Features; Opinion

Is Basic Income the next big population health intervention?

Why it’s useful to see Basic Income through the lens of Population Health Intervention Research

Thanks in part to the health sciences, there is widespread public acceptance that being poor is bad for your health. It doesn’t take much for us to make the connections. We might expect that less to eat and poor housing conditions interfere with our ability to maintain healthy bodies and immune systems. Less money may mean less access to health services that would treat or prevent illness and disease. Fewer resources might mean less opportunities, and fewer job options.  Poverty also compounds political and social injustice, with marginalized people such as women, Indigenous people and racialized groups profoundly affected by poverty. These groups often constitute much of the poor. Lastly, evidence suggest we suffer the psychological consequences of living in material deprivation, both in absolute terms and relative to others.

The immense research on poverty, income inequality, and the social determinants of health culminated in public sympathy for the plight of the poor. Yet for all the studies that have been done on poverty, perhaps it is time to develop research and public support for a solution – such as Basic Income. There are practical challenges to getting basic income into common public health parlance.

The answer may lie in the understanding of Basic Income as an ideological proposal that can affect our health. The discourse around basic income as a deeply ethical idea is necessary, but perhaps insufficient. I believe we should consider reframing the concept concretely as a population health intervention.

Why call basic income a “population health intervention”?

A concept advanced by Canadian researchers Potvin and Hawe (2012) as being policies or programs that shift the distribution of health risk by addressing the underlying social, economic and environmental conditions, population health intervention research is a unique approach to figuring out how we are affected by policies that have a wholesale effect on people. Eminent basic income economist Dr. Evelyn Forget took this approach in her paper “New questions, new data, old interventions: The health effects of a guaranteed annual income” (Forget 2013). She used old administrative data from the well-known “Mincome” experiment in Manitoba, and looked at health records from the same time-period. She saw a reduction in hospital burden relative to a similar town’s health care use that did not get the income grant.

Calling basic income an intervention means that we can treat it as a ‘natural experiment’.

We can study the impact of a policy on our health and well-being without necessarily running a Randomized Controlled Trial (where you randomly assign some people to a treatment, policy, or program, and not others).

Many have proposed that we need to conduct this sort of formal scientific experiment first. Some have questioned how useful such limited studies would be. A Randomized Controlled Trial might tell us whether basic income works in a certain social, economic, and political setting, but tells us little about whether the policy would work in other settings, or why the policy had a particular effect.

We ought to be careful not to set ourselves up to fail with studies too narrowly drawn in scope. Mixed or unexpected results from such studies also risks misinterpretation, and can be used to prevent basic income from entering policy.

Although the Ontario Pilot Program represents a step in the right direction, nothing stops us from advocating for the full national implementation of basic income. A host of different research and study designs would be embedded into the impact evaluation of this federal policy, on par with health care or public education. Framing a given policy as a population health intervention acknowledges the fact that many there are health-promoting aspects to programs outside of health care sector (Hawe and Potvin 2009).

Basic income is such a policy. Programs to alleviate poverty lie outside the doctor’s office, but nevertheless have a profound impact on health.

Population Health Intervention Research compels us to think bigger than ourselves.

Traditional medicine treats the individual person. If we are looking at the effect of social programs and policies, this unit of analysis is often too small to see measurable differences in any single person. Moreover, if we restrict a given treatment or social program to the poorest people – such as welfare, we may see limited overall benefits to the population as a whole.

Epidemiologist Geoffrey Rose recognized this problem (Rose 1985). Imagine that people lie on a continuum of ‘risk’ for certain diseases and health outcomes. For example, this could be said of high blood pressure as a risk factor for heart attack. Higher blood pressure puts you at higher risk of heart attack.

For our purposes, let’s say this distribution represents the relationship between poverty and getting sick. Higher poverty puts you at higher risk of ‘sickness’. We might expect that most people lie somewhere in the middle of the distribution, while those at very high or very low poverty sit somewhere at the tails.

Rose noted that traditional medicine’s approach was to target high risk people at the far right. However, these people are a smaller proportion, and paying attention only to them might not give us the biggest bang for our buck. Instead, he posited that interventions that reach entire groups of people would ‘shift’ the distribution itself. At the end of the day, he estimated that these far-reaching treatments would have a bigger impact overall (Rose 1985).

Basic income fits that profile – a social policy that brings everyone up, effectively ‘shifting’ the distribution. In order to examine policies that lend a helping hand to everyone, we need a scientific lens that is broad enough to capture the whole picture. Reframing basic income as a population shifter might fill that void.

Lastly, population health interventions allow us to redirect our thinking from the problem to the solution.

We keep studying poverty, not the fixes for poverty. A population health intervention approach calls for the health sciences to consider the potential gains to be made by studying the impact of income interventions on population health. We should be turning our attention from studying how poverty effects our health, to studying how fixing poverty effects our health.

You might be quick to point out that we have not eradicated poverty yet. So, how do we study this state of affairs, when it doesn’t yet exist?

In some ways, we can. We have the pilot run in Dauphin, Manitoba that in many ways, was ahead of its time. Dr. Forget was the first to recognize the strength of “intervention-alizing” the Canadian basic income experiment. We can also examine policies that get close to basic income, such as the Bolsa Família program of Brazil – a conditional cash transfer available to families with children. In Canada, the non-conditional income grant for senior citizens called the Old Age Supplement has been analyzed as an analog to basic income (McIntyre, Kwok et al. 2016) and indeed, those researchers found that participants eligible for OAS reported better self-reported physical, mental, and function health. Importantly, they also found those on OAS (which is non-conditional) where better off than those on conditional income programs. These are innovative approaches to the question of basic income’s potential impact, using information we already have. And, it might move us from studies of poverty, toward studies of basic income.

As it stands, promoting basic income as a population health intervention for the sake of our health is underutilized, yet it seems like a sensible way to communicate the idea. Poverty is intricately tied to the material conditions of our lives and societal position in the world, predicated on sex, race, and class. How a policy like basic income works among these conditions deserves no less than comprehensive and holistic look at how our health is profoundly impacted. Research that is based on an understanding of population health intervention attempts to do just this – and capture the value and differential effect of these interventions, the processes by which they bring about change and the contexts within which they work best (Hawe and Potvin 2009).

The Dauphin Experiment and the impending Ontario Pilot have and will continue to shape our thinking moving forward. They are also a testament to the desire of Canadians for a better, kinder, healthier society for all. However, we have not yet fully transformed the public’s conception of poverty alleviation as a necessary policy, worthy of widespread implementation as are universal health care, public education, or social assistance.

Implementing a basic income as an essential social program and for our health is possible, and fully within our experience of policy-making at both the provincial and national levels. The time has come to make this a reality.

Sarah M Mah is a PhD student in the department of Geography at McGill University. She is also a member of the Asian Women for Equality Society, an organization dedicated to the campaign for a Guaranteed Livable Income.

 

The opinions expressed above are not necessarily those of BIEN or BI News.

References

Forget, E. L. (2013). “New questions, new data, old interventions: the health effects of a guaranteed annual income.” Prev Med 57(6): 925-928.

Hawe, P. and L. Potvin (2009). “What is population health intervention research?” Can J Public Health 100(1): Suppl I8-14.

McIntyre, L., C. Kwok, J. C. Emery and D. J. Dutton (2016). “Impact of a guaranteed annual income program on Canadian seniors’ physical, mental and functional health.” Can J Public Health 107(2): e176-182.

Rose, G. (1985). “Sick individuals and sick populations.” Int J Epidemiol 14(1): 32-38.

 

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One comment

  • Mike

    I had an interesting thought while reading your article. But first, it makes sense to me that developing BI into something more substantial might be a good tactic in gaining acceptance. That said, I don’t know if I accept Bi as a viable solution for poverty, though I don’t really have any alternatives. It is a complex problem.

    But tying poverty and health costs/prevention together gave me another tangent to explore. The growth of the impoverished class. Better health care, longer lives. Poverty in some semblance is a sliding scale of comparison to others’ means. If your means is in the lower 10% (or whatever cutoff) then you are impoverished. Giving a BI doesn’t really change your position on that scale, just slides the scale up, still unless price controls on necessities are instituted, it follows that supply and demand will creep the costs of basics.

    That said, I know we all like to put a “monetary value” on things as it simplifies the math, however it is just an approximation and might not take in all pertinent variables. For example, I grew up poor. However, we had a large garden and we hunted and fished, albeit maybe not legally, but we did it to feed ourselves not for sport. So while we lived without a lot of money, we always had fresh food, fresher than you would get in any supermarket that is for sure. Nutrition and food sources are a huge boon to health. We were almost always healthy aside from a few injuries due to accidents.

    To me, I think you have to go further than just health care if you are going to consolidate BI into a living investment for people with meager means. Health care, at least in the US is far more corrective than preventive because well corrective medicine is more profitable. Preventive medicine costs less. To different philosophies and big business is into profits. If you make everyone healthy, the drug companies aren’t going to be happy about that. Make your food your medicine and your medicine your food.

    So how about tying health care in with good food sources and adequate shelter and I would add a safe environment since your mental state is as important or arguably more important than you physical state, into a BI package?

    That of course still wouldn’t be acceptable to some who argue that there are too many people in the world for our species sustainability long term. Population growth is directly affected by enabling the poor to live longer lives, and that issue needs to be addressed. It is all good that we believe everyone is a viable human being, but there are ramifications to uncontrolled growth that affect us all.

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