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Balance between health care spending and social supports crucial

A version of this commentary appeared in the Winnipeg Free Press, Globe and Mail and the Huffington Post

We have experienced remarkable improvements in life expectancy over the past 100 years.  Reasons for this include: sanitary drinking water, pasteurized milk, safe sewage disposal, work safety, higher standards of living, better education and cures for, or immunization against, many communicable diseases (e.g., small pox, diphtheria).

Readers may question why universal health care is not on this list.  In fact, while universal health care would be on a longer list of reasons, research indicates that our health care system is not as important as any of the top seven reasons listed.

It has been estimated that at least three quarters of the increases in life expectancy in the developed nations over the past 100 years has been due to increased prosperity and improved nutrition, housing, sanitation and work safety.

In fact, how much a society spends on health care has not been found to be directly related to any health outcome tested.  For example, at 17% of GDP, the United States spends more (by far) on health care than any other country in the world.  And yet, its life expectancy and infant mortality rates (two common measures of population health) are only just average compared to other developed nations.

So, if health care is not the primary determinant of population health, what is?

There is a huge body of research that shows a strong correlation between income and life expectancy.  The effect of income appears to be stronger than many other variables that affect life expectancy such as race and education level.

It has been known for some time that the better off people are in terms of income, social status, social networks, sense of control over their lives, self-esteem and education, the healthier they are.  Higher incomes are related to better health not only because wealthier people can buy adequate food, clothing, shelter and other necessities, but also because wealthier people have more choices and control over decisions in their lives.  This sense of overall security is intrinsic to good health.  Thus, security of income is just as important as the income level itself.

The counter argument that poor health causes low economic status does not explain the results.  If we look at sub-groups of workers by income level we find that those with lower levels of income have measurably higher mortality rates over the course of the study, even if one only considers the workers whose incomes rose over the same period.

There is also a strong correlation between the degree to which national income is equitably distributed and the health status of the population.  In other words, if a country wants to see significant improvements in its population health, the best public policy is to eliminate poverty.

This background is extremely important today as we head into an era when many social programs (including Old Age Security) will be competing with health care delivery for limited tax resources.  An appropriate balance between health care spending and social support spending is crucial.

A society that spends so much on health care that it cannot or will not spend adequately on other health-enhancing activities may actually be reducing the health of its population.

There is a threshold for useful spending on traditional health care delivery.  Beyond that threshold, overall population health may actually suffer not only because the care itself has marginal or dubious benefit, but also because less money is available to support health enhancing activities in the general social and economic policy spheres, such as in early childhood development or income security.

One poses a very real question if one asks if it is beneficial to population health to decrease one’s social security income base by, for example, raising the age of eligibility for OAS from age 65 to 67, if the reason is to find ever more money to fund traditional health care delivery.

Surprisingly, the end result could be a decrease in the overall health of our population.

Robert Brown is an expert advisor with EvidenceNetwork.ca and a Fellow with the Canadian Institute of Actuaries.  He was Professor of Actuarial Science at the University of Waterloo for 39 years and a past president of the Canadian Institute of Actuaries.

September 2012

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