An evidence-based approach to decision-making is often pushed by concerned sectors of society. Yet one has to ask: To what extent does evidence influence public policy? We answer that question and more as Cynthia Belaskie, Robbie Brydon and special guest host Jim Dunn talk to Molly Harrington, former Assistant Deputy Minister of BC, and Norm Helfand, a social policy consultant from the Ontario government. They talk about how data and evidence is used to craft public policy and the extent they can influence how these policies are created and implemented. Learn more about how public policies are made and how research and evidence are used by tuning in.
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Does Evidence Influence Policy? With Molly Harrington And Norm Helfand
CB: What are we going to talk about?
RB: A super fascinating topic for the wonks in the room is how evidence gets used in policymaking, which I suspect is the better part of our followership.
CB: Who do we have to talk about it?
RB: We’ve got a couple of awesome guests with us. We also have another awesome guest host, Jim Dunn, who you may remember from way back in Episode Zero. He will be joining me to co-host. He’s the Chair of Health, Aging, and Society at McMaster University and the Director of the McMaster Institute for Health Equity.
CB: Welcome back, Jim. It’s good to have you with us.
JD: Thanks for having me. I’m excited about this topic. This is an interest of mine. I spend probably more than the average academic time working with decision-makers, often at the municipal level. I’ve had a lot of thoughts about this. I have to say, at the provincial and federal levels, these things have been a lot more impenetrable to me. I’m looking forward to the insights that Molly and Norm might have for us.
CB: Who are Molly and Norm?
RB: We went straight to the source for this. Molly Harrington is a retired Civil Servant from British Columbia, and Norm Helfand from Ontario. Both of them worked in fairly senior roles in Social Services and Finance. Both of them had a hand in helping with their province’s respective Basic Income projects. They’ve seen lots over their careers and are here to share with us their insights on how evidence gets used in the policymaking process.
NH: Thank you.
RB: It’s good to have you both here. Norm, do you want to take a moment and tell us about your experience in the civil service?
NH: I retired from the Ontario Public Service. During my 28 or so years with the government in Ontario, I had a whole range of different jobs and positions, although a lot of it focused on income security and social programs throughout. For a while, I was the Director of the Ontario Disability Support Program. For a few years, I was engaged. I was the Chief Researcher on the Lankin-Sheikh Report, which was a review of social assistance in Ontario. It was done a few years ago.
I also spent about ten years working in the Ministry of Finance, among other things, developing and managing budget initiatives in education, social policy, and some other areas. After my stint with community social services, I went back to finance and worked on things like the Ontario Child Benefit. I played a key role in negotiating the enhancements to the Canada Pension Plan and important social security initiative and a bunch of other initiatives that we did under the former Liberal government in Ontario.
MH: I just returned from the British Columbia Civil Service. I was in the Civil Service for 26 years. Most of that time, I was an Assistant Deputy Minister. I was in charge of the income security area, income and disability assistance, disability strategy, and, eventually, poverty strategy for the province. I had the benefit of having worked in the Ministry of Finance as well for a short period of time and various other parts of government, including Indigenous relations, treaties, and negotiations. That was the span of my experience.
RB: Drawing on that experience, I’d love to ask either of you, when did you find decision-making was guided by the best available evidence that you had at your fingertips? When was it not? I’ll throw it over to either of you to pick that one up.
NH: In general, my experience has been that there’s been increasing interest in the best available evidence to support decision-making over time. There are many examples of where it has been considered or not considered. The issue for me is what is the best evidence? Hopefully, we’ll have a chance to talk about it a little bit more. What’s available? Also, the range of disciplines or views that are brought to the evidence.
I was at a forum for health researchers at the University of Toronto and a student got up and said, “We keep telling you that you should improve income support and it’ll improve health. Why don’t you listen to us?” It was a great question. I had to step back for a second and think about it and I said, “Yes, but I’m also hearing from economists that are telling me a different angle on this story.” That illustrates a little bit of the frustration of some researchers, why we don’t listen to them, and also what it means to bring in the best available evidence.
MH: Maybe I’ll build on that. In BC, we’ve gone through periods of time where evidence was paid attention to and then where evidence was put to the side. There are fairly distinct periods. In terms of a period of time when there’s been rich attention to evidence, It’s when you’ve had the benefit of some fiscal room in a government situation and a fairly progressive policy environment.
In BC, since 2017, the government changed and there was significant interest in reconnecting with the academic environment, reconnecting with research, investing in accessing data across government and integrating that data. Probably the pinnacle of that was the Basic Income Pilot work that was done in BC and the BC Poverty Reduction Strategy, where we had enough fiscal room and mandate to significantly reduce poverty in the province.
The government called upon the academic community to get them some advice about what would be the best investment streams to reduce poverty in the province. It was a rich period of time. Ultimately, some interesting decisions were made coming out of that. BC decided to institute a child benefit program through the tax system and do a number of significant policy reforms, increasing rates is an obvious one, and some improvements to its disability units and supports for single parents.
Conversely, when evidence is irrelevant, the governments change and they have a different policy agenda. The imperative is to implement that policy agenda. They have a mandate to do that. Two examples of that are when the government changed in 2002 in BC and the government had a huge mandate to reduce government and to implement significant tax reductions. Dramatic reforms were initiated at that time. Evidence was irrelevant at that point. Significant cuts to income security were made to support an overriding mandate the government had coming out of the election.There has been increasing interest in the best available evidence to support decision-making over time. But there are many examples of where it has been considered or not considered. Click To Tweet
Counter-intuitively, in 2017, a significant government mandate was to improve social welfare and social security. Instantaneously, welfare rates were significantly increased and earnings exemption and welfare reforms were undertaken. Neither one of those was evidence-based. They were executions of mandates.
It’s that in-between space where the government feels like it has room to move and it’s going like, “What’s the best possible thing to do? What’s the best bang for my buck?” It’s richest when a public policy issue emerges and there’s no obvious way to go. Evidence is important. It’s something controversial. In a funny way, it gives the government room to reach out to the academic community and ask for advice.
A couple of samples of that is as BC was hit early compared to the other provinces with a terrible overdose crisis, fentanyl came into the drug supply, they saw a rapidly escalating deaths from overdoses. More or less, the bureau would eventually emerge in the COVID crisis. It reached out to the academic community for advice about what to do about the distribution of welfare payments. Should they change the distribution systems so that not everybody gets paid welfare on “Welfare Wednesday” once a month?
There’s a lot of evidence, especially from the United States. Changing that distribution would reduce deaths from overdose. There was a decision made probably around 2014 or so to reach out to UBC and have you UBC’s researchers do a pilot project in the Downtown Eastside about check distribution because there was an agreement that nothing should be done without evidence. That was a multi-year program about what to do about check distribution.
Ultimately, the pilot showed that altering the check distribution to pay people off-cycle or pay people a couple of times a month was causing increased predation and poor health outcomes. It avoided doing something that on the face of it looked like the right thing to do and it was very much evidence-based. That’s probably the best example I have of a healthy engagement to reach out in a situation where we didn’t know what to do to get solid evidence before we made a policy change.
RB: It solidly fit your criteria of an emergent issue that was not a new government coming to power with a mandate to change something but something that arrived at the session and you had to do something about it.
MH: Also, the interplay between health policy and social security policy.
NH: I have one small addition to the excellent description that Molly provided. Another little window may arise when it’s maybe most valuable as political parties are creating their campaign platforms. Different parties may care more or less about research on this. The BC study about how to deal with poverty and Basic Income is one of the best pieces of work I have seen in decades on public policy. It’s pretty unusual.
Most of the time, parties pick their big initiatives in their campaigns and then they tell us. Our job is to implement it once it’s there. Molly identified some important areas where there’s some vagueness or clarity about some design details in issues like that that may be important in some areas. In terms of the big stuff, the main place to try to influence is in that space a lot of times.
MH: I’d love to talk about the BC Basic Income project to build on what Norm is saying. It’s extremely helpful to know that it was useful in Ontario because it was certainly useful in British Columbia. The Basic Income Pilot Project was an excellent example of collaboration between the academic community and government at its best.
RB: Molly, you said the Basic Income Pilot Project, which usually references the Ontario Pilot. Do you mean the basic income feasibility study in BC?
MH: Bizarrely, it’s called the Basic Income Pilot Project. What’s amusing to indicate is that the government was posed with a dilemma. There was political pressure to carry out a basic income pilot. We decided instead to take one step back and do a study about whether it made sense to do a pilot as a prelude. It was partly based on the fact that Ontario had already initiated a pilot. It didn’t seem like it was a good use of public funds to replicate what Ontario was doing.
The Basic Income Project happened because it convened and entered into a partnership with the academic community. It was structured in an interesting way to entice the academic community to participate in the study. What was promised was based-funding. The project was $4 million over two years, $2 million a year.
Most importantly, the quid pro quo for the academic community was that we would give the academic community two things, one was access to administrative data across our system and academic freedom for publishing the results. That opened up the machinery of government to fully engage with the academic community across not just our social security department but across all departments of government.The political cycle can open and close the research cycle and the evidence cycle, but perhaps some things can be more perpetual, that can create a healthy environment. Click To Tweet
Do the work in an ideal scenario you would want to do, which is to examine all facets of government related to a particular population. In this case, it was the population living below the poverty line and looking at all facets of their life that were possible through administrative data and then drawing conclusions about what interventions would potentially have the best return. We’re also able to do full simulations with financial data, income tax data, and social security data to simulate the impact of basic income. It was a fabulous opportunity to fully transparently examine that.
Finally, a hugely important part of the research is the engagement of people with lived experience. There was the ability to draw on lived experience research that had been done in the months prior to the initiation of the project through our BC Poverty Reduction Strategy. Also, there’s complete freedom given to the researchers to engage with the advocacy community and people with lived experience to get qualitative research that would substantiate the available quantitative research.
It was a wonderful example of public policy research. We’re able to come to some conclusions about whether or not to do a basic income pilot. Also, to not waste the opportunity and get some recommendations across the span of government about what reforms would make sense to improve the outcomes for people living below the poverty line. We’ve got multiple recommendations coming out of that report.
RB: I love these responses for two reasons, one of them is that it sinks in nicely. We had Lindsay Tedds on this program. It’s neat to hear how this worked from both angles, the research and the government sides. One of the questions I wanted to ask is what can policymakers, either on the civil service side or on the political side, do to make better use of evidence?
You spelled it out there that there’s a quid pro quo with academia. It may not be on every initiative, a government wants to invest $4 million over two years to get a big answer to a question. The pieces that you spelled out of academic freedom, freedom to publish, and access to administrative data, you can go a long way with those in a much smaller budget and be extremely enticing to researchers if you’re willing to offer that up.
MH: In terms of the quid pro quo to the government, if we had done a Basic Income Pilot, it would have cost the BC government about $50 million a year and we would have gotten the answer to one specific question. The investment of $4 million to get advice across a range of government programs for low-income people was a far better use of public funds.
JD: That’s interesting to me on a number of levels, particularly when you’re talking about the mutual interests of research between government and academia. I’ve had an experience with the government a lot. I’ve experienced this certainly where it becomes challenging for me to dive into it. I’m not going to get something that’s going to advance my career or even give me anything to put in my annual review other than I did this nice interaction. We’re broadly committed as an institution to this outreach.
I’d be interested in your thoughts on this. It strikes me as a procurement problem in a way. The way that government often procures research and advice is by maintaining secrecy. There are good reasons for that and so forth, but there may be certain circumstances where we need an alternate procurement policy, particularly if we’re going to try and engage academia that says, “It’s going to be open. We’re going to do that.” I’d be interested in your reaction to that.
NH: A couple of observations on this. One of the things that Ontario has done, which I don’t think any other province has, is we’ve made our social systems administrative data available to researchers through Statcan. I started that initiative years ago, but my better successor carried it forward and was able to implement it. That spurn quite a bit of interesting research.
I’m a bit sidestepping your point about procurement and I’m going to come back to that. It was that there are other ways to do it other than procurement and that’s one of them. The beauty of the Statcan model is that they could maintain the control and security around this administrative data, which we’re always worried about. In Ontario, we also have academic access to the health buildings’ information. I’m not that familiar with that. You guys probably are more. These are things that can be done.
In terms of procurement, you’re right. Part of the problem is that the policy cycle isn’t planned. At one point, I was in the midst of negotiations on enhancing the Canada Pension Plan. One of the things that we wanted to do was to address the potential impacts of increased contributions amongst lower-income workers that an enhanced CPP might involve. I was trying to develop a solution that would involve enhancing what we now call the Canada Workers Benefit.
I went to a couple of friends in the academic world, people who you will know about mostly in economics departments, and said, “You guys are doing evaluations. Could you please give me your results? I need it.” They said, “We’re working on it. We’re not sure if we’re getting it published.” I surprised them. The problem was that I needed that now. I hadn’t thought about the need for that earlier in a way that the more thoughtful process that BC was able to undertake on this. It was a bit frustrating for me.
Also, there is another little twist on this issue. They want to publish, so the academics are interested in statistical significance. Sometimes for policy purposes, we care more about the size of impact and whether or not it meets the .005 statistical test. That’s another fundamental conflict around this stuff. I’ll point that out. To the procurement questions, if the policy process was as thoughtful and long-term as BC has experienced, those awesome tools that Molly outlined could be used. Typically, the policy process is a little more disjointed than that.
RB: That brings up good points on a couple of different angles. I did a Master’s of Economic Policy and the question that was posed to us regularly by our instructors was, does it have statistical significance? Does it have policy significance at the end of the day? The other side is, how quickly can researchers get evidence together when policymakers have questions? Let’s hold that question and we’ll come back to that right at the end of this conversation. We can ask how researchers can better inform policy.Evidence is really important. In a funny way, it gives the government room to reach out to the academic community and ask for advice. Click To Tweet
JD: I think Molly has some thoughts on the one that Norm was speaking to.
MH: That procurement issue is critical. We had significant struggles constructing the procurement. Ultimately, we entered into a procurement arrangement with the University of British Columbia and the University of Calgary because the researcher was originally in the University of Victoria and we moved to the University of Calgary.
The procurement is critical to get over the intellectual property rights, default clauses that the government has and transfer those rights to the two universities in question. It was an unusual use of procurement arrangements. It was legally feasible and done, but it required some significant intervention from senior bureaucrats to construct agreements.
There was an advantage to the government doing that. The research was ultimately owned by the UBC and the University of Calgary. It gives the government a little bit of room. It’s not research that is done by the government. The government’s request is by the academic community. The decision about releasing the basic income report was clear that the basic income panel released it. It was not released by the government.
It then reviewed the report, the government was reviewing for errors and omissions and not in a challenge function on the policy findings. It gave a sense of integrity to the report. It also gave the government the room to take into consideration the report as opposed to the government releasing the report and immediately saying, “Yes, we’ve done this report and we’ll immediately implement all of these recommendations.” That’s the ultimate use of transparency. It has an advantage for both government and the academic community.
I agree that the political cycle can open and close the research cycle and the evidence cycle, but perhaps some things can be more perpetual that can create a healthy environment. Hopefully, those are legacy arrangements that will be in place. Perhaps I’m being naïve. One of them is that we set up an integrated data arrangement that is housed at UBC. We made sure with our information privacy commission and all of our protection of privacy, legislative requirements that its sound. The academics are under agreement to respect that and make sure that any research is reviewed for errors and omissions and any privacy breaches prior to publication.
We have something that is robust and long-term for integrated data. The researchers that use it say that it’s much more accessible than the RDC arrangement system has set up. Also, we have to be quite innovative about using some data sets that are traditionally off-limits, primarily income tax data. We came up with a solution of some researchers being deemed employees for a set period of time to go into our finance department and access the information. Also, be held to the same standards as an employee of government would be held about how they treat privacy and the protection issues.
The final thing is using the government’s web and IT presence to make sure that any of the research is transparently captured and preserved in the web environment of government and can be accessed by outside researchers. We procured a lot of research from non-academic sources as well, which was important for getting qualitative research. We’ve worked with First Nations and Indigenous organizations and poverty organizations.
We did an open call. If anybody wanted to do research, we have small convenient graphs that they could access. The quid pro quo there was that they had to publish the findings. All of that research is captured and preserved in the web environment of government for future researchers to take advantage of, including the basic income panel itself and being able to take advantage of that.
Using the machinery of government, the protection of privacy provisions, and using them for what they were designed for, which is to ensure that we can research at the same time, we protect people’s privacy as opposed to being a shield against doing research. Also, the government’s transparency onus to citizens and using it in its most robust way helps. I hope that those have some longevity and that they won’t shift with the currents of time when different governments come into being. They’re there for everybody to see. They’re in plain sight.
JD: It’s a good case study. I was getting what you’re saying, Norm. The governments do put out RFPs that are aimed at consultants and say, “We need to report on this. We need to report on that.” I’m thinking everything from municipal governments, quasi-governmental agencies, and so forth. For academic researchers, the challenge is like, “I make money and I might be able to do some interesting research, but I don’t know if it’s ever going to see the light of day. If it doesn’t see the light of day in an academic journal, it doesn’t have as much value to me.” It may be cut off from a particularly helpful source of expertise. I don’t want to go too far down this rabbit hole, but it does speak to a constructive issue for the future. Also, a case study, particularly in BC because it seems like a courageous one.
RB: It’s a fun rabbit hole to explore. One of the angles that we’re particularly interested in with the McMaster Institute for Health Equity is the relationship between income and health and how that plays out in the policy. One way to think about this is that provincial governments spend 3 or 4 times as much on health as they do on all social services, yet healthcare only accounts for a fraction of our total health. Often, income and housing mean as much, if not more.
You’ve got this division of responsibilities within the provincial government. Health is one ministry, social services, and finance ultimately is signing the cheques on who gets how much money. Both of you worked on both social services and finance. I’d love to hear a little bit about to what extent health impacts mattered in decision-making about income security programs, if at all.
NH: Somewhat, health matters. It’s growing somewhat. When I first started in this field, health outcomes were not noticed. By the way, as a student studying Epidemiology and Health, I spend most of my time reading about the correlation between income but it wasn’t there. In the last few years, there has been some interest in it, increasingly so. Some of the limitations in the research that are available make it hard to use for policy development. The summary of that is, yes, there’s an interest in that to an extent. It’s balanced against other non-health impacts. It’s one of the impacts amongst others that are also looked into. Maybe the available research isn’t always that helpful for someone.Some of the limitations in the research that is available make it hard to actually use them for policy development. Click To Tweet
MH: The correlation between poor health outcomes and low income is well documented. The quasi-relation is more difficult to track, document, and it’s controversial. We’re edged towards that by a couple of events where the Ministry of Health started to pay more attention to the income and housing policies of the government. It was starting to cause problems for the Ministry of Health and the acuity became more obvious. It was around two things, 1) The overdose crisis and 2) COVID.
In terms of the overdose crisis, the provincial health officer, the machinery of public health, and the coroner’s office are acutely focused on what was happening and started to do some data correlation. It’s always easier for the government to have the Ministry of Health reach out and grab income assistance data and other data than going the other way. The privacy considerations are much more significant for the Ministry of Health than they are for us.
The grabbing of data is starting to put together monthly information not just on deaths from the overdose crisis but from the correlation of who’s on income assistance and disability assistance, who’s experiencing an overdose, and more importantly, dying from an overdose. That is quite a rich area of deep dive about what constellation of interventions are going to reduce. Overdose deaths are not part of the acute care system. It’s not just income assistance, but it would be the provision of stable housing.
Some early academic research on that, like the Chez Soi Program in Vancouver and some of the work in the United States around Million-Dollar Murray studies. It’s about the intense draw on the healthcare system of homeless people who have mental health and substance use issues was quite important. That helped policymakers make the argument to finance that there were the beginnings of a business case and moral imperative to reduce deaths to make investments in housing the homeless population and income security.
Ultimately, some important questions about the delivery of income security and all the tension that exists about, are rate increases the right thing to do? Are you going to cause more cash on the street? Hopefully, a lot of those are starting to be resolved through some of the work that was done by UBC on cheque issues, distribution, etc.
COVID magnified that as well. There was a huge concern that having large populations outside of the reach of the formal health system living in tent cities and on the street would be more at risk of COVID. It’s causing a public health risk both in terms of increased death and hospitalization among the population itself and also exposure to the population at large because they weren’t housed in any particular location.
There’s a lot of public health research that can be done through the imperative of the public health office about the correlation between people living on the street and incidents of COVID. That helps with making a significant argument to make significant investments and housing the unhoused during the last couple of years.
JD: It’s interesting that you raised the At Home/Chez Soi trial, a randomized trial in five cities across Canada and commissioned by the Mental Health Commission of Canada for our readers. It showed that not only were their savings in health care, at least on paper, but there were savings in a whole bunch of different sectors, policing, criminal justice, healthcare, emergency response, social services, etc. For high-needs clients, the cost of the program was quite a bit less than the cost avoided and other sectors.
I don’t know that research or anything else can get you over this. From a public policy standpoint, the challenge is that it’s hard to recover those economies, in other words. While housing might be diverting the use of those other services, those services still get used. They probably already operating at 110% to 150% capacity anyways. As a hospital president put it to me one time as I was pushing this topic, he said, “Stop saying the word savings. I don’t make savings unless I lay somebody off.” He’s right. It does take a pretty bold and considered move to say, “We’re going to allocate resources differently across these sectors.” Maybe the evidence can help with that.
MH: The health savings argument can’t be made. There’s another reason for that. Moving people outside the healthcare system into the healthcare system causes an increase in health costs because people have been living with under-diagnosed chronic diseases and conditions. Bringing them into the treatment system will initially cause an increase in health costs and health care. The health outcome argument is the only one that can be made and longer-term health savings. In the long-term, we’re all dead anyway. Those arguments can’t be made to the Ministry of Finance.
Unfortunately, the argument finally won the day in BC and because of the advanced jurisdiction for overdoses, it became an argument about both reducing morbidity and reducing the complete draw on the emergency health care system. Also, the diversion of basic emergency health care from the rest of the population for heart attacks, strokes, and the burnout of emergency health care workers. That was a compelling argument that wasn’t about health savings. It was about the stability of the health care system itself.
JD: A lot of people in the early studies of those supportive housing programs were quite disappointed that they didn’t reduce symptoms all that much for people who were sick. The normal course of illness is that they’re sick, they’re going to continue to be sick, and they’re going to have bouts of illness. There will be costs associated with that. We’re increasingly realizing that people would get care eventually who were in those situations go into crisis 5, 6, or 7 times first. That’s the Million-Dollar Murray. Paying for all those responses to all those crises is the wrong approach when you can completely circumvent that and stabilize people. That’s an interesting example.
NH: It illustrates both positive things and some of the challenges around evidence and policy to me. The example of homeless folks and that target group that this work is about is it’s a lot easier to do research and figure out what expected outcomes you might have, even if they are greater access to health care costs. Most of my work has been around designing broad-based income security programs for a larger range of the population.
One way to illustrate the problem is, can I credibly provide information to the Ministry of Finance or whoever that there’s a greater health benefit from a 10% social assistance increase versus a 5% social assistance increase? It’s not the example that you’ve gone through but an example of things that a lot of people talk about around income security, which is broad-base for folks. One of the dilemmas that arise is we know that people’s health will be better with higher income over the long-term. Can measure or estimate the marginal impacts of some of these that say incremental change. It’s pretty tough to do that.One way to improve the analysis of causation is to have a multidisciplinary look at it. Click To Tweet
Honestly, it would be great to have research on that, but I suspect that it would be hard to do that because there are so many variables that occur, like economic shifts and things like that overtime when these things happen. Some economists tried to do their best to try to do that, but it is challenging. To summarize, what’s the marginal effect of an increase in income for folks? Over what time would you expect reasonably to achieve that? Both are tough questions but are at the core of the questions that get posted when one wants to do an incremental change in an income security program.
MH: I agree with such. We have to get beyond that. There are places where I saw some promise around that. The traditional research design and research look at that about tracking either, in our case, a decrease in income assistance, historically, or an increase in income assistance rates and a correlation to the population health of that group. We’ll all be retired by the time we get enough evidence to prove that correlation. That’s a fruitless effort. It’s still long-term.
I found that was starting to be quite promising because we ended up starting to work quite closely with the BC Medical Association and, in a sense, the front line of family doctors and health practitioners. They have to assist with the application for disability assistance. It was extremely interesting starting to work with them to see the difference pre and post of somebody moving on to disability assistance and the relative drop off of the need to access the family doctor. What was starting to emerge was the desire to almost prescribe disability assistance as a medical intervention. That could be something quite promising.
About amassing evidence, they’re using health practitioners as an avenue to gaining evidence. Initially, it was much more of a qualitative frame. We need to rethink and reinforce that. There’s the other flip side of the coin. The assertion that a job is the best prescription for somebody improving their long-term health outcomes and the peril of anchoring people into an income and security program rather than giving them support to move into an occupational situation where their health outcomes are improved. I throw that out for consideration.
RB: This boils back to Norm’s question at the outset, which is, what is the best available evidence? How do we judge the evidence in front of us? What else is weighed against it in the decision-making process at the policy table? There’s a bunch of ways to distill that while we’re on the topic of health before we move fully back to the question of how researchers can support policymakers.
I’ll ask that question because the two of you seem to be going in slightly different directions on how evidence around health impact might matter or might not matter. Norm was getting specific. What’s the marginal effect of this much income? Molly was getting me narrative. How does this change people’s lives?
We’re looking at a question in the research we’re about to do, trying to summarize the causal evidence or what changes in income transfers have on health? That’s something that we’re going to be doing over the next little while. The question I want to toss back is that you both talked a little bit about lots of correlation evidence, but causal evidence is weaker. What if there were better causal evidence? Do you think it would change anything or not?
JD: Would it depend on the orientation and the mandate of the government in the first instance? I’ll augment this a little bit with a funny quote. Somebody that you probably know is Bob Evans, the health economist. He’s retired. Bob was fond of saying, “In the words of the great American philosopher, Homer Simpson, ‘Just because I don’t care, it doesn’t mean I don’t understand.’” That harkens back to the question you got from the student, Norm, in my view. There will always be a fair bit of frustration for those of us who are on the evidence-producing side. Why don’t you do something about this that there is on the other end?
NH: I’m sorry that what I said earlier made me sound like I was going in different directions. I agree with Molly that it’s a bit of a difficult thing to show that incremental numbers. The world is a complex place and there are lots of things going on. In some cases, narrative can be more powerful than numbers in persuading people, so I agree with that.
I was posing that earlier point because there is a bit of an expectation. If you want to bring to the finance table an argument in favor of a 5% versus 10% increase, that’s like, “Can you show me this?” It’s there. Even though I agree with Molly, it’s a bit of a dead-end. There are a couple of things that I would say. It’s worthwhile. One of the great things about the BC work is it was multidisciplinary. I’ve experienced a lot of this. People from different disciplines tend to do their results out of the context of the complexity of design, politics, bring that forward, and get annoyed somehow that you’re not doing something about it.
One way to improve the analysis of causation is to have a multidisciplinary look at it. For example, Molly identified what always comes up in income security: Does this dissuade people from employment? What would be the impacts? Are there negative health impacts from dissuading? To be of value, we have to bring in all these various perspectives.
I’ll put in a word for all time social workers that I used to be trained as. Social work has become out of fashion even in social work departments. We sometimes know that we have to provide services to help people even if they have income support. Usually, in most cases, a policy is a package of things that deal with design, implementation, and different kinds of impacts of that. Doing work in that space, which the BC work did, look carefully at target groups, design issues, federal-provincial jurisdictions, and all kinds of stuff. That creates a package that’s quite useful for policy purposes.
As a bit of an analogy. There was a big push from the health research area during the write-up to create a Universal PharmaCare Program. There’s lots of information that was put out about how that would save costs in pharmacy but also improve health outcomes. I don’t think anybody questioned that. That wasn’t the reason why the federal Liberals dropped the PharmaCare initiative. It wasn’t because they didn’t believe that research or they didn’t think it was valid. It was because it’s hard for the federal government to put forward a National PharmaCare Program without a major agreement from all the provinces, which probably the federal government viewed as impossible in that context.
The biggest question that I had, which there was no public discourse about, is what do we do about people who have drug benefits from their employer? In Ontario, it’s roughly 60% of the working-age population. Those questions were the questions that the Federal PharmaCare initiative stumbled upon. My point is this. In the US, when they did the Obamacare, the issue of how to integrate with employer benefits, one or the other, was a key part of the discussion.If something is to be a value, we have to bring in all these various perspectives. Click To Tweet
I’m not saying that health researchers need to address that question. If they want to pursue a policy initiative, they need to acknowledge that those issues are there and open public discourse on how to solve them because there are different ways of solving that particular problem. It would have been important and helpful in supporting the government to be able to make a decision. That was left, “That’s a technical detail that some folks will have to work out.” It was core. I’m not sure if I’m going off a little bit around stuff. It goes back a lot on how good BC’s work was, in my view. They took a look at all facets of the issues.
JD: You’re making a great point, Norm. I’m curious about Molly’s view on this, too. I started to see this as a distinction between research that you would call agenda setting, which is, “We want to draw your attention to this government. Get it on your agenda. You should do something about this,” versus implementation research, which is about, “We need to do some research.” If a government wanted to do this, how would you accomplish it?
It seems to me that the BC report did a pretty good job of weaving both together. In academia, particularly in health and related areas, we focus too much on agenda-setting. We say, “We showed an association between this and this.” Even if it’s a causal one, it’s like, “Somebody should do something about this.” That’s it. That’s the end of what we do. I’d be interested in your thoughts on a similar vein, Molly.
MH: It comes down to the ability to persuade. The ability to persuade means that you have to have a range of things at hand. One is quantitative data. We have lots of data, but we don’t have access to an integrated approach to data. I would hope, in BC, that the integrated data lab continues to exist. Two is you need some access to the population that is living with the experience of what you’re looking at, some qualitative evidence and respectful dialogue.
Probably the most acute example of that is with the Indigenous community. There’s a heightened need for that and a heightened legislative requirement that is quite healthy. The third thing is there’s the need for some arm’s length advice on the academic community can provide, a little bit of telescoping back about what’s here.
I agree with Norm wholeheartedly. We’ve long past the point where we can look at one intervention whether it’s welfare rates or child benefit levels. BC has a fair PharmaCare program. It’s a basket and the impact of that basket of services and income transfers on a particular population group that will give you the best information. We have to accept that maybe there are some surrogate indicators.
Poverty rates are probably better than anything at this point, as flawed as it is and looking at that population that lives below that level. There are probably about 150,000 people that are on income assistance. There are about 500,000 people that are poor. It’s important to look at the 500,000 and not just the 150,000 population group. What is the cluster of interventions that can work best to improve their ability to not live in poverty?
If you accept the fact that living in poverty means that your health outcomes are worse and that people who are poor have worse health outcomes and not worry too much about the causal relationship, let’s accept the fact that there’s a correlation. The correlation is weaker for people who live the next income bracket up, low to middle income. It makes sense to try to move people up that ladder. What cluster of interventions are you going to need to get people moving up up that ladder? I don’t know. That’s my thought at that point.
You need to talk to people who have made that transition and talk to people who haven’t made that transition. Sometimes things are counterintuitive. Sometimes things are implemented as opposed to what it is. An example of that is we had an earnings exemption structure for people on disability assistance.
If you accept as a public policy goal that you want to maximize the amount of benefit and amount of earnings that population group has as opposed to a public policy goal being to encourage people to accept the benefit, we pull the disability community together. The solution we came up with and piloted it and then implemented was that it didn’t make sense to have the earnings cap monthly. It made sense to have the earnings cap on an annual basis because a lot of people have episodic disabilities, so we changed it. We didn’t even increase the amount initially from $1,000 a month to $12,000 a year.
Over a short period of time, we saw the amount of work that people undertook increase by 300%. It went from people earning $50 million a year to people earning $150 million a year. A lot of it was the same people were earning more, but also we saw about an increase of about 20% of the people deciding to work. That was co-designed and co-validated by the disability community. Not only do we change the structure, but the disability community validated it.
The government is moving into a situation where they’re not going to be interested in it. If you work more, it looks like you’re more able to be of benefit. They’re comfortable with people with disabilities working more. The validation of the disability community and that move encouraged people to take more of a risk of working more as much as anything else.
There’s a richness of policy interventions like that. That didn’t cost the government much. It cost the government a couple of million dollars more a year. We had $150 million as opposed to $50 million of earnings going into the pockets of people with disability assistance and all the attendant benefits. There’s a whole range of things like that. There’s magic in the combination of quantitative and qualitative research. The people who have lived experience community, government bureaucrats, and the academic community are looking at things to come up with, things that aren’t going to be controversial because they’re expensive and improve social and health outcomes. I’m optimistic.
RB: That’s a great example. There’s such an incredible ROI on the administrative change. That’s of zero cost.
JB: Norm, do you have any final thoughts that you wanted to share?
NH: I’ll think about it. Switch over to Molly.
MH: I don’t know if I can eloquently rehash what I said. The last thing I would say is the conversation between Norm and me is quite important. There’s a lot of inter-jurisdictional learning, and the academic community can facilitate that quite a bit. It’s a funny story. As COVID was hitting, we were going like, “We’re running blind. What the hell should we do? Should we exempt serve?” Thankfully, we decided to do it in the end.
All of a sudden, the benefits were incredibly complex because the federal government was introducing so many benefits in such a rapid-fire away to try to deal well with the emergency situation. All the provinces and the territories are doing things. I had my stuff. I tried to keep tabs on what was happening.
We had all of our doors open, picking up the phone, talking to Ontario, talking to Alberta, talking to the other provinces. It’s like, “What are you going to do about X, Y, Z?” My staff said, “We found this academic. The University of Carleton is putting together and releasing publicly this good ongoing matrix of everything that’s happening. It was Jennifer Robson.” We used Jennifer’s work after that. It was so much more rapidly fired. She must have had a whole bunch of research assistants doing it. It was helpful.
The academic community working with the government can help with that inter-jurisdictional research, keeping us informed about what’s happening in an open and transparent way. Maytree tries to do that with welfare. The NGO community is hampered in a different way. It’s biased towards a progressive representation of things. Having the academic community and the ability to come forward to policymakers and politicians who sign it looks a little bit more arm’s length. A correlation between what’s happening and what the results are is extremely valuable. Perhaps tedious work but extremely valuable work.
JD: That’s a good charge to us.
MH: Also, to facilitate those conversations. Right. Yeah.
JD: Norm, any final thoughts?
NH: There are a couple of things. First of all, the question about, is it worth doing? It is, despite some of the challenges. Is it worth doing the research in relation to income security? It is worth it, despite my earlier comments about its limitations. It may not have had a specific tangible impact on specific initiatives but the general tone of discussion around social policy has incorporated these issues in there. Continuing to do that is good. Maybe this is discipline-specific with researchers. Multidisciplinary design-oriented research would be helpful. If you’re in the Department of Sociology, you can’t publish that. I’m not sure, but you can in some of the policy areas of publication.
Jim and I were saying before the meeting that we met at a conference of labour economists that happened to be in Montreal a couple of years ago. One of the things that impressed me about that work and also work that I have seen coming into the United States on specific income security and retirement security research, which I drew on a lot in my work on the pension plan. There’s government funding specifically for policy research. I don’t think we have a lot of that in Canada. In the area of senior income security, there is an entire survive the Trump world department that funds policy work in that outcome research as well as policy design research. I don’t think we have that in Canada or much of it. That would also help a lot to be able to engage academics better in supporting policy work.
MH: I would agree with you about that. It was the MDRC research. We used it a lot and was it helpful in substantiating with the Ministry of Finance about doing child benefits and refashioning the Canada Workers Benefit on the provincial part of it. Thank God we had to close the minister when we got the Canada child benefit. There’s a piece of an example of academic and it’s having an influence in public policy.
RB: That’s been sacrificial to do that.
MH: It’s probably the most important thing that’s happened in a decade. I don’t know if you’d agree with that Norm, but I would say.
NH: I do.
JD: I look at it through the lens of housing, which is one of my core areas of research. It had a huge impact because he was effectively the minister responsible for housing. Between him and Adam Vaughan, they’ve made significant progress.
NH: Molly mentioned earlier the data on the numbers of folks who are on income assistance versus the total number of folks below whatever poverty line you’re using. The numbers are similar in Ontario and the ones that Molly did. For me, the last few years of work that I did in finance primarily focused on that group. For years, I have been advocating for improvements and, in part, succeeded in the Canada Workers Benefit. There are a bunch of other initiatives I’ve been involved with that were going to that space.
Before the liberals were kicked out in Ontario, we did a little mini health benefits program for low-income workers. It was a crummy little program, but it was a little effort to move into that space in the absence of a national program and a number of other ones. That insight about numbers is important because sometimes, there is a focus on those social systems as if they were representative of all the low-income folks in the income security advocacy research world. That’s not necessarily the case.
We have a lot of low-income working families, gig economy, and part-time work. You know the whole story on that. From my personal perspective, the social challenge that we’ve got is the long-term social group and helping the people on social assistance to keep up with that. That’s a fundamental point. I’m not sure that a lot of the academic community has focused on that.
MH: I agree with you, 100%. I also think that that is a safe public policy space. It has that advantage too. Also, work as an intervention in somebody’s life with obvious extreme limitations and not having work, not welfare, and going back to run away is important. Like some ancillary health benefits program for that group to bridge them until they get into an employer plan, and all sorts of things are quite possible.
Maybe an interesting project, Robbie and Jim, is what an ideal state is for that population? I don’t think a lot of work has been done on that. We toyed here with that and having a supplementary health benefits program for that group, having an ability to make sure they’ve got some bridge to retirement savings. It would include the group that’s on welfare and supporting much more fluidity going back and forth. People can leave and try out work.
For labour market job opportunities, you make sure people could have full access to training, tuition, support, childcare, etc. That would be an extremely fruitful study. Fluidically, across the spectrum, that would have much more profound support. You can imagine that overall impact on health outcomes bridging people like that group bridging up. The dynamics right now would lend yourself to it.
JD: This is a fantastic conversation. I’m sure we could go on for another hour. Unfortunately, this is all the time that we have available. Thank you so much, both, for speaking with us and sharing your wisdom accumulated over the decades. Hopefully, I look forward to continuing conversations with both of you and informing the research that we do.
MH: Thank you. It’s a pleasure. It’s lovely meeting you, Norm.
NH: It’s lovely to meet all of you and Molly especially. Thank you for inviting me to this.
JD: Take good care.
CB: That was a neat conversation, useful takeaways for both policymakers and researchers.
RB: We need to meet each other’s needs to make each other’s work better. I was struck by that conversation about procurement and how British Columbia developed a process that worked for academics. I wonder if we could organize a session with the Institute of Public Administration of Canada and see if other provinces can pull on some of that knowledge.
JD: The experience in BC was different from what we had in Ontario. In Ontario, instead of this flexible approach where they wanted everything to be transparent and so forth, the government took more of a standard procurement approach where they own all of the intellectual property. Also, they control its distribution and its dissemination.
CB: Another key point that we should think about here is about policymakers getting evidence quickly when a decision needs to be made. This is something that I see being done well at McMaster Health Forum. Usually, their work focuses on health, but they’re moving into social systems and looking at some social services work. I’ve gone through their training for evidence synthesis as has Robbie for doing some work on income and policy. I can see how something like that could play a good role here.
JD: As academics, I’ve learned this over the years and somewhat inadvertently. A lot of what we do and those of us who are concerned about inequality and those things is we work in the problem space. We say, “There’s a problem here. We’ve collected some data and we’re showing you how much of a problem it is. Somebody should do something about it.” That’s the end of our engagement. Except that we might go out to policymakers and say, “We’d like you to do something about this.”
What I heard from Norm and Molly is that, in a lot of cases, in their position, they’re not making the decisions about what’s being done and what’s not being done. They’re told to implement this. What they need to know is what the difference between a 5% marginal increase and a 10% marginal increase is? Those are the things that are harder for us to do. There are more barriers to us. It’d be great if we could figure out a way to eliminate those barriers and make those activities work on both sides of the equation.
RB: In that training that Cynthia talked about, my team is running a test of that methodology on the question of the impact of income transfers on health. If you’re reading this and you’re interested in the answer to that question or if you’ve got a research question of your own that you want to be answered, please feel free to reach out. You can find us at BestEvidence.ca and we would be happy to connect.
- Episode Zero – Past episode
- McMaster Institute for Health Equity
- Molly Harrington – LinkedIn
- British Columbia
- Norm Helfand – LinkedIn
- Lindsay Tedds – Past episode
- McMaster Health Forum
About Molly Harrington
Molly Harrington is a recently retired senior public servant. Since joining the BC civil service in 1994, her career focussed on public policy analysis with over 15 years experience as an assistant deputy minister. She has provided public policy and legislative advice to Cabinet, Treasury Board and government ministers resulting in transformation projects for vulnerable adults in BC. Molly served as the BC government policy lead for poverty reduction and supports for low-income adults in BC for 12 years and was the policy lead for income and disability assistance programs in BC. In this role she led BC’s first disability strategy and poverty reduction strategy and legislation. This included leading extensive public consultation processes including citizens, NGOs, academics, municipalities and First Nations and Indigenous groups.
Molly also served as the BC government civil service executive lead for the BC Basic Income project. This included the establishment of an expert panel which advised government on a basic income approach in BC including comprehensive reforms to supports for low-income residents. Molly also led the Crown Agencies Secretariat for government and established a modern system of crown agency governance for the province based on leading international standards. Molly retired from the BC civil service in January 2021. She continues to be engaged with the disability and poverty communities in Canada, providing advice on topics including the emerging Canada Disability Benefit and basic income and poverty in Nunavut.
About Norm Helfand
Norm has over 28 years of experience in evidence-based policy development and the design, administration and evaluation of income security programs.
While with the Ontario Ministry of Finance, Norm worked on the preparation of provincial budgets under three different political parties. He led the development of a range of budget initiatives related to post-secondary education, child care, and social assistance. As Director of Income Security, he led a team that developed initiatives to support low- and modest-income families and individuals. These included the design of the benefits used in the Ontario Basic Income Pilot, developing income eligibility tests for a dental program for low-income children, and implementing the indexing of the Ontario Child Benefit. As Dir ector of the Ontario Disability Support Program, and later as Research Director for a major review of social assistance in Ontario, Norm championed efforts to change social assistance from a program focused on the enforcement of complex eligibility rules and onerous reporting requirements to a more simplified system that supports well-being and dignity.
Norm played a significant role in federal-provincial-territorial negotiations to increase retirement incomes through an enhancement to the Canada Pension Plan (CPP). He championed a design, adopted by Finance Ministers in their 2016 agreement to enhance the CPP, that included an increase in the WITB (now the Canada Worker Benefit) to mitigate higher contributions among lower-income workers.
Since leaving the Ontario government in 2019, Norm traveled to Nepal where he worked on rural women’s economic development and provided training for youth on how to do policy research. Currently, he is working as a consultant with First Nations and social agencies. Norm completed graduate studies in Epidemiology and Community Health from Queen’s University and an MSW in Policy and Community Development from Laurier.