As Ontario braces for the report from economist Don Drummond on provincial public service spending, an early leak from his work raises a powerful question. In a Toronto Star column by Martin Regg Cohn, Drummond is reported to be ‘staggered by the statistic that a mere 1 per cent of the population accounts for fully half of all hospital spending, or about one-third of total health expenditures’. The facts behind the reported numbers remain to be confirmed, but the notion that a tiny portion of the population is consuming a large share of public services is not new. Malcolm Gladwell’s 2006 essay on ‘Million Dollar Murray’ – an account of a homeless man who used a huge amount of public services because of his homeless status, even as authorities failed to provide even minimal housing at a much lower cost – has prompted a powerful policy response in the US and Canada on housing and homelessness services. The lesson from Million Dollar Murray is that a relatively small amount of investment in the social determinants of health – housing, income and supports – saves huge amounts of ‘downstream’ spending to pay for the health and social consequences of precarious housing and homelessness. ‘Housing first’ has been adopted by local, state / provincial and even the US federal government as the most humane and cost-effective response – and case study research has confirmed the personal, social and financial value of the up-front investments.
So, what can Ontario learn from Million Dollar Murray as it considers the province’s significant health spending budget? Research from the Wellesley Institute and others at the national and international level has already demonstrated the strong links between poverty, inequality, precarious housing, precarious employment and poor health. Some of the WI’s own research includes Work & Health, Poverty Is Making Us Sick, and Precarious Housing in Canada. This is just a small sample of a large amount of qualitative and quantitative research and policy work that links poor health to fundamental structural issues like employment, income and housing.
So, if Drummond is right that a tiny portion of Ontario’s population are sick and consuming a large portion of hospital and health spending, then the logical question is: What is making these people so sick in the first place? Is it precarious housing or employment, homelessness and inadequate income? Tackling the fundamental determinants of health – jobs, income and housing, to name three – usually requires fewer public dollars than waiting until people suffer the health consequences arising from the neglect of these critical requirements, and then rushing people into emergency wards and expensive hospital care.