The long-term care (LTC) home crisis in Ontario is a case study in the perils of treating healthcare as a vehicle for profit.
A recent report from the Canadian Medical Association (CMA) on the risks of COVID-related deaths in Ontario residences found significantly worse outcomes in for-profit and non-profit homes than in publicly run homes – outbreaks were far more likely in both for-profit and non-profit facilities and the death rate was nearly double that of the public sector.
As an overwhelming majority of Ontario’s 623 residences are run by chain companies – 57.7 per cent for profit, 26 per cent non-profit and 16.2 per cent municipal – the necessity of including long-term care in a truly universal, publicly funded and accessible healthcare system has never been clearer.
Those in power have ignored strong criticisms of the living and labour conditions in Canada’s LTC system for decades. But the research is unambiguous: for-profit facilities offer comparatively substandard care. In fact, the CMA recommended a transition away from private facilities as far back as 1984. It should come as no surprise that LTC homes were woefully unprepared to survive the impact of the virus.
The private care horror show
The poor living and labour conditions in LTC facilities have made them petri dishes for rapid contagion. Across Canada, 80 per cent of COVID-related fatalities have occurred in LTC facilities – double the average of other OECD countries. Ontario itself is struggling to cope with an embarrassing 70 per cent of its total deaths in LTCs. What’s worse, mismanagement and neglect within Ontario’s long-term residential homes are disturbingly widespread. Reports of LTC misconduct reveal that an alarming number of those who died from COVID-19 were already suffering in environments marred by gross indignity and, in some cases, abuse.
Military intervention during the first wave of the pandemic attracted significant media attention across Canada. The struggles of care workers and residents – long hidden from sight – finally came into public view. The military personnel sent to five homes in the Greater Toronto Area – four run by for-profit firms and one non-profit – were asked to compile an official report based on their observations.
The findings are as heartbreaking as they are horrifying. They include numerous instances of elder abuse, physical violence, forced feeding (“audible choking”) and a liberal use of chemical restraints. Staff were seen ripping out catheters, leaving wounds and infections untreated and using unsterile equipment. Residents often waited for assistance while in soiled diapers.
Military personnel also noted extremely poor environmental standards and widespread bedbug and pest infestations. Cramped LTC living quarters offered little room for quarantining. And because a majority of staff are employed part-time at several different homes, workers have unwittingly ferried COVID-19 across sites and made outbreaks extremely difficult to contain.
An investigation by the CBC revealed that 85 per cent of LTC homes in Ontario have routinely violated healthcare standards for decades with near-total impunity. One family featured in the investigation grew suspicious after witnessing a significant decline in their mother’s wellbeing shortly after moving into a private nursing home. They decided to hide a camera in her room. The footage has been described as akin to “watching a horror film.”
How has it come to this?
The LTC crisis is a result of decades of welfare-state retrenchment and the general weakness of Canada’s pension-plan model. In 1995, Ottawa dramatically overhauled the system of federal transfer payments to the provinces. These transfer payments had previously funded the bulk of Canadian healthcare, education and social services. Over the course of this transition, governments quietly cut billions of dollars from these essential programs. This downloading of costs from federal to provincial governments was a trend from the late 1980s to mid-90s as all levels of government moved toward fiscal conservatism and privatization.
With far fewer revenue-generating mechanisms for the provinces, the programs now faced significant funding challenges. Partnering with the private sector became an increasingly attractive proposition for cash-strapped local governments.
These revenue constraints contributed to the development of Ontario’s patchwork LTC system. The history of LTC in the province is one of path dependency and neglect. The core of the problem is that the present LTC system, as Richard O’Donnell, former president of the for-profit Ontario Nursing Home Association puts it, “was never planned; it has simply evolved.”
Prior to any form of private or institutionalized care, families were expected to look after their own elderly relatives. The late 18th and early 19th centuries saw the emergence of a two-tier system marked by privately owned boarding homes for seniors and Dickensian public options like the poorhouse. These enterprises were eventually absorbed into an emerging and rapidly expanding private hospital sector across Canada. By the 1940s, the commercial provision of nursing home care as a distinct service had proliferated, with both public provision and regulation lagging far behind.
Since the 1990s, most provinces have been dependent on the commercial sector to meet needs. Ontario covers all “medically necessary” services for seniors, even those that are undertaken by homes run by for-profit companies and the non-profit sector. Outside of the public system, room and board is generally paid out-of-pocket by residents and can cost anywhere between $1,800 to $3,000 per month. Homes for wealthier seniors can cost thousands of dollars more.
The perils of privatization
Because LTC facilities service an aging population – what’s known as a “guaranteed consumer-base” – they are understood to provide lucrative opportunities for private profiteering. The introduction of debt-financing for private operators has ensured corporate hegemony over LTC provision. And the entry of real-estate investment trusts (REITs) – companies that own or finance income-producing real estate assets – into LTC investment has accelerated the financialization of the sector. This, in turn, has attracted the interest of private equity firms.
Over the past two decades, REITs, international investors and private equity firms have acquired control of 17 per cent of all LTCs and 38 per cent of retirement homes across Canada. Many of the financial firms profiting from the commodification of elder care such as Chartwell, Revera and Sienna will sound familiar to anyone who has been following the horrific revelations about the state of long-term care in Ontario. Three of the largest for-profit LTC home operators in Ontario – Extendicare, Sienna Senior Living and Chartwell – have together spent millions on executive compensation and stock buybacks and have paid out more than $1.5 billion in dividends to shareholders over the last decade.
Both the privatization and financialization of long-term care are consistent trends across Canada. But Ontario has the highest proportion of for-profit LTC homes in the country. Some scholars estimate that, compared to all other provincial healthcare systems, Ontario’s delivery and management of LTCs is Canada’s most commercialized area of healthcare “with the possible exception of pharmaceutical manufacturing.” Study after study finds that for-profit facilities offer lower quality care, lower staffing levels and engage in egregious labour practices.
Despite lower death rates and flattening the curve far more effectively than the for-profit and non-profit sectors, inadequate funding from all levels of government has taken a toll on the public system as well. A city-run facility in Ottawa recently made headlines for much the same reasons as private LTC homes: inadequate infection control, repeated medication errors, poor skin and wound care and accounts of abuse.
Private LTCs don’t care about the labour in care
The overwhelming majority of expenditures for LTC homes are labour costs. Keeping these costs low is key if LTC businesses want to maintain their profits. According to the latest available data on staffing in Ontario’s LTCs, personal support workers (PSWs), registered nurses (RNs) and nurse practitioners (NPs) in for-profit homes are paid less than those in public ones. An overwhelming number of staff in private homes – 48 per cent of PSWs and 30 per cent of nurses – work part-time across multiple facilities and hold two or more jobs to stay afloat. Workers in public facilities have more job security, higher wages and dramatically higher rates of unionization compared to both the for-profit and non-profit sectors.
What’s more, the pandemic has also exposed critical vulnerabilities in the not-for-profit model. Major revenue sources like charitable donations and fundraising events are highly sensitive to market instability. The sector has been calling on the government for increased funding and resources to address staffing issues for years.
In its report, the Canadian military noted a “culture of fear” among exhausted and poorly paid workers who are afraid to speak out or question employer practices. Precarious and perilous conditions of employment in private residences have led to high staff turnover; disrupted care; dangerous communication issues during shift changes; poor continuity of care (especially important for seniors with dementia or Alzheimer’s); and little opportunity for staff to build meaningful, therapeutic relationships with residents.
The absence of any political will to address long-standing issues of neglect in LTC facilities impacts residents and workers alike. The exploitative labour practices in most LTC facilities have taken a huge toll on a predominantly female and racialized workforce. Recent research from the Canadian Union of Public Employees found that 88 per cent of staff in LTC facilities endure physical violence, sexual harassment and verbal abuse at work; 70 per cent of racialized and Indigenous staff experience routine racism; and 75 per cent felt they were unable to provide adequate care due to staff shortages.
Staffing skills also impact quality care and the wellbeing of workers thrown into complex clinical situations without much support or training. It’s estimated that unregulated, non-professional workers provide 75 to 80 per cent of direct care to nursing home residents in Canada. These workers are burdened with excessive and grueling work and an inordinate amount of responsibility. The current LTC system treats residents and care workers alike as highly disposable.
It is time for universal and entirely public long-term care
Over the past few months, grieving families have launched class-action lawsuits against LTC facilities in which they believe family members have suffered “unnecessary and preventable” COVID-19 related deaths. The province is also being held to legal account for its negligence and inaction – a Toronto-based firm has served the government notice of a proposed class-action suit following hundreds of avoidable illnesses and deaths during the pandemic.
Ontario Premier Doug Ford has come to the swift defense of the for-profit LTC sector, introducing a bill to extend liability insurance to businesses, workers and non-profits. The government has given assurance that the law will not absolve healthcare providers of responsibility in the face of “gross negligence.” But personal injury lawyers and the New Democratic Party have slammed the bill as dangerous on the grounds that it will make the definition of “negligence” open to debate.
Prioritizing liability concerns is all about preserving markets rather than protecting some of the most vulnerable members of our communities. Liability protection might shield homes from some undue indemnity costs but it offers little to no incentive to these companies to enact meaningful change.
To be accessible and universal, we need to see a massive investment in a public system, eliminate waiting lists, and provide a sufficient number of beds to meet growing needs. It may not be easy to change ownership models in the middle of a crisis but some countries have moved in this direction. This past spring, Spain nationalized its private hospitals and care providers.
The LTC crisis in Ontario, and elsewhere, offers the opportunity to re-imagine elder care environments as rewarding places to work and centres of compassion. This means, among other things, supporting workers by ensuring living wages, appropriate training, health benefits, full-time employment, adequate staffing and paid sick days as well as meeting the physical, social, and emotional needs of residents.
The contingent nature of life affects every stage of our existence. But the more we view healthcare, including long-term care, as a universal right, the more we can mitigate the harmful impact of life’s exigencies on our wellbeing. Long-term care should not be a commodity. It should be an essential component of a profoundly important stage of life that everyone deserves to experience in comfort and dignity.
This article was originally published in Jacobin.