By skyforbes 
Oral health has been described by the Mayo Clinic as the “window” into an individual’s overall health. When this window is closed and shuttered, critical insights into patient health become inaccessible, and the effects can be grave. In January of 2007, Deamonte Driver, a healthy, energetic twelve-year old boy, mentioned to his mother that he had a toothache. Following a series of misdiagnoses, the family learned that Deamonte had an infected molar, which, due to lack of treatment, had formed an abscess in his brain. Deamonte passed away on February 25th, 2007. Early intervention or a routine $80 tooth extraction even at a more progressed state of decay might have saved him (Otto).
The story grabbed the nation’s attention, with parents, healthcare workers, and government officials alike asking: How could this happen? How could a child not have ready access to sufficient preventive and routine dental care to avoid such a horrific outcome?
Unfortunately, Deamonte and his family were not alone in their struggle to find and access adequate, timely dental care in the U.S., and this struggle continues for low-income families even today, 18 years following Deamonte’s tragic passing. These families often face a host of obstacles — of “if onlys” — similar to those that the Drivers faced: “If his mother had been insured. If his family had not lost its Medicaid. If Medicaid dentists weren’t so hard to find. If his mother hadn’t been focused on getting a dentist for his brother, who had six rotted teeth” (Otto). Removing the obstacles to effective oral healthcare for low-income families, including the obstacles still present in the Medicaid system, remains crucial to improving the overall health of these populations.
Currently, Medicaid is the largest program funding medical and other health-related services for low-income individuals and households within the United States. Medicaid is administered by the states within broad federal rules and jointly funded by the state and federal governments through a federal matching program (“EPSDT in Medicaid”). However, the dental coverage provided through Medicaid, on which more than 83 million people in America rely today, has many faults. To address these shortcomings, the Medicaid dental program and policies need to be more comprehensively developed and integrated with Medicaid’s medical health coverage. This change is crucial to recalibrate the societal perception of dental health and well-being from luxury to necessity. To thereby increase coverage, driving accessibility of dental care, and improving the overall health of our nation and our people.
To tackle the perception issue, it is essential to first examine the longstanding divide between dental and medical healthcare within the United States. The bifurcation of these disciplines began in the 1800s. Notably, the nation’s first dental school, opened in 1840, was created after the University of Maryland School of Medicine rejected the integration of a standard dentistry curriculum. This divide persisted; in the 1900s, oral health was widely perceived as disconnected from overall health, with dentists disagreeing with efforts to combine the fields. At that point, dentistry was considered a separate “craft” (rather than a science), with a separate education track and separate practices. Further reinforcing this perception of dentistry as being outside of medicine rather than a specialty within it, emerging U.S. insurance was modeled as “sickness insurance,” not covering dental needs and thereby further solidifying the divide that we see today (Braunold).
In the late 1920s, ideas for comprehensive health services including dentistry were promoted by the Carnegie Foundation. However, dentists were not on board, and subsequent federal efforts to provide dental coverage were permitted to stagnate, resulting in a health insurance landscape by the 1970s in which medical healthcare coverage was prevalent (85%), but dental coverage all but non-existent (Braunold). This divide in insurance coverage has since persisted in the United States. As explained by Dr. Lisa Simon, “both medical and dental insurance in the United States … traditionally served very different functions: medical insurance was designed specifically to cover large, unpredictable expenses, while dental insurance was and is intended to fund predictable and lower-cost preventive care. While protection from catastrophic medical costs was perceived as a necessity, coverage of dental services, from its origin, was conceived as a benefit” (Simon).
The perception of dental care as a luxury versus necessary healthcare is ubiquitous in the current landscape of our society. Whereas Medicaid is available and required for most traditional medical issues, dental coverage through Medicaid is selective. Currently, although “dental care must be funded for low-income children as a component of Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, dental care for adults is considered an optional service administered on a state-by-state basis” (EPSDT in Medicaid). As a result, in recent years, at least “four states did not cover any adult Medicaid dental services, and fifteen states only reimbursed providers for emergency dental treatment… Even among states covering non-emergency dental services, Medicaid plans differ across states in benefits and services covered” (Semprini and Wehby). And, even for children, there remain issues with the execution of the policies that are in place: “Medicaid covers dental care for an estimated 37 million children from low-income families. The state and federal Medicaid program varies by state, but there are national shortages of dentists who participate” (“Many Children With Medicaid”). As a result, rates of routine dental care remain low even for children.
These low rates of dentist participation in the Medicaid program are driven to a great extent by low reimbursement rates for dental care through Medicaid (Appel). Among the reasons for low reimbursement rates, in turn, are the fact that these rates frequently fail to keep up with the rising cost of dental procedures, the complexity of reimbursement processes, denials of reimbursement requests, and broken appointments (Flynn et al.). Consequently, addressing the need for broader access to dental care for low-income children and adults starts with growing the number of participating dentists by addressing the barriers to their participation. To accomplish this, state-level Medicaid programs, including state budget offices and Medicaid administrators, need to scrutinize reimbursement rates to ensure that they reflect actual costs to dental providers. In addition, administrative burden needs to be reduced, and reimbursement guidelines clarified to increase the likelihood and transparency of reimbursement (Burns et al.). At the same time, Medicaid programs need to help beneficiaries better understand the importance of these services and how to access them, thereby reducing missed appointments and facilitating smoother program utilization. Without these changes, the number of participating dentists are likely to remain low or even shrink, and the waitlists to visit dentists serving lower-income individuals will grow, leading to prolonged, unaddressed oral health issues and more severe health impacts to patients. And even more fundamentally, to better enable these changes across the board, dental care must be understood by all as a healthcare necessity.
To provide an example of today’s challenges and how we must address them: Medicaid dental insurance within Connecticut, for example, is exemplary in some regards; but Connecticut continues to struggle when it comes to reimbursement rates. Currently, “Connecticut finds itself ranked fourth in the nation in [quality of] dental care. This is an extremely gratifying accomplishment; however, Connecticut is tied as the worst state when it comes to the cost for dental coverage” (Milarch). Moreover, despite Connecticut’s overall high-quality dental care, its provider participation rate in Medicaid programs remains at only 40% (Serban et al.). Katy Golvala, in an article for the CT Mirror, described a study that “analyzed Medicaid reimbursement rates for more than 11,000 physician specialist, dental and behavioral health services.” She noted that “[t]he findings reveal that Connecticut paid less than a peer state benchmark for 85% of services analyzed and less than [the] benchmark for 94% of services analyzed.” (Golvala).
The article then highlighted the practical impacts of this disconnect, stating that “these lower reimbursement rates can impact access to dental care for Medicaid beneficiaries, as providers may be less willing to accept Medicaid patients due to financial constraints… there are concerns about access to care and the availability of providers” (Golava). Simply put, despite CT’s significant accomplishments in terms of dental care, the state Medicaid program’s failure to reimburse commensurate with costs may ultimately be discouraging provider participation in Medicaid programs and, consequently, impeding low-income individuals’ access to such care. Hence, even in Connecticut, Medicaid coverage of dental needs should be more comprehensively developed and integrated with overall health insurance. In order to eliminate the disconnect, further focus on aligning the increasing costs of dental procedures with coverage through the Husky Medicaid plans is essential. And the same approach needs to be applied across the other states.
How can the system be improved upon? What are the solutions, and how can we achieve them? There are certainly many components of the equitable and accessible dental care solution. It is essential that there is a push for a change in Medicaid policies, cost-based reimbursement rates, and increased participation of dentists in the program; these are all essential pieces of a puzzle that needs to be solved for the betterment of our nation and its health. But most importantly, a shift toward integration of medical and dental healthcare is critical. “The largest barrier to that may be insurance coverage. If dental insurance remains a separate entity, then so will dental care in the minds of patients who only have health insurance. To best serve our patients, we must consider becoming champions of combining dental insurance with existing health plans” (“Health Insurance Should Cover”). This barrier exists for many reasons, but it is essential that this barrier be eliminated, and that bridges be provided in order for all people to have access to dental care. Everyone’s overall health is greatly impacted by oral health — “the mouth is the gateway to the body. It’s the canary in the coal mine: Dentists have a clear picture of how healthy someone is the moment they look inside their mouth” (“Health Insurance Should Cover”). This is why we have to pay attention and make a change.
The divide started with public perception, and changing this perception is, accordingly, a crucial part of driving toward change — of American people across the nation recognizing that dental and oral health is an integral part of overall well-being. Additionally, When dental insurance is more comprehensively developed and integrated with overall health insurance in general and under Medicaid in particular, we will also see a change in the societal perception that dental health and well-being is not just a luxury — it is essential to an individual’s overall health.
Federal legislators play a key role in helping to shift the public perception regarding the necessity of dental care for all. Explicit inclusion of dental care for both children and adults in an amendment to federal Medicaid legislation would be a significant — in fact, is likely the most crucial — step in the right direction. This step toward integration of medical and dental care in a more comprehensive package would require Medicaid administrators and state budget offices to appropriately allocate tax dollars and federal funding to stop the cycle of dental care disparity for low-income Americans. And this change would reinforce the crucial public perception of dental care as a necessity — not only among those who provide and those who receive this care through Medicaid, but among all who receive dental care across the United States. Ensuring that not only are critical healthcare services mandated for Medicaid beneficiaries, but also that dentists are willing to participate, and that patients are able to effectively utilize the program — thereby making timely and effective dental care accessible and improving the overall health of our nation. Creating a healthier America benefits us all at the end of the day. And this begins with ensuring the health of our dental insurance system.
Works Cited:
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