Sorry doctor, I can't afford the root canal, I have a job: Canadian dental care policy and the working poor.

Quinonez, Carlos ; Figueiredo, Rafael

Canada's national system of health insurance does not include dental care. Governments pay for only 4-6% of all dental care expenditures. (1) Dental care is delivered in the private sector, financed by out-of-pocket expenditures (43%) and by employment-based insurance (53%).1 This method of structuring dental care has developed in relation to social need and employment status, meaning governments finance care for groups receiving social transfers (e.g., welfare), while employment-based insurance plays the dominant role in the private sector.

This level of public financing has led to a social discourse on access to dental care, and increased attention is being paid to the challenges experienced by low-income Canadians, in particular the working poor (WP). (2-4) The WP, or individuals who maintain regular employment but remain in relative poverty, (5) do not qualify for welfare insurance that covers some dental care, yet they rarely enjoy employment-based dental benefits. In 2001, approximately 75% of Canadians living in non-poor families reported having access to dental insurance, whereas only 26% of the WP reported such access. (5) That same year, there were 650,000 WP persons in Canada, and including dependants this totalled 1.5 million Canadians, approximately 4-5% of the national population. (5)

From the point of view of dental care policy, social concerns are not unfounded. National population estimates demonstrate that those with no income report more dental visits than those making $15-30,000 a year, pointing to the role of public insurance and the importance of insurance generally.6 The WP highlight a gap in how dental care has become structured in Canada, as the country's dental care policy has defined itself along moralized lines, meaning that the basis upon which social need is assessed turns on personal responsibility, and employment is an exemplar of this social standing. So by its very definitions, Canadian policy recognizes the WP as persons with employment, yet through historically developed biases, fails to recognize them as persons in social need.

Through a mixed methods approach, this research aims to explore the development of Canadian dental care policy and the place of the WP within it. This paper describes this development, and presents findings from a 2007 national survey of WP adults concerning their oral health and dental care experiences within the context of such policy. Ultimately, the aim of this research is to inform debates on access to dental care and the working poor.

METHODS

Historical review

The development of Canadian dental care policy was detailed through a series of document reviews. All current volumes of the Journal of the Canadian Dental Association (1935-2008) were searched for pertinent issues (e.g., dental insurance). Federal, provincial and municipal websites were searched for documentation that defined the broad and specific bases of dental care policy (e.g., legislation, policy directives). Other primary sources included reports from major public commissions on health and social policy in Canada (1938 Royal Commission on Dominion Provincial Relations, 1964 Royal Commission on Health Services, 2002 Royal Commission on the Future of Health Care in Canada), and submissions to these commissions by the Canadian Dental Association (CDA).

Telephone interview survey

A national telephone interview survey of WP Canadians was conducted from March to September of 2007. A private firm was contracted to collect the data via computer-assisted telephone interview technology. A provincially stratified sample of 1,067 people was considered representative (for a sample with a maximum variance and standard confidence interval of 95% [+ or -] 3%, then n = ((P)(1-P))/[(C/Z).sup.2] = ((1.96)(0.5)/(0.03))2). The WP are defined as individuals aged 18 to 64 who have worked for pay a minimum of 910 hours (part-time) in the reference year, are not full-time students, and have a low family income according to the Market Basket Measure (MBM). (5) The MBM defines a low-income person as someone whose disposable income falls below the cost of the goods and services (e.g., food, clothing, shelter) in the market basket in their community. The MBM ranges from $22,017 to $29,343 across Canada. With this knowledge, the private firm purchased a telephone listing of households making less than $35,000 per year, compiled by a major retailer and containing approximately 10,000 numbers. A regionally stratified quota was set by province, and numbers were called until the quota was satisfied. On average, 1.25 numbers were called for every person who qualified. This resulted in a final sample of 1,049 WP adults.

The telephone interview began with eligibility questions (i.e., 18 to 64 years, worked a minimum of part-time hours, not a full-time student, a family income below the MBM). Questions were asked regarding oral health and dental care (e.g., self-reported oral health status, dental insurance status) and socio-demographic characteristics (e.g., age, sex, income). Table 1 describes these variables, all of which are recognized in the literature as outcomes of dental care policy (e.g., dental insurance status, visiting behaviour), are correlates of dental care access (e.g., last dental visit, toothache in previous month), or are deemed relevant when discussing working poverty (e.g., income from self-employment, history of social assistance). Where possible, our findings were compared with Statistic Canada's 2005 Canadian Community Health Survey (CCHS), a Human Resources and Social Development Canada (HRSDC) report (5) outlining a WP subsample from Statistic Canada's 2001 Survey of Labour and Income Dynamics, and a national public opinion survey on dental care that we conducted in 2006. Simple descriptive analyses were undertaken, and multivariate logistic regression odds ratios were calculated for variables that again are recognized as outcomes of dental care policy, are related to dental care access, or are relevant to working poverty. Table 2 describes these variables along two axes, dental insurance status and history of social assistance, both of which are considered fundamental when discussing access to dental care (i.e., insurance is the dominant predictor of dental care utilization, and social assistance provides such insurance).

RESULTS

The development of Canadian dental care policy

In the 1870s, the Canadian father of 'public health dentistry', John Adams, opened a free dental hospital for poor children and published mass health education material. (7) This reference contains much of what concerns dentistry in its response to social need, namely public support for the treatment of marginalized groups, in particular children, with a heavy emphasis on prevention. By 1902, the CDA was calling for the legislated coverage of children's dental examinations and the inclusion of education materials in public settings. (7) By the Roaring Twenties, the average Canadian was spending $25 a year on dental care. (8) The 1920s boom gave way to the Great Depression, and with the widespread social suffering, the idea that the state should have a role in the delivery of health services gained prominence. (9) This growth in social thinking, or social responsibility, led to the 1938 Royal Commission on Dominion Provincial Relations, which considered a potential system of national health insurance that included dentistry. In its brief, the CDA characterized dental care in terms of: "Those able to provide adequate dental services for themselves [...]. Those only able to provide partial and inadequate dental services for themselves [and] [t]hose unable to provide any dental services for themselves". (10) Note the strong emphasis on individual responsibility. The profession continued to advocate for a preventive approach that focussed on children, and with this, dental care policy in Canada was essentially defined: a strong bias towards children, prevention and personal responsibility.

World War II played a strong role in establishing dentistry as a social priority, as 1 in 5 recruits were reported as unfit for enlistment due to dental disease. (11) Dental care gained new prominence and dental departments were incorporated into health ministries across the country. (7) This was linked to the major social investments made after the war, which for health involved federal grants that promoted investments in government-delivered dental care. (12) Canada began adopting community water fluoridation at this time as well, and by the 1950s, had nationalized the delivery of hospital care, which included some dental care. (13,14) Based on the plans of the 1964 Royal Commission on Health Services, the country had nationalized payment for physician services by 1968, giving rise to Medicare. Dentistry was not included, as the Commission defined dental care as a personal responsibility, and for the most part only supported dental care for children and for those receiving welfare assistance. (15) Canada thus guaranteed a social minimum, but one based on age, employment and a particular conception of social need.

Concurrently, private, employment-based dental insurance was taking hold through government tax incentives for both employer and employee. The growth in the private sector was significant (Figure 1), as across many industries, employer contributions for health benefit plans increased substantially. (8) Public investments also grew, as almost all provinces established children's and welfare programming during this period. By the 1980s, public investments had slowed, and with the impacts of two economic recessions and subsequent governmental cutbacks, public financing for dental care began a steady decline.

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[FIGURE 2 OMITTED]

The experiences of the working poor

The entire sample met HRSDC criteria for WP. The majority were male, aged 35 years and over, had postsecondary educations, pretax incomes between $15-30,000, were married and born in Canada (Table 1). Similar to HRSDC findings, approximately 15% of the sample had previously received social assistance, but significantly fewer reported self-employment income. Of those who reported a history of social assistance, approximately half had accessed dental care at such time. Our sample reported significantly lower dental insurance coverage when compared to the general populations that make up the CCHS and the public opinion survey (Table 1). Yet the HRSDC sample reported much less insurance coverage. In terms of self-reported oral health status, our sample was equivalent to the general population. In terms of dental visits, our sample reported visiting more frequently when compared to the general population. Yet for those who did not visit regularly, our sample reported cost as the main barrier to accessing care, compared to not thinking the visit necessary as reported by the general population (Figure 2). Our sample also sought regular preventive care, reported a slightly higher level of toothache in the previous month, and a greater inability to afford dental care.

Logistic regression analyses demonstrate that WP persons with no dental insurance coverage were more likely to report poorer outcomes, such as worse oral health, visiting a dentist only in emergencies, having a functionally impaired dentition, and/or being unable to afford dental care (Table 2). The uninsured were also more likely to have reported self-employment income. Those with no history of social assistance also appeared to be better off, reporting a lesser likelihood of poor oral health, visiting only in emergencies, having a functionally impaired dentition, and/or being unable to afford dental care.

DISCUSSION

Canadian dental care policy has historically placed emphasis on children, social assistance recipients and the employed. In this sense, a bias has developed towards age, employment status and personal responsibility. This has resulted in a dental care system that finances care in both public and private ways. Yet with this policy approach, a significant contradiction has appeared: by using age, employment status and personal responsibility as proxies for social need, Canada recognizes that unemployment and limited incomes generally define a greater likelihood of disease and barriers to accessing dental care, and that children in particular cannot be held responsible in any regard. Nevertheless, Canadian dental care policy does not adequately assess need by its very own standards, as it does not merit those who are conceived as being responsible (because they are employed) and whose families may experience barriers to care because of limited incomes or a lack of dental insurance (public or private).

The importance of dental insurance is key. In this sample of WP Canadians, a lack of insurance was consistently associated with the worse oral health and dental care outcomes. These data also suggested that there is a strong social gradient to inequalities in oral health, meaning that those WP individuals who had never been on social assistance were consistently better off than those who had received social support.

These findings are supported by several Canadian and American studies. Guendelman et al. (16,17) have demonstrated that for health services, the largest disparities between WP and non-poor American families concerned access to dental care. They also noted that WP families reported significantly more unmet dental care needs. In Canada, analyses by Williamson and Fast (18,19) demonstrated that a lack of insurance had important implications for the achievement of overall health, and that participants living in WP families are generally healthier than participants living in families that have received social assistance. These authors also argue that Canadian public policy compromises accessibility to health services for WP families.

What are the policy implications of this study's findings? Initially, it is evident that need exists in WP families. It is also clear that Canadian dental care policy needs to be reassessed on the basis of how it determines need in order to close a gap that holds important consequences for many families. Policy-makers may consider broadening the eligibility for public insurance on the basis of a more accurate understanding of the variety of employment conditions present in the country (e.g., low paid work, self-employment, increases in part-time employment with few fringe benefits), and may also consider legislation designed to improve entitlements to employee benefits. (20)

It is important to consider the limitations of the study's findings. For example, compared to the HRSDC survey, our WP sample appears to have under-represented adults aged 25 and 44, and overrepresented those between 55 and 64. The sample also underrepresents women, is biased towards those who are married, and over-represents those with postsecondary educations. In effect, as a result of sampling phone numbers to collect data, we have likely captured a particular segment of Canada's WP population, namely those who have land lines. Recent Statistics Canada data demonstrate that those with the lowest incomes are more likely to opt for cellular phones. (21) Our sample has thus likely under-represented the lower income segment of Canada's WP population. This can explain why this study observed a significantly greater level of insurance coverage when compared to the HRSDC report, and why this sample appears to be on par with the general population in terms of oral health status and dental care visiting patterns. Nonetheless, this simply implies that the situation may actually be worse than what is presented here.

In closing, this paper has informed an understanding of why Canada has certain gaps in its dental care policy. It suggests that our policy approach to dental care has important impacts on WP Canadians, in that oral heath and dental care outcomes can be significantly mitigated by the presence of dental insurance. It is hoped that these data can be used to inform future discussion on investments aimed at improving access to dental care for the working poor.

Received: November 2, 2009

Accepted: June 28, 2010

REFERENCES

(1.) Canadian Institute for Health Information. National Health Expenditure Trends, 1975-2005. Ottawa: Canadian Institute for Health Information, 2005.

(2.) Blackwell T. Extend dental coverage, doctors urge. Toronto, ON: The National Post October 12, 2007.

(3.) Picard A. Doctors' orders: Expand medical coverage to long-term care. The Globe and Mail October 21, 2007.

(4.) Welsh M. He has a new smile; system still in decay. The Toronto Star July 10, 2007.

(5.) Human Resources and Social Development Canada. When working is not enough to escape poverty: An analysis of Canada's working poor. Ottawa, ON: HRSDC, 2006.

(6.) Bhatti T, Rana Z, Grootendorst P. Dental insurance, income and the use of dental care in Canada. J Can Dent Assoc 2007;73:57.

(7.) Gullet D. A History of Dentistry in Canada. Toronto, ON: University of Toronto Press, 1971.

(8.) Social Science Federation of Canada. Historical statistics of Canada. Section B: Vital Statistics, Table B82-92. Ottawa: Statistics Canada, 1983.

(9.) Naylor D. Health care in Canada: Incrementalism under fiscal duress. Health Aff 1999;18:9-26.

(10.) Canadian Dental Association. A submission to the Royal Commission on Dominion-Provincial Relations. Ottawa: CDA, 1938;14.

(11.) Canadian Dental Association. Health insurance. J Can Dent Assoc 1943;9:227-29.

(12.) Canadian Dental Association. Health insurance bill at coming session. J Can Dent Assoc 1948;14:158.

(13.) Canadian Dental Association. Fluoridation. J Can Dent Assoc1956;22:164-68.

(14.) Author unknown. Does Bill 320 affect dentistry? J Can Dent Assoc 1958;24:415-16.

(15.) Government of Canada. Royal Commission on Health Services, Volume I. Ottawa: Government of Canada, 1964.

(16.) Guendelman S, Angulo V, Oman D. Access to health care for children and adolescents in working poor families: Recent findings from California. Med Care 2005;43:68-78.

(17.) Guendelman S, Pearl M. Access to care for children of the working poor. Arch Pediatr Adolesc Med 2001;155:651-58.

(18.) Williamson D, Fast J. Poverty status, health behaviours and health: Implications for social assistance and health care policy. Can Public Policy1998;24:1 25.

(19.) Williamson D, Fast J. Poverty and medical treatment: When public policy compromises accessibility. Can J Public Health 1998;89:120-24.

(20.) Reesor M, Lipsett B. Employer-sponsored health and dental plans--Who is insured? Publication no. W-98-2E. Ottawa: Applied Research Branch, Human Resources Development Canada, 1998.

(21.) Sciadas G. The digital divide in Canada. Ottawa: Statistics Canada, Science, Innovation and Electronic Information Division, 2002.

Carlos Quinonez, DMD, MSc, PhD, FRCDC, Rafael Figueiredo, DDS

Author Affiliations

Correspondence: Dr. Carlos R. Quinonez, Faculty of Dentistry, University of Toronto, 515C-124 Edward Street, Toronto, ON M6G 1G6, Tel: 416-979-4908, ext. 4491, Fax: 416-979-4936, E-mail: carlos.quinonez@utoronto.ca

Conflict of Interest: None to declare. Table 1. Sample Characteristics, Comparing With Other Population Samples Sample Percentage * HRSDC WP Survey, Survey, 2007 2001 (n=1049) (n=40,200) Sex Male 49.4 56.5 Female 34.8 43.5 Age (years) 18-24 14.4 11.9 25-34 19.4 24.8 35-44 22.0 31.7 45-54 22.3 21.9 55-64 20.2 9.7 Education High School or less 45.9 45.5 College/University 48.5 41.5 Income Less than $15,000 20.2 -- $15,000-$30,000 77.7 -- $30,000 or more 2.1 -- Income from Yes 17.8 40.7 self-employment No 82.2 59.3 Previous history of Yes 15.2 18.2 social assistance No 84.8 81.8 Born outside of Yes 30.4 11.5 Canada No 69.2 77.8 Married Yes 74.5 54.4 No 25.5 45.6 Dental insurance Insurance 50.5 25.6 status No insurance 49.5 74.4 Oral health status Poor/Very poor 11.2 -- Good/Excellent 88.9 -- Last dental visit Less than 3 years 89.3 -- 3 or more years 9.5 -- Never 1.2 -- Visiting behaviour Regular check ups 76.3 -- Only in emergencies 23.5 -- Had toothache in Yes 11.9 -- previous month No 72.3 -- Reported inability Yes 29.3 -- to afford dental No 69.1 -- care Sample Percentage * Public CCHS, Opinion 2005 Survey, 2006 (n=132,221) (n=1006) Sex Male 49.3 48.5 Female 50.7 51.5 Age (years) 18-24 11.3 7.6 25-34 15.4 21.6 35-44 18.8 18.8 45-54 17.6 22.4 55-64 13.1 14.8 Education High School or less 43.9 39.1 College/University 56.1 58.9 Income Less than $15,000 5.6 6.8 $15,000-$30,000 12.8 12.8 $30,000 or more 81.6 62.1 Income from Yes 16.9 -- self-employment No 83.1 -- ([dagger]) Previous history of Yes -- -- social assistance No -- -- Born outside of Yes 20.9 -- Canada No 79.1 -- Married Yes 50.3 -- No 30.4 -- Dental insurance Insurance 62.4 62.3 status No insurance 37.6 35.3 Oral health status Poor/Very poor 14.4 13.9 Good/Excellent 85.6 85.4 Last dental visit Less than 3 years 80.4 84.6 3 or more years 18.6 13.5 Never 1.0 1.4 Visiting behaviour Regular check ups 75.0 84.5 Only in emergencies 25.0 15.5 Had toothache in Yes 9.8 -- previous month No 90.2 -- Reported inability Yes -- 25.8 to afford dental No -- 73.3 care * Percentages may not equal 100 due to missing cases and/or categories. ([dagger]) From CCHS, 2003 (n=134,072). Table 2. Age- and Sex-adjusted Odds Ratios for Various Outcomes, by Insurance Status, and by Reported History of Social Assistance WP With No Dental Insurance OR (95% CI) Reported oral health as poor or very poor 1.81 (1.36, 2.41) Only visits for emergencies 3.80 (2.62, 5.51) Had visited dentist within the previous year 0.29 (0.17, 0.49) Impaired dental functioning (less than 21 teeth) 1.81 (1.05, 3.11) Perceived a need for dental treatment 2.28 (1.69, 3.07) Reported inability to afford dental care 2.19 (1.60, 3.00) Gave something up to pay for dental care 2.00 (1.29, 3.10) Reported self-employment income 2.97 (2.00, 4.40) High school education or less 1.45 (1.09, 1.93) WP With No History of Social Assistance OR (95% CI) Reported oral health as poor or very poor 0.45 (0.31, 0.67) Only visits for emergencies 0.53 (0.35, 0.79) Had visited dentist within the previous year 2.27 (1.31, 3.94) Impaired dental functioning (less than 21 teeth) 0.31 (0.17, 0.55) Perceived a need for dental treatment 0.41 (0.28, 0.62) Reported inability to afford dental care 0.49 (0.27, 0.59) Gave something up to pay for dental care 0.56 (0.34, 0.94) Reported self-employment income 1.30 (0.77, 2.19) High school education or less 0.54 (0.37, 0.79)