Fewer than one in eight North Carolina children ages 1 to 5 who qualify for free dental treatment through Medicaid visit a dentist in any given year. As a result, they and older poor children, whose visits are not much more frequent, often live with strong physical and emotional pain, according to a unique new University of North Carolina at Chapel Hill study. Cavities can hurt a lot -- disrupting sleep and meals -- and other children ridicule their unsightly front teeth.
Despite substantial federal funding, barriers to dental care for such youngsters are just too great for many to overcome. The new work was confined to the Tar Heel state, but many parts of the nation and many of the more than 20 million children enrolled in Medicaid face comparable problems, the researchers say. Their investigation involved forming 11 racially and ethnically diverse focus groups of parents and other caregivers across North Carolina, holding intensive discussions with participants about their experiences and analyzing what they found.
"I could not get a dentist to take Medicaid," one mother said. "I got the book out, the telephone book, and I went through about 10-15 dentists, and no one wanted to take Medicaid. I just gave up." Another complained about the time it took to have her child treated while paying patients came and went quickly: "You checked in at 10 in the morning...and it's 4 before you can get seen because you're on Medicaid. It's just the way it makes you feel. I've sat five, six hours.... I'll never do it again."
Atop all life's other pressures, the stress in finding a dentist and subsequent interactions in the dental office can be enormous, forcing some parents to just give up. The study also found that language is a particular frustration for Latinos, and some minorities perceive prejudices against them that make them want to stay away.
"Why do they work like this?" a potential patient asked. "If they don't work with Medicaid, or if they don't want Latinos, they should put a sign on the door -- 'No Hispanic people.'"
A report on the study, the first peer-reviewed investigation to document perceived discrimination against young Medicaid dental patients and related problems, appears in the January issue of the American Journal of Public Health. Authors are Drs. Mahyar Mofidi, a dentist and doctoral student in health behavior and health education at UNC, R. Gary Rozier, professor of health policy and administration, and Rebecca S. King, a dentist working with the oral health section of the N.C. Department of Health and Human Services' public health division.
"We wanted to explore and develop a broad understanding of access to dental care from the perspective of families as consumers," said Mofidi, who began the work during a residency with the state and now is a fellow at UNC's Cecil G. Sheps Center for Health Services Research. "Up to now, we knew very little about how families negotiated barriers to dental care for their Medicaid children."
Researchers sought to hear families' stories in their own words, he said. Responses provided both first-hand information about problems with access and cues-to-action for alleviating those difficulties.
"Participants expressed a wide range of emotions, from despair to anger to disappointment, in describing a health-care system that, in their words, is not sensitive or responsive to their needs or to those of their children," Mofidi said. They "considered the demeaning and discriminatory attitude and behavior of front-office personnel as a major barrier. To avoid encountering such attitudes and behaviors, some participants often postponed or canceled dental appointments."
Among other findings were that many dentists decline to accept Medicaid patients while others do so only reluctantly, he said. Some have policies that restrict such visits to a single day per week or a single child per visit, which puts a heavy burden on parents who must miss work and those with little or no transportation. Statistics show that fewer than 20 percent of 15- to 20-year-old and fewer than 30 percent of 6- to 14-year-old Medicaid patients saw a dentist in 1998, Rozier said. Only 2 percent of 3-year-olds receive routine care, and getting a non-emergency appointment sometimes takes three months or more.
Directors of social service and health service agencies, as well as the public, consider dental disease one of the state's top unmet health-care needs, he said.
"Raising reimbursements is a necessary first step to ensure greater participation of dentists in the Medicaid program," Mofidi said. "But raising reimbursements is not enough. That has to be complemented by serious attempts to address the problems families encounter in the dental care setting."
Reasons for inequities in getting dental care include:
* North Carolina ranks 47th in the nation in the number of dentists and 45th in pediatric dentists.
* Only 50 pediatric dentists practice here, and general dentists are less likely to accept the youngest patients.
* The state ranks 44th in dentists' Medicaid participation.
* Medicaid-eligible residents in 40 counties have no private dentist available.
* Government fees range from 42 percent to 62 percent of usual charges, and close to 70 percent of dental office income goes for overhead.
Besides lower pay for treating Medicaid patients, previous studies report that some dentists complain that such patients' parents are unreliable and that the paperwork and bureaucracy are excessively burdensome, said Rozier, who oversaw the study. Parents and other caregivers interviewed in the new investigation say some dentists or their staffs make them feel unwelcome and embarrass them by allowing others in the waiting room to learn of their Medicaid status.
"Some of the caregivers' perspectives were surprising, and some were heart-wrenching," he said. "We need to do better for these children."
Numerous prominent organizations ranging from the American Dental Association and the General Accounting Office to the National Governors' Association and the N.C. Institute of Medicine have wrestled with the problem of preventing dental disease in low-income people and boosting access to care, Rozier said.
"Our study generated findings on (dental care) providers that have not been observed in previous studies," Mofidi said. "Many participants were dissatisfied with the attitudes and behaviors of dentists, describing them as impersonal and disrespectful.
"By listening and identifying the specific barriers and needs expressed by families, the health-care community and policy-makers can tailor strategies that help disadvantaged families."