Income is the determinant of the other determinants of health.
When a patient goes to see their doctor, they do so hoping for help to understand or treat an acute illness or a longer-term problem.
It might be something as simple as a rash or a cut, a chronic illness like asthma, or something more socially and psychologically complex like depression or addiction.
What do people expect from a health care provider? Usually some sensible, evidence-based advice, perhaps a plan for further investigations, and sometimes a prescription for a medication or referral to an expert.
"A growing body of evidence shows that allowing poverty to continue is far more expensive than investing to improve people’s economic well-being."
The goal of these interactions, and the real purpose behind our health care system, is the best health for Canadians. But the evidence on what makes the biggest difference in our health is clear: health care matters, but it isn’t what matters most in making a population healthy.
Social factors such as income, education, employment, housing, food security and the wider environment play a much larger role than health care in achieving the best outcomes for any population. Of these social determinants of health, the most influential is income. Income is often referred to as the “determinant of the determinants” because it influences access to other essentials for good health, such as where people can afford to live and how far they can go in school.
A growing body of evidence shows that allowing poverty to continue is far more expensive than investing to improve people’s economic well-being. In Ontario, the cost of poverty has been calculated to be upwards of $30 billion per year. This cost may be the strongest motivator behind the resurgence of interest in a basic income, but the health case cannot be far behind.
Poverty leads to higher rates of heart disease, depression, diabetes and scores of other illnesses — so doctors should, and do, care about poverty. This understanding has led to greater emphasis on assessing income status in primary care.
Clinical Poverty Tools are being developed across the country, following the model developed by Dr. Gary Bloch and Health Providers Against Poverty in Ontario, to help front line health care workers support their patients to access the financial help they need. But just as health is far more than health care, improving health through increasing access to income has to go far beyond clinical efforts. This has led physicians to move outside of their traditional roles and start advocating for upstream policy changes that will have real impact on the health of the people they serve by reducing poverty.
A basic income guarantee is, of course, not the only option for addressing poverty as a social determinant of health and a social justice issue. But for the same reasons economists, activists and others are expressing renewed interest in basic income in recent months and years, it is gaining considerable support among physicians across Canada.
In Saskatchewan, physicians have advocated for the development of a poverty reduction strategy that includes a trial of basic income. In Ontario, 194 physicians signed a letter to Minister of Health Eric Hoskins calling for a basic income pilot program—and in its 2016 budget, the government committed to such a pilot.
"Poverty leads to higher rates of heart disease, depression, diabetes and scores of other illnesses — so doctors should, and do, care about poverty."
Doctors have also come forward at a national level, with the General Council of the Canadian Medical Association — “the Parliament of medicine” — passing a motion in support of basic income at its 2015 meeting in Halifax. Where more extensive basic income pilots have been tried, both internationally and in Canada, the results with respect to health outcomes have been impressive. The MINCOME experiment in Dauphin, Manitoba in the 1970s resulted in higher school completion rates and a reduction in hospitalization of 8.5 per cent, largely due to fewer accidents, injuries and mental health admissions.
According to the Canadian Institute for Health Information, Canadians spent $63.6 billion on hospital services in 2014; a decrease of 8.5 per cent in health spending in today’s environment would result in savings of $5.4 billion.
A more recent study, again in Manitoba, evaluated the impact of the Prenatal Benefit Program. Between 2003 and 2010, low-income expectant mothers received an extra $81 per month. This resulted in decreases in low birth weight (21 per cent) and pre-term birth (17.5 per cent). This kind of positive early childhood intervention can lead to long-term cost savings and, more importantly, significant improvements in health for the entire life of that child.
As with universal health care or any other large public benefit program, details matter. In order to have an impact on health, the program would need to provide adequate support to really pull people out of poverty.
Any version that leaves people stuck behind a welfare wall or that allows only for the most basic survival impedes their ability to thrive. And, of course, doctors know well that there is no such thing as a panacea: no single treatment can cure all ills. Some people have envisioned a version of basic income that replaces all other social programs, commodifying every part of our lives.
A well-designed basic income program would certainly simplify the complex labyrinth of programs and barriers to their access currently faced by people living in poverty. But we still need minimum wages and strong labour laws. We need a well-designed public health care system that includes coverage of prescription medications. We need affordable housing and affordable child care.
"A wise approach to implementation of a basic income guarantee could give us the most significant change to the health of Canadians since the introduction of medicare."
In other words, we need to find the balance between making sure people have the money to afford what they need and making sure that what they need is affordable. We also need to ensure that where public policy principles and economies of scale point to government provision of services, such services should not be left to the free market — even if people have a little more money to bring to market.
Some policy changes happen slowly, with incremental movements in public opinion. But every once in a while, an idea that had seemed outside the realm of possibility quite suddenly gathers momentum. In the last couple of years the concept of basic income has moved from the margins to the mainstream.
It now feels that Canada has gone from the question of "if" to "how". A wise approach to implementation of a basic income guarantee could give us the most significant change to the health of Canadians since the introduction of medicare.
Like medicare, it has the potential to be a universal program that reflects our values and informs our identity as Canadians.
Danielle Martin is a family physician and vice president, Medical Affairs and Health System Solutions, Women’s College Hospital, and a member of Upstream's Advisory Board.
Ryan Meili is a family physician, founder of Upstream: Institute for A Healthy Society, and an expert advisor with the Evidence Network.