We Can Do Better Than This

by hilzoy

From the Washington Post:

"Twelve-year-old Deamonte Driver died of a toothache Sunday.

A routine, $80 tooth extraction might have saved him.

If his mother had been insured.

If his family had not lost its Medicaid.

If Medicaid dentists weren't so hard to find.

If his mother hadn't been focused on getting a dentist for his brother, who had six rotted teeth.

By the time Deamonte's own aching tooth got any attention, the bacteria from the abscess had spread to his brain, doctors said. After two operations and more than six weeks of hospital care, the Prince George's County boy died."

The story is long, complicated, and tragic. But a couple of things stand out for me, apart from the fact that this should not happen in one of the richest nations on earth.

First, one of the factors involved is that the family's Medicaid lapsed, possibly because the paperwork was mailed to the wrong address. One of the main advantages of a single-insurer model of health care -- a sort of Medicare for everyone -- is that if everyone were covered, there would be no need for families to prove that they were covered, and thus no need for paperwork that might get lost when a family becomes homeless, or simply moves. A huge set of pointless hoops that people have to jump through before they can get medical care -- hoops that don't provide any health benefit at all -- would simply be removed.

Second, consider the costs this family will run up. Deamonte's care cost a quarter of a million dollars, and even then did not save his life. His brother has six abcessed teeth that have to be removed. All of this could have been prevented by normal routine dental care. Part of the reason they did not get that care is that their mother didn't move heaven and earth to make sure that they did. But part of the reason is also that Medicaid, which covered them for a while, doesn't reimburse dentists well enough, and as a result dentists who accept Medicaid patients are hard to find. I don't know the figures, but it's worth considering the possibility that better reimbursements to dentists might actually save more money than it costs, by keeping kids' teeth from reaching the point where they require dental surgery or hospitalization.

And that, of course, is just counting the dollars and cents, not the suffering of the kids, the time and energy that the parents spend trying to find someone to care for them, let alone the fact that in this case, a twelve year old died.

When you read about cuts to Medicaid, this is what it means. Eligibility goes down, and families like this one might find their access to care cut completely. Reimbursements to providers go down, more and more doctors and dentists ask, why bother?, and those families who are still covered have a harder and harder time finding someone who will care for their child.

This should not happen in our country.

Comments

[trilobite]

Ow.

I HATE stories like this.

I have never understood why it is so hard for this country to adopt a single-payer system. I went to an arch-conservative law school, where I learned all the arguments against such a system; none of them stand up under close examination.

Foremost, it is often said that in a single-payer system, we will quickly go broke paying for maximum health-care for everyone. But, of course, single-payer need not imply unlimited pay, any more than our current system does. My employer-paid health plan has a benefit maximum; so would a government plan. People could, if they chose and could afford it, buy private gapfilling insurance, just as they can now. And that's not even considering the fact that we already pay for socialized catastrophic care in the form of the EMTALA law (free ER service for the uninsured), and, as Hilzoy says, we would save a lot on cases like Deamonte's if we extended the protection to non-catastrophic care.

It is also said that under a universal Medicaid system, providers would have no incentive to keep costs down, whereas now, competing HMOs and insurers force costs down. Oddly, Western Europe and Canada have not experienced this inflationary effect. Instead, it is our competitive system that, notoriously, costs more per procedure.

In practice, the competing HMOs and insurers force provider costs up by making them jump through endless hoops and adding levels of salaried middlemen. They also arbitrarily deny care, or force providers to stop providing certain sorts of care at all, in their desperation to squeeze out some sort of advantage over their competition. Government bureaucrats might do the same thing, of course -- but at least they wouldn't be as motivated by the whims of the market, and they are rather more accountable than HMO penpushers.

Finally, it is said that the more government controls this area, the less innovation there will be. I.e., we're sacrificing Deamonte on the altar of progress. Or, to put it another way, we're all overpaying for health care so that medical research will stay profitable. Somehow, I find it hard to believe that with 6 billion potential consumers, medical research would not stay reasonably profitable.

OK, over to the conservative contingent for rebuttal.

[Adam]

One of the main advantages of a single-insurer model of health care -- a sort of Medicare for everyone -- is that if everyone were covered, there would be no need for families to prove that they were covered, and thus no need for paperwork that might get lost when a family becomes homeless, or simply moves.

When I lived in Canada, there was a somewhat complex signup process. I needed to prove I was eligible for coverage, and when I showed up for treatment, needed to show that I was still covered. So you might be being a little idealistic about this aspect of the system.

[double-plus-ungood]

When I lived in Canada, there was a somewhat complex signup process. I needed to prove I was eligible for coverage, and when I showed up for treatment, needed to show that I was still covered. So you might be being a little idealistic about this aspect of the system.

As proving that you're covered is as simple as showing your card, I don't think that this is a great inconvenience. Even if the card is not available, a simple lookup on the computer is also possible.

I don't recall the the sign-up process being very complicated, but as I did that about thirty years ago and haven't had to do it since, I may be incorrect.

[Adam]

As proving that you're covered is as simple as showing your card, I don't think that this is a great inconvenience.

Agreed. But Hilzoy's scenario is that paperwork may have been lost because addresses were out of date. If that's the case, and essential paperwork goes missing, and the system requires a response for something, then the poor fellow could lose insurance coverage even under a single-payer system.

[Jesurgislac]

I've told this story before on health care threads on ObWing: I once had occasion to register with a GP after I'd moved 400+ miles to change jobs. I didn't have my NHS card and I couldn't remember my NHS number.

Didn't matter. I walked in, asked if I could register, gave my full name and date of birth, apologized for not having my NHS number (it makes registering a new patient faster/more convenient), gave them the name and address of my previous GP, and made an appointment to see the doctor. I don't know exactly when the paperwork went through, but within three weeks I had seen the doctor, arranged to have my blood tested, had the blood test results back, and had another appointment to argue with the doctor about explaining to me what the blood test results meant. Free at point of access health care means minimal paperwork and minimal headaches for all concerned.

[double-plus-ungood]

If that's the case, and essential paperwork goes missing, and the system requires a response for something, then the poor fellow could lose insurance coverage even under a single-payer system.

As I said, simply supplying a former address along with your name is sufficient to find the records because there is a single database to examine.

Having said that, dental care is not under our single-payer health system, which strikes me as idiotic.

[Adam]

As I said, simply supplying a former address along with your name is sufficient to find the records because there is a single database to examine.

You assume that (1) we'll do this rationally and (2) have no issues with (eg) identity theft which will lead to a requirement for the paperwork.

As to 1, I note that the US is just now thinking about introducing a first-class rate stampe. As to 2, medical id theft is already a problem, and the single database makes it more dangerous if that database contains treatment info.

[double-plus-ungood]

You assume that (1) we'll do this rationally and (2) have no issues with (eg) identity theft which will lead to a requirement for the paperwork.

(1) No, I'm discussing the Canadian system. I'm making no assumptions one way or another about how the US would implement such a system.

(2) When everyone is covered by health insurance, there is little need to steal an identity to get coverage.

[Adam]

(1) fair enough!

(2) I don't agree that there won't be a reason to steal--there are 11 million 'undocumented workers' in the US, who might or might not be covered. So a lot hinges on the question of how broadly we define "everyone."

[John Thullen]

Clearly, if the government would get out of the business of health care altogether and let the market work its magic, Deamonte could have died a cheaper and more efficient death.

A quick back of the napkin calculation (the front of the napkin was filled with the Laffer Curve, the Phillips Curve, and the Anna Nicole Curve) will show that having Medicaid available is a perverse incentive, in that it encourages people to work for the minimum wage at McDonalds, where they consume too much sugar, and rot their teeth.

Further, forcing government bureaucrats to be accountable and to be good stewards of the taxpayers' hard-earned tax dollars is a perverse incentive for dentists everywhere, who overpaid for their education. Letting the market dictate prices in response to supply and demand would have dentists falling all over themselves lowering their own wages voluntarily to roughly minimum wage, and thus incentivize them to seek a pay raise at McDonalds, which keeps losing employees to tooth decay.

They could then offer pro bono dentistry in the McDonalds parking lot out of the back of their vans, thus cutting overhead.

Plus, if Deamonte's mother had taken the time to shop around for emergency hospitalization and surgery by biding her time like she was shopping for shoes while the hospitals outbid each other to serve her son, she could have received the same commodity for, I'd say, $214,567,000. And that includes anesthetics. If you got rid of the government regulatory roadblocks to letting patients stay awake during surgery, you could yield further savings.

Who is the government to mandate no screaming during surgery? The pain alone would have made Deamonte and his brother think twice about wetting the toothbrush while the water runs to make their mother THINK they were brushing.

Get third party insurance out of the way, either government or employer-provided, and she might have decided not to seek medical care altogether. That's what we call free medical care in the business.

And, why was home dentistry taken off the table? Brain surgery is not that difficult either, if the home doctor has been drinking heavily.

Why can't people be more self-reliant?

[double-plus-ungood]

I don't agree that there won't be a reason to steal--there are 11 million 'undocumented workers' in the US, who might or might not be covered. So a lot hinges on the question of how broadly we define "everyone."

Biometrics is an advanced technology these days. Besides, one of the advantages of a single-payer system is that a great deal of data is quickly available to the medical personnel. Our system in BC, for example, tracks prescription usage to (a) look for abuses of various sorts, and (b) to ensure that contraindications do not occur. As medical records by themselves are a form of biometrics (blood type, for example), a single payer system would also provide a means to avoid identity theft.

[Adam]

Biometrics may be an advanced technology, but no system I'm familiar with is error free and easy as it scales to even millions of people, never mind hundreds of millions. (Look up 'insult rate.')

They can also interact poorly in a medical environment. "Sorry, can't treat your missing hand, we need your fingerprints."

I would also hate to be denied treatment based on a database lookup error.

[double-plus-ungood]

Biometrics may be an advanced technology, but no system I'm familiar with is error free and easy as it scales to even millions of people, never mind hundreds of millions.

I'd think that the advantages of a single-payer system far outweigh the negative effects of the potential for some abuse. Financially, that is.

I would also hate to be denied treatment based on a database lookup error.

I can understand that. I would hate to be denied treatment because of my economic situation.

[Adam]

Going back to my original comment, I said "you might be being optimistic." I'm not going to disagree with your statement that you "would hate to be denied treatment because of my economic situation."

I think that there are substantial issues of how people will prove their identities and ability to pay, and that a US single payer system has a high burden of proof for the idea that we could balance security, privacy, accuracy and other details. Your desire to get care doesn't lead to those being overcome, and recent programs created by the US government, here and overseas, lead to me being pessimistic.

[gwangung]

Your desire to get care doesn't lead to those being overcome, and recent programs created by the US government, here and overseas, lead to me being pessimistic.

Yes, but is the alternative a superior situation? It's all very well to point out that single payer is not a panacea, but it's not particularly useful to do so without figuring out that the costs far outweighs the benefits.

[LizardBreath]

I think that there are substantial issues of how people will prove their identities and ability to pay, and

More or less substantial issues than those in the current hodgepodge we have now? I can see that it's possible there might be an error somewhere, sometime, making it hard for someone to access care, but I can't see any reason why it would be worse under single payer than it is now. Now, you can lose your ID card or have a database error -- how would simplifying the system make it worse? (Answers incorporating 'government programs are just always messed up' will be treated as unserious -- how often does the DMV lose track of your license?)

[Adam]

Gwangung & Lizardbreath: I'll beg your forgiveness for not trying to have a full debate in these very small boxes. My point was to illustrate the possibility of optimism in what Hilzoy wrote, not to offer up a complete alternative.

Lizardbreath: Two seperate DMVs have each lost track of my license once, and I was (apparently, allegedly) once driving on a suspended license for two years because of a paperwork error on their part. They never notified me of the suspension.

[Jesurgislac]

Adam, in fact I think you'll find that "undocumented workers" already get health care under the US system: it just costs the US tax payer a lot more when they do. The US already has a national health care system. It just costs Americans twice as much to deliver far less effective health care. The main beneficiaries of the current system are the health insurance companies, not Americans.

[Baskaborr]

Adam,
I understand your point concerning the less that stellar results of many recent government programs. May I suggest that we stop electing people who hold as a matter of faith that nothing the government does can turn out well? Would you continue to use a physician who tried to sell you the notion that modern medicine never helped anyone?
Who knows, if we elected competent officials maybe we could implement a solution as good as the worst among all other developed nations. Which would be a big improvement.
It really bothers me that so many believe that the United States is incapable of acheiving that minimal level of competence and compassion.
Somehow reminds me of the old saying about optimists and pessimists. The Optimist believes we live in the best of all possible worlds. The pessimist is afraid the optimist is right.
I'll be even more upset if turns out the nay sayers' low opinion of the US is correct.

[cleek]

the Horrible Browning of America is an issue all by itself (as is identity theft), which needs to be addressed in some way, regardless of our health care situation. so, why not just assume it's going to be dealt with and not use it to complicate the health care issue ?

[Stephen Frug]

I don't know how to do trackback, but I have a post riffing off this one at my blog here:
http://stephenfrug.blogspot.com/2007/02/deamonte-driver-is-dead-and-you-can.html

[dutchmarbel]

All health insurance for kids till 18 is free over here, incl. basic dental care.
Everybody is oblidged to have an insurance - basic insurance does not cover basic dental care anymore (though the new government wants to put it back in) so that is optional.

In effect it means that I don't need prove to go to my own dentist/GP. But when I go to hospital/specialist I ought to have proof of identity & my medical insurance card. The latter is mainly to make it harder for illegal aliens (who can only get help in case of lifethreatening diseases).

My kids got two dental checkups a year in the basic care, and around 6 yrs their teeth are 'sealed' when they get their real teeth/molars (they fill the tracks in the molar surface, so food can't get in there).

In practise we still see that a lot of kids in poorer area's won't go to the dentist. Parents aren't sure it is free and aren't used to visiting dentists twice a year. If you only go when a kid has pain, you usually are too late and the teeth allready are bad. A lot of people need better information too; giving babies a bottle of milk (or even juice/lemonade) in bed for comfort is a disastrous yet very common habit for instance.

[dutchmarbel]

I looked up the stats, and 20% of the kids under 14 don't (or hardly) go to the dentist, and about a quarter of those have really bad teeth allready.

90% of the holes in the teeth of 5yo kids are not treated (often because parents assume that it doesn't matter when it is in milkteeth).

In other words: free dental care is not enough. Though it could have prevented this case.

[Michael Cain]

But part of the reason is also that Medicaid, which covered them for a while, doesn't reimburse dentists well enough, and as a result dentists who accept Medicaid patients are hard to find.

I have an acquaintance who owns a firm that operates a chain of dental clinics, which accept only children who qualify for Medicaid as patients. I have asked how he manages to operate at a modest profit when I hear so many complaints that Medicaid doesn't pay well enough. His answer is that the difference is in the paperwork. Each of his clinics need deal with only a single process and set of forms, and they can handle that set very efficiently. If he had to staff to handle dozens of insurance plans, he says, Medicaid wouldn't be paying enough.

[Jesurgislac]

Marbel, when I was a kid at primary school there was a free annual checkup by a dentist at school: I don't know if UK schools still do this (come to that, I don't know if all schools did it then - our headteacher was a bastard, but very pro-active in getting "his school" into every program going - we were the only primary school in the area with our own swimming pool, for example) - but it meant every child under 11 got their teeth checked at least once a year, and a letter sent home to their parents - by post, as I recall, instead of the usual by-hand delivery - if anything needed to be done. I don't know, but I would guess the letter explained that treatment would be free.

[Hartmut]

Over here there is actually an incentive to visit the dentist twice a year. If you do for a number of years (in steps of five), you have to pay less for treatment that is not completely covered by the basic insurance.
Unfortunately the prophylaxis bonus is shrinking despite it saving money in the long term.

[dutchmarbel]

Jesurgislac: we had those too, but they changed that system a few years ago. On one hand bad - less dentist visits. On the other hand; I have some horrible memories of the school dentists I've seen in those years. I'm still scared to go to the dentist, which is why I treasure my current dentist - finding another one is really scary.

I still believe that good information is as important as free dental care, but I am used to our socialized culture of course ;)

[nonvelocitous]

Yes, you forgot one "if"

If these children's mother had made sure they brushed their f*cking teeth, one would not be dead and the other wouldn't have six, SIX! abscessed teeth.

Yes, Medicaid should be fixed etc. etc. but that is criminal child abuse.

[Hartmut]

I brush my teeth thoroughly at least twice a day and still 5 teeth had to be extracted, 1 crowned, 1 root-resected and 1 root-canaled.
Okay, 4 of them were the #8s that came up the wrong way and would have catapulted the #7s out, if not removed. Bad teeth can run in the family even with the best dental hygiene.
So, before someone shows to me that the children didn't fall into that category, I am not willing to accuse anyone of abuse in that matter.

[Jesurgislac]

nonvelocitous, I brushed my teeth twice a day under supervision from my mom, because I had terrible milk teeth - some pharmaceutical drug I was given when I was two, so I was told, because my brother and sister didn't have this problem - and I still had fillings and extractions - I lost 6 milk teeth by extraction because they were too rotted to be saved. But I had free dental treatment.

[RW]

*****But I had free dental treatment.****

I wonder what the people who actually pay for it think about all these 'free' services. Lord knows the USA's "free" education system is just fantastic, especially in the inner-cities where the 'free' high school scores are wonderful.

Criminey...

[dutchmarbel]

I have bad teeth too, despite brushing properly with adult supervision. My mum actually paid for a private dentist because she wanted to make sure we had the best care (and she had to take care of three kids by herself, on a low paid job). No extractions (except wisdom teeth - not enough room), but two crowns, three root canals and if they still used metal fillings I'd be able to listen to radio directly ;)

[Phil]

Lord knows the USA's "free" education system is just fantastic, especially in the inner-cities where the 'free' high school scores are wonderful.

Criminey...

As opposed to the SAT curve-breakers pouring out of Missisippi and Alabama, I suppose.

[John Thullen]

I began taking flossing seriously after watching "Marathon Man".

Is it safe? No, it's not, especially if you've undergone muttiple years of orthodonture in your tender youth. The sheer, frightening apprehension as the rather severe-looking dental assistant arranges the gleaming instruments on the chrome tray is enough to make me consider jumping out of a window.

Not for me the Bill Murray masochist to Steve Martin's sadist.

I have a distant memory of a humorless orthodontist putting his foot against my chest to hold me down as he tightened the braces with a pair of large pliers.

Maybe that was a W.C. Fields short.

To this day, my heart sinks when the cheerful dentists of today hold the X-rays up to the light and announce that I have a small cavity.

My eyes roll around looking for an escape route.

[Jesurgislac]

RW: I wonder what the people who actually pay for it think about all these 'free' services.

True, RW, I didn't pay a thing for all those visits to the dentist, or to the optician, or the doctor, until I got my first job. Then I started paying National Insurance stamp tax, like every other working adult in Britain, and I've been paying ever since. I've told political representatives, and answered polls, and voted in elections, for raising the stamp tax to improve the NHS. Every working adult in Britain pays for the NHS, and it's the most popular single state-run institution in the country. Even Margaret Thatcher, who loved to sell off publicly-owned institutions to people who could afford to buy them (Two Cows Thatcherism: "You and your neighbors own a herd of cows and share the milk. The government sells them. You're allowed to buy two.") knew she didn't dare touch the NHS, though for 19 years of Conservative economy, it was systematically starved of funds.

The people who actually pay for the free-at-point-of-use services use these free services, RW. Of course we complain about them. It's our NHS and we have a right to. But at least we try to stop kids dying of tooth abcesses because their mom can't afford a dentist.

[BigHank53]

I will reiterate the bad-teeth point: the resistance of teeth to decay is largely out of the hands of the owner of said teeth. Most people here are too old to recall the last big mumps epidemic in the US. Thousands of kids who were growing adult teeth when they got sick wound up with teeth made of chalk, and many of them had full dentures before graduating from high school.

The part that astonishes me about single-payer health care arguments is how quickly the topic of people 'stealing' medical care comes up. (Cue 'welfare queen' theme music!) What deep part of Americans' psyche is so horrifed at the thought of a poor person getting something for free?

[Peter Clay]

Look, the eligability thing is easy. You deal with it via the following procedure:

1) Treat the person if they need medical care.
2) Fund hospitals so they can treat the number of people that require care.

Eligability and identity have never been a signifigant issue in the NHS.

What deep part of Americans' psyche is so horrifed at the thought of a poor person getting something for free?

This is the real problem.

[Eric]

I am a dentist who practices in the public health sector. Demonte's death is very tragic I think everyone can agree. While I do champion a universal health care system.. I also believe that lack of parenting plays a HUGE role here. If Demonte's mother would have cared enough about him to make sure he brushed his teeth he'd still be alive... without a question. I believe everyone should have access to care. I also believe Demonte's mom should be prosecuted for neglect and relieved of her responsibilities as a parent... she obviously does not measure up.