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With the recent torrent of bad news on the state of our health-care system, it comes as a welcome surprise that we will soon see one of the biggest expansions of public medicare in 50 years. The Liberal government, as required by a supply-and-confidence deal struck with the NDP, will offer dental insurance coverage for households with incomes of less than $90,000 a year.
Given the time frame set by the NDP, the federal government perhaps had no choice but to bypass the same old way of negotiating with the provinces. In a groundbreaking policy innovation, the government will directly insure eligible Canadians for dental care. Of course, the announcement was met with the usual clamour that health care falls within provincial jurisdiction. But, as we explain with our colleagues in a paper published by the Institute for Research on Public Policy, it is constitutionally feasible for Parliament to use its spending power this way; whether it is the best approach is another question.
The Canadian Dental Care Plan is an important step forward in helping Canadians avoid pain and suffering from untreated dental conditions. And the plan has the clear upside of getting the job done quickly, rather than being mired in endless federal-provincial debates.
However, there are downsides.
First, people who have private insurance won’t be covered. More than half of Canadians have some private dental coverage, but often face inadequate coverage limits and high deductibles. In our view, the goal should be to provide universal coverage, so all Canadians are publicly insured for essential dental services. Continued reliance on private insurance will result in a dental-care system that is inequitable and inefficient. Over time, the public plan will be forced to pay ever-higher prices to entice dentists to treat public patients rather than higher-paying private ones. Promising a large role for private finance may sound fiscally prudent, but usually isn’t. Universal coverage could be achieved by combining a public plan with mandatory and regulated private insurance for wealthier Canadians, but this would require significant regulation and would be difficult for the federal government to achieve on its own.
The second problem is the insufficient emphasis on ensuring actual access to care. There is evidence that many low-income Canadians who have public dental insurance provided under one of the few federal and provincial government plans don’t access care. To its credit, the government set aside $250 million to address oral health gaps and access issues among vulnerable populations, but this is just 1.9 per cent of the total budget. Greater emphasis should be placed on ensuring access to dental care — for example, within schools and community settings.
A third problem relates to a desire to eliminate co-payments and extra-billing. It is unclear if and how the government could impose such limits on dentists, and attempts to do so will likely be viewed as straying into provincial jurisdiction and may be constitutionally challenged.
In our paper, we explore different ways to achieve a dental care plan, drawing lessons from the successes and failures in other parts of our health-care system. We argue that all levels of government should work together through an arm’s-length agency. The agency would be federally funded but empowered by the provinces and territories to regulate issues such as user charges and extra-billing.
This expert agency would be a one-stop shop tasked with ensuring real access to dental care and providing insurance coverage for essential care. Given that many services offered by dentists are cosmetic, it is important that we have a clear, fair and expert-led process for determining what falls within the public plan and what can be left to private providers.
The agency must be empowered to collect data on oral health to monitor the accessibility, quality and appropriateness of care, and patient and provider experiences. With a stronger evidence base, Canada can build a better and more responsive dental health program that not only provides universal coverage and access, but also promotes prevention.
At its core, a pan-Canadian dental health agency would reflect a spirit of co-operative federalism. However, provinces must be willing to participate, and no doubt some will refuse. But this is the kind of solution we need now — not only for dental care, but for our entire health-care system.
Colleen M. Flood is the Research Chair in Health Law and Policy in the Faculty of Law at the University of Ottawa and the incoming dean of the Faculty of Law at Queen’s University. Sarah J. Lazin is a candidate in the Master of Law program at the University of Ottawa.
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