Canada’s health-care system is under siege. The country is still grappling with an acute crisis in our hospitals stemming from the COVID-19 pandemic while the slow-moving quagmire caused by the country’s aging population threatens to become a larger disaster. Can our system handle it? This joint five-part Medicare Meltdown series produced by the National Post and The Hub looks deep into the world of Canadian health care, not just to identify problems, but to offer solutions for the future.
Anyone sitting in a hospital waiting room for hours on end, hoping for an ambulance that may never come or watching their local hospital close the ER may reasonably wonder how Canadian health care could possibly get worse.
While these problems dominate the media and the minds of Canadians, something much worse is headed our way. The pandemic’s impact was bad but the relatively glacial crisis caused by Canada’s aging population could cause deeper disruptions.
The collateral damage from the pandemic has been severe: a massive and growing backlog of medical services, staff burnout and shortages, and overall strain on a system that struggled to meet demands in a timely and effective manner even before the pandemic. So it’s not surprising that a growing chorus of medical leaders say the system is on the brink of collapse and in crisis.
These challenges are serious, but Canada’s aging population is a health-care problem that threatens the long-term sustainability of public health care. And although the fact that our population is aging is well-known, the conversation has lacked urgency among our policymakers, even while some experts have started ringing alarm bells.
“Canada’s health-care system was not built to meet the challenges of our aging population. Canada’s Medicare system was established to deal largely with acute, episodic care for a relatively young population,” says the Canadian Medical Association. “Today our system struggles to properly care for patients—many of whom are elderly—managing complex and ongoing health issues. Approximately 75-80 percent of Canadian seniors report having one or more chronic conditions.”
The CMA issued that warning seven years ago, arguing that not only is our system poorly designed to handle the massive wave of seniors, but that it wasn’t built for seniors at all. Most experts agree that if reforms are not enacted today, delaying the hard decisions will make it more difficult to ensure the viability of public health care.
The demographic wave
Population projections from Statistics Canada illustrate the demographic headwinds facing Canada’s health-care system.
Canada’s elderly population has already grown from 3.99 million in 2002 to 7.34 million in 2022, which amounts to 84 percent growth. Over the next 20 years, the number of Canadians aged 65 and older is projected to grow by another 49 percent to 10.93 million in 2042. By 2062, the number of seniors in the country is expected to reach almost 14 million.
These projections rely on a number of assumptions about the fertility rate, life expectancy, and immigration and they are relatively conservative, meaning Canada’s population could age at a much faster pace.
The fastest-growing population group is our oldest Canadians.
“Seniors aged 85 and older are growing in number and as a proportion of the population. Despite being impacted by the COVID-19 pandemic, this population continues to increase faster than Canada as a whole. The growth of this population will accelerate even further in coming years, as the first baby boomer cohorts will turn 85 in 2031,” warns Statistics Canada.
Today, an estimated 888,400 Canadians are aged 85 and older. Two decades from now, there will be 2.14 million Canadians in this age group—a remarkable 141 percent growth rate.
Canadians aged 65 and over made up nearly 13 percent of the total population in 2002. Their share has increased to 19 percent in 2022 and is projected to reach nearly 24 percent in 2042 and 25 percent by 2062.
Put differently, at the turn of the 21st century, approximately one in every eight Canadians were seniors. Four decades later, nearly one in every four Canadians will be in this age group.
Two main demographic trends are behind our aging population: declining birth rates (we’re having fewer children) and longer life expectancies (we’re living longer). Together, both forces have resulted in an increasing median age that even a significant ramp-up in immigration would have trouble reversing.
The baby boom is, of course, a key factor in all of this. In the two decades following the Second World War, Canada’s fertility rate exploded, remaining above three children per woman between 1946 and 1965 and nearly reaching four children per woman in the 1950s. With Canada’s fertility staying below two children per woman since the early 1970s, and life expectancy increasing, the growth among older segments of the population has outpaced the infusion of younger Canadians, causing the population to age. The baby boom has placed, and will continue to place, growing demands on the country’s health-care system. The first group of baby boomers turned 65 in 2011.
Within Canada, aging is not equally distributed geographically. Some provinces are older than others, which means the effects on provincial health-care systems will be different and, similarly, other countries are watching their population age faster than Canada. This could be useful for policymakers.
“I think it’s helpful for us to look at other jurisdictions and other countries, and see if we can, in fact, learn from their experiences,” said Dr. Adam Kassam, the past president of the Ontario Medical Association, in an interview with The Hub.
Statistics Canada provides population projections for the provinces up to 2043 and it shows that the Western provinces, except for British Columbia, tend to be much younger while the Atlantic provinces tend to be older. Quebec and Ontario are in the middle. British Columbia is the oldest Western province and is in line with its Central Canadian counterparts.
Newfoundland and Labrador is currently Canada’s oldest population; seniors in that province are projected to make up one-third of the population by 2042—by far the highest share among the provinces and almost double the projected amount in Saskatchewan, which is projected to be the youngest province two decades from now. Alberta is currently the youngest province and projected to remain young by 2042, with 19 percent of the population aged 65 and over, only slightly older than Saskatchewan.
Internationally, Canada’s population is slightly older than the average of other developed nations, but some nations are much older still.
Canada is older than Australia and the United States and slightly older than the United Kingdom. However, Japan, Italy, Germany, and France are much older than Canada with their senior populations projected to reach 30.0 to 37.7 percent by 2050—compared to approximately 25 percent in Canada.
Canadian policymakers could learn from how these older nations are managing their health-care systems the same way younger provinces can learn from older ones.
“Perhaps from their pitfalls, but perhaps even some of the ways in which they’ve adapted their models over the course of the past, let’s say 10 years, but even through the pandemic perhaps, and what can we do better. I think we should always be striving to be better and deliver better care, and I think we are very much at a tipping point,” said Kassam.
Why does it matter?
So why does population aging matter for the future of Canadian health care?
The short answer is: a disproportionate amount of our public health-care usage occurs during our older years. With a growing number of older Canadians, the demands on health care will intensify. If you think the system operates sub-optimally today when 19.0 percent of the population is aged 65 and over, without substantial change to how we deliver health care, imagine how things will be in 20 years from now when nearly a quarter of the population is in that age group.
It’s a fact of life that people are more likely to require medical services to maintain their health and lifestyles as they age. Improvements in health prevention and education may allow the elderly to delay the onset of disease later in life, but it will always be true that the elderly typically interact with the health-care system more frequently than the young, with the majority of health-care costs incurred during the last few months of life.
In 2019, 17.6 percent of Canada’s population was aged 65 and over but this age group was responsible for 45.1 percent of the country’s public health spending. For the age group 85 and older, this segment represents just 2.2 percent of the total population but consumes 12.8 percent of all government health spending. And that’s in 2019, before the demographic tsunami hits.
After isolating the impact of aging on increased health costs, the Conference Board estimates that population aging alone will drive 20 percent of all health-care spending growth in the coming decade.
What can we do?
The cold, hard math of demographics might mean policymakers will have to get creative with solutions.
“I think that there’s probably a general consensus in the medical community, but also sort of in legal and public policy circles, that we do need a modernization of the Canada Health Act,” said Kassam.
“How do we appropriately fund the important things that we need to? And then, ultimately, not be afraid to have tough, honest conversations with voters, with taxpayers, with citizens about what they think are the priorities,” said Kassam.
Many of the proposed solutions will require the fairly complicated step of legislating changes to the Canada Health Act, but not all of them. Economist Maria Lily Shaw has argued that getting our electronic health records in order would be a huge boon to the health-care system.
Shaw says that in Quebec, physicians often have to play detective to find vital records like past vaccinations, hospital summary sheets, and even allergy records.
This is one more area where Canada’s decentralized health-care system can be helpful. Any province looking to upgrade its electronic records can simply send someone to Alberta to learn about its Netcare system, which has been emulated around the world.
Shaw says the dire situation in Quebec even has ramifications for researchers who use health data, which could deprive Quebecers of homegrown health-care innovations.
Former Medtronic president Neil Fraser also painted an encouraging picture of the potential for technology to improve Canadian health care in an interview with The Hub.
“Patient records need to attach to patients and follow them wherever they engage with the health-care system so that the health-care providers can be duly informed and don’t have to repeatedly ask all the same typical questions that you get when you go to a doctor’s office or hospital,” said Fraser. “But even more importantly, that they can see the history of the patient, what kind of conditions that they have or have had, what kind of restrictions they may have so that they can be very thoughtful in how they provide care,” he said.
Fraser said he’s also excited about the possibility of artificial intelligence being used to save time for health-care workers. Once our health-care systems start keeping better data, it can be analyzed to help with patient diagnosis.
“I think one of the things that’s very, very promising in this regard is artificial intelligence. If you have this data that follows the patient, you can also pool this data with patients with similar conditions,” said Fraser.
After studying the health-care systems in Sweden and the United Kingdom, Shaw has also proposed some more drastic ideas that involve some under-the-hood changes for Canada’s health care.
In 2010, Sweden started allowing its citizens to purchase duplicate health insurance, which covers the cost of care that was already covered under the public system, allowing people to undergo certain procedures in an independent facility.
“The reason why this is important is because right now, in a lot of Canadian provinces, this is actually not allowed as people can’t buy a duplicate health insurance, which means that if they want to receive, let’s say, an operation on their knee, this is usually an operation that’s covered under the public insurance scheme,” said Shaw, in an interview with The Hub.
The aging population also presents a problem that Canadians are becoming all-too-familiar with: staffing shortages.
The supply of physicians, nurses, and other health-care workers is currently insufficient to meet demand, with chronic shortages in some areas. And the shortages will worsen as many older health-care workers from the baby boom generation exit the workforce and retire in the coming years. A study conducted before the pandemic that analyzed 483 retired registered nurses found that 85 percent of them retired early, many due to caregiving responsibilities in their own homes.
The pandemic seems to be turbo-charging that phenomenon, with workers retiring early or quitting. Canada’s July jobs report showed a massive exodus of health-care workers, driven primarily by voluntary quits caused by burnout.
This labour shortage will put double strain on the system—a reduction in the supply of health-care workers at the same time as the demand for their services increases from aging demographics.
“This is a supply and demand issue. So, the first is that we just don’t have enough doctors. We could talk about how we just didn’t plan enough early on or haven’t done so over the past 10 or 20 years to really meet the demands of, firstly, an aging population,” said Kassam.
“We’re also seeing commitments by all levels of government and across all party stripes, to grow our domestic population through immigration in order to support a growing economy, to support a growing country. And so, we now have both a growing population but also an aging population, and both are happening at a very rapid pace. Demand is outstripping supply first and foremost, in terms of health human resources,” said Kassam.
There is no silver bullet for the labour shortage, but experts suggest ideas like labour force incentives for older workers, medical school quotas, and faster and more permissive credential recognition for foreign-trained health professionals.
Although the pandemic has shown us how bad our health-care system can get, it has also forced innovations that could make it more efficient in the future.
“The technologies for remote patient management have been around for a very long time if you want to include the telephone in that. More recently, Zoom, and of course, the potential for remote physiologic monitoring of patients’ conditions, which is much more recent,” said Fraser. “During the pandemic, virtual care went from single-digit percentages to 90 percent because patients didn’t want to go in to see a doctor, and doctors didn’t want to see patients just because of the risk of COVID.”
Virtual care was held back for a number of reasons but most prominently because doctors assumed that patients wouldn’t like it. The pandemic proved that, along with remote work, Canadians are fairly amenable to doing things in their pajamas, rather than traveling out into the real world.
“But all those concerns were completely blown up during the pandemic. Patients loved getting remote care, it saved them driving downtown and parking and paying too much just to be in a hospital parking lot or whatever, and providers found they could see a lot of patients and provide a good level of care,” said Fraser.
If Canadians are in the mood for change, so are the politicians. The Canadian health care discussion has always stayed within narrow parameters, especially during highly-charged election campaigns. As recently as last year, former Conservative leader Erin O’Toole was forced to play defence for several days because he had mused about the idea of private delivery for health care.
But in the wake of a majority victory in the recent Ontario election, Premier Doug Ford has already touched what was assumed to be a political third rail.
“We can’t do the same status quo. The status quo has been broken,” Ford told the Ontario legislature in August. “We’re going to deliver health care in a different fashion.”
It could be a sign that, as our aging population grows, Canada’s health care conversation is changing.