Introduction by Croakey: A recent survey by the Australian Dental Association found that one-third of Australians postponed dental treatment in the past year due to ‘COVID-related concerns’, including perceptions their issue was not urgent, concerns about catching COVID at the clinic or not being able to afford dental care.
As regular Croakey contributor Charles Maskell-Knight and Winthrop Professor Marc Tennant AM write below, “access to dental services is dependent on income, and as a result low-income groups have poor access and hence poor dental health, which affects their health more generally”.
Making dental care and treatment more affordable and accessible is a critical determinant of health.
In the second of two in-depth articles on this topic, Maskell-Knight and Tennant outline some financial and practical challenges in making dental care accessible through Medicare, in addition to alternative recommendations for improving access to dental care.
Charles Maskell-Knight and Marc Tennant write:
Problems with access to dental care in Australia are widely known and have existed for many years. The most recent National Study of Adult Oral Health, carried out in 2017-18 by the Australian Research Centre for Population Oral Health, found that:
overall, over one-third of the Australian population aged 15 years and over reported that they avoided or delayed visiting a dentist due to cost (38.8%), and just under one-quarter reported they would have a lot of difficulty paying for a $200 dental bill (24.0%).
In addition, just under one-quarter of all dentate Australians who visited in the previous 12 months reported that cost prevented the recommended treatment (22.6%).”
Access to dental services is dependent on income, and as a result low-income groups have poor access and hence poor dental health, which affects their health more generally.
In the first article in this two-part series, Charles Maskell-Knight set out the recent history of Commonwealth government dental policy, including the efforts of the Rudd-Gillard governments to address the low-income access problem by a large investment in public dental services, and the dismantling of that solution by the Abbott-Turnbull-Morrison governments.
The article identified three important issues as emerging from this history.
First, any future scheme needs to have a legislative basis if it is to endure. Commonwealth-state agreements can be terminated by executive fiat; but legislative schemes can only be stopped with the concurrence of 39 senators.
Second, the design of any scheme needs to take into account the very substantial unmet demand for dental services. AIHW pre-COVID data shows that in 2017-18 just over half of the adult population had a “favourable” dental visiting pattern (visiting a dentist at least annually), and one-third had untreated dental decay.
Third, the Chronic Disease Dental Scheme showed that it is possible to spend a lot of money on prosthodontics such as implants and bridges, most of which will have no impact on ongoing dental disease and very little impact on dental function.
Any proposal to extend Medicare to cover dental items should incorporate a mechanism to ensure that taxpayers only fund services which are necessary to address active dental disease or maintain a functional dentition.
The social lockdowns and disruption caused by the COVID-19 pandemic appear to have further disrupted access to dental services, and there is now some evidence emerging of an association between long COVID and tooth loss.
There is also a link between poor dental health and the severity of COVID-19 infection, which is a particular concern for aged care residents with very limited access to dental care.
Adam Bandt, the leader of the Australian Greens, has made it clear that expanding Medicare to include dental care by simply adding dental item numbers to the Medicare Benefits Schedule will be a priority for the party during the 47th Parliament.
Universal dental care
In an article published by Croakey in 2015, Dr Marc Tennant and colleagues concluded that universal dental care through Medicare would not make sense financially or practically.
We believe this is still the case.
Financially, the additional taxation burden required to fund such a scheme – after allowing for increased utilisation of dental services – would equate to a doubling or tripling of the Medicare levy, which would prove a politically unpalatable outcome.
Practically, the combination of a doubling in demand and the government’s inability to control fees would result in large and increasing gap payments, particularly in areas with a low supply of dental services.
More broadly, as observed in 2015, “we don’t have the workforce, capital, or systems in place to actually manage all the latent needs for dental care”.
In the lead-up to the last election, the Parliamentary Budget Office costed the Greens’ proposal at about $8 billion annually.
However, this costing assumes that “the take-up of the expanded dental coverage to all Australians eligible for Medicare would be 65 percent of those eligible for Medicare, based on current dental attendance rates for the Australian population and data for the Child Dental Benefits Schedule (CDBS)” [our emphasis].
It also assumes that “eighty percent of dental care services would be routine dental care which consists of low to medium cost dental care services”.
Given current attendance rates are depressed by affordability concerns which the measure is intended to address, using these rates is unduly conservative. It essentially assumes that the measure will fail in its main objective of increasing access!
If attendance rates could be increased to 95 percent, the annual cost would be close to $12 billion – and could easily be more if the service backlog included more expensive services.
One incremental option would be to build on the CDBS by removing the income test and extending the eligible age range annually until the whole population was covered. This would avoid the massive spike in cost to government and market disruption inherent in a big bang introduction of a universal scheme.
However, even if the age range was extended by two years every year, it would take over 25 years for the scheme to reach the over-70s who face the greatest barriers in access to services. Until then government support would be directed to a group with relatively low dental needs.
The CDBS currently solves the problem of low value high-cost services by not paying for any of them, even when they might be clinically justified. This would not be sustainable in a universal scheme.
Another option would be a substantial increase in Commonwealth grants to the states to expand the public dental services which are the main providers of services to low-income groups. This approach would target assistance to the groups in most need. However, as the past decade has shown, these grants are subject to the whim of the Commonwealth government.
We believe the best option would be a legislated, entitlement-based scheme cost-shared with the states and delivered by state public dental services.
Eligibility would initially be limited to the concession card holders who are already eligible for state public dental services. Children would not be covered under the scheme. The CDBS – which state public dental services can access – would be maintained.
The Commonwealth would pay a benefit equal to 50 percent of the existing DVA schedule fee – in the longer term the Independent Hospital and Aged Care Pricing Authority could be used to set the fee based on its assessment of the efficient cost of delivery.
The states would agree to pay the balance of the costs of services, and to maintain current aggregate levels of expenditure. This would result in a doubling of resources available to public dental services.
The states would manage service delivery, including developing and applying rules around access to prosthodontics and orthodontics (subject to Commonwealth oversight). The states would also manage outsourcing of service delivery to the private sector if they considered this appropriate. Some states currently charge co-payments.
The future of these would need to be negotiated between the Commonwealth and the relevant states, but the Commonwealth should press for the elimination of these imposts for full pensioners and JobSeeker recipients.
Over time eligibility under the scheme could be expanded to other low-income groups under the 50:50 cost sharing basis if the Commonwealth and the relevant states agree. However, if the Commonwealth chose to expand eligibility unilaterally it could agree to pay 100 percent of the fee for the additional population.
Initially this would cost the Commonwealth about $850 million annually – a little more than the share of the private health insurance premium rebate attributable to dental services. Given the rebate largely subsidises people who could afford to pay for their own dental care (and physiotherapy, and spectacles) there would be a strong equity case for offsetting the cost of the dental scheme by abolishing the rebate on extras insurance.
The fundamental arrangement and nature of public dental services mean that they can provide care to the target group of people in need in a more cost-effective manner than the private sector. They are generally placed in locations of need and have a mix of providers that optimise provider to need.
Clearly, a slow expansion model provides the opportunity for an orchestrated increase in workforce, harnessing the wider network of dental educators that now exists. This expansion, as well as a redirection of employment opportunity, can stabilise and enhance the education institutions at the same time – a double win.
Charles Maskell-Knight PSM was a senior public servant in the Commonwealth Department of Health for over 25 years before retiring in 2021. He worked as a senior adviser to the Aged Care Royal Commission in 2019-20.
Marc Tennant AM is a Winthrop Professor at the University of Western Australia. He is the Director and Founder of the International Research Collaborative – Oral Health and Equity in Human Sciences, which is a global leader in driving reform focused on marginalisation and addressing health inequality.
Read Croakey’s archive of articles on oral health