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Hidden RationsWhy poor kids can't find a dentist.

By Anne Alstott
Posted Tuesday, May 29, 2007, at 1:42 PM ET
Illustration by Robert Neubecker. Click image to expand.

Earlier this year, Deamonte Driver, a 12-year-old boy living in Maryland, died after he got a tooth infection that led to a brain infection. Deamonte had never had routine dental care.* The problem wasn't that he was among America's 47 million uninsured. He was covered by Medicaid, the federal health-insurance program for the poor, which includes dental care for kids. But Medicaid reimbursement rates for dentists in Maryland—as in many states—are set at such low rates that few dentists accept Medicaid patients.

Deamonte's death reveals the ways in which hidden restrictions undercut formal entitlements to social welfare benefits. These below-market payment rates really amount to rationing medical care for the poor, which politicians don't like to talk about openly. Several years ago, the state of Oregon ignited a political firestorm when it began to ration Medicaid services by category, allowing some treatments (such as hospice care) while denying others (such as tonsillectomies.)

And so now we have rationing without calling it that. Politicians trumpet gains in Medicaid coverage for children, while the reality is that the shortage of providers leaves sick, poor children without care. In 1999, according to the GAO, Maryland's Medicaid payments for common dental procedures ranged from 37 percent to 73 percent of the market rate; a 2000 state-by-state report by the Government Accountability Office documents that such below-market rates are the norm. As any economist will tell you, when prices are set below market levels, a shortage results. Congress and state policy-makers have known for years that there is an acute shortage of Medicaid dentists, especially for children. And the problem extends beyond dental care. In New York City, for instance, many primary-care doctors refuse to treat Medicaid patients, sending them to emergency rooms instead, which cost more and are less effective.

Deamonte's story, told in testimony before a House oversight committee in early May, starts with abscessed teeth that he and his brother, DaShawn, developed because of untreated tooth decay. Any dentist could have told the family that tooth decay can lead to serious complications—but the family had no dentist. The boys' mother, Alyce Driver, had worked at typical low-wage jobs—in a bakery, in construction, as a home health worker—that offered no health or dental insurance. On average, two-thirds of Medicaid children do not visit a dentist in a given year. The Department of Health and Human Services says that neglected teeth represent one of the most prevalent medical problems for poor kids.

While Deamonte didn't complain of pain from his rotted teeth, DaShawn experienced excruciating pain. Still, it took Alyce six months and the help of homeless-shelter staff to find a dentist and an oral surgeon who would take Medicaid to extract DaShawn's six rotten teeth. While Alyce and the shelter workers focused on him, Deamonte went untreated. It may be that Deamonte's abscess had progressed to the point that the nerve endings were dead, so he didn't feel the pain for a time. Or maybe he was just a child who complained less. In any case, Deamonte eventually developed headaches, because the infection had reached his brain. A hospital emergency room gave him antibiotics, but within days he was back in the emergency room, this time for brain surgery. He died after six weeks of hospitalization.

After hearing Deamonte's story, Rep. Dennis Kucinich, D-Ohio, had his staff call the 24 dentists listed by Deamonte's Medicaid provider. Twenty-three of them either were wrong listings or would not take Medicaid. The 24th was a specialist, not a dentist. In congressional testimony, one Maryland dentist reported that his staff called 748 dentists listed as Medicaid providers and found that only 23 percent would take new Medicaid patients. The representative of the Medicaid managed-care group that covered Deamonte told Congress that other pitfalls of poverty contribute to poor dental care for low-income children—transience, lack of knowledge, lack of transportation, and economic stresses. But even the federal administrator of the Medicaid program admitted that low dental-payment rates impair children's access to care.

Whatever the merits of explicit rationing along the lines of Oregon's model, there is little to be said for rationing by underpaying dentists. Preventive dental care for children is cheap and cost effective, too. The obvious way to make sure more poor kids go to the dentist is to raise Medicaid dental payments to market rates. Maryland, to its credit, plans a major increase in 2009. In 2000, Michigan enrolled Medicaid children in an insurance plan also sold to private customers, and more recently, Alabama has adjusted dental payment rates to market levels. Both states report impressive increases in the number of Medicaid children who are going to the dentist.

There's more that the states can do: Alabama also mounted an education campaign about the importance of dental care. Vermont set up dental clinics to address the backlog of poor children. A largely symbolic bill introduced in Maryland after Deamonte's death would provide $10 million over five years for pilot programs in community dental care and dental education. Dental screenings in schools are another good idea. But the first step is to pay dentists who fix poor people's teeth the same rate they get for taking care of anyone else.

Correction, June 1, 2007: The original sentence inaccurately stated that Deamonte had never seen a dentist. (Return to the corrected sentence.)

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Anne Alstott is Jacquin D. Bierman professor at the Yale Law School and the author, most recently, of No Exit: What Parents Owe Their Children and What Society Owes Parents.
Illustration by Robert Neubecker.
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