Australia’s dental health has been in decline since 1996 when (then) prime minister John Howard scrapped the Commonwealth Dental Program in his first budget. With the states and territories refusing to make up the axed funds, public dental systems languished, leaving many Australians unable to access dental treatment. Children born that year are now turning 16: an entire generation has grown up without adequate dental care.
The result of this political neglect has been an increase in untreated dental problems, leading to more serious complications and significant health, social and economic costs.
Health economist Jeff Richardson estimates that untreated dental problems cost the economy up to $2 billion per year in avoidable hospitalisations, other health care costs and lost productivity. Harder to measure is the cost of inadequate public dental care to our sense of fairness and cohesiveness as a community.
The Gillard government’s package aims to reverse this trend by ensuring that everyone can afford at least basic and preventive care. Its main target groups are children from low-income families and adults currently eligible for public dental services. This targeting, and the overall design of the package, reflects the extensive consultation by the government with health groups and experts who have lobbied long and hard for the initiative.
Sensibly, the government has listened to the significant input from the sector and the resulting package is much fairer and more efficient than previous Commonwealth dental schemes. It clarifies the roles of the Commonwealth and states in public dental care, giving the Commonwealth responsibility for children’s services and leaving the states with responsibility for adults’ services. This should help reduce the buck-passing and political tap dancing between these two levels of government over dental issues.
Symbolically, it is important as it recognises dental care as an integral part of overall health care. This has been resisted steadfastly by successive federal governments, terrified about the implications for their bottom lines.
While not the universal system called for by most stakeholder groups, it is much more comprehensive than previous schemes and provides a solid foundation on which a universal system could be built. This makes it more difficult for a future Coalition government to unravel — an important consideration for Labor’s legacy-building agenda.
On the negative side, the government again has failed to address the problem of co-payments in the health system. Despite the rhetoric about supporting disadvantaged families, even the poorest parents will still face the risk of open-ended out-of-pocket costs if they access private dentists under this scheme.
Out-of-pocket costs are a problem across the spectrum of the health system but in particular in dentistry where consumer co-payments comprise more than 60% of our total $7.7 billion spend on dental services every year (2009-10).
Also, while the package targets those most in need, it leaves a significant proportion of the population without assistance in accessing dental care. In fact, about a third of all Australians will fall in a crack between these schemes and private health insurance and so miss out on subsidies from either source. Many of these people are not rich and may have difficulty affording dental care, particularly if they have other chronic health problems.
A more sophisticated targeting system, which focused on out-of-pocket health costs rather than income, along with a comprehensive health care safety-net, would address this problem.
As with many of the other government’s health reforms, this measure entrenches an episodic, fee-for-service, system of care, which we know doesn’t work for many consumers and many conditions. In particular, this type of care fails the most vulnerable and at risk people who require a more integrated, longer-term and co-ordinated approach to address their complex and individual needs.
A major challenge in the implementation of the package will be to integrate dental with other aspects of health care, in particular for vulnerable and at risk groups. Medicare Locals could be important in this role as they should have developed relationships with other community care providers and have the infrastructure required to support this more comprehensive approach.
Other challenges include the shortage or mal-distribution (or both) of dental practitioners, particularly in rural and remote areas. The government has introduced some workforce measures and allocated funding for infrastructure in the package but there will need to be more action in this area, including increased roles for dental assistants and hygienists, if the access goals of the package are to be realised.
Tony Abbott’s response to the package was to criticise the government for spending this money in preference to preserving a budget surplus. However, his attempts to present the Coalition as the party of fiscal restraint lack any credibility when he continues to support a non-means tested and open-ended subsidy for private dentistry via the private health insurance rebate.
His opposition to the government’s plan has, however, put him at odds with the vast majority of the health and social welfare sector (including conservative groups such as the AMA), perhaps not the smartest move for an opposition looking to build support for its policy agenda.
Either way, Abbott’s position on dental presents the electorate with a clear choice about the priorities and values of the major parties — something for voters to chew over as we approach the next federal election.
*Declaration: Jennifer Doggett has provided consultancy services for several groups lobbying for dental reform (AHHA, CHF, ACHRA)