Starting in 2016, a Cree child’s struggle to get braces became national news. Thirteen-year-old Josey Willier from the Sucker Creek First Nation suffered from chronic pain from her crooked teeth. Her dentist said that she needed braces to avoid more expensive and invasive surgery in the future, but the federal government, which administers the program that provides dental benefits for First Nations and Inuit people, denied her claim. The family took the government to court, and the government spent $100,000 on lawyers defending its decision to deny the $8,000 procedure. Finally, just before the Federal Court of Appeal was to decide the case, the government settled with the family. In July 2018, the government expanded eligibility for orthodontic treatment.

Even with this step forward, the Non-Insured Health Benefits (NIHB) Program constantly frustrates both patients and service providers, remains inefficient and inconsistent, and fails to address the underlying causes of poor oral health among Indigenous people. These issues have been recognized for decades — by the Auditor General of Canada and others — and action is badly needed. The need is all the more pressing because First Nations and Inuit people in Canada are much more likely to have cavities, lose their teeth prematurely and suffer from orthodontic problems than their non-Indigenous counterparts.

Predetermining failure

First Nations and Inuit people have experienced many and varied difficulties with the dental benefits provided by the NIHB Program. Many of the Indigenous people who rely on the NIHB Program say that it is often extremely hard just to find a dentist and that, when they are available, dentists often charge additional fees or ask people to pay up front. What’s more, services that many insured Canadians take for granted are subject to an unpredictable process called “predetermination”: permission has to be received from Health Canada before treatment can go ahead.

The predetermination requirement has caused people considerable distress. As the Assembly of First Nations (AFN) put it in 2005, “The current system of predetermination for many routine dental procedures causes a prolongation of illness, lacks in compassion and adds considerable cost to the program, particularly if clients have travelled long distances.” Predetermination means that people often need to make a second trip to the dentist — which is both frustrating for the dentist and inconvenient for the patient. The AFN reported that William Descalchuk, a First Nations man living in Alberta, complained that he had been waiting a month for approval to treat an infected molar and, due to ongoing pain, had resorted to extracting it himself.

It’s not just patients who have problems with the program. Service providers complain that the process for receiving payment and approval is much more onerous than with private insurance companies. Some providers have opted out of the program, which means that many patients have to pay directly for dental treatment. Given the disproportionately low incomes of many First Nations and Inuit people, this makes it impossible for them to access care. In Nunavut, the predetermination process has been found to act as a serious deterrent to service provision. But, given the difficulties in receiving approval, many dentists in Nunavut have done the work — only to be later denied compensation. In 2014, Peter Doig, president of the Canadian Dental Association, told Windspeaker magazine that the NIHB covered only 86 to 88 percent of treatment costs, meaning that dentists needed to either bill the patient for extra costs, lose money on doing the work or reject the patient. He asserted that many dentists would not take patients who were covered only by the NIHB.

The federal government must improve the NIHB immediately. Most important is a funding increase that will allow the program to begin to shrink the dental health disparities between Indigenous and non-Indigenous people.

Some dental care has been provided to Indigenous people in Canada since the 1930s, though usually on an inconsistent and intermittent basis. Services expanded in the postwar period, when the Indian Health Service began employing dentists — and eventually dental therapists — to provide services directly to communities. The Indian Health Service also reimbursed private dentists who provided care to reserve residents who were deemed to be “indigent.” When the federal government attempted to standardize practices in 1978 by introducing a means-tested program that would serve only those living on reserve, there was widespread opposition from First Nations and Inuit people. The government responded in 1979 by introducing a new Indian Health Policy that promised to provide benefits for noninsured health services to people living off reserve and dropped the requirement for a means test — effectively establishing what is now known as the NIHB Program.

More than 850,000 First Nations and Inuit people now rely on these benefits, but there has never been any federal legislation recognizing the NIHB Program. In 1993, this led the Auditor General to complain that “there is still, after almost fifteen years, no consensus in the Department as to the exact nature of the program.” In order to contain costs, an “envelope” system was put in place in the early 1990s under which each region had a specified funding amount that it could spend. But this resulted in significant inequalities because some regions were managed by bureaucrats committed to staying within the envelope, while others regularly overspent. In 1996, there were major cutbacks. Eligibility for services such as exams, scaling, root canals and prosthodontics (including crowns, bridges and dentures) was significantly reduced. In a study in Manitoba, Peter Cooney — who would later become the director general of the NIHB program and, eventually, Canada’s chief dental officer — determined that clients would be better served by making more procedures subject to predetermination than by restricting the number of services provided under the program. As a result the guidelines were changed again to include a greater role for predetermination in conjunction with an expansion of eligibility for benefits.

Long overdue for a cleaning

Core to the inadequacies of the NIHB program have been disagreements over treaty rights, escalating costs and jurisdictional issues. While the government of Canada has insisted that health care is provided as a matter of policy, not obligation, a “medicine chest” clause was included in the text of Treaty 6 and was promised orally during other treaty negotiations. The Assembly of First Nations, for its part, has long argued that health care is a treaty and Indigenous right.

If access to dental care is a treaty right or an Indigenous right — and given that Indigenous people had very little tooth decay before the imposition of the Indian Act — then the program can only be seen as deeply unjust in its policies and procedures. The administration of the program is complicated by the fact that the NIHB sees itself as the payer of last resort, meaning that it requires services to be covered by private insurance in the case of those lucky enough to have it or by the provincial patchwork of publicly provided dental services. This stance contributes further to the variations in administration and benefits across the country. Another result of making NIHB an “insurance” program is that it does not see its mandate as improving the oral health of First Nations and Inuit peoples. The government’s emphasis has been on restricting access to services to control costs, rather than on providing the education, clean water, nutritious food and regular access to care that is required to improve oral health.

From the government’s perspective, the NIHB is provided as a “service” and — because it’s one that other Canadians do not have access to — the cost control emphasis is justified. The rapidly rising costs of the program, after all, have attracted the attention of the Auditor General and others. Expenditures for the dental benefits have skyrocketed from $38.4 million in 1987-88 to $235.8 million in 2016-17.

The problem with the federal government’s cost containment approach to the NIHB is that it completely ignores the central role that federal policies have played in producing the health disparities between Indigenous and non-Indigenous people in Canada in the first place. As numerous health researchers and the Truth and Reconciliation Commission have shown in recent years, residential schools alone have had multigenerational impacts on the health of survivors and their families. When combined with impacts of other official policies — ranging from the Indian Act to the system of underfunded, racially segregated hospitals established during the postwar period — it is clear that Canada has a responsibility to ensure that Indigenous people have access to adequate health care services.

We urge the federal government to take a number of immediate steps to improve the NIHB Program. Most important is an increase in funding big enough to allow the program to begin to actually shrink the oral health disparities between Indigenous and non-Indigenous people. Canada must also reduce the amount of predetermination required and acknowledge that many so-called “cosmetic” procedures like orthodontics have become a necessity: straight white teeth have become a societal norm that can impact an individual’s employment opportunities and self-esteem. And, finally, we urge that First Nations and Inuit people be engaged as equal partners in the development of NIHB policies and practices — something that was demanded by the Assembly of First Nations in 2005 and that we believe is long overdue.

Photo: Shutterstock, by jannoon028.

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Ian Mosby
Ian Mosby is a postdoctoral fellow in the Department of Geography at the University of Guelph and an adjunct lecturer in University of Toronto’s Dalla Lana School of Public Health.
Catherine Carstairs
Catherine Carstairs is a professor and chair of the Department of History, University of Guelph. She has published extensively on gender, health and social inequality in Canada.

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