Seven Days in November:
Healthcare and the Road Ahead

As if an acrimonious campaign and stunning election were not enough, the past seven days have been rife with anxiety and fear that the Republic is crumbling. In healthcare, the Affordable Care Act (ACA), Medicare, Medicaid–and you name it–many federal entitlements– are at risk of evisceration, with nothing substantive to replace it intended or on the drawing board. How will people get and afford healthcare under this order with no safety net?

Today, PatientPOV returns to its roots and gets back to the work of uncovering the gaps between the powers that be and the people. Any of us could be patients and caregivers at some point in our lives. Some of us have had terrible illnesses, been taken up with caregiving, and as a result, experienced economic hardships and disruption in work.

In the past few days, I began to talk with people in red states who are worried about the future of healthcare as the new order frames it. It’s premature to put it into a story, but I will write about it soon.

During the campaign, Trump didn’t have much of a health plan unless you want to call promoting health savings accounts a platform. But health savings accounts are largely limited to people with disposable incomes who can shelter money for health expenses. It’s not insurance at all. Clearly, health savings accounts were the bare minimum that alone, would not fly, post-election.

In the last seven days, Trump and Republican leaders sure have amplified their intentions. Now we are hearing about the dismantling of popular programs that have insured millions or provided a a safety net for many others. It’s overwhelming to consider the programs Trump and Republican leaders are earmarking for extinction. But I hope to air here people’s discontent about the proposed overhaul of healthcare as we know it.

If you’ve got something to say about this, please put it in the comments below. To quote Yogi: “It’s not over till it’s over.” It’s been seven days. Stand up now. Get ready for the long haul. It’s the only way forward.


My $5,000 Tooth and the Institute of Medicine Dental Report

What a coincidence! The Institute of Medicine released a report today titled Improving Access to Oral Health Care for Vulnerable and Underserved Populations and I am one step further in my saga of trying to save a tooth! It is looking good in the save-the-tooth department, but this dental care is breaking my wallet. I lost a bit of time this week blogging and working because of pain. I don’t have the money to pay for this.

I am sad to say that no matter what I do, in New York City, this was bound to cost me thousands of dollars. I have no dental insurance. Not mentioned in the report are the extraordinary numbers of Americans out of work. Affordability is mentioned, of course, but the report doesn’t get into fixing that very much. Dental care is a luxury for people unemployed or under-employed and I put myself in that camp. I have been in a tizzy about what to do most of this week.

The Limits of Shared Decision Making

The shared decision making (SDM) people would have thought the world of my dentist, who kept trying to explain various treatment options, as if I was sizing up whether to buy a sofa, or a loveseat and a chair, or two chairs. Missing from the script was any discussion of dollars, as if it was a variable that was beyond the scope of the decision-making. I think that is a big mistake. I was buoyed this week, when an SDM proponent told me that the community is debating just how to bring $$ into treatment discussions.

I investigated the $$ situation on my own. I quickly learned that the cheapest course of care would have been pulling the tooth and getting a flipper (a tooth that you remove at night).  This is the course of action that the poor and the vulnerable get. But the other options—#2 – a root canal plus a post, core, and crown, can put you out a few thousand dollars. That is what I opted for. Option 3 is a tooth pull, combined with an implant,  a crown, and depending on the tooth, possibly a sinus flap, that can put you out thousands of dollars. It’s not uncommon to see payment plan brochures at dental offices, meaning that in the end, the dentist gets these fees, plus you shell out interest, bringing your out of pocket costs way up.

In high school, I had an after-school job with a dentist, who ended up removing teeth in an emergency for a lot of first-generation immigrants. Aside from preparing his instruments, my job was to hold the hands of these people; many came to the office in agony. Some had tried unsuccessfully to pull their own teeth. For the most part, we didn’t see these people again for a bridge. Some lived with a half a set of teeth. It was one of the first jobs where I felt that I was helping people feel better. I cannot say it is reassuring to see that, years later, I am in the same predicament as new immigrants in seeking dental care. I have worked hard all my life, but I cannot afford quality dental care.

Well, I am glad that Congress got the IOM panel to look at dental care for the poor and underserved, but I know that the Health Resources and Service Administration and the California Healthcare Foundation did not quite have me in mind when they solicited this report. It addresses vulnerable and underserved children, Medicaid, and Medicare patients, showing that in 2006, 4.6 million children missed dental check-ups, only 38 percent of retirees had dental coverage,  Medicaid providers are poorly reimbursed. I agree that these are  high-priority populations for basic dental coverage.

The report recommends expansion of the use of dental hygienists and assistants in areas of high need, underserved areas. The American Dental Association praised the report in a statement, particularly applauding the recommendation of increasing Medicaid reimbursement and support  for dental training programs.  If initiatives come forward that threaten the income of dentists in caring for less vulnerable, patients , it would not surprise me if ADA caused a ruckus.

I am glad that dental health care is being discussed nationally, but I can’t say the IOM report is cause for encouragement. Across town from the Institute of Medicine, major efforts are afoot to dismantle Medicare and Medicaid. I don’t see dental care becoming affordable for the vast numbers of Americans.