Canada is long overdue for an expansion of public dental care, but it seems that the federal government is weakening the Canadian Dental Care Plan (CDCP) before it gets off the ground.
Canada’s public dental spending is a paltry six per cent of total dental spending, ranking second last amongst countries that are members of the Organization of Economic Cooperation and Development (OECD). This means far more Canadians forgo dental care due to the cost than other developed countries.
One in three Canadians lack dental insurance, and over one in five avoid the dentist each year due to financial constraints. These are problems that have been worsening as employment becomes more precarious and fewer employers are providing work related dental insurance. On top of this, the last few decades have seen the erosion in quality and quantity of public dental programs, with income cutoffs becoming more restrictive, coverage focusing on the most basic emergency procedures and the fees the programs payout being deindexed from inflation.
Lacking access to dental care causes undue pain, but it also leads to many problems that extend beyond the mouth. Poor oral health has been associated with cardiovascular disease, diabetes, low-birth-weight infants, aspiration pneumonia, erectile dysfunction, osteoporosis, metabolic syndrome and stroke. Having missing front teeth and visible decay can affect employability and self-esteem. Further, one per cent of ER visits are for people with non-traumatic dental pain.
For all of these reasons, Canadians were excited to see the federal NDP force the Liberals to implement a dental plan, the CDCP, as part of their confidence and supply agreement. The CDCP seeks to provide dental insurance to those without access to private dental insurance and have a combined family income of less than $90,000 per year, with no copayments for those making less than $70,000. Those with a family income between $70,000-80,000 will face a 40 per cent copayment and those with a family income between $80,000-90,000 will face a 60 per cent copayment.
This plan will provide some level of dental coverage to around 8.5 million people and will be the largest investment in dental care in Canadian history. More than a million seniors have already signed up.
While the CDCP is undoubtedly a step in the right direction, the details of the plan are showing major cracks that will leave many Canadians without access to care. A report from the Canadian Center for Policy Alternatives shows that the means testing of the CDCP will leave 4.4 million Canadians without access to any dental insurance, whether private or public. On top of this, millions of Canadians will be underinsured with high copayments and minimal coverage leading to insured people avoiding care.
To understand the largest disappointment with the CDCP thus far, we need to understand how billing works in dentistry. Each procedure a dental provider performs (e.g. simple extraction or a two-surface filling) has a code associated with it, and the provincial and territorial dental associations make a fee guide each year stating what each procedure should cost. These fee guides are just a suggestion, so dentists are free to bill above the fee guide, but many follow them as this is what most private insurance plans follow.
In order to prevent discrimination against people relying on public dental plans, the fees those plans pay out need to be the same as the provincial fee guides, otherwise dentists can make more money treating people with private insurance. Despite this problem, the Liberals decided to set the CDCP fees at around 80 per cent of what the provincial fee guides recommend. Seeing this, organized dentistry on behalf of dentists, lobbied aggressively to be able to charge patients the difference between the CDCP fees and the dentists fees—a practice known as balance billing.
Allowing balance billing in the CDCP means the Liberals are breaking from their promise to implement a dental plan with no copayments for those with a family income of less than $70,000 per year. Balance billing will mean those people will face around a 20 per cent copayment to make up the difference from the lower fees in the CDCP guide. On top of this, those who expected to face a 40 to 60 per cent copayment because their family income was between $70,000-$90,000 per year, will see an additional 20 per cent copay.
While coverage under the CDCP is not perfect, it is more comprehensive than other public dental plans, like the Ontario Works and Ontario Disability Support Program. The problem arises with the higher than expected copayments that will lead many people to only use their newfound dental coverage for emergencies rather than comprehensive care.
Balance billing also leaves the program more vulnerable to political problems that could erode the program in the future. In order for the CDCP to stand the test of time, the most powerful group involved—organized dentistry—needs to fight for the fees the program pays out to keep up with inflation.
The problem is that organized dentistry has never wanted public dental care to be a large portion of the dental field. In Saskatchewan, organized dentistry successfully dismantled the most successful children’s dental program in North American history because it threatened their monopoly on care. Dentists were strongly opposed to the inclusion of dental care in Medicare.
If the Liberals chose to not allow balance billing, they could have goaded dentists into defending the CDCP out of fear of losing income if fees were deindexed from inflation. But with balance billing, dentists can just push the added costs of lower fees onto patients, leaving far less political will for organized dentistry to defend the CDCP. This is how the existing provincial dental programs have become so meager. With recent polling showing a Conservative majority is likely in the 2025 federal election, this is a serious threat to the long term viability of the CDCP.
While the CDCP is welcome news for anyone who has lived with dental pain because they were unable to afford care, it is clear our work is just beginning. When the widely influential Hall Commission was released in 1964, laying the groundwork for Medicare in Canada, it stated that dental care should be included at a later date. Now is the time to follow through with that promise.
