Three accounts of our new, happy life on Airstrip One:
For Want of a Dentist
Pr. George’s Boy Dies After Bacteria From Tooth Spread to Brain
By Mary Otto
Washington Post Staff Writer
Wednesday, February 28, 2007
Twelve-year-old Deamonte Driver died of a toothache Sunday.
A routine, $80 tooth extraction might have saved him.
If his mother had been insured.
If his family had not lost its Medicaid.
If Medicaid dentists weren’t so hard to find.
If his mother hadn’t been focused on getting a dentist for his brother, who had six rotted teeth.
By the time Deamonte’s own aching tooth got any attention, the bacteria from the abscess had spread to his brain, doctors said. After two operations and more than six weeks of hospital care, the Prince George’s County boy died.
Deamonte’s death and the ultimate cost of his care, which could total more than $250,000, underscore an often-overlooked concern in the debate over universal health coverage: dental care.
Some poor children have no dental coverage at all. Others travel three hours to find a dentist willing to take Medicaid patients and accept the incumbent paperwork. And some, including Deamonte’s brother, get in for a tooth cleaning but have trouble securing an oral surgeon to fix deeper problems.
In spite of efforts to change the system, fewer than one in three children in Maryland’s Medicaid program received any dental service at all in 2005, the latest year for which figures are available from the federal Centers for Medicare and Medicaid Services.
The figures were worse elsewhere in the region. In the District, 29.3 percent got treatment, and in Virginia, 24.3 percent were treated, although all three jurisdictions say they have done a better job reaching children in recent years.
“I certainly hope the state agencies responsible for making sure these children have dental care take note so that Deamonte didn’t die in vain,” said Laurie Norris, a lawyer for the Baltimore-based Public Justice Center who tried to help the Driver family. “They know there is a problem, and they have not devoted adequate resources to solving it.”
Maryland officials emphasize that the delivery of basic care has improved greatly since 1997, when the state instituted a managed care program, and 1998, when legislation that provided more money and set standards for access to dental care for poor children was enacted.
About 900 of the state’s 5,500 dentists accept Medicaid patients, said Arthur Fridley, last year’s president of the Maryland State Dental Association. Referring patients to specialists can be particularly difficult.
Fewer than 16 percent of Maryland’s Medicaid children received restorative services — such as filling cavities — in 2005, the most recent year for which figures are available.
For families such as the Drivers, the systemic problems are often compounded by personal obstacles: lack of transportation, bouts of homelessness and erratic telephone and mail service.
The Driver children have never received routine dental attention, said their mother, Alyce Driver. The bakery, construction and home health-care jobs she has held have not provided insurance. The children’s Medicaid coverage had temporarily lapsed at the time Deamonte was hospitalized. And even with Medicaid’s promise of dental care, the problem, she said, was finding it.
When Deamonte got sick, his mother had not realized that his tooth had been bothering him. Instead, she was focusing on his younger brother, 10-year-old DaShawn, who “complains about his teeth all the time,” she said.
DaShawn saw a dentist a couple of years ago, but the dentist discontinued the treatments, she said, after the boy squirmed too much in the chair. Then the family went through a crisis and spent some time in an Adelphi homeless shelter. From there, three of Driver’s sons went to stay with their grandparents in a two-bedroom mobile home in Clinton.
By September, several of DaShawn’s teeth had become abscessed. Driver began making calls about the boy’s coverage but grew frustrated. She turned to Norris, who was working with homeless families in Prince George’s.
Norris and her staff also ran into barriers: They said they made more than two dozen calls before reaching an official at the Driver family’s Medicaid provider and a state supervising nurse who helped them find a dentist.
On Oct. 5, DaShawn saw Arthur Fridley, who cleaned the boy’s teeth, took an X-ray and referred him to an oral surgeon. But the surgeon could not see him until Nov. 21, and that would be only for a consultation. Driver said she learned that DaShawn would need six teeth extracted and made an appointment for the earliest date available: Jan. 16.
But she had to cancel after learning Jan. 8 that the children had lost their Medicaid coverage a month earlier. She suspects that the paperwork to confirm their eligibility was mailed to the shelter in Adelphi, where they no longer live.
It was on Jan. 11 that Deamonte came home from school complaining of a headache. At Southern Maryland Hospital Center, his mother said, he got medicine for a headache, sinusitis and a dental abscess. But the next day, he was much sicker.
Eventually, he was rushed to Children’s Hospital, where he underwent emergency brain surgery. He began to have seizures and had a second operation. The problem tooth was extracted.
After more than two weeks of care at Children’s Hospital, the Clinton seventh-grader began undergoing six weeks of additional medical treatment as well as physical and occupational therapy at another hospital. He seemed to be mending slowly, doing math problems and enjoying visits with his brothers and teachers from his school, the Foundation School in Largo.
On Saturday, their last day together, Deamonte refused to eat but otherwise appeared happy, his mother said. They played cards and watched a show on television, lying together in his hospital bed. But after she left him that evening, he called her.
“Make sure you pray before you go to sleep,” he told her.
The next morning at about 6, she got another call, this time from the boy’s grandmother. Deamonte was unresponsive. She rushed back to the hospital.
“When I got there, my baby was gone,” recounted his mother.
She said doctors are still not sure what happened to her son. His death certificate listed two conditions associated with brain infections: “meningoencephalitis” and “subdural empyema.”
In spite of such modern innovations as the fluoridation of drinking water, tooth decay is still the single most common childhood disease nationwide, five times as common as asthma, experts say. Poor children are more than twice as likely to have cavities as their more affluent peers, research shows, but far less likely to get treatment.
Serious and costly medical consequences are “not uncommon,” said Norman Tinanoff, chief of pediatric dentistry at the University of Maryland Dental School in Baltimore. For instance, Deamonte’s bill for two weeks at Children’s alone was expected to be between $200,000 and $250,000.
The federal government requires states to provide oral health services to children through Medicaid programs, but the shortage of dentists who will treat indigent patients remains a major barrier to care, according to the National Conference of State Legislatures.
Access is worst in rural areas, where some families travel hours for dental care, Tinanoff said. In the Maryland General Assembly this year, lawmakers are considering a bill that would set aside $2 million a year for the next three years to expand public clinics where dental care remains a rarity for the poor.
Providing such access, Tinanoff and others said, eventually pays for itself, sparing children the pain and expense of a medical crisis.
Reimbursement rates for dentists remain low nationally, although Maryland, Virginia and the District have increased their rates in recent years.
Dentists also cite administrative frustrations dealing with the Medicaid bureaucracy and the difficulties of serving poor, often transient patients, a study by the state legislatures conference found.
“Whatever we’ve got is broke,” Fridley said. “It has nothing to do with access to care for these children.”
Chasm of poverty grows deeper
The percentage of poor Americans who are living in severe poverty has reached a 32-year high. A McClatchy Newspapers analysis of 2005 census figures, the latest available, found that nearly 16 million Americans are living in deep or severe poverty.
A family of four with two children and an annual income of less than $9,903 — half the federal poverty line — was considered severely poor in 2005. So were individuals who made less than $5,080 a year.
Kansas ranked fifth in the nation in its increase of the most extreme poor — 126,446, up 42 percent from 88,904 in 2000.
“The face of poverty is going to be different, based on really where that family lives and the resources available for them, even in our own state,” said Tawny Stottlemire, executive director of the Kansas Association of Community Action Programs in Topeka.
KACAP helps coordinate community resource programs for the needy across the state.
“In some cases, we’re going to be talking about homeless families,” Stottlemire said. “In other cases, we’re going to be talking about large rural families, isolated from community services, job opportunities and transportation.”
Needing the basics
The McClatchy analysis found that the number of severely poor Americans grew by 26 percent from 2000 to 2005. That’s 56 percent faster than the overall poverty population grew in the same period.
One of Kansas’ richest areas, Johnson County, led the nation’s largest counties with a 358 percent increase in severely poor, from 2,100 to 9,608.
Sedgwick County, with 26,824 severely poor, saw an 88 percent increase in the five-year period.
In Sedgwick and Johnson counties, the growth in deep poverty far outpaced the growth in poverty.
Catholic Charities of Wichita has seen requests for emergency services, including food and utility assistance, more than double. In 2001, the charity’s emergency services served about 4,000 people. In 2005, that number increased to more than 10,000.
“There’s been so much growth with people just coming in for basic needs,” said spokeswoman Teresa Kunze. “That includes our food pantry, and you can’t get any more basic than food.”
The review also suggested that the rise in severely poor residents isn’t confined to large urban counties but extends to suburban and rural areas.
“They can be living at 150 percent of the poverty level and still not be able to pay their bills,” said Marion Nichols, Community Service Director for the Mid-Kansas Community Action Program in Augusta, which serves the poor in 13 counties outside of Wichita.
Living at half the poverty level qualifies people for food stamps, but that doesn’t pay for laundry products, cleaners or toiletries.
“Most of the folks we serve are working couples,” Nichols said. “But they probably don’t have health care for the adults, just medical cards for the kids. They don’t have dental care for anyone, and just staying housed is quite the chore.”
A growing population
The growth of the severely poor comes during an unusual economic expansion. Worker productivity has increased dramatically since the brief recession of 2001, but wages and job growth have lagged behind.
At the same time, the share of national income going to corporate profits has dwarfed the amount going to wages and salaries. That helps explain why the median household income for working-age families, adjusted for inflation, has fallen for five straight years.
These and other factors have helped push 43 percent of the nation’s 37 million poor people into deep poverty — the highest rate since at least 1975.
The share of poor Americans in deep poverty has climbed slowly but steadily over the past three decades. But since 2000, the number of severely poor has grown “more than any other segment of the population,” according to a recent study in the American Journal of Preventive Medicine.
“That was the exact opposite of what we anticipated when we began,” said Steven Woolf of Virginia Commonwealth University, who co-authored the study. “We’re not seeing as much moderate poverty as a proportion of the population. What we’re seeing is a dramatic growth of severe poverty.”
The growth, which leveled off in 2005, in part reflects how hard it is for low-skilled workers to earn their way out of poverty in a job market that favors skilled and educated workers. It also suggests that social programs aren’t as effective as they once were at catching those who fall into economic despair.
According to the KACAP, more than 40,000 Kansans lost higher paying industrial and manufacturing jobs between 1999 and 2003.
By June 2004, more than 18,000 Kansans had exhausted their unemployment and were unable to secure additional benefits.
And they remained jobless — the third-highest number of unemployed Kansans without benefits in 30 years, Stottlemire said.
That includes not having health insurance, so anyone needing medical attention faces a disaster.
“If you’re living right on the edge of scraping enough money together each month — each week — each day, just to live, an unexpected health care issue can blow the ground right out from under your feet,” Stottlemire wrote in a follow-up e-mail to The Eagle.
A question of when
Nationally, about 1 in 3 severely poor people across America are under age 17, and nearly 2 out of 3 are female. Female-headed families with children account for a large share of the severely poor.
It’s the same in Kansas.
“We have a really high population of single mothers who live in poverty,” Stottlemire said. “Anytime you increase the household, you’re increasing the needs but not necessarily the income.”
According to census data, nearly 2 of 3 people in severe poverty are white (10.3 million) and 6.9 million are non-Hispanic whites. Severely poor blacks (4.3 million) are more than three times as likely as non-Hispanic whites to be in deep poverty, while extremely poor Hispanics of any race (3.7 million) are more than twice as likely.
As more poor Americans sink into severe poverty, more individuals and families living within $8,000 above or below the poverty line also have seen their incomes decline.
Woolf, of Virginia Commonwealth University, attributes this to what he calls a “sinkhole effect” on income.
“Just as a sinkhole causes everything above it to collapse downward, families and individuals in the middle and upper classes appear to be migrating to lower-income tiers that bring them closer to the poverty threshold,” Woolf wrote in the study.
One in three Americans will experience a full year of extreme poverty at some point in his or her adult life, according to long-term research by Mark Rank, a professor of social welfare at the University of Wisconsin, Madison.
An estimated 58 percent of Americans between the ages of 20 and 75 will spend at least a year in poverty, Rank said.
These estimates apply only to non-immigrants. If illegal immigrants were factored in, the numbers would be worse, Rank said.
“It would appear that for most Americans,” Rank wrote in a recent study, “the question is no longer if, but rather when, they will experience poverty.”
Our Children’s Homeland Insecurity
February 06, 2007
Steady progress was made for decades during the 20th century in health, education and social indicators for children thanks to long-term voter support for federal spending on maternal and child health services, hospitals, medical research, higher education for doctors and nurses and other public health measures. Many of these social gains are now stalled or at risk of being reversed thanks to two myths underpinning the conservative political ideology dominant since the early 1980’s: first, that the federal government can’t do anything right, and second, that taxes are akin to outright thievery.
This ill-conceived ideology accounts for the indifference and near-total silence from conservatives in the administration and Congress about the plight of millions of American children who are without health insurance, are abused and neglected, are left unsupervised every day after school or whose parents are caught in a criminal justice system that is crushing families.
Proven programs and policies that could actually reduce these social ills have come under repeated attack by conservatives ever since the Reagan administration. Reagan’s even more conservative successors, after taking virtual control of the entire federal government in 2001, expanded these attacks directly and indirectly on programs benefiting children. Cuts in federal taxes and reduced state revenues forced many states to cut child care programs, child support enforcement, health care assistance, Head Start and more, ignoring decades of documentation showing that more, not less, federal spending on children was needed. There is now a huge investment gap, producing much worse outcomes for U.S. children and families than found in other rich democracies.
The children harmed most live primarily in the South, where the anti-tax/anti-government ideology has been embraced most enthusiastically. Nowhere is this more evident than in Texas, a classic low-tax, low-service state and home to such conservative ideologues as President and former governor George W. Bush and ex-congressmen Tom DeLay and Dick Armey. Arguably the epicenter of compassionate conservatism, how effective has conservative ideology been in Texas? Nationally, Texas ranks:
1st in the percentage of uninsured children
1st in food insecurity
1st in child abuse deaths
1st in the number of incarcerated adults
2nd in the percentage of the population that goes hungry
2nd in teen pregnancy
5th in the overall poverty rate
6th in crime
47th in income and food stamps benefits for the neediest
50th in the percentage of fully-immunized two-year-olds
These poor outcomes in Texas are the direct result of conservative principles. Yet the politicians whose harsh policies produce these outcomes stubbornly insist that more tax breaks and more cuts in programs are good for America’s children.
In a counterpoint to the hollow offerings of compassionate conservatism, a new report by Every Child Matters Education Fund, “Homeland Insecurity … American Children at Risk,” drawing from official data, presents 17 charts related to the well-being of children in the states. They show that nine of the 10 top-ranked states in terms of the best outcomes for children, based on 11 child-related statistical measures, are “blue”—they voted for the Democratic presidential nominee in 2004. These states generally tax themselves at higher rates and make more investments in programs serving children. In these states, more children are insured, more are enrolled in after-school programs and are more likely to be aided if abused. All 10 of the bottom-ranked states in outcomes for children are “red”—they voted for the Republican presidential nominee in 2004. They generally keep taxes lower, but at the expense of children and other vulnerable groups who would benefit from publicly financed health and social programs
Do we know how to reduce child poverty and the other social ills afflicting millions of children and families? We do. The Great Society initiatives of the mid-1960’s, for example, helped knock back child poverty to a record-low 14 percent by 1969.
Conservatives have taken pains to misrepresent the effectiveness of government poverty programs, loudly proclaiming that only the private sector could help the poor while ignoring evidence that the much lower child poverty rates in other countries are the direct result of public, not private, policies. Most telling, government data show that since the latest round of conservative tax and budget dogma was imposed in 2001 household income has dropped, poverty has increased and health coverage has declined even while the administration makes discredited claims that their policies revived the economy.
If we are going to invest in children’s programs, we have to pay for them. Earlier generations of Americans understood that progressive taxes are essential to democracy and its commitment to equal opportunity for all children. The current generation of anti-government, anti-tax conservatives seems determined to prove our ancestors wrong.
Our children deserve much better.
Michael Petit is president of the Every Child Matters Education Fund. He served as commissioner of Maine’s Human Services Department and was deputy director of the Child Welfare League of America.
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