December 8, 2023


A Passion for Better Health

Steven Lewis: Does Canada truly want a universal dental care program?

The case for a medicare-like universal program for dental care depends on where we believe oral health belongs in overall health.

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Medicare is Canada’s universal lottery scheme. If your health problem needs a physician, you win – the cost is publicly financed. If you’re sick enough to be hospitalized, bingo, you win again.

If you need expensive drugs while in hospital, another winning ticket; if you need those same drugs at home, try again next time. You break your leg or get cancer, covered. If your eye problem needs an ophthalmologist, covered; if an optometrist can handle it, out of luck.

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You break a tooth, or need a root canal to relieve the searing pain, thanks for playing, gamble safely.

Dictionaries define “comprehensiveness” as “covering completely or broadly,” “all-embracing,” “inclusive,” “exhaustive,” etc.

The Canada Health Act begs to differ; it defines comprehensiveness as “all insured health services provided by hospitals, medical practitioners or dentists, and where the law of the province so permits, similar or additional services rendered by other health care practitioners.”

What? Dental care is in? Alas, no — in law it means services provided by dentists in hospitals, which are a tiny fraction of the total.

Oral health affects how you look, self-esteem, ability to eat certain foods, and, according to several studies, romantic prospects. It is often a window on serious underlying health conditions; it can be the cause or the result of serious health breakdown.

Some health risks like heart disease or degenerative joints appear later in life; poor oral health can seriously compromise children’s development. Instilling good dental health practices in young kids will prevent a great deal of tooth decay and loss, gum disease, and pain throughout a lifetime.

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The consequences of excluding dental care from medicare were predictable. Like medical care prior to 1962, about two-thirds of Canadians have some form of private dental insurance.

This majority includes most public sector workers, whose governments use everyone’s tax dollars to fund services for their employees that they don’t fund for all but the poorest of the rest of us.

The employer-sponsored private dental insurance market is large and fragmented — 30,000 different plans in Ontario alone according to the provincial dental association — with a wide array of coverage options, exclusions, deductibles and co-pays.

All told, a little over half of dental costs are funded through insurance, about 40 per cent out of pocket, and just six per cent by governments.

This arrangement creates winners and losers. The big winners are insurance companies, the toll collectors on the dental services freeway. Dental needs are predictable; there are no catastrophic claims from earthquakes or tankers lost at sea. If costs rise, they simply raise premiums.

Claims processors and adjudicators earn a stress-free living from this cozy compact.

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Employers and employees of organizations that provide dental insurance are also winners. The employees get a benefit that isn’t taxed as income. The private sector employers’ contributions are tax deductible, so neither pays the full cost.

But they may still be paying too much: the evidence suggests that some services built into plans, such as routine checkups or frequent cleanings, provide little clinical value.

Dentists are winners. Their bills are paid. They know that neither the employer nor the employee has a strong incentive to restrain utilization, since both are subsidized by the general public.

They can recommend more frequent visits or promote new and allegedly superior services that may become entitlements under an insurance plan.

People who buy their own dental insurance are among the losers. They pay the entire premium rather than the fraction paid by beneficiaries of employer-sponsored plans.

If their plan is approved by the Canada Revenue Agency, the premiums are tax deductible, which makes them modest winners compared to people with no dental insurance. 

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Consumer Reports and other analysts have concluded that for most people, buying individual dental insurance makes little sense. Humans are notoriously poor risk estimators.

The one-third of Canadians with no dental insurance, most of whom pay for services on a cash basis, are the big losers. Unless their costs are very high, they pay entirely with after-tax dollars. To add insult to injury, uninsured and self-insured taxpayers also subsidize the dental benefits for those in on the game.

To which a plausible response is: so what? Lots of public policies — how capital gains are taxed, farm fuel subsidies — favour some over others. Canadian dental health status is pretty good by international standards.

Canadians aren’t marching in the streets to protest the state of dental care; a public program is a promise extracted by the NDP as part of its pact with the Liberals. There are lots of dental clinics in most cities eager to take on new patients.

Dental care may be haphazardly organized, but, in the grand scheme of things, is there a strong case for a medicare-like dental program?

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It depends on our ambitions for health care and where oral fits into the picture. If the problem with dental care is only that too few Canadians have private dental insurance, the solution is to use subsidies or tax credits to nudge more people into existing plans.

If necessary, also enhance efforts on behalf of lower-income people who need fuller public support.

But suppose we think oral health is as important as the health of our hearts or kidneys; that dental care providers should be part of multidisciplinary primary care teams; that a great deal of routine work could be done by dental nurses; and that we are falling woefully short on prevention, leaving too much to be repaired.

It might concern us that dental care is off on its own, and that dentistry is increasingly corporatized as more and more practices are bought up by investors. It might raise eyebrows that per capita spending on dental care in Canada is nearly as high as in the U.S., while overall health care spending is about half.  

When John Diefenbaker’s Progressive Conservative government asked Justice Emmett Hall to produce a blueprint for national medicare, few expected that he would recommend the universal, tax-funded Saskatchewan approach so bitterly fought over only two years prior to his 1964 report.

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Despite medicare’s ups and downs, there is no public appetite to recreate for physician care the system we still have for dental care.

We are six decades removed from that defining moment. What can Ottawa realistically do for dental care in 2023? What can we learn from previous attempts to chart a new path?

Next month, the main options.

Steven Lewis spent 45 years as a health policy analyst and health researcher in Saskatchewan and is currently adjunct professor of health policy at Simon Fraser University. He can be reached at [email protected].

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