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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.

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