Congress was days away from passing health reform this spring when the line began forming in Middletown. Hundreds of people waited hours, some overnight, for a chance at a free visit with a dentist. And by the time it was done, the Connecticut Mission of Mercy free dental clinic attracted more than 2,000 people over two days, a small fraction of the estimated 1 million Connecticut residents without dental insurance.
Ten days later, President Obama signed the sweeping health reform bill into law, putting 32 million uninsured Americans on a path to receive health coverage over the next four years.
But for adults without dental insurance, like those who waited overnight to get a tooth pulled, the health reform law offers little chance for improvement.
Connecticut is one of just a few states that offer dental care for adults under Medicaid, so if Medicaid coverage expands, so would dental benefits. But providing dental care is optional and, as the state faces a $3.4 billion budget deficit, vulnerable to cost-cutting.
More than 2,000 people lined up to receive free dental care in March (Connecticut Foundation for Dental Outreach)
Research has found links between oral health and general health, including connections between oral infections and diabetes, cardiovascular disease and adverse pregnancy outcomes.
But in many public policy debates, and in the minds of many people, dental and medical care remain separate, and often unequal. It’s a problem rooted in the development of separate professions and institutionalized in different insurance coverage systems that treat the mouth one way, and the rest of the body another.
“It seems like anything above the neck is not covered,” said Jon Davis, a Fairfield dentist and president of the Connecticut State Dental Association. “If it’s oral health or mental health, it gets very little coverage.
“We all know you can’t separate one from the other. If you don’t have good oral health, your general health is probably in question also.”
Dentistry vs. medicine
The roots of the separation are not entirely clear, but they stretch back for generations.
“As a professor of public policy, it is something that I have tried to figure out now for a long time,” said Burton Edelstein, a professor of dentistry and health policy and management at Columbia University and president of the Washington DC-based Children’s Dental Health Project.
Part of the divide is historical, dating back to the mid-19th century, when the nation’s first dental school was established separate from the first medical school.
Jack Mooney, a Putnam dentist, noted other factors: The two fields largely function differently, with medicine focused on treating problems while dentistry focuses on educating people about oral health and preventing problems through routine care. Evidence of the link between oral and general health has been relatively recent, he said.
“We’re kind of a stepchild in the whole health care big ball of wax, and it’s just taking time for us to keep knocking on doors and saying oral health is part of overall health,” said Mooney, the chairman of the Connecticut State Dental Association’s access to care committee and co-chairman of its council on legislation.
Consumers often view them separately too, giving medical care high priority while treating dental work as something to have done only if money allows, Mooney said.
Whatever the source of the separation, it produced two independent professions, with separate systems for delivering care, separate workforce structures, and separate methods of billing, Edelstein said.
“It becomes increasingly difficult to reintegrate the mouth into the body through public policy,” he said.
And, critical for efforts to change the coverage system, the separation has also been institutionalized through two different models of insurance coverage.
Health insurance, like car insurance, is based on a model that assumes most people will not need acute medical care in a given year, and can subsidize those who do.
Dentistry works differently. Everyone is supposed to receive dental care every year, making it difficult to build an insurance model based on only some people needing services. It would be like trying to build a car insurance plan that covers not just accidents but routine maintenance.
Instead, most dental plans remain financially viable by imposing coverage limits, deductibles and co-payments – things that the health reform law limits in medical plans. Taking those away from dental insurance, Edelstein said, could undermine the viability of those plans.
“If dentistry had never separated from medicine and dental care were just another surgical subspecialty, then the overall medical plan could handle the losses on dental through gains on other services,” Edelstein said. “But as soon as you pull dental out and you ask it to stand on its own two feet, then the business model is no longer one of insurance but one of cost-sharing.”
Changes for children
While the federal government has done little to expand dental coverage for adults, the health reform law does include changes for children – a sign, Edelstein believes, that federal policymakers have begun to recognize the connection between oral health and general health.
Oral health risk assessments and screenings for cavities in children are among the preventive services that must be covered, at no cost to the patient, by any new health plan as of Sept. 23.
And as of 2014, dental coverage for children will be required in any new insurance plans sold to individuals or small businesses, and in any plans sold on the exchanges, the market places for purchasing insurance created by the health reform law.
Other portions of the law address infrastructure and workforce issues meant to improve access to dental care.
For children, at least, the landscape has changed dramatically. Before the State Children’s Health Insurance Program extended coverage to uninsured children in 1997, an estimated 26 million to 30 million children lacked dental coverage, Edelstein said. In 2008, it was more than 20 million children, according to The Henry J. Kaiser Family Foundation.
By 2014, after health reform rolls out, all children but those who are undocumented immigrants will be eligible for coverage.
“That is a phenomenal change in a relatively short period of time,” Edelstein said.
Adults Left Waiting
But for adults, the prospects are less promising.
Medicare, which primarily covers people over age 65, does not include routine dental care.
Medicaid covers dental care for children and, in Connecticut, for adults. Connecticut’s HUSKY insurance program for low-income children and their families – which is partly funded through Medicaid and which covers one in four children in the state – has made strides in increasing children’s access to dental care in the past two years. The state has raised rates paid to providers – a result of a settlement to a class-action lawsuit – and more than tripled the number of providers in the program. But dental care for adults on Medicaid lags behind. Dentists who treat them are paid just over half what they would receive for treating a child, and few dentists are willing to take many patients whose care pays so little.
In the past, Gov. M. Jodi Rell has proposed cutting nonemergency dental coverage for adults who receive Medicaid. Legislators rejected the cuts, but with a looming budget deficit, Davis and Mooney said they expect the cuts to be back on the table soon.
Dentists offer free care to some patients – Davis said practices can give an average of $15,000 to $20,000 in free care a year. But there’s a limit to how much they can give, he said.
Next year’s Mission of Mercy clinic will begin April 15.