Natasha Fecteau’s mouth was a mess. The Bremerton resident had an abscessed tooth in the rear of her mouth that she routinely drained with a stab from a safety pin -- until it swelled again and she had to repeat her crude dental relief.
Fecteau had dental insurance through Medicaid, but dentist after dentist turned down her low-paying government plan. When she finally found a Tacoma dentist who accepted her insurance, it was too late. Another molar had to go.
Fecteau’s story illustrates a common complaint by health-care advocates here: Dental insurance doesn’t mean access to care. Part of the problem: Washington has one of the nation’s lowest reimbursement rates for dental care provided through Medicaid, the state-administered health-care program for low-income patients.
As a result, the state’s poor, particularly Native Americans and other minorities, generally have lousy oral health.
But a coalition of state public-health officials and others believe they have a solution: dental therapists.
These therapists, found in states such as Alaska and Minnesota, are the dental version of physician assistants -- midlevel licensed health-care professionals who can perform simple procedures, in this case doing cleanings, filling cavities, pulling teeth and the like. Dental therapists are vastly cheaper to train and employ than dentists.
But some dentists and their powerful trade group, the Washington State Dental Association, have thwarted five years of efforts to bring dental therapists to Washington state, according to interviews and a review of campaign-finance records by The Seattle Times.
Bracken Killpack, 32, the state association’s executive director, said he believes therapists can pose risks to a patient because they are not trained to handle serious dental problems.
Washington’s dental lobby is following the lead of the well-funded American Dental Association (ADA), which has opposed therapists nationwide, denigrating them as unneeded and unsafe -- even as numerous studies show that therapists provide quality care and can even boost revenue for many dentists.
Rather than create more dental caregivers, Killpack said, the state should address this public-health need by raising rates for Medicaid dental-care reimbursement. State Medicaid pays 29 cents on the dollar for dental costs, with dentists absorbing the rest.
Meanwhile, advocates are frustrated that deep-pocketed dentists are blocking an evidence-based way to improve America’s oral health.
“We’re hampered by the disproportionate power that the (WSDA) has in the Washington legislative arena,” said Jon Gould, deputy director of the Children’s Alliance, a Seattle nonprofit. Therapists “could make the biggest, long-term, sustainable difference in access to care ... for the whole population.”
Tired of waiting, the members of the Swinomish Indian Tribal Community in Skagit County have chosen to ignore federal restrictions and state licensing. On Monday, the tribe’s first dental therapist will begin seeing patients.
Brian Cladoosby, head of the Swinomish tribe and president of the National Congress of American Indians, hopes the Swinomish solution spreads to “260 Indian nations in the Lower 48.”
He isn’t counting on smooth sailing. “We expect to get sued by the American Dental Association,” Cladoosby said.
Experts agree that poor oral health can lead to far costlier diseases -- including diabetes, heart disease and osteoporosis.
In 2000, the U.S. surgeon general called a lack of access to oral health care “a silent epidemic.” Studies show tens of millions of Americans still go without dental visits each year.
In Washington, about 1.7 million people receive Medicaid, a quarter of the population. Of those who are adults, only 17 percent receive dental care.
Community health clinics and a state Medicaid effort aimed at children have improved access to dental care in some parts of the state. But Native American, minority and low-income children still suffer disproportionate rates of tooth decay. Among all ages, only 28 percent of Washington’s dental needs are met, according to federal data.
“There is a hidden opportunity for improving overall health by treating the infection in the mouth,” said Diane Oakes, deputy director of the Washington Dental Service Foundation.
But the state’s low reimbursement rate for dental care (only four states have lower rates) has resulted in only three in 10 dentists here accepting Medicaid for adults, according to the foundation.
That leaves Medicaid patients with tooth pain, gum disease and other oral troubles in the hands of hospitals that often are ill-equipped to handle dental complications. In 2010, the Washington State Hospital Association said dental problems were the number one reason uninsured people went to the emergency room.
Dr. Morgan Ball, the dentist who treated Fecteau, said he has worked up to 70 hours a week with Medicaid and other patients for the past three years at Comfort Dental in Tacoma. Root canals, fillings, cleanings and other procedures paid for with Medicaid essentially equate to “free” care, he said. For a cleaning that typically costs more than $100, the state reimburses $24 to Comfort Dental, he said.
“It is not the dentists’ fault that nobody on Medicaid can find somebody to treat them,” said Ball, who performed a root canal on Fecteau. “If we did nothing but Medicaid, we would go out of business.”
Washington’s Medicaid reimbursement rate for dental care has not increased since at least 2007.
In Alaska, dental therapists have improved oral health in rural and tribal communities for the past decade. Therapists train for 3,000 hours over two years, said Mary Williard, director of the dental-therapists education program for the Alaska Native Tribal Health Consortium. They learn 46 basic dental procedures such as exams, cleanings, sealants and simple tooth extractions that Williard said form the bulk of services for underserved communities.
In fact, the dental therapist starting Monday for the Swinomish Tribe has six years of experience in Alaska, according to the tribe.
In Minnesota, therapists for the past five years have increased the number of Medicaid patients seen at dental practices, raising revenue while decreasing wait times. Their malpractice insurance costs only about $100 a year, records show.
With their shorter training, therapists in these two states typically work under the supervision of a licensed dentist. In Washington and other states, proposed legislation has followed suit.
Marc Cooper, who runs the Mastery Company, a dental consulting firm based in Woodinville, says dentists claim that therapists pose health risks in order to mask their real concern: Therapists may threaten dentists’ small-business model.
“Dentists are profit-driven,” Cooper said. Their concern is “drip theory. You put [therapists] in the rural areas. You put them on the reservation. Then pretty soon, they’ll come to the outskirts of suburbs.”
Killpack denied blocking therapists because they threaten his members’ business model.
Not all dentists oppose creating midlevel dental professionals. The National Dental Association, which aims to improve oral health for minorities, and the American Association of Public Health Dentistry both support dental therapists.
In Olympia, the Washington Dental Access Campaign, a coalition of more than 40 health-care, minority, union and social organizations, has been pressing lawmakers to allow therapists.
The group points to one man as being the most influenced by the dentists lobby: Kevin Van De Wege, D-Sequim. His district encompasses most of the Olympic Peninsula, including all or part of seven Indian reservations.
Gould and tribal leaders say Van De Wege, as a member of the House Health Care and Wellness Committee, has joined Republicans as a tiebreaking Democrat to keep dental-therapist bills from leaving committee. Cladoosby, the Swinomish head, described Van De Wege as “bought and paid for by the ADA.”
“That’s just not something you want to say to politicians,” said Van De Wege of Cladoosby’s comment.
In 2012 and 2014 election cycles, of Van De Wege’s political contributions from individuals, 77 percent -- some $6,850 -- came from dentists or dental-industry advocates, including the current and most recent head of the Washington State Dental Association. However, businesses and political organizations gave him more total dollars, a pattern similar to that of other lawmakers.
Van De Wege said that since he did not solicit individual contributions from constituents in 2012 and 2014 (he was unopposed that year), the donations from dentists appear disproportionately high.
He said he opposed the dental-therapist legislation because “the proposals were to do invasive stuff without much schooling.”
As for constituents who may lack access to dental care, “there are Medicaid populations that have a problem seeing a dentist, and there are others that don’t,” he said. In rural Jefferson County, which is entirely within Van De Wege’s district, only 7.6 percent of adults with Medicaid receive dental services.
Fights in several states
Some tribal leaders say their dental-care crisis got more complicated when the Indian Healthcare Improvement Act was reauthorized in 2009. It contained a provision, lobbied for by the ADA, that said dental therapists could not work on reservations unless the state legislature of a tribe’s home state authorized it. Tribal leaders say the restriction flies in the face of their sovereignty.
In the last two legislative sessions, Native Americans have pushed bills in the Washington House and Senate to allow for therapists, but not one has succeeded. They will try again this session.
Similar bills in Texas, New Mexico, North Dakota, Kansas and Vermont lingered in committees in the 2015 legislative sessions, according to a review by The Times.
In the past five years, the WSDA has spent $1.06 million on lobbying and contributions, up sharply. This pattern mirrors national spending by the ADA.
Gould said lobbying by the pro-therapist coalition has been minuscule in comparison.
“The frustration that I have is the Washington State Dental Association represents Washington dentists yet, by and large, does not serve the Medicaid population,” said Steve Kutz, chair of the American Indian Health Commission of Washington State.
For nearly three years, dentist Rachael Hogan has run the Swinomish dental clinic, a modern, white office compound across the Skagit River from La Conner.
Hogan, 40, has performed hundreds of fillings, extractions and cleanings. “I’m swamped,” she said.
She believes the Swinomish plan to deploy dental therapists will help her meet the crushing needs of her patients.
The needs of Native American children are acute; 3- to 5-year-olds are four times more likely than white children of the same age to have untreated, decayed teeth, according to a 2014 Indian Health Service study.
In addition to the new dental therapist from Alaska, Hogan’s office may eventually benefit from a Swinomish woman who has been training in Alaska since last summer to become a therapist. The Swinomish are paying $70,000 a year for her training.
Mary Anne Lindeblad, the state Medicaid director, said she is open to dental therapists in the state.
The Swinomish are “looking for a local solution and if it works for them, it’s good,” she said.
Will Drabold, a senior at Ohio University, reported this story as an intern on The Seattle Times investigations team. He can be reached at firstname.lastname@example.org.