This past July, the last few dental clinics in the city that still accepted MediCal were working weekends and late nights, fitting in as much work as they could before the state of California eliminated all dental from its MediCal coverage.
Since then, those clinics have been pulling teeth. Literally. Fillings are gone, cleanings are gone, exams are gone, dentures are gone. The only people who once qualified for and who can still get dental under MediCal are children (in the world of Medicaid, childhood lasts until age 21) and pregnant women (the last predicated on studies that have shown that dental problems in pregnant women can affect the health of their unborn children).
“We used to be the clinic of choice for residential drug treatment programs,” says Carolyn Brown, General Director of the Native American Health Center. “Before, we were able to do fairly comprehensive work if their front teeth were destroyed. Anterior teeth equal employability, and if you don’t have canine to canine tooth coverage, it’s hard to get a job even as a line cook at McDonalds. It’s a matter of self-esteem as well as employment,” Brown adds. “People will say, “I’m clean now, but people still treat me like a junkie. Because I look like one.”
San Francisco has lost well over half of the dental chairs in the city that used to provide services to low-income residents. Brown estimates that there are perhaps 20 left in the city. “It shrunk in the last four years,” she says. “The dental schools had about 100 chairs, and used to provide free dental to the homeless. But they had their own budget cuts, and decided to use those chairs to decrease their dependence on outside funding.”
“It’s horrible,” says Farra Bracht, of the California Legislative Analysts Office. “There’s no good reason to defend ending it. But a lot of people have gone without dental care in this country. It isn’t good for your health, but it isn’t going to kill you.”
Dental costs weren’t an outrageous part of the state budget, says Bracht – the state had already made efforts to control those through cutting certain procedures, and only allowing $1800 in treatment per person per year. What they were was optional – the Federal government doesn’t require that states provide dental to Medicare recipients in order to qualify for matching funds.
Also eliminated in the purge of optional benefits: speech therapy, podiatry, audiology (that is, treatment for hearing disorders), chiropractic services, acupuncture, optometry, psychology (psychiatry remains covered) and, somewhat mysteriously, “incontinence creams.” There is currently a lawsuit in the works to have the nine benefits restored.
“The cuts have nothing to do with the necessity of dental,” says Bracht. “When Medicaid was born in the 1960’s, medicine was very different. Prescription drugs are also considered an optional benefit, and no state in their right mind would eliminate those.”
Another reason the cuts were made, according to Jean Ross, Executive Director of the California Budget Project: more broke Californians mean more Californians who suddenly qualify for Medicaid. With the California budget the way it was, programs had to be cut in order to absorb the costs of new users.
Dentistry makes a convincing budget target for another reason: it is disproportionately expensive compared to other branches of clinic medicine, A doctor can spend ten minutes examining a patient and listening to them talk about their symptoms, and then write a prescription and move on. Meanwhile, almost every visit to a dentist involves that dentist spending four times that amount of time with a single client, drilling holes their teeth and then filling them. The equipment is expensive: $80,000 to install and outfit a dental chair, and supply orders that are about four times the cost of supplies for a regular medical clinic.
The Native American Health Center has responded to the crisis by raising its prices at the upper end of its sliding scale, “Upon closer examination, a few of our patients actually could afford to pay more for dental care, and just were exceptionally good dental shoppers,” reports Brown. “And 35% of our patients are children.”
Avantika Nath, the director of the dental program for the San Francisco Department of Public Health, says that adding dental to Healthy San Francisco has never really been on the table as an option. “It is strange to totally ignore a part of your body that is so reflective of your health,” she says, with an audible shrug.
Like the Native America Health Center, Nath reports that the clinics affiliated with the SFDPH has also been engaged in a lot of teeth-pulling, though they also have access to a small amount of funding meant for homeless and HIV-positive individuals. “We are the end of the line,” Nath says. “We’re supposed to be the safety net – where people can go where there is no where else to go.” Every large city has some form of public health dentistry available for those in need, says Nath. A few, like Boston, even manage to do it well.
CARECEN, another nonprofit in the Mission District, never even bothered to qualify for Medi-Cal in the first place. “It was complicated,” says Scott Meyers, the dentist hired by CARECEN to manage their clinic. “The reimbursement wasn’t that great to begin with. And we would have had to have special ramps put in.” Instead, about 95% of CARECEN’s dental clients paid cash for almost at-cost dental services.
And still, CARECEN also shut down its dental program a few weeks ago, despite its relative independence from the state and local budget. It was simply costing the nonprofit too much money, in relation to the funding that it was bringing in. “It’s surprisingly hard to find support from foundations for dental,” says Joel Streicker, Development Director for CARECEN. Causes go in and out of vogue like everything else, Striecker says, and nutrition programs are the new hot thing.
CARECEN’s website still lists details about making a visit to the clinic, complete with staff photos. Scott Meyers, the dentist hired to manage the program, is still in shock. “I thought it was a great program. We were trying to develop something like a private dental practice in a clinic setting. I had some connections with specialist friends, and plans to expand the services we offered. It was something that I’d always wanted to do.”
He pauses. “I guess I got lucky for awhile.”