Dr. Kurt Meyers recognized the woman immediately. She’d been a patient at Chesterbrook Dental, the practice he runs with Dr. Jack Fitzgerald. But that day, Meyers wasn’t in his tony Berwyn office. He was in West Chester at Community Volunteers in Medicine, a clinic that provides free dental and medical care to economically disadvantaged patients.
That’s not a gentle way of describing illegal immigrants and the unemployed, although they are in the mix. No, the majority of CVIM’s patient population is low-income senior citizens, kids who haven’t been enrolled in Pennsylvania’s Children’s Health Insurance Program (CHIP), and people who don’t have health or dental insurance.
That was the situation of the woman whom Meyers welcomed into his chair at CVIM. “She fell on hard times and could no longer afford to visit my practice,” he says. “I think she was a bit embarrassed to see me, but I was glad she was getting dental care at all.”
Fitzgerald had a similar experience. “I had a patient who saw me while she was working, but retiring put her in a lower income bracket, and she couldn’t afford to come to my office,” he says. “We are happy to treat these patients. It’s our way to give back to the community with the skills that we have.”
Volunteers for more than a decade, Meyers and Fitzgerald are two of the 32 dentists who spend one day per month at CVIM. They do cleanings, fillings and extractions for adults and children. If the work sounds routine, the volume of patients is not. In fiscal year 2016, those 32 dentists provided services for over 2,000 patients and their 6,758 dental appointments.
To qualify for free dental or medical care, patients must live or work in Chester County. CVIM takes patients who earn up to 300 percent of the federal poverty level. In 2017, that equals $36,180 for an individual and $73,800 for a family of four. Documentation is required to verify that. Patients also may be asked to provide paperwork demonstrating their enrollment in Medicaid or Medicare and their disability or unemployment benefits, and to show their Social Security card and photo ID. What’s not requested is citizenship.
When asked about illegal immigrants, Maureen Tomoschuk, CVIM’s president and CEO, is ready with an answer. “Citizenship is not what we are verifying,” she says. “We are looking to see that patients are in our coverage area and at the eligible income level.”
Fitzgerald and Meyers don’t need to ask patients about their backgrounds. Their teeth tell their stories. Years of neglect leave obvious signs—and many patients have never seen a dentist. Fitzgerald has a lot of compassion for these people and admires their bravery in seeking dental care. “Imagine not having any dental experience but lying back in the chair and, in good faith, hoping a doctor you’ve never met is going to do the right thing for you,” he says. “That requires a lot of trust. And you really have to give credit to parents who, despite their hesitancies about any number of issues, bring their kids to CVIM because they want what is best for them.”
That may be why Tomoschuk gets noticeably protective when describing CVIM’s patients. About half of them are Latino, she says, hastening to add that many are U.S. citizens and most pay their taxes. Tomoschuk isn’t immune to concerns about illegal immigration, but as she explains, her patients are much more affected by the status of their bank accounts than the status of their citizenship.
In fact, CVIM stands at the unfortunate crossroads of several U.S. crises. Factors like the high costs of dental and medical care, unaffordable health insurance, and inadequate healthcare for low-income seniors have created a huge swath of people who are medically underserved and have severe oral-health disparities. In 2016, the Pew Charitable Trusts reported that more than one-third of Americans face serious barriers to accessing dental care. According to Pew, one in five older Americans has untreated tooth decay, and over 40 percent have periodontal diseases. Approximately 70 percent of seniors have limited or no dental insurance.
A tangled road map of failed government policies, high costs and unregulated insurance companies leads patients to medical dead ends. Tomoschuk says many of her patients, exhausted by their efforts to navigate the system, have given up. “Most of the patient population we see tried, in good faith, to enter the system, but they fell through the cracks,” she says.
These are the people whom the Affordable Care Act, also known as Obamacare, was designed to help. Signed into law in 2010, the ACA was implemented in stages. One of the ACA’s first steps was to allow children to remain on their parents’ policies until they turned 26. As a result of that and other ACA reforms, 479,000 Pennsylvanians gained health-insurance coverage from 2010 to 2016. That statistic comes from the U.S. Department of Health and Human Services. Similar numbers were reported by the Henry J. Kaiser Family Foundation, which showed that, as of February 2016, 439,000 Pennsylvanians had selected an Obamacare health-insurance plan.
But how many people kept those insurance plans? Tomoschuk says many were unable to pay for the high—and ever-rising—costs of plans offered through the insurance marketplace. “We have people who were enrolled in insurance plans through the Affordable Care Act but incurred high co-pays for medical care, then couldn’t afford to continue paying their premiums, so they got dropped from their policies,” she says.
In fact, the ACA has not reduced CVIM’s patient load in dentistry or general medical care. “We’ve seen double-digit patient increases in each of the last few years,” Tomoschuk says, volunteering numbers to prove it.
In fiscal year 2014, CVIM had 1,980 medical patients. By 2016, the number jumped to 2,244. It’s the same with dentistry. In fiscal year 2013, CVIM had 2,004 dental patients. In 2016, it had 2,385 patients. While she diplomatically declined to assign more blame to one factor over another, Tomoschuk did point out that Pennsylvania’s ACA-inspired expansion of Medicaid coverage has helped people—12,000 of them in Chester County alone.
Nevertheless, a new patient population has been created. “We have a whole group of people who are in and out of insurance coverage,” Tomoschuk says. “We had to adjust to that, including helping people find medical providers willing to take their insurance.”
Although Tomoschuk declined to elaborate on that point, it’s well known that many physicians don’t accept Medicaid. And many dentists accept only certain insurance plans.
Dental-insurance reform is a thorny issue on both the national and state levels. The Pennsylvania Dental Association has a long wish list of reforms that are as head-spinning as the Affordable Care Act itself. In a succinct, if oversimplified, statement, the PDA says that, “of all factors impacting the dental practice, the practices of third-party payers are probably the most important. Enacting insurance reforms in Pennsylvania is no easy task, but we are committed to representing members’ interests before the legislature and the Governor’s administration.”
The PDA advocates for dentists. Where that leaves patients remains to be seen.
In the meantime, CVIM offers dental care in a surprisingly state-of-the-art setting. Fitzgerald and Meyers affirm that CVIM’s offices and operatories are not only stylish but also professionally impressive. “The instruments are not exactly the same as what we have in our office,” Meyers says, “but only because they are a different brand. And of course, we’re not working with our own staff. Other than that, we’ve never had a problem working there.”
CVIM’s 10,000-square-foot facility includes seven dental operatories and 10 medical exam rooms. In 2015, the clinic launched its Mobile Dental Program to expand its free dental services across Chester County. At the same time, CVIM grew its senior outreach through a partnership with Surrey Services for Seniors and Avondale’s St. Rocco Center.
While providing regular dental hygiene is a priority, CVIM treats dental emergencies every day. “If someone wakes up in severe pain, we’ll get them in that day for an exam, X-rays and initial medication, which is often antibiotics,” Tomoschuk says.
Service is quick even for nonemergencies. Appointments are made immediately after people provide documentation qualifying them as patients.
In all of its efforts, CVIM is supported by Main Line Health, Penn Medicine, Chester County Hospital, and “companies of caring” that are as varied as Carlino’s Specialty Foods, Pohlig Builders and the law firm MacElree Harvey.