Cost-related avoidance of oral health services

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Introduction

Cost is a major obstacle to accessing
dental care, and subsequently, an impediment to achieving good oral health
outcomes.^Note  Out-of-pocket expenses for dental care are
often high, particularly for those without adequate dental insurance and a
lower ability to pay.^Note  In 2001, households spent an
average of $274 on services related to dental care.^Note  By 2011, this rose to
approximately $341 per household, and by 2021, it reached $461. After adjusting
for inflation^Note  to 2021 dollars, the costs in 2001 and
2011 were about $502.88 and $447.97, respectively. This means that while part
of the increase over time is due to inflation, out-of-pocket costs have
fluctuated in real terms. Although costs decreased in real terms between 2001
and 2011, they have risen again since 2011. This could be due to higher fees
for services, less insurance coverage, or other factors making oral health care
less affordable.^Note 

Previous
research has found that many Canadians avoided visiting an oral health professional
and/or did not obtain necessary dental care because they cannot afford it.^{Note  ,Note}  Avoiding seeing an oral
health professional can contribute to the progression of preventable oral
diseases, such as tooth decay and gum disease that eventually require more
costly and invasive treatments.^{Note  ,Note} 

In response to the need for
more comprehensive data on oral health in Canada, Statistics Canada in
partnership with Health Canada developed the Canadian
Oral Health Survey (COHS).
This is the first ever national survey dedicated to oral health in Canada. The
COHS provides key baseline for understanding Canadians’ oral health and
their access to oral health care ahead
of  the introduction of the Canadian Dental Care Plan
(CDCP).^Note 

This
study uses data from COHS to determine the prevalence of individuals who: a)
avoided visiting an oral health professional in the past 12 months due to cost,
or b) avoided recommended dental care in the past 12 months due to cost. It
also explores how person-level characteristics, are associated with cost-related
avoidance of oral health services. All results presented pertain to individuals
aged 12 and older
residing in private households across the 10 provinces, as data on cost-related avoidance is
only available for this group.

About one in four Canadians have not visited an oral health professional in the past
12 months

Visits to an oral health professional
play an important role in maintaining optimal oral health. Despite these
benefits, significant disparities in access to oral health care persist across
population groups in Canada. In 2023-24, about one in four (28%) Canadians aged
12 and older reported not visiting an oral health professional in the past 12
months.

For many of these individuals, cost was a
barrier.
Avoidance due to cost of both visits to an oral health professional and dental
care recommended by an oral health professional were reported more frequently
by those who had not been to see an oral health professional recently. Among
those who had not had a recent dental visit, about half (49%) said they avoided
going to an oral health professional due to cost (Chart
1-A), and 34% said they avoided recommended dental treatment for the
same reason (Chart 1-B).

However, even
among those who did recently see an oral health professional, cost was a
barrier for further visits and treatments, with 14% reporting avoiding visits
due to cost (Chart 1-A) and 16% avoiding
recommended care (Chart 1-B). This
suggests that even though some Canadians attended a dental appointment, financial
concerns led them to limit other necessary or recommended care.

Cost remains a major barrier to accessing dental care

Overall, 24% of Canadians aged 12 and
older avoided visits to an oral health professional due to cost. This is
slightly higher than the 22% previously reported in 2018^Note  but is similar to the 24% reported
in 2022.^Note  Similarly, 21% of
Canadians reported avoiding recommended treatment for the same reason.

While the rates of avoidance
due to cost remained relatively stable over the past decade,^{Note  ,Note}  the rising cost of living in
Canada has likely increased the financial burden of out-of-pocket dental
expenses. As a result, while the avoidance rates may not have changed
significantly, the relative cost of dental care has grown, making it even
harder for many Canadians to access necessary services.^Note 

The results indicate that avoiding visits
to an oral health professional due to cost varies by age, with cost-related
avoidance being greatest among young adults. In 2023-24, 32% of young adults
aged 18 to 34 avoided visits to an oral health professional due to cost – 4.5
times higher than adolescents aged 12 to 17 (7%), and significantly higher than
adults aged 35-to-49 (24%) and those aged 50-to-64 (21%). These age-related patterns in avoidance
could be related to the type of employment and insurance coverage held by young
adults entering the workforce, who often find part-time, contract work or are self-employed,
and are typically lacking health benefits.^Note 

It is important to note that many
provinces have programs that provide public funding for dental care for youth
(aged 17 and younger) and the older population (65 years and older).^Note  Further, many private or
employer-paid plans likely cover dependents (i.e., children). These factors may explain
why avoidance due to cost is significantly lower among those aged 12 to 17 (7%)
and those aged 80 years and older (18%).

Along with age, gender played a role in avoidance
due to cost (Chart 2). Overall, women (27%)
were more likely than men (22%) to report cost as a barrier, with young women
aged 18 to 34 (38%) being most likely to avoid visiting an oral health
professional because of cost. This may be because women are more likely than men to work part-time or in
positions without benefits, resulting in lower access to employer-sponsored
dental insurance.^Note 

Insurance and income are important
determinants in dental care access

As noted in previous research,^Note  dental insurance is a key
predictor of access to and use of dental care services. In Canada, about
one-third (33%) of people over the age of 12 do not have any dental insurance.
Among those without insurance (regardless of their income level), about two out
of five (45%) avoided dental visits because of cost (Table 1). This was almost four times higher than those with
public and/or private insurance (12%), and nearly 2.5 times higher than those
with public insurance only (18%).

In addition to insurance, income plays a
crucial role in dental care access.^{Note  ,Note}  Avoidance of visits
to an oral health professional due to cost was more than two times higher for
those with an adjusted family net income (AFNI) of less than $90,000^Note  (33%), compared to those
with an AFNI of $90,000 or more (12%).

When looking at income and insurance
together, foregoing visits to an oral health professional due to cost was
highest among those with a family income below $90,000 and no dental insurance (50%),
followed by those with a family income of $90,000 or higher and no dental
insurance (30%) (Chart 3).
This suggests that while income and insurance are important factors associated
with access to oral health care, out-of-pocket expenses is a consistent consideration for
visiting an oral health professional, highlighting the need to address broader
cost-related issues in oral health care access.^Note 

Similar patterns in cost-related
avoidance were observed for getting any dental care treatment recommended by an
oral health professional.

Cost-related avoidance of dental services higher among equity-seeking populations

Racialized Canadians were
much more likely than non-racialized Canadians to report avoiding visits to a
health professional (33% versus 21%) and avoiding recommended care (28% versus
19%) due to cost (Chart 4). These
differences persisted even when considering income and insurance. That is,
cost-related avoidance was consistently higher among racialized Canadians than
non-racialized Canadians, including among those with lower-income regardless of
whether they had insurance, as well as the insured and uninsured with
higher-incomes.

Having a disability was also linked to
cost-related avoidance. In 2023-24, 36% of persons with a disability avoided
visits to an oral health professional due to cost, compared to 22% of people
without a disability. Similarly, those with a disability were also much more
likely to report cost as a barrier to obtaining recommended dental care (31%)
compared to persons without a disability (20%). The differences in cost-related
avoidance between persons with and without disabilities were observed in the
lower-income insured population, but not in the lower-income uninsured or
higher-income insured population.

It should be noted that the
above differences, particularly among equity-seeking populations, do not fully
account for other demographic characteristics such as age, employment, and
income. However, past research has shown that cost-barriers remain higher among
these populations after controlling for these factors.^Note  More detailed analysis is
needed to better understand disparities in access to dental care among
equity-seeking groups.

Conclusion

Using data from the Canadian Oral Health
Survey (COHS), this article examined characteristics of individuals who avoided
visits to an oral health professional in the past 12 months because of the cost,
as well as those who avoided recommended dental care for the same reason.
Overall, one in four Canadians had avoided visits to an oral health
professional in the past year because of cost.  This proportion was much higher
among Canadians with a family income of less than $90,000 without dental insurance
coverage (50%).

Lower-income individuals, even when
insured, face greater financial barriers, leading to higher rates of avoiding dental
visits and recommended care. However, avoidance patterns even among
high-income, insured populations indicate that financial concerns can still
affect access to care. Notably, this study underscores that cost remains a
major barrier to dental care access, highlighting the complexity of the issue, particularly
for equity-seeking groups like racialized individuals and people with
disabilities, who face additional challenges.

Given the intricate relationship between
cost-related avoidance and the associated factors (e.g., insurance and income),
more comprehensive analyses are necessary. Previous research^{Note  ,Note}  has revealed these
complex interactions, emphasizing the need for a deeper understanding of their
associations. Future studies should aim to integrate these nuances to provide
clearer insights into the factors associated with avoidance to oral health care
due to cost.