Ru­ral Amer­ica has be­come cav­ity coun­try

Den­tists and pa­tients both strug­gle to get by, says jour­nal­ist Anne Kim

The Washington Post Sunday - - OUTLOOK - akim@ppi­online.org Anne Kim is do­mes­tic pol­icy di­rec­tor at the Pro­gres­sive Pol­icy In­sti­tute and a con­tribut­ing edi­tor at the Wash­ing­ton Monthly.

Lyn­nel Beauch­esne’s den­tal of­fice hugs a ru­ral cross­roads near Tun­nel­ton, W.Va., pop­u­la­tion 336. Acres of empty farm­land sur­round the weath­ered on­estory white build­ing; a cou­ple of houses and a few barns are the only neigh­bors. But the park­ing lot is full. Some peo­ple have driven hours to see Beauch­esne, the sole den­tist within 30 miles. She es­ti­mates that she has as many as 8,000 pa­tients. Be­fore the of­fice closes at 7 p.m., she and her two hy­gien­ists will see up to 50 of them, not count­ing emer­gen­cies.

About 43 per­cent of ru­ral Amer­i­cans lack ac­cess to den­tal care, ac­cord­ing to the Na­tional Ru­ral Health As­so­ci­a­tion, and West Vir­ginia, among the poor­est and most ru­ral states, is at the cen­ter of the cri­sis. All but six of the state’s 55 coun­ties in­clude fed­er­ally des­ig­nated “Health Pro­fes­sional Short­age

Ar­eas,” “Med­i­cally Un­der­served Ar­eas” or both. The state’s Oral Health Pro­gram found in 2014 and 2015 that nearly half of its coun­ties had fewer than six prac­tic­ing den­tists, just half of adult West Vir­gini­ans had vis­ited a den­tist in the pre­vi­ous year, and more than one-fifth hadn’t seen a den­tist in five years. By com­par­i­son, a U.S. Cen­ters for Dis­ease Con­trol and Pre­ven­tion study in 2015 found that 64 per­cent of all Amer­i­can adults ages 18 to 64 re­ported see­ing a den­tist in the pre­vi­ous year. The rate of to­tal tooth loss is 33.8 per­cent among West Vir­gini­ans over 65, com­pared with roughly 19 per­cent for all se­niors na­tion­ally.

One seem­ingly ob­vi­ous so­lu­tion is to per­suade more den­tists and other oral-health providers to come to places like West Vir­ginia, a goal of var­i­ous pub­lic ef­forts. The fed­eral Na­tional Health Ser­vice Corps pro­gram, for ex­am­ple, of­fers up to $50,000 in loan as­sis­tance to doctors and den­tists willing to work two years in a des­ig­nated short­age area. And sev­eral states have passed or con­sid­ered leg­is­la­tion au­tho­riz­ing “den­tal ther­a­pists” — mi­dlevel providers akin to nurse prac­ti­tion­ers — to pro­vide cer­tain kinds of pri­mary den­tal care in ar­eas where den­tists are scarce.

But while it is true that West Vir­ginia has a den­tist short­age, adding more providers will not solve the prob­lem of ru­ral oral health. Peo­ple don’t go to the den­tist if they can’t af­ford to, no mat­ter how many den­tists there are. “Af­ford­abil­ity is the big thing,” said Richard Meck­stroth, chair of the de­part­ment of den­tal prac­tice and ru­ral health at West Vir­ginia Univer­sity.

And af­ford­abil­ity cuts both ways. Re­cruit­ing more providers into short­age ar­eas can com­pound the prob­lem, said Meck­stroth, putting lo­cal den­tists into tougher fi­nan­cial straits by in­creas­ing com­pe­ti­tion for a rel­a­tively small pool of paying pa­tients. The den­tists who ar­rive un­der loan for­give­ness pro­grams also tend to leave after their two-year obli­ga­tion is up, what Meck­stroth calls a “re­volv­ing door” that de­prives pa­tients of con­ti­nu­ity of care.

As busy as Beauch­esne’s Pre­ston County prac­tice is, it brings in only enough to stay afloat. A scant 53 per­cent of the county’s pop­u­la­tion is in the la­bor force, and the poverty rate is 17 per­cent. Den­tal care is a rel­a­tive lux­ury, so Beauch­esne (bo-SHANE) keeps prices barely above costs. The of­fice charges $90 for a clean­ing, an exam and bitew­ing X-rays — about half the na­tional av­er­age fee and a third of what many big-city den­tists would charge for the same ser­vices. “I try to keep my prices in the realm of what peo­ple can af­ford and so they will want to come,” she said. “I don’t want peo­ple to come just for ex­trac­tions. I want them to come for clean­ings and to keep the teeth they have.”

Beauch­esne’s pa­tients strug­gle to af­ford her all the same. Ac­cord­ing to the state’s Bureau for Pub­lic Health, only 40 per­cent of adults in West Vir­ginia have ac­cess to den­tal ben­e­fits of any kind, com­pared with about 65 per­cent of work­ing-age adults na­tion­wide. While the state’s Med­i­caid pro­gram cov­ers pre­ven­tive care for chil­dren, adults get no cov­er­age ex­cept for ex­trac­tions or treat­ment for in­fec­tions. Medi­care of­fers no den­tal ben­e­fits, ei­ther. As a re­sult, ac­cord­ing to the West Vir­ginia Oral Health Coali­tion, 43 per­cent of West Vir­gini­ans ages 55 to 64 have lost six or more teeth be­cause of dis­ease or de­cay; 61 per­cent of res­i­dents older than 65 with­out a high school diploma have lost all their teeth.

Poor oral health has an im­pact be­yond mere toothache. A land­mark 2000 re­port by the U.S. Sur­geon Gen­eral found that oral health is in­ti­mately linked to peo­ple’s over­all phys­i­cal health and is of­ten as­so­ci­ated with se­ri­ous sys­temic con­di­tions such as di­a­betes and heart dis­ease, as well as the like­li­hood of com­pli­ca­tions in preg­nancy. Nev­er­the­less, some 74 mil­lion Amer­i­cans had no den­tal cov­er­age in 2016, ac­cord­ing to the Na­tional As­so­ci­a­tion of Den­tal Plans, putting the den­tally unin­sured rate at nearly four times the rate for the med­i­cally unin­sured. Ac­cord­ing to a 2014 re­port from the Amer­i­can Den­tal As­so­ci­a­tion’s Health Pol­icy In­sti­tute, nearly 20 per­cent of adults ages 21 to 64 said they’d fore­gone needed den­tal care in the past 12 months, with the most com­mon rea­son be­ing: “could not af­ford the cost.”

Pa­tients’ in­abil­ity to af­ford care is one rea­son younger den­tists — many fac­ing up to $250,000 in school debt — are re­luc­tant to set­tle in ru­ral ar­eas and why den­tists like Beauch­esne find them­selves work­ing hard to keep their doors open. Chip Per­rine has owned a prac­tice in Cowen, W.Va., for 30 years. He and his daugh­ter, Valerie, say they are the only pri­vately prac­tic­ing den­tists in Web­ster County, which has about 8,300 res­i­dents, but they of­ten have open­ings in their sched­ule. “I keep hear­ing we’re un­der­served, but I don’t feel I’m un­der­served — I feel un­der­uti­lized,” he said. His son joined the prac­tice after grad­u­at­ing from den­tal school but even­tu­ally left to start a prac­tice else­where be­cause he couldn’t af­ford to stay.

“We are open to any in­sur­ance, in­clud­ing Med­i­caid and CHIP,” the Chil­dren’s Health In­sur­ance Pro­gram, said Valerie Per­rine. “It’s not an is­sue that some­one can’t get an ap­point­ment.”

The Per­rines charge a lit­tle more than Beauch­esne — $158 for clean­ing, bitew­ing Xray and exam — but Chip Per­rine es­ti­mates that he gives away about $400,000 a year in free care, in­clud­ing write-offs from low Med­i­caid re­im­burse­ment rates. It’s tough for the prac­tice to swal­low be­cause ex­penses are also ris­ing. “On av­er­age, my den­tal sup­plies go up 12 to 15 per­cent a year, but I can’t raise prices,” said Chip Per­rine. “It’s use­less. I can charge what I want, but it won’t get paid.”

Beauch­esne of­ten re­sorts to creative strate­gies to help her pa­tients af­ford care. For in­stance, the prac­tice of­fers a 15 per­cent dis­count for those who pay cash and a 20 per­cent dis­count for pa­tients over 80. “I fig­ure if they made it that far, they’re on a re­ally tight in­come,” she says.

She’ll also barter for ser­vices. “If I needed a cow or a [side of] beef or a hog, what­ever the nor­mal cost would be, they can get a fill­ing or a crown,” she said. Still, Beauch­esne’s of­fice man­ager and as­sis­tant, Alice Deakins, es­ti­mates that be­tween 10 and 15 per­cent of the care the prac­tice pro­vides is given free.

Beauch­esne, who is in her late 40s, said she still owes about $35,000 in school debt. Her of­fice is no-frills, and she spends her days off mow­ing the lawn, paint­ing the walls and car­ry­ing out re­pairs. Her panoramic X-ray ma­chine dates from 1990 — she bought it used for $6,000 — and she re­cently won a $26,000 grant from the state of West Vir­ginia to buy some com­put­ers for her of­fice and re­place one of her chairs. But she can’t af­ford to dig­i­tize. “That would cost me $100,000, and I can’t af­ford to take more loans out,” she said.

The lack of af­ford­abil­ity and ac­cess to den­tal cov­er­age in West Vir­ginia is, of course, tied to the state’s over­all eco­nomic pre­car­i­ous­ness. Bruce Cas­sis, a den­tist who prac­tices in Fayet­teville, said ac­cess to high-qual­ity den­tal in­sur­ance in his area has de­clined along with the for­tunes of coal. “Less than 5 per­cent of my pa­tients are af­fil­i­ated with the coal in­dus­try,” Cas­sis said. “Thirty years ago, they used to be 60 per­cent of my pa­tient base.” To­day, the ma­jor em­ployer in his re­gion is the county school board. “They have the best in­sur­ance in the area.”

The same is true for the Per­rines and Beauch­esne, whose best-in­sured pa­tients typ­i­cally have govern­ment jobs, such as with the school dis­trict or the fire de­part­ment.

When it comes to oral health, said Beauch­esne, the loss of jobs is per­haps felt most acutely by the area’s el­derly, who may have once had pri­vate den­tal in­sur­ance but now have no cov­er­age be­cause they are on Medi­care. “These are the ones that took care of their teeth while work­ing and are now on a fixed in­come,” she said. “It is sad to see the de­te­ri­o­ra­tion.”

Pro­vid­ing den­tal ben­e­fits un­der Medi­care — at least for pre­ven­tive ser­vices such as an an­nual clean­ing — would both ben­e­fit se­niors and help den­tists in ru­ral ar­eas sur­vive. Also help­ful to pa­tients and providers would be ex­pand­ing Med­i­caid cov­er­age of pre­ven­tive care to adults in­stead of end­ing it at age 21. Cov­er­ing pre­ven­tive care would also re­duce the amount spent on emer­gency room den­tal vis­its, which the Amer­i­can Den­tal As­so­ci­a­tion es­ti­mates cost the U.S. health sys­tem $1.6 bil­lion in 2012.

Still, the den­tal-care cri­sis in ru­ral Amer­ica is closely linked to the broader eco­nomic chal­lenges in the parts of the coun­try that have not yet caught up in this re­cov­ery. “How you im­prove ac­cess in ru­ral Amer­ica,” says Meck­stroth, “is to get peo­ple jobs.”

PHO­TOS BY RICKY CARIOTI/THE WASH­ING­TON POST

ABOVE: Beauch­esne’s den­tal of­fice, lower right.

TOP RIGHT: Lisa Haller of Ju­nior, W.Va., right, sits with her chil­dren, Cheyenne Wy­att, 12, lower right, Ser­ena Wy­att, 14, on chair, and Bray­den Wy­att, 11, rear, whose braces were ad­justed last month at Beauch­esne’s of­fice.

TOP LEFT: Hy­gien­ist Misty Calvert at the West Vir­ginia den­tal prac­tice of Lyn­nel Beauch­esne.

BE­LOW: The den­tist and her daugh­ter, Lan­dyn.

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