Across Florida, thousands of children and adults go about their daily lives with missing teeth, untreated toothaches and worsening tooth decay.
For the working poor and the needy, it's a monumental challenge to get dental care. Medicaid, the government insurance program for the poor, covers very little in the way of dental services for adults: basically only extractions and one set of dentures per patient.
The program is more generous for children, but even so, Florida has the unhappy distinction of being rated the worst state in the nation when it comes to providing dental care to low-income kids.
A recent study by the Pew Center on the States found that only 23.5 percent of Medicaid-enrolled children, age 18 and under, received any sort of dental care in 2008, the most recent year for which federal data were available. (In Idaho, the top-ranked state, 61 percent of eligible children saw a dentist.)
In a separate 2010 study, the center gave Florida an "F" grade for failing to enact stronger policies to improve access to dental care for disadvantaged children.
The state has struggled with access to dental care for more than a decade.
In 2000, a federal General Accounting Office review of dental disease among low-income groups found that only 11 percent of Florida adults on Medicaid made a yearly trip to the dentist. The problem: Too few dentists will treat low-income patients because they say the Medicaid reimbursement rates, fixed by the state Legislature, are woefully inadequate.
For example, Medicaid pays dentists $34 to fill a cavity. A private dentist may charge $180.
The upshot: Dentists say often with Medicaid they can't even cover their expenses.
"Our state's Medicaid program . . . has some of the most awful reimbursement rates for dentists in the United States," said Frank Catalanotto, chairman of the Department of Community Dentistry at the University of Florida. "The result is that very few dentists in the state of Florida participate in the dental Medicaid program."
Three North Florida counties and Glades County have no Medicaid-enrolled dentists at all, according to the state Agency for Health Care Administration.
Urban counties fare better, but the need far outstrips available dentists — as can be seen whenever health departments or private dentists hold special clinics, often as children head back to schools.
Medicaid recipients report long waits for appointments, restricted hours and limited services. Of dentists who will accept Medicaid, some will see children only; others only see adults; still others are not accepting new patients.
In a federal courtroom in Miami, Florida's pediatric dentists are battling the state government to force an increase in the Medicaid reimbursement rate, arguing that Florida is violating federal law by not ensuring that poor children receive regular dental exams and treatment.
After five years, the class-action suit is still ongoing. To date, it has cost Florida taxpayers more than $5 million to defend against the suit, according to records from three state agencies. The case is expected to carry on into 2012.
Florida last raised the Medicaid rate for dentists in 1998. Despite pleadings from the dental profession, as well as the state's own health care administrators, the Legislature, even in better economic times, has rejected efforts to boost the fees.
This year, to save money, the Legislature is considering dramatic revisions to the state's Medicaid program, including a House-approved bill to steer patients into managed care plans. Those companies would be required to ensure that dentists are available to treat low-income children and could, if they chose, make more dental care available for adults, too. The Senate has a similar proposal, but the Florida Dental Association says it's too vague.
"These bills say you have to provide dental service, but they don't say what provision of dental services will be required," said oral surgeon Dr. Larry Nissen of Merritt Island, association president.
Some in the public health community are concerned that the HMOs might pay doctors and dentists a flat amount per patient enrolled, leaving little incentive to provide vigorous care.
Legislative leaders say they would require the managed care providers to monitor and report on the dental services they furnish or risk losing their Medicaid contracts.