SADOW: They’re Arguing About Dentists, But The Real Fight Is About Responsibility

An intramural argument has broken out between the dentistry profession and those seeking expanded dental preventive care for children of poorer families. But unless a larger question is resolved first, regardless of which side gains the upper policy hand taxpayers will be the loser.

In the wild, wide world of Medicaid coverage, dentistry is an outlier with federal law and regulation essentially making its provision optional. Louisiana provides some emergency care, although it recently had to drop regular care for expectant mothers due to budget concerns. But what many don’t realize is dental care is available to these children in one area, right at their schools, where some perform sealant procedures on teeth, designed to reduce the incidence of cavities that may prevent future access of Medicaid emergency-based services.

In fact, as of the latest statistics available, Louisiana is rife with such clinics, which were encouraged to be established by the state by legislation in 1991 and now have 64, which ranks ninth highest in number but sixth-most per capita. Should a school establish one, they are not cheap; the state Department of Health and Hospitals requires a minimum of six different kinds of professionals mandating six broad areas of performance.

One optional service, requiring an additional professional, is dentistry. And on the heels of a report criticizing the state (and many others) for lack of access to sealants in school-based programs, has triggered a policy debate over Louisiana, and a handful of other states, requiring prior dental examination for authorization of applying sealant, which does not have to be done by a dentist and can be performed by a specially-trained hygienist. The state’s dental profession argues trained dentists should make the call on whether a sealant is appropriate (as something more drastic like a filling may be better), while others, including the report’s authors, say hygienists can be trained to do this.

We’ll leave it to the professionals in the field to debate what kind of training is appropriate. Of greater concern is adding this to the extensive menu already operating at school-based clinics, in part because of controversy over the value of sealants themselves compared to a simple regiment of regular brushing and flossing and the expertise in knowing when and if it is appropriate to do it.

Sealants have no utility when basic, adequate oral hygiene care is performed. They only have value when the process of decay has begun, in an attempt to slow it. Unfortunately, it is used as a substitute for learning these beneficial habits and having them provided free and willy-nilly in school-based clinics only discourages acquisition of these habits and encourages taxpayers footing the bill for a treatment unnecessary in almost all cases if families would just take some personal responsibility.

It should be the job of government to promote this responsibility. Thus, the real policy debate should be over whether to allow school-based clinics, which already function far beyond immediate and emergency care by provision of preventive services in other areas, even to offer this particular service. The wisest course would be not.

Instead, the state should mandate, just like every year before enrolling for the school year proof of certain vaccinations must be provided, that all children have had a dental exam. If as a result of that parents wish to have sealant for their child, they may go for it out of their own resources – insurance, out of pocket, or by charity, with no government financing, just like in paying for the exam. Denied the easy, taxpayer-financed option, this will spur families to take dental care more seriously if faced with the consequences of poor decision-making in this regard, lowering aggregate costs systemwide. If school-based clinics wish to contribute, they can dispense toothbrushes and floss and instructional materials on their use.

It’s not government’s job to make one’s life easier, but to create the opportunity to make it better. Fostering personal responsibility through use of financial and regulatory incentives can accomplish that. The real argument isn’t over who can authorize and apply sealant, but whether school-based clinics ought to be in the business of doing this at all. And they shouldn’t be.

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