Wiseman, Nelson

Because federal funding for long-term care was not included as part of Canada's publicly-funded universal health care system, provincial governments have been free to determine how much, or how little, they will rely on the for-profit sector to meet the long-term care needs of their senior populations. The proportion of beds in the for-profit sector differs in each province, demonstrating that policy approaches to this type of care have developed according to distinct provincial political contexts. In this dissertation I explain why governments in two provinces, Manitoba and Ontario, have come to rely on the proprietary sector to markedly different degrees. While in the federation Manitoba stands out for its restrained reliance on this form of care, Ontario stands out for its exceptional dependence on commercial provision. In the chapters that follow I employ an historical institutionalist framework of analysis to explain why these neighbouring provinces initially pursued different policy paths in long-term care and how these paths have been sustained over time.

Following an introductory chapter in which I explain the reasons for the marginalization of long-term care within national health policy making, I provide in-depth analysis of these case studies in policy divergence. I argue that contemporary policy differences between these neighbouring provinces cannot be understood in isolation from long-term historical processes. Focusing largely on the period from the 1960s to the 1990s, I emphasize that present differences in ownership are a reflection of the different constellation of actors, events, ideas and institutions that came together at critical junctures in time, and the lasting legacies that these early windows of opportunity for reform have had on subsequent rounds of long-term care policy-making. In each province, diverging ideas about the appropriate role of the for-profit sector in meeting the long-term care needs of an aging population rose to prominence on the political agenda. Over time, rigidities developed in each system, making it difficult for actors advocating for new directions in ownership to realize their ambitions.

In both provinces policies put in place at earlier times greatly influenced future political dynamics, altered the guiding principles of government departments and policy makers, provided incentives for different interest group formations, and led to contrasting public expectations about the proper balance of the for-profit and non-profit sectors in long-term care provision. I conclude this dissertation by arguing that its findings can contribute in important ways to present discussions about long-term care reform in Canada generally and about the future role of for-profit providers specifically.

Author Keywords: Comparative Politics, Health Policy, Historical Institutionalism, Long-Term Care, Path Dependency, Provincial Politics