Mouths in Need

How often do you think about your mouth? Of course you use it to speak, eat, and breathe, perhaps to kiss loved ones. Your mouth is a pretty important part of your life. But how often do you think about how it’s doing? I never used to, until I learned how much it matters to how the rest of me is doing.

Mouths are the gateway to the rest of the body. Good oral health is absolutely necessary for good overall health. In fact, studies have linked untreated dental decay with increased rates of diabetes and heart disease. This makes sense when you think about a cavity as really being a bacterial infection. It does a lot of damage to have a bacterial infection in your body for a long time.

Given how important oral health is, I was shocked to learn that dental decay is the most common chronic childhood illness. According to the Surgeon General’s 2000 report, “Oral Health in America,” dental decay in children is five times more common than asthma. More than 50 percent of 5- to 9-year olds have at least one cavity or filling. Perhaps unsurprisingly, poor children suffer from twice as many cavities as other children, and 25 percent of poor children have not seen a dentist before entering kindergarten.

Poor oral health leads children to miss 51 million hours of school every year, also according to the Surgeon General’s report. We have only to remember our last toothache – or for that matter the last time we had any ache or pain – to realize that it is extremely difficult to concentrate when our bodies hurt. Dental decay also makes it difficult to eat healthy foods, because so many of the fruits, vegetables and lean meats that benefit growing bodies require vigorous chewing. It isn’t surprising that oral health matters for school achievement and nutrition, once we start to think about how much we need our mouths every day.

Fortunately, these problems are almost entirely preventable. Fluoride rinses, dental sealants and regular check-ups can prevent 90 percent of all dental decay.

The key to receiving this care is to have dental insurance. Children without dental insurance are three times more likely to have oral health problems. Unfortunately, the primary medical insurance for the poor in the United States, Medicaid, does not do a very good job of ensuring care. The Surgeon General found that fewer than one in five Medicaid kids had seen a dentist in a given studied year.

In general, we can identify two main reasons for this failing of Medicaid programs. First, reimbursement rates tend to be dramatically below what dentists receive from private insurance companies. Second, the paperwork is often quite burdensome.

In Massachusetts, health care advocates have noted that children on Medicaid have significantly worse oral health than their peers. Federal Medicaid law requires that states provide children on Medicaid with “early, periodic screening, diagnosis, and treatment.” Health care advocates sued the state under this federal law, and in 2005 they won that suit, Health Care For All v. Romney. The remediation effort since the legal victory points to some solutions with national implications.

Although the remediation process has been rather complicated, three big changes stand out. Reimbursement rates were increased, making it more reasonable for dentists to accept Medicaid patients. Dentists were allowed to cap the total number of Medicaid patients they accepted, which increased the total number of dentists willing to accept any Medicaid patients at all. Finally, a private insurance company, with which nearly all dentists already contracted, began to administer the program. This eased the administrative burden because dentists no longer had to manage different paperwork systems.

Different states will have different approaches, but improving reimbursement and easing paperwork burdens will probably help almost everywhere.

There are a lot of complicated problems in health care. Preventing dental disease, however, is pretty straightforward.

Kids need access to the basic care that will get them fluoride rinses, sealants and fillings when needed. Kids on Medicaid, already a more vulnerable population, should be getting these benefits through their medical insurance, but do not because the program underpays dentists and makes paperwork a hassle. Advocates may need to sue some states to get them to spend the money needed to improve their programs, but advocacy efforts within state legislatures and administrations may be able to make a difference in some cases.

All children deserve the benefits of good oral health. It is my hope that in the next several years, advocates across the country will open their mouths wide on behalf of children’s oral health and begin making a difference in state Medicaid programs.