 Good afternoon. I'm Sheila Wildman, Associate Director of the Health Law Institute. I have the pleasure of introducing our new speaker today. But first I'd like to say a couple of words on behalf of the institute, which is co-sponsoring the Ines Christi Sipotian this year. The idea for this co-sponsorship and all the planning is really down to Bruce Archall, while Bruce and Elizabeth Sandberg and Mark Carter. It was Bruce who proposed bringing together our respective audiences, that of the Health Law and Policy seminar series, and the Ines Christi Sipotia. More generally, Bruce came up with the idea of integrating the symposium's traditional focus, the labor and employment law, with perspectives from the fields of workers' compensation and occupational health and safety. So the theme of the day is work and health. Those of you in the Health Law and Policy seminar series crowd are encouraged to stay on for the panels that will run through the afternoon. Work and health, yeah. There are copies of the program around with Ines' mug on one side of the paper. Work and health were also intertwined at the origins of the Health Law Institute. Well, Bruce mentioned this morning in his remarks that Ines Christi was Dean of the Law School when the Institute was created in 1991. Ines brought Bob Elgi and Philanterio to serve as the inaugural director of the Institute, and Dr. Elgi served in that role until 1996. Now Robert Elgi, who I never met, was one of those, you want to say, aggressive overachievers. Actually, I was advised by the Institute's administrative assistant, Bart Carter, who worked for Dr. Elgi when he was director and was a small shrine to him in a famine cabinet that he was gentle as a lamb. He passed away last year at the age of 84. Dr. Elgi trained as a lawyer and then a doctor, a brain surgeon in the West, and also held various positions in government in Ontario, including services minister of labor for a number of years. He was chair of Ontario's Workers' Compensation Board prior to moving to Nova Scotia and taking up the directorship of the Health Law Institute. And in 1992, while serving as director of Dow's HLI, he became part-time chair of the Nova Scotia Workers' Compensation Board. Ines, soon after, became the deputy minister of labor and then chair of Workers' Compensation, her Nova Scotia. So I think it's pretty clear that Ines had some big plans when he brought Dr. Elgi to Nova Scotia back in 1991, plans that crossed the borders, not only of law and medicine, but also work and health. Let me just say a couple of things about Ines. Ines Christie, as most of you are well aware, was one of those big people who saw the big picture and pointed you away to your place in it if only you pay attention. And it seems he did a little of that with Dr. Elgi. Certainly he did that with me. Like some of you in the room, I was in Ines's Labor Law class. He gave me a prize. A few years on, he was chair of the appointment committee when I was hired. I've never really got a proper chance to stay in a public space. Thanks, Ines. I owe you. I thought the world of Ines Christie, I loved his big, rough way of getting the job done. I loved his generosity of mind and spirit and the intensity with which he lived his life. I loved his enormous, world-rocking laugh. I'm told he was not always an absolute gentleman on the slush court. He took a few pages from the Don Cherry playbook. But that fits right in with all the rest. So I'm so glad that we're able to come together on this and on other occasions to remember Ines Christie in a manner so good by thinking out loud together. So with that, let me turn to today's speaker, another publicly-minded intellect crossing the borders of work and health, Dr. Cameron Mustard. Dr. Mustard is president and senior scientist at the Institute for Work and Health, which will tell you a little bit more about an independent, not-for-profit research center in Toronto. He's also a professor in the Dallas Land School of Public Health at the University of Toronto. He completed his doctoral training in epidemiology, health policy and behavioral sciences at the John Hopkins University School of Hygiene and Public Health until 1999. He was a member of the Manitoba Center for Health Policy and Evaluation at the University of Manitoba. Dr. Mustard's research takes up a range of questions relating to work environments, labor market experiences and health, including inquiry into the distributional equity of publicly-funded health care programs in Canada and the epidemiology of socio-economic health inequalities across the life course. Today he'll speak to us about disability and conspiracy programs in Canada. Thank you. Thank you, Sheila, very much. It is a real pleasure to be here and thank you for the invitation. For a lot of reasons, thank you for the invitation, but not for the weather. The metaphor here in the title, a patchwork quilt, I'll open this idea up for you as I go further into my remarks. Just for my benefit, how many of us in the room consider themselves lawyers, legal scholars? And how many here are people who see themselves in the sphere of protecting and caring for the health of Nova Scotians? So it's about half and half. That's useful to me. I'm an epidemiologist. It's kind of a weird species of public health, research disciplines concerned with the distribution of health in populations. But what I'm going to talk to you about today is the way in which in this country we have evolved income security programs for working-age adults who are having difficulty working because of their health. That's the disability idea. I'm going to talk to you about how over time in this country we've evolved a system which if I was an emerging economy asking for advice on how to do this, I wouldn't recommend the Canadian example. So I'm going to be, I hope, informative in my comments about what isn't actually optimal about the way in which disability income security programs play out for working-age Canadians. But I'm also going to draw, I hope, our eyes to the very great importance of social security programs that account for the fact that in the course of our working age some proportion of us are going to be unable to work either on an episodic basis for a period of six months recovering from a mental health disorder or perhaps more substantially we're going to have difficulties participating in work on a go-forward basis. And thinking about how we design income security programs that both provide adequate security but perhaps most importantly don't forget that each of us potentially has some contribution we can make to the world of work and thinking about how to design the supports and services so that that potential is realized is a societal ambition, a goal. We've eliminated mandatory retirement so it's increasingly unclear at what age we no longer are concerned about disability income security and are now talking about retirement pensions and we're an aging workforce. So there are themes in my talk that will be I think continuously present over the next 15 to 20 years as this country and all the other developed economies work through an aging workforce the importance of engaging as much participation from working age adults in the labor force as we can and improving, ensuring economic security for people who at various points in time have difficulty working. I'm gonna be drawing on work of myself and my colleagues at the Institute for Work and Health which I'll describe in a second. I'm gonna draw a bit on other work by Canadians and I'll draw on a little bit of international work as well but the primary focus of my remarks is on this country the state of play at this point in time. So here's a brief sketch of the Institute for Work and Health as Sheila mentioned we're an independent not-for-profit research center. The independent piece means we have our own board of directors it's multi-partied, there are labor representatives employer representatives and people who have experience in administering and leading research institutions established in 1990 so that's 25 years of contribution. We do work on the effectiveness of efforts to prevent the causes of work-related injury and illness and that effort focuses both on what workplaces do or don't do but also what regulators and institutions that can provide economic incentives are doing by way of orienting workplaces to preventing the causes of work-related injury and illness we do work on what is effective about treating and managing work-related disorders the majority of which or at least the largest share of which are arising from non-traumatic musculoskeletal disorders and we've been focused particularly in the last 10 years in thinking about how to support workplace practices around returning people to work who have been out of the labor force for a period of months due to work-related disorder how to bring people back to work successfully and retain their participation both in that workforce and in the Canadian labor force and the last bullet point is it may be not transparent to many of you but I'll open it up for you the idea that as an applied research organization that seeks to spend our resources in such a way that we're producing knowledge that's actually we hope relevant to contemporary practices in workplaces in Canada to figure out a way to help get that information to the many, many professional communities and workplaces in this country that might be able to use it so that's what that idea of knowledge transfer and exchange represents and about 20% of our resources are devoted to that engagement it's probably useful to provide a little bit more information we run on about 7 million dollars a year the staff of about 70 people of whom 15 of them are PhD-trained scientific staff that works out to about a dollar a worker a year in Ontario it's not a lot of money but on the other hand there's no other with the exception of Quebec there's no other research molecule in Canada that's funded as generously as we are to attend to or support the efforts in a provincial economy to reduce the burden of work-related injury and illness and our funding comes from the Provincial Workers' Compensation Authority so you can think of it as a contribution from employers workers' insurance premiums towards generating knowledge that is non-proprietary, hopefully beneficial and available to all workplaces in Ontario and I'm just gonna, Sheila, just acknowledge one thread here that ties the Health Law Institute and the Institute for Work and Health Together and that's Bob Elgy. So this is a lovely story. So when Bob Elgy was the chair of the Ontario Workers' Compensation Board one of the challenges that he and his senior leadership were facing is the decisions, sorry, decisions about what therapies to pay for in the treatment of work-related musculoskeletal disorders and Elgy, being a physician, recognized that maybe what we needed here was some evidence about what works so Elgy advocated for it, he wasn't the only voice the establishment of an independent research organization that provided advice to the Workers' Compensation Authority on the purchase of effective health services and that was the genesis of the Institute for Work and Health and it was shortly after that that Bob Elgy came here to do something else equally innovative which is to set up the Health Law Institute I think the first in the country, you know and maybe at the time people were scratching their heads going what do we need that for? Well, we know now why we need that. There are so many dimensions of the way life unfolds for us where our health and the legal framework in which we respond to that is absolutely fundamentally important and I think perhaps that the discussion today about disability income security will take us to that place although I'm not going to be able to speak to those of you in the room who are legal scholars, I'm not going to be able to speak to you particularly insightfully about what are the frameworks of legal, what are the legal frameworks that have set out the context in which we're in today. So the outline for my talk today I'm going to give you a brief summary of where we are in this country in terms of the prevalence of disability among working age adults I'm going to spend only maybe about five or ten minutes talking to the second point which is it's an idea that I think we can give some greater attention to which is the ways in which within workplaces we can actually prevent disability and I'll try to illustrate the ways in which we're making I think important progress in this country the third theme will be to illustrate for you how the disability income security programs in this country are best I think described as a patchwork quilt and that metaphor contains a lot of ideas in it the idea that the parts of the quilt are composed from fundamentally different pieces of fabric in terms of who made them and what they're intended to do but also the idea that it's been stitched together to try to build I shouldn't even use it that way it's been stitched together in a way that there are gaps and disparities in the way the income security programs play out for Canadians I'm going to offer a few international comparisons and then provide a summary of some observations good so far? So some remarks at a very high level the health benefits of employment we can sometimes perhaps be come to think of work experiences as in some over to say the period of a working career contributing to the deterioration of our health and for some of us that's true that the occupational experiences the occupational demands that we are engaged in 20 or 30 years can take a toll but the general I think finding across many different societies in many different times is in addition to being the mechanism by which we distribute economic resources in a society that's work it has other benefits it contributes to somebody's identity in terms of who they are lots of psychological needs are fulfilled and there are ways in which work can contribute to better physical and mental health and if you flip it around the other way and compare the opportunity to be engaged in employment to be to the opportunity not to in other words unemployment the evidence from the field of epidemiology around the adverse health effects of unemployment are very clear mortality, poor mental health and higher use of health services among those of us who are exposed to either temporary or chronic episodes of unemployment so the health benefits of employment are substantial but so are the negative effects of employment on health these negative effects are I think what's the word as we pass through each of the last 50 decades these negative effects have been declining so I could say work is safer work is healthier over the last 50 years without any hesitation but work can continue to be improved in terms of the ways in which it causes preventable morbidity among the Canadian workforce if you were to sort of cost out what the economic burden of work-related injury and illness in Ontario represents it's about 3% of GDP it's not a number you can just sweep under the carpet it's a lot of money and that's an estimate of both the direct costs and indirect costs to just paint a portrait of what the personal burden is in terms of lives changed in my province two traumatic fatalities or about 100 a year now three times that annually number of deaths due to occupational disease where it was a work exposure that was the underlying cause of the development of the disease in this case primarily cancers and more than 1,500 disabling injuries a week in my labour market of 6 million people ok and then if you were to look in the province in terms of lost work days both due to work-related and non-work-related injury or illness in the course of a year you're looking at about 135,000 person years of work that are missing because of work-related non-work-related illness or disability so the health effects are not insignificant of employment to then just draw our eyes a bit to the idea of disability I'm going to spend a moment just talking about exactly what do we need and I'm going to use the I'm going to reference the way in which our national statistics agency approaches this so these data are from statistics Canada so the idea of disability is that a health condition or a health impairment has the consequence of limiting our ability to do certain things tasks or activities that are valuable to us that we value so the idea is that a health impairment results in a limitation around activities that we would wish to engage in in order to participate in activities that we value one of those activities being work that's one but so are leisure activities so the statistics Canada measure of disability in Canada goes something like this a respondent to a survey is asked the question do you have a physical or mental condition that's lasted at least six months that limits your ability to and I'm not going to bring it with me did I do it? I did okay it goes like this does a long-term physical condition or mental condition or health problem reduce the amount or kind of activity you can do sometimes often never and these estimates here are the people answering sometimes or often there are further questions asked about in what way in what domains of your life does this limitation occur does it occur at school or at work in other activities it's a really important thing to try to measure but it's a really tricky thing to measure with a degree of precision confidence, reliability and I think to the credit of statistics Canada they've always been uncomfortable that they're not entirely sure what this is but that they know that it's important so with that as a background and I would say let me put it this way most of the developed economies now estimate the proportion of say working age adults who have a disability by using a similar framework is there's something about your health that's limiting what you do and what you do is something that's important to you so this is all cause disability whether this is vision impairment musculoskeletal impairment cognitive impairment whether it's congenital or acquired whether it's been around only for the last six months or from the day you were born it's the composite of all of those causes produces estimates like this such that by the time we get to 45 to 54 year olds in 2006 15% of us are saying yep there's something about my health that's getting in the way of stuff I like to do so it rises with age and it's been going up a little bit in the population so you can see the difference in the bars between 2001 and 2006 some of this increases due to the way in which the population is aging but you can see this is age stratified so other things are going on we are probably expanding in our minds as we respond to these surveys individually what we think is an appropriate answer and there's probably a reduction in social stigma concerning the reporting of disability that's contributing to this gentle rise as far as I think we would it would be our view let me put it this way it would be our view that the underlying health impairments that result in disability are not rising particularly quickly in the Canadian population in fact for many conditions we're seeing improvements over time such that the health impairment piece of this is not what's driving this and here's one of the ways in which in which health impairments disable people and that's in terms of their participation in the labour force so two time periods, five years apart the labour force participation of people without disability and the participation of people with some degree of disability some of it is severe, some of it is mild and we're reporting the proportion of people in those categories who are participating in employment and one of the important observations here from 2000 to one to 2006 is the proportion of people who reported that they had some degree of disability who were in employment was going up and we can see this in the developed economies, I don't think this is some artifactive measurement I think this is for example in this country an expression of the impact of in Ontario the reform to the human rights code in 1987 Bob Elgie Bob Elgie did that as the minister of labour I may have the year wrong, no it was before that 1978, Bob Elgie, minister of labour reformed the human rights code this is before the federal charter to add to the to add that people with disabilities cannot be discriminated against the disability discrimination piece so we've been seeing over time in this country an expanding expectation that disability is not a barrier to employment should not be a barrier to employment but the gap in labour force participation remains very substantial about 22% difference now I'm going to change the theme a little bit to the idea of how are we doing in this country these snapshots are mostly from Ontario in terms of our efforts to accommodate people who have health impairments in employment and I think these examples if I'm not mistaken these examples are not exclusively drawn from the workers compensation regime and I'll explain that in a bit more detail but they mostly are so here's an example of positive progress in 1994 which is now 20 years ago we had the opportunity to interview 1500 workers who had been disabled by a musculoskeletal disorder and the interview took place at about the 30th day of disability one of the questions that was asked to them was has your employer spoken to you about how he or she the employer could modify work in order to accommodate you coming back to work before you fully recovered so this is the idea that I've got mobility but I've got a lot of pain I'm not sure I can go back to work and the employer if the employer can accommodate that by modifying work you could come back to work that's the idea here 1994 25% of workers said yeah yeah my employer called it's not a very good number meaning 75% of workers were essentially out of touch with their employer 2005 only 10 years later 600 workers it's the same model 30 days into the disability episode asked the question has your employer been in touch with you 60% said yes it's actually a pretty important change in a short period of time why did it change it's changed because legal counsel speaking with employers has been saying you have a duty to accommodate it's because workers compensation schemes have a set of financial incentives that may get a positive action for employers to do this bring people back to work before they fully recover so this is a portrait of a change in the right direction this is another example of a change in the right direction this is just a snapshot from a a very high quality service in Ontario that is advisory to both workplaces and labour unions about labour law called Lancaster House quite good they do workshops and conferences and webinars and stuff and here's just an example of an hour and a half webinar on what are the employer's obligations around the duty to accommodate an employee who has a health impairment excellent this is not easy to do you want to build skills in most workplaces all workplaces you want to build skills to be able to respond to this legal duty in human rights and the charter to accommodate people with disabilities so that you're not discriminating okay and here's just take me a moment to explain this to you but it's a portrait of diversity it's not a portrait of progress this is a snapshot at two points in time 40 long term care facilities in the province of Ontario nursing homes caring for primarily elderly often cognitively very seriously cognitively impaired members of the community the work in these facilities which is what we're showing you here is very high in terms of physical demands caregiving in these settings very high physical demands and it's low wage work okay and it's gendered okay mostly women okay but it's very important work so the left hand side is showing a portrait of the dot each dot is a long term care facility and it's the facilities disability days at two points in time 2005 on the bottom axis 2006 on the vertical axis and the point of this is that a facilities the intensity the number of disability days per hundred staff is not a random event it's a trait almost of the facility to try to put this in proportion for you a thousand disability days for every hundred staff let's imagine that each person works 200 days a year yeah that's about right sort of a thousand disability days means that in that facility there are five person years of absence for every hundred staff five full person years of absence that's a lot of disability okay and what the left hand side is saying is that there are a small number of facilities in which the incidence of disability is very very low these are disability days counted as the persons not able to be at work because of their health and the health issue is primarily work related in other words it was caused by work that's how we were counting it in this context there are a small number of facilities with very good outcomes but the majority of them have some work to do okay the right hand side is a different portrait of the disability days that a facility was the staff were experiencing in the facility what proportion of them were managed to use an awkward word by the employer providing modified work this is we believe largely a good thing so modified work is where the employer says okay and you can't do your regular work because of that sprained knee but we have something equally useful for you to do that doesn't require that you use your knee and if you could do that for two weeks for us we'll bring you back to work okay so that idea here is represented by the long-term care facilities in the top right corner and again this is the same this is 40 facilities two points in time separated by year how are they doing and again it's a trade of the facility that about a third of the facilities are figuring out ways to bring people back to work by adjusting the work that they're asking people to do and about a third of the facilities in the bottom left hand corner are not doing that okay so some themes over the last 10 or 15 years and I think we can say this is pretty much the case across this country it's not just Ontario that the influence of employment law council to employers and the behavior of disability income insurers has had the following influences I think that in medium and large employers it's increasingly rare that you will not find something called an accommodation policy or a disability management policy it's increasingly rare generally these policies are supported by organized labor in fact I think it is fair for the steel workers of this the United Steel Workers the Canadian you know the Canadian arm of the United Steel Workers to say that they've actually led this country in terms of embedding in collective agreements the principles of disability management okay so this is not adversarial employers can do this they can do it cooperatively or with the participation of organized labor and it's very much good thing a good thing what it does is it creates a platform of discipline in the workplace about fairness of process everybody should be treated the same and the process is clear it has been the case that increasingly the insurers in long term disability plans which I'll describe a bit in a moment have introduced active case management what that means is that the insurer just doesn't pay the benefits to the disabled worker the insurer is actually making phone calls that's case management the insurer is calling up the healthcare provider and saying how come you're not more optimistic that you know and could maybe get back to work it's that kind of thing not coercive just looking for ways in which there may be opportunities to advance progress towards getting people back to work we see the same thing in workers compensation boards historically in this country workers compensation boards saw their job as adjudicating entitlement and paying benefits but increasingly across the country while those two functions continue they're also engaging with the question of what's not going right here in terms of getting somebody back to work is it an obstinate workplace is it a healthcare provider who's actually a barrier to a worker returning to work where is the obstacle and the final point that we're seeing some significant information technology investments which are really necessary to support high quality case management services so the summary to this point about the prevention of work disability and the idea here is if the employer is vigilant and attentive and is able to and is committed to accommodating people with health impairments we can prevent the kind of disability at work that we really really want to prevent which is somebody gets knocked out of the labor force for the rest of their life that's what we want to prevent so that's the idea here of work disability prevention and I think we're making important and sometimes quite impressive progress at the level of what our workplace is doing so I'm now going to turn to the theme of the metaphor of the patchwork quilt and I just want you to work with me on this scenario and tell me what you think the outcome is the idea about this scenario is it depends what kind of work you do what your occupation is it depends those things influence which disability income security program you end up having entitlement or access to so the scenario unfortunately is the same motor vehicle collision, spinal cord injury permanent disability these are all men the first man self-employed construction worker driving to his work site second is a male insurance manager with 10 years of employment tenure and the third is a male commercial truck driver so the self-employed construction worker would he or she be eligible for employment to workers' compensation benefits in the province of Nova Scotia okay we're not sure okay in Ontario not if you're self-employed whether you're a self-employed videographer whether you're a self-employed filmmaker self-employed musician, self-employed construction worker you're not eligible to ensure the male commercial truck driver is in an employment relationship would he be covered workers' compensation this is just driving to work no sorry the first one the first case was driving to work the third case he's driving in the course of employment and he has an employment relationship so the third one is covered by workers' compensation the second one it's a little unclear whether this individual was driving in the course of employment but it kind of doesn't matter because this individual is probably covered by a workplace long-term disability plan okay so here's the story the first person probably did not take out an individual LTD plan probably didn't because they're fairly expensive he is not covered by workers' comp because of his self-employment we'll explore then what sources of disability and come security might he have and we'll explore that this is the Canada Pension Plan disability benefit if he has paid in if he has paid in his contributory requirements absent that let me pause and say he would probably qualify for CPP disability because of the nature of the severity of the disability but absent that entitlement the building up of the contributions this individual would be likely a social assistance beneficiary okay the third person probably the highest paid of these three is in a workplace setting where there's employment provided LTD plan the third person would draw benefits from the provincial workers compensation scheme because the injury arose in the course of employment so let me then just now look at the this is the fiscal portrait of disability benefit expenditures in Canada it's a lot of money million dollars and I I don't want to be unkind but I'm going to be critical statistics Canada can't count this this is twice the amount of money that is paid this is an amount of money twice that that employment insurance pays out in this country employment insurance is a very important social security program covers people for the economic losses arising from loss of employment we hope that loss of employment is temporary and EI fills in that gap but this is 25 billion dollars it's twice the 12 billion dollars we pay it annually in EI and statistics Canada can't count this up this work was done by somebody who we have a great deal of respect for John Stapleton who did spent his career in the Ontario Public Service working in the social assistance policy area and John's taken it upon himself to build this information up from provincial and national sources the point here though is to give you a sense of how this is the beginning of the portrait of the patchwork quilt we have in the top left hand corner about 5 billion dollars a year paid out for employment based long term disability plans we have at least twice that much paid out in provincial social assistance programs for people who are qualifying for a disability benefit we have about 5 billion dollars in workers compensation the oldest social security program in this country coming up on its 100th anniversary may have already been 100 in Nova Scotia not quite, thank you it's such spring, alright thank you just note that damn the oldest social security program in this country founded in 1907 depends on which province 1915, 1617 it's been with us continuously since then it's funded by the insurance scheme is funded by contributions premiums paid by employers there's a wonderful historic compromise about how this all came together and it's still with us we still need it it's 5 billion dollars a year paid to cover the cost of medical care and the wage replacement benefits for temporary and permanent disability arising from work related causes 5 billion dollars a year okay there's some tax measures that are relatively small and 2008-2009 the Veterans Affairs federal government program the responsibility for disability benefits of about 2 billion dollars for people who've served in the Canadian Armed Forces and about 1995 I think the employment insurance scheme introduced a sickness benefit which is time limited benefit of I think maximum of 15 weeks that people can qualify for if their health is impairing their ability to seek to look for and find employment just by the way the tax measures I think is now up to about 2 billion dollars this snapshot is about 5 years old because I won't go into the detail of what it is but the Canadians are drawing upon that tax credit instrument fairly actively and among the things that we lost when Jim Flaherty died was a champion in the federal current federal government for addressing the needs of Canadians with disabilities and many of the tax measures that we see here are not exclusively but are largely out of Flaherty's leadership in the current conservative federal government okay so this is just a snapshot of a short document that is the summary work that underlies that pie graph that John Stapleton put together that Stats Canada account for reasons that's another story but they should count it because it's 25 billion dollars and it represents an important intersection between health and economic security of Canadians okay so I'm now going to do a sketch of four of the seven disability income security schemes to try to communicate a bit of a flavor about how easy it is for this patchwork quilt to create gaps where either eligibility can't be established by somebody where the benefit amount would probably not meet our standards of sufficiency okay so the opening statement is unlike many OECD countries disability income insurance programs in Canada are poorly integrated there are many countries that just use one they tend to be northern European stereotypically you know Scandinavian but they're not exclusively Scandinavian we've managed to evolve a system that is reliant on a diversity of programs we have the national pension plan which has a disability benefit program in it the Canada pension plan is financed by contributions from employers and employees okay it's contributory jointly we have the provincial workers compensation agencies they're publicly administered they're monopoly insurers it's mandated that employers if they're in scope have to participate and it's funded by premiums paid by employers so the employee isn't contributing here we have provincial social assistance programs they're funded by general tax sources and they have a disability benefit program and the last example or the last model I'm going to describe are employment based long term disability plans and these employment based LTD plans they're voluntary there's no mandate that employers must provide them the provider is the private insurance industry in this country which is I won't go there for a moment and although who's actually paying the premiums in these plans is variable it depends on what the arrangements are it's not unusual to find LTD plans that are fully funded by employee contributions where the employer doesn't contribute okay is that for tax reasons I don't know that it's a taxable benefit for you that's a false it doesn't lead you anywhere because what employers do is say the employees will pay 100% because they will benefit back yeah okay so there's a little sketch of who's paying into what for what purposes but here's a little bit more detail the Canada the Canada pension plan the disability benefit it's a national program so this is federal so if you're a CPP contributor you're eligible to build up entitlement towards the disability benefit the number of beneficiaries about 300,000 the benefit expenditures in the years about $4 billion the plan elements it's contributory in other words you have to contribute as an employee and employer in order for the employee to have the opportunity to apply the benefits are not generous about 30 to 40% of I'm just using the phrase the average industrial wage they're not generous benefits the CPP disability plan has a very stringent definition of disability severe and prolonged disability such that a person is incapable of any gainful employment this is a very stringent definition as a consequence CPP has no history of providing service supports for labor market reentry if you're a CPPD beneficiary you will endeavor historically up until recently you would not have gotten any advice from CPPD about what your potential might be to return to the labor force in some role a technical detail that CPP is treated as the first payer and not surprisingly but related to the stringency of the definition about 30% of only about 30% of applications are approved so there's an extensive appeal of activity it takes a long time to get a CPPD application approved it's an administrative frictional process workers compensation these are provincial programs so to the credit of the federation every province has one they are remarkably similar despite that sort of stewardship by 10 and now 10 provincial legislatures they're remarkably similar the beneficiaries annually in terms of number of new I'm getting confused here between new cases and stock I think that's the numbers of people in any year receiving a long term disability benefit in other words expected to be paid over multiple years it's not an incidence every year it's 130,000 in a year expenditures about 5.4 billion the entitlement here arises from the employment relationship so people who are self-employed in Ontario are not eligible to contribute here but the large majority of we shouldn't say that look up at the top the coverage of these programs ranges from about 96% of workers to 70% of workers in Ontario so there's some uncovered employment relationships in Ontario that are covered in Newfoundland this is just to describe some provincial differences the benefits are relatively generous in fact they are intended to be they are intended to replace the wages of approximately 85% of post-tax pre-injury earnings definition of disability permanent and permanent effecting work capacity and interestingly the workers' compensation schemes across this country have had very strong service supports around helping people get back to work contrast that with CPPD which has the expectation that you're never going to work again so we won't provide you any service supports the workers' comp schemes are very active in making investments to help people get back to work with full assistance the disability benefit these are provincial programs everybody who's a citizen is eligible beneficiaries it's a hard number to come at it's probably about 500,000 people at any point in time expenditures about 8 billion dollars it's not contributory in the sense that you don't pay in contributions to earn eligibility but the entitlement is means tested you have to be you have to show that you have no income and that your wealth your stock of wealth is very low the benefits are very low it's basically poverty if not it's below poverty it's a fairly stringent definition of disability and again the social assistance plans in this country really don't have an expectation of labor market reentry and the last of the four that I want to illustrate are the employment based LTD plans they begin to show up in Canada I think in the 1980s I could be wrong in my sense they're voluntary this is the private insurance industry making available to employers and their workforce insurance plans to cover wage loss in the event of work disability typically for causes that wouldn't be covered by workers' compensation so a woman with breast cancer in her 50s or somebody who is knocked out of work due to a chronic depressive condition would be the kinds of conditions where we're not attributing the health condition to work causes but the consequence is the person can't work maybe 200,000 beneficiaries but this is hard to tell because this is the private insurance industry at work and they will report on their benefit expenditures but they don't really talk much about how many Canadians are receiving benefits they do talk about how many Canadians are insured but they don't talk about how many people are receiving benefits contributory typically employee funded benefits are moderately generous 65% of pre-disability earnings a moderate definition of disability very high expectation of labor market reentry actually these plans drop benefits after 24 months from the from compensating people for the earnings they would have had in their previous occupation to compensating them for earnings they would have in any occupation so the benefit amount at 24 months just drops right down so there's a sketch of how we've built things in this country it is a bit of a patchwork quote and you think back to the three scenarios that I opened this section of the talk with and you can appreciate that depending on what occupation you're in and what the circumstance of the moment was you may end up in any one of these circumstances and I do just want to point out that the coverage of the Canadian workforce by private LTD plans has basically stalled at about 50% it's been 50% for employers it hasn't gone up why hasn't it gone up hasn't gone up because the part of the market that is feasible for the private insurance industry to insure is insured the part of the market that's hard to do smaller employers less stable workforces the insurance industry is not really reaching out to cover them so there's about 50% of the labor force it's probably 45% does not have access to this kind of insurance I'm just thinking about where I am in my remarks how's it going so far is it good the right amount of information more than you ever wanted okay there's not actually that much data in this talk for an epidemiologist this is a portrait I think what I do is just draw your eye and call them where we've got men and women in three age groups and these are rates per thousand so the idea here is that by the time we get here 55 to 64 years of age my age 1 out of 10 women and 1 out of 10 men is receiving a disability income security benefit in this country 1 out of 10 and where are they receiving it from is what the columns are I don't think that's particularly germane today but 1 out of 10 at the highest age groups that's the impact of probably two things it's the way in which as we grow older our health can start to be more consequential for our labor force participation but it's also telling us something about the way in which at the end of our working career people may have certain choices about how they're going to leave work before they're eligible for retirement it may be telling us something about that too and the overall number for the Canadian Labor force in 2001 which is now a long time ago is about 5% of women and 5% of men so no gender differences in the prevalence I guess I would say of disability income security beneficiaries but a strong age gradient as you probably would expect so you may be asking yourself the question I know we did we got hit by and we're still working through the impact of the global financial crisis in 2008-2009 what happened as people in the labor market got knocked out how did the disability income security programs how did they fare people in the Canadian labor market either fell out of employment or we're seeking employment in the post recession period when the unemployment rates up the number of job opportunities is down what happens well one of the scenarios that labor economists will talk about I'm not one of those people so this is what they talk about is that people will seek out alternate sources of income that can't succeed in the labor market so the speculation that during periods of economic challenge in a developed economy you will see an increase in people applying for social security benefits certainly but perhaps disability benefits and certainly the US social security what's that benefit called social security disability benefit we've seen very large increases since the recession in Ontario we basically saw only one program spike so there's six programs here there's six programs here they're generally all going up at about what sort of inflation plus labor market aging would expect us to see over about a five year period this one here is the social assistance for the disabled program the provincially administered essentially welfare program lowest benefits but universal entitlement okay that it would appear that all of the other programs kind of however they did it sort of held the line in terms of maintaining the entitlement criteria that they had before the recession blew through and didn't substantially increase the number of beneficiaries is that the story kind of clear maybe maybe say again no government's vote for reelection okay so as we move towards I think I'll skip over this let me just do a few things about some international comparisons the I think I'll go here first okay so over the last ten years there's been a very talented team in the OECD the organization for economic cooperation and development which has been looking in at a fairly fine degree of detail at the disability policies in about 15 member countries in the OECD and it's been a fascinating set of studies about the diversity of ways in which these are mostly northern European countries have built policies which try to achieve two things you want to provide economic security to people during their working age if they can't work because their health is getting in the way so the economic security piece but you also want to have policies that are actively supporting people participating in work and returning to work and it's they're not contradictory but they're by no means mutually supportive policy goals and the OECD work has identified sort of typologies of countries if you will so the UK for example is a country that has adequate benefits but almost no encouragement over the last 20 years to help people get back to work Scandinavian countries are a good balance of adequate benefits and pretty aggressive efforts to help people go back to work and Canada there's a country study of Canada in this series which was one of the last countries and we met with the study team and after they'd sunk their teeth into Canada for about two months they came by our offices and they said is this really what we think we're seeing here all of this bits and pieces and federal and provincial and and I said yep that's what it is so the OECD recommendations for Canada the study team recommendations for Canada are very thoughtful around the necessity of figuring out a way in this federation to improve the coordination of services between these programs this is largely for the benefit of the beneficiaries in the programs anyhow just let's see Sheila says I've got a few minutes left okay let me just do one other little observation here this there's a portrait of a small number of countries we would think of them as our economic competitors we probably see them as our social peers in terms of what these countries have accomplished for their citizens the first column is of all the people in these countries who are disabled what proportion are employed so Canada is at the lower end of a scale that doesn't go very high right so in Canada who are disabled 40% are in employment according to the date of this work and that's at the low end of what we observe in other countries move over to the the second last column on the right of those people who are unemployed or not active in the labour force because of disability right how many don't receive any benefits at all so that's 15% which is a concerning number it's not the worst on the chart but it's by no means the best on the chart so the 15% are persons with disability who are neither in employment nor receiving benefits sorry would it be part time yeah okay so I think I'm going to wrap up because you might have some questions of me that you'd like to kick around okay I'll do it here okay so here's a summary of the patchwork quilt the historic scheme in this country for protecting workers in the event of disability at work limited to those causes that are attributed to exposures at work ensures approximately 25% of the disability that we see in this country these days that's not bad but it's just to put it in context that the workers' compensation schemes 100 years old their coverage is only 25% of the disability that we see in working age adults disability benefit coverage is very uneven from universal to in the case of LTD plans only 50% of the population there's large differences in benefit generosity and with one exception which was the example of the expansion of social assistance beneficiaries in Ontario for the disability benefit we haven't really seen any significant trends in the incidence of disability beneficiaries and I think the final slide the final point here is consequential and I'm thinking back over the last 10 years we really haven't seen any significant reforms of public programs and especially the concern that the public programs are this is a strong word discouraging labour force participation but perhaps put it more positively not doing enough to encourage labour force participation and I would acknowledge that those people who are policymaking or have been policymaking over the last 10 years have had to fight some pretty damn significant fires arising from the global financial crisis so perhaps understandable that at this moment in time we haven't seen any particular attention to how can we enable the participation of people with disability in the labour force Sheila, I'll stop there thank you very much so I just call it a I feel a lot of times it's there and understanding whether these people are able to work with their employers or creating more accessible work places or is it because people have disabilities and don't have accessible work places that can't afford to not work I don't know the answer I think it's a bit of both my sense in general is that the access to disability income security benefits has not become more constrained over the time period so I think it's probably more the former that employers are seeing slowly but surely the ways in which people with health impairments can be productive workers in their hiring good question, thank you from my experience it seems some of these programs seem to think that making accessibility to the benefit more difficult and more stringent is a way to incur additional force to people that have to work with and my sense is and I don't know just the question you use is there been any studies where the adverse effects with that kind of stress on employees who are disabled and can't benefit and they may for example have different social systems with all that and instead of taking long-term disability or WCD that's a great question so one of the ways in which this patchwork quilt fails us as a society is we don't have good information there's no accountability for documenting the journey so the journey is I'm a full-time trades person I've worked for ten years I had a pretty serious upper extremity injury I received workers compensation benefits for a period of time and then that program made the decision that I'm okay to go back to work an adjudicated decision that I'm okay to go back to work but I can't what happens to that person on their journey their next stop is probably social assistance so that the way in which people move through programs is not documented in this country nobody's accountable for it no authority is accountable for it you'd hope in a province that somebody would say to those two authorities you need to tell us how that's happening but nobody has so it's a great question yes sir these disability programs for payments are they very taxable like when you're calculating the cost to groups are you right paying it out but then so they're not they're not taxable I'm just pausing on the private LTD plans but I don't think they're taxable one of the reasons statistics Canada can't count disability benefits is because they're not we're not required to record them when we file our income tax returns because they're not taxable yeah exactly yeah it's an astonishing blind spot as a consequence we don't know we just don't know did you have a question hi Diane um when you're talking about accommodation there's a specific focus only on individual accommodation and I think that a public force of individual versus systemic accommodation and what I mean by systemic accommodation is designing the things in a way that avoid problems that don't do in a way that's most on the individual I'm I'm I'm I'm I'm I'm I'm sorry individual accommodation enabled me to use this a car to read um I'm now a child the last few years of my employment I got an iPad and it made things in a lot of it it's not perfect it works from my perspective but it dealt with a whole lot of issues quite well and still doesn't know what it is definitely not but an example of how somebody out there who's a systemic accommodation I hope right through it in terms of being able to read things in a font that's comfortable for me even though the blackest font is small so it's obviously not that it can't come down that's a great example that's a great example but if we use one more example I don't know if you will consider this um your slides I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I