It’s always a busy day at the Gary Center in La Habra, which runs one of Orange County’s few dental practices providing safety net care.
And despite efforts by the center to reduce its waiting list, which at one point was four months, the requests for help pour in: a mother who can’t afford to replace a dental bridge and never smiles, or a woman with a cavity that is turning her front tooth black.
The center provides a window into the dental needs of disadvantaged residents of Orange County – at a time when new state and federal policies are poised to improve access to care dramatically.
At least in theory.
Under the Affordable Care Act, more low-income Californians than ever before are enrolling in Medi-Cal, the state’s public insurance program. Medi-Cal provides dental benefits to children and recently restored them to adults after canceling them almost five years ago.
Since January, about 100,000 people in Orange County have enrolled in Medi-Cal under the ACA, which means they can begin making appointments with dentists who participate in the program.
In addition, 88,500 children in the county who were previously covered by a public insurance program called Healthy Families were transferred to Medi-Cal under state edict. These patients will now obtain dental care from Medi-Cal’s dental program, also known as Denti-Cal.
But while health advocates applaud the changes, noting a significant drop in the ranks of the uninsured, there is great uncertainty about whether these new patients will have dentists to see.
“Right now a lot of dentists are not Denti-Cal providers, which is sad,” said Dulce Medina, the director of prevention and community programs at Healthy Smiles for Kids of Orange County. “We can’t blame them because their reimbursements are extremely low.”
Healthy Smiles, a nonprofit based in Garden Grove and serving disadvantaged children, is already feeling the impact of more demand for services.
The nonprofit operates two mobile dental vans that comb the county, regularly setting up shop in the parking lots of schools and community centers. Ideally, Healthy Smiles dentists treat uninsured children and refer those with Medi-Cal or private insurance to other providers.
But with some Medi-Cal providers reporting three-month waits or longer, Healthy Smiles is opting to treat some insured patients.
“We are not a primary care facility but we’re adapting to current and immediate needs. We need to get some patients in before decay worsens. We still have a waiting list,” Medina said.
An Acute Shortage
Dental care has long been an overlooked and under-insured element of health care. Even families with private insurance often don’t receive dental coverage through their employer, a situation that may be improved by the ACA’s requirement that standard insurance packages cover pediatric dentistry.
But the shortage of dentists participating in Medi-Cal may be getting worse, not better. Medi-Call pays as little as one-third of what it costs to provide the service, dentists say. California’s reimbursement rates for an oral exam are 42nd in the nation.
“The dentist is taking money out of his or her pocket to pay for the services. Sounds like a great deal for the taxpayer… The problem is it’s not sustainable,” said pediatric dentist Dr. Paul Reggiardo of Huntington Beach.
Reggiardo accepts Medi-Cal out of a lifelong commitment to treating all kids. But when a colleague tells him he no longer accepts new Medi-Cal patients, he said, “I understand completely.”
Dr. Gary Glasband stopped seeing Medi-Cal patients because of the reimbursements and frustrating bureaucracy. A 10-percent reimbursement reduction that took effect recently has only added insult to injury, he said.
“More and more providers seem to be pulling out, leaving a larger pool of patients,” said the Long Beach-based dentist who practiced for years in Orange County and serves on the policy development council of the California Dental Association.
Glasband added that professional ethics preclude dentists from accepting Medi-Cal patients selectively, and as a result many dentists drop out of the program altogether, which then places more demand on the remaining participating dentists.
“It’s kind of like dominoes,” he said.
Confusing Rules and Complicated Cases
As fewer dentists are available, it becomes harder for Medi-Cal patients to identify them and travel to participating offices. Transportation and time off work are major impediments to low-income patients getting health care services.
A Denti-Cal website maintains a list of at least 400 dentists in Orange County (not including orthodontists or surgeons) who are accepting new Medi-Cal patients. The county is by one estimate home to at least 2,500 licensed dentists.
But Glasband said the dental association challenges the list’s accuracy, and some consumers find it hard to locate and use the list – part of a general confusion navigating Medi-Cal’s rules and procedures.
Those patients who do find their way to a dentist after years without coverage are more likely to need complicated treatment, Glasband said.
Such was the case with Victor Brazao, a patient at the Gary Center who went for two years without visiting a dentist for lack of insurance. With help from the center, the valet parking attendant from Inglewood has since found relief from his bleeding gums and has learned more effective brushing and flossing.
Brazao kept his teeth, but not everyone is so lucky. Sometimes patients can’t afford a root canal so they opt for a lesser expense – extraction.
“We’d rather save a tooth than pull it,” said Aida De Leon, dental office manager at the center.
Even before the point of removal, the cost of neglect is high. In Orange County, 10 percent of children between the ages 2 to 11 have never been to a dentist, and they are susceptible to toothaches that lead to missed school and serious infections brought on by oral decay.
Further, people who develop disfiguring dental problems have a hard time advancing on the job or interacting socially, and emergency room treatment of dental problems is highly expensive.
Health experts call for a number of reforms in dental care besides better reimbursements.
One proposal is to develop more of a professional role for what are commonly known as “mid-level providers” such as advanced dental therapists and hygiene practitioners to administer some patient care, under the supervision of a licensed dentist.
Other options are teledentistry, which would allow access to providers from remote or underserved areas, and fluoridation in the water supply.
In addition, Medi-Cal patients need to be educated on the dental benefits available to them and in some cases on the benefits of regular preventive care.
CalOptima, which coordinates public insurance programs in the county, is planning a one-time, $500,000 initiative in health education and prevention with an emphasis on dental care. These efforts will be based at schools and in communities rather than in dental offices, said Mike Ruane, chief of strategy and public affairs at CalOptima.
“We’re going to where the families are,” Ruane said.
Prevention is a smarter and more cost-effective strategy than treatment, Ruane said. But when prevention fails, there’s no substitute for a dentist.
“Fifty-one percent of children in California are Medi-Cal eligible,” Reggiardo said. “Where are the adequate number of providers for the kids?”
Amy DePaul is a Voice of OC contributing writer and lecturer in the University of California, Irvine Literary Journalism program. You can reach her directly at firstname.lastname@example.org