The growing divide between rich and poor
in the United States manifests itself in many ways, but there’s one that is easy to spot: a person’s teeth.
Even under the Affordable Care Act, dental coverage isn’t an essential health benefit
, and many employer-based plans long ago stopped offering dental plans or contributing to them. Dental care for children is required under Medicaid, but for adults, the decision is up to states. That means for more than 108 million poor and lower-income working adults, dental coverage is unaffordable; for many more, expensive restorative work is out of reach.
In Michigan, health officials in Ingham County came up with a solution: they offered a group of low-income adults $25 in dental services for every hour of volunteer work, during a program that ran from January 2014 to October 2015.
Called Pay It Forward, the program attracted 38 patients, including 27 who took part in a survey afterward. While 80% of the respondents liked the program and would do it again, about 12% said that juggling their volunteer hours with work and family responsibilities was a struggle. What drew them to the program? About 70% who signed said they were in pain, and 38% said their dental woes affected "all aspects" of their lives.
Lorene Kline, who surveyed both patients and providers for her master's thesis at the University of Michigan School of Dentistry, said in a statement
that the results raise questions about whether the model is fair to the working poor, some of whom already work more than one job.
"That made us question whether it's a good model for working adults who have families and children," said Kline. "It's probably more difficult for them to find the time to dedicate to community service."
The Michigan experiment could play out more broadly. Kentucky Governor Matt Bevin has asked CMS to change the terms of his state’s Medicaid program, so that adults who received coverage under Medicaid expansion would have to earn “rewards,” which could include community service
, to retain dental coverage.
Groups like the American Dental Association argue that barriers to the dentist’s chair are short sighted, since trips to the emergency department (ED) tied to dental problems are increasing
, primarily among adults ages 18 to 44. A report earlier this year in The Washington Post
about the lack of dental care for the poor said rotting teeth can signal health problems like diabetes and cause new ones, like heart disease and depression. People who have decayed or missing teeth are hard to employ, especially in customer-facing service jobs.
A 2011 Delta Dental study that Kline cited found that 7000 visits to the ED could be prevented with better dental care, including 1000 visits that require hospitalization. Hospitals collected only about $15 million of the estimated $58 million cost.
Kline said the programs like Pay It Forward could help address unmet need for low-cost dental care, but they were not a panacea. The program covered adults who earned less than 250% of the federal poverty line but did not qualify for Medicaid. They could earn hours to cover basic cleanings, x-rays, extractions, and simple restorations; the program was not designed for major restorative work, although some dentists did provide more extensive procedures.
Overall, patients performed an average of 33 service hours and received more than $1150 in treatment. The total value of the treatment was $43,815. The value of the services varied, from $195 to $5056, Kline said.
Besides most patients being in pain, one-third said their teeth or gums limited what they could eat, and 40% said they were uncomfortable eating in front of others. Among the dentists, 7 of 9 who responded to the survey rated the program favorably on all aspects. Two said they didn't find volunteering rewarding and voiced issues with the volunteer activities, and said that the quality of care wasn't comprehensive enough.
The study was published recently in the Journal of the Michigan Dental Association