Imagine if the government offered dental care. New federal rule could make that a reality.

Even when she had a massive infection and grueling pain from a cracked tooth, Nicole Sutton could not get a dentist to provide timely care.

Sutton, a single mother based in Tampa, Florida, could only get herself on a waitlist where she got in line to see one of the few dentists who take Medicaid, the government insurance for low-income families. She visited a hospital emergency room and a federally funded community health center, but those appointments only yielded prescriptions for antibiotics and pain pills. Neither offered to treat her dental crisis.

It wasn’t until she secured a loan from a friend that she could afford to see a specialist and an oral surgeon who extracted her tooth in an emergency procedure. Both demanded cash upfront.

It took months to clear the infection and return to health. The protracted dental episode two years ago exposed Sutton to the lurking disaster millions of Americans face because they don’t have robust dental insurance that guarantees access to oral care. A solution from the federal government may be forthcoming, which could have made a huge difference for Sutton.

“A dental infection can kill you,” Sutton said.  “Yes, there's pain, but it can also really impact your health.”

Introducing Affordable Care Act dental insurance

Americans experience dental emergencies every year and the U.S. health care system is ill-equipped to help them, according to advocates.

The Affordable Care Act extended health insurance to tens of millions of Americans, through federal and state marketplaces that sell subsidized health insurance and Medicaid expansion adopted by all but 10 states.

But President Barack Obama's signature 2010 health care law excluded dental coverage for adults. The health law required states to offer pediatric dental care as an essential health benefit for ACA plans.

In a move last month that received little fanfare, the Biden administration finalized a rule that would give states the option of adding adult dental insurance coverage as part of their Affordable Care Act plans.

In another attempt to bolster dental coverage, Sen. Bernie Sanders, I-Vt., on Friday introduced the Comprehensive Dental Care Reform Act of 2024, a bill that would expand dental coverage through Medicare, Medicaid and the Veterans Administration and increase the number of dentists, dental hygienists and dental therapists nationwide.

The deficit in dental coverage is immense: Nearly 69 million U.S. adults did not have dental insurance or access to routine oral health care last year, according to a survey by the nonprofit CareQuest Institute for Oral Health. Millions more lost dental insurance last year when states began to unwind Medicaid coverage for people who signed up during the COVID-19 pandemic.

People who don't have coverage often wait before seeking care, and minor infections turn into life-threatening ordeals, advocates say. Those who rely on safety net programs such as Medicaid or community health centers that are federally qualified often end up on wait lists and struggle to get timely dental appointments. Only 1 in 3 U.S. dentists agree to take care of Medicaid patients. Even fewer dentists see a lot of Medicaid patients.

Dentists can limit which insurance plans they take and require uninsured patients to pay cash upfront. Others steer patients to credit-card-style companies that extend credit with high interest rates. Under the arrangement, dentists get paid immediately, and patients get bills and face high-interest penalties if they don't pay the balance during a grace period of several months.

Advocates like Melissa Burroughs, director of public policy at CareQuest Institute for Oral Health, aim to level the playing field, making dental care accessible to all.

“For far too many people in this country, oral health care is unaffordable and out of reach,” Burroughs said. “And that's largely because there are very significant gaps in insurance.”

Under Biden's rule, states have until 2025 to decide whether to mandate that insurers cover dental benefits for adults. The dental benefits would not take effect until 2027. No states have publicly signaled yet that they intend to require ACA dental benefits in 2027, however, advocates say the new rule could represent a significant expansion of dental insurance, which gets less scrutiny than medical insurance for hospital, doctor and pharmacy bills.

Sanders has rallied for dental reforms for more than a decade. In 2022, the senator unsuccessfully pushed for Medicare to provide comprehensive dental coverage for older Americans. During a hearing Thursday of the Senate Health, Education, Labor and Pensions Committee he chairs, Sanders said tens of millions of American adults either can't afford or are unable to get necessary dental care. The hearing featured testimony from dentists, advocates and academics who discussed the depths of the challenge of providing nationwide oral care access.

"This is an issue we do not discuss enough," Sanders told the committee. "It is a crisis issue."

Advocates cheered the renewed attention to dental health insurance. The Biden rule is "pretty monumental" because it could pave the way for more robust dental coverage, said Colin Reusch, senior adviser for oral health policy at Community Catalyst, a health advocacy organization.

Reusch said about a half dozen states have previously explored the possibility of adding adult dental benefits, but, he said, it's too early to say whether any would consider adding coverage under the Biden rule.

Americans are more likely to skip dental care because of the cost than to forego other types of health care such as costly doctor visits or prescriptions.

Dental coverage and access is "one of the places where people face significant affordability barriers," Reusch said. "In fact, dental coverage presents a higher out-of-pocket burden compared to just about any other category of health care."

'Beauty and smiles' stymied by gum disease

New York City native Shaena Morris became accustomed to top-notch medical and dental care as a child and young adult. She took diligent care of her teeth, getting routine cleanings and checkups.

But when she moved to Florida with her family a decade ago, she could no longer count on timely appointments or access to care.

When her gums became inflamed after the birth of her first child, one dentist recommended a $4,000 deep cleaning that her dental insurer, Medicaid, would not cover. Now a resident of Dania Beach, Florida, Morris has cycled on and off of a public health insurance program as her household income has changed. Even when she's on Medicaid, she often cannot get timely appointments or coverage of dental specialists that she needs.

Beyond dealing with pain and discomfort, she feels her inconsistent dental care has harmed her career as a cosmetologist doing hair and makeup for the likes of Paris Hilton. She believes her clients and managers have noticed her dental problems. She ultimately walked away from a profession she'd been in for nearly two decades because of what limited dental care did to her oral health.

"Beauty and smiles − that's my life," Morris said. "My talent can no longer sustain me because people need you to look like Photoshop."

Dental care and job prospects

About 30% of low-income adults nationwide and nearly 60% of Medicaid beneficiaries without dental access believe the appearance of their mouth and teeth has limited their ability to interview for a job, according to a document filed by the Centers for Medicare & Medicaid Services as part of the rule change.

"Try to get a job without any teeth in your mouth," Sanders proposed. "Good luck, because you're not going to get it."

Delayed dental care doesn't just impact appearance and job prospects, it's also linked to an array of medical problems. Nearly half of U.S. adults have periodontal disease and more than 40% of children have developed tooth decay by Kindergarten.

Poor oral health is also associated with risk of high blood pressure, diabetes, heart disease, dementia and adverse birth outcomes, research shows.

Lisa Simon worked as a dentist in a community health center where the waiting period for an appointment often exceeded four months. She said she routinely had to extract teeth that she could have saved if Medicaid funding had been sufficient to get patients timely appointments.

Now an internal medicine doctor at Brigham and Women’s Hospital in Boston, Simon sees more adult patients who have never been to a dentist, including people hospitalized with life-threatening sepsis that resulted from an untended dental infection. Other patients who couldn't afford to remove infected teeth and had to delay chemotherapy. Doctors often recommend patients get dental infections treated before starting chemotherapy.

"Both my medical and dental patients asked me the same question: Why is it so hard for me to get dental care?" Simon said. "There is no good reason."

Dental infection turns fatal

Dentists say the costs of operating a practice, including hiring support staff and hygienists, make it difficult financially for them to take a large number of Medicaid patients. Young dentists often must repay student loans that typically carry higher balances than what medical students owe. The low reimbursement rates from Medicaid make it difficult for some practices to make ends meet.

These issues are especially acute in rural communities that face dental provider shortages. Young dentists who must repay hundreds of thousands of dollars in student loans may be reluctant to practice in rural communities with higher rates of uninsured patients. Two-thirds of rural communities nationwide are designated as having a shortage of dental professional, Sanders said.

Dr. Gordon Roswell Isbell III, who runs a dental practice with his son in Gadsden, Alabama, said the economic and workforce challenges for independent dentists are daunting. His practice employs six dental hygienists who are all near retirement age.

Insurance payments have decreased as business costs have risen, Isbell said, which makes it hard to keep the business afloat.

Dentists who are just getting out of school have a long way to go, said Brian Jeffrey Swann, a private and public health oral physician who lives in Greenback, Tennessee, and also practices in North Carolina and Massachusetts. "It's going to take them five to seven years before they start breaking even," he said.

Swann serves on the board of Remote Area Medical, a nonprofit that provides care at pop-up dental, vision and medical clinics around the U.S. at no cost to patients. People flock to these clinics, often driving across state lines to access care from dentists, hygienists and other volunteer health care workers. Some arrive days in advance of the clinics, sleeping in cars and wrapped in blankets, just to get a chance at free dental or other health care, Swann said.

Swann recounted the case of a 27-year-old Appalachian woman who had a range of health problems and developed swelling under her chin because of an infected, decaying molar. She went to a hospital emergency room where she was given antibiotics and pain pills and instructed to seek dental care.

She visited a dentist who told her it would cost $900 to remove the infected molar. She didn't have the cash, and decided to wait for a refund check before she saw a dentist to extract the tooth.

But her condition worsened over the ensuing months. She had trouble swallowing. Her neck turned black. She ended up at a university hospital where she received IV antibiotics and had her infected tooth extracted. She died two days later. The cause of death: sepsis from an infected tooth.

Swann said the hospital doctors who initially cared for the woman had received no training in oral health. The woman's mother and husband lamented the fact that nobody warned them about the seriousness of her condition.

The mother told Swann, "If they had only told us that a tooth infection could kill my daughter."

Have you had trouble accessing dental care due to cost or lack of health insurance? Please share your story with consumer health reporter Ken Alltucker, alltuck@usatoday.com

This article originally appeared on USA TODAY: Dental care and insurance costs too much. ACA rule could change that