THE BLOG
10/31/2013 10:00 am ET Updated Jan 23, 2014

What Really Scares Middle-Income Americans Away From the Dentist

Author's Note: This is the second in a series of articles examining America's oral health care crisis. Be sure to read part one, "America's Hidden Epidemic That Obamacare Barely Touches."

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If you think that lack of access to dental care is just a problem for the poor in this country, think again. More and more middle-income Americans, even those with dental insurance, are finding that going to the dentist for even routine care is not a possibility because of the cost.

Just ask Mike King, who works for a family-owned print shop in St. Johnsbury, Vermont. King has worked for Silver Mountain Graphics for several years and owns his own home. "I make pretty good money," he says, but not enough to pay the mortgage and also buy health and dental insurance.

As a consequence, he postponed going to the dentist -- he hadn't been in years -- until a toothache became unbearable. Unfortunately, he lost the tooth that was causing the pain. A root canal would have saved it, but he says it would have been five times more expensive than getting the decayed tooth pulled. "There's no way I can spend that much money here," he said he told the dentist.

It is an all too common cycle: People can't afford preventive care, they end up with a serious oral health problem as a result, and then can't afford to treat it. They suffer and often lose their teeth.

Consumer and patient advocates had hoped the Affordable Care Act would help people like Mike King who are among an estimated 130 million Americans without dental insurance. But while the health care reform law will reduce the number of people without medical insurance, it will barely make a dent in the need to broaden access to affordable dental care for most U.S. residents. The law does expand pediatric dental benefits, but many children who already have access to such benefits still can't find a dentist to treat them, especially children of color.

Anyone who has gone to a dentist recently -- including those with dental insurance -- have found that taking care of our teeth is an increasingly expensive proposition. According to the Center for Medicare and Medicaid Services, U.S. residents spent $108 billion on dental care in 2011 -- much of it out of pocket.

The Government Accountability Office reported in a recent study that the average annual out-of-pocket payments for dental services in the United States increased 26 percent -- after accounting for inflation -- between 1996 and 2010, from $520 to $653. The more than one-third of us without dental insurance have been hit much harder. Their costs increased 38 percent during that time frame.

A Healthcare Transparency Index analysis of 2011 prices for dental services showed just how expensive dental care has become in the United States. The cost of pediatric preventive exams with x-rays ranged from $65 to $300. Removal of a wisdom tooth ranged from $1,375 to $3,735.

"I don't go to the dentist unless it's an emergency," said King, even though he knows he's running the risk of a life-threatening infection that could result from an abscessed tooth or diseased gums. "I'm worried about down the road what's going to happen, but there's really nothing I can do about it except do my daily maintenance and hope for the best."

Because of the rapidly increasing costs, more of us are postponing or forgoing needed dental care. In a survey conducted by the Children's Dental Health Project (CDHP) and released Tuesday, 39 percent of those polled said they or a family member had delayed a dental visit during the last 12 months. Of those who postponed care, 41 percent were middle income Americans.

"Affordability is not just an issue for lower-income Americans," said CDHP executive director Patrice Pascual. "Our survey showed that a significant share of middle-income people had also put off a dental visit because of the out-of-pocket costs they expected to pay."

Other recent surveys have had similar findings. One conducted this summer by Empirica Research found that about five million Los Angeles-area residents -- the equivalent of the population of Colorado -- lacked dental insurance. Half of them reported not getting any preventive dental care. The survey, which was conducted for Brighter.com, an online service that provides self-pay patients access to pre-negotiated prices at dentists in Los Angeles and other markets, found that three-fourths of LA's uninsured -- and half of those who did have insurance -- have missing teeth, bleeding gums, toothaches or other unmet dental care needs.

Even those of us who have the financial means to visit the dentist on a regular basis are paying a price in the form of a hidden tax to cover the cost of care of those who delay care so long they wind up at hospital emergency rooms in agony and with often dangerous infections. A recent study found that over a five-year period, the cost of treating children in emergency rooms in New York State nearly doubled, from $18.5 million to $31.5 million. The average cost per ER visit increased 30 percent over that time frame, to $5,501.

Needless to say, the parents of many of those children didn't have an extra five grand to pay for that care, meaning that taxpayers and people with private insurance picked up the tab in the form of higher taxes and higher insurance premiums to cover what hospitals refer to as "uncompensated care."

When adults are factored in, the total amount of money spent on dental care in the ER skyrockets. A recent analysis commissioned by the Florida Public Health Institute found more than 115,000 hospital emergency room visits across the state in 2010 for treatment of dental conditions were considered avoidable. Total ER charges that year for dental emergencies that could have been prevented exceeded $88 million, an increase of $20 million from 2008.

"This is not a problem of just the poor and those on Medicaid," said Frank A. Catalanotto, professor and chair of the Department of Community Dentistry and Behavioral Science at the University of Florida.

In my next column in this series, I will focus on the connection between oral health and overall health and the all-too-frequent tragic consequences of waiting too long to get appropriate dental care.

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