Do health systems cover the mouth? Comparing dental care coverage for older adults in eight jurisdictions

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ContentslistsavailableatScienceDirect

Health

Policy

jo u rn al h om ep a ge :w w w . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l

Do

health

systems

cover

the

mouth?

Comparing

dental

care

coverage

for

older

adults

in

eight

jurisdictions

夽

Sara

Allin

a,b,∗

_,

_Julie

_Farmer

b,c

_,

_Carlos

_{Qui ˜}

_nonez

c

_,

_Allie

_Peckham

b,d

_,

Gregory

Marchildon

a,b

_,

_Dimitra

_Panteli

e

_,

_Cornelia

_Henschke

e,f

_,

_Giovanni

_Fattore

g

_,

Demetrio

Lamloum

g

_,

_Alexander

_C.L.

_Holden

h

_,

_Thomas

_Rice

b,i

a_Institute_of_Health_Policy,_Management_and_Evaluation,_University_of_Toronto,_Canada

b_North_American_Observatory_on_Health_Systems_and_Policies

c_Faculty_of_Dentistry,_University_of_Toronto,_Canada

d_Edson_College_of_Nursing_and_Health_Innovation,_Arizona_State_University

e_Department_of_Health_Care_Management,_Technische_Universität_Berlin,_Germany

f_Faculty_of_Health_Sciences_Brandenburg,_Brandenburg_University_of_Technology_Cottbus_{-Senftenberg,}_Germany

g_Department_of_Social_and_Political_Sciences,_Bocconi_University,_Italy

h_The_University_of_Sydney_School_of_Dentistry,_Faculty_of_Medicine_and_Health,_Australia

i_Fielding_School_of_Public_Health,_Department_of_Health_Policy_and_Management,_University_of_California,_Los_Angeles,_United_States

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received24February2020

Receivedinrevisedform17June2020

Accepted26June2020 Keywords: Healthsystems Dentalcare Olderadults Universalcoverage High-incomecountries

a

b

s

t

r

a

c

t

Oralhealthisanimportantcomponentofgeneralhealth,yetthereislimitedfinancialprotectionforthe costsoforalhealthcareinmanycountries.Thisstudycomparespublicdentalcarecoverageinaselection ofjurisdictions:Australia(NewSouthWales),Canada(Alberta),England,France,Germany,Italy,Sweden, andtheUnitedStates.DrawingontheWHOUniversalCoverageCube,wecomparebreadth(whois covered),depth(shareoftotalcostscovered),andscope(servicescovered),withafocusonadultsaged 65andolder.Weworkedwithlocalexpertstopopulatetemplatestoprovidedetailedandcomparable descriptionsofdentalcarecoverageintheirjurisdictions.Overallmostjurisdictionsofferpublicdental coverageforbasicservices(exams,x-rays,simplefillings)withinfourgeneraltypesofcoveragemodels: 1)deeppubliccoverageforasubsetoftheolderadultpopulationbasedonstricteligibilitycriteria: Canada(Alberta),Australia(NewSouthWales)andItaly;2)universalbutshallowcoverageoftheolder adultpopulation:England,France,Sweden;3)universal,andpredominantlydeepcoverageforolder adults:Germany;and4)shallowcoverageavailableonlytosomesubgroupsofolderadultsintheUnited States.Duetothelimitedavailabilityofcomparabledatawithinandacrossjurisdictions,furtherresearch wouldbenefitfromstandardizeddatacollectioninitiativesfororalhealthmeasures.

1. Introduction

Oralhealthisanimportantcomponentofgeneralhealthand overallwell-being [1]. Untreatedand poorly managedoral dis-eases,such as toothdecay and periodontal (gum)disease, can impactnutritionalintakeandincreasebacterialevelsand inﬂam-mation;thesefactors playa role in systemicinﬂammation and

夽 OpenAccessforthisarticleismadepossiblebyacollaborationbetweenHealth

PolicyandTheEuropeanObservatoryonHealthSystemsandPolicies.

∗ Correspondingauthorat:InstituteofHealthPolicyManagementand

Evalua-tion,UniversityofToronto,155CollegeStreet,suite425,Toronto,Ontario,M5T1P8,

Canada.

E-mailaddress:sara.allin@utoronto.ca(S.Allin).

overallhealthoutcomes[2].Toothdecayandgumdiseasecanlead topainandinfection,whichcannegativelyimpactanindividual’s qualityoflife[1].Theseconditionsarelargelypreventablethrough populationandindividualhealthpromotionstrategies,including communitywaterﬂuoridation,andregularoralhygiene.Further, routineaccesstoprimaryoralhealthcareenablesearlydetection andmanagementoforaldiseases,andcanmitigatethenegative impactsofpoororalhealthonindividualsandfamilies,and poten-tiallyavoidablecoststothehealthcaresystemandsociety[3,4].

Financial protection against the cost of dental care services varies widelyacrossand within high-incomecountries. Among 11high-incomecountries,theUnitedStatesandCanadahadthe highestpercentagesofthepopulationthatreportskippingdental careoradentalcheck-upbecauseofcostaccordingtothe2016 CommonwealthFundInternationalHealthPolicySurvey,with

sig-https://doi.org/10.1016/j.healthpol.2020.06.015

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niﬁcantdisparities by income. Anestimated 45% of Americans withlower-than-medianincomeand40%ofCanadianswith lower-than-medianincomereportedskippingdentalcareduetocosts, comparedto21%ofhigherincomeAmericansand17%ofhigher incomeCanadians[5].CostbarriersalsoexistinFranceandSweden, wherenearlyonequarterofrespondentsreportedskippingdental careduetocosts[5].InEurope,costbarrierstodentalcareforadults andolderadultsappeartobemorepronouncedinItaly,France, andSwedencomparedtoGermanyandtheUnitedKingdom[6,7]. AlthoughcostbarriersmaybelowerintheUnitedKingdomthan inothercountriesonaverage,signiﬁcantgeographicand socioe-conomicinequalitiesinbothaccesstodentalcareandoralhealth outcomesarestillpresent[8].Thus,itisnotsurprisingthatthere hasbeeninternationalinterestinstrengtheningdentalcare cov-erage programs aimedto bettermeet theoral health needsof populations[9–12].Currently,mosthigh-incomecountriesprovide someformofdentalcarecoverageforchildrenandyouth,with vari-ationintheextentofcoverageavailabletoadultandolderadult populations[13].

Thereareatleasttworeasonstofocusondentalcarecoverage forolderadults.First,peoplearelivinglongerwhilealso retain-ingmostoftheirownteeth.Thistrendincreasesthelifetimeriskof toothdecayandgumdisease,whichareassociatedwithother exist-ingchronicconditions[3].Forexample,poororalhealthismore prevalentinpatientswithdiabeticcomplications(e.g.,neuropathy) comparedtothosewithout[14].Also,poororalhealthamongolder peoplecanaffecttheirabilitytochewandeat,whichcanworsen theiroverallnutritionalintake[15].Second,insomecountriessuch asAustralia,Canada,andtheUnitedStates,theworking-age pop-ulationreliesheavilyonprivateinsurancetohelpcoverthecosts ofdentalcare,withdentalcoveragestronglytiedto employment-baseddentalinsurance.IntheUnitedStates,forexample,lossof dentalcoverageamongolderadultshasbeenassociatedwithno longerseekingdentalcareservices[16].

Theroleofpubliccoverageinprotectingagainstthecostsof dentalcareservicesforolderadultsaged65yearsandolderisnot wellknown.Whileinternationalcomparisonsondentalcare out-comesandinequalitieshavebeenconductedforadultsandolder adults[6,17–20],therehasbeenminimalattempttousethe char-acteristicsofpublicdentalcarecoverageasbasisforcomparison [21,22].Further,therehasbeennostudytoourknowledgethat hasdescribedthemodelsofdentalcarecoverageforthisagegroup acrossarangeofhigh-incomecountries.Thispaperaimstoprovide adescriptionandmappingofpublicdentalcarecoveragemodels inarangeofcomparablejurisdictionswithafocusonolderadults (individuals65yearsandolder).

2. Methods

2.1. Conceptualframework

Todescribeandcomparepublicdentalcarecoveragemodels forcommunity-dwelling(non-institutionalized)adultsaged65and olderacrossjurisdictions,coveragemodelsweredescribed accord-ingtothethreecorefeaturesoftheWHOCoverageCubeframework (Fig.1);theseinclude:(i)breadth-olderadultpopulations(≥65 yearsold)eligibleforpubliclyfunded dentalcareprograms; (ii) depth-theshareofthetotalcoststhatarebornebythe govern-ment/publicpayer;and(iii)scope-therangeofservicescovered underpubliclyfundeddentalcareprograms.Withinthecoverage cubeframework,thegapsoutsidethebreadth,depth,andscope ofpublicdentalcarecoveragemaybecoveredinpartwithprivate (mostlyvoluntary)dentalinsurance,andtheremainderwouldbe fromoutofpocketpayments(includingbothdirectpaymentsfor servicesnotincludedinanypubliccoveragemodel,andcost

shar-ingforservicesthatarenotfullypubliclyfunded).Duetoextensive variationintheroleofprivatedentalinsuranceplansacross juris-dictions,wedonotrevieworcomparemodelsofprivateinsurance coverageinthispaper.

2.2. Jurisdictionsandtargetpopulation

Weselectedeightcountriestocomparepublicdentalcare cov-eragemodelsforcommunity-dwellingolderadults(_≥65yearsold): Australia,Canada,England,France,Germany,Italy,Sweden,andthe UnitedStates.Ourselectionconsidered(i)high-incomecountries thataremembersoftheOECDthatarefrequentlycomparedand includedininternationaldatasourcesandsurveys;and(ii) varia-tioninhealthsystemfundingandorganizationalmodels[23].(See SupplementalTable1forsomecomparativedataonhealthsystem anddentalcarespendingandutilization).InFrance,areformto dentalcarethatisintheearlystagesofimplementationwillreduce out-of-pocketpaymentsforseveraldentalcareservices[24];the datacollectedforthisstudyreflectthesituationasofJune2020. In three of thecountriesin our study– Canada,Australia, and UnitedStates–wefocus ononesub-nationaljurisdictiongiven health and dental coverage varieswidely across provincesand states.In Canada,publicly fundeddentalprogramsand services areorganizedattheprovincial/territoriallevel;theyarelargely designedtofillinthegapsnotcoveredthroughemployment-based benefitplanswhichgenerallycoverbasicdentalservices.Alberta, Ontario(asofNovember2019),NewfoundlandandLabrador,and YukonTerritoryaretheonlyjurisdictionsinCanadawithpublicly fundeddentalprogramsspecificallytargetingolderadults[25,26]. WeselectedAlbertaforinclusioninthisstudyasithasthe longest-standingpublicdentalcareprogramforolderadultscomparedto otherprovincesandterritories[25].InAustralia,publicdentalcare receivesfundingfromboththestateandCommonwealth(federal) governments,andstateandterritorygovernmentsareatlibertyto takedifferentapproachestoprovidingpubliclyfundeddentalcare [10].Inthisstudy,weincludethemostpopulousstateinAustralia: NewSouthWales.Finally,intheUnitedStates,publicdentalcare coverageforsomeolderadultsisprovidedthroughbothfederal (Medicare)and/orstate(Medicaid)programs.We describe den-talcoverageavailablethroughMedicarebasedontwocoverage streams:traditional Medicareand Medicare Advantage,andwe describetheMedicaidprograminCalifornia,themostpopulous stateintheUnitedStates.

Wefocusedon adults65andolderwholiveindependentlyin communities(community-dwelling)and whoaccessdentalcare servicesthroughfixedormobiledentalclinics;wedonotinclude adultslivingin institutions(e.g.,nursinghomes,long-termcare facilities,oraged-carehomes),olderadultswhoreceivedental ser-vicesintheirhome(e.g.,domiciliarycareorhomecare),orolder adultswhohavepublicdentalcoveragebasedonspecialstatus(e.g., eligibleveteransinAustralia,CanadaandUnitedStates,Indigenous specificcoveragemodelssuchastheNon-InsuredHealth Bene-fitsinCanada,andIndian HealthServicesintheUnitedStates). We focusedonnon-emergencydentalcareservicesprovidedin out-patientdentalsettings(dentalclinics).

2.3. Datacollectionandsynthesis

Wecollectedinformationonpublicdentalcarecoverage mod-elsforcommunity-dwellingolderadults(≥65yearsold)fromlocal contentexpertsineightjurisdictions,publiclyavailableresources, andpeer-reviewedpublications.First,wedevelopeddatacollection templatesguidedbytheWHOCoverageCubeframework(Fig.1). Membersoftheresearchteamandlocalexpertscompiled den-talcaresystemcharacteristicsfrompublicly availableresources onnational,provincialand/orterritorialgovernmentwebsitesand

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Fig.1. Dimensionsofcoverageforpublicdentalcaremodels.Notes:AdaptedfromtheWorldHealthOrganizationCoveragecubeframework(WorldHealthOrganization.

Chapter2:PrimaryHealthCare-NowMoreThanEver.In:WorldHealthReport2008[Internet].2008.p.41–60.Availablefrom:https://www.who.int/whr/2008/08chap3

en.pdf?ua=1).ThescopeofservicecoverageisdescribedaccordingtoprivateinsurancepackagegroupingsinCanadaacrossmultipleprivateinsurersthatbelongtonational

organization-CanadaLifeandHealthInsuranceAssociation.

fromaseriesoforalhealthreportspublishedintheBritish Den-talJournal[27–30]. Weobtainedestimatesofhealthand dental carespendingineachjurisdictionfromtheOrganisationfor Eco-nomicCooperationandDevelopment(OECD)[31].ForItaly,dental spendinginformationwasnotreportedintheOECDHealth Statis-ticsdatabaseandwasprovidedbylocalexperts.Wethencarried out a literature review to supplement thedata collected from localexpertsandfromOECDwithanaimtoidentifystudiesthat described,compared,and/orevaluateddentalcareprogramsfor adultsintheeightjurisdictions.Dataonallelementswereveriﬁed bylocalcontentexpertsineachjurisdiction(completedtemplates for each jurisdictionare availableupon request).Our synthesis offersanoverviewofpubliclyfundeddentalcoverageprogramsand doesnotcapturesomekeyfeaturesofdentalcoverageprograms thatmayvaryacrossthejurisdictions.Theseincludeinformationon whethertherearefrequencyrestrictionsandlimitationsonservice coverage,anddetailsontheamountofco-paymentsorvariationin coveragewithinjurisdictionsiftheyexist.

3. Results

3.1. Breadthofcoverage:whoiscovered?

Amongtheeightincludedjurisdictions,therearetwogeneral modelsforbreadthofpublicdentalcarecoverageforolderadults, whichwesummarizeas1)universalpopulation(allolderadults arecovered)and2)targetedpopulation(onlyolderadults who meetaneligibilitycriterionarecovered).Amongthejurisdictions examined,fourcountriesincludeabasketofdentalcareservices withintheirbroaderstatutoryhealthsystemonauniversal popula-tionbasisthuscoveringallolderadults(England,Germany,France, Sweden).Theremainingjurisdictionsdonotincludedentalcare coverageforolderadultsintheirstatutoryhealthsystemsand pub-licdentalcoverageforseniorsisonlyavailablefortargetedgroups thatmeetspeciﬁceligibilitycriteria(Alberta,New SouthWales, Italy,andtheUnitedStates).Thus, inthesecondgroupof juris-dictions,thereisastarkdifferencebetweenhealthcare,whichis offeredto(virtually)allolderadults,anddentalcare,whichisonly availableforsome.Thisdistinction becomesapparentwhen we comparethepublic/privatemixofﬁnancingthatmakesuptotal healthspendingwithdentalhealthspending.Comparable spend-ingdataareonlyavailableforthegeneralpopulation(wecannot

isolatespendingforolderadultsonly),andtheyareonlyreported atnationallevel(wecannotisolatesub-nationaljurisdictionssuch asprovincesandstates).ItisclearthatinCanada,Australiaand Italy,healthcareismostlypubliclyfunded,yetdentalcareis pre-dominantlyprivatelyfunded(withacombinationofout-of-pocket paymentsandprivateinsurance)(SeeFig.2)[[31,32]].TheUnited Statesistheexception,whereprivatefinancemakesupa signifi-cantshareofbothtotaldentalcareandtotalhealthcarespending (thoughifweweretoisolatethepublicshareoftotalhealthcare fundingforthepopulationaged65yearsandolder,thiswouldbe muchhigherthanforthewholepopulation,atroughlytwo-thirds oftotalspending[34]).Wecategorizethesefourjurisdictionsas “targeted”intheirbreadthofcoveragegiventhatonlyatargeted subsetofolderadultsiscoveredinthepublicdentalcareprogram; thus,publicfundsareaimedatspecificpopulationsubgroups.Fig.2

showsthattheshareofpublicfundingfortotaldentalspendingis generallylowerthanfortotalhealthspendinginthefourcountries withuniversalpopulationcoveragefordentalcare,butthe differ-enceislesspronouncedthanintheotherfourcountrieswithonly targetedcoverageprograms.

Amongthejurisdictionsforwhichonlyasubsetofolderadults iseligible forpubliccoverage,there is someconsistencyinthe criteria usedtodefine eligibility.Table 1 describesthe eligibil-itycriteriaforpubliccoverageinthefourjurisdictionsthathave “targeted”populationcoverage:UnitedStates,Alberta,NewSouth Wales,andItaly.IntheUnitedStates,nearlyallolderadultsare eli-gibleforMedicare,whichisafederalprogramthatcoversthecosts ofhospitalandphysicianservicesaswellasprescriptiondrugs. However,underMedicare,coveragefordentalcareservicesisonly availabletosubgroupsoftheolderadultpopulationwhoeither chooseaMedicareAdvantageplanthatincludesdentalbenefits,or areeligibleforstateMedicaidcoverage.Olderadultswhoarenot enrolledintheseplanscanpurchaseastand-alone/supplemental coverageplan[35].Approximatelyone-thirdofindividualswhoare eligibleforMedicareenrollinMedicareAdvantage.Through Medi-careAdvantage,enrolleeshavetheoptiontochooseaplanthat includesdentalbenefits,whereapproximately60%ofenrolleesdo so[12,36].InCalifornia,anestimated2.6millionadultsage65years andolder(orroughly47%ofallseniorsinthatstate)wereenrolled inaMedicare Advantageplanin2018[37].NearlyallMedicare AdvantageplansinCaliforniaprovidetheoptionofobtaining den-talcoverage,althoughnormallythisentailsanadditionalmonthly

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Fig.2. Sourcesoffundingtotalhealthanddentalcareacrossincludedjurisdictions(2017orlatestavailableyear).

Source:OECDHealthStatistics2019(31);*Italianestimateprovidedseparately[32].Notes:Privateinsuranceincludesbothvoluntaryandcompulsoryprivateinsurance,

whicharereportedseparatelyinOECDHealthStatistics.Thedatadonotpermitseparationofspendingbyagegroup,sowerefertotheentirepopulation.

fee.OlderadultswhoarenotenrolledinMedicareAdvantageplans, butwhoareduallyeligibleforMedicareandMedicaid(low-income status),areeligiblefordentalservicecoverageonlyinsomestates. InCalifornia,dentalcareisincludedintheMedicaidProgram,called Medi-Cal,whichcovered23%ofCalifornianseniorsin2017[38]. Takingthetwopublicprogramstogether,inCalifornia,between onehalfandtwo-thirdsofseniorshavesomeformofpublicdental coverage,thoughthisislikelyanoverestimatesincesomeseniors couldbecoveredinbothprograms.

AlbertaandNewSouthWalesbothoffertargetedpublic cov-eragetoolderadultswhomeetspecificlow-incomecriteria,and inItalythecriteriaconsiderbothincomeandhealthconditions.In Alberta,theincomethresholdissetatalevelthatmeansroughly lessthanhalfofthepopulationofadultsage65yearsandolderin theprovincewouldbeeligibleforanypubliccoverage[39].InNew SouthWales,theincomecriteriaforthatstate’spublicdentalcare aredefinedbytwoCommonwealth(national)programs:the Com-monwealthSeniorsHealthCardandthePensionerConcessionCard. Approximately10%and60%ofresidents65yearsandolderinNew SouthWaleshaveaccesstoaCommonwealthSeniorsHealthCard orPensionerConcessionCard,respectively,andmaybeeligiblefor publicdentalcarecoverage[40,41].InItaly,thereisabroaderset ofeligibilitycriteriathanintheotherjurisdictions,theseinclude low-income,socio-economicvulnerability,andspecifichealth con-ditions(healthvulnerability),which,takentogether,meansthat

roughly25%ofolderadults(age65yearsandolder)areeligiblefor somepublicdentalcoveragethroughtheNationalHealthService.

3.2. Scopeofcoverage:whichdentalservicesarecovered?

Theseconddimensionofcoverage–scope–isaddedtothe com-parisonofdentalcoverageacrosstheeightjurisdictionsinTable2. Mostjurisdictionsincludedinthis studycommit toaminimum scopeofbasicdentalcareserviceswithintheirpublicprogramsthat includeroutineandpreventivedentalcare,suchasexams,x-rays, scaling,ﬁllings,andtoothextractions(Table2).Whilebasicdental careservicesarecoveredinthepublicprogramswereview,the oneexceptionisﬂuoride,alow-cost,preventivetreatment,which isnotincludedorroutinelycoveredinthepublicprogramsinfour jurisdictions(Alberta,Italy,FranceandGermany).

IntheUnitedStates,there isvariationinthescopeofpublic coverageavailabledependingontheprogram.Thetwomain pro-gramsarethroughMedicaidforlowerincomeolderadultsdually eligibleforMedicareandMedicaid,andMedicareAdvantage.For theformergroup,thescopeofcoveragedependsonstateMedicaid dentalpolicies;thisrangesfromemergencyonlycare,limitedcare, tocomprehensiveservicecoverage[12].Thestate-runprogramin California(Medi-Cal)providescomprehensivescopeofcoverage. Thescopeof dentalcoverage forMedicare Advantageenrollees varieswidelybytheparticularMedicareAdvantageplaninwhich

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Table1

Breadthofcoverage:eligibilitycriteriafortargetedpublicdentalcarecoveragefor

individuals≥65yearsoldinfourjurisdictions.

Overviewofeligibilitycriteria

UnitedStates(Medicare) • Income:duallyeligibleforMedicareand Medicaid(i.e.lowincome)inastate providingoptionaldentalbeneﬁts.In California(Medi-Cal),theincomethreshold issetat138%ofthefederalpovertyline. UnitedStates(Medicare

Advantage)

• Choice:joinsaMedicareAdvantageplan thatincludesdentalcare.

Alberta(Canada) • Income:notearnmorethanthefollowing

establishedprogramthresholds:CA$27,690 (single)orCA$55,380(couple)for100% coverage;andCA$27,690toCA$31,675 (single)orCA$55,380toCA$63,350(couple) forpartial(10−99%)coverage.a

NewSouthWales(Australia) • Income:eligiblefortheCommonwealth

SeniorsHealthCard(e.g.,notearnmorethan

establishedprogramthresholds),orthe

PensionersConcessionCard.b

Italy • Income:declarationofﬁnancialhardship;

OR

• Clinicalneed:certiﬁcateofsystemicdisease

ordisability.c

a_Based_on₂₀₁₉_income_thresholds_[₁_]._In₂₀₁₈_the_average_individual_income_for

seniorsinAlbertawasCA$44,100,andthemedianincomewasCA$32,200(Statistics

Canada2020).ThismeansaboutnearlyhalfofallseniorsinAlbertareceivesome

publicdentalcoverage.

b _The_annual_income_threshold_for_the_Commonwealth_Seniors_Health_Card_for

olderadultsage60yearsandolderis:AU$55,808(single);AU$89,290(couples);

AU$111,616(couplesseparatedbyillness,respitecareorprison).Eligibilityforthe

PensionersConcessionCardisreceivinganyofthefollowingCommonwealth

pay-mentsformorethan9months:JobSeekerPayment;ParentingPaymentpartnered,

PartnerAllowance,SicknessAllowance,SpecialBeneﬁt,orWidowAllowance.

c _In_Italy,_the_income_and_clinical_needs_criteria_apply_both_to_the_older

popula-tion(65yearsandolder)andtothegeneralpopulation(allages).Roughly25%of

the65yearsandolderpopulationwouldmeetthesecriteria.Thespeciﬁccriteria

varybyregion.Forexample,intheLombardyregion,thelow-incomethresholdis

determinedbyayearlypensionbelowD11,500forafamilyoftwo.

thepersonenrolls.Theseplansrangefromnodentalcoverage(40% ofallenrollees),preventiveonly(examsandcleanings)(19%ofall enrollees),comprehensivecoverage(42%ofenrollees),withsome plansprovidingcoverageofmajorservicessuchasdentures[12].

Manypublicprogramsalsoprovidecomprehensivecoverage, whichincludesrootcanaltherapy(alleightjurisdictions),and peri-odontaltreatment(managementofgumdisease)(inallbutAlberta andFrance).Thereisalsosomecoverageformajorservices,such ascrownsandbridges,anddentures,whichareoftenhighercost procedures;allthreeof thesemajorservicesarecoveredinthe publicprogramswereviewedexceptAlbertaandItaly.Nopublic programcoversestheticservices.Overallthenarrowestscopeis seeninAlberta,followedcloselybyItaly.

3.3. Depthofcoverage:howmuchofthecostsarecovered?

Acrosstheeightjurisdictions,thedepthofdentalcoveragefor mostdentalservicesrangesfromshallow(i.e.,thepublicprogram coversonlypartofthetotalcosts)todeep(thepublicprogram cov-ersmostorallofthetotalcosts).Wherethereisshallowcoverage, theremainingcostsmaybepaiddirectlybypatientsthroughout ofpocketpaymentsorprivate(voluntary)dentalinsurance.

Threeofthefourjurisdictionswithuniversalpopulation cover-ageofolderadultsoffershallowcoverageforbasicdentalservices (England,Sweden,andFrance),withdeepcoverageinGermany. InEngland,unlikeotherhealthserviceswherethereisfull ﬁnan-cialprotection,fordentalcare,adultpatientsofallagespaypart ofthecostsintheformofaﬂatfeeforacourseoftreatment(in 2019thefeewas

£

22.70orroughly27EurosforBand1services includingpreventiveexaminationanddiagnosis,and

£

62.10,or75 Euros,forBand2serviceswhichincludessomebasicservicessuch asfillingsbutalsosomemoreexpensiveservicessuchasrootcanal, toothextraction)[42].InSweden,individualsaged65yearsand olderreceiveafixedannualsubsidy(orallowance)of600SEK(57 Euros)tobeusedtowardpreventivedentalcare,andthentheypay anyamountthatexceedsthisvalue.Patientscanusethisgeneral dentalallowanceforexaminations,preventivetreatmentsandany otherdentalcarethatentitlesthemtostatedentalsupport.In addi-tion,thereisanallowanceof600SEK(57Euros)every6months towardspreventivedentalcareforpatientsofallages(including seniorsage65yearsandolder)whoarediagnosedwithamajor diseasewithimplicationsfororalhealth(e.g.,drymouthdueto radiation,Crohn’sdisease,severediabetes).Thus,dentalcareis cov-ereddifferentlyfromotherhealthserviceslikeprimarycareand specialistcarevisits,forwhichtherearefixedco-paymentsinstead ofallowances[43].Inadditiontotheannualsubsidy(allowance) forpreventivedentalcareinSweden,thereiscatastrophiccoverage

Table2

Overviewofthescopeofpublicdentalcoverageavailabletoindividuals≥65yearsoldacrosseightjurisdictions.

Comprehensiveservices Majorservices

Esthetic Basicservices Root canal Periodontal (gum) treatment Crowns& bridges Dentures

Preventiveservices Simple

Fillings Tooth extractions Routine exams Routine x-rays Scaling Fluoride Targeted (sub-setof olderadults) USMedicare/Medicaida √ √ √ √ √ √ √ √ √ √ _– USMedicareAdvantageb √ √ √ √ √ √ √ √ √ √ _– Canada(Alberta) √ √ √ – √ √ √ – – √ – Australia(NSW) √ √ √ √ √ √ √ √ √ √ – Italy √ √ √ – √ √ √ √ – – – Universal(all olderadults) England √ √ √ √ √ √ √ √ √ √ – Sweden √ √ √ √ √ √ √ √ √ √ – France √ √ √ – √ √ √ - √ √ – Germanyc √ √ √ _– √ √ √ √ √ √ _–

Note:√indicatescoverageisavailable,-indicatesnotcovered.Thistabledoesnotcapturefrequencylimitations,discretions,ordepthofcoverageforservices.Preventive

servicesincluderoutineexams,routinex-rays,scaling,ﬂuoride;Basicservicesincludepreventiveservices,simpleﬁllingsandtoothextractions;Comprehensiveservices

includebasicservices,rootcanaltreatment,andperiodontal(gumtreatment);Majorservicesincludecrowns,bridges,anddentures.

a_The_scope_of_coverage_varies_widely_across_US_states_so_we_focus_here_on_Medi-Cal,_the_Medicaid_program_in_California.

b _The_scope_of_dental_coverage_for_Medicare_Advantage_enrollees_is_the_same_regardless_of_income_or_clinical_need_criteria.

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forotherdentalservices.Fordentalcarecostsabovetheallowance, patientspaythemselvesoutofpocketupto3000SEKinayear (about284Euros),patientsthenpay50%ofthecostsupto15,000 SEK(1420Euros),andtheypayonly15%ofcostsabove15,000SEK (1420Euros).Inaddition,inSwedentherearereferencespricesfor dentalcarewhichplacelimitsoncoverageforpatients,whereby thereisnopubliccoverageofserviceortreatmentcoststhatexceed aﬁxedreferencepriceforthatserviceortreatment[44].InFrance, patientscontributeintheformof30%co-insurance[33]withthese costsoftencoveredbyprivateinsurance,aswithallotherhealth (non-dental)services[33].InGermany,thefullcostofbasicdental careservicesthatfollowadeﬁnedstandardoftreatmentiscovered bythestatutorysocialhealthinsurance(SHI)system,aswithother healthservices.

Amongthesefourjurisdictionswithuniversalpopulation den-talcoverage,coverageisshallowformajorservices,suchascrowns and bridges, and dentures. In England, these servicesare con-sideredaspartof“Band3”courseoftreatmentfor whichthere isa co-payment of

£

256.50(roughly 290Euros).In Franceand Sweden, major services are subject to the same cost sharing arrangementsasforbasicservicesdescribedabove.Dentalcare reformsinFrancethatarecurrentlyunderwaywillremove out-of-pocketpayments formajordentalservicesandthereforewill changethedepthofcoveragefor theseservicesinFrancefrom shallowtodeep,oncethesearefullyimplementedin2023[24]. In Germany, while basic services are fully covered (when the patientfollowsthedefinedstandardoftreatment),thereis shal-lowcoverageofprosthetictreatments(e.g.crowns,dentures).For thosewhohavedefinedclinicalindications,theyreceivea fixed subsidyof50%forstandardcaretreatmentbySHIformajor ser-vices, withhigher fixedsubsidiesavailable for individuals who visitthedentistforregularpreventivecareanddental examina-tions.ThesameamountoffixedsubsidyispaidbySHI(leviedon thecostsofstandardcare)evenifindividualschooseadifferent treatmentoption thanwhatis definedasstandardcare.Thisin turnmeansthatchoosingadifferenttreatment(e.g.higherquality materials)mayleadtohigherout-of-pocketcosts(orthesemay becoveredbycomplementaryprivateinsurance).Thesubsidyis settoincrease to 60%of thecosts ofstandard care in October 2020.

Inthefourjurisdictionswithtargetedpopulationcoverage,the depthofcoverageofbasicdentalcareservicesrangefromshallow todeep(fullycovered)forolderadultswhomeetspecificincomeor clinicalcriteriadependingontheirjurisdiction.InAlberta,thereis deepcoverageforbasicservicesforthelowestincomeolderadults, andshallowcoverageforthosewhomeetaslightlyhigherincome threshold.Howeverpubliccoverageforallenrolleeshasalimitin Alberta:thereisamaximumcoverageofCAD$5000(about3400 Euros)overfiveyears,andsomeserviceshavefrequencylimits(e.g., onecheck-upexaminationperyear).InNewSouthWales,thereis deepcoverageforbasicandmajorservicesforeligibleolderadults whohaveaCommonwealthSeniorsHealthCardorPensioners Con-cessionCardwithnopre-specifiedcapsoncoverage.InItaly,the depthofcoverageavailabletoeligible(targeted)adultsvariesfrom shallowtodeep,since,asnotedintheprevioussection,eligibility isrestrictedtoparticularhealthandsocio-economicconditions, andco-paymentsmayberequiredforsometargetedgroupsfor someservicesaccordingtoamixofnationalandregional provi-sions[45].Forexample,inLombardyRegion,thereisdeepcoverage (noco-payment)forseniorswithayearlypensionbelowD11,500 (forafamilyoftwo),orwithothersocio-economic(unemployed) andhealthvulnerabilities,andincludesbasicservices(preventive visits,fillings,andscaling).IntheUnitedStates,low-incomeolder adultswhoareduallyeligibleforMedicareandMedicaid,orthose whoenrollinMedicareAdvantageplans,sometimesreceive shal-lowcoverage(co-paymentsrequired)fordentalservicesthrough

theseprograms.IntheMedicaidprograminCalifornia,Medi-Cal, there isshallowdepthofcoverage becauseof theco-payments (US$1peroutpatientvisit)andannualcoveragelimitofUS$1800 per year (about 1500 Euros). Note that this coverage limit in California is a soft cap,as it can beexceededin some circum-stancesdeemedmedicallynecessarywithpriorauthorization.For majorservices,thereiseithernopubliccoverage(e.g.,forcrowns andbridgesinAlbertaandItaly),orshallowcoverage.An excep-tionisNewSouthWaleswhichhasdeepcoverageforalleligible seniors.

3.3.1. Extendeddepthofcoverageforvulnerablepopulations Amongthefourjurisdictions withuniversalbreadthof pub-lic dental coverage for older adults (England, France, Sweden, and Germany),there isextended depthof coverageforspeciﬁc sub-groupsofthepopulationthatareconsideredvulnerable(see

Table3).EnglandandGermanyprovideextended(deep)coverage toalllower-incomeadults(e.g.,thosewhoreceiveincomesupports, orsocialassistance)andinFrance,itisprovidedtoalladultswith low-income(throughoneofthreeprograms-couverturemaladie universelle-complémentaire(CMU-C),aideàl’acquisitiond’une com-plémentairesanté(ACS)andaidemédicaledel’état(AME))orwith speciﬁclong-termmedicalconditions[33].Swedenconsidersage (65yearsandolder)asoneofthecriteriaforextendedcoverage, whereasotherjurisdictionssetcriteriathatapplytoadultsofall ages.AlladultsinSwedenareeligibleforsubsidizeddentalcare, buttheamountofcoveragevariesbyagegroup:individuals24–29 yearsoldandthose65andolderreceive600SEK,roughly57Euros, peryear,whereasindividuals30–64yearsoldreceive300SEK,or 28.4Euros,peryearforpreventivedentalcare[44].

4. Discussion

Thereisaconsiderablevariationinthebreadth,scopeanddepth ofpublicdentalcoverageforolderadultsacrosseight compara-blehigh-incomejurisdictions.Thesecoveragemodelsfallintofour broadcategories:[1]deeppubliccoverageofbasicdentalservices forasubsetoftheolderadultpopulationdefinedbasedonstrict eli-gibilitycriteria(Alberta,NewSouthWalesandItaly)[2];universal, shallowcoverageofbasicdentalservicesforallolderadults (Eng-land,France,Sweden)[3];universal,deepcoverageofbasicdental servicesforallolderadults(Germany);and[4]shallowcoverage ofbasicservicesavailabletosomesubgroupsofthepopulation (forlower incomeolderadults duallyeligibleforMedicare and Medicaid,e.g.,inCalifornia, andfor olderadultsinsome Medi-careAdvantageplansintheUnitedStates).Withineachofthese categories,therearesomevariations,andnuancesworthnoting. Twojurisdictionsplacefinanciallimitsonthedepthofcoverage, withanannual(or5-year)spendinglimit overwhich thecosts areshiftedontoindividuals(Alberta,andMedi-CalintheUnited States).Twojurisdictionsimposestandard,fixedfeesperservice itemabovewhichthecostsareshiftedtoindividualsiftheychoose amorecostlyserviceorprovider(GermanyandSweden).Inother jurisdictions,coverageisnotlimitedbyfinancialcaps,butisrather throughlimitedsupply,wherebylengthywaitlistsareusedtolimit patientsfromaccessingthepubliclyfundeddentalcareforwhich theyareeligible(NewSouthWales,andItaly).

Amongtheeightjurisdictionsincludedinthisstudy,themodels ofpublicdentalcoveragerelatetosomeextenttothemainmethod offinancingthehealthsystem.Dentalcarecoverageisconsistent with,andtreatedsimilarlyto,otherhealthservicesandincluded inthestatutorybenefitspackageonlyinthetwosocial insurance-financedsystems– FranceandGermany.InFrance,areform to dentalcarethatisintheearlystagesofimplementationaimsto increasepubliccoverage,andreduceout-of-pocketpayments,for

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Table3

Overviewofthedepthofpublicdentalcoverageavailabletoindividuals≥65yearsoldacrosseightjurisdictions.

Comprehensiveservices Majorservices

Esthetic Basicservices Root canal Periodontal (gum) treatment Crowns& bridges Dentures

Preventiveservices Simple

Fillings Tooth extractions Routine exams Routine x-rays Scaling Fluoride Targeted population (sub-setof older adults) USMedicaid (Medi-Cal)a

Shallow Shallow Shallow Shallow Shallow Shallow Shallow Shallow Shallow Shallow –

USMedicare

Advantageb

Deep Shallow Shallow Shallow Shallow Shallow Shallow Shallow Shallow Shallow –

Canada

(Alberta)c

Deep Deep Deep – Deep Deep Deep – – Shallow –

Australia (NSW)

Deep Deep Deep Deep Deep Deep Deep Deep Deep Deep –

Italy Deep Deep Deep – Deep Deep Deep Deep – – –

Universal population (allolder adults) England Shallow+ Deep Shallow+ Deep Shallow+ Deep Shallow+ Deep Shallow+ Deep Shallow+ Deep Shallow+ Deep Shallow+ Deep Shallow+ Deep Shallow+ Deep –

Sweden Shallow Shallow Shallow Shallow Shallow Shallow Shallow Shallow Shallow Shallow –

France Shallow+ Deep Shallow+ Deep Shallow+ Deep – Shallow+ Deep Shallow+ Deep Shallow+ Deep - Shallow+ Deep Shallow+ Deep –

Germanyd _Deep _Deep _Deep _– _Deep _Deep _Deep _Deep _Shallow₊

Deep

Shallow+

Deep –

Note:-indicatesnotcovered.Preventiveservicesincluderoutineexams,routinex-rays,scaling,ﬂuoride;Basicservicesincludepreventiveservices,simpleﬁllingsandtooth

extractions;Comprehensiveservicesincludebasicservices,rootcanaltreatment,andperiodontal(gumtreatment);Majorservicesincludecrowns,bridges,anddentures.

a_This_{classification}_reflects_the_coverage_for_older_adults_dual_eligible_for_Medicare_and_Medicaid_in_California_(in_Medi-Cal),_and_does_not_reflect_the_scope_coverage_for

acrossallstates.Forexample,thescoperangesfromlimitednumberofexamsorcleanings;emergencyservicesonly;moreextensivebeneﬁtswithannualcaponbeneﬁts.

b _The_scope_of_dental_coverage_for_Medicare_Advantage_enrollees_is_the_same_regardless_of_income_or_clinical_need_criteria.

c _This_“deep”_{classiﬁcation}_in_Alberta_only_pertains_to_the_lowest_income_group_for_which_there_are_no_co-payments,_and_within_the_limit_of_CA$5000/5_years.

d _Only_for_pre-deﬁned_basic_standard_care,_see_above;_Coverage_for_major_services_is_set_at_50%_(60%_in_October₂₀₂₀₎_of_total_cost,_and_requires_a_substantial_OOP_co-payment.

Thiscoveragecanincreaseforpatientswhomakeregularuseofpreventiveservices.Additionalcoverageisavailabletoindividualswhofulﬁllincomecriteria.

severaldentalcareservices[24].InGermany,dentalcareservices areawell-establishedcomponentofhealthcare,and,consequently, thebenefitbasket.Thisisreflectedintheparticipationofthe Fed-eralAssociationofDentistsintheFederalJointCommittee,which decidesthescopeofcoverage.Itisthereforeunlikelythatdental carewouldbefullyremovedfromthebenefitcatalogue.Incontrast, inthetax-fundedsystemswithuniversaldentalcoverageforall adults-EnglandandSweden,thedepthofcoverageandmechanism offinancearedifferentfordentalcarethanforotherhealth ser-vices.IntheEnglishNationalHealthService(NHS),whichdoesnot haveanexplicitlydefinedbenefitspackage,therehasbeenasteady declineinthepublicfinancingofdentalcaresincetheearly1990s, asco-paymentshaveincreasedsincetheywereinitiallyintroduced shortlyaftertheintroductionoftheNHS[46].Germanyrecently passedalawextendingpublicfinancingfordentures,crowns,and bridgesfrom50%ofthedefinedcostofstandardcaretreatment to60%(this willtakeeffectinOctober 2020),witheven higher fixedsubsidiesinthecaseofregularpreventivecareanddental examinations.Theremainingfourjurisdictionsprovidedental cov-erageonlytoasubsetofitspopulation,thustreatingitmorelikea safetynetprogramthanaspartofthebroaderhealthcoverage sys-tem.Interestingly,onlyinGermanyisthereanexplicitattemptto usefinancialincentives(deepercoverage)tosteerpatientstoward morepreventivedentalcareseekingbehaviours(e.g.,check-ups). InSweden,theuseofallowancesforpreventivedentalcaremay alsoincentivizeannualpreventivecheck-upsbecausethereareno co-paymentsfordentalcostswithinthatallowance.

4.1. Populationcoverageforolderadults

Whilethefocusofthisstudyisonolderadults,itisimportant tonotethatthreeoftheeightjurisdictionsweincludedonotmake anydistinctiontocoverageforolderadultscomparedtoyounger adults(France,Germany,England).Olderageisoneofthecriterion fordeterminingcoverageintheotherﬁvejurisdictionsweinclude (UnitedStates,Sweden,Italy,Alberta,andNewSouthWales).The

MedicareprogramintheUnitedStatesisage-based:itcoversthe 65yearsandolderpopulationalongwithsomepeoplewith disabil-ities,anddentalcoverageisavailableforthosethatarelowincome andqualifyforMedicaid,orthosewhooptforaspeciﬁcMedicare Advantageplanthatincludesdentalcare.ForthestateofCalifornia, betweenhalfandtwo-thirdsoftheolderadultpopulationwould becoveredbyeitherMedicaid(Medi-Cal)orMedicareAdvantage. InSweden,ageisonlyconsideredasacriterionfortheextended depthofcoverage.InItaly,AlbertaandNewSouthWales,theage criterioniscombinedwithadditionalﬁnancialeligibilitycriteria. 4.2. Financialprotectionandtheroleofprivateinsurance

Thereissomeevidencefromtheliteraturetosuggestthat cost-barrierstodentalcareareloweronaverageinjurisdictionswith universalpopulationcoveragethatisshallowthanthosewith tar-getedpopulationcoveragethatisdeepforasubsetofolderadults [6,7,47]. While jurisdictions withtargeted population coverage providedeepcoverageofsomeservicestoeligibleolderadults,the designofthecoverageprogramsmeansthatthoseineligiblefor publiccoverage(e.g.,withincomethatfallsjustabovethe thresh-old)maynotbeabletoafforddentalcarecosts.

Private(voluntary)insuranceplaysanimportantroleinsome jurisdictionsinﬁnancingdentalcareforthegeneralpopulation,as notedinFig.2;italsoplaysaroleinprotectingolderadultsfromthe costsofdentalcare,inparticularinAustralia,FranceandtheUnited States.InAustralia,anestimated46%ofindividualsaged65years andolderhavesomelevelofprivatehealthinsurancethatcovers dentalcare[46].IntheUnitedStates,nearly8%ofMedicare beneﬁ-ciarieshaveprivateinsurancethatcoversdentalcare,comparedto 27%withcoveragethroughMedicareAdvantageorMedicaidwhich leaves65%withnodentalcarecoverage[12].Intheother coun-tries,dataonprivateinsurancecoverageisavailableonlyforthe generalpopulationandsoweareunabletoestimateandcompare coveragefortheolderpopulation.Forexample,inFrance,nearlyall individualshavevoluntaryhealthinsurance(96%),coveringthe

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co-insuranceforhealthanddentalservices[48],whichsuggeststhat mostolderpeopleholdthiscoverageaswell.Inothercountries, privatehealthinsuranceislessprevalent,e.g.,lessthan5%ofthe generalpopulationinSweden,andabout11%ofthegeneral pop-ulationtheUK[48].InCanada,privateinsuranceiscloselytiedto employmentandthereislimiteddataonthedentalcarecoverage ofolderadults,withsurveydatasuggestingadecreaseinemployer coverageinthispopulationoverthedecade2005–2014[49].While someolderadultswillcontinuetobecoveredthroughtheir pre-viousemployersandsomemaychoosetopurchaseanindividual plan,otherswouldpayoutofpocket.Furthercomparativeresearch onthebreadth,depthandscopeofprivateinsurancecoveragefor dentalcarewouldhelptoshedlightontheextenttowhichthey provideﬁnancialprotectionforolderadults.

4.3. Servicecoverage

Ingeneral,eachjurisdictioncoversabasicsetofserviceswithin theirpublicprograms.Withintheseprograms,mostjurisdictions coverpreventiveservices,suchasdentalexams,x-rays,and scal-ing,butfourofeight(Alberta,Italy,France,andGermany)donot routinelycoverfluoridetreatmentsforolderadults.Olderadults areatgreaterriskofdevelopingdecayondentalrootsurfacesof theirteeth,whichcanbepreventedthroughregular profession-allyappliedfluoridetreatments[50].Intermsofcomprehensive andmajorservices,allpublicprogramsincludesomecoveragefor rootcanals,andmostcoverperiodontal(gum)treatment,crowns andbridges,anddentures.Thelackofpubliccoverageforthese servicesinsomejurisdictionsmaybeduetotheriskof overtreat-ment,lackofevidenceontheeffectivenessofthesetreatments, andlackofclinicalguidelinesindentistry[51,52].Itisimportantto notethatwhilesomepubliccoverageisavailableformajorservices acrossmostofthejurisdictionsinthisstudy,barrierstoaccessing theseservicesmaystillexist.Forexample,priorapprovaland co-paymentsmayberequiredbeforeservices,suchascrowns,root canaltherapy,ordentures,canberendered.Buildingonprevious workfromEatonandcolleagues(2018),caseprofilesandvignettes canbeutilized tocomparethetypesofcareandservices avail-ableforindividualswithdifferentclinicalconditionsandtreatment needs[53].Thistypeofanalysiscanhelpdescribetheextentto whichdifferentcoveragemodelsaddressdifferentdentaldiseases andconditions,suchastoothdecayand/orgumdisease.

4.4. Contextualandsystem-levelconsiderations

Whilethis studydescribesaspectsofpublicdentalcare cov-eragemodelsforolderadults,thereareseveralotherfactorsthat mayaffecttheaccessibilityandeffectivenessofdentalcare cover-age.First,socialandculturalfactors,includinglanguage,education, andhealthliteracymayimpactaccesstocareforparticular sub-groupsofolderadults(e.g.,immigrants)[54].Second,clinicalneeds anddentalutilizationpatternsmaydifferbetweenlow-and high-incomeearningolderadults[55],whichwould beimportantto considerwhendevelopingcoveragemodelsforsubgroupsofthe population.Third,modelsoforganizationanddeliveryofdental caremayimpactaccess.Thereissomeevidencethatclinicsetting maynotimpactaccesstocarewithinpublicdentalcareprograms: studiesfromSwedenandtheUnitedKingdomsuggesttheredoes notappeartobedifferencesinperceptionsofqualityofcareor costbarrierstocareforadultsand olderadultsbetweenpublic andprivateclinics[56,57].Fourth,themethodofpayingdentists and deliverysetting appearstoimpactoutcomes: one studyin Australiafoundthat salarieddentistsinpublicclinics aremore costeffectiveand haveloweroverall coststhandentistsin pri-vateclinicswhoarepaidbyFFSorvouchers;yetdentistsinprivate clinicspaidbyvoucherswereassociatedwithhighervolumeof

servicesprovidedthantheothertwopaymentanddelivery mod-els[58].Paymentreformswithinpublicdentalcaremodelscanalso inﬂuenceproviderbehaviours[59].Finally,accesstodentalcareis limitedduetocapacityandsupplyconstraintswithinpublicdental careclinicsandhighdemandfordentalcareinsomejurisdictions. Forexample,onlyabout20%ofindividualseligibleforpublicdental coverageareabletoreceivedentalcareinAustralia,whichhasled tolongwaitingtimesforcare[10].Thus,whilethemodelofdental coverageintermsofitsbreadth,depthandscopelikelyimpacts accesstodentalcareandrelatedoralhealthoutcomesforolder adults,therearemanyothersystemstructuressuchasprovider paymentmodels,extentandtypeofout-of-pocketpayments, sup-plyandorganizationalfactorsthatalsoimpactﬁnancialprotection andaccessibilityofdentalcareacrossandwithinthese jurisdic-tions.Thesecontextualandsystem-levelfactorsimpactingaccess todentalcarewarrantfurtherattention.

4.5. Limitationsandstrengths

Thisreviewdrewonpubliclyavailableinformationand contri-butionsbylocalexperts.Therearelimiteddataavailableonoral healthoutcomes,qualityofdentalcare,dentalvisitingbehaviours, anddentalcareutilization.Therearenoconsistentorstandardized oralhealthindicatorstocomparejurisdictions(OECD,WorldBank, WHOandtheEuropeanUnion).Ourcomparisonsreliedlargelyon datacollecteddirectlyfromlocalexperts,includingmembersof ourprojectteam,and internationalsurveysthathad consistent methodologyandthatreportedestimatesforjurisdictionsinour study.DentalcarespendingdatawerealsonotavailableforItaly andthuswereliedonlocalsources,whichmaynotbedirectly com-parabletotheOECDestimates.Thisreviewdidnotdescribeother keyfeaturesofdentalcoverageprogramsthatvaryacrossthe juris-dictions,suchasnon-ﬁnancialbarrierstoaccesssuchaswaiting times,continuityofcare,ordifferencesthedeliveryofdentalcare acrosspublic(e.g.governmentownedclinics)andprivatesectors. Finally,wedidnotcomparetheproviderfeeswithinandbetween dentalservicefeeschedulesofprivateandpublicsystems.Many jurisdictionshaveprivateandpublicdentalservicefeeschedules (e.g.,inFrance,Sweden,andCanada)wherethefeesarehigherin privatecomparedtopublicfeeguides.Theseaspectsofdentalcare coveragecouldbetopicsforfutureresearch.

5. Conclusion

Thisstudyprovidesanin-depthcomparisonofthepublic cov-erageofdentalcareforolderadultsacrossarangeofhigh-income jurisdictions.Whileolderageisanimportantconsiderationinthe design ofpubliccoverageinAlberta,New SouthWalesand the UnitedStates,severaljurisdictionsdonotconsiderageasan eligi-bilitycriterionforpubliccoverage(England,France,andGermany). Moreover,alljurisdictionsweinclude,exceptSweden,provide dif-ferential (e.g.,extended depth)coverage for those who meet a specificlow-incomethreshold.Oneoftheprioritiesforimproving oralhealthoutcomesacrosscountriesistointegratedentalcare ser-vicesintothebroaderhealthsystem[60,61].Ourfindingssuggest thatthelevelofintegrationmaybemorefeasibleinsome coun-triesthaninothersdependingonthecurrentapproachtocoverage thatrangesfromfullyintegratedintothebenefitspackagetoalmost completelyseparatefromthecoverageofhealthcaremorebroadly. Furtherresearchcantestthesepatternsacrossalargernumberof countriesandtesttheimpactsofthesestructuraldifferenceson accessandoral healthoutcomes.Duetothelimitedavailability ofcomparabledatawithinandacrossjurisdictions,inparticular thoseoutsidetheEuropeanregion,furtherresearchwouldbenefit fromstandardizeddatacollectioninitiativesfororalhealth

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mea-sures.Futureworkshouldalsoconsidertheroleofdifferentsystem andprovider-levelfactors(suchaspublic/privatedeliverysetting andproviderskill-mixwithinpublicdentalcoveragemodels),the impactsoflimitedsupplyonaccesstocareevenamongeligible individuals,andtheextenttowhichcost-effectivenessorclinical effectivenessevidenceinformsdecisionsonwhichservicesare cov-ered.Finally,thereisaneedtoconsiderhowmodelsofpublicdental carecoveragecouldenabletheintegrationoforalhealthcarewith medicalcaretobettermeettheneedsofthegrowingpopulationof olderadultswithmultiplehealthconditions.

DeclarationofCompetingInterest None.

Acknowledgements

Weacknowledgetheexpertinsightsandreviewofprevious ver-sionsof this paperbythe followingindividuals:PaulBatchelor (University College London), Marie Böcker (Technische Univer-sität Berlin), Susanne Felgner (Technische Universität Berlin), RainerJordan(InstitutderDeutschenZahnärzte),Daniela Carmag-nola(MilanMunicipality,Italy),SandyLantz(MalmöUniversity, Sweden),RebeccaNg(UniversityofToronto),andSylvie Azogui-Lévy(DepartmentofPublicHealth,UniversityParis-Diderot).We receivedfundingfromConverge3,apolicyresearchcentrebasedat theUniversityofToronto.

AppendixA. Supplementarydata

Supplementarymaterialrelatedtothisarticlecanbefound,in theonlineversion,atdoi:https://doi.org/10.1016/j.healthpol.2020. 06.015.

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