Trends in Access to Dental Care among Middle-Class Canadians by 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 © Copyright by Laleh Sadeghi 2012 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. ii 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. iii 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 iv 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 ....................................................................................................................................