Trends in Access to Dental Care Among Middle-Class Canadians

Trends in Access to Dental Care among Middle-Class Canadians

Laleh Sadeghi

A thesis submitted in conformity with the requirements for the degree of Master of Science in Dental Public Health Graduate Department of Dentistry University of Toronto

Trends in access to dental care among middle-class Canadians Laleh Sadeghi Master of Science in Dental Public Health, Faculty of dentistry University of Toronto 2012

Abstract

Objective: To explore the changes in the accessibility of dental services among middle-class

Canadians in response to recent changes in the labour market and the increasing costs of dental plans. Methods: Secondary analyses of all Canadian surveys that collected information on dental insurance, utilization and out-of-pocket expenditures were conducted. Descriptive analyses were used to identify and compare trends among middle-class against the Canadian average. Results:

Since 1996, the number of insured middle-class grew from 43% to 48%, with the number perceiving cost-barriers to dental care increasing by 2.7 times. In 2009, 30% of middle-class visited a dentist only when emergency happened. Since 1978, fewer middle-income households spent out-of-pocket on dental care, while per capita costs per household spending increased.

Compared to national average, middle-class trends implied to poorer access. Conclusions:

Access to dental care issues might be ascending from lower income sectors to involve middle- income earners as well.

Acknowledgments

This research project would not have been possible without the support of many people. I wish to especially thank my advisor, Dr. Carlos Quiñonez, whose encouragement, guidance and support from the initial to the final level enabled made this possible. Many thanks are also due to the members of my advisory committee, Dr. Laura Dempster and Dr. Herenia Lawrence without whose knowledge and assistance this study would not have been successful. I also wish to thank

Dr. William Ryding for his supports at work which made the completion of this study easier.

My deepest gratitude goes to my family for their understanding & endless love through the duration of my studies; this dissertation was simply impossible without them.

Finally, I would like to thank for the financial support provided by the Population Health

Improvement Research Network of the Applied Health Research Network Initiative,

Government of Ontario.

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TABLE OF CONTENT

ABSTRACT...... II

ACKNOWLEDGMENTS ...... III

INTRODUCTION...... 1

STATEMENT OF THE PROBLEM ...... 1 ORAL HEALTH AND ACCESS TO DENTAL CARE...... 1 CANADA’S DENTAL CARE SYSTEM...... 4 FUNDING AND DELIVERY ...... 4 ACCESS TO DENTAL CARE IN CANADA...... 5 EMPLOYMENT-BASED DENTAL INSURANCE IN CANADA ...... 7 EFFECTS OF INSURANCE ON ACCESS TO DENTAL CARE ...... 9 EFFECTS ON UTILIZATION...... 9 EFFECTS ON AFFORDABILITY ...... 10 EFFECTS ON ACCESS INEQUALITIES ...... 11 EFFECTS OF TYPES OF DENTAL INSURANCE ON ACCESS...... 12 DENTAL INSURANCE TRENDS IN CANADA ...... 13 CHANGES IN THE LABOUR MARKET...... 14 CHANGES IN THE COSTS OF EMPLOYMENT-BASED DENTAL INSURANCE ...... 17 CHANGES IN OUT-OF-POCKET EXPENDITURES ...... 20 EVIDENCE FROM THE AMERICAN HEALTH CARE SYSTEM...... 23 THE MIDDLE-CLASS ...... 24 OBJECTIVES OF THE STUDY ...... 25 HYPOTHESES ...... 25

METHODOLOGY ...... 26

DESIGN OVERVIEW ...... 26 DATA SOURCES ...... 26 DATA MANAGEMENT ...... 29 VARIABLES OF INTEREST ...... 31 MIDDLE-INCOME ...... 31 ACCESS TO DENTAL CARE MEASURES ...... 33 Dental insurance and dental benefits...... 33 Utilization ...... 33 Out-of-pocket expenditures ...... 34 SOCIODEMOGRAPHIC VARIABLES...... 34 ANALYSIS PLAN AND DATA LIMITATIONS...... 35

ANALYSIS...... 35 Middle-income trends...... 35 Comparative analyses ...... 35 DATA LIMITATIONS...... 36

RESULTS...... 39

MIDDLE-INCOME TRENDS ...... 39 DENTAL INSURANCE STATUS ...... 39 LAST YEAR’S DENTAL VISIT ...... 45 PERCEIVED COST-BARRIER REPORTS ...... 50 FREQUENCY OF VISITS ...... 54 EXPENDITURES ...... 56 MIDDLE-INCOME TRENDS IN COMPARISON TO NATIONAL TRENDS...... 59 DENTAL INSURANCE ...... 59 LAST YEAR’S DENTAL VISITS...... 62 PERCEIVED COST-BARRIER REPORTS ...... 66

DISCUSSION ...... 70

DENTAL INSURANCE ...... 70 DENTAL VISITS ...... 72 DENTAL CARE EXPENDITURES...... 73 SUBGROUP ANALYSES...... 74 DENTAL INSURANCE ...... 75 SELF-EMPLOYMENT STATUS ...... 75 WORK SCHEDULE...... 76 AGE ...... 77 EDUCATIONAL ATTAINMENT ...... 78 SEX ...... 79 LIMITATIONS ...... 79 POLICY CONSIDERATIONS ...... 80 CONCLUSION...... 82

REFERENCES...... 83

APPENDIX A: CHARACTERISTICS OF SURVEYS THAT WILL BE REVIEWED ...... 88

LIST OF TABLES

Table 1– Consistency of questions collected common variables through different surveys ...... 29 Table 2– Summary of the variables as used in the analysis ...... 30 Table 3-Middle income brackets 1978- 2009...... 32 Table 4- Consumer Price Index of Canada 1971 to 2010 ...... 32 Table 5- Coverage of each outcome variable according to the province and reference year ...... 38 Table 6- Availability of dental insurance among middle-income Canadians by sociodemographic characteristics, 1996-2009 ...... 41 Table 7- Comparisons between middle-income and other income levels ...... 42 Table 8- Dental benefits available through workplace and work schedule and indexes of change, 1999-2006 ...... 45 Table 9- Self-reported dental visits in the last year among middle-income Canadians, 1985-2009...... 49 Table 10- Perceived cost-barriers reported by middle-income Canadians, 1996-2009 ...... 53 Table 11- Visiting a dentist only in case of emergency reported by middle-income Canadians, 2003-2009...... 55 Table 12- Out-of-pocket expenditures on dental care reported by Canadians (2002 constant dollars), 1978 -2008 ...58 Table 13- Availability of dental insurance, middle-income and national average 1996-2009*...... 60 Table 14- Self-reported dental visits in the last year by Canadians, middle-income and national average, 1985-2009 ...... 65 Table 15- Perceived cost-barrier reported by Canadians, middle-income and national average, 1996-2009* ...... 67

LIST OF FIGURES

Figure 1- Full time/ part time workers (as a % of Canadian population 15 and older) ...... 15 Figure 2- Permanent and temporary employment rates, 1997-2009 (percent) ...... 15 Figure 3- Number of firms based on their size (in thousands), 1985-2005...... 15 Figure 4- Number of self-employed workers (in thousands), 1982-2010...... 17 Figure 5- Unionization rates (as a percentage of all employed workers), 1997-2009...... 17 Figure 6- Household Budgetary shares for dental care, 1969-2003 ...... 22 Figure 7- Availability of dental insurance among Canadians according to income level, 1996 -2009 ...... 40 Figure 8- Availability of dental insurance among middle-income Canadians, indexes of change as of 2009 ...... 43 Figure 9- Availability of dental insurance among middle-income Canadians and sex, 1996-2009 ...... 43 Figure 10- Availability of dental insurance among middle-income Canadians and educational attainment, 1996- 2009...... 44 Figure 11- Dental benefits available through workplace and work schedule, 1999-2006...... 44 Figure 12- Self-reported dental visits in the last year and income level, 1985-2009 ...... 45 Figure 13- Self-reported dental visits in the last year among middle-income Canadians, indexes of change as of 2009 ...... 46 Figure 14- Self-reported dental visits in the last year among middle-income Canadians and job characteristics, 1991- 2009...... 46 Figure 15- Self-reported dental visits in the last year among middle-income Canadians and age, 1985-2009...... 47 Figure 16- Self-reported dental visits in the last year among middle-income Canadians and self-employment, 1985- 2009...... 47 Figure 17- Self-reported dental visits in the last year among middle-income Canadians and educational attainment, 1985-2009 ...... 48 Figure 18- Last Self-reported dental visits in the last year among middle-income Canadians work schedule, 1985- 2009...... 48 Figure 19- Self-reported dental visits in the last year among middle-income Canadians and dental insurance, 1985- 2009...... 48 Figure 20- Perceived cost-barriers reported by Canadians according to income level, 1996-2009 ...... 50 Figure 21- Perceived cost-barriers reported by middle-income Canadians and age, 1996-2009 ...... 50 Figure 22-Perceived cost-barriers reported by middle-income Canadians, indexes of change as of 2009 ...... 52 Figure 23 - Perceived cost-barriers reported by middle-income Canadians and dental insurance, 1996-2009...... 52 Figure 24- - Perceived cost-barriers reported by middle-income Canadians and work schedule, 1996-2009...... 52 Figure 25 -Perceived cost-barriers reported by middle-income Canadians and immigration status, 1996-2009 ...... 54 Figure 26- Perceived cost-barriers reported by middle-income Canadians and educational attainment, 1996-2009 54 Figure 27- Visiting a dentist only in case of emergency reported by Canadians according to income level, 2009 ...... 55 Figure 28- Percentage of households reporting expenditures on dental care and income level, 1978-2008...... 56 Figure 29 -Average expenditures on dental care per household reporting any expenditure and income level, 1978 - 2008...... 57 Figure 30- Availability of dental insurance among 60-79 year olds, middle-income and national average, 1996-2009 ...... 59 Figure 31- Availability of dental insurance among lower education group, middle-income and national average, 1996-2009 ...... 61 Figure 32- Availability of dental insurance and sex, middle-income and national average, 1996-2009...... 61 Figure 33- Availability of dental insurance and work schedule, middle-income and national average, 1996-2009....62

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Figure 34- Self-reported dental visits in the last year, middle-income and national average, 1985-2009 ...... 62 Figure 35- Self-reported dental visits in the last year by immigrants, middle-income and national average, 1985- 2009...... 63 Figure 36- Self-reported dental visits in the last year by lower education group, middle-income and national average, 1985-2009...... 63 Figure 37- Self-reported dental visits in the last year and self-employment, middle-income and national average 1991-2009 ...... 64 Figure 38- Perceived cost-barrier reported by Canadians, middle-income and national average, 1996-2009...... 66 Figure 39- Perceived cost-barrier reported by the uninsured, middle-income and national average, 1996-2009...... 68 Figure 40- Perceived cost-barrier reported by 60-79 year olds, middle-income and national average, 1996-2009 ....68 Figure 41- Perceived cost-barrier reported by 20-39 year olds, middle-income and national average, 1996-2009 ....69 Figure 42- Perceived cost-barrier reported by higher education group, middle-income and national average, 1996- 2009...... 69

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Introduction

Statement of the problem

Middle income populations in Canada rely heavily on their employment-based dental insurance in order to access dental care, as they are not covered under public programs and their income, although not low, may not be high enough to enable them to pay for all their needed dental care. Access difficulties and oral health inequalities are now documented among the working poor. However, sufficient evidence is not available on middle income Canadians, even though they have been anecdotally reported to be contacting local public health agencies in order to seek oral health care within public plans.

Existing evidence on recent trends in expenditures and employment characteristics can partly help explain this issue among this income group. In this study, we will mainly focus on the availability of dental insurance as the main determinant of access. Importantly, as the study group is of a defined income range, we also expect a fairly homogenous sample in regards to educational attainment and social status.

Oral health and access to dental care

Access to care is defined as “the timely use of personal health services to achieve the best health outcomes” (Institute of Medicine, 1993). While the direct effects of the social determinants on health status are significant, it is estimated that about 25% of health disparities are associated with health care system characteristics and its accessibility (The Senate Standing

Committee on Social Affairs, 2009). As embedded in the definition of access, utilization of

health care services is an important indicator of access. Hence, while access is more than just the use of services, it is generally the default measure, however weak, of access, through the collection of self-reported data. For dental care, access is represented by dental visits and visiting patterns such as number, frequency and types of visits (Quiñonez, 2009; Agency for Healthcare

Reseach and Quality, 2004).

As dental diseases are largely preventable, appropriate access and regular utilization of dental services are crucial in achieving optimum oral health, even among edentulous groups

(Millar & Locker, 1999). Large-scale studies have shown that regular dental visits can cause fewer decayed teeth and better oral health (Bailit et al., 1985; Sintonen & Linnosmaa, 2000;

Nguyen, Hakkinen, Knuutiila, & Järvelin, 2007). Better access to preventive dental care may also result in cost-savings in future dental treatment (Sintonen & Linnosmaa, 2000). On the other hand, those who do not make regular visits to a dental professional demonstrate poor oral health.

For instance, while not causal, the results of the Canadian Health Measure Survey 2007-09

(CHMS) illustrate that those who did not visit a dental professional in the last year were almost two times more likely to report their oral health as fair or poor compared to those who made dental visits in the last 12 months. These people also had significantly higher numbers of untreated decayed teeth at all ages. Canadian adults who did not make a dental visit in the last year were more also likely to demonstrate worse gingival and periodontal measure scores, report more soft tissue oral lesions and have more treatment needs (Health Canada, 2010).

Despite the significant improvements in the oral health of the world‟s population in recent decades, oral health disparities based on social and economic factors are still persistent

(U.S. Department of Health and Human Services, 2000; Petersen, 2003). In a recent Swedish study, lifestyle factors could only explain one third of the variance in oral health status while

about 60% of the observed variance among different socioeconomic groups was explained by inequitable access to services (Wamala, Merlo, & Boström, 2006). While equitable access is achieved when the need for care rather than socioeconomic status (SES) is the major predictor of service utilization (Andersen, 1995); worldwide the greatest burden of oral diseases is bared by those with the highest need and the least access to care. SES is a composite feature based on factors such as demographic characteristics (age, sex and ethnicity), income, health insurance, education and employment status. It has been shown that SES has significant effects on health care access and utilization as it influences the ability of individuals to recognize, seek and obtain the care they need (Andersen, 1995; Morreale, 1998). It is well-established that younger, more affluent, higher educated people with higher social status have the best access to dental care irrespective of their need and enjoy better oral health as a result (Sabbah, 1998; U.S. Department of Health and Human Services, 2000; Petersen, 2003; Schwarz, 2006).

Income and dental insurance are the most dominant factors in determining access to dental care (Millar & Locker, 1999; Bhatti, Rana, & Grootendorst, 2007; Health Canada, 2010).

In the context of the Canadian dental care system, Bhatti et al. (2007) found that oral health needs, measured through self-rated oral health, was the most important determinant of dental visit frequency, while dental insurance, income and education were dominant factors in the probability of receiving care. Yet, this study did not differentiate between preventive and non- preventive services. However, another Canadian study that assessed income related inequalities in the use of preventive visits, found that these differences are much larger in utilization of preventive services compared to utilization of non-preventive services (Grignon, Hurley, Wang,

& Allin, 2008). They further confirmed that even adjusting for oral health needs does not significantly affect inequitable utilization of services, meaning that with similar need people with

higher income use more services compared to those of lower income. They found that inequities are most striking in the probability of receiving preventive care, especially in terms of frequency of preventive visits (Grignon et al., 2008). Another Canadian study concludes that while poor general health was associated with higher medical attendance, poor oral health was related to lower use of dental services; based on the results of this study, unlike medical care, higher use of dental services was strongly associated with higher income and education (Sabbah, 1998).

Canada’s dental care system

Funding and delivery

Despite the universal coverage of medical care in Canada, and despite the substantial evidence on the association between oral health and general health (U.S. Department of Health and Human Services, 2000) dental care is not publicly covered in Canada, partly because dental diseases are not considered life threatening and dramatic (Millar & Locker, 1999).

Dental care in Canada is mostly delivered by a private for-profit system, financed dominantly through private dollars. The total costs and demand for dental care are increasing sharply. Adjusting for inflation, total per capita dental expenditures rose from about $6 in 1960 to close to $50 in 2008 (Health Canada, 2010). Meanwhile, public per capita dental expenditures declined from a peak of $25 in the early 1980s to less than $15 by 2005 (Quiñonez, 2009). In

2009, Canadians spent about 13 billion dollars on dental care, the second highest expenditures only after cardiovascular disease, yet about only 6% of total expenditures were paid through public programs and the rest was paid through private resources, namely employment-based insurance and/or out-of-pocket expenditures (Health Canada, 2010).

It has been shown that in areas with limited public coverage income inequities are larger compared to when universal insurance is provided (Van Doorslaer, Masseria, & Masseria, 2004).

Yet, public programs in Canada are limited to those with minimum income, or those on disability assistance. Even within eligible groups, coverage for basic services is largely limited to children and adolescents while adults only benefit from these services on a discretionary basis. In the majority of cases, only emergency treatments are provided to eligible adults (Quiñonez et al.,

2005). Hence, private dental insurance plays a significant role in Canada‟s dental care market with employment-based dental insurance being the most significant form of dental coverage

(Millar & Locker, 1999). In 2008, the private dental insurance industry in Canada financed $6.4 billion dollars of expenditures for dental care, covering over 20 million Canadians (62% of the population) (Canadian Dental Association, 2010). In 2009, of all private expenditures 35% were paid for out-of-pocket and about 60% were financed through employment-based dental insurance

(Quiñonez & Grootendorst, 2011). Lack of sufficient support from governments regarding access to dental care and the dominant role of third party payers in the dental care market creates an environment within which access to dental care is strongly associated with one‟s income and access to insurance.

Access to dental care in Canada

Overall, Canadians enjoy good access to dental care. Over 70% of Canadians reported having a dental visit within the last 12 months and about the same number reported regular visits to dentist at least once a year. Yet, uninsured and low-income Canadians faced significantly higher challenges accessing dental care. Only about 60% of uninsured and low-income

Canadians reported visiting a dentist in the last year, and even fewer reported regular visits to a dentist for check-ups and treatments within the last year (Health Canada, 2010).

In the Canadian system, income and insurance are the two most important determinants of access to dental care, even after controlling for different sociodemographic factors (Millar &

Locker, 1999; Bhatti et al., 2007; Health Canada, 2010; Locker, Quiñonez, & Maggirias, 2011).

In addition, it is well- known that there is a positive correlation between these two features, meaning that those with higher income are more likely to have dental insurance and vice versa.

While only 19% of the highest income earners were uninsured, about four out of ten and close to half of middle and lower income Canadians did not have dental insurance respectively (Health

Canada, 2010). Nonetheless, dental insurance has independent effects on access to dental care, meaning that at any given income level insured people have better access to services compared to the uninsured (Millar & Locker, 1999; Bhatti et al., 2007; Muirhead, Quiñonez, Figueiredo, &

Locker, 2009; Locker et al., 2011). Importantly, over one-third of Canadians say that dental insurance coverage is the most important factor in determining their frequency of visits to the dentist (Canadian Dental Association, 2010).

Nonetheless, Canada‟s dental care system still arguably represents an underinsured environment, as almost one in every three Canadians does not have any dental insurance (Health

Canada, 2010). With employment-based dental insurance being the most common form of coverage, employment characteristics are an important factor determining the availability of such coverage. Employed individuals have statistically significant higher rates of having dental insurance even after adjusting for factors such as income, education and age. In 1998, 65% of those who were employed had dental insurance compared to only 41% of the unemployed

(adjusted OR=1.4, C.I:1.28-1.53, p<0.05) (Millar & Locker, 1999). In addition, there is a steep decline in the number of dentally insured among older adults, related to retirement and loss of employment dental benefits (Manski, Goodman, Ried, & Macek, 2004; Bhatti et al., 2007). For

instance, in 1998, only 21% of Canadians aged 65 and older had dental insurance (Millar &

Locker, 1999). This has been supported by an American study of adults 55 to 75 year olds which demonstrated lower utilization rates associated with loss of insurance after retirement (Bendall &

Asubonteng, 1995). Similarly, CHMS data shows that about half of those aged 60-79 were uninsured, while only 27% of these uninsured older adults reported visiting a dental professional in the last year (Health Canada, 2010). Importantly, the effects of employment status on facilitating access is shown to be only due to the increasing the odds of having dental coverage.

In other words, when controlling for sociodemographic factors, including dental insurance itself, employed individuals did not show higher utilization rates (Manski et al., 1998; Millar & Locker,

1999).

It is worth noting that, although the effects of other socioeconomic factors such as education and immigrant status on access to dental care are acknowledged, my study is mainly focused on the role of dental insurance and employment characteristics (as a proxy to the availability of employment-based dental insurance), as dental insurance remains the most important predictor of access to dental care when holding constant the effects of income.

Employment-based dental insurance in Canada

Overall, in 2000, 55% of employed Canadians had dental benefits as provided by their employers (Marshall, 2003). Yet the availability of employment-based benefits is strongly related to job characteristics that are usually used to describe “good” jobs. The most significant of these characteristics are full-time, permanent, unionized jobs in large firms (Reesor & Lipsett,

1998; Marshall, 2003; Zeytinoglu & Cooke, 2005).

Based on 1995 data, the odds of having dental benefits for permanent employees was six times higher than temporary workers, and the odds of full time employees was four times higher than their part-time counterparts (Human resources and Skills Development Canada, 1998).

Analysis of data from the Workplace and Employee Survey (WES) of 1999 showed that the highest rates of employment-based dental benefits was among permanent full time workers

(60%), almost two times higher than that of temporary full time workers. Availability of dental benefits was the lowest for temporary part time employees, with around only 10% of them receiving dental benefits (Zeytinoglu & Cooke, 2005).

Working in a bigger firm size and having “unionized” status are also associated with the higher probability of entitlement to dental benefits (Human Resources and Skills Development

Canada, 1998; Reesor & Lipsett, 1998). A 1997 analysis showed that 77% of unionized workers had dental benefits, as opposed to less than half (41.9%) of those who were not in a union or collective bargaining agreement (Akyeampong, 1997). The larger a firm, the more likely its employees are offered health benefits. For instance, 71% of employees working in firms with

100 or more workers had employment-based insurance (extended health, dental and life disability). While only 27% of those working in small firms and just over half of those working in medium size firms were entitled to such benefits (Marshall, 2003). However, union status has

“equalization” effects on firm size. This means that there is less difference in the probability of having employment-based health benefits among different firm sizes when unionization is in place (Human Resources and Skills Development Canada, 1998; Reesor & Lipsett, 1998).

Unionization gains extra significance considering that non-unionized workers whether full time or part time generate less hourly wages (Akyeampong, 1997), and wage rate has been confirmed

to be a major factor in determining the likelihood of entitlement to employment-based benefits

(Reesor & Lipsett, 1998; Marshall, 2003).

As finding a “good” job with employment-based benefits is to some extent a product of longer experience in the labour market (Reesor & Lipsett, 1998), it is expected and confirmed that younger workers are less likely to be provided with these types of benefits (Reesor &

Lipsett, 1998; Marshall, 2003). Based on 2000 data, only 17% of those aged 16-24 had employment-based dental insurance as opposed to 60% of those 45-54 years old (Marshall,

2003).

Effects of insurance on access to dental care

Effects on utilization

Many agree that oral health status is the product of frequent preventive dental visits in addition to the types of treatment received when needed (U.S. Department of Health and Human

Services, 2000) with dental insurance being a significant determinant of such patterns (Millar &

Locker, 1999). A joint Canada-US study reports that over 70% of individuals with dental insurance visited the dentist in the past 12 months compared to 47% of those without insurance

(Sanmartin & Ng, 2004). The insured tend to seek and receive more preventive care while the uninsured receive more radical treatment such as extractions or dentures (Millar & Locker,

1999). Studies on children also suggest that insured children visit the dentist more frequently

(Waldman, 1989), and receive more preventive services compared to children without insurance

(Lewis, Mouradian, Slayton, & Williams, 2007).

Some have argued that higher utilization among insured people might be the effect of adverse selection, meaning that those with more oral health problems selectively purchase dental

insurance because they perceive they need it. Bhatti et al. (2007) examined this theory by testing the relationship between self-assessed oral health and the probability of having dental coverage.

The results suggested that those who rate their oral health as poor were actually less likely to have dental coverage. Their study concluded that the effect of dental insurance is due to its cost reduction role at the point of service rather than adverse selection (Bhatti et al., 2007).

Effects on affordability

Despite the association between regular visits to dental professionals and better oral health status, not everyone uses dental services regularly. While the common belief that cost is the most cited barrier to access, other reasons such as not perceiving a need for dental care and not having teeth are cited more frequently (Millar & Locker, 1999; U.S. Department of Health and Human Services, 2000). Yet, affordability issues for those who pay out-of-pocket for their dental care has been targeted historically as a policy issue. Financial barriers are especially important as they are one of the most mutable barriers through policies (Locker et al., 2011) and shown to increase the utilization significantly when removed (Bendall et al., 1995).

At any given income level, the uninsured report cost-barriers more often compared to the insured (Muirhead et al., 2009; Health Canada, 2010; Locker et al., 2011), with such barriers being associated with unfavourable utilization patterns and oral health independent of income, dental insurance and other sociodemographic characteristics (Locker et al., 2011). For example, in Locker et al.‟s study (2011), perceived cost-barriers were associated with lower self-rated oral health, having lost a tooth in the previous year and overall greater oral health impacts as measured by the Oral Health Impact Profile (OHIP-14) even after adjusting for socioeconomic factors. In 2009, the number of uninsured Canadians citing cost-barriers to dental visits in the last year was twice as high as the national average (Health Canada, 2010).

In some cases, such as among the working poor, the high costs of dental care has been shown to compete with other expenses in a household and has been associated with food insecurity and irregular emergency-based dental visits (Muirhead et al., 2009). Food-insecure working poor families were twice as likely as food-secure families to report a cost barrier in the past, while being less likely to have dental insurance. On the other hand, significantly higher number of food-insecure respondents reported visiting a dentist only when in pain/trouble (40% of food-insecure compared to 18% of food-secure) (Muirhead et al., 2009). Although the directions of these associations are unknown, one possible explanation could be that in times of financial difficulties and in the absence of sufficient coverage, household members forego obtaining needed dental care unless there is an emergency. When dental care becomes necessary for the specified households, being one of the more flexible items in households, food expenses are more likely to be cut back, pushing the family to the food insecurity position.

Effects on access inequalities

Dental insurance can effectively diminish but not eliminate the gaps between different income levels through increasing affordability. For example, in their study Millar & Locker

(1999) show that higher numbers of lowest/ lower middle income earners with dental insurance reported visiting a dentist in the last year compared to their middle- and upper-middle-income counterparts. However, the uninsured with the highest-income level still had higher rates of reporting dental visits in the last year compared to the insured of lowest income (Millar &

Locker, 1999). One might conclude that dental insurance especially in lower- and middle-income brackets plays an important role in closing the gap, but does not eliminate it.

Effects of types of dental insurance on access

Although having any insurance plan results in better utilization rates as opposed to no insurance plan (Mueller & Monheit, 1988), the amount of coinsurance paid by enrolees is a significant determinant of utilization as well. Bailit et al. (1985) performed an analysis on data collected through a randomized trial to investigate the effects of dental plans with different levels of cost sharing on oral health status of users. In this trial, 4,815 subjects aged 6 to 61 were randomly assigned into free, 25%, 50% and 95% coinsurance plans. The results of the analysis confirm that the individuals in a free plan had better oral health than those who were subject to cost sharing. Further analysis of the enrolled children reveals that those in the free dental plan had significantly lower deft and were more likely to be caries-free compared to those who were enrolled in cost-shared plans (80% vs. 60%) (Bailit et al., 1986). This study concluded that low and middle income children benefit the most from free plans (Bailit et al., 1986).

Access to low-cost care or free dental care does not rectify all oral health disparities based on income (Muirhead et al., 2009). It is worth noting that having dental insurance does not always translate to higher utilization of services especially in the case of public coverage. Fisher

& Mascarenhas (2007) compared oral and general health of insured and uninsured Medicaid- eligible children in respect to service utilization, self-report health status and treatment needs.

Their findings suggest that Medicaid coverage improves utilization of physician services, yet it does not enhance dental care utilization. They did not find any association between not having

Medicaid insurance and not visiting a dentist within last year. While 32% of uninsured

Medicaid-eligible children visited the dentist within the last year, only 39% of those enrolled in

Medicaid made such visits and the difference was not statistically significant. Yet, uninsured but

Medicaid-eligible children had more dental treatment needs compared to the insured which again

suggests that having dental insurance can improve oral health (Fisher & Mascarenhas, 2007).

Yet, in this study the main barrier for visiting the dentist among the insured was difficulties in finding a provider and when in one state Medicaid children were provided with the same insurance as privately covered children access was highly improved. Similarly in Nova Scotia,

Canada, when a universal appropriately funded dental plan was established for children, 94% of children between 6 to 7 years old visited a dental professional in a one year period, and dental treatments were received based on need rather than sociodemographic characteristics of families.

For instance, children from lower education households received dental fillings two times more than those from higher educated families (Ismail & Sohn, 2001).

Dental insurance trends in Canada

In the Canadian system, limited public programs cover a portion of the lowest income earners for their dental expenses, while the highest earners are able to pay out-of-pocket if uninsured. Nonetheless, for the rest of the population, including middle income earners, dental benefits provided through employment represents the main mediator of access to dental care.

Although there are very limited studies on recent trends of employment-based dental insurance especially in Canada, there is evidence suggesting that access to dental care through insurance might have been challenged over the last two decades. Evidence on this matter can be divided into three major groups: changes in labour market and types of jobs, the increasing costs of employment-based dental benefits on both employees and employers, and changes in household expenditures on dental care. The last two are indirect measures for employment-based dental insurance.

Changes in the labour market

As employment-based benefits are strongly associated with the types of jobs, exploring the trends in labour force market will be a good indicator of the availability of dental benefits for employees. The following changes in the labour force market may imply a lower accessibility to dental benefits:

1. Firms started to hire more part-time temporary and fewer full time, permanent workers

(Figures 1 and 2) while employment benefits are largely limited to permanent full time positions

(Quiñonez & Grootendorst, 2011). As shown in Figure 1, part-time employment has increased over the last three decades from 7.1% in 1976 to 11.8% in 2009. The rate of increase was highest among youth aged 15 to 24. Almost half of the employed 15-to-24 year-olds worked part-time

(47%) in 2009, compared with only one in five (21%) in 1976 (Human Resource and Skills

Development Canada, 2010).

2. The labour force moved from bigger size firms to medium and smaller size firms

(Marshall, 2003; Akyeampong & Sussman, 2003). Figure 3 illustrates the significant rise in the number of small size as opposed to large size firms. Again, this is important as employment benefits are strongly tied to the size of the firm. In Canada, the number of employees in large firms (100 or more workers) who had employment-based insurance (extended medical, dental, life/disability) was more than three times higher compared to those working in firms with less than 20 employees (71% vs. 27%) (Marshall, 2003).

Figure 1- Full time/ part time workers (as a % of Canadian population 15 and older)

100

60 FULL-TIME EMPLOYMENT RATE

40 PART-TIME EMPLOYMENT RATE

% ofCanadian% andyrs older15

1976 1982 1984 1990 1998 2004 2006 1980 1986 1988 1992 1994 1996 2000 2002 2008 0 1978

Source: Statistics Canada. Labour Force Historical Review, 2009 (Table 002). Ottawa: Statistics Canada, 2010 (Cat. No. 71F0004XVB)

Figure 2- Permanent and temporary employment rates, 1997-2009 (percent)

100

% PERMANENT EMPLOYMENT RATE

40 TEMPORARY EMPLOYMENT RATE

1997 1999 2001 2003 2008 1998 2000 2002 2004 2005 2006 2007 2009

Source: Statistics Canada. Labour Force Historical Review 2009 (Table 080). Ottawa: Statistics Canada, 2010 (Cat. No. 71F0004XVB)

Figure 3- Number of firms based on their size (in thousands), 1985-2005

1100

1000

900 800 700 0 TO 19 EMPLOYEES 600 20 TO 99 EMPLOYEES 500 400 100 TO 499 EMPLOYEES 300 500 EMPLOYEES AND OVER

Number Number inthousands 200

100

1986 1987 1990 1991 1994 1995 1998 2002 1988 1989 1992 1993 1996 1997 1999 2000 2001 2003 2004 2005 0 1985

Source: Statistics Canada, Longitudinal Employment Analysis Program, 1991 to 2005

3. The number of self-employed workers has been on a significant incline in the last three decades (Figure 4). In the 1990s alone, self-employment grew from 14% in 1990 to 16% by

1997. The majority of the self-employed were without any paid help, which adds financial insecurity to the lack of employment-based benefits including dental care. In 2000, only 35% of the self-employed had dental benefits and among those who had it 52% were covered through spouses or family members. 40% of uninsured self-employed workers cited cost as the main reason for not purchasing dental insurance (Akyeampong & Sussman, 2003).

4. The number of employees covered by unions decreased from 3.8 million in 1990 to 3.5 million by 1997 (Akyeampong, 1997). Although this number increased after 1997, the rate of this increase was outpaced by the employment rate. Hence, the percentage of unionized workers, as a fraction of all workers, has been on the decline since 1997 (Figure 5).

Overall, the labour market is moving towards more non-standard jobs. Similar trends are observed in the United States. As of 1980, 56% of all full-time employees of medium and large private establishments in the US participated in an employer-provided dental care plan.

Participation reached 77% in 1984, but fell to 57% by 1995. A recent survey of full- and part- time workers in private industry found that only 32% received dental care benefits through their employers in 1999 (Wall & Brown, 2003). As the number of temporary, part-time, self- employed and smaller size firms continues to increase, it is expected to observe larger numbers of people without dental benefits.

Figure 4- Number of self-employed workers (in thousands), 1982-2010

3,000

2,500

2,000 F/M 1,500 M 1,000 F

Number Number in thousands 500

1983 1988 1990 1993 1995 1998 2000 2003 2005 2008 2010 1984 1985 1986 1987 1989 1991 1992 1994 1996 1997 1999 2001 2002 2004 2006 2007 2009 0 1982

Source: Statistics Canada, CANSIM, table (for fee) 282-0012 and Catalogue no. 89F0133XIE

Figure 5- Unionization rates (as a percentage of all employed workers), 1997-2009

33 UNION MEMBERSHIP 32

31 As a % of all employed workers all of a%Asemployed

1997 2004 2005 2006 2007 1998 1999 2000 2001 2002 2003 2008 2009

Source: HRSDC calculations based on Statistics Canada. Labour Force Historical Review 2009. Ottawa: Statistics Canada, 2010 (Cat. No. 71F0004XVB)

Changes in the costs of employment-based dental insurance

The rapid rise of employment based dental insurance since its start in late 1960s in addition to its tax subsidies characteristic, caused a significant increase in the number of enrolees and a rise in the expenditures paid by employers. For example, the number of dental benefit contracts rose from 5,000 in 1976 to 18,000 by1982 (Quiñonez, 2009).

As of 1976, the annual cost of providing dental benefits for each employee varied from about $800 in the finance sector to as high as $2000 in the natural resource sector (Quiñonez,

2009). Despite the slower growth rate of employment-based dental benefits in late 1980s, in response to economic recession, the growth in non-wage benefits was greater than that of wages and salaries, to the point that by the end of 1980s, the share of supplementary labour income had doubled since 1976. Dental benefits consisted about one third of all supplementary labour income by 1989; a rise from 23% in 1976 (Quiñonez, 2009).

In addition, the constant increase in the costs of dental care mandates further rise in the costs of dental plans. In response, the sustainability of private dental insurance system in Canada has been criticized as the costs of providing such coverage outpaced the purchasing power of many employers in their role as the main payer for insurance costs (Leake, 2006). For instance, between 1992 and 1993 when the inflation grew by only 1.4%, insurance costs rose up to 21% for some employers. In 2001, a 3% increase in dental fee guide was calculated to impose a rise of

6-7% on costs for employers, and in 2004, the costs of dental plans were sought to rise between

9.5% and 11%. Overall, the 60% rise in dental plan costs since the 1990s as reported by the

Canadian Institute for Health Information (CIHI), makes dental benefits the second-largest cost component of an employer‟s overall health benefit plan (French, 2006).

This sharp rise in the costs of providing dental benefits in concert with economic difficulties affected the dynamic of employment-based dental insurance on both employer and employee sides. First, the overall participation of employers in health insurance premiums decreased and employees‟ share of costs increased. It has been reported that 11% of Ontario employers considered cutting back or removing dental benefits for their employees (Leake,

2006). In the United States, in 1999 about 41% of premiums were paid by employees, a

significant rise from 23% in 1990 (Bailit, 1999). In addition, employers paid for the entire premiums of 30.7% of employees in 1999, while this number dropped to 27.6% by 2002. This decline was more dramatic in smaller firms (39.2% to 33.6%) (Holahan, 2003).

Also, while some employers dropped offering dental insurance completely, many began to offer other forms of benefits such as voluntary (employee pays the entire premium) or referral

(employee pays the entire service fee) plans that let the employees use discounted fees from selected providers (Bailit, 1999). “Flex benefit plans” were also invented, which gave the choice to employees to pick from different benefits (Leake, 2006; Quiñonez, 2009). To further control expenditures, policies were put in place in order to restrict the maximum annual expenditures by each enrolee. Importantly, this maximum amount has not been changed considerably in Canada and the US over more than 10 years despite the continuous growth in dental care costs (Bailit,

1999; Scott-Clarke, 2009).

On the other end, many employees started to decline health benefits due to the increases in costs of being enrolled in such plans. Some believe that the employees‟ role in the decline of overall employment-based dental insurance is more prominent than the employers‟ (Bailit,

1999). In Canada, for example, the annual growth rate of private health insurance declined from around 17% in 1989 to around only 4% (its lowest) by 1997 (Quiñonez & Grootendorst, 2011).

Reportedly, these changes affected employees disproportionally, with low and middle-income earners being most affected (Quiñonez & Grootendorst, 2011; Blumberg & Holahan, 2004). In the United States, among lower-middle income families (200-400% of Federal Poverty Line) employment-based dental insurance declined from 80.2% in 1999 to 77.4% by 2002. However, this decrease was offset by the rise in public coverage and individual private insurance. Yet, the upper-middle class (400-600% of FLP) has experienced a slight increase in their health benefit

plans. Further analysis revealed that this was only true among non-parent employees. In fact, children in these upper-middle income families faced an actual decrease in dental insurance and their overall uninsured rate was increased due to the high costs of the premiums for dependents.

Importantly, self-reported unmet needs increased as the coverage declined. For example, reported unmet needs for dental care among the upper middle income (who experienced a decrease in insurance) rose from 3.9% in 1999 to 5.4% by 2002 (Blumberg & Holahan, 2004).

Generally speaking, the availability of employment-based dental insurance is on the decline. While there is no data on this topic available in Canada, it is estimated that in the United

States 1 to 2 million people lose their employment based dental insurance each year (Bailit,

1999). The number of enrolees in the employment based health insurance system decreased significantly from 72.2% in 1999 to 70.5% in 2002 for all income levels (Holahan, 2003).

Changes in out-of-pocket expenditures

Changes in the out-of-pocket expenditures represent both the level of affordability as well as individual preferences. In the absence of appropriate coverage, households are forced to spend more money on dental care if they decide to seek care (Chaplin & Earl, 2000). Hence, out-of- pocket expenditures on dental care by households have been previously used as a proxy measure for access to dental care (Quiñonez, 2009; Quiñonez & Grootendorst, 2011). As dental plans increase affordability for the enrolled population, the amount of out-of-pocket expenditures among enrolees is negatively associated with the extent of coverage the plan provides (Quiñonez,

2009).

Existing literature on total dental expenditures indicates that dental care expenses have increased well beyond the rate of inflation and population growth since the 1980s (Leake, Porter,

& Lewis, 1993; Baldota & Leake, 2004). Nonetheless, this increase is largely associated with the rise in private out-of-pocket expenditures as opposed to an increase in public financing or insurance. For instance, during the 1990s and despite the decline in public funds for dental care, private expenditures substantially increased from $3.7 billion to $6.4 billion dollars. Importantly, the percentage of private expenditures which was paid through insurance only rose slightly from

53.2% to 55% (Baldota & Leake, 2004).

Figure 6 represents the results of a study by Quiñonez & Grootendorst (2011). The curves in this figure show the level of out-of-pocket expenses determined by the level of coverage and a household‟s income in different time periods. Up until the 1960s when public and private financing were at their minimum levels, expenditures for all income earners were strongly and linearly correlated to a household‟s income. During the 1970s, both public and private financing grew rapidly and public financing reached its peak in the early 1980s accounting for about 25% of all dental expenditures. As a result, in this time period all households spent less on dental care.

Over the 1980s and 1990s, government financing and employment-based dental insurance began to decline significantly due to economic recession. In response, out-of-pocket expenditures on dental care increased among households with lower and middle incomes starting from the early

1980s, and the specified households spent more out of their pocket on dental care compared to their highest income counterparts (Quiñonez & Grootendorst, 2011).

Figure 6- Household Budgetary shares for dental care, 1969-2003

Source: (Quiñonez & Grootendorst, 2011)

Demonstrated by this study, is the negative association between lessened public and private financing on out-of-pocket expenditures. It is worth noting that the unfavourable effects of this association burdens those in the lower and middle income range more significantly, meaning that lower and middle incomes show the most sensitivity to changes in amounts and types of available dental plans. In addition, those in the middle income spectrum have the highest budgetary share for dental care which has increased steadily from 1982 to 2003. Importantly, the authors indicate that those paying out-of-pocket for their dental care are more likely to report unfavourable oral health indicators (i.e. oral pain, staying in bed due to oral health issues within last two weeks) (Quiñonez & Grootendorst, 2011).

In summary, there is a correlation between being uninsured or underinsured and out-of- pocket expenses. The steep rise in total out-of-pocket expenditures across the whole population, with middle income households being the highest payers and those most sensitive to insurance

fluctuations, bring up concerns about insufficient dental insurance and potentially compromised access to dental care among this income group.

Evidence from the American health care system

The type of delivery and financing of the American health care system is comparable to the Canadian dental care system in the sense that access to both systems is highly dependent on having insurance, specifically employment-based dental insurance. Hence, evidence from the

United States can be relevant to the Canadian dental care system.

In the United States, increasingly being uninsured is a concern for those with middle and higher-incomes. For example, between 1995 and 2001, the number of uninsured households with annual incomes of more than $77,000 and between $50,000 to $74,999 rose by 77% and 47% respectively, while the number of uninsured households with annual incomes less than $25,000 dropped by 22% (Benko, 2003).

According to a 2001 survey, 40% of large employers declared the need for their employees to pay a higher percentage of total costs of premiums and co-payments in the coming year (Falen, 2004). Whereas between 1999 and 2009 in the United States, the average annual health insurance premiums and workers‟ contributions for family coverage rose 131% and 128% respectively. If this trend continuous middle-income families may eventually be left out of the health insurance market. More than 80% of uninsured children and adults younger than 65 years live in working families, which conflicts with the common concept that uninsured people are young, healthy adults who voluntary opt out of their employment coverage because they feel they do not need it. Although working improves the likelihood of being insured both for workers

and their dependants, it is not a guarantee. Even members of families with 2 full-time earners still have almost a 10% chance of being uninsured (Kaiser Family Foundation, 2009).

The middle-class

Different definitions of middle class have been developed by different studies and many of them are based on an income level reference (Savage, 2009). In my study, middle class will be defined based on the middle income level as established by Statistics Canada, and is a product of household‟s annual income and a household‟s size. More details about middle income are provided in the “Methodology” section of this study.

Not to lose their ground, middle-class Canadians struggle with a number of social dilemmas. On one hand, the earning of middle-class workers in Canada grew close to nothing during a 25 year period, from 1980 till 2005, after adjusting for inflation (Statistics Canada,

2008). On the other hand, middle- income jobs (mostly manufacturing jobs) have been transferred to lower-wage countries to the point that Canada lost nearly 322,000 manufacturing jobs from 2004 to 2008, with more than one in seven manufacturing jobs disappearing over the period (Statistics Canada, 2009). Therefore, middle-class Canadians are being moved to the edges such that between 1970 and 2000 the number of middle-income areas in Toronto diminished significantly and consistently while the number of low-income neighbourhoods increased (Barber, 2007). It can be noted that as a result of these transitions, the middle-class are losing their two main means of access to dental care: income and employment-based insurance.

Objectives of the study

This project aims to identify the trends among middle-class Canadians in terms of access to dental care through the secondary analysis of data regarding dental insurance and utilization patterns. It is hoped that the results will contribute to policy making and will provide direction to future studies on this topic by representing the issue historically.

Hypotheses

This study hypothesizes that since the late 1970s:

1. The number of middle income earners with lower access to dental care has increased;

2. The number of middle income earners who are uninsured has increased;

3. The number of middle-income earners who report out-of pocket expenditures on dental care and the amount of these expenditures have increased.

Methodology

Design overview

This study represents an historical and secondary data analysis of a series of Canadian surveys as provided by Statistics Canada. These surveys were accessed online through the

University of Toronto‟s Data Library, and in person via the Regional Data Centre (RDC) of the

University of Toronto. Due to the sample characteristics of these surveys (provided in Appendix

A), this analysis was limited to Canadians aged 12 years and older living in private households.

This study examined and analysed surveys that collected data on direct and indirect measures of access to dental care, such as utilization of dental care services, dental insurance/benefits and out-of-pocket expenditures on dental care, in order to identify the trends in access to dental care among middle-income Canadians. Due to the limited scope of this project, the initial aim was to restrict the analysis to the variables available through Public Use Microdata Files (PUMF) of the respective surveys. While this remained the main focus, access to extra data through RDC became necessary in few cases as the project unfolded.

Data sources

Relevant and significant secondary data were found in the Canadian Health Measures

Survey (CHMS), Canadian Community Health Surveys (CCHS), National Population Health

Surveys (NPHS), General Social Surveys (GSS), Surveys of Family Expenditures/ Health

Expenditures (FAMEX/ SHS), and Workplace and Employee Surveys (WES). Response rates varied from 65% to about 85% (Appendix A). PUMFs were used for the analysis of CCHS,

NPHS, GSS, FAMEX/SHS. To be able to access data from CHMS and WES a separate proposal

was prepared and an application to RDC was made. After obtaining approval from RDC, data from these sources were allowed to be used only in the University of Toronto‟s RDC area. For any disclosure of these analyses, a disclosure request application needed to be filled and approved. A RDC analyst would review the application and in case of approval, only the requested results of the analysis would be emailed to the researcher. The unweighted counts would not be disclosed.

 The Canadian Health Measure Survey (CHMS) was conducted from 2007 to 2009. The oral component of the CHMS is the most recent and comprehensive data set since 1972 providing data on the oral health status of Canadians, but only on a national level. Oral health status estimates were derived from oral examination of 5,586 participants in 15 sites across

Canada. The CHMS represents 97% of the Canadian population aged 6 to 79 years (Health

Canada, 2010).

 The Canadian Community Health Surveys (CCHS) are a series of cross-sectional surveys collecting data related to the health status, health care utilization and health determinants of

Canadians. Up until 2007, the CCHS was conducted every two years, and since 2007 it began collecting data every year. Its target population was Canadians aged 12 years and older and represents 98% of Canadian provincial residents. Oral health variables are included in the common and optional contents. Common contents were asked from all respondents and were fairly consistent over the years. On the other hand, optional contents were designed to address unique regional level needs, therefore were asked only in some regions in each cycle, and vary in content (Statistics Canada, 2008).

 The National Population Health Survey (NPHS) collected information on the health status and utilization of the Canadian population in addition to socio-demographic data. It

collected both cross-sectional and longitudinal data from 1994 to 1998 (3 cycles), and since 2000 it gathered strictly longitudinal data. NPHS data is composed of three components: the

Households, the Health Institutions, and the North components. This study used health files of the cross-sectional components and the variables of interest were found in 1996/1997 and

1998/1999.

 The General Social Survey (GSS) was designed to monitor changes in the general well- being of Canadians and collected data on social support and living condition trends over time.

These series of surveys were conducted annually since 1985 (except 1987 and 1997). Data on dental care was only gathered in 1985 and 1991.

 The Survey of Family Expenditures/ Health Expenditures (FAMEX/SHS) records detailed annual spending patterns for a nationally and regionally representative sample of private households in Canada, and started in 1978. This study included data from FAMEX/SHS from

1978 to 2009.

 The Workplace and Employee Survey (WES) is designed to explore a broad range of issues relating to employers and their employees. The survey aims to shed light on the relationships among competitiveness, innovation, technology use and human resource management on the employer side and technology use, training, job stability and earnings on the employee side. WES series have collected data annually from 1999. It has longitudinal and cross-sectional components. This study analyzes only the employer side of the cross-sectional components from 1999 to 2006.

Data management

Variables have been checked for their consistency over the years by reviewing and comparing the questions asked to collect each variable (Table 1). A similar approach was applied to explore the consistency of common variables among different surveys. Whenever possible, inconsistencies in categorization were minimized by recoding the original variables into a reference set of variables as provided in Table 2. These reference variables are adopted from the

CHMS. However, when recoding was not allowed due to the surveys‟ administrational limitations, variables were used in their original format and an explanation of their inconsistency is detailed in Tables 1 and 2.

Table 1– Consistency of questions collected common variables through different surveys

DERIVED VARIABLE SURVEY ORIGINAL QUESTION LAST TIME VISITED A GSS (1985, 1991) Not counting when you were an overnight patient, in the DENTIST/ORTHODONTIST NPHS (1996/97, 1998/99) past 12 months, how many times have you seen, or talked CCHS(2001,2003,2005,2007) on the telephone, about your physical, emotional or CHMS (2007-09) mental health with a dentist or orthodontist? PERCEIVED COST-BARRIER REPORT NPHS (1996/97) What are the reasons that you have not been to a dentist CCHS (2001, 2003, 2005, 2007) in the past 3 years? CHMS (2007-09) CHMS: In the past 12 months, have you avoided going to a dental professional because of the cost of dental care? FREQUENCY OF VISITING DENTIST CCHS (2003, 2005, 2007) Do you usually visit a dentist for check-ups: (a) More than once a year; (b) about once a year; (c) less than once a year; (d) only for emergency care?

CHMS (2007-09) CHMS added another response option as “never” DENTAL INSURANCE NPHS (1996/97, 1998/99) Do you have insurance or a government program that CCHS (2003,2005,2007) covers all or part of your dental expenses? CHMS (2007-09) DENTAL BENEFITS PROVIDED BY WES(1999-2005) Please indicate which of the following non-wage benefits EMPLOYER are available to permanent full-time employees at this location Available to all? Dental care Are the following non-wage benefits available to any part- time employees at this location? Dental care % OF MIDDLE-INCOME HOUSEHOLDS FAMEX (1978, 1982, 1984, 1986, In [the reference year].what were the direct costs to WHO REPORT SPENDING ON DENTAL 1990, 1992, 1994, 1996) members of your household for: Dental services, and CARE orthodontic and periodontal procedures, e.g., SHS (1997-2009) examinations, cleanings, fillings, extractions, x-rays, root HOUSEHOLD EXPENDITURES ON canals, and the prescription and fitting of dentures? DENTAL CARE

Table 2– Summary of the variables as used in the analysis

CATEGORIES DESCRIPTION/ COMMENTS INCOME ADEQUACY (MIDDLE) From 1994-2009: - Annual before tax income of family/household, which is a 1. $15,000-$29,999 if household size product of combining household income and size. 1-2 When income adequacy was not available directly through 2. $30,000-$59,999 if household size survey administration: 3-4 - From 1994-2009 used as it was described by Statistics 3. $60,000-$79,999 if household size 5 Canada. or more - Before 1994, middle-income bracket was calculated by using the consumer price index of Canada and converting From 1978 to 1990 shown in Table 3. the Statistics Canada’s categories to the current dollars of each year and rounding the numbers to the nearest thousand SEX 1. Male NA 2. Female AGE 1. 12-19 - Age of the reference person 2. 20-39 - Recoding was done according to the age groups used by 3. 40-59 CHMS 4. 60 and older EDUCATIONAL ATTAINMENT 1. Less than post-secondary - Highest level of education attained by someone in the degree/diploma household/family 2. Post-secondary degree/diploma - Recoding was done according to the categories used by CHMS PROVINCE OF RESIDENCE 1. Ontario - Available through survey administration 2. SK (Not all the variables were collected from all the provinces 3. Quebec each year, Table 5) 4. Alberta 5. BC 6. Manitoba 7. NF 8. PEI 9. NS 10. NB IMMIGRANT STATUS 1. Immigrant - CHMS categorization (born in Canada; born outside 2. Non-immigrant Canada) was used when survey administration directly did not provide immigration status variable.

CHARACTERISTICS EMPLOYMENT SELF-EMPLOYMENT 1. Self-employed - When self-employment was not directly provided by the 2. Employee survey, it was indirectly derived from the other variable indicating the main source of income for household/ family. Those whose main source of income was “self-employment” grouped as “self-employed” and those with the main source of income being “wages and salaries” were grouped as

“employees” WORK SCHEDULE 1. Full time worker - No recoding needed; available through survey 2. Part time worker administration LAST TIME VISITED A DENTIST 1. < 1 year ago -When this variable was not directly available through 2. >= 1 year ago survey administration it was derived by dichotomizing the variable “last time visited a dental professional”, to “within the last year” and “more than one year ago”. PERCEIVED COST-BARRIER REPROT 1. Yes - Available through survey administration 2. No FREQUENCY OF DENTAL VISITS 1. Regularly/occasionally for - The original variable was dichotomized into “only in prevention emergency” and “regular”, including more than once a year, 2. Only in emergency cases once a year, less than once a year DENTAL INSURANCE 1. Yes - Available through survey administration 2. No DENTAL BENEFIT PROVIDED BY 1. Yes - Available through survey administration EMPLOYER 2. No % OF MIDDLE-INCOME Continuous - % of middle-income households reported expenditures on HOUSEHOLDS REPORTING dental care out of all middle-income households EXPENDITURES HOUSEHOLDS EXPENDITURES ON Continuous - Average expenditures per middle-income households DENTAL CARE (2002 constant dollars) reported any spending on dental care

Variables of interest

Middle-income To define the middle-income group, the notion of “income adequacy” was used. Income adequacy is a derived variable taking into account total income of a family and the household‟s size (Statistics Canada, 2009). Income adequacy for Canadian families has been calculated by

Statistics Canada in previous surveys (e.g. NPHS which provides a reference source for years

1994 to 2009). However, before this time period there were no direct calculations regarding income adequacy.

This study used Statistics Canada‟s definition of middle-income bracket for the time period 1994-2009 (Table 3). Initially, contacts were made with Statistics Canada‟s Income

Statistics and Consumer Prices Divisions via email, in order to identify possible sources of information for the pre-1994 period regarding income adequacy, however no relevant data could be gained. As an alternative, income adequacies were manually calculated for those years where categorization was not provided by survey administration. To do this, the original income brackets of 1994-2009 were converted to current dollars for each year prior to 1994 using the

Consumer Price Index (CPI) of Canada. The adjustment between current and constant dollars usually is done to eliminate the impact of widespread price changes. CPI is the most widely used index for household or family incomes, which reflects average spending patterns by consumers in Canada. Table 4 shows the annual rates of the CPI from 1971 to 2010. To convert constant dollars of any year to current dollars, the amount was divide by the index of the aimed year and multiplies by the index of the base year chosen (Statistics Canada, 2011) (in this study, year 2002 was used as the base year, as it is the median year in this time period; therefore minimizing the risk of over- and under-estimation). For example, using the information in Table 4, $10,000 in

1997 would be $11,602 in 2002 constant dollars ($10,000 × 100/90.4 = $11,602). In this study, the calculated brackets were rounded to the nearest thousands. It is worth mentioning that the only surveys that did not provide income adequacy variables were FAMEX/ SHS and GSS 1985.

Table 3-Middle-income brackets 1978- 2009

1978 1982 1984 1985 1986 1990 1992 1994-2009* 1-2 members 5000-10999 8000-15999 9000-17999 9000- 10000-19999 12000-23999 13000-24999 15000-29999 18999

3-4 members 7000-14999 11000-21999 12000-23999 13000- 13000-25999 16000-30999 17000-33999 20000-39999 24999

5 or more 11000-21999 16000-32999 18000-35999 19000- 20000-38999 24000-46999 25000-49999 30000-59999 members 37999

*Defined by Statistics Canada and extracted from different surveys’ documents NOTE: income brackets were only used for those years that were used in this study

Table 4- Consumer Price Index of Canada 1971 to 2010

Year CPI Year CPI Year CPI Year CPI 1971 20.9 1981 49.5 1991 82.8 2001 97.8 1972 21.9 1982 54.9 1992 84.0 2002 100.0 1973 23.6 1983 58.1 1993 85.6 2003 102.8 1974 26.2 1984 60.6 1994 85.7 2004 104.7 1975 29.0 1985 63.0 1995 87.6 2005 107.0 1976 31.1 1986 65.6 1996 88.9 2006 109.1 1977 33.6 1987 68.5 1997 90.4 2007 111.5 1978 36.6 1988 71.2 1998 91.3 2008 114.1 1979 40.0 1989 74.8 1999 92.9 2009 114.4 1980 44.0 1990 78.4 2000 95.4 2010 116.5 Source: Statistics Canada, CANISM tables; http://www40.statcan.ca/l01/cst01/econ46a-eng.htm

Access to dental care measures Dental care utilization and the availability of dental insurance were used as proxies for access to dental care in this project.

Dental insurance and dental benefits

Measures for dental coverage were dental insurance referring to any type of dental coverage available. Dental insurance was derived from the question “Do you have insurance or a government program that covers all or part of your dental expenses?” from all respondents of the respective survey.

The only available survey collecting information on the provider (i.e. employer) side was

WES. It should be considered in the interpretation of the WES data that although data were collected on dental benefits provided by the workplace for full/ part-time employees, such information was only collected from those employers who provide any non-wage benefits for the respective employees (Statistics Canada, 2005).

Utilization

Measures of utilization derived from previously mentioned Canadian surveys and used in this study include: 1) visiting a dentist in the last year; 2) use/ no use of preventive services; and

3) experiencing cost barrier in accessing dental care. Being the most consistent form of question, measures of visiting a dentist in the past were derived from the question “Not counting when you were an overnight patient, in the past 12 months, how many times have you seen, or talked on the telephone, about your physical, emotional or mental health with a dentist or orthodontist?” which was dichotomized as 0 visits and 1 or more visits. Measures of preventive care utilization were derived from the question: “Do you usually visit a dentist for check-ups: (a) More than once a year; (b) about once a year; (c) less than once a year; (d) only for emergency care?”. A

dummy variable was created with the value of 0 if the answer to the question was a, b, or c

(regular/occasional visits for preventive care) and a value of 1 otherwise (visiting only in emergency cases). Measures of financial barriers to accessing dental care in the past were obtained from the question “In the past 12 months, have you avoided going to a dental professional because of the cost of dental care?” in CHMS, and the question “What are the reasons that you have not been to a dentist in the past 3 years?” in other cases. The responses to both questions were grouped as yes or no, with yes indicating an experience of cost restrictions in the past.

Out-of-pocket expenditures

Out-of-pocket expenditures were used in this analysis as an indirect measure of access to dental care. The data was collected consistently from 1978 to 2009 by asking “what were the direct costs to members of your household for: Dental services, and orthodontic and periodontal procedures, e.g., examinations, cleanings, fillings, extractions, x-rays, root canals, and the prescription and fitting of dentures?”. This study analyzed the percentage of middle- income households who reported any out-of-pocket expenditures, as well as the average expenditures per those [middle-income] households who reported spending. The expenditures are reported in continuous format and in 2002 constant dollars.

Sociodemographic variables In addition to reporting the frequency/distribution of each outcome variable among the middle-income as a whole, the middle-income bracket was broken down into subgroups based on the following sociodemographic characteristics:

- Sex - Age

- Education - Province of residence

- Immigrant status - Employment characteristics

Household expenditures and WES data were not further stratified due to data limitations and complexities that were out of the scope of this study.

Analysis plan and data limitations

Analysis For this study, the analysis framework can be divided into two parts:

Middle-income trends

Simple descriptive analyses were conducted to identify historical trends in middle- income dental care access indicators (i.e. utilization patterns, dental insurance, out-of-pocket expenditures). Sociodemographic characteristics as specified previously were taken into account through stratification and reporting of the results as available.

Comparative analyses

In addition to identifying simple trends among middle-income Canadians, comparisons were made between the general trends of middle-income to other income levels (i.e. lowest, lower-middle, higher-middle, and the highest income levels). For the out-of-pocket expenditure data and the years of 1985 and 2005 the comparisons were made between middle-income and high/ low income levels, as due to data and time limitations more detailed categorization was not feasible. Furthermore, detailed middle-income patterns identified among sociodemographic subgroups were compared to those of all the Canadians (referred to as national level), in terms of

dental insurance, last year‟s dental visits, perceived cost-barrier reports, and frequency of visiting.

All PUMF data were analyzed using the Survey Documentation and Analysis (SDA) online tool available through the University of Toronto‟s Data Library Services. SPSS 18 was used for the analysis of those data accessed through the RDC. Sample weightings as calculated by Statistics Canada were used in the analyses. Graphs were created using only years that data were collected nationally. In addition, for all the years with national level data, indexes of change have been calculated using the following formula: the value of each of the years in a time period/ beginning year‟s value × 100 (Organization for Economic Co-operation and Development

(OECD), 2008).

Data limitations This study had several limitations. It is a secondary analysis of data provided by Statistics

Canada therefore relies heavily on the availability of consistent data. Although most outcomes and sociodemographic variables were collected consistently over the years as well as between different surveys, unfortunately there were some instances of inconsistency. These inconsistencies were minimized by using CHMS variable definitions as reference and re- categorizing variables whenever necessary (Table 2). Nonetheless, still some inevitable variations in data collection and definitions exist which are as follows:

 Income: The years 2005 and 2007 of the CCHS did not provide income adequacy data and the categorical income variable available did not allow for recoding into the desirable format. The available income variable had 5 categories: 1) NO OR <$15,000 2) $15,000-$29,999

3) $30,000-$49,999 4) $50,000-$79,999 5) $80,000 OR MORE. This variable was recoded and middle-income defined as $15,000-$29,999 if household size 1-2 and $30,000-$49,999 if

household size 3 or more. It is recommended that data from these two years be interpreted with caution.

 Dental insurance: As illustrated in Table 4, dental insurance data in the CCHS for the years 2005 and 2007 was only collected from some provinces, as opposed to the whole Canada.

In 2005, it was asked in Ontario and Saskatchewan, while in 2007 data were collected only from the province of Newfoundland and Labrador. To be more generalizable, these years were excluded from graphs and interpretation of the results.

 Survey coverage: Some oral health variables in the CCHS series are part of the optional module. This means that these variables have not been collected from all 10 provinces, rather asked only in a few provinces each year. This leads to less generalizable results. Table 5 illustrates types of data collected in each year and the provinces they represent. While the CHMS

2007-09 does not allow for provincial level analysis, but because the data was estimated to be

97% representative of Canada, it is marked as covering all provinces in this table. Only years with national level data were included in graphs and interpretation of the results. Data regarding perceived cost-barrier from year 2003 was treated as national level data as it was collected from the majority of the provinces.

Table 5- Coverage of each outcome variable according to the province and reference year

1985 1991 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2009 Dental insurance O ntario ● ● ● ● ● SK ● ● ● ● ● Q uebec ● ● ● ● Alberta ● ● ● ● BC ● ● ● ● Manitoba ● ● ● ● NF ● ● ● ● ● PEI ● ● ● ● NS ● ● ● ● NB ● ● ● ● ● Visited a dentist in the last year O ntario ● ● ● ● ● ● ● ● ● SK ● ● ● ● ● ● ● ● ● Q uebec ● ● ● ● ● ● ● ● ● Alberta ● ● ● ● ● ● ● ● ● BC ● ● ● ● ● ● ● ● ● Manitoba ● ● ● ● ● ● ● ● ● NF ● ● ● ● ● ● ● ● ● PEI ● ● ● ● ● ● ● ● ● NS ● ● ● ● ● ● ● ● ● NB ● ● ● ● ● ● ● ● ● Perceived cost-barrier O ntario ● ● ● ● ● SK ● ● ● ● Q uebec ● ● ● Alberta ● ● ● ● ● BC ● ● ● Manitoba ● ● NF ● ● ● ● PEI ● ● ● NS ● ● NB ● ● Frequency of visits O ntario ● ● ● SK ● ● Q uebec ● Alberta ● BC ● ● Manitoba ● NF ● ● PEI ● NS ● NB ● Dental benefits on the employer side O ntario ● ● ● ● ● ● ● ● SK ● ● ● ● ● ● ● ● Q uebec ● ● ● ● ● ● ● ● Alberta ● ● ● ● ● ● ● ● BC ● ● ● ● ● ● ● ● Manitoba ● ● ● ● ● ● ● ● NF ● ● ● ● ● ● ● ● PEI ● ● ● ● ● ● ● ● NS ● ● ● ● ● ● ● ● NB ● ● ● ● ● ● ● ● % of households spending on dental care and average out-of-pocket expenditures on dental care Asked in all 10 provinces in specified years

Results

Results are presented in two parts: 1) middle-income trends which includes access to dental care patterns identified among middle-income Canadians as well as trends identified among middle-income subgroups. Also, comparisons are made between overall trends seen among middle-income and other income levels; 2) middle-income trends in comparison to national trends which presents comparisons between each middle-income subgroup and their national counterparts. It is important to consider that this second section is only limited to those access variables that were stratified based on sociodemographic characteristics as well as having national level trends available. Therefore, out-of-pocket expenditures and frequency of visits are excluded.

There are some points that should be highlighted again before presenting results:

1. Only years with national level data were taken into account in identifying patterns, calculating the indexes of change and creating graphs. Yet, the results for all years are provided in Tables 6,

9, 10 and 11 where it indicates, at each given year, which provinces contain data.

2. In the text and graphs lower education refers to those with lower than post-secondary degree/diploma, and higher education refers to those with post-secondary degree/diploma and higher.

Middle-income trends

Dental insurance status

The number of middle-income Canadians with dental insurance increased only slightly from about 43% in 1996 to 48% in 2009, yet there was a decrease between 1998 and 2003 from

43.7% to 40.4%. More details about dental insurance status of middle-income earners is

provided in Table 6. Importantly, by 2009 middle-income earners had the lowest rate of dental insurance compared to all other income levels (Figure 7 and Table 7).

As represented in Table 6, adolescents from middle-income households had the highest rates of dental insurance between 1996 and 2009, while the lowest rates were among older adults and self-employed respondents. For instance, in 2009, about 61% of 12-19 year olds were insured whereas only 27% and 29% of elderly and self-employed middle-income earners were insured.

Figure 7- Availability of dental insurance among Canadians according to income level, 1996 -2009

100%

80% LOWEST

60% LOWER-MIDDLE

MIDDLE-INCOME OVERALL 40% HIGHER-MIDDLE 20% HIGHEST

0% 1996 1998 2003 2009

Table 6- Availability of dental insurance among middle-income Canadians by sociodemographic characteristics, 1996-2009

1996 1998 2003 2005* 2007* 2009 SEX FEMALE 43.0% 43.2% 40.4% 45.7% 59.1% 51.8% INDEX OF CHANGE 100 100.5 94.0 NA NA 120.5 MALE 43.3% 44.2% 40.4% 44.5% 47.5% 44.9% INDEX OF CHANGE 100 102.1 93.3 NA NA 103.7 AGE GROUPS 12-19 62.4% 59.5% 59.9% 61.9% 63.2% 61.0% INDEX OF CHANGE 100 95.4 96.0 NA NA 97.8 20-39 47.2% 46.8% 47.8% 55.2% 53.5% 52.6% INDEX OF CHANGE 100 99.2 101.3 NA NA 111.4 40-59 45.0% 43.1% 43.3% 51.4% 55.0% 48.5% INDEX OF CHANGE 100 95.8 96.2 NA NA 107.8 60-79 25.3% 23.9% 23.3% 24.2% 45.4% 27.4% INDEX OF CHANGE 100 94.5 92.1 NA NA 108.3 EDUCATIONAL ATTAINMENT = POST-SEC GRADUATION 45.8% 45.1% 64.2% 47.0% 58.2% 48.3% INDEX OF CHANGE 100 98.5 140.2 NA NA 105.5 PROVINCE OF RESIDENT ONTARIO 52.2% 50.2% 46.4% 44.5% NA ** INDEX OF CHANGE 100 96.2 88.9 85.2 NA ** SK 45.1% 46.5% 48.2% 52.5% NA ** INDEX OF CHANGE 100 103.1 106.9 1.6 NA ** QUEBEC 27.8% 30.4% 28.3% NA NA ** INDEX OF CHANGE 100 109.4 101.8 NA NA ** ALBERTA 54.3% 56.4% 52.0% NA NA ** INDEX OF CHANGE 100 103.9 95.8 NA NA ** BC 46.8% 43.2% 40.0% NA NA ** INDEX OF CHANGE 100 92.3 85.5 NA NA ** MANITOBA 46.9% 48.2% 49.1% NA NA ** INDEX OF CHANGE 100 102.8 104.7 NA NA ** NF 37.5% 31.1% 32.1% NA 53.2% ** INDEX OF CHANGE 100 82.9 85.6 NA 1.4 ** PEI 42.1% 38.7% 40.7% NA NA ** INDEX OF CHANGE 100 91.9 96.7 NA NA ** NS 43.7% 46.3% 40.6% NA NA ** INDEX OF CHANGE 100 105.9 92.9 NA NA ** NB 49.6% 49.3% 41.0% NA NA ** INDEX OF CHANGE 100 99.4 82.7 NA NA ** IMMIGRATION STATUS IMMIGRANT 42.1% 41.2% 37.8% 40.1% 77.7% 46.4% INDEX OF CHANGE 100 97.9 89.8 NA NA 110.2 NON-IMMIGRANT 43.3% 44.3% 41.2% 48.1% 52.9% 49.7% INDEX OF CHANGE 100 102.3 95.2 NA NA 114.8 EMPLOYMENT CHARACTERISTICS SELF-EMPLOYED NA NA 26.5% NA 24.6% 29.2% INDEX OF CHANGE NA NA 100 NA NA 110.2 EMPLOYEE NA NA 49.6% NA 61.8% 50.9% INDEX OF CHANGE NA NA 100 NA NA 102.6 FULL-TIME 48.9% 47.9% 45.8% 53.6% 60.2% 47.6% INDEX OF CHANGE 100 98.0 93.7 NA NA 97.3 PART-TIME 46.2% 42.8% 44.6% 51.2% 46.3% 47.5% INDEX OF CHANGE 100 92.6 96.5 NA NA 102.8 MIDDLE-INCOME 43.1% 43.7% 40.4% 45.2% 53.2% 48.7% INDEX OF CHANGE 100 101.4 93.7 NA NA 113.0 NATIONAL AVERAGE 55.1% 58.9% 61.0% 67.7% 55.8% 68.1% INDEX OF CHANGE 100 106.9 110.7 NA NA 123.6 * 2005 and 2007 used different definition of middle-income. Refer to methodology section. ** Provincial level data not available NA= data not available/applicable

Table 7- Comparisons between middle-income and other income levels 1985 1991 1996 1998 2001 2003 2005* 2007* 2009 DENTAL INSURANCE LOWEST NA NA 25.4% 35.2% NA 45.3% 40.4% 25.0% 60.7% INDEX OF CHANGE NA NA 100 138.6 NA 178.3 NA NA 239.0 LOWER-MIDDLE NA NA 23.5% 32.0% NA 33.7% NA 27.7% 52.8% INDEX OF CHANGE NA NA 100 136.2 NA 143.4 NA NA 224.7 MIDDLE NA NA 43.1% 43.7% NA 40.4% 45.2% 53.2% 48.7% INDEX OF CHANGE NA NA 100 101.4 NA 93.7 NA NA 113.0 HIGHER-MIDDLE NA NA 68.2% 67.1% NA 62.6% NA 74.5% 63.5% INDEX OF CHANGE NA NA 100 98.4 NA 91.8 NA NA 93.1 HIGHEST NA NA 76.7% 80.0% NA 79.6% 77.1% 86.2% 80.3% INDEX OF CHANGE NA NA 100 104.3 NA 103.8 NA NA 104.7 LAST TIME VISITED THE DENTISTI LOWEST 32.6% 33.4% 42.4% 39.9% 44.0% 45% 43.3% 41.7% 45.2% INDEX OF CHANGE 100.0 102.5 130.1 122.4 135.0 137.1 132.8 127.9 138.7 LOWER-MIDDLE 32.6% 36.4% 43.3% 40.9% 38.7% 41% NA 49.9% 60.9% INDEX OF CHANGE 100 111.7 132.8 125.5 118.7 126.7 NA 153.1 186.8 MIDDLE 38.1% 46.7% 54.1% 48.9% 46.8% 49% 48.7% 60.2% 61.3% INDEX OF CHANGE 100 122.6 142.0 128.3 122.8 128.1 127.8 158.0 160.9 HIGHER-MIDDLE 58.2% 61.5% 67.7% 64.0% 61.9% 64% NA 68.5% 69.3% INDEX OF CHANGE 100 105.7 116.3 110.0 106.4 110.7 NA 117.7 119.1 HIGHEST 58.2% 76.3% 80.0% 77.7% 75.8% 78% 71.3% 78.9% 83.7% INDEX OF CHANGE 100 131.1 137.5 133.5 130.2 133.8 122.5 135.6 143.8 PERCEIVED COST- BARRIER LOWEST NA NA 19.0% NA 16.7% 23.4% 23.1% 17.6% 40.0% INDEX OF CHANGE NA NA 100 NA NA 123.2 NA NA 210.5 LOWER-MIDDLE NA NA 13.1% NA 19.2% 17.0% 23.1% 16.1% 33.2% INDEX OF CHANGE NA NA 100 NA NA 129.8 NA NA 253.4 MIDDLE NA NA 12.6% NA 16.5% 20.3% 29.8% 15.0% 34.1% INDEX OF CHANGE NA NA 100 NA NA 161.1 NA NA 270.6 HIGHER-MIDDLE NA NA 9.7% NA 14.1% 17.3% 17.5% 19.2% 19.5% INDEX OF CHANGE NA NA 100 NA NA 178.4 NA NA 201.0 HIGHEST NA NA 8.8% NA 10.8% 13.0% 17.5% 13.2% 8.8% INDEX OF CHANGE NA NA 100 NA NA 147.7 NA NA 100 FREQUENCY OF VISITS LOWEST NA NA NA NA NA 39.1% 41.5% 57.7% 29.2% INDEX OF CHANGE NA NA NA NA NA NA NA NA NA LOWER-MIDDLE NA NA NA NA NA 45.0% 41.5% 57.7% 30.1% INDEX OF CHANGE NA NA NA NA NA NA NA NA NA MIDDLE NA NA NA NA NA 35.0% 36.3% 36.7% 30.0% INDEX OF CHANGE NA NA NA NA NA NA NA NA NA HIGHER-MIDDLE NA NA NA NA NA 19.0% 13.9% 12.8% 19.8% INDEX OF CHANGE NA NA NA NA NA NA NA NA NA HIGHEST NA NA NA NA NA 8.6% 13.9% 12.8% 8.1% INDEX OF CHANGE NA NA NA NA NA NA NA NA NA * 2005 and 2007 used different definition of income levels. Refer to methodology section. NA= data not available/ applicable

Figure 8- Availability of dental insurance among middle-income Canadians, indexes of change as of 2009

140 120 100 80 60 40

Indexes of change 20

20 40

12_19

NON

SELF

EMPLOYEE FULL

60+

POST

F PART

0 M

MMIGRANT

ESS

EMALE

IPLOMA

SECONDARY

IDDLE

ALE

- -

39 59

OVERALL

EMPLOYED

THAN

IMMIGRANTS

TIME

SECONDARY

TIME

INCOME

DEGREE

POST

…

The growth of dental insurance varied among middle-income Canadians with different sociodemographic characteristics (Figure 8). The highest growth in dental insurance rates, as represented by the index of change, was seen among females and those with educational attainment of lower than post-secondary graduation (Figures 9 and 10). In fact, by 2009, 54% of middle-income earners with lower than post-secondary graduation were insured as opposed to about 48% of those with higher educational attainment. Importantly, while between 2003 and

2009 the latter experienced a decline of 58% to about 48%, those with lower than post-secondary graduation experienced a rise from 40% to about 54%. The lowest growths were among adolescents and full-time workers with indexes of change of 97.8 and 97.2 respectively.

Figure 9- Availability of dental insurance among middle-income Canadians and sex, 1996-2009

100%

80%

60% FEMALE 40% MALE

20%

0% 1996 1998 2003 2009

Figure 10- Availability of dental insurance among middle-income Canadians and educational attainment, 1996-2009

100%

80%

60% LOWER EDUCATION 40% HIGHER EDUCATION

20%

0% 1996 1998 2003 2009

Looking at non-wage benefits provided through the workplace shows that the number of

Canadian employers offering dental benefits to their employees, whether full- or part-time, has increased between 1999 and 2006 (Figure 11 and Table 8). By 2006, the number of employers who offered dental benefits to their permanent full-time employees was close to four times higher than that of part-time employees.

Figure 11- Dental benefits available through workplace and work schedule, 1999-2006

100%

80%

60% FULL-TIME PERMANENT 40% PART-TIME 20%

1999 2000 2001 2002 2003 2004 2005 2006

Table 8- Dental benefits available through workplace and work schedule and indexes of change, 1999-2006

PERMANENT FULL-TIME PART-TIME NO NON-WAGE BENEFIT Dental benefit index of change NO NON-WAGE BENEFIT Dental benefit Index of change (%) (%) for dental benefit (%) (%) for dental benefit 1999 59.5 28.1 100 76.3 8.8 100 2000 55.9 31.6 112.5 73.9 9.3 105.7 2001 59.3 30.5 108.5 76.2 9.3 105.7 2002 56.4 30.9 110.0 74.9 8.8 100.0 2003 56.2 31.8 113.2 73.5 10.9 123.9 2004 52.7 35.2 125.3 72.1 12.1 137.5 2005 53.1 34.6 123.1 72.8 10.2 115.9 2006 50.2 38.4 136.7 69.1 11.7 133.0

Last year’s dental visit The number of middle-income Canadians who reported dental visits in the last 12 months rose from about 38% in 1985 to 61% in 2009. Yet, there was a slight decrease between 1996 and

2005, from 54% to 49%. More details about middle-income utilization rates are provided in

Table 1. Compared to other income levels, since 1985, middle-income Canadians had the second highest increase in the number of self-reported dental visits after lower middle-income earners

(Figure 12 and Table 9).

Figure 12- Self-reported dental visits in the last year and income level, 1985-2009

100%

80%

60% LOWEST

LOWER-MIDDLE 40% MIDDLE

20% HIGHER-MIDDLE

HIGHEST

1991 1996 1998 2001 2003 2005 2007 2009 0% 1985

Although the overall utilization rate among middle-income Canadians increased since

1985 (index of change=160), not all middle-income groups were affected similarly. The rise

among young adults (20-39 years old), those with higher educational attainment, and the uninsured was only modest (Figure 13). Importantly, the rates of dental visits in the last year among self-employed and part-time workers at the middle-income level have declined over the years (Figure 14). In 2009, only about 40% of self-employed middle-income earners reported any dental visits in the last year, the lowest rate among all middle-income earners and the lowest number since 1991. Between 1985 and 2009, the largest growth in the number of those who made such visits was among older and middle-aged adults in the middle-income group (Figures

13 and 15).

Figure 13- Self-reported dental visits in the last year among middle-income Canadians, indexes of change as of 2009

200

150

100

Indexeschange of

60 40

12_19 I

0 DIPLOMA

UNINSURED

MALE

SELF

EMPLOYEE FULL

PART

MMIGRANT

NSURED

EMALE

IPLOMA

IDDLE

- -

79 79 59 59

OVERALL

ESS

EMPLOYED

TIME

IMMIGRANT

TIME

YEARS YEARS

THAN

INCOME

DEGREE

OLD OLD

* Reference year 1996 ** Reference year 1991

Figure 14- Self-reported dental visits in the last year among middle-income Canadians and job characteristics, 1991-2009

100%

80%

60% SELF-EMPLOYED

40% PART-TIME MIDDLE-INCOME OVERALL

20%

1996 2005 1991 1998 2001 2003 2007 2009 0% 1985

While the rate of utilization decreased among self-employed respondents, it increased among middle-income employees, resulting in a larger gap (58.4% and 39.7% respectively)

(Figure 16). In contrast, the inequalities in visiting a dentist in a one year period based on educational attainment and job schedule have been reduced over the years (Figures 17 and 18).

Similarly, the gap between insured and uninsured middle-income earners became slightly smaller since 1996 (Figure 19)

Figure 15- Self-reported dental visits in the last year among middle-income Canadians and age, 1985-2009

100%

80%

60% 40-59 YEARS OLD

40% 60-79 YEARS OLD

20%

1991 1998 2005 2009 1996 2001 2003 2007 0% 1985

Figure 16- Self-reported dental visits in the last year among middle-income Canadians and self-employment, 1985-2009

100%

80%

60% SELF-EMPLOYED

40% EMPLOYEE

20%

2003 2005 2007 1991 1996 1998 2001 2009 0% 1985

Figure 17- Self-reported dental visits in the last year among middle-income Canadians and educational attainment, 1985- 2009

100%

80%

60% LOWER EDUCATION 40% HIGHER EDUCATION

20%

1985 1991 2003 2005 1998 2001 2007 2009

0% 1996

Figure 18- Last Self-reported dental visits in the last year among middle-income Canadians work schedule, 1985-2009

100%

80%

60% FULL-TIME 40% PART-TIME 20%

1991 1998 2003 2007 1996 2001 2005 2009

Figure 19- Self-reported dental visits in the last year among middle-income Canadians and dental insurance, 1985-2009

100%

80%

60% INSURED

40% UNINSURED

20%

1991 1998 2003 1996 2001 2005 2007 2009 0% 1985

Table 9- Self-reported dental visits in the last year among middle-income Canadians, 1985-2009 1985 1991 1996 1998 2001 2003 2005* 2007* 2009 SEX FEMALE 42.4% 51.4% 57.0% 50.2% 50.6% 52% 52.8% 66.4% 65.3% INDEX OF CHANGE 100 121.2 134.4 118.4 119.3 122.6 124.5 156.6 154.0 MALE 33.9% 41.6% 50.9% 47.5% 42.4% 45% 43.8% 53.8% 56.3% INDEX OF CHANGE 100 122.7 150.1 140.1 125.1 133.3 129.2 158.7 166.1 AGE GROUPS 12-19 62.5% 70.2% 76.7% 70.1% 70.9% 71% 69.8% 76.3% 74.9% INDEX OF CHANGE 100 112.3 122.7 112.2 113.4 114.1 111.7 122.1 119.8 20-39 50.6% 54.9% 57.4% 49.2% 53.3% 51% 52.0% 56.2% 54.9% INDEX OF CHANGE 100 108.5 113.4 97.2 105.3 101.4 102.8 111.1 108.5 40-59 32.1% 41.4% 52.7% 47.7% 54.0% 50% 51.0% 60.3% 60.1% INDEX OF CHANGE 100 129.0 164.2 148.6 168.2 155.5 158.9 187.9 187.2 60-79 28.4% 31.5% 37.9% 34.6% 42.6% 37% 37.4% 58.4% 54.6% INDEX OF CHANGE 100 110.9 133.5 121.8 150.0 131.3 131.7 205.6 192.3 EDUCATIONAL ATTAINMENT = POST-SEC GRADUATION 57.7% 56.2% 68.2% 52.5% 53.7% 54% 54.5% 62.3% 63.5% INDEX OF CHANGE 100 97.4 118.2 91.0 93.1 93.6 94.5 108.0 110.1 PROVINCE OF RESIDENT ONTARIO 47.7% 57.5% 63.8% 53.8% 52.1% 54% 54.4% 63% ** INDEX OF CHANGE 100 120.5 133.8 112.8 109.2 113.8 114.0 132.9 ** SK 32.5% 45.2% 44.9% 45.2% 40.6% 44% 46.4% 55% ** INDEX OF CHANGE 100 139.1 138.2 139.1 124.9 135.4 142.8 168.3 ** QUEBEC 28.6% 36.3% 47.2% 45.5% 41.5% 43% 42.8% 58% ** INDEX OF CHANGE 100 126.9 165.0 159.1 145.1 150.7 149.7 204.2 ** ALBERTA 36.4% 50.2% 52.8% 46.2% 46.7% 48% 47.3% 57% ** INDEX OF CHANGE 100 137.9 145.1 126.9 128.3 132.7 129.9 157.1 ** BC 45.5% 52.0% 58.4% 50.6% 52.6% 56% 53.4% 63% ** INDEX OF CHANGE 100 114.3 128.4 111.2 115.6 123.1 117.4 137.8 ** MANITOBA 41.7% 45.1% 53.3% 48.9% 48.2% 45% 51.4% 58% ** INDEX OF CHANGE 100 108.2 127.8 117.3 115.6 108.4 123.3 138.8 ** NF 32.9% 28.0% 37.3% 39.7% 29.6% 33% 32.9% 50% ** INDEX OF CHANGE 100 85.1 113.4 120.7 90.0 101.2 100.0 151.7 ** PEI 16.3% 51.6% 53.1% 54.5% 50.9% 53% 49.0% 65% ** INDEX OF CHANGE 100 316.6 325.8 334.4 312.3 324.5 300.6 400 ** NS 38.4% 44.4% 50.2% 47.2% 44.0% 46% 45.0% 57% ** INDEX OF CHANGE 100 115.6 130.7 122.9 114.6 118.5 117.2 147.7 ** NB 35.6% 43.1% 43.5% 40.6% 38.9% 39% 43.0% 52% ** INDEX OF CHANGE 100 121.1 122.2 114.0 109.3 109.3 120.8 146.1 ** IMMIGRATION STATUS IMMIGRANT 40.5% 56.8% 59.1% 49.2% 50.0% 50% 51.5% 57.5% 64.0% INDEX OF CHANGE 100 140.2 145.9 121.5 123.5 123.5 127.2 142.0 158.0 NON-IMMIGRANT 37.5% 44.4% 53.0% 48.8% 45.8% 48% 47.8% 61.1% 60.2% INDEX OF CHANGE 100 118.4 141.3 130.1 122.1 129.1 127.5 162.9 160.5 DENTAL INSURANCE INSURED NA NA 70.1% 62.4% NA 63% 71.2% 67.2% 72.9% INDEX OF CHANGE NA NA 100 89 NA 89.9 101.6 95.9 104 UNINSURED NA NA 41.6% 38.1% NA 40% 41.0% 31.6% 49.6% INDEX OF CHANGE NA NA 100 91.6 NA 96.2 98.6 76 119.2 EMPLOYMENT CHARACTERISTICS SELF-EMPLOYED NA 45.0% NA NA 48.2% 52% NA 54.7% 39.7% INDEX OF CHANGE NA 100 NA NA 107.1 115.1 NA 121.6 88.2 EMPLOYEE NA 51.9% NA NA 50.7% 52% NA 60.0% 58.4% INDEX OF CHANGE NA 100 NA NA 97.7 99.6 NA 115.6 112.5 FULL-TIME NA 48.3% 55.5% 49.4% 48.2% 50% 50.5% 58.2% 54.3% INDEX OF CHANGE NA 100 114.9 102.3 99.8 104.1 104.6 120.5 112.4 PART-TIME NA 65.1% 61.8% 55.3% 58.4% 56% 59.2% 64.3% 57.7% INDEX OF CHANGE NA 100 94.9 84.9 89.7 85.9 90.9 98.8 88.6 MIDDLE-INCOME 38.1% 46.7% 54.1% 48.9% 47.1% 49% 48.3% 60.2% 61.3% INDEX OF CHANGE 100.0 122.6 142.0 128.3 123.6 128.1 126.8 158.0 160.9 NATIONAL AVERAGE 50.8% 54.8% 61.6% 59.7% 60.3% 64% 63.8% 64.6% 75.0% INDEX OF CHANGE 100 107.9 121.3 117.5 118.7 125.4 125.6 127.2 147.6 * 2005 and 2007 used different definitions of middle-income. Refer to methodology section. ** Provincial level data not available; NA= data not available/applicable

Perceived cost-barrier reports The number of middle-income Canadians who reported financial barriers to dental care increased notably from 12.6% in 1996 to about 34% in 2009 (Figure 20). Importantly, middle- income Canadians had the largest rise in the rates of these reports among all income groups with an index of change of 270.6 by 2009.

Figure 20- Perceived cost-barriers reported by Canadians according to income level, 1996-2009

100%

80%

60% LOWEST LOWER-MIDDLE

40% MIDDLE

HIGHER-MIDDLE 20% HIGHEST 0% 1996 2003 2009

As shown in Table 10, among all middle-income groups, older adults and the insured were least likely to report cost-barriers to dental care since 1996. Adolescents had very low rates of reporting cost-barriers in 1996 and 2009, yet the rates were higher in 2003 (Figure 21).

Figure 21- Perceived cost-barriers reported by middle-income Canadians and age, 1996-2009

100%

80%

12-19 60% 20-39 40% 40-59 60-79 20%

0% 1996 2003 2009

Young adults had one of the highest rates of reporting cost-barriers from 1996 to 2009

(Table 10). Interestingly, as represented by the indexes of change, the number of these reports grew the fastest among older and middle-aged adults as well as the uninsured whereas the respective rise among young adults and those with higher educational attainment was the lowest

(Figure 22). It is worth noting that as a result of varying growth rates, inequalities among some middle-income subgroups have increased since 1996. The widest gap regarding financial barriers to dental care was seen among the insured and uninsured (Figure 23). While the number of insured persons reporting such barriers grew from about 9% in 1996 to 17% in 2009, the number of uninsured who made such reports rose from 14% to 50%.

Similarly, while in 1996 the number of full- and part-time middle-income workers reporting cost-barriers was almost the same (about 20%); by 2009 higher number of full-time workers reported such cost-barriers compared to their part-time counterparts (47.2% and 32.7% respectively) (Figure 24). A similar trend was found when looking at immigrant and non- immigrant middle-income earners (Figure 25).

Importantly, middle-income Canadians with higher education were more likely to report financial barriers to dental care compared to those with lower educational attainment (Figure 26).

As well, self-employed workers were less likely to cite cost as their main reason for not visiting a dentist compared to paid employees.

Figure 22-Perceived cost-barriers reported by middle-income Canadians, indexes of change as of 2009

800 600 400

200

Indexe of change

SELF

UNINSURED

HIGHER HIGHER EDUCATION

LOWER EDUCATION

20 40 60

12_19

PART

EMPLOYEE FULL

0 M

NSURED

MMIGRANT

EMALE

IDDLE

ALE

- - -

39 59 79

EMPLOYED

IMMIGRANT

TIME

INCOME

Figure 23 - Perceived cost-barriers reported by middle-income Canadians and dental insurance, 1996-2009

100%

80%

60% INSURED 40% UNINSURED

20%

0% 1996 2003 2009

Figure 24- - Perceived cost-barriers reported by middle-income Canadians and work schedule, 1996-2009

100%

80%

60% FULL-TIME 40% PART-TIME

20%

0% 1996 2003 2009

Table 10- Perceived cost-barriers reported by middle-income Canadians, 1996-2009 1996 2001 2003 2005* 2007* 2009 SEX FEMALE 14.2% 18.1% 20.8% 19.9% 18.2% 37.1% INDEX OF CHANGE 100 NA 146.5 NA NA 261.3 MALE 11.2% 14.9% 19.8% 19.6% 13.0% 30.6% INDEX OF CHANGE 100 NA 176.8 NA NA 273.2 AGE GROUPS 12-19 7.1% 15.5% 27.3% 22.8% 26.7% 18.7% INDEX OF CHANGE 100 NA 384.5 NA NA 263.4 20-39 32.6% 36.9% 40.3% 40.5% 35.5% 45.8% INDEX OF CHANGE 100 NA 123.6 NA NA 140.5 40-59 11.2% 21.7% 28.0% 26.8% 7.5% 41.0% INDEX OF CHANGE 100 NA 250 NA NA 366.1 60-79 3.2% 4.0% 5.4% 6.3% 1.4% 23.5% INDEX OF CHANGE 100 NA 168.8 NA NA 734.4 EDUCATIONAL ATTAINMENT = POST-SEC GRADUATION 21.7% 19.9% 24.9% 27.6% 17.3% 37.5% INDEX OF CHANGE 100 NA 114.7 NA NA 172.8 PROVINCE OF RESIDENT ONTARIO 15.3% 15.7% 24.5% 22.1% NA ** INDEX OF CHANGE 100 102.6 160.1 144.4 NA ** SK 12.2% NA 18.4% 13.3% NA ** INDEX OF CHANGE 100 NA 150.8 109.0 NA ** QUEBEC 11.8% NA 14.9% NA NA ** INDEX OF CHANGE 100 NA 126.3 NA NA ** ALBERTA 21.4% 19.2% 23.0% NA 18.0% ** INDEX OF CHANGE 100 89.7 107.5 NA 84.1 ** BC 8.7% NA 27.7% NA NA ** INDEX OF CHANGE 100 NA 318.4 NA NA ** MANITOBA 11.0% NA NA NA NA ** NF 7.5% NA NA 7.2% 5.3% ** INDEX OF CHANGE 100 NA NA 96 70.7 ** PEI 8.5% NA 20.2% NA NA ** INDEX OF CHANGE 100 NA 237.6 NA NA ** NS 11.6% NA NA NA NA ** NB 8.6% NA NA NA NA ** IMMIGRATION STATUS IMMIGRANT 13.1% 13.0% 23.2% 22.2% 9.1% 39.7% INDEX OF CHANGE 100 NA 177.1 NA NA 303.1 NON-IMMIGRANT 12.6% 18.2% 19.3% 18.5% 16.3% 31.8% INDEX OF CHANGE 100 NA 153.2 NA NA 252.4 DENTAL INSURANCE INSURED 8.9% NA 12.7% 17.0% 2.1% 17.1% INDEX OF CHANGE 100 NA 142.7 NA NA 192.1 UNINSURED 13.8% NA 30.6% 23.5% 6.8% 50.0% INDEX OF CHANGE 100 NA 221.7 NA NA 362.3 EMPLOYMENT CHARACTERISTICS SELF-EMPLOYED NA 20.4% 25.8% NA 20.1% 34.6% INDEX OF CHANGE NA NA 126.5 NA NA 169.6 EMPLOYEE NA 29.8% 34.9% NA 20.3% 44.3% INDEX OF CHANGE NA NA 117.1 NA NA 148.7 FULL-TIME 19.6% 28.2% 32.5% 30.2% 18.2% 47.2% INDEX OF CHANGE 100 NA 165.8 NA NA 240.8 PART-TIME 19.9% 26.4% 34.4% 29.4% 51.3% 32.7% INDEX OF CHANGE 100 NA 172.9 NA NA 164.3 MIDDLE-INCOME 12.6% 16.5% 20.3% 20.8% 15.0% 34.1% INDEX OF CHANGE 100 NA 161.1 NA NA 270.6 NATIONAL AVERAGE 12.2% 15.0% 17.8% 19.2% 16.2% 17.3% INDEX OF CHANGE 100 NA 145.9 NA NA 141.8 * 2005 and 2007 used different definition of middle-income. Refer to methodology section. ** Provincial level data not available; NA= data not available/ applicable

Figure 25 -Perceived cost-barriers reported by middle-income Canadians and immigration status, 1996-2009

100%

80%

60% IMMIGRANT 40% NON-IMMIGRANT

20%

0% 1996 2003 2009

Figure 26- Perceived cost-barriers reported by middle-income Canadians and educational attainment, 1996-2009

100%

80%

60% LOWER EDUCATION 40% HIGHER EDUCATION

20%

0% 1996 2003 2009

Frequency of visits In 2009, about one in every three middle-income Canadians reported that they visited a dentist only when emergencies occur (Table 11). In 2009, among all income groups, middle and lower middle income earners had the highest rates of reporting such visiting patterns (Figure 27).

Unfortunately, the only national level data available on this matter comes from the CHMS 2009.

Figure 27- Visiting a dentist only in case of emergency reported by Canadians according to income level, 2009

100%

80%

60%

40%

20%

0% Lowest Lower-middle Middle Higher-middle highest

Table 11- Visiting a dentist only in case of emergency reported by middle-income Canadians, 2003-2009

2003 2005* 2007* 2009 SEX FEMALE 31.4% 32.4% 27.0% 24.7% MALE 39.4% 41.5% 46.0% 36.5% AGE GROUPS 12-19 12.5% 16.2% 18.7% 22.9% 20-39 33.0% 32.0% 34.2% 26.0% 40-59 34.3% 33.6% 38.4% 33.4% 60-79 47.1% 48.7% 43.8% 45.1% EDUCATIONAL ATTAINMENT = POST-SEC GRADUATION 31.1% 31.0% 30.2% 24.7% PROVINCE OF RESIDENT ONTARIO 34.4% 36.1% NA ** SK NA 38.7% NA ** QUEBEC NA NA NA ** ALBERTA NA NA NA ** BC 30.7% NA NA ** MANITOBA NA NA NA ** NF NA NA 36.7% ** PEI NA NA NA ** NS NA NA NA ** NB NA NA NA ** IMMIGRATION STATUS IMMIGRANT 39.1% 37.8% *** 32.0% NON-IMMIGRANT 32.3% 35.5% 37.1% 29.2% DENTAL INSURANCE INSURED 20.2% 19.9% 20.9% 15.3% UNINSURED 47.2% 50.5% 54.5% 43.6% EMPLOYMENT CHARACTERISTICS SELF-EMPLOYED 37.0% NA 45.7% 35.6% EMPLOYEE 32.6% NA 32.0% 30.2% FULL-TIME 34.9% 34.9% 34.7% 35.3% PART-TIME 28.7% 23.9% 21.5% 22.2% MIDDLE-INCOME 35.0% 28.7% 36.7% 30.0% NATIONAL AVERAGE 19.8% 20.2% 36.9% 16.6% NOTE: National level data was available only for the year 2009; therefore indexes of change were not calculated. * 2005 and 2007 used different definition of middle-income. Refer to methodology section. ** Provincial level data not available; NA= data not available/applicable *** sample number too small to report (unweighted N< 30)

Expenditures The number of middle-income households reporting out-of-pocket expenditures on dental services decreased from 43.4% in 1978 to 36.6% in 2008 (Figure 28). However, the average expenditures per household reporting any expenditures rose from $394 in 1978 to $538 in 2008

(2002 constant dollars) (Figure 29). It is worth noting that between 1996 and 2008 when the number of middle-income households reporting expenditures on dental care declined from about

47% to 37%, the relative change for higher and lower income households was subtle (Figure 28).

Figure 28- Percentage of households reporting expenditures on dental care and income level, 1978-2008

100%

80%

60% LOWER 40% MIDDLE 20%

HIGHER

1978 1982 2002 2003 2004 2005 2006 1986 1990 1992 1996 1997 1998 1999 2000 2001 2007 2008 0% 1984

Average expenditures per household reporting spending is represented in Figure 29 and

Table 12. Looking at average expenditures, between 1978 and 1982 the average expenditures declined for all income levels. Between 1982 and the early 1990s, middle-income families showed the most dramatic changes in out-of-pocket expenditures (as represented by the indexes of change) with a large rise between 1982 and 1984, followed by a steep decline. From early

1990s to early 2000s dental expenditures per middle-income household began to rise faster relative to other income levels with the index of change increasing from 94.0 in 1990 to 124.3 in

2000. In the early 2000s, middle-income household expenditures began to decline, despite a rise

among lower income households. By 2003, lower income households reported more expenditures per household compared to middle-income households. Over the same period, higher-income household expenditures remained relatively stable. Since the mid-2000s, household dental expenditures rose among all income levels yet at different paces. By 2008, middle-income households had the largest rise in out-of-pocket expenditures since 1978 (index of change=136.7).

Figure 29 -Average expenditures on dental care per household reporting any expenditure and income level, 1978-2008

$800 $700 $600 $500 LOWER $400 MIDDLE $300 HIGHER $200

$100

1978 1982 1984 1986 1990 1992 1996 1997 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 $0 1998

Table 12- Out-of-pocket expenditures on dental care reported by Canadians (2002 constant dollars), 1978-2008

AVERAGE EXPENDITURES PER HOUSEHOLD REPORTING % OF HOUSEHOLDS REPORTING EXPENDITURES Year Low- Low- Middle- Middle- High- High- Low- Low- Middle- Middle- High- High- income income income income income income income income income income income income (index of (index of (index of (index of (index of (index of change) change) change) change) change) change) 1978 327.10 100.0 393.69 100.0 563.66 100.0 21.8% 100 43.4% 100 61.3% 100 1982 245.96 75.2 324.50 82.4 509.85 90.5 21.1% 96.8 39.7% 91.5 54.1% 88.3 1984 301.49 92.2 452.26 114.9 554.39 98.4 17.7% 81.2 41.0% 94.5 58.5% 95.4 1986 338.08 103.4 404.09 102.6 552.07 97.9 21.1% 96.8 40.2% 92.6 56.4% 92.0 1990 320.63 98.0 369.96 94.0 556.12 98.7 18.3% 83.9 40.1% 92.4 56.9% 92.8 1992 323.11 98.8 416.11 105.7 504.74 89.5 20.4% 93.6 41.3% 95.2 55.0% 89.7 1996 342.82 104.8 406.02 103.1 535.86 95.1 24.9% 114.2 47.1% 108.5 59.2% 96.6 1997 448.04 137.0 450.17 114.3 533.51 94.7 21.0% 96.3 44.8% 103.2 57.0% 93.0 1998 354.22 108.3 465.17 118.2 549.22 97.4 21.4% 98.2 41.3% 95.2 57.4% 93.6 1999 366.56 112.1 482.50 122.6 594.67 105.5 20.8% 95.4 44.7% 103.0 57.4% 93.6 2000 325.43 99.5 489.35 124.3 575.00 102.0 21.1% 96.8 41.5% 95.6 58.9% 96.1 2001 395.09 120.8 481.98 122.4 581.49 103.2 21.1% 96.8 42.0% 96.8 58.3% 95.1 2002 430.55 131.6 437.52 111.1 587.64 104.3 22.9% 105.0 41.3% 95.2 59.4% 96.9 2003 454.63 139.0 416.11 105.7 598.35 106.2 21.4% 98.2 38.5% 88.7 58.2% 94.9 2004 335.78 102.7 455.65 115.7 579.71 102.8 20.4% 93.6 40.9% 94.2 60.6% 98.9 2005 409.56 125.2 434.27 110.3 633.85 112.5 19.5% 89.4 41.4% 95.4 60.9% 99.3 2006 471.92 144.3 472.39 120.0 666.55 118.3 21.5% 98.6 38.0% 87.6 57.8% 94.3 2007 460.45 140.8 581.76 147.8 660.68 117.2 21.8% 100.0 35.5% 81.8 58.7% 95.8 2008 430.89 131.7 538.02 136.7 725.56 128.7 21.5% 98.6 36.6% 84.3 56.7% 92.5

Middle-income trends in comparison to national trends

Dental insurance

Comparing national trends in dental insurance to middle-income earners, it is clear that while the rates of having dental insurance at a national level rose constantly between 1996 and

2009, from 55.1% to 68.1%, the number of the insured middle-income declined from 43% in

1996 to about 40% in 2003, only increasing to around 48% in 2009. Similar findings appeared when comparing each middle-income subgroup to their national counterparts, resulting in larger gaps in 2009 as compared to 1996 (Table 13). For example, the rates of having dental insurance among those 60-79 years old across all of Canada increased 1.7 times than that of their middle- income counterparts (Figure 30). One exception was the trend seen among middle-income earners with lower education where the gap between them and their national counterparts became smaller over the years (Figure 31).

Figure 30- Availability of dental insurance among 60-79 year olds, middle-income and national average, 1996-2009

100%

80%

60% 60-79(MIDDLE-INCOME)

40% 60-79 (NATIONAL)

20%

1998 2003 2009 0% 1996

Table 13- Availability of dental insurance, middle-income and national average 1996-2009*

1996 1998 2003 2009 SEX FEMALE (M) 43.0% 43.2% 40.4% 51.8% FEMALE (N) 53.9% 58.1% 60.1% 67.8% MALE (M) 43.3% 44.2% 40.4% 44.9% MALE(N) 56.0% 58.8% 62.0% 68.4% AGE GROUPS 12-19(M) 62.4% 59.5% 59.9% 61.0% 12-19(N) 67% 68% 75% 78% 20-39(M) 47.2% 46.8% 47.8% 52.6% 20-39(N) 59% 60% 65% 70.1% 40-59 (M) 45.0% 43.1% 43.3% 48.5% 40-59(N) 62% 65% 68% 71.3% 60-79(M) 25.3% 23.9% 23.3% 27.4% .460-79(N) 29% 31% 36% 46.9% EDUCATIONAL ATTAINMENT < POST-SEC GRADUATION (M) 41.9% 39.8% 35.8% 53.7% < POST-SEC GRADUATION (N) 51% 53% 50% 60.2% >=POST-SEC GRASDUATION (M) 47.0% 45.1% 43.9% 48.3% >=POST-SEC GRASDUATION (N) 63% 65% 66% 71.4% PROVINCE OF RESIDENT ON (M) 52.2% 50.2% 46.4% ** ON (N) 63% 66% 68% ** SK (M) 45.1% 46.5% 48.2% ** SK (N) 50% 58% 65% ** QC (M) 27.8% 30.4% 28.3% ** QC (N) 40% 43% 47% ** AB (M) 54.3% 56.4% 52.0% ** AB (N) 62% 67% 71% ** BC (M) 46.8% 43.2% 40.0% ** BC (N) 59% 60% 61% ** MB (M) 46.9% 48.2% 49.1% ** MB (N) 58% 59% 65% ** NF (M0 37.5% 31.1% 32.1% ** NF (N) 43% 46% 50% ** PEI (M) 42.1% 38.7% 40.7% ** PEI (N) 48% 47% 54% ** NS (M) 43.7% 46.3% 40.6% ** NS (N) 50% 55% 59% ** NB (M) 49.6% 49.3% 41.0% ** NB (N) 53% 57% 60% ** IMMIGRATION STATUS IMMIGRANT (M) 42.1% 41.2% 37.8% 46.4% IMMIGRANT (N) 50% 51% 55% 61.4% NON-IMMIGRANT (M) 43.3% 44.3% 41.2% 49.7% NON-IMMIGRANT (N) 56% 60% 63% 69.9% EMPLOYMENT CHARACTERISTICS SELF-EMPLOYED (M) NA NA 26.5% 29.2% SELF-EMPLOYED (N) NA NA 44% 50.3% EMPLOYEE (M) NA NA 49.6% 50.9% EMPLOYEE (N) NA NA 72% 75.3% FULL-TIME (M) 48.9% 47.9% 45.8% 47.6% FULL-IME (N) 65% 66% 69% 72.6% PART-TIME (M) 46.2% 42.8% 44.6% 47.5% PART-TIME (N) 55% 59% 63% 64.7% MIDDLE –INCOME 43.1% 43.7% 40.4% 48.7% NATIONAL AVERGAE 55.1% 58.9% 62.3% 68.1% M=middle-income, N=national average, NA= data not available/applicable * Only years with national level data included ** Provincial level data not available

Figure 31- Availability of dental insurance among lower education group, middle-income and national average, 1996-2009

100%

80%

60% LOWER EDUCATION(MIDDLE- INCOME) 40% LOWER EDUCATION(NATIONAL) 20%

2003 2009 1996 1998

Another finding that is worth highlighting is the rate of dental insurance among males and females at the middle-income and national levels. While at the national level the numbers of males and females with dental insurance were almost similar since 1996, the number of middle- income females with dental insurance grew larger than their male counterparts between 2003 and

2009 with about 52% of females and 45% of males in the middle-income level being insured in

2009 (Figure 32).

Figure 32- Availability of dental insurance and sex, middle-income and national average, 1996-2009

100%

80%

FEMALE(MIDDLE-INCOME) 60% MALE (MIDDLE-INCOME) 40% FEMALE (NATIONAL) MALE (NATIONAL) 20%

0% 1996 1998 2003 2009

Importantly, while similar numbers of full and part-time middle-income workers reported having dental insurance in 2009, at the national level more full-time workers reported being insured compared to their part-time counterparts (Figure 33).

Figure 33- Availability of dental insurance and work schedule, middle-income and national average, 1996-2009

100%

80%

FULL-TIME (MIDDLE-INCOME) 60% FULL-TIME (NATIONAL) 40% PART-TIME (MIDDLE-INCOME) PART-TIME (NATIONAL) 20%

0% 1996 1998 2003 2009

Last year’s dental visits

Overall there was an increase in the number of Canadians who reported visiting a dentist in the last year as well as among middle-income Canadians since 1985 (Figure 34). Compared to the national average, the middle-income group had lower rates of visiting. In addition, between

1996 and 2005, while the national rate grew slowly, the rate decreased among middle-income earners from 54.1% to 48.7% (Table 14). From 2005 to 2009, both national and middle-income rates began to rise albeit at different paces, especially between 2007 and 2009.

Figure 34- Self-reported dental visits in the last year, middle-income and national average, 1985-2009

100%

80%

60% Middle-income 40% National average

20%

1991 1998 2003 1985 1996 2001 2005 2007 2009

While most middle-income subgroups experienced similar overall changes over the years, there were few exceptions: first the rates of reporting a dental visit among middle-income immigrants rose constantly since 1998 and as a result the respective gap between middle-income immigrants and all Canadian immigrants became smaller in 2009 (Figure 35). The second exception was the trend among middle-income earners with lower educational attainment in comparison to all Canadians with similar educational attainment (Figure 36). Between 2001 and

2007 the rates of dental visit reports among middle-income earners with such educational attainment increased while the national average declined.

Figure 35- Self-reported dental visits in the last year by immigrants, middle-income and national average, 1985-2009

100%

80%

60% IMMIGRANT (MIDDLE-INCOME)

40% IMMIGRANT (NATIONAL)

20%

1991 1996 1998 2001 2003 2005 2007 2009 0% 1985

Figure 36- Self-reported dental visits in the last year by lower education group, middle-income and national average, 1985- 2009

100%

80%

60% LOWER EDUCATION(MIDDLE- INCOME) 40% LOWER EDUCATION (NATIONAL) 20%

1985 1998 2001 2007 2009 1991 1996 2003 2005

Another important pattern was seen when comparing employees and self-employed individuals at the national and middle-income level. At the national level, the number of dental visits in the last year rose among both groups with slightly different rates, with more employees making such visits. Yet, looking at middle-income earners, between 2003 and 2009, the number of visits grew from about 52% to 58% among employees, while it dropped considerably among self-employed workers from 52% to about 40% (Figure 37).

Figure 37- Self-reported dental visits in the last year and self-employment, middle-income and national average 1991-2009

100%

80%

SELF-EMPLOYED (NATIONAL) 60% EMPLOYEE(NATIONAL) 40% SELF-EMPLOYED (MIDDLE-INCOME) EMPLOYEE(MIDDLE-INCOME) 20%

0% 1991 2001 2003 2007 2009

Table 14- Self-reported dental visits in the last year by Canadians, middle-income and national average, 1985-2009 1985 1991 1996 1998 2001 2003 2005* 2007* 2009 SEX FEMALE (M) 42.4% 51.4% 57.0% 50.2% 50.6% 52% 52.8% 66.4% 65.3% FEMALE (NL) 52.6% 57.0% 61.5% 61.6% 62.3% 66% 66.1% 67.6% 75.9% MALE (M) 33.9% 41.6% 50.9% 47.5% 42.4% 45% 43.8% 53.8% 56.3% MALE(N) 48.9% 53.2% 58.2% 57.5% 57.5% 61% 61.3% 61.3% 73.1% AGE GROUPS 12-19(M) 62.5% 70.2% 72.7% 70.1% 70.9% 71% 69.8% 76.3% 74.9% 12-19(N) 68.6% 72.5% 75.2% 76.2% 76.1% 80% 78.9% 79.0% 84.0% 20-39(M) 50.6% 54.9% 53.9% 49.2% 53.3% 51% 52.0% 56.2% 54.9% 20-39(N) 58.2% 60.9% 59.8% 59.6% 61.3% 63% 63.1% 63.4% 67.8% 40-59 (M) 32.1% 41.4% 48.4% 47.7% 54.0% 50% 51.0% 60.3% 60.1% 40-59(N) 45.0% 54.1% 60.1% 63.4% 61.3% 67% 67.5% 67.6% 76.7% 60-79(M) 28.4% 31.5% 34.3% 35.1% 42.6% 37% 37.4% 58.4% 54.6% 60-79(N) 33.2% 38.4% 42.5% 42.7% 44.4% 50% 51.2% 55.0% 68.4% EDUCATIONAL ATTAINMENT < POST-SEC GRADUATION (M) 34.2% 43.5% 47.8% 45.9% 39.2% 43% 40.6% 55.4% 56.4% < POST-SEC GRADUATION (N) 46.2% 50.3% 54.3% 55.8% 59.8% 51% 49.7% 50.3% 64.6% >=POST-SEC GRASDUATION (M) 57.7% 55.1% 57.9% 52.5% 53.7% 54% 54.5% 62.3% 63.5% >=POST-SEC GRASDUATION (N) 64.7% 66.0% 67.7% 68.2% 60.0% 70% 69.3% 69.9% 77.9% PROVINCE OF RESIDENT ON (M) 47.7% 57.5% 63.8% 53.8% 52.1% 54% 54.4% 63% ** ON (N) 58.4% 62.7% 67.6% 64.3% 66.9% 69% 69.8% 69% ** SK (M) 32.5% 45.2% 44.9% 45.2% 40.6% 44% 46.4% 55% ** SK (N) 45.1% 42.7% 48.9% 51.7% 51.9% 55% 58.0% 56% ** QC (M) 28.6% 36.3% 47.2% 45.5% 41.5% 43% 42.8% 58% ** QC (N) 40.1% 47.4% 53.7% 55.4% 52.1% 57% 57.3% 60% ** AB (M) 36.4% 50.2% 52.8% 46.2% 46.7% 48% 47.3% 57% ** AB (N) 53.8% 52.8% 53.7% 56.4% 55.4% 63% 61.9% 64% ** BC (M) 45.5% 52.0% 58.4% 50.6% 52.6% 56% 53.4% 63% ** BC (N) 54.4% 59.4% 63.0% 62.9% 63.3% 68% 65.4% 66% ** MB (M) 41.7% 45.1% 53.3% 48.9% 48.2% 45% 51.4% 58% ** MB (N) 49.6% 53.3% 65.0% 58.2% 59.3% 61% 60.9% 62% ** NF (M0 32.9% 28.0% 37.3% 39.7% 29.6% 33% 32.9% 50% ** NF (N) 37.3% 37.3% 44.7% 45.9% 43.1% 48% 48.4% 53% ** PEI (M) 16.3% 51.6% 53.1% 54.5% 50.9% 53% 49.0% 65% ** PEI (N) 51.8% 55.1% 61.3% 59.3% 58.2% 65% 61.4% 63% ** NS (M) 38.4% 44.4% 50.2% 47.2% 44.0% 46% 45.0% 57% ** NS (N) 51.7% 52.1% 55.9% 55.2% 57.5% 62% 60.1% 59% ** NB (M) 35.6% 43.1% 43.5% 40.6% 38.9% 39% 43.0% 52% ** NB (N) 45.9% 49.9% 50.3% 51.4% 54.7% 53% 55.4% 54% ** IMMIGRATION STATUS IMMIGRANT (M) 40.5% 56.8% 59.1% 49.2% 50.0% 50% 51.5% 57.5% 64.0% IMMIGRAN(M)T (N) 53.6% 58.1% 58.5% 57.9% 59.6% 63% 61.7% 62.4% 73.0% NON-IMMIGRANT (M) 37.5% 44.4% 53.0% 48.8% 45.8% 48% 47.8% 61.1% 60.2% NON-IMMIGRANT (N) 50.2% 54.6% 60.2% 59.9% 59.9% 64% 64.6% 65.4% 74.8% DENTAL INSURANCE INSURED (M) NA NA 70.1% 62.4% NA 63% NA NA 72.9% INSURED (N) NA NA 72.0% 70.8% NA 75% NA NA 81.4% UNINSURED (M) NA NA 41.6% 38.1% NA 40% NA NA 49.6% UNINSURED (N) NA NA 42.0% 43.9% NA 47% NA NA 59.2% EMPLOYMENT CHARACTERISTICS SELF-EMPLOYED (M) NA 45.0% NA NA 48.2% 52% NA 54.7% 39.7% SELF-EMPLOYED (N) NA 57.2% NA NA 59.8% 65% NA 64.7% 69.3% EMPLOYEE (M) NA 51.9% NA NA 50.7% 52% NA 60.0% 58.4% EMPLOYEE (N) NA 61.4% NA NA 59.9% 68% NA 68.9% 74.4% FULL-TIME (M) NA 48.3% 55.5% 49.4% 48.2% 50% 50.5% 58.2% 54.3% FULL-IME (N) NA 61.8% 61.7% 63.1% 59.5% 67% 67.3% 67.8% 73.3% PART-TIME (M) NA 65.1% 61.8% 55.3% 58.4% 56% 59.2% 64.3% 57.7% PART-TIME (N) NA 55.9% 64.4% 65.9% 62.2% 70% 70.7% 71.5% 75.8% MIDDLE –INCOME 38.1% 46.7% 54.1% 48.9% 47.1% 49% 48.3% 60.2% 61.3% NATIONAL AVERGAE 50.8% 54.8% 61.6% 59.7% 60.3% 64% 63.8% 64.6% 75.0% M=middle-income, N=national average, NA= data not available/applicable * 2005 and 2007 used different definition of middle-income. Refer to methodology section ** Provincial level data not available

Perceived cost-barrier reports

The number persons reporting perceived cost-barriers to dental care grew since 1996 both at the national and middle-income levels. Yet, the rate of growth was much higher among middle-income earners. While in 1996 the rates of reporting financial barriers to dental care among middle-income Canadians were only slightly different from national rates, by 2009 middle-income earners made such reports about twice more than the national average (34.1% and 17.3% respectively) (Figure 38) (Table 15). The national data on perceived cost-barriers were only available for the years of 1996, 2003 and 2009. Therefore, the comparisons are made only for these years. Importantly, between 2003 and 2009 when reports made by middle-income

Canadians increased from about 20% to 34%, the national average decreased slightly from

17.8% to 17.3%.

Figure 38- Perceived cost-barrier reported by Canadians, middle-income and national average, 1996-2009

100%

80%

60% MIDDLE-INCOME 40% NATIONAL AVERAGE

20%

0% 1996 2003 2009

Table 15- Perceived cost-barrier reported by Canadians, middle-income and national average, 1996-2009* 1996 2003 2009 SEX FEMALE (M) 14.2% 20.8% 37.1% FEMALE (NL) 14% 17% 19.3% MALE (M) 11.2% 19.8% 30.6% MALE(N) 11% 17% 15.5% AGE GROUPS 12-19(M) 7.1% 27.3% 18.7% 12-19(N) 11% 18% 9.5% 20-39(M) 32.6% 40.3% 45.8% 20-39(N) 29% 33% 23.9% 40-59 (M) 11.2% 28.0% 41.0% 40-59(N) 10% 19% 17.6% 60-79(M) 3.2% 5.4% 23.5% 60-79(N) 3% 6% 13.2% EDUCATIONAL ATTAINMENT < POST-SEC GRADUATION (M) 10.8% 16.1% 27.4% < POST-SEC GRADUATION (N) 11% 14% 21.2% >=POST-SEC GRASDUATION (M) 21.7% 24.9% 37.5% >=POST-SEC GRASDUATION (N) 18% 20% 15.9% PROVINCE OF RESIDENT ON (M) 15.3% 24.5% ** ON (N) 15.60% 22% ** SK (M) 12.2% 18.4% ** SK (N) 12.70% 10% ** QC (M) 11.8% 14.9% ** QC (N) 7.60% 12% ** AB (M) 21.4% 23.0% ** AB (N) 18.0% 18% ** BC (M) 8.7% 27.7% ** BC (N) 16.4% 22% ** MB (M) 11.0% NA ** MB (N) 9.9% NA ** NF (M0 7.5% NA ** NF (N) 7.4% NA ** PEI (M) 8.5% 20.2% ** PEI (N) 6.50% 15% ** NS (M) 11.6% NA ** NS (N) 13.20% NA ** NB (M) 8.6% NA ** NB (N) 10.80% ** IMMIGRATION STATUS IMMIGRANT (M) 13.1% 23.2% 39.7% IMMIGRANT (N) 14% 21% 23.0% NON-IMMIGRANT (M) 12.6% 19.3% 31.8% NON-IMMIGRANT (N) 12% 16% 15.9% DENTAL INSURANCE INSURED (M) 8.9% 12.7% 17.1% INSURED (N) 6% 9% 7.6% UNINSURED (M) 13.8% 30.6% 50.0% UNINSURED (N) 15% 22% 32.7% EMPLOYMENT CHARACTERISTICS SELF-EMPLOYED (M) NA 25.8% 34.6% SELF-EMPLOYED (N) NA 22% 17.0% EMPLOYEE (M) NA 34.9% 44.3% EMPLOYEE (N) NA 25% 16.3% FULL-TIME (M) 19.6% 32.5% 47.2% FULL-IME (N) 16% 24% 17.9% PART-TIME (M) 19.9% 34.4% 32.7% PART-TIME (N) 23% 28% 19.1% MIDDLE –INCOME 12.6% 20.3% 34.1% NATIONAL AVERGAE 12.2% 17.8% 17.3% M=middle-income, N=national average, NA= data not available/applicable * Only years with national level data included ** Provincial level data not available

Yet, when comparisons are made within different sociodemographic characteristics, different trends were found for the 2003-2009 time period. The number of reports rose at both middle-income and national levels among females, those with lower educational attainment, immigrants, the uninsured and older adults. This rise was especially higher among middle- income elderly and middle-income uninsured compared to their national counterparts (Figures 39 and 40).

Figure 39- Perceived cost-barrier reported by the uninsured, middle-income and national average, 1996-2009

100%

80%

60% UNINSURED (MIDDLE-INCOME) 40% UNINSURED (NATIONAL)

20%

0% 1996 2003 2009

Figure 40- Perceived cost-barrier reported by 60-79 year olds, middle-income and national average, 1996-2009

100%

80%

60% 60-79 YEARS OLD (MIDDLE-INCOME) 40% 60-79 YEARS OLD (NATIONAL)

20%

0% 1996 2003 2009

Another important trend concerns the number of reports made by middle-income earners, which increased despite a decline at the national level. Such a trend was found among males,

young and middle-aged adults, respondents with higher educational attainment and non- immigrants. Importantly, the national level data shows that in the case of 20-39 year olds and respondents with higher education, the number of reports made in 2009 were lower than that of

1996, and therefore the gaps between the national average and that of middle-income earners widened (Figures 41 and 42).

Figure 41- Perceived cost-barrier reported by 20-39 year olds, middle-income and national average, 1996-2009

100%

80%

60% 20-39 YEARS OLD (MIDDLE-INCOME) 40% 20-39 YEARS OLD (NATIONAL)

20%

0% 1996 2003 2009

Figure 42- Perceived cost-barrier reported by higher education group, middle-income and national average, 1996-2009

100%

80%

60% HIGHER EDUCATION (MIDDLE-INCOME) 40% HIGHER EDUCATION (NATIONAL)

20%

0% 1996 2003 2009

Discussion

This study is the first of its kind in the context of the Canadian dental care system. The results of this study confirm that access to dental care among middle-income Canadians may have become challenged over the years. The number of middle-income earners with dental insurance has only grown slightly since 1996 with the number of those avoiding dental visits due to its financial burdens doubling over the same period. Moreover, my analyses reveal that despite considerable progresses in the utilization of and access to dental care among Canadians overall, middle-income earners lagged behind these national improvements, especially since 1996; to the point that, by 2009, among all income levels, middle-income Canadians had the lowest rates of dental insurance, second highest rates of avoiding dental visits due to the costs, and highest rates of reporting dental visits only in emergency cases.

Dental insurance

The major finding of this study, showing that the lowest rates of dental insurance are among middle-income Canadians, is not consistent with previous literature (Millar & Locker,

1999; Bhatti et al., 2007; Health Canada, 2010). This study found that just below half of all middle-income Canadians were dentally insured since 1996. This is especially important when considering that the alternative means of access to dental care, income, has not appreciably increased over the last few decades for most Canadians despite the significant rise in dental care prices. The average income for all economic families only grew from $59,000 in 1976 to

$68,800 in 2007 (2007 constant dollars) (Statistics Canada (CANISM), 2009).

As discussed Chapter 1, the slow rate of dental insurance growth can be largely attributed to changes in the labour market that happened in response to macroeconomic trends. The overall impact of economic recessions created a shift towards non-standard jobs such as part-time or temporary jobs. In addition, there has been a significant increase in the number of jobs created in the services and trade sectors while those jobs in sectors such as manufacturing, construction, and transportation have declined significantly (Tapp, 2009). This switching between sectors can be important as usually jobs in services and trade sectors are accompanied with lower rates of wage and employment-based benefits including dental insurance (Reesor & Lipsett, 1998). Other influential changes in the labour market include the increase in the number of self-employed persons, the number of workers in smaller firm sizes, and a decline in union membership, all of which have important implications for dental insurance as outlined in Chapter 1.

The burden imposed by employment-based dental plans on both employers and employees is another major factor in the decline of robustness in such benefits (Bailit, 1999;

Leake, 2006). However, this study does not support such trends on the employer side, as the results show that the number of employers providing dental benefits for their employees rose since 1991. Yet, the scope of this study as well as data limitations do not allow for further investigations on the employee side, nor of the nature of the dental benefits offered by employers

(e.g. while overall non-wage offers from employers may be increasing, is the quality of the dental insurance as robust as it used to be?). In other words, it is likely that to compensate for the increasing costs of providing dental benefits, employers increased cost-sharing arrangements with their employees, causing lower acceptability by employees, and potentially lower enrolment in such plans. It should also be noted that this study does not look at the third-party payer role in

influencing dental insurance rates or adequacy, as the cost containment policies put in place by these parties can have adverse effects on all of these matters.

Importantly, as previously found in some studies, my study implies that these changes in the labour market may have challenged the middle-income sector more than the rest (Quiñonez

& Grootendorst, 2011; Blumberg et al., 2004). To be sure, despite the increase in the number of employers providing dental benefits to their workers and while at the national level the number of insured full- and part-time workers grew considerably over the years, among middle-income workers whether full- or part-time, the growth was close to zero between 1996 and 2009.

Dental visits

The number of middle-income Canadians who reported any dental visits within a one year period increased between 1985 and 2009. Yet, the largest part of this growth happened prior to the mid-1990s; a time period corresponding to a constant growth in private dental plans across all income levels (Quiñonez, 2009). Interestingly, between the mid-1990s and mid-2000s, when a decline in the number of insured middle-income families was found, the rates of reporting yearly dental visits decreased for middle-income Canadians. Importantly, since the mid-1990s the number of middle-income Canadians who avoid dental visits due to financial reasons increased close to three times, the highest increase among all income groups. Furthermore, as of

2009, more than three out of ten middle-income Canadians said they do not visit a dentist regularly and would only do so if an emergency happens, a rate almost equal to that of the lowest- and lower-middle-income earners. Yet, these findings are not unexpected given the previous studies that demonstrate a positive relationship between dental insurance and one‟s

visiting patterns, especially when controlling for the effects of income (Millar & Locker, 1999;

Bhatti et al., 2007; Locker et al., 2011).

Overall, the patterns found among middle-income Canadians, especially in comparison to overall Canadian trends, leads to the conclusion that access to dental care has arguably become challenged over the years, especially since 1996. This is again a consequence of the 1990‟s economic recession and the unfavourable effects of the labour market. In addition, with middle- income earners showing the most dramatic downfalls in their visiting patterns, it can be suggested that this population is the most vulnerable to labour market changes and is most dependent on their employment-based dental insurance in order to access dental care.

Dental care expenditures

It is known that the less effective dental plans are the ones where individuals have to also spend out-of-their-pockets (Quiñonez & Grootendorst, 2011). In this regard, my analysis of out- of-pocket expenditures on dental care supports other findings and the initial hypothesis that access to dental care has become an issue among middle-income Canadians. Since 1978, the number of middle-income households that reported out-of-pocket expenditures on dental services has declined. Considering the number of insured middle-income did not change much since the mid-1990s, it can be proposed that more middle-income families forewent using any dental services rather than paying out-of-pocket. On the other hand, when compared to other income levels middle-income Canadians had the largest decline in terms of the number of households reporting such expenditures. Importantly, after 1996 when the number of middle-income households had the largest decline in dental expenditures, the number of high- and low-income households spending out-of-pocket did not change. This indicates that middle-income

households had the most difficulties in keeping up with paying out-of-pocket for dental care in the relative absence of dental insurance.

The increase in average out-of-pocket expenditures on dental care is arguably a product of the lower effectiveness of current dental plans, overall increases in dental prices beyond inflation rates, and the shift toward demanding more expensive services (Quiñonez &

Grootendorst, 2011). In addition, the average expenditures for middle- and low-income households show volatility while the respective changes for high-income households are far smoother. For instance, middle-income household expenditures reached three peaks in the mid-

1980s, late 1990s and late 2000s corresponding to the economic recessions. As discussed earlier, in times of economic difficulties third party payers, whether public or private, start cutting back on health plans especially dental insurance. Also, economic recessions affect employment status, the types of jobs and types of employment benefits provided. All of these together result in less effective dental plans. With the variability seen among middle- and low-income households, it can be said that these households‟ access to dental care is more vulnerable than the rest, especially when dental insurance is unavailable or severely constrained.

Subgroup analyses

An important contribution of this study is that it provides further insight to the challenges faced by certain middle-income subgroups regarding access to dental care. It shows how inequalities within middle-income subgroups or between these subgroups and their national counterparts have changed over the years. The inequalities discussed here are those based on dental insurance, self-employment status, work schedule, age and educational attainment.

Dental insurance

This study found that within the middle-income bracket the largest inequalities are present in the absence of dental insurance. This again makes sense as dental insurance is arguably the most important predictor of utilization and access to care when the effects of income are held constant. Uninsured middle-income families are far less likely to report annual dental visits compared to the insured. The largest gap between the middle-income insured and uninsured appears in relation to the reason for not visiting a dentist: the number of the uninsured who avoid dental visits because of costs increased more than 3.5 times since 1996 and by 2009 three times as many uninsured middle-income families faced financial barriers compared to their insured counterparts. This finding complies with existing literature explaining the main effects of dental insurance as reducing financial barriers to access (Bhatti et al., 2007; Locker et al., 2011).

For this reason, when uninsured middle-income families made dental visits it was far more likely to be due to emergency rather than preventive reasons. It is worth noting that uninsured middle- income families had even worse utilization patterns compared to the lowest income earners, highlighting the crucial role of dental insurance in facilitating access, especially among middle and lower income levels.

Self-employment status

As hypothesized, this study found that self-employed workers within the middle-income range are subject to major disparities in terms of having dental insurance and making annual dental visits. Among all middle-income subgroups, self-employed workers were the least likely to have dental insurance or have visited a dentist in the last year when asked in 2009.

Nonetheless, financial barriers were not cited as frequently by self-employed workers compared

to employees. One hypothesis that involves further investigation can be that time factors may be of higher priority for this class of worker compared to costs.

Although at the national level self-employed workers have similar overall access patterns compared to employees, there are major differences in terms of the size and the historical trends of these disparities. The gaps between self-employed and employed middle-income workers are larger compared to their national counterparts. More importantly, the situation has become worse for self-employed middle-income workers over the years. Since the early 2000s, while the number of middle-income self-employed persons holding dental insurance has only changed slightly, notably lower numbers have reported at least one dental visit in the last year, with more people avoiding such visits due to financial barriers. In contrast, self-employed workers at the national level experienced improvements in terms of all the specified factors, especially the rates of cost-barrier reports, which declined considerably over the same time period.

Work schedule

Despite the existing literature, my findings suggest that within the middle-income class, full-time workers‟ access to dental care appears to have suffered more than their part-time counterparts over the years. While among middle-income Canadians the differences between full- and part-time workers in terms of having dental insurance and last year‟s dental visits disappeared over the years, costs of dental visits became a bigger concern for those working full- time, showing a 2.5 times increase between 1996 and 2009. Full-time workers were also more likely to avoid dental visits unless an emergency occurs which can be a result of cost and time barriers to regular dental visits. In fact, middle-income full-time workers showed less favourable access to dental care and utilization patterns even compared to part-time workers at the national level. One explanation for such findings could be the relative changes in the quality of dental

insurance for full- and part-time workers. In other words, full-time workers experienced more negative changes as, compared to part-time workers, they had better dental insurance plans to start with; hence feeling more squeezed when restrictions applied to their dental benefit plans .

In contrast, the national averages indicate that the only major difference between full- and part-time workers are in terms of dental insurance, which the former are more likely to have. The differences regarding cost-barrier reports or emergency visits based on work schedule were subtle. The findings reveal that the utilization of dental care has improved for part-time workers at the national level despite becoming challenged for those at the middle-income level. Both middle-income and national data reveals that more part-time workers visit a dentist at least once a year compared to full-time job holders. This can be due to the time constraints imposed by a full-time working schedule, or the higher number of females among part-time workers. However, this study did not look into such associations; therefore further investigations are needed to draw such conclusions.

Age

Recent studies on the relationship between dental insurance and age suggest that the lowest rates are among older adults followed by young adults, while the highest rates of having dental insurance are seen among adolescents and middle-aged adults (Reesor & Lipsett, 1998;

Millar & Locker, 1999; Health Canada, 2010). While this pattern is confirmed at the national level, my study shows an age gradient in the likelihood of being insured at the middle-income level meaning that the rates of having dental insurance decrease with the increase in age. It should be taken into account that the age groups used in this study were identical to the most recent Canadian survey (CHMS) while being slightly different from the previous studies, but not appreciably enough to have analytical implications.

The elderly are again the least likely to have dental insurance with no major change in rates since the mid 1990s. The number of elderly who avoided dental visits due to costs has increased by more than 7-fold with close to half of them making only emergency visits rather than preventive visits. However, the number of elderly who reported annual dental visits grew over the years. One explanation for these findings is that the number of people who retain their teeth into older age as risen; hence larger numbers of elderly need or demand dental work thus facing potential access difficulties.

Educational attainment

A major unexpected finding of this study are the trends in access to dental care based on educational attainment. It is well-known that those with higher educational attainment are more likely to have dental insurance, hence better access to care (Sabbah, 1998; Millar & Locker,

1999; Bhatti et al., 2007; Health Canada, 2010). However, when only looking at those within the middle-income bracket, this study found that access to dental care has improved more for those with lower educational attainment as opposed to those with higher educational attainment. In other words, access inequalities based on educational attainment have become smaller among middle-income Canadians, and even reversed in the case of dental insurance. This means that the growth in the number of insured was much higher among those with lower educational attainment, and by 2009 they were more likely to be dentally insured compared to their higher educated counterparts.

An equally important finding is in financial barriers to dental visits: middle-income earners with higher educational attainment have remained more likely to perceive cost as a barrier to dental visits since 1996, although the growth in the number of such reports grew at a faster rate among those with lower education. One possible explanation can be the increase in the

number of highly educated workforce especially since the 1990s (Human Resources and Skills

Development Canada, 2006). This causes an increase in the number of higher educated people outpacing their employment rate. For instance, between 1990 and 2003 the employment rates for university graduates aged 25-64 years old dropped from 86.7% to 81.6% (Statistics Canada,

2003). Based on the same argument, the decline in the overall number of lower educated labour force can inflate their employment rates. However, considering that the specified access trends are only present among middle-income Canadians, while at the national level the gaps have become larger, one can conclude either that the above dynamic affects middle-income workers more, or that the educational attainment is less influential in determining access to dental care in the specified income bracket.

Sex

Another unexpected trend among middle-income Canadians is the dental insurance rates among males and females. More recent Canadian literature implies that there are no significant differences between males and females regarding dental insurance (Bhatti et al., 2007; Health

Canada, 2010). Although this was the case for middle-income persons up until 2003, by the end of the 2000s, higher number of females had dental insurance compared to males. This can be due to the differences in the labour characteristics of men and women. For example, men are more likely to be self-employed, and have experienced higher unemployment rates in the recent economic recessions (Tapp, 2009).

Limitations

This study has a number of limitations. The most important of these limitations is related to the consistency of data collection over the years as well as between different surveys. Such

limitations are detailed in the methodology section. Furthermore, like any other survey, the surveys used in this study relied heavily on participants‟ reporting of behaviour rather than observation. Therefore, measurement error could have been introduced by respondent recall errors, instability of their opinions, misunderstanding of questions, and the possibility that the respondents might have given „socially desirable‟ answers. Response bias especially in terms of revealing income level should be considered as well.

In addition, as stated previously, the objective of this study was merely to identify the trends among the target population; therefore the results do not provide information on cause- effect relationships or statistically significant differences. Finally, it should be noted in the interpretation of the results that although utilization is the most commonly used proxy of access to dental care, it is acknowledged that access encompasses a wider range of factors than utilization.

Policy considerations

Being the first of its kind in the Canadian dental care context, this study makes an important contribution in highlighting a rising issue among the middle-income sector of

Canadian society. A major shortcoming identified by this study is the lack of systematic and consistent data in terms of access to dental care factors at both the national and provincial levels.

To increase the effectiveness of policies in addressing the varied issues, systematic and timely data collection is strongly recommended.

Despite its limitations, this study established that middle-income Canadians face barriers accessing dental care on the grounds of their considerably low dental insurance rates. With respect to accessing dental care, middle-income Canadians are being pushed to the same levels

of accessibility as historically reported by the lowest income earners, except that middle-income earners have not been on the policy agenda for public assistance to this point. Hence, the results of this study may encourage investigation into the possibility of including this group in public dental care policies. The subgroup analyses conducted in this project may be a useful cornerstone in directing such decision making. Middle-income subgroups such as self-employed or full-time workers were especially highlighted by this study. Policies may be put in place aiming to increase the enrolment of these types of workers in employment-based dental insurance plans, largely on the basis of increasing tax benefits for employers, or legislating the presence of these benefits in as many employment settings as possible.

Being a secondary analysis and of retrospective design, this study does not provide the reasons for such low dental insurance rates. Yet, the literature indicates that the imposed costs of enrolment in dental plans whether on employees or employers are one of the major reasons.

Therefore, it is recommended that governments establish policies to control the costs and contribute to the dental plans for the identified vulnerable sectors. One example can be limiting the tax breaks to the dental plans and invest the revenues originating from the taxation. Another implication for policy making comes up when noting that the costs of dental care are becoming a barrier for middle-income Canadians, forcing many to forego regular dental visits. Policies should target controlling the costs of dental services, and/ or increasing the affordability of such services for vulnerable groups.

Lowered quality of current dental plans especially in response to cost control policies imposed by third-part payers is another potential reason for poor access. Given the nature of the data analyzed, it was not possible to examine this topic, yet this study‟s findings point to the need for future studies to investigate the quality of dental insurance plans and how they have

been affected over the years. Qualitative studies of the specified vulnerable subgroups and more detailed analyses of employment-based dental insurance dynamics can be especially important.

Conclusion

Within its limitations, this study suggests that access to dental care issues might be ascending from lower income sectors to involve middle-income earners as well. Although most middle-income Canadians still enjoy good access to dental care, compared to the past their access conditions are now much closer to low-income earners, while experiencing larger gaps compared to higher income earners. In other words, in the context of Canadian dental care system, middle-income earners are being squeezed. The situation can even be worse for middle- income earners considering that they cannot benefit from public dental plans as those of lower- income do. Among all middle-income groups, uninsured, self-employed, full-time workers and elderly face the most challenges accessing dental care.

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Appendix A: characteristics of surveys that will be reviewed

Survey Year Design Sample size (population Response rate Sample characteristics Sampling method Data collection method coverage)

CHMS 2007-09 Cross sectional 5600 (97%) Household Age 6-79 a stratified, multi- Personal household and inclusion: 69.6% stage Individual interviews followed by a visit to a mobile interviewed: 88.3% examination centre

Clinical exam:84.9%

CCHS 2001-02 Cross sectional 130,880- 134,972 Ave. 80.1% Ages 12 and older living in private stratified, multi- Computer-Assisted Personal Interviewing 2003-04 (98%) occupied dwellings a stage method and Random Digit Dialling 2005-06 2007-08

NPHS 1994-96 Cross sectional and 17,276- 20,095 Ave:83.6% Household residents in all provinces a stratified In person and Computed Assisted 1996-98 longitudinal two-stage sample Interview Cross sectional used design in this study FAMEX 1978;1982;1984 9,492- 15,140 70% 1986;1990;1992 Private households in Canada b stratified, In person and Computed Assisted SHS include territories since 1998 multi-stage Interview SHS 1996-2008 every 14,635 - 15,457 private 65% year households

WES 1999-2006 every Cross-section and Employers:5,818- 6,693 2006: 74.9% All employees/ employers in Canada that stratified two-stage In person and Computed Assisted year longitudinal have paid/ being paid in March c sample design Interview Cross sectional used in this study GSS 1985; 1991 Cross sectional 11,200- 11500 Approximately 80% Person 15 and older b stratified, multi- 1985: Age 15-64 telephone and age 65 stage and older face-to-face interview-

1991: telephone interview

a Persons living on Indian Reserves or Crown lands, residents of institutions, full-time members of the Canadian Armed Forces and residents of certain remote regions are excluded from this survey. b The following groups are excluded from the survey:

 those living on Indian reserves and crown lands;  official representatives of foreign countries living in Canada and their families;

 members of religious and other communal colonies;  members of the Canadian Forces living in military camps;  people living in residences for senior citizens; and  People living full time in institutions: for example, inmates of penal institutions and chronic care patients living in hospitals and nursing homes. c excluding those in Yukon, Nunavut and Northwest Territories; and those operating in crop production and animal production; fishing, hunting and trapping; private households, religious organizations and public administration. d excluding residents of the Yukon, the Northwest Territories and Nunavut, residents of institutions (more than 6 months) and p ersons living on Indian reserves.

® A new panel starts at the specified reference year and is followed for a 6-year period