PowerPoint Presentation prepared by Terri Petkau, Mohawk College

PowerPoint Presentation prepared by Terri Petkau, Mohawk College

CHAPTER SEVENTEEN Health and Aging
Neena L. Chappell Margaret J. Penning

Copyright © 2011 by Nelson Education Ltd
INTRODUCTION Will examine: Individual and population aging, including aging and ageism Diversity within aging Apocalyptic demography Inequality, health, and aging Informal and formal types of health care Brief history of Medicare Health-care reform Globalization and profit-making* Copyright © 2011 by Nelson Education Ltd

INDIVIDUAL AND POPULATION AGING
Life expectancy: Number of years the average person can expect to live Has increased steadily in Canada during the 20th century Canadians can also expect to live longer after age 65 than generations before them Increased life expectancy into old age is distinguished from previous historical period: Never before in history did vast majority of people in a particular country expect to live to old age* Copyright © 2011 by Nelson Education Ltd Canadians can expect to live 20 years longer than if they had been born in 1920. Copyright © 2011 by Nelson Education Ltd.

LIFE EXPECTANCY IN CANADA, 1920–2005
Copyright © 2011 by Nelson Education Ltd Today, most Canadians can expect to live to old age, barring accidents and wars; this was not always the case, as we can see in Table 17.1. In 1920, at birth, Canadian men lived to their late 50s, women to around 60. People can now expect to live more than 20 years longer than if they had been born in 1920. Once they reach age 65, they can expect to live even longer. In 2005, a 65-year-old could expect to live another 19.5 years (17.9 more if a man; 21.1 more if a woman) or to age 84.5. That is 4.1 years more than could be expected at birth. It is not until their 90s that men and women can expect to have approximately the same number of years left to live. Copyright © 2011 by Nelson Education Ltd.

POPULATION AGING: FACTORS
Main reason for increasing proportion of seniors is due to decreases in fertility: With declines in number and proportion of children in population, proportion of older persons necessarily increases Fertility was major predictor of population aging until a population reached life expectancy at birth of 70 years, at which point almost all young persons survive: Further declines in mortality now concentrated at older ages, resulting in relatively larger older age groups* Copyright © 2011 by Nelson Education Ltd Deaths in old age usually result from chronic degenerative diseases. Circulatory diseases, including heart disease and stroke, are the major causes of death, followed by cancer, respiratory diseases, and infectious diseases (Statistics Canada, 2006a). Copyright © 2011 by Nelson Education Ltd.

CANADIAN POPULATION AGE STRUCTURE, 1851-2006
Copyright © 2011 by Nelson Education Ltd The fact that almost everyone can expect to live to old age distinguishes our era from earlier historical periods. In the past, some individuals lived as long as people live today, but never before has the vast majority expected to live to old age. With most of us now living to old age, it will not surprise you that older adults represent an increasing proportion of the Canadian population. We now live much of our lives assuming that an extended future is before us. Now that mandatory retirement has disappeared from virtually all Canadian provinces, more people will likely continue to be employed into their 70s and 80s (see Figure 17.1). Copyright © 2011 by Nelson Education Ltd.

AGING AND AGEISM How the lives of elderly people are experienced is influenced by social construction of old age (i.e., how society views elderly people) In contemporary Western societies, we tend to stereotype older persons, a tendency referred to as ageism Elderly people stereotyped as poor, frail, having no interest in - or capacity for - sexual relations, being socially isolated and lonely, and lacking a full range of abilities in the workplace* Copyright © 2011 by Nelson Education Ltd Researchers have documented ageism in students’ attitudes toward older people, health-care treatment, literary and dramatic portrayals, humour, and legal processes (Chappell, McDonald, and Stones, 2007); they have called it a “quiet epidemic” that contributes to indifference (Stones and Stones, 1997). However, ageism speaks to our treatment of older people as a social category and not necessarily to interpersonal antagonism; we may treat our grandmothers well while also referring to and treating other older adults with indifference or even contempt. Copyright © 2011 by Nelson Education Ltd.

AGING AND AGEISM Factors in ageism: Lack of knowledge about aging Lack of interaction among cohorts Younger people’s fears of their own future Equation of old age with poor health or disease Result of increasing medicalization of old age  Medicalization refers to social and political process whereby increasing areas of life come under authority and control of medicine* Copyright © 2011 by Nelson Education Ltd Because of the legitimacy accorded to medicine in present-day society, the appropriate response to aging (defined as disease) becomes treatment by physicians (Estes, 1979). Copyright © 2011 by Nelson Education Ltd.

DIVERSITY IN AGING Socioeconomic and class differences: People who enjoy socioeconomic advantages tend to experience better health and live longer than others do Economic disadvantage follows many people into old age Having few economic resources affects one’s everyday life in profound ways…* Copyright © 2011 by Nelson Education Ltd In 2003, 38 percent of all older (65+) unattached adults in Canada lived below the low-income cutoff (on which see Chapter 6, Social Stratification). The figure was 32 percent for unattached older males and 41 percent among unattached older females (Chappell, McDonald, and Stones, 2007). The protection of living in a family is striking—only 5.3 percent of older adults living in families were living in poverty. Having few economic resources affects one’s everyday life in profound ways; everything from the type of house and neighbourhood you live in to the schools you attend, the food you eat, the people you associate with, the leisure activities and vacations you can afford, whether you have a car, a pension, investments, and much else. We carry all of these experiences into later life and, as we will see, they have important implications for our health. Copyright © 2011 by Nelson Education Ltd.

DIVERSITY IN AGING Gender: Is gender difference in mortality rates  Elderly women have lower mortality rates than elderly men for all causes of death Factors in women’s lower mortality  Possibly biological/genetic component, but also determined by social and economic factors Implications of gender differential: Women more likely than men to be widowed, not remarry, live alone, and be poorer; but also more likely to maintain social support networks into old age* Copyright © 2011 by Nelson Education Ltd In 2006, 56 percent of those aged 65 and over in Canada were women. The comparable figure for those aged 80 and over was 65 percent (Statistics Canada, 2007b). Women live longer than men do partly because women are the hardier sex, biologically speaking, but social and economic reasons are also important. Thus, the female–male difference in the mortality rate (deaths per 1000 people in a population) is lower among more highly educated and wealthier people than among others (Rogers, Hummer, and Nam, 2000). That is partly because working-class men often engage in dangerous jobs such as construction and mining that increase the risk of an early death. Women also tend to be grandparents for a longer period than men and are more likely to be poor in old age, not only because of their general lower earning power when younger but also because their savings have to cover a longer time. Women are likely to have more age peers in the same situation and are therefore able to maintain their social support networks into old age. Men tend to die before their spouses do because they have shorter life expectancies and because they tend to marry women younger than they are. Copyright © 2011 by Nelson Education Ltd.

DIVERSITY IN AGING Ethnicity and race: Among Canadian seniors, are more foreign-born individuals than in the younger population Aboriginal seniors comprise less than 5% of Canada’s total Aboriginal population because of high fertility rates and high mortality rates Although is expected that number of seniors in Aboriginal population will more than double by 2017 and will represent about 6.5% of population at that time* Copyright © 2011 by Nelson Education Ltd Like gender, ethnicity and race represent fundamental organizing principles of society that are pervasive, socially constructed, and operate throughout the life course. In 2006, 19.8 percent of Canada’s total population was foreign-born compared to 28 percent of the older adult (65+) population; most foreign-born seniors immigrated to Canada when they were younger. Thus, the ethnocultural composition of our older adult population is heavily influenced by the immigration policies that were in effect in the past. Older Aboriginal adults are more likely to live on reserves than younger Aboriginal people are, raising questions about the availability of appropriate care to older adults. Reserves, like most other rural locations across the country, see young adults leave for educational and employment opportunities in urban settings; most do not return. Copyright © 2011 by Nelson Education Ltd.

APOCALYPTIC DEMOGRAPHY
Demography: Study of characteristics of populations and dynamics of population change Apocalyptic demography: Belief that demographic trend (e.g., population aging) has drastic negative consequences for society, including the following: Inability to afford growing percentage of elderly people Tremendous strain on state-financed services Rise to dangerous levels in government debt and deficits Claim that most elderly sufficiently well off to pay for services themselves but expect subsidization* Copyright © 2011 by Nelson Education Ltd Apocalyptic demography reduces the complex issue of an aging population to the notion that society cannot afford a growing percentage of elderly people. In this view, the increasing proportion of elderly adults places tremendous strain on government-financed services, especially Medicare, so government debt and deficits rise to dangerous levels. At the same time, most elderly adults are supposedly well off, and can afford to pay for such services themselves. It follows that we can and should dismantle or at least cut back on social services. If we don’t, the country could go bankrupt. Costs for Canada’s health-care system are increasing, but mainly because of the rising price of pharmaceuticals and biotechnology rather than aging. In short, apocalyptic demography does not withstand a careful review of the evidence. Copyright © 2011 by Nelson Education Ltd.

APOCALYPTIC DEMOGRAPHY
Apocalyptic demography is faulty, and ignores the following: We actually can afford better social services for the elderly because of economic activity, which continues to increase over time Nearly half of elderly women without a spouse live in poverty Population aging accounts for only small part of future health-care costs and will require little increase in public expenditures* Copyright © 2011 by Nelson Education Ltd Economic productivity is increasing—over time, each Canadian produces more goods and services—and partly because the proportion of young people is decreasing as fast as the proportion of elderly people is increasing. Apocalyptic thinkers also ignore government statistics showing that, by any reasonable definition of the term, fewer than half of Canada’s elderly population is well to do; in fact, nearly half of elderly women without a spouse live in poverty. Finally, although we spend much money on pensions and health care, population aging accounts for only a small part of future health-care costs and will require little increase in public expenditures (Evans, McGrail, Morgan, Barer, and Hertzman, 2001). Costs for Canada’s health-care system are increasing, but mainly because of the rising price of pharmaceuticals and biotechnology rather than aging. In short, apocalyptic demography does not withstand a careful review of the evidence. Copyright © 2011 by Nelson Education Ltd.

HEALTH AND OLD AGE Although equation of old age with declining health is valid with regard to physical health, is less true of psychological and emotional health and social well-being With advancing age, about 77% of men and 85% of women aged 65+ suffer from at least one chronic condition; i.e., persistent physical or mental health problem Chronic conditions do not necessarily interfere with day-to-day functioning…* Copyright © 2011 by Nelson Education Ltd The most common chronic conditions are arthritis and rheumatism, eye problems such as cataracts or glaucoma, back problems, heart disease, and diabetes (Gilmour and Park, 2005). Such conditions do not necessarily interfere with day-to-day functioning. Copyright © 2011 by Nelson Education Ltd.

HEALTH AND OLD AGE A functional disability exists when a health problem interferes with day-to-day functioning About one-third of adults age 65+ (25% of men and 34% of women) experience restrictions in their daily activities because of health problems (figure rises to 40% among those aged 75+) Pain is problem for many but not all elderly adults Elderly adults also subject to mental or brain disorders (e.g., dementia – most prevalent form: Alzheimer’s disease)…* Copyright © 2011 by Nelson Education Ltd The most prevalent form of dementia is Alzheimer’s disease; in Canada, 6 to 8 percent of adults 65+ have dementia (Canadian Study of Health and Aging, 1994). About three-quarters of elderly adults with dementia live in long-term care facilities. As is true of other illnesses, the “old old” (variously defined as those aged 75+, 80+, or 85+) are more likely to have this illness; about 20 percent of those aged 80 and over have some form of dementia. Copyright © 2011 by Nelson Education Ltd.

HEALTH AND OLD AGE Elderly adults do not have poorer mental health or poorer sense of psychological well-being than younger age cohorts Self-esteem and feelings of mastery or control also seem to improve with age, peaking in middle age, followed by modest declines in later life Seniors’ social lives tend to be healthy and characterized by social integration, not social isolation Most seniors are embedded in modified extended family networks, characterized by mutual and close intergenerational ties, responsible filial behaviour, and contact between the generations…* Copyright © 2011 by Nelson Education Ltd A correlation exists between mental and physical health. People in better physical health tend to enjoy better mental health. Therefore, as people age and their physical health declines, one would expect their mental health to decline, but this is not the case. Although physical health deteriorates as people age, older adults tend to rate their general health as good, very good, or excellent (73 percent overall, with little difference between men and women). For those aged 75 and over, the overall figure is 68 percent (Statistics Canada, 2007b). A similar picture is evident if we examine measures of psychological well-being. Sociological research conducted since the 1970s has debunked the notion that families abandon their older members. Most elderly adults enjoy extensive social contacts, live close to at least one of their children, and can name friends and confidantes (Antonucci, 1990). Copyright © 2011 by Nelson Education Ltd.

HEALTH AND OLD AGE According to compression of morbidity hypothesis, Western industrialized nations are successfully postponing age of onset of chronic disability Many analysts think that eventually we will all be able to live relatively healthy lives until very shortly before death, when our bodies will deteriorate rapidly Until recently, evidence on this subject was contradictory* Copyright © 2011 by Nelson Education Ltd Although sociologists of health and aging often focus on the problems of old age, and particularly on how elderly adults can prevent, delay, and cope with declining physical health, they also study quality of life. They want to know how society can ensure that old age is a stage of life when individuals are valued and consider their lives worthwhile. This focus has led to an interest in increasing the number of years of life that are free from disability. Recent research suggests that although we are far from a dependency-free old age, Canadians nonetheless are experiencing a later age of onset of functional limitations (however, the same is not necessarily true of chronic illnesses such as diabetes). This is good news, especially if the trend continues; to do so, it would probably need to occur in all segments of the population. Copyright © 2011 by Nelson Education Ltd.

INEQUALITY, HEALTH, AND AGING
Inequalities in health and longevity are reflected in stratification within our society based on factors, such as: Education Income Gender Race, ethnicity, and immigration status…* Copyright © 2011 by Nelson Education Ltd Although less frequently recognized, the aging process itself brings with it differential treatment and resources. Copyright © 2011 by Nelson Education Ltd.

Education People with more education are able to avoid or postpone disability to a greater extent than those with less education But education may be of less benefit once disability is present People with a university degree often feel healthy and function well late into their 60s, 70s, and 80s, whereas those with less education do not…* Copyright © 2011 by Nelson Education Ltd A recent Canadian study focused on changes in health over a three-year period among adults aged 50 and over, all of whom were in good health in the first year. It found that the likelihood of remaining in good health was greater among men and women in the highest educational and income groups (Buckley, Denton, Robb, and Spencer, 2005). Copyright © 2011 by Nelson Education Ltd.

Income: Is estimated that 23% of premature mortality (i.e., years of potential life lost) among Canadians is linked to income differences High-income earners (using various definitions) experience considerably more years of good health than those with lower incomes (also defined variously) Low-income elderly adults with disabilities tend to be more functionally disabled than their high-income counterparts…* Copyright © 2011 by Nelson Education Ltd Some studies report high-income earners enjoy as much as an additional 12 years of good health (Segall and Chappell, 2000); the pattern holds among elderly adults. Even though people with low income are less likely to live to old age, those who do so are more likely to be institutionalized in long-term care facilities than those with higher income are (Trottier, Martel, Houle, Berthelot, and Légaré, 2000). Copyright © 2011 by Nelson Education Ltd.

Gender…In comparison to men: Women, who tend to live longer, are generally found to be less healthy and report more severe disability Women report more multiple health problems associated with chronic conditions (e.g., arthritis, rheumatism, high blood pressure, back problems, and allergies) Women are more likely to report limitations in activities of daily living or disability in later life (although likelihood of disability increases with age for both sexes)…* Copyright © 2011 by Nelson Education Ltd Among elderly women, 85 percent report one or more chronic conditions, compared to 78 percent of elderly men. Although men have lower life expectancy, they live a greater proportion of their lives without disabling conditions. While recent evidence suggests that men and women experience similar levels of mental health problems, they manifest them differently—for example, as depression in women and as alcohol and drug abuse and suicidal behaviour in men (Simon, 2000). Copyright © 2011 by Nelson Education Ltd.

Race, ethnicity, and immigration status In comparison to non-Aboriginal adults, Aboriginal Canadians… Have life expectancy six years shorter Suffer from more chronic illnesses and disabilities, including heart disease and diabetes Do not generally rate their health as excellent or very good Fewer than one-half of non-reserve Aboriginal adults over age 64 report having excellent or very good health…* Copyright © 2011 by Nelson Education Ltd

ABORIGINAL AND NON-ABORIGINAL POPULATION AGE, 2006 (PERCENTAGE)
Copyright © 2011 by Nelson Education Ltd Aboriginal seniors comprise less than 5 percent of Canada’s total Aboriginal population because of high fertility rates and high mortality rates (and therefore shorter life expectancies; see Figure 17.2). However, it is expected that the number of seniors in the Aboriginal population will more than double by 2017 and will represent about 6.5 percent of the population at that time (Statistics Canada, 2005b). These older adults are more likely to live on reserves than younger Aboriginal people are, raising questions about the availability of appropriate care to older adults. Copyright © 2011 by Nelson Education Ltd.

ABORIGINAL AND NON-ABORIGINAL CANADIANS’ LIFE EXPECTANCY AT BIRTH BY SEX, 1991 AND 2001 Copyright © 2011 by Nelson Education Ltd In Canada, big differences exist in the health and wellbeing of Aboriginal versus non-Aboriginal adults. Although the gap appears to have decreased somewhat in recent years, the life expectancy of Aboriginal Canadians currently remains six years shorter than that of non-Aboriginal Canadians (Cooke, Mitrou, Lawrence, Guimond, and Beavon, 2007). Differences are also evident within the Canadian Aboriginal population (see Figure 17.3). Aboriginal populations also suffer from more chronic illnesses and disabilities, including heart disease and diabetes, than non- Aboriginals do (Anand et al., 2001). In 2001, 70 percent of Aboriginal adults aged 65 and over reported one or more disabilities, including difficulties hearing, seeing, walking, climbing stairs, bending, and doing various other activities, nearly twice the rate for non- Aboriginal people of the same age (Statistics Canada, 2007b). Although most elderly Canadian adults rate their health as excellent or very good, fewer than one-half of non-reserve Aboriginal adults over the age of 64 report having excellent or very good health. Copyright © 2011 by Nelson Education Ltd.

In Aboriginal populations… Have death from infectious and parasitic diseases, which is associated with inadequate housing and unsanitary conditions Have (i) high suicide rates; and (ii) high death rates from drowning, fire, homicide, and motor vehicle accidents Are affected by racism and discrimination, which increases risks of psychological distress, depression, and unemployment Often faced with lack of access to opportunities and resources* Copyright © 2011 by Nelson Education Ltd Reasons for differences between non-Aboriginal Canadians and Aboriginal Canadians in both health and life expectancy are numerous. Copyright © 2011 by Nelson Education Ltd.

Health inequities are also evident when comparing other ethnic and racial groups Less than 25% of Canadians aged 65+ born in Canada or U.S., Europe, Australia, and Asia tend to report fair or poor health Contrasts with roughly 33% among those born in Central and South America and Africa Health and longevity also vary widely from one country to the next…* Copyright © 2011 by Nelson Education Ltd

Immigrants, especially recent arrivals, generally enjoy better health than their Canadian-born counterparts Healthy immigrant effect reflects Canadian government requirement that potential immigrants meet minimum standard of health before they are admitted to the country However, immigrants’ health tends to decline after immigration Factors: Negative health implications of changes in diet and activity levels, discrimination, declines in income and other resources, and difficulties in accessing health-care services in years following immigration* Copyright © 2011 by Nelson Education Ltd

EXPLAINING SOCIAL INEQUALITIES IN HEALTH
First explanation  Research findings support link between (i) social location and individual behaviour; and (ii) lifestyle factors Compared to those with lower levels of education and income, individuals with higher levels of education and income are: More likely to engage in health-promoting practices Less likely to engage in risky health practices  But…* Copyright © 2011 by Nelson Education Ltd Early research focused on biological explanations and on differences associated with health services use, including differences in the likelihood that people would follow doctors’ orders and inequalities in access to health-care services. Indeed, the view that creating a universally equitable health-care system would eliminate or at least reduce health inequalities was a major argument for the creation of a universal health-care system in this country. More recently, evidence indicating that inequalities in health and longevity have persisted despite the introduction of a universal health-care system has led to renewed attempts to account for such differences (Crompton, 2000). Some researchers have offered explanations that are specific to one or another type of inequality; others have focused on explanations associated with many sources of inequality. Copyright © 2011 by Nelson Education Ltd.

Overall, studies suggest impact of health behaviours is minor compared with other factors, such as income inadequacy Focus on individual role in health is criticized for: Ignoring more important structural inequalities that contribute to health outcomes and even limit potential options for health behaviours Encouraging a blame-the-victim mentality for what are socially-produced structured inequalities* Copyright © 2011 by Nelson Education Ltd Although research finds a link between social location and lifestyle factors, sociologists often criticize such explanations because they ignore how social inequalities typically trump individual decisions in determining health outcomes. Thus, studies comparing the importance of individual decisions against social factors such as income adequacy routinely find that the latter are more important (House, 2001; Williamson, 2000). Moreover, when researchers focus on individual decision making, they often neglect the fact that people rarely make choices freely from a full range of possible options. We can criticize low-income earners for failing to exercise more, but only if we ignore that they may live in neighbourhoods where an evening jog is dangerous, affordable recreational facilities don’t exist, and lack of child-care options means they have little time for such pursuits in any event. As this example shows, social inequalities structure choices; attending only to individual decision making often amounts to blaming victims for structured inequalities. Copyright © 2011 by Nelson Education Ltd.

Second explanation  Stress associated with (i) lack of access to economic and other resources; and (ii) perception of inequality = Hierarchy stress perspective: Stress and depression may result from perception of relative deprivation when people compare own situation with that of others Stress also can indirectly negatively affect health by leading people to smoke, consume too much alcohol, and eat too much or too little* Copyright © 2011 by Nelson Education Ltd Inequality and lack of access to economic and other resources generate stress, leading to poor health. In addition, some analysts argue that more than poverty is at work here. They note that if poverty were the only problem, we would expect to find substantial differences in health between the poor and the non-poor, but little or no difference between those who are only moderately well off versus those who are wealthy; yet this is not the case. Instead, each increment in education and income brings additional health advantages. Copyright © 2011 by Nelson Education Ltd.

Third explanation: Emphasizes resources and material conditions as mechanisms linking people’s social location to health outcomes Such arguments hold that one’s social class, age, gender, race, ethnicity, etc. contribute to differential access to range of resources that contribute to good or poor health Resources include enough income to buy nutritious food; enough education to be aware of health issues Examples of resources: What constitutes a nutritious diet; access to means of illness prevention; ability to avoid risk factors, such as living in environments where dangerous chemicals are present, etc.* Copyright © 2011 by Nelson Education Ltd Some researchers operating in this tradition insist that we should focus less on the resources that contribute to good or poor health and more on the way social class, age, gender, race, and ethnicity, directly contribute to “systematic material, social, cultural, and political exclusion from mainstream society” (Raphael, 2005: 4). These structural factors are the fundamental causes of health status, influencing access to health-related resources (Link and Phelan, 2000). Debate continues regarding whether individual behaviours and lifestyle characteristics, stress and other psychosocial factors, or material conditions and resources are important for understanding inequalities in health; the answer may well be “all of the above.” Copyright © 2011 by Nelson Education Ltd.

INTERSECTING INEQUALITIES AND HEALTH OVER THE LIFE COURSE
Increasingly, sociologists are interested in effects of multiple statuses on health outcomes: Age as leveller hypothesis  Argues age effects cut across all other statuses, in effect levelling inequalities from earlier in life Competing multiple jeopardy hypothesis  Argues effects of membership in multiple low-status groups is cumulative Example: Being female and old has more negative consequences than being either female or old…* Copyright © 2011 by Nelson Education Ltd Copyright © 2011 by Nelson Education Ltd.

INTERSECTING INEQUALITIES AND HEALTH OVER THE LIFE COURSE
More recently, researchers have argued that statuses cannot simply be added together to judge their effects Instead, statuses intersect and interact, and we cannot fully understand them apart from one other Researchers also note as a person ages, the social and economic factors that influence health change According to the life course perspective, the circumstances of later life and those of early life combine to influence what happens to health in later life* Copyright © 2011 by Nelson Education Ltd For example, occupations influence health but do so differently for men and women. Living in poverty has a stronger negative effect on women’s health than on men’s health (Prus and Gee, 2002). As a result, the greatest differences in life expectancy between men and women occur in the poorest areas (DesMeules, Manuel, and Cho, 2004). Similarly, the gap in perceived health status of Aboriginal people and the total Canadian population widens in older age groups (Statistics Canada, 2003). Copyright © 2011 by Nelson Education Ltd.

HEALTH CARE: IMPLICATIONS OF VARIOUS UNDERSTANDINGS OF CAUSES OF HEALTH PROBLEMS If health problems of older adults viewed only as result of what happens in later life, interventions will be targeted to older adults If health problems attributed to freely chosen personal behaviours, interventions will be aimed at educating people If life course perspective adopted and health problems viewed as arising from social structural inequalities, attempts will be made to improve health beginning early in life…* Copyright © 2011 by Nelson Education Ltd If we attribute health problems to personal behaviours and see these as freely chosen, we will consider older adults responsible for their own health problems and will likely implement solutions aimed at educating people, hoping they will make different choices in the future; or we will demand that people deal with the problems they themselves have created. If we adopt a life course perspective and conclude that many of the health problems of elderly adults have their roots in lifelong experiences with poverty, inequality, and lack of access to social, economic, and other resources, we will want to address what happens earlier in life as well. Copyright © 2011 by Nelson Education Ltd.

HEALTH CARE: IMPLICATIONS OF VARIOUS UNDERSTANDINGS OF CAUSES OF HEALTH PROBLEMS If health inequalities attributed to perceptions of stress, we may focus on altering how people view their circumstances rather than changing circumstances themselves If organization of society and distribution of economic and social resources regarded as main determinants of health, we will likely direct attention to economic and social policies as means of improving health* Copyright © 2011 by Nelson Education Ltd Copyright © 2011 by Nelson Education Ltd.

SELF CARE AND INFORMAL CARE
Primary form of care when health declines is self care: Range of activities that individuals undertake to enhance health, prevent disease, and restore health Except in emergencies, when we do need help from others, we turn first to our informal network of family and friends Despite claim for modern Western societies (such as Canada) being dismissive of the elderly, about 75% of all care provided to seniors comes from their informal network (usually readily provided and primarily by family members, mostly women)* Copyright © 2011 by Nelson Education Ltd Most people care for themselves most of the time; self-care is the primary form of care even when health declines and we require help from others and the health-care system; we wash our hands, exercise, choose what to eat, establish any number of lifestyle practices, try to have a positive attitude toward life, and select healthcare providers. First turning to our informal network of family and friends when we need help is as true in old age as it is when we are young; indeed, throughout history networks of family members and friends have been the first resource for care. It is, first of all, the spouse who provides care when the health of the other spouse fails. Typically, the wife first provides care for her husband because men have a shorter life expectancy and women tend to marry men a few years older than them. As a result, the husband’s health often begins to fail before that of his wife and his wife is usually available to care for him in his last years. After the husband’s death, the wife may enjoy a few more years of good health before she needs assistance. In this situation, it tends to be her children, typically daughters, who provide most of the care before her death. Notice that informal caring comes primarily from wives and daughters. Sons provide mainly financial assistance and advice, while daughters provide mainly emotional support and hands-on caring. Copyright © 2011 by Nelson Education Ltd.

FORMAL MEDICAL AND HOME CARE
Canada’s publicly-funded health-care system offers “Medicare”: Universal access to physicians and acute care hospital services for its citizens based on need Prior to establishment of Medicare, people needing health care were required to pay for it, or do without Situation was especially problematic for poor people whose health needs were great, especially given disproportionately large number of the elderly, the unemployed, and chronically disabled among the poor…* Copyright © 2011 by Nelson Education Ltd Copyright © 2011 by Nelson Education Ltd.

BRIEF HISTORY OF MEDICARE IN CANADA
Gaps in access to health care particularly apparent in years that followed WWI and Depression of 1930s 1957: Hospital Insurance and Diagnostic Services Act introduced, leading to hospital care coverage for entire population 1966: Medical Care Act passed, laying groundwork for universal health insurance for physician services By 1972, all provinces and territories had joined program, which operated on 50/50 cost sharing arrangement between federal government and provinces…* Copyright © 2011 by Nelson Education Ltd Copyright © 2011 by Nelson Education Ltd.

From the outset, health care was structured as provincial responsibility Federal government develops policy and assists with funding services, but each province is responsible for delivering services Through Medicare, every province offers physician and acute care hospital services at no out-of-pocket cost to its residents Services are publicly funded (paid for by the government)…* Copyright © 2011 by Nelson Education Ltd

Most physicians operate as private entrepreneurs: Government pays them for services that they deem necessary and that they render The more services physicians provide, the more they earn Difference between their jobs and those of other private entrepreneurs is that their incomes are virtually guaranteed…* Copyright © 2011 by Nelson Education Ltd We publicly finance health care but physicians provide it privately. Physicians’ incomes are virtually guaranteed because of the importance society attaches to their specialized expertise, which makes them the gatekeepers to our health- care system. Only physicians can order medical tests, prescribe certain drugs, admit us to hospital, and certify that we are sick. Copyright © 2011 by Nelson Education Ltd.

Historically, Canada structured its health-care system mainly to provide physician-dominated medical care in physicians’ offices and hospitals We defined health as absence of disease, excluding from coverage preventative measures and those that took a broad view of health as a state of physical, social, and psychological well-being…* Copyright © 2011 by Nelson Education Ltd Initially, we did not cover home care, services of chiropractors and physiotherapists, and drugs prescribed outside the hospital. Copyright © 2011 by Nelson Education Ltd.

MEDICARE IN CANADA TODAY
2006: Health-care expenditures in Canada totalled $151.3 billion Availability of many types of health care (e.g., home care, nursing homes, physiotherapy, home nursing, counselling, chiropractic services, podiatry, and massage therapy) varies across provinces Some provinces provide these services as part of their healthcare system at no cost to the user Others provide them at minimal cost or on a means-tested basis* Copyright © 2011 by Nelson Education Ltd Of 2006 health-care expenditures, most of the funds (69 percent) were used to cover the cost of physicians and other medical professionals, hospitals, and drugs. In means-tested case, people’s finances are assessed, and if they can afford a required service, they pay for it. Otherwise, the government subsidizes the cost. Access to such services also varies—for example, some places require a physician referral while others permit self-referral. Services also vary across regions within provinces. Copyright © 2011 by Nelson Education Ltd.

HOME CARE SERVICES IN AN AGING SOCIETY
One type of health service especially important in an aging society is home care, which brings services into people’s homes to help them live there rather than move to a nursing home Most people, including older adults, prefer living in own home as opposed to a long-term care facility Adequate home-care services are critically important because they allow older individuals to remain independent Despite importance, home care receives relatively little governmental funding* Copyright © 2011 by Nelson Education Ltd Home care brings services into people’s homes to help them live there rather than move to a nursing home. Most people, including older adults, prefer living in their own home as opposed to a long-term care facility. Adequate home- care services are critically important because they allow older individuals to remain independent. Home care lies outside Medicare; today, most provinces favour a system in which about half the cost of home care is borne by government-subsidized nonprofit agencies and the other half by patients who buy services from for-profit businesses. Copyright © 2011 by Nelson Education Ltd.

HEALTH-CARE SYSTEM CHANGE AND REFORM
In years following establishment of Medicare, cost of health care rose leading federal and provincial governments to try to contain costs Was widespread recognition of need to shift away from system almost entirely biomedically-focused and concerned only with treatment and cure of disease, and towards broader conception of care that incorporates health promotion and disease prevention Result: Deinstitutionalization of health services and providing more care outside hospitals…* Copyright © 2011 by Nelson Education Ltd Without denying the importance of medical care by physicians, nearly all of the reviews of the healthcare system carried out in the 1980s and 1990s reached the same conclusion: We need to shift away from a system that is almost entirely biomedically focused and concerned only with the treatment and cure of disease; we must pay more attention to a broader conception of care that incorporates health promotion and disease prevention. Copyright © 2011 by Nelson Education Ltd.

HEALTH-CARE SYSTEM CHANGE AND REFORM
Other major reforms followed Most provinces regionalized health-care services, yielding authority to subprovincial health boards Fewer people received acute and extended care; hospital admissions fell; length of hospital stays dropped; and many surgical treatments moved to outpatient settings Reforms also failed to acknowledge need for enhanced long-term home-care services* Copyright © 2011 by Nelson Education Ltd Still, major components of the recommended reforms have yet to be adopted (Lewis, Donaldson, Mitton and Currie, 2001). For example, there is little evidence of an expanded focus on health promotion and disease prevention. While home-care budgets have increased, it appears that funds are being directed mainly to short-term post-hospital and nursing care rather than meeting the long-term chronic care needs of elderly adults (Penning, Brackley and Allan, 2006). Increased demand for intensive short-term post-hospital care is a result of the shortened length of hospital stays and the increase in outpatient surgeries. The Commission on the Future of Health Care in Canada (2002), widely known as the Romanow Commission, argued that short-term post-hospital home care should be part of Canadian Medicare, but this has not yet happened. The Romanow Commission did not discuss the needs of older adults who suffer primarily from chronic degenerative conditions; medicine does not have cures for such conditions. Failure to acknowledge the need for enhanced long-term home-care services is tied to the internationalization of capital, often referred to as globalization. Copyright © 2011 by Nelson Education Ltd.

GLOBALIZATION AND PROFIT MAKING
Economic globalization involves use of variety of technologies to boost transnational investment, finance, advertising, and consumption, thereby increasing profitability of multinational corporations Proponents of globalization emphasize need for: Privatization  Turning publicly-owned organizations into privately-owned companies Profitization  Turning institutions into profit-making organizations…* Copyright © 2011 by Nelson Education Ltd The privatization and profitization of state services (including health-care services) expands the playing field for big business but renders low-income citizens less well protected. Copyright © 2011 by Nelson Education Ltd.

For-profit health care tends to be more expensive than universal public schemes For-profit health care costs governments less, but people who use the services pay more Much of increased cost comes from administrative “overhead” charges…* Copyright © 2011 by Nelson Education Ltd Some analysts interpret recent changes in Canada’s health-care system, such as shortened hospital stays, removal of beds from the system, and the decline of long-term chronic home care, as symptoms of globalization. Private funding accounts for an increasing share of Canada’s health-care budget (Armstrong, Armstrong, and Coburn, 2001). Increases in outpatient surgery and post-surgical care have created profitable opportunities for private corporations with headquarters outside Canada In the United States, one-sixth of the population lacks such insurance and another one-sixth lacks adequate coverage; Canada’s Medicare system provides adequate care to all people in need. People who earn low income, the elderly population, and women receive more services because their needs tend to be greater. Copyright © 2011 by Nelson Education Ltd.

A for-profit system also leaves many citizens without any health insurance Risk is that as more of our health-care services are profitized, more people with health-care needs are going to be disadvantaged Many sociologists argue that economic globalization does not support type of health-care system appropriate for an aging society; i.e., a system that combines medical care and strong long-term home-care program, including social services for the elderly** Copyright © 2011 by Nelson Education Ltd Access to needed care will increasingly vary by class, gender, and racial and ethnic inequalities; with fewer health-care options available, people lacking economic resources will do without health services or will rely on self-care or care from family and friends (Arber and Ginn, 1991). Globalization is dismantling many existing services; it is adding new inequalities in access to health-care services to existing inequalities in health-care needs. Disadvantaged seniors and their families are feeling most of the resulting pressure. Copyright © 2011 by Nelson Education Ltd.

PowerPoint Presentation prepared by Terri Petkau, Mohawk College

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PowerPoint Presentation prepared by Terri Petkau, Mohawk College

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