The inequitable distribution of professional dental care is a major concern facing the field of dentistry. Of course, dental institutions such as the American Dental Association and dental schools are clearly aware of this issue. There is conflict, however, between the private practice model and the oral health needs of the U.S. population. The private practice model currently privileges a dentist’s decision to practice in certain areas while not in others and to provide care to certain individuals while not others. This paper focuses on how the choices of dentists negatively affect the equitable distribution of dental services and examines the extent to which dental schools and the government ought to respect the autonomous decisions made by graduating dental students and private practicing dentists to serve wealthier populations while not underserved ones.
Health officials have offered many different policies at an attempt to fix a broad range of access to dental care issues by focusing on how dental schools and private practices are structured. However, many of these policies avoid addressing the issue of dentists’ refusal of service to underserved populations, and so fail to effectively address present inequalities in dental service and professional obligation. I argue that the private practice model, which favors the autonomy of dentists over effective policies that aim to fix inequities in dental services, should be gradually replaced with programs that locate health professionals to populations with oral care demand and ones that require professionals to address health inequities in dental service more effectively. This recommendation raises issues of desert and paternalism, which are addressed throughout the paper.
Professional Dissonance and Just Desert
There seems to be a clash between the different characterizations of dentistry as a worthwhile and publicly needed career. Dharamsi and MacEntee sugguest that there are“tensions between the moral values that identify it as a health profession and the commercial values of practice where the impetus is on entrepreneurial self-interest” (324). Prospective students who stubble over American Dental Association’s “Be a Dentist” webpage may not at first notice this kind of inconsistency. Examining American Dental Association’s “Ten Great Reasons to Be a Dentist,” dentistry is certainly an appealing field for both the first reason, i.e., “Service to Others: Help people maintain and improve their oral health, quality of life and appearance,” and the tenth, i.e., “Self-Employment: Own a dental practice and be your own boss” (“Be a Dentist”). However, I find it inappropriate for ADA to simply encourage potential students to pursue a career in dentistry by acknowledging that “in 2009, the average earnings for a general practitioner who owns his/her practice was over $207,000” and to claim that dentistry needs motivated students because “a ten-year-old, who has very limited access to dental care dies from an abscessed tooth that has been left untreated for a very long time” (“Be a Dentist”).
Many practicing dentists and dental students may disagree with my criticisms of organized dentistry for indulging entrepreneurial pursuits. One question they may arise for many is: “don’t dentists deserve such high compensation for the good they do for society?” An agent who intentionally seeks to gain specialized knowledge and a specialized skill set gives him or her the potential to do much good (i.e., improve the mental or physical health of others) in some cases and even much harm (i.e., worsen or cause disease) in others. One is not entitled compensation simply for understanding or retaining large amounts of valuable knowledge/skills, but for utilizing this potential for doing good. Since dentists possess knowledge and skills that are both valuable for improving mental and physical health, it is only when they materialize that value onto select patients are dentists deserving of reward. So, obviously dentists deserve some level of reward for the good they do for society.
I remind them, however, that the prima facie principle of justice requires the health professional to distribute his or her dental services in a equitable manner (Gillon 184). It must also be taken into account that the knowledge and skills a dentist utilizes ought to be distributed equitably to those in need rather than those that can simply afford it. Illnesses and physiological pain are no more different from populations who easily can afford care and those that cannot. Thus, the level of compensation a dentist ought to receive can only be determined once distribution of dental service is equitized according to need rather than affordability. Also, a board certified dentist is one who becomes a health professional (Welie 675). And as a health professional, a dentist is expected by the public to care for its dental care needs and overall oral health since they lack the means to do so. Public trust is connected to the level of respect and the amount of profit a dentist enjoys from his or her practice. Taking on the role of a health professional and diverging from what is expected by the public is morally and finically exploitive.
Inequitable Distribution of Resources
Which areas a dentist chooses to work, how he or she structures his or her practice, and whom he or she accepts as patients partly determine which parts of the public have access to certain dental services. Though dentistry is a field where individual dentists are allowed to a large degree to set up private practices based on their own interests, to what extent should dentists be allowed to balance their entrepreneurial interests with pursuits to ensure equitable distribution of dental services? Current inequalities in the distribution of dental services suggest that too much power has been given to individual dentists and that the field of dentistry is not upholding to what the public expects.
Garcia et al. make aware that there is a “maldistribution of dentists, with few practicing in areas that are economically disadvantaged” and that “while we may have a system that provides dental care for those who can afford it, it fails to provide basic preventive and primary oral health services for nearly one-third of Americans” (S59). Fisher-Owens et al. point out that “lower-income, less-educated, and racial/ethnic minority populations have higher prevalence of caries, periodontal diseases, and oral cancer than other adults have” (406). Delivery of dental care based on a private practice system neglects these populations as well as military members/veterans and prisoners (409). What is more unfortunate is that private dental offices are even located in populations with lower disease rates than areas with higher oral health care needs (Garcia et al. S60). Garcia explains that this is probably due to the fact that populations of higher socioeconomic status individuals are healthier than ones of lower status (S60). The current system of distributing professional dental care service is not equitable according to need.
The issue is not simply that private practicing dentists do not practice in areas where there is greatest need of dental services. Private practicing dentists, in areas they are well represented in, also refuse services to some that demand it and even have the means to afford treatment. The National Academy for State Health Policy states that “dentists’ participation in Medicaid is also very low, with fewer than one in four dentists seeing at least 100 Medicaid patients in a year” (Borchgrevink, Snyder, and Gehshan 1). Practicing dentists usually cite 1.) low reimbursement rates, 2.) burdensome administrative requirements, and 3.) problematic patient behaviors as reasons for refusal of service (1). It is the case that Medicaid paperwork and regulations are excessive or difficult to follow and that there is complex set of circumstances which prevent many Medicaid patients from complying with dental appointments and a dentist’s instructions (U.S. General Accounting Office 12). Thus, the second and third citied reasons are usually out of the dentist’s control and are so legitimate reasons.
However, claiming that reimbursements rates are less legitimate for a health professional to cite. The U.S. General Accounting Office (GAO) states that “for dentists, the fees they charge are fairly representative of the amounts they generally collect,” which is usually around 95% of the price charged (12). Welie implies that the actual problem is that too many dentists are attending how-to-build-a-million-dollar-practice secessions and are spending too much focus on making money on cosmetic procedures (678). He warns that though dentistry was largely a business before the mid 19thcentury, “it could certainly revert to that status once again” (678). More and more private practicing dentists seem to be swayed by entrepreneurial interests rather than professional obligations to treat disease.
Dentistry as an entrepreneurial pursuit has also hindered pursuits to address inequalities in the distribution of dental services in certain areas. Catalanotto makes aware that “in response to the University of Florida College of Dentistry’s Robert Wood Johnson Pipeline grant proposal to develop a student rotation in the local community college dental hygiene program to improve access to oral health care on the west side of town, the local dental society in Alachua County wrote to the president of the University of Florida expressing concerns about potential competition” (1121). The author argues that political pressure from private dentists largely prevented needed oral care from reaching those underserved populations located around the university (1121). Such political conflicts look poorly on the field and hinder the public’s trust in organized dentistry to fix inequalities in oral health. Power should be redistributed away from dentists who are able to neglectfully utilize the private practice model toward government and public health officials to rebuild the trust of the public in a genuine manner.
Promoting Professional Responsibility
In addition to mending the trust between professional dentistry and the public, power in the field of dentistry must be structured to ensure that the inequitable distribution of dental service, which disproportionately affects low-income children, veterans, minorities, etc., is addressed more effectively. Many of the policies suggested by health officials simply attempt to avoid paternalistic policies or try to panderer to the existing private practice model. As a consequence, these polices neither effectively address inequalities in professional dental service or hold all professional dentists responsible to meet the needs of the public in an equitable manner. As the ethical nature and effectiveness of present policies are evaluated on the basis of past attempts and economic trends, the need for enacting paternalistic policies that require compliance by all dentists gradually becomes unavoidable.
Dentistry remains to be the least diverse health care profession (Fisher-Owens et al.407). Improving the representation of minority dentists is a substantial goal to meet for many philosophical reasons. Since “dentists from minority populations are more likely than whites to practice in underserved, minority communities,” one suggestion is that underrepresented minorities should be recruited to improve access to dental care for underserved populations (407). I find that this deliberate recruitment places too much burden, however, on minorities to address inequities in dental service. All health professionals, not just certain groups, are required to distribute their health services in an equitable manner.
Obviously, a dentist cannot be expected to provide equal amount of service to everyone in the world; this would be physically impossible. However, they are able to provide their services equitably (i.e., each dentist should take an equal share of the responsibility to provide dental service to underserved, minorities as part of an organized health profession). I agree that having a dentist from a specific Native American tribe is needed in a Native American reservation of the same tribe as to promote the autonomy of the tribe and utilization of dental services. On the other hand, relying on minority dentists in general to treat underserved, minority patients softens the responsibly that non-minorities have to treat minorities. This type of policy legitimatizes the ability of dentists to refuse service to patients based on racial preferences, and so panders to the existing private practice model. Policies should be designed to promote the professional obligations of all dentists, than give such weight to their preferences.
Nurturing Future Professionals
Catalanotto raises the concern that dental students may lack the first-hand experience or awareness of the extent to which the dental service is inequitably distributed (1121-2). On the other hand, Dharamsi and MacEntee insist that “dental professionals, like other health professionals, are well aware that the public expects oral health-related services that are effective, accessible, available and affordable” (323). Of course, offering service-learning type experiences (e.g. Pipeline, Profession, and Practice program) may aide in producing “graduates who desire to fulfill their obligations to society and serve the public good” (Daviset al. 1009). These nurturing programs provide the necessary skills and exposure to equitize the mal-distribution of dental service.
However, service-learning experience fails to incite dental students more than educational debt discourages them. As suggested by Bailit et al., dental school graduates are less willing to treat underserved patients as the amount of debt they maintain increases (255). A study done by Davidson et al. demonstrates that “access to a state or federally sponsored loan repayment program was the most significant predictor of public service plans” (73). Analyzing over 5 years of trend data of the Pipeline Program, these researchers found that the percentage of students planning to serve underserved populations remanded at a flat rate of 8-10% and concluded that the program “had no significant effect on the public service plans of dental school seniors” (75). Even after first-hand knowledge of inequities, it does not seem that dental students are able to accept the responsibilities that come with ensuring the inequitable distribution of dental services on their own.
It is obvious that “graduating socially aware, culturally sensitive, and community-oriented practitioners” is what the public expects and is needed to improve other barriers to access, such as language and patient’s perceptions of oral problems (Davis et al.1018). More dental schools ought to adopt such programs so that dentists are equipped to care for populations that lack access to needed oral care. However, being qualified to serve certain underserved populations clearly does not ensure that the dentist necessarily will, given the limitation of educational debt. Davidson et al.finds that it is “unlikely that the cost of dental school will decline” in the near future (77). Four-year cost of education is projected to increase by more than $50,000 for non-resident and around $30,000 for resident dental students by 2015 (Bailit et al.252). Officials advocating for programs that aim to nurture future dentists into public servants fail to take into account that current commercial values hinder nurturing efforts.
Publicly Funded Programs
Wall and Brown suggest that “nonmarket programs” such as publicly funded programs will be “necessary to supplement market forces” to ensure that professional dental service is equitable (1009). By publicly funded programs, these authors are referring to the National Health Service Corps (NHSC), Indian Health Service (IHS), etc. The NHSC offers scholarships and educational loan repayment plans to dental care providers who agree to “accept Medicare and Medicaid patients and offer a sliding fee scale based on the patient’s ability to pay” (U.S. General Accounting Office 9). The U.S. GAO reports that many newly graduating dentists have participated and that the number participating has grown from its initial implementation (9). The appeal that these kinds of programs have for dental students is not surprising (see Nurturing Future Professionals section). This policy may be the most effective one aimed at getting graduating dental students to offer their services to underserved populations since educational debt is the greatest reported barrier to service.
One problem with these federally funded programs is that they tend to have “relatively small capacity to provide dental care, especially when compared with the total number of Medicaid patients and other low-income or vulnerable people” (U.S. General Accounting Office 19). Another problem is that since these programs usually require only a minimum of two years of compliance, publicly funded load repayment programs are only short-term solutions for fixing inequities in dental service. Ensuring that participating dentists continue to practice in underserved areas requires even more financial incentive. And the issue of the program’s capacity (i.e., it’s available federal or state funding) once again arises when trying to expand the program to include more recent graduates who wish to participate for just the minimum two-year period. Publicly funded programs do not simply have the finical capacity for promoting the equitable distribution of dental service.
The weakness of publicly funded programs to promote equitable distribution of dental services amongst newly graduating dental students does not only stem from the fact that they require vast amounts of public capital and are short-term solutions. They attempt to entice dental professionals with money rather than require them to fulfill their obligations to the public. Available public funding should be directed toward supporting dental clinics that cannot be sustained by market forces alone rather than attracting heavily debated dental school graduates. Graduating dental students should be required to participate in these programs to fix the inequitable distribution of dental service, rather than be paid to uphold their obligations to the public.
While publicly funded programs are currently the most effective way to motivate graduate students to provide oral care to underserved populations, what about inciting practicing dentists to meet obligations to distribute their services equitably? Philanthropic programs are suggested as a viable method for dentists to fulfill the needs of underserved members of their communities (Wall and Brown 1009). These officials must be reminded that “only 2.4 percent of total dental expenditures” consisted of uncompensated care, in 1998 (Catalanotto 1121). Comparing this to the “5 percent of total physician expenditures” in uncompensated care, it can be understood that dentists can do much more to address access to dental service issues (1121).
It seems that insisting on the advocacy for philanthropic dental work is a very wish-full strategy since “data from the American Dental Association demonstrate that while dentists’ mean net income increased approximately 35 percent from 1996 to 1999, free dental care provided by dentists decreased 6.6 percent and discounted dental care decreased about 10 percent” (Catalanotto 1121). Focusing on implementing philanthropic programs brings its own challenges of organizing them and only attempts to complement the current private practice system, which privileges those that can afford care. Philanthropic programs rely on the deliberation of the same dentists who are reluctant to address inequalities in the first place. Though more funding is needed for the organization of philanthropic programs, government officials should look at designing programs that require the participation of practicing dentists as to equitize the distribute of dental services more effectively.
The amount of money dentists make on average currently is the result of an unjust system that tends to privilege those who can afford dental care and neglects those that cannot. Though dentists are bound by the principle of justice and their role as health professionals to meet the public’s expectations, the field of dentistry is lacking in its effectiveness to fix the inequitable distribution of dental services. As long as dentists are allowed to place their entrepreneurial interests and preferences over their obligations to provide care to those that need and demand it, dentistry is neglectful and exploitative toward the public it supposedly serves.
Policies advocated for by health officials tend to be too soft on dental students and practicing dentists. Health officials suggest policies that are compatible with the private practice model and give excessive weight to the commercial values held by dental students and practicing dentists. Programs that nurture future dental students, provide educational debt forgiveness, organize philanthropic dental care, and promote equal representation of racial groups are needed, but they do not hold all dentists responsible for fixing current inequalities in dental service. I urge that dentistry should be further removed from its entrepreneurial heritage, and toward one that meets its moral obligations to society.
 Public Health dual-enrollment programs in dental schools may also seem promising but they usually require more years of education, at least an extra year, and so more educational debt. Thus, they fall suspect to the same restriction that other programs aimed at nurturing dentists do.
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