Politics

How and Why Politics Affect Dentistry

Cathy Mudge

Copyright 2001 Journal of the California Dental Association.

Dental practices are under scrutiny every day. The dynamics of the public, the media, the lawmakers, the regulators, and other special interest groups create endless possibilities for influence over a practice and continue to challenge a dentist’s ability to provide quality dental care to patients. This article describes examples of laws and regulations affecting dentistry and the impetus for them, whether real or perceived.

Politics and government affect a dentist’s ability to practice dentistry. Whether the issue is infection control, employee safety, labor laws, hazardous waste disposal, medical waste disposal, specimen handling, water and air quality, Proposition 65 disclosure requirements, the use of anesthesia, licensing and scope of practice issues for dentists and dental auxiliaries, professional liability insurance, third-party payer policies and reimbursement rates, or government programs such as Denti-Cal and Healthy Families, it can affect a dentist’s ability to practice quality dentistry in California.

California has a Democrat-controlled administration, Senate, and Assembly. The United States has a slight Republican edge with a Republican president and a Republican-dominated House of Representatives. Local governments, although nonpartisan, often lean one way or the other -- liberal or conservative. Government agencies most often reflect the politics of the politicians in the majority. These dynamics change at minimum with every election cycle, and the laws created during each administration are the direct result of many factors.

A short list of some of the federal, state, and local government entities that can affect a dentist’s ability to practice is shown in Table 1.

Government mandates come about for any number of reasons. Voluntary programs can sometimes be used to stave off more formal government solutions. For example, best management practices are being tested in San Francisco to reduce mercury levels in office effluents. If it is determined that those best management practices can be effective in reducing mercury levels, and dental offices consistently follow them, there may be an opportunity to forego more onerous legislative remedies. Dentists’ efforts in this area may very well affect the outcome of this issue. In many cases, however, although voluntary programs may be able to address some of the concerns, lawmakers believe it is necessary to legislate to solve a problem.

Some examples of laws and regulations affecting dentistry are described here, along with the impetus for them, whether real or perceived.

The federal Occupational Safety and Health Administration recently adopted the final version of some controversial ergonomic standards (29 CFR Section 1910.900). The Bush administration has, however, postponed implementation of these regulations; and it has not indicated what its final recommendations or regulations will be. Changes to OSHA are often initiated by large labor unions that believe new laws must be passed in order to protect their members and employees in general.

Cal-OSHA implemented regulations requiring the use of safety needles following legislation that resulted from a union representing health care workers concerned about the transmission of AIDS, hepatitis, and other diseases contracted through needlestick injuries. In hospitals and emergency rooms across the nation, the danger of exposure is very real to many of the health care workers providing care. At the request of the union, coupled with an effective media campaign, a San Francisco legislator carried a bill to require the use of safety needles. Although not a target of the legislation, dental offices are health care facilities and were included. CDA’s efforts during the implementation of regulations resulted in a temporary exemption from the requirement pending proven safety results from the use of safety needles in dentistry.

The media has a very significant effect on legislation. In 1997, a 4-year-old boy in a dental clinic in Orange County died following an overdose of chloral hydrate. Following investigations by the Dental Board of California, significant media attention, and the cries of concerned citizens, legislation was proposed in an attempt to prevent such an event from happening in the future. Although it may be debated whether there was a need for additional regulation, the political reality of the situation demanded action. The Dental Board was proposing a significant and onerous solution; and following discussions with CDA, dentists, and legislators, a much more reasonable approach resulted. There continues to be interest in this area, vis-à-vis children’s safety, in the legislative arena.

Several years ago, some children took a specimen storage box from outside of a clinical lab, broke it open, and played with the contents (blood and lab specimens). The public outrage that a child could gain access to these specimens translated into broad-based legislation placing many constraints on the ability of medical and dental offices to store and transport specimens. Again, CDA and its members voiced their concerns, and the resulting legislation took into consideration the operational and logistical requirements of the dentist.

Local water agencies must meet wastewater pollution limits set by the federal and state Environmental Protection Agencies. As a result, many have had to address the level of mercury in water prior to entering a wastewater treatment plant. In one instance, EPA levies against a county that does not meet the minimum standard a fine of $10,000 per day, which is a significant burden on financially strapped counties. In other cases, the overall level of mercury in the local water supply could prevent further business expansion in a community by limiting planning commission approvals until limits are under control. And although dentistry may not be the primary producer of mercury in wastewater, the profession is an easily isolated and regulated one from the local agency’s perspective. Because the entities regulating wastewater throughout the state are not uniform in their standards, the profession must deal with regional and local government agencies to develop solutions.

Generally, consumer organizations exist to protect the public. Some organizations, however, may believe -- based on their own personal experience, anecdotal evidence, or poorly designed and implemented "scientific" studies -- that a product is dangerous. Their approach is often to raise a certain level of concern and doubt in the public -- enough to make lawmakers aware of the concern their constituents have on an issue. A combination of grass-roots activities and public relations campaigns is usually used to help move the consumer group’s cause forward. Several years ago, a television news magazine segment on the dangers of bacteria in dental unit waterlines caused undue concern among dental patients. Legislation was proposed in California, and an educational effort by CDA postponed any activities in this area.

The Dental Board is responsible for the safety of dental consumers. The board is involved in licensure, educational standards, advertising, and discipline, among other issues. They determine who should practice dentistry in California, how often they must take continuing education courses, and whom should be disciplined and how. Its decisions are heard far and wide; and reactions come from the public, the media, legislators, consumer advocates, dentists, and auxiliaries.

Dental insurance company policies and reimbursement rates affect the practice of dentistry. Legislators want plans to cover as many Californians as possible but at rates that families and/or their employers can afford. State lawmakers and government officials want to see a balance of quality coverage and cost, adequate availability, and quality care.

Conclusion

Dental practices are under scrutiny every day. Perhaps today dentistry is being affected by the actions of Congress, or the local firehouse is reviewing a hazardous waste permit, or a Los Angeles journalist has just written an article about the uninsured, or a dental plan is reviewing billing procedures. Perhaps a local city councilmember has just called together a task force to ban the use of mercury products or asked for a local vote on fluoridation. The dynamics of the public, the media, lawmakers, regulators, and other special interest groups create endless possibilities for oversight of a practice and continue to challenge a dentist’s ability to provide quality dental care to patients.

Author

Cathy Mudge is a legislative advocate in CDA’s Government Relations Office. She provides legislative lobbying and political advocacy for the association.

To request a printed copy of this article, please contact/Cathy Mudge, CDA Government Relations Office, 1201 K St., 15th Floor, or at cathymu@cda.org.

Table 1. Government Entities That Can Affect the Practice of Dentistry

Federal Government

Congress

Environmental Protection Agency

Department of Health and Human Services

Internal Revenue Service

Occupational Safety and Health Administration

State Government

Governor

Attorney general

State senators and assemblymembers

California Occupational Safety and Health Administration

Employment Development Department

Department of Consumer Affairs, including the Dental Board of California

Department of Industrial Relations

Department of Health Services

Office of Environmental Health Assessment

Franchise Tax Board

Local Government

City councils

County boards of supervisors

Publicly owned treatment works

Certified unified program agencies

Water agencies