July 5th, 2013 · Janine Farrell http://www.policynote.ca
The recent announcement of a $25/month user fee for wheelchairs used by people in long-term care facilities in the Fraser and Vancouver Coastal health regions has been unpopular – particularly given the simultaneous announcement of pay raises for top government political staff.
Premier Clark has since withdrawn the promise of pay raises, except for her chief of staff, saying she heard BC residents’ objections and acknowledging, “the message isn’t consistent with my determination to control government spending.”
Unfortunately, the government has not ‘heard’ the popular outcry over the wheelchair fees. On June 20 our new Minister of Health, Terry Lake, said in a letter to The Province newspaper that the fees are entirely ‘fair.’ Minister Lake argued that because people who live in private homes have always had to pay for their own personal-aid equipment, charging wheelchair fees in public care homes is in alignment with current policy on maintenance fees, and no one will be denied the use of a wheelchair if they cannot afford the cost. Christy Clark, too, said the fees are ‘fair.’
It is always interesting to observe different notions of ‘fairness.’ The new fees undermine the human rights of persons with disabilities and seniors in this province and will hit those least able to afford it the hardest.
How is that fair?
A more complete understanding of the issue lies beyond what is covered in BC’s Home and Community Care Policy Manual. While these policies may justify the fees in home and community care, there is more to know about this issue to understand why there are user fees being charged when we have a universal public health system.
Other policies that play a major role in this issue:
Under the Canada Health Act, universal health coverage guarantees all ‘necessary hospital and physician services’ are publicly funded (paid for by your tax dollars) and universally available based on need, not ability to pay. ‘Necessary hospital and physician services’ generally mean what happens at the hospital, in your doctors office, at a public clinic, in emergencies, etc.– that is, what is provided in “acute” and “primary” care.
In addition to primary and acute care, we have a number of public services available in community and in private homes.
However, when services are delivered as part of home and community care, they are often no longer considered ‘necessary’ – that is publically funded – under the Canada Health Act. The result is that the home and community care sector is especially vulnerable to creeping user fees that undermine the universality of our public system1,2.
It is significant that Minister Lake noted people who live in their own homes ‘have always had to pay’ – then likened people’s own residences to long-term residential care homes. Residential care facilities fall under the umbrella of home and community care, even if they are partially or fully funded by the public health system. In these spaces (as opposed to hospitals) the health authorities are free to impose additional cost without legal implications. Home and community care should not be used as a Medicare loophole to raise extra funds1,2.
The shift of care from inside expensive hospitals and clinics to home and community settings is a positive and more cost efficient way to manage our health spending. For example, approximately 70% of Demarks health spending is allocated to home and community care, whereas we currently allocate approximately 80% of our health spending to acute care.
The CCPA-BC and many seniors serving organizations have called for a shift toward home and community care in BC. However, if we’re going to make this shift, we should first invest in a well-coordinated system of services that are available to all seniors as their health needs change. This is in contrast, as BC’s Ombudsperson has already pointed out, to what we have now – a fragmented system of supports and services that depend on the capacity of each individual community to support their elders where our broader system has major gaps in services or funding.
The unintended impacts of introducing user fees:
People simply do without ‘universal’ medical services if they cannot afford to pay for out of pocket fees associated with them– for example, the cost of necessary aid equipment like a wheelchair or cane or parking fees at a public hospital or clinic deter people from accessing universal health care at all.
The paperwork and embarrassment involved in proving one cannot afford the fee (called a ‘hardship waiver’) often deters individuals from getting a waiver or accessing the associated service at all.
In sum – even small out of pocket charges deter those who are poor or low-income from accessing and benefitting from our public health system – these same people tend to be less healthy.
In comparison, out of pocket costs have little impact on those in mid- to high- income ranges, who tend to be healthier.
Other important policies to consider –a human rights approach:
In their 2008 guidelines for the provision of manual wheelchairs, the World Health Organization states “the right to a wheelchair must be an essential component of all international endeavors to secure the human rights of people with disabilities.”
The WHO reminds us that the wheelchair is one of the most commonly used assistive devices for enhancing the personal mobility of people with disabilities.
Wheelchairs enable “people with disabilities to become mobile, remain healthy and participate fully in community life. A wheelchair is the catalyst to increased independence and social integration…it is not an end in itself.”
Although these guidelines were developed with resource-poor countries in mind, perhaps we should order a copy for our current government.
Ironically, just days before the announcement of the wheelchair fees, the Health Minister released a statement regarding World Elder Abuse day, saying that “Every senior deserves to age with dignity and to feel appreciated and respected in their communities…As part of our Families Agenda, we have developed polices that ensure families are protected and feel safe.”
One key ingredient to aging with dignity is maintaining mobility for as long as possible. User fees for wheelchairs directly undermine this human right.
These plans go into effect on September 1st.
The BC Health Coalition is coordinating a response to the Fraser and Vancouver Coastal health authorizes – click here if you would like to send a quick message to the Health Authorities, the incoming Minister of Health; BC Opposition Critic for Health; Hon. Christy Clark, BC Premier; and Adrian Dix, Leader, BC Opposition.
 Sullivan, T. & Baranek, P.M. (2002). First do no harm: Making sense of Canadian health reform. UBC Press: Vancouver, BC.
 Shamian, J. (2007). Home and community care in Canada: The unfinished policy. In Medicare: Facts, myths, problems & promise. Eds. Campbell, B. & Marchildon, G. James Lorimer & Company Ltd., Publishers: Toronto, Canada.