Doctors Within Borders

Peter Cunningham, a researcher with the Center for Studying Health System Change in Washington, D.C., agrees: "Yes, in Appalachia, the need is extreme, but this isn't just an isolated problem. This is just where all our national health-care problems converge: high cost, lack of access. This is where the most number of people fall through the cracks." According to a recent study he coauthored, about 20 percent of all Americans reported not getting or delaying needed medical care in the previous 12 months, up from 14 percent in 2003.

Cunningham says that for Medicaid patients, including 29 million children, the dental benefit is really a "phantom" benefit because of the challenge of finding a dentist who will accept Medicaid's low reimbursement rates. The problem is worse in rural areas, where there are too few dentists to begin with.

Governor Kaine points to the fact that two thirds of the 46 million uninsured in the United States have jobs but can't afford health insurance. "This is a matter of political will," he says. "Other nations have a lower GDP than we do, and they've made a political decision that their people are going to have health coverage, but we keep deciding not to."

"We like to believe that everyone can get the care they need," says Diane Rowland, executive vice president of the Kaiser Family Foundation. "But people who are low-income, work hard and don't have coverage through a job have to make harsh economic choices about their health care. That might be to have a tooth pulled instead of getting a crown. Or to go without care at all."

Kaine has gotten funding to set up a small satellite program of the Virginia Commonwealth University Dental School in Wise to serve some of the community year-round. Other programs, such as Save the Children, are setting up nutrition, exercise and health-education programs in schools that they hope will help improve both dental and overall health.

The Virginia Dental Association's Dickinson says that education of the next generation is key in changing the culture in this part of Virginia, where knowledge about dental care and nutrition is poor. The dire dental situation among the low-income populations of southwest Virginia, and parts of Kentucky and West Virginia, is emblematic of the larger health-care crisis—the region has higher rates of tooth loss than almost anywhere in the United States. (Nationally, 108 million people don't have dental insurance.)

"The diet here, which is high in processed, sugary foods because they're cheaper, promotes decay. And when your teeth hurt, you aren't going to be eating salads," he says. "And now we know that there's a suggested link between all kinds of systemic diseases from diabetes to heart disease and oral cancer and the bacteria in the mouth. It's a cascading effect."

Sheila Fowler and her daughter bear out Dickinson's emphasis on education. Martha Hopkins, like her mother, believes teeth are mostly a source of trouble and pain. She wasn't able to have all her teeth removed this year but will come back again next year, she says. Her mom, who wasn't one of the lucky 30 to get dentures fitted, explains why she thinks spending money on your teeth is a bad idea: "I had to have fillings when I was a kid, and that's the worst thing you ever did to your teeth. I really believe that. I'd never have fillings put in my teeth if I knew what I know now. Because when those fillings fall out, stuff gets in there and rots those teeth, and then you have to get them pulled anyway. When they see it, they ought to pull it instead of fooling with it.

"For Dickinson, the philosophical battle will have to come another day. For now, he's thinking about all the patients he had to send home without care on Sunday, the last day of the RAM expedition: "I had to go to the stands, where there were hundreds of people still waiting, and say we could only take 20 more. They rushed me with questions and showed me their teeth. I said they'd have to come see us in October when we go to Grundy, Va.