The Washington Post has a horrifying story today about a 12-year-old kid who died of a toothache. The family had lost its Medicaid coverage and couldn't afford a routine tooth extraction, and so bacteria from the abscess spread to the kid's brain and he died--that is, after six weeks of hospital care and two operations that cost the state over $250,000. It's an extreme case, but it underscores the fact that the lack of dental coverage for low-income families is a much more serious problem than often thought. Malcolm Gladwell went over this in gruesome detail in The New Yorker a few years ago:

Several years ago, two Harvard researchers, Susan Starr Sered and Rushika Fernandopulle, set out to interview people without health-care coverage.... They talked to as many kinds of people as they could find, collecting stories of untreated depression and struggling single mothers and chronically injured laborers—and the most common complaint they heard was about teeth. Gina, a hairdresser in Idaho, whose husband worked as a freight manager at a chain store, had "a peculiar mannerism of keeping her mouth closed even when speaking." It turned out that she hadn't been able to afford dental care for three years, and one of her front teeth was rotting. Daniel, a construction worker, pulled out his bad teeth with pliers. Then, there was Loretta, who worked nights at a university research center in Mississippi, and was missing most of her teeth. "They'll break off after a while, and then you just grab a hold of them, and they work their way out," she explained to Sered and Fernandopulle. "It hurts so bad, because the tooth aches. Then it's a relief just to get it out of there. The hole closes up itself anyway. So it's so much better."

People without health insurance have bad teeth because, if you're paying for everything out of your own pocket, going to the dentist for a checkup seems like a luxury. It isn't, of course. The loss of teeth makes eating fresh fruits and vegetables difficult, and a diet heavy in soft, processed foods exacerbates more serious health problems, like diabetes. The pain of tooth decay leads many people to use alcohol as a salve. And those struggling to get ahead in the job market quickly find that the unsightliness of bad teeth, and the self-consciousness that results, can become a major barrier. If your teeth are bad, you're not going to get a job as a receptionist, say, or a cashier. You're going to be put in the back somewhere, far from the public eye. What Loretta, Gina, and Daniel understand, the two authors tell us, is that bad teeth have come to be seen as a marker of "poor parenting, low educational achievement and slow or faulty intellectual development." They are an outward marker of caste. "Almost every time we asked interviewees what their first priority would be if the president established universal health coverage tomorrow," Sered and Fernandopulle write, "the immediate answer was 'my teeth.' "

Medicaid dental coverage seems to be a mess in most states--see this recent dispatch from Georgia, or this article from The Seattle Times. In many cases, recipients have dental coverage under Medicaid, but the reimbursement rates are so low that very few dentists will accept them. Legislatures rarely pay much attention. And then, of course, there's that whole slew of low-income folks who aren't even covered by Medicaid...