America’s dental-health divide
washingtonpost.com
washingtonpost.com
Systemically, we have to consider the costs of dentistry and why they are high; we have to consider the hand of the insurance company and their price regulation; the costs of materials; the costs of running a small office & regulatory compliance of same; the costs of dental school; and more. This is largely an exercise in system thinking and determining which lever is most effeciacious in improving public health outcomes. Insurance regulation is a narrow way to affect costs without disrupting the choices dentists and patients have made in their life regarding location, choice of careers, etc.
Grew up poor, but we had floridated mouthwash to help cope with well water, and my parents made sure we hit the dentist 2x a year for cleaning & sealants. I wonder if the cost curves for dental care are different now, 20 years later. I'm very grateful to them for taking me to the dentist as diligently as they did.
These days I have dental insurance, but still do the 2x/year clean.
Anecdotally, I always drank bottled water growing up in the US. I also never had a cavity. Is it genetic? Both of my parents have terrifying teeth issues. Is it diet? Partly - thanks to my mom, I was never obsessed about sweets.
Anecdotes aside, why does fluoride belong in drinking water?
In summary: The beneficial and the detrimental effects of fluoride naturally present in water were well established by the early 1940s. High levels of fluoride present in concentrations up to 10 mg l–1 were associated with dental fluorosis (yellowish or brownish striations or mottling of the enamel) while low levels of fluoride, less than 0.1 mg l–1, were associated with high levels of dental decay (Edmunds and Smedley, 1996), although poor nutritional status is also an important contributory factor. Concentrations in drinking-water of about 1 mg l–1 are associated with a lower incidence of dental caries, particularly in children, whereas excess intake of fluoride can result in dental fluorosis. In severe cases this can result in erosion of enamel. The margin between the beneficial effects of fluoride and the occurrence of dental fluorosis is small and public health programmes seek to retain a suitable balance between the two (IPCS, 2002). The various in
Basically: appropriate amounts of fluoride help your teeth to not decay.
Fluoride belongs in drinking water in much the same way iodine belongs in salt---it's an extremely cheap, low-risk, and effective way to improve public health. Read some of the references for more details https://en.wikipedia.org/wiki/Water_fluoridation#Effectivene... but the short version is that fluoride is safe and effective and because it's so widespread in use, even if you only drink bottled water you're probably getting secondary exposure from other food/drink sources. And if you brush your teeth regularly with a fluoride toothpaste, then you've got that delivery mechanism covering you as well. In the end, the public health benefits are there because fluoridation is pervasive and hard to avoid. By similar argument, you probably also don't have an iodine deficiency because of all the iodized salt in use.
This is interesting because people relying on anecdotal evidence is pretty much the same failure mode for why so many people don't recognize the importance of vaccination. Because it's so pervasive in the US (and other places) it's easy to find stories of "I wasn't vaccinated and I didn't get sick" or similar "I didn't X and Y didn't happen" but it's not just the primary exposure, but all the secondary exposure and effects that also play an important role in public health efforts.
So, I don't think you're factually wrong in most of what you said. But I have to say, you're saying that it's pervasive in other sources besides tap water (since you raise other food/drink sources), but still in your first sentence asserting that it belongs in drinking water.
So I ask you, if these other sources of beneficial fluoride exist (like our toothpaste, or even food/drinks), why would it need to be added to the drinking water?
And why, of all things, would they choose fluoride to add to the drinking water, and not the myriad other minerals/vitamins we're deficient of. I know that's proposterous to imagine - but fluoride somehow made it.
As already stated, fluoride is cheap and safe in the water. Other substances aren't cheap, have risk of overdosing (possibly only for people with sensitivities), or are readily supplied through diet. Some substances may also not be transportable through a water system because they too readily bind with others or don't remain in suspension long enough to reach your faucet.
The people who harp on about this are equivalent to anti-vaxxers. NYC has been fluoridating since 1965, as have other cities. If there were evidence of health problems, surely there would be credible evidence by now.
Free university is about free university not about paying for your cost of living.
Collectively, we should support them, in my judgement. As we're all adults here, we know that some people don't behave well, and that's true universally.
Caveat emptor and all that. I opted out of dental insurance, even though I get my teeth cleaned twice annually. It makes sense to pay out of pocket for me.
Some plans also have bizarre reimbursement, or encourage worse treatment plans. Especially state-run Medicaid, but that's another story.
I have two dentists in my family and when this topic comes up they focus on the Medicaid issues presented in the article. Medicaid reimbursement rates haven't budged in years and for whatever there's a much higher no-show rate among Medicaid patients. The end result is there's no incentive at all for dentists or orthodontists to help these people who need it most.
A lot of people are afraid of the dentist, and I'll bet dollars to donuts that Medicaid isn't allowed to cover sedation dentistry and other enhancements that private insurance or cash patients have access to. Sure, "save your pennies," but think about the situation we're talking about here.
Maybe if you are a dentist. Having not the best teeth myself, people sometimes think I don't clean my teeth.
I think tooth health is actually similar to other parts of human health. If you maintain a healthy lifestyle from childhood on, do all recommended inspections, then everything is likely to be good. However most people don't know better or just don't do better.
Politicians would do good in truly reforming a health system. I'm only aware of one example where efficiency got a 10x improvement, which is the Chinese one in the 50s. It's cool to complain about [insert politician] about cutting health cost but add the end of the day it's not how to solve the problem. Too sad Trump is intellectually too limited to make real cost savings.
Dentists saw what happened to doctors and want no part of it. Dentistry is a simpler business.
My dentist has an outsourced biller and a secretary/clerk.
My GP has 3 clerks, a shared IT guy and two people who argue with insurance companies. His practice had to hire 3 NPs to bring in more revenue.
I'm not sure what exactly an ER would do. I guess they would write a prescription without worrying about whether the patient would pay for the visit.
(There are requirements for certain types of facilities to provide stabilizing treatment without requiring payment; I simply don't know whether the prescription would be part of that.)
It is probably best for species survival that we keep antibiotics behind a wall. But only if that wall comes down when people need it, not only when they pay the toll.
I'm not advocating that people be able to purchase antibiotics without a prescription -- that would lead to more drug resistance. However, I do think that states should consider allowing pharmacists to do more, such as allowing them to prescribe medications in "simple" cases like this. Pharmacists are the most underutilized medical professionals that we have, and using them more effectively could have a big impact.
For instance, lots of doctors would want to check for an abscess.
(I had a cavity on a tooth and the infection irritated that tooth so I had pretty good pain on that tooth and non localized pain along my whole jaw and also had never had such a painful sinus infection and went to the ER because I didn't understand why it was so painful. I bitched at them, they came back with "the doctor wanted to be sure there was no abscess". What really pisses me off is that having the radiologist do the diagnosis kicked the visit up to a more expensive billing code, because apparently it's complicated to do imaging and defer the diagnosis. They bill you to collect the information to make the diagnosis obvious and then bill you more because they collected more information.)
Doctor's advice is just that - advice.
The point is the doctor wanted to check for an abscess.
I think we're speaking to different things, though. I'm simply saying that there are ways for people without health insurance to obtain a prescription for an antibiotic without going to an emergency room and incurring a large debt.
I'm skeptical that a pharmacist would want to accept any liability to sell the $4 of antibiotics. The not simple part (my relating my experience is to argue that it isn't always simple).
I wonder what the doctor you saw would do with someone less sure of their issue.
You're right of course, but having grown up around people in this sort of situation, I'd like to point out that they view debt differently. It's exceedingly unlikely that a trip to the ER is the thing that destroys their otherwise decent credit, and it's unlikely that the collection agency that ultimately buys the debt will take them to court to collect as they don't have anything to put a lien against and may not even have an income to garnish.
In other words "leave you with crippling debt" isn't nearly as scary to the people in that situation as it is to someone who isn't.
I can heavily empathize. In the last 4 years I've had at least 4 life-threatening infections. 2 of them related to dental health, 2 of them unrelated and both leading to temporary paralysis. I couldn't afford insurance and you know how expensive antibiotics are (and dental treatment, of course).
Each time I had to either resort to finding and buying antibiotics on the street or dying within a day or two. I feel so blessed to even be alive today that it brings me to tears.
And then I think about how CorpGov tried everything they could to prevent people like me from having access to healthcare, how I came within hours of death 4 different times and was not provided aid once, and how often this must happen to people who are not as committed and resourceful as I was.
I vividly remember being paralyzed on my bed, only being able to really move my left arm, literally watching an infection travel through my bloodstream as my veins turned red and inflamed, my lungs beginning to feel hard, crying to myself, and falling asleep not knowing if the antibiotics I had found only hours before would kick in and if I would ever wake up again.
That is the healthcare system in America :)
Yes, it may not be as bad as most of Africa's healthcare system, but our government repeatedly makes the claim that we are the best and greatest nation on earth, with unparalleled opportunity for its citizens. If we are going to make that claim, the claim that we are a 1st world country and not a 3rd world country, we have to be able to back it up.
Again, I'm NOT an apologist for the system we have, but I don't understand how it got to this point for you.
I had a bullshit drug conviction from high school when an underage and unlicensed driver rear-ended my friend and I and he had a small amount of pot in his booksack that I didn't know about. The case took two years and about eight appearances, six or so conflicting testimonials by officers present at the scene, and I was given the maximum penalty possible.
I couldn't get a decent job because of the charge and I was being extorted monthly for money by the government. I had no support from family and ended up taking what I could as far as housing arrangements, leading to me getting robbed about half a dozen times by various roommates over the years for a total of a few thousand dollars.
I was still learning CS in my free time so I was limited to part time minimum wage jobs and had no disposable income.
I developed heart palpitations and visited the ER, but they laughed at me and gave me a bunch of useless crap and scans related to my lungs, didn't look at my heart, then gave me a receipt for a sum that vastly outweighed what I was told I would be expected to pay. I was diagnosed with costochondritis, and amazingly, because I mentioned I had smoked marijuana before in my life, I was also diagnosed with "marijuana abuse". I have not paid this medical bill and I consider the experience insulting and unprofessional.
My sister later developed heart palpitations as well, and when she visited the ER she was also discharged with costochondritis. She also owes a hefty hospital bill now. Neither of us know what is wrong with us and have ~1k of debt to show for it. Neither of us can afford more debt because we look in fear at the debt our mother has yet to pay off.
Without insurance or a health care credit card with high interest rates, you're usually expected to pay up front for health care. When I had these dental emergencies and blood infections, I never had enough money up front for the healthcare due to the circumstances described above, and I was not going to rack up another 1k in the ER just to get antibiotics. So it always ended up being only feasible to source them through both friends (who shouldn't have leftover antibiotics) and actual antibiotic distributors.
Any kid who's parents had money in school had braces. I remember hearing parents complain/brag about spending $3,000, $5,000, and even $7,000 on their braces. The other kids? You better hope they came in straight.
Mine came in fairly straight, but like others in my family one of the adult canine teeth never came through. It's still in my upper jaw. The baby tooth is still just barely there, and it's shifted my top row of teeth around a little bit.
The other thing with teeth is you have to take care of them. You have to brush twice a day, you shouldn't eat things that get stuck in there, and avoid crunchy things that can break them.
Even though I had dental insurance from work, I skipped out on going to the dentist after I wasn't living with my parents anymore. And like other hackers, I lived on sugary, acidic, and caffeinated drinks. Years later I succumbed to toothaches, finally went to see the dentist, and spent a couple thousand dollars (with insurance) getting fillings, crowns, root canals, and an extraction or two - all on the rear teeth that nobody can really see.
Back to the top row of front teeth, I saw a orthodontist about having those fixed. When you're an adult, insurance doesn't cover braces. So I was looking at between $10,000 and $12,000 to get it fixed, which would all come out of pocket.
Now, I don't think everyone has the right to perfect teeth, and you can't control everything about how they come in. But most people avoid the dentist until it's too late, they're in pain, need to get in right away, and the fix is expensive procedures like root canals and crowns. If you go every months (a regular visit doesn't cost much, even out of pocket) you can fix a lot of issues while they're cheap and easy to fix.
The bacteria/decay thing is a whole other mostly preventable thing.
Dental insurance doesn't help much with braces. Every dental plan I've seen maxes yearly dental coverage at $1500 or less. And at least one of those is known for having one of the best benefits packages. So while it helps, most of the cost will be out of pocket. So really either way you need $$$.
Combined with the high pressure sales tactics found in the modern dentist's office, is it any wonder people are afraid to go in?
http://www.nytimes.com/2006/05/07/world/europe/07teeth.html
Ouch!
It's one less way to spot at a glance whether someone has a large disposable income.
(#) We have plans that compensate up to 75% of €500 per year, but it will cost you €250. Doesn't really make sense.
You are saying "we are doing fine", but you provide no evidence and no explanation for it.
Social policies should be evaluated by their impact on everybody in the society, not just on you.
If your dentitst mentions gnawing marks on your teeth- get a nightguard as soon as possible. Also get rid of the stressfull situation.
This is truly sad. So many people put their faith in that con artist.
Come to think of it, I can't even remember what Hillary was running on. Bernie was someone I could believe in and wanted to vote for.
Relevant to this article, a goal was to add a public option; along with adding optional Medicare coverage down to age 55 and significantly enhancing the ideas of "community health centers", which are currently pretty effective.
Of course, the goals of a product often conflict with implementation realities in the process of getting it done, so not all the features would have landed, I think. Er, I mean political candidate & campaign promises, not product & features. What was I thinking?
That you don't remember Hillary's policy is an artifact of her marketing combined with the media's coverage, which was not on her policies.
I would also like to see a reference to Trump making the same promise as anigbrowl has claimed. Thanks in advance.
It's interesting that several people in the thread are suggesting that adult dental coverage was going to be part of the ACA insurance overhaul proposals by both Hillary and Trump. I can find no reference to either candidate making such a proposal. Those claiming they did make these promises should provide references showing so.
Can't give that, sorry. I wanted to specifically provide the high-level claims Hillary was making, as GP couldn't recall her promises. My source is the campaign promise book, Stronger Together. Dental is not mentioned in the area I surveyed.
A more policy oriented remark by HRC is found here:
> We need to address the lack of access to primary health care, dental care, and mental health care by catalyzing partnerships between public health departments, health care systems, and community-based organizations. As we do, we must promote integrated mental health care, and enforce insurance coverage parity requirements to ensure that mental health care is not siloed.
http://www.nejm.org/doi/full/10.1056/NEJMsb1612292
Clearly dental was not a headline coverage promise, unfortunately. I'm not sure it would have mattered....
With respect to Trump's promise:
> DAVID MUIR: Let me ask you, Mr. President, about another promise involving Obamacare to repeal it. And you told The Washington Post that your plan to replace Obamacare will include insurance for everybody. That sounds an awful lot like universal coverage.
> PRESIDENT TRUMP: It's going to be -- what my plan is is that I wanna take care of everybody. I'm not gonna leave the lower 20 percent that can't afford insurance. Just so you understand people talk about Obamacare. And I told the Republicans this, the best thing we could do is nothing for two years, let it explode. And then we'll go in and we'll do a new plan and -- and the Democrats will vote for it. Believe me.
Source: http://abcnews.go.com/Politics/transcript-abc-news-anchor-da...
Unfortunately it seems WaPo has merely gone from ignoring some parts of America to simply taking a few safaris there to report on the exotics who voted for Trump and have rotten teeth. WaPo will tire of its safari soon enough and return to its usual class blinders, like reporting about "how hard it is to get into a good college" and then quoting the anxieties of a bunch of upper middle class kids from the Virginia and Maryland suburbs, and somehow it won't be worth mentioning that their parents voted for Clinton.