Denticare - Good Politics & Policy, & Obama = Opportunity

The movement towards universal dental care started with Mackenzie King's Liberals in 1919, and has been carried by all political parties, Conservatives as well as the CCF-NDP & Liberals. Now is the time to make this vote-winner a reality, by leveraging Canadian pro-Obama sentiments and Canadians' awareness & approval of the Democrats' desired "public health care option" to propose a similar "public dental care option", to cover the 40% of Canadians without dental insurance, and help the even greater number who struggle with the costs of profiteering insurance companies and "gourmand" dentists.

King's Liberals proposed comprehensive national health insurance in 1919. The 1933 Regina Manifesto, strikingly relevant, called for "a properly organized system of public health services including medical and dental care". R.B. Bennett, the Tory PM, promised health insurance in the 1930s and Conservatives proposed it again in opposition during WWII. The Canadian Dental Association, representing dentists, proposed compulsory dental insurance in 1943. In 1944, the Tommy Douglas CCF campaigned & won election on a platform that included public health and dental care. Under King, Liberal PM in 1945, the Liberals favoured such comprehensive health insurance on a national basis, just as the CCF was implementing its health care plan in Saskatchewan, including dental care. But it was the Conservative government of Diefenbaker that, as Ross notes, "decided to make good on the idea of 50 per cent cost sharing for those provinces wanting to set up and administer a public health care program. While the idea of private insurance plans was already well underway in many parts of Canada, more than 30 per cent of Canadians had no health insurance at all" [EFL bold - consider that today, 40% of Canadians have no dental insurance].

It was Diefenbaker's Tory Govt which created the Royal Commission on Health Services, chaired by Justice Hall, whose 1965 report, called for, along with other health services, "dental treament costs paid from the public purse." Pearson & the Liberals, having replaced Diefenbaker, had the following response: "First, the scope of benefits should be, broadly speaking, all the services provided by physicians, both general practitioners and specialists. A complete health plan would include dental treatment, prescribed drugs, and other important services, and there is nothing in the approach we propose to prevent these being included, from the start or later, if this were the general wish. We regard comprehensive physicians' services as the initial minimum." [EFL bolding] Pearson was not able to do all he wanted, but he persisted, and national medicare was born in 1968, though fragile, until Trudeau scotched any further prevaricating.

But despite public dental care being part of the plan for public health care from the beginning, under Liberals, the CCF-NDP & Conservatives, it has yet to be achieved. During the Chrétien-Martin years, the Federal, Provincial and Territorial Dental Working Group, or FPTDWG was founded, and published the first ever Canadian Oral Health Strategy in 2005. It notes that at best, only 58% of Canadians have some form of dental insurance, however limited. As a result: "There are 30-40% of people who pay for dental services out-of-pocket. In addition, there are a percentage of insured people for whom the co-pay portion of the costs creates a financial burden. This leads to a significant number of people, measuring in the millions, for whom there is a financial barrier to access to oral health services. While 80% of high-income Canadians have dental insurance, only 11% of low-income elderly have dental insurance."

This is very serious, as dental care IS health care. Under the heading The Oral Health, General Health Connection, the FPTDWG makes this obvious point: "There is a growing body of evidence that indicates that oral health is directly linked to general health. As was stated in the first Surgeon General’s Report on Oral Health in the United States “… oral health and general health should not be interpreted as separate entities.” In order to recognize and enhance the integration of oral health to general health, it is necessary to integrate health promotion activities, health services and the measurement of health outcomes."

The subsequent heading, What governments can do to improve access to care and reduce barriers to oral health care, lists a number of measures whose obvious logic, taken together, is to make dental care affordable and accessible for all Canadians, through increased funding by all levels of government, free services for all who need it, subsidies for others, etc.. The Democrats' desired health care plan, with a public option, in effect. And this was recommendation of group representing all governments, federal, provincial & territorial, of all political stripes.

The Canadian Association for Public Health Dentistry (CAPHD) has a page that links to the mishmash of public dental programs across the country. Crazy.

It would be best, most rational and useful, to extend our current single-payer health insurance system to dental care, as was the intent from the beginning, by all parties, in all parts of the country, at all levels of government. But considering how entrenched the interests of those who are opposed, the cowardice of politicians, and perceived fiscal constraints, that would be difficult. Of course, just as public health care is far more efficient than private, so it would be with the integration of dental care into the system, as is already the case in most every developed country with public health care. And of course, all these fiscal arguments are fundamentally false, as they are parlour tricks in which one is supposed to look at health costs from the perspective of government accountants and not from a national economic perspective. It is the difference between accounting and economics. The inefficiency, high transaction costs and negative externalities (ex: increased oral hygiene problems that have to be more expensively dealt with in hospitals when they reach crisis point than if prevented earlier) of a tiered dental health care system mean that dental care, as currently structured, may be costing Canadian governments little as part of their obvious budget calculation, but it is costing Canadian society as a whole an enormous amount.

A public dental insurance option, modelled on the Obama plan, free for the poor, working- & lower-middle classes, subsidised on a sliding scale for all others, would save Canada a lot of money, reducing extreme costs of hospital emergency demands, and forcing dentists & insurers to be less "gourmand", and more efficient. It would also make Canadians healthier, happier and more productive. Just as Democrats and Republicans predict, the former quietly, the latter madly, such a system, given public administrative efficiency and bargaining power, would probably ease out all but the most niche-targetted private insurance over time. Given our existing public health system, which the USA lacks, in Canada this logic would result in an eventual complete integration of dental services into the public health system, within a generation.

Given Canadian awareness of the American health-care debate, our commitment to our own health care system, Canadians' support for Obama, the logic of the proposed reform, the popular support for accessible & affordable dental care for all, and the wide resentment for insurance companies' & dentists' profiteering among those who pay for insurance or dentistry out-of-pocket, and those who cannot afford to, now is the time to propose a national dental care plan that would mimic Obama's initial health care plan.

Dental insurance would become obligatory, so that should please the insurers and dentists. Those with dental insurance through their employer or other source (worker's comp, welfare, etc.) would keep it. Private insurance rates would be capped. But any citizen without dental insurance would have to get it, available free through the public insurer for those who can't afford it, and subsidised for those who need the help. There would be a transition period of, say, three years, during which time those with private insurance would not be able to switch to the public plan, so as to give time to the private insurers to become more efficient as they prepare to compete with the public insurer, who will also need the time to work out the kinks. But after the three years, game on: companies and people are free to switch to the public insurer. If the private insurers can compete with the not-for-profit public insurer, then good for them. But given the public insurer will command an initial market share of some 40% of the population, one imagines their administrative efficiency will allow them to gain ever more market share, which in turn will allow them to control costs (economies of scale and bargaining power), allowing them to further lower rates, etc..

There is not a lot of sympathy out there for dentists and insurers, to put it mildly. If you offer a chance for Canadians to get the dental care they need, that will be enormously popular. The fact that the private sector will be allowed to compete removes any credibility from claims of illiberal "socialistic" behaviour. Given public views of insurers and dentists, any squawking from them about competing with a public option would only make the plan more popular. Especially given our own culture.

Given present realities, it would be difficult to suddenly nationalise dentistry: the time to do it was at the beginning of medicare. In fact, it was largely achieved in Saskatchewan, until the worst government in Canadian history, the Devine Conservatives, "dismantled the dental plan, turning dental care over to private clinics", while also managing historic feats of indebtedness, corruption & incompetence.

From Mackenzie King in 1911, to Pearson to Trudeau (and Bégin's Canada Health Act) to Chrétien and Martin, Liberals have always been the ones to expand and improve medicare, nationally. They have also been at the forefront provincially, thinking back to the introduction of youth denticare under Peterson in Ontario, and McGuinty's expansion of dental services. In 2004, George Smitherman, then Ontario Minister of Health & Long-Term Care, quoted Tommy Douglas approvingly. I conclude with Smitherman's speech (he forgot a couple of Douglas' words, which I have inserted in italics). Smitherman:

Defending medicare is not the same thing as defending the status quo.

Medicare is very much a 'work-in-progress.' That was always the intent.

Tommy Douglas made the very same point. And he made it much better.

"Let's not forget," he said, "that the ultimate goal of medicare must be to keep people well rather than just patching them up when they get sick. That means clinics. That means making the hospitals available for active treatment cases only, getting chronic patients into nursing homes, carrying on home nursing programs that are much more effective, making annual check-ups and immunization available to everyone. It means expanding and improving Medicare by providing pharmacare and denticare programs. It means promoting physical fitness through sports and other activities. All these programs should be designed to keep people well--because in the long run it's cheaper than the current practice of only treating them after they've become sick."

Tommy Douglas and champions of medicare who have followed, like Bégin and Romanow paint a similar picture of a mature system where the different parts all work together ... and all work for the patient.

That's what our government's plan to transform health care is all about : taking medicare to its necessary next step – creating a comprehensive and integrated system of care that is shaped with the active leadership of communities and driven by the needs of the patient.

[EFL: Original Tommy Douglas here.]