For many low-income, Medicaid-supported, or uninsured residents in Chicago, finding a dentist is akin to finding a Black leprechaun, with a golden lottery ticket in its pocket.
Data from the American Dental Association’s (ADA) Health Policy Institute shows there are 8,674 dentists registered in Illinois, more than 2,000 of them with practices in Chicago–few of which accept public insurance. More than 79 percent of all U.S. dentists identify as white; 11.4 percent are Asians; 4.2 percent are Hispanic; and only 3.4 percent are identified as African American.
Though oral health has improved nationwide, access to dental care remains elusive for large segments of the U.S. population, many of whom are low-income or Black. Systemic racism, poverty, unemployment, low-wage employment, and a lack of private or public dental insurance are key reasons for this disparity.
The Center for Disease Control (CDC) states people are less likely to have optimal oral health when they “live in communities where they don’t have access to fluoridated water and school sealant programs, healthy foods, and public transportation to get to dental appointments.”
In a wide-ranging interview with the Chicago Crusader, Dr. Edmond Hewlett, a professor and associate dean for Equity Diversity and Inclusion at the UCLA School of Dentistry, echoed these stats.
“There has been a lot of talk about generational wealth and the ability of some populations, especially people of color, who for years, were denied the opportunity to build generational wealth through restrictive covenants and the denial of other opportunities, such as buying property and getting the jobs to build generational wealth,” Dr. Hewlett explained.
He goes on to say, “… (the lack of) generational health is very similar to that. People who don’t have the money to go regularly to the doctor aren’t like those of us who are privileged and have access to health maintenance, prevention, and other privileges. We take good access to health care for granted. However, there are people who are low-income, who live in low-income communities and who grow up in a culture where they only go to the doctor as a last resort when nothing else is going to work.”
Dr. Hewlett continued, “The idea of regular preventive care is just not part of their reality–and even if it is desired—then it’s a matter not only of affordability, but just other basic challenges that they face. It’s as simple as a matter of transportation of getting from wherever they are to a clinic that is going to be able to care for them—care for them when they can’t pay. It is also very hard for them to find providers who accept Medicaid or other government-sponsored dental programs.”
The professor acknowledged the reason few dentists accept programs, such as Medicaid, is because of the low reimbursement rates.
“For many dentists, this is one more discouragement of opening their practices (in low-income areas) and accepting these types of government benefits,” Dr. Hewlett explained. “With student loans, the cost of going to dental school, it’s very hard to open a practice that caters solely to these patients.”
U.S. News and World Report identified that dentists earned on average about $158,940 in 2020. Over the course of about four years, dental graduates begin their careers with between $151,000 to $291,000 in student loan debt (on average). The annual dental license fee in Illinois is about $250. The 2020 pandemic, which ended officially this year, shuttered the practices of many dental clinics and caused further stress to the oral health system.
“The COVID-19 pandemic has shown us what it feels like to be isolated and lonely,” said Stacey Van Scoyoc, president of the Illinois State Dental Society, in her June/July column in Illinois Dental News. “When we closed our offices, our sense of identity as dental health care providers was sidelined.”
As clinics re-open, uninsured patients or those with government-assisted plans are being frustrated by a lack of options. “It took me a long time to get this appointment and look at how many people are here,” said a young mother, waiting in a full lobby of Destiny Dental in South Shore. She declined to use her name, but added, “I’m paying out-of-pocket because (my son) needs this for school. Trust me, I wouldn’t be up in here. My job don’t have dental insurance.”
In a non-scientific experiment, the Chicago Crusader randomly contacted 10 dental offices with addresses in Woodlawn, Englewood, Chatham, and South Shore, and only one indicated it accepted Medicaid. A few practices featured an anti-Medicaid recorded phone message: “We do not accept…” in their automated, cheerful greeting. The one clinic that accepted public health dental insurance noted the waitlist for appointments was long and recommended a sister clinic in Lawndale for emergency cases.
Though the Illinois health care system provides some dental coverage to low-income people, Medicaid programs are not required to provide dental benefits to adult enrollees, so dental coverage varies widely from state to state.
Yet, some practitioners are quick to note that African American dentists are more likely to accept Medicaid than non-Black dentists, but those practices are usually full and cannot keep up with the demand or need for services.
Dr. Hewlett has practiced dentistry for 42 years. For 35 years, he has served as a full-time member of UCLA’s faculty. Still, he continues to see patients through the UCLA faculty practice or while supervising dental students in the UCLA dental clinic.
“…Low-income communities tend to, by and large, have a lower density of dentists who will accept their health benefits there–to the extent that they have any,” Dr. Hewlett shared. “I think it’s also important to point out that we know that individuals who have managed to have the opportunity to go to dental school, who come from these underserved communities and become dentists are more likely to go back and serve the types of communities that they come from. But, they face challenges as well.
“They face the remuneration challenges,” he said. “You know, the lower remuneration, the lower fees that these government benefits provide. But, they still make the commitment to serve, and there are federally funded (dental) clinics (and schools) that also serve these populations.”
In July, Aspen Dental hosted a ribbon-cutting ceremony for its new Oral Care Center for Excellence, 1040 W. Randolph, and billed it as a “clinic that will provide free dental care for an estimated 2,500 underserved Illinois residents who are at or below 200 percent of the federal poverty level,” according to a news advisory sent to reporters.
Aspen Dental noted adults who make about $25,000 annually are half as likely to visit a dentist. Executives said 40 percent of adults in Illinois reported not visiting a dentist or dental clinic within the past year, while also noting that 63 percent of Chicago residents do not have dental insurance.
Like their medical counterparts, dentists are finding it challenging in a climate advancing “value-based care” versus fee for services model, which leads to inequity in care.
To close the gap, Dr. Hewlett and others recommend expanding the roles of hygienists and dental therapists to reduce the burden on dentists, encouraging dentists to use “mobile clinics” to bring oral health care into underserved neighborhoods and offer at least some appointments—particularly for consultations or basic diagnoses—through web-enabled devices for people who cannot immediately visit a dentist’s office.
“We need more advocacy in public health. There should also be incentives in the form of loan forgiveness,” Dr. Hewlett told the Chicago Crusader. “There should be a hiring incentive for those coming out of school who choose to work in these underserved areas in order to make it more feasible for people to practice in these communities.”
This report is supported in part by the Inland Press Foundation.