When the current federal government withdrew its contribution (up to $100 million per annum) to the Commonwealth Dental Health Program in 1997, a ministerial advisor said to one of us (SL), ‘We were surprised how easy it was! We expected an outcry!’
Of course, the Minister for Health operates in a political environment where he is faced with demands from cabinet to cut his budget. Either dental health or something else would have to go especially with new programs in rural health, immunisation and medical research demanding money. But yes, it was interesting just how easily this program was folded up.
The constituency for teeth may have a weak bite, but recently its voice has become stronger.
The states and territories could have made good the program: the amount is quite trivial. But for political reasons (see last year’s Parliamentary Committee Report, The Blame Game for details) the states and territories decided not to fill the cavity – so to speak.
The Federal Minister for Heath, Tony Abbott recently remarked, ‘I know people are very unhappy about the state of [public] dental schemes. Every time dentistry is in the public arena people demand that the Federal Government take it over…Those people … should direct their concerns to the state governments. They need to take responsibility and I think that public dental care is appropriately in their domains.’
Who suffers from this buck passing? The 650,000 or so Australians on dental care waiting lists. Professionals have been disheartened. Public dentistry has fallen into professional disrepute – too many people get to see too few public dentists too late for restorative work. Who wants to pull teeth all day?
A new Australian Institute of Health and Welfare (AIHW) report provides a detailed snapshot of oral health in the adult population. Some 30 per cent of the 14,500 people aged over 15 years surveyed avoided dental care due to cost, and about 20 per cent said that cost had prevented them from having recommended dental treatment.
We got into this mess because dental care was not included in Medicare. Fierce representation from dental unions and a keen desire by the Federal Government to restrict the exposure of Medicare to risk meant that teeth were excluded as a body organ. Now no-one wants to correct that omission and add dental care to the Medicare Benefits Schedule. The Labor Party has pledged a Commonwealth-funded public dental health program but not Medicare coverage.
Meanwhile, the Federal Government, as Professor John Spencer in Adelaide has shown, is well and truly back in the dental care funding business, though now it is by way of the $260 million (in 2001/02) made available exclusively to those who hold private health insurance for dental care. This is one of the few areas in which a necessary health service is genuinely unavailable on financial grounds, except to those who have private insurance.
The ministerial advisor should not have been surprised by the lack of outcry over the abolition of federal funding for public dentistry. Think for a moment of the constituency – the aged, the indigent, those with development disability or handicap, indigenous Australians. None of whom are a strong advocate.
The Australian Health Policy Institute commissioned papers from Professor John Spencer in 2001 and 2004. Both are available on the Australian Health Policy Institute’s website. Spencer does a brilliant job of pulling together the available epidemiological evidence to establish his case, spelling out the iniquity and inequity of failed policy in this field. This failure includes poor performance in workforce development because of professional paranoia about the role of dental therapists and other dental health professionals.
What can be done? Five activities commend themselves from Spencer’s analysis.
- First, extend the coverage of water fluoridation. Fluoridation is a safe, effective and equitable measure that can prevent dental decay across all age groups and in all geographical settings. No other single action can be taken that would achieve the cost effectiveness of water fluoridation. The recent AIHW report shows that members of the fluoride generation (born since 1970) had about half the level of decay that their parents’ generation had developed by the time they were young adults. This is evidence that exposure to fluoride in water and in toothpaste during childhood produced substantial benefits for oral health among Australian adults. In 2006, approximately 8.2 per cent of NSW was not fluoridated and the estimated cost of supplying fluoridated water across the state was $16.2 million. There is still much to do to achieve full coverage.
- Second, engage in health promotion. This can be integrated into other general health promotion campaigns such as those for obesity and healthy ageing, given oral diseases share a number of risk factors with the national health priority areas.
- Children of preschool age and pregnant women should be the target of oral health campaigns. Evidence indicates that there is a high prevalence of early childhood cavaties, with 84 per cent of children under five years never before visiting a dental care provider.
- Third, reform public dental services. There is an urgent need to evaluate what works well, what doesn’t and why. We need to examine the interaction between public and private sectors in the provision of dental services, determine equitable means to prioritise people seeking public dental care and target vulnerable groups waiting for dental care with proactive intervention programs.
- Fourth, reshape funding arrangements for public dental care. In 2002–03, 68 per cent of health services expenditure was funded by government sources while only 20 per cent was sourced from individual out-of-pocket spending. This is almost the reverse of dental services expenditure, where the majority (68%) was privately funded by individuals and only 17 per cent was government funded.
- Fifth, expand the dental workforce. There is a shortage of the dental labour force and a national dental labour force plan is required.
Mertz and O’Neil (2002) remind us that the issues are wider than simply supplying more dentists: ‘Some increase may be warranted, and perhaps inevitable, but it may be more useful to understand this problem as less of a supply of practitioners and more as … poor [occlusion] between part of the current model and, patterns of disease and the people needing care.’
Time for energetic brushing and flossing in the dental policy domain.
AIHW Dental Statistics and Research Unit (2007) Australia‘s dental generations: the National Survey of Adult Oral Health 2004-06 Australian Institute of Health and Welfare, Canberra.
House of Representatives Standing Committee on Health and Ageing The Blame Game:
Report on the inquiry into health funding The Parliament of the Commonwealth of Australia, November 2006.
Mertz E and O’Neil E. ‘The growing challenge of providing oral health care services to all Americans’ Health Affairs 2002;21:65-77.
Spencer J. "What options do we have for organising, providing and funding better public dental care?" Australian Health Policy Institute Commissioned Pare Series, 2001.
Spencer J. "Narrowing the inequality gap in oral health and dental care in Australia" Australian Health Policy Institute Commissioned Paper Series, 2004.