Bad Teeth a Barrier to Health and Jobs

EAST PALO ALTO, Calif. -- For years, Eva Marie Warren, 53, avoided eye contact with passers-by as she panhandled on the streets, for fear of having to smile back or make small talk.

To smile or talk would compel her to reveal something she was deeply embarrassed about – her teeth.

Years of snorting crack cocaine – an addiction she developed after she lost the father of her three children, and that she once supported by turning tricks -- had eroded this African American woman’s teeth and gums, causing her molars to rot and the rest of her teeth to discolor.

A Future Full of Promise

“My teeth were yucky, they hurt and I looked a mess,” Warren said, as she recalled her past. Then she smiled, visualizing a future full of promise. “Having a good set of teeth is so important when you are looking for a job.”

After Warren was “discovered” on the street by Ravenswood Family Health Clinic’s homeless health advocate Tayischa Deldridge earlier this year, she benefited from major orthodontic work at the clinic’s year-old dental unit, from deep teeth cleaning to having a new set of molars implanted.

The treatment costs were partly reimbursed by the Access to Care for Everyone (ACE) program, where the clinic helped her enroll. The insurance plan is offered by San Mateo County for low-income people.

Warren is lucky to have gotten those dental services. Ever since California eliminated adult DentiCal in July 2009, the dental component of MediCal, fewer and fewer clinics have been offering dental services for low-income Californians. However, coverage for children and some emergency adult dental care were left in MediCal (the state’s Medicaid program).

The elimination deprived an estimated 3 million poor, disabled and elderly adults of oral health care, according to the California Dental Association. It supposedly saved the state $109 million, even as it caused it a loss of $134 million in federal matching funds.

Also in 2009, the state cut $3 million from school-based programs that provided preventive dental disease, such as fluoride rinses and sealants for low-income children.

Millions Without Dental Insurance

According to the 2007 California Health Interview Survey – the last for which data are available – some 9 million Californians reported having no dental insurance for the year, and another 2 million said they had dental insurance for only part of the year.

Even before DentiCal was cut, people were hard pressed to find a dentist willing to take MediCal patients because of the program’s low reimbursement rates.

Joel Cohen, director of policy and community education at the nonprofit Center for Oral Health based in Oakland, said only one in four employed Californians with medical coverage currently has dental coverage, indicating that most employers don’t prioritize oral health care coverage, either.

Research indicates that chronic oral infections can lead to heart and lung diseases, diabetes and stroke, malnutrition, premature births and low birth weight.

Given those alarming findings, dental health care advocates wonder why Congress gave short shrift to adult dental care when it drafted the healthcare reform legislation. That law, the 2010 Affordable Care Act (ACA), however, does strongly support children’s dental health coverage.

Congress did not even require the health care exchanges that every state has to set up under the ACA by 2014, to offer dental coverage. These exchange will establish health care coverage that individuals unable to obtain other affordable insurance can purchase online. The exception is that dental coverage will be included in catastrophic coverage options available only to those 30 or younger.

The American Dental Association (ADA) unsuccessfully lobbied hard to expand dental eligibility for adults, as well as improving the reimbursement rates for dentists who accept Medicaid patients.

The decision by Congress not to cover dental care for adults was the key reasons the ADA did not support the final version of the health care reform bill, said the association in an e-mail to New America Media.

“Policymakers say they understand the importance of dental care, but continue to underfund programs that would extend that care to the underserved,” the ADA e-mail continued. “This underfunding leads to greater expenditures in the long run, with lost productivity in the workplace and missed school days.”

Preventable Suffering and Cost

ADA also stated, “Adults with untreated dental programs often seek care in emergency rooms, leading to huge avoidable costs.”

Cohen of the Center for Oral Health noted that providing dental coverage to more adults would, in turn, extend coverage to more children.

The death of 12-year-old Deamonte Driver of Maryland, who died in 2007, when a tooth infection spread to his brain, supports this argument. Driver’s family was uninsured and had recently lost its Medicaid benefits.

The boy underwent two operations and six weeks of hospital care, totaling $250,000. Doctors later said a routine $80 tooth extraction could have perhaps saved his life.

Alicia Malaby, communications director of the California Dental Association, also emphasized that ACA will not close the dental-care gap left by Medicare, the federal health program for people 65-plus and those with disabilities.

“Medicare has not covered dental care in the past, except in limited specific circumstances, and healthcare reform did not change that,” said Malaby.

For people such as Eva Warren, the lack of dental insurance creates problems that are often compounded by personal barriers – lack of transportation and spells of homelessness.
“Sometimes, accessing dental care is two bus rides away,” Cohen pointed out.

Until the opening of the dentistry unit at Ravenswood Family Health Clinic in April 2010, with grants from several foundations and the California Dental Association, the ratio of low-income population to dentists in South San Mateo County was 81,521 to 1, compared to the national average of 3,000 to 1. Ravenswood alone has racked up well over 7,000 dental visits since it opened.

After receiving oral treatment at the clinic, Warren’s confidence level spiked so much that she managed to land a part-time job at the Costco warehouse in Mountain View, Calif., as well as housecleaning gigs in her neighborhood.

A healthy mouth, she asserted, “makes all the difference.”