Access to Dental Services In the richest nation on earth, half a generation of children is growing up without dental care. "Half" is an approximation. In wealthy suburbs where most parents have private health insurance, the proportion is smaller. But in rural New York, with its poverty rate of 16 percent or more, its reliance on part-time jobs and service jobs that don't offer health insurance, and its high level of families on Medicaid, children who get comprehensive oral-health care are the exception. Although there are several reasons, the bottom line is federal and state policy. From their policies, one could conclude that both federal and state governments have other things to think about. In this period of supposed economic prosperity, efforts are concentrating on maintaining prosperity for business, industry, and the people involved in them. There’s no built-in reason for state and federal legislatures and administrations to reach out to the poor. They’ll have to be pushed. Like many other rural areas, rural South Western New York is designated a Dental Health Professional Shortage Area. There are not enough dentists for the general population, let alone the poor. Federally, one dentist per 2,000 population is considered an adequate ratio. For Western New Yorkers with low incomes and/or Medicaid coverage, the ratio ranges from 1:6,278 in the small community of Arcade to 1:14,648 in the city of Olean and1: 61,535 in the city of Jamestown. Thus most poor residents have to drive to another town, often 25 miles or more, to see a dentist -- that is, if they can find one who accepts Medicaid or New York's Child Health Plus (CHP) program. Fewer than 15 percent of New York state dentists take Medicaid patients at all. Elizabeth Embser Wattenberg is president of Rural Health Resources, a private consulting firm (www.RuralHealthResources.com). She stresses that just as patients can't be blamed for their reluctance to drive 30 or 40 miles to reach a dentist who will see their children, the refusal to accept Medicaid isn't the dentists' fault. The bureaucracy involved in the reimbursement process is substantial and turns a lot of dentists off right at the on-set. Even if Medicaid raised its per-visit limit to reflect today's conditions, dentists would still hesitate to take it. "The system has made the Medicaid process incredibly cumbersome," Wattenberg says. "Dentists have to fill out all kinds of forms." And even if a dentist jumps through the correct hoops, the money is slow in coming. Unless managed properly, "no-shows" can mess up the scheduling which results in a cash flow problem. Some dentists could have a cultural bias that prevents them from serving special populations. Medicaid in New York pays only $10-$20 for an average dental visit, a rate that has stayed the same since 1966. (The amount varies by procedure.) Suppose Medicaid pays $11 for a visit. The dentist can't even afford to open the door. The receptionist and hygienist together may earn $30, plus there's overhead: rent, taxes, heat, electricity, telephone, supplies. Moreover, rural New York dentists who cheerfully accept Medicaid clients will soon have so many that they won't have time to see anyone else. Many of New York state's 34 rural health networks are trying to devise innovative ways to deliver dental care to rural residents who haven't visited a dentist for years, decades, or if they're children, a lifetime. Some have gone to great lengths to work on the problem on various fronts; others have programs still in the planning stages. Recognizing that education is crucial, several networks are working to raise awareness among both residents and government officials, and to form partnerships with local schools for screening and teaching. "As a group, we've identified the problem," Wattenberg says. "Some are addressing it in various ways, and some are even solving parts of it." At the University of Rochester, for instance, the Eastman Dental Center organized a presentation on oral health as part of the national Rochester Child Health Congress in October 1999. The experts who testified came up with the conclusion -- which seems obvious to everyone except the state and federal officials who continue to deny basic oral health care to poor children -- that "The mouth is part of the body." Moreover, prevention is more cost-effective and more compassionate than cure, they said, adding that oral health begins before birth and must start with good maternal care. The conference recommended that oral health must be integrated into clinical care, health policy, research, and training. Rochester health professionals plan to attend the Surgeon General's Conference on Children and Oral Health June 12-13, 2000, in Washington, DC. As one of the few dental facilities to accept Medicaid, the Eastman Dental Center practices what it preaches. A few other dental clinics make a notable effort to treat patients who can't get oral health care anywhere else, notably the Tri-County Dental Clinic in Gowanda. Dr. Jeff Menoff, DDS, who runs the Tri-County Dental Clinic is considered the patron saint of access to dental care. Other exceptional efforts are the Rushville, NY, Health Center, which operates the Finger Lakes Dental Clinic in Sodus and Lyons and provides care for children at Head Start sites in Wayne County; and Southern Tier Health Care Systems, which facilitated the recent opening of a dental clinic at Cuba Memorial Hospital in Allegany County, NY. But improving oral health one region at a time is like conducting foreign policy county by county. It makes no sense for each county in New York state to forge its own trade policy with China. The state licenses dentists, regulates health insurance, and sets Medicaid policy. Medicaid itself is a federal program, even if it's a pale shadow of the comprehensive health insurance it provided in the 1960s and '70s. "Medicaid is not a user-friendly system for either oral health clients or dentists," Wattenberg says. "Nationally, we need a dental-health policy that works for dentists. Medicaid needs to be made less cumbersome and more profitable for dentists. If dentists and dental clinics can't make a profit, at least they should be able to break even." In order for the poor to get the oral-health care they need, she says, "we need policy change at both the federal and state level. " Rural health advocates need to take the figures to Washington, DC, in the form of a position paper. Present it to legislative policy groups. Its authors should sit down with Congressional representatives and government representatives and tell them, 'This is the real world. This is what's happening, and this is what needs to happen. Now, what are you going to do?" The state also has an important role to play. "If change comes from the federal government, it will trickle down to New York state," Wattenberg said. "But right now, the state could take the lead and make its own policy changes." Owing to the work of rural health networks and professional associations across New York, the need has been demonstrated. The next step is to form a workable statewide policy and put it in place. And the need is urgent. With every month that passes, children's teeth are continuing to decay. Because poor oral health contributes to poor general health, half a generation is growing up without the basic human right of health. Ms Wattenberg will be joining the esteemed representatives of the Southern Tier Health Care System’s Dental Committee, to present a panel at the Children's Defense Fund's Annual National Conference New York 2000 ~ March 25 ­ 28, 2000. (Joan Dickenson is a free-lance rural writer who works closely with Rural Health Resources.)