In 2015, when Rebecca Shlafer and her husband unexpectedly became foster parents of their niece and two nephews, they figured the least thing they’d have to worry about was getting the youngsters, then ages 4, 5 and 6, good dental care.
As foster children, the kids’ medical needs were covered by a state-sponsored Medicaid plan, so Shlafer was able to take them to the pediatrician to catch up on missed checkups and vaccinations. But when her 7-year-old nephew began complaining of tooth pain and Shlafer tried to get him an appointment at the dentist, things started getting difficult.
“The 7-year-old really needed to be seen for some dental health issues,” recalled Shlafer, Ph.D., MPH, an assistant professor of pediatrics at the University of Minnesota Medical School. “These kids had never seen a dentist before. And I kept getting the runaround.”
Every dentist’s office Shlafer called, including the one her biological children visited, told Shlafer they either were not accepting children on Medicaid — or that the wait for an appointment could be nearly 12 months long.
Shlafer was beyond frustrated.
“I was floored by how challenging accessing dental care for these kids was,” she said. “I am a well-educated and well-resourced person who had the privilege to have good health and dental insurance for the rest of my family. I remember thinking, ‘I must be doing something wrong. We are living in a major metropolitan area. Why can I not get them in to see a dentist?’”
Eventually, Shlafer tried using her connections at the university to get dental appointments for the three traumatized young children in her care. “I reached out to a colleague of mine in the dental school,” she recalled. Shlafer’s colleague suggested that she speak with Elise Sarvas, DDS, MSD, MPH, clinical associate professor of pediatric dentistry at the University Medical School.
The two women eventually scheduled a lunch date, where Shlafer outlined her frustrations, and Sarvas explained that because the state of Minnesota’s dental reimbursement rates for Medicaid patients was so low (they were stuck at levels set in 1989), many dentists in private practice actually lose money on patients with public insurance and set limits on the number they treat. To make matters worse, there is no legal requirement that dentists in private practice accept patients on Medicaid.
When she heard Sarvas’ explanation, Shlafer said, “I was so disappointed. It was so depressing and sad. It felt like we were being discriminated against at every turn. It seemed like they didn’t want to see poor kids — or kids who were in foster care.”
While her conversation with Sarvas was enlightening — “She told me things I didn’t know about at the time,” Shlafer said — she felt she had to do something to help her kids and other kids like them in the state. “I said to my husband,” she recalled, “‘Once we get through this and our lives stabilize, I am going to figure out a way to fix this.’”
Sarvas said she shared Shlafer’s concerns.
“Hearing Rebecca’s perspective was so eye-opening. I live on the provider side, so it was hard for me to hear her frustration. I felt it was important to come together with a someone who found this situation so infuriating, who explained that we are leaving kids in pain and need to do something about it.”
While she said she generally considers Minnesota to be “so progressive in so many ways,” Sarvas concluded, “somehow, when it comes to dental care, we are failing kids in this state.”
Ultimately, Shlafer and Sarvas decided to collaborate on a research paper that would outline the problem as they saw it — and include recommendations for making dental care more accessible to children in Minnesota’s foster care system.
They reached out to Kimara Gustafson, M.D., MPH, assistant professor in the medical school’s Department of Pediatrics, whose clinical interests include internationally and domestically adopted children and children who have experienced foster care, and asked her to join them in their research.
“The intersection between our group was that we all at some point touch foster care kids through our work,” Gustafson said. She shared Shlafer and Sarvas’ frustration with the lack of dental care options for foster children and was excited to help them find a solution to the problem.
“Foster-care kids theoretically are covered by Medicaid,” Gustafson said. “But the way that Medicaid works in the dental world is a little bit different. The end result is that foster parents tend to have difficultly accessing dental services for these kids.”
Shlafer said that she hoped the team’s research would help expose a problem that many people (including herself before she became guardian of her niece and nephews), don’t even know existed.
“The system is broken and people don’t know,” Shlafer said. “They assume foster parents aren’t getting kids to the dentist because they don’t care. That is not what’s happening. The truth is it’s impossibly hard to get to a dentist if you are on Medicaid — even if you are a kid. We knew this had to change, and we hoped we could help influence that.”
Kids — in their own words
To gather data for their study, Gustafson, Sarvas and Shlafer set out to review research on the topic. Sarvas said that the team quickly discovered that the research on this topic was “scant,” but they did find data to back up their belief that the reason the state’s foster kids were getting such poor dental care was not because their guardians did not make time to take them to the dentist — it was because few appointments were available for kids on Medicaid.
“Just because these kids have insurance doesn’t mean they get care,” Sarvas said. “A significant reason for this care gap is that Minnesota ranks among the lowest in the nation for reimbursement rates for dental care with public insurance. This is a problem.”
Another problem, Sarvas decided, was that kids in foster care generally live their lives under the radar. “Kids aren’t going to the state Capitol, saying, ‘My teeth hurt. Please help me,’” she said. “It is hard to see this population. Somebody has to speak up for them.”
Gathering data on the dental history of a group of children with experience in the foster care system was going to be difficult, the team acknowledged. “It is a hard population to study because they are minors,” Sarvas said. “It is hard to track them down. A lot of our existing dental studies are of kids who show up in a dental clinic with their biological parents.”
While Gustafson, Sarvas and Shlafer likely could have simply announced that foster kids in Minnesota aren’t getting the dental care they need, they knew they needed to find hard data that illustrated the problem from the young people’s perspective.
“The main goal was to describe the nature of kids’ self-reported oral-health problems,” Shlafer said. ”We know this is a marginalized group of kids about whom we have little information. Highlighting that as a public-health issue is a way to show how we need to make change.”
The team found what they were looking for in the most recent version of the of the Minnesota Student Survey, a comprehensive survey administered every three years to students across Minnesota in grades five, eight, nine and 11.
Among other questions, Gustafson explained, “The survey collects information about self-perceived dental care and dental needs. It also collects information about whether or not the students have had an experience in the foster-care system.” By analyzing survey results based on this information, the team found that, “kids who had been in the foster-care system by and large had poorer self-perceived dental support or higher dental needs compared to matched peers who were not in the foster-cate system.”
This compiled data was invaluable in making the team’s case, Shlafer said: “We needed to document that kids’ needs are not being met.”
Sarvas agreed. “This was the first time that these children in their own words told us that they were in pain and they were hurting,” she said.
Their final paper, titled, “Oral Health Needs Among Youth with a History of Foster Care,” was published June 2, 2021, in the Journal of the American Dental Association. It concluded: “Youth with a history of foster care report more oral health problems than their peers. Dentists should recognize the oral health concerns of these youth in the context of their special health care needs and be prepared to render appropriate care.”
Shlafer said that she hopes her team’s work will drive home the reality that serious gaps in dental care can set children up for long-term health woes. If more people are aware of the inequities that exist and their long-term consequences, perhaps those with influence will step forward to make change, she added.
“Dental care It is not just about cosmetics like about how your teeth look. These are serious oral-health issues. Accessing proper dental care from a young age has really important indications in other areas of physical health and well-being. When foster kids can’t get good dental care, it reduces their chances for future success and well-being.”
A losing proposition
Many Minnesota dentists want to help foster kids, but the state’s low reimbursement rates make it a losing financial proposition for them to take on too many of these young patients, said Jim Nickman, a pediatric dentist, president of the Minnesota Dental Association and past-president of the American Academy of Pediatric Dentistry.
Nickman explained that about 70 percent of the state’s pediatric dentists and 40 percent of general dentists accept Medicaid patients. Because their dental care is covered by Medicaid, with its notoriously low reimbursement rates, Minnesota children in foster care often face long wait times just to see a dentist. In order to balance their books, Nickman explained, dentists in private practice set limits on the number of Medicaid patients they accept, which places foster kids and their caregivers in a bind.
“I think that reimbursement plays a huge part in their ability to access dental care,” Nickman said of children in the state’s foster system.
Nickman read Gustafson, Sarvas and Shlafer’s paper, and he said that he sympathizes with their argument, while he understands the ways that dentists in private practice are limited in the number of Medicaid patients they can serve.
“There are a number of different factors that are pointed out in the study,” Nickman said. “Kids in foster care tend to have a higher decay rate than their peers. You have these kids coming in with more needs and I assume with most foster families, while some are really great, with others it depends on the other needs of the child that may take priority over dental.”
While pediatric dentists generally budget for a greater percentage of Medicaid patients than their peers in private practice, Nickman said they are few and far between, and as many as 70-80 percent are located in the Twin Cities, putting foster families in Greater Minnesota at an even larger disadvantage.
“We’re at capacity,” Nickman said of the state’s dentists. “If you haven’t been taking Medicaid patients, to create space when you are already at capacity is tough.”
Because wait times to see a dentist can be so long, many foster children’s oral health needs can be particularly large, Gustafson said: “In general, foster families have to wait at least a year to get an appointment for routine dental maintenance. This is with children that theoretically have dental insurance.”
Hope on the horizon
Soon, Minnesota children in foster care and their families may have increased access to dental care. In this summer’s special session, the Minnesota Legislature voted to approve increases in dental reimbursements for individuals on Medicaid.
Nickman explained that the revamped dental programs, which were included in the Omnibus Health and Human Services bill, raised reimbursement rates and put a 93 percent increase in dental fees.
“This brings us off a 1989 schedule to something more contemporary,” he said. “The state is also thinking about putting in cost-of-living increases as time goes on.” Even with these increases, Nickman continued, Minnesota’s Medicaid reimbursement rates for dental care “will never be where the reimbursement rate is for commercial [insurance] — but it will make these kids more attractive patients.”
In a joint statement, Gustafson, Sarvas and Shlafer said they were “thrilled” to hear that the state was making progress toward achieving health care equity for Minnesota children.
“Moving Medicaid payments closer to parity with private insurers will give more dental providers the resources to see vulnerable children and adolescents,” their statement read. “The evidence is clear from studies of other states: Those that have raised reimbursement rates have seen an increase in utilization.” The statement goes on to conclude: “We are hopeful that this means that children and adolescents with a history of foster care will finally be able to get the care they need. Our team will continue to study how this significant policy change affects them.”