This article was originally published by The Conversation; also see What Pennsatucky’s Teeth Tell Us About Class in America

When we talk about the successes and shortcomings of the Affordable Care Act (ACA) – and health care in the U.S. in general – little attention is given to dental care.

While the ACA defines dental coverage as an essential benefit for those under 18, insurers aren’t required to offer dental coverage for adults. Medicare, the nation’s largest insurer, doesn’t cover routine dental work. And coverage for adults through Medicaid varies from state to state.

It is estimated that 108 million Americans have no dental insurance, and that one in four nonelderly Americans has untreated tooth decay.

Oral health isn’t just about nice teeth. As the surgeon general noted in a 2000 report, oral health is intimately connected to general health and can be implicated in or exacerbate diabetes, heart disease and stroke, and complications during pregnancy.

The absence of comprehensive dental care exacts a toll on millions of Americans in terms of poor health, pain and the social stigma associated with bad teeth.

People receive dental treatment at the Care Harbor/LA free clinic in Los Angeles, September 27, 2012. Lucy Nicholson/Reuters

People desperately need dental care

In 2003 and 2004 (pre-Obamacare), I conducted a national study of uninsured Americans in southcentral Illinois, northern Idaho, the Mississippi delta, the Rio Grande Valley of Texas and in eastern Massachusetts.

I asked nearly 150 interviewees: “If President Bush were to declare universal health care for everyone starting tomorrow, what is the first problem you would take care of?” The most common answer by a landslide echoed this respondent’s: “I’ll be waiting outside the dentist’s office at 5:00 in the morning waiting for it to open.”

Many of the people I interviewed lived with untreated diabetes, asthma or even cancer, yet their oral health problems presented the greatest challenges to their quality of life.

Recently I returned to these communities to reinterview the people I’d met over a decade earlier. Very little has changed. While the majority of the people I interviewed now had health care coverage of some sort (for nearly 20 percent of them, it was as a consequence of becoming sufficiently disabled to be eligible for Social Security), very few had managed to secure dental coverage.

Then and now, people told me about visiting emergency rooms in hopes of alleviating pain or using addictive pain medications to make it through the day. People even told me that they had resorted to pulling out their own teeth.

Take Misty, for instance. When I met her 12 years ago in Mississippi, she was a “dirt poor” (her words) married mother of five, and she was living with diabetes, domestic violence and excruciating headaches. Despite all of these quite serious problems, she told me that she was more troubled by her bad teeth than by anything else. In fact, Misty told me that she’d had such bad toothaches that she pulled her own teeth. When I asked her how she can face the pain of pulling out her own teeth, she said:

[the infected tooth] hurts so bad… it’s a relief just to get it out of there.… I’ve gone two weeks with just being able to eat soup, because they are just so bad.

By 2016 Misty had left her abusive husband, moved to Arkansas and was accepted onto disability (SSI), which allowed her to get health care coverage through Medicaid. Still, however, she suffered because of her teeth.

It can be very hard to find dentists who accept Medicaid, and when Misty finally did, she had the rest of her teeth – 25 in all – pulled in one day.

Misty’s situation isn’t uncommon. I have met women and men of various ages who, like Misty, have pulled their own teeth. I’ve also met people who were able to get part of their dental needs taken care of during brief periods of Medicaid coverage but then were left with unfinished treatment when the coverage ended.

Teeth aren’t included in health insurance policies. Dental x-ray image via www.shutterstock.com.

Insurance stops at the teeth

Even though the link between dental health and overall health is clear, insurance plans tend to ignore teeth.

As health insurance began to appear to appear in the U.S. – initially in the 1920s and then more widely during World War II and in the postwar era – dentistry wasn’t part of the standard package of covered services.

As the nation’s largest insurer, Medicare plays an important role in shaping health care coverage norms. Medicare does not cover dental care. Today, according to government estimates, 70 percent of seniors lack dental coverage.

Since Medicare doesn’t cover dental, Dr. David Kroll, senior program officer at the Robert Wood Johnson Foundation, argues that this “inertia spilled over into the ACA.”

Americans who purchase dental plans typically find that the plans aren’t cheap, and often don’t cover much beyond routine preventative care. Plans often require hefty copays for procedures beyond preventative care and no or very limited coverage for dentures, bridges or periodontic work.

And, in recent years, the cost of dental care has increased faster than the cost of other medical care. For those without dental insurance, there are few low-cost services available.

The ACA provided for an expansion of Medicaid eligibility, though not all states accepted the offer of federal funding to expand Medicaid coverage. Even in the states that expanded Medicaid under the ACA, strict limits on oral health care remain for most low- and moderate-income Americans.

There is one bright spot: children’s dental coverage is a required benefit included on all ACA compliant plans, and Medicaid as well. According to national calculations of the Health Policy Institute and the American Dental Association, dental care utilization among Medicaid-enrolled children increased from 35.3 percent in 2005 to 48.3 percent in 2013.

Not just about nice teeth. Shannon Stapleton/Reuters

Oral health isn’t just about nice teeth

In the absence of coherent oral health services, too many Americans end up like Gina, a young Idaho woman who holds her hand in front of her mouth while she talks so that no one will see her rotted teeth. She can’t even get a job as a telemarketer because she cannot speak distinctly enough to be hired.

Many Americans incorrectly assume that rotten teeth are the product of bad decision-making; if someone had just brushed and flossed then they’d have nice teeth. But routine dental care – think of the twice-yearly checkups that are routine for people with dental insurance – keeps teeth healthy and can catch problems when they are easy to treat.

The reality is that tooth decay signifies poverty in pernicious ways. Without expanding insurance to cover oral health, millions of Americans will continue to live with pain, stigma and the risks of systemic diseases that could be averted through an accessible and integrated system of dental care.

Christmas House Decorations wallpapers

Maybe it’s because of the bitterly cold temperatures at night this week, or maybe it’s my own visceral response to overdosing on television shows with happy family Christmas scenes and neighborhood holiday lighting competitions, but I’ve been giving a lot of thought recently to how housing and homes impact health.

About a decade ago I traveled to the Mississippi Delta, Texas’s Rio Grande Valley, south-central Illinois, the mountains of northern Idaho and the cities of eastern Massachusetts to speak with individuals and families scraping by without health insurance. Most of these people worked in construction, retail, agricultural or service jobs. The details varied, but across the country I heard about spiraling poor health, declining employability and growing poverty. In 2015 I made return trips to check in with the people I’d met ten years earlier.[i] While I was able to locate nearly all of the original interviewees who owned their homes (including very modest homes of immigrants in colonias in the Rio Grande Valley), I only located a minority of the renters. Typically, their original phone numbers were disconnected and original addresses belonged to subsequent tenants. When I knocked on neighbors’ doors the most common response was, “I don’t know [so-and-so]. I’ve only lived here for a few months myself.”

In previous posts I’ve written about marginalized Boston-area women who cycle through shelters, jails and the streets. In those contexts the “problem of homelessness” is relatively easy to see and define – all I had to do was visit shelters or walk through the public parks in which people without homes congregate during the day. But for me, it took weeks of trudging through muddy housing developments on the outskirts of Mississippi towns and knocking on doors in public housing complexes in a central Illinois cities to get a glimpse of the lives of those less visible Americans who generally manage to rent housing of some sort for periods of time but teeter on a financial edge that keeps them moving from place to place.

Unfinished housing project at 47-04 198th St. in Auburndale stands abandoned for several years.

On my 2015 reprise tour I looked for a total of 145 people in five states and was able to locate 98 of them. The missing people were not evenly distributed either geographically or by race. In Mississippi, the state that consistently has the poorest health profile in the country, I managed to locate only 11 of the 28 people whom I sought. The utter disappearance of 17 of 28 people did not surprise one local healthcare advocate (he asked to remain anonymous): “People move away to Birmingham or Tupelo to look for work. There is very little home ownership in Mississippi. The common thing is ‘lease to own’ in which a developer arranges for people to ‘lease’ (pay rent) and after 20 years they have an option to buy – to switch the rent to a mortgage. But people almost never make it to the 20 years so the developers keep leasing the same houses over.” Many of these houses would not pass even the most cursory safety inspection in other states.

I was able to locate 70 out of 88 white people I’d originally interviewed and 21 of 28 Latinos / Latinas (mostly in the Rio Grande Valley), but I only found 10 of 29 African Americans. This is consistent with national patterns. According to the US Census, the homeownership rate for the fourth quarter 2014 for non-Hispanic White householders was highest at 72 percent. The rate for All Other Races householders was 55 percent. And for Black householders it was only 42 percent. According to researchers Gregory Sharp and Matthew Hall, “The 1968 passage of the Fair Housing Act outlawed housing market discrimination based on race. …  However, emerging racial disparities over the next three decades resulted in black owners who bought their homes in the 2000s being 50 percent more likely to lose their homeowner status than similar white owners.” Even after adjusting for socio-economic characteristics, debt loads, education, and life-cycle traits like divorce or job loss, blacks were more likely to lose their homes than whites.”

Shanice’s Story

I first met Shanice in 2003 at one of the larger Black churches in Decatur, IL – a church known for its strong fellowship and advocacy on behalf of the community. She was happy to share her story with me:

“When I was 18 I worked a job, it was right after coming out of high school. No insurance and they said I wasn’t eligible for Medicaid. My doctor said that I needed to get my tonsils taken out cause they were so swollen it was almost causing me not to be able to breathe. … And so I had to go on like a payment plan with the doctor. … The whole surgery, the surgeon, the day at the hospital and then I had a setback and had to go back into the hospital cost $15,000. During the following year collection agencies called day and night, often making threats. They’d [especially] call on Sunday nights. Said that I would be going to jail if I didn’t pay them.” At age 20, Shanice filed for bankruptcy.

A few years later Shanice gave birth to her daughter. By this time Shanice was working for a storefront loan company that provided health insurance for her, but not for her daughter (she would have had to pay a premium that she could not afford on her salary.) A few years later their statuses reversed: When Illinois expanded Medicaid for children (Kid Care) her daughter became covered but Shanice, having made the decision to go back to school and learn a skill, became uninsured. Shanice was well aware of the risk she was taking was determined to build a better future for herself and her daughter. “It wasn’t just me living this carefree don’t worry about tomorrow life. Now I have someone that was dependent on me so I had to make decisions for the future. … We moved into a nice apartment, we got power, cable, phone and I got a new car.” During that time Shanice began to eat healthier meals and lost over one hundred pounds. In order to pay tuition, “I got Pell grants and student loans.” I asked Shanice how she was able to get credit to buy a car so soon after declaring bankruptcy. “Oh, they go after bankruptcy people like crazy [to sell them stuff]. I was getting credit cards in the mail every night.”

In 2003, after spending time with Shanice and her daughter at the church where they sang in the choirs, participated in groups and clubs that helped them focus on making good decisions, and volunteered helping out the poor in their community, I described Shanice in my notes as “a young woman on the way up.” She was working part-time at her church with youth and looking for her first professional job. “I just completed 1540 hours of cosmetology school and I just graduated last Friday.”

When Shanice and I walked out of the small room where the church choir stored its robes, I asked her if as a cosmetologist she would get health insurance. She answered, “I can get a job but in this field they don’t give insurance. You have to arrange that yourself.”

….

A year or so later I spoke with Shanice again. With a sense of resignation, she told me that medical and credit card debt had piled up and she was preparing to declare bankruptcy a second time.

….

Fast forward twelve years. I returned to the address at which Shanice was living when I initially met her. She had moved on and none of the current neighbors even knew her name. On USSearch I found six other addresses for her and visited each one of them. Two of the addresses did not exist. One was in a decrepit housing project that had been shut down for several years, though some people continued to squat in the apartments. (I was warned that mostly gang members were there and that it wouldn’t be safe for me to go poking around.) One address was in a middle-class, white neighborhood – none of the neighbors whom I could find knew of anyone named Shanice. Two were inhabited by other Black families who had moved in recently. Stopping by her church, I was told that, “Shanice is no longer a member of this church. She’s moved.” No one at the church knew where.

Health and Housing

It’s not hard to understand the devastating health consequences of homelessness. Living on the streets exposes people to cold, rain and assault. Without a home it’s a challenge to eat proper meals, get enough sleep and keep oneself and one’s clothing clean. The stress of not knowing where one can lay one’s head contributes to misuse of drugs and alcohol. And infections of various sorts tend to spread quickly in crowded homeless shelters. Like the people in the shelters, these health consequences are easily identified and counted.

The health consequences of moving around are less immediately visible to the casual eye. But at a community health center in Decatur Illinois, nurse administrators Karen Schneller and Tanya Andricks elaborated on ways in which churn in housing is related to churn in healthcare. Different states and even different counties and towns have different healthcare resources available to residents. Different providers have different medication preferences and treatment protocols so people stop and start treatments. Even with dedicated staff efforts, it is impossible to provide follow-up care for patients who can’t be reached – whose phones are turned off and whose mail is returned “addressee unknown.”

Jenny Trimmell, public health administrator and Melissa Rome, community liaison at the Vermilion County (Illinois) Health Department explained that children like Shanice’s daughter particularly suffer from frequent moves. “When the Cabrini Green housing project in Chicago was closed to pave the way for gentrification former residents were offered vouchers by the Housing Authority and promised housing and jobs in towns in central Illinois. But there was not enough housing and not enough jobs, so people go back and forth to Chicago. There was a cultural adjustment for many moving from Chicago to more rural downstate.  People were unaware that services outside of the city of Chicago may be limited, such as access to health care providers; bus services that do not run 24/7, etc.  Everyone is frustrated. The kids are in and out of schools and medical records kept by parents are incomplete or non-existent. It is difficult for the Health Department to determine immunization status for these children and frequently immunization series have to be started over due to the unknown immunization status.” Trimmell and Rome went on to explain that without the kinds of community support children develop when they stay put in one school, “there are high drop-out rates, teen pregnancies and drug use.”

Musings

Getting to know and then losing track of Shanice and others in similar situations has made me more attuned to the health privileges of stable and secure housing. My home allows me to accumulate the material objects that anchor and enhance my life, both in immediate ways by giving me space to store medication and in less tangible ways by grounding me in the photos, books and furnishings that tie me to my past and to the people I love. My home provides a hidey-hole for times when the outside world feels overwhelming. It gives me a familiar bed and private bathroom when I am sick, and a kitchen in which I can cook the food that I want to eat when I want to eat it. My home allows me to cultivate neighbors who can lend a hand at times of need and offers me the space to nurture those special bonds with the family that looks out for my well-being. In my own home I have the power to keep out rats, roaches, mold and the dust and down that I am allergic to. I am not dependent on the vagaries of landlords or property management companies. No less important, my home gives me an address at which I receive and retain the paperwork that helps keep my financial, medical and legal life in order as well as reminders of when and where to exercise my right to vote (yes – for candidates who support legislation that makes my community healthier).

I plan to return to Decatur next week and resume my search for Shanice. Maybe she has found another supportive church community somewhere else in the area. Maybe she finally has her healthcare coverage straightened out. Maybe her daughter has escaped being one of the kids who’s been subjected to multiple rounds of vaccinations. Maybe she’s become the star of her high school marching band or debate team. I hope so.

 

 

[i] In each community I began with the contact information people had given me when we first met. Only a minority still lived at the same address or had the same phone number. Then I turned to phone books, social media, Google and other public-access online search engines, including USSearch that listed multiple address histories for many of the people. In each community, if my initial attempts to make contact failed, I then called on common acquaintances, knocked on doors of neighboring houses, and asked at local grocery stores, libraries and churches.

For more on this project:”The State(s) of the Affordable Care Act”

For more on housing struggles, take a look at this article about “Carly”

feature image via thebluedolphins.blogspot.com

A few days ago I listened while Francesca, a woman I’ve come to know during a decade of working with criminalized women, ranted about “the bitch” over at the welfare office who refused to give her food stamps. According to Francesca, “the bitch” didn’t believe that Francesca had not received the letter telling her that she needed to re-certify her eligibility. This, I thought, is a systematic problem: Access to vital services typically is tied to having a permanent address. As a consequence, the ability to receive services is linked to a level of financial stability that the people who most need these services are unlikely to have. Since Francesca had not had a secure place to live for over a decade, it’s no surprise that the letter didn’t reach her. But for Francesca, at least at that moment, the systemic problem was not on her mind. Rather, she focused her attention on “the bitch” who, so it seemed to her, wanted Francesca and her children to starve. Never one to hold back, Francesca had “let the bitch know what I thought about her” before she stormed out of the office.

Francesca is a fabulous raconteur and as I listened to her retelling of the food stamp office story I shared her outrage, and probably would have joined her had she proposed a return trip to yell at “the bitch”. But when I had the luxury of some time to think over what she’d told me I realized of course, that the welfare worker had no authority in this matter: However much she liked or disliked, sympathized with or looked down on women like Francesca, she was not authorized to give food stamps to someone who had not re-certified her eligibility.

Over the years Francesca has confronted two other “bitches” in my presence. One was a hospital nurse who “refused to let me see the doctor.” The other was a parole officer who told her that if she didn’t keep up restitution payments on an old crime committed by her ex-husband she would be sent to jail. Both times Francesca barraged the “bitches” with pleading, tears and finally curses. I don’t know if they felt fear, anger or shame (probably a combination of all three), but I do know that they are placed in untenable situations like this on a daily basis.

As the public face of social services, they face the despair and rage of people trying to maintain a sense of dignity – albeit sometimes in ways that backfire — in a culture that treats food and housing and freedom as commodities rather than as human rights. Perceived (mistakenly) as the gatekeepers to food, medicine and freedom, the “bitches” Francesca confronts are targets for the anger of hungry, sick, homeless, battered and poor clients who cannot access the help that they need, especially in this era of cutbacks in social services.

In popular culture, “Type A” men drop dead from heart attacks brought on by the stress of their powerful positions. Yet a weighty body of literature shows that the most severe job strain is not characterized by high levels of authority but rather by low levels of authority coupled with high levels of responsibility. Workers tasked with keeping people alive while lacking power over the necessary resources and policies to do so are especially likely to suffer poor health, chronic physical and mental distress, and greater risk of death.

The hundreds of thousands of women who predominate in the lower and middle rungs of the health and social service professions live with the heavy responsibility of granting or denying access to potentially life-saving goods and services to desperate women like Francesca. Deflecting the anger that should be directed at the (usually male, certainly higher paid) policy makers, administrators and supervisors, they are stuck enforcing rules that they have no power to shape or change.

The “bitches” at whom Francesca vents her (righteous) anger are butts of nasty comments about government bureaucrat “fat cats” though they often earn salaries that are barely above minimum wage. As women they most likely carry the double load of paid employment and house / wife / mother work – the impossible task of trying to raise healthy, well-adjusted children in a world of violence, air pollution, aggressive consumerism and 24/7 headsets. It’s likely that they themselves have applied for – and perhaps been denied – food stamps; that they have children or siblings struggling to pay court fees in order to stay out of jail; and that they too can’t get the kind of medical attention that they need.

I’m not sure how I’ll react the next time Francesca blows up at a clerk or a caseworker. I’d like to think that I’ll be able to persuade everyone concerned that the real enemy is not the woman on the other side of the desk but rather the powerbrokers who keep them there. But in truth, I’ll probably be so wracked with feeling both responsible for keeping Francesca in line and powerless to ameliorate her situation that I’ll come down with a migraine.

 

“Caste Away” originally appeared as part of the University of California Press’s blog series coinciding with this month’s American Sociological Association’s annual conference: “Hard Times: The Impact of Economic Inequality on Families and Individuals.”

I first met Elizabeth at a drop-in center for poor and homeless women shortly after she was released from prison. Elizabeth’s father was a firefighter. Her mother worked for years at a stable job in a factory. Her parents owned their home in a working-class white community in a Boston suburb, and raised their children with aspirations of college and a middle-class life. By the time Elizabeth came of age America’s economic landscape had changed. Secure jobs that pay good wages were scarce and even though Elizabeth earned an associate’s degree she wasn’t able to do better than a series of unreliable jobs in food service. When a family tragedy (her sister’s illness and eventual death) made her too sad to smile at restaurant patrons she was fired. Broke and depressed, she lost her apartment, began to drink excessively, suffered several assaults, and was arrested and incarcerated on charges of creating a public disturbance and shoplifting. “Free” now for more than five years, she is stigmatized, unemployable, and sick.

As wealth and income gaps in the United States have dramatically widened over the past decades, the life paths of rich and poor Americans have diverged to the point in which, I believe, we should consider using the language of “caste” to describe American society. Caste arises when social differences become so significant that individual personalities, preferences, talents and weaknesses become subsumed to stereotypical images of the characteristics of a community or group as a whole – what we often call profiling. Groups are identified in terms of physical differences (real or imagined), inter-group interactions become formalized and limited, group characteristics become infused with moral meanings which justify and enforce differential access to valued resources and occupations, and group characteristics come to be seen as inherent and unchangeable.

Elizabeth has helped me understand the workings of caste. She experiences geographic segregation, whether in jail, in homeless shelters or in public housing. She has been arrested for trespassing simply for sitting down and relaxing in neighborhoods not assigned to, in her words, “people like me.” Elizabeth recognizes that there are structural barriers to changing her status, but most days she attributes her position to classic caste-like physical traits: a genetic tendency for alcohol abuse or to PTSD that has “rewired my brain.”

Having been raised in a working-class community, Elizabeth is aware of how differently she is treated now that she has lost some of her teeth and acquired the clothes and mannerisms of the untouchable caste. She once told me that people don’t like to sit next to her on public transportation. “They look at me like I smell bad even though I shower every day.” The only non-poor people she has contact with these days are service providers such as therapists and doctors, or law enforcement agents. Her caseworkers berate her for being involved with men who are, as she puts it, “messed up.” But, Elizabeth explains, “no man who is any good is going to want a woman like me.”

In the twenty-first century health and wealth are tightly correlated. Poor Americans are sick because the housing they can afford is clustered in environmentally unsound neighborhoods; the jobs they can get involve debilitating physical labor, ongoing exposure to toxic chemicals, or harassment by bosses or customers; the food they can afford is nutritionally unsound; and access to consistent health care (especially dental care) is limited. In a cyclical manner, poor health, and especially visually obvious signs such as rotting teeth, limits the ability to get the kinds of jobs that pay living wages.

For Elizabeth, as for many Americans, a prison record sealed her caste membership. She is not alone. By age 23, 49% percent of black men and 16% of black women, 44% of Hispanic men and 18% of Hispanic women, and 38% percent of white men and 20% of white women have been arrested. Poor and low-income Americans are far more likely to be arrested and incarcerated than better off Americans. Over half of the incarcerated population has been diagnosed with a mental health issue and at least 40% suffer from chronic illness. Unhealthy prison conditions partly explain the substandard health profile of Americans involved with the correctional system. But the fact is that people entering prison are already sicker and poorer than other Americans.

Elizabeth often says that before her life fell apart she didn’t even know that there are people who live the way she lives now. But of course, caste is not a new phenomenon. In the United States racial categories traditionally have constituted a caste system and African Americans have long experienced segregation, barriers to occupational advancement, and ascription of morally suspect traits and behaviors such as mental illness, cognitive impairment, infectious diseases, hypersexuality, promiscuity, drug use, defective parenting, and childlike dependence on public assistance. The news, then, is not that America is a caste society. Rather, it’s how easy it has become to join the ranks of the caste of the ill, impoverished and criminalized.

You can read more about Elizabeth in my new book: Can’t Catch a Break: Gender, Jail, Drugs, and the Limits of Personal Responsibility.

Author’s note: Friends and colleagues who know that I’ve spent most of the past decade working closely with criminalized women have asked me what I think of “Orange is the New Black”. While I could do without the dubious emphasis on sex among the women, and I doubt that women prisoners ever have the kind of power attributed to Red or Gloria, overall I think the series does a good job portraying women prisoners as real, complex human beings and of showing the miseries of life inside and outside of prison for most incarcerated women.

(A version of this post with fabulous photos: http://bitchmagazine.org/post/what-pennsatucky%E2%80%99s-teeth-tell-us-about-class-in-america)

I know she is supposed to be a cross between a villain and comic relief, but Tiffany “Pennsatucky” Doggett is my favorite character to watch this season on Orange is the New Black. For those (few) who have not watched the series, Tiffany is a caricature of an ignorant / hillbilly / Jesus freak / meth head. In the first season we saw her provoke and eventually fight Piper, the attractive, articulate protagonist and author of the book on which the series is based. At the start of season two, when Tiffany returns from a three week stint in solitary, even her former friends – the other poorly educated, young white women – turn on her.

Tiffany isn’t cute or funny or even a font of homespun southern wisdom. But in the midst of a prison culture formally and informally divided by race, Tiffany embodies an equally powerful yet rarely articulated social divide: class. Though white, she has nothing in common with the other white women: Machiavellian Alex (Piper’s lover and nemesis), gender savvy Nicky, hip Sister Jane or even Russian entrepreneur Red, all of whom are presented as smart, literate, able to plan and scheme, and holding some understanding of the outside world. Tiffany doesn’t even fit in with Morello, a none-too-bright white woman with a working-class accent who lives in a fantasy world of romance and Hollywood magazines.

The producers of the series provide viewers a clear visual cue to the class divide. The first time Pennsatucky opens her mouth we see a hideous display of broken and missing teeth. More than any other marker, teeth indicate class status. Perfectly white and straight teeth – the kind we see on celebrities — belong to the super rich who can afford costly cosmetic dentistry. Nicely aligned and healthy teeth are the sign of professional and upper middle class individuals who can afford regular dental care and basic orthodontia. Crooked teeth with delayed root canal work and a few crowns means the mouth belongs to a young or middle-aged middle or working class individual (someone with access to basic dental care but no more); a complete set of dentures indicate an older working class individual. And rotted teeth, like those sported by Tiffany, marks one as poor, a status with both economic and moral meaning. As I’ve been told countless times by Americans who do not earn enough to scrape by, being too poor to have respectable teeth is like wearing an “L” for loser on your face.

Teeth: The Orphan of the Healthcare SystemContinue reading