America’s dental crisis: do we need an Affordable Dental Care Act?

by Rob Cullen on January 28, 2013 - 8:44 AM

kid at the dentist

Since our last post was all about soda and other sugary beverages, we figured now might be a good time to look at a related topic: dental care (and the lack thereof) in America. 

According to a report from Senator Bernie Sanders (I-Vermont) on America’s “dental crisis”:

  • more than 47 million Americans live in areas with too few dentists (or sometimes none at all);
  • over 130 million Americans do not have dental insurance;
  • about 17 million low-income children see a dentist less than once a year; and
  • only 45 percent of Americans age 2 and older saw a dental provider in the past 12 months.

In 2010, The Washington Post reported from a temporary free health clinic in rural Virginia and found that most of the 2,300 people waiting in line came for dental care:

“The kids have got Medicaid, but no one will see us,” Lucinda Honaker said. The family lives on about $800 a month. So dental problems steadily progress, causing infection, pain and difficulties with speaking and eating. Ultimately the only answer is extraction, but it can be an imperfect solution.

Charles Honaker had his infected teeth pulled two years ago at a RAM event, but he is still on a long waiting list for free dentures. With the help of the family vegetable garden, he is trying to eat right to keep his diabetes under control.

But without teeth he finds it hard.

“For the stuff I’ve got to eat, I need teeth,” he said. In the meantime, he just cuts his food into tiny bits and swallows the small pieces whole.

Meanwhile, states hoping to save money have been cutting Medicaid dental benefits (and most dentists don’t except Medicaid anyways, saying it doesn’t pay enough), which just pushes many low income patients to the ER. In 2009, over 830,000 emergency room visits were for avoidable dental problems, costing states tens of millions of dollars (ER visits for oral health problems cost over $88 million in Florida alone).

The Affordable Care Act

The Affordable Care Act will help improve access to dental care somewhat, particularly for children. One of the categories of “essential health benefits,” which insurers have to cover starting in 2014, is oral health care for children, and Medicaid will continue to cover dental care for kids as well. All together the new law will provide coverage for an estimated 5.3 million children.

Adults get less help. Insurance plans won’t have to cover oral health care for adults, but insurers can sell stand-alone dental plans on the exchanges created by Obamacare. And if you’re eligible for a subsidy to help pay for health care, you can use it to help pay for dental coverage in addition to your regular health plan. States can still choose not to provide dental benefits to adults covered by Medicaid though– and there’s nothing increasing payments to dentists to ensure that they’ll actually see Medicaid patients.

For a list of all the dental health care provisions in the Affordable Care Act, check out this post from Oral Health Watch or this one from Healthcare Reform Magazine.

Solving the dentist shortage… without dentists

One of the biggest problems with American dental care is that there simply aren’t enough dentists, especially in low-income and rural communities. However, as June Thomas points out in an excellent article for Pacific Standard magazine, there is a potential solution:

The idea is to supplement the country’s system of private dental practitioners with a corps of “mid-level providers”—nurse practitioners, essentially, for the world of teeth and gums, who can operate out in the field. It’s not an untested notion. At least 54 countries, including Canada, Australia, New Zealand, and the United Kingdom, have expanded their workforces with these so-called dental therapists, with splendid results.

So far only two states– Minnesota and Alaska– have moved towards a mid-level provider model, allowing certified “dental therapists” to do perform basic procedures, like filling cavities. However, the Affordable Care Act sets up a two-year, 15-site demonstration program to “train or employ” alternative dental health providers, and other states have already started to consider allowing non-dentists to do basic dentistry in underserved areas.

The dental lobby is pushing to repeal this part of the new law and has attempted to block states from utilizing dental therapists. Dentists claim they’re concerned about creating a “two-tier dental system,” but Sarah Wovcha, employs both dentists and dental therapists as executive director of Minnesota’s Children’s Dental Services, doesn’t buy that argument:

“What dentists are saying is, ‘Poor people are going to be served by dental therapists, and wealthy people are going to be served by dentists.’ Well, the issue here is that many dentists weren’t willing or able to serve the poor,” she says. “Their argument is, ‘We’re not serving them, but you can’t either.’ So we created an affordable, quality workforce model. To me, that’s not a second tier of care. It’s an ingenious innovation.”

A more likely motivation for the dental lobby is to keep prices for dental services high by preventing cheaper providers from entering the market.

In the end though, no matter how dental care is provided, we need to stop treating it as an optional luxury. Everyone should have access to affordable dental care. As Thomas writes:

Research has linked gum disease with diabetes, heart and lung ailments, strokes, and premature births. Children who don’t see a dentist are more likely to miss school because of infected teeth and gums, and to grow into adults with serious dental problems. And missing teeth make it all but impossible to secure a middle-class job. Dentistry, it turns out, is destiny.

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