For poor kids, fewer dentists, but a pilot program offers hope

The Affordable Care Act has in theory made it easier for poor children in California to get their teeth cleaned or have a cavity filled. But getting into a dentist’s chair appears to be harder than ever, as fewer dentists accept patients on Denti-Cal, the dental insurance program for children in families on Medi-Cal. 

At the same time, a pilot program expanding which procedures dental hygienists can perform may contain at least a partial solution to the problem. 

A visit to Long Beach illustrates the difficulty many communities face trying to provide dental coverage for poor kids. Of the roughly 20 private pediatric dentists in the area, "there is currently only one that accepts Denti-Cal," said Dr. John Blake, director of Long Beach's nonprofit Children’s Dental Health Clinic. 

The reason is simple, Blake said. For every dollar a dentist spends to treat a patient on Denti-Cal, he said, the state reimburses an average of 28 cents, one of the lowest rates in the nation. 

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An analysis by the California Healthcare Foundation found that from 2003 to 2010, the portion of the state’s dentists who saw Denti-Cal patients fell from 40 percent to 24 percent. The state has cut reimbursement rates multiple times since 2010, and Blake said more dentists are dropping out all the time.  

The problem is becoming more acute. More than a million new children have recently enrolled or become eligible for Denti-Cal, in part because of the Affordable Care Act, which expanded the eligibility levels for Medi-Cal. 

The top priority for most dentists and children’s advocates is increasing Denti-Cal reimbursement rates so dentists can at least cover their costs.

Another possible solution currently being tested in 13 communities across California is the Virtual Dental Home. It’s a pilot project set up by the state that’s exploring whether dental hygienists armed with additional powers and a little technology can be the new front line of care for poor children.

Under the program, which is run by the University of the Pacific, hygienists working under the supervision of a dentist treat kids at Head Start programs, community centers and schools.

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Hygienists in the pilot carry a portable X-ray machine and a laptop, take images of a child’s mouth and upload the images for the dentist to review back at the office. If the child has cavities, the dentist authorizes the hygienist to administer temporary fillings. 

The economics behind the pilot are simple. A hygienist’s time costs less than a dentist’s, and treating a child at a preschool is cheaper than doing so at a dental office. So if a dentist can hire two or three hygienists to go out to do temporary fillings, treating Denti-Cal patients could become financially viable again.

Over the course of four years, the pilot has proven to be very successful, with no adverse outcomes, said Dr. Paul Glassman, a dentistry professor at the University of the Pacific who is overseeing the pilot project.

The pilot is operating under an exception to current state rules, which do not allow hygienists to administer temporary fillings. 

The state legislature is considering a bill that would give all hygienists in California the authority to do temporary fillings once they receive the necessary training. The state assembly approved the legislation in January. It’s pending in the senate.