SPRINGFIELD — For decades, dentists across Illinois have taken time out of their daily schedules to swap sterile offices for public schools, providing checkups, fluoride treatments and cleanings to children who might otherwise go without dental care.

In Chicago Public Schools alone, city officials say the program has reached more than 1.3 million students, serving children in some of the city’s most underserved neighborhoods at no cost to families.

But in recent years, frustration with the Chicago Department of Public Health, which oversees dental providers in CPS schools, has begun to erode the program, with the number of participating dental groups and the share of CPS students being cut nearly in half. And some providers now are saying they are on the verge of walking away entirely.

Amid the decline, a bill is advancing in the Illinois General Assembly that would strip the city of its oversight role and hand it to the state.

While city health officials warn such a switch would remove critical safeguards and undermine a partnership they say has long served students well, some dental providers say it is needed to fix a city bureaucratic breakdown that has grown increasingly difficult to navigate under new CDPH leadership. It’s been marked by what those providers describe as hostile inspections, interference with clinical decisions and billing rules that can force them to absorb the cost of treating uninsured students with no reimbursement.

“Dental teams started receiving unusually harsh reviews. Clinical treatment decisions were questioned or even dictated. Some teams were sanctioned and even threatened with closure,” Dr. Luciana Sweis, whose Dental Caravan had provided dental services to CPS schools for two decades, told the Illinois Senate Health and Human Services Committee in February. “Over time, qualified employees chose to leave rather than work under those conditions.”

Unlike the rest of Illinois, where a single statewide program governs school-based dental visits, Chicago runs its own parallel program jointly administered by CPS and CDPH. Across the rest of the state, providers mail permission forms asking parents to supply their child’s insurance information and may follow up if anything is missing. In Chicago, providers say they are barred from contacting parents to finalize incomplete forms. If a student’s insurance cannot be verified, the provider must treat the child free of charge — a policy that, compounded by low Medicaid reimbursement rates, can quickly render participation financially untenable.

“We are trying our best to do this, but … it’s too expensive to see kids at no charge,” said Dr. Dave Trost, a dentist with Miles of Smiles, one of the largest school dental providers in the state. “We have to pay our people and we have to pay our bills.”

Trost said the billing policy may also expose providers to legal risk: treating uninsured students for free while billing those with Medicaid or the state’s All Kids program could run afoul of state and federal Medicaid rules. The Chicago Association of School Dentists, of which Trost is president, sued CPS over the policy in 2023. That lawsuit is ongoing.

The push in Springfield to fold Chicago’s program into the state version run by the Illinois Department of Healthcare and Family Services comes as the number of contracted dental groups in Chicago’s program has fallen to 10 from 17 in 2016, according to CDPH data. With fewer dental groups, the percentage of CPS students served by the dental program also fell to 16% in the 2024 school year from 28% in the 2016 school year.

CDPH Commissioner Dr. Olusimbo “Simbo” Ige said the percentage of students the program serves does not accurately measure its success because parents can opt their children out. She added that declining interest from providers could be due to the growing number of uninsured people, making participation more costly than in past years.

“Everyone who applied, we brought on,” Ige said. “Some providers say, ‘You know, the juice is not worth the squeeze. We don’t want to be a part of this anymore.’ That’s fine. It’s an opt-in program.”

Ige said she could not speak about the ongoing Chicago Association of School Dentists lawsuit, but said treating every student is a requirement of the program.

“The lawsuit was a consequence of us saying, ‘You have to see all students, and if you don’t want to see all students, then this is not the program (for you),’” Ige said.

But Sweis, who is also CASD’s secretary, told the legislative committee in February that when providers raised concerns about potential conflicts with Medicaid billing rules, CDPH officials were dismissive — and later used those concerns as justification for not renewing her provider’s contract. Several dentists who spoke with the Tribune said fear of retaliation is real; some declined to speak on the record.

Ige said the city is upholding the contract that every provider voluntarily opted into.

“What will retaliation look like when we don’t pay them?” Ige said.

The city is under no obligation to assist with billing questions or pay providers in any way, according to the confidential agreement dentists must sign to work in CPS schools. The city is also not required to provide legal help if a provider is sued for work related to the program.

Providers also take issue with who is doing the oversight. Chicago’s program is run by Ann Tuscher, a dental hygienist, and both the state and city programs rely on hygienists as on-site examiners who review documentation, inspect dental work and verify that providers have adequate equipment. Dental hygienists perform cleanings but cannot do invasive work such as permanent fillings and are not trained to identify oral cancers.

“Hygienists are only trained on hygiene and pre-gum disease,” said Dr. Ahmed Ramaha of Universal Dental Clinics, who provides school dental visits outside CPS. “They don’t have the training to provide the exams and the services to students, especially students who don’t have access to care, and this is the only chance for them to see a dentist.”

Ige said the hygienists’ role is more administrative — ensuring providers screen every student and complete required paperwork — than clinical work supervision.

“The primary role of the hygienist is ensuring adherence to the terms of the contract, so it is more of an administrative role than we are supervising the dentist,” she said. If the bill passes, only licensed dentists could serve as on-site examiners.

CPS and CDPH said in a joint statement that the Springfield legislation would unnecessarily eliminate Chicago’s independence while removing important safety checks the city provides.

“The bill does not reflect or recognize the working partnership between CPS and CDPH,” the two city departments said in the joint statement. “To date, more than 1.3 million students have received oral health services. Chicago Public Schools values this partnership and does not want to see students lose access to high-quality dental care provided at no cost to families or to CPS.”

Ige said the bill jeopardizes student safety by removing the city’s merit-based process for selecting providers and replacing it with a first-come, first-served method.

Spokespeople for IDHFS and the Illinois Department of Public Health declined to comment on the legislation.

Supporters of the bill counter that the existing partnership is already failing students.

State Sen. Julie Morrison, D-Lake Forest, the bill’s chief Senate sponsor, said providers deserve more support than the city is offering.

“When you’ve got dentists who do not want to serve, who are not being given the information that helps them bill, and they’re expected just to do it for free or find out the Medicaid information themselves, that’s not supporting the dentists who are coming in to underserved neighborhoods,” Morrison said.

Despite the organizational disagreements, the stakes are real. Roughly 1 in 4 U.S. children did not receive preventive dental care in 2022, according to the Annie E. Casey Foundation, with children from low-income and rural households most likely to go without it. Students with dental problems are significantly more likely to miss school, perform worse academically and report feelings of unhappiness, according to research published in The Journal of Pediatrics.

Ramaha, who grew up poor and lost a molar because he never learned how to properly care for his teeth, said the program represents a chance to intervene before that happens.

“I felt like, if my parents knew about it, if I knew about it when I was a kid, the importance of how to prevent it, we could have prevented losing that tooth,” he said. “And I felt like I could make a difference by doing this.”

Trost said he has navigated friction with Chicago’s program before, but that recent years have been different — and that his company is now weighing whether to leave CPS altogether. For him, the issue comes down to a simple calculation: fewer providers means fewer children who desperately need dental care are getting it.

“I’ve been doing this for 30 years,” he said, “and after 30 years, I’ve never seen the bad health vibes that I’m getting from this group of people before.”