William Welch didn't always take the best care of his teeth. But he never had dental insurance, either.
"I remember always thinking I wish I had the money to go to the dentist. It's so expensive," said Welch, 43, a waiter.
But in 2010, he moved from Detroit to Lawrence, where he learned about the Douglas County Dental Clinic. The clinic, which provides dental services to uninsured residents making up to 200 percent of the federal poverty level, helped restore his smile and, he said, give him a better outlook on life.
But even though Lawrence is home to one of the roughly two dozen safety-net dental clinics in the state, many local residents still can't afford dental care. And while Douglas County, unlike about a fifth of the counties in Kansas, doesn't have a shortage of dental providers, it is classified by the Kansas Department of Health and Environment as having a population that is dentally underserved. That's due in part to the relatively high number of people living in poverty here and the lack of providers who accept Medicaid.
"Our community is pretty fortunate to have a safety-net dental clinic," said Julie Branstrom, executive director for the Douglas County Dental Clinic, which facilitated 7,670 patient visits in 2012. "But I will also be honest and say that even the fees that we charge at the clinic so that we can keep our doors open and operating are still out of reach for a lot of people."
That's why Branstrom wishes the clinic could offer preventive services for free or a nominal fee to uninsured people at or below federal poverty level ($11,490 for a single person; $23,550 for a family of four). But, as of now, it doesn't have the revenue to do so. The dental clinic is funded by fees, a grant from the Kansas Department of Health and Education and the United Way of Douglas County, along with a few other sources including the county, the Kansas Bureau of Oral Health and private donations. And even with its sliding-scale fee schedule, the Douglas County Dental Clinic, like many private dental clinics, ends up providing thousands of dollars worth of free care every year. In addition, its free dental day provides care at no cost to about 75 people annually.
Access to dental care an issue elsewhere
This issue isn't unique to Lawrence, or even Kansas. About 108 million Americans lack dental insurance, more than twice the number who go without medical coverage. And while the government pays for roughly half of all health care services in the U.S., it funds just 4 percent of dental care.
"It's symptomatic of how we have dealt with health care for a very long time," said Sheldon Weisgrau, director of the Health Reform Resource Project and a local health-policy expert. "We deal with it in a fragmented way, in silos. Rather than looking at the health of the whole person, we look at parts of people. Dental has always been left out. It has not been considered a medical issue."
One piece of legislation that could change that is the Affordable Care Act, which requires that health insurers offer dental coverage to all beneficiaries under the age of 19. Dental coverage will also be available in some of the plans sold on the 2010 health care law's health insurance marketplaces, which go online Tuesday. The American Dental Association reported that Obamacare stood to provide dental insurance to an additional 8.7 million children and 17.7 million adults over the next five years, but that was before several states, including Kansas, declined to participate in the law's Medicaid expansion.
Pediatric dental care is offered by the state's Medicaid program, KanCare, which also provides adults with basic cleanings and tooth extractions. But because of the state's relatively low reimbursement rates and the program's administrative hassles, many dentists choose not to accept Medicaid.
The lack of access to preventive services is one reason many low-income people end up with painful dental problems that warrant a trip to the emergency room. The 2012 Douglas County Community Health Assessment found that there were more than 270 preventable emergency room visits due to dental problems in 2011. The report also revealed that one in five Douglas County residents had not been to a dentist in the past year.
Some advocates in Kansas believe the best solution for improving access to dental care would be for the state to approve mid-level dental providers, similar to physician assistants or nurse practitioners. The Kansas Dental Association has opposed the proposal, which has not moved forward in the state Legislature.
Care begins at home
Chris Leizsler, a dentist who practices in Baldwin City, said that while dental care can be expensive, the value that many people place on taking care of their teeth is comparatively low.
"I see it often, where things begin to deteriorate and before the patients know it they have a bigger problem on their hands, which could have been preventable," he said. "People have to take personal responsibility and do their share of the work at home."
That said, he agrees that dental health is often seen as something separate from the rest of the medical system, largely because it has commonly been treated that way by insurers. "It's become kind of a stepchild of health care," he said. "The mouth is part of the body too."
Part of the reason dental care is often overshadowed is that not as many people die from dental disease as they do from other illnesses, said Cheryl Biesterfeld, dental director at the Douglas County Dental Clinic. "But more and more information is coming out about the connection between disease and bacteria in the mouth," she said. "It can have a big effect on your overall health if you've got an infection in the mouth."
For now, the Douglas County Dental Clinic will continue to be the location of last resort for those who can't otherwise afford care. Not long ago that profile fit Welch, the Lawrence waiter. He went to the clinic and found out he could receive the work he needed for about a third of the price it would cost him elsewhere. After years of neglecting his teeth, he finally got his smile fixed.
"Having a good mouth is good news," he said.