No Dentist For You

Inability to afford basic dental services is a large problem for many poorer Americans, so naturally when an entrepreneur comes along ready to offer basic dental services at a more affordable price dentists' trade organizations leap into the fray to get the operation shut down. It's proprietor, after all, isn't a dentist and just because it only takes a dental hygenist to do a basic cleaning is no reason you should be able to get a basic cleaning without paying top dollar for a dental school graduate. No reason, that is, unless you want to make dental care affordable.

The focus on America's horrible, horrible system of financing health care tends to obscure the fact that it's layered on top of a horrible, horrible system of delivering health care in which there are all kinds of restrictions on the supply of services that make basic care substantially more expensive than it ought to be.

Comments

It's proprietor, after all, isn't...

The question: is this merely a typo, or does MY not need a refresher on the difference between the possessive form of "it" and how to contract "it is"?

Posted by MY Strikes Again | May 1, 2008 3:53 PM

err, and then I have a typo.

That resulted from indecision b/n saying "does not know" and "need a refresher."

Oops.

My bad.

Posted by MY Strikes Again | May 1, 2008 3:56 PM

The simple way around this, for those who want dental cleanings but don't have dental insurance and don't want to pay for a dentist visit out-of-pocket, is to contact your local community college. Many community colleges have a dental hygienist program, and you can usually have a professionally supervised student clean your teeth for a nominal fee (e.g., $10). Dental insurance tends to be relatively cheap though, and it usually covers most of the cost of regular dental visits, so it's worth paying for.

Posted by Fred | May 1, 2008 3:57 PM

Yeah, Matt, but do you know how many Americans suffer traumatic (and often fatal) injury from having their teeth cleaned without a fully trained dentist nearby in the building? Do you, Mr. Dental Know-It-All?

Jeez, Matt, I wish you'd get your facts straight before going out on a limb like this.

Posted by James "Waiting In The Lobby" Gary | May 1, 2008 3:58 PM

Dental care is weird. I know a fair number of people who have been ripped off by their dentist. In some ways the practice is weird because many of the techniques come from the era of bloodletting (drilling and filling cavities). True, though, dentistry has made some amazing advances over the years. Perhaps they are strapped for cash because of water fluoridation? Honestly I don't know. At least this isn't England, with genetically bad teeth. Not having dental coverage isn't so bad unless you are of English ancestry.

Posted by freddiemac | May 1, 2008 4:00 PM

Friends in med school tell me costs are now above 60K a year. That means graduating with something around 300K in debt. No wonder the doctors and dentists want to gouge us. They should reduce the price of professional school along with the price of medical care all around. Everything is inflating everything else.

Posted by Craig | May 1, 2008 4:01 PM

Not having dental coverage isn't so bad

I haven't been in close to eight years and people compliment me on my teeth all the time. I don't even brush twice every day because I usually fall asleep without planning on it. I do have one molar that's in pretty rough shape, and I probably should've had my wisdoms pulled, but all in all I've gotten along fine without a dentist.

Posted by mark f | May 1, 2008 4:08 PM

"Friends in med school tell me costs are now above 60K a year."

Have you noticed a similarity between higher education and health care? Both sectors receive copious amounts of government funding, and both have had costs rising faster than overall inflation.

Posted by Fred | May 1, 2008 4:11 PM

The big news with this is that it's occurring in Alaska, though, and particularly only difficult-to-reach areas of Alaska similar to the reservations in the continental US.

Surprise surprise, no dental graduate wants to work in these native areas, because of the low level of work, mediocre pay, and being in the middle of nowhere in Alaska. Some dental groups have tried to set up programs to train natives (my dad is part of one such group which does similar work overseas) to at least be able to do some basic care, but that's leading to the problems with the ADA. Those groups doing the training are threatened with the withdrawal of ADA support (usually critical for dentistry NGOs)and the graduates themselves are being put out of work by lawsuits because the ADA doesn't want the precedent to exist. It's a real mess, and even many dentists agree with that, but the association has its own agenda.

Posted by Po-Mo Polymath | May 1, 2008 4:23 PM

I regularly get 1 or 2 cavities every 6 months even with brushing, flossing, flouride treatments. No I'm not English. (Will that joke ever end? Please?)

Posted by Headache | May 1, 2008 4:27 PM

Headache,

Sorry, the joke won't end. I don't have the best of teeth, thanks to my English ancestry. My mother, also of English ancestry has even worse teeth. My father, not of English ancestry, has perfect teeth. I can't figure out why, but there must be something genetic about the English peoples and our bad teeth.

Posted by freddiemac | May 1, 2008 4:52 PM

Craig -

Everything is inflating everything else.

I couldn't agree more, but this statement could describe just about everything in our economy right now.

Posted by Trigger | May 1, 2008 5:04 PM

I hope you understand this is a very libertarian point of view. Not that that is a bad thing. I encourage you to apply the same reasoning to the entire medical profession. Why is it that the government is enforcing this outrageous standard of care for doctors? Consumers would gladly trade off some experience and training for most of their medical problems if this meant lower prices. It is not necessarily a matter of price gouging but more a matter of controlling supply.

Posted by Gordon | May 1, 2008 5:25 PM

Gordon,

Look up the recent WSJ article about the new clinical doctorate in nursing (DPN, I think is the designation). Physician assistants, nurse practitioners and these new doctors of nursing are already moving into some routine care roles.

Posted by Fred | May 1, 2008 5:46 PM

1) There are some fairly rare dental conditions that can become dangerous -- infections traveling into the bones, for example. Plus people with rheumatic fever , diabetes, and some other conditions have to watch for infections.

2) But I think a fair amount of dentistry could be delegated to the assistents.

3) The is a Do-It-Yourself book called "Where there is no Dentist" that is distributed out to Third World villages by Hesperian Foundation.

There's also a Do-It-Yourself book called "Where There is No Doctor". (Obviously, for some things your have to travel to the city and see a real doctor. )

Survivalists buy copies of these books -- along with the Nato Manual on Emergency War Surgery (treatment of burns, knife and gunshot wounds.)

4) They're available online -- although you should really get paper copies if you think the Investment Banks or Avian Flu are going to destroy Western Civilization.

Actually, real doctors and dentists can't do much more than Joe Blow if things turn to shit -- i.e., if they lose access to hospital operating rooms and if there's no electricity to run all the modern electronic equipment. And you're fucked without antibiotics (hint: Vet supplies).
On the other hand, ether can be made from battery acid and alcohol (for surgery) and opium is avialable from opium poppies. (Look for Papaver Somniferum in the seed catalog.)

See http://www.hesperian.org/publications_download.php

5) Behold the Republican Healthcare Plan.

Posted by Don Williams | May 1, 2008 5:59 PM

I see this as an opportunity to pile on optometrists who frickin make me come see them every year to get the same prescription I've had for 10 years in order to by contact lenses. What sort of monstrous law was passed that made it illegal for someone to sell me contact lenses without a prescription?

This reminds me. I need to make an appointment with an optometrist. I'm running out of contact lenses.

Posted by KJ | May 1, 2008 6:07 PM

This critique appears to be along the lines of Dean Baker's observations on the various forms of protectionism for the upper class. It makes sense to say that health delivery is a big part of the problem, and that putting doctors, dentists, and other highly paid, highly educated health care professionals in competition with their counterparts in other countries or just in different parts of the same country is a great way to bring down inflated health care prices and, along with trade protectionism for unskilled labor, close the inequality gap. That would actually be making the free market work for us rather than having it destroy lives in order to make money for the already wealthy as economists typically advocate.
Of course, making sure educational institutions must also compete with a large field for student clientele and thus bring down tuition prices, preventing an academic choke point in the system, would have to be part of the project.

Posted by Jack | May 1, 2008 6:18 PM

It should be noted that many doctors get badly fucked by the current system as well.

They have to go deeply in debt for medical school, serve as coolie labor (intern, resident) for years and then get screwed like dogs by state malpractice insurance assessments.

A bunch of doctors are leaving Pennsylvania because our corrupt state legislature has been bought off by the trial lawyers and are hitting doctors for about $150,000 per year for malpractice insurance.

Doctors provide a very valuable service. Politicans and lawyers ..er..not so much.

And why do our doctors have to waste hours per day arguing on the phone with HMO accountants?

Assuming they can get through -- given that the politicans spend half their day hitting up HMOs and other donors for campaign money. Which doesn't leave politicans much time to address problems like ..oh..healthcare.

Posted by Don Williams | May 1, 2008 6:33 PM

As I said at Ezra's place, there's a reason why Barry the cheating ex-fiance in Friends was cast to be an orthodontist and not an orthopedic surgeon.

Posted by pseudonymous in nc | May 1, 2008 7:12 PM

Those are called work rules. Who likes them?

-- Unions
-- Doctors
-- Lawyers

I see a lot of Democratic interest groups in that mix.

Posted by James Robertson | May 1, 2008 7:13 PM

I would take issue with Matt's use of the word "entrepreneur".

The Times article characterizes the group as "a nonprofit group financed mostly by federal money that provides medical and dental care to tribal communities". If this is the work of an entrepreneur, I would suggest its nonprofit status alone indicates a weak business plan.

Posted by beowulf | May 1, 2008 7:22 PM

In certain parts of CA it's actually cheaper to hire a dentist than a dental hygenist.

Posted by flory | May 1, 2008 7:30 PM

Hey Don, Cut it with the Doctor love. I'm sick of doctor love. Their service is no more valuable than that of a Politician or a Lawyer, they just think it is. I'd trade access to a doctor for law and democracy any day.

but that's beside the point as I want all three. And if we want good healthcare we need to afford a bit less respect to doctors and start paying them less, especially specialists. Up Family practice salaries with part of the savings and give the rest back to the system. Remember it was the AMA that successfully fought the original National Insurance plan put forward by Truman (or was it FDR). They fucked us all over then and only now that the insurance companies are annoying the hell out of them are they coming around to a better solution.

Disclaimer: My wife's a lawyer and I plan to be President someday as soon as I get done with Henry James's "Portrait of a Lady". I'm averaging 10 pages a year but, as my last 5 New Year's resolutions atest, I plan to pick it up.

Posted by KJ | May 1, 2008 8:20 PM

It's posts like this that make some libertarians out there (well, me at least) like the work of Yglesias.

Posted by thehova | May 1, 2008 8:51 PM

I am a dentist in Michigan. I have never heard such popycock. We are small bussiness owners just like small store owners and such and with 8 years of college education and $300,000 of education and several of my friends with basic educations and stores or restaurants, make more than I do. Now before you say "well he must be a lousy dentist" my income is in the top 10% of dentists.
As for "there are a few rare conditions" before the advent of anti-biotics tooth abcess was the #1 cause of death in the US and still is in some parts of the world.
I can't believe I'm waisting my time on this...........................

Posted by Dr. J | May 1, 2008 8:53 PM

Physicians generally do not get a salary. They have an income based upon their workload, speciality, and location. The only way to cut their income is to cut the reimbursement from medicare. However, they means that fewer physicians will offer the service.

Posted by superdestroyer | May 1, 2008 9:12 PM

Re Dr J's comment "As for "there are a few rare conditions" before the advent of anti-biotics tooth abcess was the #1 cause of death in the US and still is in some parts of the world.
I can't believe I'm waisting my time on this........................... "

Well, and the fix for those deaths was developed by the biologists who developed antibiotics, no?

Not by the dentists. Although you guys did use to throw in a haircut as well, didn't you?

I don't need a dentist to tell me to take antibiotics. Or which ones to take. I don't even need a dentist to do a Gram's stain.

But control of antibiotics is another one of those trade union rules, isn't it? Which might be fine if there weren't people going without care. Including some with abscessed teeth.

Gee, I wonder how the rest of the world survives without Dr J and his dental plan? Probably better than some of our citizens.

I suggest readers here look at Hesperian's "Where there is no Dentist" for a description of austere dental care -- which is better than no dental care at all.

I acknowledge that a dentist is needed for advanced procedures -- crowns, root canals, wisdom teeth extraction,certain infections,etc and other cases noted in the manual.

But if you're not a Hollywood star, you don't need crowns or root canals. According to the manual, you can take antibiotics to reduce any abscess and then pull the damm tooth out. Preferably with an injection of novacaine --which the manual also explains how to do.

What does Dr J see wrong with that? It will clear the riffraff out of his small business and leave him time to put some shiny white dazzlers on the local plutocrats.

Posted by Don Williams | May 1, 2008 9:46 PM

Dental insurance tends to be relatively cheap though, and it usually covers most of the cost of regular dental visits, so it's worth paying for

I don't have dental. My boss says it costs a fortune for small businesses in NYS, so we have general health insurance plus those personal savings accounts which help defray dental costs.

I can sort of see the dentists' point of view here. A cleaning may be simple, but at the end, the dentist comes by to make sure nothing more serious is afoot. It seems a rip to pay so much for that...until he finds something serious.

Posted by Ronnie P | May 1, 2008 9:49 PM

Contrary to what some have said, there's nothing particularly "libertarian" about this kind of argument. Some regulations are useful, while others are harmful. Some regulations are the result of genuine concerns about social outcomes, while others are the result of self-interested rent seeking by influential groups.

One can oppose specific regulations that appear to fall into the latter categories without extrapolating that opposition into a set of all-encompassing ideological dogmas or moralistic principles.

Posted by N | May 1, 2008 9:51 PM

To follow up and clarify my last post - everyone knows that narrow interests can and do press for regulation that benefits them at the expense of overall social welfare. From far left to far right, I don't think any ideological perspective denies this reality.

The main difference lies in the preferred response to this concern. For many libertarians, the answer is always the same: an overall reduction in the size and scope of government. This is like the the governance equivalent of chemotherapy, killing good policy along with bad policy.

Other responses are also possible - for example, one could start by trying to insulate regulators from special interest pressure.

Posted by N | May 1, 2008 10:10 PM

Re: optometrists.

This last summer, after a few too many beers, I jumped off a boat into Halong Bay in Vietnam. I accomplished my short-term goal of a cooling dip in the bay, but I forgot to remove my glasses beforehand, and they were lost to the sea. I was mildly concerned that I failed to bring my prescription with me. However, a few days later, I managed to find my way to the Vietnamese equivalent of an optometrist, which was basically a roadside stand. Despite the language barrier, the proprietor administered a five-minute version of an eye exam, and my glasses were ready about 20 minutes later. I'm sure it's not as precise as my prescription would be at home, but when I got back I got proper exam and glasses, and I can't tell the difference at all.

The total cost in Vietnam was about 13 dollars, which is less than half my copay at home.

Posted by djw | May 1, 2008 10:32 PM

Dentists making more on average than physicians, these days.

Posted by bob h | May 2, 2008 7:10 AM

Fred, could you post some links to that "relatively cheap" dental insurance that covers most of the cost of regular visits? If it exists as you describe it I'd certainly be interested in checking it out.

Posted by Blorp | May 2, 2008 9:43 AM

A well-versed PA or an ok-versed PA and an expert system could do 98% of the diagnostics and treatments that people go to doctors for. Those with humongous investments in time and money in providing for the last 2% of poor health like to pretend that medical care can't be industrialized, but it can be.

Posted by Jeffrey Davis | May 2, 2008 10:43 AM

For those of young folks talking about how dental visits, flossing, brushing etc are a waste of time (esp. mark f): That was my view until I got into my 60's and found out about gum disease. If you don't have cavities, you may not need a dentist, but if you don't brush and floss you'll probably need a periodontist.

Posted by Michael L | May 2, 2008 10:53 AM

My dental plan is fairly cheap but it is-- you guessed it!-- subsidized by my employer. Lack of access to dental care is a big problem in this country-- in Vermont and New Hampshire there are many, many kids who are 'covered' by dental insurance thanks to SCHIP but who cannot find dentists willing to accept them (in part because the SCHIP payments are so low).

Posted by Persia | May 2, 2008 11:24 AM

On djw's eye care in Vietnam...note that $13 for an exam and glasses might be the equivalent of $40 or so in the US (when you adjust for cost of living). That's still a lot cheaper than what you could find here, but not as big a difference as it might seem from the dollar amounts.

A basic eye exam and glasses can be obtained pretty inexpensively in the US. Of course, if only ophthalmologists were allowed to perform eye exams, they might be a bit more expensive.

Posted by N | May 2, 2008 11:39 AM

I agree with the post, and think the same concept extends to the AMA and the ABA as well.

However, I can't get over the interesting coincidence that dems get all upset over dentists conspiring to keep their income artificially high while defending the rights of union workers to do exactly the same thing.

Posted by mike | May 2, 2008 1:04 PM

might be the equivalent of $40 or so in the US

Maybe it's just because I live in a semi-expensive city but I couldn't get close to that.

Exam: 75
lenses: around 90
frames: 30-40 for cheap and ugly.

My copay brings it down to 35 if I go with the cheap and ugly.

Posted by djw | May 2, 2008 1:15 PM

might be the equivalent of $40 or so in the US

Maybe it's just because I live in a semi-expensive city but I couldn't get close to that.

Exam: 75
lenses: around 90
frames: 30-40 for cheap and ugly.

My copay brings it down to 35 if I go with the cheap and ugly. Maybe there are better deals out there I haven't bothered to explore b/c of my insurance.

Posted by djw | May 2, 2008 1:17 PM

might be the equivalent of $40 or so in the US

Maybe it's just because I live in a semi-expensive city but I couldn't get close to that.

Exam: 75
lenses: around 90
frames: 30-40 for cheap and ugly.

My copay brings it down to 35 if I go with the cheap and ugly. Maybe there are better deals out there I haven't bothered to explore b/c of my insurance.

Posted by djw | May 2, 2008 1:17 PM

djw -

I mean that when you compare prices across countries, you have to adjust for differences in cost of living ("purchasing power parity" is the term). Overall, $13 buys a lot more in Vietnam than in the US.

Posted by N | May 2, 2008 2:19 PM

You guys are a bunch of fools. Please name ONE THING (besides surgery) that an MD can do that is illegal for NPs to do. Please just fucking name one.

Everybody always trumps this bullshit "PAs and NPs should be allowed to do more" but they have no clue that they can already do everything that a doctor can do EXCEPT surgery. Even ezra doesnt advocate allowing nurses to do heart transplants, so I think everybody agrees that surgery should be left to doctors.

So when you exclude surgery, what you are really comparing is: 1) diagnostic tests; 2) prescriptions; 3) non-surgical procedures.

NPs and PAs can script for any drug that a doctor can script for. NPs can run and order any diagnostic test that an MD can run or order. NPs/PAs can do any non-surgical procedure that an MD can do.

So all you geniuses out there, please research what the current state of practice is before you spout your mouth off about crap you know nothin about. NPs and PAs are already functionally equivalent to doctors in every single way except surgery.

They can order any test and script for any drug that any doctor can do, so there's nothing more you can really give them except surgical privileges.

NPs can open their own clinics and run them solo with absolutely ZERO doctor oversight or supervision. So please explain to me what "extra powers" you would give to NPs that they dont already have.

BTW, take a look at the percentages of NPs and PAs choosin to work under MDs in subspecialty clinics as opposed to starting their own primary care gigs and you will see that anybody who claims that NPs and PAs are going to solve the "primary care problem" is a joke. They are running just as fast to the subspecialties as the MDs are.

Nobody wants primary care, not even the lowly midlevel providers.

So you'll have to dumb it down even further. Create some kind of "healthcare practitioner" that can script drugs out of high school with a 2 years associates degre

Posted by anon2 | May 2, 2008 5:10 PM

Re anon2's comment "NPs can open their own clinics and run them solo with absolutely ZERO doctor oversight or supervision. So please explain to me what "extra powers" you would give to NPs that they dont already have."
------------
Since we were discussing dentistry and you are discussing medical care, I don't see your point.
Where is the equivalent of a NP in dentistry?

Posted by Don Williams | May 2, 2008 6:02 PM