Most Americans—and by extension, their policy makers—view dental care as either being about receiving superfluous cosmetic procedures or getting relief from tooth pain, said Dr. Mona Van Kanegan, DDS. Rarely do they think of it as an integral part of their overall health.
"Your mouth is the first part of your digestive system, and it's what most people use to communicate," added Van Kanegan, who is co-director of Chicago Community Oral Health Forum, a community initiative committed to improving oral health services and programs for Chicagoans. "It's also what you use to express confidence and self-esteem. If you are missing teeth, or in pain, you're obviously not going to be smiling very much."
Monitoring oral health is even more important for persons with HIV/AIDS. According to the U.S. Department of Health and Human Services, about a third of people living with HIV have an oral health condition related to their infection.
Healthcare providers and policy advocates are conscientious about maintaining access to oral health services for lower-income persons with HIV/AIDS; in Cook County they can obtain dental health services through providers such as Heartland Alliance and the Ruth M. Rothstein CORE Center. Those services are largely covered under Part A of the Ryan White program, when a patient has no other means by which to pay.
But thanks to a shift in the state's budget, those funds are becoming increasingly difficult for the state to leverage, according to providers. Van Kanegan called the Ryan White money, "the funds of last resort. Unfortunately, they're now becoming funds of last resort more often."
John Peller, vice-president of policy for AIDS Foundation of Chicago ( and its incoming interim president ), said, "As a whole, our health care system thinks of oral- and physical-health as two disconnected things, and the consequences of that for low-income people can be devastating."
SMART mistake
In 2012, the Illinois legislature and Gov. Quinn passed the SMART Act, which scaled back health care services to fit available funding sources. Medicaid spending for adult dental care was cut completely, except in cases of extraction. Many services leading up to the extractions would have to be conducted in emergency rooms. Impoverished Illinoisans with tooth problems have few remedies save for having their teeth pulled. This is not a problem unique to Illinois either; according to the American Dental Association, only 11 states offer extensive Medicaid coverage for adult dental services.
Experts agree that the 2012 cut did nothing to save the state money. Research shows that it's more expensive to treat patients in the emergency room setting than provide access to regular preventive care. Van Kanegan said that a dental-related emergency room visit costs about ten times what a preventative care regimen would.
Van Kanegan also noted that there were 77,000 emergency-room visits in the Chicago area for non-injury dental issues during 2008-2011: "The emergency room provider provides what they can—antibiotics, pain medication—but that problem doesn't go away. That person is going to be back in there to alleviate infection and pain again."
The Affordable Care Act for the moment can't provide much remedy, as it requires dental coverage for children, but not adults. The ACA offered few incentives to states to expand Medicaid benefits beyond what were already in place when the legislation took effect; states wanting to add benefits had little financial reason from the federal government to do so.
Experts say that it will cost about $36 million a year to reinstate comprehensive adult dental benefits in Illinois. Under the ACA, the federal government would pick up half that cost for the first three years. But policymakers have so far been reluctant to take on the long-term obligation, for fear that other health appropriations will then be reconsidered and throw off the state's already precarious finances.
"They're afraid that by making that money available, they'll be opening up Pandora's Box," said Ramon Gardenhire, who has lobbied to have the funds restored on behalf of both Service Employees International Union and AFC.
But in 2013 state Sen. Donne Trotter sponsored legislation that would restore adult coverage; it passed the Senate 42-16 last November. The bill is currently with the House Rules Committee, and is sponsored in the House by state Rep. Mary Flowers.
Trotter told the Illinois Issues Blog in November that the money needed to reinstate the cuts was already budgeted, and a wiser determination of how the funds were to be spent was needed. "The elimination of the adult dental programs certainly was more than just skinning the cat," Trotter said. "It was beheading the cat."
"When the SMART Act was being discussed, everything was on the table and we had a target that we had to meet," said state Sen. Heather Steans, a co-sponsor of the bill. "The dental coverage was the item that was most problematic for me. Now there is a sense that [restoring the funding] is good not just for health outcomes, but also in terms of overall costs."
Funding strain
Some advocates argue that until the Medicaid situation is resolved, the city's Ryan White funds will be strained by the cost of dental care for persons with HIV/AIDS who otherwise might have been covered by Medicaid.
"When we get requests for help in accessing care, dental care is always on the 'top five' list of what people need," said Peller.
Chicago Department of Public Health, which administers Ryan White grants to health providers locally, has not captured any data directly linking reductions in Medicaid funds to an increase in spending for Ryan White, said Marjani Williams, CDPH's HIV/STI Information Coordinator. The uncertainty, she added, stemmed from differences in Medicaid and Ryan White's payment structure—Medicaid is fee-for-service while Ryan White funds are largely distributed through grants to providers.
But Williams added that Ryan White-funded providers were definitely seeing more dental patients.
"What is clear is that we've seen a significant increase in the number of dental visits over the past few years from residents requiring quality care," she said. "In FY2012, there were more than 12,500 visits—an increase over the 9,200 visits in 2010—and in the first two quarters of 2013, we know providers saw significantly more clients than the original planned numbers."
According to Williams, CDPH has not yet compiled the number of visits, but said the agency provided $1.1 million for dental services in the greater Chicago area in 2013.
"Persons on Medicaid used to be able to go to a variety of providers," Peller noted. "Now they can only obtain services from providers affiliated with Ryan White. Medicaid has completely abdicated its responsibility, and there's less money to go around."
Getting treatment
Van Kanegan is also director at both the Oral Health Program Development at Heartland Health Outreach and Midwest AIDS Training & Education Center. She sees a panel of about 250 patients, many of whom are HIV-positive, in part-time clinical work for Erie Family Health Services.
Most patients with HIV/AIDS she sees are trending younger, she noted. "They usually need pretty extensive periodontal therapy. They usually need multiple teeth out, and multiple teeth repaired and restored to replace some ability to chew."
There is no assurance that patients requiring more expensive or complex work will be able to have all their dental needs met.
"Sometimes it's difficult—if it's a surgical extraction, I have to send them somewhere else and there's no guarantee that it will get done, or that the patient can get care, because they'd have to pay out of pocket. Once in a while, a very generous private practitioner can help me out and they figure out a way to provide the service for free," said Van Kanegan.
When she sees new patients, Van Kanegan first addresses immediate problems, then does a thorough exam of hard and soft tissue in the oral cavity, checking closely for conditions such as candidiasis, Kaposi's Sarcoma or Epstein-Barr Virus. A large percentage of persons with HIV will experience an oral infection at some point; Van Kanegan has seen numbers ranging from 30-80 percent. "A dental professional has to treat it so it doesn't spread or prevent that person from taking care of themselves," she noted, adding that dentists also have to check for co-morbidities such as diabetes or cardiovascular disease; both are chronic conditions that have close relationships to oral health.
Van Kanegan tries to develop a long-term plan with most patients and admits it takes a lot of gumption for many of them to adhere to it. "They might be struggling with drug use or uncontrolled health issues. Managing their home lives can be difficult. They have challenging lives, so I give them a lot of slack."
But she has had numerous patients whose dental health has managed to turn around. She said a patient had recently asked her to take a picture with him when she'd finished an exam; he was going to be speaking in public about overcoming a fear of the dentist.
"He was really afraid," she said. "But he feels so much better as a result of overcoming his fears. He was so focused on completing his treatment."
It's an outcome she would like to see even more, provided funding for dental services can be readjusted in the state.
"The reality is that the money is already being spent in hospital emergency rooms," said Van Kanegan. "We're talking about the money that's already being spent on cycling patients in and out."
