The following is an excerpt from the forthcoming book, About Canada: Dental Care, by Brandon Doucet. The book examines the history of dentistry in Canada, demonstrating how private business interests have prevailed over public health. It is scheduled to be released in April 2023. For more information, visit www.fernwoodpublishing.ca.
Canada’s dental care system does not have common-sense priorities because the right incentives are not in place. Why does someone who wants veneers get precedence over a child who needs to go to the operating room? Why are dentists busy placing implants while people are in emergency departments seeking relief from dental pain? Why do people vacation in other countries in order get their dental work done cheaper than it would cost at home? These are the consequences of a private system that prioritizes profit over public health. The policies that governments do or do not enact directly shape the priorities of the system. If the policies support the for-profit health insurance industry and dental corporations, then the system will be shaped by institutions that care about their bottom line and not public health.
In Europe, many countries have universal or near universal dental coverage for their population. This is achieved by different policies, with some placing a greater focus on government-funded insurance and others mandating that employers provide insurance and target public funding to specific groups. In Germany the government provides everyone with a base level of dental insurance, but many use private insurance to gain more comprehensive coverage. In many European countries, the private health insurance market is more heavily regulated than it is in Canada in order to curb some of its downsides.
In some instances, rather than a private for-profit company running the insurance plan, it is run by an organization that is mutually owned by the policyholders. This is called mutual insurance, and policyholders can vote on how the plan is run and what is done with excess funds. For example, the surplus could be given back to policyholders directly or used to lower the copayments for the following year.
In the United Kingdom, the dental care that is covered by the National Health Service is effectively a plan for the uninsured. While many people in the UK access dental care through private clinics that do not accept NHS patients, those without private insurance are guaranteed a base level of coverage by the NHS. This coverage is strengthened for certain populations deemed at risk. While years of underfunding and neglect have led to fewer dentists working for the NHS, public spending still accounts for just under half of all dental spending in the UK.
In Denmark, dental care, including orthodontics, is provided to all children under 18 in schools, and there are targeted programs for people with disabilities, the elderly and those relying on social assistance. In New Zealand, dental care for children is provided by dental therapists in school-based dental clinics. In these two countries, dental care for children is included in their universal health care systems, along with targeted public investments and subsidies for specific adult populations.
East Asian countries have taken a more comprehensive approach. For example, Taiwan and Japan include dental care in their universal health care systems. Japan’s system pays 70 percent of the cost of almost all dental services. Many people have private insurance to help with the copayments, and certain populations, like low-income seniors, are given reduced rates of copayment. Japan’s dental care system has been very successful at helping people keep their teeth into old age and at decreasing the rate of decayed, missing and filled teeth in children.
While the dental care systems described above are not perfect, particularly after decades of neoliberal-driven austerity, they show that policy options that provide greater equity in access to dental care are achievable. These policies directly shape the priorities of the dental system, with countries that include dental care in their universal health care system having more equitable outcomes than those where the private sector is dominant.
The politics of changing dental care
In terms of moving forward with a more equitable dental policy in Canada, advocates need to know what policies they want and to develop a strategy for how they are going to achieve these policies. The strategy needs to include short- and long-term goals that help gauge progress, and it should focus on placing organized pressure on politicians at both provincial and federal levels to obtain specific policy changes that increase access to dental care. In Canada, universal health care was achieved in an incremental manner through a mix of provincial and federal initiatives, and this could also apply to dental care.
On one hand, public pressure could lead a provincial government to championing access to dental care, as Tommy Douglas and the NDP did with Medicare. It took more than a decade to implement universal health care in Saskatchewan, starting with insurance for hospital services in 1946. A similar situation would likely be true with universal dental care. It takes time to set up dental therapy training programs and hire graduates to work in publicly owned dental clinics. It would also take time for provincial governments to negotiate a cost-sharing agreement with the federal government.
In 2018 and 2022, the Ontario NDP under the leadership of Andrea Horwath proposed a dental plan that would cover the 4.5 million uninsured people in the province at a cost of $1.2 billion per year.14 The NDP lost both these elections to the Progressive Conservatives. In order for the NDP to increase its chances of winning in the future, it is important that popular issues like dental care be highlighted during non-election seasons. With 86 percent of the public supporting a dental plan for the uninsured, it seems the NDP has struggled turning their popular proposals into seats in the legislature.
On the other hand, the federal government can take the lead on dental care, and this would most likely take place during a minority parliament where the Liberals are propped up by the NDP. The NDP would have to leverage their support for the Liberals in exchange for public dental spending, although the current political landscape does present more difficulties for the NDP to get concessions. In the 1960s the Pearson Liberals had fewer options to gain support, which helped the Douglas NDP to achieve some of their goals. In the 21st century, the Liberals can potentially seek support from the Bloc Québécois or the Conservatives if they are not willing to meet the NDP demands.
Jagmeet Singh’s NDP placed dental care as a high priority when negotiating the confidence-and-supply agreement during the minority parliament with the Trudeau Liberals. On March 22, 2022, the Liberals agreed to implement the NDP dental plan in a stepwise fashion, along with other concessions, in exchange for support from the NDP in votes of confidence until the 2025 election. The dental plan would be for the uninsured with family incomes below $90,000 per year, with a sliding copayment for those with incomes above $70,000. The stepwise implementation plan was to create a program for those under 12 years of age in 2022, expanding it to under 18, seniors and persons living with a disability in 2023, with the remainder of the uninsured people below the income threshold to be included in the program in 2025. If fully implemented, this program is estimated to insure between seven and nine million Canadians and cost approximately $1.7 billion per year after the initial backlog of dental disease is treated.
If implemented, this plan would be the largest investment in oral health in Canadian history, almost tripling Canada’s public dental spending. The April 2022 federal budget set aside $300 million for the under-12 portion of the program. However, the Liberals were unable to create an insurance program for children under 12 in time, and as an interim measure are offering cash payments directly to families to pay for dental care. Further, if the confidence-and-supply agreement falls apart before the definitive dental plan is in place, the cash payments could disappear without an insurance plan replacing it.
For the dental plan to come to fruition, the Liberals need to believe the NDP are willing to follow through with their threat to withdraw support if the Liberals fail to keep their promises. The Liberals are aware that polling would influence the NDP’s willingness to potentially trigger an election, and they could renege on their commitments if they are polling in a range where they could win a majority government. The NDP may choose not to trigger an election out of fear of moving from a minority to majority Liberal parliament. In another scenario, the NDP could vote against the Liberals in a vote of confidence, but the Bloc Québécois or the Conservatives could vote with the Liberals to avoid an election. Former NDP leader Ed Broadbent has warned that the Liberals may not keep their promises and that the public needs to keep up the pressure to make it more difficult for them to back down.
The NDP dental plan would fill many of the gaps in coverage left from the existing inadequate public programs and the increasing number of low- and middle-income jobs that do not provide dental coverage. The program would also help many seniors who lose coverage when they retire. While the NDP plan is a great start, it should not be viewed as the end goal. With the NDP program, dentists will still prefer to treat people who rely on private plans due to the higher fees paid. Those who are underinsured on the current public programs will still be left with inadequate coverage. Many people will still struggle to afford the out-of-pocket expenses, and plenty of middle-income Canadians will still lack dental insurance. Further, the gravy train will continue for dental corporations and insurance companies. In this context, the NDP dental plan should be seen as a stepping stone to a universal system.
While it appears that the NDP dental plan will be administered federally to speed up its implementation, over time the administrative control may be shifted to provinces through a cost-sharing agreement. Having provinces administer the new dental program from the beginning would slow the start of the program and likely prevent it from being implemented before the next election, in 2025. In the long run, transferring administration of the program to provinces can create an opportunity to establish national standards for dental care in the same way the federal government does with medical care under the Canada Health Act. This means the federal government would place conditions on its funding of the dental program, and if provinces do not meet these standards, they risk losing out on the much-needed transfer payments.
The five principles of the Canada Health Act are as follows:
- comprehensiveness: all medically necessary services must be covered;
- accessibility: people must have reasonable access to these services without charge or user fees;
- portability: access to care is available even outside of home provinces;
- universality: everyone must be covered for all medically necessary procedures; and
- public administration: the province must administer the program and be accountable for the funds.
Including the principles of the Canada Health Act as part of the conditions for the transfer payments to the provinces for dental care would be a great start. Other conditions could be added, such as effective regulation of overtreatment, limits on wait times for children needing dental surgery and the setting up of publicly owned clinics in dental deserts, i.e., areas with an insufficient dental workforce. The conditions tied to transfer payments would be an effective approach to creating and upholding national standards for dental care, even when governments that are hostile to the program are in power.
Universal dental care
Clearly, Canada’s dental care system is dysfunctional, and Chapter 4 explores policy options that would ameliorate some of these problems, but ultimately, what is the ideal solution? In order to address the core flaws of Canada’s dental care system, policy must convert both the funding and delivery of care from the profit-seeking private sector to the health-focused public sector. The public sector has the ability to treat dental disease as a public health problem to be solved, whereas the private sector can only chase profits. This system of public financing and increasingly public delivery of dental care is known as “universal dental care,” a concept conceived through conversations held in a group I founded in January 2020 called the Coalition for Dentalcare. We are health professionals, students and members of the public who highlight the shortcomings of Canada’s dental care system while advocating for a more humane alternative. Universal dental care seeks to take the beneficial elements of both denticare and the school-based dental therapy model used in the SDP to create the most efficient system possible.
With denticare, there is public financing of dental care for all, but delivery remains in private practices. Universal dental care takes the public financing of dental care for all from the denticare model but prefers delivery to be in publicly owned clinics. This design learns from the strengths of Canada’s universal health care system while overcoming its weaknesses. A core component of universal health care in Canada is that everyone is guaranteed health insurance throughout life, and this is essential to universal dental care. This insurance would make dental care free at the point of access, which means there would be no out-of-pocket expenses that could deter people from accessing care. Having the government provide dental insurance to all would provide stability, as people would not have to worry about losing work-related coverage for an essential health service when they retire, become unemployed or lose spousal benefits. If the entire population had quality dental insurance throughout their lives, far greater numbers of people would seek preventative services and early intervention. Oral health outcomes would improve, which has many benefits to the health and well-being of individuals and society.
With everyone relying on the same publicly financed dental plan, dentists would no longer have a preference for treating people who have private plans. This would ensure that those with poorer oral health receive more dental services than those with better oral health. In other words, dental care would be provided based on need rather than ability to pay. Universal programs tend to create a sense of pride in society as everyone relies on the same program, whereas targeted programs create tension between those who are eligible and those who are not. This phenomenon was described by the Swedish social researchers Walter Korpi and Joakim Palme:
By practicing positive discrimination of the poor, the targeted model creates what amounts to a zero-sum conflict of interests between the poor on the one hand and, on the other, the better-off workers and middle classes, who have to pay for the benefits of the poor without themselves receiving any benefits. The targeted model thus tends to drive a wedge between the short-term material interests of the poor and the rest of the population.
Such tensions within the working class are easily exploited to reduce benefits to the poor, whereas universal programs create a sense of solidarity in protecting a program that everyone uses. This pride means universal dental care would fundamentally shift public dental spending from welfare to health care and would not be as susceptible to funding cuts as denticaid. Funding cuts would receive a much broader backlash if they are seen as an attack on society as a whole. Considering that everyone would be relying on the program, universal dental care would have to be of high quality to keep everyone happy.
This is beneficial for the public relying on the universal program but also for dentists. Many dentists fear the expansion to a universal dental plan will result in them only getting paid the low fees that currently exist for targeted programs. A universal program would be funded more reliably than targeted programs and would have to pay dentists sustainable fees. Further, a universal dental plan would provide dentists with more patients to treat, benefitting dentists and patients by allowing people to access comprehensive care. This means people could save their teeth rather than opting for the cheaper extractions.
Guaranteeing publicly financed dental insurance would also encourage dentists to set up clinics in communities where there is a need for basic dental care as opposed to being deterred by the socioeconomic status of the individuals within the community. Universal insurance through denticare would help ameliorate some of the disparities in dentist-per-capita ratios in poor versus affluent communities. While universal insurance would help with this problem, it would not eliminate it, as seen with Medicare in Canada.
A shortcoming of insurance-based programs is that having insurance does not mean you have access to a provider. This makes insurance-based programs more prone to reacting to dental disease once it has occurred. In comparison, a system that seeks to guarantee access to a dental provider would allow more focus on prevention and early intervention. To address this problem, universal dental care would expand the dental workforce, which would include dental therapists, hygienists, assistants, denturists and dentists, among others, and distribute that workforce based on public health needs. The Saskatchewan Dental Plan, discussed in Chapter 3, was a great example of how this could be done. The SDP expanded the dental workforce in a cost-efficient manner by bringing dental therapy into the mainstream. These dental providers worked on a salary in easily accessible schoolbased clinics. The combination of these two factors led to the virtual elimination of the disparities in access to dental care for children from rich versus poor and urban versus rural communities.
Under a public ownership model, salaried providers could take the time needed to treat people with more complex oral health needs, rather than feeling rushed to get to their next patient like practitioners do under the fee-for-service model. This would be particularly beneficial for disabled people and those who are fearful of the dentist, as the added time would allow providers to find out how to accommodate their specific needs. Having salaried providers also removes the incentive to overdiagnose dental disease, whereas the fee-for-service model encourages it.
Since cost is only one barrier to accessing dental care, publicly owned clinics can be designed in ways that reduce the other barriers, such as accessibility and geography. Having dental care providers work in easily accessible clinics ensures that people not only have dental insurance but also access to a provider. It is much easier to bring a dental therapist to a long-term care facility than it is to have each person in the facility brought to the nearest private clinic. This model should embed dental care providers within the existing provincial and territorial health care systems, which would include ensuring patients receive routine oral care when in hospitals and long-term care homes, which is often overlooked and leads to increased cases of aspiration pneumonia as people inhale the bacteria in the plaque buildup on their teeth. This means residents would be more likely to access comprehensive care rather than just pain relief, and a great deal of dental disease could be prevented. Since some publicly owned clinics would be in specialized settings, they could be designed in ways that are more accessible for those populations. For example, clinics in long-term care settings could have added measures to make sure they are wheelchair accessible.
Public ownership is an opportunity to expand the dental workforce to include the use of dental therapists and dental hygienists. Organized dentistry has fought to exclude dental therapy from the mainstream in Canada, and public ownership of dental clinics is an opportunity to change this. Dental therapy would be a cost-efficient way to fill the gap for dental deserts, communities that currently do not have a sufficient dental workforce to meet the populations needs. Many rural communities have little to no dental workforce, and publicly owned clinics could be set up in these communities, with dental therapists, hygienists and denturists doing the bulk of the work. Publicly owned dental clinics like this would work well in schools, long-term care facilities, prisons and community and Indigenous health centres, among other locations. Clinics could be placed next to public transit routes to ensure easy accessibility.
It is important that dental therapists only work in publicly owned clinics. If dental therapists work in private practices, the cost savings from using them would accrue to the owners of the private practice rather than the public. Further, allowing dental therapists to work in private practice would greatly hinder the public sector’s ability to recruit them to work in poor and rural communities, which happened in the SDP in the 1980s.
These publicly owned clinics with dental therapists are an essential component of the Coalition for Dentalcare’s vision, but universal dental care does not need to be in place for these clinics to be built. Governments can start now setting up these clinics to treat underserved populations. If the federal NDP’s dental plan comes to fruition, there will be many people who gain coverage but are unable to find a dental provider willing to do comprehensive treatment. The same is true for those who rely on the existing public dental programs. Publicly owned clinics are the perfect place to help these people.
Considering the opposition from organized dentistry to the SDP and the inclusion of dental care in Medicare, it is safe to say there will be strong opposition to universal dental care. Building publicly owned clinics with dental therapists in the meantime could create leverage for future governments that want to bring dental care fully under Canada’s universal health care system. If organized dentistry does not negotiate the terms of a universal system in good faith, then the government can continue building these clinics and bringing dental therapy further into the mainstream until they cooperate. These publicly owned clinics could ensure access to care if private dentists ever went on strike like physicians did during the creation of Medicare.
In order to grow the public dental sector, a dental therapy training program would have to be established. In 2021, a partnership between the Northern Inter-Tribal Health Authority, Saskatchewan Polytechnic, Northlands College and the University of Saskatchewan received $150,000 from Indigenous Services Canada to develop dental therapy program in Canada. Their proposal was approved, and the first class will begin in the autumn of 2023. While this is a great start, the program will only graduate 21 students per year, which is well below what the population needs.
In the past, dental therapy was a standalone field, but there can also be dual-trained dental hygienists and therapists. This means there could be combination dental therapy and dental hygiene degrees and also programs where dental hygienists could return to school to learn the skills to become a dental therapist. The more than 30,000 dental hygienists in Canada who already have significant dental knowledge are a great asset to grow the workforce and increase access to preventative and restorative care. There can be combinations of these programs across the country, but there would need to be standardization across the different programs.
The dental workforce can also be expanded by reforming how internationally trained dentists come to Canada. Many foreign trained dentists want to practise in Canada, but the burdensome process for entry acts as a deterrent. Foreign-trained dentists need to take several tests, each of which costs thousands of dollars, before they can apply to Canadian dental schools, which have very few seats set aside for foreign-trained dentists. Two years of schooling cost $150,000. The Canadian government could make it less burdensome for foreign-trained dentists to enter the country in exchange for a commitment to work in underserved communities in publicly owned clinics for a period of time after graduation. The same could be applied to domestic dental students, who also pay absurdly high tuition rates. This is already done for dental students who join the military, and it could be done elsewhere. Generous benefits like pensions and maternity/paternity leave could attract more oral health professionals to the public system.
The interests of both dentists and insurance companies do not align with admitting more foreign-trained dentists or bringing dental therapy into the mainstream. For the dental profession, more foreign-trained dentists and dental therapists would mean increased competition. For insurance companies, more dental providers mean more billing to insurance companies, which decreases profitability. The public ownership model would be a great point of leverage to overcome these hurdles and increase the dental workforce while also benefitting public health.
The public ownership model could also help with the problem of dental corporations. With a dental insurance model of public dental spending and no other reforms, dental corporations would gain access to the public purse. This would lead to a form of public private partnership that would increase spending without added benefits. In order to create a sustainable public dental care plan, the dental corporations need to be excised from the system. If the right conditions were in place, dental corporations could be nationalized and used as public dental infrastructure that seeks to further public health rather than maximize profits.
Governments could use some of the techniques that dental corporations use, but for the public good. For example, a crown corporation could be set up to buy dental equipment and supplies in bulk, greatly reducing the per unit cost. This is a technique that could entice dentists to work in the universal dental care system, even if in private practices. Dentists could gain access to this lower cost equipment and supplies if almost all their work is done within the public system.
While the goal of universal dental care is to grow the public dental sector, it is unreasonable to expect that all private practice dental clinics will disappear overnight. At first, governments should focus on building publicly owned clinics to treat underserved communities, and over time the public sector should take over a greater share of the medically necessary dental work for the population. Universal dental care needs to find a way to engage private dental clinics while minimizing the downsides of this model. This means that some rules would need to be in place, like regulation of prices and overtreatment/ fraud that is independent of the dental profession. With all the dental claims streamlined through a single plan, universal dental care would help acquire the data necessary to know which decisions are based on scientific evidence and which on opinion. This will help re-establish trust in the dental profession and shift public opinion towards seeing dentists as health care providers rather than as business people.
Historically, public ownership of clinics did not come from the medical profession, and its origins highlight an important lesson in how our society makes decisions. In the years before universal health insurance was implemented in Saskatchewan, community medical clinics (publicly owned) were set up to treat people based on need. Supporters of these clinics were strong advocates of universal health care and wanted space for public funding of community clinics within that system. Many believed that public funding of community clinics would promote greater democratic input into how medical care was provided, which would allow for more focus on prevention. This was noted by Stan Rands in Privilege and Policy: “Physicians tend to seek medical solutions to social problems. Thus, the clinics (private practices) opened minor surgeries, pharmacies, and optometries, but they did not hire social workers or community developers.
Rands and advocates of community clinics view health care as more than just treatment but rather as a holistic system that helps people live healthy dignified lives. In the context of dentistry, publicly owned clinics could allow for easy accessibility and a focus on education, prevention and early intervention. Since most dental diseases are preventable, this would be beneficial from both public health and financial points of view. Universal dental care should look at metrics like the percentage of people who keep their teeth into old age as a sign of success.
The Saskatchewan NDP were put in a difficult situation when physicians went on strike, and they felt the need to make concessions in order to move forward with the first universal health care system in North America. Unfortunately, these concessions meant that the community clinics would no longer be sustainable after signing the Saskatoon Agreement. This ensured that public financing of private clinics would dominate the new system. Rands explains:
The government of the day consciously chose to avoid further conflict with the organized medical profession and, in doing so, promoted fee for service medicine (private practice) and the continued dominance of the health care system by the medical establishment.
Excluding community clinics from Canada’s universal health care system was a mistake. It was done to appease the medical profession, which had already been trying to undermine the community clinics long before the Saskatoon Agreement.
When building universal dental care, there needs to be a grassroots movement that is strong enough that politicians do not have the leeway to concede to the professions involved. It is time to stop looking to professions for answers to problems in which they clearly have a conflict of interest. This was shown in how the dental profession acted towards the SDP and how both the medical and dental professions treated the idea of universal health care. Some self-regulating professions in Canada have used their power to stand in the way of progress rather than helping with the process.
A 2009 poll of Canadian dentists found that only 15 percent believe the government should provide dental insurance to everyone without private coverage, something that 86 percent of the public agrees with. How might the dental profession and other monied interests like the insurance industry and dental corporations respond if a government tries to implement the even bolder universal dental care? These interests clearly have an outsized voice in the democratic process, and overcoming this financial voice is necessary to build a better society. It requires a population that is actively engaged with the democratic process, as it is not enough to just show up to the polls every few years.
The movement advocating for universal dental care should not shy away from confronting the monied interests that stand in the way of progress. Access to dental care is one of several social components that shape a person’s oral and overall health, and these other parts should not be overlooked. These issues include, but are not limited to, income inequality, housing and food insecurity, lack of clean water infrastructure, racism and poverty.
Universal dental care is an opportunity to lessen inequality in Canada in two ways. First, everyone deserves to smile, chew and live without dental pain. Currently, a person’s smile is a class marker, and universal dental care seeks to minimize this problem by ensuring that everyone has access to dental care. Good oral health being a sign of status is also a reflection of wealth inequality in the broader society. How governments pay for universal dental care could lessen inequality by shifting the cost of care from regular people under the private system to the incredibly wealthy under a public system. From March 2020 to January 2022, during the COVID-19 pandemic, Canadian billionaires added $111 billion to their wealth while most Canadians were struggling. Universal dental care can take a bite out of inequality by shifting the cost of this program onto the wealthy through a wealth tax and cracking down on tax havens.
While the topics discussed throughout this chapter are bold, it is important to remember that they are achievable. The great achievements of our time, such as Medicare, were once viewed as unreasonable. Through hard work, dedication and organization we can shift the political landscape to take power from the wealthy and put it into the hands of regular people. Only by doing this is universal dental care possible.
Clearly, oral health and access to dental care are of the utmost importance. The actions currently being made by governments to address lack of access to dental care are wholly inadequate. The history of dental care in Canada shows how we got the flawed system we have in place. People have amassed tremendous wealth and power from the current system, and they will continue to wield that power to maintain the system that has benefitted them at the public’s expense. This is why public pressure is essential to building a movement that can confront the core problems in order to implement a system that prioritizes public health over profits. Dental care is health care, and it is time the government starts treating it that way.
The Coalition for Dentalcare welcomes anyone interested in building public pressure to change the current dental care system. Please join by emailing us at [email protected].
Brandon Doucet is a practicing dentist currently based in Newfoundland.