Must Poor Kids have Bad Teeth?

For many poor children, a trip to the dentist isn't a source of terror; it's an unknown experience. Although we have programs to care for children's dental needs, they aren't working for the poorest kids.

Toothaches. Just the thought makes even the most stouthearted flinch. The pulsating pain of dental disease sends us running to our dentist for relief and therapy. Now imagine this scenario without the dentist.

"Children are needlessly suffering from preventable dental disease that threatens their growth, early childhood development and their ability to function at home and in school," says Burton Edelstein, a dentist and director of the children's Dental Health Project. He says the amount of tooth decay in a child is inversely related to income.

"Eighty percent of dental disease is found in 25 percent of the poorest children," he says, "and about half of this disease goes untreated." For the most part, he is talking about children who are eligible for Medicaid and the State Children's Health Insurance Programs (SCHIP).

So why are children eligible for public programs missing school, being admitted to emergency rooms and suffering pain because of untreated dental disease? State legislatures are attempting to answer this complex question and create acceptable solutions. In 1999 more than 40 bills were introduced across the country to improve access to oral health services. Seventeen bills were enacted.

Connecticut Representative Vicki Orsini Nardello remembers that "five years ago you could not get a legislative discussion on oral health." She attributes this to our attitude toward dental health. "Because we look at teeth as expendable, we diminish the impact of the pain and the disease," she says. However, research showing the correlation between dental and cardiac diseases in adults, and poor nutrition and growth, low self-esteem, missed school days and other medical complications in children brought this public health issue to the legislative floor in many states.

MEDICAID, SCHIP AND ORAL HEALTH

Federal law entitles all children enrolled in Medicaid to comprehensive dental services. Medicaid's Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program, the nation's primary source of well child care for low-income youths through age 20, must provide dental examinations and necessary treatment or services to correct or ameliorate defects.

Children who do not qualify for Medicaid because of their parents' income may be eligible for the state SCHIP plan. All but two state SCHIP plans--Colorado and Delaware--include dental services in the approved benefit package. The services provided vary from state to state, but most plans provide basic prevention and restoration. Having an insurance card and actually receiving the entitled services are two different things. Only one in five children eligible for Medicaid actually gets the required dental screening. Statistics for the relatively new SCRIP plans are not yet available, but many people working on this issue expect children with these new insurance cards to have the same problems finding a dentist as those in Medicaid. Edelstein points out that this is a significant public health problem since "the children enrolled in these programs have about double the need for dental health care" as children living in more affluent households.

DENTISTS DON'T PARTICIPATE

Many eligible children lack access to comprehensive dental care because of the shortage of dentists participating in the Medicaid program. Medicaid relies on dentists in private practice to provide the majority of services. These dentists claim that the low reimbursement rates, the bureaucratic red tape and the number of broken appointments by these clients keep them from signing up.

Nancy Schoyer, executive director for dental clinics in the Denver area for low-income, uninsured children, claims that dentists would rather volunteer for the clinics than participate in the Medicaid program. There are over 400 dentists in the area who regularly donate their services for thousands of children.

"There are many reasons why dentists desiring to help those who need it most turn to our clinic instead of Medicaid," she says. "The dentist may disagree with Medicaid's dental practice rules; they may not want to deal with the extra paperwork and billing requirements that comes along with taking Medicaid clients; and they want to avoid the missed appointments that are common for these patients. It is not just the money that keeps them away," she says.

An estimated 152,000 dentists practice in the United States, and most are located in the affluent rings around cities, according to Edelstein. Although the dentists take care of oral health in the suburbs, families on Medicaid in the inner city and rural areas are left without a dental provider. Many families with Medicaid-eligible kids have transportation problems and this can be an insurmountable barrier.

Families whose children are eligible for Medicaid and SCHIP may not be familiar with "going to the dentist," which adds to the challenge of finding a dentist and seeking appropriate care. They may not realize the value of preventive dental care because of their own history of poor oral health. Parents also may find it difficult to take time off from work to take their children to the dentist.

Finally, Nardello believes that the dental public health system is inadequate. "Public dental care in the United States does not come close to the system that exists for medical care. We need to invest in a dental public health system if we want to fix the problem," she claims. The children eligible for dental services rely disproportionately on the public sector and public clinics for their health care needs, yet only about 30 percent of the country's community health clinics have any element of an oral health program, according to Edelstein.

That may be more difficult than it appears. More than 90 percent of all dentists are in the private sector. Because of this statistic and the likelihood that it will not change soon, Edelstein says services for vulnerable children require the help of private sector dentists.

IS THERE A SOLUTION?

There is no simple, quick fix to this problem. States making comprehensive reforms to their oral health delivery systems show the greatest improvements in the number of children receiving care. The package of reforms that states are experimenting with include increasing dentist reimbursement rates, simplifying administrative tasks, educating Medicaid clients about the dental system and the importance of preventive care, expanding the scope of practice for dental hygienists, and creating loan forgiveness programs for dentists willing to take public insurance.

Increasing the number of school and community health clinics and mobile vans is another approach. Nardello is convinced that this is the most effective way to deliver services to the Medicaid and SCHIP kids and is the best use of scarce financial resources. To support her claim, she points to Hartford, Conn., which has a successful system of school-based dental clinics for kids from kindergarten to sixth grade. About 70 percent of the eligible youngsters get dental services.

"The school-based programs hurdle many barriers," claims Nardello. Since the child is already at school there are no problems with lack of transportation and missed appointments. The school has interpreters to overcome language barriers, and the child has an existing relationship with the school, which may reduce some of the fear associated with a dental appointment.

However, Edelstein cautions policymakers to consider that these types of clinics can be an expensive way to deliver services because of the cost of setting up the clinic and purchasing the necessary equipment. "Overhead for dental offices runs about 60 percent to 70 percent. Small clinics with one or two dental chairs may not be the most efficient, cost effective way to deliver comprehensive dental care." He says that getting kids linked to the private sector whenever possible is the best way to assure continued care.

MAKING IT WORK

Dental disease is preventable. After the initial investment of treating the disease, it is relatively inexpensive to maintain healthy teeth through education and regular hygiene. "We really have to believe in the power of prevention to make a dental health program for kids work. When you believe in it, you invest in it. It comes down to the dollars," says Nardello. Many states have come to the realization that with careful evaluation and a few key reforms in both the public and private sectors and resources, they can improve the oral health of their children.

Laura To bier is NCSL's expert on the uninsured and primary care issues.

SOME TITLE V MONEY GOES TO DENTAL PROGRAMS

While dental care is on the list of health services that qualify under the Maternal and Child Health Title V programs, funded with federal and state dollars, less than 2 percent of the overall block grant goes to dental care.

At least nine states have no state oral health program and many of the remaining states function on relatively small budgets.

Where it is being used, Title V money goes to fluoridate water, provide dental screenings, arrange transportation to dental clinics and sometimes even provide the services of dentists to repair teeth