In the Deep South, it’s not uncommon to meet someone who has lost every tooth in their mouth—not because they lacked personal responsibility, but because they lacked access to dental care.
In some Southern states, Medicaid won’t cover a single dental cleaning for enrolled adults. Rural towns throughout the region often go years without having a practicing dentist nearby, and several counties in states such as Texas, Louisiana, Arkansas, and Alabama have been deemed “dental deserts” with no access to dentists within a thirty minute drive of the region. In several small and mid-sized municipalities—often rural or with limited public-works budgets—community water systems have quietly stopped using fluoride, a mineral commonly added to drinking water to prevent tooth decay, due to both rising operational costs and growing public distrust in the extensive evidence that fluoridation is a safe practice. For people living in these communities, oral diseases often go untreated for years—until the pain becomes unbearable, or an infection turns fatal.
This isn’t a fluke of geography or an accidental budget shortfall, but rather the result of deliberate policy design. The South’s oral health crisis is a consequence of political choices about what kind of care is considered “essential,” who deserves to live without pain, and which bodies are allowed to quietly fall apart.
Oral health neglect is not a regionally specific problem. Across the country, more than 72 million adults have no dental coverage of any kind. More than 20 percent of U.S. adults have untreated tooth decay, and nearly one in five Americans over 65 has lost all of their natural teeth. But the deepest disparities, including those in tooth loss, untreated decay, and access to preventative care, are concentrated in the South. States such as Arkansas, Mississippi, West Virginia, and Texas—where poverty rates are high and Medicaid coverage is limited—consistently report some of the nation’s worst oral health outcomes, particularly among low-income and rural populations.
Oral health affects everything from employment prospects to nutrition to self-esteem. Yet it remains an afterthought throughout most of the country. Dental care is siloed from the rest of medicine, both financially and administratively—a division rooted in how we train providers and fund care. Though dental health is an essential component of overall health, dentists receive different education and training from physicians, and operate under distinct licensing boards, billing systems, and insurance structures. This separation allows policymakers and insurers to frame oral health as a specialized, elective service that can be excluded from standard medical coverage. Medicare largely excludes dental services, while Medicaid enforces punishing limits on dental care benefits, and most private dental plans cap coverage at around $1,000 to $2,500 per year—barely enough for a single dental crown.
Though the Affordable Care Act initially mandated that states expand their state Medicaid programs with federal funds in 2010, the provision was overturned by a 2012 U.S. Supreme Court decision, making Medicaid expansion optional for states. Subsequently, several Republican-controlled states—including those with large Black populations, such as Texas, Florida, and Georgia—declined the federal expansion funds, to the detriment of their poor and working-class residents.
But denying dental coverage through Medicaid doesn’t save these states money in the long term—it simply shifts the costs back to the state and federal governments through high emergency costs. Without access to preventative care and early treatment, people eventually end up in the emergency room for non-traumatic dental conditions to treat symptoms such as oral pain, swelling, and infection. Those visits cost $3.9 billion per year nationwide across all payers in the health care system, including Medicaid, private insurance, and the absorption emergency dental care cost for uninsured individuals. What’s more, emergency rooms typically don’t treat the root cause of dental problems: They prescribe antibiotics and opioids, and send people home.
In Alabama, nearly half of third grade students in the state’s public schools have experienced tooth decay, and about one in four has untreated cavities. What’s more, racial disparities in oral health are widespread among children nationwide, and continue into adulthood. According to Centers for Disease Control and Prevention (CDC) data, non-Hispanic Black adults experience untreated tooth decay at just under twice the rate (42 percent) of non-Hispanic white adults (22 percent). Additionally, 36 percent of Hispanic adults had untreated tooth decay.
What’s more, low-income and rural communities throughout the country also experience increased tooth loss, greater pain, and far less access to preventive services than wealthier, urban regions. For these communities, the disparity isn’t just a matter of insufficient insurance coverage—it’s about who is available to provide care. 24.7 million people across the country live in dental shortage areas, where there is less than one dentist per 5,000 residents. The federal Health Resources and Services Administration estimated last year that the United States would need more than 10,093 additional dentists to meet the current demand.
Many of Alabama’s rural counties, which comprise most of the state, have only one dentist, if that. And the already limited dental care workforce is in danger of shrinking in the near future: More than 20 percent of the state’s dentists are over the age of sixty, and in twenty-five counties, there are no dentists under forty.
These patterns echo across the South and Midwest, where aging workforces, low Medicaid reimbursements, and long-standing provider shortages make care inaccessible, even for those with insurance. The lack of access leaves poor and rural residents suffering from preventable and treatable dental issues with only one option: wait until the pain is unbearable, and then extract the tooth.
As a result, the United States operates under a two-tiered system of dental health care, in which middle-and-upper-class patients with good employer-sponsored insurance can access regular cleanings, cosmetic orthodontics, and multi-thousand-dollar implants, while poor and uninsured patients must delay care, suffer in silence, or settle for emergency extractions.
The proposed solutions aren’t hypothetical. Expanding adult Medicaid dental benefits leads to fewer emergency room visits, better health outcomes, and long-term savings. In states that have expanded Medicaid, improved access to appropriate care led to a significant decrease in emergency department visits for dental problems, which has in turn saved costs. By preventing cavities, community water fluoridation returns $20 in savings for every $1 of investment. When implemented, school-based sealant programs, which bring dental professionals into schools to apply thin, protective coatings to children’s molars, are estimated to prevent 485 fillings for every 1000 children who receive the sealant.
Each year, community-based organizations known as Federally Qualified Health Centers provide dental services to more than 31 million patients nationwide, many of them uninsured or underinsured. Mobile clinics and teledentistry have also extended care into schools, nursing homes, and rural communities, reducing the need for treatment services further down the line. Communities have even benefitted from efforts to expand the dental workforce in areas where there are shortages. Dental therapists—licensed mid-level providers with advanced training beyond that of a dental hygienist, who can perform cleanings, fillings, and basic extractions—are now authorized to practice in fourteen states. But though use of mid-level providers can be instrumental in relieving shortages in the short term, many Southern states refuse to allow them to practice independently.
Dental pain is not inevitable, but rather, an outcome based in a vast inequity of investment in public health. In Alabama, the pain is acute, but the inequities themselves are national, rooted in the assumption that some people’s pain doesn’t matter. However, it doesn’t have to be that way. By choosing to make these evidence-based effective changes, we can ensure that every person in this country can see a provider before their pain becomes unbearable. What we cannot do is pretend we didn’t choose.