Let’s Not Forget Affordable Dental Care

A comment posted some time ago raised an issue about Medicaid that seems even more timely now because it opens to the door to larger current and prospective issues.

Seems the commenter had to have some teeth pulled. Her dentist told she would have to wait for dentures until her mouth heals instead of getting a temporary set. She felt that she and others covered by Medicaid were “treated differently from other people,” who aren’t doomed to toothlessness. Would I look into this?

And I did, learning more in the process about not only the source of her problem, bur dental care in our health insurance system — today and prospectively. Results, as follows.

The commenter is actually quite fortunate. States don’t have to include dental services in their Medicaid programs, except when they administer the Children’s Health Insurance Program by expanding them.

For adults, dental care is an optional benefit, both for those whom states covered before the Affordable Care Act and those who became newly eligible when states opted for expansion. Those states must provide “essential health benefits” for the latter, but dental care isn’t one of them.

Virtually all states and the District of Columbia do cover some dental services, but only fifteen cover a comprehensive mix, the Kaiser Family Foundation reports.

Many cap per person spending or the number of services covered. And thirteen cover only emergency treatment. Even coverage doesn’t ensure affordability because beneficiaries may face high out-of-pocket costs.

Not all states that cover dental services cover dentures. And even fewer cover dentures for all beneficiaries as often as they might need them. They’re responding here to limits the federal government sets on reimbursements.

But low-income adults aren’t treated all that differently from their better-off peers. Traditional Medicare provides no coverage for dental services, except in certain limited cases when the beneficiary is in a hospital.

We who’ve had employer-sponsored health insurance also know that incomplete—or no—coverage for dental services is more common than the commenter apparently assumed.

But better-off people can shell out for dental care or supplementary insurance. Not so for low-income working age adults. Only 19% of those who were officially poor went to a dentist in 2013. And 44% had had untreated cavities in the prior two-year period.

Nearly a third of those with incomes low enough to qualify for an expanded Medicaid program reported an unmet need for dental care last year.

Without it, they may not only lose teeth and have to live with gaps in their mouths. Untreated oral diseases, including cavities can cause or worsen a range of other health problems.

Lack of sufficient coverage is obviously a major barrier, but it’s not the only one. In some places, e.g. rural areas, inner cities, there simply aren’t enough dentists. That’s partly due to an unwillingness on their part to treat low-income patients, especially those covered by Medicaid.

Dentists object to the paperwork and lost income because Medicaid patients—at least, by reputation—often don’t show up for appointments. But dentists also cite low reimbursement rates—sometimes so low as to not even cover costs.

Now, we know that states often cut provider reimbursement rates when economic downturns drive up their Medicaid costs because that’s more politically palatable than tightening up on eligibility or coverage.

And we know they’d face budget crunches—and not only during recessions—if Republicans in Congress convert Medicaid to a block grant and the President agrees.

Not much of an “if” here. The Trump’s campaign’s policy positions included a block grant. And Congressman Tom Price, his choice for Secretary of Health and Human Services, folded a block grant into the House budget plan when he chaired the responsible committee.

Looking at how states now use their flexibility to limit dental care coverage, we could reasonably expect them to make further cuts there.

They might instead (or also) cut dentists’ reimbursement rates. More than half the states did that in the aftermath of the Great Recession. So Medicaid beneficiaries who still had dental coverage may have had more problems finding someone to treat them, as certainly seems the case in Washington and in Florida.

Some states might instead join those that provide no coverage whatever.

The block grant is only one of the clear and present dangers to the health of poor and near-poor people, including the health of their teeth, gums and everything else in and around their mouths.

The impending repeal of the Affordable Care Act would immediately deny higher federal reimbursement rates to the 31 states and the District of Columbia that have expanded their Medicaid programs.

The repeal, in and of itself, would free them to shrink or eliminate dental health benefits for the newly-eligible children they enrolled because they’d no longer have to provide the essential health benefits the ACA specified.

This would also be true for most other insurance plans, unless state regulations required them because the same EHB requirements apply. And if, as predicted, premiums soar, one could expect plans to drop dental care or, at least, radically cut back coverage.

Some of you may recall the boy who died from a brain infection because his mother couldn’t find a dentist to treat him in time—this for wont of Medicaid. We might have more such cases, with or without it.

We’d almost surely have more low-income adults toothless (and not only temporarily) and more dead too because they couldn’t afford dental care—or related medications.

I know this seems a worst case scenario and perhaps an unwarranted leap from a singular problem to a vast array. But when we think about what will happen in the aftermath of health care “reforms,” we need get beyond the numbers, as important as they are.

Price objects to our government programs because they get between doctors and their patients. But, in fact, people who should be patients won’t be.

And when we think of them, we shouldn’t forgot those who need dental care because, as one dentist said, “the mouth and the head are connected to the rest of the body.”

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