From a
Washington Post story about a kid who died from an abscessed tooth:
DaShawn saw a dentist a couple of years ago, but the dentist discontinued the treatments, she said, after the boy squirmed too much in the chair. Then the family went through a crisis and spent some time in an Adelphi homeless shelter. From there, three of Driver's sons went to stay with their grandparents in a two-bedroom mobile home in Clinton.
By September, several of DaShawn's teeth had become abscessed. Driver began making calls about the boy's coverage but grew frustrated. She turned to Norris, who was working with homeless families in Prince George's.
Norris and her staff also ran into barriers: They said they made more than two dozen calls before reaching an official at the Driver family's Medicaid provider and a state supervising nurse who helped them find a dentist.
On Oct. 5, DaShawn saw Arthur Fridley, who cleaned the boy's teeth, took an X-ray and referred him to an oral surgeon. But the surgeon could not see him until Nov. 21, and that would be only for a consultation. Driver said she learned that DaShawn would need six teeth extracted and made an appointment for the earliest date available: Jan. 16.
But she had to cancel after learning Jan. 8 that the children had lost their Medicaid coverage a month earlier. She suspects that the paperwork to confirm their eligibility was mailed to the shelter in Adelphi, where they no longer live.
Brad Plumer, writing at the Plank, has a
round-up of readables on the problem of Medicaid and dental coverage. States are currently
required by Congress to provide dental services to people under 21 as part of their Medicaid benefit package, but the problem is that dentists in many states
won't take Medicaid recipients because they claim the states' re-embursements are too low and the process too complicated.
My first reaction to horror stories like this is to shake my fists at those selfish dentists. But remember, this sort of thing is the real upshot of
sausage-making like this and
this from early 2006. Capping case-by-case reimbursements of health-care providers results in greater case-by-case losses for dentists who take on Medicaid patients. And that's assuming the patients actually show up and sign on the dotted line. Provisions for higher "cost-sharing" with Medicaid patients mean that cash-strapped patients are less likely to do do so on any given day, leaving their dentists in the lurch. Stricter Medicaid eligibility requirements also increase the risk of no-shows because (like the family in the
Post story) they suddenly find out they're ineligible. And then there's the uncertainty introduced by the much-vaunted "flexibility" in state Medicaid standards, which in some cases puts even federal mandated services like child dental service in limbo -- for both the patients and for their dentists.
Public health insurance can only work if health care providers are willing to participate, which means that public insurees aren't too unattractive relative to private ones. This becomes less and less the case as Medicaid costs-cutting, and the chaos created from euphemizing the cost-cutting, shows up on the doctors' bottom lines. The
Georgia example Brad links to suggests (informally) that dentist participation in Medicaid is at least somewhat elastic with respect to reimbursement rates. So if you want to keep strictly public health care limited to the poor, states are going to have to pay (or else require doctors and dentists to take on some percentage of Medicaid patients by law). The status quo isn't cheap: keeping more poor kids from dying of tooth infections means bigger state payouts to the health care professionals who can stop it from happening. Even if some of them are in fact selfish jerks.