KEY POINTS * A healthy oral apparatus providing masticatory/digestive functions, speech and cosmetics is necessary for the general health of the patient. * Improving the oral health of a

region, so improving the general health status of the labour force of that region, indirectly augments the regional economy. * Government-provided dental benefits are the most likely to

reach the largest proportion of a given population. ABSTRACT This opinion paper explains the unique and favourable terms of dental health insurance coverage available to residents (both

permanent and temporary) of the Province of Québec, Canada. In comparison, the United States and British Canada are the poor stepchildren of government-mediated provision of dental health

Dental care has almost always been the poor stepchild of medical care in all national healthcare systems and generally in privately insured plans. Although not generally specified in

'healthcare for all' documents like the Declaration of Alma Ata1 in 1978 or the Ottawa Charter2 in 1986, 'dental care for all' is a humanistic concept with great public

appeal and potentially large economic dividends in the form of augmenting the health of a nation. The premise of this work is that a dentally-fit population is medically healthier and more

economically productive than a corresponding population beset by dental problems. Therefore, a state or nation with dental insurance coverage will have a healthier population and

subsequently a more robust economy than its uninsured counterpart. THE FINANCES OF DENTAL CARE IN QUÉBEC Unlike the other nine provinces and three Territories of Canada (collectively known

as British Canada), dental healthcare is largely covered by state insurance in the Province of Québec (ie except for only very limited coverage of dental procedures in the Ontario). The

dental insurance programme in Québec is largely funded under a state income tax on personal income.3 Lower federal taxes are levied (ie the taxes are 'abated') and the nationwide

personal income tax in Canada is not applied in Québec.4,5 Expenses for non-cosmetic dental services over and above those covered by government or private insurance are tax-exempt6 and

eligible for tax credits towards the Québec provincial income tax.7 Dental healthcare insurance in Québec is implemented in a unique fashion compared to the rest of Canada – especially when

it comes to children and the lower socioeconomic class.8 Children and people of low income are highlighted by Québec's healthcare system that includes the following insurance

coverages:8 * Oral surgical procedures treating the results of trauma or illness (eg TMJ, fracture reduction, removal of a cyst or tumour) are covered for all residents of Québec. Although

covered in children, tooth extraction or root tip removal is not covered in adults * General dentistry for children under age ten whose parent(s) are residents of Canada except procedures

involved in the application of topical fluoride. Children and teenagers up to 18 years are provided with free dental exams and X-rays at no charge * General dentistry (with exclusions) for

all persons receiving government financial assistance (eg welfare recipients) for 12 or 24 consecutive months with the same coverage for their dependants. Why is dental care important? The

proper functioning of the oral cavity, mouth, and jaw apparatus are necessary for good health. The aim of dental treatment is to provide and maintain an oral system providing optimal

masticatory, cosmetic, and linguistic function. The objectives of dental practice are to relieve and prevent pain, to remove decay, and provide cosmetics. The goal of the dentist and of

modern dentistry is to provide these services in the best interests of the patient and her/his general and oral health. Without a functional oral system one can hardly be productive at work

or socially competent. DENTAL CARE: BRITAIN VS FRANCE It is obvious that the political culture of mostly ethnic French-speaking Québec resembles the country of France more than it does of

the rest of Canada or the United States. Political-cultural similarities between the healthcare system of Québec and that of France are rooted deeply in the history of American colonisation

and settlement (ie, the concept of Québec as a French 'island' in a British sea). Logically, the subsequent development of political and economic culture of Québec follows a

similar timeline as does that of France itself. Consider dental healthcare in France. The French finance their healthcare system by a complex mix of private and public sources.9 There is a

clear and direct parallel to the government dental insurance coverage that is present in Québec, Canada. In the news literature, France's national healthcare system is widely lauded as

excellent;9,10 it was even depicted as a very effective healthcare system in the 2007 documentary film _Sicko: the movie_ by Michael Moore.11 High quality, affordable dentistry is available

in France due to the policy of the government which closely regulates prices that can be charged for most general dentistry procedures.10 Although dental specialty treatment is not directly

controlled, the French government has an enlightened policy of 'tact and discretion' for the prices that specialists can charge.10 By policies of price controls on general

dentistry and of not covering specialty treatment, the French national healthcare system can continue to insure dentistry for large segments of their population. Compare the French with the

British healthcare system (with no government-run dental insurance coverage). Is the assumption that the British have 'bad teeth' a myth propagated on the Internet or is it a

factual assertion? Certainly, the availability of dental care in Britain is low compared to the rest of Europe and North America;12 dental care in Britain is also the _most expensive_ in the

European Union.13 Dental procedures are generally not covered by the National Health System in Britain. Furthermore, it is assumed that the practice of dentistry in North America is

superior to that in Britain, eg more dental research is conducted in North America and is applied to practice as evidence-based dentistry. However, none of these aspersions on the dental

health of Britain has been substantiated by epidemiological or public health research and they are surely the result of stereotypical thinking. The United States and British Canada inherited

their political culture from the application of English Common Law by the colonisation of North American territories that were to become the original 13 US States and the Canadian

Provinces/Territories. Even in modern times, our bonds with the British are strong, as revealed through the substantial support of the British in armed conflicts like WWII and the

Falkland's War. Today, Britain (ie the United Kingdom) is the closest ally of the United States and British culture has become fashionably pervasive in American music, literature,

journalism, and many other segments of our cultural life. DISCUSSION The role of the US government in financing dental services is controversial. The US federal government makes a feeble

attempt at dental coverage of young children with the Head Start Program, providing no more than an 'introduction to the dentist' and only for poverty-level children. Often, the

average 3-5-year-old receives a simple prophy (cleaning) and perhaps a filling under the Head Start Program. It is far from comprehensive dental care. No other significant federally-funded

dental services are provided for any other demographic group. However, the federal Medicare programme is well administered and could be a framework or model for insurance coverage of dental

services by the US Federal government. The time has never been better for healthcare change, with an enlightened administration such as that of President Obama and an American people ripe

for change. All Canadian residents are covered medically by the Universal Health Care system (also called Canadian 'Medicare'). The legislation creating the healthcare system was

consolidated in 1984 as the Canada Health Act14 with principles acting in health promotion, health education, and disease prevention.14 Basic healthcare in Canada is regarded as a public

service.5 The Universal Health Care system in Canada relies on providers from the private sector, paid by insurance from the government.15 However, only Québec has Province-wide

government-provided dental insurance for residents.8 For the rest of Canada, like Great Britain, dental care is inaccessible and expensive; ordinary Canadian families generally cannot afford

dental care.16 The results of a study of dental expenses in the Canadian Provinces and Territories during the formative decade of the 1990s are shown in Table 1.17 Québec Province, although

an average spender in gross dental expenditures, excels in the percent use of public funds for dental care, ie considering the territories and sparsely populated provinces.17 During the

period of change during the 1990s represented by Table 2, Québec leads the other provinces and Canada overall in a calculated 'index of change' of per capita expenditures for

dental care.17 Canadian 'Medicare', including its Québec component, promotes evidence-based practice, ie it stresses medical and dental practice based on high-quality research

employing the scientific method.18 CONCLUSION Is it not the case that the policies of the French model of healthcare provision and its socio-political culture are naturally echoed in Québec?

In the opinion of the authors, it is a resounding _oui_! The government of Québec, as the ongoing legacy of French colonialism in the New World, follows the French lead in providing for

dental services in its healthcare system. In the opinion of the authors, the United States (and British Canada) will continue to evade providing dental insurance for its population –

possibly because they continue to follow a British and not French political culture. What lessons can the United States learn from the Québec experience in the provision of dental health

insurance, given the origins of its political culture and governmental healthcare policy? In the United States dental care is not covered in its remarkably and effectively well-administered

Medicare Program. Medicare provides an existing framework on which Federal dental insurance can be built. We propose that new healthcare finance policies be formulated by President Obama and

Congress on the model of the policies effectively working in Québec. Changes in dental health policy in the United States would have measureable benefits for both medical and dental

healthcare of its people. Further, such augmentation of overall healthcare would have positive implications for the nation's economy. Better dental healthcare would mean fewer

toothaches and oral infections, which translate into less time lost at the workplace. Commitment to dental coverage in addition to medical insurance is a commitment to the health of the

labour force and the people of the United States. REFERENCES * World Health Organization. Declaration of Alma-Ata, 1978 [cited 14 Feb 2011]. Available from:

http://www.who.int/publications/almaata_declaration_en.pdf. * World Health Organization. Ottawa Charter for Health Promotion, First International Conference on Health Promotion, 1986 [cited

14 Feb 2011]. Available from: http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf. * Bhatti T, Rana Z, Grootendorst P . Dental insurance, income and the use of dental care in Canada. _J

Can Dent Assoc_ 2007; 73: 57. PubMed  Google Scholar  * Department of Finance Canada. Your tax dollar, 2009 [cited 18 Feb 2011] Available from: http://www.fin.gc.ca/taxdollar09/html-eng.asp.

* Department of Finance Canada. Tax expenditures: Notes to the estimates/projections, 2010 [cited 18 Feb 2011]. Available from:

http://www.fin.gc.ca/taxexpdepfisc/2010/taxexp1004-eng.asp#tocnotes-04. * Revenu Québec. Healthcare Services, 2011 [cited 6 Apr 2011]. Available from:

http://www.revenuquebec.ca/en/entreprise/taxes/tvq_tps/perception/cas_particuliers/sante/services_de_sante.aspx. * Revenu Québec. Tax News: Changes to the tax credits for medical expenses,

2005 [cited 6 Apr 2011]. Available from: http://www.revenuquebec.ca/en/centre-information/nf/archives/nf2005/in-136_68/credit_frais_med.aspx. * Régie de l'assurance maladie Québec.

Dental Service Coverage, 2010 [cited 7 Apr 2011]. Available from: http://www.ramq.gouv.qc.ca/en/publications/documents/depliantscitoyens/depl_dentaires_en.pdf. * Capell K . The French lesson

in health care. Businessweek: Bloomberg, 2011 [cited 12 Feb 2011]. Available from: http://www.businessweek.com/print/magazine/content/07_25/b4042070.htm?chan=gl. * Nvillas.com. Dental

treatment in France: News article, 2011 [cited 12 Feb 2011]. Available from: http://www.nvillas.com/news/?id=142. * Moore M . Sicko: the Movie. Denver CO: Dog Eat Dog Films, 2007. *

Answerbag. Why is there a stereotype that British people have bad teeth? Do they really have bad teeth? 2006 [cited 14 Feb 2011]. Available from: http://www.answerbag.com/q_view/47408. *

Ward P . Mail Online: British dental care is the most expensive in Europe, 2008 [cited 15 Feb 2011], Available from:

http://www.dailymail.co.uk/health/article-507319/British-dental-care-expensive-Europe.html. * Madore O . Canada Health Act (as revised May, 2005). Overview and Options, 2005 [cited 16 Feb

2011]. Available from: http://www2.parl.gc.ca/content/lop/researchpublications/944-e.htm. * Reid T R . 5 Myths about health care around the world. The Washington Post. Opinion and Outlook

Section (23 August 2009). * Goldfinger. Canadian Universal Dental Care: The Time is Now, 2009 [cited 17 Feb 2001]. Available from:

http://www.healthmad.com.com/healthcare-industry/canadian-universal-dental-care-the-time-is-now/. * Baldota K K, Leake J L . A macroeconomic review of dentistry in Canada in the 1990s. _J

Can Dent Assoc_ 2004; 70: 604–609. PubMed  Google Scholar  * Health Canada Webpage. Highlights – 2008 – Health Care System, 2008 [cited 15 Feb 2011]. Available from:

http://www.hc-sc.gc.ca/hcs-sss/news-nouvelles-eng.php. Download references AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * Dade County Dental Research Clinic/'Community Smiles',

Miami, Florida, USA P. L. Benjamin * Jackson State University, Jackson, MS, USA M. Z. Younis * Department of Health Information & Administration, Faculty of Allied Health, Kuwait

University, Kuwait M. Al-Hajeri Authors * P. J. Flaer View author publications You can also search for this author inPubMed Google Scholar * M. Z. Younis View author publications You can

also search for this author inPubMed Google Scholar * P. L. Benjamin View author publications You can also search for this author inPubMed Google Scholar * M. Al-Hajeri View author

publications You can also search for this author inPubMed Google Scholar CORRESPONDING AUTHOR Correspondence to M. Z. Younis. RIGHTS AND PERMISSIONS Reprints and permissions ABOUT THIS

ARTICLE CITE THIS ARTICLE Flaer, P., Younis, M., Benjamin, P. _et al._ The political culture of healthcare: why substantial dental care in Canada is covered by government insurance only in

Québec – lessons for the United States?. _Br Dent J_ 210, 519–521 (2011). https://doi.org/10.1038/sj.bdj.2011.427 Download citation * Accepted: 06 April 2011 * Published: 10 June 2011 *

Issue Date: 11 June 2011 * DOI: https://doi.org/10.1038/sj.bdj.2011.427 SHARE THIS ARTICLE Anyone you share the following link with will be able to read this content: Get shareable link

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