Symposium: Is it Time for a Universal Dental Scheme in Australia?

The road to oral health policy innovation in Australia

Jenny M. Lewis, University of Melbourne

Since the Howard Government abolished the Commonwealth Dental Program shortly after gaining office in 1996, public dental waiting times have been steadily rising around the Australian states and territories. The program was abolished, with a memorably ironic flourish by Peter Costello in his budget speech of 1997: he claimed that the program had served its purpose by reducing waiting times for public dental care, and so was no longer required (Lewis 2000).

Recent figures from the Australian Institute of Health and Welfare Dental Statistics Research Unit (2006) indicate that fourteen per cent of adults did not seek dental treatment because of the cost, while thirteen per cent said they would have significant difficulty paying a $100 dental bill. The private health insurance rebate, which provides incentives for the well off to take out insurance, adds to the inequity by effectively subsidising the wealthy for a range of health services, including dental services. The Australian Labor Party (ALP) claims that there are now 650,000 people on public dental waiting lists around the country. Clearly, those languishing on these lists are not people who can afford to pay for private dental care, either by direct out-of-pocket costs, or through both individual and private health insurance contributions.

Oral health is central to overall health and wellbeing.

What explanation can be found for the general lack of governmental attention and policy innovation in oral health since the program’s demise a decade ago? In the context of the upcoming 2007 Federal Election, what are the major parties promising and what chance is there of this situation being addressed? Are there signs of major policy innovation in oral health on the horizon in Australia?

Oral health is central to overall health and wellbeing. It is related to how easily people can chew healthy food, and is crucially tied to appearance and self-esteem. Yet oral health is regarded as a separate territory in the health sector, outside the realm of doctors and medicine, and largely outside the concerns of Medicare.

The reasons for this are many, but include the professional boundary lines between dentistry and medicine, the traditionally low government contributions to funding dental services and the associated lack of attention paid to it, and the fact that dentistry rarely deals with matters of life and death. The dental profession has invested heavily in staking out a professional territory of its own, outside of medicine’s control. This cements dentistry’s position at the top of the hierarchy in relation to oral health matters, but also has the consequence of rendering it a separate sphere, not integral to health overall. When major decisions about health policy have been made in Australia, including the introduction of universal health insurance, this separation has provided a line which can be drawn between the essential and not so essential components of a health system.

In other words, the separation of dentistry from medicine points to what must be included and what can be regarded as an ‘optional extra’. Medicare is largely about funding doctors and hospitals. In recent years there have been some changes to allow health professionals other than doctors to use Medicare items, but these are marginal. For example, services provided by nurse practitioners under Medicare for 2006–7 amounted to 1.4 per cent of all Medicare services for that financial year. While government is heavily involved in funding for services provided by doctors and hospitals, this is not the case for dental services. The total contribution of all levels of government to medical and hospital expenditure is 78 per cent and 81 per cent, respectively, in contrast to 21 per cent for dental services (Australian Institute of Health and Welfare 2006).

Where government funding is low, policy attention is also low. It is telling that in previous reviews of what should be included in Medicare, other professions have argued for why they should be allowed to provide services through Medicare, but the dental profession has argued for why they should not be included. Organised dentistry has been reluctant to become involved with government funded schemes because they potentially reduce dentists’ ability to choose which patients to take, limit their ability to set their own fees, and lead to greater government scrutiny of both the quality of services and how the money is spent. The Commonwealth Dental Program was astutely constructed with the executive of the Australian Dental Association in mind, allaying their worst fears about the loss of autonomy for the dentists involved, by making it a stand alone scheme, which was tightly bounded in terms of the services included, and available only to health card holders.

CURRENT POLICY POSITIONS

The Labor party is promising to re-establish the Commonwealth
Dental Program.

The Coalition Government’s introduction of dental care items for patients with chronic and complex conditions, through the Enhanced Primary Care item under Medicare in 2004, has provided some access to dental treatment, through referral from a GP. The Government announced in the 2007 budget that it will extend this scheme, promising services up to a maximum of $2,000 per year, and a total allocation of $377.6 million over four years to treat 200,000 patients (Department of Health and Ageing 2007). As the Labor opposition points out, in the first three years of this program, a total of just 7,228 people from around Australia benefited from this scheme. The restrictive referral process via GPs, the eligibility criteria which limits coverage to people with chronic health problems, and the previous three items per year limit of the scheme, have all contributed to a low take up (Australian Labor Party 2007). This seems to be the limit of how the Howard Government wants to be involved in oral health policy. The standard response by the Howard Government to criticisms about lengthy waiting times for public dental care is that it is a state responsibility.

The Labor party is promising to re-establish the Commonwealth Dental Program, should it become the next federal government. Details of the ALP’s plans beyond this are sketchy, but given the use of the same name and the indication that it will be a ‘re-establishment’, it seems likely that the program would operate on similar principles as the previous one. The main features of the previous program, available to all health card holders, included that a limited number of items were available with a set fee paid for each of them. There was a fixed total amount that could be spent on any one individual per annum. Public dental clinics used the program in addition to the resources they currently allocated to dental care, and individual private dentists were free to decide whether to take patients through the program, and how many.

One major change over the last decade, and a challenge for the reintroduction of this program, is the now serious shortage of dentists. Not only are public dental services groaning under the weight of demand, and finding it hard to attract dentists to work in them, private dentists are also thin on the ground. A telephone call to a dentist you have not been to before is likely to result in you being asked to wait two or three or even six months for an initial appointment. John Spencer and his colleagues have been mapping the growing gap between demand and capacity to supply dental services for some time, and have argued that by 2010 Australia will be short of some 1,500 dental professionals (Marshall & Spencer 2006; Teusner & Spencer 2005; Spencer et al. 2003). This begs the question, what would be the incentive, beyond altruism, for a private dentist with a full list to take on new patients through such a program, particularly when these patients will be less profitable?

A DIFFERENT FOCUS FOR POLICY INNOVATION

A bolder alternative to reinstating the Commonwealth Dental Program, would be to add a range of dental items to Medicare. Is it a good idea to take a more universal approach to the provision of dental services in Australia, or would it make more sense to have a highly targeted program? Given the workforce shortage, adding dental items to Medicare will in principle make them universally available, but in practice, the (likely relatively low) fee set for dental items, combined with the shortage of dentists, will immediately lead to a set of incentives to charge more than the scheduled fee, and there would be little incentive to bulk bill even health card holders. Even before such a scheme made it onto the books, it is likely that the dental profession would oppose its inclusion in Medicare. The inclusion of oral health items in Medicare would bring dentists under even greater governmental attention and scrutiny than would be the case for a dental program, and would bring them into the realm of medicine where they would not inhabit the ‘top of the professional tree’ position. It would also generate pressure for them to provide services at lower rates to all patients, not just health card holders.

The position of dentistry within the oral health hierarchy is jealously guarded.

A more innovative solution, but one likely to excite even greater antagonism from the dental profession, would be to allow a range of oral health professionals to provide services, either through Medicare, or under a dental program. The position of dentistry within the oral health hierarchy is jealously guarded. Dental hygienists are already able to provide a range of services. Dental therapists are able to do simple fillings in addition to preventive services, but are currently only legally able to work on children and adolescents. There are good reasons why we should worry about the quality of care and pay close attention to the differences in training and skill levels of different professions. But there are now precedents in the growing acceptance of nurse practitioners undertaking additional training and taking on more responsibilities. If psychologists can deliver counselling items alongside psychiatrists under Medicare, why couldn’t dental therapists and hygienists deliver an expanded range of oral health services?

Both of the alternatives discussed here are federal government responses, and it is at this level that action is required to overcome the cost and blame shifting that characterises so much of health policy in Australia, and which over the last decade has only exacerbated the inequities in the health system (Lewis 2006), including in relation to oral health. In equity terms, the Medicare alternative is better because it would help low and middle income earners with neither health care cards nor private insurance to access dental care. On the other hand, a program targeted at health card holders is likely to be more acceptable to the dental profession than the addition of oral health items to Medicare. But neither of these policy innovations are going to prove to be solutions without a substantial growth in the capacity of the oral health workforce, either through inducing more dentists to come to Australia from elsewhere (short term), or training more of them (longer term), or by allowing existing oral health professionals other than dentists to expand their allowable range of treatment. This is now a major roadblock to innovation in dental policy in Australia, and one that must be removed if significant change is to occur.

REFERENCES

Australian Institute of Health and Welfare 2006, Australia’s Health 2006, Australian Institute of Health and Welfare, Canberra.

Australian Institute of Health and Welfare Dental Statistics Research Unit 2006, Access to Dental Services Among Australian Children and Adults, Research report No 26, University of Adelaide, Adelaide.

Australian Labour Party 2007, ‘New dental program not so new’, Media statement 16 August [Online], Available: http://www.alp.org.au/media/0807/mshea160.php [2007, Aug 26].

Department of Health and Ageing 2007, Dental treatment—Enhanced Medicare item for patients with chronic and complex conditions [Online], Available: http://www.health.gov.au/internet/budget/publishing.nsf/Content/budget2007-hfact04.htm [2007, Aug 26].

Department of Health and Ageing 2007, Medicare Statistics [Online], Available: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/medstat-jun07-tables-b [2007, Sep 5].

Lewis, J.M. 2000, ‘From “Fightback” to “Biteback”: The rise and fall of a national dental program’, Australian Journal of Public Administration, vol. 59, no. 1, pp. 84–96.

Lewis, J.M. 2006, ‘Health policy in Australia: Mind the growing gaps’, in Social Policy in Australia: Understanding for Action, eds A. McLelland & P. Smyth, Oxford University Press, Melbourne.

Marshall, R.I. & Spencer, A.J. 2006, ‘Accessing oral health care in Australia’, Medical Journal of Australia, vol. 185, no. 2, pp. 59–60.

Spencer, A.J., Teusner, D.N., Carter, K.D., & Brennan, D.T. 2003, The Dental Labour Force in Australia: The Position and Policy Directions, Australian Institute of Health and Welfare, Canberra.

Teusner, D.N. & Spencer, A.J. 2005, Projections of the Australian Dental Labour Force, Australian Institute of Health and Welfare, Canberra.

Dr Jenny M. Lewis is Director of the Master of Public Policy and Management program at the University of Melbourne. She has published widely on policy, governance and professions, and is the author of Health Policy and Politics: Networks, Ideas and Power (2005, IP Communications).

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