Social determinants, more than cost of care, key to sustainability

Critics of Medicare often point to Canada’s dubious population health record as evidence of the need for system reform, but seldom do these critics spend much time looking at the social determinants of health or actions by increasingly right-wing governments that take us further from good population health principles.

The most obvious determinant is the growing levels of income inequality in Canada. While still below the levels of inequality in the United States, we are doing our best to catch up by enacting policies that place downward pressure on incomes for the majority while doing little to address the excessive concentration of wealth at the very top.

This February TD Economics notes that while there is significant demand for high skilled workers, both medium and low skilled workers have lost considerable ground in Canada as job opportunities disappear. Given the recent controversies around outsourcing by Canadian banks, TD brazenly reports: “these workers have become increasingly vulnerable to computer automation or outsourcing to low-wage jurisdictions.”

TD notes that Canada has not had quite the same hollowing out of the middle skilled/middle class workers as our southern neighbours due largely to a rebound in government spending following the 1990s era of austerity.

TD is also likely overlooking the importance of union density in preserving what’s left of Canada’s middle class. For the past decade almost one in three Canadian workers have been members of unions, while in the United States union membership has been in sharp decline. In the U.S. that decline will soon leave just one in 10 workers with union representation.

For all the hand wringing about middle class decline and growing inequality, governments appear to be not only failing to stem the tide, but appear to be adding fuel to the fire. Public spending is now under direct attack by governments implementing a new wave of austerity, while Conservatives are working hard to soften public opinion to undermine union and worker rights. In Ontario Tim Hudak’s Conservatives have vowed to make it more difficult for unions to finance themselves by allowing workers to opt out from dues payment and by disallowing automatic dues check off. In U.S. States where this has already taken place, overall family incomes have gone into significant decline. Both government austerity and the attacks on labour raises questions about what happens to the demand for public health care if the key supports for the middle class further decline.

There is no question that this economic “transformation” is already creating new demand for health care services. We noted last week that anti-stigma campaigns are being credited for the rise in demand for mental health services here in Canada, yet one of the hallmarks of rising inequality is a proportional escalation of mental illness, including depression and suicide. The anti-stigma campaigners may be a bit quick to take all the credit.

Of course, the government’s reaction to a sharp rise in mental illness is to create even more of it by further cutting middle class jobs in the public sector, including many jobs directly in the provision of health care. As if that wasn’t enough, we have yet to see any significant increase in funding since 2008 to support escalating numbers of adults facing mental illness. Last year the Mental Health Commission of Canada released its national strategy, including a plan to increase spending on mental illness as a proportion of overall health spending. While other provinces are already on board, there appears to be few tangible signs that Ontario is about to embrace it or to begin appropriately funding mental health.

This new attack on the public sector also raises questions about how well existing programs support Canadians through bad times.

One 2007 OECD report shows Canada ranks 24th of the 30 OECD nations on social safety net spending. We are 26th for spending on early childhood education, 22nd for unemployment benefits, 26th for seniors benefits and supports, 23rd in benefits and services for people with disabilities. Only 40 per cent of Canadian workers are eligible for employment insurance benefits should they lose their jobs.

The high cost of housing has left many families choosing between rent, food, clothing or needed medicines. In 2007 the United Nations noted that in Canada housing, homelessness and inadequate housing is a “national emergency.” How many people even know that?

Housing is a major determinant of health. A 1990s 10-year St. Michael’s Hospital study of the mortality rates of homeless and “marginally housed” individuals showed the probability of survival to age 75 was 32% in men and 60% in women. This compared to 51% and 72% among men and women in the lowest income group in the general population.

According to a 2010 report on the Social Determinants of Health by Juha Mikkonen and Dennis Raphael, “children who live in low quality housing conditions have a greater likelihood of poor health outcomes in both childhood and as adults.”

The authors note a comprehensive OECD report ranked Canada 12th of 21 nations in children’s health and well-being.

Canada is also one of the few developed countries without a national plan for universal drug coverage. One in 10 Canadians cannot afford to fill a doctor’s prescription. That often leads to much greater use of the public system as symptoms deteriorate further.

Lack of housing, food security, and declining real incomes are all contributors to stressful lives, as is the rise in less secure forms of employment.

Successive governments have done much to erode job security in Canada, to the point where only half of working-age Canadians hold a permanent full-time job.
Canada is again among the bottom of the list of OECD nations when it comes to employment protection policies. We have the same degree of protection as the UK – only the U.S. is worse. As much as employers argue for greater flexibility to utilize temporary workers, economic powerhouse Germany has far greater labour protections than a country like Canada.

According to Raphael and Mikkonen insecure jobs often consist of intense work with non-standard working hours that are associated with “higher rates of stress, bodily pains, and a high risk of injury.” The authors note such work can lead to problems including sleep deprivation, high blood pressure, and heart disease.

Given this level of work intensity, you’d think Canada would be among the more generous nations when it came to holidays and vacation.

A 2007 U.S. study entitled “No-Vacation Nation” shows Canada, Japan and the U.S. to be at the bottom of the list of developed countries when it comes to time off.

The social determinants of health clearly show Canada to be not only a nation in steep decline, but one that will face increasing health challenges if we cannot right our ship.

Thirty years of Neo-Conservative or Neo-Liberal policies have not produced a robust economy benefiting all. If anything, it has created a situation where we are building towards a cascading failure of nationhood.

If families have been able to retain some of their material wealth it is only because they are working longer and harder. Whereas a single income could once sustain a family, now most require at least two incomes. At least five per cent of working age Canadians are employed in more than one job.

It is clear we need to view public policy differently. Whereas most municipalities require staff reports to indicate the financial implications surrounding a decision, it should be mandatory that provincial and federal governments look at all decisions in the context of their impact on population health.

All tax cuts should be measured against the opportunity costs lost, including the lives of citizens who won’t be able to access the health care they need.

That would at least be a real starting point in the debate on health care sustainability.

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For a free download of Juha Mikkonen and Dennis Raphael’s book Social Determinants of Health: The Canadian Facts, click here.

If you are attending OPSEU’s Broader Public Sector Conference this weekend, Rick Janson will be expanding on this topic Saturday morning during the Health Care Divisional Council plenary.

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