Specialty dental care remains out of reach for many poor Illinois children
Medicaid patients needing oral surgery, other procedures face delays, lack of treatment options
One of the first dentists to examine the teeth of Maria McCarthy, center, found 23 cavities, said Ana McCarthy, who adopted Maria and her sisters, Veronica, left, and Sofia. (Chris Sweda, Chicago Tribune)
Confident and poised, the Skokie girl smiles easily. But five years ago, when she arrived as a foster child at the home of Michael and Ana McCarthy, her baby teeth were practically rotting out of her mouth.
As one of roughly 1.6 million children in Illinois covered by Medicaid, Maria waited for months, teeth aching, to undergo surgery. She might have waited longer had a pediatric dentist in Buffalo Grove not agreed to waive thousands of dollars in fees to treat her.
"Her teeth were black, and she hardly ever smiled or spoke. She was in pain," said Ana McCarthy, who has since become the adoptive mother to Maria and her two sisters, Sofia and Veronica. "We couldn't find a dentist willing to treat the children. What we were told is, 'You need a surgeon.'"
Many Illinois children who are covered by government-sponsored insurance programs often go without much-needed specialty dental treatment or wait for extended periods because of an ailing Medicaid system.
The biggest issues, advocates say, are Medicaid reimbursement rates in Illinois that are among the lowest in the country for specialized care and administrative hassles that go along with treating low-income patients. Dentists say they can't make ends meet.
"Nobody wants to make a profit on (Medicaid patients), but they have to allow us to pay the bills," said Indru Punwani, head of the pediatric dentistry department at the University of Illinois Medical Center in Chicago, the largest provider to Medicaid-covered children in the state.
Barriers to specialty dental care for low-income children remain a problem almost seven years after a federal judge ruled that the state had violated the rights of several hundred thousand poor children in Cook County.
The class-action lawsuit, filed in 1992, argued that Illinois had violated federal law mandating that children covered by Medicaid have equal access to medical and dental services as those children covered by private insurance.
Forced to take action, the state settled the lawsuit and agreed to increase Medicaid payments for various preventive care procedures, including the amount it pays dentists for cleanings, which went from $25.40 to $41, and the rate for sealants, which jumped from $14.10 to $36.
The changes made a difference: The number of Medicaid-enrolled dentists increased from 1,845 in 2006, the year the increased rates went into effect, to 2,625 in 2011, according to the Illinois Department of Healthcare and Family Services, which administers the Medicaid program. That's out of roughly 8,500 practicing dentists in Illinois.
But specialty care, including more expensive and complicated procedures like the oral surgery Maria needed, remain out of reach for some children covered by Medicaid.
Punwani, who also is executive director of the Illinois Society of Pediatric Dentists, said the fact that almost half of children in the U.S. starting kindergarten suffer from tooth decay is proof that the state has not gone far enough.
According to the Illinois State Dental Society, the average funding rate for the five most frequently performed specialty dental procedures covers 16 percent of the dentist's costs.
Illinois is among the lowest-ranking states for procedures categorized as specialty care, including a one-surface resin — a type of filling — and an anterior root canal, for teeth located in the front of the mouth.
The health department does not track how long children who need specialty care have to wait to see a dentist. However, by law, dentists who receive Medicaid payments are required to see patients who are suffering from pain, infection, swelling or traumatic injury within 24 hours.
But because demand greatly exceeds supply, Medicaid patients in Cook County wait an average of three months for a follow-up visit and three weeks for emergency care, according to Bridge to Healthy Smiles. The advocacy organization has been lobbying the Legislature to increase reimbursement rates.
For young children with complex dental problems, options are more limited.
Out of about 240 licensed pediatric dentists in the state, only 83 are enrolled in Medicaid, according to figures from the Department of Healthcare and Family Services and the Illinois State Dental Society.