Comfort, Security, Dignity: The Veterans Independence Program, A Policy History James Struthers, Ph.D © December, 2004 Comfort, Security, Dignity: The Veterans Independence Program, A Policy History James Struthers © December, 2004 CONTENTS Preface…..i-ii List of Acronyms…. iii Introduction…..1-4 Chapter 1: Origins of the Aging Veterans Program …..5-42 Chapter 2: The AVP ‘Pilot Project’ 1981-1983 …..43-56 Chapter 3: Extension of AVP …..57-76 Chapter 4: From the AVP to the VIP: The George Hees Era …..77-111 Chapter 5: The VIP, 1989-1993: Caseload Expansion and Fiscal Restraint …..112-159 Chapter 6: From Entitlement to Need: Transforming the VIP…..160-217 Conclusion…..218-226 Appendices…227-232 References….233-235 PREFACE This policy history of the Veterans Independence Program, Canada’s national home care strategy for veterans, is based primarily on an exploration of 85 linear feet of archival records pertaining to the program’s origins and subsequent development over the past quarter century, a collection currently housed at Veterans Affairs headquarters in Charlottetown PEI. The archival research was supplemented by interviews with 25 individuals who played important roles in the program’s history as policy-makers, administrators, district counselors, external advisors, or representatives of veterans organizations. During the summer of 2003 Veterans Affairs provided me with wide access to the rich body of correspondence, policy memoranda, reports, background studies, and minutes of meetings which constitute the historical record of the VIP. Department officials and others involved with the program were also generous with their time in granting me interviews to discuss their recollections of formative moments in its evolution. I am particularly grateful to Darragh Mogan, previously Director-General of Health Services for Veterans Affairs, and David Pedlar, Director of Research for the department, for their commitment to the writing of a history of the VIP, to the assistance of Stephanie Larter in the department’s Records Centre, to Michael Zinck and Mary Scott of its Research Directorate, to Johanne Nault, formerly of Veterans Affairs Canada, and to Peter Neary for his advice and encouragement. The importance of devising effective home care strategies for a rapidly aging Canadian population has never been more apparent or more widely discussed. Almost twenty-five years ago Veterans Affairs Canada began the task of ensuring that aging veterans could live in comfort, security, and dignity in their own homes for as long as possible as an alternative to institutionalization. Exploring the significance of that journey is the purpose of this study. LIST OF ACRONYMS AA Attendance Allowance ADM Assistant Deputy Minister ARC Adult Residential Care AVP Aging Veterans Program CPC Canadian Pension Commission CCSI Client-Centred Service Initiative CSO Canada Service Only (veteran) CWA Civilian War Allowance DVA Department of Veterans Affairs DPPE Directorate of Policy, Planning and Evaluation FAC Field Advisory Committee GAC Gerontological Advisory Committee GIS Guaranteed Income Supplement MSVU Mount Saint Vincent University NCVA National Council of Veterans Associations NDP New Democratic Party OAS Old Age Security OSV Overseas Service Veteran RCVN Review of Veterans Care Needs project TAP Treatment Accounts Processing VAC Veterans Affairs Canada VON Victorian Order of Nurses WVA War Veterans Allowance INTRODUCTION ‘By the end of the first decade of the twenty-first century, Canada as a whole will face the same pressure for a diversity of age-related support services now faced by Veterans Affairs. Departmental experience in this area could form the basis for preparing age-related health and social services for all Canadians.’ -- Veterans Services Headquarters Management Review, Aging Veterans Program - Extension, 15 June 1984 In recent years the cost of caring for an aging society has risen to the top of the Canadian political agenda at both the federal and provincial level. Ballooning health budgets, overcrowded emergency rooms, lengthy waiting lists for institutional care and the patchwork nature of home care are regular staples of media coverage of Canada’s health care landscape. These same issues also loom large in the recent Romanow Report, Building on Values: the Future of Health Care in Canada, commissioned by the federal government. Although the causes of a perceived ‘crisis’ in health care are complex, the relationship between population aging and rising health care expenditure is an ongoing and often ‘alarmist’ feature of current policy and media debate. Increasingly, it has also driven discussions around the need for a national home care strategy as a more cost effective alternative to the potentially crippling burden of institutional care, over the next three decades, for Canada’s burgeoning population of seniors. A quarter of a century ago the Department of Veterans Affairs confronted similar concerns as it faced the demographic consequences of its aging population of First and Second World War veterans and veterans of the Korean War. By the end of the First World War the Government of Canada had created a network of fifty hospitals and sanitoria to provide 10,754 beds for veterans across the country. By the 1960s the number of veterans hospitals had shrunk to eleven with a total capacity of 6871 beds. Faced with an aging population of increasingly indigent and elderly First World War patients, and growing difficulties in attracting doctors and nurses to work in what were becoming ‘rest homes with obsolescent facilities’ the Department of Veterans Affairs decided to get out of the hospital business altogether. Over the course of the 1970s 10 of its 11 veterans hospitals were turned over to the provinces in return for agreements guaranteeing space in provincial facilities for Canadian veterans requiring institutional bed care. Although with the exception of St. Anne’s in Montreal the department was no longer running hospitals or, more accurately, long-term care facilities itself, it still faced a substantial and ill-defined financial commitment to the much larger cohort of a million Second World War veterans, with an older age profile compared to the general population, who were now entering their retirement years. Through a gradual series of regulatory changes in veterans treatment benefits stretching from 1928 to 1966, veterans serving overseas in time of war gained the right to institutional bed care, financed by Veterans Affairs, in a long-term care facility. Out of the imperatives of this moral and fiscal commitment emerged a remarkable social policy experiment: Canada’s first and to date only national home care initiative, the Veterans Independence Program. Launched in April 1981 as the Aging Veterans Program - the ‘VIP’, as it was renamed in 1986, has become one of Canada’s least known but most successful examples of community-based home care as an alternative to institutionalizing the elderly. The purpose of this historical policy review of the VIP is twofold. First, the story of the program’s origins, evolution, and pioneering work on behalf of elderly veterans is an important chapter in the still underdeveloped history of Canada’s response to an aging society in last quarter of the twentieth century. As will be shown in the pages to follow, through the Veterans Independence Program, the Department of Veterans Affairs anticipated the needs of an aging population and developed coherent, effective, and cooperative policy models for the delivery of community-based home care, albeit for a select clientele, from one end of the country to another long before debates around the need for a national home care strategy emerged in force during the 1990s. The VIP, as an earlier in-house evaluation argued, was ‘one of the few programs in Canada to fully experience the demographic aging of its clientele before [similar] impacts [were] felt at the national level.’ It was also one of the first to embrace gerontological perspectives on the alternatives to institutionalization as well as the needs of caregivers. Its history thus provides a remarkable success story which deserves a wider audience as Canada as a whole now confronts similar challenges posed by a rapidly aging population over the next three decades. Second, as the VIP approaches its first quarter century and the numbers of its principal clientele of Second World War veterans have begun to shrink, it is timely to look back on the key decisions, turning points, and significant debates within the program’s history to discover what can be learned from a policy cycle which saw its caseload grow from 300 to more than 87,000 veterans over its first decade before entering into a period of gradual decline in the 1990s. Finally, the story of the VIP is also part of a major cultural and policy transition within the Department of Veterans Affairs itself which has moved increasingly away from a heavily benefit-driven or pension focus to a more client-centred and needs-based approach to serving veterans and their families. As historian Julian Zelizer argues, ‘by showing specific links between the past and present, [policy history] can provide policymakers with strategies for success. Explanations of how conditions stifled or supported previous initiatives can be instructive to those who design new programs.’ It is to be hoped that, along similar lines, this policy history of the VIP’s first quarter century will prove instructive to decision-makers within Veterans Affairs as the department once again charts a course for dealing with the needs of a changing clientele in the 21st century. Chapter 1 ORIGINS OF THE AGING VETERANS PROGRAM In the late autumn of 1957 Dr. E.B. Convery, Adviser in Geriatrics for the Department of Veterans Affairs penned a ‘Charter for our Aged Veterans’ which he forwarded to senior officials within the department. ‘The time has come to develop a concentrated, coordinated programme to deal with the many facets of the problem of the ageing veteran (citizen),’ Convery argued.