Welfare and Health Care Systems at Cross-Purposes: Interactions Between Institutional Capacity and Institutional Design As Impediments to Reducing Social Inequalities in Health

Recent scholarship on the relationship between welfare states and population health has identified mechanisms of redistribution, compression, mediation and imbrication (i.e., overlap) that modify the impacts of the social determinants of health (Beckfield et al. 2015). Similarly, health care systems may reduce social inequalities in health, contingent on their relative capacity to provide quality, accessible and public health-promoting services across axes of inequality. The effective reduction of social inequalities in health relies on these systems’ combined and complementary ability to mitigate social and structural health disadvantage, particularly for individuals who are highly marginalized in complex ways. This paper theorizes that persistent social inequalities in health are linked to the interaction between the institutional capacity and institutional design of both welfare and health systems. The character of this interaction influences whether and how these systems reduce or exacerbate health inequalities. Through a case study examining the relationship between social assistance provision and drug-related harm in British Columbia, Canada, this paper highlights how deficiencies in the design and capacity of income assistance provisions can produce and reinforce institutional tension between welfare and health systems, with significant consequences for health inequality. The case draws on a growing body of evidence that links the monthly, synchronized disbursement of income assistance payments and insufficient income support levels to monthly spikes in drug use, subsequent and sometimes unmanageable escalations in drug-related health service utilization and elevated morbidity and mortality. By creating significant negative impacts on health service provision and health outcomes, deficiencies in the capacity and design of social assistance arrangements entrench health disadvantage for people who use drugs. The article concludes with a proposal to evaluate whether changing the design of income assistance provision away from monthly synchronized disbursement could mitigate tension between the welfare and health systems that exacerbate health inequalities in this context.