Dental Dilemmas and the Limits of Charity

krazyglue.jpgIf states are to the be “laboratories of health care reform,” we should be sure to look not only at pioneers at expanding coverage, but also at what happens to those left behind. For example, Texas has a “has the highest rate of uninsured children in the nation, with 20.2% lacking coverage.” Today Ian Urbina of the NYT covers Kentucky’s dental care crisis, where “pain caused by dental problems is a leading cause of missed school days in Kentucky . . . [and] about 1 in 10 state residents are missing all their teeth.” As I suggested a few months ago, the lobbying of the American Dental Association, combined with pathetic Medicaid reimbursement rates, are giving rise to some new tiers of health care for the poor.

When “almost half of the state’s children ages 2 to 4 have untreated cavities,” one response is, of course, old-fashioned DIY ingenuity:

At his private practice, Dr. Smith said that at least once a month he sees a patient who has used Krazy Glue to reattach a broken tooth to the root or to an adjacent tooth. Just as often, he sees patients who have tried to avoid the cost of a dentist by swishing with rubbing alcohol to deal with a tooth infection or by rubbing crushed aspirin pills on gums to numb pain. Both tactics worsen the situation by burning the gums and creating ulcers, he said.

A step above are the “denturists,” unlicensed practitioners who produce dentures designed to make up for the damage almost inevitable in a state where Medicaid reimbursement is 50-65 percent below the market rate. Though they are “allowed to practice independently in Idaho, Maine, Montana, Oregon and Washington,” the ADA is still trying to stamp them out. One can laugh at the strength of, say, a florist cartel, but it’s pretty extraordinary that the ADA both lobbies against the training of more dentists and moves to stop others from filling the resulting gap.

Surely there are some saintly dentists out there working to respond to this problem (I nominate the group (less than a fourth) of Kentucky dentists who “regularly take Medicaid”). But Princeton health economist Uwe Reinhardt provides some perspective that may lead us to question the role of charity here.

In a letter to the BMJ, Reinhardt argues that “Health professionals’ benevolence has enabled politicians to resist moving the United States to a fully universal system of health insurance.”* As he explains,

For more than half a century now US health professionals have sought to operate, for the nation’s ever growing number of poor and uninsured citizens, an informal health insurance system by providing care to them without being compensated. The premiums for this informally extended coverage are collected from payers who do not have the market power to resist that “cost shift,” as it is called in the US. Large government payers—mainly the federal Medicare programme for elderly people and the federal and state Medicaid programme for the poor—simply refuse to accept that cost shift into the medical fees they pay.

Indeed these payers often, quite irresponsibly, pay less—sometimes much less—than the full cost of providing care to their beneficiaries. Although the federal and state governments try to undo that impropriety through sundry backdoor subsidies, they typically do not fully compensate the providers. Until now, therefore, the brunt of the cost shift has been absorbed by private insurers, who under the competitive pressure they face may at any time try to turn off that spigot. Many US hospitals already totter near the point of bankruptcy, mainly because of underpayment by government and the burden of their uninsured patients.

So while the “free clinic movement” may be heartwarming, it may well be mistakenly attempting to substitute charity for social justice. As Reinhardt explains,

Absolutely without intending to do so, the efforts of US healthcare providers to cater to uninsured people have aided and abetted great irresponsibility among the nation’s political leaders, thereby perpetuating the plight of the uninsured. This is so because the benevolence of health professionals has provided political leaders with moral coverage for resisting any and all efforts to move the nation at long last to fully universal health insurance. By their benevolent ingenuity healthcare professionals in the US have, albeit unwittingly, allowed politicians to go to church or synagogue and feel right with God, just after voting down the latest proposal for universal coverage.

I wonder if today’s Medicaid program would tell Tiny Tim to limp to physical therapy, rather than paying for a ride for him?

*Reinhardt Citation: BMJ 2007;335:1020 (17 November), doi:10.1136/bmj.39398.601655.59.

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