Like Pulling Teeth…

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Surprise! Medicaid dental care ends up hurting poor kids.

Earlier this year, Deamonte Driver, a 12-year-old boy living in Maryland, died after he got a tooth infection that led to a brain infection. Deamonte had never seen a dentist. The problem wasn't that he was among America's 47 million uninsured. He was covered by Medicaid, the federal health-insurance program for the poor, which includes dental care for kids. But Medicaid reimbursement rates for dentists in Maryland—as in many states—are set at such low rates that few dentists accept Medicaid patients. …

And so now we have rationing without calling it that. Politicians trumpet gains in Medicaid coverage for children, while the reality is that the shortage of providers leaves sick, poor children without care.

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  1. Ah hah! But Canada has already solved the problem (not with dentistry, the Canadian system doesn’t offer dental care, but in the medical system).

    You simply ban all insurance except Medicare… and don’t allow patients to pay for the care themselves. Then, the doctors will be FORCED into recieving little pay!!!

    Of course, if you force the doctors to make half as much money per patient, the doctors are going to have to see twice as many patients in a work day. But, you know, it is not like doubling someone’s workload has a negative effect on their work or anything.

    (To be fair though, there are plenty of people in India or Eastern Europe, etc., who are more than happy to take advantage of Canada’s liberal immigration to practice medicine in Canada, because being a doctor in Canada for weak pay is still better than what they would make back home. But in America, the socialized medicine types are also the Lou Dobbs “Stop Immigration” types, so importing cheap labor just isn’t going to work for our medical system).

  2. The only solution is obviously to force the dentists to accept less money or revoke their licenses to practice dentistry.

  3. So what’s the argument here? Medicaid needs to pay more? He’d be better off if there was no medicaid and he experienced the exact same outcome?

    Is there a point or are we just taking potshots at a libertarian boogeyman? Eh, who needs content, work’s almost out

  4. The only solution is obviously to force the dentists to accept less money or revoke their licenses to practice dentistry.

    But that isn’t socialized enough! We should force dentists to work without pay, or revoke their licences to practice dentistry! After all, people with dental problems should never, ever, in a moral society, be exploited for profit!

  5. So if he didn’t have Mediciad coverage, his familiy would have found a dentist to treat him for free? Huh?

  6. I gotta agree with Jack here.

    The points that you make could easily be taken as arguments for spending more money, but I doubt that’s what you want to argue. So what is your point?

  7. KMW links a slate article but doesn’t quote this part:

    The obvious way to make sure more poor kids go to the dentist is to raise Medicaid dental payments to market rates. Maryland, to its credit, plans a major increase in 2009. In 2000, Michigan enrolled Medicaid children in an insurance plan also sold to private customers, and more recently, Alabama has adjusted dental payment rates to market levels. Both states report impressive increases in the number of Medicaid children who are going to the dentist.

    There’s more that the states can do: Alabama also mounted an education campaign about the importance of dental care. Vermont set up dental clinics to address the backlog of poor children. A largely symbolic bill introduced in Maryland after Deamonte’s death would provide $10 million over five years for pilot programs in community dental care and dental education. Dental screenings in schools are another good idea. But the first step is to pay dentists who fix poor people’s teeth the same rate they get for taking care of anyone else.

    But really she just hates the government so much that even though she doesn’t think the government should do anything to help the poor get medical coverage, she also will blame them for not quite doing enough.

  8. semm11…
    isn’t that called slavery? or at the very least wage/price control?

  9. Dan, it’s not clear whether KMW was blinded by ideology or a simple inability to reason.

    You know, for a magazine called Reason…

    Drink!

    (And then spit into the cup so the dentist can inspect your teeth.)

  10. So what’s the argument here? Medicaid needs to pay more? He’d be better off if there was no medicaid and he experienced the exact same outcome?

    We are arguing that price is a function of scarcity. If something is so expensive that only half the people can afford it, it is because there is only enough supply to provide for half the people. Likewise, if something is so easy to come buy that there is enough for everyone, then it will be cheap enough for anyone to afford.

    If a government program doesn’t address supply (or demand, I suppose the government could ban tooth decay), then the government program will be at best a rationing scheme, at worst will have no effect.

  11. I have a medical diagnosis for this post: bloody terrible.

  12. Sigh, Sorry, I should have included sarcasm tags.

  13. Well, rather than Medicaid, the libertarian bogeyman we should be focusing on is the ADA’s statutory authority to limit the number of dentists in the US. Supply and demand.

    If it weren’t for the ADA, this poor kid’s family would have at least been able to find a cut-rate dentist to examine him.

  14. If a government program doesn’t address supply (or demand, I suppose the government could ban tooth decay), then the government program will be at best a rationing scheme, at worst will have no effect.

    No need to ban tooth decay…you KNOW what we need to ban…

  15. What’s the libertarian solution Katherine? Raise taxes to allow normal rates of pay or force dentists to work for less than they usually charge? By the way, when HMOs screw their policyholders (like denying payments to those who were unconscious at the time of treatment because it was not preapproved), that’s rationing by another name too.

  16. This goes along well with the AMA’s recent attempts to get state govts to ban the discount mini-clinics staffed by PhysAsst’s and nurses at Wal-Mart and similar stores. Apparently they’re worried about the quality of care or something…

  17. Next thing you know you’re saying they should have their own schools!

  18. Government Bad!

  19. They do have their own schools!

  20. Yeee-ah!

  21. So what is your point?

    That government-paid health care is synonymous with rationed health care.

  22. All health care is rationed in one way or another. No system can provide high quality care to everyone who needs it right when they need it.

  23. > What’s the libertarian solution Katherine?

    I don’t think the point of the post is to imply that there is a libertarian solution. I think the point is to illustrate the inevitable inflexible rationing of medicine that occurs when government controls medicine, as illustrated in this country by the microcosm of poor people on Medicaid.

  24. Children need some sort of crushing debt to keep them enserfed to the corporations and keep them from having enough time to threaten the existing order. I suggest an IOU system where a company pays for something a child needs but is not affordable (dental care, education, shoes) that this debt is consolidated and resold and then when the child is old enough to work agents are sent out to collect these debts with interest of course. Don’t want a bunch of freeloading welfare princes and princesses. Most children should be able to make enough to pay back these debts.
    There a sensible libertarian solution.

  25. Dental coverage — public or private — exists in this strange limbo between ‘necessity’ (medical coverage) and ‘luxury’ (plastic surgery coverage).

    I have serious dental issues. I have dental coverage provided by my employer. But my coverage doesn’t extend to my dental issues. The insurance will happily pay for preventative care, but as soon as ‘root canal’ and ‘crown’ come up, they stop taking my calls (metaphorically).

    Now, the root canals and crowns I need aren’t exactly luxuries. But from the insurance company’s point of view, I *could* just have any bad tooth pulled. I could have 10 teeth in my mouth, and that would be OK with them. Less to cover, after all!

    So I pay for crowns out of my own pocket. This has two libertarianoid ramifications:

    1) I pay a shit-ton for crowns. Every one I’ve ever gotten was in excess of $500. I asked the dentist why the cost so much. The answer was ‘medicaid’. Prices for crowns are set by the government.

    2) I would not want to have a system of insurance where the insurer’s belief that I should just suck it up and lose the tooth was enforced in some way. I don’t like shelling out $500+ for crowns, but I like it a hell of a lot more than the idea of losing my teeth.

  26. All health care is rationed in one way or another. No system can provide high quality care to everyone who needs it right when they need it.

    The difference is this: Without rationing, the price moves freely so that you can always get care if you’re willing to pay enough. With rationing, the price is capped such that you can’t bid above a certain amount and thus can’t be certain of getting all the care that you’re willing and able to pay for. You’re not allowed to use your money as an expression of your need. (Although you can still use it illegally, through bribes and black-market trades.)

  27. Yes JP, what you’re talking about is rationing by price. Those that can’t afford prevailing rates rely on charity or go untreated. Let kids break open their piggy banks to pay for treatment!

  28. What’s the libertarian solution Katherine? Raise taxes to allow normal rates of pay or force dentists to work for less than they usually charge?

    They could lower the requirements to a 4 year degree instead of a graduate degree in order to do basic dentistry (and let the guys with graduate degrees do the oral surgery).

    They could keep liability more in line with that of Canada or Europe, so dentists wouldn’t have to purchase insane amounts of insurance and pass the costs on to the customer.

    They could make it easier for people with dentistry skills to immigrate to the United States.

    Of course, government has no interest whatsoever in expanding dental care to the poor, so these cheap and easy solutions will never happen. The “benifits” government provides are rationalizations for increased government power. Anything that gives the government less power is undesirable to policians and the people caught up in their cult of personality.

  29. Actually, now having read TFA, it seems that this kid wouldn’t have seen a dentist even if Medicaid paid more. His mom didn’t know he had anything wrong with his teeth because he never told her about the pain, or about the pus that must have been flowing out of his mouth. And after she managed to find a Medicaid-accepting dentist to see his brother, who had similar problems, she never thought to bring him in for a checkup as well.

    This particular case looks more like a Darwin problem to me than a Medicaid problem. People too stupid to notice that yellow gunk streaming out of their teeth might indicate something’s wrong aren’t contributing anything to the gene pool.

  30. When I first saw this post I thought it would be about a Medicaid dentist who screwed up a kid’s teeth so badly the kid died, not a post about how Medicaid doesn’t spend enough money.

  31. Yes JP, what you’re talking about is rationing by price. Those that can’t afford prevailing rates rely on charity or go untreated. Let kids break open their piggy banks to pay for treatment!

    As opposed to rationing by political power, where those who can’t afford the prevailing rates of buying off politicians rely on charity or go untreated?

    You are not eliminating profit, or giving everyone health care, by putting government in charge. You are simply letting the politicians extract the profit instead of the people who actually produce the medical products and services.

    Rationing by price often has the side benifit of creating an incentive to increase supply. Rationing by politics has the opposite effect.

  32. Yes JP, what you’re talking about is rationing by price. Those that can’t afford prevailing rates rely on charity or go untreated. Let kids break open their piggy banks to pay for treatment!

    I do think “rationing by price” is the fairest way to distribute the limited amount of dental care.

  33. This particular case looks more like a Darwin problem to me than a Medicaid problem. People too stupid to notice that yellow gunk streaming out of their teeth might indicate something’s wrong aren’t contributing anything to the gene pool.

    Clearly what we need is a federal program to fund educational PSAs featuring Marty the Molar and Cary Caries.

  34. Bill Pope says: “Yes JP, what you’re talking about is rationing by price. Those that can’t afford prevailing rates rely on charity or go untreated. Let kids break open their piggy banks to pay for treatment!”

    Thank you for pointing out the libertarian, free market solution. Now try it without the sarcasm, and pointing out the worse outcomes you get with socialized medicine and its rationing by waiting. There are no perfect economic systems where everyone gets everything they want whenever they want it. Deal with it.

  35. All that was needed to solve this kid’s problems was a pair of channel locks, maybe some needlenose pliers, and some guys to hold him down. Professional dental care is for spendthrifts.

  36. All health care is rationed in one way or another. No system can provide high quality care to everyone who needs it right when they need it.

    You are correct. All economic systems are essentially how we want to ration scarce goods.

    However, there are undesirable effects to giving sole power of rationing to a tiny political elite.

  37. I think the other “point” here is that if a single-payer system were extended over the entire medical establishment, what happened in this case would happen in all areas of care across the board.

    Once single-payer is a reality, the bureaucrats will ABSOLUTELY attempt to contain costs by brutalizing providers. It would be every HMO story you’ve ever heard multiplied by 1000. And to some people that’s all well and good, until the day when they wake up and the providers have voted with their feet.

    The demographic reality is that the populace will enter into its period of peak demand for medical care right at the moment that we start hemorrhaging providers to retirement. If you choose that moment in time to institute fiat pricing, it will be like kicking out the bottom of a bucket. Providers will exit the field so fast it will look like someone shouted fire in a crowded theatre.

  38. I should point out that Medicare and Medicaid drive up the cost of medicine.

    The price of a good drifts towards the point where the supply of a good is completely consumed. This is called the market-clearing price.

    Now the price that people are willing to pay is based on how much they want something in relation to other potential goods and services they could spend their money on, and the quantity of money they have.

    For example, Paris Hilton might, if hungry enough, be willing to pay $10,000 on a hamburger since she has the money and is so desperate for one.

    On the other hand, a similarly hungry person with $500.00 in the bank will probably balk at paying more than $5.00 for a burger.

    Programs like medicare and medicaid increase the pool of dollars available to pay for medical care for the consumer. Thus, a consumer who would balk at spending more than $50.00 of their own money for a cleaning will happily purchase the services of someone charging $350.00 for the cleaning because someone else is picking up the tab.

    So, a dentist who would have trouble in a free market filling his schedule charging $50.00 an hour can with government subsidies fill his schedule at $500.00 per hour.

    And, as the market-clearing price rises, more and more people find themselves suddenly unable to afford the medical services. These people lobby for relief, and are frequently added to the pool of people receiving subsidies. This additional pool of money available for the services increases the price point that people are willing to pay, thus increasing the market-clearing price, leasing to increased political pressure to increase the subsidies.

    It becomes a vicious positive feedback loop that continues until the limit of the government’s ability to suck money out of the economy is reached. Of course, once the “shoe-event horizon” is crossed things get a mite unpredictable.

  39. “Rationing by price” has, I believe, been referred to as a market economy.

  40. You know, I think the real problem here is the lack of old Lil’ Rascals/Our Gang reruns. They would have informed the child and his family on a low-cost method for treating a toothache. Clearly all they had to do was tie a string around the tooth, tie the other end to a door handle, and slam the door. Not only is it medically sound, but it’s bound to provide ten to fifteen minutes of wacky slapstick fun.

    Also, if they followed the Irish example and replaced sugary snacks with a healthy diet of babies…

  41. Ryan | May 31, 2007, 6:09pm | #
    “Rationing by price” has, I believe, been referred to as a market economy.

    Except in a free market solution, as price drops increase scarcity, prices tend to rise again, causing a corresponding increase in supply, which would more-or-less equilibriate at some point. This would be “Rationing by price controls” which is a different animal. If the price cannot rise with scarcity, then what you get is accelerated scarcity. And then you get kids dying of toothaches.

  42. Wait a second — doesn’t that 47 million uninsured number *include* those covered by Medicaid? Isn’t it a little disingenuous for this author to say this kid is not one of those 47 million, when in fact the statistic includes him?

  43. If the price Medicaid pays does not suffice to encourage enough licensed dentists to meet demand, an alternative would be to permit the unlicensed practice of dentistry (also in this case to permit sale of antibiotics without a prescription). Regardless, dental services are no different than any other good — their supply is limited and thus, one way or another, will be rationed.

  44. Perhaps the point of linking the story was to suggest… “if you think Medicare is expensive now, just wait until it actually starts providing sufficient medical care to the poor”. That said, it’s possible that the shortage of dental care could be alleviated in ways other than matching the market price — for example, easing the licensing requirements for dental practice so as to increase the supply of dental labor, altering state-provided financial aid to medical professionals to require that they take Medicare patients, or allowing dentists who are serving Medicare customers to elect to go to a Medicare board instead of the courts in the event of a malpractice claim. The first and last options take a chance of decreasing quality, but if the increased availability makes up for the lower quality, it could be worth exploring. The first is really the only libertarian solution, though.

  45. semm11
    damn right you otta sigh…damn snide sarcastic sob’s like u ruin it for all us high minded yahoos

  46. Since this blog is talking about dental care , and what can happen due to mistreatment. Let me say that NEWPORT DENTAL located in southern california in claremont is the worst. They are a bunch of rude , not mannered people. Scam !!!! They are a bunch of thieves taking your money. And what is even worse than that; is the fact that the doctor will not come to see you.He sends his comments with a nurse!!!!! and when you ask for him/her. The nurse will say he is busy !!!! BUSY FOR THE PATIENTS WHO MAKE HIM/HER RICH!!!!

  47. All your teeth are belong to us.

  48. Tarran is absolutely correct in his statement regarding government subsidies increasing the cost of goods (in this case medicaid increasing the cost of dental care).

    Like almost all things, dental care is scarce, in that there is not an unlimited supply of dental care. As such, it must be rationed somehow. What is the most efficient way of rationing dental care, such that the most people enjoy the most utility from receiving and supplying dental care? Why, the free market, of course.

    Unfortunately, interference with the free market almost always results in inefficient results, such that some people who would otherwise have received dental care, and some people who would otherwise have provided dental care, do not receive such utility.

    Tarran pointed out one way in which the government has interfered in the market, by providing subsidies. This results in price increases by artificially inflating demand. Yes, some people who would not have received dental care now do because of the subsidies, but the trade-off (and there is always a trade off) is that others who would have received dental care do not because the price has increased and their dental care is not subsidized. Furthermore, those not receiving the subsidy will face higher prices themselves. And of course, there is the overall cost of the subsidy, which in this case directs resources to dental care that would be more efficiently used elsewhere (say for consumers purchasing food, or health care, or investing).

    Normally, if the only interfernce in the market is a subsidy, this will result in an increased supply that matches the new price caused by the increased demand. However, in the area of dental care, the market is unable to respond so freely. This is primarily caused by the government restrictions on supply in the case of licensing requirements. The more stringent the requirements, the more costly the initial costs of providing dental care (including time spent in school and training, lost income while attending school, cost of schooling, cost of board exams, licensing fees, etc..) the less dental care that will be provided. And with such restrictions it is very difficult for the market to respond efficiently to price changes caused by changes in demand.

    Thus, we have in the area of dental care a two-front assault on efficient distribution of resources. One the one hand we have the government artificially inflating demand with subsidies, and on the other we have government artificially limiting supply with increased costs in the form of barriers to entry in the market. This of course results in artificially inflated prices much higher than what the market price would be.

    So how does all this relate to the child who dies because he didn’t receive dental care? Would he have received it if the government had not interfered with the market? Who knows. This is a single claim for demand, whereas the market looks to the aggregate. He might have fallen into the category of those who would not have received dental care even in a free market. It is of course a terrible tragedy that this boy died. But from the perspective of government policy, which must deal in the aggregate, it remains but a single isolated incident.

    One thing that can be said…the more government interferes in markets (all markets), the less efficient the markets become, and the greater the burden on consumers overall. This has two results that directly impact a case like this one.

    First, because of inefficient allocation of resources, consumers cannot receive and pay for all goods and services that they would have otherwise; their resources become diverted to other areas, such as paying for taxes to cover subsidies, paying increased prices for other goods and services deemed more important, etc.. (This is represented by the deadweight loss resulting from subsidies, taxes, and the like that causes inefficiencies in the markets). In other words, the child’s parents might have been able to provide dental care if not for government interference in the market; they might be paying more for housing, food, transportation, clothing, health care, etc, than they would otherwise, and could not afford to provide dental care.

    Second, the inefficiences caused by government interference reduce the amount of charitable giving, since those who would have made charitable gifts cannot due to increased costs associated with said inefficiences. Perhaps this child would have received aid from a charitable organization or individual that would have provided some or all of his dental care expenses.

    Overall though, it seems that in this isolated case, the resulting tragedy falls most likely on the parents shoulders. A reasonable parent would have remained aware of their child’s well-being and would have taken steps to deal with it. Given that the preventative costs of this death would not have been abnormally high, it is likely that they could have acquired sufficient resources to provide appropriate dental care, either through attempts to increase income or through charitable gifts.

    However, this should not cause confusion over the fact that government interference in the market does cause inefficient allocation of resources, and those inefficiences DO result in such societal costs as unnecessary deaths.

  49. ” (also in this case to permit sale of antibiotics without a prescription).”

    See, that scares the crap out of me though.

    WBUR in Boston recently did some reporting and found foreign prescription drugs including antibiotics, for sale without prescription in ethnic bodegas around the city.

    The scary part was the way the buyers apparently have no clue how you’re supposed to use antibiotics. One Dominican woman said how she takes an antibiotic pill after her period as a ‘cleansing’. Not a full course, just a pill. The woman’s a superbug factory.

  50. Come on people. The kid died because he lacked will. Everything’s possible with enough will.

    Except when it isn’t. If he couldn’t muster up the will, I bet we could have waterboarded the sick out of his face. Torture cures everything.

  51. Walter Block gives a pretty good critique of socialized medicine in the latter part of this audio file (quicktime) on health and the market:

    http://www.mises.org/multimedia/mp3/MU2004/Block6.mp3

    The number of people who die waiting for care in the supposedly benevolent nations which have instituted socialized health care is despicable. The solution to the U.S.’s health care woes is to get rid of the AMA and other licensure practices–the only “regulation” you really need is liability to those you hurt and the free market place,

  52. Thank you for saying this. Plus, as someone who spent a few years advocating for the poor, who are mostly neglectful of their children, how the fuck did his mother not address this sooner?

  53. ‘See, that scares the crap out of me though.’

    Regulation of antibiotics is one of those things that the government *should* be doing. I don’t think you need to be a medical doctor to hand them out, but you should be licensed and regulated.

    That’s a public health issue regardless of whether medicine is socialized or not. I don’t want dipshits breeding killer bacteria because they don’t understand how antibiotics work. It’s the biological version of ‘everyone can build their own nuke’.

  54. The solution to the U.S.’s health care woes is to get rid of the AMA and other licensure practices–the only “regulation” you really need is liability to those you hurt and the free market place,

    Right, I think it would be great to only find out my doctor is a quack after he’s f’d me up.

  55. Right, I think it would be great to only find out my doctor is a quack after he’s f’d me up.

    You mean compared to our current system, where doctors never fuck up and if they do it’s immediately trumpeted throughout the land? Ah.

    Dan, the quality of your trolling has deteriorated significantly these past few weeks. I am very concerned about this. You should maybe see a doctor or something. Perhaps you’re suffering from “tired blood”? Try Geritol.

  56. You mean compared to our current system, where doctors never fuck up and if they do it’s immediately trumpeted throughout the land? Ah.

    Yes, I do prefer the current system that ensures me that when I see a doctor I can be sure that he or she is educated in medicine. Just like any non-insane person.


    Dan, the quality of your trolling has deteriorated significantly these past few weeks. I am very concerned about this. You should maybe see a doctor or something. Perhaps you’re suffering from “tired blood”? Try Geritol.

    I’ll let you in on a secret – when people go out of their way to complain about the “quality” of my trolling, I know it means I’m doing it well.

  57. Yes, I do prefer the current system that ensures me that when I see a doctor I can be sure that he or she is educated in medicine. Just like any non-insane person.

    Oh yeah? How are you sure your doctor studied medicine? Because he has a convincing piece of paper on his wall!

    You hear stories all the time of people who practice medicine or dentistry without licences. They usually only get caught if they screw up so bad that they kill someone. Otherwise, anyone with a digital printer to print a fake degree can practice medicine without problems.

  58. What do you call a doctor that graduated last in their class??

    That’s right we call them doctor.

  59. “So what’s the argument here? Medicaid needs to pay more? He’d be better off if there was no medicaid and he experienced the exact same outcome?”
    Yeah, Dan T. and Jack are right on with this one. Did KMW even think about this before posting, or does she just have a list of programs that are government and therefore BAD and said, ah, ha, BAD program implicated in BAD result! Of course, the same result, if not worse, if left to laissez-faire…This is like arguing against police because the poolice failed to catch someone they were looking for in time to prevent his next crime. One would think detecting the fallacy inherent would have been covered in a Yale education: https://www.reason.com/staff/show/161.html

  60. “You mean compared to our current system, where doctors never fuck up and if they do it’s immediately trumpeted throughout the land?”
    Jennifer, you don’t have much room to complain about the quality of anyone else’s posting. Let’s see, since there are fuck ups that get through our current system of carefully accrediting who can practice the highly dangerous (to patients) profession of medecine, then there would clearly be less fuck ups if we stopped checking altogether.
    Riiight…And since some people snuck past our doorman we should fire him and open the doors, that’ll keep ’em out!

  61. I’ll let you in on a secret – when people go out of their way to complain about the “quality” of my trolling, I know it means I’m doing it well.

    I’ll let you in on another little secret: you’re wrong.

  62. David Frum already debunked the idea that this is a story about government, as opposed to a story about bad parenting. Very bad parenting.

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