Pursuing Different Paths in Long-Term Care: Manitoba, Ontario and the Politics of Commercialization”
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“Pursuing Different Paths in Long-Term Care: Manitoba, Ontario and the Politics of Commercialization” A Dissertation Submitted to the Committee on Graduate Studies in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy in the Faculty of Arts and Science TRENT UNIVERSITY Peterborough, Ontario, Canada (c) Copyright by Amy Twomey 2014 Canadian Studies Ph.D. Program May 2014 ii ABSTRACT Pursuing Different Paths in Long-Term Care: Manitoba, Ontario and the Politics of Commercialization Amy Twomey Because federal funding for long-term care was not included as part of Canada’s publicly-funded universal health care system, provincial governments have been free to determine how much, or how little, they will rely on the for-profit sector to meet the long- term care needs of their senior populations. The proportion of beds in the for-profit sector differs in each province, demonstrating that policy approaches to this type of care have developed according to distinct provincial political contexts. In this dissertation I explain why governments in two provinces, Manitoba and Ontario, have come to rely on the proprietary sector to markedly different degrees. While in the federation Manitoba stands out for its restrained reliance on this form of care, Ontario stands out for its exceptional dependence on commercial provision. In the chapters that follow I employ an historical institutionalist framework of analysis to explain why these neighbouring provinces initially pursued different policy paths in long-term care and how these paths have been sustained over time. Following an introductory chapter in which I explain the reasons for the marginalization of long-term care within national health policy making, I provide in- depth analysis of these case studies in policy divergence. I argue that contemporary policy differences between these neighbouring provinces cannot be understood in isolation from long-term historical processes. Focusing largely on the period from the 1960s to the 1990s, I emphasize that present differences in ownership are a reflection of the different constellation of actors, events, ideas and institutions that came together at critical iii junctures in time, and the lasting legacies that these early windows of opportunity for reform have had on subsequent rounds of long-term care policy-making. In each province, diverging ideas about the appropriate role of the for-profit sector in meeting the long-term care needs of an aging population rose to prominence on the political agenda. Over time, rigidities developed in each system, making it difficult for actors advocating for new directions in ownership to realize their ambitions. In both provinces policies put in place at earlier times greatly influenced future political dynamics, altered the guiding principles of government departments and policy makers, provided incentives for different interest group formations, and led to contrasting public expectations about the proper balance of the for-profit and non-profit sectors in long-term care provision. I conclude this dissertation by arguing that its findings can contribute in important ways to present discussions about long-term care reform in Canada generally and about the future role of for-profit providers specifically. Key Words: long-term care, health care, provincial politics, comparative politics, interest groups, policy development, path-dependence, historical institutionalism iv Acknowledgements I am very thankful to those who have helped make this dissertation possible. Jim Struthers has been an incredible supervisor. Never wavering in his support and enthusiasm for my work, Jim has helped me reach heights I did not know were possible. I owe much to Jim for my growth as a student, and as a person, during my tenure at the Frost Centre. I am fortunate to have had his guidance, and to call him and his wife Betsy friends. Collectively, my committee has made this long journey worthwhile and rewarding. I am thankful to Sally Chivers for her advice and support along the way. Sally was always encouraging of my work and offered much appreciated feedback. From Carleton, Hugh Armstrong provided me with helpful comments and advice on new research directions. In was pleased to have Dimitry Anastakis serve as my internal/external examiner. Since my first days in the program I have appreciated and valued Dimitry’s input. I am also grateful to my external examiner Nelson Wiseman, who first encouraged me to study comparative provincial politics while I was an undergraduate student at the University of Toronto. I am thankful to Trent University for financially supporting my research through the Dean’s Ph.D. and Research Fellowship Grants, the Shelagh Grant Endowment Fund, and the John Wadland Scholarship. Receiving a scholarship in John’s name is one of my fondest memories at the Frost Centre. John, along with Julia Harrison, helped make my experience as a doctoral student enjoyable. I would also like to thank the financial support of the Reimagining Long Term Residential Care SSHRC project. The project provided me with important research opportunities and greatly contributed to my development as a scholar. v I am thankful to the support of my family and friends. My parents, John and Lenore Twomey, instilled in me from an early age the belief that I can do big things. Pursuing a Ph.D. is an emotionally trying experience, particularly during the writing process. Feelings of grandeur and great accomplishment are easily exchanged with feelings of inadequacy and impossibility. When such feelings crept in, it was always helpful to call home and be reassured that I could indeed do this, and do it well. I am also very thankful to my sister Tracey and her husband Greg for their support and love in the lead up to my defence. Whether it was reading through my dissertation, indulging me as I practice Power Point presentations, or helping me forget about school and have fun on a Saturday night, they were a great source of support. Finally, I am so very thankful to my partner Chris Grady. Completing a dissertation that I can feel a great deal of pride and accomplishment in has taken time. Throughout the entire process Chris has been patient, compassionate and incredibly supportive. In short, he has been my biggest fan. I dedicate this dissertation to him. I also owe much thanks to Chris’s parents, Joan and Paul Grady, for their support. When you have a great group of people behind you, it is indeed possible to accomplish big things. vi Table of Contents Abstract ........................................................................................................................................... ii Acknowledgements ........................................................................................................................ iv Table of Contents ........................................................................................................................... vi Chapter 1: “Making Sense of Long-Term Care Policy Divergence in Manitoba and Ontario” ....... 1 Works Cited ...................................................................................................................... 23 Chapter 2: “The Marginalization of Long-Term Care in National Health Policy Making: Canada, Britain and the Path of Least Involvement” ................................................................................... 26 Works Cited ...................................................................................................................... 80 Chapter 3: ‘In from the Fringe’: Entrenching Non-profit Long term care within Manitoba's Welfare State, 1969-1999” ............................................................................................................. 87 Works Cited .................................................................................................................... 149 Chapter 4: “‘Open for Business’: Expanding Privatization within Ontario's Long-term Care Sector, 1966 1991” ....................................................................................................................... 154 Works Cited .................................................................................................................... 219 “Conclusion: Lessons Learned and Future Directions in Long-Term Care” ............................... 225 Works Cited .................................................................................................................... 244 1 Chapter 1. Making Sense of Long-Term Care Policy Divergence in Manitoba and Ontario When thinking about those aspects of our social fabric that define us as a nation, many Canadians are often inclined to point to the health care system. Indeed, as Naylor has argued, “Canada’s publicly funded health care system is more than a social program; it is a unifying force, a national obsession, and, not least, one of the few features that allows Canadians to differentiate themselves from their neighbours to the south” (Naylor, 1999, p. 24). The defining features of Canadian medicare – that care provided in hospitals and physicians’ offices should be universal, publicly administered, comprehensive, accessible and portable – are viewed by many as “a hallmark of Canadian society” (Romanow, 2002, p. 60). As more people are living longer into old age with chronic conditions and long-term disabilities, and as media and political accounts often point to a looming demographic crisis, or ‘grey tsunami’, brought on by aging baby