“What’s wrong?” my friend asked.

“I think I just chipped my tooth.”

My other friend waved her hand at me. “Just go to the dentist.”

It wasn’t an unreasonable suggestion, but I didn’t have medical insurance, let alone dental: a whopping 33.6 percent of US adults don’t have dental coverage.

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Not only did I not have dental insurance, but I hadn’t been to the dentist in more than a decade. My parents, who both had all their teeth pulled in their forties, had stopped taking me to the dentist when I was around ten. I assumed it was because of the cost. Even with dental insurance, most plans only cover one to two grand of dental work per year, with a deductible. This seems reasonable until you need something more than a cleaning, like a crown, which costs between $750 and $1200.

When I got back home, to the house that I lived in with six other people, I looked in the bathroom mirror and discovered a whole side of the tooth had come off, right down to the gum line. I didn’t want to get an infection, so I did a Google search for cheap dental care.

There was a college nearby with a teaching school, meaning that students worked on you while supervised. The only problem was that it required an initial interview and then a separate exam on a different day before they even started treatment. A car was a luxury that I couldn’t afford, and the trip to the dental school would take hours and multiple buses, not to mention unpaid time off of work.

The next best option was Superteeth, a dental clinic that advertised most basic dental services at $99. Fortunately, Superteeth was on a busy road easily accessible by one bus. A few days later, I headed to the clinic. It was hard to miss, as the outside of the building was covered with signs advertising cheap dentistry.

I walked in without an appointment and filled out some forms, crossing out the insurance section. After an hour, the dentist saw me and told me, without even doing an x-ray, that I needed a root canal.

“How much is that going to cost?”

“The procedure is between six and eight hundred dollars.”

Six hundred dollars was what I made in two weeks. I did not have that kind of money. Then she explained that it was just the cost of the root canal. I’d also need a crown, which would push the total past a thousand dollars and require multiple visits. I must have looked shocked, because she added that they could just pull the tooth for $99.

“Can I think about it and come back?” I asked.

“Sure, but don’t wait too long.”

For the next week, I smiled in front of mirrors and windows, trying to figure out if a missing tooth would be noticeable. The tooth was on my left side, third from the back. My biggest concern was how a missing tooth would affect my job prospects. In a list of common nonverbal mistakes made during job interviews, not smiling came in third, with 38 percent of hiring managers citing it as an issue. Smiling is hard when you’re self-conscious about your teeth. Sure, I could do a closed-mouth smile, but it doesn’t have the same effect on people.

In the end, I decided that I’d rather have a missing tooth that wasn’t too noticeable than a rotting tooth that could get infected and cause further, more expensive issues. Even if I could get my hands on a thousand dollars, I would have used it to pay down my credit card that was maxed out from college expenses instead.

When I got the courage to go back, the dentist asked for the $99 upfront. I wasn’t sure what to expect, since I’d never had a tooth pulled before. My friends all had their wisdom teeth pulled and they were all knocked out for the procedure. This was not the case for pulling other teeth.

The dentist shot up my gums to numb them. She then grabbed what seemed to me like regular pliers that you would find in a hardware store. I was awake as she clamped down on the tooth and used all her strength to yank it out.

I was expecting something more surgical and less brutal. I heard the tooth shatter and then the sounds of the dentist scraping the area.

“I think I got all the bone fragments out, but it’s hard to tell. You might have some bone fragments come through the gums in the next few weeks. You can just pull them out yourself or you can come back and we can do it.”

She didn’t mention if it would cost me or not to come back. I didn’t ask, because I knew I’d just go the DIY route. She told me not to drink from straws, as this could cause the blood clot to dislodge, and then sent me on my way without so much as a Tylenol.

I was planning to take the bus home but called my sister for a ride instead. I didn’t want to scare strangers with my bloody gauze and slack mouth. A day later, I was back at work, as I didn’t have vacation days and was now out $99.

I remembered the dentist telling me to “get back in for an exam soon.” She looked concerned. I was having pain in other teeth and was using copious amounts of Orajel to deal with it.

I landed a job with better pay and benefits a few months later. As soon as my dental insurance kicked in, I made an appointment. I had 16 cavities and had to get them filled four at a time over four sessions. As I’d just started work three months earlier, I still didn’t have the money to pay all the out-of-pocket costs and ended up putting some of the expenses on a high-interest credit card.

My dentist kept pushing me to get a dental implant. He warned me of gum loss that could disfigure my face. He also told me my teeth would shift to fill in the gap, causing my bite to change. He did a thorough job of scaring me, but I didn’t have the $2400 to cover the out-of-pocket costs.

A few years and a few raises later, I was able to get the dental implant. I had been experiencing TMJ jaw pain due to the shifting teeth that got so bad that I went to the dentist to make sure I didn’t have an infection.

Like getting the tooth pulled, I was awake for the whole implant procedure. The dentist drilled into my gums, placed a metal screw in the hole, and stitched my gums back up around it. It would be a couple of months before the gums were healed enough to place the fake tooth on top of the screw. Again, I was thankful that the tooth was in the back. A missing tooth was one thing, but a screw sticking out of the gums was quite another.

Years have gone by and the fake tooth still gives me issues. Because I waited too long, I lost a lot of gum tissue and the fake tooth doesn’t fill the space well. Food gets stuck underneath the tooth and when I run the floss all the way under, I sometimes cut the gums. This leads to bleeding, puffiness, and a few days of pain. Once, it led to an infection.

The implant troubles are a constant reminder of how lucky I was to find a job in time, before I — like my parents — lost all my natural teeth. Not everyone is as fortunate.

I lived with that smile for 16 years. My family constantly struggled to stay afloat, and even though my single mother worked a full-time job, she couldn’t always afford health care. We went to the doctor when we were sick, not for checkups. Sometimes important issues got pushed to the back burner to make room for the day-to-day necessities, and one of those issues was dental hygiene. The appearance of my teeth felt like a declaration of my family’s lack of wealth. There are photos of me smiling brightly throughout that time, though, because even though a sense of shame followed me, I tried not to allow myself to be defined by what I looked like.

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When I turned 17, my best friend’s mother started bringing me to and from the dentist’s office, a place that I hadn’t visited in almost a decade, though I don’t know how those trips came to fruition. The topic of health insurance was never brought up, and my friend’s mother never mentioned having to pay a cent. It was suddenly available to me, and I didn’t bother to ask any questions. All I knew was that I was being helped and I was so grateful. I didn’t realize just how much pain the years of neglect would cause me, though.

My mouth would fill up with blood at any opportunity, to the point where my dentist would whisper to his assistant that he wasn’t sure if he would be able to continue with that day’s work. Even a basic routine cleaning would cause my hands to shake, and soon the assistant would be packing my mouth with cotton balls in an attempt to soak up the blood. The assistant would change with every session, but the dentist and I developed a routine because he never changed. He was a kind man, always asking how my classes were and if I needed more procaine. I’d shake my head or make a noise to answer, and then he would stare back into my mouth while tears ran down the side of my face.

On the worst days, the room filled with the smell of my teeth being filed down to make room for silver caps. One evening, as I was coming home from the dentist, I coughed up blood onto a bus seat as it was pulling up to my stop. I confessed to the driver and quickly ran out the door. At home I would eat soft food, wincing when cold hit the caps, freezing them for a moment. They weren’t joking when they said beauty was pain, but “it will all be worth it,” I told myself, massaging my sore jaws.

When I listened to the voicemail from my dentist telling me my insurance was covering the cost of five porcelain veneers, I smiled to myself as I cried on the school bus. I replayed that message over and over, and the next time I climbed into the dentist’s chair, I did it with pride. It still hurt, don’t get me wrong, but when he handed me the mirror and I saw myself with my new teeth, I burst out in tears. The sounds of those children taunting me were gone; I was one of the lucky ones.

Then I grew up.

As I grew older, I fell into the same trap as my mother. Cleanings became few and far between because I was working two jobs and the dentist’s office closed too early. When I was 22, the veneer placed on my right tooth fell off in the middle of the night and I swallowed it in my sleep. That morning, I had to rush to the emergency dental clinic on my one day off. The location closest to me was a short bus ride away, and I managed to keep my mouth shut tight the entire ride there, nodding “yes” or “no” in response to questions that were thrown in my direction by the bus driver or other friendly riders.

The office receptionist told me the procedure would cost me around $2,000, and when I told them I didn’t have anywhere near that amount in my bank account, they told me to sign up for the credit card the practice offered and start a payment plan. I sat in the chair, filling out my personal information, and was approved for an even $1,000. I sobbed as I walked down to the bank, punching my PIN into the ATM to get some cash for my first payment. I got a new temporary crown, and while I knew it was important and I desperately needed it, I asked myself if the cost was worth it.

I still believe that it was. I knew that if I went backward, if I came anywhere close to having my former smile, I would be screwed. I hadn’t been able to get a job with my old grin because the boss would spend the whole interview watching my mouth move, but after my teeth were fixed, the job offers came closer and closer together. I hadn’t been able to date comfortably beforeand now, with the gift of new teeth, I was suddenly lucky and in love. These teeth had saved me from a life that I was too afraid to think about.

It has been almost five years since I last went to the dentist. Every morning I wake up and press the tip of my tongue along the backs of my front teeth, hoping I haven’t swallowed another one in the middle of the night. I brush my teeth, ignoring the way the toothpaste turns a brownish-red color, and head off to work, where I work close to 50 hours a week between two jobs. Because I can’t afford to leave one and work full-time at the other, I don’t have health insurance, much less dental insurance. My dental plan consists of aspirin and liquid numbing medicine. It runs me an average of $12 every couple of months. I didn’t even know the pain in my tooth could be connected to the pain in my ear until I googled it. (That’s another thing that people don’t tell you about being poor: Google and WebMD are part of your health care plan.)

Now when people stare directly at my teeth, they are noticing how white the front row is. They remark that my teeth are perfect and want to know my secrets: Is it a special toothpaste? Mouthwash? Did I just get lucky? I always joke and tell them that they better be perfect because they cost me a lot, physically and emotionally.

The dentist still scares me, and I don’t know when I will be able to schedule another visit. I hope that one day, I’ll scrape together the money to have my wisdom teeth taken out. Better yet, I hope that one day, I’ll be able to work one single full-time job, a job that will offer me benefits including dental. I hope that one day, I’ll be able to have my teeth cleaned every six months instead of once every decade.

It occasionally hits me that even after all this, I’m still one of the lucky ones. People still think that I’m beautiful, and that’s enough to get me through this life. All I can really do is keep smiling.

The only thing that made paying them realistic, she said, was that she received a $4,200 tax refund this year.

“I would have put off my medical payments [without the refund],” she told me via email. “Between rent and day to day expenses, I don’t have the income to pay both. … Even with insurance the numbers seemed insurmountable until I got my refund. If it wasn’t for that I would have had to reapply for payment plans with the risk of being sent to collections.”

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Tax returns were officially due this week, which means that the roughly 80 percent of filers who receive refunds will soon have their money, if they don’t have it already. The average tax refund so far this year is $2,995, which is roughly in line with last year. For the average family that receives a refund, the amount is equal to nearly six weeks’ income. And a big proportion of the money Americans receive during refund season, like Megan’s, goes to pay for health care.

According to a report from the JP Morgan Chase and Co. Institute, families who receive a tax refund increase their out of pocket health care spending by 60 percent the following week. Spending on health care remains higher than normal for 75 days post-refund.

“The cash infusion represented by a tax refund payment allowed more people to make more purchases of healthcare goods and services, but, even more consequentially, it facilitated larger payments,” the report said. “This implies that the cash infusion generated by a tax refund payment triggered additional spending on large healthcare ticket items that consumers could have least afforded out of their pre-refund cash flow.”

“100 percent of ours is going to pay for prenatal care and the birth of our second child, due in June,” said Molly, who received a refund of around $2,000 for her family’s state and local taxes. “Our first child’s 2017 birth was uncomplicated and routine, and while I don’t remember what we paid out of pocket versus what insurance covered, the birth, the epidural anesthesiologist, the recovery, and a one-day stay in pediatrics (due to jaundice, probably the most common newborn treatment there is) was a little over $20,000. So we’re counting on the 2019 refunds going to paying off this birth as well, as we will easily hit our deductible.”

62 percent of the additional health care spending triggered by refunds went to in-person payments to health care service providers. That indicates that the higher spending isn’t limited to paying bills for past services, but that tax refunds actually led families to seek care that they had put off until they received a cash infusion. Dentists receive a disproportionate share of the additional spending: One in four adults with incomes below the poverty line skip needed dental work because of costs, and dental-related issues are responsible for about $1 billion per year in emergency room spending.

That so many Americans need a refund windfall in order to access medical care, sadly, makes sense. About one in four adults – 65 million people – reported skipping a medical treatment due to costs in the last 12 months, according to a recent West Health-Gallup survey. Last year, Americans borrowed a collective $88 billion for medical treatments, which doesn’t include the totals from the now ubiquitous medical crowdfunding campaigns that have proliferated on social media.

So tax season injects cash for those households to get the care they either would have had to delay or go into debt to obtain.

It’s worth noting that receiving a big refund means a taxpayer overpaid her taxes during the year, whether via automatic withholdings from paychecks or by paying quarterly estimated taxes (which is a requirement for the self-employed and independent contractors), thus giving the government an interest-free loan. A refund is just that overpaid amount being paid back.

However, the public doesn’t really view it that way: According to a recent New York Times poll, 77 percent of people would prefer to overpay and receive a refund come tax time, which makes sense. 40 percent of people don’t have $400 to cover an emergency cost, and the average savings amongst the poorest 20 percent of households is zero dollars, so an unexpected tax payment can deal a real blow.

But people also use their refund as a way to enforce savings: Paying their money to the government and then getting it back means they can’t spend it in the interim. Recent reports have shown that the Trump administration, in an attempt to inject money from its 2017 tax bill into the economy sooner, decreased withholdings so that people had less taken out of each paycheck for taxes throughout the year, meaning they were less likely to overpay their taxes and require a refund. But that ploy has backfired spectacularly. Many taxpayers were reportedly upset at getting smaller refunds than they expected come Tax Day, even if their overall bill was in many instances lower than the year before.

“We actually aren’t those types who try to have a big refund each year. We’d rather not allow the government to keep an interest-free loan all year. My husband has tweaked his withholdings so we do get more in the paycheck each week because we need it for all the copays, gas, etc,” said Lindsey Cox of Thomasville, North Carolina. Both she and her husband carry a gene for a rare disease called Van Maldergem Syndrome, which two of her three children have, while the third has severe nervous system issues. Their health care bills total hundreds of thousands of dollars annually. This year, their tax refund of $2,940 went to an array of household needs.

“Our tax return went to catch up on the house payment, electric bill, other small miscellaneous bills, and some car maintenance we had been putting off, like inspections, tire rotations, oil changes, etc.,” Cox said. “We’ve become experts at gaming our system and know for instance, we can be 60 days behind on electric before we face it being cut off. We’ve learned very well how to rob Peter to pay Paul and stay afloat in the process.”

That so many Americans need a quick injection of money in order to see a doctor or access other necessities is a problem that can be addressed by policy: Think universal health care, or the proposals to both expand the pool of those eligible for the Earned Income Tax Credit and allow low-income households to receive some of their refund early. As Bryce Covert explained, “as powerful as the EITC is, there are plenty of people who receive barely any money from it or miss out entirely.”

Tax Day should be a celebration of America’s commitment to civic responsibility and collective welfare, not a grim reminder that far too many people can’t access things that should be basic human rights. However, for too many, a tax refund isn’t just the difference between staying afloat and not, but between seeing a doctor and not, which can literally be the difference between life and death.

Editor’s note: When requested, last names have been withheld to allow people to talk freely about their finances.