Introduction: Residential long-term care (LTC) is an important component of the care continuum for older adults in Canada. Three factors related to population aging are contributing to an increased demand for LTC services: 1) an increased prevalence of age-related health disorders; 2) reduced societal capacity to provide unpaid care; and 3) a lack of available substitutes for LTC. LTC is not one of Medicare’s insured services and as such great variation in the provision of LTC services exists across provinces. Provincial governments are currently grappling with how best to provide and pay for quality LTC services while also weighing investment in other aspects of the care continuum to delay or prevent LTC admission. Purpose: The purpose of this thesis is to examine LTC policy changes since 1990 and the impact these have had on LTC spending and quality in three provinces that represent natural policy experiments: British Columbia, where a disinvestment in LTC and concurrent investment in assisted living has taken place; Manitoba, one of the largest per capita spenders on both LTC and home care; and Ontario, which has essentially maintained the status quo. Methods: A retrospective comparative case study approach adapted from the work of Richard Rose (2005) is used to compare provincial experiences. Evidence was drawn from a comprehensive literature review of not only peer-reviewed literature but also grey literature, including policy and planning documents and advocacy group and think-tank reports. Descriptive analysis was performed on spending data obtained from the Canadian Institute for Health Information’s National Health Expenditures Database, and Quality data obtained from the Canadian Institute for Health Information’s Continuing Care Reporting System. Results: British Columbia’s strategy of investment in assisted living in lieu of LTC resulted in substantial cost savings since the early 2000s. LTC quality was best in Manitoba, where the per capita spend on LTC is highest, although resident populations varied slightly between provinces. Conclusions and Recommendations: While British Columbia has successfully reduced costs in the LTC sector by substituting assisted living, there is some evidence to suggest that this approach may create barriers to access and lead to downward pressures in other parts of the health system, particularly acute care. Investment in a robust continuum of care that includes support for informal carers, home care, respite care, assisted living, and LTC where appropriate seems the best way to meet the needs of the aging population while providing affordable and high quality LTC. Additionally, paradigms such as aging in place, although well-intentioned, may be misused by governments to achieve policy ends and can be a barrier to effective reform in the LTC sector. Keywords: Long-term care, continuing care, aging, health policy, health services.