A Better Way to Give Dental Care to the Poor

This article appeared in the Baltimore Examiner on March 13, 2007.

Deamonte Driver was just 12 years old when bacteria from an abscessed molar spread to his brain. By the time his mother realized he needed attention, it was too late. Not even two brain surgeries and six weeks of hospitalization - at a cost of $250,000 - were able to save him.

Deamonte’s tragic death demonstrates how our health care system so often fails the poor. And the way that policymakers have responded to his death demonstrates why that system so often fails the poor.

Deamonte and his siblings did not receive routine dental care, at least in part because of the shortcomings of Maryland’s Medicaid program, created to provide health care to the poor. It’s tough to get an appointment with a dentist if you’re on Medicaid. The program pays so little, only one in six Maryland dentists participate.

Unfortunately, some policymakers are pushing legislation that would put even more people in the same situation. In Washington, Sens. Ben Cardin (D-Md.) and Jeff Bingaman (D-N.M.) responded with legislation that would increase Medicaid payments to dentists. In Annapolis, Del. Nathaniel T. Oaks (D-Baltimore) and Sen. Thomas Middleton (D-Calvert County) used Deamonte¹s story to argue for similar legislation.

Given that Medicaid offers paltry access to care, and that better access might have saved Deamonte, that approach holds some appeal. But Medicaid would quickly swallow up the additional funding, and leave even more low-income families in the same terrible bind.

Here’s why. At any moment, only two out of three people who are eligible for Medicaid are actually enrolled in the program. Lousy access to care is one of the reasons many eligible families do not enroll.

Spending more per enrollee would improve access initially. But it would also increase enrollment by making the program more attractive to those currently not enrolled.

The added cost would leave lawmakers with two options: Increase taxes or reduce per-enrollee spending. Increasing taxes would just add fuel to the fire by making it harder for families to avoid enrolling. Eventually, lawmakers would have to reduce spending, and access would return to previous levels. At the end of the process, the only difference would be that even more Deamontes would be dependent on a lousy government program for their health care.

The politicians have thus far ignored another way that society failed Deamonte - one that actually offers some hope of expanding access to dental care.

In the name of “consumer protection,” the state of Maryland reduces access to the very type of early intervention that Deamonte needed. Twenty states allow dental hygienists direct access to patients, which makes basic, preventive care more affordable. But not Maryland, which requires licensed hygienists to work under the supervision of a licensed dentist. That makes it impossible for hygienists to offer lower-cost basic and preventive care by striking out on their own.

The usual justification for that requirement is that it improves quality. The real reason for its existence is that it protects dentists from competition. But it may not even live up to its stated purpose. Studies show that over-regulation of dental hygienists increases the cost of dental care. If those higher costs prevent people from getting any care at all, that reduces quality.

If Maryland officials want to improve access to dental care, they must deregulate hygienists.

No one can say whether that would have made the difference for Deamonte. But such laws do cost lives. Duke University professor Christopher J. Conover estimates that health care regulations cost 22,000 lives every year. Some of those are lost because regulation cuts off access to affordable, basic care.

Given greater freedom, hygienists could educate more people about proper dental care and catch problems like Deamonte’s before they turn deadly. Unfortunately, most politicians seem genetically programmed to reject any reform that would reduce their influence. There’s a good case to be made that improving access to care for the poor requires exactly that.

Michael F. Cannon is director of health policy studies at the Cato Institute, and co-author of Healthy Competition: What’s Holding Back Health Care and How to Free It.