The importance of lifelong prevention and management of dental caries and periodontal diseases to address the problem of multiple tooth loss in older people has been highlighted, so the Korean government initiated the expansion of the national health insurance coverage to provide dental prosthetic services for older people, mainly because there was a social consensus among the Korean population regarding its rapid aging society and the serious problem of poverty among the Korean elderly. However, such expansion had not been attempted elsewhere in the world because dental prosthetic services are costly, so this provision may incur in financial burden. Thus, we aimed to review the usefulness of this policy by investigating its effects on dental care utilization according to sociodemographic characteristics of the Korean older people.
First, implementing health insurance coverage of dentures and dental implants for older people in Korea increased the utilization of the said services as well as annual outpatient dental care (Table 1). However, over the three years we analyzed (during which insurance coverage was expanded), the increase in the rates for outpatient dental utilization, denture use, and dental implant use were only 5.7%, 1.4%, and 2.8%, respectively; this suggests that the policy has enhanced the access to dental care for a particular populational group as opposed to promoting universal health coverage. This may have been inevitable, as there were clear limitations in improving access to dental care by expanding coverage to dental prosthetic services. In 2015, the percentage of Korean older people who needed dentures was 22.7% , while it was around 31.5% from 2007 to 2009 . Further, such low increase may also be attributable to the high coverage cost per dental implant and denture (1.3 million South Korean Won, or 1,126 United States of America dollars [USD], for dentures) , which incurred in various restrictions for the insurance benefit to be accessed, such as age limit, high OOP cost, and a limited number of covered dental implants. In fact, the rapid escalation of the values spent by the government on the national health insurance owing to the dental care coverage expansion (31.05 million USD in 2012 ; 128.55 million USD in 2015) confirms that there are practical limitations for this expansion owing to financial burden . Therefore, we suggest that the government should take a high-risk approach by focusing on mitigating sociodemographic disparities in access to such services as opposed to promoting universal health coverage.
Next, logistic regression models revealed varying changes regarding access to dental care according to sociodemographic characteristics following the studied expansion (Table 2); it indeed alleviated inequalities in access among social characteristics (such as duration of education, household income, and type of health insurance), but not to a statistically significant extent. One of the main changes was that it increased dental care utilization by 2.5–3.7 times among people aged 70 years or older compared to people aged 65–69 years. A study on Brazilian adults also found that the need for a complete denture increased with age and that it was closely related to an individual’s socioeconomic position . Further, expanded dental implant coverage mitigated gaps among different age groups and people with differing duration of education—except for uneducated people; still, it also induced a clear stepwise pattern of inequality according to household income. The reason for these differences may be that, although denture provision is perceived as an essential service that is utilized by people aged 70 years or older upon need, high-income individuals are more likely to utilize dental implants owing to the different perceptions of OOP cost between low- and high-income individuals. Therefore, this shows that there is a need for a complete review of the policy, mainly because it seems that the dental implant coverage actually worsened access inequality, contradicting its original intent, which was to alleviate sociodemographic inequalities in access to the service through breaking down financial barriers (by lowering eligible age and OOP rate).
For this policy review, we suggest referencing the Sweden coverage system, where dental implants are covered only in essential cases: Since the launching of a dental insurance in 1974, Sweden has been offering a comprehensive and costly prosthetic care to middle-aged or older people , and the Dental Health Insurance Plan implemented in 2002 mentions the provision of subsidies for costly dental prostheses for people aged 65 years or older ; moreover, the scope of the dental implant coverage is determined by the number of lost teeth . Contrastingly, the Korean health insurance covers only two dental implants for people aged 65 years or older during their whole lives. Considering that, in 2015, the average number of remaining natural teeth was 17.5 among older adults aged 65 years or older , the coverage of only two dental implants during Korean older people’s lifetime is not consistent with their current oral health status. Therefore, the dental implant coverage policy should focus on restoring their minimal masticatory functions to ensure QOL as opposed to simply increasing the number of teeth. To this end, policies that take into consideration the oral health status and socioeconomic levels of the target population should be implemented.
Although the annual outpatient dental care utilization increased by 5.7% over three years of the expansion, the utilization rate still remained at 30.4%, highlighting that most Korean older people still struggle to utilize the national dental care coverage. Universal health coverage refers to the assurance that everyone can receive high quality essential health services without experiencing financial difficulties . In 2001, the Ministry of Health and Social Care of the United Kingdom published the “National Service Framework for Older People,” and it has been endeavoring to provide fair, high-quality and comprehensive healthcare and social welfare services to British older people . Fisher et al. suggested including dental insurance as part of health insurance and thus expand universal health coverage to include oral health . The Japanese government, which deal with an already super-aged society, implemented the Medical Aid policy for the elderly in 1973, in which all medical costs for people aged 70 years or older are paid by the government ; it is also planning to complete the provision of a regional care system by 2025, which aims to comprehensively provide health services, health promotion, home care, rehabilitation, and welfare to the entire Japanese older adult population . Borreani et al. suggest the need for individual change and systemic change at the societal level for enhancing elderly’s access to care . Thus, taking into account the current situation of older adults’ access to oral health care, and the fact that Korea is facing an aging society that may become similar to that of Japan, we believe that the Korean government may need to adopt Japan’s healthcare delivery system to diminish health disparities among Korean older adults. Most of all, we believe that the national health insurance should mainly cover preventive care services for oral health of older adults, rather than providing dental prosthetic services; further, older adults with physical or cognitive disabilities having access to dental care need policies targeted at them, which should provide home visit services and community care.