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Ounce of prevention

What good is dental coverage for low-income Vermonters is none of the dentists are taking new adult Medicaid patients?

Wendy M. Levy, by day a cheesemonger and cheese retailing consultant, is a regular food section columnist and feature writer for The Commons. She notes: “If you would like to join forces with others who are concerned about the lack of access all Vermonters have to dental care, regardless of their insurance or income status, it’s worth taking a look at Vermont Oral Health Care for All.”

Brattleboro

I recently received some good news regarding my health insurance — except it turned out to be not so good after all.

I am a low-income Vermont resident. I qualify for Vermont Medicaid. I used to qualify for VHAP (Vermont Health Access Program), which turned into Green Mountain Care.

Neither of those plans covered adult dental care — even basic care — unless, as a friend who was also on VHAP, put it, “You’re bleeding severely from the mouth.”

When I signed up for Vermont Medicaid with the help of a Vermont Health Connect “navigator” at Putney Family Services, she gave me some good news: I now had dental coverage!

This revelation made my frustrating experience with the clunky Vermont Health Connect website worthwhile: Had I been able to do so and sign up on my own, I might not have learned of my new, additional coverage.

Oh, but there’s a cloud to that silver lining.

I was told: Good luck finding a dentist in Brattleboro — or anywhere in Windham County — who takes Medicaid.

When I went home, the Vermont Medicaid Provider Portal showed me 15 providers in Windham County — 11 in Brattleboro — who take Vermont Medicaid.

But only one is taking new adult patients, and the portal says there’s a waiting list.

So I called that dental practice, and the receptionist informed me that that office is no longer taking new, adult patients with Medicaid.

In case you missed the point here, let me reiterate: There are no dentists in Windham County taking new adult Medicaid patients.

At Putney Family Services, I was encouraged to consider dentists in Bellows Falls if I could not find a local dentist. Bingo!

According to the portal, there is one dentist in Bellows Falls who takes new adult Medicaid patients. I called and the receptionist confirmed this in a cheerful tone.

Oh, boy! I might get a dentist!

Then she asked me, “Where are you calling from?”

I answered, “Brattleboro.”

“Oh,” she said, as her voice became rather grave. “The demand for Medicaid patients is too high, so we can only accept local people.”

Feeling dejected and angry, I hung up. I also wondered how this was legal. But last time I checked, “being from Brattleboro” isn’t a federally protected ethnicity.

* * *

Recently, a bill was proposed in the Vermont Legislature to create a third category of dental-care provider: “dental practitioner.”

This trained, licensed dental professional would provide more services than hygienists but not as many as dentists. The bill would have permitted a dental practitioner to work solely in dental offices, supervised by a dentist.

This new category would theoretically provide expanded access to all Vermonters, because it’s not just Medicaid patients who are having a hard time finding oral health care.

We can only speculate, because the Vermont dental lobby successfully killed the bill.

According to a recent article on VTDigger.org, the most recent figures from the state show 368 dentists practicing in Vermont — roughly 59 per 100,000 residents.

“Vermont will [have a shortage of dentists] in the next decade,” the story warns, adding that the state has the oldest dentists in the United States, “with 34 percent over age 60 and many are likely to retire over the next decade.

According to data collected in 2011, 23 percent of Vermont residents — or just over 140,000 Vermonters — received Medicaid. The state projects that number will increase by 40,000 in 2014, according to another VTDigger report.

Currently, 514 dentists are listed on the Vermont Medicaid provider portal, but only 441 are in state. It’s worth noting one dentist each in Utah, San Francisco, and South Carolina accepts Vermont Medicaid, so when all of us poor people go on vacation in these spots, we can see a dentist, too.

All sarcasm aside, when we look for dentists accepting new Medicaid patients, the number decreases to 335 total and 63 out-of-state (including the three faraway dentists mentioned previously).

So, realistically, there are only 272 total dentists in Vermont and adjoining states accepting new Medicaid patients — provided the portal is up-to-date, and I learned it is not.

So 40,000 people get to try to make an appointment with 272 dentists.

Good luck with that.

* * *

The dental lobby argued against the dental practitioner bill, claiming, among other things, that lack of access was more of a “distribution” problem, with rural areas being underserved.

When we look at some numbers, that argument rings as less than true. Essex County, with a 2010 population of 6,303, has four dentists who take patients receiving Medicaid. And they all take new, adult patients.

Sure, I could expand my reach and try to make an appointment with a dentist in, say, Bennington or Keene, if one will have me. And because I am fortunate enough to own an automobile and I am currently in good enough health to drive it, I can get myself to a faraway appointment.

But I am on Medicaid because I am low income. And gas is increasingly expensive. Can I afford to get myself there? And what of those of us who have no car, or are too sick, or in pain from bad teeth, to drive half an hour or more to get dental care?

And what about in the winter, when roads are bad? Would you like to drive from Brattleboro to Bennington, over Searsburg Ridge, while your head is throbbing in pain from a problem with your teeth, during a snowstorm?

Well, you could take the bus or train, if Vermont....

Oh, never mind.

* * *

For anyone who doesn’t understand what the term “downward spiral of poverty” means, allow me to illustrate.

Picture a person — we’ll call her Betty — living here in Brattleboro.

Betty once had a great job that paid well, but she got laid off five years ago. She’s had a hard time finding another job that pays more than minimum wage, which doesn’t support her.

Meanwhile, Betty has been on VHAP since losing her job, and has been unable to receive regular oral health care because VHAP didn’t cover cleanings or fillings.

She has developed a problem with a front tooth, and because her savings have been exhausted with day-to-day living (rent, utilities, etc.), Free Dental Care Day is her only option. (More on that presently.)

Rather than give her a root canal or a bridge because those services are not offered, Betty’s tooth is extracted. Now she has a hole in her mouth where her tooth used to be.

One day, a job opens up for which she is qualified. She applies and is granted an interview. The human resources manager takes one look at Betty and sees a missing tooth. Another qualified applicant gets the job and Betty does not.

Why?

As Susan Hyde, dentist and population scientist with the University of California at San Francisco, points out, “If you want to portray someone as being wicked, they have missing front teeth. If they’re ignorant, they have buck teeth.[...]

“Even from a very early age, we associate how one presents their oral health with all kinds of biases that reflect some of the social biases that we have. []

“If they have a job that requires them to interact socially with the public, it’s almost impossible for them to get that job.”

As if we didn’t know.

How can Betty get a good job and get herself off of the “welfare rolls” if she has not been able to receive adequate dental care?

And how can she receive adequate dental care if she only just got on Medicaid, which provides for basic dental care?

And if she lives in Brattleboro, or anywhere in Windham County, she can’t even find a dentist to take her Medicaid insurance, so, in reality, Betty continues to have no regular dental care.

If Betty’s dental health continues to deteriorate, she could find herself at higher risk for other serious conditions.

According to the report of the Vermont State Dental Society on dental health and diabetes, “Diabetes and pre-diabetes are common conditions affecting one in four Vermonters. People with both diabetes and periodontal disease suffer from two related inflammatory conditions.

“Recent research associating the two conditions strongly supports the notion that each condition adversely affects and intensifies the other. In most situations, both conditions are clinically manageable and often can be prevented or delayed.”

(To avoid glaring irony, the VSDS should have encouraged the Vermont Legislature to approve the dental practitioner bill.)

Heart disease is also a risk for those not receiving regular oral health care, according to the American Dental Association in a study examining the correlation between periodontal infections and cardiovascular disease.

“Evidence continues to support an association among periodontal infections, atherosclerosis and vascular disease,” the study says. “Periodontal treatment must be recommended on the basis of the value of its benefits for the oral health of patients, recognizing that patients are not healthy without good oral health.”

Patients with diabetes and heart disease, along with most of the rest of us, are recommended to eat a diet high in fiber, but with poor teeth, it’s difficult or impossible to chew foods high in fiber, such as vegetables, thus increasing the risk of these illnesses as well as other gastrointestinal disorders.

Should Betty’s lack of dental care continue, she could develop one of these conditions, which will not only adversely affect her ability to find decent work — because who can excel at an interview, let alone look for work, when they are ill? — but it could severely limit her ability to work at certain jobs because of illness or chronic pain.

So Betty’s opportunities diminish and she falls into that aforementioned downward spiral of poverty.

* * *

Not wanting to end up like Betty, on a recent Saturday I arrived at Brattleboro’s Elks Lodge just before 7 a.m. to join other locals for the United Way’s yearly Free Adult Dental Care Day, where local dentists and dental hygienists offer people free basic dental care.

There are no income requirements, and — lucky for me — you don’t have to prove you don’t have insurance, which is fortunate for me, as I have insurance but cannot find a provider.

The event’s volunteer organizers began letting people in the building at 7:30 a.m., but they only let in only the first 100 people in line last year.

So I arrived at about 7 a.m. and my number was in the 60s. This year, when I left for my assigned dentist’s office, referral slip in hand, at about 9:15 a.m., people were still allowed to enter, and 127 people had done so.

When I had lined up almost three hours before, I learned that the man who was first in line got there at 2:30 a.m.

The services are limited: fillings or extractions. I chose “fillings,” even though I doubted I had any cavities, because I had hoped to get a cleaning. (You know, so I could avoid really having to get a filling later on.)

And I got an excellent cleaning, just as I did last year, along with a bag filled with oral hygiene information, dental floss, a toothbrush, and a toothpaste.

It’s truly a mitzvah, what the United Way, its many volunteers, the Brattleboro Elks Lodge, and the participating dentists do for people every year.

But couldn’t it be avoided altogether?

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Originally published in The Commons issue #254 (Wednesday, May 14, 2014). This story appeared on page D1.

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