Elsevier

Social Science & Medicine

Volume 71, Issue 11, December 2010, Pages 2028-2037
Social Science & Medicine

False hope: Effects of social class and health policy on oral health inequalities for migrant farmworker families

https://doi.org/10.1016/j.socscimed.2010.09.024Get rights and content

Abstract

Few studies have engaged issues of social class and access related to dental health care policy from an ethnographic perspective. The state of Florida in the US has one of the poorest records in the nation for providing dental care for low-income children, falling especially short for Medicaid-enrolled children. In this paper, we discuss unmet dental health needs of children in migrant farmworker families. Although one of the most marginalized populations, most are eligible for Medicaid and are thus covered for dental services. However, serious disparities have been linked to the lack of access through the public insurance system. This study was informed by participant observation at dental clinics and a Migrant Head Start Center and interviews with dental health providers (n = 19) and migrant farmworker parents (n = 48) during 2009. Our results indicate that some typical factors associated with poor oral health outcomes, such as low dental health literacy, may not apply disproportionately to this population. Instead, we argue that structural features and ineffective policies contribute to oral health care disparities. Dental Medicaid programs are chronically underfunded, resulting in low reimbursement rates, low provider participation, and a severe distribution shortage of dentists within poor communities. We characterize the situation for families in Florida as one of “false hope” because of the promise of services with neither adequate resources nor the urgency to provide them. The resulting system of charity care, which leads dentists to provide pro bono care instead of accepting Medicaid, serves to only further persistent inequalities. We provide several recommendations, including migrant-specific efforts such as programs for sealants and new mothers; improvements to the current system by removing obstacles for dentists to treat low-income children; and innovative models to provide comprehensive care and increase the number of providers.

Introduction

Social class and poverty are literally marked on children’s teeth as a visible sign of inequality and suffering (Horton & Barker, 2010). Low-income children experience a disproportionate share of dental disease burden worldwide, and in the United States tooth decay has been characterized as a “silent epidemic” among poor and minority children (USDHHS, 2000). Health researchers have long privileged medical issues over dental, ignoring developmental and social consequences of poor dental care for children and its subsequent impact on working adults. Oral health is not accorded the same importance at the policy level as is general health (Fisher-Owens et al., 2008), although it is a much more sensitive measure of the overall strength of the health care safety net (Horton & Barker, 2010).

Social science perspectives on oral health are necessary to not only fill the gaps in our holistic understanding of community wellbeing, but also provide specific insights for the critical study of poverty and health disparities. Most studies have focused on operationalizing inadequately understood variables of socioeconomic status, race, and ethnicity, along with vague notions of “culture,” rather than engaging with underlying issues of social class and structural access as they relate to health care policy. Despite the wealth of information that teeth can provide, there is a lack of research in both anthropology and sociology on oral health and oral health care (Exley, 2009, Graham, 2006, Horton and Barker, 2010).

This paper answers the call for more rigorous qualitative studies on oral health (Butani, Weintraub, & Barker, 2008), contributes to the sparse literature examining caregivers of Medicaid-insured children (Mofidi, Rozier, & King, 2002) and also includes the voices of dental providers. Two-thirds of US states fail to ensure that disadvantaged children receive the dental health care they need (Pew Center on the States, 2010), even though oral health complaints are a primary issue facing the public health system. Florida has one of the poorest records in the nation when it comes to providing dental care for low-income children, and in a recent report was awarded a grade of “F” for meeting only two of eight benchmarks (Pew Center on the States, 2010). The state falls especially short in providing care for Medicaid-enrolled children.

Here, we discuss the unmet dental health needs in one of the state’s most marginalized populations, namely, children in migrant farmworker families. Farmworker children are precariously marginalized on numerous levels; however, as US citizens, most are eligible for Medicaid and are thus covered for basic dental services and preventive care. This means that the outright cost of services is not a primary barrier. However, serious disparities have been linked to the lack of access through the public insurance system, with less than one out of every five children enrolled in Medicaid using preventive services (Casamassimo, 2003, Mofidi et al., 2002). This paper explores some of the reasons for the persistence of these disparities. We characterize the situation for migrant farmworker families in Florida as one of “false hope,” that is, the promise of services with neither adequate resources nor the urgency to provide them.

Section snippets

Migration and health care access

Studies from across the United States have noted that children in migrant farmworker families are more likely than their counterparts to suffer from tooth decay (Call et al., 1987, Chaffin et al., 2003, Lukes and Simon, 2006, Ramos-Gomez et al., 1999). Mexican-origin children have poorer levels of oral health than children from any other racial/ethnic group (USDHHS, 2000) and persistently lower dental care utilization rates, even after adjusting for age, income, education, and dental insurance

Setting

This study was conducted in rural Central Florida, a region heavily reliant upon recent, Mexican-origin migrant labor for its strawberry, tomato, and citrus industries. Since the 1990s, these laborers have increasingly replaced African Americans and rural whites in farmwork. Data on the status of farmworker health in the eastern US, which lacks historically large rural Latino populations, are limited and focus on a few states (e.g., North Carolina) (Arcury, Wiggins, & Quandt, 2009).

Like all

Dental health literacy

Because of the emphasis on individual beliefs and behaviors, many existing efforts to improve migrant children’s health strive to increase dental health literacy (or “dental IQ,” as many providers called it) through education programs and products. Indeed, many providers we interviewed stated that level of education and parental habits impeded good oral health. For example, one stated:

“When we tell them to have their children brush twice a day, they are sometimes surprised, have a real

Discussion

Our data suggest that some of the “usual suspects” associated with poor oral health outcomes, such as language barriers and low dental health literacy, may not apply disproportionately to this population. While limited English proficiency is frequently cited as a barrier to dental care in the US (Flores & Tomany-Korman, 2008), our research suggests that it does not seem to be the case for this population. This is due to the sizeable Latino population in the region, which increases the

Conclusion

Our results indicate that some typical factors associated with poor oral health outcomes, such as low dental health literacy, may not apply disproportionately to this population. Instead, we argue that structural features and ineffective policies contribute to oral health care disparities. Dental Medicaid programs are chronically underfunded, resulting in low reimbursement rates, low provider participation, and a severe distribution shortage of dentists within poor communities. We characterize

Acknowledgements

We thank our community partners and the study participants for sharing their insights and experiences with us. We are also grateful to Angela Galceran for assisting with transcription and Mackenzie Rapp for helping with the final version of the manuscript.

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