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• What the new Brain Research Tells Us: Implications for Child Care in Maine
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• Child Health Care Access Project: Maine's Crisis In Access To Dental Care
• Child Health Care Access Project: Who are the Uninsured in Maine?

Issue Papers

Child Health Care Access Project: Maine's Crisis In Access To Dental Care

Mary lives with her three children in a coastal Maine community. Although Mary works, all of her children are eligible for Medical Assistance, which provides coverage for dental services through the Medicaid Program. Last year, Mary's oldest daughter, Jennifer, who was 17 at the time, experienced a significant amount of pain resulting from a condition called Temporomandibular Joint Disorder (TMJ.) Pain, particularly in the chewing muscles and/or jaw joint, is the most common symptom of TMJ. Other symptoms include to radiating pain in the face, neck or shoulders and limited movement or locking of the jaw. In fact, Jennifer experienced such discomfort that she lost over 12 pounds, and became quite thin during her ordeal with TMJ. Mary brought Jennifer to the closest dentist she could find who would accept her daughter's medical coverage as payment. The dentist was over one hour away from their home. Although somewhat helpful, the dentist was unable to successfully treat the condition and recommended Jennifer be seen by an oral surgeon. Mary contacted all the oral surgeons in the area, finding none who would accept her Jennifer's health insurance coverage. She then searched beyond the area, and found only one, , about an hours driving distance from their home, who would accept Medicaid as payment. The oral surgeon's office staff informed her, however, that the office was not currently taking any new patients with such coverage. After assuring the office that she would pay the bill herself, Mary was shocked when the response from the office was that it was against the law for a dentist to take her money if her child was receiving Medical Assistance, and that the dentist would be committing fraud if he did so. Mary had no other choice than to take Jennifer off of Medicaid, that included coverage for all of her health care needs. She was also forced to take her other children off the plan, because if one child was eligible, she was told that they all were, which would once again prevent her daughter from getting the relief she so desperately needed. Mary has not enrolled her children in Medicaid since this experience, and they are currently without health insurance coverage. (picture of daughter will be included)

Other individuals who appeared at a free dental clinic in Maine include:

• A divorced mother, struggling to support several children with a patchwork of jobs. She badly needed a root canal. The pain became so excruciating, she found it difficult to work, which threatened to land her family on welfare...
  
• A young child experiencing significant pain resulting from tooth decay. The only dentist in the area who would accept the child's Medicaid coverage had a two month waiting list...
  
• A pregnant woman unable to get emergency dental care, who couldn't eat properly, potentially endangering herself and her unborn baby...
  

 

Access to dental services in Maine for many children and adults is increasingly limited. In some areas and for certain populations, the situation is reaching crisis proportions. Low income people particularly have difficulty finding a dentist who will treat them or their children, and frequently have to travel significant distances in order to get the care they need. Because of these barriers to access, they often wait to seek out care until the problem has become unbearable.

A recent forum that focused on the lack access to dental services provided descriptions of many instances where children and adults experienced significant problems obtaining dental services many of us take for granted. A Head Start teacher tells of the many 3,4 and 5 year old children she sees daily who have never seen a dentist. Many parents don't realize that they should bring their kids to the dentist at an early age. Many parents who are aware of the importance of early preventative dental care are unable to find a local dentist who will treat their children. A school nurse described the many children she has seen who were reluctant to smile or eat for lack of dental care. A hospital emergency department worker described an increase in the number of patients with mouth pain appearing at the hospital. Because emergency departments are not usually equipped to deal with dental procedures, antibiotics and pain killers are usually given for relief from pain or infection. This treatment may alleviate the symptoms, but does not treat the problem. That worker told of patients, unable to find or afford the dental care they needed, who came back to the hospital with an infection that had worsened and sometimes with addiction problems from the use of pain killers.

Consumers, representatives from state government, advocates and dentists all frequently use the word "crisis" to describe the problem of access to dental services for low income people in Maine. They agree that the problem is complex and requires realistic solutions that address its financial, administrative and socio-economic aspects.

Many people in Maine are able to purchase the dental care they need. Some though their jobs, have dental insurance that covers a portion of the costs of dental care. The general belief is that these people are probably getting adequate care. For most low-income families and individuals, however, affordable dental care is an oxymoron. Even some moderate wage earners have problems finding a dentist who will treat them, knowing that a bill might remain outstanding for more than, say, a three month period.

What does the crisis in dental access mean for very young children?
It means that they are not seen by a dentist early in their early lives, and that the opportunity to receive education on proper oral hygiene is not likely to be available to them. Most of us learned the importance of brushing our teeth at a very young age. Many young children in Maine, however, are not taught this basic and important habit. They are more at risk of suffering from significant problems such as tooth decay and gum disease. As a result, these children, may experience significant pain and suffering that could have been avoided had they received the education and preventative services necessary to reduce the risk of dental problems that can affect them for the rest of their lives.

The American Dental Association(ADA) recommends that children should first be seen by a dentist at twelve months of age. Recognizing that this recommendation is not practical in Maine, where there are few Dentist who are willing or able to seen children at such a young age, the Maine Oral Health Program suggest children be seen by a dentist by their third birthday. The ADA indicates that the earlier the child begins to receive regular preventive dental care, the better chance there is of preventing future dental problems. In addition to checking for decay and other problems, a dentist or dental hygienist can teach parents how to properly clean their child's teeth daily, evaluate any adverse habits such as thumbsucking, identify a child's fluoride needs, and help children build a lifetime of good dental habits. Unfortunately, it is estimated that only about one-third of children eligible to receive early dental assessments through the Maine Medicaid Program in 1993 actually received such assessments.

What does the crisis in dental access mean to Maine families?
For many of them, oral health is a neglected part of their general health care. Imagine, being the head of a household with very limited income, regardless of the fact that you work 40+ hours a week at a job that offers no health insurance. Imagine sitting at the kitchen table in your apartment trying to decide which bills to pay, and which to put off for another month. When the choice is between food, rent, heating fuel, and dental care, paying the dental bill is often put on hold. If you make the dentist wait, he or she may be reluctant to schedule you or your child for another appointment. This can be problematic to your youngest son, who experienced dental related pain for the first time last month, due to a significant cavity in one of his molars.

What does the crisis in dental access mean to health care providers?
It means frustration to most providers of dental services throughout Maine. Many of those who refuse to treat low income individuals are hesitant because of the level of difficulty in treating patients who have waited to seek care for acute problems. Many feel justified in not treating patients with Medicaid as a form of health insurance, since this program does not adequately cover the dentists' costs of providing care. In fact, many suggest that the system pays less then 30% of the costs of providing services to other patients. The rate of payment, however, is not the only problem in treating people with Medicaid coverage. The administrative burden of submitting and getting a claim for payment processed is significant, to the point where most dentists in the state are unwilling to deal with the program. This is problematic for the few who do accept patients with Medicaid coverage. These dedicated providers carry the burden of treating patients who frequently present with severe dental problems. They carry the burden of having to tell a mother that her child can be seen, but not for another two months, because that is the first available slot in their very busy schedule. And they experience a financial burden, due to the fact that, as one of a few willing to treat those with Medicaid Insurance, their practices usually include a high percentage of such individuals, limiting the income they can earn from their practices.

What does the crisis in dental access mean to the State of Maine?
It means many of its citizens daily experience needless pain and suffering from untreated dental problems. It means that the state pays for unnecessary health care related services that could have been prevented. For example, a transportation provider for the Medicaid program describes significant problems in finding local dentist for children with Medicaid. That agency's average trip to the dentist for children with Medicaid is 94 miles one way. Such trips usually mean taking a child out of school for at least one day, usually more, as dental services usually require follow-up. That agency provided over $20,000 in publicly funded services to transport children to dental services outside its usual catchment area last year. In 1996 Maine hospitals received over $38,000 in Medicaid reimbursement for emergency department services provided to individuals with Medicaid coverage who were experiencing abscesses, infection or pain due to untreated dental problems. That same year, in Washington and Hancock counties alone, 300 people with dental-related crisis sought care in hospital emergency departments from Bar Harbor to Machias..

Possible Solutions:

No single solution will "fix" Maine's crisis in access to dental care. An approach that utilizes a variety of options to meet the needs of each Maine community needs to be developed. An insufficient number of general practice dentists in some areas of the state, for example, make it extremely difficult for even people who can afford to find the dental services they need. Some counties simply do not have access to the same resources that are available in other areas of the state. As of 1994, the rate full time equivalent dentists per 1,000 children aged 0-19 in Oxford and Aroostook Counties, for example was 49.5-52% below the state average, compared to Cumberland County, which experienced a rate over 59% above the state average. Maine needs to provide incentives to existing and new dentists to attract them to underserved areas of the state.



Although raising rates of Medicaid reimbursement would provide incentives to some dentists to increase services to low income families, fee increases in other states have not proven effective in improving access for these populations. A good faith effort to increase access must be made by providers of dental services, if access is to improve statewide. Examples include the availability of dental clinics, where certain dentists may provide office space while others provide services at reduced rates, depending on the funding structure of such clinics. A dental hot-line could be developed that would link people with dentists or clinics where they can receive care, even if they have Medicaid coverage. Such services could be also provided at reduced fees or at no charge to patients without coverage, once again depending on the funding structure or other incentives that may be provided. A mobile dental clinic could be developed that would provide preventive services to children in a school setting in underserved regions of the state or perhaps, as part of a well child clinic.

Dentists can't be expected to tackle the access problem alone, however. Simplifying the administrative burden of getting claims processed under the Medicaid Program, would be another step state government could take to encourage more provider participation. Most important, however, is increased emphasis on the importance of early, high quality oral health and preventive dental services. Education and outreach opportunities in the area of prevention, particularly to children must be developed and available to all those who them. An effort that would combine and utilize existing resources state-wide, such as dental hygienists, community health nurses, school nurses, health educators, WIC Program nutritionists, and pediatricians must be made. Such an effort could not only enhance any of the other solutions suggested, but also eliminate much of the unnecessary dental related pain and suffering experienced by many children and other individuals throughout Maine.

June 1997

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