Canada is currently at the crossroads of coping with increasing health care expenditure and a growing aging population. Economic uncertainty and growing fiscal deficits make it harder for provinces to contain their escalating health care budgets. A recent Nanos poll (May 3, 2010) indicated that health care concerns had surpassed jobs and the economy as Canadians’ number one concern. The perfect storm of expanding provincial deficits, increasing health care costs and a rapidly aging population mean there is a growing rift between what Canadians expect and what their governments are willing to provide.

This exploding population of seniors is linked to the retirement of the Baby Boomer generation combined with ever-increasing life expectancy, and is leading to what has been termed the “grey tsunami;” a metaphor that calls to mind the swamping of the systems, policies and available dollars needed to support this population from a health perspective. Canadians can now expect to live an average of 82.7 years from birth1 – the third-highest average of the G7 countries¹. Within 30 years, one in four Canadians will be a senior, representing a significant proportional increase².

Groups advocating for specific chronic disease areas are quantifying the bleak picture ahead – Alzheimer’s and dementia are expected to double in the next generation³; diabetes prevalence in older Canadians is expected to increase by 44 per cent in the next 20 years⁴, and the list goes on.

More senior citizens do not automatically equal exponentially higher health care expenditure; in fact, the overall cost impact may be reasonably gradual, provided rates of resource use by different age groups remain constant⁵. It is critical to assess not just the cost of resources, but where we focus our efforts. Without question, on-going careful examination of the scope of the issue, Canada’s definition of health care, its priorities, and its focus on prevention and using available tools for maximizing outcomes, will help fortify against the coming storm.

Quantifying our Destiny
According to an OECD report on aging and disability, it is expected that the proportion of Canadians aged 65 and over in 2030 will be 23 per cent. In comparison, the expected share of 65+ population in the US, UK and Australia will be 20 per cent, 23 per cent and 22 per cent respectively. These proportions suggest that Canada has similar social and economic burden to other OECD countries in coping with this issue.

A report released recently by TD Economics⁶ says health spending is set to rise to 80 per cent of total program spending in Ontario by 2030, up from its current 46 per cent today. This will leave other important sectors of the economy (e.g., education, social service) with very few resources. According to the study, the number of seniors in Canada will increase by over 230 per cent. This would invariably put into question the sustainability of health care financing and overall economic stability in Canada.

Another recent Statistics Canada report⁷ indicates that Canada’s changing age structure will affect many aspects of society, from health care to pensions. Indeed, Statistics Canada said the ratio of working-age people to seniors would decrease from five to one in 2009 to about 2.5 to one by 2036. The national statistics agency said seniors would account for between 23 per cent to 25 per cent of the overall population by 2036, nearly double the 13.9 per cent recorded in 2009. As well, the proportion of the population aged 15 to 64 – the traditional work force – would decline from about 70 per cent to 60 per cent.

The reality we are facing is that aging and health issues go hand in hand; the prevalence of specific age-related health disorders accentuates with increasing age. How to address it remains the enigmatic question.

Steps Forward
One consideration for successful navigation is to start by re-examining and challenging our definitions. The Canada Health Act holds that the primary objective of health care policy is “to protect, promote and restore the physical and mental well-being of residents in Canada and to facilitate reasonable access to health services without financial or other barriers.” This definition focuses squarely on the patient. Without question, increasing prevalence of chronic disease means an equally increasing burden on caregivers. Coupled with this are individuals’ preferences, such as the desire of many Canadians to be cared for or die at home⁸. While all provinces offer basic coverage for home care and some fund a broader range of services8, health care renewal strategies that include expanded support can help ensure better home care. A 2008 survey by Pollara indicated fully 92 per cent of Canadians polled support or strongly support a federally-led national home care program⁹.

Along with re-examining home care is the need to ensure we have the long-term institutional care that will be required. When one looks at the number of long-term beds in hospitals and nursing homes across various OECD countries, it is evident that some OECD countries are doing better than others. Notably the Nordic countries have more access to these long-term facilities than people in the US, Canada or Australia. Canada should look to the resources of these countries as an example when formulating policies around long-term care.

The changing face of the burden of disease also creates a strong case for ongoing review of policy prioritization. Diseases that particularly affect the elderly, and have not traditionally taken a central focus, such as Alzheimer’s, Parkinson’s and osteoporosis, will be an increasing burden.

Take osteoporosis: one in four women over the age of 40 has osteoporosis; the lifetime risk of hip fracture is one in six; research has shown that 25 per cent of patients die within one year of hip fracture from complications such as pneumonia or blood clots, 24 per cent are institutionalized, 40 per cent of those living in long-term care facilities die and 10 per cent experience another fracture in the follow-up year¹⁰. Osteoporosis is a chronic disease whose incidence, without intervention, will increase as the population ages. Yet, a 2008 report by Osteoporosis Canada, Breaking Barriers, Not Bones¹¹, gave generally failing grades to access to bone mineral density testing, medications and provincially/territorially-funded initiatives in risk reduction, diagnosis and treatment of osteoporosis.

Alzheimer’s and dementia will also be increasingly significant. An OECD report¹² looked into dementia care in nine OECD countries for which comparative data were available. From a prevalence perspective, Canada has higher prevalence of dementia per 100 persons for all age groups over 65 for both sexes. Similarly, when one looks at Alzheimer’s disease, the Canadian prevalence estimates are higher than many other OECD countries.

This report indicated that the economic and humanistic burden associated with dementia and Alzheimer’s disease is substantial. Managing people over 65 with dementia and Alzheimer’s disease requires coordinated health care management, which is expensive. The OECD conclusion was supportive of an integrated policy to ensure early diagnosis and treatment, and to provide institutionalized and home-based care to affected people. OECD argued that managing people with these diseases early on will have a greater cost-offset to caregivers who often have to take their time away from work to provide care, representing a substantial cost to society.

Between 1996 and 2003, the prevalence of obesity and hypertension among people aged 65 and over has also increased significantly in Canada. So far, the growing prevalence of these conditions does not appear to have led to higher rates of severe disability among elderly people, possibly resulting only in moderate disability or being offset by more positive trends in the prevalence of other diseases. That said, the trend for the future is not great as economic constraints and smaller tax base will put significant strains to the system. The results from both the “static” and “dynamic” projections by OECD indicate that the number of severely disabled elderly people can be expected to rise over the next few decades in all countries due to population aging.

The face of the diseases an aging population deals with is changing the health care landscape in Canada, and demand for better solutions, already emerging in these and other disease areas, will continue to escalate. Looking at disease-specific strategies and resource allocation to meet these emerging needs makes sense.

Finally, seeking ever-improving ways to both prevent and effectively treat chronic illness must be a priority. Prevention programs have gained some traction in Canada – in heart disease, for instance, campaigns focused on risk factors such as smoking outline the immediate and long-term preventive impact of quitting on reducing risk¹³. Along with prevention, policy makers must look critically at the allocation of resources to ensure not only adequate acute care, but that the needs related to managing chronic illness can be met.

The reality is that longer life spans today bring higher rates of common – but, through medicines and lifestyle changes, manageable – chronic illness; an evolution from the experience of earlier generations’ experiences. While the rates of mortality from cardiovascular disease have decreased steadily over time – more than 50 per cent between 1969 and 1999¹⁴, the rates of diabetes, on the other hand, have increased – and its prevalence in older Canadians is expected to increase dramatically⁴.

Chronic illness can be managed effectively, if the right support, treatment and care are available. Medicines are one important component of care that can have a positive impact on the burden of illness, helping reduce the need for costly hospitalization and surgery. A study by Frank R. Lichtenberg, the Courtney C. Brown Professor of Business at Columbia University, examined the association between the use of newer medicines and health spending. The study found that for each additional dollar spent on newer pharmaceuticals, $7 is saved in total health care spending. In combination with lifestyle changes, innovative medicines have greatly improved the chances of survival and the quality of life for people suffering from heart attacks and strokes¹⁴, for instance. Continued innovation will see this value, and the value of other important interventions for chronic disease management, continue to grow.

There is no doubt that the face of our population will look different in the coming years; their needs will also be different. The impact of this evolution from an overall cost perspective may be manageable within a changing economy; however, new patterns of health services utilization, driven by the increasing burden of chronic illness, mean policy makers must continually evaluate their definition of who among those affected most require support, as well as the prioritization and optimal management of age-related chronic disease.
^1. Health Canada, Government of Canada. Healthy Canadians: A Federal Report on Comparable Health Indicators. 2008. Pg 47.http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/system-regime/2008-fed-comp-indicat/index-eng.pdf
^2.Public Health Agency of Canada, 1 October 2009; ‘Demographic Profile of Canada’s Aging Population’, www.phac-aspec.gc.ca
^3. Alzheimer Society of Canada. Rising Tide: The Impact of Dementia in Canada. 2010. Site
^4. Public Health Agency of Canada, ‘Report from the National Diabetes Surveillance System: Diabetes in Canada 2009’
^5.Canadian Health Services Research Foundation. MythBusters. Myth: The aging population will overwhelm the health care system. January 2002. Site
^6.TD Economics. Special Report: Charting a Path to Sustainable Health Care in Ontario. May 27, 2010. PDF.
^7. Site
^8. Health Council of Canada. Fixing the Foundation: An Update on Primary Health Care and Home Care Renewal in Canada. January 2008.
^9. 10th Annual Health Care in Canada Survey, 2008. POLLARA Research. PDF
^10. Papaioannou A., Wiktorowicz M., Adachi J., et al. Mortality, Independence in Living and Re-fracture, One Year Following Hip Fracture in Canadians. Journal SOGC, August 2000.
^11. Breaking Barriers, Not Bones. 2008 National report Card on osteoporosis Care. Osteoporosis Canada. Pg.5.PDF
^12. Trends in Severe Disability Among Elderly People: Assessing the Evidence in 12 OECD Countries and the Future Implications.PDF
^13. Heart and Stroke Foundation of Canada. Smoking, heart disease and stroke.Site.
^14. Rx&D . Value of medicines in the treatment of cardiovascular disease.PDF