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Early Childhood Caries (ECC) is a serious disease that is about much more than cavities on baby teeth. In Canada, it is a growing public health problem with adverse long-term effects on children's physical, emotional and intellectual well-being. The failure to invest in preventive care has resulted in reactive, rather than proactive, measures against this disease. These measures are expensive and a needless drain on costs in the public health-care system. Children with severe ECC end up in hospital; in fact, in Canada, this disease is the most common reason children undergo day surgery. From 2010 to 2012, one in 100 children under age five required day surgery for ECC, with approximately 19,000 of these surgeries performed each year on children under age six. Canadian hospital costs for ECC day surgery in children aged one to five ranged from $1,271 to $1,963 per child, totalling $21.2 million between 2010 and 2012. Children from low-income families, along with aboriginal, immigrant and refugee children are disproportionately affected by dental disease, with between 50 per cent and 90 per cent of suffering from some form of ECC. This compares to an average of 57 per cent of children affected in the general population. A recent Alberta study indicates that when municipalities cease fluoridating their water supplies, children suffer increased levels of tooth decay. This has reignited the discussion around whether municipalities should add fluoride to the drinking water, or reinstate it in places where the water used to be fluoridated. While fluoridation can be an effective prevention strategy, this study also shows that fluoride alone is not enough. To reduce the costs and developmental consequences associated with severe ECC and improve well-being, oral health policies focused on disease prevention and health promotion are still necessary. This briefing paper provides background on the etiology, risk factors and prevalence of ECC in Canada to provide scope for the magnitude of this preventable disease in children. To address the avoidable socioeconomic costs, three areas require policy development. First is the need for increased public education and access to ECC prevention services for at-risk populations. Parents need to know they should reduce their children’s intake of sweet drinks, and avoid filling bottles with sugar water, juice or soft drinks, especially at night. They should also clean an infant’s gums with a soft toothbrush or cloth and water starting at birth. When the baby’s first tooth erupts, parents should commence daily brushing with toothpaste and book a first dental visit. Second is the need to empower health-care professionals to integrate ECC prevention in their early visits with parents of young children. Such visits are more common in family medicine, and these primary care providers can play a critical role in educating parents and promoting children’s oral health. Curriculum and continuing education for these health professions should be enhanced to emphasize ECC’s long-term health effects. Third, government should invest in preventive oral health services for children rather than relying on emergency dental care. Children should have access to early preventive dental services to instill in them habits for lifetime oral health. Provinces without universal public funding for children’s preventive dental health should remove the access barriers that children without dental insurance face., The School of Public Policy Publications, Vol 9 (2016)

Teen violence in dating and peer relationships has huge costs to society in numerous areas including health care, social services, the workforce and the justice system. Physical, psychological, and sexual abuse have long-lasting ramifications for the perpetrators as well as the victims, and for the families involved on both sides of that equation. An effective violence prevention program that is part of a school’s curriculum is beneficial not only for teaching teenagers what is appropriate behaviour in a relationship, but also for helping them break the cycle of violence which may have begun at home with their own maltreatment as children. The Fourth R program is an efficacious violence prevention program that was developed in Ontario and has been implemented in schools throughout Canada and the U.S. Covering relationship dynamics common to dating violence as well as substance abuse, peer violence and unsafe sex, the program can be adapted to different cultures and to same-sex relationships. The program, which gets its name from the traditional 3Rs — reading, ’riting and ’rithmetic — offers schools the opportunity to provide effective programming for teens to reduce the likelihood of them using relationship for violence as they move into adulthood. The federal government has estimated that the societal costs of relationship violence amount to more than $7 billion. These costs can continue to be incurred through the legal and health-care systems as the ripple effects of violence play out over the years, even after a relationship has ended. Other types of violence are also costly to society and not just in terms of dollars, but in young lives diverted into criminal activity. Up to 15 per cent of youth who become involved with the justice system grow into serious adult offenders who develop lengthy criminal careers. Yet, research shows that if prevention programs such as the Fourth R can deter just one 14-year-old high-risk juvenile from a life of crime, up to $5 million can be saved in costs to society. Research involving 1,700 Grade 9 students in 20 schools showed that those who did not take the Fourth R programming had a rate of relationship violence 2.5 times greater than those who did, and that the program had the greatest impact on boys, who are the most frequent perpetrators. There was also a significant reduction in violence towards peers, especially for youth who were at risk to be violent because they had experienced previous child abuse. Students likewise became more aware of violence and its impacts on others, and they gained a greater command of coping strategies. The program’s start-up costs vary depending on the school’s geographical location. This paper shows that the program’s costs per student are small compared to the savings to society in terms of violence avoidance. In a large Ontario school board, costs were down to $5 per student. In the Northwest Territories, smaller class sizes and bigger geographic distances make implementing the program more expensive, but still only $15-33 per student. The authors calculated savings based on costs avoided related to dating and peer violence at $2,101 per student. Violence prevention is an ethical imperative and it must start with teenagers. In an era of fiscal restraint and demand for more financial accountability, the Fourth R has proven to be a pro-active success in terms of saving both public money and young lives from the deleterious effects of violence., The School of Public Policy Publications, Vol 10 (2017)

Homelessness in Alberta is overwhelmingly concentrated in Calgary and Edmonton, with almost two-thirds of total provincial shelter usage in the former. Calgary also experiences much greater fluctuations in shelter use. Three interconnected economic factors — the supply of rental accommodations, the state of the labour market and the inward flow of jobseekers — go a long way toward explaining both Calgary’s unusually large share of Alberta’s homeless as well as the swings in shelter use. Calgary has proportionately less than half as many rental units as Edmonton and this gap is widening. Simultaneously, Calgary, more than any other Canadian city, attracts a significant share of migrants during times of economic growth increasing demand for affordable housing and then shelter space when the availability of housing approaches zero. The recent fall in shelter use in Calgary (and so Alberta) may therefore prove temporary should a recovering economy attract more arrivals and so drive up shelter use again. The provincial government’s recent efforts to increase the stock of affordable housing are appropriate but greater progress could be made if it devised ways to enlist the energy and efficiency of the private sector to expand Calgary’s rental market., The School of Public Policy Publications, Vol 4 (2011)

Surprisingly little attention has been paid to how we pay for health care affects how much we spend on health care. In this paper, I discuss how noncontributory finance and effective subsidization of public health care spending with federal cost sharing crowded out demand for private insurance as voters opted for high levels of public health spending. From this perspective, the Romanow Report’s call for increases in federal cash transfers to provinces for health care spending would result in an increase in provincial health spending and a diminution of the demand for private health insurance. It is not clear, however, that federal subsidization of health spending is either sustainable or socially desirable. Indeed, as Canada’s population ages, the current financing of health care represents enormous unfunded liabilities for the provinces. To sustain current levels and growth rates of health spending without tying current revenues to that objective means asking the next generation of working Canadians to pay far more for their health care than do working Canadians today. Although the effect of population aging on health care expenditures is projected to be modest, it could trigger a serious political crisis for Canadian medicare as taxes rise., The School of Public Policy Publications, Vol 3 (2010)

With rising health care costs, often health research is viewed as a major cost driver, calling to question the role and value of provincial funding of health research. Most agree that the quality of healthcare provided is directly linked to our ability to conduct quality research; however currently there is little empirical evidence supporting the link between engagement in health research and healthcare performance. In Canada this has resulted in funding for health research that varies over time and between provinces. While medical knowledge is a public good, we hypothesize there are local benefits from health research, such as the attraction of a specialized human capital workforce, which fosters a culture of innovation in clinical practice. To address this question, we look at whether health outcomes are impacted by changes in provincial research funding in Alberta compared to other provinces. Provincial funding for medical research, which varies greatly over time and among provinces, is used as a proxy for medical treatment inputs. Trend rates of reduction in mortality from potentially avoidable causes (MPAC) (comprised of mortality from preventable causes (MPC) and mortality from treatable causes (MTC)), are used as a proxy health outcome measure sensitive to the contributions of technological progress in medical treatment. Our analysis suggests that investment in health research has payback in health outcomes, with greater improvements in the province where the research occurs. The trend declines seen in age standardized MPAC rates in different Canadian provinces may be impacted by shifts in provincial research funding investment, suggesting that knowledge is not transferred without cost between provinces. Up until the mid-1980s, Alberta had the most rapid rate of decline in MPAC compared to the other provinces. This is striking given the large and unique investment in medical research funding in Alberta in the early 1980s through AHFMR, the only provincial health research funding agency at the time. However in recent years, Alberta’s rate of decrease in MPAC has occurred at a rate slower than the other provinces (British Columbia, Ontario or Quebec) with provincial medical research funding. This is striking at a population level, where Alberta’s failure to achieve a reduction in age standardized rates of MTC comparable to British Columbia, Ontario or Quebec after 1985 represents 240 unnecessary deaths in 2011 and 48,250 Potential Life Years Lost worth around $4.8 billion. The findings from our study suggest that some of the divergence in the rates of reduction in MPAC between provinces may be due to beneficial changes in institutional structure and human capital, resulting in differences across provinces in the capacity to adopt new effective healthcare innovations. While health indicators such as MPAC are the result of complex interactions between the patient, treatment and the healthcare system, as well as socioeconomic and demographic factors, this analysis suggests that a different capacity for health research within the provinces impacts health outcomes. The findings from this analysis are limited by the lack of data related to research funding and the health research workforces within provinces. This analysis has important implications for health research policy and funding allocations, suggesting that decision makers should consider the long-term impact provincial funding for health research has on health outcomes. This study also highlights the lack of longitudinal public data available for provincial health research funding. This information is critical to inform future health research policy., The School of Public Policy Publications, Vol 8 (2015)

As part of our analysis in the paper published in January 2015, “Bending the Medicare Cost Curve in 12 Months or Less: How Preventative Health Care Can Yield Significant Near-Term Savings for Acute Care in Alberta,”1 we had carried out analyses of sub-groups of interest, such as workers at Canadian Natural Resources Ltd. (CNRL) and seniors (participants aged 55-plus) that, for reasons of length, we did not include in the published paper. The details for the data, the models estimated, the statistics calculated and the sample inclusion and exclusion restrictions are described in the full paper that was peer reviewed. This addendum discusses the results of the analysis of the sample of seniors (participants aged 55 and up at the time of joining Pure North, n=5,516, made up of 2,758 Pure North participants and 2,758 age- and sex-matched controls). The models estimated are described on pages 9 and 10 of the published paper. Persisting participants are Pure North joiners who have a 25OHD (vitamin D blood serum) measure at the time of joining and one year later. We interpret participants with two 25OHD one year apart as persisting in the Pure North program but we do not infer the degree of adherence to the program. The In-Clinic Seniors Program (ICP) sub-sample of Pure North senior participants had over 90 per cent persistence in the program for at least one year. For this sub-sample, relative to the frequency of hospital and emergency department visits of the ICP seniors program participants and matched controls in the year prior to joining the program, the program reduces hospital visits for seniors in the program by 22 per cent, emergency department visits by 34 per cent and avoids 22 per cent of annual health-care costs. For the 68 per cent of the full sample of Pure North participants aged 55 and over who we can confirm persisted in the program for at least one year, relative to the frequency of hospital and emergency department visits of the program participants and matched controls in the year prior to joining the program, the program reduces hospital visits for seniors persisting in the program by 39 per cent and emergency department visits by 24 per cent. These reductions in health care system contacts result in public health-care expenditures avoided of 35 per cent per year. These magnitudes are comparable to what we calculated for the overall and Vital 2.2 samples in the full 2015 report. Not accounted for in those direct health-care costs avoided is the relief that preventative care can provide to the medical treatment system. Scaled to the population level, the reductions observed in the Pure North seniors sample would represent at least six per cent fewer visits to Alberta emergency departments per year and reduce the need for hospital beds by at least six per cent in the Alberta hospital system. In terms of freed-up hospital beds, this is equivalent to adding another Foothills Medical Centre to the Alberta health-care system., The School of Public Policy Publications, Vol 8 (2015)

The federal Conservative government recently began phasing in a plan to raise the age of eligibility for Old Age Security from 65 to 67. But a more sensible move for improving the effectiveness of Canada’s social safety-net system may be to actually lower the age below 65 and rely strictly on an income test instead, regardless of age. The government could go a lot further toward the reduction of poverty in Canada by building on the success of its income supports for seniors, and making them available to poor Canadians of all ages. Canada can boast of having one of the lowest rates for poverty among seniors in the world, largely due to its guaranteed income programs for those 65 years and older. When low-income Canadians turn 65 years old and leave behind low-paying, often unstable jobs, their poverty levels drop substantially. What a guaranteed income provides, that their vulnerable job situation did not, is a form of protection against budget shocks — a sudden volatility in income or expenses without the access to savings or credit to smooth things out until stability returns. A guaranteed income provides a kind of “disaster insurance” that can protect someone in a crisis situation from going without necessities such as food or even shelter. Statistics show that the rate of Canadians experiencing “food insecurity” — that is, lack of access to food because of financial constraints — is half that among Canadians aged 65 to 69 years than it is among those aged 60 to 64. Self-reported rates of physical and mental health improve markedly as well after lowincome Canadians move from low-wage, insecure employment to a guaranteed income at the age of 65. That dramatic shift in physical and mental health indicates that expanding guaranteed income programs to younger Canadians is more than a simple cost calculation: there are potential savings to be found as poorer Canadians, given a guaranteed income, become healthier and therefore reduce the burden on the public health-care system. Canadian governments already spend billions of dollars on the downstream effects of poverty, but scant emphasis is put on programs targeting poverty’s roots. There is no evidence, where smaller-scale experiments have been tried, to show that a guaranteed income program creates a serious problem with negative incentives and discourages people from working who otherwise might. But because this is a common worry with working-age guaranteed income eligibility, phasing in the program gradually, by lowering eligibility a few years at a time, will allow ongoing investigation and analysis of the effects, before the program is rolled out on a large scale. The tremendous impact that guaranteed incomes have had on reducing poverty and improving health among seniors is something for which Canadians can be rightly proud. So much so that it is incumbent upon us to investigate whether Canada could use the same policy tools to drastically reduce poverty and improve health among Canadians of all ages., The School of Public Policy Publications, Vol 6 (2013)

While Canada has socialized most of the costs of treating illness, Canada has maintained a reliance on individuals interacting through private markets to invest in upstream health promotion and disease prevention. The failure of the market to provide the efficient level of upstream investment in health is leading to large and avoidable increases in the need for downstream medical treatment. The way to reduce the future deadweight loss of illness and disease is for provincial governments to address the upstream market failures through an expansion of the scope of public payment for health care to include upstream services for health promotion and disease prevention. Perhaps somewhat counterintuitively, spending public health-care dollars across a broader range of health and wellness services can result in spending less in total, because of the efficiency gains that will come from better health in the population. That is certainly what the evidence from a unique Albertan pilot project leads us to conclude. The Pure North S’Energy Foundation is a philanthropic initiative that pays for and provides preventative health-care services for Albertans drawn from groups that are vulnerable to poor health. This includes homeless people, people suffering from addiction, people with low incomes, people in isolated areas and susceptible seniors. The health improvements observed in those participating in the Pure North program have been significant. Effective health-promotion and disease-prevention services obviously benefit patients. But there are also substantial benefits to society as well. The annual health-care bill for a Canadian in poor health is estimated to be more than $10,000 higher than for someone in good health, meaning that keeping people in good health can be an important means for controlling public health-care budgets, and can free up scarce acutecare hospital resources. If the Pure North program were scaled-up province-wide to cover the nearly quartermillion Albertans in poor health, the resulting health improvement seen in Pure North participants could translate into a nearly 25-per-cent reduction in hospital days used by Alberta patients every year and a net savings of $500 million on hospital and physician costs. That does not even include the economic benefits of keeping workers in better health and productive, while spending fewer days ill or hospitalized. To date, Canada’s approach to health care has largely left it to patients to choose whether to seek healthpromotion and disease-prevention services on their own, suggesting an implicit deference to an individual’s rights and responsibilities. But for many low-income, isolated, addicted or aboriginal Canadians, there often is no choice: These services, when delivered privately, are often too expensive or may be otherwise inaccessible. The initial spirit behind Canadian medicare was to correct a health-market failure, so that no patient would face barriers to accessing necessary treatments. That same philosophy also recommends extending universal coverage for health-promotion and disease-prevention to vulnerable Canadians who today face similar barriers to access. If the Alberta government wants to show both foresight and fairness, the benefits from this kind of program, economically and societally, are simply too attractive to disregard., The School of Public Policy Publications, Vol 6 (2013)

The boom and bust in energy prices experienced recently has its parallels in the boom and bust of energy prices in the 1970s and 1980s. The earlier boom period saw the Government of Alberta struggle with restraining spending and so became heavily dependent on high energy prices. When in 1986 energy prices crashed the government suff ered a string of large defi cits that was followed by draconian cuts to spending. From 2000 to 2008 the government enjoyed another boom in energy prices and again found it diffi cult to restrain spending. The recent crash in energy prices threatens the government with repea ng the earlier experience of defi cits followed by drama c spending cuts. As it prepares its 2009 budget the government has an opportunity to learn from the past and to quickly and decisively put its budget on a path toward a much smaller reliance on energy-related revenues., The School of Public Policy Publications, Vol 2 (2009)