That, of course, is how capitalism is supposed to work: Patients are willing to pay for the social and professional benefits of an attractive smile, and dentists are more than happy to provide them. Even so, when I asked public health dentists what would most help their profession better serve the broad population, they all answered with variations on the same theme: dial back the obsession with aesthetics. If dentists spent less time giving wealthier Americans artificially whitened grins, they would have more time to treat the serious oral disease that plagues millions of poorer Americans. "What would I do if I could start over?" mused Edelstein. "Part of it would be to dissuade people from making expenditures for intensities of care that are not necessary, that don't affect the state of health."
In the U.S. economy, lots of goods are distributed unequally, but perhaps none more conspicuously than healthy smiles.
Why Poor Folks Are Short on Teeth
So far, I've focused on the 152 million Americans with dental benefits. That ignores the 21 million enrolled in public programs (mostly Medicaid) and the 130 million—43 percent of the population—without any kind of coverage. American dentists provide outstanding care to the people who can afford it, but they are failing the other half of the nation that can't.
The main problem is a lack of decent low-cost options. Chester Douglass, emeritus professor in the department of Oral Health Policy and Epidemiology at Harvard's School of Dental Medicine, puts it this way: "If you want to buy a good, inexpensive car, Volkswagen proved you could do it, then other people started being able to do it." The Volkswagen of dentistry has yet to be built.
In 2007, the difficulty Medicaid recipients experience acquiring dental treatment hit the news when Deamonte Driver, a 12-year-old from Prince George's County, Md., died after bacteria from an untreated dental abscess spread to his brain. His mother, Alyce Driver, had tried with little success to get dental care for Deamonte and his younger brother, DeShawn, who also suffered abscesses related to rotting teeth. Driver was able to enlist the help of Laurie Norris, a lawyer who worked with homeless families, but a Washington Post story reported that Norris and her staff had to make more than two dozen calls before they could locate a dentist who would treat Driver's boys. Driver arranged a cleaning, an X-ray, and a referral for consultation with an oral surgeon for DeShawn, but before Deamonte could be treated, Driver lost her Medicaid coverage (possibly as a result of official paperwork going astray, a constant problem for families without a fixed address).
The Deamonte Driver case was unusually tragic in its particulars, but it served to inform the larger public that only about 900 of Maryland's 5,500 dentists were accepting Medicaid patients and that fewer than one-third of all children enrolled in Maryland's Medicaid program were receiving dental care. (The proportion for Virginia was even lower.)
If you have no money and your appendix bursts, you can walk into a hospital emergency room. If you have no money and your teeth hurt like a son of a bitch, you can walk into a hospital emergency room, but it won't do you much good. According to a 2003 study published in the Annals of Emergency Medicine, an average of 738,000 people visit an emergency department for tooth pain or injury each year. In Washington's King County, which includes the city of Seattle, dental issues represent three of the top 10 factors driving uninsured patients to the ER. The problem is, most hospital emergency rooms have no real way to treat dental problems. They can provide pain medicine and perhaps an antibiotic for the infection—but after that, they can do little more than offer a list of dentists who might be willing to treat the diseased teeth.
Dentists often cite low fees to explain their reluctance to see Medicaid patients. "You can't drive a delivery-care system on charity," a representative of the Washington State Dental Association told me. On average, around 60 percent of dentists' fees are eaten up by the costs of doing business. Medicaid reimbursement levels vary by state, but in Washington state, they're little more than half of usual and customary rates, and dentists claim they don't cover their costs. Another frequent complaint concerns Medicaid's onerous paperwork and slow payment. "The time lags for getting paid by the state are three to six months," says WSDA's Bracken Killpack. "You can't take that hit on your receivables."
Others argue that this is not the whole picture. Columbia's Burton Edelstein points to unpublished research conducted by one of his Columbia graduate students that stated, "in a substantial portion of the states, the package of common pediatric dental services exceeds 60 percent of dentists' usual and customary charges." When states have raised Medicaid fees, the result has typically been an increase not in dentists' participation rates but rather in the number of patients treated by dentists who were already participating. Edelstein also says Medicaid's paperwork demands are no more daunting than those imposed by private health insurers.