Lack of dental insurance creates familiar pressures

The call for increased access to dental care in the United States and Maine has escalated over the last 10 years. The underlying premise has been that a tremendous number of children and adults do not have access to dental care, and the primary solution has been to increase the number of providers. Though some evidence may exist to justify this expansion of the dental work force, we have seriously neglected the underlying cause of the lack of access – the proper financing of dental care, or lack thereof.

We are all well aware of the number of medically uninsured in this country. Recent estimates show that about 47 million people, or roughly 16 percent of Americans, do not have health insurance coverage. This large number of individuals without coverage causes diseases to be diagnosed late or not diagnosed at all, which results in higher health care costs. This puts a great burden on hospitals and clinics that absorb these costs and then must share these costs with insured patients through cost-sharing or write-offs. No matter how these costs are managed, all members of society end up paying for this care.

The addition of new providers has not lowered the cost of receiving medical care, it simply lowered the cost to provide the care. Health insurers are still billed the same fees whether a patient is seen by his physician or by a nurse practitioner. We should assume the same would occur in dentistry if and when we create a new dental provider. The translation is that dental care may be cheaper to provide through a community health center or dental office, but it won’t be cheaper for the patient to receive that dental care than it is today.

The issues surrounding dental care are more extreme than medicine but rarely if ever addressed when we discuss policy issues in health care. Though 16 percent of Americans have no health insurance, almost 50 percent of people in the United States do not have private dental insurance. This means more than 100 million Americans have no private dental insurance coverage, a number that is shocking. This number is compounded by the fact that there is no dental coverage for the elderly. More than 70 percent of people over age 65 lack dental coverage, even though their medical care is covered under Medicare benefits. This would translate to more than 650,000 Mainers living without private dental insurance.

Access to dental care is highly dependent on whether or not one has private dental insurance. In fact, the greatest indicator of the likelihood of an individual having had a dental visit in the last 12 months was based on insurance status. This indicator doesn’t change if one is in an area of high or low concentrations of dental providers.

In Maine, as in most states, we also must deal with the issue of being underinsured. The state Medicaid system, MaineCare, pays providers a fraction of the fees billed for most services, creating a severe disincentive for greater participation. Most MaineCare reimbursement for dental procedures is below the cost of providing this care. Even though more than half of dentists are active MaineCare providers, this number is inadequate to manage the extent of disease in this population. It is estimated that 80 percent of dental disease occurs in 20 percent of the population, the 20 percent being primarily low-income populations. More importantly, MaineCare only provides emergency coverage for adults, leaving MaineCare adults to pay cash out of pocket for comprehensive dental care.

Not surprisingly, the No. 1 unmet health care need reported by enrollees into the Dirigo health plan was dental care. Yet as a society, it seems that we do not place enough value on dental care to include it as a standard component of basic health benefits.

The risk of expanding the dental work force without addressing the enormous gap between the insured and uninsured is clear. Though some in need may be able to access care through an expansion of the dental work force, the realistic result will be that more care will be provided to those with resources and dental insurance, further widening the gap in dental disparities in Maine and the United States. This is what happened in Canada after they created a new dental provider intended for poor native populations – these providers went into more lucrative private practices.

Real change will require real dental benefits, which would then allow an expansion of the dental work force with a more equitable distribution of services. However, the real solution to change the oral health of our most needy is primary dental prevention, not treatment.

Considering we know how to prevent tooth decay and with the limited available public resources we have for dental services, it is imperative that we develop and implement a universal early dental preventive system for children 3 years of age and younger using nondental health professionals in nondental settings. Dental care financing and then work force expansion should follow the development of a universal prevention system.

Jonathan Shenkin is a pediatric dentist in Bangor, and on the faculties of health policy and pediatric dentistry at Boston University and public administration at the University of Maine.