America's dental-care gap is wide. How some states are trying to close it.

It’s only 10 miles as the crow flies to Boston from this coastal city. For Dorothy Macaione, a 97-year-old with false teeth that no longer fit, it felt like a bridge too far.

But like many without insurance who can’t afford private dentists, she faced few good options. Which is how she found herself taking a public shared-ride service in May, headed back to a dental school in Boston for the next stage of discounted dental work.

Her first trip to Boston for a consultation had been long and exhausting, and this day would turn out to be even more so. 

In the national debate over health-care, dental insurance is often overlooked. But its inequities run deep: One-third of Americans have no dental coverage. For the poor, Medicaid mandates dental coverage only for children, and it can be hard to find a dentist willing to accept lower rates. Families on a budget often forgo check-ups and wait for free clinics; some end up seeking urgent care in hospital emergency rooms. Teeth are often a class marker, a way to pick out society’s winners from its losers.

Enter the dental therapists.

In Minnesota and other states, dental hygienists are being trained to pull teeth, fill cavities, and do other basic dental care, all at a lower price than standard dentists’ billings. They are licensed as dental therapists, a mid-level position similar to that of nurse practitioner. A key benefit, say proponents, is that dental therapists can fan out into communities, visiting schools, health clinics, and nursing homes, targeting people who find it hard to get to a dentist’s office. Telehealth systems allow them to share records and consult with dentists on complex cases.  

“We have hygienists who are active, well-trained, and well equipped to help these people. They can serve as caregivers for people who have no caregivers for oral health,” says Harriette Chandler, a state senator in Massachusetts who has sponsored legislation to license therapists.

A model from Minnesota

Maine and Vermont have passed similar laws. Several other states are also mulling legislation, says Kristen Mizzi Angelone, a dental policy expert at Pew Charitable Trusts, which has supported the legalization of therapists. Many are encouraged by what’s already happened in Minnesota, where therapists are helping to expand coverage, particularly in rural areas and poor inner-city communities, at a time when finding new money for public health spending is scarce.

“No matter what Congress does [on health-care] it’s clear that every state around the country is in a budget constraint, and there are millions of people who aren’t getting dental care,” says Ms. Mizzi Angelone.

In 2011, Minnesota created two categories of therapists. Advanced therapists, who have a wider scope of practice, make $40 to $45 per hour, compared with $50 to $78 for dentists, according to a Pew study. By lowering their costs, say advocates for therapist licensing, dental practices can expand to treat uninsured patients who might otherwise depend on charities. It also becomes more viable to accept Medicaid recipients with lower reimbursements than the privately insured, and to offer care on a sliding scale to those without coverage.

Last year, Senator Chandler sponsored a budget rider to authorize dental therapists in Massachusetts that passed the Senate unanimously but was dropped from the final budget amid strong opposition by dentists. The American Dental Association has argued that creating a new class of provider is risky, since procedures can be irreversible, and instead urged states to increase Medicaid spending.

Earlier this year, Chandler filed another therapist bill in the Senate; the same bill was filed by a House representative. Both are waiting for joint committee hearings.

A rival bill backed by the Massachusetts Dental Society would allow therapists to perform basic dental work, subject to strict rules on supervision and where they can work. Katherine Pelullo, a dental hygienist who represents the profession in the legislature, says that bill is overly restrictive and would limit the expansion of therapists, unlike Chandler’s bill.

Chandler says she would be happy to see either bill pass if it succeeds in expanding access in Massachusetts at a time when Washington appears poised to cut federal healthcare spending. “We have some people who are getting care for their oral health needs and other who aren’t, and may be scarred by that for the rest of the lives,” she says.

President Obama's Affordable Care Act (ACA) mandated dental benefits for children on Medicaid and the Children’s Health Insurance Program. In theory, that means all children in low-income families receive regular screenings, though experts point out that working parents often struggle to find appointments, given dentists’ hours and their reluctance to take Medicaid patients.  

For adults, states determine their own level of Medicaid coverage; Massachusetts is among 15 states that provide comprehensive care, though it was cut during the "great recession." Overall, 5.4 million adults have received dental benefits under the ACA’s Medicaid expansion, according to the American Dental Association. The House bill that passed in May would roll back that Medicaid expansion, reduce future Medicaid funding, and would also allow states to apply for waivers from federally mandated areas of coverage, such as dental.

'To talk without messing up'

Macaione, who goes by Dot, isn’t eligible for Medicaid or MassHealth, as the program is known here. As a senior, she is enrolled in Medicare, but it excludes dental care. She doesn’t remember how many years she’s had her current set of teeth, nor when she last saw a dentist before her recent trips to Boston.

What she does know is how she's impeded by pain. “I want to be able to talk without messing up. I want to continue with my way of life,” she says.

That way of life includes volunteering in community organizations and running a small library in the senior housing where she lives in Lynn. It was from her neighbor, Irving Rouse, that she learned about Tufts University School of Dental Medicine in Boston, where trainee dentists see uninsured patients.

Mr. Rouse, who used to work at General Electric’s jet-engine plant here, also needed major work done on his teeth. He shopped around in Lynn and was told that he’d need to pay several thousand dollars, even after a discount for seniors. He calls it discouraging. “Once you get up to a certain age, they don’t want to bother with you,” he says.

So one morning in April, Rouse and Macaione boarded the van that would take them downtown to Tufts. It took three hours there in the traffic with multiple pick-ups, and Macaione fretted about what the dentists would say. “It was a little nerve-wracking,” she says.

That day, their consultations went well. “They were lovely people. They made us feel very comfortable. It didn’t feel like we were getting something for nothing,” she says.

Trips for treatment

Both were asked to come back to Boston to begin their dental work and given cost estimates. So they decided to team up again for the next stage of treatment.

Therapists aren’t a substitute for complex dental work like denture replacements, says Carolyn Villers, executive director of Massachusetts Senior Action Council. “It’s clearly not an immediate fix in providing comprehensive care to seniors,” she says.

But Ms. Villers says dental therapists could offer on-site checkups to retirees like Macaione, as well as make sure that seniors with their original teeth keep them intact. A 2009 survey of seniors in nursing homes in Massachusetts found that 59 percent had untreated decay.

Last month, Rouse and Macaione made their second trip to Tufts. But after Rouse was taken ill there, Macaione missed her ride-share home and had to call her daughter to come pick her up. 

Macaione says she’ll go back to Tufts to resume her treatment, even if it means another long day. Still, she wishes there was affordable dentistry closer to home for people like her. “Why do we have to go to Boston?” she asks.