Polishing-up for the Election: Lessons from Indigenous Dental Care

With the 43rd federal election under way, two political parties have made history by pitching to remove long-standing financial barriers to dental care in Canada. The New Democratic Party (NDP) has proposed creating a public insurance program for Canadians not enrolled in a private or existing public program. The Green Party of Canada has proposed a public dental insurance program for low income Canadians

Both proposed policies would increase government involvement in this essential health discipline. Oral health has been increasingly implicated in determining chronic and even fatal conditions that are treated under Medicare, such as Alzheimers, heart disease, and diabetes. New cases of oral cancer have now surpassed cervical and liver cancers in Canada. But for all its importance, public oral health care accounts for less than 6% of the country’s total dental expenditures.

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The Parliamentary Budget Office released a cost-estimation of both party’s proposals. However, the limited details suggest that these policies would be modelled after the dental coverage provided through the Non-Insured Health Benefits (NIHB) program for Indigenous peoples. The NIHB dental program has been such a disaster that it does not make a good model for a new public program.

 
 

There is a common misconception that Indigenous peoples receive comprehensive dental services, paid entirely by the Government of Canada. The conclusion that Indigenous peoples face no financial barrier to dental care is far from the truth, because the services offered under NIHB are extremely limited and only offer partial coverage. For both patients and their dentist, getting an NIHB claim processed and approved by Health Canada is a lot like pulling teeth. If the NDP and Greens believe more NIHB is needed in Canada, then we need to understand the harsh realities of this program.

Under the NIHB, Status Indians and Inuit are eligible to receive dental insurance via Health Canada. However, this is not a free ride, and it is nothing like first-dollar Medicare. Annual coverage limits and procedure frequency limits are extremely restrictive. According to the Canadian Dental Association, the recommended frequency of dental examinations depends entirely on an individual’s oral health needs. Higher risk patients (such as the socially marginalized) should have a dental examination every six months or more, but NIHB only covers one recurrent examination per year and one complete exam every 60 months. Full x-rays are also only permitted once every 60 months. The NIHB guidelines fall far from supporting Canadians' dental care needs. Under the NIHB, your personal oral health does not dictate your dental care utilization – the government does. If, on a second annual visit, your dentist requires a follow-up X-ray for an accurate diagnosis, you are going to be paying 100% out-of-pocket.

The basket of dental services covered is extremely limited, especially when it comes to advanced procedures. In 2017, an Alberta Indigenous woman underwent a lengthy battle with the government to cover her cleft palate procedures – one of the few dental procedures non-Indigenous Canadians can receive under Medicare. Both the patient and the oral surgeon were backstabbed by the NIHB. The woman’s claim was ultimately denied by Health Canada, and the oral surgeon was not compensated for his work. The real tragedy is that at the time, cleft palate procedures were fully covered by the Alberta Cleft Palate Dental Indemnity Program, but because of her Indigenous status, the woman in question was ruled ineligible for the province’s program, as well as the federal government’s NIHB coverage.

 
 

Whether it's engaging in a three year court battle for your braces, or asking Health Canada, in advance, whether you qualify for a treatment (a relatively new NIHB practice called ‘predetermination’), the NIHB has become no more than a series of bureaucratic hurdles over which both patients and dentists must jump. Dentists across Canada have reported very low satisfaction with federal dental programs, especially with the NIHB. In some cases, dentists require full payment upfront from their Indigenous patients, prior to submitting an NIHB claim to Ottawa, since the coverage limits are so notoriously low and the claim processing time is excruciating. For the dentist, this is a business decision, but if the patient is part of a marginalized demographic, or qualifies as low-income, upfront payments can become a massive barrier to oral health care.

In Canada, dentists typically have free reign over how much to charge for their services. However, dentists whose patients are under the NIHB are encouraged to follow the program’s fee schedules. These NIHB fees may be less than what a dentist would normally charge a non-Indigenous patient. Dentists may find themselves in a position where their NIHB patients are worth less than others. Almost a third of Canadian dentists have reported reducing the amount of public insurance patients they accept into their dental practice. Many dentists have outright refused to service NIHB patients. If the NDP and the Greens model their new dental care policies after the NIHB program, even more dentists will reject public insurance patients, as part of their business strategy. 

 
 

Under the NIHB, Indigenous peoples face disproportionate financial and social barriers to dental care, compared with individuals covered under private-sector dental plans. As such, the NIHB has become an entrenchment mechanism for the health disparities of Indigenous peoples. It is not a program that Canadians should look to, saying ‘I want that’. In the spirit of reconciliation, policy-makers should step up and reform this program.

Now, there is one dental program paid for with federal tax dollars that offers far more robust levels of coverage than the NIHB: The Public Servant Dental Plan by the federal government. This is provided to all federal employees, through 100% employer contribution, and is therefore funded by tax dollars. It is not delivered by Health Canada or any other crown agency, but rather through private enterprises. The table below compares some of the benefits offered in the NIHB with those offered to public employees, active soldiers, and veterans. Here, the federal government seems capable of providing strong dental benefits to more than just Indigenous peoples:

 

Table 1: A comparison of federally funded dental benefits programs in Canada.

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*For any coverage, NIHB patients must undergo a predetermination process with Health Canada to ascertain whether the prescribed dental treatment is at all eligible for any reimbursement.

 **The current NIHB annual limit is unclear and is now largely determined through Health Canada’s predetermination process. These estimates come from the 2003 Standing Committee on Health.

 

The NDP and Green Party could consider modelling their programs after the Federal Public Servant Dental Plan, but this would be an expensive option, given that those benefits are administered through a private for-profit insurance provider. The federal government contributes up to $1600 per employee in dental benefits, and that is not just a federal government deal. The City of Calgary recently disclosed that it contributes $1100 per employee for level 1 dental benefits. Adding low income individuals or currently uninsured Canadians to these programs could drive up the annual premium contribution costs. This is because the private insurance company must turn a profit by gathering more in premiums than what it pays out in dental benefits; this is called the medical loss ratio. Low income individuals represent a higher risk of dental care utilization. Thus, by incorporating them into the federal public employee plan, the government would encourage higher insurance premiums to adjust for greater risk.

The fact that the health insurance industry’s business model relies on a medical loss ratio is a testament to the fact that private health insurance is a highly efficient model for providing equitable access to care. In private dental insurance, you cannot be exempt from premiums because of your income. In the instances where Canadian provinces have levied a premium for public health care, low income individuals have often been exempt, thus providing equitable access to coverage. So, the private sector currently offers better levels of coverage than the public sector – since they have all the ‘good dental risk patients’  – and the public sector currently has more ‘bad dental risk’, and so it must dilute program coverage to a minimum, as it does with the NIHB.

Federal candidates should consider moving away from the public-private mixture of dental care insurance across Canada. We have a longstanding tradition of keeping two-tiered care out of Canadian health care. Yet, when it comes to dental care, the most left-wing candidates in the federal election are fine with a two-tiered dental care system. This is extremely short-sighted. Oral health is intrinsic to overall health status. There is no medical, ethical, or economic reason why dental care should be treated differently than hospital and physician services.

Canadian Medicare is a source of both pride and exasperation for many. Canadians receive comprehensive first-dollar coverage for medical services… until their teeth ache. Despite the misconception that dental care is part of Medicare (propagated, mostly, by the hip-hop artist Drake), and claims that the private sector adequately compensates for extended health benefits (propagated, mostly, by the Conservative leader Andrew Scheer), each year, 17% of Canadians skip the dentist’s chair due to out-of-pocket cost.

Canada needs to pursue a public dental care program that would provide equitable access to medically-necessary dental procedures – whether that’s a routine cleaning or an advanced root canal operation. This scheme ought to be thought of as a replacement for the NIHB and the smattering of small-scale public initiatives that exist throughout this country. No political candidate should uphold the NIHB as a mold for future federal dental care programs.