HCR -- Dental Care Reflects a Perfect GOP Marketplace

By John Ballard

Next time you come across that foolishness about how well competition in the marketplace improves quality and drives down costs, think of dental care. Thanks to the fact that losing all your teeth is not fatal, dental care in America is a textbook illustration of how everyday medical problems are handled by a "free market." I watched it for years as I managed so many of the working poor, that vast group of hard-working ordinary people, many of whom don't earn enough to be taxed, but who spend their entire lives living paycheck to paycheck, sometimes enduring toothaches until the pain gets so bad the tooth has to come out.

Next time you walk through a crowd of strangers (at the mall, sporting event, sidewalk, whatever) try this little experiment. Strangers can't usually know for sure if a smile is real or fake, so pick a face in the crowd, make quick eye contact, and flash a big, toothy smile at them. Really show some teeth. You may be surprised how instinctively even a stranger will return the gesture. It's almost a human reflex. (If someone flashes you a smile, you don't stop to reflect if maybe that person recognizes you from somewhere else and you forgot, or that's the person your boss or neighbor introduced to you and she remembers you but you already forgot who she was. Or maybe you are a twin to someone he knows....) The safest response to a flashy smile is at least a bity of a quick, tight grin. but plenty of people will just smile right back.

But all that's beside the point if you are serving food in a hot, fast-moving cafeteria line or working the register at a fast food restaurant. That smile is the face of the operation and if you don't do it right you're apt to be setting up a public relations failure if anything even slightly goes wrong. I've seen it a thousand times. I've been in the middle of it more times than I can recall. When a public transaction between strangers is about to go off the rails, even a ten-cent flash of a smile is better than none at all. Believe it.

I said to my staff "Show some teeth! I don't care if the smile is real or not. No one will notice. But if you don't smile they will figure you're grumpy instead of friendly. You want people to be nice to you? Then be nice to them. Even if you fake it. If you smile, most of the time they'll never know if you mean it. But if you don't, you're setting up a situation that can be avoided."

But I quit saying "Show some teeth" because several times I was talking to workers without any teeth. In a couple of cases they even had dentures, but after years of going toothless, they were more comfortable without them. (And I have to admit, they were sometimes easier to meet and be comfortable around when they went without them. Kinda like someone losing their hair for whom you feel embarrassed when the attempt to hide the fact is failing.)

My flashback here is prompted by Bernie Sanders.

"The overwhelming demand by Vermonters for dental service is proof that people are struggling to pay for basic expenses - fuel, housing, and groceries -- and can't afford the added expense of taking care of their teeth," Sen. Bernie Sanders said. "At time when so many Vermonters are struggling, it's not unusual to hear stories like Larry's. We must continue to fight to ensure dental care is available for all people, regardless of income or ability to pay."

During the Free Adult Dental Care Day, which was held in five locations throughout Bennington, Rutland, and Windham Counties, Wojenski had a tooth repaired and crown put on at no cost. "That $700 to $1,000 probably takes me two months to save after working full time," he said.

[...]    Expanding the reach of community health centers is one solution. The number of Vermonters receiving dental care through the federally qualified health care centers has grown to roughly 20,000 people, said Sanders, who chairs the Senate Subcommittee on Primary Health Care. "One of the areas that I have long-worried about is dental access in Vermont," the senator said. "While we still have a long way to go, there is no question that we are making real progress."

In 2002, for example, there was just one community health center dental practice in Vermont. The Island Pond location served about 1,000 Vermonters. This year, an eighth dental practice, located at the community health center in Morrisville, further broadened the reach of the dental network that has grown to more than 19,000 Vermonters. A ninth dental practice will be opening soon in Ludlow. Aside from the initial Island Pond location, dental services are available in the health centers in Hardwick, Plainfield, Richford, Rutland, and the two sites in Burlington.

Sanders emphasized the successes in bringing dental services into Vermont's schools. "In 2002, there was one school-based dental program in Bennington serving about 150 students," he said. "Today, Vermont has four school-based dental programs and a dental van program that serve more than 2,200 students."

When 's the last time you heard of a medical practice doing anything complimentary?

"Hell.  People go to the ER all the time and get free treatment."

Yeah, right.
Keep on believing that.
Just hope the day never comes when you or a family member sinks to that point.

I worked five years in a hospital system and never knew about an "indigent clinic" less than a block  from where I was working.  Only after I was gone did I discover, quite by accident, about "indigent care." Apparently staff physicians took turns manning the place, but it was way off from the emergency room and main hospital entrance where most people were admitted. I had an interesting exchange with someone working in the clinic with two decades of experience.

"Really? An indigent clinic? I suppose that's where Medicaid beneficiaries go, right?" 

"Oh, no," she said. "Medicaid people go to the main hospital." 

"So where do the people come from who use the indigent clinic?"

"DFCS, mostly. Family and Children's Services sends them to us.The hospital takes care of Medicaid."

I never quite worked it out.  And I'm not if a position to investigate without violating good employment practices.

But my instinct is that the indigent clinic serves a population of local people who for some reason are not officially poor enough to qualify for Medicaid, or whose health problems have left them unable to pay more. It would make a horrible investigative news story if hospital bills at a local facility caused them to liquidate and "spend down" all their earthly assets (like the home they invested a lifetime to own and the final few thousand dollars in savings, the only financial threads by which they were hanging).

Make no mistake about it. Both Medicare and Medicaid are essential parts of the revenue streams for both doctors and hospitals. With the exception of concierge practices, arguments to the contrary are simply false and misleading.

There may still be a few practitioners with an old-fashioned idea of heal first, get paid later, who from time to time might comp the bill. But they are few and far between. And my guess is that if they need access to a lab, imaging facility or device supplier to properly treat someone unable to pay, they would have to reach in their pocket or call in an old personal favor to get it done. And we all know what happens to people who call in too many favors. Pretty soon they wear out their welcome.