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A Cavity in Medicaid Dental Coverage

Image has not been found. URL: /wp-content/uploads/2009/10/kucinich.jpgRep. Dennis Kucinich held hearings in October on low-income childrens' access to dental care. (WDCpix)

Not even a third of the nation’s lowest-income children receive dental care, and Congress isn’t doing a thing about it.

Although Medicaid, the federal-state partnership covering America’s poorest kids, provides dental coverage for all children enrolled in the program, it’s a phantom benefit for most: roughly 12.6 million kids, or 66 percent, don’t get dental care at all. The reasons vary — from low participation rates among dentists to high frequencies of broken appointments among patients. Yet, despite all the talk this year of improving the nation’s health care system — not to mention the hundreds of billions of dollars going toward that effort — none of the bills moving through Congress addresses the dismal discrepancy between dental coverage and access to care for the nation’s most vulnerable youngsters.

Congress.jpg
Congress.jpg

Illustration by: Matt Mahurin

“As much talk as there is, there aren’t a lot of [lawmakers] willing to stick their necks out and do it,” said Mike Graham, managing director of government affairs at the American Dental Association.

The lack of dental care in Medicaid can have tragic results. In 2007, Deamonte Driver, a 12-year-old Maryland boy suffering an abscessed tooth, was hospitalized when bacteria spread to his brain. Six weeks and two operations later, he died. An $80 procedure might have saved him, but his mother struggled to find a dentist who would accept his insurance plan. He was on Medicaid.

“His life was sacrificed to an uncaring system,” Rep. Dennis Kucinich (D-Ohio), chairman of the House Oversight and Government Reform Subcommittee on Domestic Policy, said Wednesday during a hearing on Medicaid’s dental benefit. “We can’t have any more Deamonte Drivers out there.”

Yet such passionate appeals don’t mean that reform is forthcoming. Indeed, of the five enormous health care proposals making their way through Congress, none takes steps to ensure that dental coverage translates into dental care for the nation’s poorest kids.

A 2007 ADA study reveals a chief cause of the access problem: fewer than 27 percent of respondents said they treat Medicaid-insured patients. Many dentists, not to mention their lobbyists, say the reason for the low participation is simple: Medicaid simply doesn’t reimburse enough in most states to cover costs, let alone earn a living.

“If you increase reimbursement rates to levels at or above their costs, you will get them to participate — period,” Graham said. “Why would I be involved in a system where I lose money every time I see a patient? That’s charity care. It’s not health care.”

Lawmakers on both sides of the aisle have, during this year’s health reform debate, acknowledged the insufficient doctor payments that practically define Medicaid — a particular concern because much of the Democrats’ strategy to cover the uninsured revolves around a Medicaid expansion. But their efforts to provide a fix haven’t extended to include dentistry. During the Senate Finance Committee’s marathon markup of health reform legislation last month, for example, Sen. Charles Grassley (Iowa), senior Republican on the panel, offered an amendment designed to encourage physician participation by hiking Medicaid rates to match those in Medicare. The trouble is, Medicare doesn’t cover oral health. To increase dental services under Medicaid, then, would require hitching the new rates to another index.

Rep. Mike Ross (D-Ark.), a member of the House Energy and Commerce Committee, proposed such a bill in April, which would hike the federal share of Medicaid dental payments by 25 percent. Yet Ross didn’t offer his proposal during the panel’s July markup of comprehensive health reform legislation. Ross’s office did not respond to requests for comment.

Another Energy and Commerce member, Rep. G.K. Butterfield (D-N.C.), did offer a dental amendment to the panel’s bill, though it does nothing to help kids in Medicaid. Instead, it would merely require the administration to study and report on “the need and cost of providing accessible and affordable oral health care” — but only for adults.

An outright hike of Medicaid dental reimbursements is sure to find opposition among lawmakers already wary of the cost of the Democrats’ health reform bills. Rep. Jim Jordan (Ohio), senior Republican on the domestic policy subpanel, voiced concerns about the lack of access, but also said he’d like to find ways to address the problem without spending more tax dollars. Penalizing parents when kids missed appointments, for example, might reduce the number of no-shows and encourage dentist participation, he said. Jordan, a former wrestling coach at Ohio State University, also wondered why more Medicaid patients don’t utilize the low-cost services of the nation’s dental schools, as he’d done at OSU for his young children.

Cynthia Mann, Medicaid director at the Centers for Medicare and Medicaid Services, said that academic settings “can be very critical” in meeting the dental needs of low-income folks. But there are limitations. Kansas, for example, doesn’t have a dental school in all the state, she said.

There’s strong evidence that dental care under Medicaid is begging for reform. Nearly one in three children in Medicaid suffers from tooth decay, with one in nine showing decay in three or more teeth, Katherine Iritani, acting director of health care at the Government Accountability Office, told House lawmakers Wednesday.

“In too many cases, this need is urgent,” she said.

Without much in the way of federal help, nearly all states have taken their own steps to increase Medicaid patients’ access to dental care, Iritani said. Some have hiked reimbursements to providers; others have created hotlines to point families to locally participating dentists; still others have tried to simplify the claims process. Yet those efforts have met with only meager success. In 2007, only one state reported that more than half of enrolled Medicaid kids had received dental care, and 12 others reported dental utilization below 30 percent.

Burton Edelstein, professor of dentistry at Columbia University, told lawmakers Wednesday that, while reimbursement is certainly a factor, there are others barriers to care as well. Complex paperwork, high rates of broken appointments and the recession’s pressure on state budgets have all contributed to the access problem. “We still have Deamonte Drivers out there,” Edelstein warned.

Ann Kohler, director of the National Association of State Medicaid Directors, pointed to yet another factor: the rising frequency of dental students choosing cosmetic dentistry in lieu of general practice. “The dental industry on the whole is changing,” Kohler said. “More and more dentists won’t take any insurance at all.”

An ADA Medicaid analysis, published last year, provided a sum of the concerns: “There is a definite fear among some dentists that their private practice will be overrun by Medicaid patients,” ADA concluded.

The combination of factors creates a tough road ahead for Mann, not least of all because she’s following in the footsteps of Bush-era appointees who were loathe to intervene in what they considered to be, more or less, state problems. Mann, former head of Georgetown University’s Center for Children and Families, a patient advocacy group, said CMS is drafting dental health quality standards and reviewing state strategies in search of those that work best. But the access problem, she added, won’t be solved without addressing the dearth of dentists participating in the program.

“We don’t have providers in many states — in many parts of the country — who are willing to take Medicaid patients right now,” Mann emphasized.

She could have added, “And we’ll need Congress’s help to fix that.”

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