On Aging: Section C. Political & Public Policy Considerations Regarding Aging

This section deals with the consequences of balancing public policy for all segments of society, and in particular describing and understanding the demographics of a growing aging citizenry. The consequences affect many areas: health care, pension plan policies, labour markets, long-term care systems, immigration. A plea is made for a coordinated national plan for supporting our aging population. 

1. Life expectancy has increased dramatically: For much of humankind’s existence we did not even live long enough to exhaust our reproductive potential. In the wild, death after the end of the reproductive years was the rule. Man is one of the few animals to survive much beyond that point. 

As late as the time of the Roman Empire, when modern Homo sapiens had already been in existence for some 70,000 years, average life expectancy was less than 30 years (the big killers: infectious diseases and trauma). At the turn of the 20th century, life expectancy still had not gone much beyond 45 years. As Montaigne wrote, “To die of age is a rare, singular, and extraordinary death, and so much less natural than others: it is the last and extremest kind of dying.”

The 20th century saw a 33 year gain in life expectancy, an astonishing figure compared to any comparable period in history. The queen sent 100th birthday wishes to 255 people in 1952; it is now well over 5,000. The US Social Security systems served 25 million people in 1935; it was 70 million in 2011. The number of what geriatricians call the “oldest old” (those over 85) increases with each passing year of improvement in life expectancy.

2. Life expectancy increases have resulted from multiple factors, many of which are a result of public policy: Among them are: 

1. Improvements in public health (immunizations, antibiotics, water purification, more adequate housing, better clothing, enhanced sanitation); 
2. Medical progress. Including treatments for cancer, lung disease, stroke, chronic diseases such as diabetes, hypertension, osteoporosis, kidney failure, dementias, arthritis; 
3. Higher socio-economic status and net worth, e.g. 35% of the US elderly population lived below the poverty line in 1959 vs 10% in 2003; 
4. Improved diet through better education and increased knowledge of nutrition plus improved food supply;
5. More understanding of the importance of physical and intellectual activity; 
6. Public health campaigns resulting in such critical initiatives as laws mandating seat belt use and smoking cessation efforts (cigarette smoking is implicated in eight of the top 14 causes of death for adults 65 years of age or older)
7. Continuing research on the biology and medical consequences of aging

3. Canada’s population is aging and below replacement: We are not making babies like we used to. In 1959, when the baby boom peaked, the total fertility rate (the average number of children a women would have in her lifetime) was 3.9. Today it is a record low of 1.4. (Safe legal abortion and the pill helped. Note: a 2.1 fertility rate is needed for a population to remain stable.) While immigration will reduce the impact of societal aging, it can’t reverse it. In 1950 the mean age of Canada’s population was 27.7 years; in 2020, it was 41.1 years.

Those over the age of 65 outnumber children under the age of 14. There are more seniors (5.9 million) than children (5.8 million) in Canada. In 2021, 1 in 5 people will be over the age of 65, and 1 in 3 over the age of 55. Ten years ago, 14% of the population were seniors; by 2030, it will be 23%. By 2061, it is projected that there will be 12 million seniors to 8 million children. This coincides with the increase in the Baby Boomer cohort (born in the period 1946-1965).

As the Canadian workforce ages, a quarter-million employed will reach the traditional retirement age of 65 in the next year (the number will creep higher until late in the decade). Since 2008-09, an aging workforce has subtracted one million workers from the economy. 

Also many major cities have birth rates below the national average (Vancouver 1.09; Calgary 1.33; Toronto 1.21; Montreal 1.41; Halifax 1.1) creating further labour shortage situations where they are really needed.

Interestingly, the calculation of life expectancy shows how long someone born today could expect to live if they experienced current conditions at every stage in life. (It does not describe how many years a baby born today should expect to live.) Thus it becomes a revealing measure of a country’s well-being at a given moment. In 2020, US life expectancy was 77 years; Canada is 81.7. (It has been speculated the reasons for the difference include the heavier pandemic toll on conservative jurisdictions in the US with their greater hostility to vaccinations and masks).

4. The largest age cohort, called the Baby Boomers, will strain the health care and pension systems: Boomers remain the most populous generation in Canada and they are still making waves as they age: Boomers will strain the health care and pension system. By 2030, every member of the Baby Boomer generation will be 65 or older; the oldest will be in their 80s.

The Boomers may be the first-generation whose health, energy, resources, and self-image will enable them to be rebellious change-makers even in old age. Michael Adams in his book “Stayin’ Alive: How Canadian Baby Boomers Will Work, Play, and Find Meaning in the Second Half of Their Adult Lives” said “What the Elders (parents of Baby Boomers) experienced in the 1950s as a long-awaited reward after years of sacrifice and toil, the first wave of Boomers experienced as normal, even boring.” (It was “soft hedonism”, i.e. a house in the suburbs, wheels, a drink before dinner.) The Boomer values are significant. As Adams said  “The notion that every Canadian should have a few decades of robust good health at the end of life, to be filled not with economic productivity but with travel, tinkering, gardening, golf, reading, and lying around watching reruns, is quite new.”

Pete Townsend spoke for many of his fellow Boomers when he wrote (at age 20) in The Who’s hit song “My Generation”, “I hope I die before I get old.”

5. Canada’s immigration strategies are one lever for rejuvenating our aging workforce and helping stimulate economic activity: Immigration is a source of growth and economic dynamism. According to the Business Development Bank of Canada, immigrants are more than twice as likely as their Canadian-born peers to engage in entrepreneurial activity. 

Canada has a points-based immigration program; it favours skills but those at prime working age. (In a typical year, almost 60% of Canada’s new immigrants are between 20 and 39 – a valuable labour demographic that accounts for just 27% of the country’s overall population.) Under Express Entry, the selection tool used for the vast majority of Canada’s economic immigration programs, candidates receive a score based on their age and the age of their spouse or partner. Age points are important, i.e. while a 29-year-old scores a maximum 110 Comprehensive Ranking System (CRS) points for age, those points begin a sharp decline from the candidate’s 30th birthday onwards. By the time they reach 39, just 55 points are available, and none from age 45 on.

Ottawa planed 401,000 in 2021 (and were on track despite closed borders and other pandemic restrictions), and 411,000 in 2022, and 421,000 in 2023 (well in excess of 1% our 36.9 million population). With the acceleration of digital, AI and green technologies, infrastructure needs and health care, we need people in advanced technology occupations, skilled tradespersons and health care workers. And as the pandemic has shown, we need supermarket workers and truck drivers and others who keep the wheels turning.

Overall immigration targets are and will be challenged. On the one hand, organizations such as the Conference Board of Canada insist high levels of immigration are needed to offset aging and maintain economic growth, plus bring in the entrepreneurial spirit and creative energy that immigrants add. On the other hand, some have been warning that the increased immigration levels will exacerbate the overinflated housing market (this from Howard Anglin, former chief of staff to Stephen Harper) and some believe businesses rely on immigrants to keep wages low (this from Don Wright, the former head of the public service in BC).

6. Our health care system is under pressure from an increasing and rapidly aging population: While Canada is among the highest spenders on health care per capita among comparable countries, we have some of the poorest results. In particular we wait longer for specialists than do residents of peer countries; have among the fewest beds per 1,000 people – 2.5, vs 5.8 in France and 7.9 in Germany; rank nearly last for acute-care spaces; wait longer for “elective” procedures – 39 weeks for orthopedic surgery; hospitals routinely operate at or exceeding max capacity (this leaves little flexibility with situations such as the COVID pandemic where there are few acute care beds). Throw into the mix the consequences of dementia, as mentioned, and it becomes quite serious.

7. There aren’t enough geriatricians in Canada to cope with the number of older adults: A paper published in the Canadian Geriatrics Journal in 2012 stated that “There are currently 242 certified specialists in geriatric medicine in Canada, 35% of which are more than 55 years old. According to conservative estimates, the health-care system needs at least 700 geriatricians to meet basic needs.” Furthermore, mainstream doctors appear to be turned off by geriatrics. Older people “just don’t have a chief complaint – they have fifteen chief complaints.” 

According to Dr. Atul Gawande, “Medicine has been slow to confront the very changes that it has been responsible for – or to apply the knowledge we have about how to make old age better. Although the elderly population is growing rapidly, the number of certified geriatricians the medical profession has put in practice has actually fallen in the US by 25% between 1996 and 2010.”

8. Seniors require support to alleviate physical and mental limitations, housing, lifestyle and social needs: The four are interrelated and must be advanced together if seniors are to age well. The current model gives predominance to the first. Regarding housing, many options should be available that seniors can choose in a flexible way as their state of health changes. It can range from the family home at one end and a LTC facility or continuing care hospital at the other.

9. Not everybody gets to die where they wish: In Canada 61% of deaths occur in hospital (In the Netherlands, it is 30%; in the US it is 20%). While 85% of Canadians say they want to die in a homelike setting, only 15% actually do. According to the authors of a recent C. D. Howe report, “Canadians spend more on end of life care than other high-income countries, including the US, yet we receive poor results compared to most.”

The way people die is actually quite predictable. Each year, about one in every 100 Canadians dies. 80% are people over the age of 65, and most die of chronic illnesses such as cancer, cardiovascular disease, diabetes and COPD. But 2 in 5 end up dying in hospital. Most of the health care costs in our lifetime are incurred in the final months. Canadian costs are high because they often get all manner of unnecessary treatment in intensive care units (as opposed to just focussing on quality of life), and that’s because of the way our system is structured. First of all we have too few palliative care beds; we also have very few hospice beds in specialized facilities that deliver end-of-life care (and they depend largely on private funding and charitable donations to operate.)

Then there is home care which doesn’t have the resources to deliver palliative care. But the biggest problem with end-of-life care is in the long-term care (LTC) homes.

10. Aging at home as long as possible is sought by seniors but Canada significantly under invests in home care: As many as 97% of seniors want to age at home as long as possible (according to a September 2021 poll by Campaign Research). There is a fondness for things like a garden, familiar possessions and memories, plus the neighbours and local facilities you know well. This is also generally a cheaper, more efficient way to treat seniors, plus the cost of selling and finding a smaller alternative is climbing (the cost of new dwellings, many with condo fees, etc., are not much less than the homes they’re in). 

As the November 2020 Aging Well report (led by Don Drummond of Queen’s University) said, “The great majority of seniors want to age well and in place, in homes and communities they can call their own. They want to be able to choose where they live and the structure of their living arrangements. Far too many Canadian seniors get placed where they do not want to be and do not age well. Many remain in alternative level of care beds in hospitals for long periods and are then placed in long-term care homes (LTC-homes).”

Funding will need to shift away from creating beds in hospitals and nursing homes and instead supporting people in their homes (it’s cheaper). This can include day programs in the community or services provided in the home.

The 0.2% of GDP Canada spends on home care is one of the lowest allocations to home care in the OECD. And even worse than that, the ratio of more than 6 dollars spent on institutional care for every dollar spent on home care is one of the most imbalanced resource allocations in the developed world. Many countries spend equally on institutions and home care and some that are renowned for the life satisfaction of seniors, Denmark being a good example, spend more on home than institutional care.

11. Eldercare in Canada needs serious reform particularly in long-term care homes: As just stated the biggest problem with end-of-life care is in the LTC homes. The Aging Well report states “If the current propensity to place seniors in LTC-homes continues, the number of beds needed will double between now and 2041, adding another 250,000 beds. Current plans would only supply a fraction of that – the train is moving with a lot of momentum on a straight track that no government seems to see. There is a valid need to upgrade LTC, but nobody is talking about it in the context of the pending surge in the number of older seniors.”

There are approximately 200,000 LTC beds in Canada, but the Canadian Association for Long Term Care said in 2018 that as many as 42,000 more were needed by 2023. According to the Royal Bank there will be about 650,000 people living in Canadian seniors’ residences or nursing homes in 2030, up from 450,000 now. Public and private resources needed to build the extra capacity will cost at least $140 billion. Numerous recent reviews have resulted in a number of recommendations for LTC-homes (more and better qualified workers, better infrastructure, more sanitary protocols, greater safety, etc.) 

Even before COVID-19, the LTC sector was failing to meet the challenge of an aging population. According to Ontario’s Financial Accountability Office, the number of LTC beds in Ontario increased by only 0.8% from 2011 to 2018, while the number of people over 75 grew by 20%. And from 2005 to 2015, the number of LTC beds for every 1,000 Canadians over the age of 65 actually fell by 12.2%, according to the OECD.

It is estimated that the current 1.3% of GDP spent on LTC will surge to 4.2% by 2041. As the Drummond Report says “Nobody can afford it – individuals, families, nor governments – and few want to be in LTC-homes in the first place…In addition to being the least desired, continuing care hospitals and alternative levels of care in hospitals are the most expensive care options available for seniors, ringing in at almost $1,000 per day. LTC-homes are less expensive at about $142 a day. Communal housing is much less expensive still and formal home care can provide a lot of the services needed to support ‘Ageing Well’ for around $45 per day.”

There is concern with what is happening to those in LTC facilities which bore the brunt of the COVID pandemic (deaths, isolation, etc). About 81% of Canada’s reported COVID-19 deaths occurred in long-term care – by far the highest proportion of OECD countries, where the average was 38%! There has also been an uneven consequence across Canada. For example, nearly 10% of Quebec’s long-term care patients died of COVID-19 in the early stages of the pandemic – a rate five times higher compared to Canada as a whole (revealed at a Nov 1/21 coroner’s inquest regarding long-term care patients in Quebec).

The sub-title of André Picard’s recent book Neglected No More says it all: The Urgent Need to Improve the Lives of Canada’s Elders in the Wake of a Pandemic. He doesn’t pull punches: “Eldercare in Canada is so disorganized and so poorly regulated, the staffing so inadequate, the infrastructure so outdated, the accountability so non-existent and ageism so rampant, there seems to be no limit to what care homes can get away with.” His book is about fixing the system. It’s a plea to stop dehumanizing elders, and to reimagine long-term care. 

12. Political consequences of societal aging include financing the resources needed: “Supporting and caring for a larger number of older Canadians will be a primary theme of the 2020s”, predicted a Royal Bank report published in 2020. The report said that “working-age Canadians will feel the financial squeeze. There will be fewer of them to shoulder the additional costs of our aging society. In 2010, there were 2.3 working-aged Canadians for every youth and senior. By 2030 we expect that number to fall to 1.7.” The slowing growth of the labour force will be a problem for governments, who will have to shoulder an increased burden.

Medicare was based on equal medical access for all. So why is it different when an aging population needs chronic rather than acute care? Our current system was invented back in the mid-1950s. As Dr. Samir Sinha, director of geriatrics at Sinai Health System, said in a recent interview, “At that time very few lived beyond our 60s and 70s, so we built the system we needed then.” It was one based on doctors and acute care in hospitals, not one that catered to the needs of an aging and infirm population with complex chronic diseases. 

The feds transferred health care dollars to the provinces but there were gaps, such as home care and pharmacare. We have a long-term care system that “exists on the edges and that’s underfunded to the tune of one-third of what the average OECD country spends.” Denmark back in the 1980s discovered that by providing more care in the community, they didn’t need to build more LTC facilities, and they could actually close acute-care beds. In Canada, according to Dr. Sinha, 15% of acute-care beds are filled with people waiting to go to their own homes or to nursing homes, which are in short supply. 

The boomer cohort will require more and more resources (until in 30 years or so they will be gone); as they become senior citizens they will be needing care. Dealing with this will compete with resources for other priorities, currently such as climate change, housing supports, and a national child care program (although these can change), all requiring large increases in spending.

13. Labour shortages due to aging are creating difficulties in rural areas: The food sector, for instance, is limited by this fast-aging population on our farms and in fish processing plants. The average farmer in Canada is 55 years old, and it’s about the same for fish plant workers. The average for fish harvesters is 50, and recent research shows that inland captains are finding it extremely difficult to find crew members. One potential solution is for the government to tailor its immigration policy to encourage new Canadians to go to rural communities (as they have done to small urban centres).

14. The idea that nearly everyone should expect to retire is very recent: Just a couple of generations ago, it was assumed that you would work until you were physically incapable of doing so. Now retirement age is the age at which a person is expected or required to cease work and is usually the age at which they may be entitled to receive superannuation or other government benefits, like a state created pension. Policy makers now usually consider the demography, fiscal cost of aging, health, life expectancy, nature of profession, supply of labour force, etc. while deciding the retirement age. The increase in life expectancy is used in some jurisdictions as an argument to increase the age of retirement in the 21st Century.

As Michael Adams, president of Environics, in his book Stayin’ Alive: “The notion that every Canadian should have a few decades of robust good health at the end of life, to be filled not with economic productivity but with travel, tinkering, gardening, golf, reading, and lying around watching reruns, is quite new.”

15. Canada’s old-age pension system is an accepted, mainstream aspect of post-work life: The old-age pension is a government initiative to help Canadians avoid poverty in retirement. It has changed from a strictly anti-poverty measure, that often humiliated the elderly, into an accepted, mainstream aspect of post-work life. Some fear the system is unsustainable and heading toward bankruptcy, while others argue it is financially sound. The debate is too complicated for this blog, except to acknowledge the current plans in place and identify the pressures.

The following are the current Canadian support systems:

-The Old Age Security (OAS) Act: the first old-age pension was enacted by the federal parliament in 1927. It was updated in 1951 so that all Canadians aged 70 and over who could meet the more liberal residence requirements were eligible

–The Canada Pension Plan (CPP/QPP): the federal government introduced this in 1965

–The Guaranteed Income Supplement (GIS): as the C/QPP would not pay full retirement benefits for 10 years, and to assist those low-income seniors already retired, the federal government, through an amendment to the Old Age Security Act, introduced a tax-free, income-tested supplement beginning in 1967

–Spouse’s Allowance: In 1975 the OAS/GIS were improved for a small proportion of the population by a Spouse’s Allowance (SPA)

–Registered Retirement Savings Plan (RRSPs): in 1957 the federal government introduced changes to encourage self-employed Canadians to provide for their own retirement. Money placed in a RRSP account, as well as investment earnings on the money, are tax-deferred until withdrawn on retirement or earlier 

See Attachment #5: Old Age Security In Canada in my attachment document for a brief summary of the above. https://powellponderings.com/on-aging-attachments-1-5/

The aging of the Canadian population, the unexpected increase in disability pensions and the declining ratio of workers to retired persons meant to some observers, notably those associated with the private pension industry, that the CPP was headed for trouble. Suggestions were made that benefits be reduced, that the age of qualification be raised from 65 to 67 and that the wage-replacement ratio, set at a barely adequate 25 per cent. In the 2012 federal budget, the Conservative government introduced plans to gradually raise the retirement age for the OAS and GIS from 65 to 67. The change is scheduled to roll out between 2023 and 2029.

16. Government pension plans are beginning to crack: Having described Canada’s current plans, the reality is that throughout the rich world the pressure of increased demands on benefits and diminished contributions (because generations entering their prime working years are smaller than those beginning to draw their pensions) is creating extreme pressure. The reality is that personal retirement savings are pretty lean. About a third of all Canadians have no retirement savings at all; of the remaining two-thirds, only a minority believe they’ve saved enough to ensure that their retirement is comfortably independent. (Household saving rates have declined from the early 80s at 20% of annual disposable income, to under 5% now.)

However Canada has one of the lowest rates of elder poverty in the world: 4.4% as compared to an OECD average of 12.3%. Most Canadian seniors are currently eligible for OAS and CPP funds, funds that will cover many of the basics. The “problem” is that we are living longer. So the financial dilemma is whether it is practical to fund a large cohort for thirty idle years between the day they retire and the day they die (especially given that the government will also be paying health care costs, etc.)

17. There are strategies to increase the financial security of older Canadians: John Ibbitson, in a recent Globe & Mail article suggested: A. Publicly supported long-term care insurance, financed by employee and employer contributions, which pays for home or institutional care for people for later in life; B. For governments to facilitate dynamic pension pools, in which retirees have the option to pool their retirement savings, with the funds of those who die earlier remaining in the pool to subsidize those who live longer; and then C. There is always the strategy of encouraging seniors to not access their Canada Pension Fund Plan payments until they turn 70, which then provides a substantially higher monthly benefit (it more than doubles). There is also D. The strategy of utilizing a reverse mortgage (as one can get up to 55% of a home’s current value).

18. The above issues suggest that Canada needs a national plan to support our aging population: We are headed to be a super-aged society; the pandemic has highlighted LTC weaknesses; access to primary care is restricted and not adequate to meet future demand (witness the shortage of family docs); geriatricians are needed; older women have unique medical needs; access by seniors (and especially women) is often restricted to noninsured health services, such as dental, vision and hearing. 

An integrated national federal/provincial plan is urgently required. It needs to examine elements of what other successful countries are doing, including an increased, but scrutinized, role for the private sector. (Over 30% is already being spent on private care, and around 70% is delivered privately.) It needs also to be dove-tailed into an improved national health-care system (currently more accurately a sickness-care system), one that at some point needs to face the overpowering financial realities, where many options to close the revenue/expense gap need to be explored. (On that list, I suggest, would be some sort of income adjusted user pay system at both the hospital and doctor level.)

We need to continue the innovations begun in Peterborough in the early 2000s with the Family Health Teams made up of doctors, nurses, physiotherapists, nutritionists, pharmacists, counsellors, social worker, etc. Huge benefits would result from a renewed vigour in dealing directly with the underlining social determinants of health as well as a rejigging of our health care emphasis from one oriented to a repair mentality to one promoting healthy living. 

For the final two sections, click on D. Ken’s Influencing factors/personal approach, and E. Wrap-up. https://powellponderings.com/on-aging-section-d-kens-influencing-factors-personal-approach-section-e-wrap-up/