Below are two further analyses of the dental reforms:
• Dental reforms are welcome but also entrench some of the health system’s structural problems, by health policy analyst Jennifer Doggett
• A universal system would bring economic, social and health benefits, by Dr Alexis Zander, a dentist convenes the NSW Oral Health Special Interest Group of the Public Health Association of Australia.
Dental reforms are welcome but also entrench some of the health system’s structural problems
Health policy analyst Jennifer Doggett writes:
Australia’s dental health has been in decline since 1996 when (then) Prime Minister John Howard scrapped the Commonwealth Dental Program in his first ever Budget. With the States and Territories refusing to make up the axed funds, public dental systems languished, leaving many Australians unable to access dental treatment. Children born that year are now turning 16: an entire generation of low income and disadvantaged children who have grown up without adequate dental care.
The result of this political neglect has been an increase in untreated dental problems in the community, leading to more serious complications and significant health, social and economic costs.
Health economist Jeff Richardson estimates that untreated dental problems cost the economy up to $2 billion per year in avoidable hospitalisations, other health care costs and lost productivity. Harder to measure is the cost of inadequate public dental care to our sense of fairness and cohesiveness as a community.
The Gillard Government’s package aims to reverse this trend by ensuring that everyone can afford at least basic and preventive care. Its main target groups are children from low-income families and adults currently eligible for public dental services. This targeting, and the overall design of the package, reflects the extensive consultation by the Government with health groups and experts who have lobbied long and hard for the initiative.
Sensibly, the Government has listened to the significant input from the sector and the resulting package is much fairer and more efficient than previous Commonwealth dental schemes. It clarifies the roles of the Commonwealth and States in public dental care, giving the Commonwealth responsibility for children’s services and leaving the States with responsibility for adults’ services. This should help reduce the buck-passing and political tap dancing between these two levels of Government over dental issues that has occurred since 1996.
Symbolically, it is important as it recognises dental care as an integral part of overall health care. This has been resisted steadfastly by successive federal governments, terrified about the implications for their bottom lines.
While not the universal system called for by most stakeholder groups, it is much more comprehensive than previous schemes and provides a solid foundation on which a universal system could be built in the future. This makes it more difficult for a future Coalition Government to unravel – an important consideration for Labor’s legacy-building agenda.
On the negative side, the Government has yet again failed to address the problem of co-payments in the health system. Despite the rhetoric about supporting disadvantaged families, even the poorest parents will still face the risk of open-ended out-of-pocket costs if they access private dentists under this scheme.
Out-of-pocket costs are a problem across the spectrum of the health system but in particular in dentistry where consumer co-payments comprise over 60% of our total $7.7 billion spend on dental services every year (2009-10).
Also, while the package targets those most in need, it leaves a significant proportion of the population without any assistance in accessing dental care. In fact, about a third of all Australians will fall in a crack between these schemes and private health insurance and so miss out on subsidies from either source. Many of these people are not rich and may have difficulty affording dental care, particularly if they have other chronic health problems.
A more sophisticated targeting system, which focused on out-of-pocket health costs rather than income, along with a comprehensive health care safety net, would address this problem.
As with many of the other Government’s health reforms, this measure entrenches an episodic, fee-for-service, system of care, which we know doesn’t work for many consumers and many conditions. In particular, this type of care fails the most vulnerable and at risk people who require a more integrated, longer-term and coordinated approach to address their complex and individual needs.
A major challenge in the implementation of the package will be to integrate dental with other aspects of health care, in particular for vulnerable and at risk groups. Medicare Locals could be important in this role as they should have developed relationships with other community care providers and have the infrastructure required to support this more comprehensive approach.
Other challenges include the shortage or mal-distribution (or both) of dental practitioners, particularly in rural and remote areas. The Government has introduced some workforce measures and allocated funding for infrastructure in the package but there will need to be more action in this area, including increased roles for dental assistants and hygienists, if the access goals of the package are to be realised.
Tony Abbott’s response to the package was to criticise the Government for spending this money in preference to preserving a Budget surplus. However, his attempts to present the Coalition as the party of fiscal restraint lack any credibility when he continues to support a non-means tested and open-ended subsidy for private dentistry via the private health insurance rebate.
His opposition to the Government’s plan has, however, put him at odds with the vast majority of the health and social welfare sector (including conservative groups such as the AMA), perhaps not the smartest move for an Opposition looking to build support for its policy agenda.
Either way, Abbott’s position on dental presents the electorate with a clear choice about the priorities and values of the major parties – something for voters to chew over as we approach the next federal election.
• This article was also published today in the Crikey bulletin.
Declaration: Jennifer Doggett has provided consultancy services for a number of groups lobbying for dental reform (AHHA, CHF, ACHRA).
A universal system would bring economic, social and health benefits
Dr Alexis Zander writes:
The Hon Tanya Plibersek has announced significant reforms to Australia’s dental system, which will see $4B spent on providing services for children, low-income earners, people living in rural and remote areas and pensioners.
Senator Richard Di Natale said the reforms ‘lay the foundations for Denticare’, a system of universal access to dental care mirroring Medicare whereby everyone could see a dentist of their choice, and receive a government rebate for that service.
Beginning this process is so important because Australia’s current dental system is both inefficient and inequitable.
Every year, we spend around $7B on dental care but waiting lists for public dental treatment extend up to five years in some areas, and many low and middle-income earners fall through the net, being ineligible for public care but unable to afford private care. Reform of the system toward universal access to care is expensive, but delays to treatment under the current system mean it’s already expensive, and a universal system would be both more efficient and equitable.
Australia’s current dental system is split between public and part private providers.
Children, healthcare and concession cardholders are eligible for public dentistry, which is funded predominantly by the federal government but administered by the states. This part of the system costs taxpayers around $3B per year. The remaining 65% of the population are ineligible for public dental care, and can only access dental care via the private sector.
For many who are ineligible for public care, seeing a private dentist is a financial hardship that cannot be justified on a regular basis.
Figures from the Australian Research Centre for Population Oral Health show that around 45% of Australians delay going to the dentist because of cost. For those who are eligible for public care, treatment can be delayed months or years because of long public dental waiting lists, which extend up to five years in some areas.
Delaying treatment often means that minor problems that could have been fixed relatively easily become more serious and expensive to treat. A small cavity can be restored with a small filling, but without treatment it will progress to a large cavity, needing a large filling, root canal treatment, a crown or extraction.
Every year 60,000 Australians are hospitalised with potentially preventable dental problems, occupying costly hospital beds that could instead be used to clear public hospital waiting lists. If people were seen regularly and earlier, their dental problems would be picked up when they’re relatively small and cheaper to treat.
It has been estimated that each potentially preventable hospitalisation costs $38,000. Data published by the Commonwealth Department of Health and Ageing shows that the average cost of a check-up, scale and clean and fluoride treatment at a private dentist is around $180, and a small filling is around $130. Preventing one hospitalization through early treatment could pay for preventive and maintenance visits for around 200 patients.
In addition to the direct costs to our health care system, dental decay impacts indirectly on our economy through reduced productivity and participation in the workforce. Some have estimated the cost to the economy could be up to $2 billion per annum through reduced productivity, well-being and workforce participation.
Private health insurance companies further complicate the problem. Data from the Australian Dental Association shows that over the past 10 years, private health insurers paid out $5.5 billion less in rebates than they charged in premiums for ancillary items such as dental cover, and made a profit of 23% on ancillary insurance. Collectively, we’re paying out more to these companies than we’re getting back.
If Australia had an integrated system for dental care, we wouldn’t use private insurance for basic dentistry and these private companies would not be profiting from individual’s payments. Instead, that money would stay within the system and be used to improve care and help those who need it.
A universal system for dental care will remove some of the barriers to dental treatment, and should encourage prevention and early treatment, which is a more efficient use of money, not to mention a better experience for patients and dentists alike.
Further, a greater proportion of the money spent on health will stay within the system, rather than to private companies. Finally, everyone could access care in the same way we do for medical treatment. Australia’s Medicare system and welfare systems show that giving everyone a fair go is a value Australians hold dear. For oral health, it’s not that hard to do.
We need to support our politicians to change the system, by helping them see the economic and social opportunities a universal system poses.
• Dr Alexis Zander is a dentist who convenes the NSW Oral Health Special Interest Group of the Public Health Association. She works both as a clinician and public health researcher.