Lynnel Beauchesne’s dental office hugs a rural crossroads near Tunnelton, W.Va., population 336. Acres of empty farmland surround the weathered one-story white building; a couple of houses and a few barns are the only neighbors. But the parking lot is full. Some people have driven hours to see Beauchesne, the sole dentist within 30 miles. She estimates that she has as many as 8,000 patients. Before the office closes at 7 p.m., she and her two hygienists will see up to 50 of them, not counting emergencies.
About 43 percent of rural Americans lack access to dental care, according to the National Rural Health Association, and West Virginia, among the poorest and most rural states, is at the center of the crisis. All but six of the state’s 55 counties include federally designated “Health Professional Shortage Areas,” “Medically Underserved Areas” or both. The state’s Oral Health Program found in 2014 and 2015 that nearly half of counties had fewer than six practicing dentists, just half of adult West Virginians had visited a dentist in the previous year, and more than one-fifth hadn’t seen a dentist in five years. By comparison, a U.S. Centers for Disease Control and Prevention study in 2015 found that 64 percent of all American adults ages 18 to 64 reported seeing a dentist in the previous year. The rate of total tooth loss is 33.8 percent among West Virginians over 65, compared with roughly 19 percent for all seniors nationally.
One seemingly obvious solution is to persuade more dentists and other oral-health providers to come to places like West Virginia, a goal of various public efforts. The federal National Health Service Corps program, for example, offers up to $50,000 in loan assistance to doctors and dentists willing to work two years in a designated shortage area. And several states have passed or considered legislation authorizing “dental therapists” — midlevel providers akin to nurse practitioners — to provide certain kinds of primary dental care in areas where dentists are scarce.
But while it is true that West Virginia has a dentist shortage, adding more providers will not solve the problem of rural oral health. People don’t go to the dentist if they can’t afford to, no matter how many dentists there are. “Affordability is the big thing,” said Richard Meckstroth, chair of the department of dental practice and rural health at West Virginia University.
And affordability cuts both ways. Recruiting more providers into shortage areas can compound the problem, said Meckstroth, putting local dentists into tougher financial straits by increasing competition for a relatively small pool of paying patients. The dentists who arrive under loan forgiveness programs also tend to leave after their two-year obligation is up, what Meckstroth calls a “revolving door” that deprives patients of continuity of care.
As busy as Beauchesne’s Preston County practice is, it brings in only enough to stay afloat. A scant 53 percent of the county’s population is in the labor force, and the poverty rate is 17 percent. Dental care is a relative luxury, so Beauchesne (bo-SHANE) keeps prices barely above costs. The office charges $90 for a cleaning, an exam and bitewing X-rays — about half the national average fee and a third of what many big-city dentists would charge for the same services. “I try to keep my prices in the realm of what people can afford and so they will want to come,” she said. “I don’t want people to come just for extractions. I want them to come for cleanings and to keep the teeth they have.”
Beauchesne’s patients struggle to afford her all the same. According to the state’s Bureau for Public Health, only 40 percent of adults in West Virginia have access to dental benefits of any kind, compared with about 65 percent of working-age adults nationwide.While the state’s Medicaid program covers preventive care for children, adults get no coverage except for extractions or treatment for infections. Medicare offers no dental benefits, either. As a result, according to the West Virginia Oral Health Coalition, 43 percent of West Virginians ages 55 to 64 have lost six or more teeth because of disease or decay; 61 percent of residents older than 65 without a high school diploma have lost all their teeth.
Poor oral health has an impact beyond mere toothache. A landmark 2000 report by the U.S. Surgeon General found that oral health is intimately linked to people’s overall physical health and is often associated with serious systemic conditions such as diabetes and heart disease, as well as the likelihood of complications in pregnancy. Nevertheless, some 74 million Americans had no dental coverage in 2016, according to the National Association of Dental Plans, putting the dentally uninsured rate at nearly four times the rate for the medically uninsured. According to a 2014 report from the American Dental Association’s Health Policy Institute, nearly 20 percent of adults ages 21 to 64 said they’d foregone needed dental care in the past 12 months, with the most common reason being “could not afford the cost.”
Patients’ inability to afford care is one reason younger dentists — many facing up to $250,000 in school debt — are reluctant to settle in rural areas and why dentists like Beauchesne find themselves working hard to keep their doors open. Chip Perrine has owned a practice in Cowen, W.Va., for 30 years. He and his daughter, Valerie, say they are the only privately practicing dentists in Webster County, which has about 8,300 residents, but they often have openings in their schedule. “I keep hearing we’re underserved, but I don’t feel I’m underserved — I feel underutilized,” he said. His son joined the practice after graduating from dental school but eventually left to start a practice elsewhere because he couldn’t afford to stay.
“We are open to any insurance, including Medicaid and CHIP,” the Children’s Health Insurance Program, said Valerie Perrine. “It’s not an issue that someone can’t get an appointment.”
The Perrines charge a little more than Beauchesne — $158 for cleaning, bitewing X-ray and exam — but Chip Perrine estimates that he gives away about $400,000 a year in free care, including write-offs from low Medicaid reimbursement rates. It’s tough for the practice to swallow because expenses are also rising. “On average, my dental supplies go up 12 to 15 percent a year, but I can’t raise prices,” said Chip Perrine. “It’s useless. I can charge what I want, but it won’t get paid.”
Beauchesne often resorts to creative strategies to help her patients afford care. For instance, the practice offers a 15 percent discount for those who pay cash and a 20 percent discount for patients over 80. “I figure if they made it that far, they’re on a really tight income,” she says.
She’ll also barter for services. “If I needed a cow or a [side of] beef or a hog, whatever the normal cost would be, they can get a filling or a crown,” she said. Still, Beauchesne’s office manager and assistant, Alice Deakins, estimates that between 10 and 15 percent of the care the practice provides is given free.
Beauchesne, who is in her late 40s, said she still owes about $35,000 in school debt. Her office is no-frills, and she spends her days off mowing the lawn, painting the walls and carrying out repairs. Her panoramic X-ray machine dates from 1990 — she bought it used for $6,000 — and she recently won a $26,000 grant from the state of West Virginia to buy some computers for her office and replace one of her chairs. But she can’t afford to digitize. “That would cost me $100,000, and I can’t afford to take more loans out,” she said.
The lack of affordability and access to dental coverage in West Virginia is of course tied to the state’s overall economic precariousness. Bruce Cassis, a dentist who practices in Fayetteville, said access to high-quality dental insurance in his area has declined along with the fortunes of coal. “Less than 5 percent of my patients are affiliated with the coal industry,” Cassis said. “Thirty years ago, they used to be 60 percent of my patient base.” Today, the major employer in his region is the county school board. “They have the best insurance in the area.”
The same is true for the Perrines and Beauchesne, whose best-insured patients typically have government jobs, such as with the school district or the fire department.
When it comes to oral health, said Beauchesne, the loss of jobs is perhaps felt most acutely by the area’s elderly, who may have once had private dental insurance but now have no coverage because they are on Medicare. “These are the ones that took care of their teeth while working and are now on a fixed income,” she said. “It is sad to see the deterioration.”
Providing dental benefits under Medicare — at least for preventive services such as an annual cleaning — would both benefit seniors and help dentists in rural areas survive. Also helpful to patients and providers would be expanding Medicaid coverage of preventive care to adults instead of ending it at age 21. Covering preventive care would also reduce the amount spent on emergency room dental visits, which the American Dental Association estimates cost the U.S. health system $1.6 billion in 2012.
Still, the dental-care crisis in rural America is closely linked to the broader economic challenges in the parts of the country that have not yet caught up in this recovery. “How you improve access in rural America,” says Meckstroth, “is to get people jobs.”