Canada has long been an outlier internationally in funding public dental programs. Among countries in the Organization of Economic Cooperation and Development (OECD), Canada ranks second last in its share of public dental spending as a share of total dental spending, ranking even worse than the US. In 2017, only 6% of dental spending came from government programs, whereas countries like Germany and Japan have rates of 64 and 77% respectively.
Dental inequity
This lack of public dental spending leads to more people struggling to access dental care than other developed nations, with those having the greatest dental needs having the greatest difficulties accessing care. In 2018, one in three people across Canada lacked dental insurance and over one in five avoided the dentist each year due to financial constraints, both of which are numbers that have been increasing. Having missing front teeth or visible decay effects employability, which further perpetuates the cycle of poverty and lack of access to dental care.
Lack of access to dental care is problematic because one’s oral health is intimately tied in with their overall health. Poor oral health can cause or worsen: cardiovascular disease, diabetes, having a low birth weight infant, aspiration pneumonia, erectile dysfunction, osteoporosis, metabolic syndrome and stroke. Untreated dental infections can lead to life threatening illnesses.
Further, one percent of ER visits are for people seeking treatment for dental pain. This costs around $150 million per year, while still leaving these people in need of treatment from a dentist.
Federal program: potential and pitfalls
The good news is that the NDP placed their dental plan as a high priority when negotiating the supply and confidence agreement with the Liberals last spring. By 2025, this could provide dental insurance to all uninsured people with a family income below $90k per year, with no copayments for those with incomes below $70k per year. In 2022, the Canada Dental Benefit gave cash payments to families for children below 12, and by the end of 2023, an insurance program could be in place for those below 18 years of age, seniors and people living with a disability.
While the potential for a federal dental program is promising, as it would be the largest investment in dental care in Canadian history, we should be wary of the supply and confidence agreement holding until 2025. If the Liberals are polling well, they could try to trigger an election in the hopes of winning a majority government. This would likely kneecap the dental program, as the NDP had to use their support in a minority parliament as leverage to get the Liberals to agree to implement the dental program in the first place.
If the federal dental program is implemented, it would clearly be a step in the right direction, but ultimately more is needed to fix Canada’s dental care system. According to estimates from the Parliamentary Budget Officer, the federal dental plan would cost around $1.7 billion per year. This would bring public dental spending in Canada to around 15-20% of total dental spending, still well below the OECD average of 31.5%.
The need for universality, not financial means-testing
The federal dental program would help around two thirds of those from low-income families without dental insurance, but leave millions of those with middle-incomes without coverage. This newly expanded public dental coverage will have yearly limits, and the program’s success will depend on the willingness of dentists in private practice to see these patients. Further, targeted dental programs are prone to cutbacks as the marginalized groups relying on the programs can be framed as getting “free stuff”. This makes targeted programs less popular amongst the people paying into the program, but not receiving any benefits.
This dynamic has led the existing targeted dental programs to be undermined. In the 1980’s targeted dental spending accounted for 20% of overall dental spending, but the programs have been cut back to 5% of overall dental spending. These cutbacks have led to fewer people being covered by public dental programs, fewer services being covered, and the fees the programs pay out being much lower than private plans—further engraining the discrimination against those relying on public dental programs.
Universal programs, on the other hand, are more stable politically as the programs are more popular and cutbacks result in broad public backlash. If the federal dental plan is not a stepping stone to integrating dental care into Medicare, future governments that are hostile to public dental care could more easily cut funding for the program. As NDP MP and health critic Don Davies has stated, the federal dental plan needs to be seen as a down payment on incorporating dental care fully within Canada’s universal healthcare system.
Dental care needs to be publicly funded and publicly delivered
Traditionally, the idea of incorporating dental care into Medicare meant that public funding would guarantee access to dental insurance with no out of pocket expenses. While this is great, it does not guarantee access to a dental provider who is willing do the work. This is why every Canadian has medical insurance, but six million people do not have a family doctor.
The private delivery of dental care has led to a disproportionate number of dentists working in wealthy urban areas where they can focus on luxury and cosmetic procedures. As a result, if we continue to rely exclusively on the private delivery of dental care, public funding will focus more on treating dental disease rather than preventing it. In contrast, increasing public delivery models of dental care has been shown to eliminate disparities in access to dental care and place a greater focus on prevention.
Public delivery of dental care seeks to distribute the dental workforce based on oral health needs rather than profitability. This uses of the entire dental team—including dental hygienists, assistants and denturists—which increases efficiency in these clinics, allowing dentists to focus on more complex procedures. Further, the public delivery model can break dentists’ monopoly on care by bringing dental therapy into the mainstream. Dental therapists are to dentists, as nurse practitioners are to physicians. Dental therapists can do fillings, cleanings and simple extractions—all at a fraction of the cost of a dentist.
This public delivery-dental therapy model was very successful in school-based dental clinics in Saskatchewan and Manitoba in the 1970-80’s. We no longer reap the benefits of these school based dental clinics because the private dental lobby has effectively fought to eliminate it from existence. With the federal government showing a newfound interest in improving the oral health of people across Canada, there is a window of opportunity to bring this public delivery-dental therapy model back.
While the potential for a federal dental plan to come to fruition is welcome, more work is needed to ensure every person across Canada has access to comprehensive dental care. It is time to finish Tommy Douglas’s dream of putting teeth into Canada’s universal healthcare system.
For more, visit the Coalition for Dental Care and read Brandon Doucet’s new book “About Canada: Dental Care”, which is being launched this April for oral health month
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