Handing Back Contracts - not only Britain
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- Published: Wednesday, 05 November 2025 10:48
- Written by Peter Ingle
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It is easy to see the problems of NHS dental care as a particularly British phenomenon. Those problems include, a system that has been creaking for years, funding issues, a workforce pushed to their limits, and those with the least being the most likely to bear the brunt of these failures.
But Dr Carson Cruise is not agonising over handing back an NHS contract, his dilemma is whether he can continue to see patients on Medicaid.
In another similarity with remaining UK NHS dentists, he already has some patients travelling over an hour to attend, because up until now he has accepted Medicaid. This is because the low payments where he works have led many paediatric dentists there to stop seeing patients covered under the federal-state insurance system.
At his practice in Florence, a small town in Alabama, Dr Cruise runs through the financial numbers. They make a cold but compelling case: If he dropped all of the Medicaid patients from his small-town paediatric dental practice, he could maintain the practice’s income, while working less hours. Dr Cruise and his family have already taken the difficult decision to sell their small family farm, because it became too difficult to keep up with it and the practice, and still have time for a home life.
At present about half of the patient list have their dental care covered by Medicaid, the joint federal-state health insurance program for people with low incomes. There is a four to five months waiting list to be seen.
Over 50% of Alabama children are enrolled in Medicaid, but Dr Cruise says that he is the only board-certified paediatric dentist in the area who still accepts it. He said: “I have great relationships with a lot of these families I’ve been seeing for years. I don’t want to leave them hanging, but it’s getting to a point where it’s really difficult to keep working at the pace we’re working and seeing the volume that we’re seeing.”
As States Newsroom, describing Dr Cruise’s predicament explained, Alabama is an example of a national problem. Indeed, it uses an expression familiar to UK readers, “Dental Deserts” which are defined as areas where patients need to drive for more than half an hour to be seen.
Most state Medicaid programs pay dentists significantly less than private insurers do for the same services. Increasingly dentists are less willing to take Medicaid patients, leaving low-income patients unable to access care.
Within the US federal structure there are variations, and States have flexibility in how they structure their Medicaid programs, including in how much they reimburse providers. Alabama Medicaid reimburses dentists about 46% of what they charge, on average, for their privately funded services.
In another similarity with those providing NHS care, Dr Cruise said that dentists lose money by providing some types of treatment under Medicaid.
Dr Cruise summarised his dilemma: If he only accepted patients with private insurance or who could pay out of pocket, the practice would earn far more per patient. That would allow him to cut his patient volume in half and reduce staff and overhead costs. He could work less days a week and potentially take home a bigger salary for himself.
“I love helping these kids,” he said. “I also have two kids of my own to take care of, and I can’t subsidize this care for the state of Alabama.” UK dentists know how he feels.
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