“I eat on one side. I can’t chew, you know, because the teeth are very weak.”

I’ve researched various issues at the boundaries of public health and poverty policy. One basic issue seems to always lurk: bad teeth. I can’t count the times this health problem has come  up when I’ve talked with a homeless person, someone with a mental health or substance use disorder, or someone who is simply quite poor. When I meet people who have gotten past a bad patch in their lives, their dental problems -- including missing teeth or yellowed gums -- still need treatment, stigmatizing reminders of what these people otherwise had left behind.

The populations most affected by dental health issues are sadly familiar. According to the Florida Dental Care Study, “African Americans and persons of lower [socioeconomic status] reported more new dental symptoms, but were less likely to obtain dental care. When they did receive care, they were more likely to experience tooth loss and less likely to report that dentists had discussed alternative treatments with them.”

Let's put it simply: Over a four year period, respondents with incomes below the poverty line lost three times as many teeth as those with higher incomes.

Access problems have worsened during the great recession, as states and localities curtail Medicaid and non-Medicaid oral health services. Here in Illinois, Medicaid for adults doesn’t cover regular cleanings, and no longer covers routine care such as dental X-rays, filling of cavities, or root canal surgery. You can get an emergency tooth extraction; that’s about it. California and many other states enacted similar policies. State cuts in the adult Medicaid program have put severe pressure on federally funded health centers and dental education institutions; they can no longer afford to provide previous level of care and cross-subsidized services to uninsured adults.

You might wonder what you would do if you were uninsured or on Medicaid and you woke up with a piercing toothache. I wondered that, too. So I called Dr. Mona Van Kanegan, a public health dentist who provides safety-net care at Chicago’s Heartland Alliance. Her answer wasn’t reassuring:

Most people with a dental emergency live with the pain for months or even years. Some self-medicate, and when they can't bear it any longer, they go to the ER.  Most ERs do not have the ability to provide definitive oral health treatments, and the best that they can do is provide pain medication and antibiotics.  The person may also be given a phone number of a community clinic where they can receive further care.  If the person cannot find affordable care in their community, they may repeat the ER cycle again and again.

Unfortunately, these glaring issues went virtually unaddressed in the health reform measure. Pediatric dental services are covered in Medicaid. They are also essential health benefits within the new health insurance exchanges. The Affordable Care Act also provided resources for Federally Qualified Health Centers. That was helpful. Yet adult dental care was otherwise barely mentioned in ACA.

In large part, this omission reflected the longstanding preferences of dentists, themselves. As Dr. Van Kanegan explains:

On a policy level, oral health care should have been part of the core services covered in health care reform. We talk so much about how the oral cavity is connected to the rest of body, but we don't want to be part of an integrated health care system… We isolated ourselves in the '60s when Medicare was being planned.  Many in my profession see that as the first mistake -- like when Adam and Eve ate the apple.  I have seen many, many seniors, having to make do with poor oral health because they do not have the wherewithal to obtain care at market rates; so many seniors with chronic disease living with oral abscesses, inability to chew nutritious fibrous foods and therefore compromising their health.

On Friday, my student Pierre Rowen and I visited Heartland’s primary dental care clinic in Chicago’s Uptown neighborhood. An easy bike ride from the city’s most affluent communities, this clinic mainly serves people who are extremely poor, who are homeless,  or who have other special needs. The clinic stays open with dedicated funding from an alphabet soup of government safety-net efforts, such as the Ryan White Care Act and Health Care for the Homeless, along with philanthropic support.

I spoke with two patients at some length. With their permission, I’m showing their pictures and sharing some of their personal stories. I think it’s important to see real people when we ponder what’s at stake in health policy.

Robert. (Photo: harold Pollack)

Robert (pictured right) has been homeless for years. When I asked about his dental problems, he pulled his lips back to show the damage.  A sweet, soft-spoken man, he has unfilled cavities. He needs a crown. He is waiting on a long-overdue root canal. It would cost about $1,000, which he doesn’t have. He doesn’t have the $50 needed for a basic cleaning. So he hasn’t had his teeth cleaned in two years. All that time, he has chewed all his food on the left side: “These teeth are very weak.”

Heartland staff are trying to help him, but he’s just one of thousands of people facing bottlenecks in specialty dental care. Dr. Kanegan expects him to confront a further wait at the University of Illinois at Chicago or another facility.

I asked Robert what readers should know about the predicament of people like him. He responded with some bitterness about what he called "Obama’s Care": “I don’t see any improvement…  It is becoming worse. They are taking away the free clinics, taking away everything.”

Doris. (Photo credit: Harold Pollack)

Doris faces less profound dental problems. Like Robert, she has faced personal difficulties. She’s now living with family as she participates in a job training program. She’d been waiting at the clinic since 7 a.m., and was lucky enough to be squeezed in:

When you are low-income, if you have a toothache you will be in trouble. I’ve just been asking around trying to find a place I can go. They’ve got one or two places, you know. But it’s so hard to get on the waiting list. There’s one place called Goldie's. You have to call every first Wednesday of the month…. You have to call at 6 on the dot to get in…. I have been trying to get in over six months. I finally got in, which was last month. And I was in school taking my test, and they said that they called [and they went to the next person]… Unfortunately, I had been trying all that time. So you have to try the next month, and that’s a long time when you need help.

I asked what brought her:

I am in pain right now… I have cavities and everything, and it costs money to get them done…Dental just has not been available. It’s mostly for people 21 and under…. You’re pretty much on your own as an adult.

Doris went to a “bootleg dental” storefront clinic to get her teeth cleaned last summer. She can’t afford much else. We talked while she waited to have a tooth pulled.

I love my teeth, you know. Unfortunately, this one has to go. I waited too long. I could have gotten it filled if I had gotten the help earlier. Now it’s too late.

This is just a tooth. Its loss is not the worst thing in the world. It’s not even the worst thing in Doris’s life. Still, it’s unnecessary and permanent. The same thing happens every day to thousands of people across America. We spend $2.8 trillion on health care in America every year. Yet somehow we can’t get even this incredibly basic thing right.

I’d like to thank Heartland’s Beth Horwitz, one of my former students, who introduced me to Dr. Van Kanegan.

Harold Pollack is the Helen A. Ross professor of social service administration at the University of Chicago. He writes a weekly column for Wonkblog.