A Dental Scandal
The death of Deamonte Driver shocked the country. Deamonte, a 12-year-old from suburban Prince George's County, Maryland, died in February 2007 when bacteria from an abscessed...
The death of Deamonte Driver shocked the country. Deamonte, a 12-year-old from suburban Prince George's County, Maryland, died in February 2007 when bacteria from an abscessed tooth spread to his brain, leading to a fatal infection that basic dental care could easily have prevented.
There were national headlines and even a congressional investigation. Health care specialists were asked what could have gone wrong for a child to die from a seemingly innocuous condition.
But almost as disturbing as Deamonte's death was a second disclosure that emerged from the controversy. The death wasn't exactly a freak occurrence. "I don't think there was anything unusual in Maryland that wasn't happening nationwide," says Harry Goodman, the state's director of oral health. "We were probably right in the middle for access to care for Medicaid children."
Goodman isn't being unduly defensive. Advocates, dentists and state government officials all agree that the nation's system for providing dental care to the poor is broken. Medicaid beneficiaries commonly go without basic dental services, leading them to develop painful conditions that are costly to treat. Once in a while, these conditions are fatal.
For at least a decade, states have been aware of the problem. Several are now seeing some success from reforms aimed at improving dental care for the poor. But they're also running into major challenges, including turf battles among the oral health professions and shortages of dentists and money. A less tangible but equally worrisome obstacle is a mindset, shared by citizens and policy makers alike, that treats dental care as more of a luxury than a necessity.
Searching for Care
At the heart of the Medicaid dental dilemma is a paradox. Under federal rules, every state Medicaid program offers dental coverage to poor children. Yet only about one-third of those children see a dentist in any given year. The problem is this: Just because kids need to see dentists doesn't mean dentists have to see Medicaid patients. This was the situation Deamonte Driver's mother faced. She was on Medicaid and searched in vain for weeks for a dentist who would see her children.
Nationally, only a fraction of licensed dentists regularly accept Medicaid patients. There's a reason for that: States pay dentists as little as half of what they make from private patients. It isn't just a matter of avarice. In some cases, the reimbursement rates aren't enough to cover costs, meaning dentists lose money on every new Medicaid patient they see.
Dentists don't shy away from Medicaid solely because of the reimbursement rates. They also cite Byzantine processes for filing claims, which can cause payments to be delayed for months. Frank McLaughlin, executive director of the Maryland Dental Association, says many dentists in his state prefer to see poor patients for free rather than deal with Medicaid. The hassles of seeking the state's paltry payments, he says, often aren't worth the effort.
All of this is significant because, beyond Medicaid, there is virtually no dental care safety net for the poor. "If you don't have regular health insurance, but something happens, you can always show up at an emergency room," notes Shelly Gehshan, of the National Academy for State Health Policy. "If you have an abscessed tooth and show up in an emergency room, all they're going to be able to do is give you painkillers and tell you to call a dentist." The result is what the U.S. Surgeon General termed in a 2000 report a "silent epidemic" of oral health disease for poor children -- rotting teeth and gum diseases that cause pain, hamper job prospects and ultimately lead to more serious conditions.
The situation is even worse for adults on Medicaid. Only eight states offer full dental benefits for that population. Some provide no dental benefits at all.
Long before Deamonte Driver's death, states had begun looking for solutions to these problems. The most basic is to raise reimbursement rates. Gehshan recently co-authored a report that looked at five states -- Alabama, Michigan, Tennessee, South Carolina and Virginia -- that have increased reimbursements in the past decade. In every case, more dentists started accepting Medicaid patients and more children began receiving dental care.
That still leaves the administrative problems. In this regard, Michigan has come up with an interesting experiment. Starting eight years ago, in a limited number of counties, it outsourced its Medicaid dental coverage to Delta Dental, the largest oral health insurer in the state, and matched Delta Dental's standard reimbursement rates. This means dentists can follow the same familiar reimbursement procedures they use for other patients. It also means that every dentist in the target counties who accepts Delta Dental thereby accepts Medicaid. "We were purchasing their network," says Christine Farrell, of the Michigan Department of Community Health, "and taking away the stigma of Medicaid."
This is, of course, a costly solution. Michigan has to pay fees to Delta Dental, offer the higher reimbursement rates and pay for the additional care now that more kids are seeing a dentist. Those costs have led some states to try a different approach. If dentists who will see Medicaid patients are in short supply, the thinking goes, why not allow caregivers other than dentists to provide basic oral examinations?
That's what North Carolina has been trying for several years through a program that targets very young children. While many youngsters on Medicaid don't see dentists, they do visit pediatricians. So North Carolina pays to train pediatric doctors and nurses in the basics of oral health. Medicaid pays them when they conduct oral screenings, apply fluoride or counsel parents on good dental practice. North Carolina's model is spreading. Eighteen Medicaid programs now reimburse primary care providers for some dental health services.
For its part, Maryland is trying multi-faceted solutions. This year, the legislature approved a reform package that will boost reimbursements by $42 million over three years, create a single dental vendor for the Medicaid program and expand dental health clinics. Dental hygienists will be empowered to do more work in schools and clinics without a dentist's supervision.
Maryland's approach could be a template for what a comprehensive approach to dental access might look like. The question is whether other states will follow the template. If history is any guide, many won't.
Questions of Attitude
In some places, one reason is simply a fatalistic attitude toward the problem. Ken Rich, Kentucky's Medicaid dental director, says some people simply assume they will have all of their teeth pulled at a fairly young age, like their parents and grandparents before them.
But, in a sense, Medicaid recipients who neglect their teeth are simply taking cues from elected officials and other policy makers who don't make dental care a priority, either. When state budgets become tight -- as they are right now -- oral health is often one of the first budget items to get cut. California Governor Arnold Schwarzenegger has proposed cutting dental benefits for 3 million adults on Medicaid. Last year, Colorado dropped dental care for pregnant women on Medicaid. Planned expansions of dental coverage in Nevada and Ohio have been delayed.
Nowhere is this dynamic more obvious than in Michigan. Even though statistics show that the kids being served by Delta Dental have more access to care, the state hasn't expanded the program to many of Michigan's population centers. "It's a cost issue," says Christine Farrell. The state also reduced reimbursement rates for Delta Dental in 2006, resulting in a drop in the number of dentists participating.
All of this is a tremendous source of frustration to dentists, who think policy makers view oral health care as an optional service rather than a necessity, even though dental problems can lead to nutritional problems, heart disease and strokes. "The people who make decisions, who control the money and control public policy, don't have dental problems," says Paul Casamassimo, former president of the American Academy of Pediatric Dentistry. "The idea of a child dying of tooth decay is something they never would have dreamed of." Of course, since Deamonte Driver's death, fewer people need to be reminded of that possibility.
Nothing to Smile About
Medicaid children receiving dental services, 2004
Received any dental services
Received preventive dental services
Received dental treatment
Sources: Centers for Medicare & Medicaid Services
and National Academy for State Health Policy