On The Case For Universal Free Dental Care

Like Banquo’s ghost, the issue of universal free dental care keeps hovering into sight at Labour’s top table. ‘Tis a goodly, progressive idea, but it is also one that’s been done in repeatedly down the years by the shafts of political expedience, some of which were fired again this week by Finance Minister Grant Robertson:

[Robertson] said dental care had to sit alongside many other priorities in the health sector. Going straight to universal dental care right away would be well over a billion dollars a year of extra funding, we have to weigh that up against the other things that are needed in the health system."

This is very misleading. The billion dollars figure is what New Zealanders spend annually on dental care in a very largely privatised, fee-unregulated, user pays environment. In reality, an increase in government funded dental care (state subsidies are currently costing about $100 million annually) could be phased in, as part of a national dental plan that would include funding to recruit and upskill the dentistry workforce. To offset some of the longer term costs, such a plan should also include obvious preventative measures such as (a) a tax on sugared beverages and (b) a nationwide fluoridisation programme that is actually carried out.

As things stand, dental care is a socially regressive area of unmet need that’s screaming out for government attention. As the Association of Salaried Medical Specialists (ASMS) pointed out in their latest research study released this week, the 9,000 residents of Wairoa have lacked adult dental health services for the past two years. This is just one example among many of unmet community needs. Yet this supposedly centre-left government is sniffing that it has other priorities.

As indicated, the transition to universal free dental care could readily be phased in at considerably lower costs than those cited by Robertson. That is… According to these Health Ministry cost estimates revealed by Newshub in 2020, after concerted attempts had been made by the authorities to keep the figures under wraps:

• $96 million to cover everyone up to their 27th birthday
• $17 million to cover low-income pregnant women
• $30 million for low-income parents and caregivers
• $5.5 million for a one-off dental check-up for everyone turning 65.

As the ASMS has pointed out, such changes would total only $148 million all up, or less than 1% of the operational health funding as at 2018/19. In a back-of-the-envelope calculation, the MoH further estimated it would cost roughly $12 million a year for every year beyond 27 – and with Kiwis living on average to 80 years of age, the MoH ended up with an all up cost for free dental care for everyone for life of around $648 million annually.

Unfortunately, the MoH report that contained those figures was then (reportedly) shelved by then-Health Minister David Clark, with no cost/benefit analysis undertaken. Other estimates for providing significant levels of free dental care for adults have arrived at similarly sustainable costs:

Research from the New Zealand Dental Association (NZDA), published in 2019, estimated a public scheme for “basic dental services” for 380,000 low-income adults would cost between $187 million and $450 million per year – the first based on the ACC fee schedule, the second on an NZDA member fee survey.

At this point, it surely needs to be stressed that additional government funding spent on dental care would be an investment, not a cost. Certainly, it would not be a dead weight cost like the government spending north of $3 billion on four planes loaded with surveillance gear useful only for detecting a regional “threat” from Chinese submarines that Defence is simultaneously predicting will never materialise. Meaning: when it wants to, the government readily spends revenue in areas where there are no meaningful cost/benefit returns to this country.

Free dental care by contrast, is an investment known to deliver significant social, economic and individual benefits. For every dollar spent on dental care by the government, the return has been variously estimated at anything between $1.60 (by the NZ Dental Health Association, 2019) and $4.50. That latter figure (cited by the ASMS) is based on the savings made from early dental care that (a) pre-empts the development of serious dental complications and the exacerbation of other health conditions, while also (b) delivering additional advantages via the reduced need for benefits, increased employment and higher tax revenues. (For details, see p.13 of the ASMS study.)

Spelling it out

Currently, unmet dental care needs are imposing chronic pain, employment hardship and social isolation on many New Zealanders - and especially on those on low incomes, and Maori. If we’re talking about priorities, many people are already struggling to meet their rent, food and energy costs, let alone to pay for visits to private dentists. They need extra help, immediately.

Longer term, the government arguably needs to develop a national Dental Workforce Plan to address some of the deteriorating workforce shortages that are also impeding access to affordable skilled dental care. In short, New Zealand has to move beyond the Band-Aid responses we’ve seen thus far whereby (in Budget 2022) the government belatedly increased the WINZ grants for emergency dental care.

Here and elsewhere (e.g. Ireland) the take-up rate for such grants is known to be abysmal. Either the people with greatest need don’t know such grants exist, or the hoops to be jumped through to obtain this “emergency” relief amount to a significant deterrent. The grants tend to be restricted to emergency remedial care, and do not fund the preventative work required to avoid future problems.

That’s deeply unfortunate. Obviously, untreated dental conditions deteriorate and then place downstream costs and pressures on the public health system and emergency departments. Untreated oral health conditions are also known to contribute to cardiovascular disease, diabetes, septicaemia and strokes. That’s one good reason why free dental care looks more like an investment than a cost.

Tooth Be Told

All of this and more has been canvassed this week in the succinct 28 page ASMS study (called “ Tooth Be Told”) linked to earlier. The figures it contains are alarming. Every year, 250,000 New Zealanders – including one in ten children – have teeth removed because of decay. Children in the poorest 20% of the population are almost twice as likely to lose their teeth as those in the top 20% income group.

Moreover:

In 2020 well over 1.5 million or 40% of adults were estimated to have an unmet need for dental care due to cost. Among Maori and Pasifika adults the figure is more than 50%....New Zealand recorded the highest unmet need for adult dental care among 11 comparable countries in 2020, based on survey of adults in those countries, including 1,000 adults in New Zealand.

Many of those unmet needs do eventually arrive on the doorsteps of our hospitals :

Publicly funded hospitalisation rates for oral health increased by 31% from 2007/08 to 2018/19, while the population increased by 17%.

The public health system is currently ill-equipped to cope with these rising needs, which are increasing:

New Zealand’s dentist and dental specialist workforce is one of the lowest per capita in the OECD. The number of practising dentists and dental specialists has dropped….

Already, serious regional variations exist in the availability of skilled dental care:

Six territorial authorities (Kaipara, Westland, Hurunui, Mackenzie, Waimate and Chatham Islands) had no dentists and no
dental specialists recorded in 2019. [Nationwide] the number of practising dentists and dental specialists dropped from 68.2 per 100,000 population aged 15+ in 2017 to 61.3 in 2019…

And what does this worsening shortage mean in practice, in communities outside of New Zealand’s urban centres?

On the West Coast there are two Lumino dentists in Hokitika and then going south the next one is in Wanaka. From there travelling inland the next one is in Christchurch, so patients are driving more than an hour and a half one way just to get a filling.

Strange then to find an allegedly centre-left government being so dismissive of a health problem of this magnitude.

Labour’s ghost

As mentioned, the provision of free and universal adult dental has haunted Labour ever since the first Labour government passed the Social Security Act in 1938. Largely thanks to lobbying by private sector dentists, Labour fatally chose to treat dental care differently to other health needs, and effectively excluded it from the social welfare safety net.

This country has been playing catch-up ever since. At the time, the first Labour government did provide free milk in schools to improve the calcium protections to the enamel on children’s teeth. The Health Act 1956 enshrined the separation of dentistry from other forms of primary healthcare. Over the decades, successive Labour governments have gradually made free dental care available to children and to adolescents, with the age of eligibility being lifted to 18, where it currently stands.

Even so, Labour’s failure to provide free dental care to adults continues to rest uneasily on its conscience. The late Jim Anderton pressed unsuccessfully for it. In 2018 – after a CTU remit –the provision of free adult dental visits became Labour Party policy, but this has not been implemented, and the funds required were diverted into the response to the Covid pandemic Meanwhile… Emergency dental care WINZ grants have been increased as a sop to party sentiment.

Costs of inaction

If the cost of universal fee dental care is an insuperable barrier for the government, perhaps Robertson could consider trying to raise some of that revenue by enacting a tax on sugared beverages. After all… As the ASMS study points out, New Zealand has the second highest level of sugar consumption per capita in the entire OECD/EU group of nations. Moreover:

In 2014 a Treasury paper advised: “Based on international evidence and our engagement with academics in this field, we consider that the most promising regulatory approaches to explore further are a sugar sweetened beverage tax, regulation of marketing to children and a mandatory front of pack food labelling system.” The papers point out that taxes on sugar- sweetened beverages (SSBs) have been introduced in a number of countries, and evidence has shown these taxes to be effective in reducing consumption.

Unfortunately, the Ardern government has been shown to have no appetite for tax increases. It has shied away from imposing a significant capital gains tax, a wealth tax, or windfall taxes on the excessive profits being made by banks and supermarkets. Instead of implementing a sugared beverage tax, the government continues to rely on industry self-regulation. The ASMS commentary on this point is worth repeating:

In 2017 a panel of public health experts reviewing case for a “sugary drinks” (SD) tax concluded: “The proposition that a SD tax be adopted is promote child health and wellbeing in not new and is becoming standard practice in many parts of the world. The health benefits of reducing sugar intake provide compelling reasons for why a SD tax is necessary.”

According to the industry lobbyists, a tax on sugared beverages would be regressive, in that it would hit those on low incomes the hardest :

The panel countered the contention that such a tax would be regressive, arguing that a similar rationale has been used against taxes on tobacco, and “the health complications of high sugary drink intake are significantly more regressive, as these diseases disproportionately impact on poorer communities”.

Perhaps because the diseases related to sugar intake do happen to regressively hit poor communities the hardest, this poll outcome shouldn’t be surprising:

A UMR poll from July 2017 found that New Zealanders on the lowest income bracket were most supportive of a SD tax.

A tax on sugar-sweetened beverages would be a vital first step. In tandem, there would also need to be regulations forbidding the marketing of sugary drinks to children and a mandatory front-of-pack food labelling system – perhaps with health warnings akin to those on tobacco products.

Fluoride: Epic fail

The tendency for both major parties to take a light handed regulatory approach to dental care has also resulted in a failure to ensure that local councils actually do fluoridise our drinking water, despite the well-known health benefits from doing so. As a result… In this Team of Five Million, only half of us (2.5 million New Zealanders) have access to fluoridated drinking water.

The Health (Fluoridation of Drinking Water) Amendment Bill introduced into Parliament in 2016, was finally passed in November 2021 and gives the Director-General of Health the power to direct local councils to add fluoride to drinking water. Funding is to be made available to support local councils to do this.

Just when this might happen remains unclear. In the meantime… Christchurch may be New Zealand’s second biggest city, but none of its drinking water is fluoridated, with little indication of when this might happen. Given the high level of nitrates in the same drinking water, the Garden City is hardly shaping up these days as an ideal place to bring up children. Wellington also has problems with fluoridisation, as the ASMS study notes:

There has also been recent controversy in Wellington, with some parts of the region not receiving fluoridated water due to a fault at a treatment plant since last year. The public was not told for months, and the problem won’t be fixed until later [in 2022].

Politics, politics

Finally, political change in dental care will not be the end product of a gradual accumulation of research evidence about the existence of need. That’s not how political change happens. Media pressure and political champions are essential for turning a worthy case into a politically compelling priority. Winston Peters for instance, could easily make one of those MoH measures cited above – the $5.5 million for a one-off annual dental check-up for everyone turning 65 – a New Zealand First, easily deliverable via the Gold Card.

If cost is a political barrier, then this can be addressed in far more effective ways than Robertson’s preferred method of increasing the WINZ emergency dental grants already known to be unfit for purpose. (The uptake is low, WINZ is not renowned for being a benign gatekeeper, the “emergency” relief precludes preventative dental care etc etc.).

Besides imposing a tax on sugared beverages, how else can the government address the cost to the state’s revenues of providing free dental care to adults? Well… One major party – National – currently wants property developers to once again be able to deduct interest payments on their properties from their tax bill. If we’re willing to gift landlords with tax breaks, why not bestow on ordinary Kiwis a similar boon, the ability to deduct dental care costs – capped at say, $1,500 annually – from their pre-tax gross income?

If even that is considered too much of a fiscal strain- or worse, if it would incentivise taxpayers to get dental work done that they didn’t need – why not address the issue in the more controlled environment of the government’s planned social insurance scheme? Currently, that is being framed as an unemployment insurance scheme, paid into by workers and employers alike. Yet if, as Canada does, this same social insurance vehicle was extended to cover dental costs ( and again capped at say, $1500 annually) it could then be cited by employers as an offsetting contribution in the context of wage bargaining.

All it needs is some politician to pick up the cause of free universal dental care, and run with it.

Footnote One: The country’s historical emphasis on prioritising the dental care of children has always been something of a double-edged sword. As with re-defining the problem of poverty as being one of “child poverty” the approach looks less like a strategy based on compassion and need, and more like a way of rationing the expenditure. Child poverty after all, occurs within poor families and poor communities, because of structural factors in the economy that cannot be addressed merely through the lens of “child” poverty. For similar reasons, adults as well as children, need ready access to affordable dental care.

Footnote Two: To be sure, there will always be a need for ambulances at the bottom of the dental cliff. Older New Zealanders – who have suffered from decades of policy failure and dental neglect - now need attention for their dental needs as urgently as any other age group.

The dental needs of older New Zealanders – and the best available funding models and delivery mechanisms for meeting them – were the subject of an M.A. Thesis in public health by Anne Russell at Otago University's Medical School entitled“ A Gaping Hole…Oral Health Care for Dependent Older People. ” Useful comparisons were made therein as to how – and how effectively- federal and local governments in Canada, UK, Australia and Ireland have been meeting adult dental care needs.

Among many other factors, Russell’s work canvasses the merits of targeted vs universal funding, the virtues and drawbacks of fee-for service models, and also the relative benefits (and problems) involved in delivering dental care within aged residential care centres, at home, in hospital settings and via mobile dental care vans.

Russell also discusses the targeting of dental care to indigenous communities, where Canada has models for the dental care of First Nation peoples that we could usefully consider. Like the ASMS, Russell points to evidence of the severe shortages of skilled dental workers in this country, and especially for the dental treatment of those with disability and/or dementia. As one dentist told them, there is a severe shortage of skilled special care dentists:

In our region], we have two fulltime or nearly fulltime Special Care dental specialists, and we have about three or four other part-timers are dentists who have special interest in Special Care, so we're working on a similar [Full Time Equivalent] to [another region] when our population is way bigger. All dentist informants discussed how a lack of widespread industry training on older people’s health needs meant special care dental specialists were taking on a disproportionate workload.

Funding and workforce issues aside, dementia is not the only difficulty in providing effective dental care to older patients. Age and infirmity makes the option of general anaesthesia a riskier prospect.. As mentioned above, New Zealand is still grappling with the historical anomaly whereby disease gets treated differently if it happens to be located in the mouth. Russell reports on the cost problems this has fostered:

Four informants discussed how being unable to afford dental treatment costs led to adults of all ages avoiding treatment altogether: When you suddenly go to the dentist and he says “Well yes, that tooth needs to come out or this one needs replacing, we need to do something there and it’s going to cost about $3000,” there’s an immediate [reaction of] “I’ll just put up with it 'til it falls out…” “There’s this myth … that if patients have to contribute towards the cost of treatment they appreciate it more. So why aren’t we charging people for their hips? Why is it only dentistry? …”

The separation continues to have real life consequences. Another of Russell’s informants spoke of a ’silver tsunami' of older people with pressing dental needs. As one dentist informant put it: “We're going to be swamped with old people, pliers and bottles of whiskey. There’ll be [WINZ] vouchers for Bunnings.”

That’s the future we have to avoid. Yet arguably, it can be avoided only by taking a holistic approach to our current epidemic of unmet dental needs. For starters, we need to treat children, adolescents, adults in paid work, beneficiaries and pensioners equally... And provide for each, according to their dental care needs.

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