Dental care in America: A study in austerity, neglect and profiteering

By Gary Joad
1 September 2012

A Frontline production on the Public Broadcasting System (PBS) aired in June documented the painful and ill experiences of millions of working class families and their children, the disabled and poor, and retired persons as they seek dental care in the United States.

In the opening scene of “Dollars and Dentists,” hundreds of people with jaw and tooth pain form long lines in the early morning freezing rain of southern Virginia, seeking relief from a volunteer dental clinic. Most patients declare on camera that they are often too sick and sore to eat, and that they are compelled to live with pain every hour of their lives.

As the clinic’s Dr. Terry Dickenson states at the program’s beginning, “Gas, food, and rent compete with dental care for the dollars these persons have.”

Washington, D.C. resident Vanessa Nations, 31, reported that she had been significantly ill with dental and gum infections for many years, until her problems became so severe that she needed all her teeth extracted. She commented, “I feel like little bits of poison are killing me.”

She could not eat sufficiently, and therefore could not maintain a normal weight. Virtually all her teeth were chipped, broken off, and discolored. Poignantly, she brought a smiling teenage photo of herself to show the dentists how she wanted to look again, as they planned the removal of her ruined teeth and the manufacture of her dentures.

In another segment, five-year-old Trinity Way and her grandmother were filmed as they sat in a University of Florida dental clinic. Trinity’s grandmother pointed to the child’s swelled and warm jaw, and reported that they had to wait two months for an appointment.

The university dentists at Gainesville explained that the child’s problems had become too severe and numerous to be treated normally in the clinic. The delay in her care meant that she must undergo oral surgery in an operating room under general anesthesia. The university’s chief of dentistry noted that Trinity’s problems were entirely preventable. He pointed out that, due to the neglect of children’s dental needs in Florida, 1,200 youngsters a year must be treated in operating rooms with the added risk of general anesthesia.

Florida also has one of the lowest Medicaid reimbursement rates for dental care in the country. Only about 10 percent of dentists offer care via the government’s plan for the poor. About half of the children in the US rely on state aid or Medicaid for dental care.

The Los Angeles Times reported last fall that since California cut 3 million people in 2009 from Medi-Cal, California’s version of Medicaid, dentists are finding that many more patients are waiting until gum infections become so severe that little remains to be done to relieve suffering but to extract teeth.

A Kaiser Family Foundation poll released in April 2011 indicated that fully a third of Americans reported skipping dental checkups and care because of cost. Medi-Cal still pays for necessary extractions (that is, a persons’ teeth have become hopeless and insufferable), but no longer covers cleaning, x-rays, fillings, root canals or dentures. Unsurprisingly, researchers report the volume of dental extractions has increased dramatically.

The Journal of the American Medical Association notes the consequences of neglected dental care, including oral abscesses that on occasion spread to other body sites, including the heart, lung, and brain. Premature loss of primary (baby) teeth also predisposes to misalignment of teeth. Children with dental disease miss an estimated 52 million school hours annually.

A Pew Children’s Dental Campaign report indicated that between 2006 and 2009 there was a 16 percent increase in emergency department visits for preventable dental problems. More than 16 million children went without dental care in 2009 for “lack of insurance, an ability to pay or absence of a nearby dentist.”

A June 2011 survey by Columbia University’s Mailman School of Public Health and College of Dental Medicine found “that (although) about 75 percent of those surveyed (had) some form of dental coverage … survey participants often were crushed by out-of-pocket expenses and insurance complications that left them with … higher bills than expected.”

The federal Agency for Healthcare Research and Quality reports that barely one in five poor children enrolled in Medicaid receives preventative dental care in a given year.

As the now notorious Deamonte Driver case demonstrates, risks from untreated dental infections are not theoretical. Deamonte’s mother, Alyce Driver, was an unemployed bakery and construction worker living in Prince George’s County, Maryland. The family was homeless at times.

In 2006, Alyce was attempting to obtain attention for Deamonte’s brother, who was suffering from tooth pain. She had participated in Medicaid, but had the customary trouble of finding a dentist that accepted payment from the underfunded program. By the time Deamonte’s own aching teeth got attention, bacteria from abscesses had spread to his brain. Despite antibiotic treatments and two brain surgeries, he died February 27, 2007.

The American ruling elite’s answer to the suffering and misery associated with the dental care crisis should surprise no one: a ramped-up tempo of superexploitation of working people and their families, the poor and disabled, and the elderly and retired persons with no dental coverage.

Dental abuse for profit

In October of last year, a sobbing four-year-old stepped off a school bus in Camp Verde, Arizona to show his mother two steel crowns on his back baby molars, where that day he had had baby root canals performed by an outfit called ReachOut Healthcare in America, at his school.

As Bloomberg news reported in May of this year, his mother Stacy Gagnon said, “I was absolutely horrified. I never gave them permission to drill in my son’s mouth.” She observed, “They did it for profit.”

A Bloomberg piece by Sydney P. Freedberg, titled “Dental Abuse Seen Driven by Private Equity Investments,” reported that Isaac Gagnon’s case and others are under investigation by federal lawmakers and state regulators for “allegations of unnecessary procedures, low-quality treatment and the unlicensed practice of dentistry.”

ReachOut is a dental management services company in the Morgan Stanley Private Equity portfolio that operates in 22 states and has treated some 1.5 million patients. It is one of some 25 dental management companies in the US, backed or bought outright by investment companies in the last 10 years. They have mushroomed with the increase in outlays from Medicaid for the higher priced procedures in dentistry, including root canals, crowns, and extractions.

Between 2007 and 2010, Medicaid reimbursements for these types of procedures rose 63 percent. Dental care chain companies have therefore been seeking out children and adults from poor working families to perform the oral operations, especially during the Great Recession.

As M. Alec Parker, executive director of the North Carolina Dental Society, points out in the Bloomberg article, “The private equity industry has stepped up its investment in dental management in the last five years partly because health care was one of the few areas that grew though the recession.”

According to Sandy Steever with Irving Levin Associates in Norwalk, Connecticut, which monitors transactions in the health industry, Wall Street buyout groups are attracted to dental care ventures because of less government oversight and regulation of dentistry.

In March this year, a third grader named Alexander Henry returned from school in San Diego having had four teeth extracted by a visiting ReachOut group. In her complaint to the California state dental board, Alexander’s mother Tina Richardson stated that her child’s treatment was painful and bloody enough “that they had to send him to the (school) nurse’s office.” She also reported the child had seen another dentist nine days before and had had no recommendations for extractions.

Since 2007, ReachOut has received private-equity funding from Sentinel Capital Partners of New York, after which it acquired two other dental care chains and swelled its patient base by a factor of five. In 2011, as a Morgan Stanley holding, its staff saw 488,000 children in 8,700 schools.

The Frontline broadcast featured a segment on Aspen Dental management company, owned by Leonard Green & Partners, a private equity firm specializing in leveraged buyout transactions. According to the Center for Public Integrity (CPI), Aspen has 350 offices in 22 states, and specializes in the manufacture of dentures onsite at each of its offices.

CPI and Frontline studied Aspen’s business records in detail for months, which disclosed that the company aggressively locked poor people into years of crippling debt with overcharges and unnecessary treatments.

As Jenny Hayes, a former Aspen office manager in Illinois, told CPI and Frontline, “People would come into the office maybe with a toothache and come out with a treatment plan that the dentist said we need to extract all your teeth. They were made to stop in the manager’s office and sit down for an intense consultative selling process that they really didn’t bargain for when they walked in the door. I had people literally breaking down and crying in my office. And it happened quite regularly.”

Hayes, who worked in the Chicago area, said, “You’ve got people in management … they are breathing down the doctor’s back. There are goals and if you are not hitting your goals, then you lose your job.”

The company aggressively signs people up for “no interest health credit cards” marketed by Aspen through GE Capital or Chase. In 2010, Pennsylvania’s attorney general sued Aspen Dental for concealing that the credit cards carried steep penalties, 29.9 percent interest on the entire amount of the original loan, if a patient missed a payment.

According to Frontline and CPI, at Aspen’s “top producing offices” the average treatment plan marketed to new patients totaled $4,450.

CPI reported that a former Aspen dentist admitted that he had pulled teeth that he did not think needed extracting. He left the company recently, saying, “I couldn’t do it any more. … They spend most of their time trying to talk people out of their teeth.”

Some 8 percent of the country’s dentists, approximately 12,000 people, work in the dental chains. Many of these professionals finished their dental training with debts averaging almost $200,000; $300,000 debts are not uncommon. They are therefore under intense pressure to both service their large education loans, and to establish a dental practice without going into further debt.

CPI reports that Aspen Dental is a pioneer among corporate dental chains. Robert Fontana, Aspen CEO, founded Aspen Dental Management in 1998, and after five years the company had opened 50 offices. Aspen attracted the attention of Capital Resources Partners of Boston, which invested $18.7 million in 2004.

Fontana told Frontline and CPI that private-equity firms want out of a business after about five years, the key to a big buyout being growth. At one point, Aspen was opening a new office almost weekly. In 2010, Leonard Green and Associates bought the company for just under $550 million.

In late 2008, 20-year-old Sarah Keckler went to an Aspen Dental clinic in Mechanicsburg, Pennsylvania to get her teeth cleaned. She was told she had three cavities and also needed to have her wisdom teeth extracted. She was also informed she might have an oral cancer.

She had had dental visits regularly every six months, and had recently been compelled to switch offices for insurance reasons. An Aspen manager gave her a hard sell for the payment of a $600 bill and pressured her to sign up for a credit card to pay all in advance.

Keckler was angered and returned to her former dentist who diagnosed no cavities and denied any need for wisdom teeth extractions. At the request of CPI and Frontline, Dr. David Schneider, a dentist in Chevy Chase, MD examined Keckler and reviewed her x-rays in February this year. He declared there were no cavities, no need to extract wisdom teeth, and no cancer.