COVID-19 has highlighted the importance of strengthening universal healthcare to reverse the decades of cuts and to expand healthcare for all. The pandemic and economic crisis also shine a light on dental care, which is at risk of further erosion because it is already privatized and increasingly corporatized. Spring Magazine spoke with Brandon Doucet, a dentist based in Newfoundland, about the importance of oral health, the problems with for-profit and corporate dentistry, and the need for universal dental care. Contact coalitionfordentalcare@gmail.com if you are interested in helping advocate for universal dentalcare.
Can you tell us a bit about yourself, and what led you to dentistry?
Well to start off, I grew up in Saint John, New Brunswick, which is also where I did my undergraduate degree. It was early during my undergraduate degree that I became very interested in the medical field. I was doing research on antibiotic drug discovery from plants that First Nations people used medicinally. I became very interested in antibiotic drug resistance. From this, I began exploring different medical specialties and I realized that I wanted to work with my hands. As a result, I became interested in the small surgeries performed in dental clinics and pursued a career in the field.
What are the challenges you face providing dental care to those who need it when there’s no universal dental care?
As a dentist, it is very difficult to make a significant difference in peoples lives without universal dental care. Since many people cannot afford dental care, they will neglect minor problems until the issues can no longer be ignored, at which point they will visit the dentist. I end up extracting many teeth because they are too broken down to salvage.
It is common for an individual to come to the clinic requiring an extraction of all of their teeth. One of the first cases wherein a patient presented to me in this state was an eye-opening experience. Initially, I felt the procedure was too difficult, so I referred the individual to another dentist in the area who is comfortable doing these types of procedures. I later found out the dentist I referred the patient to would not see them because the patient could not afford the fees, despite the patient desperately needing care. I was surprised that someone would turn a patient away for this reason, especially considering they had coverage through social services that would cover about half of the $3000 operation. I ended up doing the procedure myself.
This experience was a harsh reminder to me regarding the limits of my individual action versus structural change. Real structural change towards universal dental care means that many people would not need all of their teeth taken out because they could seek treatment sooner.
What are the health, social and economic impacts of poor oral health?
Oral health is intimately related to overall health. According to the Canadian Association of Emergency Physicians, poor oral health may cause or worsen the following general health conditions, “cardiovascular disease, diabetes, having a low birth weight infant, aspiration pneumonia, erectile dysfunction, osteoporosis, metabolic syndrome and stroke.”Research has also shown that providing comprehensive oral health care to patients with drug addiction led to an increased likelihood of completing treatment, increased employment, decreased relapses of drug use and reduced homelessness.
Poor oral health is intimately related to the cycle of poverty for several reasons. For one, it is difficult to find a good paying job when you have missing or decayed front teeth or if you are living with chronic dental pain. Furthermore, dental care is expensive and if you need to neglect minor and preventative procedures, cavities grow, and you are left with more expensive emergency procedures to pay for.
Canadians pride themselves on public healthcare, but most dental care is private, leaving people without dental insurance to either pay out of pocket or avoid dental care. What’s the scale of the problem, and how does it disproportionately affect workers in precarious jobs, racialized and migrant communities, and elderly people?
Dental care in Canada is more consistent with a private US style healthcare system than our universal healthcare system. For example, over 1/3 Canadians lack dental insurance and 6.8 million people avoid the dentists each year due to financial constraints.
These numbers have been growing and will continue to grow for several reasons. One is that the baby boomer generation has been retiring in large numbers, and as such they have been losing dental insurance tied to their employment. Meanwhile, younger generations are increasingly working in the precarious ‘gig economy’, which provides temporary employment and does not provide dental insurance tied to their labour. This means more people will neglect dental care and live with chronic dental pain as they cannot afford care.
The inability to access dental care is experienced by certain communities more than others. Communities where people work precarious and low wage jobs are more likely to struggle accessing dental care. When the pain gets too much to handle, people are forced to use their credit card to pay for the necessary care.
The African Canadian community is particularly susceptible to lacking access to dental care. Due to historical and ongoing systemic racism, unemployment among African Canadians is 60% higher than white Canadians and African Canadians earn on average $15,000 less than white Canadians. Higher unemployment and lower wages mean African Canadians are less likely to have dental insurance and more likely to lack access dental care. Migrant communities face similar struggles to the African Canadian community in accessing care.
Free-market ideology claims that private services are more “efficient” and “cost-effective” than public services. What is the impact of private dental care on overall dental costs, and on public healthcare?
When we consider the ‘efficiency’ of private dental care we need to understand what that truly means. ‘Efficiency’ is a term often used to imply that profit making is a valuable gauge for success. However, we should ask ourselves whether profit making is a good indicator of the health of a medical care system.
One reason we should not consider profit making as a good indicator of our dental system is that it does not measure the full cost. For example, a private health insurance company is very profitable because it provides dental insurance to people with money and low dental needs while neglecting poor people with high dental needs. I would argue this is inefficient because it does not take into account the cost of leaving the highest risk people uninsured. A 2014 study in Ontario found that doctor’s offices were visited 222,000 times and emergency departments 61,000 times by patients seeking treatment for dental pain, costing taxpayers a minimum of $38 million dollars per year. Private health insurance companies are only profitable because they can externalize the cost of neglecting those who need care the most.
Forcing people to neglect dental care and allowing problems to compound is expensive and ruins the ‘cost-effective’ argument for private dental care. Those who claim private dental care is more cost-effective only refer to government spending, but they neglect overall spending. Countries with universal dental care spend significantly less than we do. In 2010. Canadians spent on average $309 USD, whereas countries with universal dental care like France and the United Kingdom spent $175 and $141 respectively.
Private dentists in Canada have fought to exclude dental therapists from the dental community in order to maintain their monopoly. Dental therapists are mid-level dental providers that perform simple procedures like fillings at a fraction of the cost of a dentist.Universal public dental care provides the opportunity for billions of dollars in savings by re-introducing the more cost-effective dental therapists on a mass scale.
What is corporate dentistry, and what impact does it have on patient care, dental costs and dental education?
Corporate dentistry is a trend where large corporations and investment firms buy up dental practices and take over the administrative aspects of the dental practices. Dental corporations (DC) are an attractive investment as they often produce a yearly return on investment of 15%. The extent of the problem in Canada is not fully known as DC do not reveal the change in ownership of a practice to the public. The Dental Corporation of Canada does boast on its website of owning 350 clinics and serving over 2 million clients per year.
Owners and investors in DC are capitalizing on trends in the dental profession. For instance, new dentists are graduating with a lot more debt than previous generations, often more thant $250,000. Since new graduates are heavily indebted, they are less likely to take out another loan to buy or set up a dental clinic. As a result, new dentists are often looking to work for an established dental office with a steady stream of patients rather than owning a clinic. While many younger dentists are not buying practices, there are many older dentists who are looking to retire and sell their dental practice. This leaves a window of opportunity for outside investors to buy up dental offices and hire younger dentists to work in them.
Owners of DC have figured out how to earn massive profits and dentists still want to earn the same salary as before, leaving the added costs to be pushed onto patients. Added costs to patients come in the form of trends that already existed in dentistry, but the rise of DC has only made it worse. These trends include dentists aggressively marketing cosmetic procedures like veneers, telling patients that a normal metal filling needs to be replaced with a metal free tooth coloured filling, or a dentist telling you that you have 3 cavities when you have 1 or 2.Many people trust their dentist and are unaware they may be doing this. While there are many reputable dentists, these trends do erode public trust in the dental profession. A 2009 Ipsos Reid poll of Canadians found more people see dentists as businesspeople than doctors.In the US, dental corporations have paid tens of millions of dollars from numerous lawsuits due to overbilling and overtreatment, and Canada is following closely in their footsteps.
Why is it important to expand dental care in the middle of a pandemic and economic crisis?
As 95% of spending on dental care in Canada is private, most people rely on work-related dental insurance to access care rather than the government. This is unstable as they can lose their dental insurance when they retire, leave an abusive relationship where they rely on a partner’s insurance, or become unemployed.
The Covid-19 pandemic and its associated economic crisis has been a prime example of this. Millions of Canadians have lost their employment or are working reduced to no paid hours. A Credit Canada survey conducted in early May found that 66% of respondents say they would, or currently are, experiencing a “severe financial crisis”. This means many Canadians are losing their dental insurance as it is tied to their employment, and people do not have the money to pay for these services out of pocket.
Poor and minority communities will be forced to bear the brunt of the outcomes of an unstable system. It is important to expand dental care in this time because universal programs do not result in this sort of instability, as universal programs provide care based on need rather than ability to pay. In the short term, the federal NDPs plan to provide dental insurance to families making $90k per year or less is needed, but in the long term we need a truly universal system.
Expanding public dental care during a pandemic and economic crisis is not just about expanding access to care, it is also about lowering costs as explained above. Not only would costs go down, the burden of who pays can be shifted onto the wealthy rather than working class Canadians.
What are the problems with targeted or means-tested dental programs, why should dental care be universal, and how can we achieve it?
I would argue that we should strive for the government to provide dental insurance to all Canadians rather than with means-tested dental programs. I see the need for means-tested programs resulting from an inefficient system that is expensive and has left so many behind, whereas a universal program provides the opportunity to confront that inefficient system rather than making minor tweaks around the edges.
Means-tested programs for dental care have had little success politically in Canada. After more than half a century of politicians promoting means-tested dental programs, only 5% of people are covered by government insurance while around 35% of people lack any dental insurance. Means-tested programs are more susceptible to austerity driven funding cuts since there are less likely to be repercussions in the form of public outrage as the cuts would only affect a relatively small, marginalized group. These cuts result in fewer people being covered and programs paying out lower fees, and as a result groups relying on means-tested programs become less of a priority to dentists. As such, many who rely on these programs are underinsured and still face many barriers accessing care.
In contrast, under a universal system dentists are paid the same amount for specific procedures regardless of the patient’s income. This means people would not be discriminated against, and it encourages dentists to set up clinics in communities where there is a need for basic dental care as opposed to being deterred by the socioeconomic status of the individuals within the community.
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