June 18, 2014
Vol: 21 No: 25

Feature

It’s like pulling teeth

By Travis Bassett , Contributing Writer
and Amy Roe , Editor

For low-income people, long-awaited dental insurance comes with a catch

A patient at the Union Gospel Mission’s dental clinic gets a set of x-rays. Since the ACA’s increased funding of Medicaid, more homeless and low-income people have access to dentists. Getting an appointment, however, might be a pain.

Photo by: Wes Sauer , Contributing Photographer

Volunteer Gwen Shattuck, background, and UGM Staff Director Juanita Richee-Banks help organize and clean the supply room adjacent to the three dental chairs in the clinic. Left, fourth year dental student Yoni Ahdut talks with Dr. Jonathan Su about an extraction he performed.

Photo by: Wes Sauer , Contributing Photographer

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Thousands of people in Washington who are too poor to afford dental care are now covered for it, thanks to the expansion of Medicaid under the Affordable Care Act (ACA).

But there’s a catch: Many are struggling to find a dentist who will treat them.

Two recent changes to eligibility for government-funded dental insurance have created a “torrent of demand in the system right

now,” for providers who serve low-income people, said Mark Secord, executive director/CEO of Neighborcare Health, the Seattle area’s largest provider of dental and medical care to low-income and uninsured people.

Despite the attention the troubled roll-out of the Affordable Care Act has received, dental care is the number-one health crisis low-income people face.

“Often you’ll hear people wringing their hands about primary care, and dental access is manifold worse,” Secord said.

Those who are newly eligible for dental care are competing for appointments with another population: people who once again have dental coverage after a three-year lapse.

In January 2011, lawmakers and the Health Care Authority (HCA), the state agency that runs Medicaid, cut coverage of non-emergency dental services for most adults, in response to the fiscal crisis, while coverage for children continued. Later that year, lawmakers brought back dental benefits for some adults on Medicaid, including pregnant women and certain disabled adults.

In 2013, recognizing widespread need, legislators in Olympia reinstated dental coverage for everyone in Washington state covered by Medicaid, effective Jan. 1, 2014.

Now, an estimated 700,000 adults in Washington are newly eligible for Medicaid and thus dental care.

“There’s more need than we have capacity for,” said Dr. Sarah Vander Beek, Neighborcare Health’s chief dental officer. “My impression is that all community health centers in King County are feeling the same way.”

The problem isn’t limited to King County. LeeAnn Cooper, public health dental hygienist for Snohomish County, said she’s heard from people at many community agencies there who can’t find a dentist who will treat adults on Medicaid.

And many of those fortunate enough to get an appointment at a clinic are exhibiting worrisome symptoms. Some are missing front teeth, making it hard for them to eat, while others have teeth and gums so diseased that “we have no other option but to take all of their teeth and make them a denture,” Vanderbeek said.

“There’s no going back from that,” Vanderbeek added, though for many, dentures are an improvement. “It serves a lot of people who have been walking around with nothing.”

Secord said though providers are scrambling to find ways to serve the massive demand, they’re not surprised by it.

“If you cut off routine and preventative care, during this three year period, dental disease has marched forward,” he said. “You now have people who are in worse shape. You have pent-up demand, pent-up need in the system.”


Low reimbursement

So why aren’t more dentists taking on low-income patients? The main reason is money.

Health care advocates and community providers say because the state reimbursement for dental services provided to adult Medicaid patients is low, few dental providers accept adult Medicaid patients.

For a comprehensive oral evaluation done on a child 5 years old or younger, Medicaid pays the dentist $40.38. For the same procedure performed on someone 6-20 years of age, Medicaid will pay the dentist $33.64, but for patients 21 and older Medicaid pays only $24.84, according to the HCA website.

There are 37 private dental offices (including 13 pediatric specialists) in Snohomish County that accept children on Medicaid as patients, but just seven private offices accepting adults on Medicaid, according to the Health Professional Shortage Areas survey, a product of the U.S. Department of Health and Human Services.

By contrast, Snohomish County has more than 367 dentists who accept new patients with private insurance or self-pay.

Adults on Medicaid can also seek care at community health centers, but in Snohomish County these centers have waiting lists for dental services. King County’s Neighborcare dental clinics eschew waiting lists, opting instead to “turn the faucet on and off,” to control flow of patients to the clinic, Vanderbeek said.

Neighborcare’s goal is to be able to complete a patient’s treatment, rather than make them wait for long periods between follow-up appointments, she said.

One recent legislative attempt to mitigate some of the challenges faced by Medicaid patients seeking dental care was HB 2321, a bill that would have created a new class of dental caregiver in Washington state called a mid-level provider. The mid-level provider would have had a more limited scope of dental training and practice than dentists, received client-oriented training, and worked under the supervision of a dentist.

Mid-level providers would only have been able to practice in certain settings, including “federally qualified health centers, clinics run by schools of dentistry and hygiene, tribal settings, and practice settings where 35 percent or more of the clientele is publicaly insured, uninsured, underserved, or low-income.”

The bill failed to pass out of committee. Jon Gould, deputy director of the Children’s Alliance, which supported the bill, said lobbying by the dental industry killed it. 

“In a nutshell, it was really the opposition of the Washington State Dental Association (WSDA) that is the reason the bill didn’t pass out of committee,” Gould said.

As of March 13, 2014, more than 357,000 new Medicaid enrollees have signed up through Washington Healthplanfinder, according to the Washington Health Benefit Exchange, which runs the website. That figure includes newly eligible Washingtonians as well as previously eligible residents who have enrolled since Oct. 1, 2013.

The change in Medicaid eligibility is the result of Washington State accepting the expansion of Medicaid eligibility and the associated federal funding under the ACA. Under new eligibility rules, most adults making less than 138 percent of the Federal Poverty Level can get Medicaid coverage in Washington.

In practice, this means that a household with one adult meeting citizenship and residency requirements and earning less than $15,856 annually is likely eligible.  (Some states didn’t accept the expansion of Medicaid, leaving many low-income Americans uninsured, even post-ACA.)

Despite the challenges, newly eligible enrollees in Washington are excited about their new dental coverage. 

Kate Allen, a health insurance navigator who has been enrolling people through the Washington Healthplanfinder since it launched in October 2013, said the coverage means people are more likely to keep their natural teeth.

“This time last year, when childless adults were looking for dental assistance their only options were low-cost clinics that would conduct extractions,” she said. “This year, childless adults in Washington State have access to preventative dental care. When I tell people that they have access to dentists, I can hear the absolute joy in their voices.”

Cooper worries that people on Medicaid who can’t find a dentist to treat them will end up in the emergency room as a result. Poor dental health has been associated with cardiovascular disease, stroke and diabetes, among other ailments.

There is also fairly strong evidence that mothers who have untreated cavities are more likely to pass those bacteria onto their child, putting the child at greater risk for tooth decay, Cooper said.

Poor dental health can even be fatal.  In February 2007, 12-year-old Diamonte Driver died when bacteria from his abscessed tooth reached his brain.  At the time, The Washington Post reported that the extraction that might have saved the Maryland boy’s life would have cost $80. 

Poor dental health can also take a social and psychological toll. In 2013, the Snohomish Health District collected the written experiences of people 20 or older seeking dental care in a document called “A Dental Access Story Book.”  The collection describes the financial struggles, fear of dentists, discomfort and social stigma low-income people face as a result of their poor oral health.

Cooper said that when she started her career with the Snohomish Health District in 1987, Medicaid dentists were in short supply. Only two dentists in the district accepted Medicaid patients, and they only worked on adult patients doing extractions on a part-time basis. 

In 1991, Cooper worked with Snohomish County and community partners to address the low number of dentists who would accept children with Medicaid as patients. Their efforts included supporting the development of a network of community health centers, providing case management, care coordination, and creating a framework within which private dentists accepted referrals from the Snohomish Health District.

In 1995 The Snohomish County Dental Access Coalition’s efforts were bolstered by an increase in Washington State reimbursement rates paid to dentists for children’s Medicaid-covered services.  Since then, the number of providers accepting children on Medicaid has slowly increased.

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