In their thorough and thoughtful August JADA guest editorial, "Paying Attention to Our Health Care System and Workforce: Time to Join a National Discussion" (
JADA 2008;139[8]:1024–1028[Free Full Text]
), Drs. David Sarrett and Cathy Bradley call for dentistry to participate in national health care policy deliberations.
Dentists have mixed feelings about this. Take, for example, some of the issues at stake with the cost of care. On the one hand, we fret over troubling statistics. Health care costs reportedly are rising twice as fast as inflation.1 From 2001 to 2006, health insurance premiums jumped 73 percent.2 As both doctors and patients, we realize that actuarial insurance leads to third-party manipulations, including, as one observer charged, "administrative dreadnoughts devoted largely to vetoing treatments, sloughing off sick or potentially sick clients, and scheming to stick someone else with the bill."3 Health professions surely must become more integrated to offer better, more comprehensive, more efficient care.
On the other hand, practicing dentists are probably grateful that dentistry was not included in Medicare, the 43-year-old model of U.S. redistributive social insurance, whose medical providers are increasingly opting out in anger and frustration. Dentists who have experienced Medicaid or one of its state equivalents—welfare programs rather than insurance—may fear in a universal health care system a similar avalanche of decreased fees, increased paperwork, bureaucracy, confusion, budget cuts of just the sort Drs. Sarrett and Bradley describe in California, and rationing.
Health insurance is not the same thing as health care, but costs and control are conflated concerns. Indeed, controlling costs comes at the cost of control. We may consider the determinative focus to be what treatment is appropriate, but a string of other questions inevitably comes attached: What will treatment cost, who will decide what gets done, who will treat and who will pay? The "more comprehensive and coordinated continuum of providers" the authors propose necessarily means sharing control, which creates an environment fraught with complexity, unintended consequences and the potential for declining doctor incomes, the fallout of which in medicine has probably sent not only medical students into non–primary-care specialties but premed students fleeing to dental school.
Participation also brings a risk of humiliation. Dentistry may be welcomed into a comprehensive health system in the soft moonlight of theory, and then (regardless of the newest research linking periodontal problems to heart disease) written off in the harsh fiscal sunshine as too expensive relative to its perceived importance.
A Daily Telegraph (London) reporter writes that British dentistry has so suffered in the National Health Service (NHS): "In Britain today, you can stuff yourself on deep-fried Mars bars, drink 20 pints a night, inject yourself with heroin, smoke 60 cigarettes a day or decide to change your sex—and the NHS has an obligation to treat you. ... But if you have bad teeth, forget it."4
Certainly, dentistry can be proud of the example it has set in such areas as prevention and patient behavior modification. But as we "increase our linkages," I worry that dentistry will absorb the troubles of other disciplines more than I trust that dentistry will successfully export its achievements. Perhaps involvement in national health care discussions is the correct move for dentistry, and avoiding our rightful place in the process the less principled, less courageous stance, but it’s hard to suppress the self-protective impulse to duck.
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