GSC talk: We've got a bone to pick (make that a tooth to pick) with the Canadian health care system...

June 1, 2021

We've got a bone to pick (make that a tooth to pick) with the Canadian health care system

One in three Canadians has no coverage for dental care. And with few public options for care (unless you’re a child or a senior, that is) that leaves millions of Canadians struggling to take care of their teeth.

And, trust us when we say that this is a big deal. Dental issues that are left untreated can lead to all sorts of nasty stuff: infection, cardiovascular diseases and diabetes, oral cancer, just to name a few. Then there’s the impact on your quality of life. The pain can make it hard to eat, sleep, and smile. Many of those with poor oral health also suffer from low self-esteem and difficulties at work or school.

Dental issues that are left untreated can lead to...

  • Infections
  • Diabetes
  • Oral cancer
  • Difficulty eating
  • Difficulty sleeping
  • Difficulty smiling
  • Low self-esteem
  • Difficulty working

And the thing is, for those Canadians who can’t access dental care, most often due to cost, it’s not like these problems just go away – regularly the issue will eventually get so bad that they end up in an emergency room or doctor’s office, with few good options for treatment. In 2014 in Ontario alone, patients made 61,000 emergency room visits for oral health reasons (for a pretty price tag of around $31 million).But, we’re not just here to pick bones, or teeth, or whatever – we’re also here to do something about it. That’s why late last year, GSC launched the Green Door Project in partnership with the University of Toronto to fill this gap in care and help change the health care system, for good.

(Wondering why a health insurance company cares about public dental care? Well, GSC is a not-for-profit social enterprise – it’s true! – so working to support a more accessible and sustainable health care system has been in our DNA since we were founded in 1957.)


Launched by Green Shield Canada in 2020, the Green Door Project partners with academic institutions and community health providers to provide no-cost care to those in need, and fund key research that will help us change the health care system – for good. The key pillars of the project are: •

  • People: Our first priority is to help more Canadians get access to care. That means funding frontline clinics, and providing dental services to people in need, at no cost to the patient.
  • Research: Good change requires good information, so we’re funding research aimed at uncovering the impacts of access to dental care on individuals, families, and the health care system.
  • Advocacy: We’ll be hitting the road to advocate for evidence-based solutions to this significant gap in the Canadian health care system.

We got the ball rolling with a gift of $6.15 million to the University of Toronto’s Faculty of Dentistry to fund both the dental care of patients in need, as well as the One Smile research program. Recently, we announced our newest partner, the Northwestern Health Unit which services a large majority of communities in Northern Ontario, and expect to continue adding partners over the next several years.

Recently on our podcast (why yes, we have a podcast) our host, David Willows, sat down with Dr. Carlos Quinonez, the associate professor leading the research program at the University of Toronto’s Faculty of Dentistry, to talk more about how our mouths got left out of the Canadian health care system, what we can learn from public dental care in other countries, and what the Green Door Project (and its research counterpart at U of T, the One Smile program) are hoping they can do to help fill this gap.

And so, it is with great pleasure (and perhaps a bit of laziness) that this writer is pleased to share that conversation with you:

DW: Carlos, welcome back to the podcast.

CQ: Thank you for having me.

DW: It’s always a great pleasure. Let’s start by talking a bit about what gaps you've seen in the Canadian health care system when it comes to oral health care.

CQ: Okay. So let's start off with the health care system generally, because I think the question today is how to deal with dental care in broader health policy. So there's a big gap in Canada's publicly-funded health care system with respect to dentistry, meaning it doesn't exist to a large extent. So for example, if we look at our major piece of health care legislation in Canada, the Canada Health Act, it actually mentions dentists and dentistry because there are some surgical dental services delivered in hospitals. So if you're driving down the highway and you get into an awful car crash and you mess up your face pretty badly, our national system of health insurance will patch you up as best as possible. But when it comes to your teeth, forget it.

Now, some dental care is available in provincial health care and social assistance legislation through funding for low-income children, low-income adults, people that experience disabilities of some sort or another, and low-income seniors, but it's incredibly marginal. I mean, it's very minor. To put it this way, if you take a dental care dollar, only about five cents of that dollar is funding that comes from governments. So that's sad.

Click the piggy bank to see what five cents really looks like...

Then there’s the private dental care system that is quite robust, and really functions around employer-sponsored dental benefits, and that covers generally an employed and healthy majority. And that system works pretty well for a good portion of the population, although we're starting to see some weaknesses in terms of issues of under-insurance – meaning I have the insurance plan but it doesn't cover all the costs.

After that you have this large section of the population who have a job, but that job doesn’t offer employee benefits, and so they have to pay for dental care out of pocket, which can be expensive. When you add this to the fact that wages haven't really grown for like 20 years or whatever and many Canadians have less disposable income because food, housing, rent, the prices for these are going up tremendously. So you set up a situation where dentistry becomes a competing financial demand that some people just cannot meet.

It’s also worth separating out the people that are like really close to the bottom. We have a threshold for certain programs here in Ontario where it's about twenty-two thousand dollars a year. What if you make twenty-three? That thousand dollars isn't going to really cover the cost of all the other things you need, right? So there's this portion of Canadians that really, really struggles to access care which has significant implications for people's overall health as it does for their psychosocial well-being, their ability to live a decent life, and so on. That's well established.

Bus Stop Illustration

DW: So we're going to get to that in a little bit, but first I’m wondering… I know that you have looked at dental public health beyond our borders. Is this situation unique to Canada where we have this good percentage of people without fair access to care? Have some of our usual comparator countries found a way to do better than us? And what did they do?

CQ: So, let's get back to this dental care dollar. I talked about five cents as what our government is spending on dental care. That puts us close to the bottom among all countries in the OECD [Organization for Economic Co-Operation and Development] – like way at the bottom. We're actually behind the U.S., which is quite surprising to many, because we spend a lot of time in Canada thinking we're better than the U.S. in a whole bunch of areas.

DW: Yeah, we Canadians would hate to hear that.

CQ: Yeah, exactly. So, I guess in one sense this problem does exist in many nations and many health systems, but it's an issue of degree. Australia has a pretty robust public system for children, and while it doesn't do all that much for adults, it definitely does more than Canada. The U.K. has a largely publicly-funded system for dentistry that also has some gaps. But then there are also a significant number of OECD nations that in some way or another achieve near universal coverage for dental care. This is what I find exciting, because right now Canada is discussing whether dentistry should be part of the Canadian public health care system. And most people don't realize what they're saying when they talk about that. That means first-dollar coverage, similar to the way it works when you visit a doctor or a hospital.  But the reality is that that kind of system for dental care would be incredibly unique internationally. I can count on my hand the number of countries where it happens that way, but there's other countries that achieve universal or near universal coverage through a more mixed system. And, here I’m going to be very pragmatic politically.

I think it's much easier to get in line with most other countries and to find some uniquely Canadian solution that may not necessarily be the best thing for every stakeholder, but still moves us forward. I’m talking about the dentists. I’m talking about the patients. I mean, imagine if you told Canadians today we're going to take away your employer-sponsored health benefits, and now it's all going to be paid through your taxes. I don't think you'd get a revolt, but you're going to get a lot of people quite upset. And to me, it's largely unnecessary because we can do things in interesting and unique ways, which could mean including some part of dentistry in the public health care system, but still leaving these other mechanisms to do what they do like private markets.

Again, just generally, if you look across the world, you see so many successful systems that combine public and private markets, allowing them to work together to achieve near universal or universal coverage. And to me that's a politically pragmatic solution to what is a political problem, not a technical problem.

DW: With the work we are doing under the Green Door Project in partnership with your One Smile Research Initiative, we have used the phrase “working poor” for the group that we're trying to connect with our clinic at U of T and our secondary clinics, like the one we just announced with the Northwestern Health Unit. Tell us more, what does “working poor” mean? Who is this group? And how have they fallen through the cracks in care over time.

CQ: Well, there's some pretty specific definitions for working poverty that I can't pull out of a hat, but I will tell you that in general terms it essentially refers to the group of people that I described before – those who have a job that, again, doesn’t offer things like health and dental benefits. This probably extends beyond the definition, but I would argue that in the City of Toronto, you're probably working poor if you're making fifty to sixty thousand dollars. Maybe even a little bit more given the state of housing and everything that it takes to live in a city like this. But, if you go to rural Ontario, rural Manitoba – I’m from Manitoba so I naturally use that as an example – you might be working poor if you're making twenty thousand dollars. Now, don’t quote me on those numbers – I think the important thing to note is that it’s all relative and in the end, it's really people who experience financial barriers to care.

At our clinic at U of T and the secondary clinics, we're recruiting these individuals to receive no-cost care. I hate the term free. Nothing's free in life. So it's no cost care. In return for this, the patients are recruited into our One Smile study where we follow you pretty closely to see what changes for you in terms of your oral health, and eventually that extends to things like your general health and even psychosocial well-being.

I’ve talked a lot about this because I think it's important. Imagine you have a young family and you as a parent have a toothache, or your kid can’t sleep because of a toothache. How does that affect the child’s ability to learn? Or maybe they don’t want to eat because it might hurt. For the parent, how do you effectively function in terms of taking care of a child when you’re in pain? The impact of this kind of care extends beyond the individual to the entire family unit. Beyond that, we’re also studying what benefit this access to care might have on the health care system and society as a whole.

DW: So how does the research spill out at the end and how long does that take?CQ: Well, we will almost immediately have information that we can use. We'll be able to tell whether we're improving anybody's oral health rather quickly after the two-week mark, and definitely after a year. At a certain point, we collect the health card number too, so that we can link each patient to their provincial health administrative data, meaning that we will know every time the patient goes to a doctor or every time they go to a hospital and compare it to their past health care utilization. Will we see reduced physician visits for oral health related complaints? Have we reduced emergency department visits for toothaches, and so on?

And then ultimately through the work that we're doing with some health economists and some really bright students, we will calculate the return on investment. So for every dollar that was put into this, what might Canadian society get in return. DW: So the working premise here is that, in fact, oral health care does have a downstream impact on a person's broader health. Is there research out there already that pointed you in this direction for your research? And if so, what has it hinted at so far?CQ: I’ll put it to you this way. If you give somebody health insurance, they start consuming dental care in much more preventive sense. Meaning they're not just going for emergencies. That's well established.  

Dental Scene Illustration

One of my former students did a study that compared diabetics who self-reported their oral health as poor to fair with those that self-reported their oral health as good to excellent, and she showed that those diabetics with better oral health had far fewer negative diabetic-related outcomes. And, we're not talking about outcomes like, “I couldn't control my blood sugar,” we're talking about far fewer serious complications like amputations, for example. These sorts of things are not only costly services in the health care system, but they also have significant impacts on people's quality of life.

DW: I know that you talk to policy makers across the country, and I’m wondering where Canadian governments are on this question of how to close the gaps in dental care? Are they talking about this, and what will we need to do to generate conversation on this?

CQ: So interestingly enough, I do a lot of historical research, and dentistry pops up on the radar every 20, 25 years in Canadian health care discussions. It came up in the 30s to the 40s. We were starting to talk about our national system of health insurance in a very serious way. Popped up again in the 60s when we were formalizing Canadian medicare in terms of what it looks like today. It popped up tiny bit in the 80s, but it was quite quiet until about the early 2000s when it really started to gain steam again as a policy issue. And your listeners might realize that it's now boiled up to the surface once again where we have the NDP arguing for – well, it's interesting… they're arguing for like a mid-step, which is let's get federal funding for a federal plan as a bridge between ultimately including it in medicare, which I think is interesting. But when you balance off or when you trade off pharmacare against dental care, you start having to trade horses, right? And I’ll speak about that in a second.

Not our last speech from the throne… but the one before… so in the last election essentially, it was mentioned in the speech from the throne as something that should be explored. There was a commitment that the House Standing Committee on Health was going to explore it. I don't know where we are with that because COVID-19 has sort of turned a lot upside down. But most recently it was brought forward again by the NDP. We're seeing governments discuss it enough at the federal level. B.C. has talked about it. Ontario has talked about it. But there's generally more movement. And you know what I find most interesting is that my own dentist colleagues who historically have been really shy about this are now starting to say, “We need to think this through a bit better,” which I think is really good. Are in fact new dentists not the same as the dentists that were maybe working in the 60s and 70s or 80s or so on? I don't know. But the point is, is that even within the dental profession there's a discussion that we need to improve the situation for the people that we're really there to care the most about in a sense, right? We obviously care about the whole population. But as a profession you tend to care for the people that are the sickest and that makes sense.

DW: So in your mind, will this require some mandate or support at a federal level or could a province sort of go and do their own thing? Do the right thing on their own? Or will they be looking for dollars?

CQ: So all of that. What's very interesting is that in the history of medicare, when Saskatchewan and places like Alberta and B.C. went to do their own thing, it kind of stirred the pot. The federal government was like – I tell my students like, “Imagine if you had a bunch of kids and some of them figured out something to do that's really well and all you needed to do was put in some money so that all the other kids could do it.” There's like some moral suasion in health care at that time throughout the 50s and 60s.

I’m not sure that would apply for dentistry. So let's just say, through some magic, that B.C. or Saskatchewan decided that it was going to ensure dental care for everybody in some form or another. I’m not sure that's going to be the moral suasion that the federal government needs to sort of make it happen across the land, but that's a hypothesis. Yeah, a province can go at it alone. But what Canadian healthcare, at least how it's organized, meaning how it's governed and managed, is that to really get something moving in Canada, ultimately you need federal policy leadership, and that really functions at two levels, which is here are the rules or best practices, and then here's some money.

And what's interesting about the current plans that have been tabled by the NDP is that they're advocating for a federal plan that directly interacts with provincial residents. That's quite unique from the point of view of health care. But then you have the Green Party who have said, “No. No. Engage traditional funding mechanisms,” which is federal money that the provinces can then use through their own effect.

I’m a big proponent of federal policy leadership and obviously supported with dollars. And very interestingly, most recently, the Canadian Dental Association has called for national standards. Well, not only has it called for more money to support more public dental care, which is great, it's actually called for national standards for oral health care and long-term care, which is a long neglected area. And maybe COVID-19 has only highlighted that even more. But the idea of national standards I think is a healthy discussion in Canadian health care policy, so back to our initial issue. This is a very healthy way by which to deal with dental care in the context of broader health policy.

DW: Terrific. I mean, at the end of the day, when we talk about the Green Door Project and the One Smile Research Initiative at U of T, we're hoping in the end to add voices to that conversation and provide data and research to decision makers, policy makers to make informed choices there. And ideally we do have this vision of all Canadians having access to adequate oral health care. So thank you for giving us this perspective today. Certainly your expertise on these topics is sort of unparalleled and does a great service to our listeners. I also want to thank you for the sort of the day-to-day on the ground work that you're doing with the clinic, with the research project as it comes into fruition. I hope that we can bring you back in a little bit of time and sort of see how is this progressing, what are some of the early learnings and keep this keep this conversation going.

CQ: Thank you very much, and, well, I very much appreciate those comments. I always want to make sure that people understand that I’m supported by a large team of really high-functioning people that make me look smart. So there you go.

DW: Good talking to you, Carlos.

CQ: Thank you.

This interview transcript has been edited for clarity and length. To catch the full conversation with Dr. Carlos Quinonez, please check out episode 29 of our podcast And Now For Something Completely Indifferent…