Without the Northwestern Dental School’s Saturday morningclinic, Esperanza Villalobos’ four daughters couldn’t get their teeth cleanedand cavities filled – she makes too much money to qualify for Medicaid, but toolittle to afford dental insurance.

“For me, going to a private doctor is too expensive. That’s why I’m soscared of going private,” said Villalobos, 31, of Cicero, who pays theclinic’s standard $20 a year for unlimited care for each girl. “With a bigfamily like mine, this is good. It’s cheaper and they do a very good job.”But the Donna Olsen Saturday Morning People’s Clinic is set to shut its doors inSeptember – and nine months later the weekday clinic at the 108-year-old DentalSchool will follow suit. For students, that means no more diplomas; but for theVillalobos girls and 5,000 other patients, the closing means no more affordableoral health care.

Public health officials are worried: By creating a major gap for low-incomefamilies and the working poor, the Dental School’s closing in 2001 will put morepressure on an already overburdened system. And on a national level, it pointsto the need for Medicaid reform and cooperation between the government andprivate dentists to solve the problem.

“I hope that something will happen, that someone will step up and take(NU’s) place,” Surgeon General David Satcher told The Daily. “They’vebeen a great model for other students in the nation.”

Following a national trend – seven private dental schools have closed in thepast 15 years – NU’s Board of Trustees decided in 1998 to act on UniversityPresident Henry Bienen’s recommendation that the Dental School was too costlyand no longer fit NU’s mission.

Although some of the closures were the result of too few applicants, the spateof school closings is an issue that concerns the rest of the industry. Accordingto the American Dental Association, private dental schools are responsible for57 percent of all access-to-care programs for underserved populations.

But Bienen said NU, as a private university, isn’t responsible for ensuring thatlow-income families have access to oral health care. “It’s not in ourmandate to provide affordable dental care,” Bienen said. “Frankly, Inever thought we had an obligation to continue (the clinic). It was a negativeside effect to the school closing. But that was not our prime function.”

“Technically, that’s true,” said Dental School Dean Lee Jameson.”But where is Northwestern’s sense of social and community responsibility?From that standpoint, would Henry Bienen choose to close the Medical School?Dentistry doesn’t have the cache that medicine does.”

Jameson added that NU makes a point of showing its dedication to improvingaccess to inexpensive medical care for low-income families.

The May 11 issue of the Northwestern Observer – NU’s official faculty/staffnewspaper – ran an article called “Tending the health of the nationalhealth care system” about NU’s Institute for Health Services Research andPolicy Studies. The institute is developing a program to “improve childhealth and development services for low-income children and theirfamilies.” But Jameson said NU is just paying lip service to the issue, andthat dental health is an important component of overall health.

And in the face of an oral health care shortage, many Dental School faculty andstudents said they don’t understand why the school is closing its doors. “Idon’t know what was really gained,” said Peter Hasiakos, associate dean ofclinical affairs. “This is a school that’s survived the economicdisturbance of two world wars, the Depression and the social unrest of the1960s. It doesn’t make sense that in the best of economic times they decided toabort the program.”

‘A real challenge’

With both Loyola University and NU eliminating their programs within just yearsof each other, Illinois dentistry has been struck hard with a shortage ofdentists, said Lewis Lampiris, chief of the division of oral health for theIllinois Department of Public Health. By 2001, about 110 new dentists willgraduate in Illinois. In 1990, there were 440 graduates. “It’s a realchallenge,” he said. “We already have an access-to-care problem forindividuals in Chicago. I anticipate it will get worse.”

Another school – the University of Illinois at Chicago’s College of Dentistry -is expected to pick up most of the slack.

But UIC doesn’t have a program like NU’s Saturday morning clinic, which isstaffed completely by volunteers and began in 1970 as an inexpensive alternativefor children whose families do not qualify for public aid. Implementing asimilar program is still at least two years away at UIC, said the school’s dean,Bruce Graham. And though their clinic treats 46,000 people a year at about halfthe cost of private dentists, those prices often are still too steep for some.

As NU has begun phasing out its weekday clinical program as well as its Saturdaymorning program, it has referred most patients to UIC – but that program isalready unable to meet all its patients’ needs.

Some of the patients have reported back to NU that UIC has a waiting list aslong as six months, said Prof. William Cornell, the director of the Saturdaymorning clinic since 1976.

“They’re upset,” said Andrea Tan, an NU senior dental student and oneof the 15 to 20 volunteers needed to staff the Saturday clinic each week.”A lot of them have been coming for years.”

UIC’s College of Dentistry is “very aware” of the impending influx ofpatients and the school is working on new ways to improve the school’s patientcapacity, which is now about 250 patients per day, Graham said.

“We’ll do whatever we can to take care of people who come to the collegefor care. We have that responsibility as a state institution,” said Graham,who has been dean for a little more than a month. “Yes, it will be achallenge, but we take our role very seriously.”

Chicago’s seven public clinics won’t be able to make much of a difference – eachis staffed with one dentist and, like UIC, has no program tailored to care forthe working poor.

And though UIC is expected to pick up most of NU’s patients, smaller localclinics also are bracing for the overflow.

“I’m sure that every facility in Chicago will feel it. Where are thosepeople going to go?” said Henrietta Barcelo, clinic manager of the MidwestDental Group, which is affiliated with Mt. Sinai Hospital.

Some fear that there won’t be an adequate alternative to NU’s clinic until afterit has closed.

“If there is going to be pressure from the public, it’s going to be afterwe close,” said the Saturday clinic director Cornell, whom students calledan “unsung hero.” “Parents coming in next year are going to feelit.”

A watershed moment

Satcher wants to make oral health care a high-profile issue and, to that end, heis scheduled to release the first-ever Surgeon General’s Report on Oral Healthon Thursday – a document he says could be a watershed moment for oral health,calling attention to the disparities in access to care.

“The report will raise the understanding of oral health to a new level ofcredibility,” he told 56 Dental School graduates in a commencement speechApril 29, comparing the report’s potential impact to the 1964 report on smoking.”We hope it will help eliminate racial and ethnic disparities in oralhealth care.”

Low-income minority children account for three-fourths of tooth decay amongchildren, although they represent only one-fourth of the population, saidSatcher, who also is the assistant secretary for health.

Tooth decay doesn’t only mean that cavities will go untreated. When children golong enough without oral health care, they start missing school. Children missedan estimated 52 million hours of school last year because of dental pain – alevel unheard of since the 1950s, when the government began promotingfluoridated water systems as an oral health solution.

“People realize that without oral health, you cannot have total health. Itreally does come down to that,” said Lampiris of Illinois’ Department ofPublic Health. He added that low self-esteem and poor nutrition often resultfrom untreated tooth decay. “Ul
timately that could lead to a failure to beaccomplished as a person.”

Although Illinois is one of only 11 states to mandate fluoridated water systems,54 percent of Chicago’s children still suffer from tooth decay, compared with 38percent of children statewide. For the children most at risk, there are fewoptions that offer care as affordable, accessible and high quality as NU.

The commissioner of Chicago’s department of public health created a task forceof area oral health care industry experts in October 1997 to work on theproblem.

Their solution: an emphasis on disease prevention in elementary school-agedchildren by placing sealants on their teeth.

That gives public health officials a chance to promote preventive programming,which they say is the most effective way to treat dental decay.

“From a public health standpoint, you can build a preventive system,”said John Wilhelm, deputy commissioner of the Chicago Department of PublicHealth. “It should help over time decrease the people in need.”

The task force launched a pilot school-based program in January in whichdentists place sealants on children’s teeth. Each of the six elementary schoolsthat participated in the program was near one of Chicago’s public clinics andeach school had a large low-income population.

Randy Grove, executive director of the Chicago Dental Society and task forcemember, said preliminary results are encouraging and the group hopes to expandthe program to 20 schools next year.

The program met one of its chief goals: Of the sealants that were placed, about80 percent remained a few weeks later, Grove said.

Establishing a network

Although access to care remains a major problem, some progress has been made infunding oral health.

In 1998, Illinois implemented the federally funded insurance program KidCare,which offers free or low-cost health insurance for children based on annualhousehold income.

The Department of Public Health estimates that 250,000 children in Illinois areeligible and about 100,000 are now enrolled in the program. Lampiris saidofficials are making a big push to promote KidCare, publicizing it at churches,health fairs and through radio advertisements.

In the end, dental industry experts are looking to a partnership between privatecorporations and the public to provide access to care for low-income families.

“We don’t have the dental public health infrastructure in place. Part ofthe answer is establishing a network of dentists,” Lampiris said. “Weneed dentists to staff (community-based) clinics.”

The Chicago Dental Society is working to build that network by encouragingmembers to take on one or more low-income children in their neighborhood.

“Ultimately, (the network) will build on any success that it has. The wordof mouth will spread,” said the dental society’s Grove.

But one of the barriers to private participation in care for low-income familiesis the level of reimbursement from Medicaid, which historically has been toolittle to cover costs.

“When you go to work and do a job, you expect to be compensated,”Wilhelm said. “Dentists expect to at least cover their costs.”

Two years ago, reimbursement rates for dentists averaged about 29 percent of thecost of their usual and customary fees. After the Illinois legislature voted inJuly to increase reimbursement rates for public aid patients, dentists now cancollect up to 54 percent of their usual charge – which still isn’t enough tocover the cost of treatment, about 65 percent of the fee.

Wilhelm said that though it’s too early to tell whether the new rates have madea difference, there is anecdotal evidence that more dentists are willing to takeon low-income patients.

“Dentists aren’t dropping out of the program,” said Wilhelm, who isoptimistic about the potential for private and public cooperation.

Added Grove: “The increase in reimbursement rates will add (more) dentiststo the rolls of those willing to treat the less fortunate.”

Taking care

But increasing insurance coverage still won’t be enough for some families.

“It’s a problem of the health care system, it’s part of the whole strugglethat’s going on in our country where we don’t provide universal access to healthcare,” Satcher said.

And access to oral health care requires more than available services: Cheaptransportation and convenient child care services also are needed.

“Their lives are difficult and adding health care appointments is often aburden they can’t cope with,” said UIC’s Graham. “If you get a sickchild, who’s going to take care of that child while you take the other childrento the dentist?”

But first, industry experts are asking who’s going to take care of the workingpoor without NU.

“Since its inception, (NU’s) dental school has provided quality, affordabledental care to community residents who otherwise may have been unable to affordtreatment,” Grove said. “The persons previously served by the NUDental School must now be absorbed into the already overburdened dental publichealth system.”