Disparities in oral health and in the access to dental care dominate the international literature on the topic. The financial burden of out-of-pocket dental care expenditure gained attention due to its affordability and weight in household budgets because dental care is typically not covered by insurance schemes or it is at a lower level. Several studies show that children [14, 26], individuals with special needs [33], elderly people [19, 41], people living in rural areas [39] and low-income individuals generally [45] are more affected by oral diseases, such as dental caries and periodontitis. In addition, racial and ethnic minorities tend to experience disparities in oral health status [18]. These disparities might be considered a consequence partially of being intrinsic to the socio-demographic group and partially of the barriers to dental care access. Disadvantaged socio-demographic groups (e.g. low-income individuals and ethnic minorities) are less likely to have private dental coverage [28, 34] while dental care is barely included in social programmes. In several countries, being part of the labour force is strongly predictive of having dental coverage [29]. For example, in the US, dental insurance is excluded from the Medicare programme and medical insurance is 2.5 times more common than dental insurance; elderly Americans are often excluded from coverage because their employer-based insurance coverage expires when they retire [20]. Consequently, middle-aged groups tend to record higher levels of coverage while elderly people out of the labour force tend to be excluded from coverage [30]. In addition, the impact of oral health on the probability of receiving dental care is controversial: according to Bhatti et al. [2], people with poor oral health are less likely to use dental services, and this is probably the reason for their poor oral health but, among those using dental services, people with poor oral health tend to visit dentists more often than those with good oral health. Listl et al. [23], using Survey of Health, Ageing and Retirement in Europe (SHARE) data for a selection of European countries, found that reasons for dental non-attendance are different in different countries. In most countries (e.g. Italy, Spain, Greece, and Germany), several people do not use dental care because they perceive it as unnecessary; in other countries, a high percentage of people declare they do not use dental services because they are not affordable.
Given these considerations, previous research identified the presence of insurance as a key factor associated with the ‘use’ and ‘non-use’ of dental care. In general, having insurance seems to increase the use of dental services significantly, as it reduces the perceived price of care [1, 12, 27, 28, 31, 35]. However, it is not clear if the relationship is causal or if greater need leads patients to obtain insurance [1, 22]. Kreider et al. [20] highlighted the relevance of the selection problem that emerges when analysing the impact of insurance on dental care use: indeed, seeking dental care and obtaining insurance might be driven by unobserved factors (e.g. aversion to risk and expectations of future needs), making the relationship spurious. For this reason, recent approaches [7, 20, 32] have tended to use econometric specifications that can deal with the selection bias problem and have still produced results consistent with the previous ones.
In addition, differences in the use pattern of dental care might be caused by the different characterization of ‘private’ (i.e. offered through employers or other organizations) and ‘public’ systems (i.e. state-run). In ‘private systems’, buying health insurance different from the plan offered by an employer usually costs more, as there is no cost sharing with the employer. On the other hand, public health insurance is a government insurance system that pays the healthcare provider for medical care. Manning et al. [25] proposed an analysis on the effect on dental care use of different insurance schemes (free or co-insured by out-of-pocket expenditure by families). The authors found that passing from a 25% coinsurance rate to free dental coverage increased the probability of using dental services from 53.6% to 68.7%. Consistent results have been obtained by Mueller and Monheit [31], who also claimed that the increase in demand consequent to extending insurance is particularly relevant for expensive dental services (e.g. bridges and crowns) but less evident for basic treatments (e.g. X-rays and cleaning) that are consumed regardless of insurance status. This means that insurance tends to change the mix of dental services consumed.
During the last 2 years, the Swiss dental care system has been placed at the centre of a heated debate concerning a reform proposal to introduce compulsory dental care insurance [13]. The proponents of reform suggest financing dental insurance through a 1% contribution to wages based on the model of the Assurance Vieillesse et Survivants, a compulsory insurance intended to support retired people and the pensions of widows and widowers. The contribution should be equally divided between the employer and employee, although each canton might decide to impose a different financing principle. In the current system, dental care is not included in the healthcare system, except for costs generated by serious and unavoidable diseases of the masticatory system or by another serious illness or its aftermath. According to the Swiss Federal Office of Statistics, in Switzerland, the total cost of dental care in 2014 amounted to 4.1 billion Swiss francs (CHF), equivalent, on average, to approximately 492 CHF per capita per year. Patients themselves directly pay 90% of all dental care costs while the remainder is covered by social and private insurance or other regimes [5]. In the European framework, Switzerland ranks first in the level of out-of-pocket expenditure for dental care [37]. According to Listl et al. [23], in Switzerland, 28.4% of non-users of dental services perceive dental care as too expensive; this percentage is the highest recorded among the countries analysed and Switzerland’s neighbouring countries record definitely lower percentages (e.g. Austria = 11.1%; Germany = 4.4%; Italy = 18.4%; and France = 18.5%). A recent study by Guessous et al. [19] applied to survey data in the Canton of Geneva found that the prevalence of forgoing dental care is highly dependent on income level.
Between 2014 and 2016, three popular initiatives for reform of the current system were proposed in three cantons (Neuchâtel, Vaud, and Geneva) and the Grand Conseils of these cantons validated the initiatives so that the votation to determine citizens’ views on the reform will presumably take place by 2018. In the meantime, several other cantons are preparing popular initiatives on this subject. Thus, the debate is moving to national level with the following two main positions at stake. On the one hand, the proponents of the reform maintain that it will bring redistributive effects that will benefit the vulnerable part of society and that it will promote equitable access to dental care [24]. In particular, the promoters of the reform claim that low-income individuals tend to be excluded from private dental care (e.g. [19]) and that the introduction of a mandatory insurance scheme might improve access to dental care for individuals currently experiencing economic barriers to access dental services. Moreover, according to the proponents, easier access to dental care would improve prevention and check-up visits, thereby reducing long-run problems. On the other hand, opponents of the proposal, led by the Swiss Dental Association (Société Suisse d’Odonto-Stomatologie, SSO), do not favour compulsory dental coverage because they do not consider it the proper response to the inequity in dental care access. Rather, they consider that it would inflate the bureaucracy of the system and have undesirable effects, such as a substantial decrease in dental care quality and excess demand. Furthermore, the SSO is concerned that the reform would release many patients from their responsibility for taking care of their teeth by means of adequate preventive oral hygiene.
This debate is a novelty in the Swiss context and international experiences about the introduction of compulsory dental insurance within the last 2 decades are rare. Some evidence on the impact of recent dental reforms have been proposed in Thailand [40], Israel [36], and Chile [8]; however, results are not consistent in terms of impact of improving coverage on dental care utilization and inequalities. Consequently, the actual impact of this reform is not clear or easy to predict. This debate is a rare phenomenon in which dental care policy is being discussed at all levels and is of widespread interest for policy-makers to find new solutions. This study attempts to assess the feasibility and impact of providing free and comprehensive dental benefit to the general population of Switzerland focusing in particular on two critical issues of the reform proposal:
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1)
Is the reform proposal justified by the presence of relevant barriers to access dental care in Switzerland?
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2)
Can the suggested scheme for financing dental insurance guarantee the economic sustainability of the reform?
The Swiss healthcare system is particularly complex owing to the sharing of decision-making powers among three different stakeholders: three levels of government (i.e. confederation, cantons, and municipalities), corporatist bodies (including insurance companies and healthcare providers), and Swiss citizens, who can pervasively influence health policy-making through veto and popular initiatives. The scheme of financing the Swiss healthcare has been found to be one of the most regressive within the OECD countries [3, 11, 44, 46, 47]. Consequently, the reform proposal can be justified by a reduction in the unfairness of the entire healthcare system by reforming the financing scheme and reducing the perceived cost of dental services for vulnerable individuals. At the moment, four forms of financing co-exist (for a more in-depth description, see [9, 11]): Mandatory Health Insurance (MHI), government subsidies and benefits, General Social Insurance, and household expenditure. Since 1996, the MHI has been in existence to cover a comprehensive basket of healthcare services fixed at the federal level. The MHI services included in the benefits package have to be simple, economical, and appropriate (Loi fédérale sur l’assurance-maladie, LAMal). Households pay monthly premiums for private insurance, which are differentiated across three age classes but not by income; households can choose different insurance programmes (characterized by higher or lower premiums) depending on the level of deducible and maximum coverage. Premiums are set at the regional level by each health insurer and consequently, they are significantly different across regions and cantons. In addition, households pay directly for healthcare services through out-of-pocket expenditure, deductions (about 330 CHF, in the standard contract), co-payments, and voluntary complementary insurance. As insurance premiums and household expenditure are not dependent on income level, these two forms of financing are regressive. The state, through lower tiers of jurisdictions/local governments, finances a further component of healthcare expenditure by providing subsides to low-income households so that premiums do not exceed 10% of household income, although different eligibility rules are set in different cantons. This contribution is financed through a mixed system using direct taxation (progressive but different across cantons) and indirect taxation through value-added tax (regressive). Depending on the proportion of the two taxes, the overall impact of this source could be regressive, progressive, or even proportional [9, 10]. Lastly, general social insurance provides benefits connected to pensions, disability, and accidents. As the social contribution rate paid by citizens is the same for everyone, regardless of income level, this third financing source is expected to be proportional.
Dental care is covered free of charge if it concerns a serious non-preventable illness of the masticatory system or if it is caused by genetic anomalies. In particular, basic treatments (scaling and root planning, decays treatment, teeth extraction, endodontic treatments, removable prosthesis if less than 20 teeth are in contact between the two arches and all the treatments that are a consequence of genetic problems or diseases such as cancers, granulomas, etc.) are allowed by LAMal, which makes provision for all these basic treatments for indigent people.Footnote 1 ‘Luxury’ or advanced treatments (fixed prosthodontic: crown onlay/overlay, implants, bleaching, micro-abrasions, orthodontic treatments, etc.) are not covered by LAMal and they are fully paid out-of-pocket. In state schools, children’s teeth are checked for free once a year. Although the check-ups are free of charge, if the child requires any treatment for tooth decay, the parents must pay but some local cantonal authorities subsidize the cost of necessary dental treatment with special reductions (up to 80% refund of dental fees) according to the different cantonal laws.
The pricing schema of privately supplied dental treatments differ substantially from that applied to treatments covered by LAMal. In general, tariffs for each treatment are not arbitrarily established or negotiated politically but their amount are based on a cost criterion that takes into account personnel costs, operating expenses, and investment costs. Since 1976, a price list of more than 500 dental services has been published by the Swiss Dental Association and each tariff is determined as the product of two components: the number of points attributable to each treatment (PP) (that depends on the type of the treatment) and the value of each tariff point (VTP) according to the self-estimated skill and expertise of the dentist.Footnote 2 For treatments covered by LAMal the value of each tariff point is set, for simplicity, to 3.1 CHF, whereas the value of each tariff point for privately supplied treatments ranges between 3.1 and 5.8 CHF. Therefore, the pricing scheme applied to privately supplied treatments allows to take into account, on the one hand, the particular circumstances of the patients (urgency, comfort, aesthetics, quality) and, on the other, the particularities of the dental practice (infrastructure costs, wages).Footnote 3 Five minutes of basic dental treatment of a professional dentist correspond to 9 tariff points (PP = 9); therefore, the basic hourly cost of a Swiss dentist ranges from 335 CHF (if VTP = 3.10) to 626 CHF (if VTP = 5.8). Conversely, under the LAMal regime, no adjustments in price are allowed depending on patient’s condition, on dentist’s experience or on materials used and the hourly wage equals 335 CHF (i.e.: VTP = 3.10).
