Stephen Lewis: Canada can target more than improved access to dental care

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Last month I outlined the policy dilemma of universal dental care. Dental care is not in crisis: two-thirds of Canadians have decent enough dental insurance; most people on low incomes get some form of government subsidy, and it’s not that hard to find a dentist.

Still, poor oral health is a significant problem among children from lower-income families and the elderly, dental care spending is about the same per person as in the US, while other health care costs are about half that, and the private dental insurance market is fragmented and administrative expensive .

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How can increasing public investment, which currently amounts to only six percent of total spending, improve things?

It depends on what universal dentistry needs to achieve. Among the possible targets:

Ensure that all children have access to good dental care regardless of family income, especially children with disabilities, who often have specialized and intensive needs. Ensure that lower-income older people receive care that allows more of them to keep their teeth so that they will need fewer braces. Remove financial barriers that discourage uninsured families with modest incomes from seeking the care they need. Replace the highly fragmented, inefficient private dental insurance market with a more modern, value-added and cost-effective alternative. Improve efficiency and reduce the cost of some services by transferring routine work now performed by dentists to other dental workers. Integrate dentistry fully into primary health care, with dental staff being part of primary health care teams. This would be a major revision of the model and a significant expansion of full health care.

Current ambitions are limited, focused on the first three goals. The goal is to improve access to basic preventive and restorative care. Services will be provided by the same people in the same settings. Ottawa will allocate $13 billion over five years to close coverage gaps.

That’s not a wild change, but it’s an increase of barely more than one per cent of total federal and provincial health care spending.

It is incrementalism by design, but depending on how the program is implemented, there could be shocks for employer-sponsored plans and the private insurance industry.

Ottawa’s plan, which includes support for families in the $70,000 to $90,000 income range, essentially extends to many people who already have employer-sponsored dental insurance, according to an analysis by the Canadian Dental Association.

This creates an incentive for employers to terminate insurance for these employees. Without a strategy to counter such a move, the public plan could find itself with millions of additional participants.

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Suppose it did happen: would it be good or bad? This would increase public costs and reduce costs for employers. Private insurers would suffer a hit to their revenues and profits. A designated public plan insurer would obviously make ManuLife much bigger.

If it is mandated to act like a true health care-type insurer, mandated to be a prudent allocator of resources, promote evidence-based care that eliminates low-value services, and be a fair but firm price negotiator for dental services, over time the program’s humble beginnings would could become usefully disruptive.

Often, new programs have design features that hinder the achievement of overall goals. Dental insurance almost always has a co-pay, often justified as a deterrent to unnecessary use. (This seems more likely for massage therapy than dentistry, but never mind.)

Where co-payments are modest, they may not generate enough revenue to be worth the administrative costs of collection. Where they are significant, medical care has shown that even modest co-payments deter some people from seeking needed care.

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The whole point of universal dentistry is to address the underuse, not the overuse, of basic preventive and restorative services. To succeed, many people will need coverage from the first dollar, including people we don’t think of as poor but who face real financial pressures that require tough choices.

Hopefully, the wrinkles will be ironed out in time. The number of people with neglected oral health will decrease. Shall we stop there? Or should Ottawa consider Denticare 2.0 venturing into more ambitious territory?

Should. What is imminent will be progress, but governments, educators and dental care providers should not lose sight of what a world-class universal dental program could achieve. Primary health care is a national crisis that threatens the foundations of health care.

There is a strong consensus on what its future should look like: interdisciplinary, holistic and comprehensive. Embedding oral health into an expanded team-based model is an opportunity not to be missed. Primary care polyclinics will need a major redesign and significant investment.

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Building and evaluating models that include oral health should be a future funding priority.

Canada has a major health human resource problem. Too many well-trained people have persistently found it difficult to apply all their knowledge and skills. Expensive staff do work that can be done by fully capable but cheaper staff.

There was a time when dental care was cutting edge. Saskatchewan used to have a two-year training program for dental nurses, the dental versions of the nurses that became the foundation of its tragically destroyed children’s dental program 40 years ago.

The program was evaluated by three academic dentists. Dental nurses were better than dentists at fillings, and equally good at placing crowns and reading X-rays. They taught children good preventive practices and took the fear out of dental care. The program was school-based, accessible to everyone.

More than 80 percent of parents enroll their children. Instead of celebrating the remarkable success of the program, dentists saw it as a threat. They convinced the horrible Grant Devines government to blow it up.

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What dental nurses did for children they could do for adults. If dental nurses took over a large proportion of routine dental work, we could have the best of all worlds: expanded public coverage, high quality services, reduced training costs and better value for money.

Over time, we may need fewer dentists, but they would be doing complex and specialized work that warrants their extensive and expensive training.

All health care improves through constant innovation. There are many dentists who want to meet unmet needs, practice effectively, work in teams, and contribute to health equity. The sector is full of promise and ripe for innovation.

Ottawa would be well served by putting more ambitious options on the table and seeking provincial partners interested in following them. Perhaps universal dentistry could model the changes we need in healthcare as a whole.

Stephen Lewis spent 45 years as a health policy analyst and health researcher in Saskatchewan and is currently an adjunct professor of health policy at Simon Fraser University. It can be reached atslevistoon1@gmail.com.

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