The introduction of Medicare in 1966 set a precedent for Canada's role as an international leader in efficient, equitable, and affordable access to healthcare. It further strengthened and engraved the Canadian national identity grounded on values of social solidarity and cohesiveness (Armstrong & Armstrong, Reference Armstrong and Armstrong2008). Although Canada's healthcare system has been successful, its full realization and potential has stalled short of the vision set forth by its early pioneers. Indeed, access to medically necessary physician and hospital care for acutely ill patients is a vital component of any healthcare system. However, acute care is only one part of an integrated, coordinated healthcare system. Whereas acute care patients will have their care needs met in an equitable manner, the fragmentation inherent in the continuum of care creates disparities in access to care for chronically ill patients (Stephenson & Sawyer, Reference Stephenson and Sawyer2002). In other words, the same principles on which our healthcare system has been built are not applicable to chronically ill patients seeking long-term care. It may be argued that the lack of equitable access to medical care on the basis of need rather than ability to pay for long-term care patients is antithetical to Canadian values. Rather than improving universality by expanding on publicly funded community-based services as recommended by several commissions on healthcare, transformative change has been in a state of inertia amidst a political climate favoring the contraction of social programs. The underlying premise in reforming and changing the structure of the healthcare system has been to reduce costs (Marchildon, Reference Marchildon2004). This assertion is plausible if one considers the monthly cost of community-based care such as home care averaging ~$7670.67 per month (Guerriere et al., Reference Guerriere, Wong and Croxford2008). Although restricting public expenditures on community- based care would initially reduce costs, over the long run it increases costs and reduces efficiency to the system as a whole, through poorer population health outcomes. In other words, as one reduces accessibility to community-based care, the result is a spillover effect with higher frequency and density of acute service utilization. In addition to this, the private responsibility for home care has indirect effects on the economy through lower labor force participation rates and greater incidence of reported poor health among female informal caregivers. Publicly funded community-based services enable citizens with functional limitations to continue living in the community with maximal autonomy for as long as possible (Stephenson & Sawyer, 2001). They are the stepping stones toward achieving a comprehensive and integrated healthcare system that is efficient and equitable to all Canadians irrespective of health status, duration of morbidity, and income. It is only through health promotion, preventative care, and health maintenance that costs are contained and health is improved. Furthermore, it is only through community-based services that women will be liberated from the gender care gap, which has forestalled labor force participation. This article is in support of the expansion and inclusion of community-based services under the scope of publicly funded healthcare services of the Canada Health Act. The expansion of publicly funded community-based care in the form of outpatient services, nursing home care, and respite care combined with home adaptations increases the efficiency of the healthcare system through a reduction in direct costs imposed on the healthcare system, a reduction in the indirect health and economic costs imposed on caregivers, and improved patient well being.

The expansion of publicly funded community-based care along the continuum of care is an essential step toward a more cost-efficient healthcare system through reduced direct healthcare expenditures and greater patient well-being in the long run. The researchers Browne et al. (Reference Browne, Gafni and Byrne1999) conducted a meta-analysis examining the impact of community-based care in 12 cohort studies in Ontario. They found a consistent linear association between fragmented community outpatient services and increased costs to the healthcare system relative to services provided on a continuum (Browne et al., Reference Browne, Gafni and Byrne1999). One example of the importance of expanding outpatient services is illustrated in Ontario's complete de-listing of community-based rehabilitation services. Gildiner (Reference Gildiner2006) argues that the fragmentation of rehabilitative community-based care in Ontario was the result of a series of policy changes in the 1990s, which set a precedent for a lucrative private insurance industry and a reduction in the provincial government's expenditures on these services (Gildiner, Reference Gildiner2006). Although it may initially appear that the province of Ontario has controlled costs to the healthcare system through its ultimate fiscal squeeze by entirely de-listing public coverage for care, this tactic has had self-defeating effects in the long run. According to Landry et al. (Reference Landry, Deber and Jaglal2006), income-related barriers to community care accessibility resulting from Ontario's decision to contract out rehabilitative services resulted in an odds ratio of 10.72 for clinical disease progression (Landry et al., Reference Landry, Deber and Jaglal2006). A question that one may ask oneself is, what effect did this clinical disease progression have on healthcare system utilization and cost containment? Further research by Paul et al. (Reference Paul, Park and Ryder2008) has shown that the frequency and intensity of physician and hospital visits increased among subjects unable to access community rehabilitation (Paul et al., Reference Paul, Park and Ryder2008). Therefore, initial cost savings associated with the private responsibility for financing rehabilitative services were offset by greater direct public healthcare expenditures.

Although the inclusion of publicly funded community-based rehabilitation is an essential variable that improves patient outcomes and reduces intensity of acute care utilization, the inclusion of publicly funded home care plays an even greater role in shaping the efficiency of the healthcare system, because of its larger target group. According to Stephenson and Sawyer, there were 839,000 Canadians in Reference Stephenson and Sawyer2002 who needed home care for a wide variety of conditions, but were unable to access it because of financial barriers (Stephenson & Sawyer, Reference Stephenson and Sawyer2002). Although the domino effect on the system associated with the contracting out of home care may be less evident initially relative to rehabilitation whose privatization effects were observed directly, international research has consistently shown that publicly funded home care controls costs. The researchers Muramatsu et al. (Reference Muramatsu, Yin and Campbell2007) studied the effects between state funding on home care and cost efficiency, and found that the doubling of public expenditures on home care reduced nursing home expenditures in the United States by 35% (Muramatsu et al., Reference Muramatsu, Yin and Campbell2007). Although home care reduces costs directed toward nursing home care among chronically ill seniors, this may in itself be insufficient to set grounds for public coverage, as nursing home care has predominantly been a responsibility of the individual consumer. Nevertheless, research evidence has further shown that publicly funded home care is directly associated with lower utilization of acute hospital care. According to the researchers Mitchell et al., Medicaid patients with extended home and community-based coverage had a lower likelihood of accessing hospital care relative to non-covered Medicaid recipients (Mitchell et al., Reference Mitchell, Salmon and Polivka2006). Therefore, the motive that home care reduces the costs associated with the utilization of expensive hospital procedures covered under the Canada Health Act among chronically ill seniors is sufficient to elicit rethinking restrictive coverage policies.

Furthermore, the relationship between publicly funded home care and cost containment not only pertains to targeted groups, such as seniors with complex care needs and disabled adults, but also to individuals who are living with and dying from advanced illness. That is, public coverage of home care enables cancer patients to receive therapy, and terminally ill subgroups to die in the comfort of their homes without the need for unnecessary hospitalizations. According to Luthi et al. (Reference Luthi, Funcina and Divorne2011), the cost of chemotherapy in the home averages ~€420 a day relative to €896 for hospital-administered therapy (Luthi et al., Reference Luthi, Funcina and Divorne2011). Whereas end-of-life care places the greatest financial burden on the healthcare system, restrictive policies supporting the contraction of publicly funded palliative home care end up costing the system far more. According to the research by Tamir et al. (Reference Tamir, Singer and Schvartzman2007), palliative care in the home reduced overall direct healthcare expenditures to the system by 30% relative to care for terminally ill patients who did not receive this service (Tamir, 2007). In addition to this, further research by Kristianson et al. (2004) has shown that specialized targeted home care respite services available during the night were associated with a reduced need for expensive hospitalization and isolation from family. This, in turn, translated into improved quality of end-of-life care through the provision of community care in tandem with familial supports (Kristianson et al., 2004). This finding supports the generalized assumption that Canadians prefer to spend the final days of their life in a familiar private setting among loved ones. Therefore, the benefits associated with the expansion of community-based care in the form of home care outweigh the costs to the healthcare system, and maximize patient dignity. These benefits are in accordance with the Canadian values of efficient, equitable, and affordable access to care upon which Medicare was founded. It is through the integration and expansion of publicly funded home care that these values may be reinforced and universalized across the continuum of care.

In order to build the foundation for an integrated cost-efficient healthcare system that supports individuals with functional limitations to continue living in the community, there is a need to publicly fund preventative services that complement traditional nursing home care. Whereas rehabilitative and nursing home care assist individuals with chronic health deficits in slowing physiological decline, community-based preventative services in the form of adaptive technologies prevent the onset of acute injuries and enable early hospital discharge. In other words, they are a vital component of a successful community-based program, as they reduce the need for costly hospitalizations and subsequent institutionalization while enabling individuals to live in the community. Although there have been projections of a fiscally unsustainable health care system because of the demographic changes inherent in an aging population, the policy debate focused on the overutilization of acute care services (Armstrong & Armstrong, Reference Armstrong and Armstrong2008). The concentration on “bed blockers” and the reduction of hospital beds has neglected the examination of the root cause of acute episodes. According to Scott et al. (Reference Scott, Wager and Sum2010) there were 53,545 falls among seniors with chronic health problems, taking a $2 billion slice from the Medicare health expenditure pie (Scott et al., Reference Scott, Wager and Sum2010). It is well known that fall-related hospitalizations are the leading cause of hospitalization among older women. It may initially be inferred that a greater aging predominantly female population will make the health care system unsustainable. From this standpoint, contraction rather than expansion of outpatient services in the community may be the policy solution in order to have sufficient supplies to meet demand. However, the question to ask is why are these injuries happening in the first place? Aging does not in itself denote greater acute care episodes, but rather a lack of community-based services in the form of home adaptations and assistive technology for older adults with functional disabilities does. Research has consistently shown a marked reduction in injury-related hospitalization rates among seniors with chronic health problems who had access to home adaptations. According to Plautz et al., (Reference Plautz, Beck and Selmar1996) the installation of grab bars, handrails, and removal of clutter reduced falls by >60%. Further benefits included a complete reduction in the incidence of scalds and burns (Plautz et al., Reference Plautz, Beck and Selmar1996). Therefore, the reduction in fall-related injuries resulting from home adaptations would reduce half of the annual expenditures on fall-related injuries. Research by Mann et al. (Reference Mann, Ottenbacher and Fraa1999) has supported similar findings along with a marked reduction in utilization of nursing home services (Mann et al., Reference Mann, Ottenbacher and Fraa1999). Rather than contracting out community-based adaptation and supports, the expansion of services ensures that savings accrue and that patient safety and well-being are maximized. According to Edwards et al. (Reference Edwards, Birke and Nair2006), a policy gap exists whereby lower-income seniors are unable to have universal access to needed home adaptations. The lack of sufficient home preventative services was associated with greater feelings of insecurity within one's home and fear of injury-related hospitalization (Edwards et al., Reference Edwards, Birke and Nair2006). Therefore, it is through publicly funded home preventative services that the Canadian value of accessibility based on need rather than ability to pay may be fully realized. Furthermore, publicly funded preventative services will reduce the disparities in health outcomes between the wealthy and less privileged, which is in accordance with Canadian values of equity. In addition to this, research by Hakim and Bakheit (Reference Hakim and Bakheit1998) has shown that there is a direct relationship between length of hospital stay and the availability of accommodating home adaptation and equipment among stroke patients (Hakim & Bakheit, Reference Hakim and Bakheit1998). This finding is significant, as it suggests that home adaptations may meet the needs of individuals with heterogeneous health needs, while controlling costs. Further empirical research on the efficacy of home adaptations in reducing transitional care stay in hospitals is needed in order to establish a causal relationship. This may further guide policy solutions in addressing the dilemma of maintaining a balance of efficient patient care while minimizing costs through early discharge. Nevertheless, based on my personal observations as a volunteer in the transitional care unit, I have found that many seniors spend up to half a year a priori to being discharged, because of income-related barriers in accessing home adaptations that would meet their health needs. Thus, it is only by moving the policy debate from contraction of services to one where services are expanded through more efficient resource use, do costs decline and patient outcomes improve.

The expansion of publicly funded community-based care in the form of home care, outpatient rehabilitation, and adaptive technology not only minimizes the direct costs imposed on the healthcare system but also the indirect costs imposed on the economy and the system. In other words, the accrued benefits associated with community-based care are not only limited to the direct costs on the health care system. The often neglected but critical part of the equation involves the indirect costs associated with the privatization of community-based services. This includes reduced labor market participation and the increased incidence of poor health among female caregivers. Thus, the spillover effect associated with the contraction of community-based services expands beyond greater costs to the healthcare system and lower patient well-being into the realms of the well-being of the economy and gender equity of informal caregivers. According to Stephenson and Sawyer (2001), caregivers are predominantly women, “outnumbering men 3 to 2” (Stephenson & Sawyer, 2001, p.271). The emphasis of shifting care from publicly funded acute care to privately funded home-based care has been viewed as a feminist issue, whereby women who a priori have lower wages and labor market participation are forced into greater depths of poverty through the provision of unpaid care (Morris et al., Reference Morris, Robinson and Simpson1999). The inability to privately fund home-based care is directly related to one's income, making female caregivers of low socioeconomic status a group that disproportionately provides care (Garcia-Calvente et al., Reference Garcia-Calvente, Rodriguez and Eqyuguren2004). If one considers the length of time invested in providing informal care, the economic costs associated with work leave are more evident. According to Stephenson and Sawyer, “employees miss 19.8 million days of work each year due to work family problems” (Stephenson & Sawyer, p. 278, as cited in Duxbury et al., Reference Duxbury, Higgins and Johnson1999). A question that one may ask oneself is how much does this translate into in terms of reduced income? According to Rubin (Reference Rubin2002) both sexes lose $566,443 annually as a result of time away from work (Rubin, Reference Rubin2002 as cited in Metlife, 1999). Therefore, the savings associated with contracting out community-based services such as home care, adult day care, and respite are offset by the economic losses to society. In addition to the economic costs incurred to society, the results of the 1998 Survey of Women's Health suggest that women experience a greater likelihood of deteriorated health associated with informal caregiving than do men (Donelan et al., Reference Donelan, Falik and DeRoches2001). One may postulate that the onset of disease among female informal caregivers may indeed have a spillover effect, contributing to a greater frequency and density of healthcare service utilization. More research is needed in order to examine the economic costs incurred by the healthcare system as a result of caregiver stress and functional decline. In addition to this, research suggests that care provided by inexperienced family members who lack formal nursing home care training may result in lower quality care. According to Van Ryn et al. (Reference Van Ryn, Sanders and Kahn2011) caregivers are uncertain about whether their caregiving skills are adequate, with “half of caregivers not getting training they perceived as necessary” (Van Ryn et al., Reference Van Ryn, Sanders and Kahn2011, p.1). Therefore, lower quality care may in turn result in greater utilization of acute care services and greater costs in the long run to the healthcare system. The lack of homogenous quality of care amidst a resource-deprived and stress-inducing environment is at odds with Canadian values of equitable care. The indirect costs associated with contracting community-based services outweigh the benefits, because of economic losses to society, gender- based perpetuation of poverty, declining caregiver health, and inadequate provision of skilled care. The expansion of publicly funded community services is the remedy for the above mentioned indirect economic and social ills. It is the most equitable solution for Canadian citizens who should not have to choose between providing care and working. It increases the quality of care and productivity. It must be noted that these indirect costs are an underestimation of the total costs, if one considers the monetary losses associated with high administrative costs in the private provision of care that is not allocated toward patient care, and the poor and unstable working conditions of private sector female employees as argued in Armstrong & Armstrong, Reference Armstrong and Armstrong2008). The sceptic policymaker who supports privatized community-based services should ask: how will the Canadian values of equity, affordability, and accessibility be maintained if one shifts the accountability of care to the home? How will Canadians be able to live productive, autonomous lives without having to reduce opportunities and live in poverty? Further questions should ask how will women be able to offer care for their loved ones without being subjected to the cyclical gender-based poverty gap?

Although many family members enjoy the informal provision of care to their loved ones, the provision of publicly funded home care, adult day care centers, and respite care reduces the restrictive choice inherent in care provision, and enables a work–life balance that is vital to Canadians. According to Navaie-Waliser et al. (Reference Navaie-Waiser, Feldman and Gould2001) 70% of informal caregivers do not receive any assistance in the provision of care for their family members (Navaie-Waliser et al., Reference Navaie-Waiser, Feldman and Gould2001). Further research by Van Excel (Reference Van Excel, de Graaf and Brouwer2008) suggests that the majority of these informal caregivers refrain from accessing respite services despite being in need of these services (Van Excel, Reference Van Excel, de Graaf and Brouwer2008). The ready availability of integrated services and income-related factors plays a role in accessing essential community-based services. Although adult day programs that provide temporary respite to caregivers are relatively inexpensive, individuals at the lower end of the income distribution may simply be unable to meet the daily costs of these services (Sawyer & Stevenson, 2001). Therefore, it is only through the public financing of community-based services that indirect societal and economic costs may be contained, and that the efficiency and social solidarity of the Canadian healthcare system may be reinforced.

In summary, this article has argued that the inclusion of community-based services under the umbrella of publicly funded services of the Canada Health Act is the most cost-efficient and equitable method for reducing the direct costs imposed on the healthcare system as well as the indirect costs incurred on the economy and society. Community-based services further improve the well-being of patients and caregivers and ensure a coordinated, comprehensive healthcare system. They support the inclusion of individuals with chronic functional limitations and caregivers within the community without reducing quality of care or productivity . The public provision of community-based services ensures that gender inequity and income-related barriers to care are minimized by pooling the risks of ill health across the population, which is consistent with the values attached to the acute care portion of the healthcare system (Armstrong & Armstrong, Reference Armstrong and Armstrong2008). As Roy Romanov discovered, the values of Medicare are a defining aspect of citizenship (Romanov, Reference Romanov2001). Without adding communityservices to Medicare, we are denying the same citizenship to Canadians with long-term care needs. This article has refuted the right- wing ideological belief that the contraction of social programs through reduced government responsibility and increased responsibility of the consumer reduces costs. This ideology translates into a healthcare system that is fragmented, more costly, and has poorer levels of health outcomes. Community-based services in the form of nursing home and palliative care, outpatient rehabilitation, adult day programs, and respite services, in conjunction with home adaptive technologies and assistive devices, control costs and improve outcomes. They are further in accord with the Canadian values on which Medicare was founded. The inclusion of community-based services will create a vision of a more inclusive and integrated healthcare system, operating on a continuum of care. It is a vision that was set forth by Hall and reinforced by Roy Romanov, the Royal Commisioner on the future of health care in Canada appointed in 2001–2002 (Armstrong & Armstrong, Reference Armstrong and Armstrong2008). It is time for Canada to expand its public provision of community-based services and to live up to its international reputation as a leader in healthcare.