ARPA: Dental symosium editors' introduction

Not so long ago, the addition of fluoride to the water supply made a big difference to the prevalence and severity of tooth decay. As the American Dental Association says, fluoridation is the ‘single most effective public health measure to prevent tooth decay’ (2005). Its success, however, had at least one unintended consequence: oral health and disease fell down the list of public health priorities. When weighed against other serious medical conditions—diabetes, cancer and dementia—tooth decay and oral disease barely features in our collective sense of illness or in demands for affordable medicine.

With the exception of the United States, all rich democracies provide free (or close to free) public medical treatment for serious illnesses and accidents—even if this is rationed by long queues and performed by staff under strain. Australia was one of the last among these countries to institutionalise public medical insurance, first as Medibank in 1974, and more permanently, in the form of Medicare in 1984—thanks to the Hawke Government. Bitterly resisted by a coalition of medical practitioners and a conservative opposition, Medicare eventually gathered bi-partisan public support as Liberal voters and then eventually the Liberal opposition endorsed the new policy. After the Coalition came to power in 1996, Health Minister Michael Wooldridge established the now oft-repeated refrain that the conservative government was the ‘best friend Medicare ever had’ (cited in Elliot 2006, p. 141).

But government support for dental treatment—both preventive and reconstructive—has not been brought within the framework of public health. Direct public dental provision has remained cramped at the margins of the Australian public health system and dental insurance remains private, largely outside the scope of Medicare. In 2007, a visit to the dentist remains a privilege for those who have the benefit of private health cover (made, by the Howard Government, cheaper for the better-off through the Private Health Insurance Rebate) or for those prepared to pay high up-front fees for services that, on occasion, are urgent.

By all accounts, dental provision in Australia is now marked by strong social and economic inequalities. Public dental programs have either been dismantled or are overburdened. Private insurance does not cover millions of lower income Australians including many in full-time work. The Howard Government’s abolition of the Commonwealth Dental Program in 1997 (a budget saving measure) has left serious gaps in dental provision that has public dental services stretched to the limit, with long queues for urgent treatment (Sydney Morning Herald, 2005). Ironically, this comes at a time when expectations of health standards are ‘ratcheting up’—with the public rightly expecting the best treatments to be made available.

Contributions to this symposium present the latest research and insights into an area of policy badly in need of attention. John Spencer and Jane Harford, from the Australian Research Centre for Population Oral Health at the University of Adelaide, establish the extent of the problem of oral health inequality in Australia arising from lack of access to dental services. Peter Saunders from the Social Policy Research Centre at the University of New South Wales reports survey findings showing that lack of access to a dentist is a marker of poverty in Australia and the Australian community expects dental care as a basic right. Jenny Lewis, from the University of Melbourne, suggests why: dental care receives little public funds support compared to other areas of medicine. As Lewis remarks, ‘where government funding is low, policy attention is also low’.

WHY SO LITTLE ATTENTION?

This collection of papers offers some accounts of the obvious and less obvious reasons for this neglect, ranging from ideology to entrenched interests and history.

In a recent conversation, John Deeble (an architect of the original Medibank scheme) put the current failings in the provision of dental health in historical perspective. For Deeble, fluoridation has made a big difference to the standard of oral health. At the time of Medibank, Labor’s success in creating a national health scheme depended on convincing critics, interest groups and the Australian public that the new scheme was viable. Deeble says that including dental treatment in the basic package of free services for the national scheme would have encountered obstacles: Medibank’s architects worried that the public was not yet used to the idea that services could be provided ‘for nothing’ through taxes; there was little knowledge about the demand (and therefore the cost) of free dental treatment; and, compared with other health inequalities at the time, dental care was lower on the list of priorities.

In her contribution, Jenny Lewis points out that dentistry has fallen outside the realm of public health for organisational reasons as well. The dental profession has spent much time and energy separating itself from medicine. Any effort to ‘socialise’ medicine would not necessarily flow on to dentistry. For Lewis, future policy reform will need to deal with dental professionals and their organised interests in perhaps a similar way earlier advocates had to overcome the entrenched interests of doctors.

Scholars of welfare have long observed that how the middle class is provided for is an important indicator of present and future pressures on public policy. And in deciding on forms of provision, we see the workings of ideology. The Coalition government has had a long history of preferring both ad-hoc and private provision of welfare goods; it has tended to accept the necessity for public provision only grudgingly—usually under considerable public pressure or when market alternatives were not viable. Since dental cover is a major incentive for taking out private health insurance, the Coalition has subsidised dental provision to the (largely middle class) constituency who have private health policies and who benefit most from generous public rebates on private cover.

But attention to dental services for poor and dependent Australians has also lagged. Although the abolition of the Commonwealth Dental Program in 1997 was partly justified as a budgetary measure, this action conformed to the Coalition’s longstanding preference for private provision, and suspicion of public health. Despite alarming statistics about lack of access, inaction (or ‘drift’, as political scientist, Jacob Hacker (2004) calls it) has been the order of the day for dental services.

CAVITIES AND DENTISTS TO FILL THEM

Is Australia doing badly compared to other countries in the provision of dental health services? Recent data from the World Health Organisation (2007a) shows that Australian children suffer comparatively little oral disease—declining dramatically since the 1970s. So far, so good.

But data like this doesn’t give a complete picture of poor dental health in early or later life for many in Australia. As our contributors John Spencer and Jane Harford show, this picture reveals a crisis in access to affordable dental care. Citing a representative study, Spencer and Harford reveal that the poorest Australians (bottom decile) have eight times the number of untreated decayed teeth as do the richest (top decile). Not only does poverty determine access to services, it also determines what type of treatment is available when accessed: poorer Australians are more likely to have their teeth extracted than repaired—with an obvious impact on personal and social esteem.

Supply problems are critical as well. The number of dentists is a factor in the cost and accessibility of treatment. According to the World Health Organisation (2007b) Australia has one dentist for every 2,300 citizens. Britain has one for every 2,300 people as well; Sweden, by contrast, has one for every 1,200. France and Germany have approximately one in 1,400 and 1,300 respectively. In Sweden, almost half the dental profession work in the public sector. One can expect that an expanded public dental scheme in Australia would also need more dentists. Greater public subsidies for dental services would operate best if more dentists were trained to meet the inevitable rise in demand without pushing up costs.

IS THERE AN AFFORDABILITY CRISIS IN DENTAL CARE?

Data presented as part of this symposium provides an up-to-date picture of the affordability crisis. Both Saunders and Spencer and Harford report the evidence. Saunders reveals that, when asked, almost one in five Australians say they don’t have access to a dentist because they can’t afford it. And, equally worryingly, almost a third say they can’t afford an annual check-up for their children. Reporting the results of an epidemiological study conducted in Adelaide in 2005, Spencer and Harford demonstrate the clear link between low income, infrequent visits to a dentist, and poor dentition. Access to dental care makes a difference. Their control sample—respondents in the lowest income quintile who visit the dentist regularly—report a level of dental health comparable to high income earners.

POLICIES FOR DENTAL EQUALITY—AUSTRALIA LAGGING BADLY

The British public is very proud of its National Health Service. Britain has gone much further than Australia with public dental provision. It did not take the step to universal public dental support, but the mandated reach of public care has been greater. Children, those depending on social security, pregnant women and new mothers, full-time students and the elderly receive free basic care including the fitting of crowns; there are public subsidies of about 20 per cent for procedures for others outside this category and an absolute cap on costs (World Health Organisation (2007c). But Britain’s case also illustrates the need for mandated policy to be supported by rigorous policy attention and financial support. A recent report in the Guardian Weekly reports on a recent survey of 5,000 that highlights the lack of available NHS dental services, with some even resorting to extracting their own teeth. The report says ‘More than three-quarters of those who used the services of a private-sector dentist said it was because they couldn’t find an NHS surgery’ (Brown 2007).

Nordic social democracies and continental European countries like France offer a similar framework of guaranteed support to poor and dependent people—but these schemes even more generous to the non-poor. In these countries, governments directly refund a substantial portion of private costs (but note that Sweden doesn’t cover fillings). Belgium and France are on paper among the most generous, returning well over half the costs of a private dental visit. Nowhere is dental care completely free for the non-poor and non-elderly. But most European countries offer a higher and much more universal level of public subsidy than Australia does through private health insurance.

Most European countries have free dental care for children. By contrast, Australian states operate a school dental service for children, funded through federal special purpose grants (Lewis 2006, 197–198). But these dental programs are not well funded. Saunders’ evidence suggests that, with almost one third of families reporting they can’t afford annual check-ups for their children, these programs certainly have their work cut out for them.

The United States has more extensive public coverage than Australia because of public welfare available to the elderly. The United States covers elderly (Medicare) and very poor (Medicaid). Private insurance covers others or doesn’t: studies show up to 25 per cent for uninsured adults cannot afford a dentist.

Australia’s public dental policies are the most limited of the rich democracies. They are also clearly under strain. The failure to provide comprehensive free treatment for children is a distinct failing.

ALTERNATIVE SOLUTIONS—RECOGNISING THE NEED FOR ACTION

One option for the federal government is to continue to do little (drift in Hacker’s terms); although we acknowledge that the 2007 federal budget has brought some of the costs encountered with chronic oral disease within the reach on Medicare. European achievements—with similar levels of affluence as Australia—surely provide one yardstick. While it is hard to measure the ‘on-the-ground’ effectiveness of free dental care in other countries, it seems clear that Australia neither promises much nor delivers much more. Guaranteeing high quality universal public dental care for children would be an important goal for policy, but action is also required elsewhere.

Treating serious oral disease among poor adult Australians is an urgent priority and remains ever more urgent for the abolition of the national scheme that previously catered for these needs. If Australia is to maintain its traditional mix of public-private provision, then restoring public dentistry is a major task. This is also a broadly held view, supported by the Australian Dental Association (2007).

Contributions from Lewis and Spencer and Harford both address major policy alternatives. In helping the non-poor or the ‘next-to-poor’, it seems Australia will need to consider two different directions—subsidising private insurance arrangements or directly subsidising dental visits (where the government is the insurer). Put simply, this might be a choice between the ‘Howard model’ and the Medicare model, with the latter closer to European alternatives. Let’s consider the alternatives briefly.

Spencer and Harford discuss extending the generosity of public subsidies to private health cover, so that more Australian get dental cover through increased take-up of private cover. But, as they acknowledge, this would involve an attempt to make insurance attractive and to ensure adequate competition. A main drawback of subsidising private insurance is the lack of universal coverage; it remains a ‘voluntary’ decision, most importantly regulated by affordability. Even if, as Spencer and Harford point out, private subsidies were increased above their current 30 per cent, there is little available evidence to show how many poorer Australians could take out private cover.

The ‘Medicare option’, like we see in Europe, provides some level of subsidy to all dental treatment—that option is currently unavailable in Australia. Although the cost of such a scheme is likely to be high, and the subsidy not close to 100 per cent, it has the great advantage of guaranteeing basic cover (or universality). European models provide policymakers with some idea of the likely cost of such schemes. In countries like Denmark, private insurance for dental services still operates profitably alongside more generous and universal public subsidies—perhaps answering any argument that public insurance would crowd out private providers. Still, a shift towards universality would necessarily involve only basic treatments and the back-log of urgent treatment required under the public system would remain a separate problem for public health policy.

The question of cost is important. European schemes offer policymakers some guide to the costs of more universal cover. As Gwen Gray (2004) points out, as the single largest purchaser of medical services, Medicare is able to exercise some degree of monopsony power over the price of consultations. The same would apply to dental treatments brought under Medicare. Dentists may initially resist this.

Containing costs is also a question of supply—a significant change in the ‘supply’ of dental professionals is needed to support affordable dental care—through public or private systems. While any revitalisation of public dentistry will require more dental professionals, so would a more generous scheme that subsidised dental services. Lewis proposes a re-working of the broader dental care workforce, where dental therapists play a larger role in dental health treatment, to achieve this end.

Election campaigns should be times for new—or renewed—thinking. In convening this symposium, we have sought to contribute arguments and evidence from some of the most distinguished researchers on oral health, poverty, and dental care policy in the country. Our aim is to inform renewal in a long-neglected field of health policy, and contributions to the symposium challenge both parties to give oral health policy the urgent attention it needs.

REFERENCES

Brown, D, 2007, ‘DIY dentistry fills hole in NHS service’, The Guardian Weekly, 19 October.

Gray, G. 2004, The Politics of Medicare: Who Gets What, When and How, UNSW Press, Sydney.

Hacker, J. 2004, ‘Privatizing risk without privatizing the welfare state: The hidden politics of social policy retrenchment in the United States’, American Political Science Review, vol. 98, no. 2, pp. 343–360.

Lewis, J. M. (2006) ‘Health policy in Australia: Mind the growing gaps’ in Social Policy in Australia: Understanding for Action, eds A. McClelland & P. Smyth, Oxford University Press, Melbourne. pp. 195–208.

World Health Organisation (2007a) World Health Country/Area Profile Programme [Online], Available: http://www.whocollab.od.mah.se/wpro.html (See results for Australia) [2007, 29 Oct].

World Health Organisation (2007b) World Health Country/Area Profile Programme [Online], Available: http://www.whocollab.od.mah.se/wpro/wpromanpow.html (See results for Australia, Sweden, Germany and France) [2007, 29 Oct].

Shaun Wilson is Lecturer in Sociology in the Division of Society, Culture, Media and Philosophy at Macquarie University.

Gabrielle Meagher is Professor of Social Policy in the Faculty of Education and Social Work at the University of Sydney, and Editor of the Australian Review of Public Affairs.

View other articles in this symposium:

Inequality in Oral Health in Australia John Spencer and Jane Harford
Dentistry, Deprivation and Poverty Peter Saunders
The Road to Oral Health Policy Innovation in Australia Jenny M. Lewis

View other articles by Gabrielle Meagher:

What Tony Abbott Talks About When He Talks About Welfare (Digest, Oct 2014)
After Howard’s Decade, is Australia More Conservative? (Digest, 23 Feb 2006)
Do Australians Want a Private Welfare State? (Digest, 3 May 2004)

View other articles by Shaun Wilson:

Labor’s Bad Year (Digest, Mar 2011)
Election 2007: Did the Union Campaign Succeed? (Digest, Feb 2008)
Did WorkChoices Impact on the NSW Election Results? (Digest, May 2007)
After Howard’s Decade, is Australia More Conservative? (Digest, 23 Feb 2006)
On Australia’s Low Tax Consensus (Digest, 30 May 2005)
Public Opinion and Democracy (Digest, 1 Oct 2004)
Obstructing Government or Stopping Bullies? (Digest, 13 Jun 2003)
Does the Social Capital Hypothesis Offer Hope for Untrusting Societies? (Journal, Mar 2003)
Supply Side Social Democracy (Digest, 13 Aug 2001)
Australia’s Secret Keynesianism (Digest, 11 Aug 2000)