The Political Economy of Dental Care

The bad teeth guy in the movie “Deliverance”

No sooner has Virginia enacted one vast new entitlement, Medicaid expansion, than the drumbeat begins on the next. No matter how much money government dedicates to health care, food, housing, education, transportation, legal aid, or whatever, there is always someone who is getting the short end of the stick by comparison. Always. And the answer is always the same: Expand entitlements. Always.

The latest case in point is an article in the Virginia Mercury highlighting the deficiencies in dental care experienced by hundreds of thousands of Virginians — a dental gap bigger than void in the bad-teeth guy’s mouth above. No question, the problem is a real one. Dental care costs too much for poor and working-class Virginians to afford, assuming dental care is even available in under-served rural areas. And the consequences of poor dental hygiene can lead to serious medical complications.

What’s the solution? Reports Katie O’Connor:

For years, advocates, such as the Virginia Oral Health Coalition have pushed the state to add a dental benefit for adults. So far, Virginia has expanded dental benefits to pregnant women and children until they turn 20.

As of the start of this year, 17 states offered extensive dental benefits — including preventive and restorative procedures — to their Medicaid populations, according to the Center for Health Care Strategies, a group that advocates for improved health care delivery for low-income Americans.

A benefit, advocates argue, would make a major difference for the 1.2 million adults covered in the state’s Medicaid program.

Creating the entitlement in Virginia would cost between $24.4 to $60.8 million, O’Connor says.

Of course, you’d expect from an alliance representing the dental profession to advocate a new entitlement that creates more business for the dental profession. It should surprise no one that the proffered solution to the problem entails transferring money from taxpayers to dentists.

Here’s a different idea. Expand the supply of dentists and dental technicians. How? Maybe start by reducing the total cost of attendance at the Virginia Commonwealth University School of Dentistry, which now runs about $133,000 to $140,000 per year over four years. Nationally, dentists graduating in 2016 carried on average $261,149 in debt, according to the American Dental Education Association. That number could well be higher in Virginia where the tuition runs considerably higher than the national average.

I don’t know why the VCU dental school is so expensive. I conjecture that the tuition bears little relationship to the cost of actually providing the education, and that someone high in the VCU hierarchy has made the calculation that the university will charge what the market will bear. I further conjecture that the School of Dentistry is a lucrative profit center, which VCU is milking for revenue to subsidize other programs. I may be entirely wrong, but when tuition is higher than almost anywhere else in the country, that’s a proposition worth looking into.

Now, if you entered a profession that took you four years to complete (which means four years of earning no money) and cost you roughly $500,000 in tuition, fees, room, board and expenses, leaving you $260,000 in debt when you graduated, would you want to move to Southwest Virginia where there is a paucity of patients capable of paying charges sufficient to help you retire your loans? No, unless you’re incredibly idealistic and willing to live at the foot of the cross, you’ll move to the suburbs where you can make $150,000 a year and pay off your debts.

Let me venture another hypothesis, which any enterprising reporter could verify or falsify: Given the sky-high cost of tuition, Virginia dentists have exercised their clout through Virginia’s professional licensing system to restrict competition from allied professions, such as dental technicians. I would conjecture that dental technicians, like nurses, are seriously circumscribed in what they can do or the circumstances in which they can practice.

Dental technicians earn about one-fifth of what dentists earn. Yet in my personal experience, dental technicians do 30 or 40 minutes of work cleaning teeth and taking x-rays while my dentist spends about 5 minutes checking things over. I love my dentist — he’s a great guy, and I’ve been using him for 30 years. But I’ve really got to wonder why it costs me $200 a visit when dental technicians are paid (on average) about $35,000 a year or the equivalent (taking benefits into account) of maybe $30 an hour.

I’m betting that (1) dentists exercise a strangle hold on the ability of dental technicians to provide independent teeth cleaning services, and (2)bill for technician’s services at a rate that many would consider obscene. Perhaps such practices, if in fact they occur, are justifiable in areas with no shortage of dental practitioners. But are they justifiable in areas that can’t attract dentists? Would it not be better to provide access to dental technicians to maintain dental hygiene at lower prices and make referrals as needed to dentists to fill cavities and perform other more advanced procedures?

I have no expertise whatsoever in the practice of dentistry, and I fully concede that I may be making some naive statements here. But I am convinced that we need to look differently at the problem. Instead of asking whether we should expand entitlements, perhaps we should be looking at how to expand supply and bring down costs.

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21 responses to “The Political Economy of Dental Care

  1. One dental school in Virginia, six medical schools. Supply and demand. Only 66 dental schools in the entire country, by one count I found online. I wonder whether Virginia Tech and Liberty University thought about dental training as they were setting up their new medical schools, given their proximity to some under-served rural areas. The schools themselves would be a great source of care for those communities as the students work in the clinics. Lots of free dental care over at VCU.

    http://jchc.virginia.gov/4.%20Untreated%20Dental%20Disease3.pdf

    That’s a recent state overview, Joint Commission on Health Care. Five years old now. The cost estimate then on a full Medicaid dental benefit was about $130 million, half coming from state taxpayers. I think since then they added the benefit for pregnant women, which was a good addition.

    • Steve,

      I think medical schools are considered more prestigious for a university, but perhaps more importantly, many schools are probably thinking they will ultimately get lots of research funding. If you look at UVA, for instance, of its $397M in research funding in 2016, $245M was for health sciences and biological/biomedical and $134M was from HHS/NIH alone. In the world of big research and research prestige, it really comes down to schools with medical schools and those without.

  2. Basic Medicare does not cover most dental, or optical or hearing… That’s one of the appeals of Medicare Advantage which may cover some or all depending on what.

    I always felt that not only is Dental expensive but so is hearing aids and just ordinary glasses.

    The internet is starting to have an impact on all three.. which is undermining the idea that a given state or professional/licensing group
    can control it all..

    but once again -we are conflating the costs of something for those who do not get entitlements with the idea of others getting entitlements and I just think it’s muddies the issues.

    For Medicaid – for instance, – it should be very possible for the State to induce a few years of service from new grads in exchange for taking care of some of their debt… Medicaid folks would get very basic care from practitioners just starting out and learning the practicalities of their profession.

    These days – it’s Pro Forma to make Good the enemy of perfect. If it has the potential to smear govt or higher ed or entitlements… it can’t be wasted .. it’s got to be blown up… yet another institution we no longer trust and have to destroy.

    I like half glass full approaches… always have and always will.. we got lots of problems …but we work on them… we get better.. that’s an optimistic view of how to go forward.

    For the record, I too pay almost $200 for a dental cleaning and then an examination by my dentist who examines my teeth, gums and mouth for abnormalities and cancer, updates my x-rays, etc… It’s a bargain….as far as I am concerned… I do not suspect her of ripping me off…but it does “ouch” when I pay…

  3. What the state really needs to do is operate a cross-region jobs network. If you want expanded Medicaid or Medicaid with Dental you have to register in a jobs database. Employers who need help also register their needs. If you’re making $10 per hour in rural Virginia and there is an equivalent long term job making $20 per hour in urban Virginia you need to either move or forfeit the additional Medicaid benefits. The state will provide re-location money to help make the move but you need to move.

  4. The picture of the Deliverance mountain man is really in bad taste. It is a demeaning put down of so-called hillbillies and is a caricature. When I did my book on coal and Appalachia I researched the movie. It is a total fraud. Author James Dickey did take a canoe ride in white water in north Georgia and did get stranded. The local residents did not rape him, in fact, they helped him continue on hi8s journey. For the scene of the poor white Allbino on banjo player, they actually went to a grade school and picked a child from special ed. Then they dusted his face with flour to give him an in-bred look.

    Also, for my book, my photographer and I were in east Kentucky and chanced upon a RAM event. We went in to a high school and there on the basketball court were dozens of dentist and assistants from Louisville and other part so the state offering free dental care in portable chairs. People actually started lining up the midnight before.

    So, Jim, you are showing a bit of snobbery in your photo choice. Who are you, a total preppy Wahoo, to put poor people down so? Do you really have such a strong sense of entitlement?

  5. Pingback: The Political Economy of Dental Care - Texas Dentists for Medicaid Reform

  6. I’ve argued that there is essentially a cartel in licensure in healthcare, which results in salaries 2X that of comparable countries (which is equivalent to a “doctors tax” of $700 per person per year in the U.S.). For some reason, this gets very little attention these days. That may be the case in dental care as well.

    • I agree. Computers make being a doctor or dentist easier. My doctor friends hate to hear this but I’m convinced it’s true. When I started in technology back in 1978 you needed to be an expert to operate a computer. Nobody would dare let you logon to their computer until you’d proven that you knew every nook and cranny of the system and could be trusted not to break the damn thing. Today children operate computers known as PCs, iPads, etc. Anybody with a credit card can have a cloud based computing complex at their beck and call. Anybody looking for a job today who is mailing out resumes is clearly on the wrong path.

      Technology makes things easier. Medicine is easier today that it was in the past because of technology. So, why is the licensure for being a medical professional essentially unchanged from 1950? Because restricting supply in an environment of growing demand creates …. rising prices. Which, of course, is exactly the goal of medical-industrial complex.

  7. Are there countries where dental services are a lot cheaper – AND the providers are qualified and skilled and they deliver quality and safety – in a free market?

    or is the reality that the countries that have the best and lowest price dental are those with more govt regulation?

    Seems to work that way with health care in general. The best countries in the world for healthcare are the ones where government is fully involved such that providers have to be qualified and skilled and the services are safe and reasonably-priced.

    so how about it. Do we need MORE govt to produce lower cost dental services or would we trust the free market version most often found in 3rd world countries?

  8. Larry, you are trying to drive a false dichotomy. Government is likely involved in healthcare regulation in all developed economies. The question is whether it is effective regulation and prevents the formation of cartels that can adversely impact supply and prices. In medical care in the U.S., medical associations have influenced regulation to greatly restrict the supply of doctors and restrict competition from lower cost alternatives like nurse practitioners. This is a significant contributor to higher healthcare costs vs similar countries. I have not researched dental care, so I am not commenting specifically on it.

  9. Izzo – no false dichotomy… I’m basically asking if the countries that have even more govt involved in health care are worse than us or better… what say you?

  10. Larry, government/compulsory expenditure on healthcare in the U.S. in nominal dollars is already far higher than any other OECD country. It is higher than almost all OECD countries even in terms of percent of GDP. Government in the U.S. regulates who can provide care, which hospitals can operate, what insurance plans must cover, which drugs are approved for use, etc., etc. So with that level of government involvement, it calls into question what your statement “even more govt involved in healthcare” means. By any definition, the government in the U.S. is already hugely involved, and is more involved than any other in terms of expenditure. The real question is whether its involvement is efficient and effective, and the answer is an unqualified no.

    Jim points out that most of the focus is on entitlement when there are major inefficiencies on the supply side that remain unaddressed. In healthcare, cartel licensing restrictions, permitted by government, have resulted in 50% fewer doctors per capita compared to OECD countries and doctors who are the highest paid in the world (about $100 billion a year more than they would be paid with typical OECD salaries). There are also severe restrictions on what can be done by less expensive alternatives like nurse practitioners.

    • Well no Izzo. What do you say to the reality that all the other countries have MORE govt involvement – and cost less ?

      Jim’s point is conflated as usual.. he’s mixing the cost of dental care to everyone – no matter entitlements… with ..those on entitlements.

      the premise is that somehow the supply of dentists is restricted… I don’t believe it. It’s an oft cited thing and no proof… are people getting turned away from dental school? Is the state only licensing a set quota? How do we know there are actual real restrictions – and who is doing it?

  11. If we want to spend less on health care in the United States, we either need to ration care or bring in massive efficiencies. And the latter means putting downward pressure on fees, which, in turn, will cause layoffs and reduced compensation. The legal industry has seen this occur since the Great Recession. It’s time for the medicos to do the same.

    A good way to get the ball rolling would be for the government, here the State AG, to start antitrust actions against the major health care companies, including nonprofits and big pharma.

    • TMT – we ALREADY ration care…. Most insurance including Medicare will not cover all procedures… Anytime you have “insurance” – they decide how much you get in benefits.. that’s rationing.

      Besides that – all other industrialized countries also RATION – but the difference is they spend 1/2 what we do – AND they LIVE LONGER so rationing seems to work “better” in those countries.

      Finally – are you actually calling for MORE govt control in healthcare in the US as a solution? That’s 180 degrees from what most Conservatives claim.. they say it’s BECAUSE of the govt that costs are high…

      so …. we need MORE govt – like they have in those other countries? you agree?

    • Double the number of applicants accepted into US medical schools. They are way too restrictive. Allow nurse practitioners to do even more of the work.

      I agree with the antitrust thinking but the coercive power of the medical-industrial complex goes well beyond INOVA.

  12. TMT, I agree with you, it’s getting past time for some serious efforts to force the health industry to play by the same rules we enforce against other businesses. Starting with transparency. Maybe antitrust is a way to force this issue.

    As for dental versus medical — let’s start with the distinction that there’s a moral element to providing universal basic medical care: the absence of access to a GP or a hospital often kills people, but the absence of dental care rarely does. I certainly don’t mean to diminish or dismiss the suffering that comes from bad teeth or the potential medical consequences, but it’s just not the same societal imperative to do something.

    • The FCC has always taken the position that competition requires at least three facilities-based providers in a market. So to me, that suggests INOVA should be broken into three parts in Fairfax County (assuming that is a market for purposes of discussion) or INOVA would be forced to divest 2/3rds of its assets in Fairfax County. I have nothing against INOVA. I had life-saving surgery there in late 2013. But we need competition in health care.

    • I do agree with Acbar’s basic position on Dental – as well as optical and hearing…. which is how Medicare works.. they do not cover those 3 for the most part…

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