Canadians can be smug about our health care system when public coverage extends to dental care

Why are we comparing ourselves to the Americans at all? The truth is that our health-care system suffers from huge flaws in both design and execution. The most obvious example of that is in the way we fund dental care.

We scoff at unequal access in the U.S., but ignore the fact that some Canadians can't afford dental care

Lack of insurance prevents one in six Canadians from visiting dental professionals to mitigate against more serious problems. (CBC)

It's very easy to be smug about the Canadian health care system. As politicians in the United States try to figure out whether to classify quality health care as a right or a privilege, Canadians enjoy a universal health care system so entrenched in the national collective consciousness that it's become synonymous with national pride.  

Indeed, a 2012 Leger Marketing poll found that 94 per cent of respondents viewed Canada's health care system as important to our identity as Canadians, and chances are this number has actually climbed in recent months, given the histrionics our southern neighbours have shown in trying to replace an imperfect Obamacare system with a likely disastrous Trumpcare one.

Comparing ourselves to the U.S.

But why are we comparing ourselves to the Americans at all?  While it's true that Canada's health care system outperforms America's in terms of coverage, expenditure per capita and cost, the reality is that the U.S. offers a terrifically low bar from which to draw a comparison. To put it in colloquial sports terminology, as our American friends are fond of doing, it's like comparing Sidney Crosby to a Peewee player – in a recreational league.

The truth is that our health care system suffers from huge flaws in both design and execution. While the Canada Health Act (CHA) of 1984 was designed to supposedly fund coverage of all "medically necessary" services, the reality is, it doesn't. Not convinced? Let's look at curious case of dental care.

Health doesn't start at the tonsils, but medicare in Canada seems to operate on the assumption it does. (Michael Conroy/The Associated Press)

Currently, the CHA only mandates coverage for surgical-dental interventions, leaving common issues such as cavities and non-surgical periodontal care to individuals to pay for or process through private insurance. This narrow funding model is premised on the idea that oral health and physical health are separate and distinct: a vestige of a historical fiction. Health doesn't start at the tonsils, and more and more literature has confirmed that good oral health is critical — not only as an indicator of general health, but as a crucial component of overall wellness.

The consequences of this gap in coverage are not simply medical. Tooth decay, for example, is preventable but Canada still loses over four million working days and two million school days to problems related to oral health per year. That's a lot of productivity wasted, and a lot of it can be traced to the fact that 32 per cent of Canadians have no dental insurance.

Lack of insurance prevents one in six Canadians from visiting dental professionals to mitigate against more serious problems. That, in turn, means that many patients wait until they're forced to visit the emergency room to access services covered under the CHA – services which do little to address underlying causes.

Simply put, dental care should not be classified as supplemental care. The negative health and social effects of failing to provide timely dental services is clear. But why, then, are dental services excluded from public health coverage?

The answer is found in a combination of political parsimony, lobbying and government short-sightedness during the establishment of modern medicare through the Medical Care Act of 1966.

 Royal Commission on Health Services

While dental disease was one of the "most frequent health defects" noted in the 1961-1964 Royal Commission on Health Services, it recommended that universal coverage should be restricted to groups with "lessened capacity" such as children, expectant mothers and those on public assistance. Dental care, it determined, was an "individual responsibility."  

This framing of dental care in moral terms represents an ongoing problem: instead of actually dealing with the public health consequences of dental diseases, we shift the burden to those affected. This is puzzling given that many other medical issues, such as sexually transmitted infections, can also be framed in preventable or individual responsibility terms.

In any event, this decision jibed nicely with lobbying by dentists to keep their fee-for-service model, albeit allowing for greater participation by supplemental commercial health insurance. Underlying all this was the fear that covering dental care would cost too much, since it was "one of the most frequent health defects found in the community."

The result? Since the early 1980s, growth of public dental care programs has "sharply reversed" in the face of economic realities. Maybe these economic pressures are why the CHA — passed during the depths of a recession — failed to mention any dental services outside of surgical-dental interventions.

Burden on the provinces

The burden, then, has fallen on provinces to provide dental care – at the very least, for the vulnerable populations, such as youth and those on public assistance, as noted by the Royal Commission on Health Services. But the implementation has been haphazard.

Take youth. Some provinces, such as Quebec, have universal public dental coverage for children while others, like B.C., only cover low-income children. The result? Middle-income kids in B.C. suffer with "the highest absolute number of children with visible dental decay."

International studies have shown that greater public contribution to dental care helps to level these sorts of socioeconomic inequalities. The federal government must work together with provincial partners, as well as doctors and dentists, to come up with a new minimum standard of acceptable public dental coverage. Until that happens, Canadians should probably turn their smugness toward the American system down a few notches.

Jason Chung, a native Montrealer and McGill University law graduate, is currently senior researcher and attorney at NYU SPS Sports and Society, in New York. He tweets at @ChungSports

Kelvin Ian Afrashtehfar, who holds a Master's degree in dental sciences from McGill University's Faculty of Dentistry, is a visiting clinical research fellow in implant dentistry at the School of Dental Medicine, University of Bern, Switzerland.  

This column is part of CBC's Opinion section. For more information about this section, please read this editor's blog and our FAQ.


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