Workforce shortages, rising prices and the huge social cost of oral disease are part of what makes providing dental care difficult. But the call to make dental care free remains.
Patients come into the clinic where Micah Church works with all kinds of oral ailments: painful tooth cavities, teeth chipped in sports games, teeth aching with an internal infection. But the recently graduated dentist, who works in Tairāwhiti, can’t always provide the care they need. “It’s quite frustrating – you want to offer people the best treatment plan, and often they’ll pick taking a tooth out over getting a root canal and saving the tooth, because of cost, essentially,” she says. Often, she ends up doing emergency work on long-neglected teeth, when the pain has gotten too bad to ignore. Her patients just want the pain to go away: sometimes they ask for the nerves to be removed from their teeth, just so it stops hurting – even if the root cause remains.
It’s not hard to find stories like this, whether it’s from your flatmates or aunty, your dentist friend, or perhaps your outgoing prime minister: there’s broad agreement that the cost of dental care in Aotearoa, a privatised exception to an otherwise fully-funded public healthcare, is excluding people from necessary treatment. More than seven in 10 New Zealanders support free dental care, according to polling commissioned by the Association of Salaried Medical Specialists (ASMS).
This widespread popularity was part of why the Labour Party promised it (albeit introduced slowly) as one of its cornerstone policies in the 2023 election. The Green Party had a universal dental care policy too. In the lead-up to the election, more than 16,000 people signed a petition for universally free dental care by campaign group Dental For All. Many left comments describing what inaccessible dental care meant to them: pensioners explain that the cost of dental care is out of reach, people pulling their own teeth out to save money, descriptions of feeling ashamed and afraid to socialise, petitioners who delayed treatment until it was urgent, worse than it had to be.
As popular as the idea of free dental might be, it wasn’t enough to win Labour and the Greens the election. In this limbo period, as the government-in-waiting thrashes out its coalition deal and tens of thousands of people across Aotearoa remain afflicted with the world’s most common non-communicable disease, what will happen to the call for free dental?
Max Harris, one of Dental For All’s core campaigners, remains positive despite the election result. Expanding dental care isn’t a write-off for the next three years: he points out that in New Zealand FIrst’s manifesto, published 10 days before the election, there’s a promise to expand free dental care to 18-25 year olds, as well as Community Services and Super Gold card holders.
“We’ll be pushing for this partial free dental to be a bottom line in negotiations,” Harris says. “Shane Reti has also said he is keen to engage after the election; another front is encouraging National and Act to take the imperative to extend our public health system seriously.” It might be tough going: before the election, the only National policy on dental care was to increase spending for the child dental package.
The call to make dental care free, in line with the rest of the public health system, is not a new one, Harris points out. The Labour Party adopted a policy for universal dental care at its 2018 conference, even though it didn’t campaign on the policy in the 2020 election. The exclusion of dental care in an otherwise publicised health system is a baffling discrepancy, Harris says. “Mouths are treated like they aren’t part of the rest of our body.”
But mouths really are connected to the body, and what happens – or doesn’t happen – to teeth have profound, and expensive, downstream effects. A report into the state of oral health called “Tooth be Told”, released by the ASMS last year, has some damning figures: every year, a quarter of a million adults in Aotearoa have teeth removed due to decay, with the poorest people worst-affected. While dental care is free for those under 18, 42% of adults, and more than 50% of Māori and Pasifika adults, have an unmet need for dental care due to cost. That’s higher than comparable countries like the US, Australia and the Netherlands.
Missing teeth, painful mouths – that’s a lot of people who then suffer all the further costs of damaged teeth. Your teeth impact how you eat. Poor oral health can effect people’s job prospects in interviews, increasing dependence on WINZ and other support services. Dental care is also especially hard to access, and expensive to travel to, for people who live rurally. “It’s the way the public health system creates barriers for people who are away from the main centres,” Harris says. Fear around cost also keeps people away from receiving care, meaning that problems often get much worse than they need to.
There are some dental grants available; administered through WINZ. Up to $1,000 is available per year to people on low incomes, regardless of whether they are a beneficiary or not. The Labour government increased this dental grant amount from $300 last year.
Yet Harris says that this doesn’t go far enough. “Lots of people don’t know about the $1,000, and it’s administered through WINZ which is a challenge if people don’t come into contact with WINZ.” The process of navigating the paperwork to prove financial need can be stigmatising. And while $1,000 can pay for lots of treatments, it’s often not enough. “If you haven’t gone [to the dentist] in many years, $1,000 won’t cut it.”
A new generation of dentists
“It’s always been confusing to me [that dental isn’t free],” says Jack Saunders, a dental student. He’s one of many in a new generation of dentists that want something to change. “Tooth decay is the most prevalent disease in the world; people let these preventable issues get to a stage where they’re not preventable.”
Saunders, who is about to graduate and will be a practising dentist from next year, says that he cares about the work because “you can see the patient through from start to finish – diagnosis, treatment and outcome – it’s a way to relieve people of pain and see the effects of your help.” He anticipates that dental inequity is going to be a big feature of his working life. “The rates of dental decay are not going anywhere – there’s a crisis in care for people who haven’t seen a dentist since they were 18, and this disproportionately affects marginalised communities.”
The discrepancies in access to dental care is mirrored by those administering it. Ana Downey remembers exactly when she realised how rare Māori dentists were. In her last year of high school, attending career events, she and a friend had a private joke: they would always see the same dentist at each event there. “We just thought it was funny, but we talked to her and she said ‘I’m legit one of the only Māori dentists in Auckland’. I thought that was kind of wild – then I thought ‘I could probably do that’. So I came to Dunedin and gave it a go.”
Now in her third year, Downey meets me in the park outside Otago Museum, dressed in her scrubs; she has class later, working with other students and tutors, learning to offer dental care. “It’s really engaging, working with people and helping them – you realise you can make a difference in people’s lives.” We’re talking before the election: promises of free dental care have been a hot topic in the dental school. There’s some scepticism.
“People are like, it’s a good idea – but how doable is it actually? Whether there’ll be enough people to staff it, whether it’ll be funded correctly.” To train to be a dentist, Downey needs practice, with supervision; that means that trained dentists, practising under their licence, need to be present. Downey says that the dental school has had a clear shortage of tutors all year, although the situation is improving. “Sometimes you get less stuff done, because there are less tutors.”
Implementing better dental care will require more dentists and better funding
A lack of dentists impacts who gets treated. The Labour policy included funding more places at the Otago Dental School, New Zealand’s only dental school, which currently has 60 places for domestic students each year; the 2021 Dental Council report estimated that training currently available would allow the profession to grow by about 3% each year.
Data published in 2019 indicates that New Zealand has some of the lowest numbers of active dentists and specialists in the OECD. “Lots of countries are leaps and bounds ahead of us in providing dental care,” student Saunders says. Dentists are also unevenly distributed; Auckland has three times as many dentists per capita than the West Coast. That said, Auckland, with its higher cost of living, is a more expensive place to receive dental care than anywhere else in the country.
“[Workforce shortage] is not a simple issue to solve, but it’s not a fatal barrier to free dental either,” says Max Harris. Importing dentists would help. Dentists are already on the Green List of roles instantly eligible for residency pathways if they apply to work in New Zealand. But a dental workforce shortage is hardly unique to Aotearoa; there aren’t enough dentists in the UK or Australia either – not to mention the rest of the world. The entire continent of Africa has only 1% of the world’s dentists; with limits on the number of dentists being trained everywhere, more dentists moving to New Zealand will mean fewer in other places.
“In the regional area it’s a question of staffing, there’s not enough staff,” Church says. “But increasing the number of students is only going to work if you get enough tutoring staff to teach those students.”
The hybrid dental system, where under-18s have their care subsidised, isn’t always financially attractive for dentists as business operators; funded contracts have caps for procedures which fall below market value, so a $250 tooth extraction will only receive $150 from the government.
Making dental care universal would require an overhaul of the whole system, rather than extending the way that children’s dental care is provided. “If you’re just doing consultations, and the kids have fairly good oral health, then you can actually make it work,” Church says. “[But] if the government’s not reimbursing at a reasonable rate, clinics just aren’t going to make it float.” Older patients may require more expensive treatments. “Patients under 30 might need root canals, need crowns, need things that will cost clinics more to provide.” Dentists' time is valuable; Church is concerned that lower-income people might not come to appointments if there wasn’t a financial penalty for not showing up. Ideally, regular treatments won’t be too expensive – it’s when teeth become an emergency that costs become especially steep.
There are glimpses of different ways to provide essential dental care, while cosmetic procedures like veneers remain private business. Organisations like The Fono, which focuses on Pasifika health, make affordable treatment more accessible to the communities who need it most. Saunders was inspired by a dentist at a work placement who offered flexible payment structures, according to need. There’s an individual role, too [in how we charge people],” he says. He suggests if tools and space could be subsidised, then patients could just pay for the time of the dentists, regardless of the procedure.
“There are lots of stories of people delaying care and having worse oral health, that then becomes more expensive – massive bills that create real distress and contribute to new mental health challenges,” Harris says. The new government may not prioritise free dental, but he wants them to know that it’s overwhelmingly popular, and an excellent investment. “The estimated benefits to society are $4.50 for every dollar spent – it pays for itself.” The Dental for All coalition, with ActionStation, has three years funding from the Clare Foundation to keep researching and working towards free dental care. That’s enough time to be armed to the teeth by the next election.
“Tooth decay is the most common disease in Aotearoa, people are walking around not receiving treatment,” Saunders says. “Free dental has been a long time coming.” There’s appetite for change, even if getting the new government to subsidise dental care will be like, well, pulling teeth.