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Canada Canada has a decentralized, universal, publicly funded health system called Canadian Medicare. Health care is funded and administered primarily by the country’s 13 provinces and territories. Each has its own insurance plan, and each receives cash assistance from the federal government on a per-capita basis. | Dental services are excluded from Medicare. About two-thirds of Canadians have private insurance to help pay for excluded services such as dental. In 2022, the federal government announced plans to create the Canadian Dental Care Plan (CDCP), providing dental care coverage for uninsured Canadians with a household income of less than $90,000 a year. For those who have a household income of less than $70,000 a year, costs will be fully covered. Coverage is set to begin by the end of 2023 with full implementation by 2025, providing coverage for up to nine million Canadians. In the federal budget for 2023,A Made-In-Canada Plan, the estimated cost of the CDCP has been adjusted to $13 billion over five years from 2023-24 (an increase from initial estimate of $5.3billion when the program was first announced). Additionally, $4.4 billion of ongoing costs to Health Canada for implementation is budgeted. The 2023 budget also proposes $250million over three years, starting in 2025-26, and $75million ongoing, to establish an Oral Health Access Fund, which will address oral health gaps among vulnerable populations and reduce identified barriers to accessing dental care, including in rural and remote communities. As an interim measure until the CDCP is implemented, the Canadian Dental Benefit provides eligible parents or guardians with direct, up-front tax-free payments to cover dental expenses for their children under 12-years-old. Eligible families are those earning less than $90,000 per year and without access to a private dental insurance plan. Depending on your adjusted family net income, a tax-free payment of $260, $390, or $650 is available for each eligible child. For an overview of the history of dental care arrangements in Canada see: Catherine Carstairs, ‘Filling the gaps: Why Canada still needs a public dental health plan despite decades of medicare’, The Conversation, 26 April 2022. |
Denmark Health system: Denmark’s tax-funded health care system has a decentralized organizational structure: the national government takes the lead in regulation, supervision, general planning and quality monitoring; the regions are responsible for detailed planning, defining and delivering health services in hospital; and the municipalities have responsibility for health promotion, disease prevention, rehabilitation, home care and nonspecialized long-term care. A growing proportion of Danish people purchase complementary voluntary insurance to pay, among other things, for dental care. In 2018, 14.2% of health spending was from household out-of-pocketpayments. | For oral examination, scaling, individual prevention, treatment for dental caries and periodontal diseases, root canal treatment, extractions and oral surgery adult patients receive a state subsidy that can vary from 35–62%, depending on the patients’ age and the actual treatment. For example, adults aged 18 to 25 years can receive a subsidy of 62% for regular diagnostic examinations and status examination (screenings, preventive care, x-rays, dental cleaning, surgery). Most adults must pay the full costs of orthodontic treatment, crowns, bridges and removable dentures themselves. In the case of dentures, the municipalities can take on 85% of the excess through the health supplement (Helbredstillæg) for pensioners and early retirement pensioners depending on the patients’ financial situation and physical symptoms. Moreover, a special subsidy for oral health care can be provided to cancer patients and to people who due to Sjögre’s syndrome have significantly documented dental problems. Around 30% of the adult population has private health insurance that includes dentalcare. A distinction is made between the scope of dental care for children and adolescents on the one hand and adults on the other. Children up to the age of 18 receive free dental care through their school, including free orthodontics. Private dental care for children is also available, but 35% of the cost of such private dental services is met by the patient. Generally, there is no free dental care for adults. Instead, a system of subsidies operates, prioritizing prevention and basic oral health care. Welfare recipients (e.g. the disabled, the elderly and those on low incomes) can have their dental expenses reimbursed by the municipalities and those who do not receive unemployment benefit such as homeless people or substance dependents generally receive treatment free of charge. |
Finland Finland has a tax-financed national health system, governed at national and local levels. The public system for oral health care has expanded gradually, starting from the youngest age groups and extending gradually to the entire population. Three quarters of health spending is financed through public sources, and out-of-pocket payments accounted for 17.4% of current health expenditure in2019. | The Finnish National Health Insurance (NHI) does not have a defined benefits package which it covers but a range of dental services is available under the public system. Private dental care is partly reimbursed by the NHI with the exception of orthodontic and prosthetic treatments (it is only reimbursed in cases when they are offered due to other diseases). All children and youths under the age of 18 years are eligible for comprehensive oral health care free-of-charge in municipal health centres, through the Public Dental Service (PDS). The care also includes preventive treatment, orthodontics and specialized care. A major reform in 2001/2002 extended subsidies for private dental services for all adults older than 46 years and they were also given access to the PDS. However, dental care for adults is not provided free-of-charge; adults pay the government set standard fees, about one third of the private sector fees. The basic cost for a dentist visit in a health centre is currently €13.30, with additional costs for procedures ranging from €8.40 for a check-up to over €200 forprosthetics. Adults in Finland may also use private oral health care and receive a small reimbursement (14.9% of the total cost in 2017) from the NHI, with the exception of orthodontic or prosthetic treatments. There is no price regulation for private services: private providers charge on average €63 for a basic check-up (range €60–70). Reimbursement for an oral and dental examination performed by a private dentist is available every other calendar year. However, it can be paid every calendar year if the health status requiresit. |
Germany Germany has a statutory health insurance system split into public social health insurance (SHI) and (compulsory) private health insurance. Germany has a multi-payer SHI system: 87% of the population belong to 109 sickness funds. Those not entitled to sickness fund membership (the self-employed and those on high incomes) must join private health insurance companies. High levels of public expenditure on health and broad coverage of health care services result in low out-of-pocket (OOP) spending, 12.7% of health spending in 2019. | Membership of a sickness fund entitles a person to a package of free basic dental care, with advanced treatment options such as crowns and bridges and orthodontics sometimes requiring significant patient co-payments. People with low income areexempted from co-payments for standard care. The SHI covers services of in-office prophylaxis for children up to 17 years old as well as outreach prophylaxis for care dependent older people. So-called group prophylaxis is provided in schools and covered jointly by the sickness funds, the federal dental chambers and associations of public dentists as well as federal stategovernments. The basic entitlement to dental care of those insured under SHI is addressed implicitly in the Social Code BookV (§28) as measures for the prevention, early detection and treatment of diseases of the teeth, mouth and jaw. Specifically, prophylactic treatments (in children and the vulnerable elderly), basic dental care and surgical treatment are included in the benefits package of the sickness funds. Formost services (except e.g. prosthetics orperiodontal treatment), no prior authorization from an individual’s sickness fund is required for dental treatment. In the case of any doubt about medical necessity, sickness funds must obtain an expert opinion on the medical necessity of a given treatment from the SHI Medical Review Board, the joint institution of all sicknessfunds. Costs of dental fillings exceeding the costs of standard care must be paid by the patient. Orthodontic treatments for persons at the age of 18 or above are not covered by SHI (except in some cases such as anomalies). For children, costs for orthodontics are covered by SHI-funds, if the need for treatment is recognized by the sickness fund. For prosthetic rehabilitations including dentures and crowns, fixed subsidies are paid to patients depending on the individual number and location of teeth to be restored or replaced. The fixed subsidy amounts to 60% of the costs of standardcare. It can be increased if the insured persons endeavour to keep their teeth healthy and prove yearly dental examinations in the last five or ten years before treatment (the subsidy increases from 60% to 70% or 75%, respectively). The amount of fixed subsidy is calculated according to the cost of the most cost-effective treatment considered “standard care” for which there is a list of prices. The fixed subsidy must be paid by sickness funds even if the patient opts for a treatment other than standard care. The difference in costs for superior dental treatments (with better aesthetic or functional performance that exceed costs of standard care) must be paid out-of-pocket. According to the list of standard care, sickness funds cover is largely provided for inexpensive prosthetic strategies (e.g. simple removable dentures) but limited for more complicated treatments (e.g. implant-supported fixed dentures). Prior to prosthetic treatment, dentists must deliver a plan to the patients’ sickness fund including a medical patient report, planned dental treatment and estimated costs. The sickness funds verify and approve the plan and the dentist will be reimbursed. For individuals with low income or welfare recipients, the initial amount paid by sickness funds (60%) increases to cover all costs of standard care for prosthetic treatment (100% of costs). |
New Zealand New Zealand has achieved universal health coverage through a mostly publicly funded, regionally administered delivery system. General taxes finance most services. The national government sets an annual budget and benefit package. District health boards are charged with planning, purchasing, and providing health services at the local level. Patients owe co-payments on some services and products, but no deductibles. Approximately one-third of the population has private insurance to help pay for noncovered services and co-payments. | Children in New Zealand who meet theeligibility criteriafor publicly funded health and disability services (this includes all New Zealand citizens) are entitled to free basic oral health services until their 18th birthday. Free standard treatments include routine examination, x-rays, fluoride treatment, fissure sealants, cleaning to remove plaque, staining and tartar from teeth, fillings and extractions. Adults have to pay privately for the majority of dental services. There is no fixed fee or recommended fee structure for private dentists. A limited range of dental services are funded for some adults. People with disabilities or medical conditions such as mouth cancer may be referred to a hospital for their dental treatment by their usual dental practitioner or GP. People on low incomes who have a Community Services Card may be able to get emergency dental care, such as pain relief or extractions. These services are provided by public hospitals or dentists contracted by the district health board. Co-payments may apply. |
United Kingdom Since 1999 health care has become a devolved responsibility in the four nations of the United Kingdom, influencing the way in which services are organised and paid for. However, the tax-funded NHS model is common in all four nations. OOP spending was relatively low (15.9% of total health expenditure) in 2019, but increasingly general dental practitioners are choosing not to work within the NHS and as a result OOP expenditure on oral health is a far higherpercentage. Theoretically patients can register with an NHS dentist of their choice. In Scotland and Northern Ireland, access depends, however, on whether the dentist in question accepts “registered patients” (and therefore also treatment and payment in accordance with NHS conditions). | In all four countries (England, Scotland, Wales and Northern Ireland) NHS treatment is free of charge to all those under 18 years of age, nursing and expectant mothers, and those with low incomes. In Wales, within the NHS, examinations are also free to those under 25 or over 60 years of age, and in Scotland examinations are free to all those under 26 years of age. This means that, if they can find a dentist who is willing to treat them under NHS contract, about 60% of “non-exempt” adults have to pay a contribution to the NHS fee paid to thedentist. An increasing proportion of patients in the United Kingdom have additional private insurance for dental treatment. This is either in the form of dental insurance or an addition to general medicalinsurance The dental services reimbursed by the NHS include diagnosis, prevention, periodontal treatment, operative treatment, surgical treatment, dental prostheses and orthodontic treatment. In the case of some treatments, such as complicated crowns or bridges, and in the case of orthodontic treatment in adults in Scotland, where the fee for item of treatment system (previously common throughout the UK) exists, prior approval from the Dental Practice Board (DPB) is necessary. In England and Wales in 2021 there are four NHS charge bands for dental treatment which non-exempt adult patients had topay: • Band 1: Patient contribution of £23.80 (€28.6) in England, £14.70 (€18) in Wales, covers examination, diagnosis and consultation. If necessary, this can also include x-rays, scaling and polishing, and the planning of furthertreatment. • Band 2: Patient contribution of £65.20 (€78.3) in England, £47 (€56) in Wales, covers all treatments which are covered in Band 1 and restorative, surgical, periodontal and endodontic therapy (e.g. fillings, root canal treatments and extractions). • Band 3: Patient contribution of £282.80 (€339) in England, £203 (€242) in Wales, covers all treatments which are covered in Bands 1 and 2 and also more complex procedures such as crowns, bridges ordentures. • Band 4: Patient contribution of £23.80 (€28.6) in England, £14.70 (€18) in Wales) covers emergency dental care. In Scotland and Northern Ireland nonexempt adult patients contribute 80% of up to £384 (€456) to their NHS fee. |