[NOTE FROM FAN: According to Oral Health in Wisconsin: A Fact Sheet: “In Wisconsin, 90% of the population on public water receives fluoridated water.”]
First of two parts
Lucia Alba knew something was wrong when her son said his teeth hurt while eating an apple.
Carlos, her son, isn’t a fussy child. But a few days earlier, he had mentioned that his teeth hurt. This time, Alba got a flashlight and looked in his mouth. She saw blood.
Her son, 7 years old at the time, had abscesses, or infections, in two of his teeth.
He had never been to a dentist. Neither had his siblings.
“I stopped trying, because every time I called up the dentist, I would get the same answer,” Alba said. “All the time. They weren’t accepting my insurance. They had a long waiting list.”
Alba’s children are insured by BadgerCare Plus, and few dentists accept patients in the state health program for low-income families.
The lack of access to dental care for children and adults on limited incomes is one of the most entrenched, widespread and overlooked problems of the U.S. health care system.
It also is one of the most marked examples of the differences in health care for the poor and everyone else. Dental care is the most common unmet medical need among children. And the children most at risk – those in families with limited incomes – have the least access to care.
“Spend a day looking in the mouth of every pediatric patient who comes into our clinic, and I guarantee that at least once or twice, you will be horrified,” said David Waters, a pediatrician at the Sixteenth Street Community Health Center, which provides care primarily to people covered by BadgerCare Plus or who are uninsured.
Wisconsin – a state that has set out to make affordable health insurance available to nearly every child – does worse than most states in providing children with access to dental care, according to the federal agency that oversees Medicaid programs such as BadgerCare Plus.
Fewer than one in four children ages 3 to 19 insured through what is now BadgerCare Plus saw a dentist in 2007, according to the state Department of Health Services.
It means more than 300,000 children in the program that year did not see a dentist.
The state budgets relatively little money for dental care: roughly $37.50 a year for each person covered by BadgerCare Plus or Medicaid outside of southeast Wisconsin in the 2008 fiscal year.
That’s less than a commercial dental plan would pay for a cleaning for a teenager or adult, or for a one-surface filling for a child.
The allocation was slightly higher for children and their parents in Milwaukee, Waukesha, Racine and Kenosha counties.
The result: Few dentists accept patients covered by BadgerCare Plus or other Medicaid programs.
At the beginning of each month, Milwaukee Health Services, a community health center that employs four dentists and a hygienist, accepts new patients. It gets 1,000 to 1,500 calls for the 50 to 100 available appointments.
Patients turned away
“The tough part is having to turn people away,” said Nicole Martin, a dentist with Milwaukee Health Services. “The need is so great that we can’t see everybody.”
The Dental Center at Children’s Hospital of Wisconsin in Wauwatosa gets 20 to 40 calls a day from parents seeking dental care for their children, said Lori Barbeau, the center’s medical director of surgery. Many of the calls are from parents with children in pain.
“You can’t do enough,” Barbeau said.
The Dental Center’s services include a clinic that one day a week will assess children who are in pain and may need urgent dental care. It typically sees eight to 10 patients each week.
The Dental Center treated Carlos, Lucia Alba’s son. His two infected molars, both baby teeth, were extracted. He also had several cavities.
“Honestly, that’s not a lot,” said Melissa McCool, the resident in pediatric dentistry who treated Carlos.
“It breaks your heart,” she added. “These children are in pain.”
For children who don’t need immediate care, Children’s Hospital has a waiting list that it limits to about 100 patients, though it will give priority to children referred by physicians. At its downtown Milwaukee dental clinic, appointments are limited to children whose parents attend a class on oral health, which guarantees an appointment in six to eight weeks.
The hospital revamped its system for scheduling patients several years ago after a parent brought a child to a scheduled appointment at the right time and day – but a year too early.
The lack of access to dental care isn’t limited to Wisconsin. The problem is nationwide. It also is widely recognized in the medical and dental communities. In 2000, a report by the U.S. surgeon general called oral disease a silent epidemic. Nine years later, little has changed.
The results can be seen in young adults: 42% of all new military recruits cannot be deployed until they receive dental care.
Eating soft foods
David Ruiz, 8, has big brown eyes and a round face. He likes to play with trucks and cars and watch cartoons after school. He also is in pain.
“When I eat, it hurts,” he said.
At school, he can eat a hamburger for lunch if he chews on one side of his mouth. Tacos are too tough. He likes applesauce, pudding, and macaroni and cheese – soft foods that don’t require a lot of chewing.
In February, David had his teeth cleaned at school by a hygienist. The evaluation he brought home recommended that he see a dentist immediately.
The following month, his molars began to hurt. Rosa Ruiz, his mother, took him to Sixteenth Street Community Health Center, where the doctor gave her a prescription for liquid ibuprofen and said her son needed to see a dentist for his cavities.
Ruiz called six dentists without finding one who was accepting new patients covered by BadgerCare Plus or who didn’t have a long waiting list.
“With what I make, I can’t afford to pay a dentist,” said Ruiz, a temporary worker, speaking in Spanish. “I barely make enough to pay for rent, utilities and food.”
In March, she was told to call the Marquette University Community Dental Clinic-South, one of three run by the School of Dentistry, in the first week of June to get an appointment.
The clinic’s waiting list for children at times can reach 200 patients.
Promise doesn’t equal delivery
By federal law, Medicaid programs such as BadgerCare Plus must provide dental care to all eligible children younger than 21.
Last year, the federal agency that oversees Medicaid reviewed 16 states that provide limited dental care to low-income families. Wisconsin was one of the 16 states.
The review faulted the state for not ensuring that children in southeast Wisconsin had adequate access to dental care.
“We keep confusing the promise of care with actual care,” said Monica Hebl, past president of the Wisconsin Dental Association.
In all, less than 1% of the state budget for BadgerCare Plus and other Medicaid programs is allocated for dental care.
For 2009, the state budgeted about $24 million to provide dental care to roughly 640,000 people. It worked out to about $37.50 a person.
The $24 million does not include money allotted for the roughly 210,000 children and parents in the BadgerCare Plus program in Milwaukee, Waukesha, Racine and Kenosha counties. They get dental care through private managed care organizations that contract with the state.
The state is paying the managed care organizations $76.56 a year on average for each child or adult in Milwaukee County and $58.92 a year on average in Waukesha, Racine and Kenosha counties.
That must cover the cost of check-ups, cleanings, X-rays and filling cavities, as well as costly dental work such as performing root canals, treating gum disease and installing crowns.
The Department of Health Services estimates that it pays about 40% of dentists’ typical fees.
$13 for regular exam
The low reimbursement – $13 to $16 for a periodic oral exam, for example – frustrates dentists.
“We want the state to pay us for the services we are providing,” Hebl said.
Hebl and her partner’s practice, Burleigh Dental, accepts patients covered by Medicaid but not BadgerCare Plus. The practice, at 76th and Burleigh streets, sets aside Thursdays for the patients.
The BadgerCare Plus and Medicaid programs also pay doctors and hospitals far less than commercial health plans do. But they can partly offset the low reimbursement by charging commercial health plans more.
That’s not an option for dentists, in part because dental insurance generally provides limited benefits and has higher out-of-pocket expenses.
In southeast Wisconsin, the private companies that contract with the state to manage the care for children and parents covered by BadgerCare Plus contract with Southeast Dental Associates S.C. to provide dental care.
Southeast Dental Associates has a network of 108 dentists, including specialists such as oral surgeons, in Milwaukee, Waukesha, Racine and Kenosha counties. That doesn’t include hygienists or students at Marquette University’s School of Dentistry.
Many, if not most, dentists in the network, though, limit the number of patients they see because of what Southeast Dental Associates pays.
“We do what we can and still stay in business,” said Michael Costello of Downtown Dental Group.
Costello, a dentist, and his staff treat 20 BadgerCare Plus patients a week, setting aside an hour each Tuesday and Thursday. The slots are limited to children.
“They need the care,” he said. “They need the help.”
The appointments are scheduled starting at 9 a.m. each Monday. The phone rings steadily for at least an hour on most weeks, with two people fielding the calls and someone always on hold.
“I can’t help everybody,” Costello said, “so I’m doing what I can.”
His system for scheduling limits the number of missed appointments – a persistent problem for dentists who see patients covered by BadgerCare Plus or Medicaid. Booking patients months in advance increases the chances of a patient not showing up for an appointment.
Costello estimates that what Southeast Dental Associates pays covers the practice’s costs if he doesn’t include his time.
For its part, Southeast Dental Associates is dependent on what the managed care organizations pay – and they in turn are dependent on what the state pays them.
“We are here to do dentistry. We are not here to fix the program,” said Deanna Janssen, Southeast Dental Associates’ administrator. “We will see as many patients in a day as we can see.”
HMOs lack timely access
A report by the Legislative Audit Bureau last year also found that managed care organizations have not consistently maintained an adequate network of dentists and timely access to dental care. Both are required in their contracts with the state.
Timely access is defined as appointments within 90 days for routine dental care and within 24 hours for emergencies.
Yet the managed care organizations are unlikely to persuade more dentists to treat children and adults covered by BadgerCare Plus given the low reimbursement.
“That is the biggest problem we are facing now – that there is not enough money allocated to dental,” said Mark Rakowski, director of Managed Care/Healthcare Reform at Children’s Hospital and Health System.
The state would need to at least double what it now pays to adequately fund dental care, Rakowski said.
The Department of Health Services doesn’t deny that children are not getting dental care or the need to increase what BadgerCare Plus and Medicaid pay dentists.
“It has to be part of the solution,” said Bob Dwyer, chief dental officer for the state Division of Health Care Access and Accountability.
Wisconsin has taken a number of steps in recent years to improve access to dental care. There also are a hodgepodge of initiatives by private organizations.
No one contends they are enough.
“How does this occur in a rich society, in a state such as Wisconsin, a sort of progressive state?” said Greg Nycz, executive director of Family Health Center of Marshfield Inc. and director of health policy for Marshfield Clinic. “It happens because well-meaning people don’t understand the breadth of the problem.
“If more people understood this, they would say, ‘Not in this nation. Not in my state. We are going to fix this.’?”
Among children nationwide ages 2 through 18 covered by Medicaid (the government health program that includes BadgerCare Plus):
BadgerCare dentists see few patients
Roughly half of the 3,376 dentists licensed in Wisconsin are certified to bill BadgerCare Plus and other Medicaid programs. Most certified dentists, though, see few low-income patients. About one in four of the state’s dentists billed more than $10,000 for seeing patients insured through state health programs in 2007, according to the state Department of Health Services.
By the Numbers
- More than 1 in 20, roughly 1.1 million children, had urgent dental problems.
- 1 in 3, roughly 6.5 million children, had untreated tooth decay.
- 1 in 9 had untreated decay in 3 or more teeth.
- 1 in 3 had received dental care the previous year, compared with half of children with private health insurance.
- 1 in 8 never sees a dentist.
- Source: Government Accountability Office
Tips for daily oral care
- Brush and clean between your teeth every day.
- Brush your teeth twice a day with a soft-bristled brush. Use toothpaste that contains fluoride, which helps protect your teeth from decay.
- Cleaning between the teeth once a day with floss or interdental cleaners removes plaque from areas the toothbrush can’t reach. It is essential in preventing gum disease.
- Eat a balanced diet and visit your dentist regularly.
Source: American Dental Association
Susanne Rust and Georgia Pabst of the Journal Sentinel staff contributed to this report.