The problems in traditional residential long-term care settings described in the lead paper are the tip of the iceberg in relation to changes in the landscape of healthcare and social policy in Canada over the past two decades. The primary purpose of this commentary is to identify some of the less visible changes and how these are affecting our perceptions, values and policy directions in "long-term care," however it is defined. The secondary purpose is to caution readers of the dangers of trying to resolve all social policy issues through medicare. This temptation is an artifact of our history and fragmented constitutional powers. It is also due to a well-intended but highly problematic shift in the nature and purpose of public health insurance (and government) in Canada during the 1990s. Without a greater understanding of these and other underlying issues, a pan-Canadian program dedicated to residential long-term care under the upcoming Health Accord risks adding to existing problems. There is also a desperate need for better understanding of the intergenerational needs of Canadian families in relation to healthcare and eldercare.