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June 2009 | Modern Hygienist Who loses out? How poverty, race and class play out in access to care.  Photo: Thomas Barwick/Getty Images When my best friend came to Chicago last fall, she wanted to do two things: attend a millionaire’s Halloween party on Michigan Avenue and see a dentist. As graduate students without dental insurance, Sophia and I were excited that Dr. Lillian Obucina was offering preventive prophylaxis for only $31 as part of an October fund-raiser for breast cancer awareness. Though 10 months had passed since I had seen a dentist, I left the office with healthy gums and zero cavities. This came as no surprise, for reliable insurance and quality care had long been staples of my privileged upbringing prior to graduate school. But not everyone is that fortunate. According to the first Surgeon General’s Oral Heath Report in 2000, nearly four out of 10 Americans, or 108 million people, lack dental insurance. That’s more than double the population without medical insurance. Rural residents, ethnic minorities, and low-income families suffer even greater challenges to access oral care. More than 37 million people, or 12.5% of all Americans, live below the poverty line, according to a 2008 U.S. Census report. The threshold used to calculate poverty for a family of three was $16,530. Blacks and Hispanics have significantly higher poverty rates than the national average, at 24.5% and 21.5%, respectively. States aren’t equal Washington’s Medicaid covers people who earn up to 200% of the federal poverty level (FPL)—or $36,620 for a family of three—and provides dental insurance for those younger than 21. Through the State Children’s Health Insurance Program (SCHIP), families who are ineligible for Medicaid but earn up to 300% of the FPL can receive medical and dental care for kids younger than 19. Any state can participate in federally sponsored programs such as Medicaid or SCHIP, but Washington also offers a third option: Children’s Health Program. This benefit extends medical and dental assistance to non-citizen children whose families earn up to 300% of the FPL. But even residents in a wealthier state, such as Washington, aren’t immune to problems accessing oral care. An estimated 20% of the state’s dental professionals oversee 80% of the state’s Medicaid and SCHIP services, according to the Washington Department of Social and Health Services (DSHS). Jim Stevenson, Communications Director for DSHS, said more access issues exist within dental care as opposed to medical care. “I think there is a perception among dentists that Medicaid and SCHIP are too low compared to private pay,” Stevenson said. “But some dentists can set up their practices properly, and they can be okay.”
Across all races rural parents are less likely than urban residents to describe their children as having “excellent” teeth (click chart above). Other choices included “very good” and “good to poor.” The disparities are especially pronounced among white and black children living in rural areas, compared with their urban counterparts. Yet, the differences are not statistically significant for rural children of Hispanic and “other” ethnicities, compared with similar urban children. Source: South Carolina Rural Health Research Center, 2008. Shortage of help The report attributes low usage rates in California to three factors. Beneficiaries lack knowledge of dental services. For example, the majority of Medicaid parents mistakenly thought their children didn’t have dental benefits when they actually did. Patients have a difficult time finding a dentist. Only 40% of California’s dentists accept publicly insured patients. Also, language and cultural barriers exacerbate the problem. While Latinos make up 49% of beneficiaries who use dental services, only 9% of participating dentists are Latino. Enabling services, such as language translation, are important to keep appointments, said Amy Brock Martin, DrPH, Deputy Director of the South Carolina Rural Health Research Center. And cancelled appointments help neither the patient nor the dentist. “Missed appointments are a real revenue loss, and a big deal,” she said. Poor patient compliance, such as failing to commit to scheduled appointments, is one of the three main reasons dentists usually cite for refusal to accept Medicaid, according to a 2008 National Academy for State Health Policy report. Employment and transportation are factors that can prevent a patient from showing up to the actual appointment. People employed at low-wage hourly jobs in manufacturing, retail and service don’t always have the luxury of leaving for part of the day to visit the dentist, said Len Finocchio, Senior Programs Officer at California HealthCare Foundation. The inability to take time off work becomes a bigger challenge if the job site is located far from the dentist’s office. In addition to educating patients on the significance of cancelled appointments, Finocchio suggested, “Dentists could try to better understand patient circumstances.” CONTINUED ON NEXT PAGE
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