Marcia Esters lives in a Hazelwood high-rise. As the result of a spinal congenital disorder that was compounded by a workplace accident, she gets around in a motorized wheelchair.
Last fall, she went to her dentist. He told her she needed crowns fused to six of her bottom teeth and her top dentures were wearing out, and because of changes made to Medicaid in the last fiscal budget, the care she needed wouldn't be covered. She would have to pay out of pocket.
"It's thousands of dollars worth of work that I cannot afford. I have one income and my family is poor," she said.
Medicaid takes care of the poor and disabled but it varies by state. Most states don't cover any dental care under the plan. Now, in Pennsylvania for adult Medicaid patients, Marcia Esters' scenario is the norm. In September, the Corbett administration reduced coverage for Pennsylvania's two million adult Medicaid patients to only having basic dental care, eliminating root canals, periodontal disease work and limiting the numbers of dentures a patient can receive. The plan now only covers cleanings, fillings and extractions.
Budgets and Health Clash
The move aimed at saving money in these difficult economic times has providers frustrated.
Adam Mychak, a dentist at Munhall Dental, a private clinic that primarily sees Medicaid patients — about 2,000 a year — is really upset about this.
"As providers, it hamstrings us. It limits us. The only thing we can do for someone who comes in is put a filling on that tooth when it has decay and when that tooth starts to hurt, because eventually that filling gets bigger and bigger over time, the only thing we can do then is take the tooth out," he said.
The state allows dentists to petition for additional funds. The criteria for a person to get the treatment a dentist is recommending is to prove that it will severely worsen an illnesses like diabetes or heart disease or that it will lead to death.
"The petition process is awful, flat-out awful," said Mychak.
In most cases, the letter must also come from a primary care provider, not a dentist.
Not Going the Extra Mile
From October 2011 through May 2012, the state received 7,699 Benefit Limit exception requests. Only 853 were approved. Marcia Ester's was one of those denied. She has spent the last few months with worsening teeth, eating puréed food and isolating herself. She's skipped weekly activities like bingo and big events like a family reunion.
"I don't go anywhere unless I have to and I feel like I'm worse. I mean, people look at you when you're in a wheelchair or, you know, have to have the kind of assistance I have anyway. But I have. If you could look or feel halfway decent, it just helps, it really does," she said.
Surveys have shown that people with disabilities, with both private and public insurance, have a harder time seeing a dentist than any other demographic.
For Marcia Esters, being a Medicaid patient with a physical disability, it already was difficult for her to access dental care. When she first became disabled in her thirties, she spent years adapting to her new life. Oral health wasn't at the top of her priority list. It was sixteen years before she sought dental care, and that was only because a tooth started hurting. Even after she decided to get help it took her a while to find a dentist who would see her.
Most dentists don't take patients on Medicaid. For those that do, Medicaid's reimbursement rate is much lower than if a person is paying for care with private insurance. The commonwealth's medical assistance reimbursement rates were only 53% of dentist's median fees, lower than the national average at 60.5%.
There are other issues as well. A dentists' office may not be able to accommodate someone in a wheelchair. Patients with behavioral issues may require sedation for basic care that only an anesthesiologist can provide. They may require dimmed lights or music.
Teeth Aren't Just Teeth
Oral health is integral to overall health.
"There's lots and lots of research that shows that when you have a problem in your mouth it dramatically affects your systemic overall physical health. It's well documented and has been for years," said Lynn Taiclet, who runs the Center for Patients with Special Needs at the University of Pittsburgh's Dental School. "The mouth is full of bacteria and that's what causes decay and gum decay and we know now that it spreads systemically and people have died from bad teeth."
For many practicing dentists, they weren't taught to work with this population because it wasn't really necessary.
With the move to deinstitutionalization and the closure of massive facilities such as Mayview and Western State School there is more of a need for dentists that can provide this care. At Pitt's Center, they treat nearly two thousand patients a year and train their students to work with those who have physical, mental and behavioral challenges.
The new provision doesn't affect those who are in institutions.
Anne Bale, spokesperson for the Pennsylvania Department of Public Welfare, said the department estimates it will have saved $42 million this year due to the reduction. "What we were doing is, while we know we have to limit it somehow and someway we can't keep up with the spending that is going on. So we have to limit the number of procedures people have so we can insure the program for the future," she said.
In this coming fiscal year, the department is looking at reducing the budget again.
For Marcia Esters, all she can do is wait to see if money comes through from a non-profit in the near future, or have her remaining bottom teeth removed. She is already struggling with digestive issues and depression. Interestingly, the treatment for those ailments is covered under her benefits.
"To me it makes no sense to spend money to take care of these conditions that having these bad teeth produce. I mean, I imagine the program was cut to save money," she said.
In the coming years, under the Affordable Care Act, Medicaid will grow to cover an additional 800,000 people in Pennsylvania.
This story was produced in collaboration with NPR and Kaiser Health News.