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Public Funds, Family Commitment A review of government policy concerning public compensation to family caregivers in British Columbia Prepared by: The Interministry Committee on Compensation for Family Caregivers Released June 3, 2002 Public Funds, Family Commitment 1 Disclaimer Care has been taken to ensure the accuracy of the information in this report; however as research concluded in October, 2001 the authors cannot be responsible for changes to legislation, programs or services that occurred after that time. Readers should satisfy themselves as to the currency of the information. Public Funds, Family Commitment 2 Table of Contents 1. Introduction .......................................................................................................................... 2 2. Context .................................................................................................................................. 3 2.1 Overview ...................................................................................................................... 3 2.2 Profiles ......................................................................................................................... 4 3. Policy and Practice .............................................................................................................. 5 3.1 British Columbia ........................................................................................................... 5 3.2 Other Canadian Jurisdictions ....................................................................................... 7 3.3 The American Experience............................................................................................. 9 3.4 The International Experience ..................................................................................... 13 3.5 Observations on Efficacy and Impact......................................................................... 17 4. Guiding Principles.............................................................................................................. 21 5. Conclusions........................................................................................................................ 21 References ............................................................................................................................. 27 Appendix A, Terms of Reference, IMCCFC ......................................................................... 30 Appendix B, Summary of Provincial Policies in BC .............................................................. 32 Appendix C, Community based health and social support programs: Clients and expenditures (BC, Spring 2001) ............................................................ 34 Public Funds, Family Commitment 3 1. Introduction The Government of British Columbia provides funding for important health and family supports that enable people with disabilities to live in their own homes, for example respite for the parents of children with disabilities and home support services for adults with disabilities and the frail elderly. Ministries provide this funding as part of an approved service plan and in some cases, people with disabilities are themselves responsible for purchasing the services. Government policy generally precludes compensating family caregivers. Some of these caregivers, consumer organizations, and the clients themselves, view the current policy as discriminatory and have initiated hearings before the BC Human Rights Commission. Relatively little is known but much conjectured about the short and long-term impact of compensating family caregivers. This report is intended to build an evidence-based foundation for considering policy options. It is based upon: ! discussions undertaken by the Interministry Committee on Compensation for Family Caregivers;1 ! reviews of policy and practices in other jurisdictions, undertaken by the Ministry of Health Services (MOHS) and the Ministry of Children and Family Development (MCFD); and ! compilations of literature assembled separately by the BC Human Rights Commission and the Ministry of Health Services. These compilations have a number of shortcomings: • they emphasize the caregiving arrangements available to the frail elderly rather than to the full range of people with disabilities; • they consider jurisdictions whose governance structures, social environments and program designs are not entirely compatible with those in British Columbia and Canada; and • They do not deal with the potential implications with respect to typical children, for example regarding child care subsidies or home schooling. 1 Appendix A includes the Committee's Terms of Reference. Public Funds, Family Commitment 4 2. Context 2.1 Overview In recent decades, governments in BC and elsewhere have developed an array of programs providing home-based health and family supports.2 These programs: ! enable people with disabilities to continue living in their homes and thereby decrease the cost of service to government; and ! recognize and support the contribution and efforts of family caregivers. As a general rule, these programs do not provide financial compensation to family caregivers. Such compensation is thought to be inconsistent with the long-established tradition of family members being responsible for each other. This tradition is particularly strong where spouses or children are involved and where family responsibilities are clear in both law and practice. The tradition is less clear for parents caring for their adult children and for adult children caring for their parents. Society's concern is that compensating family caregivers would compromise the "natural family support system" and would have a "corrosive effect … on family mores." It would replace families' sense of commitment and obligation with "more measured and more mercenary expectations that the state should compensate for family care giving." (Benjamin, 1999:241) Society is also concerned that compensation will lead to relatives withholding care unless paid. In such cases, the prospect of compensation would open the floodgates, bring applicants "out of the woodwork," generate demand that exceeds resources and threaten programs' fiscal sustainability. (Keefe, 1997:256) In contrast advocates suggest that a family compensation option would recognize the right of people with disabilities – or of those in a trusted relationship with them – to manage their own care and to be responsible for their own well-being. They further suggest that this option would broaden the choices available to people with disabilities and deepen the pool of available caregivers. They also suggest that such options will become increasingly important as the population ages and as women come to participate even more fully in the paid labour force. 2 Appendix B identifies the BC programs providing some of these health and family supports. Public Funds, Family Commitment 5 2.2 Profiles Statistics Canada data provide a profile of people with disabilities in British Columbia and indicate that this population is significant in both number and need. ! There are approximately 540,000 people with a disability in BC (1991) representing 16.7% of the population. Almost 95% live in private households. ! Figure 1 presents this population's distribution by age Fig. 1, People with Disabilities by Age, BC and indicates that the largest 1991 0-14 yrs group is 65 years of age or 10% older. There are 53,000 65+ yrs 15-34 yrs 33% children (0-14 years) with 17% disabilities. 35-54 yrs 55-64 yrs 25% ! About 47% of adults have a 15% mild disability, 32% a moderate disability and 22% a severe disability. Almost 89% of children under the age of 15 years who have a disability are classified as having a mild disability and 8% a moderate disability. People with disabilities often require some assistance with their daily activities. Statistics Canada data indicate that of those requiring assistance, 47% received all the help they needed, 42% received help but needed more and 11% received none. Fifty-six percent reported that family members provided most of this assistance. (Statistics Canada, 1995) The 1996 General Social Survey (GSS) provides an important profile of those providing care to the elderly in Canada. (Frederick and Fast, 1999) It indicates that the informal caregiver system – consisting of family, friends and neighbours – provides 80%-90% of the support given to elderly people. The GSS also indicates that of those 12,756 Canadians surveyed: ! 12% provide some informal, unpaid assistance to seniors with long-term health or activity limitations. Women constitute 61% of caregivers in the informal system. Over 65% of caregivers were in the paid labour force although women were considerably less Public Funds, Family Commitment 6 likely than men to be employed outside the home. More than two-thirds of caregivers were married and over 25% were also caring for children. ! 55% of caregivers were caring for a parent or parents and 39% were caring for a friend, sibling or other family member. Forty-two percent of women and 34% of men were caring for more than two seniors. ! only 16% of women and 11% of men were living with the person for whom they provide care although the large majority lived in the same general area. ! 83% of women and 89% of men who spent 7.5 hours or more per week in caregiving activities reported some level of emotional burden and stress associated with their efforts. ! 15% of caregivers indicated that some form of financial compensation would be useful in supporting their caregiving relationship, including over 30% of those in Atlantic Canada and 13% in BC, as opposed to other supports such as occasional relief or information on nature of illness/disability. Those under age 65 and those separated or divorced were more likely to identify financial compensation as an important support. Under the financial compensation option, the interviewer indicated that this option "includes tax breaks". 3. Policy and Practice 3.1 British Columbia Government policy in British Columbia is very consistent with regard to precluding compensation for family caregivers. In the Ministry of Health Services, for example, Home and Community Care policy (8.H) states that financial subsidies are not available "to family members to care for relatives, either through direct payment to the individual, payment through a Homemaker Agency or payment as an approved Service Provider." Its Choice in Supports for Independent Living program (CSIL) affirms that "services supplement and complement but are not intended to replace services and supports normally provided by family members." Similarly, the Ministry of Children and Family Development affirms in policy and practice that families are considered the primary caregiver for children and that the ministry's role is to supplement the family's efforts. Public Funds, Family Commitment 7 Regardless of this consistency, ministries have somewhat different concepts of family. ! The MOHS Home and Community Care policy does not formally define family members but leaves that determination to the Health Authorities on a case by case basis. Family is generally interpreted to mean the extended family including aunts, uncles and cousins. ! The MCFD Child, Family and Community Services Act does not define "family" but does define "parent" and "kin" with the latter being any individuals who are related by blood, marriage or a long-standing family-like relationship. The Ministry's At Home Respite Program precludes compensation to any person who is the parent of the child, or who resides in the family home and is a dependent of the parent or guardian, or is a spouse of the parent or guardian. Parents accessing the MCFD Supported Child Care Program may not pay themselves to provide in-home care but they can pay a relative who does not reside in the family home and is not a spouse of the parent. ! For child care programs (including Supported Child Care), the Child Care BC Act, BC Benefits (Child Care Subsidy) Act and BC Benefits (Child Care Subsidy) Regulation provide definitions for "family" and "eligible child care providers". The definition of "parent" is fairly broad, and includes a person with whom a child resides and who stands in place of the child's father and mother. The definition of "child care" excludes the parent from being the caregiver. The definition of "child care provider" can include relatives except where care is provided in the child's home and the caregiver is a relative of the child or a dependent of the parent and resides in the child's home (unless the relative resides in a private suite within the child's home). Some of the programs permit exceptions when there is no alternative care available or when it clearly makes most sense. The number of known exceptions in the different programs is very small relative to the size of their caseloads. The one clear exception to government policy arises in the BC Assistance program for students with permanent disabilities.3 It provides funds for disability-related equipment and services and can be paid to a family member. The program relies upon a test of financial need and has strict accountability requirements. 3 It should be noted that under the BC Benefits assistance programs, "single parents with at least one dependent child who (i) is under 7 years of age, or (ii) has a physical or mental condition precluding the single parent from leaving home for the purposes of employment" are exempt from the requirement to seek work, as are spouses of persons with disabilities. Recipients must first meet the normal income and asset requirements for income assistance to qualify for this compensation. Public Funds, Family Commitment 8 3.2 Other Canadian Jurisdictions A summary of information concerning family caregiver compensation policies in other Canadian jurisdictions is included as Appendix B. All research to date indicates that all Canadian jurisdictions have adopted policies and practices that consistently ban the compensation of family members for caregiving. Where exceptions are made, they are done so on a case-by- case basis, depending primarily on the availability of non-family caregivers. The Frail Elderly Most jurisdictions preclude such compensation in programs comparable to those of the Ministry of Health Services in BC. Until recently, Nova Scotia was an exception to this pattern and provided modest, largely symbolic compensation to family members. However the Nova Scotia program: ! was tied to its social assistance program with beneficiaries subject to a test of needs and income; ! was largely restricted to rural areas where few formal services were available; and ! provided a minimum level of compensation that was unrelated to the actual number of caregiving hours provided. The Quebec Respite Program provides a maximum of $600/year to people with significant special needs for the purpose of purchasing caregiver services. Recipients may use the funding to compensate family caregivers. Quebec also provides family caregivers with certain financial benefits through its provincially administered income tax program. Like Quebec, the new Territory of Nunavut will also compensate family caregivers. Here, doing so is a practical necessity since the communities are small, the labour pool is limited and many residents are related to one another. New Brunswick does not have written policy on the matter but in practice discourages compensating family caregivers. It previously clearly allowed payments to family members, but has reversed this policy due in large part to instances of fraudulent abuse of the scheme (see below). New Brunswick and Manitoba will consider compensation requests on a case by case Public Funds, Family Commitment 9 basis. The Alberta Home Care program prohibits payments to family members but will consider exceptions in cases where a qualified employee is not available. However, it has approved only a handful of exceptions in the past decade. Newfoundland policy similarly precludes payments to family members living in the same household although it has approved exceptions in isolated communities where the person with a disability requires specialized care. Saskatchewan policy also precludes compensating family caregivers but will allow home care agencies to assign staff to care for members of their own family. Saskatchewan, like British Columbia, is facing a Human Rights case on the issue. Federally, the Department of Veterans Affairs allows the payment for caregiving by relatives only where that relative lives outside the home of the person in care. Veterans Affairs places a cap on service levels and defines a relative as anyone related to the client, whether dependent or not. It should be noted that the federal government has demonstrated an ongoing interest in the topic of family caregiver compensation, having funded a number of research papers on the issue. It may be that the federal government is in the best position to adequately address this issue, as the evidence from other jurisdictions indicates that federal government intervention has been a key factor in expanding compensation to family members. The federal government might be better placed to deal with compensation to family caregivers, perhaps through the tax system or the employment insurance system. Children and Adults with Disabilities Canadian programs providing health and family supports for children and adults with disabilities generally will not compensate family caregivers. Ontario, however, appears to have different policies for the two population groups: it prohibits payments to family members providing care to children but has no policy relative to adults since adult services are funded through Transfer Payment Agencies. In several jurisdictions – New Brunswick and Newfoundland for example – the reasons underlying the prohibition relate to concerns about service quality and accountability. Other jurisdictions adhere to the principle that such care is a family rather than a public responsibility. Ontario and Saskatchewan state that family compensation is inconsistent with their program's family respite objectives. Public Funds, Family Commitment 10 Different jurisdictions define family in different ways. New Brunswick includes parents, siblings, grandparents, aunts, uncles and spouses. Newfoundland includes all blood relatives, in-laws, adopted sons/daughters or relatives of the son/daughter as well as any "person who was never formally adopted by the client/spouse but there is a recognized familial relationship with the client/spouse and relatives of that person." Nova Scotia and Saskatchewan preclude compensation for those "immediate family members living in the same home." Jurisdictions generally permit some exceptions: ! "in extreme situations when no other option is available" (New Brunswick, Ontario); ! in situations where a client has engaged home support services privately and has employed a relative during that time (Newfoundland); and ! in situations where "there is overwhelming evidence that this is the preferential delivery mechanism" (Newfoundland). A number of jurisdictions are currently re-examining their policy in this regard as a result of public pressure (New Brunswick) or Human Rights Commission appeals (Saskatchewan). Newfoundland expects to change its policy "very soon." 3.3 The American Experience In the United States, federal Medicaid law and regulations permit the hiring of most family members with the exception of those "legally responsible" for the person with special needs. In essence this precludes spouses caring for spouses and parents caring for their minor children. As of 1990, at least 35 states allowed care allowances to be paid to relatives providing personal care services. (Linsk, 1992:68) A direct comparison of American programs to the British Columbia experience is difficult and not always appropriate. There are many conditions that operate in the United States that must be considered before making direct comparisons to British Columbia's situation, including workforce issues for home support workers, eligibility for community care services, caps on services, and hourly rates available to caregivers. These are considered below4. In general, the following conditions are true for almost all American home support programs that have been reviewed, including those that allow payment to family members: • there is some kind of cap on services; 4 And are based primarily on consideration of California, Washington, Illinois and New Jersey Public Funds, Family Commitment 11 • there are eligibility restrictions based on low income (usually less than $5,000 per year) and low assets; • wages paid are not much more than minimum wage; • caregivers are often paid through an independent provider program or a consumer- directed program (rather than a home support agency), and are paid at rates that are usually close to minimum wage; and • there is a widespread difficulty in recruiting and retaining home support workers due to the low wages paid, one result of which has been the need to offer financial incentives to family members to provide care to fill this gap. Eligibility for services In most U.S. programs, a test of both need and income is applied to applicants. In most states, and indeed in almost all of the states where family members may be paid to provide care, eligibility for home support services is based solely on income levels. For states that have federally administered supplements through the Supplemental Security Income (SSI) program, applicants must have incomes below $6,360 to $7,544 and assets below $2,000 for a single person, with commensurate levels for couples. For the state home support program in Washington, assets must not exceed $10,000. Even in California, which has several different home support programs, some of which are state-funded, all clients must have low income in order to receive services. Cap on services Most states have some form of cap on hours of service provided, some depending on the level of client need. For example, in California, if an individual has impairments of two or more activities of daily living, then they are eligible for 283 hours per month; if they have less the maximum allowed is 195 hours per month. In New Jersey the cap is 25 hours per week for most clients, and for those with serious health concerns the cap is 40 hrs per week. Illinois has a cap of $1,800/month. Hourly rates paid Hourly rates for both home support agency workers and family caregivers are much lower throughout the United States than are currently paid in British Columbia and throughout Canada. Across the USA, agency rates range from $12.50 per hour to $14.50 per hour, versus approximately $26 to $27 per hour in BC. Rates paid to family caregivers are still lower, and are usually just slightly higher than minimum wage. In Oregon, the independent provider wage is $8.35 per hour. Michigan pays minimum wage to caregivers to a maximum of $333/month and does not pay benefits. California pays minimum wage plus 3% with public authorities being responsible for negotiating wages. In both the California and the Illinois programs, the individual Public Funds, Family Commitment 12 locates their own care provider but the State has a legal obligation to manage administrative tasks and costs including payroll and Workers' Compensation. In California, approximately 75% of caregivers in one large program are family members. Workforce Issues Part of the reason that states are in a position to pay such low rates is that in the United States there is currently, and has been for some time, a shortage of trained home support workers. Because the rates paid to home support workers are not a 'living wage' and do not attract individuals to the workforce in this capacity, or retain them, the federal government and the individual states have had to take action to ensure care is provided to those in need. This is in contrast to the British Columbia context, where relatively high wage rates contribute to a sustainable workforce that is able to meet the needs of clients. As a result of the American workforce shortage, the federal government modified its Medicaid rules (Supplemental Security Income, or Care for the Aged, Blind and Disabled) regarding who may be paid to provide care for personal care services. Currently, community-based waiver programs may allow for family members to be paid as caregivers except spouses and parents of dependent children (the applicable legislation was amended in 2000). Some states, like California, that do not depend solely on federal Medicaid funds for their community care programs go one step further and allow payment to spouses and parents of dependent children. Some of the Cash and Counselling Pilot sites also allow payment to spouses and parents of dependent children. Limited delegation of nursing tasks Another contributing factor to the American practice of paying family members is that some states have very strict codes of practice for various professionals, including nursing, which restricts the specific functions paid home support workers can carry out. In Washington, for example, the Nurses Practice Act is very prescriptive and allows delegation of nursing tasks only in residential facilities. In the community, the only people who can carry out delegated tasks in in-home settings are family or unpaid caregivers. This restriction makes it extremely difficult then for paid home support workers to provide appropriate care to clients in need. Thus, paying family members to provide care enables the state to still meet the individual's needs and not be in conflict with this particular piece of legislation. Who is "family"? In terms of who within a family may be eligible for compensation, American jurisdictions also often have different family compensation policies depending upon whether children or adults are affected. California, for example, believes that "family members … have less responsibility for Public Funds, Family Commitment 13 adults [than for children]." Furthermore it has drawn a line between the family's responsibility and that of the State, i.e. "families have responsibility for providing services that they would normally provide to a minor child without disabilities." The California definition of "family" may be unique in that it ignores blood relationships. Instead it identifies family members as any individuals who: ! have a developmentally disabled person residing with him or her; ! are responsible for the 24-hour care and supervision of that person; and ! are not licensed or a certified resident care facility or foster family home receiving public funds. Kansas and other states also acknowledge parents' reduced responsibility for those family members who are 18 years of age or older, including adult children. Compensation is available – in Kansas, New Jersey and New York for example – to relatives serving as caregivers for adults with developmental disabilities. Kansas controls costs by providing a maximum of eight hours/day of service. New Jersey provides vouchers to a maximum of $2400 annually that can be used for almost any purpose. It also offers eligible clients a choice between a residential care bed when available (valued at $63,000/year) or an in-home support payment of $20,000/annually. At the national level in the United States, the Veterans Administration's House Bound Aide and Attendance Allowance programs provide a cash benefit to veterans with disabilities so they may pay whomever they choose – including relatives – to provide personal assistance. (Blaser, 1998:71) To summarize, it is difficult and in many cases inappropriate to directly compare the American experience with the British Columbian context. None of the conditions noted above are currently present in BC, nor are they likely to be in the future. British Columbia has an ample supply of trained workers who are willing and able to do the work, mainly because of wage levels that are considerably higher than in any American jurisdiction. In general, British Columbian programs are far more universal, comprehensive and generous than similar programs in the United States. The successful application of American models to British Columbia would likely require a drastic remodelling of the current system in order to incorporate the restrictions that make the American models possible. Public Funds, Family Commitment 14 3.4 International Models The literature available for this report indicates that many industrialized countries compensate family caregivers and acknowledge family caregiving as work that should pay some rational level of income and should generate some pension benefits. Importantly, however, the international models are not necessarily well suited for the British Columbia context. Certain of these programs, for example: ! are administered by the national government rather than by provincial or state governments; ! are income tested rather than needs-based, so that only families with very low income and virtually no assets are eligible for services; and ! have very definite limits regarding the number of hours of service an individual may receive, which in most cases means the cost of community care cannot exceed the cost of nursing home or other residential care. These countries' models generally reflect their own social milieu and public policy context. Each country – including Canada – is different in this regard. Sweden for example has a fully developed social welfare state while Norway has a firm tradition of elder care as a public responsibility. The United Kingdom has a much more limited concept of the state's role while Germany and Australia have a century-old social security net. France has always emphasized family responsibility. The following provides an overview of policy and practice in a number of these jurisdictions. Australia has a long tradition of compensating family caregivers. The Commonwealth Government's Carer Allowance provides a cash benefit to the family caregiver of people requiring chronic at-home care, whether a child, adult or frail elderly person. The program requires that the care be provided on a full-time basis that virtually excludes the caregiver from participating in the paid labour force. The payment is intended as partial compensation and is set at a relatively low rate, i.e. 20% of the single rate retirement pension which itself represents about 25% of the average weekly full-time earnings. The allowance is neither income nor asset tested and is not taxable. The Carer Allowance has a co-residence requirement. In 1999/2000, the Carer Allowance was paid to almost 195,000 people at a cost of A$17.5 million. Public Funds, Family Commitment 15 A second national program – the Carer Payment – is means-tested, non-contributory and payable to any individual responsible for the daily care of a highly dependent person. The caregiver and client need not be co-resident. The benefit level is the same as the retirement pension and roughly comparable to the Australian unemployment insurance benefit. It is designed to support people who cannot maintain paid employment because of their caregiving responsibilities and to signal the state's recognition of caregiving as work. A person cannot receive the Carer Payment and any other Social Security or Veterans' Affairs income support pension at the same time. In 1999/2000, 47,550 clients received the Carer Payment at a total cost of A$368 million. This represents an increase of 130% over five years with the largest portion of this growth occurring in the period 1998/99 to 2000/01. Austria introduced its Attendant Allowance in 1993. It provides a basic monthly payment set according to the assessed level of dependency. The allowance is not means tested, is available for any condition reducing personal autonomy and is financed out of the tax system. It is intended only to subsidize the cost of care with the remainder coming from private sources or social assistance. Indeed Austria caps service at eighty hours/month. A program goal is to encourage reliance on family-based home care. The recipient has complete control over the Attendant Allowance and can employ family members. Recognizing their caregiving responsibilities as real work, Austria permits attendants to opt into the country's pension insurance program. Finland introduced a Pensioner's Care Allowance in 1963 as part of its national pension system. It is based upon a test of personal need rather than financial means with the benefit level being determined by the level of dependency. There are no restrictions on its use. A second home support program accords caregivers an income roughly equivalent to that of an average pension. It also gives family caregivers access to basic occupational rights and protections. Finland's Social Insurance Institution can also provide parents with both a care allowance and special daily allowance if caring for the child gives rise to extra financial or practical burdens during a period of at least six months. The special daily allowance compensates for the parents' loss of earnings during time spent caring for the child. These payments are one part of Finland's comprehensive social security system. That system includes parenthood allowances, child home care allowances, child care allowances, Public Funds, Family Commitment 16 and disability allowances for people with disabilities between the ages of 16 and 64 years who are studying or working. France, after several years experimenting with allowances to the frail elderly, introduced the Prestation specifique dependance in 1997. This is a means-tested benefit paid to anyone older than 60 years legally resident in the country. The means test considers the resources of the recipient's family and heirs and the benefits provided may ultimately be deducted from the recipient's estate. The benefit can be used either for residential or at-home care. In the latter case, the recipient has full control over the funding and may employ family members as long as they are otherwise unemployed. Spouses may not be hired as caregivers. In France, 30% of all caregivers are family members. (Tilley, 2000:9) In Germany the cost of long-term care was traditionally covered by a means-tested social assistance program "of last resort" administered by local governments. In 1995 the federal government assumed responsibility for this support and introduced the Care Insurance Act as a compulsory insurance regime providing basic benefits to those in need of care as assessed by an expert team. Benefits may be taken in cash or services although the cash benefit is set at only 50% of the value of services that would otherwise be provided. In spite of this, almost 80% of those who are eligible choose the financial benefit rather than the services. The recipient has full control over the financial benefits and may employ family members as caregivers. Indeed, families rarely go to the regular labour force for caregivers. The German benefit provides caregivers with credits toward their pensions. It should be noted that there is a cap of 60 hours/month on the number of hours allocated per individual. Norway has several programs providing some compensation to family caregivers, as part of its concept of eldercare as a state responsibility. In one program the local authority employs family members to provide home care to people with special needs. On average, relatives are paid for approximately four hours per week at a salary level roughly equivalent to that which a full-time professional Home Helper would receive from the local authority. The allowances are taxable. Norway also provides pension benefits to unmarried and otherwise unemployed family caregivers whose ability to support themselves is impaired by their long-term care commitment to parents or other close relatives. These benefits cease when the caregiver marries or becomes eligible for an old age pension. To date 72% of benefit recipients have been women and over 90% have been over 50 years of age. Other programs provide Public Funds, Family Commitment 17 pension credits for caregivers, including parents who stay at home with pre-school children or with frail, elderly parents. The credit imputes an income higher than what most employed women earn but less than the average income for women in full-time employment. (Keefe and Fancy, 1998:23) Sweden's 1990 Care for the Elderly legislation provides family members with caregiver salaries that are equivalent to those paid by home health care agencies. They are fully taxable. Caregivers are entitled to both pension and vacation time benefits. Sweden provides training to salaried caregivers when their personal caregiving experience ends. Sweden also has a care leave insurance program that continues employees' salaries for 30 days if they must leave their employment in order to care for an elderly family member. A written application and a doctor's statement of need are required for these benefits. Finally Sweden provides an allowance to parents who are caring for a child under 16 years whose functional impairments mean they need special attention and care for at least six months. It includes compensation for both the care provided and any additional disability- related costs. The allowance is taxable and provides pension credits. The United Kingdom provides a regular Invalid Care Allowance (ICA) for caregivers including family members. The benefit is income tested and available only to those who are both unemployed and low income. Caregivers must be pre-retirement age and benefits cease once the caregiver receives a pension. The caregivers earn pension rights while receiving the ICA. The country's Home Responsibilities Protection Program provides pension credits to caregivers who do not receive ICA but who are providing care for a minimum of 35 hours/week through a period of 48 weeks. (Keefe and Fancy, 1998:23) 3.5 Observations on Efficacy and Impact The literature includes some evaluations of health and family support programs that incorporate a family caregiver compensation element. These evaluations identify both the advantages and disadvantages of systems that provide payments to family caregivers. Advantages ! Paying family members expands the labour pool of potential caregivers. This is particularly important in areas where the unemployment rate is low and where there is a shortage of people to be employed as personal care workers. This factor has been Public Funds, Family Commitment 18 particularly important in a number of American jurisdictions where there simply are not enough caregivers to meet consumer demand. It is not, and is not likely to be, an issue in British Columbia. ! Family members provide care at relatively low cost compared to non-family members associated with community-based or government agencies. Again, this has been an important factor in American jurisdictions, where family members are rarely paid at a rate above minimum wage. However expectations of family members, In the current BC context, is that they will be paid at the rate of professional caregivers: approximately $26 – $27 per hour. ! People with disabilities very often prefer to receive their support from family members, particularly when personal care services are required. The UCLA evaluation of the California In-Home Supportive Services Program concluded that people receiving their services from family caregivers: • feel less risk and greater personal security; • feel they have more choice about how their services are delivered; • are more satisfied both with their ability to choose and with how their service needs are being met; and • feel closer to their service provider and are more confident of receiving back up from family and friends. ! Policies that encourage or support family caregivers help ensure that people with disabilities receive their care from someone with an emotional connection and attachment. The Statistics Canada GSS indicates that this attachment is a major contributor to quality care. An evaluation of the Illinois Community Care Program also suggested that paid family caregivers (i) provide better quality care and (ii) resulted in greater consumer satisfaction. ! A 1992 Michigan study of 24 family dyads in a family financial compensation program found no evidence to support the concern that caregivers will exploit such programs. When given a choice, caregivers and care receivers more often chose services over financial compensation. The study also indicated that caregivers would provide care regardless of financial compensation and would not perform this care unless it was for a relative. (Keefe, 1997:257) In contrast, evidence from Germany indicates that almost 80% of eligible elderly persons chose financial benefits rather than services.5 5 Information from the Home and Community Care Branch, MOHS. Public Funds, Family Commitment 19 ! The mortality rate is significantly lower among those elderly who received care from subsidized family caregivers. (England, 1989:5-6) ! There has been little recent examination of the potential number of families who would opt in to a system that allows payment to family members. In the American context of low wages, a University of Illinois evaluation (1989) suggests "there would probably be a natural limit to the number of elderly who would use this option [i.e., hiring relatives as paid caregivers]." Disadvantages ! Unless very carefully defined, payments to family caregivers could create an uncontrollable drain on public funds and could compromise the home care programs' sustainability, particularly if the concern with the "woodwork effect" is substantiated. Advocates for persons with disabilities often comment on the high degree of supplemental care that families regularly provide at no cost to government, and make it clear that if funding were made available they would happily take it. Although there is currently no hard data on this matter, the empirical evidence suggests a large number of families would opt in for funding if it was available. ! Implementing such a dramatic change in the structure of compensation for caregiving without clear study of the financial implications would require a substantial leap of faith in an environment of fiscal restraint and economy. Current levels of funding would likely be considerably impacted, and already stand at a total of approximately $824 million (see Appendix D for a full account of costs associated with community based health and social programs). ! Payments to family caregivers would become part of the family's total income rather than a resource targeted specifically to the person with a disability. ! Family caregivers receiving compensation would have a vested interest in the life choices made by the person with a disability while at the same time having an undue influence over the choices made by that person. Conceivably they would have a vested interest in keeping the person dependent. Public Funds, Family Commitment 20 ! Compensating family caregivers could further isolate the person with a disability and leave them vulnerable to abuse. There would not be non-family caregivers monitoring the situation within the household. ! Many of the management issues associated with home care – management, training, quality assurance, accountability and potential abuse – take on a very different hue if the caregiver is a family member. It may be more difficult to ensure that family caregivers are adequately trained and providing quality service. ! There is also a concern that implementing a system of payments to family caregivers could result in the fraudulent abuse of the system. This has been a documented problem, for example in New Brunswick, where the Family and Community Social Services Division previously allowed payment to family members for caregiving to children and adults. The current prohibition on payment to family members was a direct result of the discovery that a number of families were abusing the system and making fraudulent claims for compensation. ! Compensating family caregivers would have a significant impact on the stability of the overall service system, due to the potentially huge increase in expenditures that would result from government funding services that have traditionally been provided by families at no cost. ! Compensating family caregivers would represent a fundamental shift in the balance between family and the state with respect to responsibility for the care of persons with disabilities. Such a shift would increase the notion of entitlement to funding for what has always been considered primarily the responsibility of the family. ! Finally, such a shift in public policy could set a far-reaching precedent for a full range of social support programming, for example in the areas of child care, health and education. 4. Guiding Principles In this matter, as with all disability-related issues, the government of British Columbia is guided by the framework set out in In Unison: A Canadian Approach to Disability Issues. In Unison is the product of an agreement amongst the federal government and all provincial and territorial governments (except Quebec), and sets out a vision and long-term policy direction that promotes greater equality for and inclusion of persons with disabilities. Public Funds, Family Commitment 21 In Unison sets out a policy framework that is guided by the overall principle of the full inclusion of persons with disabilities into all domains of Canadian society. This overall principle is supported by the following three guiding principles: • Rights and responsibilities: Persons with disabilities have the same rights and the same responsibilities as other Canadians. They are entitled, as others are, to the equal protection and the equal benefit of the law and require measures for achieving equality. • Empowerment: Persons with disabilities require the means to maximize their independence and enhance their well-being. • Participation: Persons with disabilities require full access to the social, economic and physical infrastructure which supports our society so that they can participate fully and equally in their communities. 5. Conclusions Whether the Government of British Columbia should commit public funds to compensate what traditionally has been a family commitment is a complex, pressing and difficult question. ! The question is complex because it involves the very nature of the family and the responsibility of family members for each other. It also involves speculating on how compensation might affect personal behaviour and willingness to provide care or request compensation. In addition, the potential outcomes associated with different policy options very much depend on the specific design elements of each particular option. ! The question is pressing because it involves the health and well being of both people with disabilities and their family caregivers, in a context where the ageing of the Canadian population will only intensify pressure on an already strained health and family support system. ! The question is difficult because it involves people – particularly people with disabilities, adults with developmental impairments and the frail elderly – who often are both vulnerable and dependent. And because it must involve considering the responsibilities of different orders of government and different sectors within Canadian society. Public Funds, Family Commitment 22 ! In addition, this question arises during a time when the public in British Columbia and across Canada are actively searching for alternative methods for program and service delivery that are accountable, sustainable and effective. Clearly families remain the most important source of assistance for people with disabilities, whether a child, youth or adult. And public policy remains founded upon the belief that public services and health and family support programs should only supplement and certainly not replace family responsibility. However, the impact of family responsibility varies depending on the unique circumstances of the disabled family member. Clearly the demands placed on some families are disproportionately high. Health and family support programs, across Canada, embody assumptions that are increasingly being strained, about families, about the responsibilities and capacities of families, about informal helping networks and about voluntary groups, communities, and other social arrangements. However, much of the debate around these issues, and in particular the current issue of compensation to family caregivers, is taking place without a supporting base of applied research. Particularly important in this respect is the issue of the potential cost of a move to family caregiver compensation. Central to the creation of any new policy in this area is the determination of scope and role that government wishes to play with respect to supporting families. This invites consideration of a number of important policy questions, for example: ! what definition of family is appropriate? A BC definition would need to consider legal, social and cultural implications within the overall Canadian context. ! how should society support family caregiving and family caregivers as well as acknowledge the value, importance and benefits of their contribution. Is financial compensation the only option? ! How should financial compensation be dispensed (eg. Should it be tied to the purchase of specific services or serve as a benefit which acknowledges the 'uneven playing field' of disability)? ! if government chooses to implement a new program, is the funding to be found within the existing envelope or is funding available for a new program? Public Funds, Family Commitment 23 ! how can programs be structured – and what eligibility tests and assessments are appropriate – so as to ensure they remain fiscally responsible and sustainable? ! what safeguards can be put in place to ensure quality of care and accountability? ! what are the appropriate roles of the different levels of government? It is clear that given the many counter demands and pressures on both families and government services, any new policy developed regarding the payment of family members would have to balance public funds with family commitment. Historically in British Columbia, government has generally excluded all family members from being paid with public funds to provide services. In the event that government chooses to implement a policy permitting family members to be compensated for providing care to other family members, the policy will need to address some significant considerations. Foremost the policy must attempt to balance the legal, ethical and moral responsibilities of families with the appropriate role of the state. Care must be taken to ensure the role of the family is not undermined and to recognize the need to offset the costs of disability with adequate support to enable families to continue to provide support voluntarily. Because this policy will impact people with varying degrees of vulnerability and dependence, safeguards must be developed to ensure client needs are met in the most appropriate and effective manner. Effective assessment, monitoring and case review approaches will be important to the overall success of the policy. Finally, the policy must respect the appropriate roles of the provincial and federal governments and be fiscally responsible, balancing the varied demands on government resources and utilizing those resources in the most effective way possible. Public Funds, Family Commitment 24 References Arno, Peter S.; Levine, Carole; Memmott, Margaret M. n.d. The Economic Value of Informal Caregiving. Prepared as part of the Families and Health Care Project, United Hospital Fund, New York. Beauvais, Caroline and Jenson, Jane. 2001. Two Policy Paradigms: Family Responsibility and Investing in Children. Canadian Policy Research Network Study, No. F12. Benjamin, A.E., Todd, M.; Franke, T.M.; Matthias, R.E. and Park, Ellen. 1999. "Consumer Direction and In Home Services: Recipient Perspectives on Family and Non-Family Service Provision." Journal of Rehabilitation Administration, Vol. 22(3), January. Blaser, C. Jean. 1998. "The Case Against Paid Family Caregivers: Ethical and Practical Issues." Inside Generations. Fall. British Columbia, Ministry for Children and Families. Policy Framework for Services for Children and Youth with Special Needs. Draft, April 5, 2001. British Columbia, Ministry of Health and Ministry Responsible for Seniors. 1995. The Health of People with Disabilities. April. British Columbia, Ministry of Social Services. 1993. Community Living for Adults with a Mental Handicap. A Literature Review and Annotated Bibliography. Research, Evaluation and Statistics Branch, Corporate Services Division. British Columbia, Ministry of Women's Equality. 2001. Valued Voices: A Report on Women's Economic Equality. British Columbia, Office for Disability Issues. n.d. The Disability Lens. Campbell, Joan; Bruhm, Gail; and Lilley, Susan. 1998. Caregivers' Support Needs: Insights from the Experiences of Women Providing Care in Rural Nova Scotia. A Report to the Maritime Centre of Excellence for Women's Health. November. Canada, Federal Task Force on Disability Issues. 1996. The Will to Act for Canadians with Disabilities: Research Papers. Canadian Association for Community Living. 1999. Communities for Everyone Discovery Economic Consulting. 2001. Budget Impacts of Payments to Family Members Providing Home Care. May 31. Dowson, Steve and Salisbury, Brian. 2000. Foundations for Freedom. International Perspectives on Self-Determination and Individualized Funding. Seattle. Public Funds, Family Commitment 25 England, Suzanne; Linsk, N.L.; Simon Rusinowitz, Lori; Keigher, Sharon M. 1989a. "Paid Family Caregiving and the Market View of Home Care: Agency Perspectives." Journal of Health and Social Policy. Vol. 1(2). England, Suzanne E and Links, Nathan L. 1989b. "Paid to Care for Their Own: A Report on a Community Care Program that Permits Relatives to Be Hired as Caregivers." Home Health Care Services Quarterly. Vol. 10(1/2) Federal/Provincial/Territorial Ministers of Social Services. 1993. Mainstream 1992. Pathway to Integration. Report to the Ministers of Social Services. Federal/Provincial/Territorial Ministers Responsible for Social Services. 1998. In Unison: A Canadian Approach to Disability Issues – A Vision Paper. (http://socialunion.gc.ca) Federal/Provincial/Territorial Ministers Responsible for Social Services. 2001. In Unison: A Canadian Approach to Disability Issues – A Vision Paper. (http://socialunion.gc.ca) Federal/Provincial/Territorial Ministers Responsible for the Status of Women. 2001. Women's Economic Independence and Security. A Federal/Provincial/Territorial Strategic Framework. March. Frederick, Judith A. and Fast, J.E. 1999. "Eldercare in Canada: Who does how much?" Canadian Social Trends. Statistics Canada. No. 54, Autumn. Guberman, Nancy. n.d. Caregivers and Caregiving: New Trends and Their Implications for Policy. Prepared for the Home Care Development Branch, Health Canada. Hollander Analytical Services. 2001. Evaluation of the Maintenance and Preventive Function of Home Care. Home Care/Pharmaceuticals Division, Policy and Communication Branch, Health Canada. March. Jenson, J. and Jacobzone, S. 2000. Care Allowances for the Frail Elderly and their Impact on Women Care-Givers. OECD Labour Market and Social Policy Occasional Papers, Number 41. Keating, Norah; Fast, Janet; Frederick Judith; Cranswick, Kelly and Perrier, Cathryn. 1999. Eldercare in Canada: Context, Content and Consequences. Statistics Canada. Housing, Family and Social Statistics Division. Keefe, Janice M & Fancey, Pamela J. 1997. "Financial Compensation or Home Help Services: Examining Differences among Program Recipients." Canadian Journal on Ageing. Vol. 16(2). Keefe, Janice M & Fancey, Pamela J. 1998. Financial Compensation Versus Community Supports. An Analysis of the Effects on Caregivers and Care Receivers. Prepared for Health Canada. Linsk, Nathan L; Keigher, S.M.; Simon-Rusinowitz, Lori; England, S.E. 1992. Wages for Caring. Compensating Family Care of the Elderly. New York. Praeger. Public Funds, Family Commitment 26 Morris, Marika; Robinson, Jane; and Simpson, Janet. 1999. The Changing Nature of Home Care and its Impact on Women's Vulnerability to Poverty." Prepared for the Status of Women Canada. November. Pijl, Marja. n.d. "When Private Care Goes Public. An analysis of Concepts and Principles Concerning Payments for Care." (source unknown). Prince, Michael J. 2001. Governing in an Integrated Fashion: Lessons from the Disability Domain. Canadian Policy Research Network Discussion Paper, No. F|14. June. Rioux, Marcia H & Crawford, Cameron. 1994. The Canadian Disability Resource Program: Offsetting Costs of Disability and Assuring Access to Disability-Related Supports. An Occasional Paper from the Roeher Institute, Toronto. Roeher Institute. 1993. Direct Dollars. A Study of Individualized Funding in Canada Roeher Institute. 2001. Disability-Related Support Arrangements, Policy Options and Implications for Women's Equality. Prepared for Status of Women Canada. February. Salisbury, Brian. 1993. Individualized Funding and Service Brokerage: Where Do We Go From Here?" May. Simon-Rusinowitz, Lori; Mahoney, K.J.; and Benjamin, A.E. 1998. "Payments to Families Who Provide Care: An Option that Should Be Available." Inside Generations. Fall. SP Research Associates. 1992. Meeting the Income Support Needs of Persons Living with HIV and AIDS. Prepared for National Welfare Grants Division, Health and Welfare Canada. Statistics Canada. 1992. Health and Activity Limitations Survey, 1991 – Back Up Tables for British Columbia. Statistics Canada. 1995. A Portrait of Persons with Disabilities. Housing, Family and Social Statistics Division. February. Tilley, Jane; Wiener, Joshua M.; and Cuellar, A.E. 2000. Consumer-Directed Home and Community Services Programs in Five Countries: Policy Issues for Older People and Government. Washington. The Urban Institute. United States, Department of Health and Human Services. Correspondence. World Health Organization. 1980. International Classification of Impairments, Disabilities and Handicaps (ICIDH). Public Funds, Family Commitment 27 Appendix A TERMS OF REFERENCE INTERMINISTRY COMMITTEE ON COMPENSATION FOR FAMILY CAREGIVERS 1. Purpose of Review To review government's role in the provision of publicly funded services to families and, in particular, whether it is appropriate for government to provide compensation to a family member to provide publicly funded services to another family member. 2. Scope Review policies across all provincial government programs that affect the ability of a family member to be compensated for providing assistance or care to another family member. 3. Objectives ! To identify government policy where the payment of a family member to provide publicly funded services to another family member is prohibited, and any exceptions to the policy. ! To identify government policy where the payment of a family member to provide publicly funded services to another family member is permitted. ! To undertake an analysis of government policy in light of the human rights legislation, develop options for government and determine implications (financial, legal, other) of each option. ! To develop a consultation plan. ! To develop a cross-ministry action plan. ! To seek government approval to proceed with the action plan. 4. Management Structure A cross-ministry committee of senior officials will be responsible for overseeing the review and developing necessary policy and decision documents. a) Committee Membership Members will include representation from the Ministries of Health Services, Children and Family Development, Human Resources including the Office for Disability Issues, Attorney General, and Community, Aboriginal and Women's Services. Treasury Board staff will attend as an observer. b) Roles and Responsibilities • Members will be responsible for identifying affected policies, determining available remedies, and analysing the implications of implementing various approaches including financial analysis. • Ministry of Health will chair the committee and provide secretariat services. • Ministry of Attorney-General will provide legal advice. Public Funds, Family Commitment 28 c) Sign off process • All decision documents will be forwarded to the Deputy Minister of Health Services for approval in consultation with the Deputy Ministers of the other affected ministries. 5. Deliverables ! Action minutes of meetings will be prepared by the secretariat. ! Deliverables may include but are not limited to: policy review statements for affected programs; draft generic policy statement(s); policy framework; Treasury Board Submission, Cabinet Submission; action plan; consultation plan. 6. Timeframe ! Committee meetings will be held bi-weekly during the preparation of the decision documents. ! The Chair will provide a progress report to the Deputy Chief Commissioner, Human Rights Commission, by May 30, 2001. ! Preliminary policy review document to the Deputy Minister of Health Services by early August, 2001. 7. Resources ! Each ministry will provide dedicated staff support to ensure production of required materials in a timely fashion. ! The cost of additional resources required to meet the committee's objectives will be shared between ministries by journal voucher to the Ministry of Health. These costs will be reviewed by the committee before any commitments are made. Public Funds, Family Commitment 29 Membership List – Inter-Ministry Committee on Compensation for Family Caregivers (IMCCFC) Dyan Dunsmoor-Farley, Chair, - Ministry of Health Services Karen Archibald, Secretariat - Ministry of Health Services Mariann Burka – Ministry of Human Resources Catherine Gale – Treasury Board Staff Bonnie Hallas – Ministry of Health Services Frank Jonasen – Office of Disability Issues, Ministry of Human Resources David MacPherson – Ministry of Children and Family Development Ann Marr-Paine – Ministry of Health Services Fran Pardee – Ministry of Children and Family Development Steve Reid – Office of Disability Issues, Ministry of Human Resources Judi Ward – Ministry of Human Resources Pieta Van Dyke – Ministry of Community, Aboriginal and Women's Services Public Funds, Family Commitment 30 Appendix B SUMMARY OF BC AND CANADIAN PROVINCIAL PROGRAMS6: WHAT FAMILY MEMBERS ARE PROHIBITED FROM RECEIVING COMPENSATION7 Parent of Parent of Spouse Adult Adult Sibling Adult Other Dependent Adult Child of client Child (living in or Relative Child (in or out of (living in outside client's living in Jurisdiction client's or outside home) client's home) home) home British Columbia: Ministry of Health Services: Home Support N/A X X X X X X Ministry of Human Resources: Home Support X X X X X X X Child Care X N/A X N/A X Subsidies Ministry for Children & Family Development: Home Support N/A X X X X X X (adults) Home Support X N/A N/A N/A X X X (children) At Home X N/A N/A N/A X if in home X if X if living Respite dependent in home & (children) dependent Supported Child X N/A N/A N/A X if in home X X Care Respite X N/A N/A N/A X X X Services (children) Nursing Support X N/A N/A X X X X Services (children) Residential N/A X X X X X X Program (adults) Associate X N/A N/A N/A X N/A X Family Program (children) School Aged X N/A N/A N/A X X X Therapy Services Community X N/A N/A N/A X X X Brain Injury Program (children and youth) Training & N/A X X X X X X Support Program (adults) Alberta (Awaiting information) 6 This list includes only those programs where some form of care is provided to an individual, primarily in their own home, and where the caregivers are usually not professionally trained, like nurses. 7 X indicates prohibition in policy or practice OTHER would include any other individual related by blood or marriage SHADED sections indicate written policy – No shading indicates less formal policy or procedure Public Funds, Family Commitment 31 Parent of Parent of Spouse Adult Adult Sibling Adult Relative Other Dependent Adult Child of client Child (living in or living in Child (in or out of (living in outside client's client's home Jurisdiction client's or outside home) home) home) Manitoba (general rules X X X X X X only) New Brunswick Dept. of Family & Community Services Community X N/A N/A N/A X X (even if X Based Services outside home) for Children with Special Needs Long Term Care N/A X X X X X (even if X Services for outside home) Adults and Seniors Newfoundland Dept. of Health and Community Services Home Support N/A X X X X X (even if X (adults) outside home) Home Support X N/A N/A N/A X X X (children) Nova Scotia Dept. of Community Services In-Home N/A X X X (inhome) X Support (adults) In-Home X N/A N/A N/A X Support (children) Ontario Ministry of Community and Social Service Special N/A Permitted Permitted Permitted Permitted Permitted Permitted Services at Home (adults) Special X N/A N/A N/A X ("family X ("family X ("family Services at members"-not members"-not members"- Home (children) defined) defined) no defined) Prince Edward Island (no information available) Quebec Ministry of Health and Social Services Respite X X X X X ("family X ("family X ("family Program members"-not members"-not members"- defined) defined) no defined) Saskatchewan Department of Social Services X (if in Support X N/A N/A N/A X X home- Services-respite family not (children) defined) X (if in Developmental N/A X X X (if in X (if in home) X home- resource homes home) family not defined) X (if in Adult programs N/A X X X (if in X (if in home) X home- home) family not defined) Public Funds, Family Commitment 32 Appendix C COMMUNITY BASED HEALTH AND SOCIAL SUPPORT PROGRAMS CLIENTS AND EXPENDITURES Ministry Program Name Clientele Year No.* Year Expenditure/ Clients Budget*** MHS Home Support 19+ chronic health problem, 99/00 41,418 98/99 $216,477,944 CSIL disability 00/01 436 00/01 $ 22,000,000 Home Care Nursing Any age, short term or long 99/00 36,914 99/00 $28,875,000 term health problem MCFD Training & Support Adults with developmental 01/02 8,326 01/02 $133,440,000 Programs disabilities Residential Services 01/02 5,604 01/02 $365,000,000 Homemaker/Home Families of children with Spring 221 01/02 $1,841,558++ 2001+ Support special needs At Home Respite Families of children with Spring 3,459 01/02 $ 8,331,264++ 2001+ Program severe disabilities who are being cared for at home Supported Child Care Children aged 12 and younger Spring 4,530 01/02 $35,830,000++ 2001+ who require extra support in child care setting because of impairments Respite Services Families with children who Spring 1,342 01/02 $5,667,031++ 2001+ have special needs Nursing Support Children with exceptional Spring 769+++ 01/02 $4,065,000 2001+ Services health care needs and their parents Associate Family Children with multiple Spring 44 01/02 $2,289,055++ 2001+ Program disabilities living in institutions on a full or part-time basis whose health care needs can be safely & effectively met in the community and whose natural families are unable to assume ongoing care for them School-Aged Therapy School-aged children with Spring 4,177 01/02 $484,167++ 2001+ Services special needs Community Brain Injury Children and youth with Spring 75 01/02 $500,000 2001+ Program for Children acquired brain injuries when and Youth in BC no other funding is available MHR Homemaker Program 00/01 810** 00/01 $1,400,905 TOTAL: 89,268 $824,801,019 *MCFD Clients in Residential Programs are also involved in Training and Support Programs and have been counted only once; and number of MOHS home support clients who receive home care nursing have only been counted once . **# Clients for Homemaker Program is an estimate only – the actual # is not captured anywhere. ***Expenditures for CSIL and Home Care Nursing, MHS, are estimates only: home care nursing estimate based on $75/hour, ½ hour visits, 770,000 visits in 99/00; CSIL estimate based on 436 clients with 70,393 authorized hours x $26/hr. Information available at this time varies depending on program – some is expenditure, some is budget. + Numbers of clients in the MCFD programs is a one time snap shot. Annually numbers will be higher. ++ These figures represent the budget for 2001/2002. +++ NSS is in the process of finalizing a data base and data entry is not complete – numbers may change.
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Mint, all of it!
There are some great mint discussions here and I'm adding my two-cents worth and hoping some of you will contribute your experiences.
When I was in my early teens, my grandmother liked making tea from balm, a strong mint that grows wild in East Texas. I remember how happy she was when we kids found her a batch. My mom also used to have a really nice clump of peppermint growing by the faucet outside and I liked eating it raw but Mom also made a summertime drink by adding a few ice cubes to a blender filled with Welch's grape juice and then she added some fresh mint leaves to the blender. It sure gets a lot of green specks between your teeth but is worth it for the refreshment.
Now I have a couple of outdoor pots with peppermint and spearmint. I sometimes use fresh leaves for decorating a citrus pie and I just grab a few sprigs now and then and eat it raw. It's also really good added to your cold water pitcher in the 'fridge. It keeps well and can be refilled several times using the same mint, just to give the water a mild mint flavor.
I'm reading here in the forum that I need to re-pot my mint to keep it from becoming root bound. My planter is about 20 inches in diameter and 10 inches deep. It's currently overflowing with mint and spearmint mixed. How do I know when to re-pot? I have a bunch of extra mint growing on the ground near my air conditioner drip line so I have plenty of runners to play with. Are there any good recipies that use both mint and lemon juice? I'm also trying to figure out to use lemon juice by the gallon.
If your pot of mint continues to do well, why interfere with a good thing? When it shows signs of unhappiness due to overcrowding, imo that is the time to repot.
Since you have many runners, you can just start an additional pot. Then, if you repot later and your mint reacts poorly to the repotting, you still have your second pot to fall back on.
Mint can fill a large tub, given the right conditions.
Have you ever tried planting pineapple sage in the ground down there? It seems to me it could be perennial there, depending on what part of Texas you are in.
I have been wondering how large it would get after a few years.
Pineapple mint plus pineapple sage make an excellent tea.
elbren, thanks for the "sage", errr, mint advice! I love mint so I may see what I can do to increase my soil space without cutting too far into my meager spare time. I have found that my mint potted in sandy soil in a partially shaded place makes a lot more leaves than the mint that is growing out on the ground. I haven't heard of pineapple sage. I'm interested if it tastes like pineapple. My mint survived like a charm through two freezing rain events this year. The leaves were coated with a pretty thick layer of ice and didn't wilt a bit after thawing out. The temp was barely under freezing so I guess the leaf sap didn't get cold enough to freeze.
I planted Kentucky Colonel mint by my front door in early 2006, I guess. It's traditional in the South to do that. Used to be back in the day that when company was coming, you'd beat the mint by the door with a broom so the smell would follow visitors into the house and they wouldn't notice the lack of cleanliness so much. I did it just because it's traditional and I like it. Not so much for the other reasons. :-)
I didn't take care of it much other than to pick some once in a while. Mowed it off now and then. Smells great. I was hoping it would take over and it did spread, but not like I had hoped. That was the north side.
In 2011, I built a real house attached to this little house and all that dirt got scraped up and used later for fill around the foundation. They had no idea there was mint there and I was OK with it going away. But the following spring, I had mint scattered all over the place around the new house. The best patch I have now is on the North East corner. More on the east side spreading around the corner and back down the south direction. It must be a good 10 or 15 feet along the wall now, with at least 10 feet out into the yard in some places. it's amazing! I love it! By June, it will be knee high or higher and ready to cut back for drying.
The last two winters, it stayed green throughout. But this winter was a lot colder a lot longer and it all died back to the ground. But it's all bouncing back now and looks great! Looking forward to it taking over again.
I took a few photos before I cut some leaves. Last year my mint made lots of stems and runners but very few leaves. I'm trying to keep it cut down this year to encourage branching of the stems. This is a mixture of spearmint and peppermint. It gets full sun through an open doorway for a few hours a day and shaded the rest of the day.
Here is the open doorway facing south. So far, it's been a great place for the mint.
I experi-mint-ed a bit today and found that adding a double handfull of fresh spearmint leaves to your lemonade is quite tasty. I didn't want to heat the leavs as in making tea so I added the leaves to a cup of lemon juice, added sweetener (I like agave nectar), stirred it in and let it sit for a while, full strength. Then I added the water and chilled. I left the mint leaves in the lemonade so it will probably get stronger.
I like your brick doorway. Did you build your house yourself?
The thick herb pot is great, too, especially in a climate as warm as yours. What a good way to protect the mint from overheating!
Pineapple sage is a perennial, but not in my zone. I believe it might be in yours, although frost will almost certainly damage it. It has a nice fragrance reminiscent of pineapple, and is excellent in teas, especially if combined with pineapple mint. Pineapple mint is often sold in varegated form, with white spots on the leaf margins. It will sometimes overwinter in my climate. They enhance each other, because one has more fragrance and the other more taste.


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CHAPEL HILL, NC — Muslims gathered in cities around America carrying banners that said, "Je Suis Charlie," after Craig Lee Hicks shot three Muslims in Chapel Hill, North Carolina, allegedly over an ongoing parking row that erupted into a deadly dispute over satire.
According to protesters, they have adopted the "Je Suis . . .


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Search the POLITICO Bookshelf
6059 Books Found in All Books
The Mind of the South
Price $17.95
Ever since its publication in 1941, The Mind of the South has been recognized as a path-breaking work of scholarship and as a literary achievement of enormous eloquence and insight in its own right. From its investigation of the Southern class system to its pioneering assessments of the region's legacies of... Read more »
Price $11.99 - $24.00
"He seems to have brought to this book the ear of a musician and the eye of a painter . . . the premier war correspondence of Vietnam."--Washington Post. "The best book I have ever read on men and war in our time."--John le Carre." . . . Dispatches puts the... Read more »
Lyndon Johnson and the American Dream
Doris Kearns Goodwin's classic life of Lyndon Johnson, who presided over the Great Society, the Vietnam War, and other defining moments the tumultuous 1960s, is a monument in political biography. From the moment the author, then a young woman from Harvard, first encountered President Johnson at a White House dance in... Read more »
Seven Pillars of Wisdom
A Triumph (The Authorized Doubleday/Doran Edition)
Price $11.99 - $19.95
In his classic book, T.E. Lawrence—forever known as Lawrence of Arabia—recounts his role in the origin of the modern Arab world. At first a shy Oxford scholar and archaeologist with a facility for languages, he joined and went on to lead the Arab revolt against the Ottoman Turks while the rest... Read more »
A Novel
Price $11.99 - $15.95
This fictional re-creation of the battle of Shiloh in April 1862 fulfills the standard set by his monumental history, conveying both the bloody choreography of two armies and the movements of the combatants' hearts and minds. Read more »
Disturbing the Peace
A Conversation with Karel Huizdala
Price $14.95
An intimate history of Czechoslovakia under communism; a meditation on the social and political role of art, and a triumphant statement of the values underlying all the recent revolutions in Central and Eastern Europe. Read more »
Means of Ascent
The Years of Lyndon Johnson II
Price $15.99 - $60.00
Robert A. Caro's life of Lyndon Johnson, which began with the greatly acclaimed The Path to Power, also winner of the National Book Critics Circle Award, continues -- one of the richest, most intensive and most revealing examinations ever undertaken of an American President. In Means of Ascent the Pulitzer Prize-winning... Read more »
Rethinking the French Revolution
Marxism and the Revisionist Challenge
Price $24.95
Historians generally—and Marxists in particular—have presented the revolution of 1789 as a bourgeois revolution: one which marked the ascendance of the bourgeois as a class, the defeat of a feudal aristocracy, and the triumph of capitalism. Recent revisionist accounts, however, have raised convincing arguments against the idea of the bourgeois class... Read more »
The Six Wives of Henry VIII
The tempestuous, bloody, and splendid reign of Henry VIII of England (1509-1547) is one of the most fascinating in all history, not least for his marriage to six extraordinary women. In this accessible work of brilliant scholarship, Alison Weir draws on early biographies, letters, memoirs, account books, and diplomatic reports to... Read more »
The Journalist and the Murderer
Price $13.99 - $15.00
In two previous books, Janet Malcolm explored the hidden sides of, respectively, institutional psychoanalysis and Freudian biography. In this book, she examines the psychopathology of journalism. Using a strange and unprecedented lawsuit as her larger-than-life example -- the lawsuit of Jeffrey MacDonald, a convicted murderer, against Joe McGinniss, the author of... Read more »


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Reader comments are listed below. Comments are currently closed and new comments are no longer being accepted.
Also, Mr Urban, we have the best results ever for the F.D.P. Stop whining and join the winners. Stop investing in Windmills.
@Jan Urban: Intelligent Germans need to be sado-masochistic, is that what you suggest ? And of course, we have to bow to those clever British, because they say so. Otherwise we will have bad weather forecasts for three days. I am soooo frightened of money. James Bond will go after me. When he is done with Bin Laden, of course.
@Jan Urban asks: "What rejuvenation?"
Seems like Jan can't get them young enough, lol.
Considering my own age, I believe their average age is admirable; especially if you look at the ones on the bottom:
Karl-Theodor zu Guttenberg 37,
Phillip Rösler 36,
Norbert Röttgen 44,
Ilse Aigner 45,
Dirk Niebel 46
Guido Westerwelle 47,
Ronald Pofalla 49
This is, also by European and international "standard", quite youthful.
to Hermitter:
What rejuvenation? Some say the new German government looks like 'Jurassic Park' with some of the cabinet members being buried out of the Kohl-zoic era. Schäuble (minister of finance) was involved in a party-donation scandal, Leutheusser-Schnarrenberger (justice) already ran away from her office and had to been replaced, Brüderle (economy) was minister for wine and is known as kissers of wine queens (wine queen represent a particular wine region for a year). All in all, a very mediocre cabinet that is reflecting more the various German regions than qualifications, unfortunately.
to SagDieWahrheit:
What is wrong with you? So, you consider yourself as part of German 'intelligentsia'? For Germany's sake, I hope you are not... Or is it you, Mister 'Westerwave', practising some english and preparing for a UN appearance?
It's, in my opinion, one of the best center/liberal cabinets the Federal Republic ever had. What is really genuine about Angela Merkel's picks is her will to rejuvenate the old guard. Even her decision to shove "old nitpicker" Wolfgang Schäuble out of "interior" (police and national security) where he slowly started to threaten civic rights and democracy, into finances that needs a meticulous man like him, was a super-smart move. I personally would have rather seen Karl-Theodor zu Guttenberg as foreign minister, but this seat is traditionally taken by the vice chancellor and junior partner of any coalition.
Hope for Guido's sake that the job requires some training in good behavior and social etiquette. This would make life surely easier for him.
Thanks to The Economist for a more friendly tone this time. This election has seen German Intelligentsia deployed against stereoptypical railing of international money against Germany. The Anglosaxons thought we were so stupid that we would buy everything they feed into DER SPIEGEL (from Hamburg, British zone of occupation). We did not and we booted out the Red/Green Scare.
Well, done, now let us talk Industriepolitik, Science and Defense instead of money. Zuviel Gerede über Geld verwirrt nur !
The Amanda Knox verdict: Innocente
Harry Reid's retirement: Republicans get their wish
Democracy in America
Emerging markets: Predicting the next crisis
Free exchange
Nuclear talks with Iran: Distrust and verify
Middle East and Africa
Scientology film: Hammering at the walls
Nigeria's election: A powder keg
Graphic detail
The first televised "debate": Why the prime minister resisted
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Hopper Hotel et cetera - Cologne
Brüsseler Straße 26 - Cologne1-877-662-6988
Unwind with premium bedding in each room at Hopper Hotel et cetera! This family-friendly Cologne hotel offers a rooftop terrace as well as free breakfast and is located near a metro station in the area of New Town.
Your 3 star New Town hotel in Cologne offers free Wi-Fi, dry cleaning/laundry and an elevator (lift). You can find a sauna on site so you will be able to take some time out to de-stress. Guests can also enjoy drinks as there is a bar/lounge. Multilingual staff at the 24-hour front desk can provide tour/ticket assistance.
Whether you're waiting for friends or your partner, the lobby has a TV and free newspapers to keep you company. Planning a meeting? This hotel has 9 meeting rooms. Other amenities include a garden and laundry facilities.
We show TripAdvisor reviews for new Venere hotels that haven't been reviewed yet
Check Availability at Hopper Hotel et cetera
Breakfast at Hopper Hotel et cetera
A free buffet breakfast is available between 7:00 AM and 11:00 AM.
Facilities at Hopper Hotel et cetera
- Bar
- Restaurant/Dining
- Laundry service
- Lift/elevator
- Pets accepted
- Entire property is non-smoking
- Laundry room
- Garden
- Personal newspapers
- Multilingual staff
- Newspapers
- Front desk - 24 hour
- Luggage room
- City tour
- Sauna
- Internet/Email services
- TV Lounge
- Conference room
Know before you go
Check-in: between 3:00 PM and midnight.
Check-out: before noon.
PolicyExtra-person charges may apply and vary depending on hotel policy.
Government-issued photo identification and a credit card or cash deposit are required at check-in for incidental charges.
Special requests are subject to availability upon check-in and may incur additional charges. Special requests cannot be guaranteed.
City tax and/or any other fees charged by the hotel
The following fees and deposits are charged by the property at time of service, check-in, or check-out.
- Self parking fee: EUR 13 per night (in/out privileges)
- Pet fee: EUR 10 per pet, per night
- Crib (infant bed) fee: EUR 10 per stay
- Rollaway bed fee: EUR 25 per night
The above list may not be comprehensive. Fees and deposits may not include tax and are subject to change.
You'll be asked to pay the following charges at the hotel:
- A 5 percent city/local tax will be charged
We have included all charges provided to us by the property. However, charges can vary, for example, based on length of stay or the room you book.The city of Cologne imposes a culture tax (Kulturförderabgabe) of 5%. The amount is not included in the total price displayed. Business travelers may be exempt from this tax and need to contact the hotel for further information or ask the hotel at check-in. Guests can contact the property using the information contained in the confirmation received after booking.
Hopper Hotel et cetera is also known as
Hopper Hotel Cologne
Room Details
Book your family-friendly accommodation at Hopper Hotel et cetera, offering 50 guest rooms with climate control. Cable TV channels offer entertainment at the end of a busy day. Corporate travelers will benefit from free wireless high-speed Internet access as well as desks, complimentary newspapers and phones during their New Town visit.
A good night's sleep in supportive pillowtop mattresses with premium bedding will have visitors waking up refreshed and well-rested throughout their holiday or business trip. Private bathrooms are outfitted with hair dryers. Rooms also include minibars and safes.
Irons/ironing boards can be provided on request.
Accommodation Services
- Telephone
- Mini bar
- Extra beds
- Baby cots/cribs available
- Hypo-allergenic bedding available
- Ironing facilities on request
- Hairdryer in each room
- Safe
- Desk
- Individually controlled air conditioning
- Cable TV
- Wireless Internet access
Distances from Hopper Hotel et ceteraVolkstheater Millowitsch - 0.2 km / 0.1 mi
Cologne Synagogue - 0.4 km / 0.2 mi
Rudolfplatz - 0.4 km / 0.2 mi
Museum of East Asian Art - 0.7 km / 0.4 mi
Friesenplatz - 0.7 km / 0.4 mi
Cologne Kathe Kollwitz Museum - 0.9 km / 0.6 mi
Neumarkt - 0.9 km / 0.6 mi
Stadtgarten - 1 km / 0.6 mi
University of Cologne - 1 km / 0.6 mi
Theater am Dom - 1.1 km / 0.7 mi
Schnuetgen Museum - 1.2 km / 0.7 mi
St Gereon's Basilica - 1.3 km / 0.8 mi
National Socialist Documentation Center - 1.3 km / 0.8 mi
Cologne City Museum - 1.4 km / 0.8 mi
Colonius - 1.4 km / 0.9 mi
The preferred airport for Hopper Hotel et cetera is Cologne (CGN-Cologne - Bonn) - 13.6 km / 8.5 mi.
Distances are calculated in a straight line from the property's location to the point of interest or airport and may not reflect actual travel distance.
Distances are displayed to the nearest 0.1 mile and kilometer.
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text:
Egypt constitution: 98.1 per cent of voters approve in first vote after coup
Saturday's referendum was seen as key to legitimizing its military-backed interim government.
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CAIRO—Nearly everyone who cast a ballot in last week's referendum supported Egypt's new constitution by a margin of 98.1 per cent, according to results announced Saturday, but a boycott by Islamists and low youth turnout suggest the country is still dangerously divided.
Nearly 20 million voters backed the new constitution, almost double the number of those who voted for one drafted in 2012 under the government of toppled Islamist president Mohammed Morsi.
Only a narrow sliver of voters — 1.9 per cent — voted against the charter, after a massive government-sponsored campaign supporting it and the arrest of activists campaigning against it.
"Despite a milieu of intense social upheaval and acts of terrorism and sabotage that sought to derail the process, Egyptians have now marked yet another defining moment in our roadmap to democracy," presidential spokesman Ehab Badawy said. "The outcome represents nothing less than the dawning of a new Egypt."
The expected overwhelming support for the charter is seen as key to legitimizing Egypt's military-backed interim government, and the political plan put in place since Morsi's ouster in July.
Analysts say it also suggests military chief Gen. Abdel-Fattah el-Sissi, who led the coup against Morsi, has enough popular support to make a rumoured run for the presidency himself.
It was the first vote since the military removed Morsi following massive protests in July. Hundreds celebrated in the streets after officials announced the results, including Hoda Hamza, a housewife who waved an Egyptian flag in Cairo's Tahrir Square and carried a picture of el-Sissi.
"I wish el-Sissi will be president," Hamza said. "We have no better man. ... If it weren't for the army, we wouldn't have food on the table."
Morsi supporters, who boycotted the vote, immediately challenged the results. Despite being outlawed and labelled a terrorist group, Morsi's Muslim Brotherhood and its allies continue to hold near-daily protests that often devolve into clashes with police.
"Even if 38 per cent of the voters took part, that still means that 62 per cent of the public rejects (the interim government)," said Brotherhood supporter Imam Youssef. "They are trying to legitimize their coup."
Egypt's High Election Commission said 38.6 per cent of the country's more than 53 million eligible voters took part in the two-day poll Tuesday and Wednesday.
Judge Nabil Salib, who heads the commission, called the participation of 20.6 million voters an "unrivalled success" and "an unprecedented turnout."
In 2012, some 16.7 million voters cast ballots on the constitution drafted under Morsi, representing a 32.9 per cent turnout amid a boycott by liberal and youth groups. In that election, 63.8 per cent voted for the constitution.
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