Abstract
Background: Insurance against the cost of preventing and treating oral diseases can reduce inequities in dental-care use and oral health. The purpose of this study was to examine the extent of variation in dental insurance coverage for older adult populations within and between the USA and various European countries. Method: The analyses relied on 2006–2007 data from the Survey of Health, Ageing and Retirement in Europe (SHARE) and on 2004–2006 data from the Health and Retirement Study (HRS) in the USA for respondents 51 years of age and older. A series of logistic regression models was estimated to identify disparities in dental coverage. Results: The highest extent of significant insurance differences between various population subgroups was found for the USA. In comparison with southern and eastern European countries, a lower number of significant differences in coverage was found for Scandinavian countries. Countries categorised as having comprehensive public insurance coverage showed a tendency towards less insurance variation within their populations than did countries categorised as not having comprehensive public coverage. The exceptions were Poland and Switzerland. Conclusions: The findings of the present study suggest that significant variations in dental coverage exist within all elderly populations examined and that the extent of inequalities also differs between countries. By and large, the observed variations corroborate the perception that population dental coverage is more equally distributed under public subsidy. This could be relevant information for decision makers who seek to improve policies in order to provide more equitable dental coverage.
Key words: Dental insurance coverage, elderly populations, inequalities, USA, Europe
INTRODUCTION
Insurance against the cost of preventing and treating oral diseases can reduce inequalities in dental care use and oral health1., 2., 3.. Different countries have adopted different approaches to provide public subsidy of dental insurance. Some countries provide support through comprehensive Social Health Insurance (SHI) programmes, whereas other countries provide comparably little public subsidy4. It has generally been suggested that various countries can be clustered together, stratified according to subsidy characteristics, into welfare state regimes which, when grouped, have similarities with respect to health and health care5., 6., 7.. A relatively high level of subsidy has traditionally been attributed to Scandinavian countries in comparison with the welfare systems in other countries8., 9..
Regardless of the prevailing public subsidy system, health policy makers routinely need to weigh a multitude of arguments concerning dental and other types of medical care against each other and in relation to global resource constraints within and outside health care10., 11., 12.. Against the background of such complexities, political priority is usually given to matters of high urgency13. Yet, in the absence of reliable information about the extent and sources of unequally distributed dental coverage within their populations, health policy makers are unlikely to understand whether or not revision of currently existing dental care policies is necessary.
Equity concerns may arise, not only in countries without extensive public subsidies of dental coverage, but also in those in which dental coverage is extensively subsidised and when one part of the population has greater dental coverage than another. This implies that some people have to pay a higher proportion of the cost for the same treatment compared with others. Even if extensive public subsidies already exist, and differences in dental coverage are solely attributable to one part of society opting for complementary insurance, this may influence decision makers to reconsider the extent to which current health-care programmes are still in line with population preferences14. To date, little is known about whether there are disparities in dental coverage within older European adult populations and how they compare with those in the USA.
The purpose of this study was therefore to provide country-specific baseline data to investigate differences in the extent of self-reported dental coverage for older adult populations within and between the USA and various European countries, including Germany, Switzerland, and the Netherlands in central Europe; Denmark and Sweden in Scandinavia; Spain, Italy, and Greece in the Mediterranean (southern Europe); and the Czech Republic and Poland in eastern Europe. It was hypothesised that countries with SHI would have less variation between different population subgroups than countries without SHI. The present study also aimed to describe and contrast variation in dental coverage between the USA and various European countries.
METHODS
The data used in our study were from home-based face-to-face interviews collected in wave 2 of the Survey of Health, Ageing and Retirement in Europe (SHARE) and from wave 8 of the Health and Retirement Study (HRS) in the USA for respondents 51 years of age and older. SHARE wave 2 was conducted in 2006–2007 and contains detailed information on the health, socio-economic status (SES), and family background of nearly 35,000 older Europeans from 14 countries (Denmark, Sweden, Austria, France, Germany, Ireland, Switzerland, Belgium, the Netherlands, Spain, Italy, Greece, the Czech Republic, and Poland). As a panel survey, SHARE is designed to be similar to the HRS, except that SHARE is administered annually, rather than every 2 years (as for the HRS). More details about the methodology of SHARE are available in the literature15 and on the SHARE website (www.share-project.org). Almost 19,000 older Americans were surveyed in wave 8 of the 2006 HRS, regarding a wide range of health, socio-economic, and demographic information. Administered by the Institute for Social Research at the University of Michigan and sponsored by the National Institute on Aging, the HRS provides data for the study of ageing, retirement, and health among older populations in the USA16. More details on the methodology of the HRS are available in the literature and on the HRS website (www.hrsonline.isr.umich.edu)16.
SHARE wave 2 was reviewed and approved by the Ethics Committee of the University of Mannheim. In most countries, respondents’ consent to participate in SHARE is verbal. The text for the verbal consent is found at the beginning of the coverscreen questionnaire. In countries, such as Poland, where written consent is legally required, this was also secured. After filling out a user statement, data become available and can be downloaded for free as long as they are used for no purposes other than purely scientific ones. The HRS is under current institutional review board (IRB) approval at the University of Michigan and the National Institute on Aging. No individual identifiers or links to individual identifiers are provided to researchers. Consent to participate in the HRS is verbal, and verbal consent is obtained from all participants in every wave before the start of the interview. Separate written consent is obtained for the physical measurements and for the blood and saliva sample components of the enhanced face-to-face interview. The present study has been deemed as exempt (E4) from approval by the IRB at the University of Maryland. To the best of the author(s) knowledge, this study has been conducted in full accordance with the World Medical Association Declaration of Helsinki.
Our study analysed self-reported dental insurance coverage and its correlates in the USA in wave 8 of the HRS and in European nations in wave 2 of SHARE. Dental coverage in SHARE is measured by responses of ‘entirely or mostly paid or reimbursed by social insurance or respondent’s health insurance’ or ‘mostly paid by respondent’ to the question ‘Who finally pays for dental care?’. Persons responding ‘entirely paid by respondent’ to this question are considered to lack dental coverage in SHARE. In the 2006 HRS, persons answering ‘yes’ to the question ‘In the last 2 years have you seen a dentist for dental care including dentures?’ are considered to have coverage if they responded ‘completely, mostly, or partially covered’ to a follow-up question regarding how much of their dental expenses were covered by insurance. Persons who did not use dental care in the HRS were also considered as covered if they responded ‘yes’ to the question: ‘If you did need to see a dentist, would you expect any of the costs to be covered by insurance?’.
Explanatory variables in logistic models for dental coverage included RAND-harmonised versions of age (51–64, 65–69, 70–74, 75–79, 80–84, 85+ years), sex, educational attainment, marital status (married/partnered; widowed, divorced, separated; never married), self-reported general health status (three categories: excellent/very good; good; fair/poor), objective oral health status (SHARE: binary measure indicating whether or not the respondent wears dentures; HRS: binary measure indicating whether or not the respondent has lost all permanent teeth), the ability to bite/chew on hard foods (binary measure; only in SHARE), retirement/labour force status (retired, not retired in the labour force, not retired not in the labour force), and household income quintiles, according to country. These variables were included to identify demographic, socio-economic, and health-related differences in dental coverage.
There are subtle distinctions between HRS and SHARE harmonised variables. For example, SHARE collected post-tax income in wave 2, whereas only pre-tax income was collected in wave 8 of the HRS. Labour force status in SHARE is determined by a single question regarding which labour-force status most generally describes the person’s situation; HRS adapts responses to multiple questions to determine this status. In both SHARE and HRS, household income quintiles were computed separately for couples and single persons within each country. The International Standard Classification of Education (ISCED) was used to harmonise three categories of educational attainment in European countries with those of older Americans. European subjects with no degree qualification, or unknown or ISCED levels 1 or 2, were considered equivalent to American subjects with less than a high school degree; European subjects with ISCED level 3 were considered equivalent to American subjects with a General Educational Development, high school degree, or with some college coursework completed but not a college degree; and European subjects with ISCED levels 4–6 were considered equivalent to American subjects with a college degree or higher educational attainment. In European countries, two explanatory variables were added indicating whether the person uses dentures and has difficulty biting on hard foods. In the USA an explanatory variable was added to indicate whether the person was missing all of their permanent teeth.
The wave 2 SHARE sample of 34,415 persons in 14 European countries was reduced by 2,217 persons without weights, including all 1,134 persons in Ireland. An additional 2,590 persons with missing data on one or more of the analytical variables were deleted to produce a final SHARE sample of 29,608 older European subjects for inclusion in our study. The wave 8 HRS sample of 18,469 individuals was reduced by 1,506 persons without sample weights and by another 52 persons with missing data on at least one of the analytic variables used for the study. This produced a final HRS analytical sample of 16,911 older American subjects. Unless otherwise stated, all estimates discussed in the text were statistically significant at least at the 5% level (P ≤ 0.05). The software packages SUDAAN and STATA were used to produce our estimates17., 18.. The complex sample designs for each country were incorporated into the estimated standard errors, although Denmark used a simple random sample design and Greece, Poland, Sweden, and Switzerland adopted stratified sample designs.
In order to explore potential influences of public insurance subsidy, countries were categorised into those with or without comprehensive SHI for dental care (see the Appendix for details on the SHI categorisation). Moreover, in line with recent research on welfare state regimes in dentistry, European countries were classified as belonging to the Scandinavian, Bismarckian, southern, or eastern welfare state regimes19., 20..
RESULTS
Table 1 shows descriptive statistics of dental coverage overall and according to various covariates, without controlling for other variables, for the USA and for each European country clustered according to welfare state regime. To reduce redundancy among the Bismarckian European countries, we selected Germany as representative of the four countries in that group with comprehensive SHI for dental care and with overall dental coverage rates exceeding 90%. We excluded Austria, Belgium, and France, which had respective coverage rates of 94%, 98%, and 98%. This reduced our SHARE sample size to 22,797 observations.
Table 1.
Percentage of older individuals with dental coverage stratified according to population characteristic: data were obtained for the USA from the Health and Retirement Study (HRS), 2004–2006, and for selected European countries from the Survey of Health, Aging, and Retirement in Europe (SHARE), 2006–2007
| Population characteristic | USA§§ | European welfare state regime |
|||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Bismarckian |
Scandinavian |
Southern |
Eastern |
||||||||
| Germany¶¶ | The Netherlands§§ | Switzerland§§ | Denmark¶¶ | Sweden¶¶ | Greece§§ | Italy§§ | Spain§§ | Czech Republic¶¶ | Poland¶¶ | ||
| Total | 47.95 (0.73) | 98.35 (0.43) | 87.39 (1.54) | 21.33 (1.14) | 91.67 (0.59) | 64.44 (1.10) | 56.53 (1.05) | 20.60 (2.44) | 30.51 (1.90) | 95.81 (0.95) | 76.59 (0.98) |
| Age | |||||||||||
| 51–64 years | 61.68‡‡ (0.88) | 97.98 (0.58) | 88.98 (1.48) | 21.02 (1.53) | 92.61 (0.74) | 65.54¶ (1.54) | 54.71 (1.48) | 15.13¶,**,†† (2.37) | 25.94§,¶,†† (2.29) | 96.69 (0.99) | 72.27‡,§,¶,** (1.39) |
| 65–69 years | 41.50‡‡ (1.03) | 99.13 (0.40) | 87.01 (2.32) | 20.21 (2.98) | 90.65 (1.61) | 69.40¶ (2.42) | 52.67**,†† (2.76) | 22.17 (4.27) | 31.69 (3.47) | 95.86 (1.25) | 81.44** (2.38) |
| 70–74 years | 31.90**,†† (1.56) | 99.07 (0.74) | 82.21 (3.10) | 21.95 (3.43) | 90.84 (1.80) | 61.02 (3.25) | 59.59 (2.68) | 22.53 (3.21) | 35.44 (3.58) | 95.54 (1.44) | 81.76** (2.65) |
| 75–79 years | 29.46**,†† (1.54) | 97.97 (1.09) | 85.77 (3.19) | 18.30 (3.28) | 92.54 (1.93) | 61.77 (3.73) | 57.45 (3.16) | 29.08 (4.25) | 37.46 (4.13) | 93.20 (3.37) | 79.50** (3.01) |
| 80–84 years | 24.62 (1.56) | 98.16 (1.02) | 87.78 (5.50) | 26.32* (4.91) | 88.11 (2.81) | 53.86 (4.41) | 66.51 (3.83) | 28/39 (4.82) | 32.72 (4.37) | 92.42 (2.70) | 90.25 (3.05) |
| 85 years and over | 22.25 (1.59) | 98.12* (1.90) | 79.91* (10.24) | 25.30* (6.33) | 87.43* (3.80) | 66.32* (5.19) | 64.53 (5.07) | 31.59* (7.21) | 38.86 (6.16) | 90.95* (4.51) | 87.53* (5.32) |
| Sex | |||||||||||
| Male | 49.96 (0.80) | 97.83 (0.52) | 88.10 (1.29) | 20.22 (1.67) | 91.96 (0.85) | 65.81 (1.59) | 55.09 (1.55) | 19.89 (2.41) | 33.05 (2.34) | 96.11 (0.98) | 76.02 (1.52) |
| Female | 46.26† (0.82) | 98.79 (0.52) | 86.74 (2.06) | 22.27 (1.56) | 91.40 (0.81) | 63.23 (1.53) | 57.79 (1.42) | 21.19 (2.72) | 28.41 (2.04) | 95.58 (1.08) | 77.04 (1.29) |
| Household income*** | |||||||||||
| 1st quintile | 32.00 (1.63) | 97.29 (0.98) | 89.81 (2.39) | 23.02 (2.63) | 89.11 (1.49) | 58.35 (2.52) | 47.12 (2.36) | 29.93 (4.06) | 35.04 (4.10) | 94.51 (1.55) | 80.58 (2.11) |
| 2nd quintile | 32.39 (1.19) | 98.75 (1.04) | 89.08 (2.36) | 19.02 (2.44) | 90.62 (1.38) | 63.77 (2.49) | 59.63† (2.30) | 19.48 (3.47) | 32.45 (3.48) | 94.15 (2.06) | 83.13 (1.91) |
| 3rd quintile | 42.27‡‡ (1.26) | 98.97 (0.52) | 88.79 (2.16) | 18.37 (2.37) | 93.25† (1.19) | 65.48† (2.46) | 58.78† (2.34) | 21.24 (3.32) | 30.38 (3.16) | 95.96 (1.69) | 78.40 (2.11) |
| 4th quintile | 56.17‡‡ (1.44) | 97.92 (1.05) | 88.13 (1.82) | 25.95§ (2.73) | 92.30 (1.27) | 64.93 (2.44) | 63.48† (2.19) | 13.78† (2.90) | 27.00 (3.13) | 96.51 (1.15) | 77.33‡ (2.19) |
| 5th quintile | 66.15‡‡ (1.00) | 99.04 (0.50) | 80.56‡‡ (2.39) | 20.39 (2.57) | 92.97† (1.22) | 71.49†,‡,¶ (2.28) | 53.66¶ (2.44) | 17.37† (3.59) | 28.06 (3.36) | 97.26 (1.23) | 62.12‡ (2.52) |
| Education††† | |||||||||||
| Category 1 | 33.19‡‡ (1.52) | 98.82 (0.54) | 87.61 (2.04) | 21.10 (1.93) | 87.84 (1.47) | 60.04 (1.60) | 56.77 (1.30) | 21.53 (2.61) | 31.35 (2.13) | 95.45 (1.14) | 83.77‡‡ (1.25) |
| Category 2 | 47.22‡‡ (0.76) | 98.79 (0.40) | 90.13 (1.91) | 22.41 (1.95) | 91.80† (0.90) | 64.64 (2.55) | 57.12 (2.30) | 17.17 (5.20) | 19.89† (3.78) | 96.49 (1.01) | 74.69‡‡ (1.61) |
| Category 3 | 60.37‡‡ (1.20) | 97.28 (0.90) | 84.19‡ (1.82) | 20.27 (2.04) | 93.83† (0.86) | 71.18† (1.84) | 54.83 (2.57) | 20.11 (4.64) | 32.36‡ (4.79) | 95.26 (1.38) | 56.84‡‡ (3.29) |
| Can bite/Chew hard foods | |||||||||||
| Yes | N/A | 98.42 (0.40) | 88.09 (1.47) | 22.09‡ (1.23) | 92.18 (0.63) | 63.94 (1.14) | 55.14‡ (1.20) | 19.22 (2.59) | 29.99 (2.00) | 95.54 (1.16) | 75.41 (1.22) |
| No | N/A | 98.03 (0.82) | 83.42 (2.34) | 15.69 (3.02) | 89.40 (1.51) | 70.52 (4.08) | 60.94 (2.08) | 24.17 (3.49) | 32.62 (3.32) | 96.82 (0.90) | 79.15 (1.66) |
| Denture wearing (Europe) permanent teeth (USA) | |||||||||||
| Has dentures/All missing | 30.30 (0.92) | 97.65 (0.72) | 86.15 (2.26) | 21.17 (2.02) | 88.27‡ (1.26) | 58.78 (3.26) | 54.66 (1.98) | 22.03 (2.91) | 31.79 (2.49) | 96.21 (0.95) | 75.87 (1.30) |
| Has no dentures/None missing | 51.39† (0.78) | 99.06 (0.30) | 88.45 (1.27) | 21.40 (1.38) | 93.04 (0.64) | 65.29 (1.17) | 57.23 (1.22) | 19.85 (2.59) | 29.57 (2.13) | 95.55 (1.05) | 77.54 (1.49) |
| Marital status | |||||||||||
| Married/partnered | 51.53‡ (0.84) | 98.64 (0.49) | 87.70 (1.29) | 22.31 (1.39) | 92.40 (0.65) | 65.04 (1.19) | 54.08‡ (1.25) | 19.46 (2.54) | 29.05 (2.09) | 96.36 (0.89) | 74.12‡ (1.44) |
| Widowed, divorced, separated | 40.31§ (1.08) | 97.48 (0.77) | 85.16 (3.44) | 19.57 (2.24) | 90.89 (1.29) | 61.29 (2.67) | 63.97 (2.07) | 24.03 (3.32) | 32.82 (3.33) | 94.49 (1.65) | 81.80 (1.94) |
| Never married | 46.53 (2.55) | 98.63 (1.35) | 92.95 (3.30) | 17.55 (4.41) | 85.72 (3.55) | 69.50 (4.47) | 55.57 (4.97) | 21.27 (4.91) | 38.00 (5.95) | 98.12 (1.91) | 76.48 (5.80) |
| Retirement/Labour force status | |||||||||||
| Retired | 36.64 (1.12) | 98.54 (0.58) | 86.52 (1.59) | 21.97 (1.72) | 90.43 (0.88) | 62.62 (1.47) | 59.70 (1.53) | 19.70 (2.53) | 33.81 (2.63) | 95.59§ (1.02) | 80.85 (1.12) |
| Not retired in labour force | 61.32†,§ (0.82) | 97.72§ (0.61) | 88.93 (1.96) | 18.85§ (1.69) | 93.14† (0.84) | 67.74‡‡ (1.70) | 51.58† (1.99) | 15.94§ (2.82) | 24.33† (2.86) | 96.08 (1.48) | 61.24‡‡ (2.60) |
| Not retired not in labour force | 36.13 (1.64) | 99.18 (0.50) | 86.74 (2.98) | 26.77 (3.30) | 91.38 (2.10) | 52.83 (6.77) | 56.01 (2.01) | 26.09 (3.73) | 30.97 (2.58) | 99.04 (0.57) | 80.25 (2.34) |
| Health status | |||||||||||
| Excellent/Very good | 54.48‡‡ (0.81) | 97.74 (0.85) | 86.20 (1.82) | 21.06 (1.70) | 92.53§ (0.77) | 68.35§ (1.67) | 52.86‡ (1.83) | 22.26 (4.19) | 34.94 (3.89) | 94.35 (1.99) | 73.39 (3.94) |
| Good | 46.37‡‡ (1.08) | 98.32 (0.51) | 87.66 (1.97) | 22.02 (1.88) | 92.47 (1.13) | 63.42 (1.99) | 59.74 (1.65) | 17.05 (2.53) | 26.63 (2.30) | 96.98 (0.78) | 72.16§ (1.91) |
| Fair/Poor | 39.01‡‡ (1.12) | 98.67 (0.49) | 88.14 (1.86) | 20.52 (2.68) | 88.91 (1.38) | 60.09 (2.12) | 56.33 (1.99) | 22.57 (2.88) | 32.60 (2.50) | 95.37 (1.15) | 79.16 (1.19) |
| Sample size | 16,911 | 2,346 | 2,334 | 1,333 | 2,329 | 2,172 | 2,879 | 2,783 | 1,990 | 2,496 | 2,135 |
Standard errors are in parentheses and account for sample design. Results are weighted.
Indicates that the estimate is based on fewer than 100 observations.
Indicates significantly different from the first characteristic listed in the group (P ≤ 0.05).
Indicates significantly different from the second characteristic listed in the group (P ≤ 0.05).
Indicates significantly different from the third characteristic listed in the group (P ≤ 0.05).
Indicates significantly different from the fourth characteristic listed in the group (P ≤ 0.05).
Indicates significantly different from the fifth characteristic listed in the group (P ≤ 0.05).
Indicates significantly different from the sixth characteristic listed in the group (P ≤ 0.05).
Indicates significantly different from all other characteristics listed in the group (P ≤ 0.05).
Country does not have comprehensive social health insurance (SHI) benefits incorporating dental coverage for older persons.
Country has comprehensive SHI benefits incorporating dental coverage for older persons. See the Appendix for further country-specific details about SHI systems.
Arranged lowest (1st quintile) to highest (5th quintile).
Category 1, International Standard Classification of Education (ISCED) = 1,2 (Europe) or <high school degree (USA); Category 2, ISCED = 3 (Europe) or high school degree or some college (USA); Category 3, ISCED = 4,6 (Europe) or college degree (USA).
Overall coverage rates
Of the remaining countries, considerable variation in the overall percentage of respondents reporting dental coverage was found; the highest percentage of dental coverage was observed for Germany (98%), followed by the Czech Republic (96%), Denmark (92%), the Netherlands (87%), Poland (77%), and Sweden (64%). Among these countries, only the Netherlands had no comprehensive SHI, indicating high enrollments for the ‘voluntary’ health insurance needed for adult dental care in that country. Lower percentages of dental coverage were found for Greece (57%), the USA (48%), Spain (31%), Switzerland (21%), and Italy (21%).
Demographic variables
For the demographic variables age, sex, and marital status, we generally found more disparity in dental coverage among non-SHI countries than among SHI countries. For example, in the USA, coverage rates declined sharply between the lowest age group and the highest age group (80+ years of age). In contrast, we observed higher coverage rates among older age groups compared with younger age groups in the non-SHI countries Greece, Italy, and Spain, and even in Poland, an SHI country. The only gender disparity was found in the USA, in which a 3.5 percentage point higher coverage rate was observed for male subjects than for female subjects. Married persons in the USA have higher coverage rates compared with non-married individuals. The only other disparities found were in Greece and Poland, in which married persons had lower coverage compared with widowed, divorced, or separated persons.
SES variables
With regard to the SES variables for education, household income, and labour market status, we also generally found more disparity in coverage among the non-SHI countries. For example, dental coverage in the USA showed a steady increase above the second household income quintile, although, conversely, coverage showed a decrease at the highest income quintile in the Netherlands and Greece and at the two highest quintiles in Italy and Poland. The income patterns observed in the USA were similar to those observed in Sweden and, to a lesser extent, in Denmark.
Disparity in coverage across education categories showed a similar pattern to what we found for income: higher coverage in subjects with higher education levels in the USA, Denmark, and Sweden, and, conversely, lower coverage in subjects with higher education levels in the Netherlands and Poland. We also found a surprising decline in coverage, of about 12 percentage points, in the middle education category in Spain.
In the USA, dental coverage was nearly twice as high among persons in the labour force compared with those retired or otherwise out of the labour force. A similar pattern was found in Scandinavian countries, yet we found a contrasting pattern in the SHI countries Poland and Germany as well as in non-SHI southern European countries and in Switzerland.
Health status variables
In the USA there was considerable disparity between persons reporting excellent or very good health status and those reporting only good, fair, or poor health status. Similarly, in SHI Scandinavian countries we found that persons with the best health status had higher dental coverage compared with those with fair or poor health status, although not to the degree observed in the USA. Exceptions are found in Greece and Poland, where those reporting to be not as healthy as others were found to have higher dental coverage, by about 7 percentage points.
We generally did not find disparities in dental coverage based on oral health status. The difference, of over 20 percentage points, in coverage between those not missing all their permanent teeth and those missing all of them in the USA had no counterpart in any European country based on a measure of who did and who did not have dentures, although coverage was somewhat lower for those with dentures in Sweden compared to those without. Apart from Switzerland, with about a 6.5 percentage point higher coverage rate for those with no trouble chewing hard foods, and Greece, with about a 5.5 percentage point lower coverage rate, chewing ability had little or no correlation with dental coverage across the European countries.
Table 2 shows estimated odds ratios from country-specific logistic regression models adjusted by controls for the demographic, SES, and health status covariates. Disparity was measured only by comparing dental coverage in each population subgroup with that of the reference subgroup, rather than with all other subgroups within a variable category, as in Table 1.
Table 2.
Adjusted odds ratios from logistic regressions for likelihood of dental coverage for older individuals: data for the USA were obtained from the Health and Retirement Study (HRS), 2004–2006, and are shown in Part I of the table, and data for the European countries were obtained from the Survey of Health, Aging, and Retirement in Europe (SHARE), 2006–2007, and are shown in Parts I and II of the table
| Population characteristic | USA* | European welfare state regime |
||||
|---|---|---|---|---|---|---|
| Bismarckian |
Scandinavian |
|||||
| Germany† | The Netherlands* | Switzerland* | Denmark† | Sweden† | ||
| Part I | ||||||
| Age | ||||||
| 51–64 years (Ref.) | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| 65–69 years | 0.52¶ (0.46–0.59) | 0.44 (0.14–1.42) | 1.21 (0.67–2.19) | 1.31 (0.80–2.13) | 1.05 (0.63–1.75) | 0.71 (0.50–1.01) |
| 70–74 years | 0.37¶ (0.32–0.42) | 0.47 (0.06–3.64) | 1.90¶ (1.20–3.03) | 1.15 (0.69–1.93) | 0.90 (0.48–1.67) | 0.96 (0.65–1.41) |
| 75–79 years | 0.35¶ (0.31–0.41) | 0.82 (0.27–2.46) | 1.38 (0.77–2.47) | 1.41 (0.78–2.57) | 0.65 (0.32–1.33) | 0.87 (0.57–1.33) |
| 80–84 years | 0.29¶ (0.24–0.34) | 0.89 (0.30–2.64) | 1.14 (0.40–3.24) | 0.80 (0.42–1.55) | 1.05 (0.50–2.21) | 1.17 (0.74–1.86) |
| 85 years and older | 0.27¶ (0.22–0.32) | <0.00 (<0.00–<0.00) | 1.97 (0.67–5.82) | 0.90 (0.40–2.02) | 1.03 (0.42–2.50) | 0.67 (0.37–1.20) |
| Sex | ||||||
| Men (Ref.) | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Women | 0.95 (0.89–1.02) | 1.93 (0.60–6.25) | 0.98 (0.76–1.27) | 1.11 (0.81–1.51) | 1.01 (0.73–1.40) | 0.93 (0.76–1.12) |
| Education‡ | ||||||
| Category 1 | 0.80¶ (0.66–0.98) | 0.35 (0.07–1.68) | 0.80 (0.57–1.11) | 0.99 (0.67–1.45) | 1.74¶ (1.10–2.74) | 1.48¶ (1.17–1.88) |
| Category 2 | 0.84¶ (0.75–0.94) | 0.45¶ (0.21–0.96) | 0.65¶ (0.45–0.93) | 0.91 (0.64–1.28) | 1.27 (0.86–1.88) | 1.28 (0.96–1.70) |
| Category 3 (Ref.) | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Marital status | ||||||
| Married/partnered (Ref.) | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Widowed, divorced, separated | 0.87¶ (0.79–0.96) | 1.92 (0.63–5.82) | 1.30 (0.90–1.89) | 1.25 (0.88–1.77) | 1.02 (0.67–1.53) | 1.04 (0.80–1.36) |
| Never married | 0.749¶ (0.58–0.96) | 0.90 (0.08–10.01) | 0.61 (0.23–1.60) | 1.38 (0.73–2.57) | 2.08¶ (1.13–3.85) | 0.73 (0.46–1.14) |
| Health status | ||||||
| Excellent/very good (Ref.) | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Good | 0.97 (0.90–1.06) | 0.72 (0.37–1.44) | 0.89 (0.67–1.19) | 0.97 (0.711–1.320) | 0.88 (0.59–1.32) | 1.10 (0.87–1.39) |
| Fair/poor | 1.00 (0.88–1.13) | 0.50 (0.22–1.15) | 0.76 (0.51–1.15) | 1.08 (0.73–1.62) | 1.22 (0.83–1.80) | 1.20 (0.93–1.54) |
| Objective oral health status (Europe: denture use; USA: tooth loss) | ||||||
| No impairment (Ref.) | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Impairment | 0.70¶ (0.64–0.78) | 3.63¶ (1.70–7.73) | 1.23 (0.92–1.64) | 1.03 (0.73–1.44) | 1.39 (0.94–2.06) | 1.18 (0.86–1.62) |
| Chewing ability (Europe only) | ||||||
| Can bite/chew on hard foods (Ref.) | N/A | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Cannot bite/chew on hard foods | 0.95 (0.47–1.94) | 1.49¶ (1.19–1.86) | 1.59 (0.98–2.59) | 1.13 (0.76–1.67) | 0.58¶ (0.38–0.89) | |
| Retirement/Labour force status | ||||||
| Not retired in labour force (Ref.) | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Not retired not in labour force | 0.72¶ (0.59–0.87) | 0.51 (0.16–1.68) | 1.30 (0.70–2.41) | 0.63¶ (0.40–0.99) | 0.93 (0.49–1.79) | 1.60 (0.90–2.83) |
| Retired | 0.92 (0.83–1.02) | 0.80 (0.22–2.91) | 1.04 (0.58–1.86) | 0.66 (0.43–1.02) | 1.20 (0.72–2.00) | 1.13 (0.81–1.58) |
| Household income quintiles§ | ||||||
| 1st quintile | 0.38¶ (0.32–0.46) | 4.22¶ (1.19–14.96) | 0.37¶ (0.21–0.67) | 0.88 (0.54–1.41) | 0.95 (0.51–1.75) | 1.44¶ (1.02–2.03) |
| 2nd quintile | 0.41¶ (0.35–0.49) | 2.16 (0.30–15.83) | 0.41¶ (0.25–0.67) | 1.17 (0.73–1.86) | 0.92 (0.54–1.56) | 1.21 (0.86–1.70) |
| 3rd quintile | 0.54¶ (0.48–0.62) | 1.87 (0.38–9.09) | 0.46¶ (0.31–0.67) | 1.17 (0.74–1.87) | 0.76 (0.44–1.31) | 1.15 (0.83–1.60) |
| 4th quintile | 0.80¶ (0.70–0.92) | 3.23 (0.71–14.74) | 0.54¶ (0.37–0.78) | 0.73 (0.48–1.13) | 1.01 (0.60–1.68) | 1.29 (0.94–1.76) |
| 5th quintile (Ref.) | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Population characteristic | European welfare state regime |
||||
|---|---|---|---|---|---|
| Southern |
Eastern |
||||
| Greece* | Italy* | Spain* | Czech Republic† | Poland† | |
| Part II | |||||
| Age | |||||
| 51–64 years (Ref.) | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| 65–69 years | 1.30 (0.98–1.73) | 0.51¶ (0.32–0.81) | 0.75 (0.50–1.15) | 1.59 (0.74–3.39) | 0.98 (0.70–1.44) |
| 70–74 years | 0.97 (0.71–1.31) | 0.49¶ (0.34–0.71) | 0.62¶ (0.41–0.94) | 1.86 (0.76–4.53) | 0.98 (0.64–1.49) |
| 75–79 years | 1.02 (0.72–1.44) | 0.35¶ (0.23–0.54) | 0.58¶ (0.37–0.90) | 2.87 (0.81–10.16) | 1.23 (0.79–1.90) |
| 80–84 years | 0.69 (0.43–1.09) | 0.36¶ (0.20–0.67) | 0.77 (0.46–1.30) | 3.25 (0.94–11.21) | 0.56 (0.27–1.17) |
| 85 years and older | 0.73 (0.43–1.25) | 0.29¶ (0.13–0.66) | 0.59 (0.31–1.13) | 4.57¶ (1.15–18.19) | 0.772 (0.27–2.18) |
| Sex | |||||
| Men (Ref.) | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Women | 1.00 (0.81–1.24) | 0.88 (0.69–1.13) | 0.63¶ (0.47–0.85) | 0.96 (0.65–1.40) | 0.80 (0.63–1.01) |
| Education‡ | |||||
| Category 1 | 0.98 (0.75–1.28) | 1.30 (0.78–2.17) | 1.05 (0.64–1.72) | 0.89 (0.50–1.57) | 0.35¶ (0.25–0.49) |
| Category 2 | 0.94 (0.70–1.25) | 1.17 (0.59–2.33) | 1.67 (0.92–3.00) | 0.77 (0.45–1.31) | 0.47¶ (0.34–0.64) |
| Category 3 (Ref.) | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Marital status | |||||
| Married/partnered (Ref.) | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Widowed, divorced, separated | 0.70¶ (0.56–0.89) | 1.12 (0.81–1.56) | 0.84 (0.57–1.23) | 1.20 (0.58–2.49) | 0.84 (0.61–1.15) |
| Never married | 0.89 (0.59–1.33) | 0.86 (0.48–1.55) | 0.58¶ (0.34–1.00) | 0.43 (0.06–2.92) | 0.90 (0.46–1.74) |
| Health status | |||||
| Excellent/very good (Ref.) | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Good | 0.82 (0.66–1.01) | 1.48¶ (1.01–2.18) | 1.67¶ (1.11–2.50) | 0.46¶ (0.23–0.91) | 1.22 (0.78–1.93) |
| Fair/poor | 0.98 (0.76–1.25) | 1.26 (0.80–1.99) | 1.48¶ (0.99–2.21) | 0.62 (0.36–1.09) | 1.20 (0.77–1.88) |
| Objective oral health status (Europe: denture use; USA: tooth loss) | |||||
| No impairment (Ref.) | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Impairment | 1.46¶ (1.15–1.85) | 1.18 (0.88–1.57) | 1.06 (0.81–1.37) | 0.59¶ (0.35–1.00) | 1.30¶ (1.02–1.65) |
| Chewing ability (Europe only) | |||||
| Can bite/chew on hard foods (Ref.) | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Cannot bite/chew on hard foods | 0.79¶ (0.63–0.98) | 0.94 (0.65–1.37) | 0.95 (0.69–1.30) | 0.65 (0.31–1.36) | 1.04 (0.80–1.34) |
| Retirement/Labour force status | |||||
| Not retired in labour force (Ref.) | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
| Not retired not in labour force | 0.88 (0.66–1.18) | 0.78 (0.54–1.15) | 0.62¶ (0.39–0.99) | 0.25 (0.05–1.18) | 0.50¶ (0.30–0.67) |
| Retired | 0.74¶ (0.57–0.96) | 1.20 (0.85–1.70) | 0.84 (0.54–1.30) | 0.72 (0.33–1.55) | 0.44¶ (0.32–0.61) |
| Household income quintiles§ | |||||
| 1st quintile | 1.43¶ (1.06–1.91) | 0.53¶ (0.29–0.97) | 0.94 (0.59–1.50) | 2.22 (0.98–5.01) | 0.59¶ (0.40–0.87) |
| 2nd quintile | 0.87 (0.65–1.18) | 1.01 (0.55–1.86) | 1.15 (0.72–1.82) | 2.05 (0.93–4.53) | 0.62¶ (0.42–0.91) |
| 3rd quintile | 0.86 (0.64–1.16) | 0.84 (0.48–1.47) | 1.17 (0.75–1.83) | 1.51 (0.48–4.76) | 0.73 (0.51–1.04) |
| 4th quintile | 0.72¶ (0.54–0.95) | 1.30 (0.77–2.18) | 1.21 (0.78–1.87) | 1.34 (0.50–3.60) | 0.65¶ (0.46–0.91) |
| 5th quintile (Ref.) | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
The 95% confidence intervals are in parentheses. The adjusted value refers to the inclusion in the regression of the control variables listed in the rows of the table. The adjusted odds ratio is an estimate of [probability of dental coverage/probability of no dental coverage] for persons with row characteristic divided by [probability of dental coverage/probability of no dental coverage] for persons in the reference group. Ref. indicates reference group.
Country does not have comprehensive social health insurance (SHI) benefits incorporating dental coverage for older persons.
Country has comprehensive SHI benefits incorporating dental coverage for older persons. See the Appendix for further country-specific details on SHI systems.
Category 1, ISCED = 1,2 (Europe) or <high school degree (USA); Category 2, ISCED = 3 (Europe) or high school degree or some college (USA); Category 3, ISCED = 4,6 (Europe) or college degree (USA).
Arranged lowest (1st quintile) to highest (5th quintile).
Indicates statistical significance at least at the 5% level.
Demographic variables
The addition of control variables left the age effects in the USA unchanged, but reversed the pattern of influence in the non-SHI countries, Italy and Spain, and provided no evidence for the previous patterns detected in Greece and Poland. The only gender disparity observed was in Spain, rather than the USA, as in Table 1, showing that men had higher coverage rates than women. The marital status result for the USA still showed higher coverage rates for married persons compared with unmarried people. The previous result for Greece was reversed and is now similar to the pattern in the USA, and the previous result for the SHI country, Poland, did not hold in Table 2. Never-married persons in Denmark showed higher coverage rates compared with married persons, whereas the opposite was found for Spain.
SES variables
The correlation of higher income with higher dental coverage in the USA persisted in our adjusted results in Table 2. Previous effects in the opposite direction, found in the non-SHI countries, Italy and the Netherlands, and in the SHI country, Poland, were reversed and now resemble the pattern found in the USA (i.e. the highest coverage rate at the highest income quintile). Evidence remains that persons in the lowest income quintile in Greece have greater coverage than do those in the highest quintile. This is also now apparent in Sweden and Germany, in contrast to previous findings. Disparity in coverage across income groups was no longer found in Denmark.
We still found that higher education correlated with higher dental coverage in the USA, but adjusting for covariates reversed this unadjusted finding for the Scandinavian countries. The contrasting finding from Table 1 was also been reversed in Table 2 for Poland and the Netherlands. We also now showed that persons in the middle education category in Germany have lower dental coverage than do those at the highest level.
Persons not retired, but out of the labour force, continued to have lower dental coverage in the USA than did those in the labour force, after controlling for other covariates. A similar pattern in our unadjusted results no longer appears in Table 2 for the Scandinavian countries. Results found in Table 1 for Poland, Switzerland, Greece, and Spain, which were different from those for the USA, are now consistent by showing higher coverage for those in the labour force compared with those out of the labour force in Table 2. Previous contrasting findings for Italy no longer appear in the adjusted results.
Health status variables
Previous unadjusted findings showing higher coverage for persons in better health in the USA and the Scandinavian countries, and contrasting results for Poland and Greece, were absent from the adjusted results in Table 2. Now we find that those reporting good health in the Czech Republic have greater dental coverage compared with those with excellent or very good health, and the opposite result is found in Italy and Spain.
Persons missing all of their permanent teeth in the USA still had lower dental coverage compared with those not missing all their permanent teeth after controlling for other variables. Similarly, we now found that persons with dentures had lower dental coverage than did those without dentures in the Czech Republic. We also now found the opposite results in Poland and Greece, unlike the absence of any relationship from the unadjusted findings in Table 1. Trouble chewing hard foods was no longer correlated with dental coverage in Switzerland (Table 2). Older persons in Greece, with trouble chewing hard foods, now had lower dental coverage than did those with no trouble chewing (Table 2, unlike the opposite result found in Table 1). After controlling for other covariates, older persons in Sweden with chewing problems also had lower coverage than those who did not, but the opposite was found in the Netherlands.
DISCUSSION
In summary, we found the most disparity in perceived dental coverage with regard to various population characteristics to be in the USA compared with European countries, and the least disparity in European countries with comprehensive SHI coverage. We found more disparity among European countries with no SHI but generally not to the extent found in the USA21. The distinction between European countries with and without SHI is a better indicator of diversification of coverage than the grouping of those countries according to social welfare system. More typically, when disparities are identified in European countries, there are no clear patterns, and those patterns that are found are sensitive to controls for other covariates in the statistical models. The disparities that do persist are important because they offer evidence for potential disparities in the use of dental services in these countries, a topic we will be examining in a follow-up study.
In terms of overall country-level coverage rates, we found divergent awareness of publicly subsidised coverage across countries classified as SHI countries. Over 90% of persons in Germany, Denmark, and the Czech Republic reported having dental coverage, whereas in the SHI countries Sweden and Poland, only two-thirds to three-quarters of the older population, respectively, were aware of having publicly subsidised dental coverage.
Despite over 90% of the populations of SHI countries Germany, Denmark, and the Czech Republic having dental coverage, we still found that some population subgroups in each country were more aware than others of the publicly subsidised coverage, but there were no common patterns across these countries. In Sweden there is greater knowledge of this coverage among persons in the lowest education and income levels compared with those at the corresponding highest levels, whilst we find the opposite relationships in Poland.
Among the non-SHI countries, the low take-up of private coverage in Switzerland is widespread over all population groups. The relatively high overall take-up of private coverage in the Netherlands is, as one might expect, targeted more on the highest income and education classes than on the lower ones. The relatively low take-up rates in Italy and Spain are even lower for younger rather than older persons, those in excellent or very good health rather than those in worse health, and for those (in Italy) at the lowest rather than at the highest income level, and (in Spain) for those not retired and out of the labour force rather than in the labour force.
Most general health care is largely publicly financed in Europe, the motivation being consideration for fair distribution of services and equal access to them. However, the provision of oral health care operates outside mainstream health care, and private provision of services is more significant. Of the European countries included in this study, those belonging to the Bismarckian, Scandinavian, and eastern European welfare state regimes have universal or almost universal coverage of oral health care. In Germany and Belgium, adults having high income need not belong to the compulsory health insurance system but are free to choose from private alternatives. In the Netherlands, where public dental insurance no longer exists, most adults have private dental insurance. In addition to the public dental insurance support in Denmark and Sweden, adults having nursing support at home or having some chronic illnesses or high dental costs (Sweden) have extra support towards their dental care costs. In the eastern European countries the Czech Republic and Poland, dental insurance largely covers basic dental care (i.e. limited numbers of the most usual treatment measures). In southern Europe the situation is most variable. Greece has a National Health Service covering dental care for most adults and offering free emergency care to everyone in need. In Italy and Spain there is no uniformly organised public insurance system.
Against this background, the perceived dental coverage by the European respondents can be considered to be well in accordance with the prevailing statutes in Germany and Belgium and rather well in the Netherlands and Denmark. The perceived low insurance coverage in Sweden with universal coverage may be explained by the relatively low reimbursement rates and out-of-pocket costs for services. The discrepancy between the higher theoretical and lower perceived coverage in Poland and Greece may reflect the economic constraints in these countries.
Awareness of the existing reimbursement system can vary for many reasons both within and between countries. The elderly usually do not visit dentists as often as do younger adults. In some countries they may have visited a dental hygienist or a clinical dental technician with differing reimbursement protocols. Also, reimbursement may vary according to procedure or treatment, and older respondents may not remember these details accurately in a retrospective recall household survey.
Given the limitations of HRS and SHARE as multi-country data sources for examining the determinants of dental insurance amongst elderly populations, some caution should be applied when interpreting our results. Data on dental coverage were self-reported and were not verified against any paper records or through follow-back to insurance providers. We were unable to categorise individual persons according to generosity of public dental coverage because such micro-level data were not available from either the HRS or the SHARE surveys. Despite the fact that the US and European data were harmonised, definitions and categorisations of variables still vary between countries. Oral health status differed between HRS and SHARE – only HRS contains information on tooth loss, whereas only SHARE reports denture wearing and chewing ability. Other examples, such as retirement status and educational attainment, discussed above, further highlight the trade-off between cross-country comparability and within-country accuracy. Nevertheless, SHARE and HRS are unique in that they enable comparisons of dental insurance coverage for older populations within and across several countries with respect to a multitude of potential determinants. Moreover, to our knowledge, the present study is the first to provide information about the overall extent of perceived dental coverage for several older adult populations in Europe. It also provides relevant information for decision makers who seek to improve policies in order to provide more equitable dental care and oral health.
Acknowledgements
We gratefully acknowledge support from Michael Moldoff (RAND Corporation, Santa Monica) who helped with constructing the harmonised data file used for this study. The present paper used data from RAND HRS and RAND SHARE. RAND HRS is a user-friendly version of HRS, and the HRS public-use dataset is produced and distributed by the University of Michigan with funding from the National Institute on Aging (grant number NIA U01AG009740), Ann Arbor, MI. RAND SHARE is a user-friendly version of SHARE, created with funding from the National Institute on Aging (grant number R01AG030153). RAND SHARE used SHARE wave 4 release 1.1.1, as of 28 March 2013 or SHARE wave 1 and 2 release 2.5.0, as of 24 May 2011 or SHARELIFE release 1, as of 24 November 2010. The SHARE data collection has been primarily funded by the European Commission through the 5th Framework Programme (project QLK6-CT-2001-00360 in the thematic programme Quality of Life), through the 6th Framework Programme (projects SHARE-I3, RII-CT-2006-062193, COMPARE, CIT5- CT-2005-028857, and SHARELIFE, CIT4-CT-2006-028812) and through the 7th Framework Programme (SHARE-PREP, No. 211909, SHARE-LEAP, No. 227822 and SHARE M4, No. 261982). Additional funding from the USA National Institute on Aging (U01 AG09740-13S2, P01 AG005842, P01 AG08291, P30 AG12815, R21 AG025169, Y1-AG-4553-01, IAG BSR06-11 and OGHA 04-064) and the German Ministry of Education and Research, as well as from various national sources, is gratefully acknowledged (see www.share-project.org for a full list of funding institutions).
Sources of funding
This investigation was supported by the National Institute of Dental and Craniofacial Research of the USA National Institutes of Health (3R01DE021678-06S1).
APPENDIX
Social health insurance (SHI) coverage in the countries included in this study
| SHI status | Description | |
|---|---|---|
| Austria | Yes | Full public coverage of restorative treatment and some surgical procedures. Partial coverage of prosthetic treatment3., 4.,22 |
| Belgium | Yes | Full public coverage of basic preventive treatment and extractions. Partial coverage for restorative, removable prosthetic, other preventive, and other surgical treatment. No coverage for periodontal treatment, fixed prosthetic treatment, and implants3., 4.,23 |
| Czech Republic | Yes | Public support through social health insurance for basic dental treatments and restricted to the least expensive options. About 25% of expenditure on dental care is funded through out-of-pocket payments24 |
| Denmark | Yes | Partial public refund (30–65%) for dental treatments received from private practitioners3., 4.,25 |
| France | Yes | Mandatory health insurance system which reimburses about 70% of fees for standard dental treatment of conservative treatment (including sealing and scaling) and extractions. High proportion of patient co-payment for prosthodontic treatment3., 4. |
| Germany | Yes | Wide public coverage for diagnostics, fillings, conservative treatment, periodontal treatment, endodontic treatment; partial coverage for prosthetic treatment (50–60%). No coverage for implants3., 4. |
| Greece | No | Extensive differences in coverage between social insurance funds; large parts of the population are not covered for dental services26 |
| Italy | No | Public coverage only for emergency treatment and treatment of persons with disabilities, human imuunodeficiency virus or rare disease3., 4.,27 |
| The Netherlands | No | For young people up to the age of 21 years, dental care is covered by basic health insurance. For people 22 years of age and above, complementary voluntary health insurance is needed for dental care28 |
| Poland | Yes | Public coverage for basic dental treatment procedures which are reimbursed by the National Health Fund (NFZ); limited access to care as a result of restrictions in provider availability29 |
| Spain | No | No public funding for dental care, except extractions3,30,31 |
| Sweden | Yes | Fixed public subsidies for all types of general dental treatment, including prosthodontic and orthodontic treatment4,32 |
| Switzerland | No | No public coverage; exceptions include treatment of very severe or unavoidable disease3,33 |
| USA | No | Most dental treatment is funded privately; only 5% of expenditures are publicly funded34 |
NB: SHI = comprehensive social health insurance for the general population; ‘yes’ indicates that at least some public support exists for basic dental procedures (preventive, restorative, prosthodontic, emergency surgical care); and ‘no’ indicates that public support, if any, exists only for some exceptional cases.
REFERENCES
- 1.Grignon M, Hurley J, Wang L, et al. Inequity in a market-based health system: evidence from Canada’s dental sector. Health Policy. 2010;98:81–90. doi: 10.1016/j.healthpol.2010.05.018. [DOI] [PubMed] [Google Scholar]
- 2.Somkotra T, Detsomboonrat P. Is there equity in oral healthcare utilization: experience after achieving Universal Coverage. Community Dent Oral Epidemiol. 2009;37:85–96. doi: 10.1111/j.1600-0528.2008.00449.x. [DOI] [PubMed] [Google Scholar]
- 3.Palència L, Espelt A, Cornejo-Ovalle M, et al. Socioeconomic inequalities in the use of dental care services in Europe: what is the role of public coverage? Community Dent Oral Epidemiol. 2014;42:97–105. doi: 10.1111/cdoe.12056. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Widstrom E, Eaton KA. Oral healthcare systems in the extended European union. Oral Health Prev Dent. 2004;2:155–194. [PubMed] [Google Scholar]
- 5.Bambra C. Oxford University Press; New York, NY: 2011. Work, Worklessness, and the Political Economy of Health. [DOI] [PubMed] [Google Scholar]
- 6.Richter M, Rathman K, Gabhainn SN, et al. Welfare state regimes, health and health inequalities in adolescence: a multilevel study in 32 countries. Sociol Health Illn. 2012;34:858–879. doi: 10.1111/j.1467-9566.2011.01433.x. [DOI] [PubMed] [Google Scholar]
- 7.Bambra C, Eikemo TA. Welfare state regimes, unemployment and health: a comparative study of the relationship between unemployment and self-reported health in 23 European countries. J Epidemiol Community Health. 2009;63:92–98. doi: 10.1136/jech.2008.077354. [DOI] [PubMed] [Google Scholar]
- 8.Eikemo TA, Huisman M, Bambra C, et al. Health in equalities according to educational level in different welfare regimes: a comparison of 23 European countries. Sociol Health Illn. 2008;30:565–582. doi: 10.1111/j.1467-9566.2007.01073.x. [DOI] [PubMed] [Google Scholar]
- 9.Kim IH, Munaner C, Vahid Shahidi F, et al. Welfare states, flexible employment, and health: a critical review. Health Policy. 2012;104:99–127. doi: 10.1016/j.healthpol.2011.11.002. [DOI] [PubMed] [Google Scholar]
- 10.Williams A, Cookson R. In: Handbook of Health Economics, Vol. 1, Part B. Culyer AJ, Newhouse JP, editors. Elsevier; North-Holland, Amsterdam: 2000. Equity in health; pp. 1863–1910. [Google Scholar]
- 11.Williams A. Priority setting in public and private health care. A guide through the ideological jungle. J Health Econ. 1988;7:173–183. doi: 10.1016/0167-6296(88)90015-x. [DOI] [PubMed] [Google Scholar]
- 12.Listl S, Birch S. Reconsidering value for money in periodontal treatment. J Clin Periodontol. 2013;40:345–348. doi: 10.1111/jcpe.12085. [DOI] [PubMed] [Google Scholar]
- 13.Ham C, Coulter A. Explicit and implicit rationing: taking responsibility and avoiding blame for health care choices. J Health Serv Res Policy. 2001;6:163–169. doi: 10.1258/1355819011927422. [DOI] [PubMed] [Google Scholar]
- 14.Gafni A. Willingness-to-pay as a measure of benefits: relevant questions in the context of public decision making about health care programs. Med Care. 1991;29:1246–1252. [PubMed] [Google Scholar]
- 15.Boersch-Supan A, Brugiavini A, Juerges H, et al., editors. Health, Ageing and Retirement in Europe (2004-2007) – Starting the Longitudinal Dimension. Mannheim Research Institute for the Economics of Aging; Mannheim: 2008. [Google Scholar]
- 16.National Institute on Aging . National Institutes of Health; Washington, DC: 2007. Growing Older in America: The Health and Retirement Study. [Google Scholar]
- 17.Research Triangle Institute . Research Triangle Institute; Research Triangle Park, NC: 1995. SUDAAN Software for Analysis of Correlated Data. Release 6.40. [Google Scholar]
- 18.Statacorp . Stata Corporation; College Station, TX: 2001. Stata Statistical Software: Release 7.0. [Google Scholar]
- 19.Guarnizo-Herreño CC, Watt RG, Pikhart H, et al. Socioeconomic inequalities in oral health in different European welfare state regimes. J Epidemiol Community Health. 2013;67:728–735. doi: 10.1136/jech-2013-202714. [DOI] [PubMed] [Google Scholar]
- 20.Listl S, Moeller J, Manski R. A multi-country comparison of reasons for dental non-attendance. Eur J Oral Sci. 2014;122:62–69. doi: 10.1111/eos.12096. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Manski R, Moeller J, Schimmel J, et al. Dental coverage and retirement. J Public Health Dent. 2010;70:1–12. doi: 10.1111/j.1752-7325.2009.00137.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Hofmarcher MM, Rack H-M. Austria: health system review. Health Syst Transit. 2006;8:1–247. [PubMed] [Google Scholar]
- 23.Corens D. Health system review: Belgium. Health Syst Transit. 2007;9:1–172. [Google Scholar]
- 24.Bryndová L, Pavloková K, Roubal T, et al. Czech Republic: Health systems review. Health systems in transition. 2009;11:1–122. [Google Scholar]
- 25.Strandberg-Larsen M, Nielsen MB, Vallgårda S, et al. Denmark: health system review. Health Syst Transit. 2007;9:1–164. [Google Scholar]
- 26.Economou C. Greece: health system review. Health systems in transition. 2010;12:1–180. [PubMed] [Google Scholar]
- 27.Lo Scalzo A, Donatini A, Orzella L, et al. Italy: health system review. Health Syst Transit. 2009;11:1–216. [Google Scholar]
- 28.Schäfer W, Kroneman M, Boerma W, et al. The Netherlands: Health system review. Health Systems in Transition. 2010;12:1–229. [PubMed] [Google Scholar]
- 29.Sagan A, Panteli D, Borkowski W, et al. Poland: Health system review. Health Systems in Transition. 2011;13(8):1–193. [PubMed] [Google Scholar]
- 30.Mossialos E, Dixon A, Figueras J, et al., editors. Funding health care: options for Europe. European Observatory on Health Care Systems Series. Open University Press; Buckingham, UK: 2002. [Google Scholar]
- 31.Durán A, Lara JL, van Waveren M. Spain: health system review. Health Syst Transit. 2006;8:1–208. [Google Scholar]
- 32.Glenngård AH, Hjalte F, Svensson M et al. Health Systems in Transition: Sweden. WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies, 2005.
- 33.European Observatory on Health Care Systems . European Observatory on Health Care Systems; Copenhagen, Denmark: 2000. Health care systems in transition: Switzerland. [Google Scholar]
- 34.Birch S, Anderson R. Financing and delivering oral health care: what can we learn from other countries? J Can Dent Assoc. 2005;71(243):243a. [PubMed] [Google Scholar]