How is public dental care funded in Australia?
The past 50 years has seen a patchwork of government funded dental schemes with a lack of continuity and planning, leading to the current crisis in access to care.
Funding for dental care across Australia is manifestly inadequate, which is one of the reasons we see problems with long waiting times for public dental services and poor oral health linked to social disadvantage. Around 50% of the population do not visit the dentist on a regular basis, and cost is one of the major barriers to access care. Whereas governments fund 80% of hospital expenditure and 79% of medical care, they contribute only 21% to total dental expenditure (with a large portion subsidising private health insurance), so it is not surprising that the safety net for dental care is not meeting the needs of the community.
How did we get to this sad state of affairs?
Responsibility for the delivery of health care services, including dental care, has historically rested with the states. In 1946 an amendment to the constitution gave the Commonwealth power to legislate in the area of health, including dental services. Prior to this amendment, the Commonwealth government did not have the ability to provide health care, including dental care. This new constitutional power allowed the Commonwealth to fund and provide health services, but it didn’t impact on the ability of the states to also provide health care. One result of the expansion of Commonwealth powers was to create the two overlapping systems that we have today, with all of the problems inherent with shared responsibility and accountability.
s51. The Parliament shall, subject to this Constitution, have power to make laws for the peace, order, and good government of the Commonwealth with respect to:
xxiiiA. The provision of maternity allowances, widows' pensions, child endowment, unemployment, pharmaceutical, sickness and hospital benefits, medical and dental services (but not so as to authorize any form of civil conscription), benefits to students and family allowances.
When Prime Minister Gough Whitlam, using the constitutional powers granted in the 1946 referendum, established Medibank (the precursor to Medicare) in 1974, he wanted to include dentistry too. However there were concerns about the additional cost and the possibility of having to fight the dental profession at the same time as winning doctors over. This meant that ultimately dentistry was excluded from Medicare.
Commonwealth government involvement in dental care has been sporadic over the past 50 years – in contrast to the growth of Medicare and funding for medical and hospital services.
Australian School Dental Program (1973)
Gough Whitlam did introduce the Australian School Dental Program in 1973, which was a response to poor oral health of children at the time. The program was developed in partnership with the states*, with the Commonwealth providing funding and support, and the states responsible for the delivery of dental services. The School Dental Program was designed to provide comprehensive dental care to all children up to the age of 15 years, with the majority of care provided by dental therapists. Although the program initially commenced with specific grants to the states, the Malcolm Fraser government rolled the funding into general purpose grants in the 1980s, which effectively ended specific federal funding and responsibility for dental care.
Commonwealth Dental Health Program (1993)
Following a report in 1992 on the poor state of oral health, Prime Minister Paul Keating introduced the Commonwealth Dental Health Program (CDHP) in 1993, with the 1993/94 budget allocating $278 million to 1996/97. The CDHP was established in response to long waiting times for public dental care and a recognition that there was a need to provide greater support for low-income adults. The funding was provided to states to boost their public dental services, and dental care was provided in both the public and private sector.
When Prime Minister John Howard won the next federal election in 1996, he decided not to continue funding the CDHP, arguing that the program had achieved its aims: the target of 1.5 million services had been met, waiting times reduced and the bulk of the budget allocation ($245 million) was spent. This meant that states resumed all financial responsibility for public dental care, and perhaps not surprisingly with the withdrawal of significant Commonwealth funding, waiting lists increased sharply.
Chronic Disease Dental Scheme (2004)
In 2004 the Howard government introduced the Enhanced Primary Care Dental Scheme, which provided $220 to patients with chronic health problems which were exacerbated by poor dental health. Given the small quantum of funding allocated per patient, the uptake was poor. This scheme morphed into the Chronic Disease Dental Scheme (CDDS) in 2007, with the benefit raised to $2000 per year (and subsequently increased to $4250 over a two year period).
Prime Minister Kevin Rudd announced plans to introduce a Commonwealth Dental Health Plan and Medicare Teen Dental Plan in 2008, and planned to close the CDDS in order to fund these new programs (the CDDS was eventually closed in 2012). The Commonwealth Dental Health Plan (CDHP) was a proposal to provide $290 million over 3 years to provide an additional 1 million public dental services to financially disadvantaged adult patients.
Child Dental Benefits Schedule (2008)
The Teen Dental Plan commenced in July 2008, providing $150 vouchers to eligible patients aged 12-17 years for a ‘preventive check-up.’ Uptake of the Teen Dental Plan was poor, and was criticised for not providing funding for dental treatment that was identified following the funded check-up.
Despite the promises, the CDHP was never introduced. In 2012 Prime Minister Julia Gillard announced a plan to replace the Teen Dental Plan with the Child Dental Benefits Schedule (CDBS) – and this was subsequently introduced in January 2014. It initially provided $1000 of dental care for eligible children (Family Tax Benefit A – around 50% of children) aged 2-17 years. The CDBS could be used in either the private or public sector, providing choice for parents. The cap has subsequently increased to $1052 and is now available to children aged 0-17 years. Approximately 3 million children are eligible, and around 30-40% of those eligible children utilise the service.
There is evidence that the CDBS has increased access to dental services and led to more favourable visiting patterns in low-income households, and it has broad acceptance across the dental profession. However there are still underserved populations requiring further support to access dental services, with many eligible children not currently utilising the program.
National Partnership Agreement Funding (2012)
A National Partnership Agreement on Treating More Public Dental Patients was reached between the Commonwealth and states. The Commonwealth agreed to provide $345.9 million over the budget periods 2012/13 to 2014/15 (3 years) with a target to treat an additional 400,000 patients. The Rudd Government announced a second NPA to provide $1.3 billion from July 2014 to expand public dental care through state-run public dental services to 1.4 million additional low-income adults.
Prime Minister Tony Abbott, elected to government in September 2013 replaced this NPA with a new agreement commencing July 2015 and providing $155 million for an additional 178,000 dental services.
In 2016 Prime Minister Malcolm Turnbull proposed a new Child and Adult Public Dental Scheme, which would replace the National Partnership Agreement and the CDBS. However, they were unable to get this plan legislated. The NPA funding was further reduced in 2017 to $107 million per year and has remained at that level ever since (with a name change to Federation Funding Agreement).
In 2020/21, state and territory governments provided $946 million to fund public dental services, in addition to the $107 million provided by the Commonwealth through FFA funding.
Where are we now?
We presently have a patchwork system of funding for public dental care:
Around 50% of children aged 0-17 years are eligible to access $1052 every 2 years for dental treatment through the Child Dental Benefits Schedule. Patients can access care in either the private or public system.
Around 30% of adults are eligible to access state-run public dental services. Eligible patients include those with a Health Care Card, Pensioner Concession Card holders and Commonwealth Seniors Health Card, and some jurisdictions have additional eligibility for Aboriginal and Torres Strait Islanders and refugee and asylum seekers). Inadequate funding means that most public dental services have long waiting times for general dental care.
What do we need to do?
There is an urgent need for governments to increase funding for public dental care, and treat the mouth the same as the rest of the body. An important (and sustainable) first step would be to introduce a Senior Dental Benefits Schedule, which was a key recommendation of the Royal Commission into Aged Care Safety and Quality. This would ensure that older Australians, who have a high burden of oral disease, would have improved access to dental care, and would be an important step in expanding the range of publicly funded dental services to more Australians.
* ‘States’ refers to both states and territories
This week in dental research
Following on from my post a few weeks ago on water fluoridation, a new study published in Community Dentistry and Oral Epidemiology found that naturally fluoridated tap water in Japan was associated with less tooth decay experience throughout school age, further adding to the evidence of the effectiveness of water fluoridation.
Next week: Everyone has been talking about Chat GPT, so I’ll take a look at artificial intelligence in dentistry.
Last week: If you missed, last week, you can go back and read Why don’t we take oral health seriously?