There’s a new addition to the Senate health care reform bill that could have massive consequences for dentistry: a proposed 5% tax on cosmetic surgery and procedures that has been dubbed the Botax.

While it’s not entirely clear what this would include, cosmetic dentistry will probably be included.

The Senate bill doesn’t define cosmetic surgery, but it seems likely it would be similar to New Jersey’s tax.

In New Jersey, cosmetic procedures are subject to a 6% tax. (In effect since 2005, it’s the only state with such a tax.) It defines “cosmetic medical procedures” as those that are performed to improve appearance without providing significant health benefit.

The state’s Treasury website provides a specific example:

“For example, charges for teeth whitening will be taxable, while charges for breast reconstruction or for vision correction by laser treatment will not be subject to the gross receipts tax.”
– New Jersey State Treasury

New Jersey has netted about $11 million annually from the tax — half of what was expected.

One of the unintended consequences of the tax? Patients heading to neighboring states for aesthetic procedures.

Senators hope the proposed national cosmetic tax could raise $5 billion annually to help pay for providing health coverage over the next decade.

I’m not comfortable with trying to distinguish “cosmetic medical procedures” from ordinary medical procedures — at least not when it comes to dentistry. Presumably porcelain veneers will be taxable and root canals won’t be… but who’s to say a dental implant with a beautiful dental crown won’t be considered a “cosmetic” procedure?

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When I shared my opinion that health care reform could be good for dentistry by providing government-sponsored prophy exams, dentists flooded my blog with comments.

Even if the Botax is out, there’s still a lot to talk about here!

Last week I ran some comments from doctors, most of which suggested that dentists oppose health reform. This week, I’m continuing along the same vein.

Wouldn’t it reduce the standard of care?

“It is unbelievable there is anyone out there that thinks government health/dental care in any form will be better than what we have here today in this country. I donate many hours each year to needy patients in our area. I will be forced to stop if the government gets involved. Stop this train before it gets out of the station!”
– Gordon Rye

How much is much at stake?

“This is the end of dentistry as we know it. I get a fair bit of Medicaid patients and work pretty diligently to make a profit. With the high overhead of current dental staff (hygienist, assistants, etc), it is not is not practical to maintain a well-equipped office. It is very difficult to sell these types of insurance patients treatment plans with the attitude ‘just do what the insurance covers.’

“Just try doing $60 amalgam fillings, $45 extractions and prophys and see how much it takes to make a decent living. I have to average about five fillings or extractions an hour just to make a decent living.

“If the government expects the bankers who are responsible for making billions in profits to accept $500k salary, I shudder to think what they have in mind for the healthcare practitioners. Too bad we can’t buy our way out of this healthcare bailout.”
– doctooth

Will it really change your bottom line?

“We have a high percentage of indemnity patients who get free cleanings and a big percentage of them do not avail themselves of this unless there is pain involved. Therefore I feel that government-run health care for cleanings will not change our practice’s bottom line. But the bottom line in taxes and inflation will be great.”
-Kirk Lundell

Do the poor have a fatalistic outlook?

“You really don’t know the people you are talking about, do you?

“Poor people in the US are fatalistic in outlook. Prevention is a hard sell, because they don’t believe it it. They generally believe they are predestined to have good or bad teeth, depending on their ancestry.

“That’s why compliance for preventive Medicaid procedures is so low. All you would end up with if people got free cleanings would be a bunch of no-show appointments.”
– Kim Henry DMD

How do Medicaid patients behave?

“When I first got out of school I worked for a Medicaid practice. We had at least a 75% no-show rate when the patients were getting $1000 in free dentistry from the government, and that was in 1977, so today that would be like getting $6000 in free dentistry today.

“Even if we were successful in getting them on the phone when they no-showed, we’d usually hear ‘Momma’s at the hairdresser,’ ‘Momma’s getting her new Cadillac,’ or some other excuse for not bringing their kid AGAIN.

“That blatantly says people don’t value what they don’t pay for. The welfare worker would have to threaten the mothers with losing all their welfare money if they no-showed again.”
– Loyd

What about CA’s Denti-Cal program?

“Here in California, we have had a system where folks who didn’t have resources got care, called Denti-cal, before the budget crater. Take operating costs from the early 90’s, subtract your office staff, and then you MIGHT break even. Or you can run the Dental/Medical Clinic thing-Every person, every tooth, 50% of surfaces restored with alloy or SSC’s all that day, with indentured servants(I was a new grad once also, just not willing to compromise my ethics to this level)whether they need it or not.

“Just think, you only need to see 10 patients, and place 40 SSC’s and restore 200 surfaces of alloy to make 45% of your existing salary. Or you can Sell, Sell, Sell to the credit patients on inflated contracts, and bait and switch non-precious to ceramic crowns on HMO patients, regardless of appropriate restorations, made in Tijuana from lead glaze, and take Halcion to sleep at night.

“Or you can continue to do what you do now, morally, ethically, and hope the government health plan shift won’t dump all your patients onto the public option. I definitely am not looking forward to 50% of the indemnity patients not having coverage except for cleanings, and at $4-8 per patient reimbursement-monthly cap payment.

“How much will the care have to be discounted to keep people buying? 20-40%. Don’t they call that operating at a loss? Guess that means joining the ranks of those corporations who do not generate a profit(GE, GM) but a loss. I just assume that there will be no bailout money from the Govt.

“Sorry about the rant… just venting…”
– socaldds

Is health care a right or a privilege?

“The government, especially this administration, never does anything on a limited basis. Once they get in, we’re going to be just another frog on the stove.

“It pisses me off when I hear you or other dentists trying to find an angle on how to make bad public policy work for them. That’s why the medical profession is where it is today. Physicians get paid a quarter of what they charge and anyone inside our border can walk into an medical facility and get treatment for nothing.

“People value what they pay for. Healthcare is not a right, it’s a privilege. We earn it by going to school, getting a job, and paying for out of our back pockets.

“Get control of your expenses and dump those insurance plans and losers who steel your time, your skill, and your money. If you want to donate your services to the under-served, fine, do it. We don’t have to screw up the whole system to accomplish that.

“And for those of you who think that there is no difference between dealing with insurance companies who are still responsible to their policy holders and dealing with Washington which is no longer responsible to anyone, you are incredibly uninformed or just a idiot.”
– wrbattarbee

Are they just getting a foot in the door?

“Government intrusion into currently private dental practice is just a foot in the door… When was the last time you saw any government entitlement program get smaller. The recipient pool always expands and more ‘free’ services are promised as those in power need to buy more votes every few years.

“With regard to health care reform, don’t forget about tort reform, portability of health insurance, free care to millions of illegal aliens, etc. In dentistry, don’t forget that we are not getting a bailout. We have relatively high-wage employees, high educational debt, expensive facilities, expensive equipment and with such we are able to provide a very high level of quality care.

“As far as providing care to the under served – many of the under served are that way because they do not seek care until a problem escalates. Many have the resources to pay for the care yet they choose to put their money elsewhere (priorities). There are many free clinics around the country, dental schools, and throngs of private dentists who provide treatment for reduced rates and even at no charge on a case by case basis.

“Dentistry is known for being a resourceful industry and generally rises to the occasion – we do not need the government to tell us how to do it. No system is perfect and there will always be those who fall through the cracks – but the system works pretty well now, even if there is some room for improvement.

“Look at the deterioration of our country’s infrastructure – it is falling apart. Health care is next. Don’t let it happen to dentistry.”
-Brian