The basic incentives push providers toward affluent communities. Insurance pays for only a fraction of major work, and more than one-third of Americans have no coverage at all, so dentistry is often a cash business. Accordingly, practitioners need patients with money. “Dentists establish practices where people can pay for dental care, and they do not practice where people cannot afford to pay for care,” says David Nash, a professor of dentistry at the University of Kentucky.
“I felt like I was standing here on the line of the fire with a squirt gun.”—Dr. Nikki Stone
The 2010 Affordable Care Act, which aims to make the medical system work better, barely deals with dentistry. It deems dental coverage an essential part of any health plan for children, but regulators have yet to spell out what insurers must cover to meet that definition. The law expands existing loan-repayment funds for dentists who relocate to underserved areas, but it offers no expansion of dental coverage for adults and doesn’t try to integrate dental health into the larger health care system.
It also does nothing to fill a growing gap: The improving health of Americans’ mouths helped close seven of 61 dental schools in the 1980s and ’90s and pushed many others to scale back. Eventually, that meant 2,000 fewer dentists every year, a 33 percent drop in supply, just as an older generation of dentists started retiring. More dentists leave their practices every year than graduate from dental school; at the same time, more adults are retaining their teeth into old age, requiring ongoing care to combat decay, periodontal disease, and other problems. “If you had no teeth, you had a set of dentures, and that took care of you,” says Richard Valachovic, the executive director of the American Dental Education Association. Not anymore. All those extra teeth make the dearth of dentists more troublesome.
Unlike in medicine, where mid-level professionals such as nurse practitioners and physicians assistants are proliferating to fill shortages in primary care, dentists have fought aggressively to prevent new types of workers from entering their turf and competing for patients. Advocates and state legislators are moving to establish a new type of provider, the dental therapist, who could provide preventive care and fill children’s cavities without receiving a full debt-inducing dental education. Alaska and Minnesota have started certifying such therapists, and other states are considering it. The American Dental Association, however, argues that accrediting such providers will create a two-tiered care system. It’s also unclear if these cheaper providers would be any more altruistic or rural-minded than dentists, considering that they would practice in the same private-payment system.
In response to the unanswered demand for care, seven dental programs have opened since 2001; about 4,800 new dentists now join the ranks each year, up from 4,000 at the schools’ nadir. But few of them are gravitating toward the areas that need them most. Molly Housley, a third-year dental student at Kentucky, grew up in Hazard and likes the idea of returning. But she thinks she’s more likely to practice in a larger, more affluent community, where she can build a stable practice and maintain ties with an academic center. “I think most people want to set up near a big city,” says Housley, 24. “I wish there were more incentives to go into rural areas.” Some people joke that dental schools should admit only students who have hunting or fishing licenses, to boost the number of rural providers, Valachovic says. But as long as the financial math doesn’t work, rural recruitment will be a tough sell.
Charitable providers, like the mobile clinic that Stone oversees, have tried to plug some of the holes, but they can’t fix a systemic access problem. Most rural and inner-city communities have no special roving office to serve Medicaid beneficiaries and the uninsured. About half of all children covered by Medicaid have not seen a dentist in the past year. Even in places where children can get school-based care, such as Hazard, Ky., adults without cash have few options. And those who can pay must fight geography: 47 million Americans live in federally designated “dental shortage areas,” where there simply aren’t enough dentists practicing to care for local populations. “The people who are not getting dental care now are the most vulnerable people in this country,” says Sen. Bernie Sanders, I-Vt., chairman of the Senate Subcommittee on Primary Health and Aging, which recently held a hearing on dental access.
Across the country, people with toothaches and abscesses are turning to hospital emergency rooms for lack of a better alternative. But doctors aren’t trained to pull teeth or fill cavities, so they can do little more than prescribe painkillers and antibiotics and refer patients to a dentist. In February, the Pew Center on the States reported a 16 percent increase in preventable dental emergency-room visits from 2006 to 2009. At Johns Hopkins Hospital in Baltimore, the emergency department has seen a 14 percent jump in just the last year. “Most of the patients that we see with this complaint don’t just have one tooth that looks like maybe it has a cavity; they will have a mouth full of decay,” said Dr. Rita Cydulka, the vice chairman of emergency medicine at the MetroHealth Medical Center in Cleveland and a spokeswoman for the American College of Emergency Physicians. “It’s frustrating that they have an acute or chronic problem that we know we can’t solve.”