Since the government announced its $4 billion dental care program, attention has focused on how it will be funded and whether it is affordable. But if and when it is funded and implemented, the package will address some of the fundamental inequities in dental care in this country.
Some of the funding will come from the cessation of the teen Dental Plan, which cost around $60 million a year in each of its first three years of operation and is budgeted to cost $98 million in 2014-15.
More money will come from a cancelled program. The government announced in the last budget it would cease funding for the Chronic Disease Dental Scheme. While it is difficult to find published estimates of the cost of the Chronic Disease Dental Scheme, Health Minister Tanya Plibersek indicated it was costing $80 million a month.
If the current expenditure from these schemes falls in to fund the new announcements, it will do so to the tune of just $1 billion a year. And, in the absence of information about the timeframe for spending the $4 billion, it is not clear how much these savings will defray the new expenditure.
Research on oral health and access to dental care in Australia has consistently shown inequalities – between income groups, between people eligible for public dental care (holders of pension cards or health-care cards) and those ineligible, between people living in major cities and those in rural areas and between Aboriginal and other Australians.
A number of factors influence access to dental care and the first of these is availability. There is a mal-distribution of dental-care providers relative to population distribution – the number of dentists in major cities is double those in outer regional areas and triple those in remote areas.
And Tasmania and The Northern Territory have fewer dentists relative to other jurisdictions. This package recognises this problem and is clearly aimed at addressing workforce shortages in outer metropolitan and rural and remote areas.
Then, there are the long waiting lists for public dental care. These are impacted by a number of factors – that only 16% of dentists in Australia work in the public sector; the limited number of public dental clinics and; their unequal distribution.
The concentration of dental care in the private sector using the small business model has also had an influence on both the distribution of dental-care providers and what they charge. This is evident from the distribution of dental therapists working in the publicly provided School Dental Service, which is better spread out in rural areas than other practitioners, that the private model of care influences the availability of dentists.
The package for dental capital and workforce to expand services for people living in outer metropolitan, regional, rural and remote areas acknowledges that access to dental care is limited by factors other than income. But it remains to be seen whether, even with this additional funding, the government will be able to recruit people from more lucrative private sector employment into the public dental services.
The availability of dentists may increase over the next few years as there will be a doubling of numbers of dental and oral health graduates. This is due to both increasing intake of students in existing dental schools and the opening of new dental and oral health programs (some in rural areas) over the last five years. But the degree to which the increase in numbers will address the demand for dental care remains to be seen.
The additional provisions for funding infrastructure and workforce in rural and remote areas also needs to address the currently limited ability of people living there to gain comprehensive dental care, including specialist services for oral surgery and specialist gum and root canal treatment.
Income and waiting lists
Accessing dental care, even when it is available, is affected by income – people on lower incomes report more difficulty, and people with private dental insurance use dental services more often. Other factors such as availability of public transport and distance from the nearest clinic also play a role. The proposal to fund dental care for children on a similar footing to Medicare-funding for GP visits provides a form of insurance for dental care for children eligible for Family Tax Benefit A.
The sum of $1.3 billion will provide public dental services with resources to provide more care to low-income Australians. It’s worth noting that this money is in addition to $370 million announced in the May budget to reduce waiting lists in the public sector.
But what’s not clear is what impact this package will have on people who avoid or delay visiting the dentist due to cost and who do not qualify for public dental care. This group makes up about half of the people who avoid or delay making a visit to the dentist due to cost.
Increasing funding for public dental services, in addition to the $515 million announced in the recent federal budget will go a long way to address waiting lists for public dental care, providing a workforce can be recruited. But it’s likely that there is an unmet need for dental care by people who have not yet put themselves on a waiting list for public dental care.
Even with a higher level of activity, waiting times may not decline as sharply as hoped. More remains to be done and those who are ineligible for public dental care but who are in low-, or middle-income groups may still struggle with the affordability of dental care without further support.
The historical separation of dental care from medical care so that infection in mouth is treated under entirely different circumstances to other infections also impacts the funding of dental care. Health care is regarded as a right in Australia (hence Medicare), but not if the health problem is in the mouth where a tattered safety net applies.
In recent years, associations of oral diseases with other health problems and the acknowledgement of the burden of disease associated with oral health problems have raised questions about this separation. This is especially so because another major factor impacting inequality in access to dental care is that dental disease only becomes noticeable in its more advanced stages.
The silent nature of dental decay and gum disease results in many people attending late in the disease process when more drastic treatments such as extractions are necessary. Establishing a system that allows people to have regular checks of their mouth and teeth at least every three years is important.
Achieving equitable oral health and access to dental care in Australia requires a comprehensive approach that address workforce numbers and distribution, sufficient financing and innovative approaches to dental care delivery. This package signals a commitment to redressing of the fundamental problems in how dental care is delivered in Australia. Let’s hope the government finds a way to put its money where its mouth is.