Chapter 6Drilling down: pathways to universal access
Introduction
6.1There is broad agreement among committee members on the need to reform how dental services are funded and delivered in order to improve access for those who are currently falling through the cracks. Committee members support the goal expressed by many submitters of working towards universal access to affordable oral and dental health care for all Australians. However, there are differing views on how this could be achieved.
6.2As discussed in Chapter 2 of this report, a national reform process is currently underway, led by an Oversight Group with members from all states and territories. While the formal Terms of Reference have yet to be agreed by state and territory health ministers, the committee understands this process aims to:
establish funding certainty;
increase transparency and flexibility;
improve equity of access; and
achieve better interface and alignment between oral and dental health services and the broader health system.
6.3Committee members support these objectives.
6.4The committee understands the reform process is complex and will take time. Implementing the resulting reforms will take even longer. Regardless of which direction is ultimately adopted, there will be a need to progress reform in stages. This is because any increase to the availability of subsidised dental services would require an increase in the number of oral health practitioners, and improvements in the distribution of the workforce. Reforms may also require legislative and/or regulatory change, which would need to be progressed through multiple jurisdictions; and, of course, any reforms must be funded.
6.5Participants in this inquiry have generously submitted their substantial expertise to help the committee formulate views on the best path forward. Tofurther inform the committee's deliberations, a comprehensive set of costings was requested from the Parliamentary Budget Office (PBO). The full costings are attached at Appendix 6.
6.6In this chapter, the committee outlines and considers the major reform proposals that have been submitted during the inquiry. Using the estimates provided by the PBO, the chapter compares and contrasts a number of policy options, and looks at suggested pathways forward.
6.7Specifically, this chapter presents costings and analysis of the following options:
Option 1: Universal public dental care, provided through Medicare, or a separate 'Denticare' scheme.
Option 2: A means tested scheme, which would essentially extend the Child Dental Benefits Schedule (CDBS) to health care card holders, pension card holders and those on government income support payments.
Option 3: A seniors dental care scheme, available to holders of Commonwealth seniors health cards, pensioner concession cards and health care cards, who are 65 years or older.
Option 4: A scheme under which the Commonwealth funds preventative care only for all Medicare card holders.
6.8Each of these options has been costed in two ways—as a capped scheme, and as an upcapped scheme. For the capped schemes, the PBO has used the cap that currently applies under the CDBS. The CDBS capped amount is currently $1052 over two calendar years and is subject to indexation each year on 1 January. Uncapped schemes have no limits for eligible individuals.
6.9The committee acknowledges there is a degree of uncertainty in these costings. The PBO submitted:
The financial implications of the proposal are highly uncertain and sensitive to assumptions about the eligible population, the utilisation rate and the type of dental services consumed under each policy option, as well as the supply-side response to the proposed policy change. For example, the proposal may result in changes to products offered by private health insurers, which may have a flow-on impact to insurance rebates provided by the Commonwealth Government. This has not been factored into this costing due to the high degree of uncertainty associated with the potential flow-on effect.
6.10The PBO also noted uncertainties around whether the workforce would be adequate to meet demand, and applied 'a gradual phase-in over 5 years to reach the assumed final or static state utilisation rate of 85%'.
6.11Despite the unavoidable uncertainties, the committee believes these costings are robust. The committee notes that the Department of Health and Aged Care (DoHAC) was consulted, and:
… provided [the PBO] with available data to assist in developing costings and budget analysis prepared by the PBO. The Department has reviewed the provisional advice prepared by the PBO for the Committee in a good faith effort to assist with its inquiry.
6.12We also note that the figures are not dissimilar to estimates provided in other sources, such as the Grattan Institute's 2019 Filling the Gap report.
6.13Driving and coordinating national reforms requires national coordination. The committee also asked the PBO to provide estimated costings for:
a national education and promotion campaign to encourage better oral hygiene practices and increase knowledge around the availability of dental services; and
the establishment of a Chief Oral Health Officer, or Chief Dental Officer, equivalent to the Chief Medical Officer, and administered by DoHAC.
6.14The costings for each national funding reform option are provided with the cost of a national education campaign, and the cost to fund a Chief Oral Health/Dental Officer, incorporated.
6.15After considering the costed options in detail, the chapter looks briefly at recommendations aimed at increasing Commonwealth funding to state-based public dental services and contemplates concerns around Department of Veterans' Affairs (DVA) rebates to dental prosthetists.
6.16The chapter ends with the committee's conclusions and recommendations.
Option 1: Universal coverage
Estimated cost of a universal dental care scheme, either capped or uncapped
Source: Adapted from PBO costings, p. 3.
Note: Australian Government spending on health services has been provided as a point of comparison and was drawn from: Australian Institute of Health and Welfare, Health expenditure Australia 2021–22, last updated 25October2023
*Numbers estimated for years one to three.
6.17Despite broad agreement that the current system results in inequality, governments have not progressed any substantial reform in this area. Asoutlined in Chapter 2, numerous inquiries across decades have estimated the potential cost of a Medicare-based dental scheme, with a 1998 Senate inquiry pricing it at approximately $1billion per year, a 2003 Committee on Medicare pricing it between $2.5and $4.5 billion, and a 2009 proposal from the National Health and Hospitals Reform Commission pricing it at $3.6billion per year.
6.18More recently (2019), the Grattan Institute estimated an uncapped universal scheme would cost around $5.6 billion per year. However, the Australian Dental Association argued the cost 'could be higher', suggesting it would be closer to the amount of total spending on dental in 2020–21, which was $11.1billion.
6.19The PBO estimated that an upcapped scheme could cost $7.7 billion in its first year, rising to $9.1 billion by year three. A capped scheme, where individuals are eligible for around $1000 worth of treatment every two years (indexed), would cost less, at around $5.5 billion in the first year, rising to $6.5 billion by year three.
6.20A majority of inquiry participants advocated for a universal oral and dental health care scheme for Australia, saying a universal scheme is needed to reduce inequities inherent in the current system.
6.21Health economists, Professor Jane Hall, Professor Michael Woods, ProfessorKees van Gool and DrPhillip Haywood agreed the current system has resulted in 'profound inequity', and said there is 'a strong case' for treating dental care the same as medical care. Such an approach would conform with the World Health Assembly Resolution of 2021, which called for nations to include oral health care as part of universal health coverage.
6.22Research by Population Oral Health at UQ indicated the exclusion of dental from Medicare has resulted in 'substantial inequities' in the use of services for children of different socioeconomic status, and led to differences in oral health outcomes for Australian children. Population Oral Health at UQ suggested establishing a universaldental scheme for children to 'serve as a foundation for a broader scheme'.
6.23DrFatimaAshrafi, from the Australian Islamic Medical Association Queensland, said the need to integrate oral health care into the Medicare Benefits Schedule (MBS) has become urgent. Integrating dental is needed to curtail significant 'potentially avoidable costs to the health-care system and to people's quality of life'.
6.24The University of Sydney Dental School suggested a universal scheme could create 'a future where visiting a dentist is as simple as visiting a General Practitioner (GP)'.
6.25Dr John Boffa from the Central Australian Aboriginal Congress Aboriginal Corporation said, while the creation of a national dental program run through Aboriginal community controlled health services would be an excellent step, a Medicare-based scheme would be even better:
… if we had 'denticare', a national health insurance scheme for dentistry like we do for medicine, that would really make a difference to our ability to access income. We could then have our dentists bulk-billing and getting additional funding. That would make a big difference as well. These are big systemic problems with the way the health system in Australia delivers public dental care.
6.26Proponents of a universal scheme suggested it would need to be phased in over time, and in stages. The Australian Patients Association advocated for a 10-year plan which would begin with the Commonwealth 'properly funding' existing state-run public dental services while 'enabling private-sector dental professionals to deliver publicly funded care'; would move to a means-tested Medicare-based scheme; then be expanded to all children; and 'finally' extended to include all adults.
6.27The Grattan Institute proposed a similar phase-in:
Because the jump from the current incoherent patchwork of inadequate schemes to a national, systematic approach is significant, it would be impractical to move to a universal scheme overnight. … The first step is for the federal government to takeover funding of existing public dental schemes, fund them properly, and enable private-sector providers to deliver publicly-funded care. Coverage should then be expanded—first to people on Centrelink payments, then all children. After that, the federal government should take the final step to a universal scheme, ideally within a decade. Removing financial barriers to dental care would improve Australians' oral health.
6.28The Victorian Oral Health Alliance (VOHA) proposed that, initially, a Seniors Dental Benefits Scheme could be introduced, then expanded to 'other groups at higher risk of oral health problems'—such as Aboriginal and Torres Strait Islander people, people with disabilities, members of the queer community, asylum seekers and refugees, prisoners, people at risk of homelessness, people affected by family violence, and people with chronic health conditions. These could be 'the first steps in the pathway to universal coverage'.
6.29The ADA did not support a universal scheme. It advocated for policies aimed at ensuring all individuals have 'equitable and unrestricted access to necessary dental services, regardless of factors including socioeconomic status, geographic location, or other personal characteristics'. The ADA said universal coverage schemes, like the National Health Service in the United Kingdom (UK), are not the best way to achieve equity of access:
Internationally, comprehensive oral health care and satisfactory oral health outcomes have been difficult to achieve with universal dental schemes. In particular, the national health services in the UK and Germany have resulted in oral health outcomes worse than those of Australia. All countries, including those with universal dental schemes, exhibit disparities in oral health. We therefore do not consider a universal dental scheme a practical solution to improving oral health outcomes for Australians. Instead, we recommend targeted schemes, subsidised by public funding.
6.30Private Healthcare Australia (PHA) agreed, saying that a universal scheme is 'not a fair or equitable solution', and would be too expensive. Including dentistry under Medicare 'would subsidise the wealthy, drive up costs for dental care', and exacerbate existing workforce distribution problems. Instead, PHA offered to work with governments to improve access to dental care for low-income Australians. Mr Ben Harris, Director of Policy and Research, said PHA has 'great expertise in managing the risks', and knows how to deliver 'competitive, cost‑effective dental care'. PHA offered to 'help develop a fair and equitable system that improves access for those who need it, limits cost growth and controls out-of-pocket expenses'.
6.31The Grattan Institute disputed the assertion that universal schemes do not produce positive outcomes, saying international evidence shows universal schemes 'can substantially reduce (although not eliminate) differences in dental care use'. Public health economist, and Chair and Spokesperson for the National Oral Health Alliance (NOHA), Mr Tan Nguyen maintained that, globally universal healthcare systems which include coverage for oral health 'tend to have better oral health outcomes'.
6.32Professor Hall, Professor Woods, Professorvan Gool and DrHaywood argued there is a strong case for the inclusion of oral health care in Australia's Medicare system. However, experience with the CDBS suggests that just adding dental services to the MBS could actually lead to 'price increases', make dental services less accessible for some groups, and fail to reach 'the most vulnerable'. They proposed that Australia implement a 'staged and targeted expansion', that is 'carefully designed to ensure maximum value for money for patients and taxpayers'.
6.33Some submitters identified potential sources of funding for a universal scheme. The University of Sydney Dental School said the government could reallocate the $12 billion annual subsidy 'currently used to support an inefficient private health insurance system'. The Public Health Association of Australia (PHAA) suggested governments explore a number of possibilities, including:
raising the Medicare levy, perhaps by 0.75% of the taxable income as previously suggested by the National Health and Hospitals Reform Commission;
redirected revenue generated from the implementation of a sugar‑sweetened health levy, which has shown direct reductions in obesity and dental caries (tooth decay) and promotes health equity; and/or
a staged withdrawal of $775 million spent on private health insurances subsidisation for dental.
Cost-benefit analysis
6.34Introducing universal oral health and dental care would have both costs and benefits for the economy. Due to the inherent complexity, estimating potential economic benefits would be very challenging, and was beyond the scope of this report.
6.35When the committee originally requested costings from the PBO, it asked for an estimate of the economic benefit that may be achieved by providing universal access to free or heavily-subsidised dental care. The PBO informed the committee that it does not model second round whole-of-economy impacts of policy proposals, and as such was unable to provide a response to this aspect of the costings request. Nevertheless, inquiry participants provided relevant evidence about potential savings, and that evidence is considered here.
6.36DrAshrafi highlighted potential savings for the health budget from eliminating avoidable hospital admissions:
One patient had a left ventricular assist device implanted. The cost of this device is more than one $150,000, but the device was almost rejected by the body because it got infected. His oral health was not assessed before. He developed a life-threatening infection, coming from his grossly infected teeth and gums, and needed to have all his teeth extracted. Basic mathematics show that a further $100,000 will be needed for this patient. [intensive care unit (ICU)] is around $5,000 per day, and then there's the cost of anaesthesia and surgery. If there are even 200 patients like this per year at this hospital, it incurs an additional cost of $20 million annually, and this does not take the patients' suffering, lost earnings et cetera into account.
6.37According to COTA Australia, universal dental care would reduce presentations to emergency departments, and free up approximately 750000 GP consultations. Freeing up GP consultations would save taxpayers at least $30million a year, plus the cost of subsidising pain relief medication and antibiotics for dental conditions.
6.38The Australian Network for Integration of Oral Health (NIOH) said there would be substantial 'economic benefit' achieved through 'increased workforce participation and decreased lost productivity'. This is in line with the Grattan Institute's findings in its Filling the Gap report:
The Australian Research Centre for Population Oral Health earlier this decade found there were 2.4 million instances of Australians taking half a day or more off work or study due to dental problems. It estimates the total economic cost of reduced workforce participation due to dental conditions at $556 million per year, based on a 2010 survey. Other estimates are of a similar magnitude. Reducing the barriers to regular dental care could increase workforce participation and boost economic output.
6.39Mr Nguyen pointed out that a universal oral health care scheme would also dramatically reduce (or replace) Commonwealth spending on existing dental programs, as these would no longer be required. Current Australian Government expenditure on dental care is around $1.3 billion per year, and the states and territories collectively spend just under $1 billion. Much of this spending would be subsumed into the cost of a universal scheme.
Unintended consequences
6.40Public health experts and economists who submitted to the inquiry warned that introducing a universal scheme without careful planning, regulation, and the necessary 'checks and balances' would have unintended consequences. Professor Hall, Professor Woods, Professorvan Gool and DrHaywood identified risks based on previous health sector initiatives, including that, without careful planning, the benefits of the scheme may flow primarily to providers and high-income Australians.
6.41Dr Donna-Louise McGrath noted that private sector dentists currently have 'clinical freedom', which means they 'may perform unnecessary and excessive treatments on trusting patients to boost their income'. Dr McGrath said she believes 'overservicing' by dentists is 'common':
Overservicing occurs when excessive or unnecessary dental treatment is performed for financial gain in a fee-for-service arrangement. Historically, some dentists have exploited Medicare funded dental care by performing unnecessary treatment on vulnerable patients to extract the maximum from such schemes. Vulnerable patients cannot give informed consent … Dentists may also 'overcharge' by claiming for items with the highest rebate (e.g. for 'long' consultations that were short; 'difficult' extractions that were simple), particularly when they incur no out-of-pocket expenses for the patient.'
6.42National guidelines would be needed, 'on clinical diagnosis and treatment', in order to boost transparency and prevent price gouging. Dr McGrath observed that the profit-making imperative associated with large private dental businesses may be incompatible with the objectives of a universal public scheme. In particular, financial 'incentives for high value work, quotas, [and] commissions' for individual dentists may undermine the scheme.
6.43Mr Nguyen similarly observed that offering a 'comprehensive list of dental services' under Medicare would be 'costly', and could lead to 'fraudulent activity'. MrNguyen highlighted the need to move away from over-servicing by dentists to focus on delivering oral health services that have been 'evaluated for cost-effectiveness' and represent 'value for money':
For example, the concept of 'drill and fill' remains rampant in the dental profession, with global evidence indicating between 12-74% of restorations (fillings) are performed when alternative non-invasive preventive options are warranted.
6.44Mr Charles Maskell-Knight said that there is little health benefit in dental services aimed at replacing a missing molar or premolar, and suggested public expenditure on 'implants and bridges' for this purpose would 'generate only marginal improvements'.
6.45According to Mr Nguyen, dentistry has been 'left to the free market' for too long, leading to ever-increasing prices and making oral healthcare unaffordable: 'Oral health is a public good, and therefore, requires government intervention to readdress the monopolistic free market of dentistry'.
6.46If any kind of Medicare-linked scheme was to be introduced, the current lack of regulation around pricing and treatment 'necessity' would need to be addressed. Dr McGrath suggested a future scheme should include a 'recommended dental fee schedule', developed by 'an independent agency'. A similar schedule currently exists for psychologists:
The fees are a recommendation only and practitioners can still set their own rates … Under a universal dental scheme, dentists may still charge patients for the gap between any Medicare rebate and their fee for the dental service. Each dental business should thus publish itemised fees for their services and treatments.
6.47Professor Hall, Professor Woods, Professorvan Gool and DrHaywood advocated for funding services using 'value-based' healthcare approaches:
There is increasing experience with innovative value-based payment approaches, notably in joint replacement and some aspects of cancer care. There are promising results but also challenges in design and implementation. There is a strong case for developing a value-based payment approach for any expansion of dental insurance. Focusing on outcomes rather than inputs may allow the scarce dental resources to be used most effectively. In order to achieve this payment, reform must be undertaken with workforce and data reform.
Option 2: Means tested coverage
Estimated cost of a means tested dental scheme, either capped or uncapped
Source: PBO costings, p. 3.
Under this option, rebates at 100% of the schedule fees for all items specified in the CDBS would be made available to health care card holders, pension card holders and those on government income support – consistent with current means test requirements for the CDBS.
*Estimated for years one to three.
6.48Some inquiry participants suggested a means-tested scheme would provide better value and better target those most in need.
6.49The PBO estimated a capped means-tested scheme would cost $1.8 billion in its first year, rising to $2.2 billion in year three. An uncapped scheme would cost $2.6 billion, rising to $3.1 billion in year three.
6.50Mr Maskell-Knight observed that 'over half of the population' already has 'reasonable access' to dental care though private health insurance. As such, a means‑tested scheme could achieve the goal of universal access, and would be much more affordable than a universal scheme. He added:
… it is increasing evident that the Medicare fee-for-service model is not ideal for funding primary health care generally, and the government is seeking to move to a more blended payment system. A universal Medicare-like scheme would replicate the failings of the fee-for-service model in primary dental care.
6.51NIOH noted that dedicated funding for 'at-risk populations' reduces 'avoidable hospitalisations and malnutrition issues attributed to poor oral health function'. It provided the example of 'Senior Smiles', a preventive treatment program for aged care residents, saying the program has 'shown a potential cost saving of $3.14 for every $1 spent'.
6.52The Grattan Institute, however, asserted that there are a number of 'problems inherent to a targeted scheme'. One such problem is that excluding people without health care or pensioner concession cards 'creates a "cliff" in eligibility':
If people have incomes just below the cut-off for a concession card, they remain eligible for public dental care. But if they earn a dollar above the cut‑off, they lose eligibility. These people still have low incomes and are still likely to face financial barriers to dental care.
6.53Dr Stephen Duckett said addressing 'oral health care inequity' will not be achieved with 'another underfunded, stigmatised residual scheme'.
6.54Inquiry participants, including the Royal Australasian College of Physicians (RACP), highlighted the failings of the current means-tested children's scheme, the CDBS. RACP observed that, despite the scheme's existence, 'a significant percentage of disadvantaged Australians are still not receiving adequate dental health care'. Limitations on what can be claimed, geographical and cultural barriers, confusion around who is eligible, and lack of awareness continue to lead to low participation rates.
6.55Population Oral Health at UQ argued for:
expanding the CDBS to cover infants;
more promotion;
integration of the CDBS into Medicare; and
removing the eligibility criteria.
It claimed this would lead to more substantial improvements in population child oral health than the current means-tested scheme.
Option 3: Senior Dental Benefits Schedule
Estimated cost of an SDBS, either capped or uncapped
Source: PBO costings, p. 3.
Note: Australian Government spending on aged care has been provided as a point of comparison and was drawn from: DoHAC, 2021–22 Report on the Operation of the Aged Care Act 1997, last updated 20 September 2023.
Under this option, rebates at 100% of the schedule fees for all items specified in the CDBS would be made available to holders of Commonwealth seniors health cards, pensioner concession cards and health care cards who are 65 years or olde.
*Estimated for years one to three.
6.56The ADA, COTA Australia, and others many recommended a Seniors Dental Benefits Schedule (SDBS) be introduced as a priority reform. Recommendation 60 of the Royal Commission into Aged Care Quality and Safety is to establish a SDBS, and this option is being considered by governments. COTA Australia called upon the Australian Government to 'commit' to introducing an SDBS 'in its current term'.
6.57The PBO estimated the cost of a capped SDBS would be approximately $1 billion in the first year, rising to $1.3 billion in year three. An uncapped scheme would start at $1.2 billion and rise to $1.5 billion in year three.
6.58The ADA suggested governments employ a 'phased approach' to 'control expenditure' on an SDBS. This could start with a capped scheme. MrCoreyIrlam, Acting Chief Executive Officer at COTA Australia, said a capped scheme would be 'a reasonable start':
We think that will deal with a lot of preventative health issues. Where it will have gaps is it won't deal with some more advanced dental and oral health issues such as periodontics, dentures, which is an issue for older people. But the hope is that without restriction on what it can be spent for we can start looking at innovative solutions that might deal with partial dental plates at $1,200, for example. But we've got to start somewhere.
6.59While there was broad support for funding seniors' dental care, retired special needs dentist, Dr Peter King suggested 'a priority groups dental benefits scheme' would be more appropriate than an SDBS: 'In my experience, both private practice and public health have their roles in improving the oral health of people with additional needs'.
6.60NSW Health proposed public-private partnerships to deliver an SDBS, saying the public sector 'does not have the workforce or facilities to deliver the Seniors Dental Benefits Scheme on its own'.
6.61Owner and Director of Seniors Dental Care Australia, Ms Leonie Short was concerned that an SDBS may be underutilised, like the CDBS, unless it is properly promoted and implemented:
Approximately 50% of older Australians do not attend for regular dental check-ups, they mainly make a dental appointment with toothache or pain (extraction rather than a filling, root treatment or treatment for periodontal diseases), and they have low oral health literacy going back decades. What they thought about oral health care or dental treatment has changed a great deal since the 1940s. They may also have a fear of 'dentists' and dentistry which is passed on to their adult children and grandchildren. We need to address their dental trauma, fears, and anxiety so that they are dental patients that dental practitioners will want to treat … So, to ensure a good uptake of the Senior Dental Benefits Scheme, a national consumer-led communication program to inform older Australians about the link between general health and oral health, and the importance of twice-daily oral health care and regular dental check-ups is required for any new scheme to be successful.
Option 4: Preventative care
Estimated cost of a universal preventative dental scheme, either capped or uncapped
Source: PBO costings, p. 3.
Under this option, rebates at 100% of the schedule fees for all items under U0 Diagnostic Services and U1 Preventative Services specified in the CDBS would be made available to all Medicare card holders.
*Estimated over years one to three.
6.62Some inquiry participants argued in favour of making preventative dental and oral health care available under Medicare or a 'Denticare' scheme; and making it available to everyone. This was often suggested along with support for an SDBS and other targeted initiatives. The Consumers Health Forum of Australia suggested both preventative and emergency dental care be funded.
6.63The PBO estimated the cost of a capped universal preventative dental care scheme would be approximately $1.8 billion in the first year, rising to $2.1 billion in year three. An uncapped scheme starts at $2.5 billion and would rise to $3billion in year three.
6.64Professor Hall, Professor Woods, Professor van Gool and DrHaywood noted that dental preventative care is generally 'less costly than treatment and restoration'. However, given many Australians cannot afford regular check-ups for themselves or their children, investing in preventative care would save on down-stream expenditure.
6.65The Australian Patients Association argued that investments should be focussed on 'acting to prevent' dental conditions now, rather than funding 'treatments for severe dental conditions later on'. Effective community education, and 'properly funded' preventative dental care would 'build strong foundation for an effective dental care system'.
6.66The Dental Hygienists Association of Australia (DHAA) said a full universal scheme would be 'complex, costly and will take time to develop'. DHAA recommended a focus on 'preventive care and a minimal intervention approach' to 'reduce the burden on the clinical paradigm that has been shown to be ineffective'.
6.67The University of Sydney Dental School said research on a children's dental program has identified opportunities to make public dental care cheaper and more efficient by 'transitioning' to 'a delivery model led by oral health therapists, instead of dentists'. A preventative model would maximise the role of oral health therapists, and allow dentists to 'focus on complex procedures':
By delegating routine services such as check-ups, teeth cleaning, prevention and simple fillings to oral health therapists, the delivery of care can be streamlined and optimised. The study estimates potential cost savings of millions of dollars per year in the national dental program for children. These savings could be reinvested in initiatives such as school-based dental programs or reducing waiting lists for adult dental care ...
6.68Mr Nguyen argued that 'essential oral healthcare' is a 'fundamental right' and should be embedded under the Human Services (Medicare) Act 1973. He outlined a possible model, which provides two different preventive care packages, to be funded under Medicare, with a 100 per cent rebate. The codes used in the model are the ADA's item codes, at Department of Veterans' Affairs rates:
A standard annual preventive care package
011—Comprehensive oral examination—$57.45
114—Removal of calculus—first appointment—$97.85
121—Topical application of remineralisation and/or cariostatic agents—$37.75
Total cost = $193.05
A standard 'at-risk' preventive care package
Accessible at least 5 months after claiming the standard annual preventive care package.
115—Removal of calculus—subsequent appointment—$63.65
131—Dietary analysis and advice—$39.65
141—Oral hygiene instruction—$53.95
121—Topical application of remineralisation and/or cariostatic agents—$37.75
Total cost = $195.00.
6.69Mr Nguyen said that dental services focussed on prevention have 'demonstrated cost-effectiveness in the Australian context'. However, all oral health services to be funded by the Australian Government should be subject to the same kind of rigorous assessment as other health services are currently.
National oral health campaign
6.70Inquiry participants agreed there is a need for more and better education and information about oral health care. The lack of community awareness of public dental programs also needs to be addressed.
6.71The PBO estimated the cost of providing a national oral health campaign would be approximately $3.2 million in the first year, $1.7 million in year two, and $1.1million in year three. This is consistent with previous campaigns run by DoHAC. A campaign would run over three years (2024–25 to 2026–27) and would 'include advertisements on television, digital and social media', 'advertisements on ethnic and First Nations media [and] a limited supply of printed materials by direct mail'.
6.72The Australian Patients Association highlighted the need for comprehensive campaigns, saying 'very few people have ever actually been taught how to brush their teeth properly, how long to brush for and how often to change their toothbrush'. Only one in five Australian adults reports that they floss their teeth regularly, despite this practice being crucial to preventing gum disease.
6.73The ADA said it has worked with education sector partners to develop oral to promotion resources for schools, and offered to work with governments on new resources and implementing any programs:
The teaching resources are free and include lessons on understanding the nutrition information panel, sugar, acids, and tooth decay and other topics. A presentation by a visiting (or pre-recorded) dentist could be another way to promote oral health literacy in schools. We don't know of any such programs currently offered in schools but understand the Australian Defence Force has in the past run such programs for cohorts of new recruits with anecdotally positive effects. The ADA would willingly develop such resources, upon request from education departments, and make them available through our consumer website: teeth.org.au.
Chief Oral Health/Dental Officer
6.74There was virtually unanimous support for the idea of establishing a Chief Dental/Oral Health Officer, among inquiry participants—although contributors to the inquiry differed on their preferred naming for the role. Most agreed that the person in this role should be a dentist, or other oral health professional, and would be responsible for driving reforms with a view towards leading a national 'co‑ordinated, integrated and collaborative public oral health system'.
6.75The ADA was in favour of the title 'Chief Dental Officer', which conforms with the naming in other jurisdictions, including Queensland, Western Australia, the Northern Territory, and a number of other countries. Mr Nguyen referred to the proposed position as a 'Chief Oral Health and Dental Officer', and highlighted the importance of the role in coordinating complex national reforms.
6.76Board Director of the Australian Healthcare and Hospitals Association (AHHA), MsSusanMcKee, referred to a 'Chief Oral Health Officer', saying, as it currently stands:
[Australia doesn't] have a chief dentist or a chief oral health officer at that high level. We actually don't have oral health care as part of the health care system, where many policies are made. For example, there are lots of policies at the moment about supporting nurses, doctors and allied health professionals to work in rural and remote communities. The oral health profession gets left out. It is about that high-level policy and that high-level advocacy.
6.77The Australian Network for the Integration of Oral Health used both terms, and argued for the establishment of a national oral health unit to support the role, which would be:
A dedicated, qualified, multidisciplinary, functional, well-resourced, and accountable oral health unit should be established within/with close ties to noncommunicable disease structures and other relevant public health services. This will provide a measurable outcome and will establish national oral health leadership.
6.78Oral health policy experts, Dr John Rogers and Dr Jamie Robertson said national leadership is critical to integrating oral health with general health and improving national planning by enhancing 'population oral health skills and experience' in DoHAC. They also suggested the remit of the Australian Centre for Disease Control, which is currently being established, be expanded to include 'the prevention of oral disease and oral health promotion'.
6.79The PBO estimated the cost to establish a Chief Oral Health/Dental Officer to be around $2.7 million per year. These estimates were 'modelled consistently with those for the Chief Medical Officer but at a lower scale', with the underlying data and model provided by the DoHAC. The costing includes 11.2 full time equivalent staff (FTE) initially, rising to 12.2 FTE ongoing.
Improving state-based public dental services
6.80Most inquiry participants advocated for radical reform to the way dental services are funded and delivered, such as the introduction of a national scheme. However, participants understood substantial reforms would be slow. In the meantime, many advocated for urgent changes to the way the Commonwealth funds state-based public dental services.
6.81According to NIOH, funding under Commonwealth-state agreements is currently provided on a two-yearly basis, and the amount is 'not sufficient to address the substantial needs in the community'. NIOH said governments should move to improve the delivery of public dental services quickly, by:
Achieving consensus that dental care is a joint responsibility between all government levels.
Strengthening the public dental services by providing recurrent and sufficient funding.
Expanding the public dental services to provide modern, evidence based and clinically appropriate dental care in a patient centred manner focusing on patient's outcome rather than service output.
Addressing the chronic shortage of dental workforce by supporting and expanding the dental services to train more dental students and dental specialists.
Consider[ing] the introduction of a state or national dental internship program to provide training and mentoring to new dental graduates in the public dental services.
6.82NSW Health, and other state government departments that submitted to the inquiry, highlighted the need for sustainable, long-term funding which would ensure public dental services can 'plan strategically for the future' and deliver high-quality, safe care.
6.83According to NSW Health, there is currently 'no funding support' from the Commonwealth for the National Oral Health Plan 2015–2024, and current funding approaches do not support preventive care. Short-term funding means public dental services are forced to use:
… short-term employment contracts, with a high risk of staff attrition, or issue vouchers for private providers to deliver dental treatment at a premium cost and with less effective oversight of dental practice and patient outcomes.
6.84AHHA suggested governments should commit to providing 'longer term strategic direction and funding certainty' by aligning the term of the National Partnership Agreement for public dental services for adults with the five yearly term of the National Health Reform Agreement.
6.85Deakin Health Economics recommended the Australian Government commit to increased funding for public dental services, initially an additional $500million annually.
6.86Northern Territory Department of Health (NT Health) said the current 'uncoordinated and fragmented' system creates 'blurred lines of responsibility', and has led to 'uncertainty and inefficiency surrounding national oral health policies, programs and Commonwealth funding arrangements'. Critical of the Commonwealth's 'activity based funding model', NT Health said the model creates 'perverse incentives to increase the volume of costly treatment interventions', as opposed to preventative care. NT Health advocated for a new model, long-term sustainable funding, and increased Commonwealth investment 'to enable the provision of equitable and sustainable oral health care to remote communities'.
6.87With adult public dental services only able to provide care to a small minority of the eligible population, and waitlists excessively long, the committee asked the PBO to provide an estimate of how much additional funding would be required to meet demand.
6.88The PBO replied that it was 'not possible to reliably quantify the additional funding required to meet the current unmet demand for public dental services', because any estimate would be 'affected by multiple factors', including:
the design of the policy intervention used;
policy interactions across sectors of the dental care system; and
'patchy and inconsistent' data from state public dental services.
Department of Veterans' Affairs rebates to dental prosthetists
6.89The committee heard that the Department of Veterans' Affairs (DVA) has set the rates it uses to provide rebates to dental prosthetists at '11 per cent less than their dental colleagues for the same treatment outcome'. Ms Jenine Bradburn, National President of Australian Dental Prosthetists Association, said that dental prosthetists often receive outsourced work from dentists for DVA patients, and are paid 11 per cent less than a dentist would be paid for the same work.
6.90This pricing discrepancy 'has a flow-on effect' to the pricing in state-based public dental schemes and the Commonwealth funding provided:
DVA is used as the basis for calculating funding. This money then goes to the states, who implement it as they see fit. In some states, this 11 per cent disparity grows significantly. For example, in Victoria treatment is outsourced at a rate 11 per cent less than DVA. Noting that DVA is currently around about 47 per cent below the average private patient fee, our members are actually subsidising our public health system—and this goes to sustainability.
6.91According to DVA, the basis for the discrepancy in rebates paid 'goes back' to a 1985 decision. Mr Dylan Kurtz from DVA said:
The basis of the differentiation goes back quite some years to a historical agreement between the Australian Dental Technicians Association and the Dental Prosthetists Association. At the time, it was based on the understanding that dental prosthetics services could be provided at a lower rate due to lower laboratory and third-party costs.
6.92Mr Kurtz also acknowledged that this aspect of pricing has not been specifically reviewed since it was established, through the fees are indexed to increase annually. Any change to the remuneration structure would be 'a matter for government'.
Committee view
6.93When Australia's Medicare scheme was launched in 1984, it was described as 'a major social reform' which aimed 'to produce a simple, fair, affordable insurance system that provides basic health cover to all Australians'.
6.94Medicare was designed to provide an adequate level of health cover to all Australians, eliminating the complexities and inequities of the existing system. Then Minister for Health, the Hon Dr Neal Blewett, AC, said:
The simpler we make a health scheme the more chance it has of delivering the services to those who need the most. The more complex a health scheme, the more likely it is to favour the well -off, the articulate and those capable of manipulating a complex system.
6.95This simplicity, and the universal nature of Medicare, helps to make general health care more accessible than dental care in Australia. A 'patchwork' of state‑based services and ever-changing Commonwealth schemes has left many Australians in the dark when it comes to accessing dental services.
6.96A significant proportion of Australians do not know that public dental care exists in this country. Even when publicly-funded services are available, those who need them most are often the least likely to be aware of them. While unacceptable wait times are likely to be the strongest disincentive, differences in eligibility criteria across jurisdictions—and the fact that dentists can and do charge vastly different prices—also leads to confusion and fear, preventing people from accessing services.
6.97Lived experience stories the committee heard were remarkably similar: Aperson avoids the dentist because they afraid of the cost or simply cannot afford to go. Small, easily-treatable oral health problems compound over years, and the person eventually ends up in the emergency department, or visiting their GP for antibiotics and pain relief. Once the pain and infection are under control, they reluctantly visit a dentist who prescribes treatment such as a root canal and crown. Unable to fathom spending thousands of dollars to save a tooth, the person reluctantly says, 'just take it out'.
6.98This cycle, which often repeats and repeats over decades, is the reality for too many Australians.
6.99Participants in the inquiry offered different solutions to fill the gap and improve access to dental and oral health services for all Australians. At one end of the spectrum lies a universal dental scheme, where all essential oral health and dental services would be funded through Medicare, or a similar 'Denticare' scheme. At the other end lies the option of making changes to the existing funding agreement between the Commonwealth and the states and territories, and potentially increasing the amount of funding.
6.100The committee acknowledges that a universal dental scheme would come at a substantial cost, and with significant risks. The dental industry is currently structured for delivering services privately, and relies on making a profit. It operates with few regulatory restraints in relation to pricing and treatment provision. Governments would need to impose stricter regulation on the industry to avoid unintended consequences, such as price gouging and over‑servicing. Avalue‑based approach has merit and should be explored in the design of any new dental services funding system.
6.101A universal scheme would also be impossible to implement 'overnight'. Public dental services are ill-equipped to handle an increase in patients, and many parts of Australia are currently under-serviced in terms of workforce capacity. Any new or expanded scheme would need to be introduced in stages, and the workforce would need to be gradually increased.
6.102The committee sees merit in the idea of non-dentists, including dental therapists, being funded and empowered to deliver basic diagnostic and preventative services. It is much faster and cheaper to become qualified as an oral health therapist than as a dentist, and freeing up dentists from doing this work would enable them to focus on clearing the backlog of more serious oral health problems that have resulted under the current system.
6.103The idea of a means-tested scheme is attractive, as this would cost significantly less than a universal scheme, and would target those most in need. However, evidence from the CDBS and other schemes suggests that means‑tested schemes come with their own problems, including creating an 'eligibility cliff', and leaving a large cohort of Australians without coverage from either public dental services or private health insurance. Governments must work together to resolve these issues if they choose to pursue this option.
6.104Committee members broadly support the idea of a Senior Dental Benefit Schedule, and eagerly await the outcome of discussions currently underway regarding this proposal.
6.105The idea of a universal preventative scheme has merit and deserves further consideration. This would be significantly more affordable than a full universal scheme and would likely lead to positive oral health outcomes over time. Any decision to implement such a scheme would need to be supported by further research into the economic and health-related outcomes; this is something the Commonwealth could fund in the immediate future.
6.106Regardless of which reform is ultimately pursued, the committee believes oral health awareness and education campaigns are a necessary and beneficial use of Commonwealth resources. Education campaigns should focus on the links between oral health and general health, and provide information about accessing services, particularly for priority groups.
6.107Committee members also support the idea of a Chief Oral Health Officer, or Chief Dental Officer, within the Department of Health and Aged Care. Supported by a staff of around 10 officials, a Chief Oral Health/Dental Officer would be able to facilitate better integration of oral health into the general health care system, represent Australia internationally, and drive reforms through National Cabinet processes.
6.108The committee recommends that the Australian Government appoints a Chief Dental and Oral Health Officer, and establishes an Office of Dental and Oral Health in the Department of Health and Aged Care, to coordinate national reforms.
6.109Another area where there may be need for reform is in the DVA pricing for work completed by dental prosthetists. The committee notes inequitable rates are provided to these practitioners, and these rates do not appear to have been reviewed since 1985. A review should be conducted with a view to establishing more equitable rates.
6.110The committee recommends that the Department of Veterans' Affairs improves rebates provided to dental prosthetists to achieve parity with the rates paid to dentists, to correct the price discrepancy.
6.111Committee members agree that state-based public dental services need more funding. It is time to reconsider the activity-based funding model currently in place and move to a long-term, evidence-based, outcomes focussed model, which supports preventative care.
6.112Through this inquiry the committee has heard from many people and considered a great deal of evidence. While the inquiry was wide-ranging and substantial, some areas of interest were not explored in depth. The committee believes that there is scope for a future inquiry to continue the work of this select committee, looking further into Australia's dental and oral health, and dental services frameworks. Areas for further investigation could include:
(a)interactions between oral health and general, systemic health;
(b)interactions between oral health and mental health and self-esteem;
(c)impacts of poor oral health on employment, relationships and social inclusion;
(d)the role of oral health in nutrition, and the impacts of nutrition on oral health;
(e)strategies for better integrating dental and oral healthcare within existing general health systems and frameworks;
(f)strategies for improving the geographic distribution of the dental and oral health care workforce and growing the size and capacity of the public dental workforce;
(g)strategies for increasing availability of oral health care providers with training and capacity to provide accessible and appropriate services for people with disabilities and/or complex needs;
(h)the social and economic impact of improved dental health care; and
(i)strategies for improving national data collection and coordination.
Any such inquiry should have full access to all evidence and documents collected by this committee for its inquiry into the Provision of and Access to Dental Services in Australia.
6.113 The committee recommends that the Australian Government works with the states and territories to achieve universal access to dental and oral health care, which expands coverage under Medicare or a similar scheme for essential oral health care, over time, in stages.
Senator Jordon Steele-John
Chair