Beyond health care
How do federal election platforms stack up when it comes to health equity?
As usual, health care is taking centre stage in the upcoming federal election, figuring prominently in all of the major parties’ platforms.
This is, of course, not surprising, especially considering the seemingly never-ending COVID-19 pandemic and its consequences for health care systems.
Yet, it is also a perfect opportunity to remember that health is about much more than health care. Health and well-being are significantly influenced by the conditions in which we are born, grow, live, work, and age. These are the social determinants of health.
Inequities in the quality of those conditions create health inequities, which have always existed but which the pandemic has made especially obvious in the form of significant – and non-arbitrary – variation in who is most at risk of contracting the virus, getting sick, and dying; and who is also most negatively impacted by public health measures to contain spread.
These inequities are not inevitable. As unambiguously stated by the World Health Organization Commission on Social Determinants of Health:
The unequal distribution of health-damaging experiences is not in any sense a ‘natural’ phenomenon but is the result of a toxic combination of poor social policies and programs, unfair economic arrangements, and bad politics.
To answer this question, one must examine whether, or the extent to which, the platforms consider overarching causes of health inequities. These include public policies—and their ideological underpinnings—that shape the quality of daily living conditions and the inequitable distribution of power, money, and resources.
A health equity analysis of election platforms involves “connecting the dots” between party promises across policy domains on the one hand, and health and well-being on the other. Some illustrative examples from the 2021 party platforms follow.
Employment, income, and public services
In a liberal democracy like Canada, it is governments’ job to provide the conditions to support the well-being (i.e., the health) of the population. They can do this in a number of ways, such as by ensuring full employment in high-quality jobs; adequate and predictable sources of income, including for those who are not in paid work; and high-quality, publicly funded, universal services. None of these, alone, is sufficient.
The COVID-19 pandemic has revealed gaps in our existing income support systems, and all major parties promise improvements. These include increasing the federal minimum wage (Liberal to $15/hr, NDP to $20/hr); enhancing the Canada Workers Benefit (CWB) to support Canadians in low-wage jobs (Liberal, Conservative); introducing stronger supports for people with disabilities, through a CWB supplement (Conservative) or a new Disability Benefit (Liberal); and prioritizing a guaranteed livable income (NDP, Green).
Focusing on income alone, however, is incomplete. One must ask the larger question of what is needed for everyone to have a decent life. As argued by Armine Yalnizyan:
A market-based approach stresses the importance of more money, which buys more freedom and choice in the market. A health-based approach offers more public services that are not contingent on income, which buys more freedom from the market.
A good example is child care, which historically in Canada has been characterized by inadequate spaces, inconsistent regulation, and insufficient funding. A national child care program that is universal, affordable, high quality, inclusive, accessible, and equitable would benefit children, families, workers, and society at large.
In its April 2021 budget, the federal Liberal government announced a national $10-a-day child care program (arguably the most significant item in that budget), underpinned by research on the benefits to child development and social equity of high-quality, affordable early learning. A recent analysis estimated that the Liberals’ national program (which is substantively endorsed in NDP and Green party platforms) would save families a great deal of money, and considerably more so than the Conservatives’ intention to cancel the plan and instead – in a market-based approach – offer child care tax credits.
Perhaps the key question for the Liberals’ child care plans is whether they will survive the election.
A health equity analysis encourages thoughtful reflection about different approaches (e.g., cash transfers and public services) to population well-being, and the appropriate balance between them. It also demands critical thinking about government spending. Specifically, it involves resisting the dominant, and narrow, focus on reducing debt and deficits. It recognizes that more federal debt can help build a better Canada and, conversely, that the costs of austerity to health and well-being can be disastrous.
Climate justice and ecological determinants of health
Health and well-being of humans, and indeed of all species, are critically dependent on earth’s natural systems. Yet, commitment to substantive action to protect and preserve the integrity of our natural environment has not been forthcoming, with myths and misconceptions standing in the way of a sustainable future.
All major parties, of course, have something to say about the climate emergency. However, many climate-related promises are inadequate (for example, the Conservatives’ intention to maintain the status quo with respect to emissions reductions and oil and gas production), and/or lacking in detail (for example, the NDP’s promise of significant—but unspecified—investment in clean energy, energy efficiency, and low-carbon infrastructure).
According to some commentators, none of the parties address the underlying problem, which is that our entire way of life and our economy are unsustainable.
The Green Party platform is the closest to doing so. It privileges three interrelated pillars of a Green Future, Life with Dignity, and a Just Society. As discussed elsewhere, the Green’s platform is more ambitious than the others, though short on details and the intentions are not costed out.
It is the only platform to explicitly align with warnings of climate scientists, and to make a firm commitment to phasing out oil and gas. Moreover, it does so in such a way that aligns with climate justice (and thus health equity), by promising retraining for fossil fuel workers and new green jobs for young workers, as well as community-led plans for a just transition.
Despite the significance of ecological determinants of health, the link made by individuals between health issues and the climate emergency tends to be weak, which is regrettable because it means that health and health equity are missing or under-leveraged planks in an advocacy platform for progressive environmental policy.
Economic inequality, or a large gap between rich and poor, is toxic to the well-being of societies. During the pandemic, Canada’s billionaires have increased their wealth by $78 billion, while over 5 million Canadian workers have lost their job or had their hours cut which—especially in the context of outdated and inadequate social infrastructure—has important consequences for health and well-being.
In addition to robust income supports and universal, high-quality public services, taxation is an effective way to redress income and wealth inequity (and thus health inequity). It is also an effective way to generate revenue to fund other investments in the well-being of the population.
There is a strong case for fair taxation. For example, although corporations control almost half of Canadian assets and two-thirds of Canadian economic activity, they contribute less than 20% of federal tax revenue. Moreover, by taxing corporations (including polluting industries) and the wealthiest people more fairly, and by closing tax loopholes and havens, it is estimated that the federal government could reduce inequalities considerably and generate over $90 billion annually.
The Liberal platform contains promises to (among other things) raise corporate income taxes on the largest, most profitable banks and insurance companies; to introduce a temporary tax (Canada Recovery Dividend) to be paid by companies that profited during the pandemic; to increase the capacity of the Canada Revenue Agency to combat tax avoidance by wealthy individuals; and to implement a minimum tax rule where those in the top income tax bracket must pay at least 15% (to prevent them from reducing their taxes to zero, which currently is possible). While a step in the right direction, these proposals have also been described as lacking in ambition with respect to reducing inequity.
Making the tax system more progressive is an important issue for the NDP, whose intentions include some substantive actions like closing tax loopholes that overwhelmingly benefit the wealthiest individuals, increasing taxes on capital gains by increasing the inclusion rate from 50% to 75%, and requiring public reporting of corporate taxes.
Both the NDP and Green platforms promise to introduce a 1% wealth tax which would generate significant revenue and has considerable public support. For the Greens, fair taxation is a key element of their Just Society pillar, and the party commits to a range of measures to more fairly tax corporations, financial institutions, international transactions, wealthy individuals, and real estate; overseen by a proposed arm’s length Federal Tax Commission and grounded in the elimination of all fossil fuel subsidies.
While the Conservative Party platform recognizes that the tax system favours the rich and big corporations, it ultimately proposes only to appoint an expert panel to review the system.
As part of deep reflection on issues of fairness, a health equity analysis requires engagement with macroeconomic policy, which is – on the whole – unusual in public health (with some important exceptions). It also prompts attention to the top of the income and wealth distributions, to complement the dominant focus on those at the bottom.
It moreover demands critical thinking, and resistance to, hegemonic narratives of tax phobia, to instead recognize the value of some taxes, with strong public support, to aid substantially in pandemic recovery and beyond.
Systemic injustice and oppression
According to a Canadian Press analysis of party websites, a record number of Indigenous candidates are running in the federal election, which is an important signal of potential for meaningful change with respect to relations with Indigenous Peoples.
As for the party platforms, all four considered here espouse commitments to elements of Truth and Reconciliation, which are fundamental to health and well-being.
The Conservatives make important but modest commitments including to fund an investigation of all former residential schools for unmarked graves, and to implement some of the TRC Calls to Action. The Liberals itemize several important promises (e.g., to eliminate all long-term drinking water advisories; to confront systemic racism in health care and justice systems; and to launch an Indigenous housing strategy) but they have made some of these promises before.
Reconciliation figures prominently for the NDPs and the Greens, whose platforms contain comparatively substantive and multifaceted plans. “Reconciliation in action” is one of eight NDP commitments, and their promises range from advancing self-determination to closing the education gap to working together to protect the environment.
For the Green party, reconciliation is interwoven throughout the platform, and is a key element of their Just Society pillar which is underpinned by Canada’s “profound and moral obligation to reconcile and provide restitution for the colonial relations (…) that have undermined (Indigenous Peoples’) cultural, governance and economic foundations.”
As with the climate emergency and reconciliation, most federal platforms have something to say about the elimination of systemic racism more broadly, which is recognized as a public health issue. The main question is whether it is enough, and whether, or the extent to which, the promises will materialize. On that point, perhaps a most notable observation is that, unlike the Liberal, NDP, and Green party platforms, the Conservative party platform does not contain any mention of “racism” or “systemic racism”.
A note on health care
To be sure, equity is a goal to which the health care system must aspire. All four parties promise an expansion of health care, and the Conservatives, the Liberals, and the NDP have all promised larger federal transfers to provinces and territories to support expansion of services such as mental health and addictions, pharmacare, dental care, and palliative care.
To the extent that these expansions enable all residents of Canada to access needed services, without paying out of pocket, they contribute importantly to health equity.
It is important to keep in mind, however, that health care already constitutes a large – and growing – proportion of provincial and territorial government budgets. It thus tends to supplant spending in other ministries, which are more directly positioned to improve social determinants of health and health equity.
Under the Canada Health Act, federal health transfers must be spent in particular ways. From a health equity point of view, one could envision revised legislation where spending on health—in line with the voluminous evidence on the social determinants of health and health equity—must include ministries other than health. One example is to implement the evidence-based recommendation to (re)allocate public monies from health to social ministries, which does not appear in any party platform.
A health equity analysis of federal election platforms demands critical thinking about party promises across policy domains. This brief analysis, while incomplete (key omissions here include, but are not limited to, commitments around housing, long-term care, and democratic reform), nonetheless illustrates the type of cross-government thinking required if our goal is to improve health and health equity, that is, a broader vision of public health.