Sunday, June 10, 2018

Rural America has too few dentists, partly because it has too few patients or Medicaid programs that can pay

Dr. Lynnel Beauchesne's clinic in Preston County, West Virginia,
at lower right. (Photos by Ricky Carioti for The Washington Post)
Efforts to recruit dentists to rural towns, and expand state scope-of-practice laws to allow basic services to be delivered by dental therapists, have long been regarded as two of the best ways to improve oral health in rural America, where 43 percent of residents lack access to dental care. But because the care is so expensive, those efforts may sometimes be counterproductive, Anne Kim, domestic policy director at the Progressive Policy Institute, writes for The Washington Post.

"People don’t go to the dentist if they can’t afford to, no matter how many dentists there are," Kim writes, citing Richard Meckstroth, chair of the department of dental practice and rural health at West Virginia University. "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."

Beauchesne and 15-month-old daughter, Landyn, in the office
And in states like West Virginia, where poverty is widespread and Medicaid doesn't cover adult dental care except for extractions or infection treatment, even dentists can have it tough. Kim's object example is Dr. Lynnel Beauchesne of Preston County, who "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."  Beauchesne tols her, “I try to keep my prices in the realm of what people can afford and so they will want to come. I don’t want people to come just for extractions. I want them to come for cleanings and to keep the teeth they have.” The closest dentist is 30 miles away.

"Poor oral health has an impact beyond mere toothache," Kim reminds us. "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." A 2014 report from the American Dental Association said nearly 20 percent of adults under 65 "said they’d foregone needed dental care in the past 12 months, with the most common reason being “they couldn't afford it.”

Which brings us back to recruiting dentists. "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," Kim writes, adding, "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." As Meckstroth told her, “How you improve access in rural America is to get people jobs.”

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