Long waits, big bills: Everett mom’s painful search for dental care

EVERETT — Gabriela Kelpe was pregnant when she felt a throbbing pain in one molar one day in spring 2022. It was incredibly disruptive to her life because she didn’t want to take pain medicine that could hurt the baby.

Her dentist at the time, at Sea Mar in Mount Vernon, said she would probably need a root canal, not just on the molar causing her pain but on two others. This was all a shock as she had never had serious tooth problems before.

“In my mind, I thought, ‘I should have gone to the dentist earlier,’” Kelpe said. “When I found out that I needed a root canal, I read it was dangerous — if there was an infection, it could go to the baby.”

She was about to embark on an unwanted journey into the complexity of dental care, with expensive options, even when people have Medicaid. A molar root canal can cost an insured patient nearly $2,000 out of pocket in the Puget Sound region.

Kelpe, now 39, was and still is covered by Apple Health, the state’s Medicaid program. She works as a self-employed private investigator for criminal defense attorneys. Her partner recently left active duty in the Navy as a 100% disabled veteran.

Even though she worried after the visit to Sea Mar, Kelpe had to delay care by about a month because she and her partner were moving from Oak Harbor to Everett. She quickly established all of her health care at Community Health Center of Snohomish County. A dentist there also saw her quickly, bypassing a longer wait because the clinic prioritizes pregnant patients.

She was right to be concerned. Anna Scheglov, dental operations director with Community Health Center, said a tooth infection is associated with low birthweight, preterm labor and preeclampsia.

Kelpe doesn’t remember perfectly all the details of last summer, because not only did they move, while pregnant, but they also ended up in a small house where the previous resident left cat hair and cat urine, to which Kelpe is allergic. So they were figuring out what to do about a dishonest landlord, while she was in near-constant pain, trying to work some and trying to limit stress for the health of her unborn baby.

Community Health Center dentists can do some root canals, but they referred Kelpe to the UW School of Dentistry clinics. The predoctoral clinic is staffed by dental residents, while the graduate endodontic clinic is staffed by dentists in a two-year program to be endodontists. The prices are discounted.

For adults, Apple Health does not cover root canals for molars, only front teeth. Nor does it cover porcelain crowns for molars. Apple Health does cover extractions and partial or full dentures. Apple Health does not cover bridges or implants, which could be other options after an extraction. Some of these coverages and exclusions differ for children.

Kelpe feared the wait would be long for the UW dental clinic. Eventually she was scheduled for October 2022. Since she stressed over an infection spreading, Kelpe continued to call around seeking an endodontist who might offer a discount or sliding scale.

She said none of the dental offices she found nearby, through a long DentistLink list, would take Apple Health. She needed such a provider because exams and X-rays could be covered by Apple Health, even though the root canal was not.

“I don’t know if I should have waited,” Kelpe said. “There was so much going on and there was so much stress. I didn’t know the wait times were going to be months.”

But she didn’t see how she could pay full price.

‘Everybody has the opportunity’

Washington state’s Medicaid program provides relatively “extensive” dental coverage, according to Pixie Needham, clinical dental program manager with the state’s Health Care Authority. The Centers for Medicare and Medicaid Services do not require states to include any dental coverage in Medicaid benefits.

Molar root canals have a high success rate, but they aren’t perfect, Needham said. And they generally need to be done by an endodontist. Because state reimbursement rates are so low, relative to insurance companies, Needham said she can count on one hand the number of endodontists enrolled in Medicaid.

So Apple Health covers root canals for front teeth only, which can sometimes be done by a general dentist. The front teeth are considered important to maintain someone’s physical appearance.

But molars are less visible. If adults with Apple Health cannot pay for a place like the UW dental clinics, they must have the tooth extracted and then use a partial denture.

“We want to manage the public funds well, and we want to make sure people can eat their food and speak and go out into in public and get a job,” Needham said. They also want to “make sure that everybody has the opportunity to get care.”

For adults who, like Kelpe, figure out how to pay for a molar root canal, Apple Health will cover a temporary stainless steel crown. This can give the patient more time to pay off the root canal bills and save up for a permanent porcelain crown.

Dr. Avina Paranjpe, directs the graduate endodontic program at UW and oversees some of the dentists who care for Kelpe. She explained that they carefully assess the long-term prognosis of a tooth before recommending extraction versus a root canal. Not every tooth can be saved, but Paranjpe said they try to do so if possible.

“If everything checks out — and we know we can get the root canal done, we know we can get the crown on that — then yes, a root canal is always going to be the better option,” Paranjpe said.

And that is what Kelpe remembers hearing and feeling after her first visit to the UW dental clinic.

Paranjpe added that molar root canals now have nearly a 95% long-term success rate, with good oral hygiene and restorative work. She said 95% of patients will need a crown or some sort of restorative work after the root canal.

A look at two plans

The pain continued for Kelpe, right up until that first root canal in November, the same month her daughter was born. She had part of the second root canal in April, and is scheduled for the endodontist-in-training to finish it later in June. She has a temporary crown in place.

Kelpe guessed after some of the early assessments that all of the root canal care would cost her $2,000. She’s already looking at $1,400, with uncertainty about the price of the third. The first root canal was more simple, and it cost $476. The second will cost $940. These prices don’t include an exam, X-rays or the crowns that would ensure the long-term success of the root canals.

The Daily Herald compared two employer-based dental insurance plans. One would cost $1,950 for the root canal, paid fully by the employee. The other plan had a negotiated rate of $890, and the employee would pay half, or $445.

Kelpe pays with cash or a debit card at each appointment, before she sees the provider. Apple Health has paid for an exam and an X-ray, she thinks. The dental clinic does not offer payment plans. Patients must pay up front: Credit cards are also an option.

Her daughter, Winter, is six months old now. Kelpe currently works 30 to 40 hour weeks, squeezing in work whenever she can and commuting across Skagit and Snohomish counties. Her partner attends classes at UW, studying for a bachelor’s degree. They don’t have much money left over at the end of each month.

Recently she learned that with Community Health Center of Snohomish County’s sliding scale, she would pay about $600 per molar for a crown. This was a pleasant surprise to her. She understands that a crown would cost about $900 per molar at the UW dental clinics.

In addition to work and parenting an infant, Kelpe has two teenage sons with her ex-husband, who all live one to two hours away, depending on traffic. She sees them as much as possible on weekends and special occasions, and everyone gets along well.

Kelpe doesn’t have time to sort out the complicated bills. The statements were confusing, and she was not sure if she owed money.

“Every minute of my life is calculated. I often work late night. I don’t have time to deal with medical billing. I have no idea what the codes mean, and the amounts that they provide do not make sense,” Kelpe said.

Kelpe gave UW permission to communicate about her bills and treatment to a Herald reporter, who had failed to decipher it independently.

In the end, with help, Kelpe figured it all out.

“I still cannot believe the amount of money people spend on going to the dentist. It’s outrageous,” Kelpe said. “It’s been a challenge moving to Everett, but diamonds are made under pressure.”

Joy Borkholder: 425-339-3430; joy.borkholder@heraldnet.com; Twitter: @jlbinvestigates.