The federal government is about to embark on the largest investment in oral health in Canadian history. But critics say this landmark investment may not reach the people who need it most.
The Canadian Dental Care Plan (CDCP), estimated to cost $13 billion over the next five years, will provide dental coverage to an estimated 9 million uninsured Canadians with an annual family income of less than $90,000. The plan is expected to begin rolling out by the end of this fiscal year, with initial coverage for children 18 and under, people with disabilities and seniors.
But Brandon Doucet, the founder of Coalition for Dentalcare, a group of health-care providers that advocates for universal publicly funded dental care, says that while it’s a great start, “financial barriers aren’t the only issue.” Doucet, a 29-year-old Nova Scotia dentist who treats federal prison inmates and has been called the “Tommy Douglas of dentists,” says people living with disabilities, Indigenous people and those living in rural areas are still going to have to overcome hurdles such as annual limits for treatment.
“The dental care program will not be like medical care where if you have lung problems this year and you get those fixed, and then you have heart problems, you can also get those fixed,” he says. “With the dental care plan, if someone needs their teeth extracted, they may have to wait until the next year to get dentures. People should not have to worry about going without teeth for a year.”
Although limits for various dental treatments have not been announced, the plan is expected to be similar to the Non-Insured Health Benefits (NIHB) program for people with First Nations and Inuit status. Under the NIHB, each kind of treatment has a different limit. For example, dentures can only be replaced every eight years even if a dentist recommends five years. There are frequency limits on preventative treatments such as cleaning and polishing. And there are limits on anesthesia treatments.
Another challenge will be the plan’s reliance on dentists in private practice, Doucet says. “You need to have dentists be willing to see these patients. And I worry that these low-income people who rely on public dental programs are going to be more of an afterthought for a lot of dentists.”
Doucet says the number of patients dentists will take on will depend on how attractive the program is to dentists. “If dentists have openings in their schedule, they may see it as financially beneficial to fill those gaps with patients under this new program, if the program is attractive enough to dentists.”
Brock Nicolucci, president of the Ontario Dental Association, says that if the program is structured correctly and with the input of dentists, “We feel like there’ll be great participation rate in the program.”
On Nov. 15, provincial dental associations across Canada released A Proposed Framework for the Canadian Dental Care Plan, outlining that the plan should respect current workplace, school and other group dental insurance systems; allow people to choose their own dentist in their community; minimize administrative delays; avoid overlap with existing government dental programs; address the shortage of dental hygienists and dental assistants; and compensate dental professionals fairly.
“People should not have to worry about going without teeth for a year.”
Nicolucci says a meeting between dental leaders and Health Canada is scheduled for this month. “The concern we have is that they’ve come to us at the eleventh hour.”
But Doucet worries that even if the program pays out 90 per cent of regular fees, because the program is targeted to specific populations, it could be eroded over time. “For example if the Conservatives win the next election, the fees could be de-indexed and gradually the program becomes less and less attractive to dentists, which has occurred with targeted provincial programs in the past.”
A federal dental plan should be a stepping stone toward a universal system of care rather than a program that targets special populations, Doucet says.
“We need to move away from viewing a cavity as an opportunity to make money and see it instead as a public health problem. It’s too easy to erode programs aimed at poor and marginalized populations with very little pushback.”
Joan Rush, a disability advocate whose 36-year-old-son, Graeme, has autism and is developmentally intellectually disabled, says the infusion of federal money is not going to help people with severe disabilities. Rush, who chairs the Advocacy Committee of the Canadian Society for Disability and Oral Health, says her son, like many others, requires general anesthesia in hospital to undergo dental treatment, even for a filling. “Access to dental care for these people is seriously restricted by lack of access to general anesthesia in hospitals because dental care doesn’t fall under our public health-care system,” she says.
Graeme suffered excruciating dental pain, biting his arms and beating his face, waiting for treatment in a hospital.
“The lack of access and equity for people with disabilities does not match what we believe about our health-care systems,” says Rush, a lawyer, who wrote Help! Teeth Hurt, a legal analysis of the government’s role in providing oral health care to people with disabilities. She adds that oral health care should be integrated into the Canadian medical health-care system so that patients with special needs do not face lengthy wait times for access to dental treatment with general anesthesia in a hospital.
Rush adds that there is a shortage of dentists who are both trained to treat people with disabilities and have access to hospital surgeries. She says there needs to be mandatory training in dental schools on how to treat people with special needs.
The concerns of Rush and other disability advocates are documented in a recent Canadian Society for Disability and Oral Health (CSDH) submission to the federal Minister of Health that highlighted the lack of data and dearth of knowledge about the oral health of Canadians with disabilities. Rush says that poses a real challenge when “we are trying to design a program that is intended to meet the needs of lower income Canadians and most persons with disabilities fall within that demographic.”
The CSDH submission also notes that while there is oversight to ensure competency of dental care, there is no public oversight to ensure access.
There also are concerns that the plan will do little to address the barriers faced by Indigenous people. Sheri McKinstry, a pediatric dentist and cofounder of the Indigenous Dental Association of Canada (IDAC), a group of health-care providers working to improve Indigenous oral health, says, “Indigenous people are still going to be left behind.”
Although status First Nations and the Inuit already have dental coverage as part of the NIHB program, “the real issue is access” since dental care in rural and remote communities is very difficult to obtain and often dependent on transient dental practitioners who visit communities on unpredictable schedules.
McKinstry, a member of the Sagkeeng First Nation in Manitoba who now practices dentistry in Saskatchewan, spent 12 years providing dental services to First Nations communities in Manitoba. There is such a need for emergency treatment that there is no time for routine preventative care, she says. “Getting in for a cleaning is almost non-existent.”
McKinstry, whose Master of Dentistry thesis was on the oral health experiences of First Nations children, says stereotypes and racism also create difficulties.
“We need to treat the underlying factors that determine Indigenous oral health. Many dental practitioners don’t understand how living as an Indigenous person, especially those with intergenerational trauma, impacts on oral health,” she says. For example, “transient dental practitioners may blame the mother because a child has cavities without understanding that they may be living in overcrowded housing without access to healthy food or running water. It is a really hard thing to understand, especially if you’re not Indigenous and don’t have any lived experience.”
Parents may be apprehensive about using their child’s status/registration number for NIHB coverage because of the stigma associated with it, she says. They are also afraid. “They feel fear for their children in the dental chair” based on their own or their elders’ traumatic experiences receiving dental treatment often in residential schools.
McKinstry says IDAC is working on looking into what Indigenous specific racism looks like in dentistry so it can develop cultural safety training specific to dentistry for dental schools and practitioners across Canada.