In California, it's been seven months since some 3 million poor and disabled adults lost their dental coverage to budget cuts.
And in thousands of dentist's offices and community clinics — from the rocky north coast to the Mexican border — it's the receptionists who are left to counsel and console patients who have lost their benefits.
"They will come here, crying they need help," says Claudia Rico, a receptionist at Clinica de Salud del Valle de Salinas, a safety-net dental clinic in the central coast town of Salinas.
While the recession may be easing, California and other states across the country continue to face eye-popping budget deficits. As a result, states are cutting deep into public health programs, and dental benefits for Medicaid recipients top the list.
Rico says more patients are showing up each day with swollen gums and infected teeth. Before the state budget cuts, Medicaid patients here could get annual exams, cleanings and, if needed, root canals to save their teeth.
Now, Rico says, patients can't afford to pay for root canals themselves — even at the discounted rate of $600. So they end up getting their teeth pulled.
"They'd rather take it out because they don't have the money," Rico says. "It's either rent, food or dental work, and they opt for the most convenient — well, inconvenient for them — but the only thing they can do to relieve the pain."
Waiting Until The Pain Is Unbearable
In interviews with dozens of dentists and safety-net clinics around California, providers say patients are forgoing routine cleanings and delaying care until the pain is unbearable. Dentists are offering discounts and payment plans, but they say few patients can afford them. Dental schools and free clinics are overrun, and some private dental offices and at least one community dental clinic have closed.
Under federal law, dental coverage is considered an optional benefit that states don't have to provide when insuring poor or disabled residents. In fact, at least seven states — Virginia, Delaware, Alabama, Texas, Colorado, Utah and Missouri — provide absolutely no coverage, even for emergency relief of pain and infection. And a growing number of states have scaled back their programs and cover dental emergencies only.
"In the last recession and this recession and when states are under severe budget strains, dental benefits for adults, since they are an optional benefit, are among the first things to go," says Julia Paradise, a Kaiser Family Foundation health researcher.
In California, the state will still pay to have a tooth pulled in an emergency, but it no longer covers the cost of expensive dentures. That's a big problem for seniors. Medicare doesn't cover dental, so poor seniors in California have long relied on state dental benefits when they need dentures.
'An Orphaned Organ'
Lucresha Renteria runs the Mendocino Coast Clinics in Fort Bragg, a fishing-and-lumber town.
"The nutritional needs of the patient can't be met if they can't chew and eat food appropriately," Renteria says. "So we have patients that suffer from a form of anorexia or have to have soft food only."
The mouth has long been an orphaned organ, says Dr. Burton Edelstein, a Columbia University professor of dentistry and health policy. When Medicaid and Medicare were created in 1965, Edelstein says, oral health was not well understood, and Congress didn't think to mandate dental coverage.
"It reflected policymakers' misunderstanding that the mouth is not part of the body and that oral health is not an important component of general health," Edelstein says.
That has largely changed. Over the last decade, federal public health agencies have aggressively promoted oral health, stressing its connection to diabetes, stroke and heart disease. Oral health advocates say the cancellation of dental coverage for poor and disabled adults in California — and elsewhere around the country — comes just as they were gaining ground on dental disease.
Not Likely To Change
But Michael Bird, from the National Conference of State Legislatures, says it will be a long time before states restore optional benefits, like dental coverage.
"The fiscal downturn is so severe that, even if you were to raise taxes or fees, you still aren't going to be able to plug all of the holes that exist right now," Bird says. "This is all about saving part of the school year versus the early release of prisoners versus an optional dental program versus whether you're going to be able to fill the potholes on the roads."
Bird says state coffers are empty and all the easy choices were made long ago.