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HOW DENTAL AND VISION CARE WOULD IMPROVE THE EMPLOYMENT SITUATION FOR PARTICIPANTS IN THE WELFARE-TO-WORK TRANSITION

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:

  1.   Wisdom teeth not pulled – affected overbite and alignment of other teeth
  2.   Abscesses, sick in hospital with blood infection and endocarditis
  3.   Severe pain requiring narcotics, so severe had to miss work, could not care for children
  4.   Had to get teeth pulled, rather than fillings or root canals after coverage cut
  5.   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:

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:

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:

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:

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:

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:

2. How would proper vision care help you at work, or to get the job you would like to have?

Focus Group & Interview Comments:

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

Vision Care

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.