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Dental Insurance, but No Dentists

By LOUIS W. SULLIVAN

Published: April 8, 2012

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Atlanta

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WE know that too many Americans can't afford primary care and end up in the emergency room with asthma or heart failure . But in the debate over health care coverage, less attention has been paid to the fact that too many Americans also end up in the emergency room with severe tooth abscesses that keep them from eating or infections that can travel from decayed teeth to the brain and, if untreated, kill.

More than 830,000 visits to emergency rooms nationwide in 2009 were for preventable dental problems. In my state of Georgia, visits to the E.R. for oral health problems cost more than $23 million in 2007. According to more recent data from Florida, the bill exceeded $88 million. And dental disease is the No. 1 chronic childhood disease, sending more children in search of medical treatment than asthma. In a nation obsessed with high-tech medicine, people are not getting preventive care for something as simple as tooth decay .

It's easy to understand why. Close to 50 million Americans live in rural or poor areas where dentists do not practice. Most dentists do not accept Medicaid patients. And the shortage of dentists is going to get only worse: by 2014, under the Affordable Care Act, 5.3 million more children will be entitled to dental benefits from Medicaid and the Children's Health Insurance Program . Little is being done — by the dental profession or by the federal or state governments — to prepare for it.

During the physician shortage of the middle of the last century, the federal government began creating about 50 new medical schools , doubling the number of graduating doctors. Today our government can and should train more dentists to address the long-term problem. But there is no guarantee that the new recruits would practice in underserved areas, and we need practitioners now.

A more immediate solution is to train dental therapists who can provide preventive care and routine procedures like sealants, fillings and simple extractions outside the confines of a traditional dentist's office. Dental therapists are common worldwide, and yet in the United States they practice only in Alaska and Minnesota, where state law allows it. Legislation is pending in five more states.

The dental profession has resisted efforts to allow midlevel providers to deliver this kind of care, and the government has so far failed to push for the change. It must do so now. The federal government could encourage states to pass laws allowing these providers to practice by calling for demonstration projects proving their worth.

The best model for how this system can work is found in remote Alaska Native villages, many accessible only by plane, snowmobile or dogsled, where high school seniors once graduated with full sets of dentures. Unable to recruit dentists to these areas, Alaska has been training its own dental therapists.

When Alaska began the project in 2003, there were no training programs in the country, so the state first sent students to New Zealand, which had a rigorous training program for dental therapists. These therapists now travel to small clinics and schools, often carrying their equipment with them. They consult with a supervising dentist from the region but do most procedures themselves. Many were raised in the communities in which they now work, so they understand the culture, children trust them and they have quickly become local health care leaders. Thanks to the program, around 35,000 people now live in communities where there is regular access to dental care .

We have two years to prepare before millions of children will be entitled to access to dental care, and Alaska shows us the way forward. Access means more than having an insurance card; it means having professionals available to provide care. Public officials should foster the creation of these midlevel providers — and dentists should embrace the opportunity to broaden the profession so they can expand services to those in need.

Louis W. Sullivan, a physician, was the secretary of the Department of Health and Human Services from 1989 to 1993.

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