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Submission from the Association of Ontario Health Centres to Consultations on Ontario’s Poverty Reduction Strategy October 2013

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Contact: Jacquie Maund, Policy and Government Relations Lead Association of Ontario Health Centres (AOHC) / Association des Centres de Santé de l'Ontario (ACSO) Tel: 416.236.2539 x 234 jacquie@aohc.org


Introduction The Association of Ontario Health Centres (AOHC) is the voice of community-governed primary health care in Ontario. We share the government’s commitment for a fairer society where every person has the opportunity to achieve his or her full potential for health and wellbeing. Our vision is the best possible health and wellbeing for everyone living in Ontario. We know that reducing and eradicating poverty is essential to achieve this vision. Recommendations in this submission are based on the frontline experience of our member centres: 123 Community Health Centres (CHC), Aboriginal Health Access Centres (AHAC), Community Family Health Teams (CFHT), and Nurse Practitioner-led Clinics (NPLC). As they deliver Primary Health Care throughout the province, health providers in these Centres see how strategic investments in poverty reduction, health and wellbeing not only improve health outcomes but also ease financial burdens on the health care system. As noted in the Drummond Commission report, more than 50% of population health outcomes are determined by socio-economic factors such as income and education. Community Health Centres and Aboriginal Health Access Centres have a special mandate to serve people with barriers accessing health services. These include low income people, Aboriginal People, people with disabilities, newcomers, people who are LGBT, Francophones and people in rural or remote communities. Our members provide both primary health care services and a wide range of health promotion and community development services which address the social determinants of health. Their work at the community level will be more effective if the Ontario government continues along the path to develop a bold Poverty Reduction Strategy for 20132018 with a comprehensive action plan and a commitment to invest the funds required to meet poverty reduction targets.

Analysis of Ontario’s Poverty Reduction Strategy 2008-2013 Ontario’s first Poverty Reduction Strategy demonstrated a significant new commitment for the province to make progress toward eliminating poverty. Initiatives within the Strategy helped reduce Ontario’s child poverty rate by almost 10% between 2008 and 2011. For these efforts we commend the government. Initiatives which helped achieve this success and which worked well include:  Setting specific targets for poverty reduction and tracking the results with annual progress reports;  Introducing the Ontario Child Benefit (although annual increases were halted in 2012);  Increasing the minimum wage (although increases stalled after 2010);  Bringing in full day kindergarten, and investing in early learning and childcare;  Expanding oral health programs for low income children (but income eligibility criteria are set too low);  HST tax credit for low income people and the Trillium Benefit;

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Capital investments to expand access to 16 Community Health Centres and Aboriginal Health Access Centres.

However, progress stalled during the economic downturn when the government failed to make the necessary investments in poverty reduction. The decision to postpone full implementation of the OCB in the 2012 and 2013 Budgets makes it unlikely that Ontario will reach the target to cut child poverty by 25% by 2013. Freezing the minimum wage and cutting the Community Start Up and Maintenance Benefit (CSUMB) for people receiving social assistance drives more people into poverty and increases inequality in our province. With respect to health care delivery, the Ministry of Health and Long Term Care (MOHLTC) has not implemented a population and health equity planning approach to provide primary health care services which meet the special needs of populations living in poverty. Primary care providers can establish their services wherever they want, although the need may be highest in low income, rural and remote communities. Community Health Centres and Aboriginal Health Access Centres specialize in providing medical and community services which address the complex medical and social needs of vulnerable populations, including low income people. Yet they currently serve only 4% of the Ontario population. AOHC commissioned a detailed research study which examined where people in poverty live by sub LHIN and where vulnerable populations experience greatest barriers accessing health care. This research found that 15.2% of Ontario’s population is most in need of primary health care and recommended expansion of CHCs and AHACs to reach these populations. [1]

Recommendations for Ontario’s Poverty Reduction Strategy, 2013-2018 1.Set bold new poverty reduction targets AOHC supports the targets of the 25 in 5 Network for Poverty Reduction which in 2008 called on the government of Ontario to reduce poverty by 25% in five years and 50% in ten years. We recommend that the government set the next target to cut poverty for everyone in Ontario by 50% by 2018. This means that Ontario’s next Poverty Reduction Strategy should aim to reduce the overall poverty rate in Ontario to below 6%, and the child poverty rate to below 7.5% (Low Income Measure After Tax, LIM-AT). These figures use 2008 as the base year. We recommend the Strategy aim to eradicate deep poverty in Ontario by 2018. People who live on less than 40% of median adjusted household income (LIM40) live in deep poverty. In 2010 a single person with an income of less than $15,328 (LIM40 AT) would be considered living in deep poverty. No one should live in poverty in a province as rich as Ontario, especially in deep poverty. Yet Ontario's basic income security system relegates thousands of households to living in deep poverty.

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2.Develop and implement a comprehensive action plan including: Secure and Livable Incomes Everyone is entitled to an adequate income, regardless of whether you are working or receiving government funded assistance. All Ontarians deserve secure and adequate incomes that enable them to live in dignity with good health and wellbeing. Access to nutritious food is a key component of health, but the fact that 400,000 people in Ontario need to rely on food banks each month is evidence that too many Ontarians are struggling to afford the basics. The next Poverty Reduction Strategy should: 

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Increase income supports for people relying on social assistance. Implement the Commission for the Review of Social Assistance recommendation to increase OW rates for single people by a full $100/month to begin to bring rates up to an adequate level. Do not fund this by cutting the Special Diet Allowance. Keep raising income supports for all people on assistance to ensure an adequate income that meets the costs of living Enrich the Ontario Child Benefit and index it to inflation Reform social assistance so that it provides adequacy and dignity, and supports inclusion in the community and the workplace

Address Higher Poverty Rates faced by Diverse Communities The next Poverty Reduction Strategy should set a target to cut poverty for all in Ontario by 50% by 2018. The Strategy should not have a specific focus on any one group. But it should include programs to address the inequities of diverse communities who experience disproportionately higher rates of poverty: Aboriginal People, people in racialized groups (whether immigrants or Canadian born), single mothers, and people with disabilities. Such programs should include: strong employment equity programs, and more effective training and employment programs focusing on people in communities with higher poverty rates. A separate Aboriginal Poverty Reduction Strategy should be developed to address the specific challenges faced by Aboriginal People, both on and off reserve. Aboriginal Health Access Centres are well positioned to play a supportive role in a strategy that addresses the social determinants of health in First Nations communities. Ensure Access to Good Jobs A recent report from the Wellesley Institute found that the working poor in Ontario experienced the sharpest decline in their health between 1996 and 2009 resulting in a widening health gap between low income and upper income workers. [2] The shift towards part-time and contract work, and work without health and pension benefits puts our communities at risk. To lift working Ontarians out of poverty there must be better access to stable and sustaining jobs. Ontarians require training and upgrading programs which enable them to acquire the skills necessary to pursue employment opportunities 4


and support a thriving economy. To ensure that work is a path out of poverty, Ontario must:   

Increase the minimum wage Update and rigorously enforce Employment Standards for all workers Provide more accessible and effective training, workforce development and job placement programs.

Invest in Strong Public Programs and Services Effective public programs and services that appropriately address the needs of Ontario’s vulnerable populations are critical to improving our quality of life. Many of these programs address the social determinants of health such as education, and safe housing. Ontario needs to invest in programs and services that build healthy communities where everyone thrives. This means:  Building more affordable housing;  Establishing a new Housing Benefit for low-income households to help meet high rent costs. This could be flowed through the Property Tax Credit components of the Trillium Benefit;  Ensuring access to affordable, high-quality, non-profit childcare for families;  Offering affordable public transit options for low income people in urban areas, and appropriate transportation solutions for people in rural and remote communities with low incomes;  Sustained investments in community services, including expanded mental health and addictions programs, and services for marginalized youth;  Extending dental care to low-income adults and creating a prescription drug benefit program. Oral Health Programs – Detailed Recommendations There are no public oral health programs in Ontario for low income adults who do not receive social assistance. Public Health Ontario reports that 1 in every 5 Ontarians does not visit a dentist because they cannot afford the cost.[3] Many people with decaying, broken and abscessed teeth have no choice but to visit hospital emergency rooms. In 2011 there were almost 57,000 visits to Ontario hospital emergency rooms for dental problems according to data from MOHLTC IntelliHEALTH Ontario. In 2010 the Ontario government took an important step forward when it introduced the Healthy Smiles Ontario program which offers preventive and early treatment dental care for low income children under 18. Twenty-six Community Health Centres (CHC) are now offering oral health services as a result of this program, but a number of these centres are experiencing operating shortfalls as they were not provided operational funding by their public health units. Two of the CHC dental suites have had to close. Many CHCs and public health units report they have to turn 5


children away because their family income is just above the $20,000 eligibility level. Yet the program reached only 12,000 children and was underspent by $4.2 million in 2011/12.

AOHC recommends:  Operational funding should be provided by public health units to all CHCs offering oral health services.  To ensure more low income children can benefit, MOHLTC should increase the income eligibility criteria so that the children of any family receiving the Ontario Child Benefit are eligible for treatment in the Healthy Smiles Ontario program.  As recommended by the Chief Medical Officer of Health, Dr. Arlene King, the government should better integrate low income oral health services and seek efficiencies to extend programs to other low income populations. AOHC calls for the five fragmented oral health programs to be unified into one quality program managed by MOHLTC. A logical first step would be to combine the programs for low income children: Healthy Smiles, CINOT and Ontario Works / Ontario Disability Support Program dental programs for children.  The province should develop a pilot program to extend publicly funded oral health care programs to low income adults. Community Health Centres and Aboriginal Health Access Centres are well positioned to play a strengthened role given their experience in working with marginalized and vulnerable people.

Pharmacare Nearly one in every ten Canadians cannot afford to fill, renew or follow a prescription for medication. [4] Due to the ad hoc nature of prescription drug coverage, many people are not getting the medicine they need because of their economic situation. Community Health Centres and Aboriginal Health Access Centres witness this on a regular basis. We believe it is critical to make medicine more accessible in Canada in order to improve health outcomes, particularly for those living in poverty and on low incomes. An economic study done for the Canadian Centre for Policy Alternatives found that implementation of universal pharmacare in Canada could generate savings for all Canadians of up to $10.7 billion in prescription drugs. [5] An upcoming report prepared for the Canadian Federation of Nurses will identify the cost savings for Ontario if a provincial pharmacare program were put in place. 6


 AOHC recommends that Ontario take a lead role in developing a publicly funded provincial universal drug plan which ensures equitable access for everyone to prescription drugs.

Shift Ontario’s Healthcare System to an Upstream Approach Ontario’s Poverty Reduction Strategy should recognize that the biggest barrier to good health is poverty. But our health care system is poorly equipped to address the most important determinants of health such as access to good nutrition, housing, adequate income, employment and education. Ontario needs to shift the health care system from a focus on treating sickness, to an upstream approach that prevents illnesses before they take hold. An upstream approach to promote health and wellbeing includes:  Investing in Community Health Centres and Aboriginal Health Access Centres which provide both medical services and a wide range of health promotion and community development services to vulnerable people in their communities. The Canadian Index of Wellbeing in their 2012 report call for a strategy to expand access to Community Health Centres stating that this would benefit the long-term health of Canadians and that expanded access to the CHC model would help to reduce health disparities in Canada. The benefits would include: a better start for children, fewer avoidable hospital visits, better prevention and management of mental illnesses and complex chronic diseases, and improved opportunities for seniors to age at home. [6] 

MOHLTC and the LHINs implementing a population-needs based planning approach to the provision of primary healthcare services with an equity focus to ensure expanded access to CHCs and AHACs for vulnerable populations. Research has identified where the 15.2% of Ontarians with barriers to access to healthcare are located.

An effective Poverty Reduction Strategy with investments in the social determinants of health to ensure secure and livable incomes, safe housing, and accessible education and training programs.

3. Ensure Sufficient Public Revenues to Make the Needed Investments These investments require a significant investment of public revenue during a period of deficit. We believe it is time to move beyond austerity and rebuild Ontario’s fiscal capacity. According to analysis done by the Canadian Centre for Policy Alternatives, Ontario loses $17 billion of revenue each year as a result of tax cuts made by governments since the mid- 1990s. [7] In 2012 the Ontario government received the Drummond Report with a deficit elimination plan focused on cost cutting measures. The provincial government should now identify the revenue tools necessary within the context of a progressive tax system to ensure sufficient public revenues to invest effectively in Ontario’s Poverty Reduction Strategy. The work of the Canadian Centre for Policy Alternatives provides a menu of options to begin the discussion on 7


how Ontario can raise additional revenues to help balance the budget and fund important health and social investments. Poverty reduction should be prioritized in every Ontario budget over the next five years to achieve the targets of reducing overall poverty by an additional 25% and eradicating deep poverty by 2018.

Conclusion As primary health care providers AOHC’s 123 members know that treating illness is important. But we also need to look at the root causes of what makes people ill or well – income, education, employment, social supports, housing, nutrition and our environment. Public investment to address the social determinants of health is part of the shift required to move Ontario’s health system to an upstream focus which promotes the best possible health and wellbeing for everyone in the province. AOHC urges all parties in the Ontario Legislature to make a renewed commitment to taking the bold steps needed to make a real difference toward eradicating poverty for all Ontarians.

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Sources: [1] Steps to Equity, “Towards Equity in Access to Community-based Primary Health Care: A Population Needs-Based Approach” 2013 report for AOHC. [2]Block, Sheila. ”Rising Inequality, Declining Health: Health Outcomes and the Working Poor” Wellesley Institute, July 2013.http://www.wellesleyinstitute.com/publication/risinginequality-declining-health/ [3] L Sadeghi, H. Manson and C Quinonez, “Report on Access to Dental Care and Oral Health Inequalities in Ontario”. Public Health Ontario, July 2012. http://www.publichealthontario.ca/en/eRepository/Dental_OralHealth_Inequalities_Onta rio_2012.pdf [4]M.R. Law, L. Cheng, I.A. Dhalla, D. Heard and S.G. Morgan, “The effect of cost on adherence to prescription medications in Canada,” Canadian Medical Association Journal 184(3) (February 21, 2012): 297-302, http://www.cmaj.ca/content/184/3/297.full.pdf+html [5] M.-A. Gagnon, The Economic Case for Universal Pharmacare: Costs and Benefits of Publicly Funded Drug Coverage for all Canadians, Canadian Centre for Policy Alternatives & Institut de recherche et d’informations socio-économiques (2010), 8


https://s3.amazonaws.com/policyalternatives.ca/sites/default/files/uploads/publications/ National%20Office/2010/09/Universal_Pharmacare.pdf

[6] “How are Canadians Really Doing? 2012 Canadian Index of Wellbeing Report” https://uwaterloo.ca/canadian-index-wellbeing/sites/ca.canadian-indexwellbeing/files/uploads/files/CIW2012-HowAreCanadiansReallyDoing-23Oct2012_0.pdf [7]“Austerity is holding back Ontario’s economy’, by Hugh Mackenzie and Trish Hennessy. Toronto Star, March 20, 2013. ttp://www.thestar.com/opinion/commentary/2013/03/20/austerity_is_holding_back_ont arios_economy.html

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