Angelito Haney was just over a year old when his teeth started to fall apart. Chips of the curly-haired toddler's baby teeth would come out if he bit down on a plastic toy.
The SeaTac boy's pediatrician gave his mother the card of a local dentist. But when Tammy Haney called to make an appointment, she was told the dentist wouldn't accept her son's Medicaid coverage.
These days, only one in three practicing dentists in the state accept the low-paying government insurance for poor families. But it's not just the poor who have trouble obtaining care.
More than three times as many Americans lack dental insurance as lack health insurance. About 3.1 million people in Washington -- half the state's population -- have no dental insurance or rely on Medicaid. For them, care has become a luxury afforded only after the rent has been paid and food put on the table -- and often only when tooth pain becomes unbearable.
The U.S. surgeon general has called this growing lack of dental access a national "silent epidemic."
Angelito's mother lost her family's insurance when she was laid off from her $15-an-hour job in the accounts-payable department of a large painting company. She had no savings to pay for a private dentist.
When she finally got her son to the non-profit Odessa Brown Dental Clinic in Seattle a year later, the damage was done. The painful toothaches keeping Angelito awake at night had come from dying nerves and an abscess in the bone threatening the development of his permanent teeth.
After a six-month wait, a surgical team at Children's Hospital and Regional Medical Center sealed, capped and filled as many of his teeth as they could. They had no choice but to send the talkative boy home earlier this month without any front teeth.
In recent years, surgery to repair badly decayed teeth has become one of the top 10 procedures to fill Children's operating suites. Pausing after pulling the last of six unsalvageable teeth, pediatric dentist Barbara Sheller remarked, "It's heartbreaking to face the same difficulties in family after family. This is a really complex way to manage dental disease. If kids were getting routine dental care, we could avoid this."
Disparities in Washington
About 40 percent of people under age 65 and 77 percent of seniors in the state are making do without dental insurance, according to estimates by the Washington Dental Service Foundation.
The only insurance that guarantees quick access to care is the increasingly expensive private kind. In 2002, just a third of the 1.1 million low-income people in Washington eligible for Medicaid-covered dental care actually saw a dentist, according to state data.
Meanwhile, those who do have the private insurance accepted by mainstream dentists are sometimes getting more treatment than they need, experts say. Tooth-whitening, a $600-million-a-year industry, has become the fastest growing segment of dentists' practice, according to a 2002 American Dental Association survey.
"We have one group of people that is way over-seen, and another that is not being seen at all," said Dr. Peter Milgrom, director of the University of Washington's Northwest and Alaska Center to Reduce Dental Disparities.
A common rule of thumb in the dental world is that 80 percent of cavities are found in 20 percent of the patients -- people who tend to be poor, elderly and members of immigrant and minority groups.
Local experts say the access problem is acute in Washington. Despite a slow economic recovery, the state continues to have one of the highest unemployment rates in the country -- the vestige of a recession that stripped nearly 100,000 jobs from the Puget Sound region, many of which had offered medical and dental benefits.
Faced with budget shortfalls and ballooning health-care costs, state lawmakers cut dental coverage for low-income adults by 25 percent in 2003. Nearly 30,000 undocumented children also lost their state dental coverage in Washington in 2002.
The result of these shifts is that dentists are finding more cavities and pulling more teeth, said Dr. Marty Lieberman, dental director at Puget Sound Neighborhood Health Centers. The agency serves about 15,000 mostly uninsured patients a year in five Seattle-area clinics.
When clinic dentists arrive at 7 a.m. to open doors in Georgetown, the Central Area and Holly Park, they often find patients with throbbing teeth huddled at their doors.
"So much of our practice is about getting people out of pain," Lieberman said.
About a fifth of the children in Washington have untreated cavities, according to a state health department survey of nearly 2,700 second- and third-graders in 2000. Left unchecked, cavities affect how well kids eat, speak and concentrate in the classroom.
And low and middle-income children miss about 13 days of school every year because of dental problems, according to U.S. Government Accountability Office data.
At High Point Elementary School in southwest Seattle, where 98 percent of students qualify for free and reduced-price lunches, educators got so frustrated by the sight of kids laying their heads down on their desks because of tooth pain that they formed a partnership with the nearby High Point Dental Clinic.
Principal Cothron McMillian said many of her students' parents work in low-wage jobs, so it's not easy for them to slip away to take kids to daytime dental appointments. Now, armed with parental permission slips, the school nurse regularly walks children back and forth to the clinic for fillings and repair work during the school day.
"We want our kids to be able to excel in school, and they can't do that if they are in excruciating tooth pain," McMillian said.
Among adults, untreated tooth decay can affect employability. West Seattle father Jeffrey Kimsey started developing several unsightly brown cavities in his front teeth just before he was laid off three years ago from his $18-an-hour job as a machinist.
Falling back on his past experience as a restaurant manager, he began looking for waiter work at eateries in the Northgate Mall and downtown hotels. Pieces of his teeth began falling out, but Kimsey had lost his health insurance with his job, and a private dentist was several thousand dollars out of reach.
"There were a couple of interviews where I know I didn't get the job because of my teeth," he said. "You just don't want your server smiling at you with holes in his front teeth."
Finally, a clinic dentist who was caring for his 5-year-old son's teeth took a look at Kimsey and handed him the number of the Southeast Family Dental Clinic, one of the few serving uninsured adults. After a two-month wait, Kimsey, 36, began a series of eight $25-apiece appointments. And now he says, "I've got my smile back."
The fluoridation conundrum
Experts blame widespread dental decay in part on the relative lack of fluoridation of public water systems. The National Centers for Disease Control and Prevention considers fluoridation one of the 20th century's top-10 public health achievements because it can reduce cavities by up to 40 percent in a population. But just 57 percent of the state's systems are fluoridated, putting Washington at 34th in the nation, according to the CDC.
Here the decision to fluoridate is left up to locally controlled water districts and city councils answerable to citizens convinced fluoridation causes cancer, brittle bones and acid rain -- fears roundly disputed by the CDC and national dentists' groups. Despite a statewide education campaign by the Washington State Dental Association, in recent years concerned voters have turned down fluoridation measures in Spokane, Olympia and Wenatchee. (King County's public water supply is 75 percent fluoridated -- considered a great enough concentration by dental experts to protect all residents adequately.)
The state Supreme Court ensured that battle will remain a local one when it ruled in May that the Tacoma-Pierce County Health Department had overstepped its bounds when it ordered 14 large water systems to fluoridate.
"If you mention the word fluoride in a public meeting, there will be a cadre of people booing," said Ellen Jeffcott, oral health manager for Public Health -- Seattle & King County. "The opponents are organized and they are loud."
Also missing from the state's oral health system are dentists themselves. In 2003, parts of 35 of 39 Washington counties were federally designated as dental health professional shortage areas, either because not enough of the dentists there would see poor or migrant clients or because there were too few dentists to serve even those with private insurance. Rural Wahkiakum, Skamania and Garfield counties each had one practicing dentist remaining in 2002.
Further complicating the picture is that half of the 3,841 practicing dentists surveyed by the state dental association in 2001 said they were over age 50 and expecting to retire by 2013.
David Hemion of the state dental association said new flexibility in rules allowing dentists to relocate to Washington and the hit that many dentists' investment portfolios took during the recession may stabilize the number of dentists here and slow retirement rates.
But Vince Schueler, a health-care-access analyst for the state health department, said the situation "certainly is not going to get better for low-income people."
Long drives for care
For patients, and particularly those with special health-care needs, the lack of access translates into drives of hundreds of miles to get to the few overburdened institutions in the state that will let them in. Kids from Aberdeen, Yakima and even Montana, Wyoming and Idaho travel to Children's Hospital for dental care.
Because of its commitment to see anyone, regardless of ability to pay, Harborview Medical Center on Seattle's First Hill has become one of the few places in the state adults without insurance can get dental surgery. Dr. Marco Alberts, director of Harborview's oral and dental clinics, said patients face a yearlong wait before they get into a Harborview operating room.
And the Harborview clinics are able to collect less that half the cost of the care they provide to about 10,400 patients annually, raising questions about the program's sustainability.
Snohomish grandmother Dorothy Sheriff spent a year and a half trying to find treatment for her disintegrating teeth in Snohomish County, finally ending up under Alberts' care. With just $500 a month coming in Social Security disability income, Sheriff said she struggles to come up with the gas money to get her '95 Chrysler Le Baron to Seattle for appointments. But the 48-year-old considers herself lucky compared with an uninsured cousin of hers who recently pulled out an infected tooth with a pair of pliers.
"Dr. Alberts has given me wonderful care," she said
Activist dentists and public health programs have made some strides in increasing access in recent years. Since 1993, the percentage of Medicaid children seeing a dentist in a given year has increased from 27 percent to 40 percent, according to state data. Much of the credit goes to the Access to Baby and Child Dentistry program, a partnership between the state, local health departments, dentists' associations and the dental service foundation that has provided specialized training and better Medicaid payments to encourage private dentists in 20 counties to see more poor children.
In Spokane, Bremerton, Yakima and South King County, efforts are under way to train pediatricians to check children for dental decay and provide a fluoride varnish for kids at high-risk for cavities.
But at the heart of the access problem is the reality that private dentists believe they cannot keep their small businesses afloat if they see significant numbers of patients covered by Medicaid or nothing at all.
Hemion of the state dental association said state Medicaid reimbursement rates cover only about 35 percent of a dentist's typical office fee for an adult and 65 percent of the fee for a child. And dentists face unusually high overhead costs because their offices are expensively equipped surgical suites, he said.
"It's just baloney to say that dentists don't care about poor people, because every time a dentist sees a Medicaid patient, it's charity," he said.
He predicted that access for poor people will remain limited "unless the reimbursement programs funded by public dollars come closer to market rates."
With budget cuts looming because of the federal deficit and continued shortfalls at the state level, policy experts aren't anticipating any dramatic funding increases. The state now spends about $103 million on dental care. Some activists, like the UW's Milgrom, are pushing for the creation of a new breed of dental nurse similar to a physician's assistant who could deliver dental services at lower costs.
It's not an idea the state dental association supports as practical.
Tammy Haney, Angelito's unemployed mother, isn't waiting for a Medicaid miracle. The stress of seeing her son endure so much pain has motivated her to pursue a career in community corrections -- with health insurance included.
"Seeing him in pain has inspired me to gain profitable employment again," said Haney, 39. "I want my choices back."
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