Catherine Outlaw misses steak. It’s the hardest part about not having bottom teeth, says the 58-year-old Westside Santa Cruz resident.
She lost most of them during a visit to a San Jose dentist in the 1990s. Outlaw says she went under anesthesia expecting to have one tooth pulled, and woke to discover that half of her bottom teeth were gone. When she demanded an explanation, the dentist slipped out the back door, she says.
At the time, Outlaw had Denti-Cal insurance, which is provided free for low-income Medi-Cal subscribers. She suspects her dentist was fraudulent, milking the system for reimbursements by performing unnecessary treatments.
For years, Outlaw just got by with less teeth, since Denti-Cal didn’t cover partial dentures, and she couldn’t afford to pay out of pocket.
“I cut my food up real fine,” Outlaw says. “That’s all I could do.”
Her dental hygiene took a backseat to other issues. She broke her back four years ago, and has been on disability ever since. Before that, she worked as a home health aide, caring for elderly people.
She’s largely avoided dental screenings, besides attending a few free dental pop-up clinics in a San Jose parking lot. A few years ago, she paid out-of-pocket for a one-time $99 exam special at a Santa Cruz office.
“My brother gave me a lottery ticket and I won $200 bucks and I took $100 of it and I went and I had them check my teeth,” Outlaw says.
But three years ago, she began visiting Dientes Community Dental Care, a Santa Cruz-based nonprofit clinic, where she receives free service due to the sliding scale, she says. She began the process of having her teeth pulled and getting dentures, which has taken more than a dozen visits so far.
She still doesn’t have her bottom set of dentures.
“I’ve been going there for a while, and they really help, but then, you know, it just takes this long, drag-out thing,” says Outlaw.
She says the staff at Dientes is courteous and respectful.
“They’re good. They’ll take care of you, but you have to be patient. It’s going to take a while, but you know, that’s the way it is when you don’t have real insurance,” Outlaw says.
BROKEN SYSTEM
Pediatric dentist Marc Grossman, who practices at Freedom’s Pajaro Valley Children’s Dental Group, says his office stopped taking Denti-Cal two years ago, because it cost the clinic too much time and money.
Private offices like Grossman’s are reimbursed by Denti-Cal for only 30 percent of their fees. That barely covers half the cost for materials and labor, he says, and dental offices end up eating most of the costs.
“So, do the math,” says Grossman. “You can’t keep losing money and survive. You have staff and everybody to pay.”
Around 13 million of the state’s 39 million residents rely on Denti-Cal, and fewer than half use their benefits, due to the shortage of dentists who will see them.
In Santa Cruz County, 80,000 residents have Denti-Cal, yet only 25,000 visited the dentist in the last year, according to a 2014 report. Perhaps even more shocking, only 31 percent of children in the county aged 11 or younger, regardless of income, have ever seen a dentist.
Last year, a coalition filed a civil rights complaint with the U.S. Department of Health and Human Services, alleging that Medi-Cal/Denti-Cal is a separate and unequal health-care system that “effectively deny the full benefits” to more than 7 million Latinos. More than two-thirds of Medi-Cal enrollees are Latino, and lawyers contend that Medi-Cal reimbursement rates have fallen as the proportion of Latinos with Medi-Cal has risen.
Only six dentists in Santa Cruz County take new Denti-Cal patients—four in Watsonville, and one each in Santa Cruz and Freedom.
That’s not enough to meet the need, says Grossman, who co-founded Dientes Community Dental Care in 1992.
Denti-Cal subscriptions in Santa Cruz County have ballooned in recent years. The Affordable Care Act has added an estimated 21,000 Santa Cruz County residents to Denti-Cal. And in 2013, when the state began cutting the insurance programs Healthy Families and Healthy Kids, around 5,300 low-income Santa Cruz County residents transitioned to Denti-Cal.
Part of the problem with Denti-Cal, says Grossman, is that it assumes dentists are fraudulent. For example, Denti-Cal requires dentists to take X-rays showing that the treatment is necessary, then later take more X-rays showing the treatment is complete.
That’s not only inefficient, but also unethical, since it exposes patients to unnecessary radiation, Grossman says. It creates an enormous bureaucratic backlog, resulting in only a tiny portion of the budget going to care, and most going to administration.
“We never get to see the workings of it,” says Grossman. “We just get to play the game, basically. You wouldn’t believe the number of things that are denied [by Denti-Cal] once they’re done.”
Another option for people with Denti-Cal is Western Dental, a corporation with offices across the country, including in Santa Cruz and Watsonville. Mark Ebrahimian, a dentist at Santa Cruz’s Harbor Dental who is part of a team advocating for local dental health reform, says he’s never been to a Western Dental office, but he’s spoken to many of its former patients. He once worked for a similar dental corporation, and says it’s a different world from the private dental offices that most people know.
For starters, these corporate clinics usually have 10 or more chairs in a single, large room with one or two dentists treating dozens of patients a day.
“It’s an assembly line, and it’s all an attempt to control costs,” says Ebrahimian—that’s how Western Dental can afford to take Denti-Cal, he says.
Dentistry is trending toward corporations, away from the small, individual business owners, since the technology and materials are so costly, he says. That trend hasn’t yet hit Santa Cruz County, since the area doesn’t have enough people to attract more corporations, he says.
“Until there’s this dramatic shift where there are more group practices that can pool their resources, it’s unfortunately going to be really hard for people who are economically stressed to be able to get dental care,” Ebrahimian says.
LOCAL PLAN
Ebrahimian is one of 17 community leaders who form the Oral Health Access Steering Committee put together by Dientes Community Dental Care in June. Members include Supervisor Zach Friend; David Brody, executive director of First 5 Santa Cruz County; and Michael Watkins, Santa Cruz County superintendent of schools.
The committee formed after Dientes commissioned a county dental health needs assessment in 2014, and Dientes staff realized the problem was bigger than they alone could solve, says Sepi Walthard, Dientes dental director.
The committee whittled their priorities to a list of three, which they presented at an oral health summit at Seascape Golf Club on Dec. 5. First, they plan to launch an education campaign informing parents that babies should see a dentist by their first birthday or their first tooth.
“We have kids coming to us at 4 or 5 for the first time, and by then, it’s really late,” says Walthard. “They have a lot of cavities. They need to be sedated, and it becomes complicated. So it’s a lot easier and a lot more cost-effective to focus on them when they’re little.”
Second, the committee wants to make dental screenings mandatory in kindergarten or first grade. That used to be required, but when the state lost funding a few years ago, it became optional. In Santa Cruz County, some schools have continued requiring screenings, but others have stopped.
Third, the committee plans to increase access to dental care and serve an additional 8,000 county residents by 2020. Plans include building a new 10-chair clinic at Santa Cruz’s East Cliff Family Health Center, training medical providers to apply fluoride and conduct oral screenings at pediatric check-ups, and recruiting more dental providers, especially pediatric dentists.
Walthard says she’s glad the steering committee is finally bringing the dental health crisis to light. If you have bad teeth, cavities and pain, it’s hard to function, and too many local residents lack access to care, she says.
“Sometimes we feel like the redheaded stepchild of issues,” Walthard says. “It’s not easy. Nobody wants to hear it. Nobody wants to think about it. Even in movies and TV shows, it’s always portrayed in a negative light. It’s just something that nobody wants to talk about.”
Santa Cruz Gives
Dientes Community Dental Care is one of the nonprofits GT and its partners is asking readers to support during this year’s Santa Cruz Gives holiday giving campaign. For more information and to contribute, go to santacruzgives.org through Dec. 31.
