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To shed new empirical light on this old debate, we quantified the impacts of demographic and non-demographic determinants of healthcare expenditure using data for British Columbia (BC) over the period 1996 to 2006. Using linked administrative healthcare data, we quantified the trends in and the determinants of expenditures on hospital care, physician services and pharmaceuticals. To our knowledge, this is the first time that all three of these major components of healthcare costs have been analyzed in a single Canadian study.

We found that population aging contributed less than 1% per year to spending on medical, hospital and pharmaceutical care. Moreover, changes in age-specific mortality rates actually reduced hospital expenditure by –0.3% per year. Based on forecasts through 2036, we found that the future effects of population aging on healthcare spending will continue to be small. We therefore conclude that population aging has exerted, and will continue to exert, only modest pressures on medical, hospital and pharmaceutical costs in Canada. As indicated by the specific non-demographic cost drivers computed in our study, the critical determinants of expenditure on healthcare stem from non-demographic factors over which practitioners, policy makers and patients have discretion.

We found that population aging in British Columbia contributed less than 1% per year to total growth of expenditures on hospital, medical and pharmaceutical care from 1996 to 2006. We also found that changes in age-specific mortality rates reduced (albeit modestly) per capita healthcare costs over time, confirming what other researchers have suggested (Fries 1980; Breyer and Felder 2006). With rigorous analysis of recent healthcare data, we can therefore confirm what studies spanning earlier decades for British Columbia, elsewhere in Canada and other comparable health systems have found: the net impact of demographic factors on major components of the healthcare system is moderate (Denton and Spencer 1983; Fuchs 1984; Barer et al. 1987, 1995; Gerdtham 1993; Evans et al. 2001; McGrail et al. 2001). Moreover, when we forecasted the effects of expected demographic changes in British Columbia through 2036, we found that the future effects of population aging on healthcare spending will continue to be modest (1% or less per year).

Our findings also indicated that average payment per unit of hospital care increased over the period. The increase in hospital unit costs may have been an appropriate policy response to increases in age-adjusted clinical complexity per patient remaining in care following reductions in the average length of stay

After taking into account population aging, the average number of days of prescription drug therapy received by British Columbia residents grew more than 5% per year during the first half of our study period and plateaued in the latter half of the period (data not shown)

Despite popular claims about population aging and the sustainability of healthcare in Canada, demographic changes exert steady, predictable and modest forces on the cost of major components of our healthcare system. This is likely to remain true for the foreseeable future.

Canada's median age is now about 40, and heading upward. It was 26 in 1971. The median age could be worse; it's 46 in Germany and higher still in Japan. The total fertility rate (TFR) is about 1.6 children per woman. Population replacement rate is two per woman. As a result, and even after accounting for immigration, the annual population growth rate for the next half-century will be the lowest in Canadian history. More seniors means fewer people in the labour force, even if a few seniors keep working into their late 60s. The ratio therefore between those in the work force and those outside of it will change dramatically over time. What used to be a 5-to-1 ratio will slip to something like 2.5 to 1.

Both the federal Department of Finance and the Parliamentary Budget Office have alerted us to what lies ahead: Economic growth will be slower, the burden of expenditures on government for seniors programs will increase and government revenues will be stretched. It's arithmetic, not politics. The arithmetic of aging is politically uncomfortable. It's especially uncomfortable for provinces, the level of government that delivers labour-intensive services such as health, education, policing and welfare. The provinces' burden will also rise because, unless a new federal government changes the decision, Ottawa's yearly transfers to provinces for health care will increase less rapidly past 2017. The result will be a hole of some billions of dollars. Aging with its higher costs and lower growth is the context by which the electoral promises of every party might usefully be judged. They are all catering to today's middle class, fighting over which cares the most about their "anxieties." And they are fixated on seniors, too, since seniors vote.

You could say that the NDP daycare promise is future-oriented, in that if fully implemented it would encourage more women to work, which in turn would ease the ratio of those adults working to those who are not. It might up the fertility rate, which would help, as it has in Quebec. You could say that the Conservatives' decision to raise the age level for receipt of the Old Age Supplement to 67 from 65 recognizes that people are living much longer than when the OAS was implemented. (Women in the next decade are expected to have a life expectancy of 87.) All parties pledge to stoke up the engines of economic growth: in the NDP's case by lowering the small-business tax rate by two points. Except the party then proposes to raise the tax for large companies by two points, an impediment to creating more large companies of the kind Canada needs in a global economy.

Pledges to increase manufacturing are not worth much, since manufacturing has been more or less in decline in North America and Europe (except Germany) for a long time, for reasons rather outside the capacity of governments to influence, except by subsidies and other forms of direct or indirect help. Promises predictably have been pouring forth from every party, without any of them yet providing some sort of overall accounting for how they will be financed. Even when (if?) this accounting is provided, the chances are excellent it will be based on falsely optimistic assumptions about economic growth and the revenues it will provide. The demographic shift now beginning will likely mock those assumptions.

In 2012, age-related needs were identified as the single most common problem requiring help from caregivers (28%) (Chart 1). This was followed by cancer (11%), cardio-vascular disease (9%), mental illness (7%), and Alzheimer’s disease and dementia (6%).

The majority of caregivers reported providing transportation to their primary care receiver, making it the most frequent type of care provided in the last 12 months (73%)

In addition, about half of caregivers (51%) reported that they performed tasks inside the care recipients’ home in the last 12 months, such as preparing meals, cleaning, and laundry. Another 45% reported providing assistance with house maintenance or outdoor work.

The most common types of care were not always the ones most likely to be performed on a regular basis (i.e., at least once a week). For instance, despite the fact that personal care and providing medical assistance were the least common forms of care, when they were performed, these tasks were most likely to be done more regularly.

Emotional support often accompanied other help to the care receiver. Nearly nine in ten caregivers (88%) reported spending time with the person, talking with and listening to them, cheering them up or providing some other form of emotional support. Virtually all caregivers (96%) ensured that the ill or disabled family member or friend was okay, either by visiting or calling.

Overall, caregivers spent a median of 3 hours a week caring for an ill or disabled family member or friend. This climbed to a median of 10 hours per week for caregivers assisting a child and 14 hours for those providing care to an ill spouse (Chart 3).

Most often, caregivers spent under 10 hours a week on caregiving duties. In particular, one-quarter of caregivers (26%) reported spending one hour or less per week caring for a family member or friend. Another 32% reported spending an average of 2 to 4 hours per week and 16% spent 5 to 9 hours per week on caregiving activities.  

For some, caregiving was a large part of their life - equivalent to a full time job. Approximately one in ten caregivers were spending 30 or more hours a week providing some form of assistance to their ill family member or friend.  These caregivers were most likely caring for an ill spouse (31%) or child (29%).5

The actual time spent performing tasks is often combined with time needed to travel to provide care. Approximately three-quarters (73%) of caregivers indicated that they did not live in the same household or building as their care receiver, meaning they often had to travel to reach the care recipients’ home. Just over half (52%), however, reported having to travel less than 30 minutes by car.  Roughly 12% of caregivers provided help to a family member who lived at least one hour away by car.

Certain health conditions required more hours of care. This was the case for developmental disabilities or disorders, where 51% of these caregivers were spending at least 10 hours a week providing help

Caring for an ill or disabled family member or friend can span months or years. For the vast majority of caregivers (89%), their caregiving activities had been going on at least one year or longer, with half reporting they had been caring for a loved one for four years or more.

Four provinces had rates above the national average of 28%, including Ontario (29%), Nova Scotia (31%), Manitoba (33%) and Saskatchewan (34%) (Textbox Chart 1). The higher levels of caregiving in Ontario, Nova Scotia and Manitoba were largely related to caring for a loved one suffering from a chronic health condition or disability, whereas in Saskatchewan, the higher level of caregiving was attributed to aging needs. 

Historically, caregivers have been disproportionally women (Cranswick and Dosman 2008). This was also true in 2012, when an estimated 54% of caregivers were women.

Although the median number of caregiving hours was similar between men and women (3 and 4 hours per week, respectively), women were more likely than their male counterparts to spend 20 or more hours per week on caregiving tasks (17% versus 11%). Meanwhile, men were more likely than women to spend less than one hour per week providing care (29% versus 23%) (Chart 5).

For instance, they were twice as likely as their male counterparts to provide personal care to the primary care receiver, including bathing and dressing (29% versus 13%).

Caregivers have multiple responsibilities beyond caring for their chronically ill, disabled or aging family member or friend. In 2012, 28% of caregivers could be considered “sandwiched” between caregiving and childrearing, having at least one child under 18 years living at home

The aging of the population, higher life expectancies and the shift in emphasis from institutionalized care to home care may suggest that more chronically ill, disabled and frail people are relying on help from family and friends than in the past. Using the GSS, it is possible to examine the changes in the number of caregivers aged 45 years and older, recognizing that methodological differences between survey cycles warrant caution when interpreting any results.

Bearing in mind these caveats, results from the GSS show that between 2007 and 2012, the number of caregivers aged 45 and over increased by 760,000 to 4.5 million caregivers, representing a 20% increase in the number of caregivers over the five years.

Having less time with children was an often cited outcome of providing care to a chronically ill, disabled, or aging family member or friend. About half (49%) of caregivers with children under 18 indicated that their caregiving responsibilities caused them to reduce the amount of time spent with their children.6

Overall, the vast majority of caregivers (95%) indicated that they were effectively coping with their caregiving responsibilities, with only 5% reporting that they were not coping well.7 However, the feeling of being unable to cope grew with a greater number of hours of care. By the time caregivers were spending 20 or more hours per week on caregiving tasks, one in ten (10%) were not coping well.  

In addition, while most were able to effectively manage their caregiving responsibilities, 28% found providing care somewhat or very stressful and 19% of caregivers indicated that their physical and emotional health suffered in the last 12 months as a result of their caregiving responsibilities.

The health consequences of caregiving were even more pronounced when caregivers were asked specific questions on their health symptoms. Over half (55%) of caregivers felt worried or anxious as a result of their caregiving responsibilities, while about half (51%) felt tired during the past 12 months (Chart 8). Other common symptoms associated with providing care included feeling short-tempered or irritable (36%), feeling overwhelmed (35%) and having a disturbed sleep (34%).8

The financial impacts related to caring for a loved one can be significant. Lost days at work may reduce household income, while out-of-pocket expenses, such as purchasing specialized aids or devices, transportation costs, and hiring professional help to assist with care, can be borne from caring for a loved one. In many cases, financial support, from either informal or formal sources, can ease the financial burden associated with caregiving responsibilities. Overall, about one in five caregivers (19%) were receiving some form of financial support. 

Japan is far from alone. Dementia is increasing across the globe - 47 million people already live with the disease, with more than 130 million projected by 2050. But the first waves have crashed over Japan. When it comes to dementia - a group of disorders affecting memory and cognition, for which there is no known cure - age is the greatest risk factor. No country has gotten older faster than Japan, the world's first "super-aged" nation. In the early '60s, Japan was the youngest of today's G7 countries. Now, it is the oldest - a dramatic shift fuelled by plummeting birth rates and the world's highest life expectancy, according to the World Health Organization, with an average of 84 years (in Canada, it's 82).

A quarter of Japan's 128 million people are already elderly, meaning over 65. By 2060, the elderly will make up 40 per cent of the population. Many will spend their dying days addled by dementia, which already affects 4.62 million Japanese. Ten years from now, an estimated 7.3 million people in Japan will have dementia - more people than live in Hong Kong, Rio de Janeiro or the entire GTA. "The impact will be so huge," said Dr. Koji Miura, director general of the Ministry of Health, Labour and Welfare's bureau for the elderly. "The burden on younger people is very rapidly increasing. If we don't do anything, society will be in trouble." Last year, more than 10,700 people with dementia went missing in Japan. The vast majority were found - some dead - but 168 were not. Violent crimes fuelled by kaigo jigoku, the Japanese term meaning "caregiver hell," are increasingly making headlines.

In July, 83-year-old Kyuji Takahashi was accused of stabbing his wife. He allegedly told police: "My wife has dementia and I am worn out from looking after her." Right now, these stories are still the exception, but Japan's challenge is to stop a public health crisis from unspooling - while battling the world's highest debt.

There is little any government can do about changing the course of dementia. The only thing Japan can change is Japan. "We see the crisis point as 2025," said Mayumi Hayashi, a research fellow with the Institute of Gerontology at King's College London. "And to cope with that crisis point, Japan is trying to create a society where everybody contributes and people with dementia have a better experience and quality of life." Grassroots efforts play a leading role in building this new society, with volunteers spearheading efforts to increase awareness and to form networks to find wanderers - those who go missing after becoming disoriented or confused.

Over the past 15 years, Japanese policy-makers have also changed everything from the social welfare system to the very word for "dementia." Before, the commonly used term was chiho, meaning "idiocy" or "stupidity," even in medical literature. In 2004, the government made an unusual announcement: chiho would know be known as ninchisho, meaning "cognitive disorder." "After the change of the name, the knowledge and acceptance of dementia has spread widely all over this country," said Dr. Takashi Asada, a psychogeriatrician who was a member of the renaming committee.

Japan's all-hands-on-deck dementia strategy - introduced in 2012 and revised last year - involves not just the health ministry but 11 other ministries and agencies. The strategy funds research but also prioritizes early detection, training front line health workers, support for caregivers and creating "dementia-friendly" communities. But the single most important - and radical - change Japan has made to improve dementia care came in 2000, when the government introduced mandatory long-term care insurance.

A primary goal was to help seniors live more independently and reduce the burden on relatives - particularly women, who are often the caregivers. So unlike long-term care insurance in countries like Germany, which offer cash, Japan's system offers services - and consumer choice. The scheme works like this: at age 40, every Japanese resident pays a monthly insurance premium. When they turn 65 - or get sick with an aging-related disease - they become eligible for a range of services: everything from dementia daycare to lunch delivery and bathing assistance. Depending on income, users also pay a 10- or 20-per-cent service fee - a measure that discourages overuse. This system also created something crucial in the field of long-term care: a market.

"Lots and lots of services developed very rapidly," said John Creighton Campbell, a University of Michigan professor emeritus and expert on Japan's long-term care system. "Without the long-term care insurance system, they wouldn't be conceivable." Campbell believes Japan is "better than any other place in the world for dementia care." Of course, Japan's unique and complicated system won't necessarily translate in other countries and significant issues remain, particularly when it comes to financial sustainability; the number of Japanese using long-term care has more than doubled since the program began, with 5.6 million people accessing it in 2013. Japanese families also continue to demand institutionalized care for their relatives and caregiver burnout is still a growing problem. But Japan's trials and errors are instructive for other nations, marching their own paths toward the destination of super-aged. The country is already living the future that countries like Canada are bracing for.

In September, national anxiety followed Statistics Canada's announcement that, for the first time ever, Canada's elderly population had surpassed its population of children. Japan hit this same milestone - in 1997. Clearly, there is good reason to keep an eye toward the Land of the Rising Sun, the Lancet medical journal recently suggested. "How Japan addresses the challenges - and opportunities - posed by a rapidly aging society will become a model for other countries facing their own demographic time bombs."

Dementia by the numbers 61,568 Japanese centenarians today 153 Japanese centenarians in 1963 1 in 5 Elderly Japanese who will have dementia in 2025 1 million

Nurses and care workers needed by 2025 to deal with dementia 40% Percentage of Japan's population that will be over 65 in 2060 15,731 Number of over-65 Japanese abused by families or relatives, according to a 2013 survey 14.5 trillion yen

Cost of dementia on the Japanese economy in 2013 6.2 trillion yen Estimated cost of informal care for de

24.3 trillion yen Estimated cost of dementia in 2060

Elderly people work out with wooden dumbbells in Tokyo to celebrate Japan's Respect for the Aged Day in September. A quarter of Japan's 128 million people are over 65. By 2060, that figure will be 40 per cent. • Nobuko Tsuboi runs a seniors daycare, covered by Japan's long-term care insurance. • Tomofumi Yamamoto is staying fit in hopes of warding off dementia.

Women, as well as Canadians aged 34 to 54, and those already caring for an elderly person, are among those least confident that hospitals and long-term care facilities can handle the demands of a population that is living longer

he Ipsos Reid poll of 1,000 Canadians was released to coincide with Monday's opening of the CMA's annual meeting

Overall, the 2011 census counted nearly five million people aged 65 and older in Canada.By 2031, 22.8 per cent of the population will be 65 or older, jumping to one quarter - 25.5 per cent - by 2061.

Three-quarters, or 75 per cent, of those surveyed gave an "A" or "B" grade

overall

To make aging at home a reality for all Canadians, we must redesign the delivery of home care to make it more accessible, accountable and affordable.

As government funding continues to decline, unpaid caregivers — typically a spouse or child — are having to fill the gap or pay out of pocket to hire care privately. In 2007, approximately 3.1 million Canadians, largely women between the ages of 45–64 years old (44%) (StatsCan 2012), were estimated to act as an informal caregiver to their loved ones, providing over 1.5 billion hours of care annually.

These caregivers provide 10 times the number of care hours by formal services, which is not only taxing on their personal well-being and their relationship with their recipient, but also on Canada’s economy — the cost to businesses from absenteeism and turnover related to unpaid care was estimated to be $1.28 billion in 2007.

The Caring Economy is made up of for-profit marketplaces that serve the needs of others. Like the Sharing Economy, it is a marketplace that empowers neighbours to care for neighbours— removing the need for corporations to intervene. Through the latest mobile technology, businesses in the caring economy connect the supply of care to the demand for care.

In the Caring Economy, there are two key end users: the demand side that needs to hire care and are willing to pay and the supply side that has time and is looking to help. Demand side users can build their own personalized team of care providers, communicate directly within the platform, and pay on demand via mobile payments — a seamless, convenient and transparent process. This is made possible through a peer-to-peer marketplace that uses mobile technology to efficiently manage the relationships between paid care-workers to primary caregivers and their loved ones — on demand. Simply put, it is Uber for home care.

At its core, this model redesigns how care is delivered to make ‘aging in place’ a reality. The model’s objective is threefold — to help seniors age with dignity, to unburden their family caregivers, and to turn compassionate people and Personal Support Workers (PSWs) into ‘micro-entrepreneurs’ — providing them with an opportunity to earn a 20–30% higher wage- a win, win, win.

The Uplift® smartphone platform delivers on-demand home care services — at the touch of a button. As a company, we are laser focused on harnessing the latest mobile technology and analytical problem solving to deliver a superior user experience that fulfills the aging population’s demand for higher quality care. We are setting the new standard.Our app is an affordable solution to expensive agency fees. We offer 30–50% lower fees than private agencies. We are also an innovative substitute to long-term care.As an organization, we are devoted to making a positive impact in the world. Moreover, we are a pioneer of the ‘caring economy’ — where neighbours can care for neighbours and caregivers are empowered.

A second poll, commissioned by the Canadian Alliance for Long Term Care (CALTC), found that just 18 per cent of citizens believe that hospital and longterm care homes would be able to meet the needs of the aging population, and only 20 per cent think there will be enough trained staff to provide adequate care. The CALTC survey also showed that the top three concerns about the health-care system are long wait times for surgery, lack of access to long-term care and insufficient home-care services. Candace Chartier, chief executive officer of the Ontario Long Term Care Association, agreed that public angst is growing. "How we are going to care for our aging population is the No. 1 concern of Canadians," she said. "The public realizes what's coming down the pipeline and they're frustrated that governments aren't reacting." In fact, both polls showed that voters want the federal government to take a leadership role on seniors' care, but they also realize this has to be done in conjunction with the provinces.

In the survey conducted for the CMA, 89 per cent said the next prime minister needs to make addressing the health needs of Canada's aging population an "urgent priority," while the CALTC poll found that 93 per cent believe Ottawa has an obligation to ensure Canadians have equitable access to care, regardless of where they live. A significant number of those surveyed, 57 per cent, said that how they vote in the Oct. 19 federal election will depend, at least in part, on which party has the best plan to address seniors' health care. Seniors now represent 15 per cent of the population, up from 8 per cent in 1971. By the time all of the baby boomers have reached 65, they will make up an estimated 25 per cent of the population.

While this demographic shift is having an enormous impact on demand for services, the health system has been slow to adjust and is struggling to keep pace. The result is seen, among other things, in the rationing of home care, ever-worsening shortages of nursing home and longterm care spots, hospital beds filling up with frail seniors with nowhere else to go, inadequate hospice and palliative-care services, and stubbornly long wait times for surgery.

Dr. Simpson stressed that the answer to these woes is not necessarily more money but delivering care differently by, for example, shifting spending from institutional care to home care, and placing much more emphasis on prevention. "Seniors today want to age well at home and in the community, and health-care professionals (and politicians) need to tune in to those aspirations," he said. The CMA poll, conducted by Ipsos Reid, surveyed 2,008 Canadian adults between July 20 and 24. It is considered accurate to within 2.5 percentage points, 19 times out of 20. The CALTC poll, conducted by Nanos, surveyed 1,000 Canadian between June 18 and 20. It is considered accurate to within 3.1 percentage points, 19 times out of 20.

Massages have become a lifestyle rather than health choice. Some children under the age of 10 are getting them. Massage allowances are mostly used by girls and women. Women at all ages use benefits at a much higher rate than men, with one exception, which is 10 years old and under. In this age group, boys tend to need speech therapy more than girls. Mental-health claims for drugs and therapy that treat depression and anxiety are starting at ever- younger ages. David Willows, vice-president of strategic market solutions at Green Shield, said spas were once considered something for the wealthy. The rest of us might manage a massage once in a while as a special treat. Not so now.

Ross Cristiano, who heads the Toronto health and benefits team for HR consultant Towers Watson, agreed payments for soft benefits are rising, but these paramedical costs are about 10 per cent of all spending. He agreed that high-cost drugs, which account for 20 per cent of all spending, are getting pricier and there's going to be a reckoning. "If you look at high-cost drugs over the last four years, the cost of providing them has increased by about 60 per cent," he said. "Given that a lot more of these drugs are hitting the market, that's probably going to increase." Adam Mayers writes about investing and personal finance on Tuesdays and Thursdays. Reach him at amayers@thestar.ca.

Failing to link the supply of health care to the needs of the population means the cost of our health care system is determined by the number of providers. Because the number of suppliers has been increasing at a rate far faster than the size of the population, even after allowing for an aging population, we now face a crisis in meeting the costs of keeping the increasing supply of health care providers fully employed.

But let's not be too hard on those economists. The rest of us don't pay that much attention to workers such as Shireen Luchuk either - not, at least, until our families need her. And not until someone such as Elizabeth Tracey Mae Wettlaufer is charged with murdering eight residents in Ontario nursing homes. Then we have lots of questions: Who is overseeing the care of our seniors? Are our mothers and fathers safe? Will we be safe, when we end up there?

The question we might try asking is this: If the care that Luchuk offers is so valuable, why don't we treat it that way? Dr. Janice Keefe, a professor of family and gerontology at Mount Saint Vincent University and director of the Nova Scotia Centre on Aging, says "the emotion attached to these jobs removes the value."

Caregiving, Keefe says, is seen "as an extension of women's unpaid labour in the home." Those jobs are still overwhelmingly filled by women. And, while times are changing, the work they do is still mostly for women - whether it's the widows needing care who are more likely to outlive their husbands, the working moms who need child care or the adult daughters who are still most likely to carry the burden of aging parents.

Yet it's as if society wants to believe that professional caregivers should do their work out of love and obligation - as if care would be tainted by higher pay and better benefits. That's an argument you never hear for lawyers and accountants. It's certainly not one that Adam Smith, the founding father of political economy, made for the butcher or the baker.

In last year's book, Who Cooked Adam Smith's Dinner?, Swedish writer Katrine Marcal argued that the market, as Smith and his fellow economists conceived it, fails to accept an essential reality: "People are born small, and die fragile." Smith described an economy based on self-interest - the baker makes his bread as tasty as he can, not because he loves bread, but because he has an interest in people buying it. That way he can go to the butcher, and buy meat himself. But Smith missed something important. It wasn't the butcher who actually put the dinner on his table each night, as Marcal points out. It was his devoted mother, who ran Smith's household for him until the day she died.

Today, she'd likely be busy with her own job. But care - the invisible labour that made life possible for the butcher and the baker (and the lawyer and the accountant) - still has to be provided by someone. Society would like that someone to be increasingly qualified, regulated and dedicated, all for what's often exhausting, even dangerous, shift work, a few dollars above minimum wage. One side effect of low-paying, low-status work is that it tends to come with less oversight, and lower skills and standards. That's hardly a safe bar for seniors in residential long-term care, let alone those hoping to spend their last days being tended to in the privacy of their homes. We get the care we pay for.

It's not much better on the other end of the life cycle, where staff at daycares also receive low wages for long days, leading to high turnover. "I am worth more than $12 an hour," says Regan Breadmore, a trained early-childhood educator with 20 years experience. But when her daycare closed, and she went looking for work, that's the pay she was offered. She has now, at 43, returned to school to start a new career. "I loved looking after the kids. It's a really important job - you are leaving your infants with us, we are getting your children ready to go to school," she says. But if her daughter wanted to follow in her footsteps, "I would tell her no, just because of the lack of respect."

It's not hard to see where this is going. Young, educated women are not going to aspire to jobs with poor compensation, and even less prestige. Young men aren't yet racing to fill them. Families are smaller. Everyone is working. Unlike Adam Smith, we can't all count on mom (or a daughter, or son) to be around to take care of us. Who is going to fill the gaps to provide loving labour to all those baby boomers about to age out of the economy? Right now, the solution is immigrant women, who, especially outside of the public system, can be paid a few dollars above minimum wage. That's not giving care fair value. It's transferring it to an underclass of working-poor women. And it doesn't ensure a skilled caregiving workforce - all the while, as nurses and care assistants will point out, the care itself is becoming more complex, with dementia, mental illness and other ailments.

Ideally, in the future, we'll all live blissfully into old age. But you might need your diaper changed by a stranger some day.

Maybe robots can do the job by then. Rest assured, you'll still want someone such as Luchuk to greet you by name in the morning, to pay attention to whether you finish your mashed-up carrots. When she's holding your hand, she will seem like the economy's most valuable worker. Let's hope enough people like her still want the job.

Has a doctor   85.1% Heavy drinkers          17.9% High blood pressure 17.7% Overweight or obese adults 54.0% Overweight or obese youth (12-17)          23.1% Physically active (leisure time)       53.7%

In 2014, roughly 3.4 million Canadians aged 12 and older (11.2 per cent) reported that they did not receive health care when they felt they needed it. Overall, females (12.4 per cent) were more likely than males (10 per cent) to have reported an unmet health-care need. Among age groups, unmet health-care needs were lowest for those aged 12 to 19 and those aged 65 or older, and were highest for those aged 20 to 54. Source: Health Canada

Top 10 Causes of Death in Canada (2012) Ischaemic heart disease       13.8% Alzheimer’s and other dementias   9.5% Trachea, bronchus, lung cancers     8.1% Stroke             5.4% Chronic obstructive pulmonary disease     4.5% Colon and rectum cancers   3.7% Diabetes mellitus      2.7% Lower respiratory infections           2.3%

Breast cancer             2.2% Falls    1.9% Source: World Health Organization International Comparison of Health Spending  Canada           OECD Average           Canada’s OECD Ranking Total Health expenditure as a percentage of GDP            10.2    8.9       10/34 Total Health expenditure per capita           $4,351            $3,453            10/34

Public expenditure on health per capita   $3,074            $2,535            13/34 Public share of total health expenditure   70.60%          72.70%          22/34 Hospital expenditure per capita     $1,338            $1,316            15/29 Physician expenditure per capita   $720   $421   27-Apr Drug Expenditure per capita          $761   $517   2/31 Source: OECD Health Statistics 2015           

Going into the premiers' conference, Ontario Premier Kathleen Wynne said health care would be on the agenda but the focus would be on how to keep the system sustainable with the fiscal pressures of an aging population.

When we established our universal health care system more than 50 years ago, the average Ontarian was 27 years of age and less likely to be living with chronic and complex health issues. In contrast, 60 per cent of our total hospital days last year were amongst older Ontarians, particularly those living with multiple health issues, and with minimal social supports.

When these patients end up in hospitals, it becomes a particular challenge to get them back in their own homes. In fact, more than 14 per cent of Ontario's hospital beds are currently occupied by patients like these who cannot be discharged because we don't have the right types of services available in the community. By having to stay in hospital, these patients aren't getting the kind of care that they should. And by remaining in hospital, the cost of their care and cost to their overall health is much higher than it actually needs to be. The majority of these patients are waiting for less costly at-home care services through home and community care agencies, or care in more supervised or assisted living environments, such as nursing homes. We also know that too many older Ontarians are still sent to nursing homes when there isn't enough home care, which is less expensive, available. With these growing pressures coming to a head, now is the time to act and make sure that our province can continue to provide the high-quality care that Ontarians want, need and deserve.

It is time to invest aggressively in home and community care, nursing home and assisted living services, and other vital areas so that patients can stay healthy and independent in their communities for as long as possible and when hospitalized, be discharged quickly and safely to get quality care in their community.

We need to identify the right mix of services to ensure all Ontarians can get the right kinds of care where and when they need it. That means knowing the right number of beds needed in hospitals or long-term care homes, as well as the number of assisted living spaces, home care hours, and primary care and mental health services required to meet the needs of our aging population. Given the exploding need for different kinds of services, it also means we need to be innovative by creating new models of care.

While the government has recently acknowledged the importance of robust health-service capacity planning, neither we nor any other Canadian jurisdiction currently has such a plan. This is worrisome because what we do know with absolute certainty is that the number of older Ontarians will double over the next two decades. With service demands growing rapidly at the same time that the system moves to further contain cost growth, we owe it to patients and clients to meet their changing health care needs not only for today but for the decades still to come.

Ontario needs clear-eyed and effective long-term planning to ensure its health care system has the ability meet the evolving health care needs of Ontarians. Until we know exactly what services the people of Ontario need, our system won't have the long-term plan required to meet them. Dr. Samir Sinha is director of geriatrics at Mount Sinai and the University Health Network Hospitals and provincial lead of Ontario's Seniors Strategy. Anthony Dale is president and CEO of the Ontario Hospital Association.

The average number of people on wait lists as of May, 2015, is 611. Some regions have shorter wait lists, such as Toronto Central, which currently has zero. Others are in the four digits, such as the Central East CCAC, which stretches east from Victoria Park Avenue in Scarborough and north to Algonquin Park, and has 1,516 children waiting for speech therapy. Waiting that long can have a large impact on a child's ability to do well in school, according to Anila Punnoose, a director of Speech-Language and Audiology Canada. During the months or years children are waiting to get speech services, they can quickly fall behind in school, she said. A 1996 study found children with language deficits are more likely to experience social difficulties including interacting with their peers, which impacts their behaviour. Other studies have shown that children who don't get speech therapy early are at a greater risk of problems in their academic performance and mental health.

A lot of speech problems carry over to literacy, because a knowledge of speech sounds is crucial when learning to read, Punnoose said. "It's all about what you hear in those sounds. ... Do you know the beginning sounds in that word? A child who doesn't have good phonological awareness doesn't understand any of that," she said. When looking at school performance, Punnoose said early struggles carry through to later years. A child with speech problems who has difficulties learning in the early years won't be able to build on those lessons in later years as effectively as their peers, she said. Early intervention can mitigate and prevent those problems, she said. "If children are having severe difficulties with speech in kindergarten, it's a predictor that there's going to be academic difficulties, and especially reading and writing difficulties, by Grade 3," she said.

Jocelyn Fedyczko, Eddie's speech pathologist, has worked in a range that includes children from preschool all the way to teenagers. She said early intervention is crucial with young children such as Eddie. "The earlier you can help a child out, the more progress you see," she said. When a child gets to the top of the wait list, they get assessed again, and receive a block of treatment, usually around 10 or 12 sessions, says Peggy Allen, president of the Ontario Association of Speech-Language Pathologists and Audiologists (OSLA). That's often not enough to treat even minor to moderate issues such as Eddie's. Fedyczko said she can get through two to three sounds in that time, depending on the child. Many children have problems with more sounds than that, she said. But when a child finishes their block of treatment and needs more, because they haven't worked through all the sounds, for example, they go back to the bottom of the wait list, Allen said.

A spokesperson for the Toronto Central CCAC said they do not have an upper limit to the number of sessions per block assigned by a speech-language pathologist. The pathologist determines three goals for a child to achieve and assigns the number of sessions according to that. If after these sessions more goals are identified, the child is re-referred to the program, the spokesperson said. Parents who are worried about the impact waiting can have on their child can go to private clinics, if they have coverage or can afford the sessions out of pocket. Trish Bentley, Eddie's mother, decided to go for private therapy with Eddie's older brother Oliver. He was put on a six-month wait list for speech problems slightly more acute than Eddie's.

B.C.: Children's speech therapy is organized through the Ministry of Health, Ministry of Children and Family Development (MCFD) and through the Ministry of Education by way of school districts. Children are divided between preschool and school age. Preschool children go through regional health authorities. School-age children go through the school boards, but the pathologists there will often offer consultative services, rather than oneon-one speech therapy. B.C. also has a "no-wait-list" policy for children with autism, which translates to parents getting around $22,000 a year for therapy until the age of six, and $6,000 a year after that. Alberta: Health Services is in charge of speech therapy in that province. It offers both a preschool and a school program. The school program, unlike Ontario's, is done completely through the schools, with no CCAC-type system to refer out to. Saskatchewan: The school districts are responsible for speech therapy. Each school district divides up services slightly differently, though they all differentiate between children under three years, from three to five years, and from six to 18 years.

Rather than wait those six months, Bentley took him to Canoe. "As time went on, we said enough of this, he's going to be past the point of catching the problem," she said. For families who don't have coverage and who can't afford private services, though, the only option is to wait. Finding the cause of the long waits is hard, but one thing is certain: It's not due to a lack of speech pathologists, according to Shanda Hunter-Trottier, the owner of S.L. Hunter Speechworks, another private clinic in Toronto. She used to have problems finding qualified speech pathologists, but now she's facing the opposite problem. "I've been practising for 26 years. ... In the last five years, [I] have more resumes than I can keep track of," she said. Rather, she says, it's a large web of problems that slows down the system. First among these is a lack of public funding. "There's a lot of speech pathologists that don't have jobs, but these places aren't hiring. The cutbacks have been atrocious," she said.

Dividing services by language issues and other issues doesn't make sense when treating a child, she said. "You shouldn't be splitting up the kid," she said. Punnoose said she wants to see speech therapy come together under one roof. It would mean co-operation from all three ministries, as well as a major reorganization of the funding, but she believes it would be a better model for children. "Students are in schools the better waking part of their lives. Why wouldn't we have the services right there in an authentic environment where it's totally accessible," she said. There are changes coming.

Last December, the Ontario government announced more funding for preschool speech and language programs, as well as efforts to integrate speech services better, through its Special Needs Strategy. Punnoose says it's a good step. "The government recognizes that the system was broken," she said. For now, the choice for parents in many CCACs will be between long wait lists and paying for private service. Hunter-Trottier said many parents, even those with coverage, don't know about the latter option. "We sometimes get parents here in tears, saying, 'Oh my goodness, the services here, I wish I had known about that a year ago,' " she said. Bentley said she won't be looking at public services for Eddie, as she's happy with the service she gets at Canoe. "I'd be open to it, but I'm not going to actively seek that out," she said.

For Eddie, what matters is the progress he makes. Within 10 minutes of his trouble saying "lipstick," he was opening up a treasure chest, with a key. With little prompting, he used the same technique as before, separating the sounds of the word. "Kuh-ey," he said. Could he try it all together? He pauses for a second. "Key," he says, almost flawlessly, beaming at his success. SPEECH THERAPY IN EACH PROVINCE

Speech therapy, like all healthcare matters, is regulated differently in each province and territory in Canada. Information on how each system works is difficult to come by. But generally, most provinces have very similar systems - and challenges - according to Joanne Charlebois, CEO of Speech-Language and Audiology Canada. Charlebois said Ontario's wait times are probably worse than those in other provinces, but she's spoken to people across Canada who tell her similar stories. Here's a breakdown of how it works across the country. Ontario: Speech therapy for children falls under the responsibility of three ministries: the Ministry of Long-Term Care, the Ministry of Education and the Ministry of Community and Social Services. Children in Ontario are divided by age and by the nature of their speech problem. Children under school age qualify for Ontario's preschool speech and language program. Once in school, those children with language problems - major problems speaking or understanding words or sentences - go to a school speech pathologist, while any other problems, such as pronunciation, stuttering, voice and articulation are referred to the Community Care Access Centres, which employ contract speech pathologists.

But the problems go deeper than a lack of funding, according to Allen. She said many of the issues in Ontario stem back to a series of agreements in the 1980s between the provincial Ministry of Long-Term Care, the Ministry of Education and the Ministry of Community and Social Services. These agreements divided up who is in charge of different treatments, between the school boards and the CCACs. At the time of their creation, these agreements made sense, but times and needs have changed, she said. "It's difficult when ministries make agreements that are frozen in time. It's very difficult to provide the kind of services that we all expect and want Ontarians to receive," she said. Dividing up the services is necessary when trying to manage resources, but the fragmentation is hurting children more than it's helping, Punnoose said.

Manitoba: School districts are also in charge here. The inschool speech-language pathologists offer services from classroom-based programming to individual therapy. Quebec: The system here is more like Ontario's. Speechtherapy services are offered through the local community service centres (CLSC), similar to Ontario's CCACs. The CLSCs are not obliged to provide speech therapy in English, though some, especially in areas with a large anglophone population, usually do. Nova Scotia: The province has 28 speech and hearing centres, with 35 pathologists in total. They assess and provide treatment for children and adults. School boards in the province also have speech-language pathologists who also have a teacher's certificate.

Prince Edward Island: The province provides free speech services for children until they enter school. Northwest Territories: Speech therapists are only able to visit some remote communities once or twice a year. Instead, the province offers a service called Telespeech, where pathologists can help people without having to be physically present. Nunavut: The territory had no speech pathologists in 2013, according to Statistics Canada.

The average person over 55 enjoys more than $165,000 additional wealth in their homes after inflation compared to 1977. I'm glad my mom accumulated this wealth. But she and I wonder why the federal government prioritized cutting taxes for the aging population. Income splitting for seniors costs $1.1 billion annually. The pension income credit costs $1.1 billion. The "age" tax break for anyone over 65 costs $3 billion.

Then, we must carry larger mortgages, working an extra month to make annual payments compared to a generation ago - even though interest rates are low compared to the 1980s. For many, this crushes dreams of home ownership, while imposing rents driven by higher property prices. The housing market that frustrates younger Canadians has been good for my mom's demographic.

The average cost of housing is up $116,000 after inflation compared to 2005. Housing costs more even as apartments get smaller in our bigger cities. This squeezes younger generations for space, time and money just when we want to start our families. Compared to when Harper began as PM, we must work an extra two to three years to save a 20 per cent down payment.

He also cut $168 million per year in taxes for affluent seniors by changing rules governing registered retirement income funds - at a cost that is greater in one year than the total Harper added to student grants over the next three. Ironically, the opposition accuses Harper of cutting government spending because of his tax cuts. But this isn't accurate. Annual spending on old age security increased by $8 billion after inflation over Harper's decade, and the Canada Health Transfer increased $10 billion. Forty-seven per cent of health-care spending goes to the 16 per cent of the population over 65.

Not done there, Harper doubled the contribution limit for tax free savings accounts in his election budget. Canadians over 60 are three to five times more likely to max out their TFSAs compared to those 18 to 49. TFSAs shelter deposits from further taxation no matter how well investments pay off.

What Harper didn't increase substantially is spending on younger generations. Ottawa contributes to a federal/provincial spending pattern that invests more than $33,000 per person over 65 compared to less than $12,000 per person under 45. This calculation includes the PM's universal child care benefit, and income splitting for one in three families with kids.

Harper's main rivals promise to do better, but don't always budget enough. The NDP talks about $15/day child care. But the $1.9 billion they budget isn't a quarter of what is required. The Liberal platform so far budgets the most of the big three parties for families raising kids. But their promise to extend parental leave by six months is backed by too little money to make a meaningful difference.

By the platform numbers, the national party last in the polls is currently first for proposing more for younger Canadians. The Greens would eliminate tuition for a first post-secondary degree, and reallocate three times more money for child care services than the NDP. The Greens promise more money than other parties for a national housing strategy.

And the Greens are concrete about pricing pollution so that markets ensure younger Canadians aren't primarily left the costs of keeping our air, water, and land clean, while mitigating climate change. No matter which party you prefer, it's time all parties commit Ottawa to reporting how spending breaks down by age, and whether we are leaving at least as much as we inherited.

Although such reporting would cost Ottawa only a little staff time, it is a prerequisite for Canada to work for all generations. Dr. Paul Kershaw is a policy professor at the University of B.C., and Founder of Generation Squeeze (gensqueeze.ca).

Canada's youth faces a precarious financial future thanks to the actions of the federal government, Paul Kershaw writes. • Melissa Renwick/Toronto Star file photo