26
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Volume1 Issue2
I
ssues and
P
eople
Accordingly, inacountry likeCanada,
whereeveryone shouldhaveequal
access tohealthcare, anelderlyperson
who is frail, shouldbeentitled tomore
care thananabledperson, if there is a
reasonableprospect that thecarewill
bebeneficial.
OralHealthCareSystem
inCanada
Canada’shealthcare system (Medi-
care) has evolved throughdecadesof
discourseonwhether healthcare is a
social goodor an individual respons-
ibility. TheMedical CareAct passed
in1966wasbasedondefinedcriteria
of comprehensiveness anduniver-
sality. However, additional criteriaon
accessibility, publicadministrationand
portabilitywereadoptedaspart of the
CanadaHealthAct in1984, such that
“insuredpersonsmust have reasonable
anduniformaccess to insuredhealth
services, freeof financial or other
barriers. Noonemaybediscriminated
against on thebasisof such factors as
income, age, andhealth status.”
9
TheCanadaHealthAct supports equity
and solidarity inCanadianhealthcare
policy. However, apart from specific
oral surgical proceduresperformed in
hospitals, dentistryhasbeen largely
excluded frommedicarebecauseof
budgetaryconstraints. Someprovinces
and territoriesprovidea limitedarray
of dental services tochildren,members
of theArmedForces and recipients
of social assistance.
10-12
OnlyAlberta
and theYukonTerritoryprovide some
financial assistance for dental services
to residentsover age65.
13,14
Apersonal dental careplancanbe
purchased fromaprivateprovider—
either directlybyaCanadian resident or
indirectlybyanemployer onbehalf of
anemployee—in the formof a tax-free,
nonwagebenefit.Manyemployees
of small businesses and the“working
poor”donot qualify for publicassist-
ance, nor do theywork thenumber
of hours required tobeeligible for
nonwagebenefits. Furthermore, people
who retire lose their employer-spon-
soreddental benefits andmust pay for
dental serviceswithafter-taxmoney.
Thus, thereappears tobe inequity
inoral healthcare,whereby insured
people receive subsidizeddental
services andpeoplewith relatively low
incomeand limitedpublicbenefits
must pay for dental careout of their
ownpockets.
15
Barriers toOralCare
Inequity inoral care is influencedby
several interrelated factors, broadlycat-
egorizedhereas financial, behavioural
andphysical barriers.
FinancialBarriers
Data from2 surveysconductednearly
20yearsapart, examining the income
andexpendituresof older adults inall
10Canadianprovinces, showed that
spendingonhealthcare tended to fol-
low income levelsclosely.
16
Possession
of dental insurancewasalsoa strong
predictorof dental serviceutilization.
Elderlypeoplehaveprogressively lower
incomeas theyageandare less likely
tohavedental insuranceor tovisit a
dentist.
17
TheCHMS found that currently,
about two-thirds (63%) of theCanadian
populationaged6–79yearshaveprivate
insurance, 5%havepublicly funded in-
surance, andaboutone-third (32%) have
nodental insuranceandpaydirectly
from theirownpockets.
4
It isparticularly
significant that abouthalf (53%) of those
age60–79yearsdonothavedental
benefits. TheCHMSalsoconfirms that
uninsuredand low- tomiddle-income
people, includingolder adults, tend to
avoiddental visitsbecauseof thefinan-
cial costdespitemanyunresolvedoral
problems.
4
Othershavedocumented
thatpeoplewith low incomes typically
seekonlyemergencycare.
18,19
The scenarioof an imbalancebetween
dental demandanddental need
contrastswith theutilizationofmedical
services inCanada,where resources
are redistributedacrossdifferent age
and incomegroups so that people
usually receive themedical care they
need.
20
Hence, thedental care system
inCanada is anexampleof an“inverse
care law,”whereby thosewith themost
needs receive the least care.
21-23
Further-
more, treatment decisionsmaybe
influencedmoreby the limitedcover-
ageofferedbyadental insuranceplan
or allowedby thepatient’s finances
thanbyadeterminationof optimal
treatment.
24,25
BehaviouralBarriers
A1995 study fromSweden showed
that evenwhenfinancial barriers are
removed, visits todentistsdonot
increaseproportionately.
26
In fact, the
relationshipbetweenpatient and
dental careprovider is also influenced
by thebehaviour of bothparties.
Peoplegenerallyareprompted to
seekdental carebyoral problems that
causepainor discomfort,
27,28
and there
are somewhobelieve that tooth loss
is an inevitableconsequenceof aging
andpostpone treatment until theyare
ready to replaceall of their remaining
natural teethwithcompleteden-
tures.
24,29-32
Inanyevent, poor rapport
withdental professionals typically leads
toadisregard for professional advice
andmisseddental appointments.
19,32
Anxietyor phobias about dentistry,
whichaffect 12%of theolder popu-
lation,
33,34
can seriously impede the
search for treatment. Thisneglect of
oral care is compoundedbyageism
andother stereotypingof thebehav-
iour of elderlypeopleon thepart of
dental professionals.
32,35
Indicationsof
ageismwereapparent in the responses
of about 80%ofVancouver areaden-
tists,who reported that theyhadnever
treatedapatient ina long-termcare
facility; furthermore, about two-thirds
of respondents expressedno interest
We believe that reducing inequity in oral care is a form
of social responsibility, the obligation toact for
the benefit of societyas awhole.
