Public insurance for dental care for chidren

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1 Public insurance for dental care for chidren Country: Israel Partner Institute: The Myers-JDC-Brookdale Institute, Jerusalem Survey no: (16)2010 Author(s): Nir Kaidar, Tuvia Horev and Bruce Rosen Health Policy Issues: Prevention, System Organisation/ Integration, Benefit Basket, Others, Access Current Process Stages Idea Pilot Policy Paper Legislation Implementation Evaluation Change 1. Abstract As of July 2010, all residents of the State of Israel up to age 8 became eligible to receive a comprehensive set of preventive and restorative dental services within the framework of National Health Insurance. Over the coming three years, the eligibility cohort will be gradually extended to include all children up to age 14. The initiative was conducted in order to improve accessibility, improve oral health status, reduce household expenditures and enhance system efficiency. 2. Purpose of health policy or idea The objective of the initiative was to improve access to dental services for children, reduce household expenditures on dental care (with an emphasis on low SES households), to enhance the efficiency of dental care and improve oral health status. Main objectives Expansion of the National Health Insurance Law to include dental care for children Type of incentives Removal of financial barriers to dental care Groups affected Children and households (and in particular low SES households) - will have increased access to dental care, Dentists and Health Plans will also be affected by this change 3. Characteristics of this policy Degree of Innovation traditional innovative - 1 -

2 Degree of Controversy consensual highly controversial Structural or Systemic Impact marginal fundamental Public Visibility very low very high Transferability strongly system-dependent system-neutral The policy represents an important innovation in Israel, where historically dental care has been financed privately and separately from other medical care. It is less innovative from an international perspective, as several countries have included dental care as part of the NHI programs for a long time. The policy was quite controversial, engendering opposition from private dentists and disease associations, as discussed below. The sytem impact has been assessed as rather fundamental as the policy begins to shift dental care from a separate/private venture to a mainstream/public activity. However, as of yet, this transition applies only to the care of children. The policy was very visible, due to the controversy and due to the fact that dental care affects all families. The policy was assessed as rather system neutral, as the change was not dependent on any particularly unique features of Israeli health care on either the financing or organizational side. The fact that the new technology funds were used as the financing source should not be seen as an inherent feature of the reform. 4. Political and economic background Shortly before assuming office, the current head of the Ministry of Health (who is official a deputy minister, but in practice functions as a minister) declared that, under his leadership, the Ministry of Health would act vigorously to include dental care for children in the publicly-financed benefits package. The prior head of the Ministry of Health had been from the Pensioners' Party; accordingly, it is not surprising that his emphasis was on expanding services for older people. The current head is from an Ultra-Orthodox party, which draws much of its support from large families with many children. For him, expanding the benefits package to include dental care for children was one of his main objectives during his iniital months in office, and he dedicated a substantial portion of his time to advancing this objective. It should be noted that when the initiative was first announced it was met with substantial public criticism, as it entailed financing the addition of dental care to the package from the budget that had been allocated for adding new technologies to the package. Implementation of the initiative will permit more effective regulation of dental care, in part because the health plans and the Ministry of Health will monitor the quality of care. Change of government The Ultra-orthodox party gives a higher priority to services for children than did the Pensioners' Party. 5. Purpose and process analysis Idea Pilot Policy Paper Legislation Implementation Evaluation Change - 2 -

3 Origins of health policy idea Over the past two decades, the idea of including dental care in the publicly-financed benefits package was discussed and endorsed by several public commissions that examined the Israeli health system. These included the landmark Netanyahu Commission of the early 1990s and the Parliamentary Commission on the implementation of NHI which met a decade later. In 1994, when the Parliament was preparing the National Health Insurance bill, consideration was given to including dental care in the benefits package. However, this idea was dropped when the decision was made to base the NHI benefits package on the set of services then being provided by the largest health plan. Periodically, the Comptroller-General has bemoaned the lack of efficiency in the dental care system. Over the years, several academic articles (Horev, 1996; Horev and Chernichovsky, 1999; National Institute, 2003; Horev and Mann, 2007) have been published analyzing the sources of the problems with Israeli dental care and possible ways to address them. Initiators of idea/main actors Government Providers Patients, Consumers Private Sector or Industry Political Parties Approach of idea The approach of the idea is described as: renewed: The notion of extending NHI to include dental care has been raised periodically over the past 20 years. Stakeholder positions Ministry of Health - the initiative was led by the Ministry of Health under the leadership of the head of the ministry. Ministry of Finance - was quite supportive of the notion of extending NHI to dental care. Its approach differed somewhat from that of the Ministry of Health in that it argued for allowing organizations other than the health plans to participate. Parliament - extension of NHI to include dental care required an ammendment to the NHI law, hence the Knesset (Parliament) played an important role in the process. The health plans expressed willingness to accept the additional responsibility on condition that it be budgeted adequately. They were not in the forefront of the efforts to advance the new policy. There were two groups that opposed the initiative: 1. Various disease-specific patient organizations contended that it was inappropriate that the inclusion of dental care in the benefits package would come at the expense of adding new technologies for treating various illnesses which were already within the scope of NHI. They even appealed to the Supreme Court, but their appeal was rejected. 2. Independent dentists concerned about the potential monopsony power of the health plans. There concerns were addressed by the Parliament, which authorized additional organizations to submit applications to provide - 3 -

4 dental care for children, alongside the health plans. Actors and positions Description of actors and their positions Government Ministry of Health very supportive strongly opposed Ministry of Finance very supportive strongly opposed Providers Health Plans very supportive strongly opposed Patients, Consumers Consumer groups representing very supportive strongly opposed patients with serious health problems Private Sector or Industry Private dentists and their very supportive strongly opposed representatives Political Parties Parliament very supportive strongly opposed Influences in policy making and legislation The initiative required two ammendments to the 1994 National Health Insurance Law. The first involved expanding the benefits package to include dental care for children; this passed without any major difficulties. The second dealt with allowing organizations other than the health plans to provide the services. The Parliament accept this change that had been proposed by the govenrment, but added the stipulations that only non-profit organizations would be authorized, in order to prevent a for-profit organisation under the NHI. Legislative outcome success Actors and influence Description of actors and their influence Government Ministry of Health very strong none Ministry of Finance very strong none Providers Health Plans very strong none Patients, Consumers Consumer groups representing very strong none patients with serious health problems Private Sector or Industry Private dentists and their very strong none representatives Political Parties Parliament very strong none Positions and Influences at a glance - 4 -

5 Adoption and implementation The adoption of the initiative was made possible by the steadfastness of the head of the health ministry and his senior management team along with the strong support of the Ministry of Finance. The health plans did not play a major role in the legislative process but will be major players in its implementation as they are to be the major providers of care in the new framework. In order to secure legislative approval and effective implementation, the leaders of the initiative had to ensure that the initiative would be adequately financed and accede to the expansion of the framework to include providers other than the health plans. It is unlikely that the legislation would have been adopted if the concerns of the independent physicians had not been addressed. Monitoring and evaluation It is too soon to tell whether the initiative has, or will, achieve its objectives. Several months into the new regime, we do know that a substantial proportion of the population is making use of the new benefits. The initiative's success will be judged according to the following criteria: higher rates of service use, lower rates of oral health problems, a decline in household spending on dental care, improved access to dental services for vulnerable populations, and the involvement of independent dentists in providing services within the new framework. Review mechanisms Mid-term review or evaluation, Final evaluation (internal), Final evaluation (external) Dimensions of evaluation Structure, Outcome, Process Results of evaluation The Ministry of Health is orchestrating a multi-pronged evaluation of the reform, involving researchers from inside and outside the Ministry. Naturally, there are no results as yet as the reform has just been launched

6 6. Expected outcome The reform is expected to improve access to care, particularly among low-income groups. Dental utilization is expected to increase, while the impact on total dental expenditures is uncertain as reductions in prices could offset utilization increases. Quality of care may increase due to improved monitoring. It will also be important to monitor how the reform affects the extent to which dentists seek out pediatric patients and specialize in pediatric care. Quality of Health Care Services marginal fundamental Level of Equity system less equitable system more equitable Cost Efficiency very low very high Improved monitoring is expected to improve quality. Reducing financial barriers to dental care for children should enhance system equity. Improved access along with restraints on prices should improve cost-efficiency. 7. References Sources of Information Berg, A., Horev, T., Zusman, S. P. (2001). Patient satisfaction, quality indicators and utilization of dental services in Israel. Harefuah. 140(12) (Dec.): , (Hebrew) Horev T, Berg-Warman A, Zussman SP. [Disparities in the Israeli oral healthcare delivery system]. Refuat Hapeh Vehashinayim Jan;21(1):35-42, 100. (Hebrew) Horev T., Mann, J Oral and Dental Health - The Responsibility of the State towards its Citizens. Taub Center, (Hebrew) Katz, J., Peretz, B., Sgan-Cohen, H. D., Horev, T., Eldad, A. (2000). Periodontal status by CPITN, and associated variables in an Israeli permanent force military population. J. Clin. Periodontol. 27(5) (May): Machnes, Y Inequality and inefficiency in dental care: The economic perspective in Dental care systems (Y. Mann and R. Fisher, eds.). Opal Press. (Hebrew) Navon, G and Chernichovsky, D Dental Health: The Burden on Households - Implications for National Health Insurance. Taub Center. Sgan Cohen, H. D., Kats, J., Horev, T., Dinte, A., Eldad, A. (2000). Trends in caries and associated variables among young Israeli adults over 5 decades. Community Dentistry and oral Epidemiology, 28 (3): Zusman SP, Ramon T, Natapov L, Kooby E. National oral health knowledge, Attitudes and behaviour survey of Israeli 12-year-olds, Oral Health Prev Dent. 2007;5(4): Zusman, S. P., Ramon, T., Natapov, L., Kooby, E. (2005). Dental Health of 12 year olds in Israel Community Dental Health: 22: Author/s and/or contributors to this survey Nir Kaidar, Tuvia Horev and Bruce Rosen - 6 -

7 Suggested citation for this online article Nir Kaidar, Tuvia Horev and Bruce Rosen. "Public insurance for dental care for chidren". Health Policy Monitor, November Available at -

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