Think about the medical knowledge base we have today and how was it formed, who suffered to get it, and who can legally use it?  I am trying to show that we really do have a logical and ethical obligation to provide basic, meaningful healthcare to all, and if we as a society choose to delegate or restrict the provision of such healthcare to a certain profession, well then that profession assumes this social obligation.  First answers to the above questions.

— the medical knowledge base we have today was formed by trial and error experiments on people and animals in the existing world of the past.

–who suffered to get it?– All our relatives for the past hundreds of years.

–who can legally use it?–In the US, certain professions such as Medicine and Dentistry have been granted the sole privilege of using this knowledge hopefully for the good of mankind.  It is illegal for others to use this knowledge in a business relationship without the indirect/direct certification of the profession and the direct certification of the state (licensure and scope of practice laws)!

Given this analysis, how is it that many of our citizens lack access to these chosen, privileged providers.  Is this situation proper, whose obligation is it to try and fix the problem, and is anything happening.

Access to care problems seem to center on two main issues, finding a provider and paying that provider.  As I said above, only providers certified by these privileged professions and the State can give the care.  Paying for the care, which is often too expensive for many/most individuals to afford directly is through third party payers.  However about 20% of Americans (>40 million people) have no third party payer.

As for finding a provider, many poor people in especially rural areas are blocked out of access to good care by a combination of not enough certified providers, and the refusal of many of these certified providers to see the poor, who may or may not have safety net insurance (Medicaid). This problem is true in both Medicine and Dentistry, but it is and has been especially acute in Dentistry.  There has been much talk in America about health insurance reform and single payer versus consumer pay etc., but there has not been much talk about the supplier side issues that drive up cost and limit/prevent access.  I want to deal with some of these issues in the rest of this diary using dentistry (which I am very familiar with) as my main example.
Medicine began using lesser trained auxiliaries as providers 30 or so years ago, and it may well be that change that has kept the lid on the system from failing at least for now.  Dentistry in America has heretofore refused to allow real, independent midlevel providers claiming that it is a patient safety issue. However, midlevel medical providers have not proven to be dangerous, and mid-level independent dental therapists have been used successfully in Australia, New Zealand, and Canada for 50 or more years.  

In rural Alaska, dental disease is rampant, and nobody in the dental profession seems to care much about leaving the disease alone.  If dentists are not available to treat the disease (and they are not), then let the people suffer.  I mean it is a patient safety issue isn’t it??  What about the disease dangers however?  Well when some public health and tribal efforts try to do something about this chronic problem, namely to train midlevel therapist to treat these folks according to the New Zealand model, well here comes organized dentistry to claim foul.  Where are they with real solution ideas when there is only suffering?  Read the article below about organized dentistry’s attempt to stop the University of Washington from being the first University in America to offer a training program for mid-level dental therapists.

Here is a link and excerpt from the article
UW debates dental therapy program for Alaskans

What do New Zealand trained-dental health therapists and tooth decay in Alaska have to do with the University of Washington? Quite a mouthful, as it turns out.

In a guest column published by The Seattle Post-Intelligencer on June 29, Peter Milgrom, a UW faculty member in dental public health, accused the UW dental and medical schools of abandoning Native Alaskans and their oral health.

At issue is a pending application with the W.K. Kellogg Foundation, applied for by the UW School of Medicine’s MEDEX Northwest, a physician assistant program, and the Alaska Native Tribal Health Consortium (ANTHC) 18 months ago.

The $2.5-million grant would provide 24 months of Alaska-based training for eight to 10 dental health aide therapists (DHAT). Upon completion, the DHATs would be able to assume mid-level oral-health functions and treat Native Alaskans in their communities on a year-round basis. The program would be administered by the UW’s MEDEX Northwest campus in Bethel, Alaska.

Native Alaskans’ rate of tooth decay is at least two and a half times that of the general population. Dentists are scarce in rural Alaska where most Native Alaskans live — many villages are accessible only by plane or snowmobile.

“Because of ADA [American Dental Association] opposition, no therapist program has ever been mounted in a United States university,” Milgrom wrote.

If any profession is derelict in meeting its social access obligation, it should expect society to take its monopoly away!  In the healthcare access crisis in America, both affordability issues and provider type issues will have to be addressed for any meaningful solutions to happen, and these issues are directly related, IMO.  We will never be able to train and afford the number of doctors and dentists, as they are currently trained and paid, to do everything people will need.  We must be less guild conscious and more outcomes conscious in our scope of practice definitions so that number of providers and future costs of care can be kept at a reasonable level with adequate access to care for all.  It is all related, and some professional obligation to cooperate and even directly solve the problem should be demanded by the public. (See Poll)