Report of the National Advisory Council on Dental Health

Overlap of Commonwealth and State and Territory Government Responsibilities and Services

The National Advisory Council on Dental Health (the Council) was established as a time-limited group to provide strategic, independent advice on dental health issues, as requested by Minister for Health and Ageing, to the Government. The Council’s priority task was to provide advice on dental policy options and priorities for consideration in the 2012-13 Budget.

Page last updated: 03 September 2012

      Government authority for dental health provision

      The Commonwealth Government has powers to legislate for: “The provision of … pharmaceutical, sickness and hospital benefits, medical and dental services (but not so as to authorise any form of civil conscription)”, under Section 51 xxiiiA of the Australian Constitution. This provides the Commonwealth with the power to provide a wide range of health services and benefits, including dental health. 46

      46 Biggs, A. (2008), Overview of Commonwealth involvement in funding dental care, Research Paper No.1 2008–09, 13 August 2008 Parliamentary Library, Parliament of Australia.

      However, the State and Territory Governments have traditionally been responsible for dental health services – prior to the above amendment to the Constitution in 1946, states and territories had sole responsibly for public dental health and the Commonwealth was only responsible for health services for war service veterans (their dependants and widows).47

      47 ibid.

      This situation, whereby both levels of government have overlapping authority, invites confusion as to whether the Commonwealth or the state governments (or both) have ultimate responsibility for government provision of dental health services.


      Who currently takes responsibility for dental service provision?

      State and Territory Governments

      As outlined earlier in this chapter, State and Territory Governments are responsible for public dental services. They provide emergency dental care and general dental treatment to eligible adults and school aged children.

      States are also responsible for water fluoridation – a preventive measure that aims to reduce dental caries by the controlled addition of fluoride into the public water supply.48

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      48 Australian Research Centre for Population Oral Health (2006), ‘The use of fluorides in Australia: guidelines’, Australian Dental Journal, Vol 51, (2), pp.195–199.

      Commonwealth Government

      Since the Whitlam Government, successive Commonwealth Governments have had differing views about the Government’s role in dental health. This is reflected in their different policies–ranging from direct roles in funding targeted dental health programs, to indirect roles such as providing some limited assistance through Medicare and offering subsidies to encourage the wider use of private health insurance.49

      49 Biggs, A. (2008), ‘Overview of Commonwealth involvement in funding dental care’, Research Paper No.1 2008–09, 13 August 2008 Parliamentary Library, Parliament of Australia.

      As at the beginning of 2012, the Commonwealth has two programs targeted to particular population groups. In 2004, the then Commonwealth Government took responsibility for providing dental services for those with chronic diseases – allowing patients with Enhanced Primary Care plans from a general practitioner to use the Allied Health and Dental Health Care Initiative to access Medicare benefits for three dental treatments a year (with a rebate of up to $220 per year).50 In 2007, these provisions were expanded to include benefits for enhanced diagnostic and treatment services and supply of prostheses, including dentures. The benefits cap was increased to $4250 over two calendar years. This resulted in the current CDDS program. However, the current Government has indicated its intention to discontinue this program in order to redirect funding and take on a greater role in providing assistance to concession card holders – by contracting the states to provide additional public dental services through a new CDHP.51

      50 Ibid.
      51 The 1993–94 Budget provided funding for a CDHP to 1996–97. $278 million was provided to the states and territories over four years to administer emergency care (Emergency Dental Scheme) and general dental care (General Dental Scheme) for healthcare card holders. With the cessation of the CDHP in 1997, sole government responsibility for public dental services returned to the states. ibid.

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      In 2008, the Commonwealth expanded its responsibilities to provide up to $150 (currently $163.05) per eligible teenager52 towards an annual preventative dental check through the Medicare Teen Dental Plan (MTDP). At the time of writing this report, the legislation that administers the MTDP, the Dental Benefits Act 2008, was undergoing a legislative review. The Council has considered the finding of the review in this report (as noted below).

      52 Eligible teenagers are 12–17 years of age in families receiving Family Tax Benefit Part A, and teenagers in the same age group receiving certain government payments.

      Other Commonwealth supported measures53 for dental services include:

      • some support through Medicare, including the Cleft Lip and Cleft Palate Scheme;
      • subsidised prescriptions by dental practitioners under the Pharmaceutical Benefits Scheme (PBS);
      • providing members of the Australian Defence Force and the Army Reserve with a full range of dental services at no cost;
      • a full range of dental services to eligible veterans;
      • partly funding university education of dental practitioners through Commonwealth supported places and the Higher Education Loan Program (HELP);
      • expanding dental training and service provision, in regional settings under the Dental Training Expanding Rural Placements (DTERP) program;
      • funding up to 50 voluntary intern placements per year for graduating dentists from 2013;
      • a 30 per cent tax rebate on private health insurance, which could cover dental services;
      • dental services provided through Community Controlled Aboriginal Medical Services;
      • dental services in the Christmas and Cocos Islands and for asylum seekers in community detention; and
      • access to broader scholarship schemes and locum support.

      53 ibid.

      Other Commonwealth Acts and regulation also apply to the practise of the dental practitioners, such as legislation governing the National Registration and Accreditation Scheme (discussed later in this chapter).

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      Individuals and private health insurance

      All other individuals (i.e. non–concession card holders and those ineligible for Commonwealth programs) are responsible for funding their own dental care. This group includes low income people on lower than average incomes. The private sector is the only place that non–card holder adults can access dental care.

      In 2008, 50 per cent of all Australian adults held private health insurance, including 26.8 per cent of card holders.54 In 2011, the average benefit paid by insurers for dental treatment was 50.3 per cent.55 A further 35 per cent of the population do not have private health insurance but use the services of private dental practitioners.56 A significant number of children are covered by private health insurance. In 2005, 43.8 per cent of children aged 5–11 years and 49.6 per cent of 12 year olds were covered by private health insurance.57

      54 Harford, J.E., Ellershaw, A.C. and Spencer, A.J. (2011), Trends in access to dental care among Australian adults 1994–2008, AIHW Dental Statistics and Research Series, No. 55, pp.10–11.
      55 Private Health Insurance Administration Council (2011), Annual Report, Data Tables, December 2011.
      56 A Healthier Future For All Australians – Interim Report of the NHHRC, December 2008, p.266.
      57 Ellershaw, A.C. and Spencer, A.J. (2009), Trends in access to dental care among Australian children, AIHW Dental Statistics and Research Series, No. 51, pp.10–11.

      There are two broad levels of cover: general dental coverage, which typically covers general dental services such as cleaning, removal of plaque, x–rays and small fillings; and major dental treatment, which often includes additional dental items such as orthodontics, wisdom teeth removal, crowns, bridges and dentures.58

      58 ibid, p.9.

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      Overlap and duplication – Commonwealth and states

      The area of most obvious overlap of responsibilities between the Commonwealth and states is services for children; states offer a range of services for most children up to the age of 18 and the Commonwealth’s MTDP offers a subsidy for preventative services for eligible 12–18 year olds.

      The services subsidised under the MTDP program also overlap with the basic preventive check–up and services subsidised by the majority of private health insurance providers (as noted in this chapter, a significant number of children are covered by private health insurance – 43.8 per cent of 5–11 year olds and 40.6 per cent of 12 year olds).

      The Second Review of the Dental Benefits Act 2008 noted that the uptake for the MTDP has been disappointing and declined in 2012–11 to only 30 per cent of all eligible teenagers. Further, the review noted that although the MTDP voucher system worked for a mainstream teenager audience, its appeal could not be assumed to extend to at–risk and hard–to–reach groups such as Aboriginal and Torres Strait Islander teenagers, culturally and linguistically diverse teenagers, disabled teenagers and homeless teenagers. The review also noted that evaluation of the operations of the program is warranted and recommended that further work to promote the MTDP to hard–to–reach teens should be undertaken. Given the overlap, poor uptake and deficiencies in reaching all eligible teenagers, it would be worthwhile re–evaluating the efficiency and effectiveness of the MTDP in achieving oral health outcomes for teenagers.

      Data published in 2011 on the MTDP voucher use (collected as part of the National Dental Telephone Interview Survey (2010)) provided the first opportunity to examine the program’s impact on visiting patterns. While the receipt of the MTDP vouchers indicated a degree of success in targeting teenagers according to income, the data indicated a generally low uptake of the vouchers and lower use among low income households. Comparison with visiting patterns for teenagers in previous years did not support a conclusion that the MTDP had a major impact on teenage visiting.59 This supports evaluating whether to extend the MTDP entitlement to include routine dental services and further considering policies to boost use of dental services by teens.

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      59 Australian Research Centre for Population Oral Health(2011), ‘Teen dental plan voucher use’, Australian Dental Journal, Vol 56, Issue 4, pp.437–440.

      There is also some degree of overlap for services provided to adults, with many patients eligible for treatment through the state’s public system and the Commonwealth’s CDDS program – approximately 80 per cent of those accessing the CDDS also have concession cards and are eligible for the dental services from the state public system. People receiving dental care through the Department of Veterans’ Affairs (DVA) may also be entitled to both of the above payments. Additional overlap exists with private health insurance through the 30 per cent rebate on premiums.

      One potential area of overlap among jurisdictions is dental graduate activities. Some states have previously and continue to offer various new graduate opportunities in the public dental sector. As a result of decisions taken in its 2011–12 Budget, the Commonwealth will also offer dental intern placements for new graduates from 2013, largely focused on the public sector, through its Voluntary Dental Intern Program. Although the program is yet to commence, it will aim to build on and complement existing jurisdictional programs rather than duplicate or replace existing efforts.

      Lack of harmonisation across the states

      There is general inconsistency in state services provided for children and adults, including the treatment that is available and eligibility and co–payment requirements. There is also a significant variation between the states and territories in the level of investment in public dental services, on a per capita basis. This variation in investment will affect the speed with which options for reform can be implemented.

      Children

      In 1973, the states and the Commonwealth agreed to establish a common Australian School Dental scheme to provide comprehensive dental treatment for all Australian school children up to the age of 15 years. Although the states were responsible for delivery of the dental services, it was mainly funded by the Commonwealth. In the early 1980s, funding was gradually subsumed into general purpose grants to the states, which effectively ended direct Commonwealth funding and responsibility for the scheme.60

      60 Senate Community Affairs References Committee (1998), Report on public dental services, Senate Community Affairs References Committee, 1998, p.48.

      Currently, only Western Australia, Queensland, South Australia and the Northern Territory operate some form of dedicated school dental program. New South Wales, Victoria, Tasmania and the Australian Capital Territory provide public dental services to children through community–based clinics. Eligibility for services and the level of co–payments also vary across states (for more detail refer to the table at Appendix E: Child dental services provided by the States and Territories).

      It is difficult to get a clear picture of the extent to which the different state–based service arrangements affect childhood caries experience as not all states participate in the national data collection. Further information on the status of children's oral health is provided in Chapter Three.

      New South Wales commissioned a Child Dental Health Survey in 2007 to establish the oral health status of primary school children aged 5–12 years. Key findings from the survey include: mean dmft for 5–6 year olds of 1.53 and mean DMFT for 11–12 year olds of 0.74; and that 61.2 per cent of 5–6 year olds and 65.4 per cent of 11–12 year olds have never experienced decay in their primary and permanent teeth, respectively. The NSW Oral Health Strategic Directions 2011 – 2020 consultation document states that these figures compare favourably to national benchmarks set in 2001.61

      61 NSW Oral Health Strategic Directions 2011–2020 (2010). New South Wales Department of Health, December 2010.

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      Adults

      Like child programs, there are variations between the states regarding the services they offer, the eligibility criteria for treatment and the levels of co–payments required for adults (for more detail refer to Appendix D on adult dental services provided by the states and territories).