Dental care in America divides people into two camps: those who can afford regular preventive care and cleanings, and those who can’t.

In 2011, 33.3 million people in the U.S. lived in health professional shortage areas, [PDF] which means that they have no access to dental care. As of May 30, 2012 that number rose to more than 49 million Americans, according to the Department of Health and Human Services.

These so-called dental deserts contribute to a deep disparity in overall health. People who live in these places are more likely to get tooth decay and develop severe health problems. They also spend more money on care, and more time seeking health assistance in an emergency.

Why Do We Have Dental Deserts?

It’s not for a lack of dentists, said Dr. Bill Calnon, president of the American Dental Association (ADA), who told FRONTLINE that the number of dentists in America is actually expected to increase over the next few years.

But dentists often graduate with heavy debt, so they tend to set up practices in populated areas where they can attract more patients who pay. That means rural areas are out: There are too few people coming in to make a profit. And areas with high poverty means that would-be patients are often on Medicaid, which means low profit-margin payouts for dentists.

Medicaid covers children and some procedures for adults, but the rate of coverage is left to states — and varies widely. For example, according to a 2008 survey of Medicaid programs by the American Dental Association that offers a partial list of reimbursements, Medicaid pays $150 for a comprehensive oral exam in Maine, and $29.37 in Idaho, but nothing in Arkansas. For a child’s cleaning, Alaska pays $62.40, Kansas an even $30. Florida offers $14. (The ADA provided us with a partial list of Medicaid payments for various procedures by state — see it here.)

[Editor’s note: The list is not representative of the full scale of Medicaid reimbursements. It does not, for example, include fees paid through managed care organizations, such as HMOs and PPOs, because they are not publicly available. In most states, according to the ADA, large numbers of patients are covered by these managed care organizations; the exact percentage for each state as of 2008 can be found on the ADA website. In New Jersey, for example, 91 percent of patients were covered under these MCOs. The paragraph above has been updated for clarification.]

Even those benefits are under threat: 13 states have said they cut dental benefits in 2011 amid the economic crunch, or plan to this year, according to research [PDF] from the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured.

To compound the problem, dental care is most effective — and least costly — when it’s routine. Preventive care is relatively cheap, and can catch small problems before they become serious. Studies show that children who see a dentist in their first year of life spend about 40 percent less in their lifetimes on dental care, according to Calnon.

“Health disparities are costing this country millions and millions of dollars, because low-income people are being diagnosed much later,” said Henrietta Logan, a professor at the University of Florida College of Dentistry who directs a health disparity center funded by the National Institute of Health.

The state-by-state map below shows the percentage of people without access to dental care using data from the Kaiser Commission on Medicaid and the Uninsured. You can check your county too, in this regularly updated database run by the Department of Health and Human Services that identifies Health Professional Shortage Areas (HPSA), which lack primary medical or dental care providers.

 

What’s Being Done About It?

No one has a comprehensive fix for the system just yet. But some states are weighing a way to broaden care without adding dentists, by training a new class of dental-care providers called “dental therapists.” They don’t have as many skills as dentists, but can perform basic procedures.

A recent study by the W.K.Kellogg Foundation found that dental therapists’ treatment is “technically competent, safe and effective,” particularly for children. Alaska and Minnesota both allow dental therapists to practice in underserved areas.

At least eight states have either had legislative discussions or considered bills to introduce dental therapists, including California and New Mexico. Ohio, Maine and North Carolina have grassroots lobbying campaigns. But as we report in our film, lobbying by dental associations so far has blocked any other state from establishing a dental therapist program.

Critics, including the American Dental Association, say dental therapists don’t have the skills that dentists do. “That model is not an answer,” Calnon told FRONTLINE. He added, “They go through training, but to compare that training to the training of a dentist, in my eyes, you just cannot do that.”

The American Dental Association instead is developing a system of Community Dental Health Coordinators to help people from low-income areas understand the importance of dental care and find them affordable options within the current system. It currently has pilot programs in Oklahoma and Philadelphia.

There are other nascent efforts to provide a kind of safety net for those who don’t have access to preventive care. In the private sector, chains offer credit cards to cover treatment. Some accept children on Medicaid. But as we point out in our film, critics have raised questions about the quality and cost of the care that some of these companies provide.

The film also profiles a nonprofit company, Sarrell Dental in Alabama, which treats children on Medicaid who otherwise might not be able to find a dentist. Since it doesn’t have to make a profit, Sarrell can accept Medicaid’s lower reimbursements. But the dental establishment in Alabama has tried —unsuccessfully, so far — to block the company from operating, FRONTLINE found. Sarrell may run into similar challenges if it tries to expand in other states.

Earlier this month, Sen. Bernie Sanders (D-Vt.) introduced legislation to expand dental care coverage for people under Medicare, Medicaid and the Department of Veterans’ Affairs. It also proposed a boost in funding for community health centers that allow people to pay for medical and dental care on a sliding scale, as well as funding for mobile clinics and dental care in schools, as well as pilot programs for dental therapists in areas with limited access to dentists.

The bill is still in committee, and without co-sponsors, it’s unlikely to gain much momentum, especially as the broader health-care law is being weighed by the Supreme Court. A twin bill introduced in the House by Rep. Elijah Cummings (D-Md.) is likely to suffer a similar fate.

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