/N)

2014 Secrétariat aux aînés

Ministère de la famille

2018 Secrétariat aux aînés

Ministère de la santé et des services sociaux Department of Social Development

Y: Francine Charbonneau (ministre responsable des aînés et de la lutte contre l’intimidation, ministre de la famille, 2016–18) Y: Marguerite Blais (ministre responsable des aînés et des proches aidants) Y: Brian Kenny (minister of state for seniors and minister responsible for the community non-profit organizations secretariat) Y: Susan Stultz (minister of social development, minister responsible for seniors, housing and non-profit organizations) N

2010 Seniors and Healthy Aging Secretariat (SHAS) 2010 SHAS

Department of Social Development

2012

Department of Healthy and Inclusive Communities* Department of Social Development Department of Social Development Department of Social Development Department of Community Services and Seniors Department of Community Services and Seniors

2014 2016 2018 PEI 2010

2011

2015

2016

Department of Family and Human Services Department of Family and Human Services

N Y: Lisa Harris (minister of seniors and long term care) N Y: Janice Sherry (minister for community services, seniors and labour) Y: Valerie Docherty (minister for community services, seniors and labour and minister responsible for the status of women) N: Doug Currie (minister for health and wellness, minister for family and human services) Y: Tina Mundy (minister for family and human services and minister responsible for seniors) (Continued)

230

Public Administration and Population Aging

Table 8.1 (Continued ) Year NS

NL

Host ministry seniors

Minister for seniors (Y/N)

2010

Department of Seniors

2013

Department of Seniors

2010 Office for Aging and Seniors

Ministry of Health and Community Services

Y: Denise Peterson-Rafuse (minister of community services, minister of seniors, minister responsible for the advisory council on the status of women, and minister responsible for the disabled persons’ commission act) Y: Leo Glavine (minister of seniors 2013–; minister of health and wellness, 2013–17, and minister of communities, culture and heritage, 2017–) N

2015

Department of Children, Seniors and Social Development Department of Children, Seniors and Social Development

2017

Seniors’ office

Y: Sherry Gambin-Walsh (minister for children, seniors and social development) Y: Lisa Dempster (minister for children, seniors and social development, minister responsible for the Newfoundland and Labrador housing corporation, and minister responsible for the status of persons with disabilities)

Source: Government annual reports and websites for 2010–18 *SHAS moved to the Strategic Policy and Planning Division Branch

Newfoundland and Labrador, there was a careful study of the Nova Scotia case, a province with a long history as a seniors’ secretariat that had recently become a full-fledged department. During an interview for this project, Russ Wiseman, former minister for health and community services, mentioned that the governmental team attached to this file considered two options. The first consisted of designating an office attached to the executive branch. It immediately provides a higher status, but it also has the disadvantage of generating a broad mandate with limited resources and not having a formal connection to community

Offces for Seniors

231

services. The second option revolved upon a traditional departmental organization. Decision-makers feared that it would be more difficult to accomplish a horizontal mandate as a new ministerial entity, since it would have had difficulty competing for resources with other ministries during the budgetary process. Therefore, decision-makers opted to establish the unit within a larger department instead (Health and Community Services), but distinct from other line divisions.12 Still, a local chapter of CARP, for instance, immediately criticized this move, stating that this organizational set-up represented “a token response compared to that of other provinces” and called for the establishment of an actual Department of Seniors and Aging.13 Other (creative) solutions have been established to accommodate the small size of these units while aiming to preserve a horizontal mandate. For example, in Ontario, the Ministry of Tourism and Culture hosted the Seniors’ Secretariat for a few years. This was an administrative decision related to human resources and communications. Second, the horizontal nature of seniors’ offices is constantly an issue on the agenda. Until recently, most provincial authorities resisted the creation of ministries to facilitate its horizontal mandate. With the exception of the powerful central agencies (such as the Ministry of Finance), ministries tend to fulfil vertical, as opposed to horizontal, mandates. These concerns have been raised consistently across seniors’ offices in the provinces. Ironically, as it was transforming into a department in 2010, the (old) Nova Scotia model became widespread in Canada. Built in the early 1980s, it consists of a secretariat that reports to a committee of ministers within government (and its equivalent at the deputy ministers level). Secretariats are in place (or were at one point) in British Columbia, Manitoba, Ontario, Quebec, New Brunswick, and Nova Scotia. The emulation of the secretariat model is quickly changing, with Ontario and Nova Scotia having departments dedicated to seniors, while Alberta, Manitoba, and Newfoundland and Labrador have created broad departments with few key social concerns, including seniors (see table 8.1). In both Nova Scotia and Ontario, the impetus for these changes came from the political side, where the transformation into a department became a topic of discussion and debate on the campaign trail in Nova Scotia, and a pre-election initiative in Ontario for the Wynne government. This change implies a more important status for the ministers involved. Prior to these changes, they were ministers responsible for seniors, implying that they were without a portfolio, which is no longer the case. In fact, interviewees operating in a division within a department or within a department pointed out

232

Public Administration and Population Aging

the advantage of having easier access to ministerial committees at the executive level.14 Another ongoing debate relates to whether the focus should be primarily on aging, seniors, or both. In some provinces, interviewees were quick to point out that their primary focus is on seniors. As stated clearly by a deputy minister, “We are not a demographic department. Our focus remains on seniors.”15 Others have sought to broaden their focus beyond older adults. In Newfoundland and Labrador, Russ Wiseman, the former minister of health and community services stressed that the wording on aging and seniors for the newly created office was designed to convey the message that aging was not just about seniors, but about the entire community. Hence, a primary objective of the ensuing consultations was to stimulate conversation on aging within communities, regardless of age.16 In its 2004 report, the now defunct Conseil des aînés in Quebec stated a similar need, albeit with an outcome different from that in St. John’s, by demanding that the government move beyond a narrow focus on seniors: “Depuis plusieurs années déjà, le Conseil des aînés recommande d’être transformé en un Conseil des aînés et du vieillissement, dont le mandat et les champs d’action seraient plus larges et porteraient plus directement sur les problématiques du vieillissement.”17 The focus on aging, as opposed to seniors, also coincides with renewed interest in broadening our understanding of aging by focusing on life course approaches and events. This brings about a much broader understanding of the policy problems in population aging. In this vein, informal efforts had been made to integrate the Secrétariat aux aînés within the Ministry of Family Affairs during most of the past 15 years. One objective had been to foster a life course vision for the ministry, whose primary programmatic responsibility is the day care program. On the basis of annual reports and two five-year assessment exercises,18 the family and seniors responsibilities coexisted rather than complemented each other. This was also part of the original idea behind the creation of the Department of Healthy Living, Youth and Seniors in Manitoba in 2009. These efforts in Quebec are likely to wane with the secretariat moved back within the Health Ministry in 2018. Third, the linkage between health and aging remains omnipresent, despite efforts to distance offices of aging from health departments. On one hand, few provinces have focused on developing seniors’ secretariats (Quebec), ministries (Nova Scotia, Ontario), and divisions within social ministries (Alberta, NL) consisting of a small team of civil servants with a lot of autonomy and independent from the health ministries. Still, action plans of these offices typically feature measures in

Offces for Seniors

233

which health ministries have the primary responsibilities and budgets. On the other hand, other provinces have opted to carve out space for health promotion dedicated to older adults, most notably with the Seniors’ Healthy Living Secretariat (BC), the Seniors and Healthy Living Secretariat (Manitoba), and the Seniors and Healthy Aging Department (New Brunswick). Interestingly, all three units were eventually reintegrated within a division or branch within health (BC and Manitoba) and social development (NB) departments. Councils on Aging Prior to discussing the activities performed by offices for seniors, it is important to review the differences between seniors’ offices and consultative bodies related to aging. Consultative bodies representing seniors have been a common feature in many provinces. Representatives are typically nominated by the minister, often on the basis of recommendations from groups that represent segments of the older population. For example, in Newfoundland and Labrador, consideration “is given to geography, cultural diversity, gender, background, experience and skills” in the nomination.19 Councils’ mandates consist typically of advising and informing governments on issues relevant to older adults. The councils also tend to be involved (or at least consulted) when provincial authorities develop action plans or strategies related to seniors. While such bodies can perform a useful purpose in identifying specific issues related to older adults and in providing advice to the minister responsible for seniors, their recommendations are typically non-binding. As with the offices for seniors, their evolution has been diverse across the country. First, some of these councils have been abolished (or simply not active) in recent years. The Quebec government eradicated its Conseil des aînés in 2010 and transferred many of its mandates to the secretariat.20 Created in 1992 to advise the minister responsible for seniors, the Seniors Advisory Council for Alberta experienced a similar fate in 2016. The government created a new council in 2017, the Seniors and Continuing Care Provincial Advisory Council. However, this consultative body operates within Alberta Health Services with priorities centred on health service and care delivery.21 The Saskatchewan Provincial Advisory Committee of Older Persons was short-lived. It was created in 2000 and vanished after the election of the Saskatchewan Party in 2007. Manitoba recently eradicated its council in the fall of 2017.22 In some cases, these have been replaced by more formal mechanisms of representation, as in Nova Scotia, with the Group of IX. Despite its name, Prince Edward Island has a seniors’ secretariat that consists of a

234

Public Administration and Population Aging

consultative body similar to that of Nova Scotia, but with two seats for members at large and some for health professionals in geriatrics and palliative care. Second, Newfoundland and Labrador went in the opposite direction by creating the Provincial Advisory Council on Aging and Seniors in 2004. Among its activities, this council has had regular meetings and exchanges with the Inter-departmental Working Group on Aging and Seniors, featuring civil servants from departments such as Finance and Advanced Education, and Skills and Labour. What Do Offices for Seniors Do? The offices for seniors typically tackle five key roles. First, they disseminate knowledge on programs available to seniors and other relevant information that could assist seniors. Second, they consult regularly with seniors, including groups representing them. Third, they aim to facilitate the coordination of seniors’ related programs and policy issues and stimulate actions on horizontal policy problems, such as ageism and elder abuse. Fourth, they dispose of limited policy instruments forcing these offices to launch joint initiatives with ministries and community organizations to improve the well-being of seniors. This can also take the form of an office for seniors seeking input within the decision-making process of policies developed in other ministries by the government. Fifth, they engage increasingly in health promotion and preventive measures associated with the social determinants of health. The section on the tension between the social gerontological and biomedical lenses tackles the last element. Here I will focus on the first four roles. Dissemination of Information One of the least controversial mandates, but also a very important one, given to offices for seniors is the diffusion of information on programs and services offered to older citizens. This originates from the fact that many programs and services beneficial to seniors are provided by different ministries at various levels of government. As such, a long-standing request from seniors has been the publication of a broad reference guide, and these provincial guides have “became some sort of bible for all things seniors.”23 Most provinces now have such a publication alongside comprehensive websites devoted to offering all information pertinent to seniors. These guides are quite comprehensive and very

Offces for Seniors

235

popular across the country. Also, many provinces have instituted tollfree information lines for seniors who have limited access to web-based sources of information. Consultations The creation of offices dedicated to seniors, accompanied by the appointment of a minister in many provinces, provides a formal entry point for seniors’ groups within government. Whether or not offices of aging have a narrow or broad mandate, all civil servants and political actors interviewed across the country have stated that maintaining strong links with seniors and seniors’ groups is a core goal of their offices. Interestingly, there are noticeable differences in the ways in which seniors’ input is institutionalized. In New Brunswick, Nova Scotia, Ontario, and British Columbia, representative organizations are involved in continuous consulting. Akin to corporatist arrangements, this has the added benefit of legitimizing further the work of these interest groups and facilitating communication between government authorities and seniors. Typically, efforts are made to ensure a broad representation of seniors. For example, the Group of IX in Nova Scotia includes a chapter from CARP, associations representing diverse professional groups (teachers, doctors, veterans), civil servants (provincial and federal), francophones, and a federation representing local clubs and councils.24 This institutional setting stands in contrast to provinces such as Manitoba, Alberta, and Newfoundland and Labrador where seniors’ offices consult with councils appointed by political authorities. In 2017, Alberta instituted a biannual Minister’s Seniors Advisory Forum to discuss broad issues facing seniors with the participation of a wide range of actors including researchers, policymakers, advocates, and seniors’ groups.25 These actions to enhance the visibility and input of seniors-related issues may seem surprising, considering the extensive literature on the rising influence of seniors’ interest groups such as AARP in the United States26 and CARP in Canada.27 These arguments are developed within the context of policy feedback, where the maturation of programs such as Social Security and Medicare in the United States prompts the creation of beneficiaries seeking to preserve them.28 As such, the focus in this literature is on preserving current social benefits in an era of retrenchment, rather than seeking to address how broader policy issues that arise from having a significant portion of older individuals within a province can be resolved. They often bring perspective or attention to issues affecting seniors that are often ignored.29 Thus, the horizontal mandate of

236

Public Administration and Population Aging

seniors’ offices helps to break the overwhelming policy attention resulting from the political dynamics created by path-dependent programs, such as public pensions. Lynch’s comprehensive study of industrialized countries has also warned against extrapolating from the American experience by concluding that many countries, including Canada, do not have an elderlybiased welfare state.30 Also, big organizations such as CARP do not necessarily represent the highly heterogeneous senior population, and offices for seniors can provide a broader view and understanding of policy issues. Coordination of Senior-Related Issues and Programs Within provincial public administrations, another important goal for seniors’ offices is to perform cross-ministerial functions to represent issues related to having an increasing number of older citizens within policymaking. Like gender, population aging is a policy issue that cuts across ministries and agencies, requiring an ability to coordinate governmental actions horizontally (see chapter 7). This remains a core mission of most offices for seniors. A 2012 inquiry in New Brunswick, the Premier’s Panel on Seniors, recommended the creation of an Aging Adults Secretariat to support the minister responsible for seniors and develop age-related policies, but also to “coordinate aging-related issues across all government departments, agencies, boards and commissions and collaborate with community organizations.”31 A motivation behind the creation of secretariats in many provinces, as opposed to a department or a directorate within a department, is to emphasize that this public organization mainly performs a horizontal function across ministries. With a small budget, few human resources, and a horizontal mandate, the policy and programmatic capacity of offices for seniors is extremely limited. The number of staff involved ranges from a handful to 25 in Quebec. A large office for seniors in the six smallest provinces has six to eight full-time employees, and a few provinces have only a handful of individuals working full-time on the senior portfolio. This makes it necessary to rely upon other ministries and community partners to launch and sustain programs and initiatives. It is worth emphasizing, however, the highly collegial nature and collaborative effort between these administrative units across the country. The Federal/Provincial/ Territorial Ministers Responsible for Seniors Forum (FPT seniors) has facilitated this process, and the understanding and knowledge of what is being done in other provinces far surpasses what is common in other policy areas.

Offces for Seniors

237

With all these constraints, the ADMs and DMs supervising offices for seniors play a crucial role in ensuring that the interests of seniors are not forgotten in the development of policies in other ministries, especially when this group does not represent a high priority. This would be the case, for example, with the Ministry of Transportation where seniors’ considerations are rarely at the top of the agenda in the maintenance and development of the road network. The ADMs, DMs, and civil servants must exercise their excellent diplomatic skills to entice officials in other departments to generate senior-friendly policy proposals before they reach Cabinet. To facilitate the execution of their mandate, few provincial jurisdictions have implemented regular round tables or crossministerial networks. For example, discussions on population and/or seniors at the ADM/DM and ministerial level are formally institutionalized in Newfoundland and Labrador (Ministerial Council on Aging and Seniors), Nova Scotia (Seniors’ Secretariat Committee of Cabinet Ministers), and, albeit with a narrower mandate, Manitoba (CrossDepartmental Coordination Initiatives). It is important to note, however, that the finance ministry is not involved in most of these round tables in Canadian provinces. Civil servants must also perform the role of advocate and networker extraordinaire, since they must create partnerships with other organizations – public and private – to launch and maintain new initiatives. This is a significant challenge, considering the limited resources of offices for seniors. Indicative of a mandate very different mandate from that of traditional civil servants, Manitoba civil servants adopted the official title of policy consultant to specify that their mandate is to assist and stimulate new collaborations. Offices for seniors have also embarked on many publicity campaigns to raise awareness of issues such as elder abuse, healthy living, and ageism. As discussed below, this has proven to be one of the most successful forms of partnership for offices for seniors. Policy Instruments and Policy Input The offices for seniors are a case par excellence for scholars of governance and network theories. Civil servants working in these offices are expected to foster and develop partnerships with public and private organizations to advance the cause of seniors. As mentioned by a civil servant working in an office for seniors during an interview, “We are building new manners, as opposed to new [policy] options.”32 This is, in many ways, a Herculean task, since offices for seniors have very limited resources to encourage others to engage in a partnership and,

238

Public Administration and Population Aging

particularly in larger provinces such as Ontario and British Columbia, it requires a vast efforts just to keep abreast of policy developments within provincial administrations, let alone find a way to influence their policy output. In addition, civil servants are expected to maintain a constructive dialogue with associations representing seniors. As a result, the civil servants’ powers of persuasion represent the core instrument of offices for seniors to resolve many of the policy problems discussed above. The offices have limited to no legislative and programmatic responsibilities but, just as importantly, this means that they are not hindered by such responsibilities.33 This has important implications for the type of policy actions that can be implemented, since it involves a third party. Some partnerships are far easier to formalize than others. Awareness campaigns and dissemination of best practices are popular policy instruments of offices for seniors. They are particularly effective instruments to achieve policy objectives such as fighting ageism, educating the population on dementia and Alzheimer’s disease, reducing the risk of accidents and falls, and raising awareness of elder abuse. An exhaustive treatment of these collaborations is beyond the scope of this chapter; actions on ageism and elder abuse are excellent illustrations of the kinds of efforts that seniors’ offices undertake. First, there is evidence that ageism remains strongly embedded, especially in the workplace.34 The best policies to integrate seniors more fully within the workplace and the day-to-day affairs of communities are meaningless if ageism prevails. It remains a core concern for seniors across the entire country, as clearly stated in consultations that underpin many provincial strategies on aging. For example, eliminating ageism was identified as the first of nine goals from Nova Scotia’s Strategy for Positive Aging that featured province-wide consultations in 2004.35 Along the same lines, a strong emphasis on recognition of older persons in Newfoundland and Labrador’s Healthy Aging Policy Framework launched in 2007.36 It comes as no surprise, therefore, that seniors’ offices have strongly advocated efforts to eradicate ageism. This objective is prevalent in all offices for seniors with measures, such as awards, to recognize the contribution of older adults and strengthen their place within society. Offices for seniors have consistently made recommendations in forums to take a strong stance against it. Second, elder abuse is a quintessential horizontal issue that requires concerted efforts from health professionals, the judiciary, policy officers, and social workers, to name a few. As such, it quickly became an important issue for seniors’ offices. The construction of a partnership with the RCMP illustrates the limitations and potential initiatives of secretariats. Elder abuse has been a recurring theme within the FPT seniors, but

Offces for Seniors

239

failed to receive funding within the FPT framework. A collection of secretariats turned to the RCMP for assistance. It led to a partnership, with many provinces developing local initiatives with the RCMP to raise awareness and develop better practices surrounding elder abuse. This was a win-win for both parties, since police forces could engage in a dialogue with a broad network of senior citizens, which was facilitated by the offices for seniors. In addition, this partnership ensured wide diffusion of this cooperation within some provinces.37 Grant programs are another policy tool frequently deployed by seniors’ offices across Canada, mostly to encourage development of age-friendly cities, with municipalities (or community groups) providing matching funds to elaborate action plans and improve facilities and services to make them more accessible for older adults. Some seniors’ offices oversee programs offering financial assistance to cover diverse needs and situations targeting seniors, as with the Seniors Services Division within the Department of Seniors and Housing in Alberta. They provide benefits such as the Alberta Seniors Benefits (an add-on to the federal Guaranteed Income Supplement) and the Seniors Property Tax Deferral program, which is a low-interest loan to cover property taxes that can be reimbursed when the property is sold (or earlier).38 The Tension between the Social Gerontological and Medical Lenses As discussed earlier in this chapter, strong pressure emanating from groups that represent older adults was a key factor leading governments across the country to establish an office away from health departments to send the message that aging was not a sickness. This criticism of aging as a pathology aligns with the analytical orientation of the social gerontological lens where the social dimensions of aging are prevalent. Despite efforts to break the association of aging with health, pressures have returned health concerns to the top of the agenda. In fact, the evolution of seniors’ offices is an excellent illustration of the difficulties in dissociating health and social concern. As such, it focuses on three trends. First, it analyses the rising importance of social determinants of health and the launch of campaigns and initiatives to encourage healthy aging. This has led to an increasing number of offices developing a preventative health mandate, rooted in the promotion and dissemination of best individual practices, distinguishable from acute concerns that dominate health departments. In fact, in the last 10 years, healthy aging had been a core of several

240

Public Administration and Population Aging

new secretariats (British Columbia, Manitoba, New Brunswick), and has immersed itself in the mandates of other seniors’ offices across the provinces. Second, this section tackles the resurgence of political pressures to return to an organizational setting where aging (and seniors as a group) is immersed in traditional health departments. Embracing Healthy Aging With a renewed commitment to consider the socio-economic determinants of health, some provinces embraced responsibilities for seniors within healthy living (or aging) secretariats. The focus was primarily on health prevention, and a core responsibility is implementation of healthy living/aging strategies (or framework). This included British Columbia (Seniors’ Health Promotion Team, which replaced the Seniors’ Healthy Living Secretariat),39 Manitoba (Seniors and Healthy Living Secretariat), New Brunswick (Seniors and Healthy Aging Secretariat), and Newfoundland and Labrador (Office for Aging and Seniors). Interestingly, these four organizations were eventually reintegrated within a health department (BC), the broadly defined Department of Health, Seniors and Active Living (Manitoba), and two social development departments (New Brunswick and Newfoundland and Labrador). These secretariats separated health prevention and seniors from acute care, addressing criticism of health departments for being too focused on hospital care. Ironically, one justification for creation of a separate entity, as opposed to a branch within a traditional ministry, is the challenge to grow preventive health within a traditional health department. There are many reasons behind this state of affairs, such as the fact that its benefits are diffuse, making it difficult to justify a share of a budget where cuts in hospital care are highly visible, and they can be interpreted in waiting time, number of doctors, and beds in care facilities. It is important to stress that other provinces have enacted similar healthy living strategies, albeit without a specific healthy living/aging secretariat. For example, Alberta adopted a 10-year Healthy Aging and Seniors’ Wellness Strategic Network, as early as 2002.40 Many of the goals and objectives of Nova Scotia’s Positive Aging Strategy also correlate strongly with the strategies developed by the offices cited above.41 The close resemblance of these frameworks/strategies is not a mere coincidence. They originate from the World Health Organization’s Active Ageing agenda,42 which featured input from Canada, and federal discussions and research on the subject. These occurred primarily within the FPT seniors network, which elaborated a National

Offces for Seniors

241

Framework on Aging in 1998,43 and at Health Canada, with its Dare to Age Well project.44 Following these initiatives, many provinces have launched broad provincial consultations or working groups to elaborate their own strategy.45 A second wave of diffusion has occurred in similar ways, with the 2005 launch of the subsequent and complementary initiative to Active Ageing: WHO’s Global Age-Friendly Cities Project,46 which was heavily influenced by Canadian researchers and officials. As a result, federal and provincial authorities embraced this new WHO initiative immediately.47 This resulted in a wave of “latecomers” embracing agefriendly communities and healthy living within the same framework.48 The latter initiative focuses strongly on transforming the individual and collective environment to facilitate aging in place. Quebec has been the most enthusiastic provincial implementer of the age-friendly city framework. Its Municipalités amies des aînés (MADA) program began allocating funds in 2009–10, and more than 950 municipalities were enrolled in the program in 2019.49 This involves a commitment to achieve objectives such as adapting policy and structures, and encouraging participation of older adults.50 Health promotion looms large in this initiative, since the program is expected to facilitate the deployment of active aging strategies. The MADA program rests explicitly upon the active aging framework developed by the World Health Organization.51 Indicative of its importance with the secretariat, one of its two divisions is actually called the “direction du vieillissement actif.” Interestingly, still within the scope of health promotion, some provinces have sought a broad representation of the population, moving well beyond seniors, which is clearly aligned with the life-course perspective. The life course approach focuses primarily on the transitions between events or stages occurring within an individual’s life.52 For example, in Newfoundland and Labrador’s Provincial Healthy Aging Implementation Plan, many measures also apply broadly to the entire population, while benefiting seniors. This particularly applies to the goals of supporting communities, celebrating diversity, and health and well-being.53 For a three-year period (2009–12), Manitoba had a comprehensive and explicit life course approach with its Department of Healthy Living, Youth and Seniors, including its own deputy minister. Other provinces such as Alberta, British Columbia, and Nova Scotia have developed strategies that have a narrower focus on older adults. For example, Alberta’s Aging Population Policy Framework aims to achieve eight policy outcomes that are all related to seniors.54 Aging is an individual and very heterogeneous process, with most seniors living lengthy and healthy lives.55 With this in mind, the adoption of practices

242

Public Administration and Population Aging

associated with healthy aging/living programs, even later in life, can produce positive socio-health outcomes for many older adults. A Return to the Ministry of Health? Most seniors’ offices have seen their configuration altered in the past 10 years and a few even found their way back within traditional health ministries (see table 8.1). The nomination of a minister of health receiving the seniors portfolio still sends a strong message that seniors are considered to be a health priority first and foremost. A change in ministerial assignation does not always prompt a change in organizational structure since the seniors portfolio is frequently added to other ministerial responsibilities. However, the limited programmatic responsibilities attached to seniors’ offices make them relatively easy to move from one department to another, and few offices have moved across departments. The organizational changes that have been ongoing in the past decade clearly indicate the struggles to decouple seniors from health priorities. A comprehensive treatment of these changes is beyond the scope of this chapter because there are so many. In Alberta, the formation of a new Cabinet by Premier Alison Redford in 2012 featured a clear statement on the needs to strengthen the link with health care: “Seniors is moving to the Ministry of Health to enhance continuity in the short- and long-term care of Alberta’s aging population.”56 This assignation with the health minister lasted only two years. September 2014 brought the creation of the Ministry of Seniors with three distinct divisions (housing, seniors’ services, and strategic services),57 which was altered again in February 2016 with the creation of the Seniors and Housing Department in the aftermath of the first Cabinet shuffle of the Notley government. This marked a return to the nomenclature during the Stelmach government. Following the election of the PQ in Quebec in 2012, the Secrétariat aux aînés left the Ministry of Family and Seniors and moved to the Ministry of Health and Social Services. This reflected the mandate given to Réjean Hébert, a well-known geriatrician in Quebec. It returned to the Ministry of Family Affairs following the 2014 election when the Liberals returned to power. Surprisingly, however, it returned to the Ministry of Health after the election of the CAQ in 2018. The CAQ recruited former Liberal Minister Marguerite Blais, with the promise of granting her responsibility for the seniors portfolio. She kept essentially the same team as the Liberal minister (Francine Charbonneau), who replaced her after the 2014 election, including the deputy minister, but moved the secretariat into the health ministry. The new government emphasized

Offces for Seniors

243

the strength of its trio of health minsters (health and social services, seniors and caregivers, and early childhood). In 2013, the NDP government in Manitoba expanded its Department of Health, resulting in the creation of a Ministry of Health, Healthy Living and Seniors, which included the Seniors and Healthy Aging Secretariat. This marked a return to its roots, since the original position for healthy living in 2003 was not a Cabinet portfolio, and the minister responsible for healthy living reported to the Minister of Health. Still, in this case, the creation of the secretariat came at the expense of the Manitoba Seniors Directorate (1988–2004), which reported to the Executive Council with a much broader mandate for seniors. However, this set-up was reformed with the election of the Conservative Party in 2016, with the new government opting for a more traditional health ministry structure. The secretariat was transformed into a branch within the ministry. Indicative of a marginal role for the seniors portfolio within the Ministry of Health, Seniors and Active Living, Cameron Friesen’s mandate letter accompanying his appointment in 2018 featured only a single priority related to seniors: the development of a sustainable funding model to build 1,200 personal care home beds.58 In the case of British Columbia, the Seniors’ Health Promotion Team replaced the short-lived Seniors’ Healthy Living Secretariat, which was part of a Ministry of Health Living and Sport, also featuring a special secretariat for the Olympics. Since March 2011, a parliamentary secretary for seniors (2011–12, 2013–18) and a minister of state for seniors have been reporting to the minister of health. Still a Social Perspective? There has been more emphasis on health promotion in seniors’ offices. Many secretariats have become a launching pad to foster and deploy public health initiatives. There is extensive literature on the potential health benefits of adopting many elements of active/healthy aging programs (with the assumption that the population complies and that there are sufficient resources). Growing emphasis on active aging, healthy aging, and/or aging successfully has not gone unnoticed in gerontology journals. As one would expect, health professionals have welcomed such initiatives. This is consistent with the medical lens. However, as discussed in chapter 1, this is not the case for professionals and experts aligned with the social gerontological lens. For example, what exactly it means to age successfully is something that differs between seniors and the medical community,59 and it downplays the importance of social stratification on health outcomes.60 These initiatives frequently promote

244

Public Administration and Population Aging

role models (such as entrepreneurs and athletes) and stigmatize individuals with limited abilities to achieve these goals.61 The prevalence of social determinants of health within policy debates represents a catch-22 for seniors’ offices. On the one hand, it remains far easier to obtain resources from a finance ministry when they come with the promise of improvement in health outcomes, since this implies potential savings in health spending later. As such, an increasing number of annual reports feature health outcome data to justify the added value of these programs. Social data are far more difficult to interpret and obtain. Consequently, it remains far easier to justify spending public money on an initiative promising a health outcome rather than a social objective. This has actually made it easier to bring back (or transform) many of the seniors’ offices under the auspice of a health department. On the other hand, the focus on public health reinforces the already dominating view of aging as being primarily a health problem. It can quickly overshadow social initiatives, lowering their importance and priorities. Within this context, social policies also become a tool to improve health outcomes, as opposed to an end in themselves. Interviews with officials in the offices for seniors across the country were quite revealing – albeit not surprising – on this issue. Respondents in offices with a mandate focusing on healthy aging (as often indicated in the name of their office) prioritized other issues confronting seniors far less than those that had maintained a horizontal structure detached from health departments. Interestingly, some have rejected the view that this health promotion turn implies a return to reinforcing the link between aging and health, as criticized in social gerontology. One respondent stated, “It is obvious that we need a minister responsible for seniors, who is outside health. Aging is not a disease. We put emphasis on prevention and not in curative health.”62 Long-Term View By the very nature of their mandate and their activities, seniors’ offices have a short time horizon. Dissemination of knowledge and resolution of horizontal issues require close attention to developments that may affect seniors. Consulting with seniors to identify policy issues and enact joint initiatives with community partners is also strongly rooted in the present. Nonetheless, two elements have a longer view. First, development of horizontal solutions requires long-term thinking simply because so many actors need to undertake meaningful actions, instead of reducing

Offces for Seniors

245

the importance of an issue caused by lack of coordination. Second, the primary objective of a healthy aging strategy is the improvement of individuals’ health. Healthy aging initiatives represent an investment, albeit modest, in the long run. The hope is that healthier older individuals will have a positive trickle-down effect by reducing needs for institutionalized health care in the future. Facilitating a Long-Term Perspective Chapter 3 identified four key actions to enhance a long-term perspective within the context of an aging population: improving learning opportunities, creating new procedures, introducing gatekeepers, and developing explicit strategies. Gatekeepers typically operate in central agencies, which leave three types of actions accessible to seniors’ offices. Of the three actions, seniors’ offices have enhanced learning opportunities that consider long-term implications in their work. Increased attention given by the media and governments to the number of baby boomers entering retirement has provided an opportunity to think about how governments can help better seniors’ lives. Although they rely on a very small staff, these offices have found creative ways to mobilize resources and raise awareness of policy issues affecting seniors. Multiple tools aim to enhance learning opportunities, such as knowledge forums, or create commissions or other types of inquiries. Seniors’ offices have been active on both fronts. On the former, Nova Scotia has organized Silver Economy summits, bringing together community and business leaders, practitioners, and researchers. And on the latter, Nova Scotia Seniors’ Secretariat/Department of Seniors, the Office for Aging and Seniors in Newfoundland and Labrador, and Quebec’s Secrétariat aux aînés have played key roles in consultations leading to strategies for future action. Regardless of the policy impact of these inquiries, they have raised awareness and stimulated learning on age-related policy issues. New procedures have been created across the provinces, even though they have also been subject to disruptions occasioned by the organizational changes common to seniors’ offices. There is nothing formal akin to gender mainstreaming, but some formal internal mechanisms have been introduced to facilitate collaboration across ministries. For example, as part of the efforts behind the Healthy Aging strategy in Newfoundland and Labrador, an interdepartmental working group (with representatives from 12 departments and agencies) was developed to enhance communication, stimulate learning across departments, and foster implementation of the provincial strategy through monthly

246

Public Administration and Population Aging

meetings. Other provinces, such as Alberta, Manitoba, and Nova Scotia have (or at least had at one time) developed similar exchange forums. Many provinces have developed strategies, frameworks, plans, or policies to tackle broad policy issues surrounding aging and seniors that involved the participation of many departments. This includes Manitoba (2003: Advancing Age), Nova Scotia (2005: Positive Aging), Alberta (2010: Aging Population Policy Framework), Quebec (2007: stratégie d’action en faveur des aînés; 2012 : Vieillir et vivre ensemble), British Columbia (2008: Healthy Living Framework), Newfoundland and Labrador (200: Healthy Aging Policy Framework), New Brunswick (2017: We Are All in This Together), and Ontario (2013/17: Action Plan for Seniors). These initiatives vary considerably in scope, depth, and length. For example, Nova’s Scotia Strategy for Positive Aging (2005) is a 196-page document organized around nine goals covering a wide range of issues (such as housing, financial security, and transportation), while Ontario’s Action Plan for Seniors consisted of only 14 pages devoted to three goals (healthy seniors, senior-friendly communities, and safety and security). A pre-electoral 2017 version was more substantial, with 37 pages. Nonetheless, the plans include broad long-term objectives featuring the communication of challenges and opportunities surrounding aging population, the identification of priorities, guidelines to allocate future resources, and ways to foster cross-ministerial collaboration. They usually also include current services and programs, recent initiatives, and ongoing projects initiated by the government. Obstacles to Implementing a Long-Term Horizon Seniors’ offices face important obstacles in the development and deployment of long-term objectives. First, as discussed earlier, these offices have faced multiple reorganizations and changes in mandate over the years. For many jurisdictions, these offices remain relatively new entities with few employees who are not anchored within the civil service, making it easy for newly elected governments to alter their mandate and ministerial affiliation. Pressed on this subject, a deputy minister said, “As we have seen over the years, cabinet comes and goes. It comes down to two factors. First, how big is the cabinet? Second, what do you want to put an emphasis on?”63 When cabinet downsizes (or expands), it rarely occurs without a noticeable impact on seniors’ offices (see table 8.1). This state of affairs makes it difficult to construct a stable structure and relationships within the civil service and older adults – essential ingredients when operating horizontally with a focus on a specific population. This is particularly the case in the four provinces that

Offces for Seniors

247

operate with a substantial public administration. In one jurisdiction, they worked with three different ministers, two different deputy ministers, and three different associate deputy ministers in a span of three years.64 Compounding this issue further, talented deputy ministers are likely to be recruited by larger and more prestigious departments rather than remain attached to a department that is prone to restructuring. From the interviews across the country, it is worth emphasizing that the impact of these frequent organizational changes is more pronounced in larger provinces because informal relationships are more difficult to cultivate. Second, and somewhat related to the previous point, changes in government are disruptive, especially when strategies or action plans are closely tied to an electoral platform. Plans whose impetus came from the Seniors’ Office or are entrenched in the policy landscape (typically when a government had more than one mandate) are more likely to attract attention from the subsequent government. A change in premier can have similar effects. For example, Premier Campbell in British Columbia launched a Premier’s Council on Aging and Seniors and supported the Aging Well initiative and the creation of the Seniors’ Healthy Living Secretariat (as part of the Ministry of Healthy Living and Sport). This momentum was cut short upon his resignation as premier and the arrival of Christy Clark. Third, seniors’ offices have limited financial means to achieve their objectives. By not having programmatic responsibilities, these offices do not benefit from the security of a strong recurrent budget. As a result, most of the policy tools employed by these offices, such as the dissemination of information awareness campaigns, and grant projects involve actions with a short-term horizon. This is notably the case with age-friendly communities/cities programs across the country, where municipalities have received one-off grants to develop action plans and engage in infrastructure improvement projects. A Third Wave of Offices for Seniors? Seniors’ Advocate Offices As we have seen, the first wave of administrative reforms to tackle horizontal issues concerning older adults resulted in the creation of offices for seniors preoccupied with a wide range of policies. The second wave features many of the WHO initiatives on healthy aging, resulting in alteration in the mandate or even the administrative structure of many offices for seniors. Recent developments raise the possibility of a third round of “administrative diffusion” with the objective to enhance the capacity of seniors to enforce their rights and access to programs

248

Public Administration and Population Aging

and services, most notably in seniors’ care. British Columbia enacted a Seniors Advocate Office in 2013, while Alberta and Newfoundland and Labrador followed suit, in 2016 and 2018 respectively. New Brunswick modified its act to add seniors to the mandate of the advocate for child and youth in 2017. These offices have a broad mandate akin to an ombudsperson, but with the ability to act as an advocate for seniors. The ombudspersons in British Columbia and Quebec have investigated a rapidly rising number of complaints from older adults and caregivers in long-term care caused in part by hurdles to enact home care and restrained health care budgets. Chapters 5 and 6 summarize key elements in these reports. In British Columbia, the Office of the Ombudsperson launched a province-wide investigation that led to a public response “unparalleled in the history” of this office.65 The investigation concluded with a highly critical multi-volume report on seniors’ care published in 2009 and 2012.66 The BC government released a Seniors Action Plan in February 2013 followed by legislation introducing the Office of the Seniors’ Advocate. Its mission is “to examine and advocate for seniors on issues related to health care, personal care, transportation, housing and income supports.”67 In addition, the office must (1) “monitor services to seniors,” (2) “provide information and referral,” (3) “analyze systemic issues that relate to the health and well-being of seniors,” and (4) “provide recommendations to government and service providers on improvements that can be made to enhance the health and well-being of British Columbia seniors.”68 Following her appointment in early 2014, the advocate embarked on a province-wide tour and identified 13 issues, which included the challenges for seniors to live where they want, inadequate income, inconsistent home care, caregiver burnout, and ageism.69 The office has been active in raising a number of issues such as caregiving burnout and the higher likelihood of private residential care facilities to send their residents into hospitals. A 2014 ministerial order paved the way for the appointment of a seniors’ advocate in Alberta, but the office really took off after the appointment of a seniors’ advocate in September 2016 and its operation as an entity separate from the Alberta health advocates. Contrary to British Columbia, the scope of actions is far more pedagogical and one of assistance to navigate through public services. As such, it is more similar to an ombudsperson, as its investigative activities are far more constrained. More specifically, the office’s mandate is primarily to (1) “provide resolution support,” (2) “provide public information,” (3) “identify trends and issues emerging from resolution support activities and from listening to seniors and stakeholder groups,”

Offces for Seniors

249

and (4) “make recommendations and provide advice to government for improvement to programs and services based on analysis of resolution support activities and by listening to seniors groups and stakeholder groups.”70 It has a staff of six individuals.71 Newfoundland and Labrador passed legislation to create an Office of Seniors’ Advocate in December 2016 and appointed the advocate in late 2017. This office has a broader mandate than Alberta’s, with the identification, review, and analysis of systematic issues at the forefront of its mandate.72 The other two key mandates are to “work collaboratively with seniors’ organizations, services and others to identify and address systemic issues and make recommendations to government and government agencies.”73 New Brunswick expanded the mandate of its child and youth advocate by adding seniors in 2017, which predisposes a small staff dedicated to seniors (two directors and an intake office).74 Indicative of the blurring line between ombud and advocate, this expanded advocacy office actually shares administrative resources with the Office of the Ombudsman, and the legislation allows the advocate to hold the office of ombudsman.75 Conclusion: Divergent Path for Seniors’ Offices? Seniors’ offices have undergone many transformations in the past 30 years, reflecting, in large part, changing government priorities. Their relatively small size and lack of programmatic responsibilities have made it easier to alter their mandates and their organizational setting, so they do not benefit from the stability associated with traditional departments or agencies. Still, they fulfil many roles and have accomplished a surprising number of actions in spite of operating under difficult conditions. Some emerging trends are noticeable across the provinces. First, there has been a noticeable shift in the priorities of horizontal actions favouring health promotion across governments. Manitoba provides a clear illustration. Originally, the Seniors Directorate was attached to the Executive Council and had a clear horizontal mandate across governments on a wide range of issues affecting seniors. The creation of the Ministry of Healthy Living in 2003 led to a shift in direction, with the Seniors Directorate becoming the Seniors and Healthy Aging Secretariat. Even though the staff remained essentially the same, healthy aging began to occupy a more central role. There is still a horizontal dimension to the secretariat’s work, but the priorities have shifted toward health promotion/prevention. In contrast, a ministry for seniors has emerged in

250

Public Administration and Population Aging

Ontario and Nova Scotia. While the emphasis on health promotion has made inroads there as well, there remains a strong structural component devoted to tackling broader issues. In addition, this organizational structure signals a distance from the Ministry of Health. Still, Ontario has increasingly coupled long-term care within this structure, and this policy sector is dominated by health actors, as we saw in chapters 5 and 6. This focus on health promotion is a vicious circle for offices for seniors. On one hand, it has facilitated the granting of additional resources from the finance ministry, which can justify this decision with the long-term benefit to mitigate future health care costs. On the other hand, it reaffirms the link between aging and health, even though these programs are not curative. Second, interviews across the country revealed that an increasing number of departments have developed the reflex to contact the Seniors’ Office when an issue concerning older adults arises. There is a fine line between working horizontally to develop initiatives (or resolve current issues) related to seniors, and attempts to offload senior issues to these small-staffed organizations. Third, many programs initiated by seniors’ secretariats in conjunction with other departments have not had the financial resources to sustain them. Many aging-related programs involve co-funding for communitybased initiatives. Fourth, the recent creation of Seniors’ Advocate Offices in British Columbia, Alberta, New Brunswick, and Newfoundland and Labrador echoes the proliferation of ombudsperson offices for different populations (women, children, homosexuals, disabled persons, etc.) in Sweden in the 1990s. These offices, like those of the Seniors’ Advocate, have moved well beyond the original mandate of the ombud, which was to appeal administrative decisions and/or processes, by engaging in “the production of ideological positions.”76 These ombudspersons take on specific causes and are active in the public arena to promote them, creating long-term impacts for the coherence of the civil service and the role of advocacy offices in the creation of policy ideas.77 With the Seniors’ Advocate Offices in their infancy, it remains to be seen how they will develop. However, the dual investigative and advocacy role of the BC seniors’ advocate has already been criticized by private sector providers of home care services. Despite these shortcomings, these offices are likely to remain and even expand with a growing older adult population. An alternative development may be the proliferation of seniors-based public organizations like the Office of the Seniors’ Advocate if current offices, such as

Offces for Seniors

251

the ombudsperson’s, are overwhelmed by the quantity of requests from seniors and the specific nature of the difficulties to resolve them. Hence, the creation of a specialized office presents an interesting response. At the most basic level, there is an important need to have an office that considers horizontal issues related to older adults, but also to communicate what policies target them.

9 Conclusion

This book displays the complexity and depth of policy issues associated with population aging across Canadian provinces, and it demonstrates the ubiquity of population aging in public administration and public policy. Analysis of all 10 provinces also illustrates the distinctive socio-economic transformations, policy environments, and political choices that characterize each province’s approach to population aging. For instance, it has showcased a distinct social approach to long-term care in New Brunswick, a surprising number of initiatives to take stock of the consequences of an aging population in Alberta (the province with the youngest population profile), an innovative way to share and disseminate socio-economic and demographic data in Newfoundland and Labrador, and one of the most comprehensive inquiries on long-term care conducted by an ombud office in the world in British Columbia. In this final chapter, I present a general assessment of the potency of the four lenses of population aging across the 10 provinces. Second, I revisit the theoretical expectations of the elements favouring development of a long view within the civil service and policymaking, as it applies to population aging. Third, I look at the ways in which federalism has facilitated learning and cooperation among the provinces in an environment with limited policy capacity and a high number of generalist, as opposed to specialist, civil servants.1 Fourth, I provide an overarching takeaway on provincial responses to the consequences of population aging and their prospects for the future, with some consideration given to the impact of COVID-19. This demonstrates how the interactions of the lenses contributes to further the marginalization of social policies for all age groups, but most notably older adults.

Conclusion

253

Revisiting the Four Lenses of Population Aging

Intergenerational Lens To reiterate, the intergenerational lens reveals a new political cleavage along generational lines. As introduced in chapter 1, this features a conceptualization of policy problems centred on the redistribution of costs and benefits of public policies, the political participation and input of various generations, and the use of dependency ratios to illustrate the challenges of population aging. While these elements arose during interviews with civil servants and feature in provincial policy documents, explicit references to intergenerational issues are relatively infrequent and tend to be specific to action plans on aging, budgetary debates, and pension reforms. Within this lens, strategies to address population aging typically feature basic statistics on the demographic shifts denoting the rising proportion of older adults aged 65 and above and a statement that policy development needs to consider intergenerational equity. This conceptualization of intergenerational equity is akin to the one employed in generational accounting, with its focus on the costs and benefits of public policies across generations over time. For instance, in one of the most explicit statements on the subject, a leading principle in Alberta’s Aging Population Policy Framework is that government programs, services, and policies will be “fair and equitable to future generations … [and] should not place a disproportionate tax burden on future generations.”2 It remains unclear, however, how this principle is articulated in practice, especially when one considers the fiscally conservative nature of Alberta politics. This understanding of intergenerational equity also features strongly in budgetary debates, where tackling the debt and reducing the deficit have been put forward as an intergenerational measure. This is most notably the case in Quebec, which even instituted the Fonds des générations in 2006 and the objective to “keep public finances healthy for generations to come” in its 2008 Sustainable Development Strategy. Still, only Ontario has a formal mechanism to conduct long-term reports on the economy, which features potential challenges arising from population aging (see chapter 7). Surprisingly, the intergenerational lens has been constrained in the policy area where it was expected to matter the most: pension policies. Intergenerational issues played a key role in the 1997 reform of the Canada Pension Plan (CPP)/Régie des rentes du Québec (QPP), which led to a rapid rise in contribution rates to sustain benefits in the long

254

The Four Lenses of Population Aging

run.3 Still, intergenerational considerations are present for defined benefit plans experiencing financial difficulties, which are regulated by provincial and federal pension authorities. In the aftermath of the 2008 economic crisis, the latest wave of pension reforms sought to compensate for the declining coverage of occupational pension plans. As discussed in chapter 4, traditional social policy concerns – adequacy and coverage – dominated pension debates across the provinces. Intergenerational considerations largely took the form of shaping reform parameters. Policy designs feature a tight relationship between contributions and benefits in the development of new public pension programs (such as the failed attempt to launch an Ontario Retirement Pension Plan), including the Canada Pension Plan/Quebec Pension Plan reform. Additional benefits are fully funded to ensure that current contributions will not be used to finance actuarial deficits originating from prior commitments. This approach, however, marginalizes redistributive mechanisms of pension systems and provides a marginal improvement on adequacy. These findings are consistent with research on the relative importance of the intergenerational lens in Canadian policy debates, compared with other industrialized countries. As discussed in chapter 1, this lens has been particularly popular in the United States with multiple contributions emphasizing a senior bias of the American welfare states, mostly due to the universal nature of Social Security and the structure of Medicare, which only covers adults aged 65 and above.4 To this day, there is an important political constellation and mobilization to sustain these benefits, resulting in reforms at the margins.5 The US intergenerational political dynamic is unique and distinct from that of most industrialized countries. In Canada, the 1997 CPP/ QPP reform removed, for the most part, intergenerational equity debates by securing its financial future. In the United States, a similar kind of reform is still lacking and would require, as of 2018, 2.78 percentage basis points in contributions, or a 17% reduction in benefits to sustain the program over the long term. The financial health of the program is expected to decline rapidly with the depletion of reserve funds at the end of 2034.6 While an aging population accentuates health care cost pressures in Canadian provinces (see chapter 5), this does not compare to the US political dynamic of having universal coverage for seniors only. This explains in large part why intergenerational equity debates have been far more pronounced and polarizing in American media than in other industrialized countries, including Canada.7 Nonetheless, as in the United States, right-wing governments in Canadian jurisdictions have been the ones advocating fiscal tightening

Conclusion

255

in the name of intergenerational equity, albeit without the animosity and belligerent illustrations employed by political actors in the United States. The two most notorious provincial cases are Alberta and Quebec. In Alberta, this took the form of the APPF, discussed above and in chapter 7, an initiative undertaken under the Conservative government led by Ed Stelmach. In Quebec, the Liberals held a series of events culminating with a generational forum when Jean Charest was premier and subsequently launched the Fonds des générations in 2006. Although originating from a Liberal government, it obtained nearly unanimous support in the national assembly. Perhaps one of the most surprising findings is that the intergenerational lens has been used frequently in Alberta, the province with the youngest population profile, but not in the Atlantic provinces, where population aging is most pressing. Problem definitions in Atlantic Canada tend to embrace a much broader socio-economic perspective, but not as a major source of tension or cleavage between generations. While policymakers recognize the challenges of an aging population and its consequences for current governmental programs, strategies and action plans to tackle these challenges do not embrace an intergenerational narrative, but rather one on the promotion of economic development and population growth. This is clear, for instance, in the Nova Scotia report We Choose Now, supported by a very wide coalition of economic, political, and societal actors, which articulates an ambitious action plan to reverse the projected 7% decline in the population.8 This prompts a return to Savoie’s Visiting Grandchildren on economic development. Despite frequent mentions of the impact of economic development on changing demographics, a core element prompting emigration of younger individuals from the Maritimes, intergenerational equity or fairness is not mentioned once.9 The core emphasis is on retaining young adults and attracting newcomers to the Maritimes while promoting reforms to facilitate economic development. As articulated in Savoie’s book and in interviews with civil servants in these four provinces, the political-economic environment, and not older adults, has been identified as the main reason why these four provinces are coping with a challenging demographic structure, which in turn compels difficult policy decisions in the near future. In many ways, the rural/urban cleavage is more relevant. As illustrated by the community account initiative in Newfoundland and Labrador (chapter 7), there are rural communities with population structures that prompt difficult political and policy decisions on their survival and the allocation of resources, such as health care facilities, in depopulating communities.

256

The Four Lenses of Population Aging

Medical Lens The medical lens focuses on the analysis of human conditions as medical problems.10 It operates at the individual level and equates population aging to a rising number of seniors with more complex and frequent health care needs. Historically, seniors as a population group have been the responsibility of health care ministries, one of many factors contributing to the medicalization associated with older adults.11 Benefiting from the importance of health care in provincial politics and the medicalization of aging, the medical lens is ubiquitous and very prominent in provincial policy debates. Many signs suggest accentuation of the medicalization of aging, despite policies and strategies prioritizing social interventions and home care. As illustrated in the introduction, health care is the most prevalent policy concern in reporting on population aging in the Globe and Mail and La Presse, as it features in, respectively, 38% and 44% of all articles. The strength of the medical lens is highly visible throughout this book, particularly in chapters 5 and 6. First, the Canada Health Act (CHA) has a narrow focus on medically necessary services and mostly covers hospital care and medical services. Provincial health care administrations have followed closely along these lines, as there is an important policy feedback privileging health services covered by the CHA. In contrast, long-term care, comprising both residential care and home care, is an “extended service” not covered by the CHA and operates at the margins of the health care system.12 It remains an essential component for the well-being of many older adults, and the lack of proper services has negative consequences not only for the individuals requiring assistance, but also for the health care system. For instance, seniors in need are likely to end up occupying hospital beds in the absence of alternatives. Thus, the CHA not only creates an institutional boundary between medical and non-medical services, it creates a policy feedback mechanism that encourages provinces to continue to develop medical services at the expense of long-term care. Second, long-term care in Canadian provinces continues to favour residential care, which accounts for more than 80% of long-term care budgets.13 As in other industrialized countries, provinces have moved away from institutionalized care. However, the shift within long-term care towards home care is complicated by its (current and former) institutionalization within health ministries. With health care policies built on a hospital model, a similar approach was undertaken with long-term care.

Conclusion

257

As illustrated in chapter 6, the structure of provincial health systems is a key factor explaining the marginalization of home care, but also of the social components of long-term care. For instance, in the 2017 OECD Health at a Glance, Sweden spends 6.2 times more on home care than Canada (0.960% vs. 0.155%, respectively, as a proportion of GDP) and it is not the leading Scandinavian country in this policy field. The OECD also divides long-term care costs according to their component (health or social), and Canada is one of the few countries where a compulsory governmental insurance scheme does not cover the social component.14 The weakness of social actors in Canadian provinces in long-term care is apparent when compared to other countries. In Scandinavia, municipalities provide home and residential care and do not operate in health care. In France, the Social Affairs Ministry has traditionally had jurisdiction over residential care (EHPAD), which is overseen jointly by departmental councils (i.e., regional governments) and regional health authorities. In the Canada, New Brunswick illustrates what a strengthening of social input means in concrete terms. The Department of Social Development continues to be a stand-alone ministry, and it has the primary responsibility for long-term care. The province has historically been a Canadian leader in home care15 and continues to have a community not-for-profit residential care approach. Latest figures from the Canadian Home Care Association show that it spends more on home support (i.e., personal assistance, home assistance, and civic support) per individual aged 65 and above than the Canadian provincial average for all home care services.16 Consequently, provinces face a home care paradox. Home care is a policy priority in all provinces and it is easy to understand why; it costs less, seniors prefer it to alternatives, and home care is even linked with better health outcomes. At the same time, however, provinces have been attempting to “bend the cost curve in health care” amidst fear that health care budgets crowd out other governmental programs.17 Population aging accentuates these financial pressures on health care systems, the extent to which this occurs being the main point of contention in the literature. Faced with budgetary constraints, health authorities prioritize medical services and hospital care. Provincial evaluations, most notably in British Columbia and Quebec, demonstrate that the expansion of home care services has been slower than the growth of other components of health care budgets (see chapter 6). Now home care is endorsed universally among policymakers and the population in principle but fails to secure a higher share of health spending, despite being a laggard relative to other industrialized countries. The lack of investments in home care, and long-term care in

258

The Four Lenses of Population Aging

general, accentuates the risks (and costs) associated with older adults requiring medical care and/or using hospital beds instead of having better home care or a place in residential care. This puts increasing pressure on caregivers to compensate for the long-term care weaknesses in Canadian provinces. Despite recent efforts to enhance their status, caregivers are still perceived as instruments of the health care system rather than as central players who provide health and social services in a way that is organized to meet their needs and those of the one being cared for. In fact, many provincial policies clearly state that family members are responsible for providing care to seniors.18 These conclusions echo similar studies that report a shift of responsibilities from the state to families in caregiving (see chapter 6).19 Social Gerontology Lens As its name suggests, the social gerontology lens targets older adults and centres on the social dimensions of aging. As such, it stands in opposition to the medical lens. Simply put, it stresses that social problems continue to matter in old age, while new ones more specific to aging arise. It also posits that population aging is a societal issue, not one confined strictly to older adults. A particularity of the social dimension of aging in Canadian provinces is the weakness of socially oriented administrative organizations in the field of social care, as discussed above, but also in public pensions. Canadian finance ministries, preoccupied mostly by sustainability, do not have to consult with social affairs ministries, concerned with adequacy, as in the European Union.20 A key development to foster socially oriented actions for older adults has been to develop offices for seniors, as we saw in chapter 8. These have taken multiple forms, including the creation of seniors’ secretariats and even ministries. With very limited resources, ranging from a handful of civil servants in smaller provinces to over 25 in larger provinces, these offices have coordinated cross-ministerial action plans such as Ontario’s Action Plan for Seniors (2013 and 2017).21 As part of these plans, there have been many initiatives to combat ageism, raise awareness of elder abuse, encourage the development of aging friendly cities, and facilitate participation of seniors in local and provincial policy debates. In these governmental action plans centred on aging and seniors, it is interesting to note the ways in which seniors’ offices conceive intergenerational issues. Intergenerational considerations typically focus on enhancing social exchanges between generations in order to valorize the

Conclusion

259

contributions of seniors beyond their participation in the labour market. Ageism is the policy problem at the root of intergenerational programs supported by these action plans. Moreover, civil servants from seniors’ offices have consistently brought up intergenerational issues in an anti-ageism context. Nova Scotia’s Strategy for Positive Ageing illustrates this nicely by including a guiding principle to “promote a culture of respect across generations and recognize the contributions of seniors.”22 The promotion and support of intergenerational programs is one of nine actions to eliminate ageism. In the most recent plan, the intergenerational focus has shifted to the workplace and food literacy programs.23 What distinguishes these efforts from other public policies and programs is their precariousness and the short-sightedness of these actions. As discussed at length in chapter 8, offices for seniors have been highly unstable, facing frequent reorganizations of their configurations and mandates, and many of them have vanished into health departments. This administrative slide towards health has also been accompanied by stronger emphasis on health prevention measures promoted by the WHO, such as healthy aging. The financial commitments to sustain seniors’ action plans have remained modest, notwithstanding those targeting long-term care, and very few elements benefit from recurrent funding. This includes, for example, calls for local projects that use a co-funding formula. Organizational Lens The organizational lens highlights the fact that population aging is primarily a horizontal issue. Population aging permeates many programs and policies. There are parallels here with how public administration tackles gender issues. However, this conceptualization is increasingly moving from a population shift dynamic to one centred more narrowly on seniors. Relatively few initiatives have embraced a macro approach centred on population aging akin to the work of the Demographic Aging Commission24 and the Aging Population Policy Framework (APPF) in Alberta.25 As illustrated in an article by Peters on policy coordination,26 Metcalfe provides a useful policy scale by which to assess the coordination of governmental authorities (see figure 9.1).27 At the lowest level of coordination, there are many measures in to facilitate communication and consultation across ministries concerning the challenges and opportunities posed by an aging society. This includes informal mechanisms, which can be very effective in smaller provinces that operate

260

The Four Lenses of Population Aging

Figure 9.1 Policy coordination scale 9. Government strategy 8. Establishing central priorities 7. Setting limits on ministerial action 6. Arbitration of policy differences 5. Search for agreement among ministries 4. Avoiding divergences among ministries 3. Consultation with other ministries (feedback) 2. Communication to other ministries (information exchange) 1. Independent decision-making by ministries Source: Metcalfe (1994, 281)

in what Craft referred to as “intimate political administrative space.”28 There are also sustained formal mechanisms. They include follow-ups on recent action plans on the policy agenda at deputy ministers’ meetings, and Quebec’s Actions gouvernementales portant sur les changements démographiques, which has been published at regular intervals (2003, 2009, 2016) by the Ministry of the Executive Council.29 There are also other occasional instances where opportunities arose, such as in the development of an aging strategy or during consultations like New Brunswick’s We Are All in This Together.30 Nonetheless, it is important to stress that this awareness of the consequences of an aging population does not equate to acknowledgment of shared ministerial responsibilities. In fact, most civil servants interviewed, especially those in the five westernmost provinces, considered population aging as primarily an issue for the health ministry. Within the mid-range coordination scale, ranging from avoiding divergences among ministries and arbitrating policy differences, the concentration of political power at the centre of government and the overwhelming stature of the health ministry matter greatly. For instance, there have been two types of searches for agreements among ministries. On the one hand, the impetus of these searches came straight from the Premier’s Office and, in some cases, were stated clearly in the mandate letter of an appointed minister. With very few exceptions, they resulted in governmental strategies. On the other hand, with lower-profile cases of coordination, offices for seniors work collaboratively with ministries to improve practices and programs affecting their target population. However, they have a very limited budget and a small staff, and many of these offices have had to deal with deputy ministers whose main priority lies with the host department. As a result, they have few tools to

Conclusion

261

resolve divergences, especially with a large department such as health. There have also been issues in some provinces concerning the projection of data in the long run where, as one example, health and finance departments may rely on different assumptions. On the highest coordination scale, there are examples of provincial governments establishing central priorities and developing governmental strategies. These align closely with McArthur’s argument of the twin development of a concentration of power at the hands of the premier with increased staff, combined with a loss of policy capacity within line departments.31 It is therefore not surprising that some premiers have pushed strategies to tackle the challenges of an aging population and, in many cases, seniors specifically. This includes Ed Stelmach, who introduced the agenda to plan for an aging population. Coming from a rural community, planning for an aging population was also a personal issue for him.32 This explains, for the most part, why the province with the youngest population profile devoted considerable resources to planning for population aging. In other provinces, Paul Davis led the launch of a population growth strategy in Newfoundland and Labrador in 2015,33 and David Alward created a Premier’s Panel on Seniors34 in New Brunswick, resulting in the Home First Strategy in 2014.35 This enhanced involvement from the centre, however, comes at a time when senior civil servants working at the centre are more politicized and eager to enact new policy agendas.36 Newly elected governments and their premiers seek to ensure that the action plan or strategy is very visible and structured in such a way that the government can take credit for it. This close identification with governments has negative consequences in the long run, since many strategies end up in relative obscurity with nebulous status after a change in government, such as Ontario’s Action Plan for Seniors37 launched less than a year prior to the elections by the Liberal government. This plan is now accessible only as a reference document for research purposes, following the election of the Conservative Party in 2018, and the new government is launching its own consultation for a new plan. A disruption or abandonment of a strategy does not even require a change in government. In Alberta, a change in premier has similar consequences, as often mentioned by senior civil servants. One of the first actions of Alison Redford, Stelmach’s replacement, was to move the seniors’ portfolio into the health department to accentuate its link with long-term care. Interestingly, the election of the NDP resulted in a reorganized administrative structure in ways similar to Stelmach’s, and the government kept the APPF. Following the election of the Conservatives in 2019, the APPF plan is still on the departmental website38 (whether

262

The Four Lenses of Population Aging

the current government utilizes it in policy development remains to be seen). The result is that the elaboration and implementation of plans and strategies can have a short life expectancy that depends, in large part, on the re-election of the sitting government and, in some cases, the longevity of a premier. As such, these plans also represent an electoral program. Beyond the level of policy co-ordination, it is imperative to analyse the depth of ambition with which actions are coordinated. Few plans have detailed measures of forthcoming actions. Most seek to establish priorities and broad policy objectives. For instance, New Brunswick’s 2017 aging strategy39 features three goals: enabling seniors to live independently, achieving sustainability and innovation, and embracing a provincial culture of person-centre care and support. In this case, the Council on Aging, appointed by the Liberal government, developed this strategy in concert with civil servants from the Departments of Social Development and Health.40 Very few plans contain detailed orientations on the coordination of policies. Among all provincial strategies, Quebec’s second aging strategies (Un Québec pour tous les âges)41 is the most comprehensive to date, with the identification of 85 measures across 11 governmental offices. Ironically, it is also unlikely to survive in its present form. The Liberal government introduced the strategy less than four months prior to the 2018 elections, which it lost. Following the election of the CAQ, the governmental priority is to develop a caregiver strategy and construct maison des aînés (a more residential infrastructure than current residential care facilities). It is unclear which elements of the ill-fated second aging strategy will be retained. Revisiting the Long-View Theoretical Expectations In the age of Twitter, the ability of public authorities to implement long-view responses to population aging is questionable. Chapter 3 introduced four approaches facilitating development of a long view: enhancing learning opportunities, creating new procedures, appointing gatekeepers, and developing new strategies. Enhancing learning opportunities refers broadly to accentuating exchanges across ministries to identify and discuss long-term issues. The creation of new procedures like gender mainstreaming compels civil servants to engage in recurrent analysis and review. The appointment of gatekeepers can refer explicitly to the appointment of a senior civil servant (and minister) operating with the specific mandate to embrace long-term considerations. This role can also be fulfilled by offices such as those of the

Conclusion

263

auditor general and ombudsperson. As its name implies, the development of new strategies entails a concerted effort with long-term policy ambitions, typically across multiple public bureaus. With particular attention to interview data and policy documents from the 10 provinces, the following section revisits the five theoretical expectations presented at the end of chapter 3. First, provinces with a highly politicized civil service will be less successful in fostering long-view approaches than provinces that rely on career public officials. While there is no comprehensive ranking of the politicization of Canadian provinces, research shows that New Brunswick and Manitoba remain closest to Weberian ideals, while Nova Scotia and Saskatchewan lie at the opposite end. British Columbia saw civil servant turnover rates similar to those of Saskatchewan in 1980–2013,42 suggesting that it is closer to Nova Scotia and Saskatchewan than it is to New Brunswick and Manitoba. Also, the lengthy tenure of the Conservatives in Alberta and the Liberals in both Quebec and Ontario has made it difficult to assess the degree to which politicization plays a role in facilitating a long view. New Brunswick and Manitoba have shown greater foresight than other provinces, despite limited policy capacities. As evidence, New Brunswick prepared a comprehensive dossier in 2010 on the pressing issues that a new government should address once in office. Under the leadership of the clerk of the Executive Council, this dossier was expanded to include a broad consultation within the civil service to identify core challenges for the province within the next 10 years. Four were identified: deficit, health and social services, size and quality of the workforce, and economic development. The new government embraced the document and mandated its widespread circulation throughout the civil service. This led to an increase in knowledge and awareness of the policy issues facing New Brunswick (see chapter 7). The closest equivalent is Quebec’s Actions gouvernementales portant sur les changements démographiques, which has been published three times since the early 2000s. However, it has not seen the same sort of government endorsement and consequently the same level of diffusion within the civil service. While a substantial number of senior civil servants interviewed for this book mentioned the New Brunswick document, this was not the case in Quebec. Of the policies analysed here, New Brunswick and Manitoba stand out on home care policies. Both showed unique foresight in initiating and expanding home care, beginning in the 1970s, and continue to be leaders now that population aging is a priority across the country.

264

The Four Lenses of Population Aging

Manitoba is the only province to have conducted an in-depth, longterm review of home care needs,43 and New Brunswick has taken preemptive measures to tackle personnel shortages in long-term care. These actions stand in contrast to three highly politicized provinces: British Columbia, Nova Scotia, and Saskatchewan. In Saskatchewan there have been minimal efforts to consider the long view since the election of the Saskatchewan Party in 2007. Amidst a legacy of planning within the civil service strongly linked with the NDP,44 this narrative distinguishes the political agenda of the Saskatchewan Party from that of its predecessor. As such, the absence of strategies akin to those developed in other provinces is not surprising. Nova Scotia is a particularly intriguing case. On the one hand, the politicization of the civil service and the relative importance of interest groups partly explains the late development of home care policies, and the findings in this study support claims that the civil service tends to be more reactionary than proactive.45 Throughout the interviews, senior civil servants mostly referred to informal practices and the names of few individuals. This stands in contrast to the other three Atlantic provinces, all of which have introduced plans and offices to encourage, for instance, population growth. On the other hand, despite this politicized environment, major political actors have rallied behind an ambitious, long-term economic plan with 19 visionary goals as a means to curtail the shrinking of its population and avert economic decline in the aftermath of the report from the Nova Scotia Commission on Building Our New Economy.46 While it is too early to assess the impact of this report, it is difficult to envision such an approach taking root elsewhere (in Saskatchewan, for example, where the polarization thesis still prevails47). In addition, Nova Scotia has one of the oldest and most stable departments of seniors (previously a seniors’ secretariat), which has served as a model for similar entities elsewhere. Second, long-term initiatives are likely to improve with the presence of a strong leader. In non-politicized settings, leaders are likely to emerge among the civil service, political appointees, and elected officials, while civil servants are unlikely to perform this role in a politicized environment. Regardless of the degree of politicization within the civil service, we have seen cases in which political leaders initiated and implemented actions with a long-term vision. The leadership of Ed Stelmach is one of the primary reasons why Alberta stands out in this regard, and that is a surprise, given the demographic profile of the province and its political orientation over time. Entrepreneurial ministers, with the explicit support of the premier, were able to mobilize many departments to launch new initiatives. This occurred primarily in the case of actions targeting

Conclusion

265

older adults and frequently led to the creation or reform of an office for seniors. In Quebec, Liberal minister Marguerite Blais played a leading role in growing the Seniors’ Secretariat and in launching Quebec’s aging policy in 2012. Following a brief hiatus from politics, Blais joined the Coalition Avenir Québec (CAQ) and regained the seniors’ portfolio in the new government. Ross Wiseman, former minister of health for Newfoundland and Labrador, had a similar role in the creation of the Seniors and Healthy Aging Secretariat (see chapter 8). There are few examples to be mentioned from within the civil service, at least without compromising confidentiality. For instance, in 2010 the New Brunswick clerk of the Executive Council conducted a survey of forthcoming policy issues in the province. This kind of initiative would not have emerged with senior civil service positions occupied by political appointees. Another good example of an initiative that did not originate from the top but still secured a strong endorsement is Newfoundland and Labrador’s Community Accounts. Civil servants within the Statistics Agency, in concert with the Ministry of Finance and researchers from Memorial University, developed this innovative webbased tool following the recommendation of a Social Policy Advisory Committee in 1996. Community Accounts presents a wealth of demographic, economic, health, and social data in an adaptable and friendly format to facilitate its use in policymaking. As such, it provides those operating in the long view with valuable statistics to make informed decisions about the future.48 Third, smaller provinces are more likely to focus on enhancing learning and will struggle with the long view – even though this affects them most – while larger provinces will embrace a wider range of approaches. The four largest provinces (British Columbia, Alberta, Ontario, and Quebec) benefit from more resources within their civil service to engage in assessment and planning exercises related to population aging and can initiate complex reforms that require depth and technical expertise. Quebec has developed aging strategies and regular assessments of measures related to population aging that clearly benefited from having a large Conseil exécutif and seniors’ secretariat, each with a deputy minister overseeing the deliverable. While the door was open to a provincial pension plan, few provinces had the comparable resources to develop something akin to the Ontario Retirement Pension Plan (ORPP). This also applies to the important role played by gatekeepers, such as Quebec’s vérificateur général, who went beyond a traditional audit when assessing government actions to plan for an aging society. In a nutshell, they benefit from an economy of scale. While small provinces can initiate similar exercises, albeit at a lower scale, long-term initiatives are

266

The Four Lenses of Population Aging

more easily deployed and sustained in the most populous provinces with favourable political conditions. Still, for lack of resources relative to larger provinces, small jurisdictions tend to operate more informally and have more regular opportunities to share information and enhance learning. It was common for an interviewee to answer questions on coordination by pointing first at an adjacent office, a hallway, or the building across the street. Also the lack of depth in expertise and resources creates a sense of urgency for policy analysts to learn about how other provinces tackle similar policy problems. Typically, interviewees from smaller jurisdictions were quick to mention colleagues in a large province willing to offer assistance when needed. In some cases, interviewees pointed to the work of a group or unit in another province that they frequently referred to. This is consistent with earlier studies demonstrating that civil servants gather their policy insights mostly from colleagues in other jurisdictions in Canada as part of informal networks.49 The potency of the economy of scale proposition rests upon the extent to which population aging is considered an important policy priority within each province. Simply put, capacity should not be equated with action. As stated earlier, from British Columbia to Ontario, population aging continues to be construed as primarily a problem for the health department. While interviewing senior civil servants in the five eastern provinces, however, one could sense a deeper appreciation and comprehension of the consequences of an aging population. This is most likely because population aging has had more repercussions in other policy areas and it is now an enduring concern. Fourth, the presence of professionals trained with a long-view perspective can accentuate learning opportunities in the long view, as long as they are integrated into broader networks. Across provinces, interviews revealed the hiring of individuals to bolster the analysis of the long-term consequences of an aging population. Most notably, this occurs in finance departments, statistical agencies, and some provincial health departments. Their influence has been primarily to present forecasts and projections to support policy analyses on a wide range of subjects such as labour market evolution, health care spending, and economic and revenue projections. Their input also consists of analyses of regional socio-economic and demographic trends relying on data from the federal census. In Ontario, this has been formalized through the creation of a small unit responsible for preparing the long-term reports on the economy. Interviews reveal an increasing demand for labour market projections and regional analyses, with population aging prompting

Conclusion

267

difficult decisions with many ramifications for the sustainability of some communities.50 Many provinces have taken steps to improve the quality of their data in rural areas because the sample size of Statistics Canada data is small. For instance, interviewees in three different provinces stated that they have deployed resources to fine-tune their projection models for rural and remote areas to better reflect current realities.51 For the most part, analysts from statistical agencies and finance units have been involved in early scans for many provincial strategies surrounding population aging and seniors more specifically. One is hard pressed, however, to conclude that there is integration within broader policy networks in other provinces. Two dynamics depend on place of employment. By design, statistics bureaus tend to have a strict delineation with policymaking units and politics in general. Many provincial statistical agencies also operate on a fee-per-service basis, which results in the execution of narrow and specific mandates for large governmental offices, such as regional health authorities and departments of education. Still, specific requests coming from central agencies arise on occasion. This is not the case for units within the Ministry of Finance. Population aging has a notable long-term impact on governmental revenues, and there has been increased attention paid to how current fiscal systems accentuate (or mitigate) the consequences of an aging population. As articulated in one interview, this has prompted economists to consider demography more seriously.52 On exchanges with other departments, the interviews revealed few interactions and limited coordination unless money was involved. As one would expect from a chief economist in the Department of Finance to say, “If it costs money, we are particularly interested.”53 In line with the earlier proposition, the mention of contacts with other departments was more frequent in smaller provinces. Unexpectedly, two public service actors who have significantly raised awareness of the consequences of population aging on public policies across segments of the civil service are auditors general and ombudspersons – two offices that answer to the legislature. Throughout their program analyses, auditors general have consistently critiqued public authorities for their lack of foresight in planning for the realities of an aging population: the population served and staff retention/recruitment. The auditor general of Alberta has voiced the need to institutionalize long-term policy analyses within governmental apparatus,54 which he had done in its interactions with civil service throughout his mandate between 2010 and 2018.55 Most notably in British Columbia and Quebec, the offices of the ombudsperson have continually emphasized

268

The Four Lenses of Population Aging

that the evolution of long-term care programs are at odds with current demographic changes. Finally, policies and strategies featuring a positive feedback mechanism or constructed within such a policy framework are likely to be more potent in the long run than alternatives. One would expect similar outcomes in the introduction of new administrative structures. Among the policies analysed in this book, strong federal policy feedback operated most notably in the field of pension policy, where provincial initiatives faced a host of obstacles that rapidly increased the appeal of a pan-Canadian solution surrounding the Canada Pension Plan. The ORPP journey revealed the depth of the difficulties in initiating a provincial pension plan. Beyond engaging in strong political opposition to the plan, the Conservative federal government refused to alleviate administrative hurdles to facilitate implementation of the ORPP alongside the infrastructure of the CPP. The election of the Liberal Party in the 2015 federal election paved the way for a quick resolution to the latest pension debate and led to a modest increase in the generosity of the CPP.56 In Quebec, the CPP reform made less-generous alternatives to reform the QPP unsustainable.57 Policy feedback is also powerful in health and long-term care policies. As discussed earlier, the Canada Health Act has compelled provinces to prioritize hospital care, which also provides an institutionalized anchor for the prevalent use of the medical lens in aging. In the field of longterm care, limited policy and programmatic capacities have meant that most provinces have turned to the private sector to bolster accessibility, and a reversal is highly unlikely. In addition, efforts to develop offices for seniors at arm’s length from health departments have failed in most provinces. Federalism, Population Aging, and Policy Diffusion and Learning The point of departure for this book was the treatment of population aging from the perspectives of the provinces. Still, federalism matters, most notably in the policy feedback identified above. Recent contributions have demonstrated that federalism has an impact well beyond the formal structures and electoral politics typically discussed in Canadian politics. Most notably, in her studies on the puzzling development of similar education standards across provinces, despite a weak influence from the federal government, Wallner demonstrates that provinces achieved this outcome through learning and cooperation.58 In the same vein, I will briefly summarize how federalism has played a fundamental role in provincial policymaking by fostering policy

Conclusion

269

learning and diffusion. As such, I seek to contribute to the growing literature on intergovernmental relations to enhance policy capacity59 and policy diffusion60 in Canada. The material is derived largely from a standard question in the interviews on the role of federalism in population aging and policymaking within one’s province. The first striking element is the immediate reference to the federal/ provincial/territorial (FPT) tables when discussing the role of federalism and its role as a benchmark when one wants to emphasize a deeper cooperation. The FPT tables are regular meetings of officials, frequently preceded by a ministers’ conference. The interviews revealed references to many FPT in line with their respective organizations within the civil services. These include labour, immigration, seniors, health, finance, Statistics Canada, pensions, social services, and even clerk of the Privy Council FPT. Few mentioned the lack of a long-term care (LTC) table and, consistent with the medical lens, others stated that the FPT health table needs to incorporate LTC. Hosting an FPT meeting was viewed favourably, particularly in small provinces, since it resulted in additional resources to investigate further what other provinces are doing on policy. Interviews denote that the functioning and usefulness of FPT tables reflect the differences in policies’ breadth and depth, and the need to exchange expertise and collaborate. In line with previous studies on FPT health,61 few officials made explicit reference to the FPT health to signal that their FPT worked significantly better. This was especially the case for those familiar with both FPT health and FPT seniors. For instance, a civil servant in a seniors’ office stated explicitly, “Monetary considerations cloud the meetings” and result in conflicts, while FPT seniors has had a far more positive atmosphere where work is always shared.62 The FPT Ministers Responsible for the Seniors Forum was endorsed the most enthusiastically by civil servants interviewed during the course of this study. Multiple factors explain this outcome. For instance, offices for seniors across the country have very limited resources and have faced frequent administrative reform/reorganization, accentuating pressures to establish their boundaries for action and, to put it bluntly, survive as an organization. Few interviewees referred to this explicitly by stating that the FPT tried to identify and “work on niche areas that are not occupied by other ministries.”63 The ubiquitous endorsement of the Aging Friendly Communities framework is a prime example of this strategy.64 Still, some members had higher expectations and mentioned that this table failed to establish a pan-Canadian approach for seniors. While very positive on the interaction with her other provincial and

270

The Four Lenses of Population Aging

federal colleagues, an Office for Seniors director was visibly frustrated with the progress made towards achieving a unified approach: “The FPT is a difficult realm: we have different parties in government, and we all have different agendas. This is especially true when it comes to the provinces versus the federal government. There are very few examples of a pan-Canadian strategy.”65 Other formal mechanisms have enhanced learning and cooperation among the provinces. Most remarkably, population aging, as a horizontal preoccupation, made its way to the Council of the Federation in 2015 at a meeting in St. John’s. In the previous year, the council had established a task force on aging to study more closely the policy impact of this demographic shift. The meeting concluded with a short press release emphasizing the impact on health care, employment, housing, social services, transportation, and infrastructure. It stated the unique qualities of each province, but the similarity of many challenges. It provided five examples: increased health care costs and social services, impacts on productivity, increased need for social housing, increased need for transportation alternatives, and addressing the needs of seniors in rural and northern areas. Still, the press release zeroed in on the growing financial pressures that population aging is applying to health care.66 As alluded to in earlier studies, informal intergovernmental exchanges also play a significant role.67 Many interviewees stated that they had developed good professional relationships with colleagues in other provinces and in the federal government on the basis of program similarity and personality. However, there were two distinct blocks of cooperation: Western Canada and Atlantic Canada. Most particularly in the latter, cooperation was also presented as a necessity to advance their agenda at the federal level. Population aging is likely to shape politics and policymaking for many years to come in Canada and other industrialized countries. The lenses approach illustrates not only different problem definitions, but also strong anchoring within those definitions. With policy actors reflecting different views such as on pension fund management, elder abuse, home support, finance, hospital care, caregiving, humanities, and seniors’ affairs, it is imperative to encourage dialogue across lenses and, more specifically, administrative and professional boundaries. Provincial civil administration would also be well served by the creation of a small unit within the Executive Council to foster a sustained dialogue on these issues, not only to coordinate action plans, but also to monitor how current policies and programs interact as the demographic shift continues.

Conclusion

271

Continuing Marginalization of Social Policies and Its Consequences in the Context of an Aging Population and the Challenges of COVID-19 As discussed in chapter 2, the lenses I have deployed throughout this book can coexist, complement, or even compete with one another. The marginalization of the social gerontology lens relative to the other three lenses represents a core finding of this book. This has multiple consequences for the development of social policy to tackle socio-economic issues in the wake of population aging, but also in the ways in which provinces enact these responses. As provinces grasp the realities of population aging and its consequences across policies and programs, they do so in an environment where public actions face significant constraints. The ability and capacity of the state to resolve social problems have been questioned since the 1980s, paving the way for the retrenchment of the welfare state.68 As part of a neo-liberal shift to reduce state interventions and their scope, finance ministries have gained prominence in the policymaking process, weakening the power of socially minded ministries.69 This has made it quite difficult for industrialized countries to adapt to new social risks if state authorities failed to enact comprehensive programs to tackle them prior to the maturation of the welfare state.70 The economic crisis of 2008 accentuated the popularity of austerity measures, leading governments to embrace cuts in state budget, deficit, and debt.71 The unprecedented governmental interventions during COVID-19 and the economic crisis following the implementation of public health measures will likely have long-lasting impacts on public finances. Hence, the current period is not favourable to the introduction of new public programs, especially social policies aimed at confronting the socio-economic realities of an aging population. These international trends find credence in Canada. Already considered a liberal welfare regime where the state tends to act as a last resort,72 the cumulation of austerity measures has significantly affected social policies, as in the erosion of the principle of universality.73 Few consequential programs have been established to tackle new social risks, with Quebec’s child care program being a notable exception. The ongoing challenges of home care policies illustrate this vividly. Regardless of the home care model, there are substantial needs gaps in accessibility and coverage for older adults. Hence, there are large gaps between the discourses and narratives surrounding policies for population aging and seniors and the actual actions undertaken. In the wake of COVID-19, the long-term care priority for provincial governments clearly resides in the improvement of residential care

272

The Four Lenses of Population Aging

facilities, which accounted for over two-thirds of all COVID-19 deaths (see chapter 5 for details). Despite being a more prevailing issue in Quebec and Ontario, it led to a wave of in-depth reports on residential care facilities and a strong push for policy action across the country. The Canadian prime minister and many premiers have already committed to act swiftly. This will likely push the prioritization of home care further. Within this context, the social gerontology lens fails to gather sufficient clout politically and even within provincial public administrations to influence policy debates. The complementarity of the intergenerational and medical lenses has essentially exacerbated the marginalization of social policy actions in Canadian provinces. Analyses with the organizational lens throughout this book reveal the absence of strong social policy–minded organizations where civil servants operating with the social gerontology lens can thrive. The way in which provincial governments have responded to COVID-19 has been particularly revealing. For instance, in New Brunswick the government introduced a multiparty cabinet with few ministers, including the minister of social development, and the leaders of the opposition parties. Residential care facilities have remained at the centre of actions taken by the province and reflect a stronger LTC anchoring in Canada. This is in stark contrast to Quebec, where the role of the minister for seniors and caregivers (with responsibility of residential care facilities) has often been questioned. In a detailed history of the early COVID-19 responses in L’actualité, the minister for seniors and caregivers was not part of the inner circle of actors – the premier, the minister of health, the public health office along with senior civil servants and communication specialists – involved in deployment of the governmental strategy.74 The strategy eventually came under sharp criticism for being too oriented towards hospitals and intensive care units. Perhaps the most interesting development is that British Columbia, a province that, like Quebec, has elicited critical reports on its longterm care policy, embraced a relatively successful strategy to contain the spread of the virus. Further research is required to identify what factors led to an internal prioritization of residential care facilities in the province and, more importantly, why Ontario and Quebec did not follow British Columbia’s example in their own residential care facilities. The intergenerational lens does not have the same potency and deployment as in the United States, in large part as the result of the age bias of its public programs. Still, the frequent use of dependency ratios and deployment of intergenerational equity arguments along the lines described in generational accounting mesh with governmental

Conclusion

273

priorities and those of finance departments to constrain expenditures and limit new public initiatives. As illustrated in this book, the influence of the intergenerational lens features the creation of generational funds, the introduction of fully funded components tied closely with contributions to increase the generosity of the Canada Pension Plan, the push to restrain health care expenditures, and timid interventions in home care. In addition, this leads to the launch of many actions and programs that rely on non-recurrent budgets with a short-term horizon. To justify the deployment of new social actions, governments increasingly transform social problems into (health) problems compatible with a medical lens. Julia Lynch illustrates clearly this dynamic in her recent contributions, where she analyses the consequences of tackling social inequalities by embracing health inequities in four jurisdictions (England, Finland, France, and Belgium).75 This shift has had broad popular and political appeal, most notably among politicians on the left to avoid “direct discussion of contentious issues like redistribution of income and wealth.”76 Yet it is also highly inefficient. Lynch demonstrates that this shift has jeopardized social inequality and health inequality objectives, because it ultimately strengthens medical institutions and actors while favouring policy approaches that value individual responsibilities. Policy actors operating with a medical lens simply do not have a good understanding of the underlying mechanisms in the social determinants of health, nor do they prioritize them. Lynch’s analysis of national documents on health inequity demonstrates that they “pay lip service” to these determinants, focusing instead on primary care and health promotion.77 This argument applies strongly throughout this book. The strength of the medical lens is highly visible in the social sphere, where initiatives have been eliminated or transformed into health actions, stretching even into the realm of public administration. For instance, originally constructed at arm’s length from health departments, offices for seniors have gradually been integrated within health departments that have embraced the healthy aging movement promoted by the WHO. This reinforces the notion of aging as an individual responsibility and minimizes the new social risks associated with population aging that affect individuals of all ages. The targeting of older adults makes it worse than the transformation of social inequities into health inequities, since aging remains strongly biomedicalized and reinforces the narrative that population aging is a “seniors’ problem” rather than a societal issue with far-reaching socio-economic and political consequences. With the imminent launch of new inquiries and policy proposals to reform long-term care, a much broader focus than residential care

274

The Four Lenses of Population Aging

facilities is needed. Already there is increasing coverage on the consequences of COVID-19 on home care services and how caregivers have had to manage with diminished (or a total lack of) services. As such, long-term care solutions must consider all aspects of LTC and the constant marginalization of the social dimensions of aging. It is not simply a funding issue. Provinces must rethink the organization and delivery of LTC. To flourish, it should be within an institutional constellation where it remains at the centre of preoccupations. The closest to this ideal in Canada is found in New Brunswick, where LTC is part of the Department of Social Development. The international literature reveals that more budgetary and programmatic responsibilities for LTC should also reside at the local/regional level.

Notes

Introduction 1 Statistics Canada (2019). “Population Projections for Canada (2018 to 2068), Provinces and Territories (2018 to 2068),” released 17 September 2019, https://www150.statcan.gc.ca/n1/pub/91-520-x/91-520-x2019001 -eng.htm. Data from Section 2: “Results at the Canada Level, 2018 to 2068: Use of the Medium-Growth Scenario (M1).” 2 Sharon Kirkey, “Canada’s Census 2011: Aging Population a Potential Health-Care Time Bomb,” National Post, 29 May 2012. 3 Bruce Campion-Smith, “Aging Population Spells Trouble for Federal Finances, Watchdog Says,” Toronto Star, 18 February 2010. 4 Marni Soupcoff, “Aging Population Emphasizes Our Heavy Dependence on Government,” National Post, 13 November 2012. 5 Catherine McLean, “How an Aging Population Will Kill the American Dream,” Globe and Mail, 5 September 2012. 6 Tavia Grant, “Aging Population Set to Sideswipe Canada’s Small Businesses,” Globe and Mail, 13 November 2012, http://www .theglobeandmail.com/report-on-business/small-business/sb-money /valuation/aging-population-set-to-sideswipe-canadas-small-businesses /article5226576/. 7 Title of a special investigation by the Province, 16 October 2011. 8 Derek Abma, “Aging Population Could Lead to Greek-Style Debt Crisis in Canada, Report Suggests,” National Post, 2 November 2011. 9 Douglas Quan, “Census: Canada’s Aging Population Doesn’t Mean We’re Safer,” Vancouver Sun, 29 May 2012. 10 Mike De Souza, “Canada’s Aging Population Fuels Retirement Home Boom: Census 2011,” National Post, 19 September 2012. 11 Ariane Lacoursière, “Vieillissement de la population: ‘l’enjeu de l’heure,’” La Presse, 27 May 2011.

276

Notes to pages 3–7

12 Les Affaires, “Le peril vieux,” 1 December 2012. 13 Casey B. Mulligan and Xavier Sala-i-Martin, Gerontocracy, Retirement, and Social Security (Ottawa: National Bureau of Economic Research, 1999); Markus Tepe and Pieter Vanhuysse, “Are Aging OECD Welfare States on the Path to Gerontocracy?,” Journal of Public Policy 29, no. 1 (2009): 1–28; Julia Lynch, Age in the Welfare State: The Origins of Social Spending on Pensioners, Workers, and Children (Cambridge: Cambridge University Press, 2006). 14 Laurence J. Kotlikoff, The Coming Generational Storm (Ottawa: National Bureau of Economic Research, 2001); Laurence J. Kotlikoff and Scott Burns, The Clash of Generations: Saving Ourselves, Our Kids, and Our Economy (Cambridge, MA: MIT Press, 2012). 15 Neena L. Chappell and Marcus J. Hollander, Aging in Canada (Toronto: Oxford University Press, 2013), 4. 16 David K. Foot and Daniel Stoffman, Boom, Bust & Echo: How to Profit from the Coming Demographic Shift (Toronto: Macfarlane Walter & Ross, 1996). 17 Berit Ingersoll-Dayton, Margaret B. Neal, and Leslie B. Hammer, “Aging Parents Helping Adult Children: The Experience of the Sandwiched Generation,” Family Relations 50 (2001): 262–71. 18 Interview 53. 19 Conseil du statut de la femme, Les proches aidantes et les proches aidants au Québec: Analyse Différiencée Selon Les Sexes (Quebec: Conseil du statut de la femme, 2018). 20 A simulation claims that Canadian immigration could alleviate the negative impact of aging population on GDP growth by 30%, but not curb the overall trend. Maxime Fougère, Simon Harvey, Marcel Mérette, and François Poitras, “Ageing Population and Immigration in Canada: An Analysis with a Regional CGE Overlapping Generations Model,” Canadian Journal of Regional Science 27, no. 2 (2004): 209–36. 21 Larry S. Bourne and Damaris Rose, “The Changing Face of Canada: The Uneven Geographies of Population and Social Change,” Canadian Geographer 45, no. 1 (2001): 105–19. 22 John D. Stephens, “Revisiting Pierson’s Work on the Politics of Welfare State Reform in the Era of Retrenchment Twenty Years Later,” PS: Political Science 48, no. 2 (2015): 274–8. 23 Paul R. Schulman, Large-Scale Policy Making (New York: Elsevier, 1980). 24 Doug McArthur, “Policy Analysis in Provincial Governments in Canada: From PPBS to Network Management,” in Policy Analysis in Canada: The State of the Art, ed. L. Dobuzinskis, M. Howlett, and D. Laycock, 132–45 (Toronto: University of Toronto Press, 2007). 25 Jonathan Craft, Backrooms and Beyond: Partisan Advisors and the Politics of Policy Work in Canada (Toronto: University of Toronto Press, 2016).

Notes to pages 7–9

277

26 Bourne and Rose, “Changing Face of Canada.” 27 David Dery, Problem Definition in Policy Analysis (Lawrence: University Press of Kansas, 1984); Janet A. Weiss, “The Powers of Problem Definition: The Case of Government Paperwork,” Policy Sciences 22, no. 2 (1989): 97–121; David A. Rochefort and Roger W. Cobb, “Problem Definition, Agenda Access, and Policy Choice,” Policy Studies Journal 21, no. 1 (1993): 56–71; Carol Lee Bacchi, Women, Policy and Politics: The Construction of Policy Problems (London: Sage, 1999); B. Guy Peters, “The Problem of Policy Problems,” Journal of Comparative Policy Analysis 7, no. 4 (2005): 349–70. 28 Imre Lakatos, “Falsification and the Methodology of Scientific Research Programmes,” in Criticism and the Growth of Knowledge, ed. Imre Lakatos and Alan Musgrave, 1–23 (Cambridge: Cambridge University Press, 1970). 29 Peter A. Hall, “Policy Paradigms, Social Learning, and the State: The Case of Economy Policymaking in Britain,” Comparative Politics 25, no. 3 (1993): 275–96. 30 Anne L. Schneider and Helen Ingram, Policy Design for Democracy (Lawrence: University Press of Kansas, 1997). 31 See, for example, Allan M. Jacobs, Governing for the Long Term: Democracy and the Politics of Investment (Cambridge: Cambridge University Press, 2011); William Ascher, Bringing in the Future: Strategies for Farsightedness and Sustainability in Developing Countries (Chicago: University of Chicago Press, 2009). 32 B. Guy Peters, The Politics of Bureaucracy, 6th ed. (New York: Routledge, 2009). 33 For a noticeable exception, see Michael Barzelay and Colin Campbell, Preparing for the Future: Strategic Planning in the US Air Force (Washington: Brookings Institution, 2003). 34 Carole A. Estabrooks, Sharon Straus, Colleen M. Flood, Janice Keefe, Pat Armstrong, Gail Donner, Véronique Boscart, Francine Ducharme, James Silvius, and Michael Wolfson, Restoring Trust: COVID-19 and the Future of Long-Term Care (Ottawa: Royal Society of Canada, 2020). 35 Daniel Béland and Patrik Marier, “COVID-19 and Long-Term Care Policy for Older People in Canada,” Journal of Aging & Social Policy 32, no. 4/5 (2020): 358–64. 36 Geneviève Tellier, “L’étude comparée des politiques publiques provinciales: un laboratoire à explorer,” Politique et Sociétés 30, no. 1 (2011): 95–115. 37 Rodney Haddow, “Power Resources and the Canadian Welfare State: Unions, Partisanship and Interprovincial Differences in Inequality and Poverty Reduction,” Canadian Journal of Political Science 47, no. 4 (2014): 717–39. 38 Mireille Paquet, La fédéralisation de l’immigration au Canada (Montreal: Presses de l’Université de Montréal, 2016).

278

Notes to pages 9–11

39 Donna E. Wood, Federalism in Action: The Devolution of Canada’s Public Employment Service, 1995–2015 (Toronto: University of Toronto Press, 2018). 40 McArthur, “Policy Analysis in Provincial Governments in Canada,” 328. 41 Chris Cooper and Patrik Marier, “Does It Matter Who Works at the Center? A Comparative Policy Analysis of Executive Styles,” Journal of Comparative Policy Analysis 19, no. 1 (2017): 1–16. 42 Statistics Canada, 2016 Census of Population: Population and Dwelling Counts Release (Ottawa: Statistics Canada, 2016). 43 Bacchi, Women, Policy and Politics; David A. Rochefort and Roger W. Cobb, “Problem Definition: An Emerging Perspective,” in The Politics of Problem Definition: Shaping the Policy Agenda, ed. Rochefort and Cobb, 000–000 (Lawrence: University Press of Kansas, 1994); Peters, “Problem of Policy Problems.” 44 See, for example, John W. Kingdon, Agendas, Alternatives, and Public Policies, 2nd ed. (New York: Longman, 2003); Bacchi, Women, Policy and Politics; Anne L. Schneider and Helen Ingram, “Social Construction of Target Populations: Implications for Politics and Policy,” American Political Science Review 87, no. 2 (1993): 334–47. 45 Aaron B. Wildavsky, Speaking Truth to Power: The Art and Craft of Policy Analysis (Boston: Little, Brown, 1979). 46 Patrik Marier, “Where Did the Bureaucrats Go? Role and Influence of the Public Bureaucracy in the Swedish and French Pension Reform Debate,” Governance 18, no. 4 (2005): 521–44. 47 Carl Dahlström, “The Bureaucratic Politics of the Welfare State Crisis: Sweden in the 1990s,” Governance 22, no. 2 (2009): 217–38; Marier, “Where Did the Bureaucrats Go?”; Steven Van de Walle and Marleen Brans, “Where Comparative Public Administration and Comparative Policy Studies Meet,” Journal of Comparative Policy Analysis: Research and Practice 20, no. 1 (2018): 101–13; Martin Egeberg, “Bureaucrats as Public Policy-Makers and Their Self-Interests,” Journal of Theoretical Politics 7, no. 2 (1995): 157–67; David A. Good, “The New Bureaucratic Politics of Redistribution,” in Inequality and the Fading of Redistributive Politics, ed. Keith Banting and John Myles, 210–33 (Vancouver: University of British Columbia Press, 2013). 48 Vernon Bogdanor, ed., Joined-up Government (Oxford: Oxford University Press, 2005); Donald J. Savoie, Governing from the Centre: The Concentration of Power in Canadian Politics (Toronto: University of Toronto Press, 1999). 49 John D. Huber and Cecilia Martinez-Gallardo, “Replacing Cabinet Ministers: Patterns of Ministerial Stability in Parliamentary Democracies,” American Political Science Review 102, no. 2 (2008): 169–80. 50 Samuel Berlinski, Torun Dewan, and Keith Dowding, “The Length of Ministerial Tenure in the United Kingdom, 1945–97,” British Journal of Political Science 37, no. 2 (2007): 245–62.

Notes to pages 11–16

279

51 Peter Aucoin, “Administrative Reform in Public Management: Paradigms, Principles, Paradoxes and Pendulums,” Governance 3, no. 2 (1990): 115–37; Christopher Pollitt and Geert Bouckaert, Public Management Reform: A Comparative Analysis (New York: Oxford University Press, 2004). 52 Erik-Hans Klijn, Joop Koppenjan, and Katrien Termeer, “Managing Networks in the Public Sector: A Theoretical Study of Management Strategies in Policy Networks,” Public Administration 73, no. 3 (1995): 437–54. 53 Gregg G. Van Ryzin, “Outcomes, Process, and Trust of Civil Servants,” Journal of Public Administration Research and Theory 21, no. 4 (2011): 745–60. 54 Dahlström, “Bureaucratic Politics of the Welfare State Crisis.” 55 Jon Pierre, B. Guy Peters, and Jenny de Fine Licht, “Is Auditing the New Evaluation? Can It Be? Should It Be?” International Journal of Public Sector Management 31, no. 6 (2018): 726–39. 56 Adam M. Wellstead, Richard C. Stedman, and Michael Howlett, “Policy Analytical Capacity in Changing Governance Contexts: A Structural Equation Model (SEM) Study of Contemporary Canadian Policy Work,” Public Policy and Administration 26, no. 3 (2011): 353–73; Adam M. Wellstead, Richard C. Stedman, and Evert A. Lindquist, “The Nature of Regional Policy Work in Canada’s Federal Public Service,” Canadian Political Science Review 3, no. 1 (2009): 34–56. 57 Kathleen Thelen and Sven Steinmo, “Historical Institutionalism in Comparative Politics,” in Structuring Politics: Historical Institutionalism in Comparative Analysis, ed. Sven Steinmo, Kathleen Thelen, and Frank Longstreth, 1–34 (Cambridge: Cambridge University Press, 1992). 58 Morten Egeberg, “The Impact of Bureaucratic Structure on Policy Making,” Public Administration 77, no. 1 (1999): 155–70. 59 Bacchi, Women, Policy and Politics, 21. 60 Tepe and Vanhuysse, “Are Aging OECD Welfare States on the Path to Gerontocracy?” 61 Jill S. Quadagno, Aging and the Life Course: An Introduction to Social Gerontology (Boston: McGraw-Hill College, 1999), 4. 62 Ellen M. Gee and Gloria M. Gutman, The Overselling of Population Aging: Apocalyptic Demography, Intergenerational Challenges, and Social Policy (Toronto: Oxford University Press, 2000). 63 Peters, “Problem of Policy Problems”; Rochefort and Cobb, “Problem Definition.” 64 Canadian Home Care Association, Portraits of Home Care in Canada 2013 (Mississauga: CHCA, 2013).

280

Notes to pages 22–5

1 The Lenses of Population Aging 1 Paul A. Sabatier, ed., Theories of the Policy Process, 2nd ed. (Boulder, CO: Westview, 2007), 5. 2 Graham T. Allison, “Conceptual Models and the Cuban Missile Crisis,” American Political Science Review 63, no. 3 (1969): 689–718. 3 Bacchi, Women, Policy and Politics, 8. 4 Schneider and Ingram, Policy Design for Democracy; Bacchi, Women, Policy and Politics. 5 PolicyNL, “Policy Analysis and Consultation Considerations (Application of Policy Lenses),” n.d., http://policynl.ca/policydevelopment/pages /consultation-considerations.html. 6 See Ontario.ca/OPSDiversity (site discontinued). Accessed 19 February 2014. 7 Lakatos, “Falsification and the Methodology of Scientific Research Programmes.” 8 Lakatos, “Falsification and the Methodology of Scientific Research Programmes,” 135. 9 Hall, “Policy Paradigms, Social Learning, and the State.” 10 Hall, “Policy Paradigms, Social Learning, and the State.” 11 Bacchi, Women, Policy and Politics, 21. 12 Tepe and Vanhuysse, “Are Aging OECD Welfare States on the Path to Gerontocracy?” 13 Simon Birnbaum, Tommy Ferrarini, Kenneth Nelson, and Joakim Palme, The Generational Welfare Contract: Justice, Institutions and Outcome (Cheltenham, UK: Edward Elgar Publishing, 2017). 14 Bryan S. Turner, “Ageing and Generational Conflicts: A Reply to Sarah Irwin,” British Journal of Sociology 49, no. 2 (1998): 299–304. 15 Bryan S. Turner, “Ageing, Status Politics and Sociological Theory,” British Journal of Sociology 40, no. 4 (1989): 588–606. 16 Alan J. Auerbach, Jagadeesh Gokhale, and Laurence J. Kotlikoff, “Generational Accounting: A Meaningful Way to Evaluate Fiscal Policy,” Journal of Economic Perspectives 8, no. 1 (1994): 73–94. 17 See, for example, David K. Foot, “Public Expenditures, Population Aging and Economic Dependency in Canada, 1921–2021,” Population Research and Policy Review 8, no. 1 (1989): 97–117. The baby-boom generation simply consists of individuals born between 1947 and 1966. 18 Jill Quadagno, “Generational Equity and the Politics of the Welfare State,” Politics & Society 17, no. 3 (1989): 353–76; Alan Walker, “The Economic ‘Burden’ of Ageing and the Prospect of Intergenerational Conflict,” Ageing and Society 10, no. 4 (1990): 377–96; Gee and Gutman, Overselling of Population Aging.

Notes to pages 25–6

281

19 Alan J. Auerbach, Jagadeesh Gokhale, and Laurence J. Kotlikoff, “Generational Accounts: A Meaningful Alternative to Deficit Accounting,” Tax Policy and the Economy 5 (1991): 55–110. 20 Auerbach, Gokhale, and Kotlikoff, “Generational Accounts”; Jagadeesh Gokhale and Laurence J. Kotlikoff, “Generational Justice and Generational Accounting,” in The Generational Equity Debate, ed. John B. Williamson, Diane M. Watts-Roy, and Eric R. Kingson, 75-86 (New York: Columbia University Press, 1999); OECD, “Generational Accounting,” in Budgeting for the Future, 13–18 (Paris: OECD, 1997). 21 Laurence J. Kotlikoff and Scott Burns, The Coming Generational Storms: What You Need to Know about America’s Future (Boston: MIT Press, 2005). 22 For a more thorough review of how generational accounts are constructed and measured, see Gokhale and Kotlikoff, “Generational Justice and Generational Accounting”; Laurence J. Kotlikoff, Generational Accounting: Knowing Who Pays, and When, for What We Spend (New York: Free Press, 1992); OECD, “Generational Accounting.” 23 Kotlikoff and Burns, Clash of Generations, 3. 24 Lynch, Age in the Welfare State. 25 Martha Ozawa and Yung Soo Lee, “Generational Inequity in Social Spending: The United States in Comparative Perspective,” International Social Work 56, no. 2 (2013): 162–79. 26 The core element to restore this balance was the increase in contribution rates, which are now set at 9.95%. This implies that younger workers will pay a noticeably higher contribution for a similar benefit. Nonetheless, this measure addressed the increasing unfunded liabilities. The situation is quite different in Quebec, since new increases to the contribution rates are being implemented to reduce the growing actuarial deficit of the QPP. The CPP does not suffer from similar financial problems. 27 Philip Oreopoulos and François Vaillancourt, “Taxes, Transfers, and Generations in Canada: Who Gains and Who Loses from the Demographic Transition,” C.D. Howe Commentary no. 107 (1998): 1–24. Interestingly, these results were far less provocative than the first iteration of generational accounting performed in 1996, which could not capture the early measures of the Martin budgets and the subsequent pension reform. See Philip Oreopoulos and Laurence J. Kotlikoff, “Restoring Generational Balance in Canada,” IRPP Choices 2, no. 1 (1996): 1–52. 28 For an excellent review of the politics behind the adoption and eventual rejection of generational accounting in the early 1990s, see Eric Laursen, The People’s Pension: The Struggle to Defend Social Security since Reagan (Oakland, CA: AK Press, 2012), 265–74. 29 Congressional Budget Office, Who Pays and When? An Assessment of Intergenerational Accounting (Washington: CBO, 1995), ix.

282

Notes to pages 27–8

30 Miles Corak, ed., Government Finances and Generational Equity (Ottawa: Statistics Canada, 1998). 31 House of Common Standing Committee on Public Accounts, Fourth Report: Public Accounts of Canada 1999–2000 (Ottawa: Government of Canada, 2001); Government Response House of Commons, Responses to Recommendation of the 4th Report of the Standing Committee on Public Accounts (Ottawa: Government of Canada, 2001). 32 Rune Ervik, “The Battle of Future Pensions: Global Accounting Tools, International Organizations and Pension Reforms,” Global Social Policy 5, no. 1 (2005): 29–54. 33 Robert Haveman, “Should Generational Accounts Replace Public Budgets and Deficits?,” Journal of Economic Perspectives 8, no. 1 (1994): 107. 34 Lars Osberg, “Meaning and Measurement in Intergenerational Equity,” in Corak, Government Finances and Generational Equity, 131–9. 35 OECD, “Generational Accounting”; Philip Oreopoulos and François Vaillancourt, “Applying Generational Accounting to Canada: Findings and Fallacies,” in Corak, Government Finances and Generational Equity, 7–20. 36 Holger Bonin, Generational Accounting: Theory and Application (Berlin: Springer-Verlag, 2001). 37 Steven James and Chris Matier, “The Welfare Dynamics of Reducing Transfers from Future to Current Generations,” in Corak, Government Finances and Generational Equity, 73–86. 38 See, for example, Gee and Gutman, Overselling of Population Aging. 39 David Davidson, Going Grey: The Mediation of Politics in an Ageing Society (Burlington, VT: Ashgate, 2012), chap. 11. 40 Christopher Buckley, Boomsday (London: Allison and Busby, 2007). 41 Ervik, “Battle of Future Pensions”; John Bongaarts, “Population Aging and the Rising Cost of Public Pensions,” Population and Development Review 30, no. 1 (2004): 1–23; OECD, “Generational Accounting.” 42 See, for example, Harold L. Wilensky, The Welfare State and Equality: Structural and Ideological Roots of Public Expenditures (Berkeley: University of California Press, 1975); Fred C. Pampel and John B. Williamson, Age, Class, Politics, and the Welfare State (Cambridge: Cambridge University Press, 1992). 43 David R. Kamerschen, “On an Operational Index of ‘Overpopulation,’” Economic Development and Cultural Change 13, no. 2 (1965): 169–87. Already at that time, the use of the dependency ratio to conceptualize overpopulation was criticized. See Gordon A. Marker, “Comments on an Operational Index of ‘Overpopulation,’” Economic Development and Cultural Change 15, no. 3 (1967): 336–8. 44 Nancy Folbre and Julie A. Nelson, “For Love or Money – or Both?,” Journal of Economic Perspectives 14, no. 4 (2000): 124–5.

Notes to pages 28–30

283

45 Vincenzo Galasso, The Political Future of Social Security in Aging Societies (Boston: MIT Press, 2008), see chap. 2. 46 For an overview and critique, see Walker, “Economic ‘Burden’ of Ageing”; Gee and Gutman, Overselling of Population Aging. 47 David E. Bloom and Jeffrey G. Williamson, “Demographic Transitions and Economic Miracles in Emerging Asia,” World Bank Economic Review 12, no. 3 (1998): 419–55. 48 Rafael Gomez and David K. Foot, “Age Structure, Income Distribution and Economic Growth,” Canadian Public Policy / Analyse de politiques 29, no. S1 (2003): S141–61. 49 OECD, Reforms for an Ageing Society (Paris: OECD, 2000). 50 Population Division of the Department of Economics and Social Affairs of the United Nations Secretariat, World Population Prospects: The 2012 Revision (New York: UN, 2012). 51 Population Division of the Department of Economics and Social Affairs of the United Nations Secretariat, World Population Prospects (New York: United Nations, 2013). 52 E. Kleiman, “A Standardized Dependency Ratio,” Demography 4, no. 2 (1967): 876–93. 53 Folbre and Nelson, “For Love or Money – or Both?” 54 Foot, “Public Expenditures, Population Aging and Economic Dependency in Canada, 1921–2021.” 55 See Statistics Canada, “Labour Force Characteristics by Sex and Detailed Age Group, Annual” (table 14-10-0018-01), https://www150.statcan .gc.ca/t1/tbl1/en/cv.action?pid=1410001801. 56 Walker, “Economic ‘Burden’ of Ageing.” 57 Ann Robertson, “Beyond Apocalyptic Demography: Towards a Moral Economy of Interdependence,” Ageing & Society 17, no. 4 (1997): 425–46. 58 Schneider and Ingram, “Social Construction of Target Populations.” 59 Pat Thane, “The Growing Burden of an Ageing Population?,” Journal of Public Policy 7, no. 4 (1987): 373–87. 60 Ellen M. Gee, “Misconceptions and Misapprehensions about Population Ageing,” International Journal of Epidemiology 31, no. 4 (2002): 750–3. 61 Frank T. Denton and Byron G. Spencer, “Population Aging and Its Economic Costs: A Survey of the Issues and Evidence,” Canadian Journal on Aging / La Revue canadienne du vieillissement 19, no. S1 (2000): S7–8. 62 See, for example, Marcel Mérette, “The Bright Side: A Positive View on the Economics of Aging,” Choices 8, no. 1 (2002): 1–28. 63 Marco Albertini, Martin Kohli, and Claudia Vogel, “Intergenerational Transfers of Time and Money in European Families: Common Patterns‚ Different Regimes?,” Journal of European Social Policy 17, no. 4 (2007): 319–34.

284

Notes to pages 30–3

64 Linda G. Martin, “Demography and Aging,” in Handbook of Aging and the Social Science, ed. Robert H. Binstock and Linda K. George, 33–45 (London: Academic, 2011), 39. 65 Gosta Esping-Andersen and Sebastian Sarasa, “The Generational Conflict Reconsidered,” Journal of European Social Policy 12, no. 1 (2002): 5–21; Jane Jenson and Denis Saint-Martin, “Building Blocks for a New Social Architecture: The Lego Paradigm of an Active Society,” Policy & Politics 34, no. 3 (2006): 429–51. 66 Alan Walker, “A Strategy for Active Ageing,” International Social Security Review 55, no. 1 (2002): 121–39. 67 For example, Kernaghan already utilized the dependency ratio in his 1982 article on the consequences of population aging in Canada. Kenneth Kernaghan, “Politics, Public Administration and Canada’s Aging Population,” Canadian Public Policy / Analyse de politiques 8, no. 1 (1982): 69–79; Rune Ervik, Nanna Kildal, and Even Nilssen, eds., The Role of International Organizations in Social Policy: Ideas, Actors and Impact (Cheltenham, UK: Edward Elgar, 2009). 68 Syed Ather Hussain Akbari, “Some Demographic Trends in Atlantic Canada: Potential Consequences and Policy Responses,” in Immigrants in Regional Labour Markets of Host Nations, ed. Syed Ather Hussain Akbari, 9–18 (Heidelberg: Springer Netherlands, 2013). 69 Erik Schokkaert and Philippe Van Parijs, “Debate on Social Justice and Pension Reform: Social Justice and the Reform of Europe’s Pension Systems,” Journal of European Social Policy 13, no. 3 (2003): 245–79. 70 John Myles, “What Justice Requires: Pension Reform in Ageing Societies,” Journal of European Social Policy 13, no. 3 (2003): 264–9. 71 Hans-Werner Sinn, “Why a Funded Pension System Is Useful and Why It Is Not Useful,” International Tax and Public Finance 7, no. 4–5 (2000): 404–5. 72 Myles, “What Justice Requires,” 265. 73 Myles, “What Justice Requires,” 266; Kenneth Howse, “Updating the Debate on Intergenerational Fairness in Pension Reform,” Social Policy & Administration 41, no. 1 (2007): 50–64. 74 P.A. Diamond, “A Framework for Social Security Analysis,” Journal of Public Economics 8 (1977): 275–98. 75 Author interviews, offices for seniors across Canada (2010–14). 76 For an overview, see Achim Goerres and Pieter Vanhuysse, “Mapping the Field: Comparative Generational Politics and Policies in Ageing Democracies,” in Ageing Populations in Post-Industrial Democracies, ed. Pieter Vanhuysse and Achim Goerres, 1–22 (London: Routledge, 2012). 77 Neal E. Cutler, “Demographic, Social-Psychological, and Political Factors in the Politics of Aging: A Foundation for Research in ‘Political Gerontology,’” American Political Science Review 71, no. 3 (1977): 1011–25.

Notes to page 33

285

78 For example, see Mulligan and Sala-i-Martin, Gerontocracy, Retirement, and Social Security; Tepe and Vanhuysse, “Are Aging OECD Welfare States on the Path to Gerontocracy?” 79 Anthony Downs, An Economic Theory of Democracy (Boston: Addison Wesley, 1957). 80 Fred C. Pampel and John B. Williamson, “Age Structure, Politics, and Cross-National Patterns of Public Pension Expenditures,” American Sociological Review 50, no. 6 (1985): 782–99. 81 See, for example, Francis G. Castles, “What Welfare States Do: A Disaggregated Expenditure Approach,” Journal of Social Policy 38, no. 1 (2009): 45–62. 82 Paul Pierson, Dismantling the Welfare State? Reagan, Thatcher, and the Politics of Retrenchment, Cambridge Studies in Comparative Politics (Cambridge: Cambridge University Press, 1994); Nicole F. Bernier, Le désengagement de l’État providence (Montreal: Les Presses de l’Université de Montréal, 2003); David Feltenius, “En Pluralistisk Maktordning? Om Pensionärsorganisationernas Politiska Inflytande” (PhD diss., Umeå University, 2004). 83 Andrea Louise Campbell, How Policies Make Citizens: Senior Political Activism and the American Welfare State (Princeton, NJ: Princeton University Press, 2003). 84 Daniel Béland, “Does Labor Matter? Institutions, Labor Unions and Pension Reform in France and the United States,” Journal of Public Policy 21, no. 2 (2001): 153–72; Giuliano Bonoli, The Politics of Pension Reform (Cambridge: Cambridge University Press, 2000); Patrik Marier, Pension Politics: Consensus and Social Conflict in Ageing Societies (London: Routledge, 2008); Bernhard Ebbinghaus, “Reforming Bismarckian Corporatism: The Changing Role of Social Partnership in Continenal Europe,” in A Long Goodbye to Bismarck? The Politics of Welfare Reforms in Continental Europe, ed. Bruno Palier, 255–78 (Amsterdam: Amsterdam University Press, 2010). 85 See Feltenius, “En Pluralistisk Maktordning?”; A. Goerres, The Political Participation of Older People in Europe: The Greying of Our Democracies (London: Palgrave Macmillan, 2009); Sean Hanley, “Explaining the Success of Pensioners’ Parties: A Qualitative-Comparative Analysis of 31 European Democracies,” in Ageing Populations in Post-Industrial Democracies: Comparative Studies of Policies and Politics, ed. Pieter Vanhuysse and Achim Goerres, 23–53 (London: Routledge, 2012). 86 Lynch, Age in the Welfare State. 87 Birnbaum et al., Generational Welfare Contract. 88 Davidson, Going Grey; James H. Schultz and Robert H. Binstock, Aging Nation: The Economics and Politics of Growing Older in America (Baltimore, MD: Johns Hopkins University Press, 2008); Tepe and Vanhuysse, “Are Aging OECD Welfare States on the Path to Gerontocracy?”

286

Notes to pages 33–5

89 Birnbaum et al., Generational Welfare Contract. 90 Marius R. Busemeyer, Achim Goerres, and Simon Weschle, “Attitudes towards Redistributive Spending in an Era of Demographic Ageing: The Rival Pressures from Age and Income in 14 OECD Countries,” Journal of European Social Policy 19, no. 3 (2009): 195–212; Goerres, Political Participation of Older People in Europe. 91 Pierson, Dismantling the Welfare State? 92 See, for example, Bernhard Ebbinghaus, ed., Varieties of Pension Governance: The Privatization of Pensions in Europe (Oxford: Oxford University Press, 2011); Marier, Pension Politics; Robert Holzmann, “Global Pension Systems and Their Reform: Worldwide Drivers, Trends and Challenges,” International Social Security Review 66, no. 2 (2013): 1–29. 93 Anne-Marie Guillemard, Le déclin du social: formation et crise des politiques de vieillesse (Paris: Presses universitaires de France, 1986); Jay Ginn, “Grey Power: Age-Based Organisations’ Response to Structured Inequalities,” Critical Social Policy 13, no. 38 (1993): 23–47. Also on the US case, see John B. Williamson, Judith A. Shindul, and Linda Evans, Aging and Public Policy: Social Control or Social Justice (Springfield, IL: Charles C. Thomas, 1985), 247. 94 Peter Conrad, The Medicalization of Society: On the Transformation of Human Conditions into Treatable Disorders (Baltimore, MD: Johns Hopkins University Press, 2008). 95 Irving Kenneth Zola, “Medicine as an Institution of Social Control,” Sociological Review 20, no. 4 (1972): 487–504; Peter Conrad, “Medicalization and Social Control,” Annual Review of Sociology 18, no. 1 (1992): 209–32. 96 On the differences between both terms, see Adele E. Clarke, Janet Shim, Laura Mamo, Jennifer Ruth Fosket, and Jennifer R. Fishman, “Biomedicalization: Technoscientific Transformations of Health, Illness, and US Biomedicine,” American Sociological Review 68, no. 2 (2003): 161–94; Conrad, Medicalization of Society. 97 Carroll L. Estes and Elizabeth A. Binney, “The Biomedicalization of Aging: Dangers and Dilemmas,” Gerontologist 29, no. 5 (1989): 587–96. 98 Josée Grenier, “Identité, reconnaissance et justice,” in La réponse de la science médicale au “devenir vieux”: prolongévisme, transhumanisme et biogérontologie, ed. Hachimi Sanni Yaya, 177–99 (Quebec: Presses de l’Université Laval, 2012). 99 Karen A. Lyman, “Bringing the Social Back In: A Critique of the Biomedicalization of Dementia,” Gerontologist 29, no. 5 (1989): 597–605. 100 Estes and Binney, “Biomedicalization of Aging.” 101 Estes and Binney, “Biomedicalization of Aging,” 588.

Notes to pages 35–6

287

102 Conrad, Medicalization of Society, 7–8; Estes and Binney, “Biomedicalization of Aging.” 103 W. Achenbaum, Crossing Frontiers: Gerontology Emerges as a Science (Cambridge: Cambridge University Press, 1995), 43. 104 Angela R. Brooks-Wilson, “Genetics of Healthy Aging and Longevity,” Human Genetics 132, no. 12 (2013): 1323–38. 105 Kaare Christensen, Gabriele Doblhammer, Roland Rau, and James W. Vaupel, “Ageing Populations: The Challenges Ahead,” Lancet 374, no. 9696 (2009): 1196–208. 106 Eileen M. Crimmins and Hiram Beltrin-Sinchez, “Mortality and Morbidity Trends: Is There Compression of Morbidity?,” Journals of Gerontology Series B: Psychological Sciences and Social Sciences 66B, no. 1 (2011): 75–86. 107 Estes and Binney, “Biomedicalization of Aging.” 108 Richard M. Titmuss, Essays on “the Welfare State” (London: George Allen and Unwin, 1958), 183. 109 Schneider and Ingram, “Social Construction of Target Populations.” 110 Conrad, “Medicalization and Social Control,” 214. 111 Clarke et al., “Biomedicalization.” 112 Steven Brint, In an Age of Experts: The Changing Role of Professionals in Politics and Public Life (Princeton, NJ: Princeton University Press, 1994), chap. 7. 113 Estes and Binney, “Biomedicalization of Aging,” 591; Elizabeth A. Binney, Carroll L. Estes, and Stanley R. Ingman, “Medicalization, Public Policy and the Elderly: Social Services in Jeopardy?,” Social Science Medicine 30, no. 7 (1990): 761–71. 114 Estes and Binney, “Biomedicalization of Aging,” 591–4. 115 Gregory P. Marchildon and Livio Di Matteo, eds., Bending the Cost Curve in Health Care: Canada’s Provinces in International Perspective (Toronto: University of Toronto Press, 2015). 116 Howard A. Palley, “Long-Term Care Service Policies in Three Canadian Provinces: Alberta, Quebec, and Ontario: Examining the National and Subnational Contexts,” International Journal of Canadian Studies 47, no. 1 (2013): 57–85. 117 S.K. Sinha, “Why the Elderly Could Bankrupt Canada and How Demographic Imperatives Will Force the Redesign of Acute Care Service Delivery,” HealthcarePapers 11, no. 1 (2011): 46–51; K. Vegda, J.X. Nie, L. Wang, C.S. Tracy, R. Moineddin, and R.E. Upshur, “Trends in Health Services Utilization, Medication Use, and Health Conditions among Older Adults: A 2-Year Retrospective Chart Review in a Primary Care Practice,” BMC Health Services Research 9 (2009): 217; J.X. Nie, L. Wang,

288

118 119

120 121 122

123 124

125 126

127

128 129 130 131 132 133

134 135

Notes to pages 37–9 C.S. Tracy, R. Moineddin, and R.E. Upshur, “A Population-Based Cohort Study of Ambulatory Care Service Utilization among Older Adults,” Journal of Evaluation in Clinical Practice 16, no. 4 (2010): 825–31. Canadian Institutes of Health Research, “About IA,” http://www.cihr-irsc .gc.ca/e/8643.html. Patrik Marier and Marina Revelli, “The Biomedicalization of Aging in Canada: An Evaluation” (paper presented at the Canadian Association of Gerontology Conference, Winnipeg, 2017). Institute of Aging, Activity Report: 2000–2012 (Ottawa: CIHR, 2013), 2. Estes and Binney, “Biomedicalization of Aging.” Martin Bauer, “The Medicalization of Science News: From the ‘RocketScalpel’ to the ‘Gene-Meteorite’ Complex,” Social Science Information 37, no. 4 (1998): 731–51. Ben A. Rich, “Medical Custom and Medical Ethics: Rethinking the Standard of Care,” Cambridge Quarterly of Healthcare Ethics 14, no. 1 (2005): 27–39. Sharon R. Kaufman, Janet K. Shim, and Ann J. Russ, “Revisiting the Biomedicalization of Aging: Clinical Trends and Ethical Challenges,” Gerontologist 44, no. 6 (2004): 731–8. Canadian Medical Association, The State of Seniors Health in Canada (Ottawa: Canadian Medical Association, 2016). M.E. Sorbero, M.I. Saul, H. Lui, and N.M. Resnick, “Geriatric Medicine: Are Geriatricians More Efficient Than Other Physicians at Managing Inpatient Care for Elderly Patients?,” Journal of the American Geriatric Society 60, no. 5 (2012): 869–76. Jean-Pierre Michel and Heung Bong Cha, “Filling the Geriatric Education Gap around the World,” Journal of the American Medical Directors Association 16, no. 12 (2015): 1010. David B. Hogan, “History of Geriatrics in Canada,” Canadian Bulletin of Medical History 24, no. 1 (2007): 131–50. Achenbaum, Crossing Frontiers, 45. Canadian Medical Association, State of Seniors Health in Canada. Canadian Medical Association, State of Seniors Health in Canada. Canadian Medical Association, Geriatric Medicine Profile (Ottawa: CMA, 2018), 6. T. Commerford, “How Many Geriatricians Should, at Minimum, Be Staffing Health Regions in Australia?,” Australia’s Journal of Ageing 37, no. 1 (2018): 17–22. Canadian Medical Association, Pediatrics Medicine Profile (Ottawa: CMA, 2018). Anita S. Bagri and Richard Tiberius, “Medical Student Perspectives on Geriatrics and Geriatric Education,” Journal of the American Geriatric Society 58, no. 10 (2010): 1994–9.

Notes to pages 39–41

289

136 A.A. Meiboom, H. de Vries, C.M. Hertogh, and F. Scheele, “Why Medical Students Do Not Choose a Career in Geriatrics: A Systematic Review,” BMC Medical Education 15 (2015): 101. 137 C. Frank and R.E. Martin, “Humanities and Geriatric Education: A Strategy for Recruitment?,” Canadian Geriatrics Journal 18, no. 1 (2015): 37–41. 138 Janet E. Gordon, “Updated Survey of the Geriatrics Content of Canadian Undergraduate and Postgraduate Medical Curricula,” Canadian Geriatrics Journal 14, no. 2 (2011): 34–9. 139 Rachel W. Cozort, “Student Nurses’ Attitudes Regarding Older Adults: Strategies for Fostering Improvement through Academia,” Teaching and Learning in Nursing 3, no. 1 (2008): 21–5. 140 S.P. Hirst, A.M. Lane, and B. Stares, “Gerontological Content in Canadian Nursing and Social Work Programs,” Canadian Geriatrics Journal 15, no. 1 (2012): 10. 141 Richard Schulz and Jutta Heckhausen, “A Life Span Model of Successful Aging,” American Psychologist 51, no. 7 (1996): 702–14; Paul B. Baltes and Margret M. Baltes, Successful Aging: Perspectives from the Behavioral Sciences (Cambridge: Cambridge University Press, 1993); P.B. Baltes and J. Smith, “New Frontiers in the Future of Aging: From Successful Aging of the Young Old to the Dilemmas of the Fourth Age,” Gerontology 49, no. 2 (2003): 123–35; John W. Rowe and Robert L. Kahn, “Successful Aging,” Gerontologist 37, no. 4 (1997): 433–40; Nina C. Franklin and Charlotte A. Tate, “Lifestyle and Successful Aging: An Overview,” American Journal of Lifestyle Medicine 3, no. 1 (2009): 6–11. 142 Paul B. Baltes and Margret M. Baltes, “Psychological Perspectives on Successful Aging: The Model of Selective Optimization with Compensation,” in Baltes and Baltes, Successful Aging, 3. 143 Ann Bowling, “Aspirations for Older Age in the 21st Century: What Is Successful Aging?,” International Journal of Aging and Human Development 64, no. 3 (2007): 263–97. 144 These secretariats were eventually integrated within health departments (see chapter 5). 145 Bowling, “Aspirations for Older Age in the 21st Century.” 146 Vincent Caradec, Sociologie de la vieillesse et du vieillissement, 3rd. ed. (Paris: Armand Colin, 2012). 147 James S. House, James M. Lepkowski, Ann M. Kinney, Richard P. Mero, Ronald C. Kessler, and A. Regula Herzog, “The Social Stratification of Aging and Health,” Journal of Health and Social Behavior 35, no. 3 (1994): 213–34. 148 Werner Greve and Ursula M. Staudinger, “Resilience in Later Adulthood and Old Age: Resources and Potentials for Successful

290

149 150

151

152 153

154

155 156

157

158 159

Notes to pages 41–2 Aging,” in Developmental Psychopathology, ed. D. Cicchetti and A. Cohen (Hoboken: John Wiley & Sons, 2006); Phyllis Braudy Harris, “Another Wrinkle in the Debate about Successful Aging: The Undervalued Concept of Resilience and the Lived Experience of Dementia,” International Journal of Aging and Human Development 67, no. 1 (2008): 43–61; Gail Wagnild, “Resilience and Successful Aging: Comparison among Low and High Income Older Adults,” Journal of Gerontological Nursing 29, no. 12 (2003): 42–9. World Health Organization, Social Determinants of Health: The Solid Facts (Copenghagen: World Health Organization 2003). Elizabeth H. Bradley, Benjamin R. Elkins, and Jeph Herrin, “Health and Social Services Expenditures: Associations with Health Outcomes,” BMJ Quality Safety 20 (2011): 826–31. Jong In Kim, “Social Factors Associated with Centenarian Rate (CR) in 32 OECD Countries,” BMC International Health and Human Rights 13, no. 1 (2013): 16. Quadagno, Aging and the Life Course, 4. Statistics Canada, Canadian Community Health Survey (CCHS), 2009 Annual Component Surveys (Ottawa: Statistics Canada, Health Statistics Division, 2011). Jean-Pierre Lavoie and Danielle Guay, “Vieillir en santé? Des inégalités persistantes,” in Vieillir au pluriel: perspectives sociales, ed. Michèle Charpentier, Nancy Guberman, Véronique Billette, Jean-Pierre Lavoie, Amanda Grenier, and Ignace Olazabal, 115–34 (Montreal: Presses de l’Université du Québec, 2010). Estes and Binney, “Biomedicalization of Aging.” Elaine Cumming and William Earl Henry, Growing Old: The Process of Disengagement (New York: Basic Books, 1961); Vincent Caradec, Sociologie de la vieillesse et du vieillissement (Paris: Nathan, 2001); Michel A.J. Philibert, “The Emergence of Social Gerontology,” Journal of Social Issues 21, no. 4 (1965): 4–12; Matilda White Riley, “Social Gerontology and the Age Stratification of Society,” Gerontologist 11, no. 1, part 1 (1971): 79–87. Carroll L. Estes, James H. Swan, and Lenore E. Gerard, “Dominant and Competing Paradigms in Gerontology: Towards a Political Economy of Ageing,” Ageing and Society 2, no. 2 (1982): 151–64; Alan Walker, “Towards a Politcal Economy of ‘Old Age,’” Ageing and Society 1, no. 1 (1981): 73–94. Ann Bowling, “The Concepts of Successful and Positive Ageing,” Family Practice 10, no. 4 (1993): 449–53. Martha B. Holstein and Meredith Minkler, “Self, Society, and the ‘New Gerontology,’” Gerontologist 43, no. 6 (2003): 787–96; Kimberly J. Johnson and Jan E. Mutchler, “The Emergence of a Positive Gerontology: From

Notes to pages 43–4

160

161 162

163 164 165 166 167 168 169 170 171

172

173

291

Disengagement to Social Involvement,” Gerontologist 54, no. 1 (2014): 93–100. See, for example, Cynthia P. Carruthers and Colleen Deyell Hood, “Building a Life of Meaning through Therapeutic Recreation: The Leisure and Well-Being Model, Part I,” Therapeutic Recreation Journal 41, no. 4 (2007): 276–97; Lynn S. Anderson and Linda A. Heyne, “Flourishing through Leisure: An Ecological Extension of the Leisure and Well-Being Model in Therapeutic Recreation Strengths-Based Practice,” Therapeutic Recreation Journal 46, no. 2 (2012): 129–52. Most notably, see Baltes and Baltes, Successful Aging; Rowe and Kahn, “Successful Aging.” B. Payne, J. Daw, R. Evans, V. Marshall, P. Clarke, D. Norris, J. Hagey, E. Shapiro, R. Wilkins, and B. Havens, “Healthy Aging: Insights for Research and Policy,” in “Aging/Vieillissement,” special issue, Canadian Public Policy / Analyse de politiques 23 (1997): 42–52. Alan Walker, “Commentary: The Emergence and Application of Active Aging in Europe,” Journal of Aging & Social Policy 21, no. 1 (2008): 75–93. For a discussion on this element, see Holstein and Minkler, “Self, Society, and the ‘New Gerontology,’” 789. Nations Unies, Déclaration politique et plan d’action international de Madrid sur le vieillissement (New York: Nations Unies, 2003). World Health Organization, Active Ageing: A Policy Framework (Geneva: WHO, 2002). World Health Organization, Global Age-Friendly Cities: A Guide (Geneva: WHO, 2007). World Health Organization, Technical Opinions: International Technical Meeting on Aging in Place (Quebec City, October 2018). Government of Alberta, Aging Population Policy Framework (Edmonton: Government of Alberta, 2010). Holstein and Minkler, “Self, Society, and the ‘New Gerontology.’” Harry R. Moody, “What Is Critical Gerontology and Why Is It Important?,” in Voices and Visions of Aging, ed. Thomas R. Cole, W. Andrew Achenbaum, Patricia L. Jakobi, and Robert Kastenbaum, xv–xli (New York: Springer, 1993). Jan Baars, Dale Dannefer, Chris Phillipson, and Alan Walker, “Critical Perspectives in Social Gerontology,” in Aging, Globalization and Inequality, ed. Jan Baars, Dale Dannefer, Chris Phillipson, and Alan Walker, 1–16 (Amityville, NY: Baywood Publishing, 2006), 2. Véronique Billette, Jean-Pierre, Anne-Marie Séguin, and Isabelle Van Pevenage, “Réflexions sur l’exclusion et l’inclusion sociale en lien avec le vieillissement. L’importance des enjeux de reconnaissance et de redistribution,” Frontières 25, no. 1 (2012): 10–30.

292

Notes to pages 44–6

174 Stephen Katz, Cultural Aging: Life Course, Lifestyle, and Senior Worlds (Toronto: University of Toronto Press, 2009); Estes and Binney, “Biomedicalization of Aging”; Baars et al., Aging, Globalization and Inequality. 175 See, for example, Simon Biggs, “Toward Critical Narrativity: Stories of Aging in Contemporary Social Policy,” Journal of Aging Studies 15, no. 4 (2001): 303–16; Holstein and Minkler, “Self, Society, and the ‘New Gerontology.’” 176 Isabelle Wallach and Shari Brotman, “Ageing with HIV/AIDS: A Scoping Study among People Aged 50 and Over Living in Quebec,” Ageing & Society 33, no. 7 (2013): 1212–42. 177 Moody, “What Is Critical Gerontology and Why Is It Important?” 178 Baars et al., “Critical Perspectives in Social Gerontology.” 179 Bo Rothstein, “The Universal Welfare State as a Social Dilemma,” Rationality and Society 13, no. 2 (2001): 213–33. 180 Williamson, Shindul, and Evans, Aging and Public Policy, 253. 181 Anna Whitaker, “In the Shade of Disability Reforms and Policy: Parenthood, Ageing and Lifelong Care,” in Ageing with Disability, ed. Eva Jeppsson-Grassman and Anna Whitaker, 91–108 (Bristol: Policy, 2013). 182 Peter Townsend, “The Structured Dependency of the Elderly: A Creation of Social Policy in the Twentieth Century,” Ageing and Society 1, no. 1 (1981): 5–28; Walker, “Towards a Politcal Economy of ‘Old Age’”; AnneMarie Guillemard, La vieillesse et l’état (Paris: PUF, 1980); John Myles, Old Age in the Welfare State: The Political Economy of Public Pensions (Lawrence: University Press of Kansas, 1989). 183 Williamson, Shindul, and Evans, Aging and Public Policy. 184 John Macnicol, Age Discrimination: An Historical and Contemporary Analysis (Cambridge: Cambridge University Press, 2006). 185 Pierson, Dismantling the Welfare State?; Campbell, How Policies Make Citizens. 186 Patrik Marier, Yves Carrière, and Jonathan Purenne, “ Living on Easy Street? The Myth of the Affluent Senior,” in Growing Wise about Getting Old: Debunking Myths about Aging, ed. Véronique Billette, Patrik Marier, and Anne-Marie Séguin, 20–7 (Vancouver : Purich Books, 2020), 22. 187 Guillemard, Le déclin du social; Myles, Old Age in the Welfare State. 188 Walter Korpi and Joakim Palme, “New Politics and Class Politics in the Context of Austerity and Globalization: Welfare State Regress in 18 Countries,” American Political Science Review 97, no. 3 (2003): 425–46. 189 B. Guy Peters, “The Challenge of Policy Coordination,” Policy Design and Practice 1, no. 1 (2018): 1–11. 190 Egeberg, “Impact of Bureaucratic Structure on Policy Making.” 191 Schulman, Large-Scale Policy Making. 192 Peters, Politics of Bureaucracy.

Notes to pages 46–52

293

193 James G. March, “Exploration and Exploitation in Organizational Learning,” Organization Science 2, no. 1 (1991): 71–87. 194 Christopher Howard, The Welfare State Nobody Knows: Debunking Myths about US Social Policy (Princeton, NJ: Princeton University Press, 2007). 195 Stephen H. Linder and B. Guy Peters, “From Social Theory to Policy Design,” Journal of Public Policy 4, no. 3 (1984): 237–59. 196 See Schulman, Large-Scale Policy Making. 197 Masahiko Aoki, “Horizontal vs. Vertical Information Structure of the Firm,” American Economic Review 76, no. 5 (1986), 971–83; B. Guy Peters, “Managing Horizontal Government: The Politics of Co-ordination,” Public Administration 76, no. 2 (1998): 295–311. 198 Tom Christensen and Per Lægreid, “The Whole-of-Government Approach to Public Sector Reform,” Public Administration Review 67, no. 6 (2007): 1059–66; Peters, “Managing Horizontal Government.” 199 Schneider and Ingram, “Social Construction of Target Populations.” 200 Pierson, Dismantling the Welfare State? 201 Alexander Sidorenko and Alan Walker, “The Madrid International Plan of Action on Ageing: From Conception to Implementation,” Ageing & Society 24, no. 2 (2004): 147–65. 202 OECD, Maintaining Prosperity in an Ageing Society (Paris: OECD, 1999). 203 OECD, Reforms for an Ageing Society (Paris: OECD, 2000). 204 Savoie, Governing from the Centre; Jacques Bourgault and Christopher Dunn, eds., Deputy Ministers in Canada: Comparative and Jurisdictional Perspectives (Toronto: University of Toronto Press, 2014). 205 Peters, Politics of Bureaucracy, 61. 206 Egeberg, “Impact of Bureaucratic Structure on Policy Making,” 158. 2 Population Aging as Policy Problems 1 Mulligan and Sala-i-Martin, “Gerontocracy, Retirement, and Social Security”; Tepe and Vanhuysse, “Are Aging OECD Welfare States on the Path to Gerontocracy?” 2 András Simonovits, “Can Population Ageing Imply a Smaller Welfare State?,” European Journal of Political Economy 23, no. 2 (2007): 534–41. 3 Sinha, “Why the Elderly Could Bankrupt Canada.” 4 Bourne and Rose, “Changing Face of Canada,” 117. 5 Gee and Gutman, Overselling of Population Aging. 6 Bacchi, Women, Policy and Politics; Rochefort and Cobb, “Problem Definition”; Peters, “Problem of Policy Problems.” 7 See, for example, Bacchi, Women, Policy and Politics; Schneider and Ingram, “Social Construction of Target Populations”; Frank R. Baumgartner and Bryan D. Jones, Agendas and Instability in American Politics (Chicago: University of Chicago Press, 1993).

294 8 9 10 11 12 13

14

15

16 17

18

19 20 21 22

23 24 25

26 27

Notes to pages 52–6 Wildavsky, Speaking Truth to Power. Kingdon, Agendas, Alternatives, and Public Policies. Peters, “Problem of Policy Problems.” Rochefort and Cobb, “Problem Definition”; Peters, “Problem of Policy Problems.” Bacchi, Women, Policy and Politics; Dery, Problem Definition in Policy Analysis. William N. Dunn, “Methods of the Second Type: Coping with the Wilderness of Conventional Policy Analysis,” Policy Studies Review 7, no. 4 (1988): 720–7. Roger Cobb, Jennie-Keith Ross, and Marc Howard Ross, “Agenda Building as a Comparative Political Process,” American Political Science Review 70, no. 1 (1976): 126–38. Christopher Bosso, “The Contextual Bases of Problem Definition,” in The Politics of Problem Definition: Shaping the Policy Agenda, ed. David A. Rochefort and Roger W. Cobb, 182–203 (Lawrence: University Press of Kansas, 1994). Baumgartner and Jones, Agendas and Instability in American Politics; Cobb, Ross, and Ross, “Agenda Building as a Comparative Political Process.” Hall, “Policy Paradigms, Social Learning, and the State”; Lucia Quaglia, “Civil Servants, Economic Ideas, and Economic Policies: Lessons from Italy,” Governance 18, no. 4 (2005): 545–66; Dahlström, “Bureaucratic Politics of the Welfare State Crisis.” Marier, “Where Did the Bureaucrats Go?”; Jae-Jin Yang, “Democratic Governance and Bureaucratic Politics: A Case of Pension Reform in Korea,” Policy & Politics 32, no. 2 (2004): 193–206. Peters, Politics of Bureaucracy. Kotlikoff and Burns, Coming Generational Storms; Kotlikoff and Burns, Clash of Generations. Ervik, Kildal, and Nilssen, Role of International Organizations in Social Policy. Crimmins and Beltrin-Sinchez, “Mortality and Morbidity Trends”; Anthony J. Vita, Richard B. Terry, Helen B. Hubert, and James F. Fries, “Aging, Health Risks, and Cumulative Disability,” New England Journal of Medicine 338, no. 15 (1998): 1035–41. Canadian Medical Association, Canada Needs a National Seniors Strategy: Make Your Voice Heard (Toronto: CMA, 2015). Crimmins and Beltrin-Sinchez, “Mortality and Morbidity Trends.” See, for example, Jean-Pierre Lavoie, with Nancy Guberman, and Patrik Marier, “La responsabilité des soins aux aînés au Québec. Du secteur public au privé,” Étude IRPP no. 48 (Montreal: Institute for Research on Public Policy, 2014). Rochefort and Cobb, “Problem Definition,” 15. Rochefort and Cobb, “Problem Definition,” 15.

Notes to pages 57–9

295

28 R. Kent Weaver, “The Politics of Blame Avoidance,” Journal of Public Policy 6 (October–December 1986): 371–98. 29 Auerbach, Ghokale, and Kotlikoff, “Generational Accounting.” 30 Paul Pierson, “When Effect Becomes Cause: Policy Feedback and Political Change,” World Politics 45 (July 1993): 595–628; Daniel Béland, “Reconsidering Policy Feedback: How Policies Affect Politics,” Administration & Society 42, no. 5 (2010): 568–90. 31 Paul Pierson, “Irresistible Forces, Immovable Objects: Post-Industrial Welfare States Confront Permanent Austerity,” Journal of European Public Policy 5, no. 4 (1998): 539–60. 32 Myles, “What Justice Requires.” 33 Chappell and Hollander, Aging in Canada; Lavoie, Guberman, and Marier, La responsabilité des soins aux aînés au Québec. 34 Estes and Binney, “Biomedicalization of Aging.” 35 Dale Dannefer, “Cumulative Advantage/Disadvantage and the Life Course: Cross-Fertilizing Age and Social Science Theory,” Journals of Gerontology Series B: Psychological Sciences and Social Sciences 58, no. 6 (2003): S327–37. 36 Estes and Binney, “Biomedicalization of Aging”; Kaufman, Shim, and Russ, “Revisiting the Biomedicalization of Aging”; Lyman, “Bringing the Social Back In.” 37 Binney, Estes, and Ingman, “Medicalization, Public Policy and the Elderly.” 38 Heather E. Dillaway and Mary Byrnes, “Reconsidering Successful Aging: A Call for Renewed and Expanded Academic Critiques and Conceptualizations,” Journal of Applied Gerontology 28, no. 6 (2009): 702–22. 39 Peters, “Managing Horizontal Government.” 40 Brian W. Hogwood and B. Guy Peters, “The Dynamics of Policy Change,” Policy Sciences 14, no. 3 (1982): 225–45. 41 Christopher Dunn, The Institutionalized Cabinet: Governing the Western Provinces (Montreal and Kingston: McGill-Queen’s University Press, 1995). 42 Peter Aucoin, “New Political Governance in Westminster Systems: Impartial Public Administration and Management Performance at Risk,” Governance 25, no. 2 (2012): 177–99. 43 Patrik Marier, “How Should We Administer Population Aging? A Canadian Comparison,” International Journal of Canadian Studies 47 (2013): 101–22. 44 David K. Foot and Rosemary A. Venne, “Awakening to the Intergenerational Equity Debate in Canada,” Journal of Canadian Studies 39, no. 1 (2005): 5–21. 45 See, for example, Emery, Still, and Cottrell, “Can We Avoid a Sick Fiscal Future? The Non-Sustainability of Health-Care Spending with an Aging Population,” SPP Research Papers 5, no. 31, 1–22.

296

Notes to pages 59–60

46 Marier and Revelli, “Compassionate Canadians and Conflictual Americans? Portrayals of Ageism in Liberal and Conservative Media,” Ageing & Society 37, no. 8 (2017): 1632–53. 47 Julia Lynch, “The Age-Orientation of Social Policy Regimes in OECD Countries,” Journal of Social Policy 30, no. 3 (2001): 411–36. 48 Jacqueline E. Stevenson, John P. Hirdes, Susan E. Bronskill, and A. Henry David, “Aging in Ontario: Using Population-Based Data in the Evaluation of Trends in Health System Use,” Healthcare Quarterly 14, no. 2 (2011): 21–5. 49 R. Hébert, “Public Long-Term Care Insurance: A Way to Ensure Sustainable Continuity of Care for Frail Older People,” HealthcarePapers 11, no. 1 (2011): 69–75; Michel Grignon and Nicole F. Bernier, Financing Long-Term Care in Canada, IRPP Study 33 (June 2012), https://irpp.org /wp-content/uploads/assets/research/faces-of-aging/financing-long -term-care/IRPP-Study-no33.pdf. 50 M.B. Lilly, C.A. Robinson, S. Holtzman, and J.L. Bottorf, “Can We Move beyond Burden and Burnout to Support the Health and Wellness of Family Caregivers to Persons with Dementia? Evidence from British Columbia, Canada,” Health & Social Care in the Community 20, no. 1 (2012): 103–12; Janice Keefe and Pamela Fancey, “The Care Continues: Responsibility for Elderly Relatives before and after Admission to a Long Term Care Facility,” Family Relations 49, no. 3 (2000): 235–44. 51 Noralou P. Roos. Janet E. Bradley, Randy Fransoo, and Marian Shanahan, “How Many Physicians Does Canada Need to Care for Our Aging Population?” Canadian Medical Association Journal 158, no. 10 (1998); Frank T. Denton, Amiram Gafni, and Byron G. Spencer, “Users and Suppliers of Physician Services: A Tale of Two Populations,” International Journal of Health Services 39, no. 1 (2009): 189–218. 52 Lavoie, Guberman, and Marier, La responsabilité des soins aux aînés au Québec. 53 See, for example, Kernaghan, “Politics, Public Administration and Canada’s Aging Population.” 54 Division of Aging and Seniors, Principles of the National Framework on Aging: A Policy Guide, ed. Health Canada (Ottawa: Minister of Public Works and Government Services, 1998). 55 OECD, Maintaining Prosperity in an Ageing Society. 56 World Health Organization, Active Ageing. 57 See, for example, Conseil des aînés, Avis sur les orientations d’une politique du vieillissement (Quebec: Gouvernement du Québec, 1997); Steering Committee for the Government-Wide Study on the Impact of the Aging Population, Alberta for All Ages: Directions for the Future (Edmonton: Alberta Community Development, 2000).

Notes to pages 60–6

297

58 François Laliberté-Auger, Aurélie Côté-Sergent, Yann Décarie, Jean-Yves Duclos, and Pierre-Carl Michaud, “Utilisation et coût de l’hébergement avec soins de longue durée au Québec, 2010 à 2050,” Cahier de recherche CEDIA, no. 15-12 (2015): 1–15. 59 Kotlikoff and Burns, Clash of Generations. 60 See, for example, Vincenzo Galasso and Paola Profeta, “How Does Ageing Affect the Welfare State?,” European Journal of Political Economy 23, no. 2 (2007): 554–63. 61 Macnicol, Age Discrimination. 62 Peters, “Problem of Policy Problems.” 63 Béland, “Reconsidering Policy Feedback.” 64 W. Achenbaum, Crossing Frontiers: Gerontology Emerges as a Science (Cambridge: Cambridge University Press, 1995). 65 Canadian Medical Association, Canada Needs a National Seniors Strategy: Make Your Voice Heard (Toronto: CMA, 2015). 66 Bourgault and Dunn, Deputy Ministers in Canada. 67 Annie Gowen, “Brave New Boomers,” Washington Post, 16 September 2007, http://www.washingtonpost.com/wp-dyn/content/article/2007/09/15 /AR2007091501654.html; see Sara Champagne, “Vieillissement des baby -boomers: alerte au ‘tsunami gris,’” La Presse, 23 August 2010. 68 Rochefort and Cobb, “Problem Definition”; Peters, “Problem of Policy Problems.” 69 This has a lot in common with some recent work on long-term planning: see Ascher, Bringing in the Future; Jacobs, Governing for the Long Term. 70 Emery, Still, and Cottrell, “Can We Avoid a Sick Fiscal Future?,” 3. 71 See, for example, Marchildon and Di Matteo, Bending the Cost Curve in Health Care. 72 Conference Board of Canada, Meeting the Care Needs of Canada’s Aging Population (Ottawa: Conference Board of Canada, 2018). 73 M.J. Hollander, G. Liu, and N.L. Chappell, “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, no. 2 (2009): 42–9. 74 Tuna Baskoy, Bryan Evans, and John Shields, “Assessing Policy Capacity in Canada’s Public Services: Perspectives of Deputy and Assistant Deputy Ministers,” Canadian Public Administration / Administration publique au Canada 54, no. 2 (2011): 217–34. 75 Wellstead, Stedman, and Howlett, “Policy Analytical Capacity in Changing Governance Contexts.” 76 Ken Rasmussen, “Policy Capacity in Saskatchewan: Strengthening the Equilibrium,” Canadian Public Administration / Administration publique au

298

77 78 79 80 81 82 83 84 85 86 87 88 89 90 91

92

93 94 95 96 97 98

Notes to pages 66–71 Canada 42, no. 3 (1999): 331–48; McArthur, “Policy Analysis in Provincial Governments in Canada.” Schulman, Large-Scale Policy Making. Schulman, Large-Scale Policy Making, 19. Schulman, Large-Scale Policy Making, 19. Emery, Still, and Cottrell, “Can We Avoid a Sick Fiscal Future?” David Cheal, “Aging and Demographic Change,” Canadian Public Policy/ Analyse de politiques 16, no. S2 (2000): S110–22. Emery, Still, and Cottrell, “Can We Avoid a Sick Fiscal Future?” Chappell and Hollander, Aging in Canada. Townsend, “Structured Dependency of the Elderly.” Amanda Grenier, Transitions and the Lifecourse (Bristol: Policy, 2012). Richard Rose, “Inheritance before Choice in Public Policy,” Journal of Theoretical Politics 2, no. 3 (1990): 263–91. Hogwood and Peters, “Dynamics of Policy Change.” Savoie, Governing from the Centre; Bourgault and Dunn, Deputy Ministers in Canada. Peters, “Problem of Policy Problems.” Lynch, “Age-Orientation of Social Policy Regimes in OECD Countries.” Chappell and Hollander, Aging in Canada, 4; Steven Morgan and Colleen Cunningham, “Population Aging and the Determinants of Healthcare Expenditures: The Case of Hospital, Medical and Pharmaceutical Care in British Columbia, 1996 to 2006,” Healthcare Policy 7, no. 1 (2011): 68–79; Kimberlyn McGrail, “Seniors Will Not Bankrupt Canada’s Health System,” Lancet 380, no. 9855 (2012): 1740. M.K. Gusmano and S. Allin, “Framing the Issue of Ageing and Health Care Spending in Canada, the United Kingdom and the United States,” Health Economics, Policy and Law 9, no. 3 (2014): 313–28; Gregory P. Marchildon and Livio Di Matteo, “Introduction and Overview,” in Marchildon and Di Matteo, Bending the Cost Curve in Health Care, xvi. Gee and Gutman, Overselling of Population Aging. Quadagno, “Generational Equity and the Politics of the Welfare State.” Gee and Gutman, Overselling of Population Aging. Schultz and Binstock, Aging Nation. Pierson, Dismantling the Welfare State? Jay Ginn, Gender, Pensions and the Lifecourse: How Pensions Need to Adapt to Changing Family Forms (Bristol, UK: Policy, 2003); Steven P. Wallace, John B. Williamson, Rita Gaston Lung, and Lawrence A. Powell, “A Lamb in Wolf’s Clothing? The Reality of Senior Power and Social Policy,” in Critical Perspectives on Aging: The Political Economy of Growing Old, ed. C. Estes and E. Binney, 95–114 (New York: Baywood, 1991).

Notes to pages 71–7

299

99 Sylvia Bashevkin, “Rethinking Retrenchment: North American Social Policy during the Early Clinton and Chrétien Years,” Canadian Journal of Political Science/Revue canadienne de science politique 33, no. 1 (2000): 7–36; Tepe and Vanhuysse, “Are Aging OECD Welfare States on the Path to Gerontocracy?”; Robert Henry Cox, “The Consequences of Welfare Reform: How Conceptions of Social Rights Are Changing,” Journal of Social Policy 27, no. 1 (1998): 1–16. 3 The Politics of the Long View 1 Interview 23. 2 See chapter on pensions in Richard Simeon, Federal-Provincial Diplomacy: The Making of Recent Policy in Canada (Toronto: University of Toronto Press, 2006). 3 Richard E. Klosterman, “Arguments for and against Planning,” Town Planning Review 56, no. 1 (1985): 5–20. 4 See, for example, Peter Evans and James E. Rauch, “Bureaucracy and Growth: A Cross-National Analysis of the Effects of ‘Weberian’ State Structures on Economic Growth,” American Sociological Review 64, no. 5 (1999): 748–65; Bo Rothstein, The Quality of Government: Corruption, Social Trust, and Inequality in International Perspective (Chicago: University of Chicago Press, 2011). 5 Barzelay and Campbell, Preparing for the Future. 6 Jacobs, Governing for the Long Term. 7 Ascher, Bringing in the Future. 8 Barzelay and Campbell, Preparing for the Future. 9 Ascher, Bringing in the Future. 10 Jan-Peter Voß, Adrian Smith, and John Grin, “Designing Long-Term Policy: Rethinking Transition Management,” Policy Sciences 42, no. 4 (2009): 275–302. 11 Bruno Jobert, Le social en plan (Paris: Les éditions ouvrières, 1981). 12 Chalmers A. Johnson, Miti and the Japanese Miracle: The Growth of Industrial Policy, 1925–1975 (Stanford, CA: Stanford University Press, 1982). 13 Peter deLeon, “Futures Studies and the Policy Sciences,” Futures 16, no. 6 (1984): 586–93. 14 Stuart S. Blume, “Policy Studies and Social Policy in Britain,” Journal of Social Policy 8, no. 3 (1979): 311–34. 15 Aaron Wildavsky, “If Planning Is Everything, Maybe It’s Nothing,” Policy Sciences 4, no. 2 (1973): 127–53. 16 David E. Smith, Prairie Liberalism: The Liberal Party in Saskatchewan 1905–71 (Toronto: University of Toronto Press, 1975), 257–8. 17 A.W. Johnson, Dream No Little Dreams: A Biography of the Douglas Government of Saskatchewan, 1944–1961 (Toronto: University of Toronto Press, 2004), chap. 5.

300

Notes to pages 77–80

18 N.H. Richardson, “Insubstantial Pageant: The Rise and Fall of Provincial Planning in Ontario,” Canadian Public Administration / Administration publique au Canada 24, no. 4 (1981): 563–86. 19 Dunn, Institutionalized Cabinet. 20 Guy Lachapelle, “Comment est-il redevenu chef du PLQ?,” in Robert Bourassa: Un bâtisseur tranquille, ed. Guy Lachapelle and Robert Comeau, 123–46 (Quebec: Les Presses de l’Université Laval, 2003). 21 Radio-Canada, “Deuxième épisode: Le député de Mercier devient le premier ministre,” http://www.radio-canada.ca/radio/profondeur /bourassa/emission2.html. Author’s translation. 22 William Ocasio and John Joseph, “Rise and Fall – or Transformation?: The Evolution of Strategic Planning at the General Electric Company, 1940– 2006,” Long Range Planning 41, no. 3 (2008): 248–72; Henry Mintzberg, Rise and Fall of Strategic Planning (New York: Free Press, 1994). 23 See, for example, Mintzberg, Rise and Fall of Strategic Planning. 24 Wildavsky, “If Planning Is Everything, Maybe It’s Nothing,” 153. 25 Wildavsky, “If Planning Is Everything, Maybe It’s Nothing,” 153; Klosterman, “Arguments for and against Planning.” 26 For a lengthier analysis on the failure of PPBS, see Mintzberg, Rise and Fall of Strategic Planning, 116–22. 27 Jeffrey L. Pressman and Aaron Wildavsky, Implementation: How Great Expectations in Washington Are Dashed in Oakland, 3rd ed. (Berkeley: University of California Press, 1984); Peter Hall, Great Planning Disasters (Berkeley: University of California Press, 1980). 28 Mintzberg, Rise and Fall of Strategic Planning; Wildavsky, “If Planning Is Everything, Maybe It’s Nothing.” 29 Donald N. Michael, Learning to Plan and Planning to Learn, 2nd ed. (Alexandria, VA: Miles River, 1997), 39. 30 See Klosterman, “Arguments for and against Planning.” 31 Donald J. Savoie, Thatcher, Reagan, Mulroney: In Search of a New Bureaucracy (Pittsburgh: University of Pittsburgh Press, 1994). 32 Pollitt and Bouckaert, Public Management Reform. 33 Michael J. Prince and John A. Chenier, “The Rise and Fall of Policy Planning and Research Units: Organizational Perspective,” Canadian Public Administration / Administration publique au Canada 23, no. 4 (1980): 519–41. 34 C. Chet Miller and Laura B. Cardinal, “Strategic Planning and Firm Performance: A Synthesis of More Than Two Decades of Research,” Academy of Management Journal 37, no. 6 (1994): 1649–65; Philip Van Auken and Donald L. Sexton, “A Longitudinal Study of Small Business Strategic Planning,” Journal of Small Business Management 23, no. 1 (1985): 7–15; John D. Aram and Scott S. Cowen, “Strategic Planning for Increased Profit in the Small Business,” Long Range Planning 23, no. 6 (1990): 63–70.

Notes to pages 80–2

301

35 J.S. Armstrong, “The Value of Formal Planning for Strategic Decisions: Review of Empirical Research,” Strategic Management Journal 3, no. 3 (1982): 197–211. 36 Wildavsky, “If Planning Is Everything, Maybe It’s Nothing”; Mintzberg, Rise and Fall of Strategic Planning. 37 Mintzberg, Rise and Fall of Strategic Planning. 38 Ocasio and Joseph, “Rise and Fall – or Transformation?” 39 Peter Schwartz, The Art of the Long View: Planning for an Uncertain Future (New York: Doubleday/Currency, 1991). 40 Michael, Learning to Plan and Planning to Learn; John M. Bryson, Strategic Planning for Public and Nonprofit Organizations: A Guide to Strengthening and Sustaining Organizational Achievement, 4th ed. (San Francisco: Jossey-Bass, 2011). 41 Barzelay and Campbell, Preparing for the Future. 42 Barzelay and Campbell, Preparing for the Future, 5. 43 Pollitt and Bouckaert, Public Management Reform. 44 See Frances Stokes Berry, “Innovation in Public Management: The Adoption of Strategic Planning,” Public Administration Review 54, no. 4 (1994): 322–30; Frances Stokes Berry and Wechsler Barton, “State Agencies’ Experience with Strategic Planning: Findings from a National Survey,” Public Administration Review 55, no. 2 (1995): 159–68; John M. Bryson and William D. Roering, “Initiation of Strategic Planning by Governments,” Public Administration Review 48, no. 6 (1988): 73–81; Rebecca Hendrick, “Strategic Planning Environment, Process, and Performance in Public Agencies: A Comparative Study of Departments in Milwaukee,” Journal of Public Administration Research and Theory 13, no. 4 (2003): 491–519; Gerald R. Kissler, Karmen N. Fore, Willow S. Jacobson, William P. Kilttredge, and Scott L. Steward, “State Strategic Planning: Suggestions from the Oregon Experience,” Public Administration Review 58, no. 4 (1998): 353–9. 45 Berry and Barton, “State Agencies’ Experience with Strategic Planning.” 46 Berry, “Innovation in Public Management.” 47 Berry and Barton, “State Agencies’ Experience with Strategic Planning.” 48 Paul C. Nutt and Robert W. Backoff, “Organizational Publicness and Its Implications for Strategic Management,” Journal of Public Administration Research and Theory 3, no. 2 (1993): 209–31; Wade R. Rose and David Cray, “Public-Sector Strategy Formulation,” Canadian Public Administration / Administration publique au Canada 53, no. 4 (2010): 453–66. 49 Nutt and Backoff, “Organizational Publicness and Its Implications for Strategic Management.” 50 See, for example, Hendrick, “Strategic Planning Environment, Process, and Performance in Public Agencies.”

302

Notes to pages 82–5

51 Baskoy, Evans, and Shields, “Assessing Policy Capacity in Canada’s Public Services”; Bryan Evans, Janet Lum, and John Shields, “A CanadaWide Survey of Deputy and Assistant Deputy Ministers: A Descriptive Analysis,” in Deputy Ministers in Canada: Comparative and Jurisdictional Perspectives, ed. Jacques Bourgault and Christopher Dunn, 324–63 (Toronto: University of Toronto Press). 52 The Swedes, for example, opted to invest in their labour rather than protect dying industries – such as their famous shipyards. Canadian authorities, however, opted to intervene to preserve employment, even if the external environment was not conducive to such actions. 53 See, for example, David R. Mayhew, Congress: The Electoral Connection (New Haven, CT: Yale University Press, 1974). 54 This should not be confused with measures that can achieve both shortterm and long-term goals, such as the strategy of Republicans in the United States to run large deficits to trigger a retrenchment to the welfare state. See Torsten Persson and Lars E. O. Svensson, “Why a Stubborn Conservative Would Run a Deficit: Policy with Time-Inconsistent Preferences,” Quarterly Journal of Economics 104, no. 2 (1989): 325–45. 55 See Savoie, Governing from the Centre; Peter Hennessy, “Rulers and Servants of the State: The Blair Style of Government 1997–2004,” Parliamentary Affairs 58, no. 1 (2005): 6–16. 56 See, for example, Bryan D. Jones and Frank R. Baumgartner, “Representation and Agenda Setting,” Policy Studies Journal 32, no. 1 (2004): 1–24. 57 Jacobs, Governing for the Long Term. 58 Jacobs, Governing for the Long Term. 59 Charles E. Lindblom, “The Science of ‘Muddling Through,’” Public Administration Review 19 (1959): 79–88. 60 Barbara Levitt and James G. March, “Organizational Learning,” Annual Review of Sociology 14 (1988): 319–40. 61 Berry and Barton, “State Agencies’ Experience with Strategic Planning.” 62 Mohamed Charih and Michel Paquin, “La planification stratégique a Ottawa et a Québec: Une comparaison de quelques ministères,” Canadian Public Administration / Administration publique au Canada 36, no. 2 (1993): 175–89. 63 Peters, “Challenge of Policy Coordination.” 64 See Shane Frederick, George Loewenstein, and Ted O’Donoghue, “Time Discounting and Time Preference: A Critical Review,” Journal of Economic Literature 40, no. 2 (2002): 351–401. 65 For an elaborated discussion on this topic, see Ascher, Bringing in the Future, 29–32. 66 Diamond, “Framework for Social Security Analysis.”

Notes to pages 86–90

303

67 See Jacobs, Governing for the Long Term, chap. 2. However, contrary to Jacobs, this book begins with the presumption that civil servants are major actors in policymaking. 68 This is also the minimum threshold employed by Jacobs. 69 The French plans were made with a five-year time horizon, but longerterm studies were also frequent. It is fifteen to twenty years in B. Schwarz, “Long-Range Planning in the Public Sector,” Futures 9, no. 2 (1977): 115–27. In studies focusing on sustainable development and the environment, this horizon is often longer, from twenty-five to fifty years. See Voß, Smith, and Grin, “Designing Long-Term Policy.” 70 See, for example, Ascher, Bringing in the Future; Klosterman, “Arguments for and against Planning”; Erich Jantsch, “From Forecasting and Planning to Policy Sciences,” Policy Sciences 1, no. 1 (1970): 31–47. 71 Barzelay and Campbell, Preparing for the Future. 72 Michael Howlett, “Policy Analytical Capacity and Evidence-Based Policy-Making: Lessons from Canada,” Canadian Public Administration / Administration publique au Canada 52, no. 2 (2009): 156. 73 Statens Offentliga Utredning, Äldrepolitik för framtiden. 100 steg till trygghet och utveckling med en åldrande befolkning, Socialdepartmentet (Stockholm: Allmäna Förlaget, 2003). 74 Special Senate Committee on Aging, Canada’s Aging Population: Seizing the Opportunity (Ottawa: Canadian Senate, 2009). 75 James Ian Gow, Learning from Others: Administrative Innovations among Canadian Governments (Toronto: Institute of Public Administration of Canada, 1994); Gregory J. Inwood, Carolyn M. Johns, and Patricia L. O’Reilly, Intergovernmental Policy Capacity in Canada: Inside the Worlds of Finance, Environment, Trade, and Health (Toronto: University of Toronto Press, 2011). For a contrary view in the Canadian context, see Michael Howlett and Sima Joshi-Koop, “Transnational Learning, Policy Analytical Capacity, and Environmental Policy Convergence: Survey Results from Canada,” Global Environmental Change 21, no. 1 (2011): 85–92. 76 See, for example, Alison E. Woodward, “Too Late for Gender Mainstreaming? Taking Stock in Brussels,” Journal of European Social Policy 18, no. 3 (2008): 289–302; Francesca Scala and Stephanie Paterson, “Stories from the Front Lines: Making Sense of Gender Mainstreaming in Canada,” Politics & Gender, 14, no. 2 (2018) : 208–34. 77 Auditor General, “Manitoba Home Care Program,” 2015, https://www .oag.mb.ca/audit-reports/report/manitoba-home-care-program/. 78 Matthieu Mondou and Éric Montpetit, “Policy Styles and Degenerative Politics: Poverty Policy Designs in Newfoundland and Quebec,” Policy Studies Journal 38, no. 4 (2010): 703–22.

304

Notes to pages 90–2

79 See, for instance, Aucoin, “Administrative Reform in Public Management”; Pollitt and Bouckaert, Public Management Reform. 80 B. Guy Peters, R.A.W. Rhodes, and Vincent Wright, Administering the Summit: Administration of the Core Executive in Developed Countries (London: Macmillan, 2000). For Canada, see Savoie, Governing from the Centre. 81 Denis Saint-Martin, “The New Managerialism and the Policy Influence of Consultants in Government: An Historical-Institutionalist Analysis of Britain, Canada and France,” Governance 11, no. 3 (2000): 319–56. 82 Luc Bernier, Keith Brownsey, and Micheal Howlett, eds., Executive Styles in Canada: Cabinet Structures and Leadership Practices in Canadian Government (Toronto: University of Toronto Press, 2005). 83 McArthur, “Policy Analysis in Provincial Governments in Canada,” 239. 84 Hans J. Michelmann and Jeffrey S. Steeves, “The 1982 Transition in Power in Saskatchewan: The Progressive Conservatives and the Public Service,” Canadian Public Administration / Administration publique au Canada 28, no. 1 (1985): 1–23. 85 Peter Aucoin and Elizabeth Goodyear-Grant, “Designing a Merit-Based Process for Appointing Boards of ABCs: Lessons from the Nova Scotia Reform Experience,” Canadian Public Administration / Administration publique au Canada 45, no. 3 (2002): 301–27; Jeffrey MacLeod, “Nova Scotia Politics: Clientelism and John Savage,” Canadian Journal of Political Science 39, no. 3 (2006): 553–70. 86 Donald J. Savoie, “New Brunswick: A ‘Have’ Public Service in a ‘HaveLess’ Province,” in Government Restructuring and Career Public Service, ed. Evert Lindquist, 260–84 (Toronto: Institute of Public Administration of Canada, 2000); Rebecca Jensen and Paul G. Thomas, “More Than Nobodies, but Not the Powers behind the Throne: The Role of Deputy Ministers in Manitoba,” in Bourgault and Dunn, Deputy Ministers in Canada: Comparative and Jurisdictional Perspectives, 201–38. 87 Christopher Cooper, At the Pleasure of the Crown: The Politics of Bureaucratic Appointments (Vancouver: University of British Columbia Press), 53. 88 On political risk and the role of planners in defending a broader interest than governments, see Klosterman, “Arguments for and against Planning.” 89 For a review of this literature, see Barzelay and Campbell, Preparing for the Future. 90 Cooper and Marier. “Does It Matter Who Works at the Center?” 91 Christopher Cooper, “The Politics of Bureaucratic Mobility: Historical Changes across Public Service Bargains in Canada’s Provincial Governments” (PhD diss., Université de Montréal, 2016), 82, 104. 92 See, for example, Michael, Learning to Plan and Planning to Learn.

Notes to pages 92–5

305

93 Thomas J. Chermack, Scenario Planning in Organizations: How to Create, Use, and Assess Scenarios (San Francisco: Berrett-Koehler, 2011). 94 See Jacques Bourgault and Donald J. Savoie, “Des gestionnaires sous influence: la nouvelle réalité des hauts dirigeants du secteur public,” Téléscope (Hiver 2009): 1–12. 95 Kingdon, Agendas, Alternatives, and Public Policies. 96 See, for example, Herman Bakvis, “Rebuilding Policy in the Era of Fiscal Dividend: A Report from Canada,” Governance 13, no. 1 (2000): 71–103; Howlett, “Policy Analytical Capacity and Evidence-Based Policy-Making”; Inwood, Johns, and O’Reilly, Intergovernmental Policy Capacity in Canada; Rasmussen, “Policy Capacity in Saskatchewan”; Baskoy, Evans, and Shields, “Assessing Policy Capacity in Canada’s Public Services.” 97 See, for example, Wellstead, Stedman, and Howlett, “Policy Analytical Capacity in Changing Governance Contexts.” 98 Baskoy, Evans, and Shields, “Assessing Policy Capacity in Canada’s Public Services.” 99 Wellstead, Stedman, and Howlett, “Policy Analytical Capacity in Changing Governance Contexts.” 100 Compounding this further is the large turnover within the civil service of both Nova Scotia and PEI following a change in government. Both have a highly politicised civil service where many positions are filled via patronage. 101 We can also hypothesise that capacity will vary at the departmental level. 102 Howlett and Joshi-Koop, “Transnational Learning, Policy Analytical Capacity, and Environmental Policy Convergence.” 103 B. Guy Peters, Institutional Theory in Political Science: The “New Institutionalism” (New York: Continuum, 1999). 104 Evelyne Huber, Charles Ragin, and John D. Stephens, “Social Democracy, Christian Democracy, Constitutional Structure, and the Welfare State,” American Journal of Sociology 99, no. 3 (1993): 711–49. 105 Daniel Béland and R. Kent Weaver, “Federalism and the Politics of the Canada and Quebec Pension Plans,” Journal of International and Comparative Social Policy 35, no. 1 (2018): 25–40; Jacobs, Governing for the Long Term. 106 Marchildon and Di Matteo, Bending the Cost Curve in Health Care. 107 Pierson, “When Effect Becomes Cause.” 108 Alan M. Jacobs and R. Kent Weaver, “When Policies Undo Themselves: Self-Undermining Feedback as a Source of Policy Change,” Governance 28, no. 4 (2015): 441–57. 109 Donald P. Moynihan and Joe Soss, “Policy Feedback and the Politics of Administration,” Public Administration Review 74, no. 3 (2014): 320–32.

306

Notes to pages 101–4

4 Pension Policies 1 Keith G. Banting, The Welfare State and Canadian Federalism (Montreal and Kingston: McGill-Queen’s University Press, 1987); Kenneth Bryden, Old Age Pensions and Policy-Making in Canada (Montreal and Kingston: McGillQueen’s University Press, 1974). 2 Interview 37. 3 Interview 110. 4 Patrik Marier and Anne-Marie Séguin, “Aging and Social Assistance in the Provinces,” in Perspectives on Provincial Social Assistance in Canada, ed. Daniel Béland and Pierre-Marc Daigneault, 339–52 (Toronto: University of Toronto Press, 2015). 5 Kotlikoff and Burns, Clash of Generations; Foot and Venne, “Awakening to the Intergenerational Equity Debate in Canada.” 6 Ervik, “Battle of Future Pensions.” 7 Myles, “What Justice Requires”; Schokkaert and Van Parijs, “Debate on Social Justice and Pension Reform.” 8 Gee and Gutman, Overselling of Population Aging; Lynch, “Age-Orientation of Social Policy Regimes in OECD Countries”; Walker, “Economic ‘Burden’ of Ageing and the Prospect of Intergenerational Conflict.” 9 Patrik Marier, “Who Pays the Piper Calls the Tune? Comparing Canada’s and the European Union’s Expansionary Roles in Pensions,” Canadia Public Administration / Administration publique au Canada 56, no. 2 (2013): 322–37. 10 Keith G. Banting, “Comments,” in Reform of Retirement Income Policy : International and Canadian Perspectives, ed. Keith G. Banting and Robin Boadway, 295–99 (Montreal and Kingston: McGill-Queen’s University Press, 1997). 11 Auditor General of Canada, 2006 November Report of the Auditor General of Canada (Ottawa: Minister of Public Works and Government Services Canada, 2006). 12 Following the 2016 CPP reform, the contribution rates and the income ceiling will be rising gradually to secure a replacement rate of 33%. This reform is discussed later in this chapter. 13 Banting, Welfare State and Canadian Federalism. 14 Daniel Béland, “Stock-Market Politics: Finance, Social Learning and Pension Reform in Canada and the United States,” Governance 19, no. 4 (2006): 559–83. 15 Banting, “Comments,” 295. 16 British Columbia and Saskatchewan, both governed by the NDP, opposed Martin’s plan in favour of an alternative that would have raised the upper limit on the contributions.

Notes to pages 105–10

307

17 Kent Weaver, The Politics of Pension Reform in Canada and the United States (Boston: Center for Retirement Research at Boston College, 1999). 18 For a lengthier discussion on the differences between both schemes, see Patrik Marier, “Improving Canada’s Retirement Savings; Lessons from Abroad, Ideas from Home,” IRPP Study 9 (2010): 1–36. 19 Statistics Canada, “Registered Pension Plans (RPPs), Active Members and Market Value of Assets by Contributory Status,” table 11-10-0106-01 (Ottawa: Statistics Canada, 2019), https://www150.statcan.gc.ca/t1/tbl1 /en/tv.action?pid=1110010601&request_locale=en. 20 Statistics Canada, “Table 11-10-0106-01 Registered Pension Plans (RPPs), Active Members and Market Value of Assets,” 2020, https://www150 .statcan.gc.ca/t1/tbl1/en/tv.action?pid=1110010601. The total does not reach 100% because Statistics Canada has other categories (such as hybrid, composite, or combination plans, and others). 21 Expert Commission on Pensions, A Fine Balance: Safe Pensions, Affordable Plans, Fair Rules (Toronto: Government of Ontario, 2008), 14. 22 Figures obtained from Statistics Canada, “Table 11-10-0094-01 Registered Pension Plans (RPPs), Active Members and Market Value of Assets, by Jurisdiction of Plan Registration,” https://www150.statcan.gc.ca/t1/tbl1 /en/tv.action?pid=1110009401&request_locale=en. 23 Interviews 61 and 110. 24 Office of the Superintendent of Financial Institutions Canada, OSFI Annual Report 2014–2015 (Ottawa: Minister of Public Works and Government Services, 2015). 25 Canadian Association of Pension Supervisory Authorities, Proposed Regulatory Principles for a Model Pension Law (Toronto: CAPSA, 2004). 26 Daniel Béland and Patrik Marier. “Universality and the Erosion of Old Age Security,” in Universality and Social Policy in Canada, ed. Daniel Béland, Gregory P. Marchildon, and Michael J. Prince, 103–20 (Toronto: University of Toronto Press, 2019). 27 Richard Shillington, “Are Low-Income Savers Still in the Lurch? TFSAs at 10 Years,” IRPP Insight, no. 27 (2019): 1–20. 28 Interview 110. 29 Philippe Gougeon, “Shifting Pensions,” Perspectives (May 2009): 16–23. 30 Wendy Pyper, “RRSP Investments,” Perspectives (February 2008), no. 75001-X. 31 Karim Moussaly, Participation in Private Retirement Savings Plans, 1997 to 2008 (Ottawa: Statistics Canada, 2010). 32 Interview 61. 33 Régie des rentes du Québec, Vers un Régime de rentes du Québec renforcé et plus équitable (Quebec: RRQ, 2008). 34 See next section for discussion on this topic.

308

Notes to pages 110–13

35 For a comprehensive review and comparative analysis of the Ontario, Alberta and British Columbia, and the Nova Scotia inquiries, see Bob Baldwin and Brian Fitzgerald, “Seeking Certainty in Uncertain Times: A Review of Recent Government-Sponsored Studies on the Regulation of Canadian Pension Plans,” C.D. Howe Institute Commentary 310 (2010). 36 Nova Scotia did not exclude the public sector in its mandate, but the primary focus remained on the private sector. Quebec also included the public sector, but only plans governed by the Retraite Québec (i.e., mostly plans covering municipal and university employees). 37 Expert Commission on Pensions, Fine Balance, 11. 38 Expert Commission on Pensions, Fine Balance, 21. 39 Pension Review Panel, Promises to Keep (Halifax: Government of Nova Scotia, 2009). 40 Bob Baldwin, Research Study on the Canadian Retirement Income System (Toronto: Ontario Ministry of Finance, 2009). 41 Ontario’s mandate clearly specified DB pension plans as the primary focus. 42 Martin Hering and Michael Kpessa, “The Integration of Occupational Pensions Policies: Lessons for Canada,” Canadian Public Policy / Analyse de politiques 34, no. S1 (2008): S137–53. 43 Canadian Association of Pension Supervisory Authorities, “Proposed Regulatory Principles for a Model Pension Law” (Toronto: CAPSA, 2004). 44 Expert Commission on Pensions, A Fine Balance, 22. 45 Expert Commission on Pensions, A Fine Balance, 198–9. 46 Joint Expert Panel on Pension Standards, Getting Our Acts Together: Pension Reform in Alberta and British Columbia (Edmonton and Victoria, 2008). 47 Pension Review Panel, Promises to Keep, 36. 48 Interview 36. 49 Interview 37. 50 Interview 26. 51 Pension Review Panel, Promises to Keep, 44–5. 52 Expert Commission on Pensions, Fine Balance, 22–3. 53 Joint Expert Panel on Pension Standards, Getting Our Acts Together, iii. 54 Comité d’experts sur l’avenir du système de retraite québécois, Innover pour pérénniser le système de retraite: Un contrat social pour renforcer la sécurité financière de tous les travailleurs wuébécois (Quebec: Gouvernement du Québec, 2013), 4. 55 Comité d’experts sur l’avenir du système de retraite québécois, Innover pour pérénniser le système de retraite, 148–9. 56 Comité d’experts sur l’avenir du système de retraite québécois, Innover pour pérénniser le système de retraite, 175–6.

Notes to pages 113–18

309

57 Comité d’experts sur l’avenir du système de retraite québécois, Innover pour pérénniser le système de retraite, 147. 58 Pension Review Panel, Promises to Keep, 56. 59 Joint Expert Panel on Pension Standards, Getting Our Acts Together, 186. 60 Pension Review Panel, Promises to Keep, 56. 61 CAPSA, “Communiqué,” June 2016. 62 Bob Baldwin, “Pension Reform in Canada: A Guide to Fixing Our Futures Again,” IRPP Study 13 (2010): 34. 63 John Myles, “Income Security for Seniors: System Maintenance and Policy Drift,” in Inequality and the Fading of Redistributive Politics, ed. Keith Banting and John Myles (Vancouver: University of British Columbia Press, 2013), 329. 64 Jack M. Mintz, Summary Report on Retirement Income Adequacy Research (Ottawa: Ministry of Finance, 2009), 27. 65 Colin Hansen, Options for Increasing Pension Coverage among Private Sector Workers in Canada (Victoria: Ministry of Finance, 2010). 66 For more information on this proposal, see Keith P. Ambachtsheer, Pension Revolution: A Solution to the Pension Crisis (Hoboken, NJ: John Wiley & Sons, 2007). 67 Hansen, Options for Increasing Pension Coverage among Private Sector Workers in Canada. 68 Moose Jaw Times Herald, “At Meeting, Western Premiers Pitch Regional Pension Program,” 12 September 2009. 69 Bill Curry, “Flaherty Pushes for Expanded CPP,” Globe and Mail, 13 June 2010. 70 Ted Menzies, Toronto, 18 July 2011, accessed 19 October 2016, http:// www.fin.gc.ca/n11/11-057_1-eng.asp (site discontinued). 71 Keith Ambachtsheer and Edward Waitzer, Saving Pooled Registered Pension Plans: It’s Up to the Provinces (Toronto: C.D. Howe Institute, 2011). 72 Michael McKiernan, “PRPPs Continue to Languish as Provinces Vary in Enthusiasm for New Option,” Benefits Canada, 1 September 2016, http:// www.benefitscanada.com/pensions/governance-law/prpps-continue-to -languish-as-provinces-vary-in-enthusiasm-for-new-option-86589. 73 Retraite Québec, “Rapport annuel de gestion” (Québec: Retraite Québec, 2020), 3. 74 Myles, “Income Security for Seniors,” 330. 75 Jean-François Venne, “Des innovations pour aider les Québécois à épargner,” Le Devoir, 15 September 2018. 76 Comité d’experts sur l’avenir du système de retraite québécois, Innover pour pérénniser le système de retraite, 2. 77 Comité d’experts sur l’avenir du système de retraite québécois, Innover pour pérénniser le système de retraite, 3.

310

Notes to pages 118–21

78 Comité d’experts sur l’avenir du système de retraite québécois, Innover pour pérénniser le système de retraite, 3. 79 Comité d’experts sur l’avenir du système de retraite québécois, Innover pour pérénniser le système de retraite, 121–37. 80 Commission des finances publiques, Consultations particulières et auditions publiques sur le rapport intitulé Innover pour pérenniser le système de retraite (Rapport D’amours): Observations, conclusions et recommandations (Quebec: Assemblée nationale du Québec, 2013). 81 Simon Boivin, “Rapport d’amours: La ‘Rente de longévité’ pose un problème,” Le Soleil, 15 August 2013. 82 Réseau FADOQ, Quel avenir pour les retraités Québécois? Réflexion sur le rapport D’amours (Quebec: FADOQ, 2013), 15. 83 Gouvernement du Québec, Plan d’action du gouvernement: Vers des régimes de retraite équitables et durables (Quebec: Gouvernement du Québec, 2013). 84 Ministry of Finance, Building Opportunity, Securing Our Future: Ontario Budget 2014 (Toronto: Queen’s Printer of Ontario), chap. 4. 85 Ministry of Finance, Building Opportunity, Securing Our Future, 305. 86 Ministry of Finance, Building Opportunity, Securing Our Future, 306–7. 87 Kathleen Wynne quoted in Will Campbell, “Wynne Fends Off Attacks from Harper Government as Campaign Begins,” Globe and Mail, 3 May 2014. 88 Sarah Boesveld, “Ontario Government’s New Mandatory Provincial Pension Plan Is a ‘Job-Killing Payroll Tax,’ PCs Say,” National Post, 1 May 2014. 89 Ontario Chamber of Commerce, Ontario Election 2014: Business Priorities (Toronto: OCC, 2014). 90 Government of Ontario, Ontario Retirement Pension Plan: Key Design Questions (Toronto: Government of Ontario, 2014). 91 Government of Ontario, Ontario Retirement Pension Plan. 92 Government of Ontario, The Ontario Retirement Pension Plan: Discussing a Made-in-Ontario Solution (Toronto: Government of Ontario, 2015). 93 Toronto Star, “War of Words Pits Stephen Harper against Kathleen Wynne,” 4 August 2015. 94 Canadian Press, “Ottawa Won’t Co-operate on ORPP,” Benefits Canada, 17 July 2015. 95 Standing Committee on Social Policy, Official Report of Debates, 24 March 2015, SP-233-SP-250. 96 Standing Committee on Social Policy, Official Report of Debates. 97 Staff, “ORPP Opposition Builds,” Benefits Canada, 3 June 2015. 98 Standing Committee on Social Policy, Official Report of Debates, sp-249. 99 Ashley Csanady, “Harper Not the Only One Eager to Criticize Wynne and Ontario’s Pension Plan as a ‘Payroll Tax Hike,’” National Post, 11 August 2015.

Notes to pages 122–7

311

100 Government of Ontario, Jobs for Today and Tomorrow: 2016 Ontario Budget (Toronto: Government of Ontario, 2016). 101 James Wood, “Alberta Backs CPP Reform Deal, Pushed for Later Phase-In Date,” Calgary Herald, 21 June 2019, https://calgaryherald.com/news /politics/alberta-backs-cpp-reform-deal-pushed-for-later-phase-in-date. 102 See Government of Canada, “Canada Pension Plan Enhancement,” modified 7 February 2019, https://www.canada.ca/en/services /benefits/publicpensions/cpp/cpp-enhancement.html. 103 Government of Manitoba, “Manitoba Government Launches Public Consultations on Canada Pension Plan,” news release, 4 November 2016. https://news.gov.mb.ca/news/index.html?item=39751. 104 Vincent Brousseau-Pouliot, “Huit provinces s’entendent, mais sans Québec,” La Presse, 21 June 2016. 105 However, claimants must have an eligible dependent. 106 Régie des rentes du Québec, Consolider le régime pour renforcer l’équité intergénérationnelle (Quebec: Gouvernement du Québec, 2016). 107 Régie des rentes du Québec, Consolider le régime pour renforcer l’équité intergénérationnelle. 108 Commission des finances publiques, Consultations particulières sur le document intitulé Consolider le régime pour renforcer l’équitié intergénérationnelle et le document de soutien intitulé Constats sur la retraite au Québec (Quebec: Assemblée nationale du Québec, 2017). 109 Commission des finances publiques, Consultations particulières sur le document intitulé Consolider le régime pour renforcer l’équitié intergénérationnelle. 110 Béland and Weaver, “Federalism and the Politics of the Canada and Quebec Pension Plans.” 111 Government of Alberta, Aging Population Policy Framework, iv. 112 Government of Alberta, Aging Population Policy Framework, 16. 113 Régie des rentes du Québec, Consolider le régime pour renforcer l’équité intergénérationnelle, 7. 114 Régie des rentes du Québec, Consolider le régime pour renforcer l’équité intergénérationnelle, 32 and 34–5. 115 Régie des rentes du Québec, Consolider le régime pour renforcer l’équité intergénérationnelle, 36. 116 Comité d’experts sur l’avenir du système de retraite québécois, Innover pour pérénniser le système de retraite, 5. 117 Comité d’experts sur l’avenir du système de retraite québécois, Innover pour pérénniser le système de retraite 7. 118 Ontario, Jobs for Today and Tomorrow: 2016 Ontario Budget, 149. 119 Comité d’experts sur l’avenir du système de retraite québécois, Innover pour pérénniser le système de retraite, 107.

312

Notes to pages 127–33

120 Comité d’experts sur l’avenir du système de retraite québécois, Innover pour pérénniser le système de retraite, 107 121 Pension Review Panel, Promises to Keep, 20. However, the panel voiced its concerns with the extension of amortization period to properly refinance DB plans experiencing actuarial deficits, indicating that this represents a de facto cost transfer to future generations. 122 OECD, Pensions at a Glance: OECD and G20 Indicators (Paris: OECD, 2017). 123 Commission des finances publiques, Consultations particulières sur le document intitulé Consolider le régime pour renforcer l’équitié intergénérationnelle. 124 Government of Ontario, The Ontario Retirement Pension Plan: Discussing a Made-in-Ontario Solution; Government of Ontario, Ontario Retirement Pension Plan: Key Design Questions. 125 Interview 87. 126 Interview 37. 127 Interview 92. 128 Interviews 36, 44, and 65. 129 Interview 36. 130 Interview 24. 131 Béland and Weaver, “Federalism and the Politics of the Canada and Quebec Pension Plans.” 132 Interview 23. 133 Marier, “Who Pays the Piper Calls the Tune?” 134 Interview 37. 135 Interview 61. 5 Health and Residential Care 1 Stuart N Soroka, Canadian Perceptions of the Health Care System (Toronto: Health Council of Canada, 2007). 2 These include action/strategic plans, progress reports, annual reports, policy frameworks, and discussion papers. 3 Conference Board of Canada, Meeting the Care Needs of Canada’s Aging Population. Study commissioned by the Canadian Medical Association with references to decreasing financial support from the federal government. 4 Emery, Still, and Cottrell, “Can We Avoid a Sick Fiscal Future?” 5 Despite the author’s best efforts, there were no interviews with senior civil servants in the health departments in British Columbia. 6 Other terms frequently used to describe residential care include “facilitybased long-term care,” “nursing home” (mostly in the Maritimes, but also employed in Alberta), and “personal care homes” (Manitoba). This can be

Notes to pages 133–8

7 8 9

10 11 12 13 14 15 16 17

18 19 20

21 22 23

313

particularly confusing when comparing across provinces. For example, contrary to Manitoba, “personal care homes” refer to private residential homes that do not require nursing or health services and employ the term “long-term care facilities” for residential care. Advisory Panel on Healthcare Innovation, Unleashing Innovation: Excellent Healthcare in Canada (Ottawa: Health Canada, 2015), 49. Government of British Columbia, Province of British Columbia: Strategic Plan 2014/15–2017/18 (Victoria: Government of British Columbia, 2014), 30. Canadian Institute for Health Information, National Health Expenditure Trends, 1975 to 2018 (Ottawa: Canadian Institute for Health Information, 2018), 6. Advisory Panel on Healthcare Innovation, Unleashing Innovation, 26. Canadian Institute for Health Information, National Health Expenditure Trends, 1975 to 2018, 11. Canadian Institute for Health Information, National Health Expenditure Trends, 1975 to 2018, 21. Canadian Institute for Health Information, National Health Expenditure Trends, 1975 to 2018, 22. Conference Board of Canada, Meeting the Care Needs of Canada’s Aging Population, 6. See, for example, Jane Taber, “Atlantic Premiers Seek More Health-Care Funding for Seniors,” Globe and Mail, 15 May 2016. Jane Taber, “Aging Population Requires New Health Funding Formula, Quebec Premier Says,” Globe and Mail, 28 August 2014. Gregory Marchildon and Haizhen Mou, “A Needs-Based Allocation Formula for Canada Health Transfer,” Canadian Public Policy / Analyse de politiques 40, no. 3 (2014): 209–23. Canadian Institute for Health Information, National Health Expenditure Trends, 1975 to 2018. Canadian Institute for Health Information, National Health Expenditure Trends, 1975 to 2018, 8–9. C. de Meijer, B. Wouterse, J. Polder, and M. Koopmanschap, “The Effect of Population Aging on Health Expenditure Growth: A Critical Review,” European Journal of Ageing 10, no. 4 (2013): 353–61; José J. Martín Martín, M. Puerto López del Amo González, and M. Dolores Cano García, “Review of the Literature on the Determinants of Healthcare Expenditure,” Applied Economics 43, no. 1 (2011): 19–46. Interview 116. Interview 56. Ronny Reinhardt and William J. Oliver, “The Cost Problem in Health Care,” in Challenges and Opportunities in Health Care Management, ed. Sebastian Gurtner and Katja Soyez, 3–13 (Springer, 2015), 9; Chris van

314

24 25 26

27 28 29

30

31

32

33 34 35

36

37

38

Notes to pages 138–40 Weel and Joop Michels, “Dying, Not Old Age, to Blame for Costs of Health Care,” Lancet 350, no. 9085 (1997): 1159–60. Canadian Institute for Health Information, National Health Expenditure Trends, 1975 to 2018, 25. Conference Board of Canada, Meeting the Care Needs of Canada’s Aging Population. John Richards and Colin Busby, “Tax Burdens and Aging,” in Marchildon and Di Matteo, Bending the Cost Curve in Health Care, 71. Population aging also has negative consequences on the labour market, resulting in a decline in GDP that adds another 2.5 percentage points in relative cost to GDP. Canadian Institute for Health Information, National Health Expenditure Trends, 1975 to 2018. van Weel and Michels, “Dying, Not Old Age, to Blame for Costs of Health Care.” Peter Zweifel, Stefan Felder, and Markus Meiers, “Ageing of Population and Health Care Expenditure: A Red Herring?,” Health Economics 8 (1999): 485–96. P.H. van Baal and A. Wong, “Time to Death and the Forecasting of MacroLevel Health Care Expenditures: Some Further Considerations,” Journal of Health Economics 31, no. 6 (2012): 876–87. Greg Payne, Audrey Laporte, David K. Foot, and Peter C. Coyte, “Temporal Trends in the Relative Cost of Dying: Evidence from Canada,” Health Policy 90, no. 2 (2009): 274. Somnath Chatterji, Julie Byles, David Cutler, Teresa Seeman, and Emese Verdes, “Health, Functioning, and Disability in Older Adults: Present Status and Future Implications,” Lancet 385, no. 9967 (2015): 563–75. de Meijer et al., “Effect of Population Aging on Health Expenditure Growth,” 374. Zweifel, Felder, and Meiers, “Ageing of Population and Health Care Expenditure.” Daniel Howdon and Nigel Rice, “Health Care Expenditures, Age, Proximity to Death and Morbidity: Implications for an Ageing Population,” Journal of Health Economics 57 (2018): 60–74. Colin Steensma, Lidia Loukine, and Bernard C.K. Choi, “Evaluating Compression or Expansion of Morbidity in Canada: Trends in Life Expectancy and Health-Adjusted Life Expectancy from 1994 to 2010,” Health Promotion and Chronic Disease Prevention in Canada: Research, Policy and Practice 37, no. 3 (2017): 68–76. Livio Di Matteo and J.C. Herbert Emery, “Common Provincial Determinants and Cost Drivers,” in Marchildon and di Matteo, Bending the Cost Curve in Health Care. Richards and Busby, “Tax Burdens and Aging,” 71.

Notes to pages 140–3

315

39 See de Meijer et al., “Effect of Population Aging on Health Expenditure Growth”; Reinhardt and Oliver, “Cost Problem in Health Care”; Marchildon and Di Matteo, Bending the Cost Curve in Health Care. 40 Carsten Colombier, “Drivers of Health-Care Expenditure: What Role Does Baumol’s Cost Disease Play?,” Social Science Quarterly 98, no. 5 (2017): 1603–21. 41 de Meijer et al., “Effect of Population Aging on Health Expenditure Growth.” 42 Canadian Institute for Health Information, Health Care in Canada, 2011: A Focus on Seniors and Aging (Ottawa: Canadian Institute for Health Information, 2011), 133–4. 43 Advisory Panel on Healthcare Innovation, Unleashing Innovation, 37. 44 Marchildon and Di Matteo, “Introduction and Overview,” xvi. 45 Chappell and Hollander, Aging in Canada. 46 Seamnus Hogan and Sarah Hogan, “How Will the Ageing of the Population Affect Health Care Needs and Costs in the Foreseeable Future?” (Ottawa: Commission on the Future of Health Care in Canada, 2002). 47 See, for example, Emery, Still, and Cottrell, “Can We Avoid a Sick Fiscal Future?”; Richards and Busby, “Tax Burdens and Aging.” 48 Interview 61. 49 Interviews 16, 21, and 34. 50 Interview 100. 51 Interview 55. 52 Interview 61. 53 Interviews 78 and 104. 54 Johnson, Dream No Little Dreams. 55 Interview 63. 56 Interview 41. 57 Office of the Seniors Advocate (BC), Monitoring Seniors’ Services 2017, (Victoria: Office of the Seniors Advocate. British Columbia, 2017), 22–3. 58 See, for instance, Protecteur du citoyen, Rapport annuel d’activités 2017–18 (Quebec: Le Protecteur du citoyen, 2018); British Columbia, Office of the Ombudsperson, The Best of Care: Getting It Right for Seniors in British Columbia (Part 2) (Victoria: Ombudsperson, 2012). 59 Canadian Healthcare Association, New Directions for Facility-Based Long Term Care (Ottawa: Canadian Healthcare Association, 2009), 24. 60 Michel Gagnon and Michel Dunn, “Are Penitentiaries Suitable Places for Older Inmates?” in Getting Wise about Getting Old: Debunking Myths About aging, ed. Véronique Billette, Patrik Marier, and Anne-Marie Séguin, 90–7 (Vancouver: Purich Books, 2020). 61 Office of the Seniors Advocate (BC), Every Voice Counts: Office of the Seniors Advocate Residential Care Survey Provincial Results (Victoria: Office of the Seniors Advocate, British Columbia, 2017), 4.

316

Notes to pages 143–6

62 Michel Grignon and Byron G. Spencer, “The Funding of Long-Term Care in Canada: What Do We Know, What Should We Know?,” Canadian Journal on Aging / La Revue canadienne du vieillissement 37, no. 2 (2018): 118. The authors criticized current indicators utilized by both CIHI and the OCDE to measure long-term care efforts and offered more compelling estimates. 63 Organisation for Economic Co-operation and Development, Health at a Glance (Paris: OECD, 2017), 217. 64 Organisation for Economic Co-operation and Development, Health at a Glance (Paris: OECD, 2017), 217 65 Grignon and Spencer, “Funding of Long-Term Care in Canada,” 111. 66 Canadian Healthcare Association, New Directions for Facility-Based Long Term Care, 36–7. 67 Canadian Healthcare Association, New Directions for Facility-Based Long Term Care, 36–7 68 Joel A.C. Baum, “The Rise of Chain Nursing Homes in Ontario, 1971– 1996,” Social Forces 78, no. 2 (1999): 543–84. 69 Charlene Harrington, Frode F. Jacobsen, Justin Panos, Allyson Pollock, Shallen Sutaria, and Marta Szebehely, “Marketization in Long-Term Care: A Cross Country Comparison of Large for-Profit Nursing Home Chains,” Health Services Ingishts 10 (2017): 1–23. 70 The Ontario Long Term Care Association published recent statistics: “About Long-Term Care in Ontario: Facts and Figures,” https://www .oltca.com/oltca/OLTCA/Public/LongTermCare/FactsFigures .aspx#Ontario’s%20long-term%20care%20homes%20(June%202017. 71 Health PEI, “Long-Term Care,” https://www.princeedwardisland.ca/en /information/health-pei/long-term-care. 72 Commissaire à la santé et au bien-être, “Les personnes de 75 ans et plus en attente d’une place d’hébergement en CHSLD,” Info-performance 16 (2017): 1. 73 Manitoba Nurses’ Union, Long-Term Care in Manitoba (Winnipeg: Manitoba Nurses’ Union, 2006). 74 Office of the Seniors Advocate (BC), From Residential Care to Hospitals: An Emerging Pattern (Victoria: Office of the Seniors Advocate, British Columbia, 2018), 1. 75 Robyn Gibbard, Sizing up the Challenge: Meeting the Demand for Long-Term Care (Ottawa: Conference Board of Canada, 2017). 76 Laliberté-Auger et al., “Utilisation et coût de l’hébergement avec soins de longue durée au Québec, 2010 à 2050.” 77 Government of New Brunswick, 2018–2023 Nursing Home Plan (Fredericton: Government of New Brunswick, 2018). 78 Commissaire à la santé et au bien-être, “Les personnes de 75 ans et plus en attente d’une place d’hébergement en CHSLD,” 2.

Notes to pages 146–7

317

79 Gouvernement du Québec, Un Québec pour tous les âges: Le plan d’action 2018–2023 (Quebec: Gouvernement du Québec, 2018), 17. 80 British Columbia, Office of the Ombudsperson, Best of Care … (Part 2), 215. 81 The number of publicly subsidized beds was 23,832 in 2005/6, according to the ombudsperson report, and 27,846 in 2018. British Columbia, Office of the Ombudsperson, Best of Care: Getting It Right for Seniors in British Columbia (Part 2), 214; Office of the Seniors Advocate (BC), Monitoring Seniors’ Services 2018 (Victoria: Office of the Seniors Advocate, British Columbia, 2019), 20. 82 Based on numbers provided from Statistics Canada, “Population Estimates on July 1st, by Age and Sex,” table 17-10-0005-01, consulted on 22 October 2020. Number of individuals aged 75+: 283,153 in 2006 and 376,441 in 2017, resulting in ratio per 100 of 84.2 in 2006 and 74.0 for 2018 (note that the number of beds is typically calculated by fiscal years, hence the 2017 census data were used as a conservative measure for this estimate). 83 From Health Quality Ontario, “Wait Times for Long-Term Care Homes,” https://www.hqontario.ca/System-Performance/Long-Term-Care-Home -Performance/Wait-Times. 84 Data for 2016/17 (7.7 weeks) from the Quick Stats website of the Manitoba Health, Seniors and Active Living, https://www.gov.mb.ca/health /quickstats/homecare.html. 85 Commissaire à la santé et au bien-être, “Les Personnes de 75 ans et plus en attente d’une place d’hébergement en CHSLD,” 6. 86 Auditor General of New Brunswick, Report of the Auditor General (Fredericton: Office of the Auditor General of New Brunswick, 2016), 12. 87 From the Nova Scotia, “Wait Times,” https://waittimes.novascotia.ca /procedure/nursing-home-placement-home#waittimes-50. 88 Margaret J. McGregor, Marcy Cohen, Catherine-Rose Stocks-Rankin, Michelle B. Cox, Kia Salomons, Kimberlyn M. McGrail, Charmaine Spencer, Lisa A. Ronald, and Michael Schulzer, “Complaints in for-Profit, Non-Profit and Public Nursing Homes in Two Canadian Provinces,” Open Medicine 5, no. 4 (2011): E183. 89 Amy T. Hsu, Whitney Berta, Peter C. Coyte, and Audrey Laporte, “Staffing in Ontario’s Long-Term Care Homes: Differences by Profit Status and Chain Ownership,” Canadian Journal of Aging 35, no. 2 (2016): 000–000. 90 British Columbia, Office of the Ombudsperson, Best of Care … (Part 2), 217. One should exercise caution with these numbers because different methods were used to calculate cost per bed, as indicated in the investigative report. 91 Office of the Seniors Advocate (BC), From Residential Care to Hospitals, 1. 92 Office of the Seniors Advocate (BC), From Residential Care to Hospitals, 1. 93 Office of the Seniors Advocate (BC), From Residential Care to Hospitals, 9–10.

318

Notes to pages 148–50

94 BC Care Providers Association, Seniors Advocate Report Fails to Provide Useful Recommendations to Strengthen Seniors Care (Burnaby: BC Care Providers Association, 2018). 95 Jean-Pierre Lavoie, “Entre État, famille, tiers secteur et marché. Les politiques québécoises à l’égard des personnes âgées ayant des incapacités,” in Le Vieillissement de la population et les politiques publiques: Enjeux d’ici et d’ailleurs, ed. Patrik Marier, 129–51 (Quebec: Presses de l’Université Laval, 2012), 134. 96 Government of Alberta, Continuing Care Strategy: Aging in the Right Place (Edmonton: Alberta Health and Wellness, 2008), 2. 97 Interviews 42 and 121. 98 Canadian Institute for Health Information, National Health Expenditure Trends, 1975 to 2018, 15. Private expenditure accounts for 31% in 2018, and the public/private breakdown is not offered per budgetary item. One would expect the percentage of hospital to be higher if the data focused strictly on public spending. 99 Percentages for residential care and home care are based on calculations from tables in Grignon and Spencer, “Funding of Long-Term Care in Canada.” 100 Interview 30. 101 Jennifer D. Walker, Kathleen Morris, and Jennifer Frood, “Alternative Level of Care in Canada: A Summary,” Healthcare Quarterly 12, no. 2 (2009): 21. 102 Walker, Morris, and Frood, “Alternative Level of Care in Canada,” 21. Quebec was not included in this study. Part of the discrepancies with the figures below may be due to the use of a different formula. since CIHI’s statistics assume a 90% occupancy rate. 103 Danielle Bender and Paul Holyoke, “Why Some Patients Who Do Not Need Hospitalization Cannot Leave: A Case Study of Reviews in 6 Canadian Hospitals,” Healthcare Management Forum 31, no. 4 (2018): 121. 104 Office of the Seniors Advocate (BC), Monitoring Seniors’ Services 2017, 33. 105 Interview 83. 106 Bender and Holyoke, “Why Some Patients Who Do Not Need Hospitalization Cannot Leave.” 107 Interview 5. 108 Interviews 69 and 121. 109 Kimberley Dandy and Ray D. Bollman, “Seniors in Rural Canada,” Analysis Bulletin (Statistics Canada) 7, no. 8 (2008): 1–32. 110 Lana Sullivan, Laura Ryser, and Greg Halseth, “Recognizing Change, Recognizing Rural: The New Rural Economy and Towards a New Model of Rural Service,” Journal of Rural and Community Development 9, no. 4 (2014): 219–45.

Notes to pages 150–2

319

111 See, for example, Demographic Planning Commission, Findings Report (Edmonton: Government of Alberta, 2008), 21–2; Gouvernement du Québec, Préparons l’avenir avec nos aînés: Rapport de la consultation publique sur les conditions de vie des aînés (Quebec: Gouvernement du Québec, 2008), 41. 112 Liyan Liu, Joanne Hader, Bonnie Brossart, Robin White, and Steven Lewis, “Impact of Rural Hospital Closures in Saskatchewan, Canada,” Social Science & Medicine 52 (2001): 1793–804. 113 Interview 14. 114 Interview 66. 115 Interview 63. 116 Interview 118. 117 Interview 72. 118 Verena Menec, Sheri Bell, Shella Novek, Gulnara A. Minnigaleeva, Ernesto Morales, Titus Ouma, Jose F. Parodi, and Rachel Winterton, “Making Rural and Remote Communities More Age-Friendly: Experts’ Perspectives on Issues, Challenges, and Priorities,” Journal of Aging & Social Policy 27, no. 2 (2015): 173–91. 119 See, for example, Nabil Annabi, Maxime Fougere, and Simon Harvey, “Inter-Temporal and Inter-Industry Effects of Population Ageing: A General Equilibrium Assessment for Canada,” Labour 23, no. 4 (2009): 609–51; Reshmi Chowdhury and Gloria Gutman, “Migrant Live-in Caregivers Providing Care to Canadian Older Adults: An Exploratory Study of Workers’ Life and Job Satisfaction,” Journal of Population Ageing 5, no. 4 (2012): 215–40; A.M. Humble, J.M. Keefe, and G.M. Auton, “Caregivers’ Retirement Congruency: A Case for Caregiver Support,” International Journal of Aging & Human Development 74, no. 2 (2012): 113–42. 120 Canadian Healthcare Association, New Directions for Facility-Based Long Term Care, 21. 121 From the 2017 tables, “Registered Nurses,” accessed 12 January 2019, https://www.cihi.ca/en/regulated-nurses-2017. 122 New Brunswick Association of Nursing Homes, Findings from the Nursing Home and Recruitment and Retention Survey (Fredericton: New Brunswick Associations of Nursing Homes, 2017). The document reported 543 registered nurses and thirty-six vacant positions. 123 Protecteur du citoyen, Rapport annuel d’activités 2017–18, 72–3. 124 Radio-Canada, “Des préposés aux bénéficiaires formés en 5 semaines,” 6 April 2017, https://ici.radio-canada.ca/nouvelle/1026497/des-preposes -aux-beneficiaires-formes-en-5-semaines. 125 J.E. Bostick, M.J. Rantz, M.K. Flesner, and C.J. Riggs, “Systematic Review of Studies of Staffing and Quality in Nursing Homes,” Journal of the American Medical Directors Association 7, no. 6 (2006): 366–76.

320

Notes to pages 152–4

126 Many interviewees discussed human resources as part of a broad longterm care policy issue, but four explicitly mentioned residential care. Interviews 52, 63, 69, and 72. 127 From Manitoba, Nurses Recruitment and Retention Fund, “Discover Nursing Opportunities in Manitoba,” https://www.gov.mb.ca/health /nurses/. 128 New Brunswick Association of Nursing Homes, Findings from the Nursing Home and Recruitment and Retention Survey. 129 New Brunswick Association of Nursing Homes, Findings from the Nursing Home and Recruitment and Retention Survey. 130 Office of the Auditor General of British Columbia, An Independent Audit of the Recruitment and Retention of Rural and Remote Nurses in Northern B.C. (Victoria: Office of the Auditor General of British Columbia, 2018), 6, 28. 131 Interview 63. 132 Chappell and Hollander, Aging in Canada; Gee and Gutman, Overselling of Population Aging; Susan A. McDaniel, “’What Did You Ever Do for Me?’: Intergenerational Linkages in a Restructuring Canada,” in Gee and Gutman, Overselling of Population Aging, 130–53; Julia Rozanova, Herbert C. Northcott, and Susan A. McDaniel, “Seniors and Portrayals of IntraGenerational and Inter-Generational Inequality in the Globe and Mail,” Canadian Journal on Aging/La Revue canadienne du vieillissement 25, no. 4 (2006): 373–86. 133 Government of Alberta, Aging Population Policy Framework, iv. 134 Emery, Still, and Cottrell, “Can We Avoid a Sick Fiscal Future?” 135 Gusmano and Allin, “Framing the Issue of Ageing and Health Care Spending.” 136 Interview 29. 137 Janet McFarland, “An Aging B.C. Deservers More Federal Health-Care Funds, Finance Minister Says,” Globe and Mail, 5 July 2013. 138 Government of Nova Scotia, Report to the Senate Committee on Aging: Nova Scotia’s Perspective (Halifax: Government of Nova Scotia, 2008). 139 Special Senate Committee on Aging, Canada’s Aging Population: Seizing the Opportunity. 140 Interview 97. 141 Interview 72. 142 Interviews 79 and 69. 143 Interviews 33 and 83. These issues are discussed in more depth in chapter 6. 144 Canadian Healthcare Association, New Directions for Facility-Based Long Term Care, 11–12. 145 Canadian Healthcare Association, Home Care in Canada from the Margins to the Mainstream (Ottawa: Canadian Health Care Association, 2009). 146 Canadian Medical Association, State of Seniors Health in Canada, 5.

Notes to pages 155–8 147 148 149 150

151

152

153

154

155

156

157

158

321

Canadian Medical Association, State of Seniors Health in Canada, 5. Canadian Medical Association, State of Seniors Health in Canada, 14. Grignon and Spencer, “Funding of Long-Term Care in Canada,” 116–17. Auditor General of New Brunswick, Report of the Auditor General. Data for health expenditures come from CIHI’s dataset. Note that the AG document indicates an increase of 285%, but this is a mistake, since its costs in 2015–16 were $313 million, compared with $110 in 2000–1. See, for example, Commissaire à la santé et au bien-être, “Les personnes de 75 ans et plus en attente d’une place d’hébergement en CHSLD,” 3. This publication indicates that the health assessment scores of residents have risen by 5% (a higher score indicates more needs). CIHI data reveal that the number of residents with Alzheimer’s disease and other forms of dementia rose by 87% between 2010 and 2016. Ministère de la Santé et des Services Sociaux, “Engagements du Forum sur les meilleures pratiques en CHSLD,” http://www.msss.gouv.qc.ca /professionnels/soins-et-services/forum-sur-les-meilleures-pratiques -usagers-chsld-et-soutien-a-domicile/engagements-du-forum-sur-les -meilleures-pratiques-en-chsld/. Health Quality Ontario, Measuring up 2018: A Yearly Report on How Ontario’s Health System Is Performing (Toronto: Health Quality Ontario, 2018). Public Health Agency of Canada, Canada COVID-19 Weekly Epidemiology Report (11 October to 17 October 2020) (Ottawa: Public Health Agency of Canada, 2020). Institut national de santé publique (Québec), “Données régionales COVID-19 au Québec,” https://www.inspq.qc.ca/covid-19/donnees /regions. Consulted on October 29, 2020. Public Health Ontario, Weekly Epidemiologic Summary. COVID-19 in Ontario: Focus on October 11, 2020 to October 17, 2020 (Toronto: Public Health Ontario). T.M. McMichael, D.W. Currie, S. Clark, S. Pogosjans, M. Kay, N.G. Schwartz, J. Lewis, A. Baer, V. Kawakami, M.D. Lukoff, J. Ferro, C. Brostrom-Smith, T.D. Rea, M.R. Sayre, F.X. Riedo, D. Russell, B. Hiatt, P. Montgomery, A.K. Rao, E.J. Chow, F. Tobolowsky, M.J. Hughes, A.C. Bardossy, L.P. Oakley, J.R. Jacobs, N.D. Stone, S.C. Reddy, J.A. Jernigan, M.A. Honein, T.A. Clark, J.S. Duchin, Health-Seattle Public, EvergreenHealth King County, and CDC COVID-Investigation Team, “Epidemiology of COVID-19 in a Long-Term Care Facility in King County, Washington,” New England Journal of Medicine 382, no. 21 (2020): 2005–11. Carole A. Estabrooks, Sharon Straus, Colleen M. Flood, Janice Keefe, Pat Armstrong, Gail Donner, Véronique Boscart, Francine Ducharme, James

322

159 160 161 162

163 164 165 166

Notes to pages 159–63 Silvius, and Michael Wolfson, Restoring Trust: COVID-19 and the Future of Long-Term Care (Ottawa: Royal Society of Canada, 2020), 5. Gabrielle Duchaine, Ariane Lacoursière, and Philippe Teisceira-Lessard, “Incités à travailler malgré des symptomes,” La Presse, 8 April 2020. Béland and Marier, “COVID-19 and Long-Term Care Policy for Older People in Canada.” Tommy Chouinard, Vincent Larouche, and Gabrielle Duchaine, “CHSLD Herron: ‘De la grosse négligence,’” La Presse, 12 April 2020. Glenn G. Brimacombe, Pedro Antunes, and Jane McIntyre, The Future Cost of Health Care in Canada, 2000 to 2020 (Toronto: Conference Board of Canada, 2001). Grignon and Spencer, “Funding of Long-Term Care in Canada,” 11. Commissaire à la santé et au bien-être, “Les personnes de 75 ans et plus en attente d’une place d’hébergement en CHSLD,” 6. Estes and Binney, “Biomedicalization of Aging,” 117. Estes and Binney, “Biomedicalization of Aging,” 117.

6 Home Care Services and Caregiving 1 Interview 69. 2 Protecteur du citoyen, “Chez soi: Toujours le premier choix? L’accessibilité aux services de soutien à domicile pour les personnes présentant une incapacité significative et persistante” (Quebec: Le Protecteur du citoyen, 2012), 6. 3 Canada (Special Senate Committee on Aging), Canada’s Aging Population: Seizing the Opportunity (Ottawa: Senate, 2009). 4 Stephane Jacobzone, Emmanuelle Chaplain Cambois, and Jean-Marier Robine, “The Health of Older Persons in OECD Countries: Is It Improving Fast Enough to Compensate for Population Ageing?,” Labour Market and Social Policy Occasional Papers, no. 37 (1999): 1–65. 5 Neena L. Chappell, Betty Havens Dlitt, Marcus J. Hollander, Jo Ann Miller, and Carol McWilliam, “Comparative Costs of Home Care and Residential Care,” Gerontologist 44, no. 3 (2004): 389. 6 Neena L. Chappell, “Home Care Research: What Does It Tell Us?,” Gerontologist 34, no. 1 (1994): 116–20. 7 G. Spiers, F.E. Matthews, S. Mofatt, R.O. Barker, H. Jarvis, D. Stow, A. Kingston, and B. Hanratty, “Impact of Social Care Supply on Healthcare Utilisation by Older Adults: A Systematic Review and Meta-Analysis,” Age Ageing 48, no. 1 (2019): 57–66. 8 M. Stabile, A. Laporte, and P.C. Coyte, “Household Responses to Public Home Care Programs,” Journal of Health Economics 25, no. 4 (2006): 674–701.

Notes to pages 163–7

323

9 F. Carmichael, S. Charles, and C. Hulme, “Who Will Care? Employment Participation and Willingness to Supply Informal Care,” Journal of Health Economics 29, no. 1 (2010): 182–90; C.H. Van Houtven, N.B. Coe, and M.M. Skira, “The Effect of Informal Care on Work and Wages,” Journal of Health Economics 32, no. 1 (2013): 240–52. 10 Canadian Home Care Association, Portraits of Home Care in Canada 2013, xv. The nine jurisdictions were British Columbia, Alberta, Saskatchewan, Ontario, Quebec, New Brunswick, Prince Edward Island, Newfoundland and Labrador, and the Northwest Territories. 11 Gouvernement du Québec, Chez soi: Le premier choix. La politique de soutien à domicile (Quebec: Santé et Services sociaux Québec, 2003). 12 Government of New Brunswick, Home First (Fredericton: Government of New Brunswick, 2014). 13 Canadian Home Care Association, Portraits of Home Care in Canada 2013. 14 Martin Turcotte, Canadians with Unmet Homecare Needs (Ottawa: Statistics Canada, 2014). 15 British Columbia, Office of the Ombudsperson, The Best of Care: Getting It Right for Seniors in British Columbia (Part 1) (Victoria: Ombudsperson, 2009); Office of the Ombudsperson, Best of Care … (Part 2). 16 Organisation for Economic Co-operation and Development, Health at a Glance, 217. 17 Canadian Home Care Association, Portraits of Home Care in Canada 2013. 18 Canadian Home Care Association, Portraits of Home Care in Canada (Mississauga, ON: Canadian Home Care Association, 2008), 21–2; Canadian Home Care Association, Portraits of Home Care in Canada 2013. 19 Canadian Home Care Association, Portraits of Home Care in Canada 2013, xi. 20 Auditor General, “Manitoba Home Care Program,” 4. 21 Interviews 51 and 53. 22 Alexandre Genest, “Le financement des soins de longue durée: Enjeux et solutions,” in Le vieillissement de la population et les politiques publiques: Enjeux d’ici et d’ailleurs, ed. Patrik Marier, 209–34 (Quebec: Presses de l’Université Laval, 2012); Neena L. Chappell, “Aging and Mental Health,” Social Work in Mental Health 7, no. 1–3 (2009): 122–38. 23 Interview 121. 24 Canadian Healthcare Association, Home Care in Canada from the Margins to the Mainstream, 10; Canadian Home Care Association, Portraits of Home Care in Canada 2013. 25 Nadine Henningsen and Marg McAlister, “Paradigm Shift: Shaping Policy to Meet the Needs of Our Aging Population,” HealthcarePapers 11, no. 1 (2011): 20–4. 26 Canadian Healthcare Association, Home Care in Canada from the Margins to the Mainstream, 31.

324

Notes to pages 167–9

27 Canadian Home Care Association, Portraits of Home Care in Canada. 28 Réjean Hébert, Nicole Dubuc, Martin Buteau, Chantale Roy, Johanne Desrosiers, Gina Bravo, Lise Trottier, and Carole Saint-Hilaire, Services requis par les personnes âgées en perte d’autonomie: Évaluation clinique et estimation des coûts selon le milieu de vie (Quebec: Ministère de la Santé et des Services sociaux, Direction de la recherche et de l’évaluation, 1997). 29 British Columbia, Office of the Ombudsperson, Best of Care … (Part 2), 3. 30 Adam Davey, Lennarth Johansson, Bo Malmberg, and Gerdt Sundström, “Unequal but Equitable: An Analysis of Variations in Old-Age Care in Sweden,” European Journal of Ageing 3, no. 1 (2006): 34–40. 31 Quebec employs a modified version of this tool, but it remains extremely similar. 32 Binney, Estes, and Ingman, “Medicalization, Public Policy and the Elderly.” 33 Canadian Institute for Health Information, Selecting Pan-Canadian Indicators for Access to Mental Health and Addiction Services, and to Home and Community Care: Progress Report (Ottawa: Canadian Institute for Health Information, 2018). 34 Auditor General of Nova Scotia, Report of the Auditor General to the Nova Scotia House of Assembly: November 2008 (Halifax: Office of the Auditor General of Nova Scotia, 2008), 47. 35 Auditor General, “Manitoba Home Care Program,” 15–17. 36 Auditor General of Nova Scotia, Report of the Auditor General to the Nova Scotia House of Assembly: November 2008, 53. 37 R. Kent Weaver, “Compliance Regimes and Barriers to Behavioral Change,” Governance 27, no. 2 (2014): 243–65. 38 Weaver, “Compliance Regimes and Barriers to Behavioral Change,” 247. 39 Auditor General of Nova Scotia, Report of the Auditor General to the Nova Scotia House of Assembly: November 2017, 51. 40 Auditor General of Ontario, Annual Report 2015 (Toronto: Office of the Auditor General of Ontario, 2015), 79. 41 Vérificateur général du Québec, “Personnes âgées en perte d’autonomie. Services à domicile,” in Rapport du Vérificateur général du Québec à l’Assemblée nationale pour l’année 2013–2014: Vérification de l’optimisation des ressources (Quebec: Le Vérificateur général du Québec, 2013), 33. 42 Auditor General, “Manitoba Home Care Program,” 15. 43 Auditor General of British Columbia, Home and Community Care Services (Victoria: Office of the Auditor General of British Columbia, 2008). 44 Vérificateur général du Québec, “Personnes âgées en perte d’autonomie. Services à domicile.” 45 Auditor General of Ontario, Annual Report 2015.

Notes to pages 169–72

325

46 Mark W. Skinner and Mark W. Rosenberg, “Informal and Voluntary Care in Canada: Caught in the Act,” in Landscapes of Voluntarism: New Spaces of Health, Welfare Governance, ed. Christine Milligan and David Conradson, 91–113 (Bristol, UK: Policy, 2006). 47 B. Manderson, J. McMurray, E. Piraino, and P. Stolee, “Navigation Roles Support Chronically Ill Older Adults through Healthcare Transitions: A Systematic Review of the Literature,” Health and Social Care in the Community 20, no. 2 (2012): 113–27. 48 Statistics Canada, “The 20 Most Common Occupations among Women Aged 15 Years and Older and the Share of Women in the Total Workforce, May 2011,” https://www12.statcan.gc.ca/nhs-enm/2011/as-sa/99 -012-x/2011002/tbl/tbl02-eng.cfm. 49 Gouvernement du Québec, Plan d’action gouvernemental pour l’entrepreneuriat collectif: Profil des entreprises d’économie sociale en aide domestique (Quebec: Ministère des Affaires municipales, des Régions et de l’Occupation du territoire, 2012). 50 Interview 32. 51 Anne Martin-Matthews, “Situating ‘Home’ at the Nexus of the Public and Private Spheres: Ageing, Gender and Home Support Work in Canada,” Current Sociology 55, no. 2 (2007): 245. 52 Canadian Home Care Association, Portraits of Home Care in Canada 2013, xiv. 53 J. Abelson, S.T. Gold, C. Woodward, D. O’Conner, and B. Hutchison, “Managing under Managed Community Care: The Experiences of Clients, Providers and Managers in Ontario’s Competitive Home Care Sector,” Health Policy 68, no. 3 (2004): 359–72; Maude Benoit, “Les frontières mouvantes des politiques de maintien à domicile. Reconfiguration de l’action sociale de l’état en France et au Québec,” Lien social et Politiques, no. 79 (2017): 35–52; Neena L. Chappell, Population Aging and the Evolving Care Needs of Older Canadians (Montreal: IRPP, 2011). 54 Statistics Canada, “Canadian Income Survey, 2016,” Daily, 3 March 2018, https://www150.statcan.gc.ca/n1/daily-quotidien/180313/dq180313a -eng.htm. 55 Following the decision to restructure into a single national entity, some branches opted to become independent. This is the case, for example, of NOVA Montreal. 56 Auditor General of Nova Scotia, Report of the Auditor General to the Nova Scotia House of Assembly: November 2008, 48, 52. 57 Jane R. Gingrich, Making Markets in the Welfare State: The Politics of Varying Market Reforms (New York: Cambridge University Press, 2011). 58 Gingrich, Making Markets in the Welfare State. 59 Gingrich, Making Markets in the Welfare State.

326

Notes to pages 172–5

60 Gingrich, Making Markets in the Welfare State, 13. 61 Gingrich, Making Markets in the Welfare State, 13. 62 Government of British Columbia, “Publicly Subsidized or Private Pay Services,” https://www2.gov.bc.ca/gov/content/health/accessing -health-care/home-community-care/care-options-and-cost/publicly -subsidized-or-private-pay-services. 63 Government of British Columbia, “Publicly Subsidized or Private Pay Services.” 64 Augusta Dwyer, “Should You Buy Long-Term Care Insurance?,” Globe and Mail, 3 February 2016, https://www.theglobeandmail.com/globe -investor/retirement/retire-health/should-you-buy-long-term-care -insurance/article28512380/. 65 Patrik Marier and Suzanne Skinner, “The Impact of Gender and Immigration on Pension Outcomes in Canada,” Canadian Public Policy / Analyse de politiques 34, no. S1 (2008): S59–78. 66 Interview 13. 67 Interview 121. 68 British Columbia, Office of the Ombudsperson, Best of Care … (Part 2), 115. 69 For alternative models, see Mireille Dumont-Lemasson, Carol Donovan, and Maggie Wylie, Provincial and Territorial Home Care Programs: A Synthesis for Canada (Ottawa: Health Canada, 1999); Aleck Ostry, Change and Continuity in Canada’s Health Care System (Ottawa: Canada Healthcare Association Press, 2006). 70 Neena L. Chappell, “Social Support and the Receipt of Home Care Services,” Gerontologist 25, no. 1 (1985): 47–54. 71 Canadian Home Care Association, Portraits of Home Care in Canada 2013, 107. 72 Bob Armstrong, “Made in Manitoba: Province’s Vision for Home Care Still a Model for the Country,” Wave 2014, 41. 73 Auditor General (Manitoba), “Manitoba Home Care Program,” 9. 74 Manitoba Health, Seniors and Active Living, Annual Report 2016/17 (Winnipeg: Manitoba Health, Seniors and Active Living), 73. 75 Canadian Home Care Association, Portraits of Home Care in Canada 2013. 76 Canadian Home Care Association, Portraits of Home Care in Canada 2013. 77 Chappell, Population Aging and the Evolving Care Needs of Older Canadians, 19–20. 78 Réseau de coopération des EÉSAD, “Le réseau de coopération des EÉSAD, en bref … ” https://eesad.org/les-eesad/le-reseau-des-eesad-en-bref/. 79 Commission de la santé et des services sociaux, L’étude des crédits 2018– 2019: Régie de l’assurance maladie du Québec (Quebec: Ministère de la Santé et des Services Sociaux, 2018), 186.

Notes to pages 175–7

327

80 Réseau de cooperation des EÉSAD, “Répit-Ressource de l’Est de Montréal,” https://eesad.org/membres/?eesadid=225. 81 Commission de la santé et des services sociaux, L’étude des crédits 2018–2019, 187. 82 Canadian Home Care Association, Portraits of Home Care in Canada 2013. 83 Blair G. Richardson, “Overview of Provincial Home Care Programs in Canada,” Healthcare Management Forum 3, no. 3 (1990): 3–10. 84 Gordon Ferguson, “Hospital without Walls: Is New Brunswick’s ExtraMural Hospital the Way of the Future?” Canadian Medical Association Journal 136 (1987): 861–4. 85 Cooper and Marier, “Does It Matter Who Works at the Center?” 86 New Brunswick Home Support Association, “About Us,” http://nbhsa .ca/english/about-us. 87 Social Development also houses the Seniors and Healthy Aging secretariat. 88 Interview 4. 89 Canadian Home Care Association, Portraits of Home Care in Canada 2013, 203. Own calculations based on the information provided in the document. 90 Abelson et al., “Managing under Managed Community Care.” 91 Auditor General of Ontario, Annual Report 2015, 70. 92 Auditor General of Ontario, Community Care Access Centres: Financial Operations and Service Delivery (Toronto: Office of the Auditor General of Ontario, 2015), 9. 93 Auditor General of Ontario, Community Care Access Centres, 15. 94 Saskatchewan Health Authority, Annual Report 2017–18 (Regina: Saskatchewan Health Authority, 2018), 3. 95 Canadian Home Care Association, Portraits of Home Care in Canada 2013. 96 Dumont-Lemasson, Donovan, and Wylie, Provincial and Territorial Home Care Programs; Canadian Home Care Association, Portraits of Home Care in Canada 2013. 97 Hélène David, Esther Cloutier, and Sara La Tour, Le recours aux agences privées d’aide à domicile et de soins infirmiers par les services de soutien à domicile des CLSC (Montreal: Institut de recherche Robert-Sauvé en santé et en sécurité du travail du Québec, 2003); Dumont-Lemasson, Donovan, and Wylie, Provincial and Territorial Home Care Programs. 98 Radio-Canada, “Soins à domicile: Québec accusé de favoriser les entreprises à but lucratif,” 9 September 2016, https://ici.radio-canada.ca/nouvelle/801622 /soins-domicile-cisss-laval-appel-offre-economie-sociale-gaetan-barrette. 99 Radio-Canada, “Nombreux ratés dans les soins à domicile,” 30 November 2018, https://ici.radio-canada.ca/nouvelle/1138979/soins-domicile -nombreux-rates-montreal.

328

Notes to pages 177–81

100 Winnipeg Regional Health Authority, “WRHA Announces Priority Home,” news release, 20 September 2017, https://wrha.mb.ca/2017/09/20/wrha -announces-priority-home/. 101 CBC News, “Pallister Tight-Lipped on Privatizing Home Care Services, but Says He Is about ‘Results,’” 1 June 2017, https://www.cbc.ca/news /canada/manitoba/home-care-private-manitoba-1.4140980. 102 Auditor General of Ontario, Community Care Access Centres: Financial Operations and Service Delivery, 16, 51. 103 Christian Jetté, Yves Vaillancourt, and Jean-Vincent Bergeron-Gaudin, “L’économie plurielle dans les services à domicile au Canada: Une comparaison des modes de régulation entre le Québec et l’Ontario,” Lien social et Politiques, no. 66 (2011): 155–75. 104 See, for example, Walter Korpi, The Democratic Class Struggle (Boston: Routledge, 1983). 105 Haddow, “Power Resources and the Canadian Welfare State” 106 Pierson, Dismantling the Welfare State? 107 Aucoin, “Administrative Reform in Public Management.” 108 Government of Alberta, Aging Population Policy Framework, iii. 109 Interview 69. 110 British Columbia, Office of the Ombudsperson, Best of Care … (Part 2), 100–2. 111 British Columbia, Office of the Ombudsperson, Best of Care … (Part 2), 97–8. 112 Gingrich, Making Markets in the Welfare State; Julian Le Grand, The Other Invisible Hand: Delivering Public Services through Choice and Competition (Princeton, NJ: Princeton University Press, 2007). 113 Cooper and Marier, “Does It Matter Who Works at the Center?” 114 , “Chez soi: Toujours le premier choix?,” 22. 115 Protecteur du citoyen, Rapport annuel d’activités 2017–18, 76–7. 116 British Columbia, Office of the Ombudsperson, Best of Care … (Part 2), 2. 117 Payne et al., “Temporal Trends in the Relative Cost of Dying,” 272. 118 Auditor General of Alberta. Report of the Auditor General on Seniors Care and Programs (Edmonton: Office of the Auditor General of Alberta, 2005). 119 Vancouver Sun, “BC Seniors Advocates Want to See Federal Standards with New Ministerial Role,” 30 July 2018, https://vancouversun.com /news/local-news/b-c-seniors-advocates-want-to-see-federal-standards -with-new-ministerial-role. 120 Auditor General of British Columbia, Home and Community Care Services, 6. 121 Auditor General of Ontario, Annual Report 2015, 77. 122 Vérificateur général du Québec, “Personnes âgées en perte d’autonomie. Services à domicile,” 3, 34.

Notes to pages 181–2

329

123 Benoit, “Les frontières mouvantes des politiques de maintien à domicile”; Lavoie, Guberman, and Marier, La responsabilité des soins aux aînés au Québec; Peter C. Coyte and Patricia McKeever, “Home Care in Canada: Passing the Buck,” Canadian Journal of Nursing Research 33, no. 2 (2001): 11–25; Chappell, Population Aging and the Evolving Care Needs of Older Canadians. 124 Office of the Seniors Advocate (BC), Monitoring Seniors’ Services 2017; British Columbia, Office of the Ombudsperson, Best of Care … (Part 2). 125 Protecteur du citoyen, Rapport annuel d’activités 2016–17 (Quebec: Le Protecteur du citoyen, 2017). 126 Protecteur du citoyen, “Chez soi,” 16; Protecteur du citoyen, Rapport annuel d’activités 2015–16 (Quebec: Le Protecteur du citoyen, 2016), 96; Protecteur du citoyen, Rapport annuel d’activités 2016–17, 110. 127 British Columbia, Office of the Ombudsperson, Best of Care … (Part 2), 43–5; Protecteur du citoyen, “Chez soi,” 17. 128 British Columbia, Office of the Ombudsperson, Best of Care … (Part 2), 57. 129 Protecteur du citoyen, “ Chez soi,” 22. 130 British Columbia. Office of the Ombudsperson, The Best of Care … (Part 2), 49. 131 British Columbia. Office of the Ombudsperson, Best of Care … (Part 2), 112–13; Protecteur du citoyen, “Chez soi,” 9. 132 British Columbia. Office of the Ombudsperson, Best of Care … (Part 2), 96–105. 133 SafeCare BC, “New Strategy Is Needed to Address Shortage of Continuing Care Workers,” news release, 16 May 2017, http://safecarebc .ca/2017/05/16/media-release-new-strategy-needed-address-shortage -continuing-care-workers/. 134 Auditor General, “Manitoba Home Care Program,” 29. 135 Data obtained from a consultant report: Reg Toews, Future of Home Care Services in Manitoba (Winnipeg: Ministry of Health, Seniors and Active Living, 2016), 3. 136 See Benoit, “Les frontières mouvantes des politiques de maintien à domicile.” 137 Vérificateur général du Québec, “Personnes âgées en perte d’autonomie. Services à domicile,” 20. 138 Janice Keefe, Supporting Caregivers and Caregiving in an Aging Canada (Montreal: Institute for Research on Public Policy, 2011). 139 Marianne Kempeneers and Isabelle Van Pevenage, “Les espaces de la solidarité familiale,” Recherches sociographiques 52, no. 1 (2011): 105–19; Chappell and Hollander, Aging in Canada. 140 Chappell, Population Aging and the Evolving Care Needs of Older Canadians, 11. 141 Hollander, Liu, and Chappell, “Who Cares and How Much?,” 48. 142 Canadian Home Care Association, Portraits of Home Care in Canada 2013, xi.

330

Notes to pages 183–5

143 Canadian Home Care Association, Portraits of Home Care in Canada 2013, xix. 144 Lavoie, Guberman, and Marier, La responsabilité des soins aux aînés au Québec, 25. 145 Ann Shola Orloff, “Gender and the Social Rights of Citizenship: The Comparative Analysis of Gender Relations and Welfare State,” American Sociological Review 58, no. 3 (1993): 303–28; Trudie Knijn and Monique Kremer, “Gender and the Caring Dimension of Welfare States: Toward Inclusive Citizenship,” Social Politics: International Studies in Gender, State Society 4, no. 3 (1997): 328–61. 146 Francesca Bettio and Janneke Plantenga, “Comparing Care Regimes in Europe,” Feminist Economics 10, no. 1 (2004): 85–113. 147 Gosta Esping-Andersen, Social Foundations of Postindustrial Economies (Oxford: Oxford University Press, 1999); Sigrid Leitner, “Varieties of Familialism: The Caring Function of the Family in Comparative Perspective,” European Socieities 5, no. 4 (2003): 353–75. 148 Esping-Andersen, Social Foundations of Postindustrial Economies. 149 Denise N. Guerriere, Ada Y.M. Wong, Ruth Coxford, Vivian W. Leong, Patricia McKeever, and Peter C. Coyte, “Costs and Determinants of Privately Financed Home-Based Health Care in Ontario, Canada,” Health & Social Care in the Community 16, no. 2 (2008): 126–36. 150 Birgit Pfau-Effinger, “Welfare State Policies and the Development of Care Arrangements,” European Societies 7, no. 2 (2005): 321–47. 151 Interview 69. 152 Chappell and Hollander, Aging in Canada, 54–9. 153 Auditor General, “Manitoba Home Care Program,” 5. 154 Protecteur du citoyen, “Chez soi”; Protecteur du citoyen, Rapport annuel d’activités 2017–18. 155 Turcotte, Canadians with Unmet Homecare Needs, 3. 156 Healthy Living and Seniors Manitoba Health, Caregiver Recognition Act Report: For the Period, 2013–2015 (Winnipeg: Manitoba Health, Healthy Living and Seniors, 2015). 157 Government of Nova Scotia, Strategy for Positive Aging in Nova Scotia (Halifax: Seniors’ Secretariat, 2005), 36. 158 Department of Health and Wellness (Nova Scotia), “Continuing Care,” updated 13 March 2018, https://novascotia.ca/dhw/ccs/caregiver -benefit.asp. 159 Government of Ontario, Aging with Confidence: Ontario’s Action Plan for Seniors (Toronto: Ministry of Health and Long Term Care, 2017). 160 For an in-depth description of these measures, see Regroupements des aidants naturels du Québec, “La nouvelle loi des normes du travail pour les proches aidants,” 15 August 2018, https://ranq.qc.ca/la-nouvelle-loi -des-normes-du-travail-pour-les-proches-aidants/.

Notes to pages 185–7

331

161 Auditor General of Ontario, Annual Report 2015, 85–6. 162 Protecteur du citoyen, “Chez soi,” 19. 163 Office of the Seniors Advocate (BC), Caregivers in Distress: A Growing Problem (Victoria: Office of the Seniors Advocate. British Columbia, 2017). 164 Government of Newfoundland and Labrador, Provincial Healthy Aging Policy Framework: Status Report (St. John’s: Aging and Seniors Division, 2015), 14. 165 I-Fen Lin, Holly R. Fee, and Hsueh-Sheng Wu, “Negative and Positive Caregiving Experiences: A Closer Look at the Intersection of Gender and Relationship,” Family Relations 61, no. 2 (2012); Barbara J. Tarlow, Stephen R. Wisniewski, Steven H. Belle, Mark Rubert, Marcia G. Ory, and Dolores Gallagher-Thompson, “Positive Aspects of Caregiving: Contributions of the REACH Project to the Development of New Measures for Alzheimer’s Caregiving,” Research on Aging 26, no. 4 (2004): 429–53. 166 Neena L. Chappell, R. Colin Reid, and Elizabeth Dow, “Respite Reconsidered: A Typology of Meanings Based on the Caregiver’s Point of View,” Journal of Aging Studies 15, no. 2 (2001): 201–16. 167 Nancy Guberman, Jean-Pierre Lavoie, Laure Blein, and Ignace Olazabal, “Baby Boom Caregivers: Care in the Age of Individualization,” Gerontologist 52, no. 2 (2012): 210–18. 168 David L. Roth, Lisa Fredman, and William E. Haley, “Informal Caregiving and Its Impact on Health: A Reappraisal from Population-Based Studies,” Gerontologist 55, no. 2 (2015): 309–19. 169 R.D. Adelman, L.L. Tmanova, D. Delgado, S. Dion, and M.S. Lachs, “Caregiver Burden: A Clinical Review,” JAMA 311, no. 10 (2014): 1052–60. 170 Lilly et al., “Can We Move beyond Burden and Burnout to Support the Health and Wellness of Family Caregivers to Persons with Dementia?” 171 Office of the Seniors Advocate (BC), Caregivers in Distress, 10. 172 Stabile, Laporte, and Coyte, “Household Responses to Public Home Care Programs.” 173 Manuela Naldini, Emmanuele Pavolini, and Cristina Solera, “Female Employment and Elderly Care: The Role of Care Policies and Culture in 21 European Countries,” Work, Employment and Society 30, no. 4 (2016): 607–30. 174 Gouvernement du Canada, Quand il faut jongler entre travail et soins; Comment les employeurs peuvent soutenir les aidants naturels (Ottawa: Groupe d’employeurs sur la question des aidants naturels, 2015). 175 Maire Sinha, Portrait des aidants familiaux, 2012 (Ottawa: Statistique Canada, 2013). 176 M.B. Lilly, A. Laporte, and P.C. Coyte, “Do They Care Too Much to Work? The Influence of Caregiving Intensity on the Labour Force Participation of Unpaid Caregivers in Canada,” Journal of Health Economics 29, no. 6 (2010): 895–903.

332

Notes to pages 187–91

177 Marier and Skinner, “Impact of Gender and Immigration on Pension Outcomes in Canada.” 178 Josephine C. Jacobs, Audrey Laporte, Courtney H. Van Houtven, and Peter C. Coyte, “Caregiving Intensity and Retirement Status in Canada,” Social Science & Medicine 102 (2014): 74–82. 179 Emma Dentinger and Marin Clarkberg, “Informal Caregiving and Retirement Timing among Men and Women: Gender and Caregiving Relationships in Late Midlife,” Journal of Family Issues 23, no. 7 (2002): 857–79. 180 Armstrong, “Made in Manitoba.” 181 Home Care Ontario, “Fact & Figures: Publicly Funded Home Care,” http://www.homecareontario.ca/home-care-services/facts-figures /publiclyfundedhomecare. 182 British Columbia, Office of the Ombudsperson, Best of Care … (Part 2). 183 Government of Quebec, Un Québec pour tous les âges. 184 Toews, Future of Home Care Services in Manitoba. 185 Toews, Future of Home Care Services in Manitoba, 4, 75–6. 186 Janet E. Fast, Deanna L. Williamson, and Norah C. Keating, “The Hidden Costs of Informal Elder Care,” Journal of Family and Economic Issues 20, no. 3 (1999): 301–28. 187 Merril Silverstein and Vern L. Bengtson, “Intergenerational Solidarity and the Structure of Adult Child–Parent Relationships in American Families,” American Journal of Sociology 103, no. 2 (1997): 429–60. 188 Berit Ingersoll-Dayton, Margaret B. Neal, and Leslie B. Hammer, “Aging Parents Helping Adult Children: The Experience of the Sandwiched Generation,” Family Relations 50 (2001): 262–71. 189 Toews, Future of Home Care Services in Manitoba, 42–3. 190 Guberman et al., “Baby Boom Caregivers.” 191 Daniel Dickson, Patrik Marier, and Anne-Sophie Dubé, “Do Assessment Tools Shape Policy Preferences? Analysing Policy Framing Effects on Older Adults’ Conceptualisation of Autonomy,” Journal of Social Policy (forthcoming). 192 Binney, Estes, and Ingman, “Medicalization, Public Policy and the Elderly.” 193 Henningsen and McAlister, “Paradigm Shift.” 194 Nancy Guberman, Éric Gagnon, Denyse Côté, Claude Gilbert, Nicole Thivierge, and Marielle Tremblay, “How the Trivialization of the Demands of High-Tech Care in the Home Is Turning Family Members into ParaMedical Personnel,” Journal of Family Issues 26, no. 2 (2005): 247–72; Binney, Estes, and Ingman, “Medicalization, Public Policy and the Elderly.” 195 Toews, Future of Home Care Services in Manitoba, 3. 196 Lavoie, “La responsabilité des soins aux aînés au Québec. Du secteur public au privé,” 9.

Notes to pages 191–201

333

197 Chappell and Hollander, Aging in Canada, 54. 198 Lilly et al., “Can We Move Beyond Burden and Burnout to Support the Health and Wellness of Family Caregivers to Persons with Dementia?” 199 For a brief review, see Chappell and Hollander, Aging in Canada, 41–5. 200 Canadian Healthcare Association, Home Care in Canada from the Margins to the Mainstream. 201 Binney, Estes, and Ingman, “Medicalization, Public Policy and the Elderly.” 202 Binney, Estes, and Ingman, “Medicalization, Public Policy and the Elderly.” 203 Donna Wilson, Corrine D. Truman, Joe Huang, Sam Sheps, Roger Thomas, and Tom Noseworthy, “The Possibilities and the Realities of Home Care,” Canadian Journal of Public Health 96, no. 5 (2005): 385–9; Chappell, Population Aging and the Evolving Care Needs of Older Canadians; Lavoie, Guberman, and Marier, “La responsabilité des soins aux aînés au Québec. Du secteur public au privé.” 204 Conseil du statut de la femme, Les proches aidantes et les proches aidants au Québec, 49. 205 Conseil du statut de la femme, Les proches aidantes et les proches aidants au Québec, 49. 206 Ministère du Conseil exécutif, Actions gouvernementales portant sur les changements démographiques – État de situation. Deuxième Partie: L’impact des changements démographiques sur l’économie et le marché du travail (Quebec: Ministère du Conseil exécutif, 2016). 207 Canadian Healthcare Association, Home Care in Canada from the Margins to the Mainstream, 25. 7 Home Care Services and Caregiving 1 OECD, Maintaining Prosperity in an Ageing Society; OECD, Reforms for an Ageing Society. 2 OECD, Reforms for an Ageing Society. 3 Peters, “Challenge of Policy Coordination,” 7. 4 Graham White, Cabinets and First Ministers (Vancouver: University of British Columbia Press, 2005). 5 Jacques Bourgault, “De Kafka au net: La lutte incessante du sous-ministre pour contrôler son agenda,” Gestion 22 (1997): 18–26. 6 Patrik Marier and Isabelle Van Pevenage, “Three Competing Interpretations of Policy Problems: Tame and Wicked Problems through the Lenses of Population Aging,” Policy and Society 36, no. 3 (2017) : 430–45. 7 Interview 77.

334 8 9 10 11 12

13 14 15 16 17 18 19

20

21

22 23 24

25

26 27 28

Notes to pages 202–6 Bernier, Brownsey, and Howlett, Executive Styles in Canada. Johnson, Dream No Little Dreams. Dunn, Institutionalized Cabinet. Savoie, Governing from the Centre; Bernier, Brownsey, and Howlett, Executive Styles in Canada. Nova Scotia Commission on Building Our New Economy, Now or Never: An Urgent Call to Action for Nova Scotians. The Report of the Nova Scotia Commission on Building Our New Economy (Halifax: OneNS, 2014). White, Cabinets and First Ministers. Government of Alberta, Aging Population Policy Framework. Interview 104. Interview 15. Interview 78. Government of New Brunswick, Population Growth Strategy 2014–2017 (Fredericton: Government of New Brunswick, 2014). Government of Newfoundland and Labrador, Live Here, Work Here, Belong Here: Implementation Framework for the Newfoundland and Labrador Population Growth Strategy, 2015–2020 (St. John’s: Government of Newfoundland and Labrador, 2015). Government of Newfoundland and Labrador, The Way Forward on Immigration in Newfoundland and Labrador (St. John’s: Government of Newfoundland and Labrador, 2017). Vérificateur général du Québec, Rapport à l’Assemblée Nationale pour l’année 2000–2001: Tome II (Québec: Le Vérificateur général du Québec, 2001). Vérificateur général du Québec, Rapport à l’Assemblée Nationale pour l’année 2000–2001: Tome II, 23. Vérificateur général du Québec, Rapport à l’Assemblée Nationale pour l’année 2000–2001: Tome II, 23. Ministère du Conseil exécutif, Veille et coordination de la démarche de réflexion portant sur les enjeux associés aux changements démographiques (Quebec: Ministère du Conseil exécutif, 2010). Ministère du Conseil exécutif, Actions gouvernementales portant sur les changements démographiques: Rapport au Secrétaire Général (Quebec: Ministère du Conseil exécutif, 2003). Ministère du Conseil exécutif, Actions gouvernementales portant sur les changements démographiques. Gouvernement du Québec, Forum des générations: Cahier du participant (Quebec: Gouvernement du Québec, 2004). Daniel Thomas, “Les coalitions de personnes aînées dans l’action publique relative à la vieillesse au Québec,” in Droits de vieillir et citoyenneté des aînés: Pour une perspective internationale, ed. Jean-Philippe Viriot Durandal, Émilie

Notes to pages 206–10

29 30 31

32 33 34

35 36

37 38 39

40 41 42 43 44 45

46 47 48 49 50

335

Raymond, and Thibauld Moulaert, 167–81 (Quebec: Presses de l’Université du Québec, 2015). Gouvernement du Québec, Forum des générations, 13. Author’s translation. Gouvernement du Québec, Forum des générations, 13. Gouvernement du Québec, A Collective Commitment: Government Sustainable Development Strategy 2008–2013 (Renewed until December 31, 2014) (Quebec: Gouvernement du Québec, 2013). Gouvernement du Québec, A Collective Commitment, 40. Gouvernement du Québec, Government Sustainable Development Strategy 2015–20 (Quebec: Gouvernement du Québec, 2015). Ministère du Conseil exécutif, Actions gouvernementales portant sur les changements démographiques – État de situation. Sommaire (Quebec: Ministère du Conseil exécutif, 2016). Ministère du Conseil exécutif, Actions gouvernementales portant sur les changements démographiques – État de situation. Sommaire, 6. Ministère du Conseil exécutif, Actions gouvernementales portant sur les changements démographiques – État de situation: Rapport Au Secrétaire Général (Quebec: Ministère du Conseil exécutif, 2009). Ministère du Conseil exécutif, Actions gouvernementales portant sur les changements démographiques – État de situation: Rapport Au Secrétaire Général. Ministère du Conseil exécutif, “Actions gouvernementales portant sur les changements démographiques - État de situation. Sommaire.” Vérificateur général du Québec, Rapport du Vérificateur général du Québec à l’Assemblée Nationale pour l’année 2009–2010: Rapport du Commissaire au développement durable (Quebec: Le Vérificateur général du Québec, 2010). Interview 117. Interview 43. Nova Scotia Commission on Building Our New Economy, Now or Never, 2. Nova Scotia Commission on Building Our New Economy, Now or Never, ix. Nova Scotia Commission on Building Our New Economy, Now or Never, 4. Peter Clancy, “Provincial Fiscal Strategies and Public-Sector Management in Nova Scotia,” in The Public Sector in an Age of Austerity: Perspectives from Canada’s Provinces and Territories, ed. Bryan M. Evans and Carlo Fanelli, 219–43 (Montreal and Kingston: McGill-Queen’s University Press, 2018). Donald Savoie, The Way Ahead for Nova Scotia: Invest More, Innovate More, Trade More, Learn More (Halifax: Office of the Premier, 2010). Nova Scotia Commission on Building Our New Economy, Now or Never, 4. Nova Scotia Commission on Building Our New Economy, Now or Never, 47–50. One Nova Scotia Coalition, We Choose Now: One Nova Scotia Coalition Collaborative Action Plan (Halifax: One Nova Scotia Coalition, 2015). Chronicle Herald, “Why Are Political Leaders Ignoring the Ivany Report? Various Community Groups Have Come Together as a Result, but Poll

336

51 52 53 54 55 56 57 58

59 60 61

62 63 64 65

66 67 68

69 70 71 72

Notes to pages 210–14 Shows Nova Scotians Know Next to Nothing About the Action Plan or Its Origins,” 5 February 2017, E4. As stated in the One Nova Scotia coalition website, https://www.onens .ca/. Bruno Jobert, Le tournant néo-libéral en Europe (Paris: Éditions L’Harmattan, 1994). Good, “New Bureaucratic Politics of Redistribution,” 211. Interview 118. Interview 118. Interviews 8, 22, 41, 46, 56, 88, 96, 101, 105. Interview 88. Ministry of Finance (Ontario), A Plan for the People: Ontario’s Economic Outlook and Fiscal Review (Toronto: Queen’s Printer for Ontario, 2018), 98–100. Department of Finance (New Brunswick), 2017–2018 Economic Outlook (Frederiction: Department of Finance, 2017), 9. Ministry of Finance (Quebec), Update on Québec’s Economic and Financial Situation (Quebec: Gouvernement du Québec, 2018), A13. Ministry of FInance (British Columbia), Budget 2018. Working for You: Budget and Fiscal Plan 2018/19–2020/21 (Victoria: Government of British Columbia, 2018). Ministry of Finance (Manitoba), Budget Paper A: Economic Review and Outlook (Winnipeg: Government of Manitoba, 2018), A8. Ministry of Finance (Manitoba), Budget Paper A: Economic Review and Outlook (Winnipeg: Government of Manitoba, 2015), A10. Ministry of Finance (Manitoba), Budget Paper A: Economic Review and Outlook (Winnipeg: Government of Manitoba, 2015), A7. Geneviève Tellier, Canadian Public Finance: Explaining Budgetary Institutions and the Budget Process in Canada (Toronto: University of Toronto Press, 2019), 81–5. Tellier, Canadian Public Finance, 102. Interview 18. Auditor General of Alberta, Putting Alberta’s Financial Future in Focus: A Commentary by the Auditor General (Edmonton: Office of the Auditor General, 2018). Auditor General of Alberta, Putting Alberta’s Financial Future in Focus, 5. Auditor General of Alberta, Putting Alberta’s Financial Future in Focus, 10–12. Ministry of Finance (Ontario), Toward 2025: Assessing Ontario’s Long-Term Outlook (Toronto: Queen’s Printer for Ontario, 2005), 3. Ministry of Finance (Ontario), Ontario’s Long-Term Report on the Economy (Toronto: Queen’s Printer for Ontario, 2017), chap. 1.

Notes to pages 214–17

337

73 Ministère du Conseil exécutif, Actions gouvernementales portant sur les changements démographiques – État de situation: Rapport au Secrétaire général. 74 Ministry of Finance (Ontario), Ontario’s Long-Term Report on the Economy, 10. 75 Ministry of Finance (Ontario), Ontario’s Long-Term Report on the Economy, 28. 76 Tellier, Canadian Public Finance, 102. 77 In the press conference, the auditor general expresses a personal preference for thirty-five years. “Putting Alberta’s Financial Future in Focus,” 19 April 2018, https://www.oag.ab.ca/news /puttingalbertasfinancialfutureinfocus. 78 Gouvernement du Québec, Stratégie d’action en faveur des ainés: Un milieu de vie amélioré, une participation encouragée (Quebec: Finances Québec, 2007). 79 Gouvernement du Québec, Stratégie d’action en faveur des ainés. 80 Healthy Living and Seniors Manitoba Health, Caregiver Recognition Act Report. 81 Donald J. Savoie, “La fonction publique canadienne a perdu ses repères,” Canadian Public Administration / Administration publique du Canada 58, no. 2 (2015): 205–26. 82 White, Cabinets and First Ministers. 83 Peters, “Challenge of Policy Coordination.” 84 Demographic Planning Commission, Findings Report (Edmonton: Government of Alberta, 2008). 85 Government of Alberta, Alberta for All Ages: Directions for the Future (Edmonton: Ministry of Community Development, 2000). 86 It has operated under various names. For example, it was called the Ministry of Community Development in 2000 and the Ministry of Seniors and Community Supports in 2008. In 2017, its name became the Ministry of Community and Social Services. However, responsibilities for seniors were transferred to the newly created Ministry of Seniors and Housing following the NDP election in 2014. 87 Steering Committee for the Government Wide Study on the Impact of the Aging Population, Alberta for All Ages: Directions for the Future (Edmonton: Alberta Community Development, 2000). 88 Steering Committee for the Government Wide Study on the Impact of the Aging Population, Alberta for All Ages. 89 Steering Committee for the Government Wide Study on the Impact of the Aging Population on Government Programs and Services, Government-Wide Study on the Impact of the Aging Population: Review of Current Government Programs and Services (Edmonton: Alberta Community Development, 1999), 7–8. 90 Alberta Community Development, Aging Together – Planning for the Future: Discussion Guide (Edmonton: Alberta Community Development, 1999). 91 Government of Alberta, Alberta for All Ages.

338

Notes to pages 217–26

92 93 94 95 96 97 98 99 100 101

Government of Alberta, Alberta for All Ages, 24. Demographic Planning Commission, Findings Report, 8. Demographic Planning Commission, Findings Report, 55. Demographic Planning Commission, Findings Report, 56. Marier and Séguin, “Aging and Social Assistance in the Provinces.” Demographic Planning Commission, Findings Report, 15. Demographic Planning Commission, Findings Report, 19. Government of Alberta, Aging Population Policy Framework. Government of Alberta, Aging Population Policy Framework, 15–16. Steering Committee for the Government Wide Study on the Impact of the Aging Population on Government Programs and Services, GovernmentWide Study on the Impact of the Aging Population, 4. 102 Steering Committee for the Government Wide Study on the Impact of the Aging Population, Alberta for All Ages. 103 Statistics Canada, Census Profile 2016, New Brunswick (Ottawa: Statistics Canada, 2019), https://www12.statcan.gc.ca/census-recensement/2016 /dp-pd/prof/details/Page.cfm?Lang=E&Geo1=PR&Code1=13&Geo2= &Code2=&Data=Count&SearchText=New%20Brunswick&SearchType =Begins&SearchPR=01&B1=All&GeoLevel=PR&GeoCode=13. 8 Offices for Seniors 1 Peters, “Challenge of Policy Coordination,” 7. 2 Feltenius, “En Pluralistisk Maktordning?” 3 A civil servant within the health department assumes the role of liaising with elderly based groups. 4 Interview 49. 5 Interview 29. 6 United Nations, Report of the Second World Assembly on Ageing (New York: United Nations, 2002). 7 United Nations, Report of the Second World Assembly on Ageing, 21. 8 Government of Manitoba, Advancing Age: Promoting Older Manitobans, ed. Seniors and Healthy Aging Secretariat (Winnipeg: Government of Manitoba, 2004). 9 Gouvernement du Québec, Une pleine participation des aînés au développement du Québec. 10 Government of British Columbia, Aging Well in British Columbia: Report of the Premier’s Council on Aging and Seniors’ Issues (Victoria: Government of British Columbia, 2006). 11 FADOQ, Des aînés sans famille … Mais avec une Ministre! (Quebec: FADOQ, 2007).

Notes to pages 231–6

339

12 Interview with Russ Wiseman, minister of business and former minister of health and community services, 15 October 2009. 13 Edgar Williams. “Seniors’ Matters Deserve More Attention,” Telegram, 3 October 2011. 14 Interview 49. 15 Interview 33. 16 Interview with Russ Wiseman. 17 Conseil des aînés, Rapport annuel de gestion, 2003–2004 (Quebec: Conseil des aînés, 2004), vii. 18 Ministère de la Famille, Bilan 2006–2010 des réalisations en faveur des familles et des enfants (Quebec: Gouvernement du Québec, 2011); Ministère de la Famille, Bilan 2010–2015 des réalisations en faveur des familles et des enfants (Quebec: Gouvernement du Québec, 2016). 19 Provincial Advisory Council on Aging and Seniors, Activity Plan April 1, 2014–March 31, 2017 (St. John’s: Office of Aging and Seniors, 2017), 5. 20 This was strongly opposed by the FADOQ and thirteen other organizations who lamented the dismantling of an organization with an extensive network and resources to represent the voices and opinions of seniors. 21 Seniors & Continuing Care Provincial Advisory Council, Work Plan 2018/2019, 2019/2020 (Edmonton: Alberta Health Services, 2017), https:// www.albertahealthservices.ca/assets/about/ac/ahs-pac-scc-2018-20 -workplan.pdf. 22 CBC News, “Manitoba Axes, Shrinks 25 Government-Appointed Boards,” 4 December 2017, https://www.cbc.ca/news/canada/manitoba /manitoba-government-boards-cut-1.4432693. 23 Interview 21. 24 Seniors (Nova Scotia), “Group of IX Seniors’ Advisory Council of Nova Scotia,” accessed 29 March 2017, https://novascotia.ca/seniors/groupIX.asp. 25 Alberta Seniors and Housing, Annual Report 2017–18 (Edmonton: Ministry of Seniors and Housing, 2018). 26 Pierson, Dismantling the Welfare State?; Andrea Louise Campbell, “SelfInterest Social Security, and the Distinctive Participation Pattern of Senior Citizen,” American Political Science Review 96, no. 3 (2002): 565–74. 27 Nicole F. Bernier, Le désengagement de l’état providence (Montreal: Les Presses de l’Université de Montréal, 2003). 28 Hogwood and Peters, “Dynamics of Policy Change”; Pierson, Dismantling the Welfare State? 29 Interview 25. 30 Lynch, Age in the Welfare State. 31 Premier’s Panel on Seniors, Living Healthy, Aging Well (Fredericton: Province of New Brunswick, 2012), 26.

340 32 33 34 35 36 37 38 39 40

41 42 43 44 45

46 47

48 49

50 51

Notes to pages 237–41 Interview 49, also alluded to by interview 100. Interview 82. Macnicol, Age Discrimination. Government of Nova Scotia, Strategy for Positive Aging in Nova Scotia. Government of Newfoundland and Labrador, Provincial Healthy Aging: Policy Framework (St. John’s: Aging and Seniors Division, 2007). Interviews 21 and 82. Alberta Seniors and Housing, Annual Report 2015–16 (Edmonton: Alberta Seniors and Housing, 2016). Ministry of Healthy Living and Sports, Seniors in British Columbia: A Healthy Living Framework (Vancouver: Government of British Columbia, 2007). Alberta Health and Wellness, Alberta’s Healthy Aging and Seniors Wellness Strategic Framework 2002–2012 (Edmonton: Alberta Health and Wellness, 2002). Government of Nova Scotia, Strategy for Positive Aging in Nova Scotia. World Health Organization, Active Ageing: A Policy Framework. Division of Aging and Seniors, Principles of the National Framework on Aging. Health Canada, Division of Aging and Seniors, Dare to Age Well: Workshop on Healthy Aging (Ottawa: Government of Canada, 2002). Seniors’ Secretariat, Strategy for Positive Aging in Nova Scotia; Government of British Columbia, Aging Well in British Columbia; Government of Newfoundland and Labrador, Provincial Healthy Aging. Other provinces have launched long-term plans based on narrower consultations relying on seniors’ advisory committees, experts, and consultants. See, for example, Alberta Health and Wellness, Alberta’s Healthy Aging and Seniors Wellness Strategic Framework 2002–2012; Saskatchewan Provincial Advisory Committee of Older Persons, Saskatchewan’s Provincial Policy Framework and Action Plan for Older Persons (Regina: Saskatchewan Health, 2003). World Health Organization, Global Age-Friendly Cities. Efforts were made to put this within a Canadian context. See, for example, Federal/Provincial/Territorial Ministers Responsible for Seniors, AgeFriendly Rural and Remote Communities: A Guide (Ottawa: PFT Seniors, 2007). This includes Manitoba’s Age-Friendly Initiative, launched in 2008, and Quebec’s Villes amies des aînés au Québec, also introduced in 2008. Gouvernement du Québec, Guide d’accompagnement pour la réalisation de la démarche Municipalité amie des aînés (deuxième edition) (Québec: Gouvernement du Québec, 2019). Gouvernement du Québec, Municipalité amie des aînés: Favoriser le vieillissement actif au Québec (Quebec: Gouvernement du Québec, 2009), 15–21. Mario Paris, Suzanne Garon, Marie Beaulieu, Anne Veil, and Catherine Bigonnesse, “Ville amie des aînés au Québec: L’apport de ‘vieillir en restant actif,’” Vie et Vieillissement 9, no. 1 (2011): 28–32.

Notes to pages 241–9

341

52 See Grenier, Transitions and the Lifecourse. 53 Government of Newfoundland and Labrador, Provincial Healthy Aging Implementation Plan – Year 1: 2007–2008 Building a Foundation (St. John’s: Government of Newfoundland and Labrador, 2007). 54 Government of Alberta, Aging Population Policy Framework, 5. 55 See, for example, Anne E. Nelson and Dale Dannefer, “Aged Heterogeneity: Fact or Fiction? The Fate of Diversity in Gerontological Research,” Gerontological Society of America 32, no. 1 (1992): 17–23; Raija Ylikoski, Ari Ylikoski, Pertti Keskivaara, Reijo Tilvis, Raimo Sulkava, and Timo Erkinjuntti, “Heterogeneity of Cognitive Profiles in Aging: Successful Aging, Normal Aging, and Individuals at Risk for Cognitive Decline,” European Journal of Neurology 6, no. 6 (1999): 645–52. 56 Government of Alberta, “New Cabinet Team Focused on Growing Alberta’s Future,” news release, 8 May 2012. 57 Alberta Seniors, Annual Report 2014–15 (Edmonton: Alberta Seniors, 2015). 58 Premier of Manitoba, mandate letter, 18 October 2018. 59 Bowling, “Aspirations for Older Age in the 21st Century.” 60 House et al., “Social Stratification of Aging and Health.” 61 Vincent Caradec, Sociologie de la vieillesse et du vieillissement, 3rd ed. (Paris: Armand Colin, 2012). 62 Interview 100. 63 Interview 33. 64 Interview 82. 65 British Columbia, Office of the Ombudsperson, Best of Care: Getting It Right for Seniors in British Columbia (Part 1), 11. 66 British Columbia, Office of the Ombudsperson, Best of Care: Getting It Right for Seniors in British Columbia (Part 1), 11; British Columbia, Office of the Ombudsperson, Best of Care: Getting It Right for Seniors in British Columbia (Part 2). 67 Office of the Seniors Advocate (BC), The Journey Begins: Together, We Can Do Better (Victoria: Office of the Seniors Advocate. British Columbia, 2014), 1. 68 Office of the Seniors Advocate (BC), Journey Begins, 1. 69 Office of the Seniors Advocate (BC), Journey Begins 2–6. 70 Office of the Seniors Advocate Alberta, Building a Strong Foundation (Edmonton: Office of the Seniors Advocate Alberta, 2017), 8. 71 Office of the Seniors Advocate Alberta, Building a Strong Foundation, 14. 72 Office of the Seniors Advocate Newfoundland and Labrador, Activity Plan 2018–2020 (St. John’s: Office of the Seniors Advocate, 2017), 5. 73 Office of the Seniors Advocate Newfoundland and Labrador, Activity Plan 2018–2020, 5. 74 New Brunswick Seniors’ Advocate, “About the Office,” accessed 19 December 2019, https://www.nbseniorsadvocate.ca/new-page-1.

342

Notes to pages 249–58

75 Child, Youth and Senior Advocate Act. 2016, c 54, s 1, p 6. 76 Johannes Lindvall and Bo Rothstein, “Sweden: The Fall of the Strong State,” Scandinavian Political Studies 29, no. 1 (2006): 52. 77 Lindvall and Bo Rothstein, “Sweden: The Fall of the Strong State,” 61. Conclusion 1 Adam Wellstead, Jonathan Craft, and Micheal Howlett, “Policy Work System Dynamics: Implications for Practice, Pedagogy, and Scholarship,” in Policy Work in Canada: Professional Practices and Analytical Capacities, ed. Howlett, Craft, and Wellstead, 325–33 (Toronto: University of Toronto Press, 2017). 2 Government of Alberta, Aging Population Policy Framework, 16. 3 Quebec, facing a more challenging demographic and socio-economic environment, adopted other contribution rate increases afterwards. 4 Lynch, Age in the Welfare State. 5 Pierson, Dismantling the Welfare State?; Campbell, How Policies Make Citizens). 6 American Academy of Actuaries, “An Actuarial Perspective on the 2018 Social Security Trustees Report,” issue brief, June 2018, 1–10. 7 Gusmano and Allin, “Framing the Issue of Ageing and Health Care Spending in Canada, the United Kingdom and the United States”; Marier and Marina Revelli, “Compassionate Canadians and Conflictual Americans?” 8 One Nova Scotia Coalition, We Choose Now. 9 Donald J. Savoie, Visiting Grandchildren: Economic Development in the Maritimes (Toronto: University of Toronto Press, 2006). 10 Conrad, Medicalization of Society. 11 Estes and Binney, “Biomedicalization of Aging.” 12 Canadian Healthcare Association, Home Care in Canada from the Margins to the Mainstream. 13 Grignon and Spencer, “Funding of Long-Term Care in Canada.” 14 Organisation for Economic Co-operation and Development, Health at a Glance, 215. 15 Cooper and Marier, “Does It Matter Who Works at the Center?” 16 Canadian Home Care Association, Portraits of Home Care in Canada 2013. 17 Marchildon and Di Matteo, Bending the Cost Curve in Health Care. 18 Janice M. Keefe, Lucy Knight, Anne Martin-Matthews, and Jacques Légaré, “Key Issues in Human Resource Planning for Home Support Workers in Canada,” Work: A Journal of Prevention, Assessment and Rehabilitation 40, no. 1 (2011): 21–8. 19 Keefe, Supporting Caregivers and Caregiving in an Aging Canada.

Notes to pages 258–64

343

20 Marier, “Who Pays the Piper Calls the Tune?” 21 Government of Ontario, Aging with Confidence; Government of Ontario, Independence, Activity and Good Health (Toronto: Ontario Seniors’ Secretariat, 2013). 22 Government of Nova Scotia, Strategy for Positive Aging in Nova Scotia. 23 Government of Nova Scotia, Shift: Nova Scotia’s Action Plan for an Aging Population (Halifax: Government of Nova Scotia, 2017). 24 Demographic Planning Commission, Findings Report. 25 Government of Alberta, Aging Population Policy Framework. 26 Peters, “Challenge of Policy Coordination.” 27 Les Metcalfe, “International Policy Co-ordination and Public Management Reform,” International Review of Administrative Sciences 60, no. 2 (1994): 271–90. 28 Craft, Backrooms and Beyond, 41. 29 Ministère du Conseil exécutif, Actions gouvernementales portant sur les changements démographiques – État de situation. Sommaire. 30 Government of New Brunswick, We Are All in This Together: An Aging Strategy for New Brunswick (Fredericton: Province of New Brunswick, 2017). 31 McArthur, “Policy Analysis in Provincial Governments in Canada.” 32 Few senior civil servants stated this when discussing how attention paid to an aging population has evolved. To preserve anonymity, no interview numbers are provided. 33 Government of Newfoundland and Labrador, Live Here, Work Here, Belong Here. 34 New Brunswick Premier’s Panel on Seniors, “Living Healthy, Aging Well.” 35 Government of New Brunswick, Home First. 36 Christopher A. Cooper, “The Rise of Court Government? Testing the Centralisation of Power Thesis with Longitudinal Data from Canada,” Parliamentary Affairs 70, no. 3 (2017): 589–610. 37 Government of Ontario, Aging with Confidence. 38 Government of Alberta, “Resources to Help Seniors Age in Their Community,” https://www.alberta.ca/seniors-resources.aspx. 39 Government of New Brunswick, We Are All in This Together. 40 Government of New Brunswick, We Are All in This Together. 41 Gouvernement du Québec, Un Québec pour tous les âges. 42 Cooper, “Politics of Bureaucratic Mobility,” 104, 82. 43 Toews, Future of Home Care Services in Manitoba. 44 David McGrane, Remaining Loyal: Social Democracy in Quebec and Saskatchewan (Montreal and Kingston: McGill-Queen’s Press, 2014). 45 Cooper and Marier, “Does It Matter Who Works at the Center?” 46 One Nova Scotia Coalition, We Choose Now.

344

Notes to pages 264–71

47 Jared J. Wesley, Code Politics: Campaigns and Cultures on the Canadian Prairies (Vancouver: University of British Columbia Press, 2011). 48 See Newfoundland and Labrador, “Community Accounts,” http:// nl.communityaccounts.ca/. 49 Gow, Learning from Others; Carolyn M. Johns, Patricia L. O’Reilly, and Gregory J. Inwood, “Formal and Informal Dimensions of Intergovernmental Administrative Relations in Canada,” Canadian Public Administration / Administration publique au Canada 50, no. 1 (2007): 21–41. 50 Interviews 8, 22, 41, 46, 56, 88, 96, 101, 105. 51 Interviews 56, 105, 116. 52 Interview 88. 53 Interview 46. 54 Auditor General of Alberta, Putting Alberta’s Financial Future in Focus. 55 Interview 93. 56 This is not the only time the federal government impeded a provincial plan. The small Saskatchewan Pension Plan (SPP) sought to increase the yearly contribution ceiling to its plan for many years before being able to raise it from $600 to its current level of $6200. 57 Béland and Weaver, “Federalism and the Politics of the Canada and Quebec Pension Plans.” 58 Jennifer Wallner, Learning to School: Federalism and Public Schooling in Canada (Toronto: University of Toronto Press, 2014). 59 See, for instance, Inwood, Johns, and O’Reilly, Intergovernmental Policy Capacity in Canada; Wallner, Learning to School 60 James M. Lutz, “Emulation and Policy Adoptions in the Canadian Provinces,” Canadian Journal of Political Science 22, no. 1 (1989): 147–54; Dale H. Poel, “The Diffusion of Legislation among the Canadian Provinces: A Statistical Analysis,” Canadian Journal of Political Science 9, no. 4 (1976): 605–26. 61 Inwood, Johns, and O’Reilly, Intergovernmental Policy Capacity in Canada. 62 Interview 25. 63 Interview 123. 64 Interviews 100 and 123. 65 Interview 82. 66 Council of the Federation, “Providing Services for an Aging Population,” news release, 16 July 2015. 67 Johns, O’Reilly, and Inwood, “Formal and Informal Dimensions of Intergovernmental Administrative Relations in Canada.” 68 Korpi, and Palme, “New Politics and Class Politics in the Context of Austerity and Globalization.” 69 Jobert, Le tournant néo-libéral en Europe.

Notes to pages 271–3

345

70 Giuliano Bonoli, “Time Matters: Postindustrialization, New Social Risks, and Welfare State Adaptation in Advanced Industrial Democracies,” Comparative Political Studies 40, no. 5 (2007): 495–520. 71 Mark Blyth, Austerity: The History of a Dangerous Idea (Oxford: Oxford University Press, 2013). 72 Gosta Esping-Andersen, The Three Worlds of Welfare Capitalism (Princeton, NJ: Princeton University Press, 1990). 73 Daniel Béland, Gregory P. Marchildon, and Michael J. Prince, eds., Universality and Social Policy in Canada (Toronto: University of Toronto Press, 2019). 74 Alec Castonguay, “Au cœur de la bataille pour sauver le Québec: un récit exclusif des dessous de la crise,” L’actualité, 6 May 2020. 75 Julia Lynch, Regimes of Inequality: The Political Economy of Health and Wealth (Cambridge: Cambridge University Press, 2020); Lynch, “Reframing Inequality? The Health Inequalities Turn as a Dangerous Frame Shift,” Journal of Public Health 39, no. 4 (2017): 653–60. 76 Lynch, “Reframing Inequality?,” 653. 77 Lynch, “Reframing Inequality?,” 656.

This page intentionally left blank

Index

AARP, 33–4, 235 accountants, 27, 59 Achenbaum, Andrew, 35 Action Plan for Seniors (Ontario), 246, 258, 261 Actions gouvernementales portant sur les changements démographiques (Quebec), 206, 263 active aging, 30, 42–3, 60, 240–1, 243 active labour market policies, 83 activities of daily living, 38 actuaries, 75, 94 Advancing Age: Promoting Older Manitobans, 225, 246 age and medical conditions, 37 Aged Society Policy Council (Japan), 47, 199 Ageing Well in BC, 226 ageism, 59, 259 Aging Friendly Communities, 269 aging mainstreaming, 43, 47, 56, 225 Aging Population Policy Framework (Alberta), 15, 43, 50, 89, 125, 141, 153, 178, 200, 203, 216–22, 241, 246, 253, 255, 259, 261 aging successfully, 243 Alberta, 7, 10, 13, 43, 50, 73, 89, 91–2, 96, 107, 109–16, 122, 125, 134, 136–8, 141–3, 148, 153, 164, 170–1,

176, 178, 180, 200, 203, 205, 213–14, 216–22, 224, 231–3, 235, 239–42, 246, 248–50, 252–3, 255, 259, 261, 263–5, 267; unique approach on population aging, 219 Alberta Association on Gerontology, 218 Alberta for All Ages, 216–18 Alberta Health Services, 171, 233 Alberta Motor Association, 218 Alberta Seniors and Community Supports, 218 Allison, Graham, 22 alternate level of care, 147, 149, 154, 155, 156; lack of beds in long-term care, 149 Alward, David, 203, 208, 261 Ambachtsheer, Keith, 115 apocalyptic: demography, 51, 71; scenario, 140, 153 Ascher, William, 76 Atlantic provinces, 30, 127, 128, 132, 136, 137, 141, 142, 143, 150, 151, 152, 153, 155, 160, 170, 204, 212, 215, 255, 264, 270. See also Maritimes auditor general, 11, 89, 96, 103, 200, 263; home care reports, 168; in Alberta, 180, 213–14, 267; in British

348

Index

Columbia, 10, 152, 165, 188; in Manitoba, 89, 165–6, 169, 184, 194; in Nova Scotia, 165, 169, 181; in Ontario, 165, 181, 185; in Quebec (vérificateur général), 10, 89, 165, 181–2, 200, 205–6, 208, 221–2, 265 Australia, 33, 39 baby boomers, 5, 31, 53, 60–2, 133, 138, 186, 190, 193, 196, 212, 245; cohort of, 82; health status of, 160 Baumol’s disease, 140 BC Care Providers Association, 147, 180 Béland, Daniel, 125, 129 Belgium, 85, 273 Bennett, W.R., 78 Best of Care: Getting It Right for Seniors in British Columbia, 164–5, 181 Binney, Elizabeth, 35, 36, 162, 190 biomedicalization of aging, 35–6, 44, 162, 168, 190, 224 Birnbaum, Simon, 33 Blais, Marguerite, 242, 265 Bogdanor, Vernon, 10 boomerangst, 21 Bourassa, Robert, 78 Bowling, Ann, 41 British Columbia, 9–10, 39–40, 77, 91–2, 107, 110–16, 137, 139, 143, 146–9, 153, 158, 161, 165–8, 170, 172, 175, 180–1, 202, 212, 224, 226, 231, 235, 238, 240–1, 243, 246–8, 250, 252, 257, 263–7, 272 Buckley, Christopher, 28 Burns, Scott, 25, 26 Busby, Colin, 138, 140 Campbell, Gordon, 247 Canada Health Act, 57, 72, 95, 134, 145, 161, 166, 195, 256,

268; critique of, 148; policy feedback, 167 Canada Health Transfer, 137 Canada Pension Plan, 16, 30, 58, 75, 86, 101–10, 114–31, 253, 254, 268, 273 Canada Pension Plan Investment Board, 105 Canadian Armed Forces, 9, 158–9 Canadian Association of Pension Supervisory Authorities, 111, 114 Canadian Community Health Survey, 41 Canadian Healthcare Association, 145, 154, 191 Canadian Home Care Association, 165, 182, 257 Canadian Institute for Health Information, 134–8, 140, 149, 168 Canadian Institute of Actuaries, 112, 124 Canadian Institute of Health Research, 37 Canadian Manufacturers and Exporters Association, 121 Canadian Medical Association, 38–9, 65, 136, 146, 154 Canadian Union of Public Employees, 118 career civil servants, 7, 8, 11–13, 30, 75, 90–1, 112, 125–8, 133, 141–2, 148–50, 159, 160, 164, 175, 200–2, 208, 210, 220, 224, 261, 264, 266, 272 Caregiver Benefit (Nova Scotia), 185 Caregiver Recognition Act (Manitoba), 185 caregivers, 6, 16, 55–6, 59, 61, 65, 69, 147, 154–5, 157–8, 163, 166, 168–9, 181–7, 190–6, 201, 215, 217, 243, 272, 274; availability of, 196; constraints, 193; contributions in dollars, 182; delegation of responsibilities to, 193; financial

Index pressures, 193, 258; gender, 6, 154, 157, 193; governmental support, 184, 185; hours spent, 184; instrumentalization of, 6, 154, 190, 191, 258; interdependencies, 186; labour conditions in formal sector, 193; labour market participation, 186, 187, 194; policy expectations, 182; recognition, 185; socioeconomic consequences, 193 care provision models, 183 CARP, 121, 231, 235–6 C.D. Howe Institute, 141 central agencies, 7, 8, 11, 17, 50, 68, 72, 76, 102, 200–5, 223, 231, 245, 267; concentration of power in, 202 central planning, 79, 142, 208 centre d’hébergement et de soins de longue durée (CHSLD) (Quebec), 143, 156, 158–9 Chagnon Family Foundation, 186 Chappell, Neena, 5, 163 Charbonneau, Francine, 229, 242 Charest, Jean, 206, 226, 255 Chez soi, le premier choix (Quebec), 164 child care, 6, 47, 183, 199, 271 Chrétien government, 104 Clark, Christy, 247 clerk of the Executive Council, 204; in New Brunswick, 208, 263, 265 climate change, 58, 76, 213; comparison with population aging, 204 Coalition Avenir Québec, 207, 242, 262, 265 Cobb, Roger, 52, 63 Comité d’experts sur l’avenir du système de retraite (Quebec), 110–12, 117–18, 124, 126, 130 Commissaire de la santé et du bien être (Quebec), 146 Commissariat général du Plan (France), 77, 79

349

Commission on Building Our New Economy, 203, 264 Community Accounts (Newfoundland), 50, 200, 214, 220, 265 Community Care Access Centres (Ontario), 165, 170, 172, 176, 181, 185 comparative policy analyses, 9 Conference Board of Canada, 65, 136, 138, 146, 160 Conseil des aînés (Quebec), 232–3 conservative governments, 79; in New Brunswick and Nova Scotia, 179 Conservative Party: Alberta, 178, 221, 255, 263; Canada, 103; Manitoba, 243; Ontario, 77, 104, 120, 195, 214, 261 Continuing Care Strategy (Alberta), 148, 318 Cooperative Commonwealth Federation, 77, 83, 202. See also New Democratic Party Couillard, Philippe, 137 Council of the Federation, 270, 344 council on aging, 233; in New Brunswick, 262 COVID-19, 9, 133, 157–8, 161, 252, 271–2, 274 Craft, Jonathan, 260 critical gerontology, 29, 41–2; definition of, 44 Cuban Missile Crisis, 22, 280 Dare to Age Well (Canada), 241 Davis, Paul, 261 de-familialization model, 183, 196; de-familializing by the market, 183 de Gaulle, Charles, 77 Deloitte, 209 demographers, 94 Demographic Planning Commission (Alberta), 216, 217, 219

350

Index

Denmark, 184. See also Scandinavian countries Department of Children, Seniors and Social Development (Newfoundland), 230 Department of Community Services and Seniors (PEI), 229 Department of Family and Human Services (PEI), 229 Department of Finance, 12, 17, 46, 50, 88, 96, 102, 106–7, 112, 129, 134, 141, 160, 164, 200, 202, 210, 215, 231, 258, 261, 266–7, 273; in Canada, 27, 210; in Newfoundland and Labrador, 215; rising prominence in policymaking, 271 Department of Health, 12, 16–17, 36–7, 43, 46, 48, 55, 69, 133, 141, 149–51, 157, 201, 224–5, 232–3, 239–40, 242, 244, 250, 256, 259–61, 266, 268, 273, 289n144; in Manitoba, 166, 228; in New Brunswick, 168, 176, 262 Department of Health and Community Services (Newfoundland), 226 Department of Health, Healthy Living and Seniors (Manitoba), 169 Department of Health, Seniors and Active Living (Manitoba), 89, 174, 228, 240 Department of Healthy and Inclusive Communities (New Brunswick), 229 Department of Healthy Living, Seniors and Consumer Affairs (Manitoba), 228 Department of Healthy Living, Youth and Seniors (Manitoba), 228, 232, 241 Department of Innovation (PEI), 204

Department of Intergovernmental Affairs, 103 Department of Labour, 12, 102 Department of Seniors (Nova Scotia), 230, 245 Department of Social Affairs, 9, 12 Department of Social Development (New Brunswick), 176, 229, 233, 240, 257, 262, 274 Department of Social Services, 12, 166, 168 dependency ratio, 15, 25, 28–30, 55, 60–1, 64, 102, 253, 272; Canada’s old age, 29; criticism of, 29, 30 deputy minister, 12, 54, 66, 75, 85, 102, 128–9, 131, 141, 148, 151, 176, 200, 203–4, 211, 213, 216, 232, 241–2, 246–7, 260; in Canada, 82; in Manitoba, 91; in New Brunswick, 91; in Ontario, 89, 214, 247; in Quebec, 89, 260; in Saskatchewan, 91 Dexter, David, 209 Direction du vieillissement actif (Quebec), 241 Downs, Anthony, 33 East Asian economic miracle, 29 economists, 24, 27, 54, 94, 139–40, 153, 267 elder abuse, 64, 157, 234, 237–9, 258, 270 England, 273 Estes, Carroll, 35–6, 162 executive council, 12, 17, 89, 96, 141, 164, 200–5, 208, 260, 270; in Nova Scotia, 209 Extra-Mural Hospital Program (New Brunswick), 175 FADOQ, 118, 190, 221, 226, 310, 338–9 federal government, 12, 30, 37, 69, 75, 93, 95, 101, 103–4, 107, 109–11,

Index 115–17, 119–23, 132, 136, 159, 161, 167–8, 195, 200, 268, 270 Federal/Provincial/Territorial Ministers Responsible for Seniors Forum (FPT), 236, 238, 240, 269 Fédération des chambres de commerce du Québec, 118 Fédération des travailleurs du Québec, 118 Felder, Stefan, 139 Finland, 273 Flaherty, Jim, 115, 309 Fonds des générations (Quebec), 207, 253, 255 Foot, David, 5, 204 Force Jeunesse (Quebec), 124 forecasting, 78–9, 94, 138, 142, 188, 200, 205, 211, 213, 214, 220, 266 Forum des générations (Quebec), 206, 334, 335 France, 34, 79, 257, 273 Friesen, Cameron, 243 Galasso, Vincenzo, 28 gender mainstreaming, 88, 96, 245, 262 General Electric, 78, 80 generational accounting, 17, 24–7, 30–1, 50, 55, 57, 64–5, 71, 88, 102, 126–7, 153, 188, 253, 272; criticism of, 27; definition of, 32, 33 generational politics, criticism of, 33 geriatrics, 34–5, 37–40, 234; status of, 39 Germany, 29, 46 gerontocracy, 5, 33, 51 Gingrich, Jane R., 171, 172 Ginn, Jay, 34 Global Age-Friendly Cities Project, 241 Globe and Mail, 21–2, 132, 256, 275 Government of Canada. See federal government

351

grandparents, 5, 6; tax credit for, 189 grey power, 32, 33 Grignon, Michel, 155 Gros Morne, 21 Group of IX (Nova Scotia), 233, 235 Guaranteed Income Supplement (GIS), 16, 101, 103, 106, 108, 118, 123–4, 187, 218, 239 Guillemard, Anne-Marie, 34 Haddow, Rodney, 9 Hall, Peter, 23 Hansen, Colin, 114; Hansen report, 115 Harper, Stephen, 107, 117, 120–1, 137; Harper government, 114 Harris, Mike, 178, 229 Hatfield, Richard, 179 Haveman, Robert, 27 Health and Community Affairs Department (Newfoundland), 208 Health Canada, 241 health care: budgets, 6, 248, 257; crowding out, 206; financial pressures, 257; policy, 5, 36, 70, 87, 132, 152 health care professionals: power of, 36; social construction of, 36 health spending 16, 134, 138–9, 141–2, 149, 155, 160, 175; consequences of interprovincial migration among retirees, 142; crowding out, effect of, 140, 141, 153; crowding out, impact of, 160; financial capacity, 160; hospital bias of, 36; primacy of, 36 healthy aging, 37, 40, 43, 55–6, 61, 64, 66, 157, 186, 217–19, 224, 226, 233, 238–47, 249, 259, 273; healthy living strategies, 240 Healthy Aging Policy Framework (Newfoundland), 238, 246

352

Index

Healthy Aging Secretariat (Manitoba), 40 Healthy Aging strategy (Newfoundland and Labrador), 245 Hébert, Réjean, 242 heterogeneity of aging, 44, 59, 68 Hollander, Marcus, 5, 182 home care: common provincial challenges, 195; compliance of governmental policies, 169; definition, 165; federal government, 196; gendered labour force in, 169; governance, 169; lack of federal standards, 167; Manitoba policy review, 189; marginalization of, 167; partisan politics in, 178; personal savings for, 173; policy comparison, 263; policy expectations, 190; policy failure and, 179; private sector role, 170, 173; shortcomings, 164; social economy enterprises, 169, 170; spending, 164, 167; status within Canada Health Act, 166–7, 170, 191, 256; vertical coordination, 194–5; vulnerabilities of policies, 195; widespread appeal of, 163 home care market models, 195; Canada, 172–3; mixed managed market model, 175; mixed public managed market model, 174; public service model, 174, 194; semi-comprehensive managed market model, 176, 194 Home First (New Brunswick), 164 home health care, 166, 174–7, 184, 190, 192, 195 home support, 84, 166, 169–70, 173–7, 179–82, 184, 186, 190, 193–5, 257, 270; marginalization of, 192; role of non-profit organizations, 192

horizontal coordination, 8, 55, 195, 208, 216 Howlett, Michael, 94 immigration, 212. See also migration informal coordination, 219 Institute of Public Administration of Canada, 215 Institut québécois de la statistique, 205 intergenerational equity, 24, 27, 31, 57, 59, 70, 108, 125–7, 153, 253–5, 272 intergenerational exchanges, 32, 71, 189 intergenerational lens: assessment of its relevance, 253; definition of, 24; fiscal child abuse, 5, 26; home care and gender, 189; interaction with the medical lens, 70; interaction with the organizational lens, 71; interaction with the social gerontology lens, 70; relevance compared with the United States, 254; relevance in health policies, 153; relevance in home care policies, 187; relevance in pension policies, 102, 125; summary of, 14 International Association of Machinists and Aerospace Workers, 121 International Year of Older Persons, 60, 216 InterRai Home Care, 168 Ireland, 33 Italy, 21, 26, 33, 294 Ivany report (Nova Scotia), 209–10 Jablonski, Mary Anne, 217, 227 Jacobs, Allen, 76 Japan, 29, 47, 77, 79, 199 Japanese miracle, 77 Joint Expert Panel on Pension Standards (Alberta and British Columbia), 110–13, 308–9 Joshi-Koop, Sima, 94

Index Kaufman, Sharon, 38 Kingdon, John, 93 Kotlikoff, Laurence, 5, 26–8, 59 Kuhn, Thomas, 23 L’actualité, 272 L’Appui pour les proches aidants d’aînés (Quebec), 186 labour market, 6, 28–30, 47, 56, 61, 83, 86, 113, 119, 126, 128, 140, 142, 152, 157, 160, 170, 183, 187, 189, 194, 196, 201, 211–14, 266, 314; gender gap and dynamics, 184, 186, 214; older workers, 201, 207; policy contradictions, 199; shortages, 204; shortages in health care, 142, 154; shortages in residential care facilities, 151, 161 labour unions, 33 Lakatos, Imre, 8, 22–3 leadership, impact on the long view, 92 left-wing governments, 33, 45, 77, 83, 178 left-wing parties, 56, 83, 84, 179 lens, definition, 21–3 lenses of population aging: assessment, 252; origins, 8 Liberal Party: in British Columbia, 134; in Canada, 103, 121, 122, 268; in New Brunswick, 262; in Nova Scotia, 209; in Ontario, 120, 195; in Quebec, 205, 242, 255, 262, 265 liberal welfare regime, 271 Local Health Integrated Networks (Ontario), 176 longevity pension, 110, 117, 118, 119 long-term care: definition, 145; insurance, 196; marginalization of, 161; primacy of residential care facilities, 256; status within

353

Canada Health Act, 145, 161, 191, 195 long view, 77; administrative procedures and, 88; assessment of theoretical expectations, 262; career civil servants and, 76, 84, 88; definition of, 86; development of strategies and, 89; elements facilitating or impeding, 90; instruments, 88; learning initiatives and, 87; partisanship and, 83; policy capacity, 93; professionalization of, 94; promotion within public administrations, 86; short-term bias, 83, 213 Lynch, Julia, 33, 236, 273 Machiavelli, 75 Madrid International Plan of Action on Ageing, 225, 293 maison des aînés (Quebec), 262 Maltais, Agnès, 118 Manitoba, 40, 89, 91–2, 107, 116, 122–3, 146, 150, 152, 164, 166, 168–74, 177–8, 182, 184–5, 188–90, 194–5, 212, 215, 225, 231–3, 235, 237, 240–1, 243, 246, 249, 263–4 Manitoba Seniors Directorate, 243 Maritimes, 10, 142, 148, 255. See also Atlantic provinces Martin, Paul, 281n27, 306n16 Martin, Xavier-Sala-i, 30 McArthur, Doug, 261 medicalization of home care services, 190 medical lens: assessment of its relevance, 256; commitment to science, 35; criticism of, 41; definition of, 34; interaction with the intergenerational lens, 70; interaction with the organizational

354

Index

lens, 72; interaction with the social gerontology lens, 72; predominance of, 132; public perception of aging and, 37; relevance in health policies, 154; relevance in home care policies, 190; summary of, 14 medical profession, 36, 38–9, 169, 217 medicare, 5, 154 Meiers, Markus, 139 Memorial University, 265 Menec, Verena, 151 Metcalfe, Les, 260 migration, 7, 89, 193, 207, 210–11; impact of interprovincial migration of retirees, 142–3 Ministère de la famille (Quebec), 229 Ministère de la famille et des aînés (Quebec), 228 Ministère de la santé et des services sociaux (Quebec), 156, 228, 232, 242 Ministère du Conseil exécutif (Quebec), 203, 205–8, 214, 218, 221–2, 260, 265 minister for seniors and caregivers (Quebec), 272 minister for social development (New Brunswick), 176, 229, 233, 240, 257, 272, 274, 327n87 Ministry of Advanced Education and Skills (Newfoundland), 204 Ministry of Citizenship, Immigration and International Trade (Ontario), 228 Ministry of Family Affairs (Quebec), 232, 242 Ministry of Finance (Alberta), 217 Ministry of Finance (Newfoundland), 265 Ministry of Health (Alberta), 227, 242 Ministry of Health (British Columbia), 172, 181, 227

Ministry of Health and Community Services (Newfoundland), 230 Ministry of Health, Healthy Living and Seniors (Manitoba), 243 Ministry of Health, Seniors and Active Living (Manitoba), 243 Ministry of Healthy Living (Manitoba), 249 Ministry of Healthy Living and Sport (British Columbia), 227, 243, 247 Ministry of International Trade and Industry (Japan), 77, 79 Ministry of Post-Secondary Education, Training and Labour (New Brunswick), 204 Ministry of Seniors (Alberta), 227, 242 Ministry of Seniors’ Affairs (Ontario), 228 Ministry of Seniors and Accessibility (Ontario), 228 Ministry of Seniors and Community Support (Alberta), 227 Ministry of Seniors and Housing (Alberta), 227 Ministry of Tourism and Culture (Ontario), 231 Ministry of Tourism, Culture and Sport (Ontario), 228 Mintzberg, Henry, 80 Mintz, Jack, 110, 114 Mintz report, 110, 115 Municipalités amies des aînés (Quebec), 241 Musgrave rule, 5–7, 25, 31–2, 59, 62, 64, 67, 71–2, 102, 126; criticism of, 31, 32; definition of, 31 Myles, John, 117 National Framework on Aging (Canada), 241 National Household Survey, 169

Index New Brunswick, 9–10, 16, 89, 91–2, 116, 146–7, 151–2, 155, 157, 160, 164, 168, 170, 173, 175–6, 179–80, 184–5, 192, 202, 204, 208, 212, 220, 224, 231, 233, 236, 240, 246, 249, 250, 252, 257, 260–5, 274 New Brunswick Home Support Association, 176 New Democratic Party: in Alberta, 122, 125, 261; in British Columbia, 179; in Canada, 83, 121; in Manitoba, 178, 195, 243; in Nova Scotia, 209, 222; in Ontario, 195; in Saskatchewan, 83, 142, 178, 264 Newfoundland and Labrador, 13, 21–2, 50, 90, 139, 149, 164, 180, 186, 203, 208, 215, 220, 224, 226, 230–5, 237, 240–1, 245–6, 248–52, 255, 261, 265 new gerontology, 42; criticism of, 43 New Public Management, 11, 47, 79, 81, 96, 170, 178, 182 New Zealand, 33, 115 Nova Scotia, 9, 39, 91–2, 108, 110, 112, 115–16, 127, 134, 136–7, 147, 153, 160, 164, 168–9, 171, 176, 179, 181, 185, 203, 209–10, 222, 225, 230–5, 237–8, 240–1, 245–6, 250, 255, 259, 263–4 Nova Scotia Office of the Ombudsman, 164 Nova Scotia Pension Review Panel, 110–13, 127 nursing, 9, 36, 40, 72, 145, 147, 151–2, 154, 156, 159, 166, 169, 171, 177, 181–2 occupational pension plan, 107, 128 occupational therapists, 166 Office for Aging and Seniors (Newfoundland), 230, 240, 245 Office of Policy and Priority (Nova Scotia), 209

355

Office of the Ombudsperson (British Columbia), 180, 248 Office of the Seniors’ Advocate, 250; in British Columbia, 248; in Newfoundland and Labrador, 249 Office of the Superintendent of Financial Institutions Canada (OFSI), 106 offices for seniors, 10–12, 37, 40, 71, 73, 87, 223–5, 233, 236–9, 244, 247, 250, 258–60, 268–9, 273; consultations, 235; coordination, 236; definition of, 17; dissemination of information, 234; diversity of organizational settings, 226; health promotion shift in, 249, 250; learning opportunities, 245; mandate, 234; obstacles to establish the long view, 246; policy instruments and policy input, 237; resources, limited, 250, 260; social perspective within, 243; staff size, 236; tension between medical and social lenses, 239; time horizon, 244; as traditional departments, 231 Old Age Security (OAS), 16, 101, 103, 105–6, 108, 118 ombud office, 12, 89, 143, 168, 182, 252 ombudsperson, 10, 180, 185, 248, 250, 251, 263, 267; in British Columbia, 146, 147, 164, 188; in Quebec, 152, 165 One Nova Scotia Coalition, 203, 209, 210, 222, 335, 342, 343 Ontario, 9–10, 16, 22, 75, 77, 89, 91–3, 102, 104, 106, 108–10, 112–14, 116–17, 119–23, 126–7, 143, 145–7, 149, 156, 158–9, 161, 164, 168–72, 176–8, 181, 183, 185, 188, 194–5, 202, 211–14, 220, 225, 231–2, 235, 238, 246, 250, 253–4, 258, 261, 263, 265–6, 272

356

Index

Ontario Chamber of Commerce, 121 Ontario Convenience Stores Association, 121 Ontario Expert Commission on Pensions, 110–12, 113 Ontario Restaurant Hotel and Motel Association, 121 Ontario Retirement Pension Plan, 102, 107–8, 110, 114, 117–23, 126, 128–30 Ontario Retirement Pension Plan Administration Corporation, 121 Ontario’s Long-Term Report on the Economy, 214 OPS Inclusion Lens (Ontario), 22 Oreopoulos, Philip, 26 Organisation for Economic Co-operation and Development (OECD), 28, 47, 60, 127, 143, 164, 199–200, 203, 208, 220, 257 organizational lens: assessment of its relevance, 259; definition of, 46; interaction with the intergenerational lens, 71; interaction with the medical lens, 72; policy coordination, 201; relevance in health policies, 157; relevance in home care policies, 194; relevance in pension policies, 128; summary of, 15 Paquet, Mireille, 9 paradigm, 8 Parti Québecois, 118, 175, 178–9, 195, 205, 242 pension fund management, 270 Peters, B. Guy, 52, 63, 68, 259 Pierson, Paul, 34 Plan for the People: Economic Outlook and Fiscal Review, 211 planners, 75–6, 78, 80, 94, 304 planning: abandonment of, 78; as the fourth power of government,

76; historical overview, 77; revival of, 80; size of civil service, 265; strategic, 78–82, 85; theology and, 78 Planning, Program, and Budgetary System, 77–8, 85 pleine participation des aînés au développement du Québec, Une, 225 policy capacity, impact on the long view, 93 policy feedback, 33, 57, 95, 129, 235, 256, 268; Canada Health Act and, 155 policy learning and diffusion, 269 policy problems: causality and, 56; characteristics of, 52; complexity of, 61; construction of problem population, 62; establishment of, 52; governmental capacity and, 66; interdependencies of, 68; monetarization of, 65; novelty of, 60; proximity of, 60; severity of, 59; solvability of, 63 political appointees, 7, 91, 93, 142, 202, 220, 264–5 political scientists, 32, 61 politicization of the civil service, 8, 68, 202, 222, 264; impact on the long view, 90 Pooled Registered Pension Plan, 107, 115–17, 120–1 population aging: challenges and opportunities, 5–6; consequences on health spending, 138; health spending and views from civil servants, 140; newspaper headlines, 21; unavoidability, 3, 7 Population Growth Secretariat (New Brunswick and PEI), 204 Population Growth Strategy: in New Brunswick, 204; in Newfoundland and Labrador, 204, 261

Index positive gerontology, 40. See also new gerontology Prairies, 151 Premier’s Council on Aging and Seniors (British Columbia), 247 Premier’s Office. See executive council Premier’s Panel on Seniors (New Brunswick), 236, 261 Presse, La, 21, 132, 256 Primary Caregiver Tax Credit (Manitoba), 185, 215 Primary Informal Care Benefit (New Brunswick), 185 Prince Edward Island, 89, 93, 106, 114, 116, 134–6, 139, 145, 149, 174, 180, 204, 220, 229, 233 Principles of the National Framework on Aging: A Policy Guide (Canada), 60 Provincial Healthy Aging Policy Framework (Newfoundland), 186 Public Accounts Committee (Canada), 27 Quebec, 9–10, 16, 45, 66, 75, 78, 85, 89–93, 102–7, 109–12, 114, 116–19, 122–7, 129, 131, 136, 143, 145–6, 148, 152, 158–9, 161, 164, 167–71, 174–5, 177–9, 181–6, 188, 191, 193, 195, 200, 202–5, 207–8, 212, 214–16, 218, 220–2, 225–6, 231–3, 236, 241–2, 245–6, 248, 253–5, 257, 260, 262–3, 265, 267–8, 271–2 Quebec Pension Plan, 16, 75, 102–6, 108–10, 117–19, 123–6, 128–31, 253–4, 268 Québec pour tous les âges, Un, 262 Redford, Alison, 242, 261 regional health authority, 141, 152, 166–7, 170, 172–7, 181–2, 184, 192, 195–6, 257, 267; Winnipeg Regional Authority, 177

357

Registered Pension Plans, 104, 108, 109, 114, 115, 127 Registered Retirement Savings Plan (RRSP), 30, 101, 104, 106, 107, 109, 115, 116, 120, 307 rente de longévité, 110 Republic of Doyle (TV show), 21 residential care facilities, 9, 16, 72, 143, 145–9, 151–2, 154–61, 164, 248, 262, 272; differences between public and private operators, 147; integration between home care and, 149; resource allocation in rural areas, 150; type of ownership, 145; waiting times, 16, 146 Retraite Québec, 113, 118, 124 Richards, John, 138, 140 right-wing parties, 56, 83, 178 Rochefort, David, 52, 63 RRQ scenario, 124 rural and remote communities, 151, 152, 161 rural/urban cleavage, 255 Russ, Ann, 38 Sabatier, Paul, 22 SafeCare BC, 182 sandwich generation, 6, 189 Saskatchewan, 7, 10, 73, 77, 91–2, 107, 114, 116, 142, 150, 171, 174, 177–8, 180, 233, 263, 264 Saskatchewan Health Authority, 171 Saskatchewan Party, 142, 233, 264 Saskatchewan Provincial Advisory Committee of Older Persons, 233 Savoie, Donald, 209, 255 Scandinavian countries, 46, 83, 167, 257. See also Denmark; Sweden Schulman, Paul, 66, 67 Secrétariat aux aînés (Quebec), 232, 245, 265

358

Index

Secrétariat aux priorités et aux projets stratégiques (Quebec), 206 Seniors Action Plan (British Columbia), 248 Seniors Advisory Council for Alberta, 233 seniors’ advocate, 143, 156, 169, 180, 186, 224, 250; in Alberta, 164, 248; in British Columbia, 143, 146–7, 149, 164, 186; in Newfoundland, 164 Seniors Advocate Office (British Columbia, Alberta, Newfoundland, and New Brunswick), 248 Seniors and Continuing Care Provincial Advisory Council (Alberta), 233 Seniors and Healthy Aging Secretariat (Manitoba), 249, 265, 338 Seniors and Healthy Aging Secretariat (New Brunswick), 240 Seniors and Healthy Living Secretariat (Manitoba), 240 Seniors and Housing Department (Alberta), 242 Seniors Directorate (Manitoba), 249 Seniors’ Health Promotion Directorate (British Columbia), 40 Seniors’ Health Promotion Team (British Columbia), 240, 243 Seniors’ Healthy Living Secretariat (British Columbia), 240, 247 Seniors’ Secretariat in Nova Scotia, 245; in Prince Edward Island, 233 Seniors’ Wellness Strategic Network (Alberta), 240 Shim, Janet, 38 Silver Economy summit (Nova Scotia), 245 Sinn, Hans-Werner, 31 social care, 166, 258

social determinants of health, 41, 72, 234, 239, 244, 273 social economy enterprises, 174, 175, 177, 179. See also home support social gerontology lens: assessment of its relevance, 258; definition of, 41; interaction with the intergenerational lens, 70; interaction with the medical lens, 72; interaction with the organizational lens, 73; politicaleconomy approach, 45; relevance in health policies, 154; relevance in home care policies, 192; relevance in pension policies, 127; summary of, 14 social policies, marginalization of, 271 Social Policy Advisory Committee (Newfoundland), 265 social services, 5–9, 36, 41, 89, 133, 151, 156, 167–9, 171, 175–6, 190, 194, 243, 258, 263, 269–70 social stratification, 24, 41, 45, 243 social work, 40, 217 Sorbero, M.E., 38 Soviet Union, 79 Spain, 21 Spencer, Byron, 155 Standing Committee on Social Policy on the legislative proposal (Ontario), 120 statistical offices, 211, 266, 267 Statistics Canada, 27, 138, 215, 267, 269, 275, 278, 282, 283, 290, 307, 317, 318, 323, 325, 338 Stelmach, Ed, 203, 217, 219, 242, 255, 261, 264 Stratégie d’action en faveur des aînés (Quebec), 215, 246 Strategy for Positive Ageing (Nova Scotia), 185, 238, 240, 246, 259 successful aging, 40–1, 43, 55, 62

Index Survey of Health, Ageing and Retirement in Europe (SHARE), 17, 30 Sustainable Development Strategic Plan (Quebec), 207, 253 Sweden, 11, 79, 87, 250, 257. See also Scandinavian countries Tax-Free Savings Account, 104, 106–7, 115 Texas Instruments, 78, 80 time to death, 17, 139 Treasury Board, 27, 200, 202 Trudeau, Justin, 129–30 tsunami, 59, 62, 67, 71 Twitter, 7 United Kingdom, 11, 23, 33–4, 37, 79, 145, 153 United Nations, 43, 47, 225 United States, 5, 25–7, 30, 33–4, 36–7, 39, 46, 59, 67, 70, 76, 78–9, 81–2, 85, 91, 104, 118, 126, 145, 153, 168, 190–1, 223, 235–6, 254, 255, 272; Administration on Aging (USA), 223; Air Force, 76, 80, 81, 86; Congressional Budget Office, 26; Department of Defense, 77; Medicare, 26, 36, 70, 191, 235, 254; Older Americans Act, 16, 223; Social Security, 26, 28, 34, 104, 235, 254; war on cancer, 67

359

Vaillancourt, François, 26 VanderBurg, George, 217, 227 Victorian Order of Nurses, 171 Vieillir et vivre ensemble (Quebec), 246 Voluntary Registered Savings Program, 114, 116, 117 Wallner, Jennifer, 268 We Are All in This Together (New Brunswick), 260 Weaver, Kent, 125, 129, 295, 305, 307, 311, 312, 324, 344 welfare state, 7, 10, 26, 28, 31, 45, 56, 57, 61, 70, 71, 178–9, 183, 194, 236, 271; comparative, 28, 45, 183; markets in, 171; typology, 183 Western Canada pension plan, 108, 115, 129 White, Graham, 203 Wildavsky, Aaron, 78 Wiseman, Russ, 230, 232, 265, 339n12 women’s offices, 12, 128, 149, 164 Wood, Donna, 9 Working Income Tax Benefit (Canada), 123 World Bank, 28 World Health Organization (WHO), 43, 60, 240, 241, 247, 259, 273 Wynne, Kathleen, 120–1, 130, 231 Zweifel, 139

This page intentionally left blank

The Institute of Public Administration of Canada Series in Public Management and Governance Networks of Knowledge: Collaborative Innovation in International Learning, Janice Stein, Richard Stren, Joy Fitzgibbon, and Melissa Maclean The National Research Council in the Innovative Policy Era: Changing Hierarchies, Networks, and Markets, G. Bruce Doern and Richard Levesque Beyond Service: State Workers, Public Policy, and the Prospects for Democratic Administration, Greg McElligott A Law unto Itself: How the Ontario Municipal Board Has Developed and Applied Land Use Planning Policy, John G. Chipman Health Care, Entitlement, and Citizenship, Candace Redden Between Colliding Worlds: The Ambiguous Existence of Government Agencies for Aboriginal and Women’s Policy, Jonathan Malloy The Politics of Public Management: The HRDC Audit of Grants and Contributions, David A. Good Dream No Little Dreams: A Biography of the Douglas Government of Saskatchewan, 1944–1961, Albert W. Johnson Governing Education, Ben Levin Executive Styles in Canada: Cabinet Structures and Leadership Practices in Canadian Government, edited by Luc Bernier, Keith Brownsey, and Michael Howlett The Roles of Public Opinion Research in Canadian Government, Christopher Page The Politics of CANDU Exports, Duane Bratt Policy Analysis in Canada: The State of the Art, edited by Laurent Dobuzinskis, Michael Howlett, and David Laycock Digital State at the Leading Edge: Lessons from Canada, Sanford Borins, Kenneth Kernaghan, David Brown, Nick Bontis, Perri 6, and Fred Thompson The Politics of Public Money: Spenders, Guardians, Priority Setters, and Financial Watchdogs inside the Canadian Government, David A. Good Court Government and the Collapse of Accountability in Canada and the U.K., Donald Savoie Professionalism and Public Service: Essays in Honour of Kenneth Kernaghan, edited by David Siegel and Ken Rasmussen Searching for Leadership: Secretaries to Cabinet in Canada, edited by Patrice Dutil Foundations of Governance: Municipal Government in Canada’s Provinces, edited by Andrew Sancton and Robert Young Provincial and Territorial Ombudsman Offces in Canada, edited by Stewart Hyson Local Government in a Global World: Australia and Canada in Comparative Perspective, edited by Emmanuel Brunet-Jailly and John F. Martin Behind the Scenes: The Life and Work of William Clifford Clark, Robert A.Wardhaugh The Guardian: Perspectives on the Ministry of Finance of Ontario, edited by Patrice Dutil

Making Medicare: New Perspectives on the History of Medicare in Canada, edited by Gregory P. Marchildon Overpromising and Underperforming? Understanding and Evaluating New Intergovernmental Accountability Regimes, edited by Peter Graefe, Julie M. Simmons, and Linda A. White Governance in Northern Ontario: Economic Development and Policy Making, edited by Charles Conteh and Bob Segsworth Off and Running: The Prospects and Pitfalls of Government Transitions in Canada, David Zussman Deputy Ministers in Canada: Comparative and Jurisdictional Perspectives, edited by Jacques Bourgault and Christopher Dunn The Politics of Public Money, Second Edition, David A. Good Commissions of Inquiry and Policy Change: A Comparative Analysis, edited by Gregory J. Inwood and Carolyn M. Johns Leaders in the Shadows: The Leadership Qualities of Municipal Chief Administrative Offcers, David Siegel Funding Policies and the Nonproft Sector in Western Canada: Evolving Relationships in a Changing Environment, edited by Peter R. Elson Backrooms and Beyond: Partisan Advisers and the Politics of Policy Work in Canada, Jonathan Craft Fields of Authority: Special Purpose Governance in Ontario, 1815–2015, Jack Lucas A Quiet Evolution: The Emergence of Indigenous−Local Intergovernmental Partnerships in Canada, Christopher Alcantara and Jen Nelles Canada’s Department of External Affairs, Volume 3, Innovation and Adaptation, 1968−1984, John Hilliker, Mary Halloran, and Greg Donaghy Federalism in Action: The Devolution of Canada’s Public Employment Service, 1995–2015, Donna E. Wood Distributed Democracy: Health Care Governance in Ontario, Carey Doberstein Top Secret Canada: Understanding the Canadian Intelligence and National Security Community, edited by Stephanie Carvin, Thomas Juneau, and Craig Forcese The Four Lenses of Population Aging: Planning for the Future in Canada’s Provinces, Patrik Marier