Barriers and Bridges to Children’s Oral Health in the City of Flint
Oral or dental health, primarily the health of teeth and gums, mirrors the health of the body and is critical to social and economic functioning at all stages of life. Yet, oral health is neglected in national health care discussions, and oral disease is a virtual “silent epidemic” (in the words of a U.S. Surgeon General’s Report) that creates disproportionate burdens for low-income populations of all ages and for ethnic minority groups. The everyday life conditions in which low-income adults and children live make it difficult both to maintain oral health and access formally available treatment services. Those unable to pay commercial rates for dental insurance or treatment generally rely upon residual public insurance or remain uninsured and less likely to receive care.
Decreasing preventable and treatable childhood oral disease, which creates pain, erects barriers to normal, healthy social development, and predicts bad teeth and gums in adulthood, is a priority for public health dentists and policymakers. After the death from an untreated tooth infection of Deamonte Driver, a 12-year old African American child whose low-income mother had struggled to secure dental care for her sons, oral health advocates redoubled their efforts. Many public health dentists have tried to address the problem of children’s poor oral health through various means, improving public dental insurance through increased child Medicaid reimbursement rates, through more intensive case management in child Medicaid projects, through developing school-based preventive programs and other partnerships, and through more culturally diverse and sensitive workforces and outreach projects. Yet the oral health of low-income and ethnic minority children remains a stubborn and worrying problem.
What does this issue of low-income children’s oral health look like in the City of Flint? Mary Robinson, an undergraduate student, and I have spent a couple of years learning about this problem primarily by talking with low-income parents, grandparents and guardians about their understanding of oral health, whether and how they had financial means to access dentists, and what their experiences of treatment have been, as well as studying child Medicaid programs, public clinics, and dental providers. This was a small-scale quasi-ethnographic project, focused upon 15 caregivers, all African-American or non-Hispanic Caucasians, with children 5-14 and households below 200% of the poverty threshold.
The City of Flint is located in Genesee County, one of 65 counties in the state of Michigan that participates in Healthy Kids Dental (HKD), an enhanced child dental Medicaid program implemented in the County in July 2008. This program is operated by the State’s Medical Services Administration and Delta Dental. Medicaid-eligible children are automatically enrolled through a series of processes in Healthy Kids Dental. Healthy Kids Dental pays participating dentists at the same reimbursement level they receive in Delta’s commercial plan and handles all administrative transactions, a huge relief to dentists who find traditional Medicaid extremely burdensome and unacceptably inadequate. Children on HKD can receive care from any participating Delta Dental dentist with no patient co-pay. Researchers report that the percentage of children on Medicaid “with at least one dental visit” in the year had risen to 56% (31,472 children of the 57,000 eligible children) in 2010, from 37% in 2005 (only 19,000 of 50,000). In addition to having what is in many ways a model enhanced child Medicaid insurance program, the City of Flint hosts a very large Foundation-supported public dental clinic which sees 8,000 low-income insured and uninsured children per year. Three sites of the largest Federally Qualified Health Clinic (FQHC), a special federally supported community clinic, host dental services for children and adults. In general, there is no identified shortage of dentists in the County, and a number are specially trained pediatric dentists.
However, County-wide over 25,000 Medicaid-insured children are still not seeing a dentist during the year, and dentists continue to report “devastated teeth” at first or intermittent visits. What might account for the continuing problem of child oral health, in a setting in which there would appear to be access to dental offices, with their teams of dentists and hygienists, which provide both preventive and restorative treatment and also oral health education?
Like many mothers, Tammy doesn’t want her children to suffer the dental pain and embarrassment to which she has been subject. She says she has heard that her boys, now 13 and 14, may be doomed to inherit her bad teeth, but that she would like to prolong their enjoyment of good dental health as long as possible. At the same time, she does not take them regularly to a dentist, and one son has been complaining of mouth pain. When her older son was 6 or 7 and needed fillings, she took him to a nearby “Medicaid dentist”. The needle used for oral numbing terrified him, reducing him to tears and howls of despair. The dentist at the “Medicaid dentist” told him to “shut up and stop acting like a baby.” The child’s distress only increased, and eventually another dentist in the practice came in and did the job. Both children were afraid to go back to this dentist. Tammy opted to protect their emotional security by not returning, believing she could not access other dentists with Medicaid. She was unaware of Genesee County’s HKD program that increased reimbursement to dentists treating children on Medicaid and that many dentists, including specially trained pediatric dentists, were participating. Despite the fact that she is on Food Stamps and Medicaid, she says no caseworker has ever talked with her about dental insurance, wanting only to know her income and expenses and sending letters about cut-offs or restorations of benefits. She says she has never received information about the expanded Medicaid child dental program in the mail. In addition, with no car, she said transportation to any other dental office would be a problem. Tammy has recently been dealing with the homelessness of an 18-year-old daughter with an infant and toddler, also without knowledge of Healthy Kid Dental options. She has been unable to maintain her family in a small house she owns in a neighborhood plagued by gunshots and arsons due to unpaid utility bills, which she has unable to pay regularly due to other expenses and her low income at a night-shift minimum wage job. She says, “I’m mainly worried about the kids, how they’re doing in school, whether they have enough to eat, whether we have a place to live,” she says, noting that dental visits are now a low priority.
First, not a single caregiver among the 15 we interviewed understood the Healthy Kids Dental program and how it increased their options compared to traditional Medicaid. They understood that their children’s dental visits were covered by “Medicaid,” but they thought it was the same old Medicaid, which many providers would refuse to accept. In many cases, lack of understanding of this complex policy was not a problem, as parents continued to take children to public clinics (the standard recommendation of Department of Human Services workers who also did not understand the program) or find private dental offices that accepted HKD patients. But when public clinics terminated child patients because of missed appointments or when parents recoiled from taking children back to a “Medicaid dentist” who had frightened and hurt a child in the past, parents did not know what to do, other than to use a phonebook or word of mouth (there is an online HKD directory and a phone number) and hope that eventually they might find a dentist who took “Medicaid.”
Majora, a 50-year-old with two school-aged children in the home, a husband, and several adult children living independently, is the full-time primary caregiver to her 60-year-old uncle who is in and out of the hospital, with diabetes and many complications, including a partial leg amputation, and dementia. She has been taking care of him for about 20 years, since her parents with whom he lived died. Lately he has been climbing out of bed at night, necessitating that she or her husband watch him continuously through the night, but the doctors finally agreed not only that he needed bed rails but also sleep medication. Majora cannot get adult services for him without drawing upon scarce household resources, already stretched to cover basic bills. Majora herself has diabetes, heart trouble, and sleep apnea and neglects her own dental health. Her son is struggling in school and now receiving special education services, and both children are considerably overweight. She reimburses neighbors who provide rides to and from the hospital for her very ill uncle, and she and the children are greatly alarmed by the shooting in the neighborhood, not daring to wait at public bus stops. Despite this, her children have been fairly regularly to the dentist, first at Mott Children’s Health Center pediatric dentistry and then at a private office, missing appointments because of transportation difficulties or when Majora has been completely overwhelmed by her responsibilities for her uncle.
Secondly, and not surprisingly, parents struggled with the usual stresses of poverty: financial stress and difficulty paying bills, food insecurity, poor housing and dangerous neighborhoods, unreliable transportation, children with special needs or problematic school performance, and their own physical and mental health issues. Some low-income parents, who are on disability and unemployed, are able to schedule their daily routines around their children and consistently ensure routine dental visits. Some low-income caregivers with work and educational obligations rely upon adult partners or older relatives, generally parents, to assist. Other parents struggle to combine work schedules, extended family responsibilities, and episodes of crisis around health or housing with maintaining their children’s oral health, a relatively low priority except in cases of pain.
Latesha is on the verge of surgery to remove a mass in her uterus, but also has fibroids, a possible thyroid problem, diabetes, and high blood pressure. She has been trying to get effective treatment for the abdominal problem for many months, and her chronic illnesses have not been effectively managed for many years. Despite her serious and painful physical problems, she has been working until recently 8 hours a week at $7.50 an hour for the Community Health Department, cooking and doing laundry for an elderly man who lives nearby, and when she has been too sick or in the hospital, she has called upon relatives to look after him. She also cooks and cleans from 3 pm to 9 pm on weekdays at a privately operated halfway house near her home for women recovering from addiction. Her 10-year-old son Brandon receives $698 a month in SSI because he suffers from chronic lung disease related to premature birth at 26 weeks, a 1lb., 5 oz. baby, a premature birth apparently related to his mother’s poorly controlled high blood pressure and other health problems. He also has speech issues, behavioral problems, and a learning disability. The other two children, 14 and 12, are doing “okay,” according to Latesha. No one in the family including the children receives regular dental care, and Latesha was unaware of any accessible options for dental treatment for the children or herself. The household has no car or other means of transportation.
On the whole, we found that the most severe barriers to children’s oral health appeared to be the stresses of everyday life in impoverished neighborhoods, which make routine oral health visits a low priority but also make timely access very difficult, especially in view of lack of understanding of expanded Medicaid insurance for children. The greatest bridges to good oral health and dental treatment were caregivers’ strong motivations to care for their children’s teeth and avoid some of the oral health problems the parents themselves experienced; the presence of Mott Children’s Health Center, a visible community treatment institution highly trusted by generations of low-income Flint residents; and some school programs that welcomed parents to dental education sessions with their children.
Dr. Kahn was assisted in her research of local dental health by UM-Flint undergraduate students. Whereas many larger universities reserve this level of research work for graduate students, UM-Flint prides itself on offering these kinds of immersive, collaborative, and illuminating research opportunities to students early their collegiate careers.
In recent years, the Office of Research and Sponsored Programs has expanded the ways in which student researchers can share and showcase their findings with peers and experts in various fields.