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This Won't Make You Smile

Harold Pollack is the Helen Ross Professor of Social Service Administration at the University of Chicago and a Special Correspondent for The Treatment.

A great NPR story by Sarah Varney highlights the growing and sometimes dire consequences of state budget cuts to medical and social services. It also highlights the systematic neglect of dental care in health reform and public policy.

Varney describes the deep cuts in California's Medicaid program brought about by recession and by the state's self-immolating budget process. Three million poor and disabled California adults have lost their dental coverage. Varney notes the consequences of these cuts: 

[Dental receptionist Claudia Rico] says more patients are showing up each day with swollen gums and infected teeth. Before the state budget cuts, Medicaid patients here could get annual exams, cleanings and, if needed, root canals to save their teeth. 
Now, Rico says, patients can't afford to pay for root canals themselves — even at the discounted rate of $600. So they end up getting their teeth pulled. 
In interviews with dozens of dentists and safety-net clinics around California, providers say patients are forgoing routine cleanings and delaying care until the pain is unbearable. Dentists are offering discounts and payment plans, but they say few patients can afford them. Dental schools and free clinics are overrun, and some private dental offices and at least one community dental clinic have closed. 
Under federal law, dental coverage is considered an optional benefit that states don't have to provide when insuring poor or disabled residents. In fact, at least seven states — Virginia, Delaware, Alabama, Texas, Colorado, Utah and Missouri — provide absolutely no coverage, even for emergency relief of pain and infection. And a growing number of states have scaled back their programs and cover dental emergencies only…. 
In California, the state will still pay to have a tooth pulled in an emergency, but it no longer covers the cost of expensive dentures. That's a big problem for seniors. Medicare doesn't cover dental, so poor seniors in California have long relied on state dental benefits when they need dentures. 

This story provides yet another example of how fundamentally broken Medicaid policies hurt millions of people. Rising costs within the core of Medicaid are killing state budgets, and are leading states to abandon key optional program components and accompanying public health measures. This pattern does not reflect mismanagement. Costs are growing because recession and the erosion of private insurance is producing record Medicaid enrollment increases. General medical inflation continues apace, even as state tax revenues sharply decline for the same macroeconomic reasons people require increased services. 

Varney's piece is one of the very few national media stories to highlight the critical roles of oral health and dental care, which has been generally overlooked in the health reform debate. 

This is a real opportunity missed. Dental care provides an untapped opportunity for needed screening and prevention interventions. I and my colleagues Lisa Metsch and Stephen Abel explored one such opportunity in the American Journal of Public Health. We examined the population of Americans who report that (a) they face significant HIV risks, (b) they have not been tested for HIV. More than 70 percent of these men and women had recently been to a dentist, even though many are not getting any other medical care. Our work focused on HIV testing. We might just as easily have focused on the millions of Americans with undiagnosed hypertension and diabetes who dutifully get their twice-yearly teeth cleaning without anyone finding (or looking for) these underlying problems. More imaginative care practices and improved dental insurance coverage of preventive services and diagnostic screening might make a big difference. 

And, as Varney makes clear, millions of Americans do not receive needed dental care. Crummy teeth have long provided a painful and stigmatizing symptom of extreme poverty. Medicaid often provides meager coverage and pays dentists very little. (Dental care is a continual problem for many low-income Medicare recipients.) The Washington-area death of 12-year-old Deamonte Driver from an untreated tooth abscess brought public attention to the most dire potential consequences of untreated dental concerns. Oral infection is increasingly linked to many serious health problems, including pregnancy complications and threats to cardiovascular health. 

Basic dental care is not particularly costly. Unfortunately, it is generally restricted to its own silo, separate from the rest of American medical care. Some dental leaders such as Burton Edelstein and Allen Finkelstein have argued for a stronger focus on prevention, and a greater integration of medical and dental concerns. They face difficult challenges in dental care financing, existing public policies, and the mores of the dental profession itself. 

At the most basic level, dental care is insured and financed through separate plans that demarcate specific boundaries from medical care. Key services such as hypertension screening would not typically fall under the scope of dental coverage. The Senate and House health reform bills are relatively silent about dentistry. (The word "dentist" appeared once in the 1,502-page Senate Finance committee draft bill.)  Child coverage has been expanded. Provisions are included to strengthen the dental work force and to address other infrastructure concerns. Yet these bills do relatively little to ensure adult access or to apply a careful delivery reform lens to dental services. (The status of stand-alone dental plans within proposed insurance exchanges raises delicate concerns, for example.) 

We also ask too little of a dental profession that could do more to protect and improve patient health. Even in matters such as smoking cessation, so intimately connected to oral health, the majority of dentists report that they are poorly-equipped to deliver basic preventive services. Few counsel patients effectively to achieve lasting behavior change. Dentists are uniquely positioned to address important public health concerns. They should embrace that, and should be paid to do so. 

P.S. As noted in Varney's piece, tens of thousands of intellectually disabled California adults are losing their Medicaid dental coverage. I will pick up on that issue in my next column.