Breaking the Chains of Pain

For months, Carlton Clemons, a 67-year-old from Nashville, Tennessee, endured agonizing pain from a decaying wisdom tooth. His sleepless nights, dwindling appetite, and reliance on painkillers had become a daily struggle. Carlton and his family subsisted on a modest income of $1,300 per month from Social Security and disability payments, making it impossible for him to afford dental care. His only hope lay in the arrival of a long-awaited program that Tennessee was rolling out this year, offering dental care to over 650,000 Medicaid recipients aged 21 and older. The state was committing approximately $75 million annually to this initiative.

“When they did pull it out, I was so happy. I was so glad. Everything just changed after that,” Carlton said, relieved, after his tooth extraction at the Meharry Medical College School of Dentistry in July. His wife, Cindy, who also relied on Medicaid, had her teeth extracted at the same clinic.

Medicaid, the federal and state health insurance program for low-income individuals, mandates dental coverage for children but not for adults. However, with an increasing realization of the economic and health repercussions of poor dental health and the injection of federal pandemic funds, six states decided to initiate or expand their Medicaid programs this year to include coverage for adults. Nonetheless, access to care remains challenging in many of these states, with some dentists declining to treat Medicaid patients. Even those willing to expand their practice find themselves entangled in bureaucratic red tape.

Dr. Victor Wu, the chief medical officer for Tennessee’s Medicaid program, expressed satisfaction with the rollout of Medicaid dental benefits that commenced in January. However, he acknowledged the need to expand the network and boost dentist participation rates.

While dental care may seem routine, many low-income individuals endure years or even decades without it. This delay imposes significant costs, both on taxpayers and those who cannot afford treatment. Research from Texas A&M University revealed that treating preventable dental conditions accounts for up to 2.5% of emergency room visits, amounting to a staggering $2 billion annually. Furthermore, untreated oral diseases lead to a loss of productivity totaling $45 billion per year in the United States, according to the Centers for Disease Control and Prevention.

“You put off care and you get sicker, and then it becomes a crisis where you’re missing work or you end up going to the emergency department where you get a big bill and you don’t get the tooth actually taken care of,” warned Dr. Rhonda Switzer-Nadasdi, CEO of Interfaith Dental Clinic, which operates in Nashville and Murfreesboro, Tennessee. “You need good teeth to have good employment.”

All states offer some Medicaid dental benefits for adults, but the coverage is often limited to specific population segments, such as pregnant women or those with intellectual disabilities, or restricted to emergency care, according to the CareQuest Institute for Oral Health, a nonprofit advocating for expanded dental care.

Hawaii, Tennessee, Kentucky, Michigan, Maryland, and New Hampshire are the latest states to have commenced or expanded dental coverage for Medicaid recipients this year. New Hampshire, for example, allocated $33.4 million over 12 months to provide dental care to its 88,000 Medicaid beneficiaries.

New Hampshire Democratic Rep. Joe Schapiro, who spearheaded the expanded dental benefits bill, emphasized the growing understanding that oral health is integral to overall healthcare. He highlighted the exorbitant expenses incurred due to oral health-related problems and the cost-effectiveness of preventive and restorative dental care.

In Kentucky, Democratic Gov. Andy Beshear took swift action to ensure approximately 900,000 Kentuckians maintained access to dental care through emergency regulations when the Republican-led legislature rejected his proposal. Gov. Beshear underscored the program’s role in removing obstacles that prevent people from rejoining the workforce.

Virginia expanded its Medicaid program in 2021, earmarking $282 million for dental procedures in the 2022 and 2023 fiscal years, benefitting over a million recipients. Kansas also granted dental access to nearly 137,000 Medicaid beneficiaries at a cost of $3.5 million in 2022 and $1.2 million in 2023.

While advocates applaud these changes, Texas, Alabama, Mississippi, Utah, and Louisiana continue to offer limited dental benefits.

Even as states introduce dental coverage, Medicaid beneficiaries are being culled from the program nationwide during eligibility reviews, a measure that was prohibited during the pandemic.

Additionally, states with expanded care, like Tennessee, grapple with various challenges. A major issue is the shortage of dentists, particularly in rural areas, willing to accept Medicaid patients, resulting in long waiting times and arduous journeys in search of care. In New Hampshire, only about 15% of dentists accept Medicaid, while Tennessee and Virginia stand at 24% and 27%, respectively.

Many dentists and advocacy groups attribute this shortage to low Medicaid reimbursement rates. In 2022, New Jersey covered only 13.3% of a dentist’s typical charges, Michigan covered 17%, and Rhode Island covered 22.4%, according to data analyzed by the American Dental Association. Several states, including Illinois, New York, Ohio, and Oregon, covered slightly over 28%. In contrast, most states covered between 30% and 50%, with Alaska and North Dakota exceeding 55%, and Delaware providing a remarkable 76.9%.

Dr. Heather Taylor, an assistant professor at Indiana University’s Richard M. Fairbanks School of Public Health, noted that some of Indiana’s Medicaid reimbursement rates for dental care had not increased since 1998. She expressed concern that these low rates incentivized dentists to avoid treating those in need, as private insurers offer significantly higher compensation.

Tennessee Family Dental, a network with four clinics in the state, faced an overwhelming influx of Medicaid patients. Dr. Ryan O’Neill, the owner of the business, revealed that he received around 300 calls on the first day alone, with patients traveling over 30 minutes for treatment. However, hiring additional dentists could take up to four months due to Medicaid certification procedures. Moreover, Medicaid billing systems often reject claims, adding to the complexity of the process.

Danielle Wilkes, a 26-year-old mother of five from Ashland, Tennessee, exemplified the struggle many Medicaid recipients face. She drove 90 minutes to see Dr. O’Neill after numerous failed attempts to find a dentist in her area who accepted Medicaid. Having lost several teeth in a car accident five years ago, she had been told that the cost of multiple crowns would be prohibitively high.

“I was mad at first, but I was like there’s nothing she could do. I’m just going to have to wait until my kids are grown up,” she said. Despite the $400 expense not covered by Medicaid, Danielle was relieved to have the work done.

In another room, June Renee Pentecost, Danielle’s cousin, was undergoing an examination for a root canal. It had been over a decade since she last visited a dentist, deterred by the cost despite years of pain. As a mother of five, she believed that spending on dental care would divert funds from her children.

“I couldn’t play with my kids because my head was hurting,” she lamented. June was relieved to finally receive treatment and wondered why the state had not offered this benefit sooner.

“I’m hoping my pain would ease up and quit once I get my teeth fixed, and then I won’t have so many headaches and feel so bad,” she expressed with hope.

In conclusion, the expansion of Medicaid dental coverage for adults in several states has brought much-needed relief to countless individuals like Carlton Clemons, Danielle Wilkes, and June Renee Pentecost. However, challenges persist, including a shortage of dentists willing to accept Medicaid patients and low reimbursement rates. The recognition of oral health as an integral component of overall well-being and the economic impact of untreated dental issues have spurred these initiatives. Yet, there is still much work to be done to ensure that all Americans have access to essential dental care, regardless of their income level.

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