Minnesota covers dental care in its biggest health insurance program for the poor, but hundreds of those families can't actually get an appointment with a dentist — and the crisis is getting worse.

Many dental offices won't accept new patients covered by Medical Assistance — or have dropped out of the program altogether — leaving the state's nonprofit dental clinics overwhelmed with requests. Of the 500,000 children on Medical Assistance, the state estimates that only one-third had seen a dentist in 2015.

In their latest effort to address the chronic problem, Senate Republicans and Gov. Mark Dayton are proposing to raise Medical Assistance payment rates, hoping doing so will attract more dentists into the system. But their approaches differ, and in a year with many other demands on the state budget, it's not clear where lawmakers will come out.

Still, public health advocates say it's time for a solution because the lack of dental care can have serious medical consequences.

"Your teeth are 3 inches from your brain," said Sarah Wovcha, executive director of the nonprofit Children's Dental Services in Minneapolis. "A tooth infection can become systemic and lead to death. And we've seen that."

The problem is especially acute in rural Minnesota, where the number of dentists has shrunk so far that most rural counties are designated as dental workforce shortage areas. That makes it even harder to find a dentist who will accept Medical Assistance, forcing some patients to travel hours to get dental care — if they can get an appointment at all.

The shortage also sends more people with severe dental pain to hospital emergency rooms, which can help only with the symptoms and not the underlying infection causing the pain.

Lowest rates

The growing crisis is widely ascribed to the low reimbursement rates Medical Assistance pays dentists for everything from a routine cleaning to an intensive root canal.

Minnesota's Medical Assistance rates for pediatric dentistry are the lowest in the nation, while its rates for adult care are the fourth-lowest.

"For a state that prides itself on good health care, that is unacceptable," said dentist Frank Dens, president of the Minnesota Dental Association. "Many dentists have chosen to make a business decision and not see those patients because basically they can't afford it."

Minnesota now pays about one-fourth of the typical fee charged by dentists, Dens said. When he started practicing in 1986, the state covered three-fourths of the fee.

While the state's payment rates have increased periodically over the decades, they have not kept pace with inflation that has pushed up the fees that dentists charge. Proposals to increase the rates are a perennial fixture of each legislative session, but rates have fallen so far behind that the money needed to catch up becomes just one of many competing priorities for limited budget dollars.

"Dental is probably the poster child for low reimbursement rates," said Michael Scandrett, who lobbies for safety net providers. "I do think it is rising in importance because people realize that it is a serious access problem."

'He didn't complain'

The family of 6-year-old Mark Meyer III, who is covered by Medical Assistance, had been trying for a month to find a dentist near their Blue Earth home. "It was very stressful," said Mark's stepmother, Gwen Stauffer. "We were very worried that we might never get in anywhere."

Then the boy's mouth started bleeding.

"He didn't complain much about pain, but seeing blood made us say we needed to get in right away," Stauffer said.

Eventually she got an appointment at the nonprofit Apple Tree Dental clinic in Madelia, about an hour's drive away. Despite learning that he had several cavities and will need more dental visits, the boy went through the visit without complaining.

"He didn't seem scared at all," said Stauffer. "No worries on him."

With six clinics around the state, Apple Tree provided 60,000 dental visits last year for people enrolled in state health insurance programs.

"Being able to cover costs is more and more challenging," said dentist and chief executive Michael Helgeson. "We've lost ground over the years. It is really critical that we get some kind of rate increase."

Although Apple Tree has been able to raise some money from donors to try to close the gap, it still can't pay salaries high enough to keep dental workers on board. As a result, it had to reduce its public program patient load last year and resort to putting patients on waiting lists, which stand at 1,000 at several clinics.

"The waiting lists are getting longer and longer," Helgeson said.

To address the problem, Gov. Mark Dayton proposed a 54 percent increase in payment rates.

While there is some support for an increase in the current session, industry representatives say that what's on the table may not be enough to spark more participation by dentists. The Senate's health care budget calls for a 25 percent increase, but the House currently has no increase written into its health bill, meaning that the issue will likely become a matter for a conference committee.

"It is an expensive issue and it is also one that we want to do comprehensively with other reforms," said Rep. Matt Dean, R-Dellwood and a House health care leader. "It is a little more complicated than just increasing rates."

Children's Dental Services, which also has a statewide presence and brings dental services to schools and Head Start centers, said it provided $4.5 million in uncompensated care last year to 35,000 children, most of them on public programs. It also needs donations to survive.

"We all pay a price when low-income people get their care in an emergency room and it costs five times what we would have paid to have prevented it," said Wovcha.