By Dr. Hasan Sheikh and Dr. Thara Kumar
This paper was produced with the support of the CDM board and staff.
To download a PDF copy of this paper, click here.
Canadian Doctors for Medicare is proud to advocate for a single-payer public Denticare system. Oral health is an important part of an individual’s overall health, and a single-payer public dental care system is an efficient and equitable way to ensure that every person in Canada has access to essential oral health care.
Oral health is an important part of an individual’s overall health; however, dental care is not included in the Canadian public health care system. The share of public dental care spending in Canada has been decreasing steadily since the 1980s. This has resulted in many Canadians struggling to access dental care: six million Canadians avoid seeing the dentist each year due to cost. The most vulnerable groups include children from low-income families, low-income adults, seniors, indigenous communities, and those with disabilities.
Canadian Doctors for Medicare supports the creation of a single-payer, publicly-funded dental care system in Canada. In addition to public financing, CDM supports the expansion of public delivery of dental care to ensure equitable, efficient, and sustainable dental care is available to every person in Canada.
Oral Health and Overall Health
Oral health is critical to an individual’s overall health. Poor oral health is associated with poor general health, specifically cardiovascular disease, diabetes, having a low birth weight infant, erectile dysfunction, osteoporosis, metabolic syndrome, and stroke(1–8).
There is increasing evidence, however, that poor oral health exacerbates other general medical conditions due to chronic inflammation(9). Treating gum disease in diabetics improves blood sugar control similar to adding an additional oral diabetes medication(10). Providing oral care in long-term care reduces the risk of aspiration pneumonia(11). Periodontal therapy can reduce patients’ cardiovascular risk category(12). Integrated comprehensive oral health care has been shown to increase completion of substance use disorder treatment, increase employment, increase drug abstinence, and reduce homelessness(13). Poor oral health also has a negative impact on a person’s self-esteem, social interactions, and employability(14).
Given the important relationship between oral health and overall health, our current dental care system conflicts with the principles of Canadian Doctors for Medicare: accessible, high- quality, equitable, and sustainable health care for every Canadian.
The History of Dental Care in Canada
In 1943, the Canadian federal government proposed a draft bill for health insurance that included dental services. After World War II, however, the plan for public dental coverage was deferred, with the Dominion-Provincial Conference on Reconstruction describing dental care as a service that would be publicly financed at a ‘later stage’, after physician and hospital services(15).
Unfortunately, we are still waiting for that ‘later stage’: dental care remains one of several unfinished pieces of Medicare to this day.
Several factors contributed to dental care being left out of the Medicare basket. Canada began adopting community water fluoridation in the 1950s during the genesis of Medicare. This led to a sharp decline in dental caries, and a false reassurance that the solutions to oral health concerns would be non-provider based(16). It was also felt at the time that the number of dental professionals working in Canada was insufficient to support a public program for all Canadians(15). The 1964 Commission on Health Services did not include dental care in its recommendation of publicly financed services, believing oral health care to be a personal responsibility. At the same time, tax incentives for employers and employees led to an expansion of employment-based dental insurance, which further reduced public investments in times of economic hardship(16).
Despite economic growth, public investment in dental care has continued to decline. In the early 1980s, approximately 20% of all spending on oral health care was public, compared to approximately 5% currently(17). Canada ranks amongst the lowest in public spending for dental care of all OECD (Organization for Economic Cooperation and Development) countries, second only to Spain. In fact, public spending on dental care in Canada is less than the United States, where 10% of all dental care is publicly financed(18). Furthermore, Canada has been reducing its proportion of public dental expenditures, while the United States and most other OECD countries have been increasing their public share of dental spending(19).
Historical justifications to exclude dental care from Medicare are no longer relevant, nor are they compatible with our current understanding of the importance of oral health to overall health. Fluoridation has been a successful oral health program, but clearly there are dental conditions that fluoridation cannot address. The number of dental professionals per capita in Canada has increased significantly: since 2000, the number of dental professionals per capita has shown higher growth than physicians in Canada(20).
Without steps to increase equitable access to dental care, Canada will continue to fall further behind other OECD nations in this critical component of our nation’s health.
Accessibility is one of the core principles of Canadian Medicare: financial barriers should not impede care. But our current dental care system is inaccessible for far too many Canadians. Approximately six million Canadians avoid visiting a dentist each year due to the cost(16). More than 1 in 5 people cite cost as a barrier for seeing a dentist(21).
Currently, dental care in Canada is almost entirely funded through the private sector. Public spending on dental care is only $24 per capita, compared to $337 on drugs, and $999 on physician services(22,23). 51% of dental spending is paid for by employment-based insurance, and 44% through direct out-of-pocket payments(17). The remaining 5% that is funded publicly is delivered through a patchwork of policies targeting marginalized and low-income groups(16).
Financial barriers to dental care do not only affect the lowest income Canadians. Middle-income earners have seen the highest increase in out-of-pocket dental expenses, and have the lowest levels of insurance coverage for dental care. In 2018, Statistics Canada estimated that the average annual household out-of-pocket dental spending was $430, ranging up to $600, depending on household income level. These often unaffordable costs deter families from seeking dental care.
A single-payer Denticare system with universal coverage would eliminate the financial barriers to accessing care, ensuring that our Canadian dental care system is consistent with the core principles of Medicare.
The lack of public dental care in Canada is an alarming equity issue. The people who experience the most difficulty accessing oral health care are also the ones who experience the highest burden of dental disease, including children, low income adults, seniors, indigenous communities, refugees, people with disabilities, and people living in rural areas(16,19,24–26). In Ontario, 1 in 30 people avoid social interactions, including conversation, laughing, and smiling, due to a dental condition; this increases to almost 1 in 10 for those in lower income groups(25). Previous research has shown that lower income Canadians shoulder a disproportionate amount of out-of-pocket dental costs compared to the affluent(24,27).
Despite having higher needs, seniors are 40% less likely to have private dental insurance compared to the general population(25). When we compare Canada with similar developed nations, our inequitable access has significant consequences. Canada is an outlier when it comes to the proportion of seniors who have lost their teeth – more than 20%(28).
These equity concerns are striking when you compare access to dental services and access to physician services based on income. Approximately 42% of low income Canadians avoid seeing a dentist when they need to due to cost, compared to only 15% of high income Canadians – a difference of 27%(19). This is in stark contrast to physician services, where only 9% of low income Canadians and 3% of high income Canadians avoid seeing a physician due to cost – a difference of only 6%(19).
Despite access and cost challenges, most Canadians still see a dentist each year, highlighting that Canadians understand that oral health is an important part of their overall health. 70% of Ontarians have seen a dentist in the last year, but there is a significant difference between those with insurance (80%) and those without insurance (50%)(25). Those without insurance are far more likely to report only visiting a dentist in emergency cases (40% compared 10% for those with insurance. Those without insurance are also far more likely to have lost their teeth (10% compared to 4% in those with insurance). This suggests that Canadians without insurance lack access to preventative dental care, likely leading to more dental emergencies and more expensive downstream care.
A single-payer Denticare system would ensure that those who need dental care the most are able to access it – an aspect of Medicare that Canadians take great pride in.
Canadians are not getting good value for the money they are spending on dental care. When we compare oral health outcomes to spending amongst similar developed nations, Canada ranks in the bottom half(28). The top three countries? Sweden, Denmark, and the UK – which all have national health insurance models that include dental care.
The lack of a universal, public dental care system puts an additional strain on our existing healthcare system. When people with oral ailments cannot access affordable, timely dental care, they often turn to the Emergency Department (ED) in desperation. In fact, approximately 1% of all visits to the ED are for dental complaints(29,30). The majority of patients presenting to the ED for dental complaints are low-income adults, and these visits in Ontario alone are estimated to cost the health care system in the range of 16 to 31 million dollars annually(26,31). This cost is particularly troubling because physicians do not have the training nor the equipment to treat most dental complaints. They can offer temporizing measures, but can rarely provide definitive treatment for these patients.
A single-payer Denticare system would improve the efficiency of public healthcare spending, protecting our patients and our current Medicare system.
Economic analyses of various dental care models suggest that, from a financial perspective, a single-payer Denticare system is within reach.
A recent costing study from the University of Calgary School of Public Policy looked at different models for a public dental care system, ranging from universal first-dollar coverage (Denticare) to a fill-in-the-gaps approach (Denticaid), which would cover children under 12 and those without private insurance. It found that the net public cost of a comprehensive Denticare system would be approximately $6 billion. This is not only achievable, but is lower than the estimated public cost of $7.5 billion associated with a fill-in-the-gaps Denticaid model(20).
Studies suggest that improving access to preventative dental care reduces dental costs in the long run. In a pilot program in Oxbow, Saskatchewan in the 1970s, dental therapists were deployed to elementary schools to provide comprehensive oral health care. Over the course of this program, the overall dental costs per child decreased significantly(32). In addition, the average number of fillings decreased by 50% over six years, highlighting that publicly funded and publicly delivered dental care can be equitable, high-quality, and cost-effective.
While there is a financial investment associated with implementing a single-payer Denticare system, it should be seen as just that: a high-return investment in Canadians. Universal dental care would improve overall health and would reduce other health care costs associated with chronic preventable diseases.
A single-payer Denticare system may not be cost-saving to the public ledger, but it is affordable and good value for money. Ultimately, the decision to move forwards with Denticare will require policymakers to recognize that oral health is a critical component of overall health, and have the courage to make a bold investment in the health of Canadians.
Canadian Doctors for Medicare Position on Dental Care in Canada
Canadian Doctors for Medicare advocates for the creation of a single-payer, publicly-funded Denticare system in Canada. This should cover an essential basket of services that every Canadian should have access to. In addition to public financing, CDM advocates for the expansion of public delivery models to ensure the efficient delivery of dental care. Similar to Medicare, Denticare would ensure high-quality oral healthcare is equitably accessed, and would efficiently control costs. It would ensure that every Canadian can access essential dental care based on need, rather than ability to pay or employment status.
The specifics of what should be included in the basket of services will need to be determined through consultation with key stakeholders including oral health providers, health professionals, policymakers, and the public. The evidence may be clear in some cases, where certain services are necessary for the prevention or treatment of overall health outcomes. In some cases, the evidence will be less clear. A reasonable smile is important for self-esteem and employability – but what is a “reasonable” smile? These are difficult determinations and will require robust and thoughtful discussion. As always, Canadian Doctors for Medicare believes that the decision of what is included should be evidence-based and values-driven.
CDM believes that the underlying principles of Canada’s dental care system should be consistent with what we expect from Medicare: access, equity, quality, and sustainability. Our current dental care system fails to achieve this, but a publicly-funded Denticare system would. We support the establishment of a single-payer public Denticare system, to ensure that every Canadian has access to essential oral, and therefore overall, health care.
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