Hundreds of US cities, and a number of US states, have inclusionary housing planning policies that ensure that a fixed percentage of all new homes are affordable to low and moderate-income households. It’s no surprise that private developers in Toronto are upset at the thought that such a sensible idea would be imported to our city and province (“Developers balk at affordable-unit idea”, Toronto Star, March 10). After all, developers expressed concern over the past two decades whenever big cities and small towns as diverse as Boston, Chicago, San Francisco and Burlington, Vermont, introduced their inclusionary housing plans. Montgomery County, just outside Washington DC, one of the richest communities in the US, has the longest-running inclusionary housing practice in America. It has generated more than 12,500 new affordable homes. Developers in Montgomery County, like others through the US, have discovered that: (1) they still make healthy profits from their developments thanks to cost-offset mechanisms in the plans; and, (2) inclusive housing projects make for vibrant and healthy communities – and, who wouldn’t be in favour of that?

In our research, the Wellesley Institute has looked at inclusionary housing practices in big cities and small towns across the United States, and found many successful models. The latest forecast from Canada Mortgage and Housing Corporation projects that construction will start on 68,400 new homes as of February (seasonally-adjusted, for all of Ontario) – just about the highest number since the start of the recession in October of 2008. A US-style inclusionary housing policy(designed and administered by municipalities based on planning authority granted by the province) would ensure that at least 10,000 of those would be available to low, moderate and middle income households.

The latest RBC Economics housing affordability survey reports that Toronto households need a qualifying income of $65,400 just to get into the bottom of the ownership market in a standard condominium. Statistics Canada tells us that 52% of all the households across Toronto earn less than that. An inclusionary housing policy is one important part of a comprehensive affordable housing plant to ensure that everyone has access to a healthy, affordable home.

• it isn’t just that’s some areas are growing, but some communities are poorer and poorer people tend to be less healthy and have greater and more complex health needs – and, at the same time, tend to have more inequitable access to the care they need;
• some areas are socially very diverse and this often means that hospitals need to provide interpretation and services in many languages.  This needs to be reflected in funding formula;
• this isn’t just a question of hospital funding – more health disadvantaged communities also rely on a dense network of often  poorly funded community services.  These community services must be funded on a more stable and flexible manner.
• looking forward, there needs to be more up-stream investment in preventative services and health promotion programs.  LHIN-wide funding formulas need to be able to support this goal of providing more services up-stream and in community settings, as opposed to only when people get sick and need hospitals. (See my report with Dr. Michael Rachlis for more on this: Ontario’s Health-Based Allocation Model through an Equity Lens.)  

There has also been discussion of “pay-for-performance” models linking funding to hospital efficiency.  Here also, we need to be very careful about equity.  if hospitals will be rewarded for doing more procedures with better outcomes, there is a real incentive to cream skim.  Poorer people will have more complex – and therefore expensive or time-consuming – needs and their post-procedure outcomes tend to be worse – all of which means that hospitals who are looking to keep their stats up have a real incentive to avoid the sicker and worse off.

The speech sets out the priorities of the government in the next session of the Legislature (the last session before the next provincial election is expected). Throne Speeches in Canada tend to be general and almost always lack specifics – and Ontario’s latest Throne Speech followed that pattern. The government has announced what it calls the “Open Ontario Plan” and has outlined general details of a series of initiatives over the next five years that include: water, post-secondary education, health care, northern resources, taxation, green energy, infrastructure, full-day learning and financial services.

In the Throne Speech, the Ontario government makes a commitment to “strengthen the non-profit sector” which the government calls the “unsung heroes of Ontario’s economy”. The Throne Speech notes the vital role that the sector plays in many aspects of the lives of Ontarians, including the province’s poverty reduction strategy. In May of 2009, the Ontario Poverty Reduction Act was passed by the Legislature, including amendment #8 proposed by the Wellesley Institute that recognizes the importance of the third sector.

 Here are some excerpts from the Throne Speech on the community sector:

 Your government is grateful for the work of Ontario’s 46,000 not-for-profit organizations that are the unsung heroes of Ontario’s economy.

 Nearly five million Ontarians volunteer their services in their communities.

 Some are helping your government reach its goal of reducing poverty rates by 25 per cent in five years.

 Some are coaching our young people — like Sandy Cooper-Ryder of London.

 For 30 years she’s been inspiring young people to reach higher, dig deeper and go further — not just on the track, but in all areas of their lives.

 Sandy is one of the many dedicated coaches training Ontario’s next generation of gifted young athletes, some of whom will compete in the 2015 Pan American games.

 On this International Women’s Day, your government particularly recognizes dedicated women like Sandy — together with all the volunteers who are making a real difference.

 Open Ontario will develop new ways to strengthen the not-for-profit sector — recognizing that in a time of more limited resources, we all need to work together to move our province forward.

 The specifics remain to be seen, but the explicit Ontario commitment to the non-profit sector is welcome news.

Event Details

As noted in our initial analysis of the 2009 federal budget, about half of the federal dollars that were promised were to go for social housing repairs (about 5% of Canadian households), with the rest being divided among seniors, on-reserve Aboriginals and a small amount for people with disabilities. The remainder of Canadians who are precariously housed (including families, youth, Aboriginal people living off-reserve, people living in substandard private rental housing, single people) got no new help last year – and they were also left out of this year’s budget.

The details of the projects “underway” are not provided by the federal government. The bulk of the funds are flowed through the provinces and territories, which makes it even harder to trace the dollars. The Ontario Auditor General reported in November that the Ontario government was unable to properly account for hundreds of millions in federal housing transfer dollars. The Ontario Auditor General also noted that more than half the new homes funded by the federal-Ontario program had rents that were unaffordable to households on affordable housing waiting lists.

The bottom line: Good news that the feds will keep the housing funding promises that they made last year, bad news that there is no new help for the millions of Canadians who are precariously housed – and it remains to be seen just how many new homes will actually be created by the federal government’s budgetary promises, and whether those homes will be truly affordable to the people who need the housing the most.

But sustainability will not be achieved by having individuals pay for care when they need it the most – i.e. when facing large hospital or treatment costs – and the impact would be harshest on the most disadvantaged, who already face poorer health and more complex care needs resulting from social inequality. What needs to change is the fundamental structures that drive costs, and one of the most important is how physicians are paid. Fee for service builds in precisely the wrong incentives: it fragments care into separate procedures, discouraging continuity; and encourages seeing more people faster than is good for quality. Capitation models in which clinics or practices receive a global budget for their population build in incentives to keep that population healthy and support the kind of coordinated multi-disciplinary care and health promotion Mr. Kent highlights.

Other key cost drivers are drugs and technology; both of which can be controlled far more effectively through stronger bargaining with industry and provincial and regional coordination.

Many of the solutions to sustainability and efficiency are already out there. There is a huge amount of front-line innovation going on across the country; the challenge is to create forums and mechanisms where lessons learned can be widely shared and the most promising initiatives can be rigorously assessed and scaled up where appropriate.

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