Jessica Theis, of Morro Bay, can’t find a dentist who will see her on the Central Coast.

Theis, 38, has Ehlers-Danlos Syndrome, a genetic disorder that degrades connective tissue throughout the body. In her case, it also causes gastrointestinal issues, including serious acid reflux that has been ongoing for the better part of a decade.

Partly as a result, Theis said she has had old fillings in cavities degrade and new cavities that have emerged, among other dental issues. She estimates she has at least 10 cavities that need to be filled, along with dental bridges that need to be repaired.

Although she has dental coverage, whether she will be able to access it remains an open question.

She and 7 million other Californian adults are part of the state’s second-tier dental system, where participating dentists are few and far between, particularly in rural regions.

The closest dentist Theis can find who will accept her insurance and is taking new adult patients is 140-miles away, in Bakersfield. And even that office, a Western Dental clinic, has a yearlong waitlist, the office told Theis when she called in January.

“That’s crazy,” she said, but it’s reality for her and other patients with Denti-Cal, particularly in rural Northern California, parts of the Central Valley, the Central Coast and even in some cities, such as San Francisco.

The problem is widespread: Only 15.4 percent of dentists who practice in the state accept Denti-Cal, according to data from the Center for Oral Health, a non-profit advocacy group based in Pomona. By contrast, 54.2 percent of the state’s physicians accept Medi-Cal patients.

In San Francisco, there are only 20 individual dentists and orthodontists to serve roughly 150,000 Denti-Cal enrollees, not counting healthcare clinics that also offer dental services.

Denti-Cal, is a subsidiary of Medi-Cal, the state’s low-income health program.

Adult Denti-Cal, was pared down to little more than tooth extractions in 2009 during the economic recession. (The state’s dental coverage for children was not affected.)

Four years ago, California restored coverage for fillings and x-rays. On the first of this year, the state brought back full Denti-Cal benefits, tagging on an additional $140 million from a recently enacted tobacco tax to boost reimbursements to dental providers.

But despite the recent expansion of benefits and boost in payments, Denti-Cal enrollees and their advocates say they are struggling to find dentists willing to see them.

Outdated Directories

The problem may be even be larger than it appears, because the state’s directories of dental providers are sometimes inaccurate or outdated. The end result may be that some Californians who have insurance for dental coverage are unable to receive care. A 2016 report issued by the Little Hoover Commission was highly critical of the program, saying that Denti-Cal enrollees had a “widespread inability to get care.”

According to data accessed in March from the Department of Health Care Services, which runs Denti-Cal, there are no standalone dental practices that accept the coverage in 12 of the state’s 58 counties, primarily in rural Northern California. There are some medical clinics in those counties that do accept Denti-Cal, but calls to them indicate that their names and other information does not always match what is on the Health Care website, suggesting the agency’s data needs updating. Some have numbers that are disconnected.

A 2014 California Health Report investigation found that Medi-Cal doctor directories were highly inaccurate, sometimes resulting in patients being unable to get care. The report spurred a state audit and legislation, which now requires doctor directories to be updated weekly. Health plans that operate dental plans are also supposed to have accurate and updated dental directory information, as part of the law.

But last year, reporters found that many directories still contain incorrect information and insurers have been slow to comply with the new law.

Unlike Medi-Cal managed care, which is governed by a series of consumer protection laws, most Medi-Cal enrollees receive their dental services through a “fee-for-service” program, which has no timely access requirements, or time and distance standards, according to Linda Nguy, policy advocate at the Western Center on Law and Poverty. This means it can take months to schedule an appointment with a Denti-Cal provider—if a patient can even find a provider accepting new patients—and often patients must travel very long distances if there’s no Denti-Cal provider in the county.

However, many low-income Californians can’t take time off of work or otherwise afford to travel for several hours to see a dentist.

“No Dentists at All”

Katharine Weir, a spokeswoman for the Health Care department, said that only two California counties—Alpine and Amador—are completely without any form of Denti-Cal services.

She added that Delta Dental of California, which has a contract with the state agency for patient outreach, provided services to those two counties in 2016 and 2017 via mobile vans.

“It’s not a matter of there being no Medicaid dental providers (in those counties); there are no dentists at all,” said Joe Ruiz, Delta Dental’s vice president of state and federal programs. Delta is trying to recruit new dentists via regular webinars informing them of the beefed-up Denti-Cal benefits, Weir said.

Industry observers say dentists are reluctant to accept Medi-Cal enrollees because Denti-Cal pays a fraction of the rates they can obtain from commercial insurers or patients who pay cash. For example, dentists who perform a root canal treatment on someone with Denti-Cal will receive between $261 and $331 per tooth. But for patients with private insurance, such a procedure can be reimbursed for $1,200 to $1,600 per tooth.

In pockets of the state, patients with Denti-Cal are able to get a relatively quick appointment with a dentist, such those in Long Beach and other parts of the Los Angeles area. Dentist Leila Khamsei is the managing dentist at the Long Beach Western Dental office, which is accepting new Denti-Cal patients. Western Dental is the largest provider of dental benefits to Medi-Cal enrollees. Western Dental said Denti-Cal patients can usually get non-emergency appointments at its offices within three weeks.

But the vast majority of dentists in the state decline to see Denti-Cal patients, Khamsei said. She briefly practiced in the high desert town of Victorville before joining Western Dental.

“A lot of my colleagues won’t see Denti-Cal patients,” she said.

The payments are one issue; another is the stability of the patient population. “They don’t want to see patients once who they will not see again,” she added.

Dentists who do accept Denti-Cal are often full, due to the increased demand. According to Rhoda Gonzales, a dental hygienist who practices in Fresno and works to find dentists for developmentally disabled Medi-Cal enrollees, only about 20 of the 90-some dentists in the county who accept Denti-Cal are accepting new adult patients. Oftentimes, Gonzales has to refer her patients to a dentist in Tulare County for treatment.

A Matter of Economics

The bulk of the $140 million in tobacco-tax funding to boost reimbursement is going to extractions, root canals and other corrective measures. The funding, from Proposition 56, will increase another 50 percent next fiscal year to $210 million.

“From a public policy perspective, (the extra payments are) insufficient and misdirected,” said Conrado Barzaga, who trained as a family practice physician in Cuba and is the Center for Oral Health’s executive director. “It increases payments for treatment, and not incentivizing for prevention. It goes to the old drilling and filling model for dentistry.”

The fluctuation in Denti-Cal funding has also put off many practitioners. “In the short term, Denti-Cal has alienated a lot of dentists,” said Doug Lewis, who practices with the Mendocino Community Health Clinics in Mendocino and Lake Counties north of San Francisco.

Although Lewis suggested that the Prop. 56 funding should entice more dentists to accept patients over the longer term, it remains difficult to get dentists to work at the rural clinic.

Resources at his clinics are devoted to pediatric patients and pregnant women first, and then slots are allotted to other adults when available. The clinics try to have three dentists on staff, but one recently left and administrators have been unable to find an immediate replacement. Although Lewis expects to be back at full staffing by this summer, it will still be a struggle to treat all the patients who are seeking care.

“Demand has always outstripped supply in Lake County and the people who cannot get in are impossible for me to count,” he said.

In the meantime, would-be patients such as Theis may have to cast wider nets to get treatment.

“I may be looking at Mexico,” she said.

This story has been updated with more details from Western Dental.