What makes us healthy? Doctors, surely. Safe and effective medicine, yes. Clean food and water, definitely. But increasingly, public policy is looking at the so-called social determinants of health: A person might theoretically have access to a doctor, but can they afford clean and safe shelter? Can they afford healthy food? Do they have enough time to relax (or even get some healthy exercise), or are they working two jobs just to afford the basics?
An article published this week in the Canadian Medical Association Journal makes a provocative argument: given how much provinces already spend on “classic” health care (hospitals, doctors, pharmaceuticals), it would make more sense for them to spend their next dollar on social services instead of medicine.
“Health-care spending is usually framed as the way governments can improve health outcomes, but we know there are lots of things that affect the health of people,” says Daniel Dutton, a post-doctoral scholar at the University of Calgary’s School of Public Policy, and one of the authors of the study. “There’s a gigantic literature on the social determinants of health. Things like child care, welfare, decreasing income inequality could improve health.
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“We wanted to connect the two, to show that increasing non-health-care spending could actually improve health.”
Dutton and his co-authors looked at the historical trends in both health-care and social-services spending, and at the ratio of the two, finding that provinces spend on average more than four times as much on per-person health costs as they do in social services. Moreover, health costs have grown rapidly (doubling in per capita spending since 1981), while expenditures in social services have been flat.
They conclude that shifting $350 million from health-care spending to social services would do more to improve health outcomes: avoidable deaths would decrease 3 per cent, and life expectancy would increase 5 per cent. Those may sound like marginal results, but they’re not bad considering the proposal wouldn’t require any net new money.
Dutton is quick to say that he supports our health-care system: “Publicly funded health care is a social determinant of health, too.” A health system that treats people regardless of income is a form of social good. His point is that the health-care system already spends so much that every marginal dollar does less than it could elsewhere.
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A related commentary published in the CMAJ by Paul Kershaw of the University of British Columbia notes that provincial governments have massively increased spending on the elderly, boosting health-care spending (which rises dramatically for people over 65) and expanding programs like Old Age Security and the Canada Pension Plan. The trend seems likely to continue. But at the same time, budgets for social services and housing supports have been cut or, at best, maintained.
“These trends raise normative questions about whether Canadian governments are finding the right balance between investing in health promotion for the aging population and for younger cohorts,” Kershaw writes. Or, to put it more bluntly, the question is whether governments are buying health and comfort for the elderly while letting younger generations suffer.
But Kershaw doesn’t just want to see social spending increase; he wants the social determinants of health to be centred in all public policy. Renters in the GTA may grumble about the latest increase from their landlord or the vanishing prospect of buying their own home. While those are obviously economic issues, Kershaw notes that housing costs are also a social determinant of health.
Governments could spend more on affordable housing, but Kershaw also recommends that they remove “outdated” policies, like zoning rules that constrain density, and change the favourable tax treatments we’ve provided for homes — ones that make them attractive for speculative investment.
More immediately, Dutton’s paper does provide some rhetorical ammunition for the Ontario government in its years-long battle with the Ontario Medical Association over fees paid for medical services. (That dispute is ongoing and now likely to head to arbitration.) The paper notes that while doctors have portrayed the government’s attempt to reduce payments to doctors as a move that endangers patients, it’s simply not true that medical services are the only or best way to improve people’s health.
“In this discussion, the focus is on health outcomes as a function of health spending, rather than a shared understanding that spending on social services may also improve health outcomes,” the paper notes.
Dutton says he wasn’t looking to reinflame tensions between Ontario doctors and the government.
“It’s an example of how health-care spending gets decided on in a public forum,” Dutton says. “Intuitively, people understand that lots of things affect your health — that’s why people quit smoking.”
“I think most medical associations would be happy to see this result, because it agrees with something they’ve been advocating for a long time.”