Why American workers don't smile

As the distance between rich and poor grows in the United States, few consequences are so overlooked as the humiliating divide in dental care. High-end cosmetic dentistry is soaring, and better-off Americans spend well over $1 billion each year just to make their teeth a few shades whiter. Poor oral health can lead to heart disease and other serious medical problems, and tooth loss can lead to depression and difficulty eating and speaking. Medicare, the federal health program that covers 55 million seniors and disabled people, does not cover dental problems. For that, people must buy dental insurance, which typically limits annual benefits to about $1,500 per person — an amount that has barely budged in decades, even as costs have risen.  More than a third of American adults have no dental coverage

Millions of others rely on charity clinics and hospital emergency rooms to treat painful and neglected teeth. Unable to afford expensive root canals and crowns, many simply have them pulled. Nearly 1 in 5 Americans older than 65 do not have a single real tooth left.  Nationwide, 25 percent of Americans are not connected to a fluoridated water system, and therefore, are missing out on what the Centers for Disease Control and Prevention called one of the 10 great health advances of the 20th century. Last year, more than 2 million U.S. emergency room visits were attributed to neglected teeth.

Dee Matello joined a line where hundreds of people from five states who possessed no dental insurance and not enough cash to pay for a dentist were waiting to get free dental treatment. “The country is way too divided between well-off people and people struggling for everything — even to see the dentist,” she said. “And the worst part is, I don’t see a bridge to cross over to be one of those rich people...“I am trying to think that this is not demeaning,” she said as she cleared the chair for the next person in line. “But it is. It’s like a Third World country.”

Although those hospital visits cost an estimated $1.6 billion a year, the ER is generally not equipped to fix dental problems, George Acs, director of the dental department at Chesapeake Health Care told lawmakers. So ER doctors just medicate people with “a perpetual cycle of antibiotics and opioids.” That cycle is feeding a nationwide epidemic of opioid addiction. 

The Washington DC region has one of the greatest concentrations of dentists in the world, with many offering high-end services in offices that resemble luxury spas. More than 50 million Americans, by contrast, live in areas officially designated by the federal government as Dental Health Professional Shortage Areas. A great many of them are working poor. “It’s completely skewed. You have the fewest dentists where the need is greatest,” Acs said. He recently sent a patient here with impacted wisdom teeth 120 miles to find a dental specialist who accepts Medicaid. New dentists often start out with significant debt, and they gravitate toward wealthy areas where they have a better opportunity at making money. The typical graduate from a four-year, post-collegiate dental school owes $260,000 — more than the average medical student. Then they set up solo practices, shouldering pricey overhead — equipment, office space, a receptionist — that accounts for much of a patient’s bill. While younger dentists are more likely to join groups that share costs, the century-old model of the solo practice has resisted change.

All states are required to provide dental benefits to children on Medicaid and the Children’s Health Insurance Program. Obama’s Affordable Care Act currently requires medical plans to offer dental care to those younger than 19. But that requirement – and the dental benefits of 5 million adults newly covered under the ACA – are jeopardized by the Trump-backed health overhaul now being debated in Congress. Adults who are poor enough, and live in certain states, can get coverage through Medicaid, the state-federal health program for low-income Americans. But only about 38 percent of dentists accept Medicaid — about half the rate of physicians — in part because of low reimbursement rates. On average, Medicaid covers about 37 percent of the bill, according to a recent ADA analysis. Dentists who don’t accept Medicaid also complain of bureaucratic hassle and high rates of canceled appointments. In a some states, Medicaid offers no dental coverage for adults.