The Gap

Why doesn’t healthcare include teeth?

By Evan Osenton

Dentists are trusted professionals. They’re also widely disliked. Having had a good dentist for decades, I was more trusting than disliking. But when my dentist reduced his hours, and new dentists joined his practice, the hygienists started to push frequent fluoride treatments and x-rays. I’m almost 40 and haven’t had a cavity since I was a teenager, so receiving these services that often seemed hardly necessary. They tried to sell me teeth whitenings and electric toothbrushes. I understand that dental care isn’t Medicare, but this was my first experience of the profit motive at work in a medical setting.

The office receptionist began calling me at home, saying I owed a balance. I asked why. “For scaling.” No, I mean why wasn’t this covered? “Our fees are higher than the insurance company allows.” You can do that? I thought.

I looked into it and one of my first discoveries was that Alberta has no dental fee schedule. Dentists can charge whatever the market will bear, and fees are skyrocketing. If a patient has insurance but their dentist wants to charge more for a procedure than the insurer will pay, the difference is called a “co-payment.” Co-payments are increasingly common.

In Canada, we’re told that health care is a benefit of citizenship, not a privilege of wealth. Yet even as our lips, tongues and throats are covered under Medicare, our teeth are not. When it comes to dental health, we’re on our own.

My concerns are what you might call “first-world problems”—annoyances and growing costs I’d rather not bear, but that won’t prevent me from having my teeth fixed. A much worse reality in Canada is the pain, poor health, underperformance at school and work, and social stigma arising from lack of dental care. These are the problems Medicare was supposed to solve when Lester B. Pearson’s government passed its Medical Health Act in 1966.

The Alex Dental Health Bus’s photos make a strong case for revisiting dental care today. These are the mouths of Grades 2 and 6 students in Calgary. Some of their teeth have such big holes they look like barnacles. Others are misshapen and black. There are gaps where children have lost adult molars to decay. These are not third-world beggars, but kids you could pass on the street. Chronic pain is a normal part of their Canadian childhoods. “When I’m overseas, I expect to see this,” hygienist and Bus program lead Denise Kokaram tells me. “But not here.”

The Bus, actually a modified RV, has two dental chairs, an x-ray unit and a sterilization bay. It is run by The Alex, a non-profit community health centre. Over the past two years the staff of four have visited dozens of “high-needs” schools. Last year they did screenings, sealants and fluoride treatments on over 1,500 students, roughly half of whom haven’t ever seen a dentist.

Their work barely scratches the surface. “The need is far more than we can meet,” Kokaram says. The Bus treats children of families that earn too much to qualify for social assistance, yet too little to afford private dental care. A few of the families who come to the Bus even have health insurance, Kokaram says, but can’t make the co-payments.

Having worked at an emergency shelter, I know poverty extends to oral health. You can smell the evidence four feet away, and some homeless people are missing most of their teeth. But they are less of an exception than I realized. A third of Canadians have no dental insurance. Uninsured and lower-income people are three to four times less likely to obtain dental care. Some 17 per cent of Canadians avoid the dentist because of cost, while 16 per cent decline recommended care because of cost. They get far more decay and other tooth problems. One in ten Canadian adults describe themselves as living “sometimes” or “often” with mouth pain.

1/6 Canadians go without dental care due to the prohibitive cost.

The prospect of Canadians going without medical care—and living in pain—is why we created public health insurance in the first place. Medicare is now one of the most highly prized Canadian institutions. In the 2004 CBC poll to decide the “Greatest Canadian” of all time, Tommy Douglas, who as premier of Saskatchewan in 1961 enacted the provincial health system that inspired Medicare, was chosen number one. Lester B. Pearson, the Liberal prime minister who took Medicare national, finished sixth.

It’s an ongoing paradox that Canadians are so keen on Medicare while accepting that our teeth aren’t included in the plan. The reasons may be that we believe needy and vulnerable Canadians are covered for dental care from the public purse, or that private dental care is shielding us from an enormous cost that would burden taxpayers and threaten the rest of Medicare. But are either of those beliefs true?

The fact is that only 5 per cent of Canadians have the right to publicly funded dental care. They consist primarily of serving members of the Canadian military, veterans, Aboriginals (assuming they can access care), prisoners and refugees. The rest of us are covered for oral surgeries necessitating hospitalization and surgeries associated with birth defects. Alberta, like other provinces, provides some subsidized care to social assistance recipients and low-income seniors. Canada’s 5 per cent public coverage overall ranks us second-last in public financing of dental care among members of the Organisation for Economic Co-operation and Development—lower, even, than the US. At the high end, Japan and Luxembourg provide public dental care to 80 per cent of their populations.

The number of Canadians going without dental treatment is increasing. The Canadian Dental Association (CDA) describes the trend this way: “Changing population demographics and disease patterns are increasing the numbers of patients who face barriers to accessing basic oral healthcare.” A 2014 Canadian Academy of Health Sciences report concurs: “The oral health gap between the advantaged and disadvantaged is getting worse.”

For those on the wrong side of this gap, untreated dental problems will lead to general health crises and hospitalizations. One in five children without dental insurance have what health professionals call “an emergency pattern” to their care, meaning that their parents bring them to hospital ERs rather than to the dentist. The same is true of 3 in 10 adults and 4 in 10 seniors without insurance. Children with many cavities must go under general anaesthesia. Some 19,000 Canadian children have this surgery annually, the most common day surgery on preschoolers at Canadian pediatric hospitals. These surgeries lengthen wait times for other urgent care. All this pain, worry and compromised health would be preventable if these people could access routine dental care.

The link between dental health and overall health is well established. Childhood tooth decay affects behaviour, self-esteem, diet and sleep. A US study found that kids with oral pain are three times more likely to miss school. Children with bad teeth become adults with bad teeth and compromised health. Poor oral health is linked to heart disease, diabetes and respiratory disease. There is also a link between dental problems and pre-term and low-birth-weight babies.

Anyone who thinks private dental care shields us from taxpayer expense is likely not considering these emergency visits, emergency surgeries and the long-term care related to untreated dental problems—costs borne by Medicare.

The case for including dental care in Medicare is so strong it is perplexing that dental health was excluded in the first place. In fact, early models of publicly funded healthcare did include dental care. In 1930s Alberta, a health care plan put together by UFA Health Minister George Hoadley and a committee that included rights pioneer Irene Parlby would have provided 50 per cent health coverage—including dental care. This Hoadley Plan had the support of dentists and was passed by Alberta’s UFA government in 1935. It would have been Canada’s first public health insurance plan except that in the same year, the UFA were stomped at the polls by Social Credit. Though it was a sex scandal—and not opposition to health care—that brought down the UFA, the Hoadley Plan became a historical footnote.

In 1961 the Diefenbaker Progressive Conservative federal government launched the Royal Commission on Health Services, chaired by Justice Emmett Hall. The 1964 Hall Report recommended a national insurance plan modelled on the provincial system Saskatchewan had adopted three years earlier. Dental care for everyone under 18 was included in the Hall Report’s recommendations. Newfoundland’s Minister of Health, James McGrath, called the Hall Report “the sick man’s Magna Carta.” Opponents of the Hall Report included Alberta’s Social Credit premier Ernest Manning, who called the plan “socialistic” and an intrusion into provincial jurisdiction. “I suppose we’ll be proposing grocery-care next,” he said.

Though the Hall Report would be an important precursor to Pearson’s Medical Care Act, dental care (even for those under 18) didn’t make it into the plan. The reasons are many: dentists feared lower incomes; it was widely believed that the booming private insurance industry would give most Canadians dental coverage; municipal water fluoridation programs were beginning to decrease tooth decay. Because dental problems were so common, some critics said Medicare couldn’t afford to treat them. The ideological opposition represented by Manning’s remarks was influential too: dental health, if not overall health, was seen as a personal responsibility. Much of the Canadian public wanted Medicare to include dentistry, but after decades of debate settled for a compromise: doctors and hospitals now, dentists later.

1/10 Canadian adults say they live “sometimes” or “often” with mouth pain.

The main factor keeping dental care out of Medicare today seems to be the belief that public coverage would mean higher costs, particularly higher taxes. Any discussion of cost, however, needs to begin with an indisputable fact: You pay either way. When dentists put down their tools, you either open your wallet or they bill your insurance provider—insurance you have paid for directly, or indirectly through your employer. (Employer-offered insurance is part of compensation, and is therefore forgone salary.) If cost were the only determinant of whether dental care should be delivered privately or publicly, all that would matter is which model costs less. In this respect, questions can be asked of our almost entirely private dental system.

According to the Canadian Institute for Health Information (CIHI), Canadians spent $11.2-billion on dental care in 2010, 95 per cent of it in the private sector. This is $328 for every man, woman and child. Canadians have the second-highest per capita dental cost in the OECD—as well as the second-lowest rate of public dentistry.

Private delivery of health services is always more costly to the society as a whole than public delivery. The US, with the OECD’s highest percentage of private health spending, also has by far the highest per capita cost ($8,745).

The dental portion of Canadian health costs seems out of control. In 2010, Canadians were spending 56 per cent more for dental care than they had been a decade previously, an increase of over twice the rate of inflation. Since the 1970s, dental cost increases have outpaced Medicare’s cost increases, growing, on average, 9.8 per cent annually in Alberta and 8.6 per cent across Canada. This compares to annual growth of roughly 4 per cent in total health expenditures.

As private-sector costs bloat, public-sector health cost has become a quiet success story. Canadian public hospital spending and physician compensation are now at their lowest rates of growth since the 1990s. CIHI president John Wright concluded in 2012 that the public sector is becoming more efficient. “Unlike in the past, they’re not cutting programs as much as looking at improving productivity, reducing overhead, controlling compensation and seeking value-for-money initiatives.”

Nowhere is the contrast more striking than in Alberta. A Calgary Herald investigation of the period from 1997 to 2013 found that dental prices rose faster here than elsewhere in Canada—93 per cent vs. 64 per cent. The $357.43 average cost for an annual dental check-up in Alberta compared to $212.30 in Manitoba, $192 in Saskatchewan and $164.90 in BC.

Alberta is the only province without a dental fee guide. It was cancelled in 1997 under the Klein regime because, we were told, it discouraged competition. In the ensuing free market, prices have ballooned. Government had the power to influence dentists’ fees before 1997, but not now. Fees and the corresponding insurance company valuations no longer match up. Also, the Alberta Dental Association and College limits advertising. Dentists can’t offer discounts; few promote or even reveal their prices. A CDA spokesman says quotes for standard units of service are “impossible” to give without first examining the patient. That is, you can’t find out what a procedure will cost without spending money.

Dental prices also vary widely within Alberta. Some insurance providers publish online fee comparisons by postal code. In my Calgary postal code, the lowest amount a dentist billed Sun Life for a recall exam, one unit of scaling and one unit of polishing last year was $184.07. Elsewhere in Alberta, dentists have charged up to $394.20 for the same procedures. Bitewing x-rays at one dentist can cost double at another. The cost of a “routine extraction” can range 300 per cent. The Herald article quoted an expert who concluded prices vary by up to 500 per cent.

None of this even gets into “creative diagnosis,” an issue the CBC explored for Marketplace in 2012. Their investigative journalist had no tooth decay and needed only a cleaning and potentially one crown, for an expected cost of $1,800–$2,000. The 20 dentists she then visited in Toronto and Vancouver recommended “treatments covering 19 different teeth, ranging from nighttime mouth guards to veneers promising a ‘complete smile makeover’ with cost estimates ranging from $144 to $11,931.” A 1997 Reader’s Digest investigation similarly saw a US journalist receive quotes ranging from $1,197 in Lansing, Michigan, to $29,850 in New York City—and from two to 28 crowns—by 50 different dentists.

From the dental industry’s perspective, increasing prices are justified by high and rising overheads, such as commercial rents and insurance. Young dentists face daunting start-up costs and student debt. Dentists employ hygienists. Technology evolves rapidly, necessitating the purchase of new equipment. And administration is not an insignificant cost. Office managers must chase down unpaid balances and deal with dozens of insurance providers. These latter costs are unique to the private sector, of course.

As for what portion of our bills goes to the dentist as income and corporation profit, dentists argue that their earnings are comparable to or below those of doctors and lawyers. While most of us don’t begrudge a highly trained and trusted professional earning a good income, dentists have sources of profit unavailable to doctors. Mature Canadian dental practices can sell for hundreds of thousands of dollars, even millions.

Private dentistry cannot be viewed as satisfactory when one in six Canadians goes without dental care and the rest face spiralling costs. In addition to what we pay for our own dental care, all of us, as taxpayers, are paying for emergency dentistry and the many complications of poor oral health.

Some agree with Ernest Manning that oral health is a personal responsibility. We all know brushing and flossing help reduce cavities. But no dentist says these can replace an annual visit. If, as many argue, our healthcare system should focus more on prevention, then ensuring that more Canadians get annual teeth cleanings is an obvious preventative measure.

Manning also said nothing about people whose teeth dissolve due to a gastrointestinal condition, or who break a tooth on a chicken bone, or whose wisdom teeth come in sideways.

It’s promising that the dental professions seem open to change. A 2014 macroeconomic review in the CDA Journal characterizes Canada’s private dental system as an example of “market failure,” explaining that “a person’s capacity to purchase healthcare is lowest when his or her need for care is greatest.” The Canadian Dental Hygienists Association (CDHA) and the Canadian Paediatric Society both call for more coverage for kids, regardless of family income. The 2014 investigation by the Canadian Academy of Health Sciences concludes: “The question remains as to why policy attempting to achieve ‘continued access without financial or other barriers’ has not been enacted for oral healthcare.”

When asked in a 2006 University of Toronto survey if dental care should be part of Medicare, 82 per cent of randomly selected Canadian respondents said Yes. When asked who should be eligible, 66 per cent said “everyone.” As to what treatments should be covered, respondents felt most strongly about check-ups, cleanings and fillings (all above 80 per cent). Half would have Medicare cover crowns and braces. Some 63 per cent believed patients should pay a deductible. Few expected cosmetic dentistry to be covered.

4/5 Canadians say dental care should be part of Medicare.

When similarly polled in 2006–2007, over 7 in 10 Canadian dentists said governments weren’t doing enough to improve Canadians’ oral health. While only 15 per cent would insure “everyone,” almost 40 per cent would insure “all children” and nearly a third would insure “all seniors.” Over 6 in 10 said if public insurance were available, their practice could handle the increased patient load. Their chief concern was lower fees.

Major changes in social policy typically happen in times of great social pressure. An economic slowdown and Canada’s skyrocketing dental costs are putting new pressure on patients and dentists alike. An aging population is another factor. The proportion of people covered by insurance in Canada drops markedly at retirement age, and fewer of us are receiving non-income employment benefits in the first place. A 2007 CDHA report, citing a survey of 500 company-sponsored retirement plans, showed that 18 per cent of Canadian companies had recently cut non-pension benefits, with an additional 25 per cent planning to do so soon. The wealth gap is also widening. Incomes are steadily falling among Canadians with the lowest earnings. Whether due to lower wages or reduced insurance, dental care is out of reach for a growing number of people.

Tens of thousands of Canadians—more each year—are now estimated to go abroad for dental surgeries, to places such as Los Algodones, Mexico, billed as having the most dentists per capita on earth. Prices are considerably lower there even after the cost of a plane ticket.

US dentist Gordon Christensen warned in a 2001 Journal of American Dental Association article titled “The Credibility of Dentists” that the perceived ethics of dentists was falling. He blamed the commercialization of the profession and excessive treatments and fees. University of Toronto dentistry professor James Leake went further in a 2006 paper in the CDA Journal: “Unless an alternative direction is taken, dentistry will lose its relevance as a profession working for the public good and this will be followed by further erosion of public support for dental education and research.”

The idea that Alberta badly needs a review of its approach to dental care is not new. In 2003 PC MLA Gary Masyk introduced Bill 210, the Dental Care Review Committee Act, which would have established an all-party inquiry “into accessibility for modest- to low-income earners, the feasibility of a fee structure, and quality care issues.” The bill stalled after first reading. In 2013 former NDP leader Brian Mason declared in a Lethbridge party convention speech that dentistry should be part of Medicare. Since taking power in 2015, Alberta’s NDP government has made one statement on dental care: New Health Minister Sarah Hoffman said in July that she will examine Alberta’s lack of a fee schedule.

The time seems right for Alberta to re-examine not just the fee schedule issue but all aspects of dental care. An all-party committee could look into providing certain procedures at no cost to the patient. At the very least, we should provide annual check-ups for all kids under 12. It’s simply wrong that our government leaves this responsibility to charities such as The Alex. If such a preventative measure decreases healthcare costs in the long term, that would just be a bonus.

Canada’s esteemed healthcare system is governed by five principles:
– Universality: services are free of charge to all Canadians;
– Portability: Canadians are covered even when they move from one province to another;
– Comprehensiveness: all medically necessary services are covered;
– Accessibility: no barriers such as user fees should prohibit those unable to pay;
– Public administration: the system is operated by a public authority responsible to the provincial government (no delivery by private, for-profit enterprises).

If dental care is medically necessary, it should be included under Medicare to uphold the principle of comprehensiveness. Having government pay for more care and rein in the private sector’s worst impulses would benefit all citizens. As Roy Romanow famously said, our healthcare system is “a moral enterprise, not a business venture.”

Evan Osenton is the editor of Alberta Views. What do you think about public dental care?



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