· Sheila Hagar, Walla Walla Union-Bulletin
· Jun 21, 2015
It hurts Jan Alexander to look at the numbers.
In the Walla Walla Valley, 192 people are waiting to see a dentist, the majority of them for the first time or after a care gap of many years.
Fifty-six are in severe pain. And another 85 people are in line for a return visit with a dentist, she notes.
Alexander volunteers at Helpline, the nonprofit organization tasked with screening those who need help getting seen by a dentist. For seven years, she’s been in charge of pairing clients with no dental insurance with providers who will accept them. It never gets easy.
“They will call me and say, ‘I am just dying, is there any chance I can get in?’ Alexander said. “I’m getting to where I just don’t feel it as much, but it is really hard when they call me and want to know when they will be called. I just don’t have any good options for them.”
Worse — people who can’t rate their tooth pain level as “very high” on an assessment scale might as well not call.
“We say if it’s below a seven, we probably will never be able to call them,” Alexander said.
Oral health care experts in America worry about “dental deserts.” Officially called designated Dental Health Provider Shortage Areas, an estimated 49 million Americans live in about 4,900 such deserts, according to the U.S. Department of Health and Human Services.
Walla Walla County is among them, due to its low-income, migrant farmworker and prison populations.
Then there is a secondary shortage, experts say, one that comes from too few dentists who will treat patients on the government’s dime.
Or the uninsured, with no dental dimes at all.
A 2013 PEW Charitable Trust report found the relatively small number of dentists who participate in Medicaid means many low-income people are not receiving dental care.
“Dentists cite multiple factors for not participating in Medicaid; chief among them are low reimbursement rates and burdensome administrative procedures,” the report states.
Further complicating the issue is more than a third of the nation’s dentists are nearing retirement age, the study’s authors noted.
Medicare’s dismal pay rate and government red tape are just part of the problem, said Graham McEntire, a dentist with Alder Family Dental and immediate past president of Walla Walla Valley Dental Society.
Dentists, like other community members, have civic obligations and other activities they’re interested in.
“They volunteer for Scouts or church or whatever else takes up people’s time,” he said.
And many dentists do free work in their offices without fanfare, but with caution.
“Dentists are small business owners, and they have to be very careful about how much free or discounted work they do,” said McEntire. “All business has overhead costs ... Most dentists come out of school with around $250,000 to $300,000 in student loan debt before they even start to work. Add a lot of debt on that to establish a practice, and you can see why they have to be careful about giving away free care.”
Mel Lang is all too familiar with unmet dental needs here. He has been director of SonBridge Community Center dental clinic in Walla Walla since it opened in 2013.
Plans then were grand, aided by donations of dental chairs and enough equipment to outfit four treatment stations. The concept was to run the clinic for those who have no dental insurance, through Walla Walla Valley dentists donating a few hours a month, Lang recalled.
However, only six dentists signed on for volunteer duty and most of them have dropped out — some through retirement — from working at SonBridge.
“We realized we could never catch up and decided to run with a paid staff, ” Lang said. “People could not find dentists. We had to.”
The clinic was approved as a Medicaid dental provider in September. Although federal law has always required states to cover dental care for children, coverage for adults has been weak, even under the Affordable Care Act in most cases.
Washington state reinstated Medicaid dental care for adults at the beginning of 2014, after limiting such assistance to emergency cases in 2011, said Amy Blondin, spokeswoman for Washington’s Health Care Authority.
Lang said many potential users of the state insurance, known as Apple Health, remain unaware of the change and could be eligible for dental coverage.
Lang and his staff facilitate two clinic days a week when possible — one for people without insurance who arrive via Helpline’s long waiting list, and one day for Medicaid patients.
Recently a Medicaid clinic, handled by Dr. Norman Passmore, a Dayton-based dentist, was offered. There were no volunteers to run the free clinic.
Even when both clinics run, they are by no means enough to diminish the waiting list.
“We see people in terrible situations, their pain level so high,” Lang said. “All they can do is go to the (emergency department) and get temporary help, some antibiotics for the infection. It’s not a solution.”
Sometimes, Lang conceded, it’s a situation people have put themselves into via prioritizing other things above dental care. There’s also a lack of understanding of what causes cavities and other problems.
“For some people it’s soda pop, for some it’s drugs,” he said.
It’s the same story, but on wheels, for Debbee Hanson, manager of Medical Teams International’s local mobile dental program.
The organization has a fleet of 12 dental vans in Oregon and Washington. Hanson said she has managed the Walla Walla-based van for two years, setting it up to make it user-friendly and ready for action.
“All the doctor has to do is step on the van,” she said.
Except they don’t, or not often enough. Although some Walla Walla dentists, and one from Hermiston, are faithful in regularly treating van patients, Hanson said she has difficulty recruiting enough to meet Medical Teams International’s goal of 12 clinics a month.
“I average between eight and 10,” she said. “Sometimes I can only do six.”
When she can’t staff the van here, Hanson must drive the van to Milton-Freewater and other areas where she can find dentists to treat patients there, be it Boardman, Pasco, Broetje Orchards or elsewhere.
Patients who need the mobile dental clinic almost always arrive with severe oral health emergencies.
“People come up to the van with a cheek swollen out to here,” Hanson said, holding her palm inches from her own cheek. “They have no insurance, no way of paying. Or they are on state insurance that doesn’t cover enough. Some (Affordable Care Act) plans cover $300 a year and that only gets them started.”
The primary goal is to get people out of pain. Secondary is to get as much work done in one appointment as possible.
While the van’s services don’t include root canals, equipment can tackle most dental emergencies.
Unlike other locations for the organization’s mobile clinics, there are no dental schools here to supply student volunteers or extra clerical help. Hanson, a former oral surgery assistant, ends up doing it all — assisting chair side, filling out paperwork and searching for dentists.
The latter is toughest, particularly by phone. “The hardest part in getting to the dentists is getting past their front desks. Now I text my ‘frequent fliers’ and ask them for help. But they have lives, too,” she added.
Hanson said she thinks the situation need not be so dire.
“There’s enough dentists in this town, if they each helped twice a year, I could staff all my clinics.”
McEntire said a solution to the deficit is not as simple as it sounds.
Most dentists are putting in long work days in their practices already, and volunteering extends that day. As well, donated equipment at other sites may be unfamiliar and outdated, discouraging to some.
“In private practice you’re used to using the right materials, having what you need when you need it. Out there, you might not have what you need,” he said.
Because the clientele at the free clinics — while very appreciative of treatment — often have “a huge mouthful of problems,” such sites are basically for emergency treatment. During his volunteer hours, McEntire finds himself primarily pulling teeth — most often severely decayed or abscessed to the point the nerve has become infected.
The same patient in a private setting would be offered a treatment plan with options including root canals. Medicaid, however, won’t pay for root canals in teeth outside of the “smile line,” and the procedure eats up about two hours in the exam chair. Enough time to see four equally-in-need patients.
“Over and over again, I’ll see people and say ‘I can’t do a root canal. If you want to save (the tooth), you’ll have to find a private dentist,’” McEntire said, adding he realizes that’s an $800 expense most dental van and SonBridge patients cannot bear. “And that doesn’t include the crown. Which will run at least $1,000 for the budget model.”
Access to care, he said, is a nationwide problem, politically as well as in health care.
“Something needs to be done on a national basis, not just here in Walla Walla,” McEntire said.
Affordable Care Act and employer-based insurance plans dictate what care patients can afford, over the old model of the dentist and patient making a decision together about treatment.
“This is a very difficult time for dentists ... there are all these forces pushing prices down but the overhead costs have to be maintained,” McEntire said.
Even employer-covered insurance plans cap yearly coverage in amounts that are outdated for today’s dental expenses, he added.
It’s a situation unchanged in the past several years, leaving many oral health providers scrambling to stay in business.
“Dentists are not rolling in money,” McEntire said.
Lang agrees there are no easy solutions. Volunteer time gets spread thin and Medicaid reimbursement is stingy for private and nonprofit practitioners alike.
At the College Place facility, the need to fundraise to cover total costs of dental care remains a necessity. Yet regular oral health attention can help ward off even more expensive issues to treat, such as diabetes and cardiovascular disease. It also promotes better sleep and nutrition, social interactions and learning.
Prevention and care among the poor requires a combined effort among social service, health care, and education services at the local or state level, the National Institutes of Health reports.
“I see the dental issue as one of the biggest health problems in this Valley,” Lang said.
“Pain is a terrible thing, it is destructive. We haven’t done well as a community in being proactive.”
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