Introduction

Dental care has almost always been the poor stepchild of medical care in all national healthcare systems and generally in privately insured plans. Although not generally specified in 'healthcare for all' documents like the Declaration of Alma Ata1 in 1978 or the Ottawa Charter2 in 1986, 'dental care for all' is a humanistic concept with great public appeal and potentially large economic dividends in the form of augmenting the health of a nation. The premise of this work is that a dentally-fit population is medically healthier and more economically productive than a corresponding population beset by dental problems. Therefore, a state or nation with dental insurance coverage will have a healthier population and subsequently a more robust economy than its uninsured counterpart.

The finances of dental care in Québec

Unlike the other nine provinces and three Territories of Canada (collectively known as British Canada), dental healthcare is largely covered by state insurance in the Province of Québec (ie except for only very limited coverage of dental procedures in the Ontario). The dental insurance programme in Québec is largely funded under a state income tax on personal income.3 Lower federal taxes are levied (ie the taxes are 'abated') and the nationwide personal income tax in Canada is not applied in Québec.4,5 Expenses for non-cosmetic dental services over and above those covered by government or private insurance are tax-exempt6 and eligible for tax credits towards the Québec provincial income tax.7 Dental healthcare insurance in Québec is implemented in a unique fashion compared to the rest of Canada – especially when it comes to children and the lower socioeconomic class.8 Children and people of low income are highlighted by Québec's healthcare system that includes the following insurance coverages:8

  • Oral surgical procedures treating the results of trauma or illness (eg TMJ, fracture reduction, removal of a cyst or tumour) are covered for all residents of Québec. Although covered in children, tooth extraction or root tip removal is not covered in adults

  • General dentistry for children under age ten whose parent(s) are residents of Canada except procedures involved in the application of topical fluoride. Children and teenagers up to 18 years are provided with free dental exams and X-rays at no charge

  • General dentistry (with exclusions) for all persons receiving government financial assistance (eg welfare recipients) for 12 or 24 consecutive months with the same coverage for their dependants.

Why is dental care important? The proper functioning of the oral cavity, mouth, and jaw apparatus are necessary for good health. The aim of dental treatment is to provide and maintain an oral system providing optimal masticatory, cosmetic, and linguistic function. The objectives of dental practice are to relieve and prevent pain, to remove decay, and provide cosmetics. The goal of the dentist and of modern dentistry is to provide these services in the best interests of the patient and her/his general and oral health. Without a functional oral system one can hardly be productive at work or socially competent.

Dental care: Britain vs France

It is obvious that the political culture of mostly ethnic French-speaking Québec resembles the country of France more than it does of the rest of Canada or the United States. Political-cultural similarities between the healthcare system of Québec and that of France are rooted deeply in the history of American colonisation and settlement (ie, the concept of Québec as a French 'island' in a British sea). Logically, the subsequent development of political and economic culture of Québec follows a similar timeline as does that of France itself.

Consider dental healthcare in France. The French finance their healthcare system by a complex mix of private and public sources.9 There is a clear and direct parallel to the government dental insurance coverage that is present in Québec, Canada. In the news literature, France's national healthcare system is widely lauded as excellent;9,10 it was even depicted as a very effective healthcare system in the 2007 documentary film Sicko: the movie by Michael Moore.11 High quality, affordable dentistry is available in France due to the policy of the government which closely regulates prices that can be charged for most general dentistry procedures.10 Although dental specialty treatment is not directly controlled, the French government has an enlightened policy of 'tact and discretion' for the prices that specialists can charge.10 By policies of price controls on general dentistry and of not covering specialty treatment, the French national healthcare system can continue to insure dentistry for large segments of their population.

Compare the French with the British healthcare system (with no government-run dental insurance coverage). Is the assumption that the British have 'bad teeth' a myth propagated on the Internet or is it a factual assertion? Certainly, the availability of dental care in Britain is low compared to the rest of Europe and North America;12 dental care in Britain is also the most expensive in the European Union.13 Dental procedures are generally not covered by the National Health System in Britain. Furthermore, it is assumed that the practice of dentistry in North America is superior to that in Britain, eg more dental research is conducted in North America and is applied to practice as evidence-based dentistry. However, none of these aspersions on the dental health of Britain has been substantiated by epidemiological or public health research and they are surely the result of stereotypical thinking.

The United States and British Canada inherited their political culture from the application of English Common Law by the colonisation of North American territories that were to become the original 13 US States and the Canadian Provinces/Territories. Even in modern times, our bonds with the British are strong, as revealed through the substantial support of the British in armed conflicts like WWII and the Falkland's War. Today, Britain (ie the United Kingdom) is the closest ally of the United States and British culture has become fashionably pervasive in American music, literature, journalism, and many other segments of our cultural life.

Discussion

The role of the US government in financing dental services is controversial. The US federal government makes a feeble attempt at dental coverage of young children with the Head Start Program, providing no more than an 'introduction to the dentist' and only for poverty-level children. Often, the average 3-5-year-old receives a simple prophy (cleaning) and perhaps a filling under the Head Start Program. It is far from comprehensive dental care. No other significant federally-funded dental services are provided for any other demographic group. However, the federal Medicare programme is well administered and could be a framework or model for insurance coverage of dental services by the US Federal government. The time has never been better for healthcare change, with an enlightened administration such as that of President Obama and an American people ripe for change.

All Canadian residents are covered medically by the Universal Health Care system (also called Canadian 'Medicare'). The legislation creating the healthcare system was consolidated in 1984 as the Canada Health Act14 with principles acting in health promotion, health education, and disease prevention.14 Basic healthcare in Canada is regarded as a public service.5 The Universal Health Care system in Canada relies on providers from the private sector, paid by insurance from the government.15 However, only Québec has Province-wide government-provided dental insurance for residents.8 For the rest of Canada, like Great Britain, dental care is inaccessible and expensive; ordinary Canadian families generally cannot afford dental care.16 The results of a study of dental expenses in the Canadian Provinces and Territories during the formative decade of the 1990s are shown in Table 1.17

Table 1 Trends in expenditures for dental care in Canada (1990, 1995, and 1999) by Province and Territory; percent paid by government17
Full size table

Québec Province, although an average spender in gross dental expenditures, excels in the percent use of public funds for dental care, ie considering the territories and sparsely populated provinces.17

During the period of change during the 1990s represented by Table 2, Québec leads the other provinces and Canada overall in a calculated 'index of change' of per capita expenditures for dental care.17

Table 2 Canada: Per capita expenditures for dental care (1990, 1995, and 1999)17 (Mean per capita [$])
Full size table

Canadian 'Medicare', including its Québec component, promotes evidence-based practice, ie it stresses medical and dental practice based on high-quality research employing the scientific method.18

Conclusion

Is it not the case that the policies of the French model of healthcare provision and its socio-political culture are naturally echoed in Québec? In the opinion of the authors, it is a resounding oui! The government of Québec, as the ongoing legacy of French colonialism in the New World, follows the French lead in providing for dental services in its healthcare system. In the opinion of the authors, the United States (and British Canada) will continue to evade providing dental insurance for its population – possibly because they continue to follow a British and not French political culture.

What lessons can the United States learn from the Québec experience in the provision of dental health insurance, given the origins of its political culture and governmental healthcare policy? In the United States dental care is not covered in its remarkably and effectively well-administered Medicare Program. Medicare provides an existing framework on which Federal dental insurance can be built. We propose that new healthcare finance policies be formulated by President Obama and Congress on the model of the policies effectively working in Québec. Changes in dental health policy in the United States would have measureable benefits for both medical and dental healthcare of its people. Further, such augmentation of overall healthcare would have positive implications for the nation's economy. Better dental healthcare would mean fewer toothaches and oral infections, which translate into less time lost at the workplace. Commitment to dental coverage in addition to medical insurance is a commitment to the health of the labour force and the people of the United States.