Putting teeth in health reform: Dental clinics aren’t enough
09/01/2014 3:17 PM
09/02/2014 2:25 PM
When hundreds of desperate dental patients converge on the Charlotte Convention Center next week, it will be a testament to civic generosity and systemic failure.
Over the past decade, North Carolina’s Missions of Mercy program has become one of the nation’s largest providers of free mobile dental clinics. The work is done by dentists and support staff working without pay, aided by community volunteers and donors.
People in pain stand in line for hours or even days, grateful for help they can’t otherwise afford.
But dentists say the demand for free emergency clinics signals the state’s failure to develop a network of affordable dental care that would avert much of the damage that sends people here. So far the Affordable Care Act has made little difference, several dentists say.
“When people come in and you’re doing piecemeal work with tunnel vision, that’s not the best approach,” says Dr. Alec Parker, executive director of the N.C. Dental Society. The society is sponsoring six “NCMOM” clinics around the state this year, with the Charlotte event expected to draw more than 2,000 patients.
“This is not the answer,” agrees Dale Dove, founder of Rock Hill’s Renew Our Community poverty relief organization. He helped bring South Carolina’s annual clinic to his city last month, creating what Dove called “an organized fire ant hill” of cleaning, drilling and pulling.
“It almost makes you cry that people are in such desperate straits,” Dove said.
As health care reform sweeps the nation, dental care advocates want to be part of the picture. Mouth pain can keep kids from learning and adults from working. Disfigured or missing teeth can hurt job prospects. And people who go to hospital emergency rooms when they need a dentist clog the system, run up costs and leave without long-lasting treatment.
The Affordable Care Act, often called Obamacare, gives a nod to the importance of dental health. But some North Carolina dentists say it stopped short of making a real difference. The act defined children’s dental insurance as an “essential benefit” but doesn’t require parents to buy it.
“We really haven’t seen anything positive from it,” said Dr. Charles Norman, a Greensboro dentist who’s president of the American Dental Association.
What’s needed, dentists and advocates say, is higher Medicaid reimbursements, changes in the insurance marketplace and expansion of the few permanent clinics that cater to low-income clients.
“If you can prevent these things from happening early on, that’s the most important thing,” said Dr. Michael Brennan, chairman of Carolinas HealthCare System’s oral medicine department.
That means starting with children. Sealants, fluoride treatments, regular cleanings and early treatment of decay offer the best hope for healthy teeth.
The Mecklenburg Health Department provides children’s dental clinics and school screenings. Medicaid also provides dental coverage for some low-income children and adults – but finding a dentist who accepts Medicaid patients can be a challenge.
Three years ago, state officials said about 45 percent of dentists accepted Medicaid. Parker estimates that rate has declined to somewhere in the 30s. Reimbursement rates, already too low to cover costs, have been cut as the state tries to rein in Medicaid spending, he said. And last summer problems with the state’s new NCTracks billing system delayed payments to many dentists.
“Some of them got frustrated and said, ‘I’ve had it. I’m not going to do it anymore,’ ” Parker said. He said Medicaid pays about half of the private-pay rate.
Education has got to be part of the picture, dentists say. Norman, the ADA president, notes that roughly 40 percent of people who have dental insurance don’t use it. “When you work at clinics and you ask people, they don’t understand the concept of a dental home,” Norman said.
Obamacare for teeth?
Across the country, about 3 million children and nearly 18 million adults are expected to get dental benefits through the Affordable Care Act. Much of that will be in the 27 states that expanded Medicaid coverage to larger numbers of low-income adults and children. North and South Carolina aren’t participating.
A recent ADA study also concluded that some young adults seem to be getting benefits when they stay on parents’ health policies. The ACA, which extended that option through age 25, doesn’t address dental insurance, but employers may offer that coverage to families.
It’s too early to tell how many bought dental coverage through the exchange that offers subsidized health insurance. But North Carolina dentists say they’re not seeing a surge in insured patients.
Blue Cross and Blue Shield of North Carolina, one of two companies offering health policies for North Carolinians on the exchange this year, includes dental care in its children’s coverage. Preventive services are free, but fillings and other care may fall under medical deductibles, requiring parents to pay the bills.
Coventry doesn’t offer dental coverage in policies sold on the ACA exchange. That helps keep premiums down, said company spokesman Walt Cherniak. Parents who want dental coverage for their kids can buy it from a company that offers dental-only policies.
Lining up for help
When the Rock Hill clinic opened Aug. 8, Barry and Carol Lowery of Fort Mill were there.
Barry, a 54-year-old former machinist, uses a wheelchair. Carol, 60, uses a walker. They got in line at 11 p.m. the night before to secure a spot and get painful teeth removed.
When both were working, they earned about $75,000 a year and enjoyed a comfortable life, according to Carol Lowery, who worked at a grocery store. Then Barry Lowery had a heart attack and lost his job. A bad auto wreck set them back further. Carole Lowery now stays home to care for her husband, and they share their house with another couple to cover the mortgage.
Despite the long lines and being treated in a church hall packed with 80 dental chairs, the Lowerys and others said they were grateful for the emergency aid. More than 1,400 were treated over two days.
Clinics like this have become an essential part of dental care for the poor across America. Thirty states have Missions of Mercy clinics. Most do one or two sessions a year, Norman said. North Carolina peaked at about a dozen clinics a couple of years ago, and the Dental Society tallied its 50,000th NCMOM patient earlier this year.
But each clinic costs about $50,000 and requires hundreds of volunteers, so the total has dropped to six for 2014. Charlotte’s 36-hour marathon, the largest in the state, is even more costly.
Finding a better way
North Carolinians are part of the national push for a broader view of dental health reform.
This year dental and medical professionals teamed with houses of worship and other groups to launch the Cary-based N.C. Oral Health Collaborative. The group is promoting better collaboration between doctors and dentists, noting that conditions such as diabetes and heart disease can complicate dental care.
A handful of clinics cater to low-income dental patients, including the volunteer-run Agape Dental Ministry in Charlotte and three Gaston Family Health Services dental offices that serve mostly Medicaid and uninsured patients.
A statewide “ Into the Mouths of Babes” program encourages pediatricians to apply fluoride varnish to young children’s teeth and make dental referrals. Medicaid already pays for the treatments, and Blue Cross will start doing so in 2015.
In Rock Hill, Dove wants to pull together a coalition to explore better options. His idea: Raise money to create a local “dental bank,” where low-income residents could get a card to present for care. Dentists would be paid without the hassles of Medicaid, he said, and recipients would repay the bank.
“Most people would feel there’s more dignity in that than waiting to get it free and feeling like they have to beg for it,” Dove said. “Free needs to be for true crisis. It can’t be the system.”
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