Measures that would make a difference

I know I should probably be paying more attention to the health care summit kabuki going on in DC today. (Or, given the current GOP obstructionism, perhaps a better metaphor would be "noh." Hey-oh!!! Oh, never mind.) Honestly, I know I should pretend to care about the summit, and be following a live-blog somewhere. But I just don't care, because I don't think anything that happens today will change the political dynamics of health care reform. This is all about giving the President political cover by having a public display of bipartisanship before they try to pass the reform bill through reconciliation (a course of action of which I approve, by the way), and the GOP is going to flog its usual talking points and there will be precisely zero deviation from a course that was determined for all involved parties long, long ago. Yawn-o-rama. (And it looks like I have plenty of company with this attitude, and I'm a political junkie.)

So, instead, I'm going to talk about kids' teeth. From the KJ:
Last November, Dr. Jonathan Shenkin, a pediatric dentist in Augusta and president of the Maine Dental Association, saw a 4-year-old patient for the first time in that child's life. The child's teeth had significant damage and needed five or six fillings, he said.

He asked the child's mother why she had waited so long to see him.

"She felt embarrassed," he said, "but she said the only reason that she didn't come sooner was because her insurance didn't allow it."

Maine law currently allows dental insurance companies to decide when to offer insurance to children. On Wednesday, the Insurance and Financial Services Committee heard arguments in favor of requiring companies that offer dental coverage in Maine to offer it to children from birth.

No one testified against the bill, though several insurer representatives expressed concerns about how it might affect their bottom lines.

Full disclosure (not that I think anyone out there cares about my Integrity as a Blogger) -- Dr. Shenkin happens to be a friend of mine. That being said, kids' dental health has been an issue of particular interest to me since we moved to Maine, to the point that I recorded public information spots for the Watch Your Mouth campaign a few years ago.

It is vitally important to children have good dental coverage. Dental problems account for significant amonts of missed school and numerous ER visits every year for millions of children, and are a source of both pain and psychological distress. (Not only are dental infections very painful, which can cause dietary problems for children who cannot chew normally, but cavities and missing teeth can make children very self-conscious. It is heart-breaking to hear stories about kids refusing to smile for pictures because they are embarrassed.) I am also powerless to help children with dental infections. I can prescribe an antibiotic, but they typically recur if the diseased tooth is not filled or extracted. For kids with no insurance, there are often few choices.

It is beyond ridiculous for insurance companies to "provide" dental coverage for children but to arbitrarily choose an age far past the recommended onset of dental care. For some children, it's already years too late. Yes, proper prevention can obviate much of the need for some of these services. However, no matter how much information we disseminate, there will still be plenty of kids who get cavities and abscesses. Public education campaigns can only do so much.

Insurance companies continue to make hefty profits, year after year. It is stomach-churning to consider that they would put those considerations before the needs of children with genuine, acute need. But there you have it. This is a need that needs to be addressed, and I wish Dr. Shenkin every success with his efforts.

Update: For a[n unsurprisingly] contrary view on the importance of today's summit, I give you The New Republic's Jonathan Cohn.


  1. Well, I'm convinced. Since somewhere, some parent might not take their child to the doctor, we must require everyone to purchase insurance, and require that children be covered for all routine medical treatments and checkups.

    Similarly, since somewhere, some parent might not take their child to the dentist, we must require that everyone purchase dental insurance, and that all children be covered for all routine treatments and checkups.

    Also, some parents might not take proper care of their automobile. Worn tires, bearings, and brakes are a real danger to children, so we must require that everyone purchase auto insurance that covers all routine inspections and maintenance.

    I know children go to bed at night in cold apartments, so we must demand everyone purchase housing insurance that covers all routine care of any occupied dwelling, including routine payments for heat, light, water, and pest treatment.

    Food and clothing are more important than even healthcare, so somehow we must make sure everyone is required to purchase hunger and clothing insurance which covers all routine meals, coats, pants, shirts, hats, gloves, shoes, and so forth.

    Needless to say, this is just a start, covering only the most essential basics that parents might, for reasons beyond their control, be unable to provide for their offspring. I'm sure we can add lots more to the list, and maybe we need insurance insurance to cover all the situations for which insurance doesn't cover the quotidian expenses of life.

    How can we call ourselves civilized if we fail to act to protect the weakest among us?

  2. Preventive dental care is inordinately cheap relative to major dental work; as with all childhood care, insurance should be begging to provide it and pushing everyone to use it.
    It costs us $200 twice a year to have a healthy three-year old's teeth examined and cleaned without dental insurance (the premiums for which are $50 a month and therefore more than two routine exams) and health insurance will only pay once someone has to drill, fill, or extract. That means there is a decided incentive to crappy oral hygiene, because we're paying more (a lot more) to brush and floss twice daily and cultivate smart eating habits than to let the kid's teeth rot and then have them fixed. Routine and preventive dental and health care for all Americans should be no-brainers.

  3. Oh, John. Please. This is not some parent somewhere who chooses not to take his kid to the doctor. These are parents who cannot afford to have their children's painful, infected teeth fixed. They exist. Their children suffer. They are poor and cannot afford to correct the problem on their own. I'm sure in your world it is their fault for being poor and un- or underinsured, but I'm not sure how you'd like me to explain that hard reality to their kids.

    What do you, with your sarcasm and your glib hypotheticals, propose they do? What shall I tell these children as they cry in my office? (They are numerous in poor, underserved places like Maine, where large numbers of children drink from wells and live in counties with no dentists.) Shall I share with them your high-minded protestations? Or shall I advocate for more comprehensive dental coverage because I am tired of trying to figure out a solution for uninsured children with swollen, infected gums?

    So you, my friend with the funny, funny "if this then that" slippery slopes, tell me what I should do. I await your answer.

  4. Dan, do you seriously claim I believe everyone is a fault for being poor? I don't. I'd appreciate if you wouldn't stoop to suggest such a thing.

    Also, I understand how bad things are; my SIL teaches at a rural school with loads of children from migrant farm workers. These workers drew life's short straw. They work really hard for very little money, invariably because they haven't the skills (or papers) for a better position. It isn't their fault. They didn't throw away their chance for a better life, they never got a chance for a better life. But maybe the children will.

    I've already told you what I'd do; I'd fix that specific problem via catastrophic coverage. I am a great believer in solving the problem at hand rather than developing an all-singing, all-dancing general solution to life's ills. I wouldn't generalize the problem and say that we need to require everyone to buy more expensive insurance with coverage for every pet cause of every cash rich, Congressional buying advocacy group so poor children would have dental care.

    What I also wouldn't do is blame insurance companies for not caring. We may as well blame dentists for not caring; dentists as a group make tons-o-money too. Why not simply require, in order to hold a license, that every dentist be required to pay for poor children's coverage? That makes as much sense as forcing NTW to buy dental coverage.

  5. NTW, yes, preventative care is cheap compared to fixing major problems. Of course dental insurance will be more than the cost of routine care; the insurance company can't sell $400 worth of coverage (minumum!) for less than $400. Insurance *always* costs more, on average, than it pays in benefits. Just as farmers charge more than the cost of growing food, insurance companies charge more than the aggregate cost of providing services. Insurance makes financial sense for covering large, unexpected, and rare expenses. Normal, routine expenses are better paid out of pocket.

    Now, if you have a group of people who can't pay the routine expenses, there are better answers than forcing everyone to buy coverage for routine care.

    I completely disagree that you are paying more to have your child brush and floss and have two out of pocket exams than you would be to let the teeth rot. It is your child, for Buddha's sake! I carry high deductible medical; that doesn't mean I have any incentive to let my children's health slide until we have an expensive problem. I buy high deductible because it is waaaay cheaper to pay for yearly physicals and an office visit or three than it is to have Federal employee level of coverage. I'm still protected in the event, heaven forbid, that a serious problem develops, but I don't need to spend an extra $400/month to cover less than a $1,000 in expected yearly expense. No reasonable person would say I have an incentive to let my family's health slide because I choose to do this.

  6. Fair enough on your first point, GJ. I retract the implication, which was admittedly unfair. I apologize.

    The measure for which Dr. Shenkin is advocating is for dental insurers to start coverage at the recommended ages for children. That is all. This is for people who are already insured but whose coverage doesn't start for their kids until some arbitrary age.

    And I favor universal health and dental coverage for all children, paid for by the state. For older patients I think there's room for debate. For kids, I have less patience.

  7. good lord gj, wow, unbelievable. Yes, we require parents to have their children attend schooling. We also require people to perform routine maintenance on their cars (or do you never get your car inspected) and if your car appears not to be in sufficient running order, your car can be impounded. (I am astounded you somehow think this is not the case), as to buying maintenance insurance - routine costs are sufficiently low enough not to make it necessary, but many people do buy extended warranties (and worst comes to worst, you can junk a car, are you proposing we junk humans?)

    And yes, there is a law stating you have to keep your home up to code, otherwise it will be condemned (again, you act like this doesn't exist). You don't need to buy insurance for this, again because routine costs are low enough. If you live on a barrier island, my localities require flood insurance, since that cost is not routine.

    And food and clothing are low costs, insurance is not necessary.

    Do you even know what the purpose of insurance is? I am astounded at how idiotic your argument is. Insurance is to protect against excessive revenue loss, not against all loss of revenue.
    Only a fool doesn't buy homeowner insurance (and it is a condition of every mortgage)

    Every Child in America should be provided with medical and dental insurance, point blank, no excuses. It would be wonderful to live in a world where every parent would and could provide it, but we don't. Every child is already provided with schooling and (theoretically) food, clothing, and housing (because if the parents don't children become wards of the state)

    Again gj, this strawman stupidity you lay forth, it is like you are trying to sound as stupid as you can. It must take work to come up with as stupid as sarcastically saying in absurdis extremis "lets make people buy food and clothing insurance" as any kind of rebuttal, since the concept is beyond braindead, it is zombie brain stupidity.



  8. charo, yes, I never have my car inspected by the State for mechanical fitness. Never, ever, ever. And there is nothing illegal about it. Open your eyes, there is a big world out there.

    You might also ask Mr. Google about the difference between revenue and expenses.

    Dan, Dr. Shenkin's proposal just nibbles around the edge. I would expect that most of the poor children do not have *any* dental insurance. Mandating uniform coverage won't help them at all.

    If you want to solve the problem of poor children with no dental care, then attack that problem directly. Your save money and fix the problem. My suggestion... the State sets up clinics all over the State, hires dental hygenists to do routine care, and hires enough dentists (not necessarily one per clinic) to handle children who require more care. To deal with parents who don't give a damn, make it a requirement for all government assistance and school attendance that every child have twice yearly exams and all necessary followup care. Parents who refuse to cooperate are counseled, fined, imprisoned, beaten with tire irons, whatever is necessary to insure compliance.

    You could also put Physician's Assistants in the clinics, and mandate routine checkups twice yearly, with referrals (paid by the State) for problems beyond a PA's expertise. Why not solve the problem directly?

  9. gj, you have never had your car inspected? That is illegal.

    The inspection process
    Make sure you have all necessary documentation (driver license, registration, proof of insurance) with you – you won't pass the inspection without them. Photocopy, fax, e-mail or online registration receipts are unacceptable.

    * Vehicles may be inspected up to two months in advance of the due date
    * Check your windshield sticker for inspection due date. Registrations and inspections do not necessarily match
    * The inspector will determine your car's engine type and prep it for testing
    * To pass a safety inspection, vehicles are expected to be maintained according to the original manufacturer’s specifications, including but not limited to: brakes, suspension, steering, wheel alignment, headlights, taillights, tires, horn, windshield wipers, window and hood operation, glazing, turn signals, mirrors, etc.
    * The inspector will perform the appropriate emissions test based on the year, make and model of the vehicle
    * The final stage of the test will assure that your gas cap is stable and limits the escape of fumes into the environment
    * Upon completion, the inspector will place a new two-year sticker in your windshield

    I mean, damn, if your state doesn't have these requirements, they are downright idiotic.
    And if you think these requirements are onerous, then you are idiotic. And that is forever and ever, ever and ever. Are you really in favor of unsafe cars being on the road?

    And one definition of revenue is income, so I got no idea what your point is, unless you are being super nitpicky that said expenses goes beyond income, which only re-inforces my point of the purpose of insurance. So fine, I will give you your little idiotic triumph and change it to insurance protects us against excessive loss, now acknowledge that if that is your only rebuttal, you are pretty pathetic.

    As to this: My suggestion... the State sets up clinics all over the State, hires dental hygenists to do routine care, and hires enough dentists (not necessarily one per clinic) to handle children who require more care.

    That is the Liberal solution, in fact, overly so. There are enough Dentists to fill the need, just ensure that every child has Dental insurance, Pa. has it based on income, and every child is eligible for S-Chip, even millionaires (they just have to pay for it).
    The problem is, as Dan is alluding to, Pa. is an exceptional state. Do you really imagine Alabama gives a rats ass about their poor? They have been at the bottom since forever by sticking to the same Conservative mindset of "every man for himself, except the rich who deserve protection"


  10. GJ, Maine (along with a heaping ton of other states) is stone broke. I would love, with sugar and a cherry on top, to see the clinics you describe. I will testify in favor of that bill with gusto.

    It won't happen until Maine suddenly gets a lot less poor.

    In the meantime, incremental measures will have to do.

  11. charo, I have no inspection sticker on my car because there is no inspection requirement. We seem to get along just fine without it. Mr. Google doesn't know of any study finding inspections are a cost effective way to increase traffic safety. If you have a cite, let's see it.

    Income is not necessarily revenue, nor is it cost, and homeowners do not insure their homes against lost revenue, excessive or not, but against unusual expense. If a storm knocks down a branch and it breaks my floodlight, I don't make a claim. Nor can I make a claim on a homeowners policy if a snowstorm keeps me from generating revenue out of my home. Yes, it is a bit picky, but you are the one claiming I don't know what I'm talking about, while spouting nonsense.

    I told you I was a Classic Liberal. I don't favor anarcho-capitalism, and I do favor helping poor children grow up to become healthy, rich adults.

    Dan, Dr. Shenkin's proposal won't come for free either. What will it cost? Could that money be better spent covering all children, not just those fortunate enough to have parents with good jobs?

  12. GJ, the costs of lowering the age of coverage would presumably be bourne by the insurance companies that grant the coverage in the first place. Being as it were that preventive care at the right age can obviate the need for more expensive corrective care later, denying the coverage is a false economy.

  13. We seem to be done, but one last question or two. Are the dental insurance companies really so stupid? If preventative care really saves money, why can't they figure this out without being compelled by law? Are they really run by robber barons rolling in piles of money in the basement vault at Corporate HQ, or is there something that we are missing?

    To me, the real question is why no one thought to start up a dental insurance company that offered early coverage with all the financial advantages, and thereby would be able to undercut the current providers on premiums, and so attract a large chunk of profitable business. Why didn't this happen?