Raise the Hammer
An aging and increasingly unhealthy population is propelling Ontario's growing health care expenditures, but a systematic shift to active, human-powered travel would make us all healthier - and fix Ontario's deficit in the process.
By Adrian Duyzer
Published April 29, 2012
Austerity is the new buzz word, and Ontario is jumping on the bandwagon with a slate of cuts based on the Drummond Report. But read the recommendations of the Drummond Report (the summarized recommendations, naturally - no normal person has time to read the entire thing) and you'll quickly realize just how profoundly uncreative it is.
The report, which recommends slashing spending on public programs, privatizing public services, increasing fees and canceling incentives, recognizes the critical role of health care expenditures. One hundred and five of its recommendations relate to health care, including limiting health care spending increases to 2.5% annually, even though Drummond admits that "not one jurisdiction in the world" has achieved that rate in the last 30 years.
There's a straightforward reason for that. Ontario's population is both aging and getting unhealthier. Dire warnings from public health officials have done nothing to stem growing rates of inactivity and related health issues like heart disease, obesity and diabetes.
But everything could change with an ambitious plan to make cycling and walking the number one way Ontarians get around.
The budget deficit for the 2011-2012 fiscal year in Ontario is $15 billion. The province currently spends more than $10 billion annually on servicing its $240 billion debt, which is more than it spends each year on universities and colleges.
In 2010, health care accounted for 42 percent of Ontario's total spending, which is by far the largest portion, as this infographic makes abundantly clear. Health care expenditures have been growing at the average rate of 6.1 percent per year since 2003. It's not an exaggeration to say that if we fix health care, we fix Ontario.
Why are health care costs growing? According to the Ministry of Finance, there are several factors:
There are a number of key drivers of the demand for, and cost of, health care services. These are broadly understood to include demographics (population growth and aging), and changes in other factors such as population health status, patients’ expectations, inflation, technology and medical practice. All these variables can have mixed impacts in the way they affect overall demand for health care services.
Ontario's aging population is a key cost driver because use of health care rises significantly after age 65. Studies have shown that over an individual's lifetime, the greatest amount of spending on health care services will usually occur within the last years of life.
Healthy eating, regular physical activity and public education can help prevent illness and avoid costly medical care in the future. This could help offset the impact of an aging population. At the same time, medical experts are raising concerns about rising obesity, especially for younger generations. Obesity is associated with many chronic diseases such as diabetes, high blood pressure, coronary heart disease and some cancers.
According to a 2004 study, 58.6% of Ontarians are overweight or obese and the rate is rising dramatically. Canada's obesity epidemic will have a profound impact on health care budgets across the nation.
If this problem were fixed it could, as Ontario's Ministry of Finance writes, "offset the impact of an aging population". In fact, if Ontarians were getting fitter, healthier, and slimmer instead the other way around, not only would we cut health care costs, we'd get the economic benefits of having a healthy, energetic labour force.
The solution for overweight adults, if you listen to the experts, is to tell them to eat better and exercise. The solution for overweight kids? Tell their parents to get them to eat right and exercise.
This is not working. Public health officials have been warning Canadians about an obesity "epidemic" since at least 2000.
Telling people they ought to exercise just doesn't motivate them to start doing it. That's too bad, because the benefits of exercise are tremendous. Exercise:
So if warning people that they risk ill health and shorter lifespans doesn't motivate them to get active, and if they aren't tempted by the benefits an active lifestyle promises, what does work to get them moving?
The answer is simple: relying on active travel, i.e. cycling or walking, to get to and from regular destinations and especially the workplace. In other words, turn exercise into a byproduct of transportation, instead of a conscious activity in its own right.
A 2010 study published in the American Journal of Public Health found that "more than half of the differences in obesity rates among countries was linked to walking and cycling rates", as this CBC story reported:
"Our results suggest statistically significant relationships - in the expected direction - between walking, cycling and health at the country, state and city levels," the study's authors concluded.
"Among the 14 countries in our international comparison, those with higher levels of walking and cycling tended to have lower levels of adult obesity, whether self-reported or clinically measured."
In Europe, about half the trips people made - for whatever purpose - were on foot or bike compared with eight per cent in Canada and 10 per cent in the U.S., the researchers found.
"Not surprisingly, the European countries had obesity rates that were half [those] in North America," [one of the researchers] said.
The link between active travel and improved health is well-documented. This study found the "estimated gain in life expectancy per person from an increase in physical activity ranged from 3 to 14 months". That study concludes by noting, "Policies stimulating cycling are likely to have net beneficial effects on public health, especially if accompanied by suitable transport planning and safety measures."
That mention of policies brings us to the next big question: how do we change our transportation habits?
Changing transportation in Ontario requires a systematic approach. The study published in the American Journal of Public Health recommended that governments:
- Provide safe, convenient and attractive sidewalks, crosswalks, bike paths and lanes.
- Modify intersections to protect pedestrians and cyclists.
- Restrict car use with approaches such as car-free zones, traffic calming in residential neighbourhoods, speed limits, and limited and more expensive car parking.
- Foster compact, mixed-use developments that generate shorter trip distances that are easier to cover by walking and cycling.
In other words, in order to change the way people get around, you must deliberately create an environment that encourages and rewards active travel.
And, since we're talking about saving lives in addition to saving the province, we should also deliberately discourage practices that inhibit active travel, such as sprawl, inner city thoroughfares that are hostile to anything that is not a car (i.e. Main Street in Hamilton), and planners who focus on traffic flow above all else.
We need to create continuous, integrated networks of bicycle paths. We need to get serious about planning the way Ontario grows to really put a halt to reckless sprawl development. We need to build healthy, complete streets. Just as Paris decided to become a bicycle-friendly city, we need to become a bicycle- and pedestrian-friendly province.
This would not be cheap, but nor would it be especially expensive. Bicycle paths are not nearly as expensive as light rail lines, and people drive themselves when they cycle (i.e. you don't have to hire conductors). I also believe there are cost-effective, creative ways for the province to incentivize municipalities to create the environments that encourage active travel.
Let's pedal our way right out of Ontario's budget mess.
Thanks to Ryan McGreal for his excellent article Can the Bicycle Save Civilization? which inspired the title and the theme of this piece.
By Michelle Martin (registered) - website | Posted April 29, 2012 at 22:57:19
It is interesting to note that the recommendations listed by Adrian from the American Journal of Public Health would also, in many ways, have a positive impact on accessibility.
By TnT (registered) | Posted April 30, 2012 at 07:47:44
It really is that simple.
By Orgone (anonymous) | Posted April 30, 2012 at 08:42:17
Good read and I admire the thought, but it the trajectory of health care spending in Ontario is not exclusively tied to "inactivity and related health issues like heart disease, obesity and diabetes."
The aging of baby boomers, along with delayed senesence in their parents' generation means people are living much longer after age 65 than they did in previous generations. That telescopes costs and exerts unusual pressures on the system (Drummond's earlier Benefactors Lecture for the CD Howe Institute -- http://www.cdhowe.org/pdf/Benefactors_Lecture_2011.pdf -- not only promotes the cause of preventative health initiatives and spotlights contributing socio-economic factors but also notes the aymmetric stresses on community, chronic/ALC/long-term care in a system that has overwhelmingly treated acute care facilities as the be-all and end-all) and the attendant stresses on resources that come with that.
Other considerations would be the fact that professional compensation is going strong (on average, up $164K per doctor since 2003) and we're operating with a thousand-doctor shortage -- around 927,000 Ontarians don't even have a family doctor.
By Kiely (registered) | Posted April 30, 2012 at 09:28:37 in reply to Comment 76325
Good read and I admire the thought, but it the trajectory of health care spending in Ontario is not exclusively tied to "inactivity and related health issues like heart disease, obesity and diabetes".... Other considerations would be the fact that professional compensation is going strong...
You can actually make the case it is tied to the cost and proliferation of prescription drugs. Drugs passed doctors as the number one cost to OHIP many years ago now and how many of those drugs are of the "mother's little helper" variety?
By Orgone (anonymous) | Posted April 30, 2012 at 10:24:53
Oh, dr_gs are definitely part of it. The fact that doctors are maxed out in terms of time-per-patient probably aggravates this. When I was a kid, I can remember doctors' visits that might have lasted 10-15 minutes on average, and now it's maybe 5 at the outside.
Because they are geared toward outputs rather than outcomes, doctors have scrips holstered at the ready and lots of samples to sprinkle around. Things that would have been mundane in generations of yore (loneliness, shyness, being a bratty/sulky teenager) have been put through the symptomization grinder to the point where introversion or adolescence are seen as correctable ailments. It's a lot easier to prescribe Pr_zac than it is to facilitate a series of life changes that would deliver a comparable end result. (The fact that we as a society seem to expect life to deliver highs more regularly than lows, and deliver on-demand, is another fundamental distortion that works in favour of big ph_rma.)
BTW, I'm not in any way disputing the merits of improved infrastructure for active living, or skeptical of the merits of widespread biking culture. Just suggesting that there is some complexity to the province's healthcare/budget mess.
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