Let’s talk about teeth, a part of the body that is mostly considered a luxury by health insurance. Your leg hurts? No problem! Go to the doctor, it’s covered (co-pays, deductibles, other bullshit notwithstanding). But when your tooth hurts? Tough! If you don’t want your tooth to hurt you should simply not have teeth, obviously; who doesn’t like soup? This is the logic of dental insurance being separate, and comparatively useless, from medical insurance, and it’s how the wonderful phrase “teeth are luxury bones” came to exist. It makes no sense, cannot be justified, and is marvelously lucrative for a few people—so it fits in perfectly with the rest of American healthcare.
On the scale of British Teeth, mine are somewhere in the middle: Visibly and horribly Un-American, but not the full-on Big Book of British Smiles. My massive overbite means my smile is pretty goofy, but the teeth aren’t exactly crooked, and most of the misalignment is in the back. I knew about this misalignment from seeing a couple previous dentists in the past three years, who both looked in my mouth and went “uh, you know your bite is terrible, right?” News to me, but news that made sense. I guess my dentist back in Britain looked in my mouth, saw my awful misaligned bite once or twice a year for my entire childhood, and said yep, looks good!
Last week, I went to the dentist for the first time since February 2020, right before the pandemic started. (Could I have safely gone months ago? Well, sure. But shut up, I can’t hear you actually, I’m going into a tunnel.) This new dentist—the first one I’ve seen in America who I actually trusted was telling me the truth—delivered some pretty grave news to me in the manner of an oncologist telling me to get my affairs in order. My misaligned bite, both an overbite and an open bite, is causing significant wear on my dumb, stupid molars. I already need a crown on one of them, which I’m delaying until January so I can get on my husband’s insurance to defray the cost—$1800 without insurance, Somewhat Less with insurance. I’m lucky it’s open enrollment season. With the couple of fillings I’ll need in addition to that, I’d be looking at $2700, and I already paid $400 for x-rays and $180 for a cleaning.
The dentist said I should see both an orthodontist and an oral surgeon, but suspects I’ll need at least braces and likely jaw surgery to correct these issues; left uncorrected, I’ll just need more and more crowns in the future. I am not thrilled about needing braces in my 30s, but I wasn’t winning any beauty contests anyway, and I just spent two years not going outside or doing much and found I did fine. Maybe I’ll finally learn to speedrun a Zelda game. (The small bit of good news is that my left front tooth, which is dead for some reason, can be saved with a root canal and won’t need an implant—which a previous dentist told me I absolutely needed, at a cost of thousands of dollars and looking like a pirate for months. Again, it is a huge problem that dentists routinely lie about this stuff for money!)
Jaw surgery is not fun nor something I would agree to lightly. You no longer have to get your jaw wired shut afterwards, but it does involve extensive recovery and bone-breaking, and all surgery has risks. I did some horrifying preliminary googling and decided to mostly put that information away for now, into the Future Problems drawer; I’m not seeing new doctors until I’ve moved to the West Coast, which we plan to do early next year. Luckily, I knew the basics of how it worked before he told me, so the blow was not so severe. How? Because a few months ago I interviewed Francis (name changed), a treatment coordinator at an orthodontic practice in Philadelphia.
Francis works at a practice that mostly treats Medicaid patients, many of them children. Still, just as he would at other practices, this means dealing with private insurance companies all the time. Like in most other states, Medicaid in Pennsylvania is run through “managed care” plans, where Medicaid contracts out the insurance to private companies instead of running it themselves. This means even if a dentist accepts Medicaid, they might not accept your particular Medicaid plan. These contracts are very lucrative for insurance companies, somehow, even though they’re providing care for the poorest and sickest Pennsylvanians. Funny how that works! (Here’s one example of how that might work: Lying about their provider networks so that they didn’t have to pay for care.)
Jaw surgery happened to be one of the things Francis mentioned as particularly galling for poor patients, specifically for treating an underbite. If it’s caught while a child is still growing, surgery can be avoided—but orthodontic treatment is still expensive if it isn’t covered. If the parent doesn’t, or can’t, fork over thousands of dollars at that point, it could cost even more down the road to get the painful surgery.
The same dynamic plays out over and over with his patients. The struggle to get plans, private or Medicaid, to cover orthodontic work—even when it’s very clearly necessary and will just cause more problems in the future—is just one area where money “saved” is not really saved at all. Often, he said, plans will reject patients who score very highly on the scale used to assess the need for treatment; other times, they don’t. Patients who haven’t been able to afford regular visits need huge amounts of work, but that very inability to afford or attend regular visits makes it difficult to impossible to actually treat the problems they’re having.
This is why the lack of access to dental care in this country is such a huge problem. The picture I used above is from a Remote Area Medical clinic; RAM holds clinics throughout the country, providing free medical, vision, and dental care to anyone who shows up. I attended one outside DC a couple years ago for The New Republic, and met people who had woken up at the crack of dawn in December to receive free dental care. One man I spoke to actually said he had dental insurance, but went to the clinic anyway, because he didn’t know how much it would cost if he went to a regular dentist. (He probably made the right call: Dental insurance is more of a discount card than actual insurance.) Another man said he had been to a free clinic at Howard University, where he had been advised to go to a RAM clinic for further dental care; he told me his teeth “mess with my self-esteem.” The dental services are frequently the most in-demand part of RAM clinics. It is simply too difficult and expensive for tens of millions of people to get basic dental care in this country.
I’m staring down the barrel of two years of braces, a painful surgery, and God knows how many thousands of dollars to correct these issues. This is awful, but it will be a version of affordable for me; I have savings, subsidized and good health insurance (currently, at least) that might cover the surgery if my doctors can prove it’s necessary, and the sort of job where recovery time off isn’t an issue. For patients who are poor enough to qualify for Medicaid, it’s a completely different and more unattainable proposition—one that’s even more galling for parents who just cannot afford to make the best medical decisions for their kid.
Our conversation has been edited and condensed.
Francis: I work at an orthodontic office in Philadelphia as a treatment coordinator. People will come in and they'll talk to me about why they want braces; I will then take the photos and x-rays for them. After that, I work with the orthodontist and then talk about the treatment plan, and then talk to them about how much it's going to be.
You have private paying patients, and then the other aspect of the office is that, at least in Pennsylvania—I believe this is in some other states—if you are on Medicaid in Pennsylvania and you are under the age of 21, you can come in and do what is known as a screening appointment. You'll get a set of photos and x-rays done, and then we then send that off to the insurance company. And then from there, they will decide whether it is medically necessary for you to get braces.
If that's the case, then you get approved at full cost—there is no out-of-pocket cost to you. If not, you're completely out of luck. When patients want to get braces and they don't have any insurance, then I talk to them, essentially. And then if they get denied, then that's when I also come in and say like, “Hey, this is how much it's going to be,” and talk to them about why they would want to do it.
Sick Note: That must be tough, because you do have to be pretty low-income to be on Medicaid.
Francis: It's all a free consultation. Patients will come in and they'll be like, “All right. I want you to look at my teeth for braces.” But I would say maybe 10 to 20% of the time, it's people coming in to us to essentially have a dental professional look at your teeth.
Sick Note: Because it's covered.
Francis: One of the interesting things about this job in the pandemic has been that you don't see people's teeth until they take the mask off. I had a patient that came in—you read through their basic medical history that we have them fill out, and as we're talking, I get ready to tell them, “Are you ready to take these photos and x-rays?” They mentioned to me, “Hey, I just want to see if I could get braces. My teeth are really messed up.”
At this point I wasn't really phased by too much. They took their mask down, ad immediately as I went to have them open their mouth, I realized their teeth had almost entirely rotted away. And so this person was about 35, really pretty young, had a bunch of comorbidities. I just looked at them and I said, “Are you really here for braces? There isn't really much that we're going to be able to do for you.” And she said, “No, I just wanted to make sure that it was bad and that you think I should go see a dentist.” And I'm like, “Yeah, yeah, you really should. There isn't anything we'd do.” And it's just experiences like that.
I think the majority of the patients that we have are Medicaid patients. We're one of the only providers, at least within the Philadelphia area. We actively try to see as many or try to see Medicaid patients as much as we can. The other one I wanted to mention was when you get the braces on, it's a one-time thing. So what that means is essentially is that let's say that you're a kid, and you got your braces on, and you have a difficult home life for whatever reason that might be. You miss appointments.
You want to get seen orthodontically every six to eight weeks or so. But if you're on Medicaid, you can make assumptions sometimes about what your lifestyle might be and it's difficult for you to get to appointments. We have kids coming in from essentially hours away. They could take the train in, and it's pretty difficult to do. So what you then find out is there are patients that get their braces on and then we never see them again. You're just like, “Oh no. Oh geez. That's not good.”
Sick Note: Can you explain a little bit about why that's so bad health-wise?
Francis: Specifically with braces, if you don't have them adjusted—it's a two-fold thing, medically. Your gums will eventually try to grow over the braces, which is a painful, terrible process. You're more at risk for cavities, essentially, they build up on your teeth because you're not generally not taking care of them. There's no one actively seeing them. If you break them, they'll scratch your mouth and gums. And there are processes like root resorption, which is when the roots of your teeth will get smaller. For the most part, people can deal with that, if you're being seen and your teeth are in good condition. But later in life, if you get gum disease or any kind of issues like that, then that's when you start losing teeth.
Sick Note: It's interesting to me that you said that your place of work is focused on Medicaid patients, because I feel like the narrative is Medicaid doesn't pay enough and no one wants to have too many Medicaid patients because they wouldn't be able to pay the bills. How do they stay afloat with these [patients]?
Francis: It's a volume thing. We have another office that is a pediatric dentist office, so they essentially feed into each other. It's a thing where the name of the game is that if you're going to focus on Medicaid patients, then there are a couple aspects with it. The orthodontist gets paid X amount of money for however many screenings come in, however many Medicaid patients come in. And then you get X amount of money for their periodic visits. It's a game of constant replenishment. You want to get as many [new] patients in as you take off braces for.
If you are really the only game in town, then you become the focal point for patients to come in at. We're a pretty busy practice. It's interesting to see how networks of people will hear about the office for different reasons. It's fascinating to me because more and more people come. For a brief period of time, we had at least 10 to 20 people come in over a span of about three or four months, all from Puerto Rico, come in because word had gotten around that if you needed to get your braces off, we were a Spanish-speaking office that would do that. And so you hear about how word of mouth travels around—you'd have people like, “We're on Medicaid. Well, this is the office that you go to.”
Sick Note: And so it becomes a thing where even if the Medicaid rates are lower, you have a monopoly on Medicaid patients, so you can see enough of them that it doesn't matter so much.
Francis: Yeah, absolutely. And then the other thing about it is the general point that orthodontics for the most part, it's different in the terms of dental or like pediatric dentistry, where it's high volume, but the actual payout for services is extremely low and you don't know how often people are going to come back. Ideally, you want patients to come back to every six to eight weeks, so you can build around that because you know that you're getting X amount of money for X amount of time. And if you keep overhead low… With that, you can make a decent amount of money off of it.
Sick Note: Do you have some private pay insurance patients as well?
Francis: Yeah. Orthodontic benefits, for a very quick break down: Let's say that you have you're out of college, your teeth are really messed up, and you want to buy marketplace insurance. Marketplace insurance, I would say 70, 80% of the time, it doesn't have any orthodontic benefits at all. So it's just one of those things where you have that, maybe you have a good dental plan or you work for a nice company and they're like, "Oh cool. I'm going to go into a place and get my teeth fixed. And because maybe I go to really good dentists and I have really good dental benefits there."
Orthodontic benefits, for the most part, are aimed for kids. There's age limits of about 21 and 26 or it'll be dependent coverage only. The way it goes is that, let's say we charge $5,000 for braces. It's based on an orthodontic lifetime benefit. So that lifetime benefit is, let's say, $2,000 at 50%. So you will get, from there, $5,000, they'll pay 50% of that up until it reaches X amount of money. And once you use that, that's it, it's gone.
They also don't pay out all at once. So if you were ever to lose your job, or your insurance, or anything like that, then you're on the hook for what the insurance didn't end up paying out. So that's been, with the pandemic, a fire we deal with every day of having to reach out to patients being like, "Hey, what can you do? What can you pay us?" And people don't have any money. So a lot of times, we're not being paid.
Sick Note: If someone has a bill that's past due or whatever, and they want to come in for more treatment, do they have to pay that off before they can be seen again?
Francis: For the most part, we try to be accommodating. And there are some patients who we're just ... So we tried to do a long process of we're reaching out to you, we want to talk to you about what's going on, all of that. From there, at a certain point, we dismiss you from treatment, and we’ll say, "Hey, if you come in within 30 days, we'll take your braces off for free." After these 30 days, we no longer consider you our patient.
This is a fun one, where the patient came in and we were talking to him and he was like, “Hey, I want to get back into treatment. I've just been going through a lot right now. I've had some personal health issues.” And we're like, “Well, what makes you want to come back into treatment? What's changed?” And they're like, "Well, I've been recovering from being shot." So we're like, “Okay. Yeah, that's fine. We understand. We'll work with what you've got.”
Sick Note: Let's imagine if we had a single-payer and you never had to deal with insurance or coverage, things being rejected; it was just, this is a covered benefit, it's the same for everybody, and if the doctor says you need braces, you need braces. How would that change your job?
Francis: I guess it would be really, if anything, a really booming sector in terms of job growth, because you would need so many people who need to do it. I mean, I love the idea of, as a person who has to deal with insurance companies every day being like, “Oh, it's very important for me to be on hold with Delta Dental for an hour and 15 minutes out of my day to deal with ...” I've never had to fight with so many automated voice systems. My favorite one, there's one specifically for MetLife that every time I call, I have to fight in order to just speak to a representative. And the worst part is, is that there's this condescending point where they're like, “I know you want to speak with a representative, but please tell me what your issue is by pressing these buttons in order for me to connect you to a representative.”
[But] it's the idea of parents and people being able to say, “Hey, my kid's teeth are messed up and it's really affecting their self-esteem.” Because kids, when they get sick, it just happens. They don't often think about that. But you know that if your teeth are messed up, that kids are going to bully you and be very upset, and they know what that's like. But there are so many kids that come in who are just so sad about what's going on, and I have to then tell their parents, “Hey, you know that fixing this for your kid, it's going to be like $4,000.” And then you watch, essentially, parents do the mental math of like, “How am I going to do this?”
Sick Note: How good are insurance companies at determining what braces are medically necessary?
Francis: Let me run you through what the process would be for Medicaid patients. We bring them in. We take x-rays and photos. And then from there, the doctor will do what we call a Salzmann, it's an orthodontic evaluation index. He will then talk about like, “Oh, these teeth are rotated,” or specific kinds of dental issues. So like an open bite being a space in between your teeth. And the big thing that you do is that, I think in the Pennsylvania, at least for us, is you have to reach the number 25-ish.
But, and this is a constant battle I have every day with parents, we do that and our office will send that information off. And ultimately, it doesn't really matter what we score them because each insurance company has their own person who looks at it and they score it as to what they believe is the case. There've been kids that we've scored them at 30 or 40 points, and they come back and say it's not medically necessary for them to get it. And then parents will call us and be like, “You know what happened? I don't understand. What's wrong?”
Ultimately, we're just information gatherers. We can put down what we think it is and tell a parent how the process goes, but we don't make that ultimate decision. And then that becomes a process of parents going through different grievances and trying to fight with insurance companies, and at every turn, them being like, “Well, it's because the orthodontist didn't say that you guys did this.” If we score a kid high, then it doesn't really matter if the insurance company doesn't believe that. That's also, I think, tied to ultimately how much money the state has.
This is one of the things that we noticed—when the most recent stimulus passed, in the weeks that we had sent out from that time of patients coming in, we had never had so many approvals for insurance. Because I would only say maybe 40 to 50% of kids get approved, and that's pretty good. If we were saying that, that's pretty solid. For the month of March, or whenever that stimulus passed—that period for one month, I think we almost reached 80%. There was no explanation why. They never explained anything other than being approved. But there were times where we scored kids low, and they were just like, “Fuck it. Go ahead, I guess.”
Sick Note: It certainly seems like if you have this one specific task of figuring out if someone needs braces, you can't really do that in the absence of other dental care. If they have, like you said, rotting teeth or other stuff.
Francis: One of the most tough things that I have to tell parents is when their children have an underbite. When you're a kid, you start finding out that your lower jaw is growing forward and it's just not going to essentially stop, so you end up with an underbite.
If you are lucky, you go see an orthodontist, maybe you get approved for Medicaid, or maybe your parents just have really good insurance, you can do something about that. And that's those archaic face mask things that kids would have to wear, in the '70s and '80s, kids would get bullied for it, and kids are so scared about wearing them. They're like, “Oh my God, it's going to be really terrible. What's going to happen?“ But I have to look at them, like, “You need to do this. You absolutely need to do this because if you don't, you can't really do anything about it until they're finished growing.”
After they're finished growing, which can be anywhere from 18 to 25, what they have to do is they have to literally bisect your jaw and break it in specific ways so they can bring your top jaw forward and your lower jaw down. That in and of itself is a very intensive surgical procedure that ends up costing like $20,000 to $30,000. Now imagine you're a kid who is on Medicaid, and it bothers you about your underbite, and knowing that there isn't really anything we can do. We can try to make your teeth straight, but we won't be able to fix that. And then the only thing that you can do is have a $30,000 surgery that puts you out for a month as you recover that is going to be obscene, to fix your teeth.
Sick Note: It must be so hard as well for having to talk to literal children about this stuff. I mean, obviously, I'm sure you deal with their parents, but that's not fun.
Francis: No, no. I was going to say, you also have parents who don't speak English. I speak Spanish. And so when I talked to low-income Latino parents, they are like, "Oh my God, it's actually someone who could explain something to me." That's not a guarantee at every orthodontist you go to.