Sharp Cuts in Dental Coverage for Adults on Medicaid
By Abby Goodnough New York Times August 28, 2012
BOSTON - Banned from tightening Medicaid eligibility in recent years, many states have instead slashed optional benefits for millions of poor adults in the program. Teeth have suffered disproportionately.
Republican- and Democratic-controlled states alike have reduced or largely eliminated dental coverage for adults on Medicaid, the shared state and federal health insurance program for poor people. The situation is not likely to improve under President Obama’s health care overhaul: it requires dental coverage for children only.
Illinois became the latest state to drastically cut dental benefits last month, when Gov. Pat Quinn, a Democrat, cut $1.6 billion out of its $15 billion Medicaid budget, reducing adult dental coverage to emergency tooth extractions. The state, whose Medicaid program was considered among the most generous, also cut vision benefits, eliminated chiropractic and podiatry coverage and started requiring co-payments for drugs.
In about half the states, Medicaid now covers dental care only for pain relief and emergencies, according to a recent report by the Kaiser Commission on Medicaid and the Uninsured, a national health research group. Other states cover preventive exams and cleanings but not restorative services, like fillings and root canals.
The federal health care law generally prohibits states from tightening eligibility for Medicaid before 2014, when a vast expansion of the program to cover people with incomes up to 133 percent of the federal poverty line is supposed to take effect. But states are still allowed to cut optional benefits, like vision, dental and drug coverage. Whether to seek broader cuts is part of a contentious debate between Mr. Obama and Mitt Romney over the future of Medicaid and Medicare, the government health care program for older Americans.
The dental benefits issue came to the forefront recently here in Massachusetts, a state known for generous Medicaid benefits. Under budgetary pressures, the state stopped paying private Medicaid providers for fillings, root canals, crowns and dentures in July 2010. But it recently decided to restore part of that coverage. Starting in January, Massachusetts Medicaid will pay for fillings - but only for those in the front of the mouth. The reasoning was that healthy front teeth were more important for getting and keeping jobs.
“A lot of folks are out of work,” said Courtney Chelo, coordinator of an oral health task force at Health Care For All, an advocacy group in Boston. “If you have a gap in the front of your mouth because you had a tooth extracted, it’s much more difficult to get a job.”
Dr. Michael Wasserman, the president-elect of the Massachusetts Dental Society, said that he was disappointed Massachusetts did not restore full coverage but that even a partial restoration was extraordinary in these fiscal times. Medicaid patients make up about 20 percent of his practice in Pittsfield, he said. “Of course we would have also liked to see the back teeth covered,” he said. “It’s nice to smile; it’s nice to chew. But we have to take what we can get at this point.”
Many adults on Medicaid have turned to community health centers. In Massachusetts, such clinics received 22,000 new dental patients statewide - 760 per site, on average - in the first six months after coverage was dropped.
At the Lynn Community Health Center outside Boston, demand has not stopped growing. The center added six dental chairs this year, bringing the total to 12, and hired more hygienists and dentists. Still, “the waiting room is packed,” said Lori Abrams Berry, the executive director.
Even in states where Medicaid enrollees can still get regular dental care, finding dentists who accept Medicaid can be next to impossible. That is partly because reimbursements, which were low to begin with, have also been cut. Dentists, many of whom do not take even private insurance, can get much higher payments from non-Medicaid customers.
At the same time, there are shortages of dentists in many poor and rural communities, according to the Pew Center on the States. In a report this year, Pew estimated that preventable dental problems were the primary diagnosis in 830,590 emergency room visits in 2009 - up 16 percent from 2006.
“It’s penny-wise and pound-foolish,” said Shelly Gehshan, the director of the Pew Children’s Dental Campaign. “Rather than an $80 extraction or a $300 filling, states are spending much more on emergency room visits that can’t fix the problem.”
Citing safety concerns, dental associations have fought efforts to allow dental therapists - midlevel providers with more training than hygienists but less than dentists - to do common procedures like filling cavities and pulling teeth. Currently, only Alaska and Minnesota allow dental therapists.
But Ms. Gehshan said other states would embrace the idea, partly because more than five million children will become eligible for dental coverage under the federal law. There are not enough dentists for them, she said, adding that research has found dental therapists to be “safe and effective.”
“There needs to be more rungs in the ladder,” Ms. Gehshan said. “The associations have taken a fearful defensive posture, but this can really be a win-win situation for dentists.”
Although the law does not address dental coverage for adults, it provides $11 billion to expand community clinics and build new ones. Many clinics, like the one in Lynn, are using the money to expand dental services as well as primary care. Of the 55,000 new square feet at the Lynn clinic - financed with $18.6 million in stimulus and Affordable Care Act money as well as private donations - 6,500 are reserved for dentistry, Ms. Berry said.
“I regret that I didn’t build more dental chairs,” she added. “It never seems to be enough.”