Oral health – if not for everyone then for whom?

When introduced in 1984 as a universal health insurance scheme, Medicare did not include dental care, which has always been and continues to be a state/territory responsibility. Access to state services has not been a universal entitlement and continues to be provided on a means-tested basis. For a brief period in the 1990s the Commonwealth provided support funding for state dental services under the Commonwealth Dental Health Program (CDHP), which was discontinued in 1996.

The National Health and Hospitals Reform Commission (the Commission), established by the Rudd Government in 2007 to review the Australian health system, concluded that there was a pressing need for a national dental health scheme. Its conclusions are summarised below:

‘A lack of universal access to high quality dental health services has a significant impact on the health outcomes of Australians.

All Australians should have universal access to preventative and restorative dental care and dentures, regardless of their ability to pay. This should occur through a new ‘Denticare Australia’ scheme. This new scheme would provide preventative, diagnostic and restorative services, including extractions and dentures. This could be funded by an estimated increase in the Medicare Levy of 0.75% in addition to existing funding by governments.

Australians would get the choice of either a dental health plan from an insurer or rely on expanded public dental services funded by ‘Denticare Australia’.

There should also be a nation-wide expansion of preschool and school dental programs’ (p. 82–84)¹

The Commission estimated the cost of such a scheme at A$3.7 billion per annum.¹

The Government did not take up the issue of dental health in its response to the Commission’s report.

In September 2011, the Government established the National Advisory Council on Dental Health (the Council) to review the current issues in dental health and recommend options for addressing needs. The Council reported in February 2012.² The Council’s report is the most recent summary of data and issues relating to dental health in Australia. In it the council concluded that that ‘a long-term goal for dental health in Australia should be a system that allows universal access to dental care²’. It identified two priority areas for immediate action, children and the needy. It provided alternative, staged options for measures for both priority areas that could be implemented separately or jointly.

In the 2012 Budget, the Government committed $515 m over 4 years to address the ‘needy’ priority group through a blitz on public dental service waiting lists. This measure aims to reduce waiting lists by over 400 000. The scheme will operate along the lines of the previous CDHP, through payments to the states and territories.

Through this measure the Government has clearly identified its priority – needy adults. This is consistent with the findings of the Council that, while children have generally good visiting patterns to dental services (although children in disadvantaged groups tend to have poor patterns), adults generally have unfavourable patterns and those in the ‘needy’ categories have high rates of poor patterns.

However, although the focus on public waiting lists is convenient and provides a simple and administratively efficient response, on its own it is little more than a band-aid and could in fact inhibit more effective approaches in the longer term.

There are major problems with the Commonwealth approach, including:

• The already stretched state systems are likely to have difficulty in finding skilled resources to ramp up services;

• It could embed the existing variations in eligibility to access state services;

• The private sector (which provides most dental care in Australia) will be involved only at the discretion of the states;

• The Commonwealth is in a poor position to assess the value for money of its investment as the focus in on throughput rather than outcome;

• It provides no structural change and effectively commits the Commonwealth to indefinite underwriting of public dental services, thereby restricting flexibility for the Commonwealth to introduce other measures in the future;

• As in any waiting list-reduction scheme, it potentially creates perverse incentives to keep waiting lists high to attract further funding (e.g. by substituting Commonwealth funds for existing state funds).

Due to its previous experience with the CDHP, it is presumed that the Commonwealth will have mechanisms in place to manage these risks and that the blitz will achieve its medium-term objective of reducing public sector waiting lists and provide opportunity to introduce more effective policies in the longer term.

Clearly the Commonwealth has focussed on the group with most urgent need; however, to provide effectively for this group and for children, and to allow for an effective and sustainable universal scheme in the longer term, the government will need to develop a much more comprehensive approach in a relatively short timeframe.