The email sent to Dr. Michal Herman in early December was like many others she has received in her 25-year dental career. It was a from a teacher at a Newark school. She had a 6-year-old who was homeless — and his teeth were rotting.

When he arrived at KinderSmile Foundation’s office in Essex County, Herman quickly determined that 16 of the boy’s 22 teeth required fillings, extractions or baby root canals.

“It’s really not uncommon for a child to come to us in this condition,” said Herman, chief operating officer of the foundation, which provides dental services to low-income children. “We see this all the time.”

More than a third of New Jersey’s children have untreated tooth decay, far outpacing the national average. And the leading cause, advocates say, is the limited access to care that low-income families have.

In a state with the second-highest average household income, poor children with poor teeth often get overlooked in New Jersey until there is a major problem. And even then, getting to see a dentist can be a major challenge, some dentists and health advocates say.

Most NJ dental practices don’t take Medicaid

Access is extremely difficult in New Jersey because the vast majority of dental practices don’t accept Medicaid — government insurance for low-income people. Even those that do sometimes won’t take an appointment.

The New Jersey Health Care Quality Institute recently put that to the test by trying to book an appointment for a fictitious 2-year-old on Medicaid with 824 general and pediatric dental practices listed as accepting the insurance.

The nonprofit group’s “secret shopper” survey found that only 49% of the practices listed by insurance companies as accepting Medicaid took the appointment. Most of the others said they were listed in error as accepting Medicaid.

Other practices were unreachable after two attempts. Based on the survey, less than 10% of New Jersey’s more than 4,500 dentists accept Medicaid.

“It shows how hard it is to get a child on Medicaid the dental care they need in this state,” said Linda Schwimmer, CEO of the Health Care Quality Institute. “Dental health is critical to infection rates, good nutrition, being focused in school — and it’s one of the largest health disparities we have.”

36% of NJ third graders have tooth decay

The report adds more evidence of a great health divide in New Jersey, where middle- and upper-class families have access to well-regarded hospitals, physicians and health care networks that are often ranked among the nation’s best.

Low-income and especially Black families are more likely to be stricken with and die from a cornucopia of diseases, state Health Department data shows.

About 36% of New Jersey third graders have untreated tooth decay, compared with the national average of 20%, according to a 2022 survey by the Health Department. Black and Hispanic children had higher rates of decay, as did children from schools in low-income neighborhoods, the state survey found.

Medicaid is supposed to narrow the divide, but it can’t if providers aren’t accepting it, Schwimmer said.

Orville Morales, a spokesman for the New Jersey Dental Association, said many of its 4,500 members don’t accept Medicaid due to “persistently low” payment rates.

Low Medicaid payments

Medicaid and the five private insurance companies that manage New Jersey’s Medicaid system pay less than commercial dental insurance for many common procedures.

While the average new-patient exam costs about $90 and a basic tooth extraction $190, Medicaid through insurance companies pays significantly less — about $25 and $75, respectively, for the services, according to data shared with NorthJersey.com.

“Some of the rates are less than a manicure,” Herman said.

The rates are in the bottom 10% in the U.S. — and the rates for children have not been increased since 2007, the report said. Dental care for children is about $50 million in New Jersey’s $20 billion Medicaid budget, Schwimmer said. And advocates are concerned that the Trump administration may push for significant cuts to Medicaid.

The institute’s report “underscores the lack of transparency in the system, which creates barriers to achieving optimal oral health outcomes for children in New Jersey,” Morales said in a statement.

There is also a reluctance to treat children. Just like primary care providers, dentistry is a volume business, where revenue and profits are often tied to the number of patients providers can see in the shortest amount of time.

But children are not the easiest customers. Many are filled with anxiety and can be less cooperative than adults. They spend more time in the dentist’s chair, which leads to extended appointments.

Another big problem is the accuracy of the Medicaid provider directories. About 37% of those contacted by the institute said they don’t accept Medicaid for young children, despite being listed. Schwimmer said insurance companies need to update these directories, or else they are merely “ghost networks” that provide no value to a Medicaid patient in need.

As for the 6-year-old with a mouthful of decaying teeth, he will require four to five visits to KinderSmile, which has offices in Bloomfield, Newark and Trenton. A dentist will work on a quarter of his mouth at a time to limit the pain and ensure that each segment heals properly.

What happens after that remains to be seen. The child, who has developmental disabilities, has a parent with cancer and is homeless.

“We hope he’s able to come back regularly so this doesn’t happen again,” Herman said.