Dental Care in Canada: the Need for Incorporation into Publicly Funded Health Care

Elisabeth McClymont

ABSTRACT

Dental care was recommended in the 1964 Royal Commission on Health Services that helped shape our current health care system but has yet to become a part of publicly funded health care. This has left almost one third of Canadians without dental insurance, leading to poor health outcomes and stark inequalities. Evidence indicates that dental care should be incorporated into Canada’s existing system as it is medically necessary, will decreased long term costs, and its inclusion will promote accessibility and comprehensiveness in our system. With the Health Accord expiring and an adequate number of dental professionals today, now is the time to incorporate dental coverage into the public health care system.

INTRODUCTION

The former Minister of State for Public Health, Carolyn Bennett, made a salient point when she said that Canada has a “health care system where the mouth is not considered a part of the body.”[1] As outlined in the Canada Health Act, Canadians receive coverage for medically necessary physician and hospital services but not dental services. This means that we receive coverage for our lips, tongues, and throats but not our teeth and gums.[2] Canada ranks second last in public financing of dental care when compared to other Organization for Economic Co-operation and Development nations[3] with 95% of all dental services funded privately, a level similar to that of the United States.[4] Canadians must pay for dental services through private health insurance, which is usually obtained from employment or by paying out–of–pocket. The 2010 Canadian Health Measures Survey found that 62% of Canadians had private insurance and 6% had coverage through publicly funded programs, leaving almost a third of Canadians with no dental insurance whatsoever.[2] What little public dental care exists is primarily for low–income children, leaving other vulnerable and low–income groups without access to care. This represents a failure of the current system, as those who need care the most are unable to access it. As a result of the exclusion of dental services from publicly funded health care, only 71% of residents of Ontario, the province with the highest dental visit rates, visited a dentist in 2012.[5] Predictably, this value is very similar to the number of Ontarians with dental insurance (68%).[5]

Beyond the absurdity of not receiving care for our mouths but receiving it for all other parts of our bodies, dental care is a medical necessity.  The most common infectious diseases in the world are dental diseases.[6] Extensive evidence validates the importance of oral health to that of the rest of our body and the fact that many health issues can first be diagnosed through the mouth.[1] For example, one of the first signs of AIDS can be severe gum infection and the first stages of osteoporosis can show up as bone loss in teeth.[7] Oral examinations can also reveal nutritional deficiencies, microbial infections, immune disorders, and oral cancers.[1]

Not only can ailments within the body affect our oral health, but oral health can also affect the rest of our body. Infections resulting from poor oral health can complicate diabetes management [7] and systemic inflammation resulting from periodontitis can complicate end–stage renal disease management.[8] Additional studies have linked poor oral health to respiratory disease,[9] premature labour, low birth weight babies,[10] pneumonia, and Alzheimer’s disease.[2] Despite the impact some diseases have on oral health, the public system does not cover the resulting necessary dental care. An example of such impacts is the effect that chronic renal disease has on the mouth including xerostomia, calcifications, enamel hypoplasia, and altered salivary pH.[8]

Largely represented in the group of uninsured Canadians are vulnerable populations including seniors, indigenous peoples, and people with low incomes.[11, 12] Having dental insurance is the largest predictor of dental service utilization because without it, costs can be prohibitive.[13, 11] Therefore, the current insurance scheme widens the gap between the rich and the poor as access to dental care is mostly provided to those with middle to high–income jobs. The situation might be worsening as costs of dental care have increased dramatically in the past 25 years while the incomes of low–income groups have remained largely constant.[14] Increasing rates of part–time and temporary employment have also contributed to a decrease in employment–provided dental insurance that the majority of Canadians rely on.[14] Inability to pay for private insurance or out–of–pocket costs can result in oral conditions causing impaired speech, impaired eating, and affected social perceptions which can in turn have negative effects on obtaining employment opportunities.[15]

The political climate of deficit reduction through program cuts that began in the 1980’s must come to an end. The absence of a single–payer system for dental care has led to increased costs and poorer health outcomes.[16] The current format of employer–based dental insurance is not sustainable due to increasing costs.[17] Canadians spent $12.1 billion on private dental care in 2010, second only to prescription drugs in terms of private expenditures.[18] Per capita expenditure on dental care was $350 [19] which, by international standards, is high.[20]

The lack of accessibility to dental care has led to increased use of expensive acute health care settings for acute dental problems that are preventable and best dealt with in a primary dental care setting.[3] In 2006, Ontario’s expenditure on these acute dental visits was $16.4 million.[3] These acute care visits increase the volume of people visiting emergency departments and the number of hospital admissions, which are costly care options for preventable oral health problems.[3] Providing individuals with an improved ability to seek regular dental care through coverage promotes the utilization of less expensive preventative care options.

Many organizations, including the Canadian Association of Public Health Dentistry, have long been asking for the implementation of universal dental coverage, [21] and now is the ideal time for this to happen. The Health Accord was a ten–year agreement that outlined the federal funding to be supplied to the provinces for health care. Following its expiration in 2014, there was no action to implement a new accord. The federal government did promise to continue providing some resources to the provinces,[22] however, the federal government has progressively decreased its influence on health care delivery since the 1970’s when it began providing transfers in relation to gross national product rather than demand, and providing tax credits in lieu of cash transfers.[22] Its increasingly hands–off approach to health care in combination with a lack of renegotiation of the Health Accord demonstrates a waning desire to coordinate health care policy across the country. It is important to seriously consider and implement universal dental coverage now, before the Health Accord has faded into a distant memory and the federal government becomes further distanced from health care policy.

The 1964 Royal Commission on Health Services, which formed the basis of our public health care system, called for the inclusion of dental care services within the framework that was to be developed.[23] It did, however, acknowledge that at that point in time, it was not be possible due to a shortage of dentists.[23] Today, the number of dentists is no longer prohibitory. Between the years of 1991 and 2001, the number of dentists in every province of Canada increased with the exception of the Yukon.[24] Between the years of 2000 and 2010, the number of dentists and dental hygienists increased by 41.6%, a growth rate almost four times that of the Canadian population.[18] In addition, it has been shown that Canadian dentists today support the incorporation into the public system.[25]

Patchworks of targeted initiatives within provinces have come and gone, proving themselves vulnerable to political will. It is time for a lasting, comprehensive approach to dental care as we are now in a position to implement such a program within the public system. Undoubtedly this is no small task; it will require the coordination of federal and provincial governments as well as the dental industry.[26] Those who are in need of dental coverage must be heard and supported by the general Canadian population, which stands for equity and public provision of health care. Canadians ranked dental care as their third choice overall in terms of spending priorities, indicating that advocates for dental coverage inclusion into the public system need to work towards improved positioning of dental care on the policy agenda.[27] It has been demonstrated that dental care should be incorporated into our public health care system due to its medically necessary nature, the fact that it will promote accessibility and comprehensiveness in our system, and will decrease long–term costs. A shortage of dental professionals no longer persists and the need to renegotiate the federal role in health care is upon us as the Health Accord has expired. Dental care was always meant to be a part of our comprehensive health care system and now this much needed coverage should be implemented.

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McClymont E. Dental Care in Canada: the Need for Incorporation into Publicly Funded Health Care. UBCMJ. 2015: 7.1 (28-29).