At the end of October, more than 4,000 people flocked to Key Arena at Seattle Center, not for a sporting event or to rock out to their favorite band, but for a more essential purpose: free medical care.
Over three days, 3,800 volunteers provided $3.7 million worth of dental, vision and medical care to patients regardless of their housing or socioeconomic status, largely attracting people with either no insurance or those on the state-run Medicaid plan for low-income individuals and families.
The dental care offered at the event represented an important opportunity. Although the majority of attendees — 63.3 percent — had seen a doctor in the past year, only 41.4 percent had seen a dentist that recently. Ten percent hadn’t gotten their teeth checked in a decade.
Perhaps unsurprisingly, 1,439 tooth extractions were performed over the course of the three-day clinic. The only procedures that beat that total were X-rays (2,255) and fillings (1,766).
It’s not easy or cheap to get regular dental care, a situation fueled by the cost of the procedures and anachronistic insurance policies that cause people to pay large amounts out-of-pocket for dental care.
Health advocates agree that the solution is two-pronged: change the way public insurance approaches dental care from an afterthought of the medical profession to an important component of health in its own right and increase the available workforce.
What these solutions look like in practice is a bit more contentious.
The problem
Access to dental care in Washington is bad, particularly if you’re a low-income adult in a rural area.
Thirty-four of the state’s 39 counties fall in what the federal Health Resources and Service Administration calls “health professional shortage areas” (HPSA), a wonky-sounding designation that can apply to a geography, specific facility or a population of patients.
That sounds complicated, but the end result is not: According to the federal government, less than one-third of dental care needs in the state of Washington were being met at the beginning of 2016.
At present, there are 114 such designations that apply to health care facilities across the state and geographic areas outside of the densely populated cities along major north-south corridors like Interstate 5.
Rural Washington falls almost exclusively in low-dentist zones.
Even if you have a dentist nearby, however, it doesn’t mean that you’re guaranteed care.
Although Washington does offer dental insurance through its expanded Medicaid program, which provides coverage to low-income adults, it has one of the lowest dentist reimbursement rates in the country.
Apple Health pays dentists under 29 percent of the rate that they get from patients with commercial insurance, according to the American Dental Association (ADA). That makes it much harder for Medicaid patients to get into a dentist’s chair and problems go untreated.
According to the ADA’s Health Policy Institute, Washington had the fifth largest gap in the country between privately insured and publicly insured adults in terms of access to dental care in 2013. Even among those with private insurance, however, less than 70 percent of adults had seen a dentist within the past year.
The solutions
There is one population in Washington that doesn’t see these dramatic disparities in oral health: children.
“If you compare kids and adults, it’s a night and day picture,” said Bracken Killpack, executive director of the Washington State Dental Association.
Unlike their adult counterparts, the gap in dental care between children on Medicaid and those with private insurance was smaller in Washington than most other states in 2013.
The Access to Baby and Child Dentistry program was created in 1994 to both increase the number of dentists trained in pediatrics and increase the Medicaid payments to them. The number of Medicaid-insured children that saw a dentist each year went from 40,000 to 107,000 in a decade, according to a 2010 report from the Pew Charitable Trusts.
Funding doesn’t work like that for adults, Killpack said.
“If every single adult eligible for Medicaid went in and got a cleaning this year, the budget couldn’t accommodate that,” he said. And complex procedures? Forget about it.
“It’s a different system,” Killpack said. “Dental insurance truly isn’t insurance, it’s a prepaid dental benefit.”
Unlike other medical bills, dental visits require a great deal of money out-of-pocket. The result is that people put off regular dental visits until problems devolve from a checkup to an emergency room, said Dr. Leon Assael, dean of the School of Dentistry at the University of Minnesota.
The dental profession wasn’t included in 1965 federal legislation that created the United States’ public health care system of Medicare and Medicaid. As a result, dental care was added on separately, and fewer than half of Medicaid plans cover adult dentistry.
“People think of oral health as discretionary health care,” Assael said.
There may be progress coming on this front.
The state dental association will work with the Health Care Authority to “better manage the Medicaid system,” Killpack said, with recommendations expected by the end of the year.
“I think that is a positive sign,” he said. “There has been some significant progress talking about making it more functional.”
Supply-side health-onomics
The funding conundrum points to one salient fact: Dental care isn’t cheap.
Dentists, like doctors, train for years in highly specialized programs that leave 75 percent of them with more than $100,000 in student debt, according to the American Student Dental Association, and the supply of people willing and able to enter the profession isn’t infinite.
The federal government put out an analysis of the health workforce in 2015 that found that not only is there a dentist shortage today, but it is expected to get worse over the next decade as the demand for dentists outpaces the supply by 8,600.
With numbers like that on the horizon, improving dental care for low-income patients is not just about increasing Medicaid dollars, but also reducing dental costs by increasing the number of people providing dental care.
Just who’s involved, however, is the question.
Jon Gould, deputy director of the Children’s Alliance, a nonprofit that advocates for policies impacting children, is part of a coalition of health advocates that see dental therapists as a long-term solution.
Dental therapists are “mid-level” dental providers with a skill set that falls between dental hygienists — who can perform cleanings, give X-rays and evaluate patients, among other things — and fully trained dentists.
They can handle the exams and cleanings, but also perform fillings and crowns and, in some cases, extract teeth, and they do so with a two- to three-year degree. In many ways, they are similar to physician’s assistants or nurse practitioners, Gould said.
“It adds a member of the dental care team that can sustain and increase access to care,” Gould said.
Although dental therapists are allowed in dozens of countries across the world, in the United States, they are sanctioned in Alaska, Minnesota and Maine only, in part because of heavy opposition by the ADA and its local affiliates.
Several bills proposed in Washington that would allow dental therapists in the state never made it past the Health Care and Wellness Committee
The association objects to adding another layer to the dental team, particularly one that can perform irreversible procedures, Killpack said.
“I would not compare dental therapists to a nurse practitioner,” Killpack said. “(Nurse practitioners) are a minimum master’s if not doctorate-level position. Some dental therapists are two years out of high school.”
Not so at the University of Minnesota, the school that pioneered dental therapy in the United States.
The advanced dental therapy program there takes students five to seven years after high school to complete and most often results in a master’s degree with the prerequisites, Assael said.
The arguments against dental therapists echo doctors’ objections to training emergency medical technicians (better known as EMTs) in the late 1980s, Assael said.
“Every physician at the time was saying, ‘How can you do that?’ … ‘You have to be a physician to do that,’ ” Assael said, referring to medical procedures such as intubation, drug administration or running an IV. “They not only did as well as a physician, they did it better.”
Dental associations would prefer to see an expansion of dental residency programs, which put fully-trained dentists in clinical settings for additional training paid for by the federal government. Such residencies are required for doctors, but not dentists.
Not only does it bring highly-trained people into the community at a low price, residents often stay in the community in which they train, Killpack said.
“It’s the most cost effective way to expand capacity in a lot of these places,” Killpack said.
Looking forward
There is one practicing dental therapist in Washington.
Daniel Kennedy joined the Swinomish tribe’s dental clinic in January 2016 to assist the dentist who was the only local dental care provider for the tribe’s 3,000 potential patients.
“We have developed a tribal approach to solve a tribal issue. This solution will help our people immediately address their oral health needs in ways that have not been possible until today,” Swinomish Chairman Brian Cladoosby told Indian Country Today Media Network.
Kennedy is unlikely to be the last.
The Commission on Dental Accreditation plans to roll out national accreditation standards for dental therapists by the end of 2017. The commission, which is housed under the ADA, doesn’t call this an endorsement of the position.
The landscape of dentistry is changing, Assael said.
“There are kind and good people in dentistry, I just think they’ve got it wrong,” he said. “If they see the benefits of this, if such a law moves forward in Washington, they’ll think back years later and ask, ‘What was I thinking?’ ”