Indigent dental care in Virginia.

I lean back, breathe deeply, and clutch the arms of the chair, preparing myself for what’s to come: the push of the needle into my gum; the thick sensation of fluid forcing itself into flesh; the bittern novocain on my tongue.

Gratitude is not a feeling that comes naturally to me right now, but I’m striving for it. I’m so grateful to have dental insurance, to have been born into an economic class that has made it possible for me to go to the dentist, to have been able to pay for teeth so straight that strangers compliment them.

But, damn, it hurts.

* * *

Two Harvard researchers released a book about our healthcare system last year, “Uninsured in America: Life and Death in the Land of Opportunity.” The authors talked to uninsured people across the nation, and found that dental care is their top concern. The New Yorker’s Malcolm Gladwell recently surveyed some of the subjects’ responses (“The Moral-Hazard Myth,” 08/29/2005), and explained what makes the loss of teeth so damaging to health and long-term economic prospects:

Gina, a hairdresser in Idaho, whose husband worked as a freight manager at a chain store, had “a peculiar mannerism of keeping her mouth closed even when speaking.” It turned out that she hadn’t been able to afford dental care for three years, and one of her front teeth was rotting. Daniel, a construction worker, pulled out his bad teeth with pliers. Then, there was Loretta, who worked nights at a university research center in Mississippi, and was missing most of her teeth. “They’ll break off after a while, and then you just grab a hold of them, and they work their way out,” she explained to [researchers] Sered and Fernandopulle. “It hurts so bad, because the tooth aches. Then it’s a relief just to get it out of there. The hole closes up itself anyway. So it’s so much better.”

People without health insurance have bad teeth because, if you’re paying for everything out of your own pocket, going to the dentist for a checkup seems like a luxury. It isn’t, of course. The loss of teeth makes eating fresh fruits and vegetables difficult, and a diet heavy in soft, processed foods exacerbates more serious health problems, like diabetes. The pain of tooth decay leads many people to use alcohol as a salve. And those struggling to get ahead in the job market quickly find that the unsightliness of bad teeth, and the self-consciousness that results, can become a major barrier. If your teeth are bad, you’re not going to get a job as a receptionist, say, or a cashier. You’re going to be put in the back somewhere, far from the public eye. What Loretta, Gina, and Daniel understand, the two authors tell us, is that bad teeth have come to be seen as a marker of “poor parenting, low educational achievement and slow or faulty intellectual development.” They are an outward marker of caste. “Almost every time we asked interviewees what their first priority would be if the president established universal health coverage tomorrow,” Sered and Fernandopulle write, “the immediate answer was ‘my teeth.'”

Heart disease, stroke, and premature births are all exacerbated by the simple inability to have regular cleanings. The matters of the mouth do not confine themselves to the mouth; professional dental maintenance mean a longer life and healthier children. Those who do not have the financial resources for dental care will make less money, suffer from more diseases, and die younger than you and I.

* * *

One in five Virginians have had all of their teeth pulled.

Boy Receives Dental Care
By Finizio. Reproduced under the Creative Commons Attribution-NoDerivs 2.0 license.

The state has no program to provide dental care to impoverished adults. If they cannot afford to have a cavity drilled, they have no recourse. Children have access to such care by way of Medicaid’s dental coverage and the state’s Family Access to Medical Insurance Security (FAMIS) program, but the reimbursement rate to dentists was long so low that dentists lost money on each patient. Dentists could afford to take very few such patients, leaving many children without any dental care.

Things have changed recently — for the better — thanks to the Virginia General Assembly. Though the problem is hardly solved, already the landscape of the dentistry business is changing in response to the improvements.

* * *

A cavity is a strep infection of the tooth. Streptococcus mutans, an anaerobic bacteria, flourishes when trapped by calculus in the fissures of the teeth. It digests sucrose — common table sugar — and excretes lactic acid. In the process it creates a sticky substance that allows the S. mutans bacteria to clump together, which are collectively known as plaque. The lactic acid eats away at the protective enamel of the tooth, exposing the sensitive dentin and pulp within.

This is the point when most of us become aware that something is wrong. The discomfort of eating cold or sweet foods lands us in a dentist’s chair to get drilled and filled. For those who cannot afford a trip to the dentist, though, it’s only the beginning. The braver among us may solve the problem with some whiskey, a pair of pliers, and a good friend. Others have to grin and bear it, while the rot spreads deep into the root of the tooth, where it will abscess. By this time the afflicted individual is in constant pain, has a difficult time eating, is running a mild fever, and has terrible breath.

If the pus-filled cavity extends down into the jawbone, it becomes a bone infection, osteomyelitis. The abscess within the bone cuts off blood to the rest of the jaw, and the bone tissue starts to die off. Pus bubbles up to the skin, and the individual becomes extremely sick. Treatment requires removing the jaw.

If, on the other hand, the cavity extends into the soft tissues, that’s a case of Ludwig’s angina, an infection in the flesh of the lower jaw, under the mouth. The individual will be terribly ill, have great pain of the neck and throat, and be dehydrated and malnourished from being unable to drink or eat. As the infection worsens, the tongue is pushed back and up, until the individual chokes to death on his own tongue.

* * *

The House of Delegates recently commissioned a pair of studies of obstacles to proper indigent dental care [1, 2], and the result looked a lot like a to-do list. It pointed out that the state’s dentist scholarship and loan repayment program isn’t doing a lot of good — it had been allocated just $25,000, a fraction of the cost of sending a single student through VCU’s School of Dentistry. The dental hygienist scholarship program was doing even worse, having been allocated $0. Virginia needs another 145 dentists, carefully distributed, in order to address the shortfall in care in the 43 underserved areas. Forty one percent of Virginians lack dental insurance. The Virginia Division of Dental Health can pay dentists just half of the private practice rate, which makes it tough to recruit. Virginia is just one of seven states in the nation that require direct supervision of dental hygienists for all services at all times, making hygienist-run cleaning clinics illegal. Though licensure by endorsement is available for every other medical profession, dentists from other states cannot easily practice in Virginia, a result of professional protectionism. And for just $8.2M, every Virginia adult enrolled in Medicaid could receive dental care.

Bad Teeth
By Curtis James. Reproduced under the Creative Commons Attribution-NonCommercial-NoDerivs 2.0 license.

There was, in short, a lot of low-hanging fruit.

Del. Preston Bryant (R-Lynchburg) was one of the representatives to take up the charge. He patroned a bill last year that made a pair of small but important changes: it repealed the prohibition of licensure by reciprocity and it created temporary permits for unlicensed graduates of dental hygiene programs who want to work in a charitable capacity.

But the real improvement came with the increase in Medicaid and FAMIS dental reimbursement rates that were a part of Gov. Mark Warner’s 2005 budget amendments. He pushed for — and received — a 10% increase in reimbursement rates for dentists under Medicaid and FAMIS, at an increased cost of $5.9M for 2006, as well as an addition $1.3M for the Department of Health for 2006 to improve access to dental services. The reimbursement increase was enough that dentists could break even treating economically disadvantaged children; an enterprising few would even retool their business models to treat only those kids.

The increase was tiny in the scope of the budget, but the change would make an enormous difference in the daily lives of thousands of children accustomed to receiving dental care in an abandoned warehouse.

* * *
Virginia by the Numbers

3,422
Dentists in general practice
73%
People who have visited a dentist in the past year
1.8%
Virginia GSP spent on healthcare
3.3%
U.S. GSP spent on healthcare
1,011,420
People without insurance
736,500
People enrolled in Medicaid
1 in 5
Children enrolled in Medicaid

Democratic Fifth District House of Representatives candidate Al Weed spent the day volunteering at a dental outreach clinic in Martinsville in 2003. He told me about the experience shortly after returning, and it was unlike anything I’d ever heard of. It sounded like something done by relief workers in El Salvador or Rwanda, not something that would exist right here in Virginia.

The Virginia Dental Association‘s Mission of Mercy clinic was held in the abandoned Tultex plant. The knit outerwear company shut down in January 2000, laying off 445 people, another victim of globalization. Nearly a thousand people showed up, some getting in line at 3:00 am, where over two hundred dentists performed 454 fillings, 787 root canals, 427 surgical extractions, and pulled 1,214 teeth over the course of two days. Forty three chairs were set up, serving absolutely anybody with the patience to stand in line and the willingness to have minor surgery performed on a factory floor.

Weed is no stranger to such medical operations of such scale, having served as a Special Forces medical sergeant in Vietnam. Yet nearly three years later, he still describes the event with something approaching awe. He was 12 years old before he went to the dentist, and so has the sort of appreciation for dental care that might be expected. Weed sees the outreach clinic as evidence that the time has come for universal health care.

Ironically, it’s likely that some of the people waiting in line at that Tultex plant were there for the first time since three years previously, when they’d been laid off.

The Martinsville clinic is just one of 22 Mission of Mercy clinics held in Virginia over the past decade. In that time they have seen over 18,000 patients and provided over $7M in free dental care. It is one of the largest such operations in the nation.

That’s nothing we should be proud of.

* * *

At least two companies that have learned how to make the most of the changes in Virginia law. Small Smiles (in Roanoke) and Kool Smiles (in Norfolk, Richmond, Newport News, Virginia Beach, Falls Church and Portsmouth) are each part of national dental chains designed to serve only children receiving public assistance.

The state’s dental fee schedule is unbelievably complex, but the key elements of it are that reimbursement rates to dentists increase in underserved areas and increase as their percentage of FAMIS patients increases. Dental practices set up in the right areas, serving only FAMIS and Medicaid patients, are able to not just break even, but actually turn a profit.

These practices require great volume in order to make money, so there’s a danger that they’ll turn into dental mills. The Virginia Dental Association’s executive director had just that concern, but he checked them out and says he’s happy with the quality of their work.

Boy In Dentist Chair
“First Dentist Trip.” By JBC Russell. Reproduced under the Creative Commons Attribution-NonCommercial-ShareAlike 2.0 license.

Of course, even if the work is mediocre, it’s got to be better than no dental care at all. When the alternative is prying out teeth with pliers, the bar is set pretty low.

* * *

It was just a few weeks ago, browsing entries on my blog from years past, that I discovered a pattern in my dental history. I neglect to get a cleaning for years. I finally go when something’s wonky. It’s discovered that I have “pitting,” or a cavity, which I get fixed. Repeat. I have every reason in the world for not getting those cleanings. I had no dental insurance for a long while. I lived in the New River Valley and figured I’d wait until I moved back to Charlottesville. I’m too busy. I forget.

But the truth is that dental care is not important to me, because I have a safety net. So what if I develop pitting? The dentist will drill it out and fix it. There’s no danger of me letting a cavity spread enough to endanger my health; I’m too much of a wimp to withstand any discomfort. Like oxygen or water, healthcare is worthless as long as you have it, but invaluable once it’s gone.

There’s a lot left on the General Assembly’s to-do list. Dental care remains out of reach for thousands of children in Virginia. There is still no program to provide dental care for adults. Dental scholarships are underfunded. Many areas of the state simply don’t have enough dentists to serve the population. Though last year’s improvements are significant, the job is only half done.

A few months ago I made an appointment for a cleaning, my first in six years. It’s coming up in two weeks. I can hardly wait.

Published by Waldo Jaquith

Waldo Jaquith (JAKE-with) is an open government technologist who lives near Char­lottes­­ville, VA, USA. more »

20 replies on “Indigent dental care in Virginia.”

  1. dude, sometimes I think you try too hard to impress yourself. We get it. You are a liberal intellectual. sheez

  2. While Waldo has brought the problems of inadequate dental care to our attention, I’d caution against reliance on the number (1,011,420) or percentage (41%) of Virginians without dental insurance as a significant metric.

    We need to worry about people not having medical insurance because medical costs can be severe and unexpected. That is, anybody is subject to a diagnosis of cancer that can cost hundreds of thousands of dollars to treat. Nobody can anticipate these costs and none but the extremely wealthy can afford them. Only health insurance can protect people from the financial disaster that accompanies medical tragedy.

    Not neccessarily so with respect to dental care. That is, dental care, if provided regularly from a young age, is usually rather predictable in terms of cost. Many middle-class families can and do budget for dental care, without need for the assistance of insurance. In fact, dental insurance may only add to the ultimate cost of care through administrative costs in running the program. The main benefit is that insurance companies are able to press dentists to accept lower payments than cash-paying patients.

    The point is, if people are without medical insurance, that’s almost certainly trouble waiting to happen. If wealthy or middle-class people are without dental insurance, they may very well get good dental care.

    The problem, as Waldo points out, is with poor people (including the working poor, who live paycheck-to-paycheck) who aren’t even able to afford preventative dental care, in the first place. The programs to treat these folks are useful, but I suggest that dental insurance is neither the best solution, nor the best metric.

  3. Nicely done Mr Jaquith.

    I agree that the real issue is not insurance but afordable access. Lots of families handle dental care on a pay as you go basis without hardship. I appreciate the information in your post about those could not afford insurance either way.

    Since insurance is a way to spread risk out over a pool of users, insurance does not lower costs. Insurance just spreads the cost out among the pool participants. But if you can’t afford to buy into the pool, it does you no good.

    Again, thanks for the info.

  4. What I like about the General Assembly’s model is that it seems to encourage innovation in business. The private sector is competing for the public dollars, which ought to serve to benefit us all. I’d like to see the existing model expanded to include Medicaid recipients. The price tag that the General Assembly put on it, $8.2M, seems like a surprisingly low price to pay for universal dental coverage.

    I’d like to know the price tag of making possible cleaning centers, staffed by hygienists, in underserved areas to cater to adults, funded by Medicaid. They’d provide nothing for people with actual dental problems — only cleanings. I assume that this would cost significantly less than $8.2M, and I suspect that we’d see a sharp drop in dental problems beginning a few years later.

  5. That’s wonderful news — I had no idea that any such thing was slated. I know that’s an area of the state that doesn’t have enough dentists.

    I’m afraid I won’t be able to come until tomorrow, but I’ll see you then. :)

  6. One in five Virginians have had all of their teeth pulled.

    Surely this is a typo… 20% of our population is toothless?

  7. Not only is it not a typo, but it’s the average for the nation. I was totally shocked, too — I had no idea.

    I’d love to see how that breaks down by age. For that matter, I’d love to see a plot of number of teeth by age.

  8. Waldo- interesting explanation of dentistry. I’m not sure of your business background, but I own a small business with many employees that choose to opt out of health insurance programs; therefore, I get to see what happens with the money that the “underpriviledged” should use on insurance. It doesn’t go to feed the children or pay the rent. It goes to the 100/mth cable bill, the furniture rental charges (late charges, repo charges), the new wheels and stereo that are so important, the CD collection- anything that isn’t really a need! If a political party wants to help out the “underpriviledged” in our country, they will take entitlements away and will find a way to teach them how to manage their money! Most of my employees who choose to forgo insurance drive nicer cars than I do. Now give me a good argument for having a state or federal plan to insure people with this obvious lack of concern for their own future.

  9. I’m not sure of your business background

    I have a) owned a small business in which my employees were given money that they could use for health insurance, if they chose to and b) worked in insurance.

    Now give me a good argument for having a state or federal plan to insure people with this obvious lack of concern for their own future.

    I’ll give you two.

    1. Your employees are not a representative sample of Virginians.
    2. Because one way or another, we’ll bear the cost. We can either pay the tiny cost of cleanings now, or the enormous cost of their ER visit when they need their jaw removed. I’ll take the former.

  10. Waldo, I wonder if there isn’t another factor in play with Virginian’s poor dental health — I know a whole lot of people who are incredibly afraid of dentists, and sometimes for good reason if their teeth are in poor shape already. It’s a cycle like yours but without being interrupted by cleanings: skip cleanings because they’re expensive or going to the dentist is too horrible to consider; develop tooth problems; realize that fixing the problems is way too expensive/terrifying; continue suffering and develop worse problems as a result, until the person can no longer stand to eat and gets the teeth pulled.

    I’m in the category of making too much money to qualify for any income-based insurance programs, but self-employed and have no access to decent dental plans. I have found that the cheapest “insurance” has been going for cleanings 2x a year. I haven’t had dental insurance since 2000, but for annual expenses of ~$200 (two cleanings and an x-ray), I’m avoiding the future cost (not to mention pain!) of fillings, crowns, root canals, implants, etc. All the dental plans I can afford have a deductible way higher than $200, although I probably should get one in case I crack a tooth or something.

    But I’m just paying for myself (not a family) and am blessed with problem-free choppers. Add in generations of poor dental habits, a fear of dentists handed down from adults to their children, and it’s no surprise Virginia has arrived where we have today. You’ve created an eye-opening summary.

    The historical but artificial distinction between “medical” and “dental” health has got to go; it makes no logical sense why dental isn’t included in every form of health insurance offered in this country. (Not that it makes sense that 40+ million Americans don’t have health coverage anyway … but that’s a comment for a different post!)

  11. Waldo, I wonder if there isn’t another factor in play with Virginian’s poor dental health — I know a whole lot of people who are incredibly afraid of dentists, and sometimes for good reason if their teeth are in poor shape already.

    I think you’re on to something with that. Now that I think about it, I think that was a part of my delays in cleanings. There’s a certain amount of shame in having dental problems, to the point of not wanting a dentist to see them. Those problems will only get worse, of course, but I think you’re right that’s part of the problem.

  12. I think that my employees are more representative of many uninsured than you would like to believe. They make poor choices with their finances because there aren’t many positive models to follow anymore. Many Americans have no concept of how to manage their money; if they did, our country wouldn’t have so many people strangling themselves with credit card debt. Americans today are about as financially naive as Americans were before the Depression. They aren’t short on cash because they paid their insurance, either! Just wait- when all those ARMs are getting into the 7-8% interest range, and homeowners have to refinance, there will probably be even more uninsured folks out there! I constantly encourage my employees to make good financial decisions, hoping that I can impact them in a way that will be lasting. No matter how much you argue it or how eloquently you present your case, people are much better off when they provide for themselves versus just giving them another government program to “help” them out. I’m not arguing from the point of the die-hard rich Republican capitalist (which is probably what you are thinking!)- I invest a good bit of time and resources into helping my employees learn how to be self sufficient and financially sound.

  13. Tom, you are of course spot-on with your assessment of why the majority of working people don’t have dental insurance, or health insurance for that matter. They make conscious decisions on how to spend their money.

    But it’s not politically correct to say that.

  14. Tom,

    I find your observations interesting. Given the poor choices that your employees make with respect to health insurance and your clear interest in having healthy employees, have you thought about using some good old-fashioned pateralism? That is, don’t offer a choice to employees about health insurance. Provide health insurance to all of your employees, without choice. Make it non-contributory. If you need to reduce salaries (yours and your employees) to be able to afford the cost, do it.

    If your employees need positive models, you can be one.

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