The inequities in the status of oral health in Australia are appalling because of a lack of political will and a resistance to recognising that all Australians deserve to receive adequate dental care. This resistance is rooted in the elitism of those in power, the belief that if one can’t earn an adequate income, then second rate access to dental care is one’s lot.
The money to improve access is available, whether from the inequitable inefficient $12 billion private health insurance (PHI) subsidy and associated tax losses, the putative savings of $100 billion over 10 years which the Treasurer says would be the cost of Labor tax initiatives, or general revenue used to invest in the future as we are doing with our $50 billion submarine contract.
Recent posts on this blog from John Menadue and John Dwyer point out the many sad statistics on oral health status, accessibility to care particularly for those on lower incomes, the lack of preventive care, and the continued failure to address social determinants of poor oral health . The Essential Report based on survey results from February 2018 found that 48% supported the redirecting of the PHI rebate to dental care with 20% not having an opinion. http://essentialvision.com.au/?s=dental&searchbutton=Search
A simple solution to oral health? Certainly a $12 billion investment would go a long way to providing adequate dental care to all Australians. The 2012 Report of the National Advisory Council on Dental Health (NACDH) stated that
‘The Council’s discussion of a particular model for a universal scheme in the short‐ to medium‐term did not receive unanimous support from all members.’
Thus, universal access to comprehensive dental care was not even considered. Why would it? We don’t yet have universal access to comprehensive medical care in Australia despite claims to the contrary. We have universal access to an inadequate rebate for doctor delivered services in the community and limited non-doctor services, all dependent on provider availability which is determined by providers. We have guaranteed access to public hospital care if one can wait long enough. We have access to subsidised medicines if one can afford the co-payments (taxes on illness) imposed by the government. It is all much better than pre-Medibank (the precursor to Medicare) but it is not universal health care.
Instead the NACDH considered options for access to limited dental care, with or without some means testing, targeted to some or all children and poorer and sicker adults, delivered either through a Medicare style rebate with provider determined optional co-payments, or through State public dental services. These options were seen as potential steps towards a more universal system. The most expensive option which reached all 5.4 million children and over 7.6 million adults was estimated to cost $2.5 billion yearly in 2012, using the public system as the service provider. Using private dental and fee for service cost $5.1 billion yearly.
The Labor Government in 2013 committed to an amalgam of the above, with limited means tested fee for service access for children and a National Partnership Agreement with the States for limited means tested access through the public system for eligible adults. The intention was to gradually build on the services, increasing accessibility to more patients and increasing capacity of the system. Instead the Coalition Government has effectively reduced both components of the plan, reducing the amount available to the States for adult care, not indexing the cap for child care, and not addressing the issue of patients requiring much more than just the basic level of care.
So where to from here? Can we heed the suggestion that dental care should be a standard part of any health system? That is difficult because we don’t have a health system. We have multiple poorly connected silos, funded in multiple different ways with world class emergency and urgent care in public hospitals, dedicated health professionals struggling to help patients negotiate the maze of care, and frustrated and at times desperate patients and relatives trying to negotiate the maze whilst governments continue to fiddle at the edges of the ‘system’. An integrated system which recognises dental care is required.
Funding is needed. It is available within the health budget. Whilst the ex-Prime Minister Tony Abbott said that ‘PHI is in our DNA’, it may be time for some genetic engineering as PHI is also well entrenched in the Labor Party. However Labor has committed to a Productivity Commission review of PHI which would reveal what most know i.e. PHI is grossly inefficient. As a first step a gradual reduction in the PHI rebate could be used to fund public access to hospital care and at the same time scale up the current dental policy as was originally intended, with a long-term view of moving to a truly integrated universal health system, inclusive of oral health. The public consistently express the desire for improved health care, even to the point of paying more taxes. Are there any political leaders who see equity as a principle to underpin policy rather than a point of differentiation from an elitist Coalition?
Tim Woodruff is president of the Doctors Reform Society, an organisation of doctors and medical students promoting measures to improve health for all, in a socially just and equitable way. On Twitter: @drsreform