Dental Cartel

posted by Frank Pasquale

What is the future of American health care? Many believe that we need less reliance on government funding. The current state of American dentistry suggests the likely consequences of such a move–along with the imbalances caused by “marketization” that focuses on the demand side while neglecting a cartelized supply side.

As social stratification deepens, ever more sophisticated cosmetic dentistry becomes the norm for the wealthy. Meanwhile,

[M]any poor and lower-middle-class families do not receive adequate care, in part because most dentists want customers who can pay cash or have private insurance, and they do not accept Medicaid patients. As a result, publicly supported dental clinics have months-long waiting lists even for people who need major surgery for decayed teeth.

[E]ven as so many patients go untreated, business is booming for most dentists. They are making more money while working shorter hours, on average, even as the nation’s number of dentists, per person, has declined.

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Even if more students wanted to enter the profession, states are not moving aggressively to expand dental schools or open new ones. Training dentists is expensive, because dental schools must provide hands-on training — unlike medical schools, which send doctors to hospitals for training after they graduate. Hospitals receive federal subsidies for the training they provide to medical interns and residents, but the equivalent system does not really exist in dentistry. Meanwhile, the A.D.A. does not support opening new dental schools or otherwise increasing the number of dentists. The association says it sees no nationwide shortage of dentists . . . .

So while the doctors’ lobby has finally acknowledged the need for more medical schools, the dental lobby is holding a hard line. One key question: is the problem that Medicaid underpays dentists, or the state’s failure to assure the training of enough dentists? Consider the hard line the dental lobby takes against the allied health professions:

Despite the rise in dental problems, state boards of dentists and the American Dental Association, the main lobbying group for dentists, have fought efforts to use dental hygienists and other non-dentists to provide basic care to people who do not have access to dentists.

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“What we’re extremely uncomfortable with is that they need to drill teeth and sometimes extract teeth,” said . . . the association’s president. Use of therapists would create a two-tier system where some people have access to dentists, while others must settle for less-qualified practitioners, she said.

I have a few thoughts below the fold.

On first blush, the crocodile tears of the ADA here appear to confirm Clark Havighurst’s classic critique of health care regulation:

[T]he elite classes, including many self-proclaimed consumer representatives as well as organized professional groups . . . design and maintain a system that meets their own particular needs but leaves less privileged citizens who are not qualified for publicly financed care with a Hobson’s choice: either coverage for ‘Cadillac’ care or no health coverage at all. Ruled as it is by and for dominant elites, the U.S. health care system imposes large, unfair, and unnecessary economic burdens on ordinary working people.

Perhaps if we lived in Brazil or some other country with an extraordinarily high Gini coefficient of inequality, I could accept Havighurst’s own Hobson’s choice: zero care or second- (or perhaps third- or fourth-) class care for the disadvantaged. However, before we accept the dentist shortage as a fact of nature, immutable as gravity, perhaps we should take a closer look at the source of the dental cartel’s power. Here’s Dean Baker on the topic:

If U.S. trade negotiators approached the highly paid professions in the same way they approached the auto industry, then they would actively be trying to uncover all the factors that prevent direct competition between U.S. professionals and their counterparts in the developing world, and then construct trade agreements that eliminated these barriers. They would be asking hospitals, law firms, and universities what is preventing them from doubling, tripling, or quadrupling the number of doctors, lawyers, and economists from developing countries working in their institutions. They would also be asking the trade negotiators from Mexico, India, or China what obstacles prevent them from sending hundreds of thousands of highly skilled professionals to the United States.

This does not happen. In fact, the exact opposite happens. In 1997 Congress tightened the licensing rules for foreign doctors entering the country because of concerns by the American Medical Association and other doctors’ organizations that the inflow of foreign doctors was driving down their salaries. As a result, the number of foreign medical residents allowed to enter the country each year was cut in half.

Baker’s free-trade tendencies would be at home on the pages of the Wall Street Journal editorial page, though he has precisely the opposite ideological commitments:

While doctors, lawyers, and accountants don’t pull down the same money as corporate CEOs or the Bill Gates types, their success is hugely important in sustaining the conservative nanny state. If the only people doing well in the current economy were a tiny strata of super-rich corporate heads and high-tech entrepreneurs, there would be little political support for sustaining the system.

Though I admire Baker’s Beat the Press blog a great deal, this particular proposal sounds a bit like an “immiseration gambit” to me; drive everybody’s wage down so there will be broad-based support for massive change.

But what happens to the countries from whom we’d import these doctors and dentists? Consider Laurie Garrett’s take on the issue:

[T]he world is now short well over four million health-care workers . . . . As the populations of the developed countries are aging and coming to require ever more medical attention, they are sucking away local health talent from developing countries. Already, one out of five practicing physicians in the United States is foreign-trained, and a study recently published in JAMA: The Journal of the American Medical Association estimated that if current trends continue, by 2020 the United States could face a shortage of up to 800,000 nurses and 200,000 doctors. Unless it and other wealthy nations radically increase salaries and domestic training programs for physicians and nurses, it is likely that within 15 years the majority of workers staffing their hospitals will have been born and trained in poor and middle-income countries. As such workers flood to the West, the developing world will grow even more desperate.

Data from international migration-tracking organizations show that health professionals from poor countries worldwide are increasingly abandoning their homes and their professions to take menial jobs in wealthy countries. Morale is low all over the developing world, where doctors and nurses have the knowledge to save lives but lack the tools. Where AIDS and drug-resistant TB now burn through populations like forest fires, health-care workers say that the absence of medicines and other supplies leaves them feeling more like hospice and mortuary workers than healers.

A “free trade” solution is a double-edged sword–perhaps it enriches other countries when the “imported” health personnel send back remittances, but it also ends up denying them much-needed health care personnel. (One ABC news story estimated that in some countries in sub-Saharan Africa, there is 1 pediatrician for every 110,000 children–compared to a 1 to 900 or so ratio in the U.S.).

So what’s the solution? I favor a great deal more investment in the U.S. health care educational system. There is a near-consensus that shortages of dentists, nurses, and doctors are here and are only worsening. A free trade approach may just create a developed world “buying power externality” as great as its contribution to global warming.

Photo Credit: Aibakker.

 October 12, 2007 at 8:19 am   Posted in: Health Law    Print This Post

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