by Worriedmom

Tax time rolls around again, all too soon, and as I tally up the itemized deductions for my 2016 return, I realize, to my sadness but not my shock, that once again this year, our dental expenses are close to $13,000. Between four adult children needing a variety of dental services, and the fact that my husband and I are beset with age-related dental woes, some months I think I pay our dentist’s office rent all by myself. Although my husband has a generous medical plan through his employer, it does not cover dental expenses, other than those incurred in an accident, and this is typical of many employer-provided benefits packages. So, we pay.

And when I pay, I take a moment to think about the people who can’t pay – but they still have teeth. What do they do? What happens to them?

First, if you’ve ever had an untreated cavity or, worse, an infection or abscessed tooth, you know that the pain involved can be incredibly intense: you can’t think, focus, or do virtually anything, until the situation is addressed. The drugstore has shelves filled with ointments and gels for treating dental pain, not all of which are for teething babies! Second, poor dental health affects nutrition. Ability to eat and appetite are adversely affected by painful or missing teeth.

According to the Kaiser Family Foundation’s “Access to Dental Care in Medicaid” report, “Research has also identified associations between chronic oral infections and diabetes, heart and lung disease, stroke, and poor birth outcomes.”

A serious side effect of poor dental health in adults is its adverse impact on employment. People whose teeth are unsightly or missing are often deterred from seeking employment, or better jobs, and can suffer discrimination in hiring. Poor dental health is not a “protected class” for the purposes of anti-discrimination law, so employers are free to decline to hire a candidate on that basis.

As a final but not at all minimal side effect, consider the psychic distress and embarrassment experienced by people with unattractive teeth. In the United States in particular, missing, crooked, or discolored teeth are associated by many people with ignorance, lower class status, poverty and other negative social qualities.

At 4thWaveNow, we do understand that the plural of anecdote isn’t evidence, but two quick stories might shed some light on the magnitude of the problem:

A 28 year old man from my church, who lacks dental insurance, is living with persistent tooth pain. One week it becomes acute. He leaves work and seeks care in the emergency room, where it is found that an infection has spread to his entire jaw, and he will now (after spending four days in the hospital), lose all of the teeth on one side of his mouth. He has also lost his job. Eighteen months later, he is unable to afford to replace his missing teeth and is still unemployed.

Another friend has a failed root canal which wakes her up with screaming pain in the wee hours of the morning. By the time she receives emergency care from an endodontist at 3 AM, the infection is already so aggressive it is invading her soft palate. The endodontist tells her if she’d waited until the next day to seek care, the infection could have potentially gone septic, and/or reached her brain.

Yet, we all treat dental care as if teeth and gums are not even connected to the rest of the body…

How widespread is lack of access to dental care in the United States? According to the Centers for Disease Control, in the period 2011-12, 17.5% of children between the ages of 5 and 17 and 27.4% of adults between the ages of 20 and 44 had untreated cavities. In 2014, 62% of adults between the ages of 18 and 64 had a single dental visit within the previous year; more than one-third of adults had not. Put another way, a 2012 Kellogg Foundation report estimated that some 83 million Americans faced barriers to dental care.

Medicaid, as our non-United States readers may not be aware, is the US health insurance program that provides health care for low-income people from birth until approximately age 65; it also pays for nursing home care for destitute adults of any age. Medicaid is the primary way for low-income or disabled people to access health care (and access to Medicaid was expanded in states which opted in via the implementation of the Affordable Care Act in 2010). Medicaid is administered through the states, and although there are some things that the federal government says that states must cover, dental care is not one of them, except for people under the age of 21. While some states have decided to provide dental care as part of Medicaid, fewer than half provide comprehensive dental care for adults and some do not even cover dental care that is required due to an accident.

The map below of dental coverage availability under Medicaid shows that 15 states provide “extensive” dental benefits (defined as benefits that can be chosen from a list of over 100 dental procedures); 19 states provide “limited” dental benefits (fewer than 100 covered procedures); and as to both of these classes, the annual benefit “cap” is $1,000. Several high-population states, including Florida and Texas, are among the 13 that cover only emergency dental care, and 4 states provide no dental coverage at all.

Access to dental care is also inconsistent: in 2009, due to severe budget strain, the state of California eliminated adult dental care as a Medicaid benefit and did not restore it until 2014. Similarly, Illinois removed this Medicaid benefit in 2012 and restored it only in 2014.

How much does dental care cost in the United States? As might be expected in a country with such a large population and highly disparate financial circumstances, the answer is, it depends. In Connecticut, a high-income state, the average cost of a cleaning ranges from a high of $85 to a low of $66. In Mississippi, a low-income state, the same cleaning cost range is $60 (high end) to $45. For full mouth X-rays, the Connecticut range is $132-$87 – and the Mississippi range is $102-$63. For a filling, the Connecticut range is $139-$84 (for a non-front tooth that hasn’t been filled before) and in Mississippi the range is $105-$65. Finally, in Connecticut the range for a root canal (ouch) is $1,258-$1,046, and in Mississippi, it’s $918-$738. (All prices sourced via Dental Optimizer, an online dental cost calculation tool.)

With prices like these (notice that the cost of a root canal would likely exhaust an entire year’s dental benefit even in a state that provided comprehensive dental benefits through Medicaid), it’s probably no wonder that so many adults in the United States go without adequate dental care. In fact, kind-hearted and generous dentists actually provide “Missions of Mercy” to underserved populations in the United States, similar to medical missions that visit places like Rwanda and Zaire. A free dental clinic recently offered in Hartford, the capitol of Connecticut, attracted over 2,000 people, including one man who waited in line for over 15 hours to see a dentist (and recall that Connecticut is a state that provides “extensive” dental benefits under Medicaid). For another recent example, a free dental clinic held in South Carolina attracted people who waited in line for over two days for dental care.

Well, that’s enough of those unsexy teeth. Although there have been several articles and studies decrying the lack of dental care provided to adults, and detailing the negative overall health impact of that deficit, it is safe to say that this subject does not begin to arouse the passion and outcry comparable to that surrounding the demands that transgender people’s transition-related expenses ought to be paid for (by somebody else). There are no groups that have formed to advocate for access to dental care. Research has not disclosed a single demonstration or protest or letter-writing campaign or organized action on behalf of adults who lack access to dental care.

By contrast, there has been tremendous activism in the United States centered on compelling private insurance companies and the Medicaid program to provide transition-related health care. Similar activist pressure for guaranteed nationwide coverage of transition services was also placed on the Medicare program, which serves seniors and disabled people, but an extensive review by CMS resulted in no national change in policy, because

Overall, the quality and strength of evidence were low due to mostly observational study designs with no comparison groups, subjective endpoints, potential confounding (a situation where the association between the intervention and outcome is influenced by another factor such as a co-intervention), small sample sizes, lack of validated assessment tools, and considerable lost to follow-up.

But putting Medicare aside, between court rulings and legislation, access to payment for transition-related medical expenses has greatly expanded in recent years. And, of even greater significance, many states have passed “non-discrimination” laws, which typically provide that public and private health insurers may not refuse to cover (“exclude”) coverage for transition-related health expenses.

The map below shows that as of 2016, 14 states had determined to provide transition-related health care as a covered benefit under Medicaid, and had also mandated that all private insurers cover transition-related health care. An additional 5 states either provide Medicaid coverage for transition-related health care or a private insurance mandate, but not both. The remaining 31 states did not, as of 2016, have legislation or rules covering transition-related care and Medicaid and/or private health insurance. By contrast, it does not appear that there is a single state that requires private health insurers to provide dental coverage.

Let us consider the case of California in more detail. Due to “intensive advocacy,” in 2012 and 2013, the state of California issued directives requiring private health insurance companies to provide transgender services. In addition, since it was ordered to do so by a court in 2001, the state’s Medicaid program has covered transition-related health care. Regular readers of 4thWave Now will not be surprised to find that the standards set by WPATH govern the criteria for “medical necessity” regarding the provision of transition services.

Recall, as noted above, that in the 6-year period from 2009 to 2014, when California was in the midst of a persistent budget crisis, the state eliminated all dental care for adults from its Medicaid program. And now, let’s run the numbers:

Going back to Dental Optimizer, the mid-range cost of a checkup in California is almost exactly $200 ($89 for the cleaning and $108 for the x-rays). Mid-range for a filling is $130 and mid-range for a root canal is $1,030.

Looking at some typical transition-related health care costs, the first case of sticker shock pops up with Lupron:

How Much Do They Cost and Are They Covered by Insurance?

These agents (medicines) are expensive. Typically, Depot-Lupron costs range from around $700 (online) to $800 (Portland area) to $1,500 dollars a month elsewhere for the monthly preparation. The 3 month preparation is equivalent in price. The histrelin implant is approximately $15,000 total for the device and the cost of surgically implanting it.

A histrelin implant would typically be used to provide the GnRH agonist medication in place of monthly Lupron shots. Estimating the cost of monthly Lupron shots at $1,000, which seems reasonable if not conservative based on the article, it appears that a year’s supply of Lupron, used to suppress puberty in a potentially transgender child, would cost $12,000, exclusive of the cost of monthly lab tests. In dental terms, 60 people could have a dental checkup, or almost 100 cavities could be filled, or almost 12 root canals could be performed. It is difficult to estimate the “average” amount of time that a child might spend taking Lupron; some providers argue that starting Lupron at age 9 or 10 is appropriate, while others wait until age 12 or 13. Assuming five years of Lupron shots, this translates into 300 dental checkups, almost 500 cavities filled, and nearly 60 root canals.

Moving on to hormones, as pretty much all puberty-suppressed children do, the price tag drops. The cost of hormone treatment is estimated at approximately $100 per month, or dental checkups for 6 lucky people, about 9 cavities, and a bit more than one root canal.

It’s when the “re-assignment surgeries” enter the picture that things really escalate.

According to multiple sources, the price of basic genital reassignment surgery or genital reconstruction surgery) for a man transitioning to a woman ranges from $7,000 for a simple orchiectomy and vaginoplasty to $25,000 for orchiectomy and the more complicated colovaginoplasty. This is often, but not always, followed up by breast augmentation, which can run anywhere from $5,000 to $10,000. That’s a total average high of $35,000, but estimates for the two procedures combined have ranged from $10,000 to upwards of $50,000. [Source.]

Taking the $35,000 number as our benchmark, and recalling that this does not include any other procedures also frequently deemed medically necessary, the dental cost of surgical transition for one male to female patient equates to 175 checkups, or about 270 cavities, or almost exactly 34 root canals. Note also that many transitioning men do not plan to “settle” for these $35,000 “half-measures:”

Some of Grey’s medical expenses are covered by her insurance, Kaiser Permanente, including her hormone therapy, a portion of her gender reassignment surgery and preparatory genital electrolysis that has to be done before the surgery. The insurance does not cover facial electrolysis (beard removal), laser body hair reduction, breast augmentation or facial feminization surgery, all of which Grey considers vital to her survival as a transgender woman. No one sees me as physically female, just obviously transgender. This makes me an outcast and puts me at an extremely elevated risk for discrimination and harassment,” Grey said. ‘Just covering hormones and gender reassignment surgery is a half measure that still leaves us exposed to great risks and complications in our everyday lives.’

The sky’s the limit, apparently.

How about women transitioning to male?

For women transitioning to men, the initial costs can be higher, and the choices more complicated. Some estimates lower-end cost of a metoidioplasty—a procedure that “frees” a hormone therapy-enlarged clitoris from the body for use as a phallus—at $2,000. That said, there are estimates of more complex metoidioplasties, as well as procedures that add testicles and involve full phalloplasties that top $100,000. Often double mastectomies, ranging in cost from $15,000 to $25,000, and sometimes hysterectomies, which run from $7,500 to $11,500, are performed. [Source.]

Although it’s clear that most women who hope to transition to male do not currently opt for the full-on phalloplasty procedure (see this recent 4thWave article for some great reasons why), the fact remains that, as a matter of California law, should a woman wish to pursue this option, private and public insurance must cover the $100,000+ cost. The dental equivalent of one phalloplasty is checkups for 500 people, or 769 cavities filled, or 97 root canals.

To further extend the analysis, prompt and competent dental care, as illustrated by the story at the beginning of the article, can often ward off much more serious and expensive dental problems. Simple cavities turn into abscessed, infected emergencies that often lead to the loss of the tooth and even body-wide illness and disability.

By contrast, we see that “reassignment” surgeries themselves can lead to serious complications and the need for multiple follow-up or repair surgeries. To take one example that has been extensively documented online, one person has to date undergone more than 20 major surgeries to attempt to repair the effects of a failed phalloplasty.

Another, unexplored, aspect of providing transition-related medical care is the long-term effects of these interventions on healthy human bodies. Will the administration of puberty-blocking drugs and massive hormonal tampering lead to long-term medical consequences (and expenses)? This is unknown at present, but some early indicators aren’t looking particularly good.

Of course, we could evaluate any medical cost trade-off relative to transgender care, not just dental care. For one poignant example, fertility treatment generally is not covered under Medicaid. The dental analysis is striking because millions of people are profoundly affected, but it is only one of many choices made in the hotly contested world of health care spending.

Every society, outside of college economics classrooms, has limited resources, and must make tough decisions about how to allocate them. In a world of scarce resources, constituencies compete for their share, and more powerful, vocal and well-financed groups, in a system such as ours, will be better competitors. This is why lobbying, according to one source, was a $3.12 billion industry in the United States last year. It must be acknowledged, however, that distributing healthcare resources in one direction automatically preferences that group at the expense of others that do not receive those resources.

I would submit that the decision to direct health care spending towards transgender people, who by all accounts comprise a tiny fraction of the population (albeit one with potentially astronomical medical costs), and not towards dental care for adults, proves the extraordinary advocacy power and reach of the transgender movement. It also demonstrates that, contrary to activists’ efforts to characterize transgendered individuals as marginalized and under-privileged, as a whole this group is remarkably privileged. When the numbers show us that phalloplasty for one person is the equivalent of dental checkups for 500 people, and we choose the phalloplasty, we cannot conclude anything other than that we have decided the needs and concerns of one person take priority over those of the 500 people who go without dental care. Are the pain and suffering experienced by the natal woman who desires an artificial penis, more important than the pain and suffering of 500 people going without dental care? It seems that the answer to this question, at least in many places in the United States, is yes. We should ask ourselves why, and we should also ask ourselves whether that is fair.

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