LACONIA — It costs nothing to smile, a common saying goes – but the cost of keeping the teeth behind that smile can sometimes be out of reach.
For low income residents, affordable dental care is extremely limited. Often, the only treatment they’re covered for is tooth extraction. On a large scale, poor dental health can lead to a cascade of corresponding health issues, and cost the economy as a whole. Thanks to the work of dental professionals around the state, new legislation is coming to confront this problem.
“When I came here, I thought that I was living in a parallel universe because I had not seen such teeth,” said Olga Minukhin, who has practiced dentistry in Laconia for 18 years. “If you come to Gilford you will not see the same picture, or Wolfeboro. Here in Laconia or Franklin especially, it’s totally low income, a lot of drug addiction.”
Just over 11% of Laconia lives in poverty according to the 2020 census, and the median household income is $55,000, about $12,000 below the U.S. national average. For low income residents, New Hampshire Medicaid is often the only affordable health care option. However, adults on Medicaid are severely limited when it comes to dental care.
“You can’t get a filling, cleaning, full exam, dentures, crowns, root canals, you can’t get anything done except get your teeth taken out,” said Dr. Kelly Perry, dental director at Mid-State Health Center. “It’s not a totally uncommon occurrence to be taking out all the teeth in someone in their 30s or 40s.”
In addition to the limited care provided by medicaid, many dentists and oral surgeons won’t take Medicaid patients.
“One, is it is very low reimbursement, and two, lots of no shows. The patients just don’t show. You do need to maintain your practice, and pay your bills, you just cannot do that,” Minukhin explained, saying that there are some oral surgeons that do take Medicaid patients, but they are far and few between. “The oral surgeons now have only two places who are accepting Medicaid patients. It’s Dartmouth-Hitchcock, and Elliot Hospital near Manchester and the waiting list is five to eight months.”
The way that the United States and insurance companies compartmentalize oral health has also contributed to the Lakes Region’s poor oral health, according to Perry.
“No health insurance comes with your dental coverage. Not only are you paying potentially a deductible, you’re also paying a percentage of the total fee, and you’re also hit with a pretty low maximum for a year. That amount hasn’t gone up in decades so as costs go up, the amount that people are insured for has stayed around $1,500 to $2,000,” Perry explained. “It’s almost a ridiculous notion that we have to discuss why oral health is important to systemic health.”
A third prong of the dental disaster is a culture of poor diet and ignorance of basic oral health practices.
“Nobody told them teeth should be brushed, nobody told them, don’t drink soda. The biggest problem is that people drink sugar like there is no tomorrow and it’s the biggest contribution to the loss of teeth, plus drugs,” Minukhin said, recalling one of her earlier pediatric patients. “In 2004, a family comes in, they bring a six-year-old child. There is no teeth. Everything was black. I start this story saying, ‘well, no soda,’ mom looks at the six-year-old child and says ‘see?! I told you not to drink soda!’ I said, ‘okay, but who’s buying it?’”
“When you have generations of people without access to care because they can’t afford it or not enough providers or appointments, or no insurance, that’s just going to push oral health down the list of things they prioritize,” Perry said, stating that many patients “accept defeat” when it comes to having their teeth removed. “The next generation is taught that teeth are expendable.”
One of the best tools to change the culture may be education.
“We operate a school program here we have two certified public health dental hygienists that go to schools to provide services for k through 12 students,” Perry said. “They’re doing preventative services but also trying to educate. We hand out toothbrushes, toothpaste, give them the tools to do it, and hopefully that will start to change the culture of why teeth are important.”
Poor adult dental health can wreak havoc on the economy via emergency room visits, increased health care costs, loss of productivity, and even create barriers to employment.
“There’s no way a 35-year-old without teeth will have the same job prospects,” Perry explained. “If you’re a younger person or older person and you’re missing teeth in the aesthetic zone that’s going to make all kinds of social things tough. You’ll have difficultly building family, finding partners and jobs.”
As oral health deteriorates, Perry argued, it can compound and start a vicious social cycle.
“All these things are cyclical. Being in pain, being embarrassed can lead to depression, anxiety, substance use disorders, and those same things are going to come back and cause worsening oral health,” Perry said.
In addition to her current work, Perry is also the dental chair of the New Hampshire Oral Health Coalition. The group and other oral health care professionals have spent years educating law makers, and it looks like their efforts might be paying off. HB103 and SB 422, a pair of bills advocating for adding more dental benefits under the state Medicaid program are gaining bipartisan support.
“It makes a great deal of sense in terms of cost benefit to provide a Medicaid benefit for many, if not all of the dental functions and care that many of us have and Medicaid recipients do not,” said New Hampshire District 2 Senator Bob Giuda. “It will help them as far as jobs, health short and long term, save money over the current paradigm which basically sends you to an ER.”
SB422 is titled as, “Establishing an adult dental benefit under the state Medicaid program,” and will utilize funds from the state’s $21 million dollar settlement with the Centene Corporation. Centene was forced to pay the sum last year, after the state found that company had inaccurately reported the costs of its pharmacy benefit services.
“Use of that data received from Centene resulted in at least a $2.4 million negative financial impact to the state during settlement period,” according to a press release from the Attorney General’s office.
SB 422’s copy states that “$2,420,203 will be used to meet the financial requirements of completing a Medicaid Care Management FY 2020 risk corridor calculation. In practice, these funds will be used to reimburse the federal government for over payments made to the state Medicaid program. The remaining $18,728,619 will be used to fund the non-federal share of the adult dental benefit. These funds shall be non-lapsing.”
As for the non-lapsing funds, Giuda reiterated that he and other law makers were in it for the long haul.
“The initial payments are covered by the Centene lawsuit payment,” Giuda explained. “We didn’t want to wait till the budget cycle. The budget writing next year will incorporate it into the state budget.”
Giuda expressed confidence that Gov. Sununu would sign SB 422 once it clears the Senate.
Should the bills pass, New Hampshire might see some better smiles over the next few years.