While comprehensive dental coverage is a required benefit for children served by Medicaid, the same is not true for adults. Dental benefits are optional for adults enrolled in Medicaid, and dental coverage is often among the first programs to be trimmed in tight fiscal times—most recently, Illinois Gov. Bruce Rauner (R) made such a proposal. Forty-six states and the District of Columbia currently offer some dental benefit to Medicaid-enrolled adults, but only thirty-two cover services beyond emergency care, and even fewer, fifteen, offer a comprehensive benefit.
As many states expand Medicaid coverage for adults through the Affordable Care Act (ACA), there are new opportunities to increase much‐needed dental coverage in Medicaid and avoid the dangerous and costly consequences of untreated dental disease.
A February 17 webinar hosted by the Center for Health Care Strategies (CHCS), “Dental Coverage and Access for Adults in Medicaid: Opportunities for States,” highlighted the experiences of two Medicaid-expansion states—Colorado and Kentucky—in implementing dental benefits for Medicaid-enrolled adults. The webinar was the first in a series funded by the DentaQuest Foundation and the Robert Wood Johnson Foundation as part of a CHCS initiative to improve oral health care access and quality for low-income adults. The webinar began by outlining the national dental coverage and access landscape for Medicaid-enrolled adults, as well as strategies undertaken to expand dental benefits.
Inadequate dental coverage is a significant barrier to oral health care access for low-income adults, who often cannot afford to pay out-of-pocket and have no other consistently available options for oral health care. Low-income people are 40 percent less likely than those with higher incomes to have visited the dentist in the past twelve months, and that frequent lack of care drives an epidemic of dental disease in this low-income population. Further, 42 percent of people with incomes below 100 percent of the federal poverty level (FPL) have untreated tooth decay, compared with 12 percent of Americans with incomes above 400 percent of the FPL. Oral health care access is even more challenging for vulnerable populations—such as people with chronic illness, racial/ethnic minorities, or people with disabilities—who have more tooth decay, dental infections, and tooth loss than the general adult population.
The nondental consequences of dental disease include elevated risks for diabetes, heart disease, and stroke, as well as potential lost workdays and reduced employability. Oral health care coverage and access challenges have also led to an increase in dental-related hospital visits over the past several years. Because up to 16 million newly eligible adults are expected to gain Medicaid coverage by 2024, many state Medicaid agencies are reconsidering how they can meet the oral health needs of this population.
During the webinar, Oral Health Colorado’s Executive Director Deborah Foote described her state’s path to covering an extensive set of dental services for Medicaid-enrolled adults. Although, with its $1,000 cap on dental expenditures, Colorado’s program is a limited benefit, the services covered are a significant achievement. Foote emphasized the importance of political support in achieving the state’s oral health goals. This included having an advocate in the governor’s office, strong oral health champions in the state House and Senate, and an effective oral health coalition. Oral Health Colorado’s “legislative frame” included: (1) oral health’s links to overall health and pregnancy; (2) the lower costs of routine and preventive dental care compared with emergency department care for acute dental symptoms or conditions; (3) the impact of dental disease on employability; and (4) the likelihood that children of adults with dental coverage are more likely to use dental services themselves.
Leaders from the Kentucky Department for Medicaid Services shared the evolution of their state’s limited dental benefit for adults. Dental Director Ken Rich and Chief Policy Advisor Erin Hoben identified three factors critical to their success: (1) leadership support from both the governor and the Cabinet for Health and Family Services secretary; (2) engagement of key stakeholders, including the state’s contracted managed care organizations, the Kentucky Dental Association, the state’s Advisory Council for Medical Assistance, and the Kentucky TeleHealth Network Board; and (3) interagency collaboration with the state Department for Public Health, the Cabinet for Health and Family Services’ Office of Health Policy, and the Kentucky Health Information Exchange.
Key lessons for states that were addressed in the webinar include the following:
- Recognize that political and agency support is critical since adult dental benefits are optional;
- Engage providers, Medicaid enrollees, managed care organizations, and other key stakeholders to garner support before and after the benefit is implemented; and
- Work with other organizations that have a stake in adult oral health—and overall health.
The DentaQuest Foundation supports activities to advance improvements in dental coverage and access for low-income adults through its Oral Health 2020 efforts, which include providing funding for the CHCS Advancing Dental Access, Innovation, and Quality for Adult Medicaid Beneficiaries initiative. Also, under that CHCS initiative, the Robert Wood Johnson Foundation is funding efforts to identify and disseminate innovative approaches to improving oral health care access and delivery for Medicaid beneficiaries.
The DentaQuest Foundation, the Robert Wood Johnson Foundation, and the Centers for Medicare and Medicaid Services are investing in improving dental coverage, access, and quality for children and adults in Medicaid by supporting state efforts to accomplish these goals. As Medicaid programs expand to provide coverage for even more adults over the next decade, these investments are exceedingly important to ensure that low-income people are able to receive the oral health care they need.