39% of Australians can’t afford to go to the dentist. But Medicare isn’t the answer.

For a country that still likes to think it has a universal health care system, the figures are shameful. According to data just released by the Australian Institute of Health and Welfare, 39.2% of adults delayed or avoided dental care because of cost in 2017-18. It was worse for people of working age, rising to 49.5% in the 25-34 age group and 45.1% for people between 35 and 44.

It’s perhaps not surprising. These are people – who are already struggling with the rising cost of living and declining real wages – raising families and paying off mortgages.

Poor oral health is about much more than unsightly teeth. It’s closely associated with cardiovascular disease, diabetes, respiratory disease, stroke, kidney disease, dementia, adverse pregnancy outcomes, pneumonia, stomach ulcers and oral cancers.

The figures also show how the situation has worsened in just a decade. And since 2017-18, there have been further pressures from rising dental fees, and soaring fuel, food and housing costs.

The federal government’s retreat from health care has been a major barrier to equitable access to all health care, including dentistry. Federal government funding reached a peak of $77.77 per head of the population in 2011-12 but was badly hit in the Abbott government’s 2014 budget. It has never recovered and by 2019-20 was 38% lower than it had been eight years earlier. The states, despite serious budget problems, have largely maintained their contribution.

 

So who pays? You do, of course – mostly by paying the dentist’s bill yourself, but also through your private health insurance premiums. As the federal government transferred liabilities from its balance sheet to yours, the non-government category (that’s you) has become responsible for a greater share of the bill.

 

 These things never hit evenly. It’s not that people in the ACT have such bad teeth, or even that their dentists are unusually greedy. It’s just that Canberrans have more money.

Private insurance is not the answer.

Only around half of all Australians have dental cover. Premiums are high and ever-rising, but the chances are that you’ll be paying most of the bill yourself anyway. In 2017-18, 20% of people with private dental insurance paid the whole cost. Only 3% found their insurer paid it all.

Charges vary massively across the country, so the AIHW looks at what happens at the half-way point. Half of all people paid less than the median price and half paid more.

For a basic consultation – the dentist has a look but doesn’t do anything – you can expect to pay around 42% of the cost yourself, or $25. The median price for having a crown fitted to a tooth is $1,600. If you have insurance, you’re likely to get just under 40% back, leaving you with a bill of $900.

 

Unfortunately, Medicare is not the answer either.

Proposals for addressing these problems usually involve either extending Medicare to cover dentistry, or setting up a Medicare-style system to do the job instead. The most comprehensive argument for this was put in a Grattan Institute report in 2019. It suggested that such as scheme should centre around a schedule of fees to which all dentists agree to charge. The government, not the patient, would pay.

It's unlikely to work, for the same reasons Medicare itself isn’t working. Dentists are unlikely to adhere to a single list of fees, essentially formulated by the government. And under the Constitution, there’s no way the government can force them.

Specialist physicians and surgeons largely ignore Medicare in setting their fees. Last year, the bulk-billing rate for all specialist services was only 35%, with patients paying an average of $94.60 each time. Over the year, that cost patients $3.3 billion and Medicare just over $1 billion.

Dentists – dental surgeons – are specialists, not GPs. If Medicare extended to dentistry, there is no reason to believe the results would be any better.

Medicare was set up as a publicly-funded insurance scheme that would be available to everyone – rich and poor alike. The ideal was that patients would be treated according to clinical need, not according to their ability to pay. It would be – and is – a much more efficient and equitable alternative to private insurance. But it has never provided universal health care.

 

Is there any solution?

Perhaps. Only perhaps. Back in 1946, Robert Menzies, then the opposition leader, put a sneaky phrase into a constitutional amendment as the price for his party’s support of the Chifley Labor government’s referendum. Section 51 (xxiii) allowed the government to provide “medical and dental services (but not so as to authorize any form of civil conscription).” Since then, the High Court has interpreted “civil conscription” very narrowly indeed. The first challenge to Labor’s health legislation under this section even prevented the government from requiring doctors to use a special form when writing prescriptions on the PBS.

Menzies’ sneaky phrase is why we have Medicare and not the much stronger National Health Scheme that Britain has and which Curtin and Chifley wanted. And it’s why the government cannot tell dentists what to charge.

But it can do so if it employs the dentists. Just as state-run dental clinics and public hospitals employ their staff and therefore control costs, a federally-funded dental network could work in the same way.

But the federal public service is no good at delivering services – as we saw with the home insulation mess under Kevin Rudd and the vaccine rollout debacle under Scott Morrison. Giving the Commonwealth Department of Health the responsibility for running dental clinics would be pure folly.

Only the states have that capability. What they don’t have is the money or the leadership. Fixing the appalling state of oral health in this country will need lots of both, and only the national government can spearhead a coordinated national approach. If the states did the service delivery, the feds could take care of funding and coordination. We would end up with a vastly expanded public dentistry capability, concentrating primarily on the people who cannot afford to pay for their own care. And it would inject a level of healthy competition into the dental industry that it has never before experienced.

It would be expensive, but poor oral health costs the country even more. According to the AIHW’s recent Burden of Disease Study, oral illnesses account for 2.4% of the burden of all diseases in Australia. That’s measured in disability-adjusted life years (DALYs), a proxy for a year of disability-free life.

A recent international study has assessed the cost of a single DALY in a country like Australia at around $US47,000, or $63,000 in Australian currency. In 2018, 119,000 DALYs were lost to oral ill-health. On that basis, oral disease costs Australia $7.5 billion a year.

With that sort of money, you can buy a hell of a lot of dentistry.