On Molokai, half the island’s dentists now require patients to pay upfront for the cost of care, a move that’s prompting some residents to forgo visits to the dentist altogether.

Chris Chow, a dentist in the island’s main town of Kaunakakai, said in a letter to patients that his decision to stop accepting insurance on Jan. 1 amounts to a refusal to lower the patient standards that he said his practice has set and maintained for 42 years.

“They are trying to force us in-network doctors to do treatment according to their rules, rather than according to your needs or even how you want to be treated,” Chow said in a letter to patients, adding that, “many insurance companies are adding more and more restrictions on what they will allow for their subscribers.”

Chow did not respond to requests for comment for this story.

Boki Chung, another Molokai dentist who, according to her website, started requiring patients to front the money for their dental care starting in January, also did not return calls for comment.

Kimberly Svetin, president of family owned Molokai Drugs, said several employees of the island’s only pharmacy have indicated that they will no longer go to the dentist because they can’t afford to dig into their wallets to pay for it. Other staffers have decided to fly to Honolulu to see a dentist that accepts their insurance, Svetin said.

Out-of-pocket costs for a routine teeth cleaning — a preventative treatment recommended biannually to remove plaque and tartar — typically costs a little over $200. For some people on Molokai — an island of 7,400 people with the state’s lowest household incomes and highest unemployment — $200 can put them over the edge. With insurance coverage, that same teeth cleaning might cost the patient $10 or $12.

Patients who front the money for dental care can seek reimbursement from their insurer. But this can take weeks and often requires a good deal of paperwork.

“I understand how difficult it is to do the administrative work required to work with insurance,” said Kelley Withy, a medical doctor and professor at the University of Hawaii’s John A. Burns School of Medicine who tracks the state’s medical professional needs. “And it’s expensive. But it’s much more difficult for individuals who don’t understand how to do it.”

“What people don’t understand is that when your claim gets denied, you have to try it again. In health care, you have to keep trying. You just resubmit and resubmit. And that’s another administrative hassle, one that’s being shifted from the dentist to the patient. Many people will just give up.”

A growing body of research links oral health with general health, especially for pregnant women, and experts say the risks of skipping routine dental care can’t be overstated. In addition to producing a cleaner, whiter smile, teeth cleanings reduce the likelihood of gum disease, which is linked to other health problems, ranging from diabetes and stroke to heart disease and dementia.

When it became clear that some staff at Molokai Drugs felt they could no longer afford to see a dentist, the pharmacy started offering a no-interest loan to help them come up with the money for treatment and tide them over while they wait for a reimbursement check. 

“We are helping out employees so they don’t have to charge the up-front amount on their credit cards,” Svetin explained in an email.

In addition to the dental-finance offering it added this year, Molokai Drugs plans to give a pharmacy gift certificate to all employees who floss twice a day during the month of March. Svetin said she recently invited a guest speaker to discuss at-home dental care strategies with staff. 

The shift to pre-paid care for patients at two of the island’s four dental practices restricts access to care on Molokai, a rural island that has long struggled with a shortage of health care providers. But there are still dentists on the island who accept insurance plans.

Shanna Willing, interim chief executive officer at Molokai Community Health Center, said a flood of new dental patients have transferred into the care of the federally qualified health center, a safety net provider that must accept all patients regardless of their ability to pay. Even before the surge in new patients, Willing said there was about a month-long wait for a dental appointment at the clinic. The wait time has since grown to several months.

Correction: An earlier version of this story attributed this information to Director of Operations Shawnna Wataoka instead of Interim Chief Executive Officer Shanna Willing.

As of Thursday, the next available appointment with the dentist at Molokai Community Health Center is June 6. The next available slot to see a dental hygienist is May 30.  

The health center late last year received a $1.6 million federal grant to expand its three-room dental practice with four additional patient rooms and more staff. Willing said she hopes the planned expansion will be completed in a year or two.

The Hawaii Dental Association does not collect data about which insurance plans its member-dentists choose to accept, according to spokesperson Melissa Pavlicek. But she said the trade group routinely advocates for legislation to widen and improve access to dental care.

“Of course we want to see people having fewer barriers to care,” Pavlicek said.

Nearly two-thirds of the island’s residents are covered by Med-QUEST, the state’s version of Medicaid, compared to about a third of all Hawaii residents. 

Civil Beat’s coverage of Maui County is supported in part by grants from the Nuestro Futuro Foundation.

Civil Beat’s community health coverage is supported by the Swayne Family Fund of Hawaii Community Foundation, the Cooke Foundation, Atherton Family Foundation and Papa Ola Lokahi.