The history of public health over the past 40 years has been to consider a need for universal healthcare for most parts of our body, but as soon as the issue concerns our teeth rather than a bone or internal organ we should pay the costs ourselves. A new report by the Grattan Institute demonstrates this has led to a massive inequality of dental care and shows it is time to move towards a universal dental scheme.

The Grattan Institute’s “Filling the Gap” report notes that when Medicare was introduced, it did not include coverage for a range of other services. However, since then it has been extended to “a number of additional health services, including nursing, psychology, physiotherapy, chiropractic, dietetics, podiatry, occupational therapy, osteopaths, audiologists, exercise physiologists and speech pathologists”. And yet primary dental care remains on the outer.

The report highlights how severe this impact is for dental care.

They estimate that in the past 12 months just over 2 million (18%) of Australians who needed to see the dentists delayed or skipped seeing a dentist due to cost. There is a straightforward link between household income and the likelihood of skipping going to the dentist – much more so than for skipping a GP visit or seeing a specialist:

And it is a tendency that holds across all ages:

And while there is the stereotype of the trip to the dentist as something that people find frightening, the reality is the real fright for most low to median income earners is the cost.

Only 19% of those in the median household income decile claimed fear or dislike of the dentist as the reason for avoiding seeing the dentist (compared with 22% of those in the highest income decile). But while 25% of those in the highest income decile said cost was the main factor, it was the reason 57% of those on median incomes avoided the dentist and accounted for two-thirds of the reason why those in the lowest income decile did so:

And this has costs to health. While for younger people the issue is not so obvious, by the time you reach your 40s the impact of not going to the dentist is very apparent, with those aged 45-64 on incomes of $30,000 having lost double the number of teeth than had those earning over $140,000:

The issue of course is that while we treat going to the GP and hospitals as something that is considered an expense to be mostly borne by the universal health system via the government, for dental care nearly 60% of the cost is borne by individuals:

This has led to Australia being one of the worst nations for seeing the dentist based on our overall wealth. Compared with nations such as New Zealand, Canada and the UK, we are much less likely to attend the dentist. Among wealthy nations, only the US with its horrendous healthcare system lags behind us:

And the problems with our dental health are getting worse – with a rise over the past two decades across a number of oral health issues experienced by adults:

The problem is that while we do have a number of public dental schemes, they are highly means-tested and are mostly targeted towards children. It results in fewer than half of all adults in only the lowest two income deciles being eligible:

The Grattan report recommends moving towards a universal dental scheme, with an ultimate goal of eliminating “financial barriers to dental care for all Australians”. They argue: “This is best achieved by requiring participating dental practices to charge fees according to an agreed schedule, without additional payments by patients.”

But there are a couple of problems. The first and biggest is the cost – some $5.6bn a year.

Rather than do one big hit, the report recommends the commonwealth government should first “take over funding of existing public dental schemes, fund them properly to the tune of an extra $1.1bn per year”.

They then argue to extend the care to those on all Centrelink payments and for all children, with a view to becoming universal within a decade.

But the second issue is the number of dentists and dental health practitioners. They note that “Australia has fewer dentists per 100,000 people than many other OECD countries” and thus we need to “further increase dentist training numbers, and maintain pathways for internationally trained dentists to practice here”.

The report does note that dentists do appear to work part-time in greater numbers than other healthcare workers and that this suggests that any increase in demand due to increased public dental funding “be absorbed, at least in part” by the current numbers.

For more than 40 years dental care has been placed in the too hard (and too expensive) basket for Medicare. The Grattan Institute’s report notes that this has led to a large inequality of dental care and an overall growing in dental care problems.

And while the cost is large, it is clear that to talk of a universal and equal healthcare without including dental health means overlooking a major aspect of our quality of life, and condemns those on lower incomes to worse health.

• Greg Jericho is a Guardian Australia columnist