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Cherishing the children's teeth equally?

Posted on November 04, 2016 by Tom Healy

Tom Healy, Director NERI
Tom Healy, Director NERI

The term ‘social wage’ is sometimes used to refer to those public goods and services consumed by workers and their families.  Apart from wages earned over a given period we enjoy the benefits of ‘free’ or heavily subsidised services in areas such as education and health (although the balance has changed over time and is tilted towards private sources in the Republic of Ireland relative to other jurisdictions). An example of the ‘social wage’ is provided by those services offered through two schemes: the public Dental Treatment Benefit Scheme (DTBS) provided to most, but not all, PRSI workers and the Dental Treatment Services Scheme (DTSS) provided to medical card holders. 

The DTSS scheme covered 1.7 million persons in December 2015 or 37% of the population of the Republic of Ireland while the DTBS/PRSI scheme covered approximately 2 million persons including dependent spouses. The DTBS is operated by the Department of Social Protection.

Oral health is a vital social concern.  The mouth is, literally, the gateway to the body and can act as a warning system for various conditions. There is a saying that someone who loses their job or suffers a dramatic fall in income (such as happened in 100,000s of households in the period 2009-2011) should go and see the dentist!  A check-up and early treatment can save a fortune later. However, dental check-ups and routine procedures such as scaling and cleaning are often outside the budget of households on low or modest income.

The Irish Dental Association has drawn attention to a probable reversal in improved dental health because of ‘draconian cuts in state support for dental patients’ ( Why Oral Health matters, Irish Dental Association ).  In 1979, for example, an estimated 72% of adults aged 72 and over were without natural teeth. By 2000/02 this figure had dropped to 41% (the corresponding figures for medical card and non-medical card holders in 2000/02 were, respectively, 46 and 29%). [Refer to research by health economist, Professor Ciarán O’Neill of NUI Galway, in his report entitled The contribution of dental services to the health and economy of Ireland   published in 2010]. 

During the years of acute fiscal austerity (2009-2011) there were severe cut backs to public services. Dental services took a particuarly severe cut. The long-term impact of this on dental health is unknown. However, we can be sure that the impact was distributed unevenly across social class groups. Out of 1,400 General Dental Practitioners in the Republic in 2008, some 800 participated in the DTSS. According to the Irish Dental Association’s 2017 Budget Submission  numbers seeking dental treatment under the medical card scheme increased sharply as unemployment rose in 2009-2011 but the number of ‘scale and polish’ treatments collapsed, fillings were up by 33% and ‘surgical extractions’ increased by 53%.  Clearly, there is no ‘free lunch’ when it comes to fiscal austerity especially that which is blunt, inequitable and counter-productive from the point of view of long-term fiscal prudence. The Table, below, summarises the cut-backs in the DTBS scheme for PRSI workers.

Pay Related Social Insurance Dental Scheme before and after austerity

Treatment available prior to 2010

Treatment Available 2010 Onwards

Annual oral examination

Annual oral examination

Biannual Scale and polish

No longer available

Extended gum cleaning

No longer available

Fillings

No longer available

Extractions

No longer available

Root Canal Treatment

No longer available

X-rays

No longer available

Dentures

No longer available

Denture repairs

No longer available

Miscellaneous items

No longer available

The main cut-backs to public support for dental care were as follows:

  • In the case of PRSI workers, abolition of support for ‘scale and polish’ treatment and subsidisation of basic treatments such as fillings, root canal therapy and dentures.
  • In the case of medical card holders, the suspension of support for treatment except in ‘emergencies’ (‘preventive treatments’ such as scaling and polishing were removed from public support.

The irrationality of cut-backs during the austerity period is illustrated by the fact that any monies saved by the State in withdrawing support for dental care are likely to be outweighed in the future by a multiple as a result of dental health costs in the long-run borne by the State or individuals.  To be taken into account, also, is the time and productivity lost as a result of poorer dental health compared to what might otherwise have been the case. Dental health like all aspects of health is rightly considered to be part of productive human capital. Poor dental health costs individuals, businesses and, ultimately, the exchequer.

Public subvention for dental services has, therefore, been significantly reduced over time. This contrasts, sharply, with the level of public support that exists in the United Kingdom including Northern Ireland. In many respects, dental care is the Cinderella of the Irish health service – regarded as something almost akin to chiropody. Going to the dentist is for those in pain and or for  people who wish to exercise responsibility by means of frequent annual check-ups.  As for orthodontic treatment, people in 30 year's time will tell your family socio-economic background by the way you smile! 

The Irish Dental Association has reported, based on information provided by its members, an increase in referrals to hospitals as a direct consequence of denial of treatment and lack of affordability of same. This trend provides an example of how under-investment in areas such as primary health care or, in this case, preventive dental care is likely to lead to higher public costs in the long-run. 

Prior to the Crash and subsequent period of fiscal austerity in the Republic of Ireland, it appears that the Republic experienced some small improvement in regards to dental health inequalities over the period 1972 to 2002 compared to other parts of the Europe Union of 15 member states (as of 1995 membership). This has been attributed to a ‘needs-based approach’ described by health economist, Professor Ciarán O’Neill of NUI Galway in The O’Neill Report published in 2010. This Report drew attention to the high risks to national dental health as well as the social and economic equality implications of this given a drastic cut-back in services in 2010. O’Neill argues that, while many factors impact on dental health including local rates of fluoridation and patterns of personal care, the evidence points to a positive role of dentistry in raising levels of dental health as well as narrowing socio-economic inequalities over time. From this analysis which only extends to 2002 due to lack of data, I think it reasonable to fear that the drastic measures of 2009-2010 have had a long-term negative impact as well as a disproportionate impact on children, the elderly and those on low incomes.

The average number of DMFT at age 12 (Decayed Missing Filled Teeth) fell from 2.9 in 1984 to 1.1 in 2001 – the last year for which data are available on the relevant OECD health status database . Does the lack of timely and comprehensive international data which encompasses the Republic of Ireland say something about the priority given to dental health, here? (The WHO dental health database shows the Republic as one of the most out-of-date data on dental health among European countries (EU and non-EU).

No discussion of dental care would be complete without mention of the “Public Dental Service” (PDS). This is vital area of service but is organised and delivered in a very uneven and incomplete way mainly to school-going children in targeted areas or ages. ‘Emergency’ care is offered for children up to age 16 in PDS clinics. According to O’Neill (2010:15-16) a ‘needs-based approach’ used in the Republic of Ireland may be somewhat more effective and socially equitable than the ‘demand-led’ approach used in Northern Ireland and the UK more generally. In the latter case ‘parents can choose to bring children to the dentist where care, if deemed necessary, is delivered free at the point of use’ (O’Neill, 2010:15).  While the level of public subvention for dental care is higher in the UK, the mode of delivery in the case of school-going children is more market based.  In addition to school-going children other groups such as those with special needs are covered by the PDS in the Republic of Ireland.

 So what?

Dental health is an important social and economic goal. While progress has been made in recent decades, this Blog has drawn attention to the risks arising from drastic cut-backs to public support for dental care in 2009-2010. Especially at risk are children as well as families reliant on the medical card where services are extremely limited or other families outside the eligibility criteria for a medical card but who cannot afford treatment (non-routine dental treatments are liable for tax relief at the standard rate of income tax of 20% for those in the income tax net). The imbalance in public and private spending on dental care is illustrated in Chart 2.

 It does appear that there is a strong economic and social argument for investing more in dental health by means of:

  • Education and promotion
  • Expansion and streamlining of the public dental scheme to better cover all children as well as particular groups with special needs including the elderly who may be housebound or in long-term care.
  • Restoration of benefits withdrawn to PRSI workers and medical card holders in 2010.

Rather than relying on tax reliefs to offset dental treatment costs it would be far more equitable and efficient to provide funding from the social insurance fund. This should involve higher contribution rates by employees and employers to pay for higher benefits for PRSI employees. Both benefit from better dental health. In the case of medical card holders there should be a proper level of prevention, care and intervention paid for out of general taxation. The total annual cost of restoring DTSS and PRSI benefits might be in excess of €100 million. Put in perspective the income tax give away by the Government in Budget 2017 would have paid for a reasonable level of public dental care.

One dentist commented as part of a survey by the Irish Dental Association (page 11 of their 2017 Budget submission):

Not doing scale and polish in mouths that clearly need it because patient can’t afford it. Only filling the 2 worst teeth and neglecting other that require treatment because patient can’t pay. Giving prescriptions for pain where a filling would fix the problem but quota has been reached for the year .

Political economy is all about choices and being at the bottom of the social ladder or below the ‘middle’ is no fun.

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