MISSOULA — Yu Yu Htwe had never had dental problems, so she was surprised when a dentist told her she had three cavities at her first appointment in western Montana.
Htwe, 38, is from Myanmar and worked as an OB-GYN there until a military coup overthrew the government in February 2021. Alongside other medical workers, she participated in a civil disobedience movement against the military, and, fearing reprisal, fled the country with her husband and young daughter.
Htwe and her family spent six months in Thailand before they resettled in Missoula as refugees early last year. That move around the globe took less time than the eight months she waited to get a dental appointment after arriving in Montana.
“In my country, dental care is not like it is here,” said Htwe, who is now a community health worker at Partnership Health Center in Missoula. “Here we need to wait for dental care. In Myanmar, it’s not like that. We can go at any time when we need a consultation or something.”
Refugee advocates in Montana hear stories like Htwe’s often. And these stories are similar to what low-income people can contend with across the U.S. Long wait times for dental appointments, high costs, and finding dentists willing to take new Medicaid patients make access to dental care difficult.
Refugees in the U.S. encounter additional challenges getting dental care because of cultural differences, and language and transportation issues, but their specific circumstances vary widely depending on where they resettle, and if the state offers dental coverage for refugees.
The flow of refugees admitted to the U.S. is growing since the Biden administration set the annual cap for the fiscal year that began in October to 125,000, up from 18,000 in 2020. More than 24,000 refugees arrived between October and April, 83 of whom resettled in Montana. The state and country are on pace to welcome more refugees than last year.
“It’s a health equity issue when patients have an array of barriers to getting care,” said Jane Grover, a dentist and the director of the Council on Access, Prevention, and Interprofessional Relations for the American Dental Association.
She added that dental pain complicates a person’s ability to eat, work, and do daily tasks. When oral health is suboptimal, the risk for gum and periodontal disease increases. That can then lead to other health issues like heart disease and diabetes.
“Often, refugees come to us with some or very little previous dental care,” said Bonnie Medlin, health and education programs coordinator for the International Rescue Committee in Missoula.
Refugees spend an average of about 10 years in refugee camps before resettlement, and those camps may or may not have dental services, said Medlin.
When refugees arrive in Montana, they are enrolled in the state’s Medicaid program and are eligible for most medically necessary dental services like exams, teeth cleanings, and X-rays. State Medicaid programs decide the level of adult dental benefits to offer, and Montana is among 18 states, plus Washington, D.C., that provide extensive coverage. But having health coverage doesn’t guarantee a person can see a dentist quickly or at all.
Montana health department spokesperson Jon Ebelt said private practice dentists are not required to have a certain percentage of their patients covered by Medicaid. They can choose whether to accept Medicaid or any other insurance.
A federal Refugee Medical Assistance program run by the Department of Health and Human Services provides short-term medical coverage to refugees who are not eligible for Medicaid, but only emergency dental treatments are covered.
In Missoula, three private dental clinics frequently work with refugees who are on Medicaid. One is strictly a pediatric dental office, however, and the other two perform only surgical procedures.
States set Medicaid reimbursement rates for dental care and Montana’s rates rank above the national average. Despite this, the numbers don’t always add up. “Dentists in private practice want to help and accept Medicaid patients when they can, but the margin just makes it impossible for them,” said Lara Salazar, CEO of Partnership Health Center, a community health clinic based in Missoula.
“We see patients regardless of their socioeconomic status, offer a sliding scale fee, and accept all insurance for the 65,000 visits we get across our clinics per year,” said Salazar.
PHC’s dental clinics provide comprehensive and emergency dental care for adults and children and see around 975 patients a month. Most mornings 10 to 20 people line up for urgent, same-day appointments at the center’s downtown clinic. Some of the patients needing urgent dental care are part of Missoula’s refugee population.
“People are dealing with abscesses, root canals and suddenly they’re in a dental chair and things are happening. It’s especially scary when they haven’t been to a dentist before,” said Helen Maas, a senior community health specialist who works on PHC’s refugee-focused health team with Htwe. “Trying to explain how the health care system works gets very complicated,” she said.
Federal and state laws require providers serving Medicaid patients to offer interpretation services when needed, but Medicaid reimbursement doesn’t cover all the costs, Maas said. “I know this is an issue for providers in town and a reason they are not able to accommodate everyone.”
Patients and providers at PHC connect with medically certified interpreters via phone and video chat. Maas said the translation service is great, but sometimes it can take up to an hour to find an appropriate interpreter for less common languages, like Dari and Pashto.
According to Maas, limited transportation is an additional obstacle for refugee families and can make getting to scheduled appointments particularly hard once they start working.
Another challenge is appointment wait times. New patient appointments for refugee children happen soon after arrival. But adults on Medicaid often wait up to nine months for an initial dental exam at PHC or another clinic in Missoula unless they are in acute pain that prohibits eating or causes major health concerns. “Timing depends on if providers outside of Partnership are accepting new Medicaid patients, and many are not,” said Maas.
To help accommodate the need, some dentists in the community donate services to refugee patients. Maas hopes to see more of this in the future.
In the meantime, outcomes look promising for refugees like Htwe who needed dental care after resettlement. “When I went to my appointment, the dentist set up a long-term plan for my teeth,” she said. “I’ve had two cleaning appointments and I now have a habit of flossing.”
A lack of access to navigators in rural locales to help Medicaid enrollees keep their coverage or find other insurance if they’re no longer eligible could exacerbate the difficulties rural residents face.
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