From May 14 to October 12, 2012, the UCSF Family and Community Medicine Project assigned students to work with the San Francisco Living Wage Coalition to study the vision and dental care needs of participants in the welfare-to-work transition. The following report is a summary of the results gathered by UCSF medical students Bob Sise, Alana Ju, Kathleen Li, Andrea Axtell and Especianise Loresca in collaboration with the SF Living Wage Coalition. Dr. Sandi Borok, the Curriculum Program Administrator of the UCSF Department of Family and Community Medicine, provided instruction and guidance to the medical students. Dr. Jayshree Chander of UCSF assisted in supervision. The content and findings of this report are solely the responsibility of the San Francisco Living Wage Coalition.
Background
The state cut vision and dental coverage out of MediCal in July 2009. State law (Welfare and
Institutions Code section 14131.10) eliminated most adult dental and vision services as MediCal benefit for low-income adults. The federal government mandated that most adult dental services are optional benefits and individual state Legislatures were authorized to decide which optional Medi-Cal benefits to cover. Unfortunately for this targeted population, the California Legislature decided to cut adult dental services due to a budget crisis. Only some limited adult dental services, mandatory under federal law, continued to be covered.
High rates of dental disease among low-income adults are long-standing concerns. The Surgeon General has recognized that tooth decay and subsequent oral disease is the silent epidemic affecting the nation’s poor. Left untreated, the pain and infections caused by tooth decay may lead to problems including aspiration pneumonia, septicemia, cardiovascular disease, and preterm and low-birth-weight babies. And yet, tooth decay is almost completely treatable, and the pain, dysfunction, or on rare occasions, death, resulting from dental disease can be avoided. In addition, the higher costs for emergency medical care associated with oral disease and its complications could be avoided.
“I had this tooth problem a little while ago. At first it wasn’t serious, just like a cavity or something, but I couldn’t afford fillings or any dental care, which was $780, so I had to endure months of pain waiting for it to become infected and develop a huge abscess. That was so painful – like the equivalent of labor pains, it was so intense. Eventually my jaw swelled up like a chipmunk and I got so sick I couldn’t work or take care of my children and my friend had to take me to the ER. They ended up pulling three of my teeth and I had to spend two weeks in the hospital because the infection spread to my blood and then the valves of my heart, leaving me with a permanent heart condition.”
– Katina Traylor, CalWORKs participant
The increasing prevalence of oral disease among low-income adults has created a significant
health need in San Francisco and has been the subject of discussion by family practice
physicians, community health providers, and Family Medicine medical students from the
University of California San Francisco, and with the Living Wage Coalition, a grassroots
Improving Access to Dental and Vision Care 2
movement of low-wage workers and their allies in San Francisco fighting to transform thinking of
the economy that makes the goals of economic development a more prosperous, healthier,
and livable community, are working together to identify emerging health issues, recommend
policy solutions, and improve city health policy and practice.
Introduction
In order to plan and implement successful healthcare programs, experience tells us that persons who will be affected by these efforts, as well as those who will implement the strategies must be involved together in the planning and developing of specific strategies. This report provides a beginning for this inclusive strategy-development process, by summarizing the messages from persons who qualify for San Francisco’s CalWORKs welfare-to-work program about access to dental and vision care, as well as barriers to care, delivery, and perceived quality of care. In addition, opinions on the importance of dental and vision care from those seeking employment opportunities as part of the Personal Assisted Employment Services (PAES) program are included in the findings of this report.
CalWORKs
is a welfare program that gives cash aid and services to eligible needy California families. The program serves all 58 counties in the state and is operated locallyby county welfare departments. If a family has little or no cash and needs housing, food, utilities, clothing or medical care, they may be eligible to receive immediate short-term help. Families that apply and qualify for ongoing assistance receive money each month to help pay for housing, food and other necessary expenses.
Personal Assisted Employment Services (PAES)
provides a monthly cash stipend to employable adults and education, training, and supportive services necessary to gain lasting employment. Participants, unless they have a verifiable exemption from work requirements, can receive counseling, expenses for work-related clothing, tools and supplies, transportation assistance to and from work activities as determined by case manager.
Methods
The information reflects the findings from 84 survey participants, 4 key informant interviews, and nine persons from a focus group session conducted between May 14 and September 17, 2012. Participants were all adult beneficiaries of the CalWORKS and PAES programs and represented diverse age-group, gender, geographic, racial, and ethnic categories. Participants volunteered to participate and were recruited outside of the Career Link Center, San Francisco Department of Human Services, and the Homeless Prenatal Program.
The data was collected by UCSF Medical Students – Bob Sise, Alana Ju, Kathleen Li, Andrea
Axtell, and Especianise Loresca, in collaboration with Karl Kramer from the San Francisco Living Wage Coalition.
This information should be examined in context with other important information about
healthcare benefits for eligible welfare / employment assistance recipients, reforms in dental
care delivery systems recommended in a March 2009 report from the National Academy for
State Health Policy, and a November 2010 report from the United States Government
Accountability Office, as well as current experiences of California’s active and engaged state agencies, dental associations, and universities, as well as planning groups and coalitions throughout the city.
Findings
Survey participants included 15 men and 69 women. All of the participants lived in San
Francisco.
The key findings regarding dental services include:
- • 79% said they could not afford routine dental care
- • 75% said they did not know of any free or affordable dental clinics
- • 63% saw a dentist only in response to a dental problem
- • 57% said dental health was important in obtaining or retaining employment
- • 52% had received no dental care for more than two years
- • 45% reported poor dental health
Significant findings regarding vision services include:
- • 99% said good vision was important in obtaining a job
- • 63% had not had an eye exam in the last two years, including 16% who had never been
examined in their life - • 48% said they could not afford care or had no vision insurance
- • 37% reported poor vision due to incorrect prescriptions, or no glasses or contacts
- • 13% said transportation, childcare, time away from work, and other barriers kept them
from receiving vision care
The results of the questionnaire and focus group discussions on dental and vision health, barriers to care, and perceived importance of care are summarized in the following tables and
participant comments.
Dental Health
1. How would you describe your dental health?
| Response | Number n=84 | Percent % |
|---|---|---|
| Good | 12 | 14.3 |
| Alright | 34 | 40.5 |
| Poor | 38 | 45.2 |
Focus Group & Interview Comments:
- Multiple cavities / tooth decay
- Missing / chipped teeth
- Toothache and oral pain
- Abscesses or bleeding gums
2. If you do not see a dentist, what do you do for dental care?
| Response | Number n=84 | Percent % |
|---|---|---|
| Brush teeth | 35 | 41.7 |
| Brush and floss teeth | 18 | 21.4 |
| Nothing | 11 | 13.1 |
|
Treat pain with Tylenol, OralGel, or pull teeth when preventative care not available |
4 | 4.8 |
| NA | 16 | 19 |
3. When was the last time you saw a dentist?
| Response | Number n=84 | Percent % |
|---|---|---|
| Saw dentist in last year | 21 | 25 |
| Saw dentist 1-2 years ago | 19 | 22.6 |
| Saw dentist 3+ years ago | 43 | 51.2 |
| Never seen by dentist 1 1.2 | 1 | 1.2 |
4. What was the purpose of your last dental visit?
| Response | Number n=84 | Percent % |
|---|---|---|
| Cleaning / Examination | 29 | 34.5 |
| Filling or Extraction | 35 | 41.7 |
|
Special treatment – gum disease, missing teeth, teeth removed |
16 | 19 |
| Dont Remember | 4 | 4.8 |
Focus Group & Interview Comments:
- Wisdom teeth not pulled – affected overbite and alignment of other teeth
- Abscesses, sick in hospital with blood infection and endocarditis
- Severe pain requiring narcotics, so severe had to miss work, could not care for children
- Had to get teeth pulled, rather than fillings or root canals after coverage cut
- Root canal infected, had to get tooth pulled
Barriers to Dental Care
1. What keeps you from seeing a dentist?
| Response | Number n=84 | Percent % |
|---|---|---|
| Cost / Lack of coverage | 66 | 78.6 |
| Lack of time | 12 | 14.3 |
| No access to childcare | 12 | 14.3 |
| Lack of transportation | 7 | 8.3 |
| Could not take time from work | 1 | 1.2 |
| No dental problems | 2 | 2.4 |
| Not necessary | 8 | 9.5 |
| Other | 3 | 3.6 |
Focus Group & Interview Comments:
- Western Dental one of few places in San Francisco to go, but have to pay $300 down payment
- First come first serve policy, hard to get into Homeless Connect program
- Can’t afford dental coverage, especially with young children when providing food, childcare, and transportation is more urgent
- Benefits cut, have to wait until dental emergency to get care
- San Francisco General Hospital only does extractions
- Doctors not providing information on where to get dental care, especially for children
- Long waits to see providers
- Need referrals from primary doctor to prove a medical emergency for extractions, but then have to wait for clinics to call you to get an appointment
- Need general preventative dental care, not just emergency extractions
S.T. is a 29 year old mother of one and a CalWORKS recipient. Due to lack of dental coverage under Medi-cal, 8 of S.T.’s teeth have been extracted due to infection. When she visited a dentist for severe pain secondary to infection and decay, she was told to pay $2,000 for root canal treatment. However, because she did not have the means to pay for this tooth preserving procedure she was advised to simply have her teeth pulled. Missing her front teeth makes S.T. very self-conscious and prevents her from smiling and seeking employment opportunities. She believes that she should have been able to get the root canal to prevent losing her front teeth.
As for vision, S.T. is nearsighted but has not been able to obtain a prescription for eyeglasses. She received eyeglasses from a homeless outreach program but it was not the appropriate prescription and no eye exam was done before she was given the eyeglasses. S.T. gets headaches if she wears these glasses for long periods of time and as a result does not use them. When she needs to go places, her 5 year-old daughter has to act as a navigator to point things out for her.
2. Do you know of any free or affordable dental care clinics?
| Response | Number n=84 | Percent % |
|---|---|---|
| Yes | 21 | 25 |
| No | 63 | 75 |
Focus Group & Interview Comments:
- No places to go that are free or affordable
- Places we can go are not high quality; afraid to go to student clinics when have serious problems
Perceived Importance of Dental Care
1. How is receiving dental care important for your job, or the job you would like to have?
| Response | Number n=84 | Percent % |
|---|---|---|
| Important for work/getting work | 48 | 57.1 |
| Appearance | 24 | 28.6 |
| Overall health | 11 | 13.1 |
| Prevent of toothache/pain | 6 | 7.1 |
| Prevent bad breath | 5 | 6 |
| Avoid absence from work | 3 | 3.6 |
| Not Important | 2 | 2.4 |
Focus Group & Interview Comments:
- Poor oral health among parents sets a poor role model for children, children ostracized for poor oral health of family members
- Affects appearance
- Want to show genuine smile, if missing teeth, lose confidence in job interviews
- Teeth are important if you are working in customer service or sales where you have to interact with people, makes you less desirable as an employee if you have poor teeth
- Went to job interview, but didn’t smile because embarrassed, didn’t get hired because they thought I was not personable or friendly
- Mouth swollen from abscesses, making customers uncomfortable, so asked to leave work
- Appearance taken into consideration when hiring
- Affects self-confidence, worried people think you have been hit or in fight if missing teeth or face swollen
- Abscesses in mouth or gingivitis, other people can smell your breath and complain
Vision Care
1. How do you see at the present time?
| Response | Number n=84 | Percent % |
|---|---|---|
| Seeing fine without glasses | 39 | 46.4 |
| Seeing fine with glasses | 14 | 16.7 |
| Unable to see, no glasses | 23 | 27.4 |
|
Unable to see, glasses not suited to needs |
6 | 7.1 |
| Unable to see, other reasons | 2 | 2.4 |
Focus Group & Interview Comments:
- Need continued visual checkups because prescription is constantly changing
2. When was the last time you had your vision examined?
| Response | Number n=84 | Percent % |
|---|---|---|
| Examined in last 2 years | 31 | 36.9 |
| Examined 2-5 years ago | 10 | 11.9 |
| Examined more than 5 years ago | 30 | 35.7 |
| Never examined | 13 | 15.5 |
Barriers to Vision Care
1. What prevents you from getting the vision care you need?
| Response | Number n=84 | Percent % |
|---|---|---|
| Cost / Lack of coverage | 40 | 47.6 |
| Lack of time | 14 | 16.7 |
| No access to childcare | 4 | 4.8 |
| Lack of transportation | 1 | 1.2 |
| No time from work | 1 | 1.2 |
| Unable to find provider to see her | 1 | 1.2 |
| Other | 4 | 4.8 |
| NA | 31 | 36.9 |
Focus Group & Interview Comments:
- Glasses from Homeless Connect not appropriate to visual needs, vision still blurry, gives me a headache, don’t have equipment to appropriately assess vision and headaches impairs ability to provide childcare
- Children get vision care but only cover certain problems, special glasses for astigmatism not covered
- Transportation – bus fares are increasing
- Coverage eliminated when over age 21. If don’t provide coverage for mothers, how can they be expected to care for children?
Perceived Importance of Vision Care
1. How important is being able to see well for your job, or the job you would like to have?
| Response | Number n=84 | Percent % |
|---|---|---|
| Very Important | 80 | 95.2 |
| Important | 4 | 4.8 |
| Somewhat important | 0 | 0 |
| Not important | 0 | 0 |
| Not necessary at all | 0 | 0 |
Focus Group & Interview Comments:
- If you can’t see, you can’t work
- I work in a Chinese medicine dispensary and I need to see fine print to do my job
- Vision is important since I’m going back to school and need to study
- Being able to see signs and kids’ faces is important for a job at daycare
- Seeing well is important to avoid accidents
- It’s important for being a mom and everyday quality of life. You have to be able to see what you’re doing so you don’t hurt yourself or anyone else
- I need to see to be a radiology technician
- I need to keep eye on things for my job in security
- I need to count what people bring in and out of fitting rooms
- If I can’t see while cooking, I could burn myself
- Essential- I drive a truck
2. How would proper vision care help you at work, or to get the job you would like to have?
Focus Group & Interview Comments:
- So you can do your work at your best
- I get headaches trying to type on the computer with bad vision
- I need to see for training since I’m switching job programs
- To stop getting get migraines from squinting a lot
- So I can see how to cut hair
The focus group was also solicited about their ideas for addressing unmet needs. Twenty-five percent said that unmet needs should be addressed with enhanced MediCal support, 24% advocated for improved education, and 12% said that care should be provided through “free government dental or vision clinics.”
Recommendations
The results of these surveys reinforce national surveys indicating low income individuals and
families are experiencing increasing difficulty accessing dental and vision care. These individuals appear to place the highest priority on securing improved access to dental care. They view good teeth and good vision as essential to their employability and self-sufficiency. As a matter of public policy, providing reasonable access to corrective vision and preventative and restorative dental care is likely to avoid substantial other public expenditures to support these individuals. Based on the barriers to care they have described, the researchers are recommending a number of innovations that have the opportunity to provide a rapid improvement in healthcare services for this targeted population.
Dental Care
- Restoring adult dental services as a MediCal benefit
-
In the event dental services are not covered by MediCal, provide dental care through the Community Health Network, e.g. San Francisco General Hospital and neighborhood clinics, starting with people in subsidized employment programs, such as the Community Jobs Program, and expanding to include others in the welfare-to-work transition - Since respondents routinely linked oral health appearance concerns to employment opportunities, more collaborative marketing to subsidized employment programs and other job training programs to increase referrals to dental clinics, and subsidize free or low cost dental clinics to enable clients to access those services
- More aggressive marketing and subsidy of preventative annual dental services to lower the high cost of repairing advanced oral health problems
- Provide greater public subsidies to oral health services at San Francisco General Hospital and UC San Francisco clinics
Vision Care
- Restoring adult vision services as a MediCal benefit
- In the event vision services are not covered by MediCal, provide vision care through the Community Health Network, e.g. San Francisco General Hospital and neighborhood clinics, starting with people in subsidized employment programs, such as the Community Jobs Program, and expanding to include others in the welfare-to-work transition
- More aggressive marketing of free or low cost vision services to subsidized employment programs and other job training programs, subsidize free or low cost vision services to enable clients to access those services, and identify after hours sites where those vision services can be provided
- Provide free or low cost vision exams and corrective glasses to low income individuals in general
Conclusions
In the decade that has passed since the Surgeon General described the silent epidemic of oral disease affecting low-income families, dental disease and access to dental services have remained a significant problem. Since the California Legislature eliminated most dental services to low-income adults, there is a huge gap in funding for programs to help the State’s most susceptible populations increase access to dental and vision services. Providing dental and vision care to those who are in the welfare-to-work transition who face the greatest barriers to long-term employment would help them in obtaining jobs with the resulting benefits of a more vibrant economy and healthier community.