By Rick Valachovic, DMD, MPH, Clinical Professor and Director of the NYU Dentistry Center for Oral Health Policy and Management

The 2022 legislative sessions in most states have come to a close, and the results are worth celebrating. Five states adopted positive changes to their dental Medicaid laws, and several other states have related legislation pending. Last year, 12 states passed similar bills, and Louisiana broke new ground, approving a comprehensive dental benefit for adults with intellectual and developmental disabilities in its various Medicaid waiver programs. 

While most state Medicaid programs have historically covered emergency dental care for adults, few states offered extensive dental benefits to this population. Recent progress builds on a history of benefit expansion, beginning with the inclusion of dental benefits in the Children’s Health Insurance Program in 2009 and the expansion of Medicaid as part of the Affordable Care Act, signed into law in 2010. As of May, this year, only three state Medicaid programs provided no adult dental benefits and another eight restricted such benefits to emergency care, but most states offered more. Fifteen states provided at least some non-emergency benefits, and 24 states and the District of Columbia provided extensive benefits to adults. Additionally, every state except Alabama provided dental benefits to pregnant women.

These changes represent a major shift in the Medicaid dental benefit landscape. To keep track of these developments, CareQuest Institute for Oral Health, working with the American Dental Association Health Policy Institute (ADA HPI) and other partners, developed a tool for tracking Medicaid adult dental benefits across states. To learn more about it, take a look at CareQuest’s recent webinar on the topic.

At the federal level, there are also glimmers of progress.  In 2021, the Centers for Medicare and Medicaid Services (CMS) appointed Dr. Natalia Chalmers as its first chief dental officer. Last month, the agency’s draft physician fee schedule for FY 2023 proposed paying for a dental exam and treatment preceding an organ transplant as well as several other services. CMS is also seeking comment on what additional dental services Medicare should reimburse.

The cumulative efforts of oral health advocates deserve most of the credit for these gains, but they were facilitated by state budget surpluses in 2021 and 2022, resulting from generous federal COVID-19 relief funding. “This environment has enabled many state legislatures to focus on improving their dental Medicaid programs for dentists and patients,” an update from ADA HPI observed. 

It’s heartening to see the pendulum swinging toward providing greater dental coverage, but even though more Medicaid beneficiaries are now eligible for a wider array of oral health benefits, that doesn’t mean people in need are receiving more care. According to a 2021 research brief from  ADA HPI, fewer than half of dentists in many states are enrolled as Medicaid providers, and even in states with relatively high Medicaid enrollment among dentists, a significant percentage of enrolled providers are not seeing any Medicaid patients. The availability of dentists to see children in the Medicaid and CHIP programs is also far from adequate, according to a recent study in JAMA Open Network.

At other times, practices that want to see Medicaid patients lack sufficient capacity to do so. When Virginia began covering dental procedures for Medicaid beneficiaries in July of last year, one clinic found itself fielding calls from patients up to 60 miles away. In February, the clinic started a waiting list, and by May more than 200 people were still awaiting care.

The expansion of benefits also triggered a 67% rise in the number of adult Medicaid beneficiaries seeking care at Virginia Commonwealth University (VCU) School of Dentistry. The influx of patients allowed students to train in more specialty areas and appreciate the extent of community needs, but these opportunities also came at a cost. “Current reimbursement rates that have not increased in approximately 15 years sometimes fail to meet the actual cost of delivering care,” Lyndon Cooper, DDS, PhD, dean of the dental school, told The Virginian-Pilot. “This challenges us and all other oral health care providers to operate in a fiscally responsible manner.”

What can be done to make Medicaid more attractive to providers and care more accessible to its beneficiaries? Mary Foley, RDH, MPH, who leads the Medicaid/Medicare/CHIP Services Dental Association (MSDA), has ideas. “States have to balance their budgets each year. Most people don’t realize the implications of that,” she points out. “When a crisis emerges — like a pandemic — all of a sudden, everything that isn’t mandated under some law goes by the wayside. The most powerful way to ensure that oral health care services are available to adults and to seniors would be through federal legislation,” she argues.

Mary would like to see passage of the Medicaid Dental Benefits Act of 2021, which would make comprehensive dental care a mandatory component of Medicaid coverage for adults. She’d also like to see federal legislation create oral health benefits in Medicare and in a Medicaid program designed especially for people with intellectual and developmental disabilities. That said, Mary is sympathetic to lawmakers, who have a host of competing priorities. “Advocates who want to mandate every single benefit possible are unrealistic,” in her view.

Unlike commercial dental plans, which typically cap dental benefits at around $1,500 a year, Medicaid plans pay for all “medically necessary” treatment, leaving states open to hefty bills. States also bear costs related to fraud, waste, and abuse, estimated at slightly more than 10% of Medicaid billings in 2017. The good news, Mary says, “Artificial intelligence (AI) is coming fast and furiously to Medicaid.” Her organization has just launched an 18-state learning collaborative to help state Medicaid programs use AI to address utilization review for fraud, waste, and abuse in their dental programs.

A lot has changed since my days as a pediatric dentist in Boston, when economically disadvantaged children lacked access to fluoridation as well as to dental insurance. While pockets of severe dental need remain, most children have better oral health today thanks to policy changes on both these fronts. The progress that’s occurred since I wrote about this topic in Academic Medicine in 2018 in the last two years is also impressive.

I’m hopeful the pendulum will continue to swing in a positive direction, but economic uncertainty makes me wary. Budget surpluses opened the door to this year’s state policy victories. In leaner times, Medicaid reimbursements, and dental benefits specifically, often find themselves on the chopping block. As we celebrate recent victories, we can’t let up the pressure on policymakers. Concerted advocacy was essential to gaining this ground. We’ll need to fight just as hard to hold it and achieve gains at the federal level.