Dental care for poor youth "a huge, huge need"
Low Medicaid reimbursements and lack of insurance complicate access
Pain and heat pulse from the teenager’s jaw, the tooth rotting from the inside and so sensitive that the slightest touch causes agonizing pain. Blood leaks from the aching tooth; a metallic taste feels cold in his mouth.
His high school nurse takes him home. The tooth has to come out, but he can’t go to the dentist because he doesn’t have insurance and local dental offices won’t take his medical card for an extraction. The closest dentist who can help him is an hour and a half away.
It’s too costly to get to that dentist. There’s only one option left. He grabs a pair of pliers and he would grit his teeth against what’s coming, but they already hurt too much. He yanks the tooth out, his fingers white-knuckled around the pliers.
Sound farfetched? It’s a true story for this student from Owensboro High School (who is not identified so as not to embarrass him). It’s also true for thousands of other young people in Owensboro and Daviess County who lack access to dental care and suffer as a result. “It’s such a huge, huge need,” said Beth Murphy, director of the Family Resource Center at Foust Elementary School.
“The problem’s almost so big it’s really intimidating to get your arms around it,” added JAT Mountjoy, director of the Daviess County Community Access Project and the Reach Clinic.
According to a Kentucky Youth Advocates study based on data from 2004, 10,780 children in Daviess County under the age of 21 were eligible for Medicaid or KCHIP (the Kentucky Children’s Health Insurance Program). Of that number, only 3,440, or 32 percent, received any dental care. More than two-thirds of eligible patients went untreated. The study reveals similar numbers across the state – only 33 percent of Medicaid- or KCHIP-eligible recipients under 21 receiving dental care.
Out of 378 students at Foust, 289 qualify for a medical card (given to Medicaid recipients to help cover health care costs). Even so, more than half have never been treated by a dentist, Murphy said.
Part of the problem is lack of access. Most dentists won’t accept the medical card for payment. Murphy estimates there are fewer than five in Daviess County who do.
The main reason is because reimbursement fees for dental procedures are so low that most dentists will lose money by accepting the card, they say. Mark Fort, an Owensboro dentist who has practiced for 22 years, used to take the medical card, but currently doesn’t. The reimbursement rate runs from 35 to 50 percent of his fee, depending on the procedure the patient needs, he said. “By the time you count in the overhead involved, at very best, it’s a break-even proposition.”
Carol Braun, another Owensboro dentist, but one who has taken the card since her practice began in 1986, understands the dilemma. Dentistry, she said, “is a business as well as a health care provider. The last fee increase (for reimbursements) for us was 12 years ago. Even though our overhead changes every year, that’s not a consideration. To not have the increase is tough to take.” Braun said she sees three or four Medicaid patients a day.
Broken appointments lead to a further loss of money for dentists. “My biggest problem was a failure for (Medicaid patients) to make their appointments,” Fort said. “You would schedule them and sometimes they would show up and sometimes they wouldn’t.” Fort and other dentists aren’t sure of all the factors involved, but say reasons for the high no-show rate among Medicaid patients include transportation issues and a fear of going to the dentist.
Carol Hulsey, another Owensboro dentist, also used to accept the medical card, but eventually decided to stop seeing patients when they didn’t show up for appointments. She ended up with only one Medicaid patient.
So where do poor children go when they’re hurting? What about the nine-year-old who needs four molars pulled, the high school student who needs dentures or the young Hispanic child who doesn’t have a medical card but needs two crowns, three extractions and six fillings ($1,500 worth of work)? Short of going to the emergency room (which is happening more often now, according to Braun), all of these real-life local examples have to struggle to find dental care.
They do have advocates. Renee Ireland, health coordinator for Daviess County Public Schools, tries to help kids on a case-by-case basis. When she discovers a need, she peruses her Rolodex, tracking down every resource she can think of. She’s sending the nine-year-old to an oral surgeon in Hopkinsville and drawing on three different sources to partially pay for three root canals for a high school girl.
The Owensboro Rotary Club has a youth fund for such needs. The Goodfellows Club can occasionally provide funds and some family resource centers have welfare funds available. As helpful as these sources are, though, they’re limited. They don’t address the larger issue.
“We need more dentists to come in and help with this need,” Ireland said. “We don’t have the resources, we don’t have the places to take them (patients).”
“There isn’t enough money to meet all the needs,” Murphy added.
The Medicaid numbers also don’t include a large population that falls through the cracks – the working poor. There are many citizens, Murphy said, who earn enough money that they are not eligible for Medicaid, but not so much that they can afford dental care.
All of which leaves many local families in quite a predicament. They can’t afford dental care, but after years of neglect, it’s often necessary. Solutions are slowly coming. The process begins, many say, with education. “Dental care is not seen (to be) as important as immunizations,” Murphy said. “Preventative care is not pushed. They only go when it hurts.”
If cavities that require simple fillings aren’t treated early, the teeth will rot from the inside out, requiring a root canal or an extraction. Preventive care would save huge amounts of time and money.
“Early prevention and education is the key,” Fort said. “If you can catch some of this stuff early, if you can foster some good dental health care attitudes and make an impression on school-age children, perhaps in a generation, we can cut it down some.”
The state government and local schools are making efforts in this direction. The Dental Health Initiative, passed four years ago by the state legislature, approved $8,000 for a sealant program in Daviess County and Owensboro Public Schools.
The program provides sealants for children’s teeth to protect them from disease and decay. Before dentists can apply the sealant, though, they must fill cavities, pull teeth and make sure the mouth is healthy.
To determine which children need treatment, Murphy or Ireland organizes a screening day at an elementary school. A note goes home to parents to obtain permission for their child’s teeth to be checked. Then a dentist such as Fort, who screens kids at Sorgho Elementary School, will conduct a brief visual exam using a handheld mirror. The dentist will look for large cavities or badly decayed teeth and assess if the child has even ever been to a dentist. Those who need treatment will get appointments with a local dentist through the program.
Murphy and Ireland are grateful for the help, but funds from the DHI will eventually run out and the grant is not renewable.
To complement the sealant program, Foust Elementary School has instituted a toothbrush program. Each classroom is equipped with a toothbrush rack that holds a brush, its cover and a small tube of toothpaste for each child. Teachers encourage their students to brush their teeth at least once a day while they’re at school in hopes that the kids will carry the habit home.
Another educational issue deals with what kids eat and drink. “One of the biggest problems we’ve got right now, in all society, is the consumption of soft drinks,” Fort said. “I see a lot of children from all socioeconomic levels that have a lot of decay. The problem is having one (a soft drink) in your hand all day long.”
Existing clinic services
For immediate, pressing, painful needs, a screening won’t help. Children need to see a dentist.
One idea is to create additional dental clinics specifically for the poor of Daviess County. One such clinic already exists, but it is staffed by volunteers and its capacity, especially for young people, is limited. A small group of local dentists established the Christian Dental Mission about 10 years ago in a small house just off Scherm Road. The Daviess-McLean Baptist Association outfitted the house as a fully functional clinic, complete with two dental chairs and an x-ray machine.
Hulsey has been involved with the project since the beginning and is the outgoing president of the clinic. She said it is open once a week for a morning or an evening session. The clinic is staffed with five or six local dentists, a couple of hygienists and several volunteers from the community.
The Help Office sends qualifying patients to the clinic. Hulsey said the clinic treats only patients whose income is below the poverty line and who are employed, recently unemployed or on disability. The clinic was getting so many calls for help that it had to arbitrarily pick the poverty line as a cutoff to reduce the patient load to a manageable level. Most patients are adults.
If more dentists and staff were willing to volunteer, the clinic could theoretically expand and even treat young people, but Hulsey doesn’t think it will happen. “I’m always recruiting,” she said. “I have no support staff. It’s hard even in your own practice to hire someone who’s an experienced dental assistant.”
On the other hand, there is a precedent for a larger, faith-based operation elsewhere in Kentucky. First Baptist Church of Frankfort opened the Mission: Frankfort dental clinic in their church building in September of 2002.
“We invested about $80,000 in the clinic itself,” said David Hinson, pastor of First Baptist and director of Mission: Frankfort, which also includes medical and pharmacy components. “It took a year to get it up and running.”
The three-chair clinic is as operational as any dentist’s office, he said. Organizers put in the chairs, pump systems, plumbing, water, even cabinets. Nashville Dental Company donated time and expertise to help them set up, Crest donated toothpaste and brushes, Kentucky State University gave surgical instruments, and many other dentists and companies also donated equipment. Monetary support came privately from church members. Since the clinic opened three years ago, the church has spent about $31,000 on dental supplies.
The clinic developed a partnership with the Franklin County Health Department, which actually makes the appointments for the clinic. “Virtually 100 percent of the people who come to clinic are uninsured,” Hinson said. “Patients we see are not patients that would come to (dentist) offices.”
The clinic is open when the nine dentists and seven hygienists who volunteer are able to be there. Some dentists will come for a morning; others will take an entire day to treat patients. They’ve seen 121 patients who have made 217 visits to the clinic, Hinson said.
The clinic has also received sets of dentures each year from two labs, in addition to medication from a couple of pharmacies. “It has really been a loose-knit coalition,” Hinson said. “The larger dental community has helped us as well.”
One woman had been missing her four front teeth and often kept her hand over her mouth for 10 years. A dentist at the clinic restored her teeth and her life has been transformed, according to her sister.
Hinson has been so involved that he even went with the Kentucky Dental Association to successfully lobby the state legislature to change a law to allow dental specialists,such as orthodontists, to practice general dentistry in a free clinic setting.
Hinson also promotes a new clinic sponsored by Calvary Baptist Church in Lexington. Twenty-five local dentists and other dental professionals have signed up to rotate over three nights a week in the facility the church has set up.
“Kentucky has the number-one dental need in the United States,” Hinson said. “It’s one of my dreams, in every major community in Kentucky, to have a mission dental clinic. I do think the dental community is looking for ways to establish coalitions.”
Expanding clinic services
Mountjoy directs the Daviess County Community Access Project (DC-CAP), which links low-income, uninsured Daviess County residents with health care providers. He said he may be able to add a dental component eventually, but in the meantime, he’s focusing on establishing the medical program with the health care community. “Once we kind of get this program more solidified or grounded, it’ll be easier to roll out an expansion with dentists,” he said.
He said the REACH Clinic, a complement to DC-CAP which he also directs and which provides health services for residents who are covered by Medicaid and Medicare as well as discounted services for the uninsured, has an extra exam room that would be a possible location for a small clinic. The primary obstacle is funding, he said. “To get a full-time person (a dentist) generating little to no income is difficult.” Then there’s the cost of equipment and assistants. “It’s definitely doable, it’s just a matter of spending time and putting hard, real numbers against it,” he said.
One possible funding source is grant money, specifically from Catholic Health Partners, a major player in Owensboro health care over the years. Doug Borders, who recently retired after years as an executive with the company, said the organization does sometimes approve requests similar to what Daviess County would need for a clinic. “They like the idea of helping out children,” he said. “They’re really interested in obviously gearing whatever funds they give to those that are in the most need. When you mention kids, it generally becomes attractive to them.”
However funding for a clinic or a full-time dentist at the health department most likely would not come from a tax increase by the Daviess County Board of Health, said Lee Denham, director of the Green River District Health Department. “It would take a very significant presentation to them,” he said. “They would have to see the extent of the unmet need.”
Denham said that in the 1970s, the health department contracted with a dentist who did cleanings for kids covered by Medicaid, but at some point, that service ended. Because the health department serves a seven-county district, it must demonstrate how a service offered only in one county will be supported by that county, whether through taxes, fees or other funding sources, Denham said. “It’s probably not feasible to offer (a clinic or a dentist) only in Daviess County if there was need in the other six counties,” he said.
Rather than working with an outside clinic, Denham said the health department would prefer to let DC-CAP, which is still a new program, try to add dental care to their services. He said he is willing for the health department to participate in discussions and plans with the community. “If it’s an identified public health need not otherwise being met, we have a responsibility to work with other groups to try to meet (it),” he said. “If this is something public health can help with, we’d be glad to.” He said the health department has so many other issues on its plate, though, that it wouldn’t be able to take the lead in a concerted effort to establish a clinic.
Other options for dental care include trying to attract new graduates from the dental schools at the University of Kentucky and the University of Louisville (Kentucky is one of the few states with two dental schools). Dr. Raynor Mullins, the head of public health at UK’s college of dentistry, said officials are working on a concept called a regional dental center that would insert dental clinics into existing medical centers across the state. The program would serve as a combined research and service opportunity and part of the mission, he said, would be to reach disadvantaged people. UK officials are currently developing a prototype in Hazard. “It’s pretty clear we have oral health access problems across Kentucky,” Mullins said. We are always willing to sit down and talk with folks who want to partner in the community to improve the health of citizens.”
Mullins and Murphy also suggested mobile dental clinics that could visit schools and provide screenings and cleanings through the Medicaid program.
Whatever the final solution turns out to be, advocates are clear about one thing: there must be a solution. Too many children are hurting.