Canadian Medicare is a source of both pride and frustration for many Canadians. Canadians have comprehensive coverage for medical services, however for the vast majority that coverage does not extend to dental coverage. Medicare instead claims that the private sector adequately compensates for extended health benefits such as dental (Lange, 2019).
There are few publicly funded dental programs throughout Canada, many targeting marginalized populations, and low-income families. These publicly funded programs only account for approximately 5.76% of all dental expenditures in 2018 (Lange, 2019).
The barriers to care for indigenous populations is directly linked to the determinants of health: low income, employment, education, social environments, geographic location and social supports all can drastically affect indigenous populations dental health. Over the past years oral health within the general public has been increasingly linked to chronic and even fatal conditions that are treated under Medicare, such as Alzheimer’s, heart disease, and diabetes. New cases of oral cancer are now higher than that of cervical and liver cancers in Canada (Lange, 2019). Aboriginal populations continue to experience poorer oral health than that of the general public. They are more likely to have cavities, lose their teeth prematurely and suffer from orthodontic problems despite a federally funded dental care plan call Non-Insured Health Benefits (NIHB) (CDA Board of Directors) (Mosby & Carstairs, 2018).
There is a common misconception that Indigenous people receive comprehensive dental services, paid entirely by the federal government. This conclusion that Indigenous peoples face no financial barrier to dental care is far from the truth. the NIHB program states that it aims to provide more than 850, 000 indigenous people with coverage for a range of medically necessary health benefits when not otherwise covered by private health plans, provincial/territorial health plans, and/or social programs (Government of Canada 2020). However, these services are extremely limited and only offer partial coverage to its users, requiring immense hurdles to obtain any coverage (Lange 2019). Annual coverage limits, and procedure frequency limits are extremely restrictive (Mosby & Carstairs, 2018).
The recommended frequency of dental examinations, and treatment options depends entirely on an individual’s oral health needs. Higher risk patients (such as the socially marginalized) should have a dental examination every six months or more, however NIHB only covers one recurrent examination per year and one complete exam every 60 months. Full x-rays are also only permitted once every 60 months. The NIHB guidelines are far from supporting Canadians unique dental needs (Lange 2019).
Difficulties Accessing Care - Indigenous Population
Indigenous populations have experienced many difficulties with the dental benefits provided by the NIHB Program. Many say that it is often extremely hard just to find a dentist that accepts the program, and when they are available, dentists often charge additional fees or ask people to pay up front. For large treatment plans many private plans request a process called a predetermination, in which the provider (dental professional) has to request permission for treatment. This processed is required (and extensive) for every single treatment option from NIHB before treatment can commence, which can often take weeks to be processed and approved (Mosby & Carstairs, 2018).
Difficulties Accessing Care - Dental Providers
Dental professionals also experience significant concerns with the program. The process for receiving payment and approval is extremely tedious compared to private insurance companies. Some providers have opted out of the program, which means that many indigenous people have to pay directly for dental treatment or find another clinic to attend. Given the disproportionately low incomes, as well as geographic distribution of many indigenous people, this makes it extremely difficult to access care.As an example In Nunavut, the predetermination process has been found to act as a serious deterrent to service provision. Many dentists in Nunavut have done work, only to be later denied compensation (Mosby & Carstairs, 2018). Dental professionals across Canada have reported very low satisfaction with all federal dental programs, especially with NIHB. In some cases, dental professionals may require full payment upfront from Indigenous patients, prior to submitting an NIHB claim, since the coverage limits are so low and the claim processing time is extremely delayed. For the dental professional this is a business decision, but for the patient upfront payments can become a massive barrier to oral health care. Almost a third of Canadian dentists have reported reducing the amount of public insurance patients they accept into their dental practice. Many dentists have unfortunately refused to service NIHB recipients (Lange 2019).
The administration of the program is complicated by the fact that the NIHB sees itself as the payer of 'last resort', meaning that it requires services to be covered by private insurance in the case of those lucky enough to have it or by the provincial patchwork of publicly provided dental services first. Another result of making NIHB an “insurance” program is that it does not see its goal as improving the oral health of indigenous people throughout Canada. The government’s emphasis has been on restricting access to services to control costs, rather than providing an upstream approach providing education, clean water, nutritious food and regular access to care that is required to improve oral health. From the government’s perspective, the NIHB is provided as a “service” and — because it’s one that other Canadians do not have access to — the cost control emphasis is justified (Mosby & Carstairs, 2018).
Examples of Lack of Care in the Media
The Assembly of First Nations reported that a First Nations man living in Alberta, had been waiting a month for approval to endodontically treat an infected molar and. Due to this ongoing preapproval process, and ongoing pain, he had resorted to extracting it himself (Mosby & Carstairs, 2018).
In 2016, a Cree child’s struggle to get braces became national news. A thirteen-year-old suffered from chronic pain from impacted teeth, and a severe overbite among other orthodontic problems. She took OTC pain medication daily for two years due to this extreme discomfort. Her orthodontist said that she needed braces to avoid more expensive and invasive surgery in the future, but the federal government denied her claim three times. The family took the government to court, and the government spent over $110,000 on lawyers defending its decision to deny the $8,000 procedure (Tasker, 2017).
In 2017, an Alberta Indigenous woman underwent a lengthy battle with the government to cover implants due to her cleft palate procedures – one of the few dental procedures non-Indigenous Canadians can receive under Medicare. The woman’s claim was ultimately denied by Health Canada, and the oral surgeon was not compensated for his work. The biggest issue is that cleft palate procedures are fully covered by the Alberta Cleft Palate Dental Indemnity Program, but because of her Indigenous status, the woman in question was ruled ineligible for the province’s program, referred to the NIHB coverage, which denied the claim (Labby, 2017).
Overview of NIHB Dental Coverage
A full list and explaination of ‘benefits’ can be seen here, I will highlight a few areas where the program is lacking individual patient based care.
This states that children must be under 5 to get their front teeth restored.. what happens after 5? Are these teeth immune? Are parents expected to wait 1-2 years with their child in pain for the teeth to naturally exfoliate?
In order for a dental professional to place a crown these are all of the criteria that the tooth/surrounding teeth must meet, and that the dentist must provide documentation about.
Again, the excessive amount of documentation a dental provider must supply for any treatment to be predetermined.
Again, the excessive amount of stipulations surrounding treating a tooth with a root canal.
Hygiene services are entirely based on individual needs. However typically an adult should come for scaling 2X yearly which is about 2-2.5 units of scaling. However, due to a number of factors (tooth alignment, tooth morphology, genetics, salivary content/flow, diet, oral hygiene habits, etc) some individuals need to come more frequently than that. This program gives anyone 17 years or older only 4 units of scaling every year.. which is hardly adequate for someone with the best homecare, the best diet, etc.
References
CDA Board of Directors. (2010). Position paper on Access to Oral Health Care for Canadians. https://www.cda-adc.ca/en/about/position_statements/accesstocarePaper/
Government of Canada (2020). Dental benefits guide: Non-insured health benefits program. https://www.sac-isc.gc.ca/eng/1579538771806/1579538804799
Labby, B., (2017). Unequal treatment: First nations woman denied medical coverage readily available to non-Aboriginals. https://www.cbc.ca/news/canada/calgary/first-nations-siksika-cleft-palate-indigenous-funding-denied-discrimination-1.4131449\
Lange, T. (2019). Polishing-up for the Election: Lessons from Indigenous Dental Care. YYC policy. https://www.yycpolicy.org/blog/2019/10/10/polishing-up-for-the-election-lessons-from-indigenous-dental-care
Mosby, I., Carstairs, C., (2018). The government's Indigenous dental health program is ignoring the role its policies played in causing Indigenous-non-Indigenous dental health disparities. Policy options. https://policyoptions.irpp.org/magazines/october-2018/federal-policies-undermine-indigenous-dental-health/
Tasker, P., (2017). Ottawa spent $110K in legal fees fighting First Nations girl over $6K dental procedure. https://www.cbc.ca/news/politics/health-canada-legal-fees-first-nations-girl-dental-coverage-1.4310224
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