Watching someone without dental insurance trying to get emergency care is exactly what it was like for all people without health care insurance before the ACA.
Bob (I've changed his name for privacy) had a tooth go bad a week before Christmas. He doesn't own a car but has Social Security Disability, Medicare, and has Medicaid with a high spend down (approx $500 a month). His city has several public health clinics that include a dentist. They charge $40 for a visit and a sliding scale payment plan for any procedures.
Medicare doesn't cover dental services and the spend down on his Medicaid is so high it would mean that Medicaid wouldn't cover the possible extraction of a tooth. Think of the $500 as a deductible - the amount you pay out of pocket before insurance pays anything. For a guy with only $200 after rent, food, and utilities each month, $500 is beyond his means unless his need is catastrophic. The Affordable Care Act only requires coverage of dental services for children.
Bob's tooth is hurting so he checks out the website of the public health dental clinic and learns they only take 3 emergency patients a day. Yes, only three a day. If you want to be seen as an emergency you have to be at the clinic by 7:45 AM and even then there is no guarantee you will be one of the three. Regular appointments are scheduled at the beginning of the month for slots in the following month.
Bob also has to have proof of income so that his sliding scale payments can be set. It's means testing. If you can afford to pay more you will. If you don't qualify for the sliding scale, the payments for service start at $279.
It's Friday afternoon so the next opportunity to go to the clinic will be Monday morning. His jaw hurts and is swollen. An abscess can kill you if not treated so he goes to a local emergency room. They won't remove a tooth unless your life is in immediate danger so Bob gets a prescription for an antibiotic and pain pills to get him through the weekend. He also gets a bill for $230.
On Monday, Bob gets to the dental clinic on time. This is when he finds out he forgot his proof of income and he knows by the time he goes home and comes back he will not be one of the golden three. He is told the clinic will be closed the next day for Christmas Eve and will reopen the day after Christmas.
Now Bob has to survive two more days in pain. Happy Holidays!
On the 26th Bob arrives even earlier then he did on Monday and has to wait for the door to be unlocked at 7:30 AM. He notices he is the only person in the clinic as he goes up to the front desk. The receptionist informs him the Dentist won't be in until January 2nd. Even though Bob was told on Monday they would see patients today now that has changed without notice.
As an alternative Bob decides to go to the major public University Hospital in town. He remembered years ago visiting their dental clinic on a Sunday when a tooth had gone bad. It was not free but reasonable. The only concern was the fact that dental school students do the treatments.
The University Dental Clinic accepts 10 emergency patients a day and when Bob arrived he was number 8 on the list. Great! He thought.
He spent thirty minutes filling out the paperwork and then is told he would need to pay $113 up front for something as simple as an extraction.
Bob doesn't have $113. That's why he's going to the particular places he's going to seeking treatment. If he had $113 in cash he would find a private dentist who could take an emergency case.
There are some charity dental clinics in the city operated by religious organizations but they don't have a regular five day a week schedule - more like once or twice a month early in the morning or in the evenings. Since it's the holidays there are no charity clinics open until after the New Year. Of course.
Now Bob has to try to survive until January 2nd.
Well on January 2nd his ride to the clinic overslept. The next day they had an emergency of their own they had to take care of in the morning so now there was another weekend Bob would go without seeing a dentist.
Early the next week Bob's city was hit by the Polar Vortex which shut down most of the public health system. The next available date he could go to the Dental Clinic would be the coming Friday.
He arrived at the clinic on Friday shortly before 7:30 and saw five people waiting around. "Oh, no," he said. "Not again." He starts thinking of plan to arrive even earlier the next day if he is shut out today.
Once at the front desk he learns that he is second on the list and four of the other people waiting there had scheduled appointments.
Bob also learns that his payment scale is 30%. His crappy basic health insurance he had in his twenties made him pay 20%. He now is expected to pay more than he would if he had crappy employer insurance - even higher than the basic ACA health plan.
Finally. After three more hours in the waiting room, he sees the dentist and the tooth is taken out.
Three weeks in pain, not able to fully eat, and having to go back to the clinic three times not to mention the failed visit to the University Hospital, Bob finally had the bad tooth addressed. He then told me the story of having a bad infection in his leg several years ago and having to wait 12 hours in an ER for treatment so the wait for the dentist rolled off his back. I was the one who was mad.
Before the ACA was passed 47 million people were without insurance. The only plan was the Emergency Room plan - need immediate care, go to the ER - the rest of the time you roll the dice and hope you don't get sick.
Charity care is still rationed and unless you are in danger of dying that day you have to wait. You also have to go through more hoops to get care just like Bob did for his tooth. We both had to laugh when we remembered the Republican's alternative to the ACA is the ER plan and churches. It's good politics for them but not good health care for the poor.
One change I would make to the ACA is to have dental insurance coverage for adults and add it to Medicare. Oral health can have a connection to our overall health. Some medicines and certain diseases can make oral health worse.
The Republicans and other cheap labor conservatives will continue to blow smoke up our collective behinds by claiming the health care system was great before the ACA. Bob's story makes that claim a lie.
Originally published on Doug's Views