Dental access is an American 'crisis': Here's how vulnerable people are shut out.

Jackie Duda spent nearly a year recovering after a life-threatening case of sepsis. Duda, of New Market, Maryland, was never denied medical care, even when bills from her extended hospital stay and doctors’ visits surpassed $250,000.

But the 61-year-old hasn’t had the same luck with dental bills. As a freelance health journalist, she learned there's no easy solution.

Her Medicaid insurance won't cover dental implants, which she needs to replace three teeth that decayed beyond repair due to sepsis and another chronic illness. Even with a discounted rate offered through the University of Maryland’s dental school, Duda doesn't have $6,000 for the required dental work – charges she hopes to put on a high-interest rate Care Credit account that will only add to her existing credit card debt. Her grown children have offered to help her and her husband, who is on disability and works part-time at Sam's Club, with these dental costs.

“Who has that kind of money just lying around?” said Duda. “At least hospitals will work with you on costs and even waive some of the payments, but all the dental providers I've ever encountered never do.”

There’s a great divide for Americans who need dental care, with some forced to live with pain and shame while others flash five-figure veneers. The government offers no backup plan for the tens of millions without dental insurance, and insured people often struggle to cover out-of-pocket costs if they have extensive dental needs. Since 2014, the Affordable Care Act has provided coverage to millions of Americans through subsidized medical insurance and expanded Medicaid, the federal and state health insurance program for low-income families. The federal law doesn't mandate adult dental insurance, which means millions of people are routinely denied necessary dental care.

But the problem runs deeper. Having dental insurance often does not amount to financial security if you have extensive needs. Many dental plans, including Duda's, require patients to shoulder pricy out-of-pocket care beyond routine cleanings and X-rays.

More: Why Bernie Sanders is targeting oral health: 'Dental care in America is in crisis.'

Duda discovered that with Care Credit, and other medical credit cards, she faces the risk of high interest rates if she can't pay the balance within six months. In a report released July 2 , the Consumer Financial Protection Bureau warned that medical credit cards generate a "significant number of consumer complaints regarding how dentists and other healthcare providers promoted, offered, and sold medical credit cards."

Duda will apply for the medical credit card before her scheduled procedure next month since there's no other way to pay for the dental care she needs.

"I'm trying to work and look like a professional," Duda said. "I can't be smiling and have holes in my mouth."

The ethics of serving everyone in need

The problem for patients begins at a philosophical level, namely, the degree to which providers consider patient care their professional duty.

In health care, the bar has always been lower for accessing care if you don't have insurance or funds.

Hospitals are legally required to assess and stabilize patients regardless of whether they can pay, but there are no such mandates for dental practices. Most dental clinics operate as independent businesses and they can – and often do – reject patients who can’t afford care.

Dentists say they need to recover operating costs, including the cost of hygienists, office workers and expensive equipment. Many providers also have hefty debt. Dental school graduates in 2023 owed an average student loan balance of $296,500, surpassing what doctors owed in student loans for medical school.

Dentists do offer discounted or free care to some patients. In 2018, the American Dental Association Health Policy Institute estimated dentists gave $800 million in discounts and $1.6 billion in free care. Another 6.1 million patients in 2022 received dental care from federally-funded community health centers, which provide medical and dental care to underserved populations.

But dentists say their charity has limits, given the nation's overwhelming, unmet oral health needs.

"We all went into business to help the communities we're serving, but there's a limit to that," said Brett H. Kessler, president-elect of the American Dental Association. "We can't give away everything for free."

There are routes to improving access, but the legislative proposals face an uphill battle with the election pending. The Biden administration has adopted a rule to let states opt into adult dental insurance coverage as part of their Affordable Care Act plans. Sen. Bernie Sanders, I-Vt., wants a more comprehensive plan : his bill would expand dental coverage through Medicare, Medicaid and the Veterans Administration and increase the number of dentists, dental hygienists and dental therapists nationwide.

Sanders told USA TODAY that U.S. dental care is "in crisis" with far too many Americans shut out of the system. Nearly 69 million U.S. adults did not have dental insurance or access to routine oral health care last year, according to the nonprofit CareQuest Institute for Oral Health.

"Most people know that our health care system is broken. It's outrageously expensive. Millions of people can't afford insurance," Sanders said. "But I think there is not that same consciousness with regard to dental care. The reality is that dental care in America is extremely expensive. Many dentists do not accept Medicaid reimbursement because it is too low or for other reasons."

Another problem in Sanders' view: "We don't have enough dentists in America and we especially don't have dentists in many underserved areas."

While there is no estimate yet on the cost of Sanders' bill, any plan that significantly expands health and dental benefits would be pricey at a time of ballooning federal budget deficits and will likely face opposition from fiscal conservatives.

Kessler, the incoming leader of the American Dental Association, acknowledges far too many Americans are shut out of dental care, but the reasons people can't access needed dental care are complex.

A major barrier, he said, is that dental insurance tends to limit coverage as costs rise. With medical insurance, once people reach their deductible, all necessary care at hospitals and with in-network doctors is largely covered. With dental insurance, the coverage tends to run out quickly. After a certain range or a few thousand dollars of service, the plans stop c.overing patients.

"That's the ridiculousness of the dental insurance model," Kessler said. "Why can't dentists offer the finest dentistry has to offer for our patients, yet medicine can? It makes no sense to me."

Carlos S. Smith, a professor and associate dean of inclusive excellence, ethics and community engagement at Virginia Commonwealth University School of Dentistry, challenged the profession to examine whether independent dentists can do more to improve access to care, in a 2022 column posted by the Academy of General Dentistry. Smith asks in the piece whether organized dentistry should be rooted in an "ethical decision-making model" or a model that supports "office profits?"

Smith recently told USA TODAY this foundational question remains essential. Too many patients are shut out of the system due to a lack of dental insurance. And patients with limited benefits through Medicaid, won't necessarily get the care they need, since many dentists don't accept those plans.

"One of the hallmarks of our profession is autonomy," Smith said. However, he thinks self-evaluation and self-analysis are essential for practitioners: "I believe it is incumbent upon the profession to ask of ourselves, how can we be better?"

'Pray to get something deadly' to get dental care

Harold Krieg is among the millions experiencing the fallout of the country's crisis in dental care. The Las Vegas resident no longer smiles. He can't remember a day when he wasn't in pain.

On good days, the discomfort from his untreated dental disease is tolerable. On bad days, he said, it “feels like somebody jabbing knives into my mouth.”

The 62-year-old former television crew worker feels “shame and ugliness” because years without care have left him with receding gums and a dozen remaining teeth. His dental disease is exacerbated by other medical conditions – esophagitis, severe acid reflux and Type 2 diabetes.

He can visit the doctor because he has Medicare and Medicaid insurance. But he does not have $35,000 to pay for the dental care he needs. That's the total he was quoted for extracting his remaining teeth and installing “All on 4” dental implants that would be screwed into his jaw.

Krieg’s doctor wrote a letter asking insurers to cover his dental care. The doctor explained stomach acid from his medical condition causes him to vomit frequently – and that has eroded his gums.

That effort went nowhere.

He also tried unsuccessfully to get the procedure at dental schools, hospital emergency rooms and through dental lotteries. A former production worker on a New York cable talk show, Krieg volunteered to tell his story on television talk shows, including on Dr. Phil and The Doctors, hoping he'd catch the attention of someone who could help. Those pitches went unanswered.

He reached out to dental companies and volunteered to be filmed for dental implant training videos. That also failed.

When he went to a periodontist in Las Vegas who advertised free consultations, he quickly learned that there was no charity care. Instead, he said, staff at the clinic chastised him “for being poor.” He left with “tears in my eyes and the sense that I don’t matter as a person.”

For more than six years, Krieg has lived with pain and discomfort. He can no longer eat foods he loves such as corn on the cob or crisp apples. Instead, his diet consists of soft foods like mashed potatoes and eggs.

He said he's landed on one final way he could get insurance coverage for necessary dental care. Medicare covers some dental procedures for cancer patients before they start chemotherapy.

He's contemplated that as a way out of the pain in the event he's ever diagnosed with cancer.

“You literally have to pray to get something deadly in order to get your teeth done,” Krieg said. “Unfortunately, I don’t have cancer and I am not on chemotherapy.”

Stuck with half a mouth of broken, infected teeth

Another firsthand witness to the dental crisis is Betty Lowe, of Jellico, Tennessee, who never had consistent access to oral health care. Her husband's employer does not offer dental insurance, and Lowe relies on that since she is raising the couple's children.

She was ecstatic last year when Tennessee expanded dental benefits to adults who qualify for TennCare, the state’s Medicaid program. She could finally address her long-neglected dental needs.

The mother of three waited months to land an appointment with a dentist who would take her new dental coverage. The dentist, Timothy Gansore, works in Jacksboro, about 30 miles south of Jellico, a small town near the Kentucky border. He told USA TODAY he is one of two dentists who accept Medicaid in the region.

During that appointment, Lowe learned the price of years without dental care: All her teeth were infected. Gansore drew up a care plan. The dentist would extract all her teeth and replace them with dentures to “get the beautiful smile I've always longed for,” Lowe recalled.

But after the dentist pulled her molars and other back teeth, she lost her Medicaid coverage when Tennessee resumed Medicaid eligibility checks halted during the COVID-19 emergency. She couldn't afford to pay Gansore to extract her remaining teeth or to finish the dentures. She now has a dozen teeth in the front of her mouth and all of them “are all broken and infected.”

At her dentist's suggestion, she applied for Care Credit but only qualified for $300 of care, far short of the $2,700 she needs to cover the remaining work. Dental office workers told her another option would be to apply for a bank loan, but that was impossible. Her husband earns $10 an hour, so there's no way they can qualify, let alone make loan payments. She can't get a job herself due to a recurring leg ulcer, for which she has unsuccessfully sought Social Security disability status.

"Not only do I feel terrible because I don't have the pretty smile, but I don't have any hopes of getting it either, because I don't have money," Lowe said.

Gansore told USA TODAY he is one of two dentists who accept Medicaid in a 25-mile region north of Knoxville including two rural counties near the Kentucky border.

He said he offers patients a discount of up to 10%, but he can't afford to lop off much more of their costs. He has to pay for staff, equipment, insurance and other expenses. Since Tennessee expanded adult dental benefits last year, his dental practice has been inundated with calls from low-income patients desperate for care. The problem, he said, is Medicaid pays far less than private insurance and customers who pay in cash. To keep his business afloat, he's had to maintain a healthy mix of insurers and payments and has limited the number of bookings for Medicaid patients.

"I cannot see all of them," Gansore said. "I take whatever I can – and the rest of them, I say, 'I cannot take any more new patients.'"

"It's unfortunate because the other providers probably would (accept Medicaid) if the reimbursements were attractive," he said. "It doesn't matter if the government offers programs like that if no doctor wants to take it."

Have you had trouble accessing dental care due to cost or lack of health insurance? Please share your story with consumer health reporter Ken Alltucker, alltuck@usatoday.com

This article originally appeared on USA TODAY: Dental access is an American 'crisis': Here's how vulnerable people are shut out.