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It’s two days after Christmas and I’m sprawled out on a plastic-lined chaise lounge, sipping fluoride and waiting for the blood to stop gushing from my gums so the doctors can get back to work. Beyond the noise of drills and X-ray machines I hear grunts from several other patients and the sounds of merchants outside hawking sombreros, sweetbread, bootleg Fendi bags, and pottery. Kind of strange, but I’m not worried anymore. This is my second day at Dr. Rafael Lopez’s dental clinic, and I’m no longer freaked out that it’s nestled among trinket stores and cantinas in a bustling bazaar in Mexico.
I also don’t care that the dentists here speak hardly any English, nor I any Spanish. I mean, it’s not like I’m alone. All the other patients at Dr. Lopez’s office are either Canadian or American, and all the people shopping out front are too. In fact, nearly every person I’ve met on the streets here is Caucasian and an English speaker. We’re all dental tourists, and we’ve come to Los Algodones — a sunny border town near Yuma, Arizona, which allegedly has more dental clinics and pharmacies per block than any other city in the world — to save money. In my case, I’m in for three root canals with posts and crowns for the price of a secondhand scooter on eBay: $1,850, about a third of what I’d pay for the same procedures in the States.
I’d heard about Dr. Lopez’s clinic through a friend of my mother’s, but Los Algodones, like other dental tourism destinations, was easy to find on the Web. In fact, the town’s Web site, www.losalgodones.com, is actually a dental clinic referral network, with pictures of smiling clinicians and graphic before and after shots flashing across its home page. Clinics like Dr. Lopez’s, which often handle 10 to 20 patients a day, are set up exclusively for foreigners. Dr. Lopez estimates that 80 percent of his customers are American and 20 percent are Canadian; most Mexicans in the area can’t afford his rates. Many of them come to towns like this for big-ticket procedures like bridges and reconstructive surgery, some of which can cost more than $10,000 at home.
And they’re coming in increasing numbers. According to HealthCare Tourism International, a nonprofit accreditation and information organization set up to monitor the medical tourism boom, an estimated 1 million Americans will travel abroad this year for some of sort of medical service, up from the National Coalition on Health Care’s figure of about 150,000 in 2004. Of the procedures sought, 40 percent will be dental related. A recent article in the New York Times on the dental tourism phenomenon cited a boom in luxury travel packages designed around dental procedures. A root canal followed by a little fly-fishing in Costa Rica? Why not? The money you save can justify a short vacation.
ROOTS OF THE PROBLEM
Dr. Lopez’s clinic is, hopefully, the end of the road for me. I’ve been struggling with dental problems (and the potential resulting bills) for years. With all this talk of health care reform, you’d think I would have been able to find a decent low-cost US dentist, especially in civic-minded San Francisco. But it just wasn’t happening. For whatever reason, dental care and health care are viewed as two separate issues in the United States. When it comes to diseases, colds, and broken bones, you can usually catch a break, but good luck trying to get your teeth fixed on a budget. The truth is, even if you have some form of dental insurance, which is unlikely — according to the American Dental Association (ADA), only about half of all Americans do — dental care is nearly impossible for average wage earners to afford. At least, I’ve never been able to afford it. And I’ve looked everywhere.
My own dental horror story began nearly a decade ago when the Marine Corps kicked me off my retired father’s lifelong dental plan. I was fine for about a year, until the day I awoke with a terrible pain in my mouth. I was 19 at the time, taking classes at a community college and working at a café — barely able to pay rent, let alone find the time and money for a visit to the dentist. So I did the next best thing: simply ignored the pain, staving it off with copious amounts of ibuprofen when it got intense. The over-the-counter denial did the trick for almost two years, but I knew I would be forced to eventually bite the bullet, however softly.
And then it happened. My teeth started breaking. Not hurting, at least no more than usual, just breaking off — in huge, gray chunks.
This went on for years. By the time I was 25, four of my teeth had shattered and the rest seemed well on their way to doing the same. I adopted the diet of a five-month-old, unable to chew anything tougher than bananas or scrambled eggs. It was time to act, but I had no idea where to go. As a full-time student, getting by on financial aid, loans, and whatever I could rake in as a part-time waiter, I was nearly destitute. I’d recently transferred to San Francisco State University, but at that time, in order to purchase the student dental plan the school offered, I also had to purchase its medical plan, a combination that would have increased my monthly bills by nearly $200.
It was tempting, particularly in comparison with most employer-related or individual plans I qualified for, which could run into the thousands. But SFSU’s dental plan screened out existing problems, like the trainwreck I had going on, and carried an annual cap of less than $1,000. (Unlike medical insurance plans, which feature deductibles, most dental plans have annual monetary ceilings.) So even with the plan I would still be unable to afford even a fraction of the work I needed to have done. Since my student days, SFSU has implemented a dental-only plan available to undergrads, but often the limits are too low to cover anything other than cleanings and fillings.
Thus I began my search for a pro bono dentist, figuring that with all the uninsured people living in the city there must be someone around. It quickly became clear, however, that scoring free dental is harder than finding a decent vegetarian restaurant in rural Alabama.
QUEST FOR DENTAL
First, I had a glimmer of hope: a medical and dental clinic in Berkeley that had the word free in its name.
The Berkeley Free Clinic (BFC) has been offering free medical and dental care to the hard-up since 1969. It provides free HIV tests, medicine, preventative education, and more. But I needed dental work — and that was another story. As the only clinic in Northern California offering free fillings, extractions, and referrals to discount dentists, BFC is insanely popular. And since it’s run by volunteers and donors, it’s also chronically understaffed. Jessica Hsieh, a clinic coordinator, explained that the facility does as much as it can with limited resources. "We used to take patients on a first-come, first-served basis," she says. "But there were so many people lined up every night that our waiting room and hallway became fire hazards."
To deal with this problems, the clinic has devised a maddening selection system, which includes spotty business hours and a name-in-the-hat-style lottery. It sounded a little sketchy, but I gave it a go.
After making the 45-minute commute from my home, I arrived at the clinic at exactly 5:30 on a Monday evening. I scribbled my name on a small slip of paper, handed it to the receptionist, and took a seat in a waiting room crowded with students, broke workers, and homeless people. A nurse came out and told everyone to sit tight; the dentists were taking our names into a separate room and she’d return soon with their random choices. Ten minutes later, she came out again, read off three names, and then told everyone else to go home.
The room had been quiet as we all waited to see who’d won, but when a young blond girl with designer jeans and a fancy cell phone rose to claim her prize, the atmosphere became tense.
"That’s fucking bullshit," said a man with dirt on his face and ripped boots. "I’ve been coming here for weeks. This is her first fucking time!"
One of the dentists apologized and reminded us that we were welcome to keep trying as many times as we liked. I took his advice and returned three more times, missing a day of study or work for every fruitless visit until I gave up. One of my teeth in the back had started aching like hell, and I couldn’t stomach the wait any longer.
I broadened my search to include dental schools like that at the University of California San Francisco, where the wait times were rumored to be long, but once on the list, getting work done was guaranteed. After talking to students at the UCSF clinic, though, I realized treatment would require several days off from work and school because each step a student made during surgery would have to be approved by a busy professor and analyzed by other students. And the discount wasn’t exactly phenomenal.
The average cost of a single complete root canal procedure (root canal, post, and crown) at UCSF is more than $1,100, almost twice the amount I wound up paying in Mexico and way more than I could afford at the time.
So I scrapped the dental-school idea and dug deeper, figuring that if I couldn’t find free or cheap dental work, I could at least find a place that offered a payment plan. And I did find such a place.
Western Dental is like the McDonald’s of dental clinics. With multiple locations in almost every city in California, it’s effectively cornered the market on affordable dental work. Only it’s not cheap. A complete root canal procedure on one tooth can cost up to $1,590 — a lot less than a regular dentist, but much more than a dental school and about three times as much as Dr. Lopez charged me in Mexico. People flock to Western Dental because it lets you pay off your dental work like you would a car. You plunk down $99 for a yearlong membership, make a 20 to 30 percent down payment, and then pay the rest off monthly over the course of one year. And Western Dental doesn’t take your credit history into account when working out a plan.
Out of desperation, I eventually did get one of my teeth fixed at the Mission and 24th Street location, and wound up paying a $350 deposit and monthly installments of $110 for the next 12 months.
CAVITY CAVEATS
With my most painful tooth taken care of, I could now focus on finding a better deal, which is how I wound up in Mexico. So far it seems to have been a pretty smart decision. My new teeth look great and they’re holding up fine. I was treated extremely well by Dr. Lopez’s staff. But there are many reasons not go to Mexico for cheap dental work. And Brad Hatfield, a Korean War vet and retired city planner from Arizona City who asked that I not use his real name, knows them all.
Hatfield has been making the three-hour trip to Los Algodones for nearly a decade. He’s seen the town evolve from a haven for cheap trinkets and booze into what it is now: a medical resort for Americans with expensive tooth and eye issues. Hatfield started going to Los Algodones when he realized that even with his insurance he’d never be able to afford necessary dental work. But now, many years and thousands of dollars later, he’s learned his lesson.
"The problem with dentistry in Mexico," says Hatfield, "is that there’s no recourse. If something bad happens, you can’t sue anyone. All you can do is ask for your money back." And that’s just what Hatfield did when he returned from Los Algodones recently and discovered that his new teeth were worthless. Indeed, he claims that almost none of the work he’s gotten in Mexico has held up longer than a year or so.
This last time was the worst. "As soon as I got home," says Hatfield, "my gums started hurting really bad and bleeding off and on." When he called his clinic to complain, they denied his request for a refund and invited him back for some discounted work instead. Hatfield went back, got the work done, and thought his problems were over. But a few days later he realized they weren’t. "I was sitting here eating a piece of chocolate, and all of a sudden I realized I was chewing on two of my teeth and the bridge that was connecting them. All the work they had done had just fallen out."
Hatfield has tried repeatedly to get his dentist to refund his money back, but all he gets in response are invitations to return for more work. "Now they want to just rip all my teeth out and give me a full set of implants. It’s going to cost thousands of dollars on top of the $10,000 I’ve already spent there over the past year."
Hatfield is currently trying to get his problems fixed at a dental college in Mesa, Arizona, but he’s facing steeper prices and will probably have to return to Mexico soon. "My dental and medical problems have ruined me as a person," he says. "I can’t get a job because my teeth are so screwed up, and I can’t think through all this pain. I just don’t understand why dental work is so expensive. It’s much worse than medical."
THE BIG YANK
Hatfield brings up a good point. For some reason dental issues aren’t included in national or local debates about health care. Healthy San Francisco, the universal, citywide health care access program operated by the San Francisco Department of Public Health, doesn’t cover access to dental services, which were never even considered for inclusion. When reached by the Guardian for comment on this exclusion, SFDPH spokesperson Eileen Shields stressed the difference between the city’s program and regular insurance plans, saying "[Healthy San Francisco] is a health access plan, providing access to basic medical care. I mean, my health plan doesn’t even include dental — does yours?"
Denti-Cal, the state dental insurance program offered as part of Medi-Cal, is an option for California residents with a low income, a social security number, and at least one child. But it obviously doesn’t help the throngs who fill the waiting rooms of Western Dental. San Francisco General Hospital keeps an oral surgeon on call for extreme emergencies but if you want your janked-out teeth replaced or aren’t doubled over in chronic pain, SF General can’t help you.
It doesn’t look like any of this is changing soon. None of the candidates running for president this year has announced a platform that specifically deals with the high cost of dental care in America. Why? Why are medical and dental issues treated as two separate entities? And why is it so hard to afford dental treatment even with insurance?
Hsieh of the BFC thinks it may have to do with the fact that dental issues aren’t thought to be as life-threatening as medical issues. But if an infected tooth is left untreated, it can lead to death just as surely as unchecked pneumonia. On its Web site, the ADA acknowledges the high cost of dental insurance but privileges prevention over treatment, claiming that most dental problems are preventable. If Americans would just take care of their teeth, use their paltry insurance plans for routine checkups, and quit eating so much candy, they wouldn’t have to get root canals. But I brush after meals, floss regularly, and stay away from sweets — and I’ve been in and out of dental clinics with major problems since I was five.
Another theory has to do with the high costs of dental school and specialized equipment, which makes sense. But the truth of the matter, commonly pointed out in the ongoing health care debate, is that mixing profit with patients is a recipe for disaster. As long as insurance companies are able to make billions by fleecing their customers, and as long as dental clinics and drug companies are allowed to set their own prices, the general population is going to be cavity ridden and kind of ugly.
For now, it seems dental tourism may be the best option for people with normal-to-low incomes and chronic problems. Two months after my visit to Mexico, my teeth feel much better and I’m back on solid food. But this kind of travel isn’t for the fainthearted. The weather and food in Los Algodones are great. But getting your teeth ripped out and reconstructed in a foreign country with no legal recourse is dangerous and scary, especially during the high-traffic winter season when the tendency to rush through patients escalates.
My triple root canal, for example, took a mere two visits. The doctors hacked away for 10 hours straight, let me heal for one day, and then stuck on the crowns and pocketed my check. I stumbled out of Dr. Lopez’s office a few days before New Year’s, in a Novocain-induced daze, with blood on my shirt and pieces of rubber molding stuck to my cheeks. My jaws and head ached as I shuffled through the mile-long border-crossing corridor, sweating and dry-heaving.
As I approached the checkpoint, I wondered if I had made the right choice.
Then I remembered that I hadn’t actually made one. It was this or nothing.
Emma Lierley contributed to this report.