Canada stands as an important lesson for the United States. At the very minimum it represents the art of the possible. For those interested in long-term care, it suggests that it is possible to include long-term care in a programme of universally accessible care without national bankruptcy. Although Canada has brought medical and social services closer together and has brought acute and chronic care under the same aegis, not all the problems of coordinating such efforts have been solved. For others, the Canadian example shows that care can be provided to all persons who need it without creating uncontrollable expenses or removing families' motivations to care for their own. In so doing, universal coverage creates the opportunity for better coordination of services and ultimately for more efficient care.
KEY woms-Long-term care, efficiency, access, cost, finance, Canada.
Canada stands as an important lesson for the United States. At the very minimum it represents the art of the possible. For those interested in long-term care, it suggests that it is possible to include long-term care in a programme of universally accessible care without national bankruptcy. Although some of the claims that health care spending as a proportion of GNP may cast the Canadian situation in too favourable a light compared to the US because of its more improved GNP, there seems to be agreement that, at a minimum, costs of health care in Canada are not rising any faster in Canada in the last quarter century despite the great increase in access to many forms of care, including LTC.' At the same time, universal health insurance is a vehicle to get to a solution rather than a panacea. It provides a structure through which other steps to reforming long term care can be taken, but its presence is not a guarantee that those steps will be taken.
An early word of caution is in order. Any model from another society, even one culturally similar, is not necessarily importable intact into our country. Differences in basic values, such as the role of government and the centrality of the individual must be recognized and accommodated. Nonetheless, the fact that quite different approaches are possible, and are associated with controlled costs, provides important evidence in the pressure for change.
WHERE DOES LONG-TERM CARE FIT?
Although the term implies a distinction from acute care, the concept of long-term care remains somewhat elusive. In the past, it has meant that portion of chronic care provided to persons who have lost (or never obtained) the capacity for providing their own medical, personal, and social needs, It has largely been thought of as care rendered in institutions like nursing homes. Indeed, the nursing home has become the