Potential Oral Health Impact of Cost Barriers to Dental Care
Potential Oral Health Impact of Cost Barriers to Dental Care
Avoiding dental care because of cost represents a barrier that is present prior to seeking care, while foregoing recommended dental treatment due to cost occurs when, after making an initial visit, cost prevents one from proceeding with recommended care. Both of these circumstances suggest the potential for progressive damage to teeth or the worsening of oral health due to cost barriers. The aim of this study was to determine the oral health status and dental treatment needs of Canadians reporting cost barriers to dental care and it was demonstrated that over one in five Canadians reported barriers. These individuals had more untreated decay, missing teeth, and reported having poorer oral health and oral pain more often. It was also found that those reporting cost barriers had a higher prevalence of needing dental treatment and had more treatment needs. Additionally, having untreated decay was found to be predictive of reporting financial barriers to care, suggesting the likelihood of negatively progressing dental conditions related to the inability to secure treatment based on cost barriers to dental care.
These findings support results from longitudinal research demonstrating that routine dental attendance results in better oral health outcomes, including fewer missing teeth, fewer decayed teeth, lower overall DMFS (decayed, missing, and filled surfaces) scores, better oral health-related quality of life and better self-reported oral health. Within the limitations of a cross-sectional study, and based on previous longitudinal findings, we can infer that once financial barriers are removed, the oral health of Canadians reporting cost barriers to care have the potential to improve.
In a privately financed dental care system like Canada's, dental insurance mitigates the potential barrier of upfront costs, meaning that the insured reported cost barriers much less often than the uninsured. Recent research shows that, even after controlling for other factors, including income, the uninsured were almost six times more likely to avoid the dentist because of cost compared with the insured. The need for policies aimed at controlling the costs of dental services, and increasing their affordability for vulnerable groups is apparent. In terms of affordability, from a policy perspective, income and insurance are queen and king. In the current economic and political environment, it is likely that more can be done to provide insurance than increasing wages or improving income redistribution, for example. Thus, in order to reduce cost barriers to care and potentially improve oral health outcomes, there is a need to improve the quality of dental insurance coverage, or to ensure that cost-sharing arrangements be kept low and that important services are not excluded from insurance plans. This is evidenced by The RAND Health Insurance Experiment, a large-scale study of health care costs, utilization and outcomes in the United States which early on confirmed the importance of affordable dental insurance to oral health, by demonstrating that a reduction in cost-sharing for dental services actually improved oral health, especially for subgroups of the population with the poorest oral health outcomes.
Unfortunately, the participation of employers in providing employment-based insurance in Canada has declined over the past decades. The continual and invariant increase in the costs of dental care has contributed to the increasing costs of dental plans. These costs ultimately fall back onto employers and have continued to rise at well beyond the rate of inflation. In response, the private dental insurance system in Canada is gradually becoming unsustainable since the costs of coverage have continued to outpace the purchasing power of many employers as the main payer for insurance benefits. In addition to the prevailing role of employer-employee contracts, inadequate financial support from governments in reducing barriers to dental care have fostered an environment where access to care is now more strongly associated with one's level of income and insurance than ever before. Much of this speaks to the "inverse care law", where people that need the most care tend to receive the least, a term that has been used to describe the dental care situation in Canada. Given the dramatic increases in the costs of providing dental benefits, in conjunction with economic challenges, we postulate that the number of underinsured and uninsured individuals will continue to increase.
Provincial governments have begun to extend affordable dental insurance to uninsured children; however, the unmet oral health needs of uninsured adults continue to be ignored in the health care system without a cohesive political response by provincial governments. This has important impacts, as one could argue that the deterioration of private and public dental benefits coverage for adults has contributed to the use of acute health care settings for basic dental problems. Quiñonez et al. demonstrated that most dental-related emergency visits are non-urgent, preventable and often result in an intervention that does not provide a definitive solution to the dental problem (e.g. pharmacotherapy). Further, it was found that the majority of individuals visiting the emergency room for dental care are low income and ineligible for public funding, such as the working poor, seniors, or those on social assistance.
Overall, improving oral health outcomes requires targeted investments in programs and services that match the needs of the public and that target financial constraints. It is important for governments to consider policies that attempt to control the costs of health care plans and contribute to plans for vulnerable populations. These policies may, for example, include mandating, through legislation, the presence of health care benefits in all employment-employee contracts.
While self-reported data are the most convenient and readily attained method for assessing oral health outcome information, it has been shown to be influenced by one's culture, personal beliefs, and other social factors, such as age, education and income. Thus, this study makes an important contribution by highlighting the oral health status of Canadians who reported experiencing cost barriers to dental care by examining their clinical oral health status and needs, as determined by calibrated dentists. Further, this study provides valuable baseline information for future studies to assess whether financial barriers to dental care are getting better or worse in Canada.
This study has several limitations, specifically the inability to make causal inferences based on the cross-sectional nature of the data and shortcomings in breadth and detail of the variables. For example, it is impossible to know whether the cost barriers caused poorer oral health outcomes. Lastly, within the confines of the data collected, it is not possible to understand what treatments were considered unaffordable. This is important information to know, particularly from a public health perspective, where the inability to afford basic restorative services is much different than not being able to afford orthodontic services, for example. Lastly, assumptions were made when analyzing the two cost barrier questions. For example, the first question, "In the past 12 months, have you avoided going to a dental professional because of the cost of dental care?" assumes that the respondent avoided the dentist altogether due to cost. For the second question, "In the past 12 months, have you avoided having all the dental treatment that was recommended because of the cost?" it is assumed that the respondent visited a dentist, was recommended treatment, and then declined the treatment due to cost. For respondents who answered "yes" to both questions, it is assumed that they had experienced both situations in the same year, on separate occasions.
Discussion
Avoiding dental care because of cost represents a barrier that is present prior to seeking care, while foregoing recommended dental treatment due to cost occurs when, after making an initial visit, cost prevents one from proceeding with recommended care. Both of these circumstances suggest the potential for progressive damage to teeth or the worsening of oral health due to cost barriers. The aim of this study was to determine the oral health status and dental treatment needs of Canadians reporting cost barriers to dental care and it was demonstrated that over one in five Canadians reported barriers. These individuals had more untreated decay, missing teeth, and reported having poorer oral health and oral pain more often. It was also found that those reporting cost barriers had a higher prevalence of needing dental treatment and had more treatment needs. Additionally, having untreated decay was found to be predictive of reporting financial barriers to care, suggesting the likelihood of negatively progressing dental conditions related to the inability to secure treatment based on cost barriers to dental care.
These findings support results from longitudinal research demonstrating that routine dental attendance results in better oral health outcomes, including fewer missing teeth, fewer decayed teeth, lower overall DMFS (decayed, missing, and filled surfaces) scores, better oral health-related quality of life and better self-reported oral health. Within the limitations of a cross-sectional study, and based on previous longitudinal findings, we can infer that once financial barriers are removed, the oral health of Canadians reporting cost barriers to care have the potential to improve.
In a privately financed dental care system like Canada's, dental insurance mitigates the potential barrier of upfront costs, meaning that the insured reported cost barriers much less often than the uninsured. Recent research shows that, even after controlling for other factors, including income, the uninsured were almost six times more likely to avoid the dentist because of cost compared with the insured. The need for policies aimed at controlling the costs of dental services, and increasing their affordability for vulnerable groups is apparent. In terms of affordability, from a policy perspective, income and insurance are queen and king. In the current economic and political environment, it is likely that more can be done to provide insurance than increasing wages or improving income redistribution, for example. Thus, in order to reduce cost barriers to care and potentially improve oral health outcomes, there is a need to improve the quality of dental insurance coverage, or to ensure that cost-sharing arrangements be kept low and that important services are not excluded from insurance plans. This is evidenced by The RAND Health Insurance Experiment, a large-scale study of health care costs, utilization and outcomes in the United States which early on confirmed the importance of affordable dental insurance to oral health, by demonstrating that a reduction in cost-sharing for dental services actually improved oral health, especially for subgroups of the population with the poorest oral health outcomes.
Unfortunately, the participation of employers in providing employment-based insurance in Canada has declined over the past decades. The continual and invariant increase in the costs of dental care has contributed to the increasing costs of dental plans. These costs ultimately fall back onto employers and have continued to rise at well beyond the rate of inflation. In response, the private dental insurance system in Canada is gradually becoming unsustainable since the costs of coverage have continued to outpace the purchasing power of many employers as the main payer for insurance benefits. In addition to the prevailing role of employer-employee contracts, inadequate financial support from governments in reducing barriers to dental care have fostered an environment where access to care is now more strongly associated with one's level of income and insurance than ever before. Much of this speaks to the "inverse care law", where people that need the most care tend to receive the least, a term that has been used to describe the dental care situation in Canada. Given the dramatic increases in the costs of providing dental benefits, in conjunction with economic challenges, we postulate that the number of underinsured and uninsured individuals will continue to increase.
Provincial governments have begun to extend affordable dental insurance to uninsured children; however, the unmet oral health needs of uninsured adults continue to be ignored in the health care system without a cohesive political response by provincial governments. This has important impacts, as one could argue that the deterioration of private and public dental benefits coverage for adults has contributed to the use of acute health care settings for basic dental problems. Quiñonez et al. demonstrated that most dental-related emergency visits are non-urgent, preventable and often result in an intervention that does not provide a definitive solution to the dental problem (e.g. pharmacotherapy). Further, it was found that the majority of individuals visiting the emergency room for dental care are low income and ineligible for public funding, such as the working poor, seniors, or those on social assistance.
Overall, improving oral health outcomes requires targeted investments in programs and services that match the needs of the public and that target financial constraints. It is important for governments to consider policies that attempt to control the costs of health care plans and contribute to plans for vulnerable populations. These policies may, for example, include mandating, through legislation, the presence of health care benefits in all employment-employee contracts.
Strengths and Limitations
While self-reported data are the most convenient and readily attained method for assessing oral health outcome information, it has been shown to be influenced by one's culture, personal beliefs, and other social factors, such as age, education and income. Thus, this study makes an important contribution by highlighting the oral health status of Canadians who reported experiencing cost barriers to dental care by examining their clinical oral health status and needs, as determined by calibrated dentists. Further, this study provides valuable baseline information for future studies to assess whether financial barriers to dental care are getting better or worse in Canada.
This study has several limitations, specifically the inability to make causal inferences based on the cross-sectional nature of the data and shortcomings in breadth and detail of the variables. For example, it is impossible to know whether the cost barriers caused poorer oral health outcomes. Lastly, within the confines of the data collected, it is not possible to understand what treatments were considered unaffordable. This is important information to know, particularly from a public health perspective, where the inability to afford basic restorative services is much different than not being able to afford orthodontic services, for example. Lastly, assumptions were made when analyzing the two cost barrier questions. For example, the first question, "In the past 12 months, have you avoided going to a dental professional because of the cost of dental care?" assumes that the respondent avoided the dentist altogether due to cost. For the second question, "In the past 12 months, have you avoided having all the dental treatment that was recommended because of the cost?" it is assumed that the respondent visited a dentist, was recommended treatment, and then declined the treatment due to cost. For respondents who answered "yes" to both questions, it is assumed that they had experienced both situations in the same year, on separate occasions.
Source...