Long-term care reform in Ontario, the influence of ideas, institutions and interests on the public/private mix

grantor: University of TorontoThis research focuses on the reform of community-based Long Term Care (LTC) services in Ontario between 1985 and 1996 during which the three major political parties governed. Each introduced its own reform of LTC. The five models that were proposed, are analyzed from a public policy perspective, and an understanding of the factors that influenced policy formation is provided. The thesis focuses on two issues: policy content (an analysis of the design decisions of financing, delivery, and allocation) and policy process (an analysis of the interacting influence of ideas, institutions, and interests on reform). Prompted by concerns of an aging population its associated medical costs, reform began as a need to improve services for seniors to enable them to live at home for as long as possible. However, with improvements in medical technology and pharmaceuticals and concurrent hospital restructuring, care formerly provided by physicians and in hospitals increasingly shifted to the home where it was no longer covered by the 'Canada Health Act'. Underlying the debate were the following: (1) the appropriate role of the state, (2) the public-private axis in financing, (3) models of delivery (not-for-profit versus for-profit), and (4) approaches to allocation (centrally planned, command and control decisions versus market-type mechanisms). To account for the shifts in models, a neo-institutional framework is adopted which argues the importance of considering the relative and interacting influence of ideas, interests, and institutions to account for policy development and change. None alone is sufficient. Unlike other health policy domains, the LTC policy sector was comprised of a strong state and a loose network of under-resourced societal interests, which allowed the ideas and interests of the government to predominate over societal interests. Institutions, rather than constraining government actions, were marshalled to facilitate state ideology and interests. The analysis of the shifting public/private mix in LTC reform has broader implications for the future complexion of health care in Canada. By considering all three constructs--ideas, interests and institutions--an understanding is not only provided of the changes in the LTC sector, but also a heuristic for comprehending policy development in general.Ph.D