A Substantial Gap in Many Medicaid Programs: Lack of Dental Benefits

The following originally appeared on The Upshot (copyright 2018, The New York Times Company).

Even before any proposed cuts take effect, Medicaid is already lean in one key area: Many state programs lack coverage for dental care.

That can be bad news not only for people’s overall well-being, but also for their ability to find and keep a job.

Not being able to see a dentist is related to a range of health problems. Periodontal disease (gum infection) is associated with an increased risk of cancer and cardiovascular diseases. In part, this reflects how people with oral health problems tend to be less healthy in other ways; diabetes and smoking, for instance, increase the chances of cardiovascular problems and endanger mouth health.

There is also a causal explanation for how oral health issues can lead to or worsen other illnesses. Bacteria originating in oral infections can circulate elsewhere, contributing to heart disease and strokes. A similar phenomenon may be at the root of the finding that pregnant women lacking dental care or teeth cleaning are more likely to experience a preterm delivery. (Medicaid covers care related to almost half of births in the United States.)

“I’ve seen it in my own practice,” said Sidney Whitman, a dentist who treats Medicaid patients in New Jersey and also advises that state and the American Dental Association on coverage and access issues. “Without adequate oral health care, patients are far more likely to have medical issues down the road.”

There are also clear connections between poor oral health and pain and loss of teeth. Both affect what people can comfortably eat, which can lead to unhealthy changes in diet.

But the problems go beyond health. People with bad teeth can be stigmatized, both in social settings and in finding employment. Studies document that we make judgments about one another — including about intelligence — according to the aesthetics of teeth and mouth.

About one-third of adults with incomes below 138 percent of the poverty level (low enough to be eligible for Medicaid in states that adopted the Affordable Care Act Medicaid expansion) report that the appearance of their teeth and mouth affected their ability to interview for a job. By comparison, only 15 percent of adults with incomes above 400 percent of the poverty level feel that way.

Some indirect evidence of the economic effects of poor oral health comes from a study of water fluoridation, which protects teeth from decay. It found that fluoridation increased the earnings of women by 4 percent on average, and more so for women of low socioeconomic status.

Other evidence comes from a randomized study in Brazil. In that study, investigators showed one of two images to people responsible for hiring: pictures either of a person without dental problems or with uncorrected dental problems. Those with dental problems were more likely to be judged as less intelligent and were less likely to be considered suitable for hiring.

The relationship between oral health and work has gained new salience in light of Kentucky’s recently approved Medicaid waiver, which permits the state to impose work requirements on some able-bodied Medicaid enrollees. It’s a step that some other states are also considering.

Medicaid takes different forms in different states, and even within states, different populations are entitled to different benefits. Though all states must cover dental benefits for children in low-income families, they aren’t required to do so for adults.

As of January 2018, only 17 state Medicaid programs offered comprehensive adult dental benefits, and only 14 of those did so for the population eligible for Medicaid under the Affordable Care Act. More typically, states offer only limited dental benefits or none.

Dental coverage under most private health care plans isn’t comprehensive, either — people who want it have to buy separate dental plans. But compared with those enrolled in private coverage through an employer or on their own, the population eligible for Medicaid is much more likely to need dental care and much less likely to be able to afford it or coverage for it. People with incomes low enough to qualify for Medicaid are twice as likely to have untreated tooth decay, relative to their higher-income counterparts.

Kentucky offers limited dental benefits to Medicaid enrollees, including those on whom work requirements would be imposed. Those benefits exclude coverage for dentures, root canals and crowns, which could challenge some enrollees’ ability to maintain good oral health and lead to greater emergency department use.

One study found that after Kentucky’s Medicaid expansion in 2014, the rate of use of the emergency department for oral health conditions tripled. Another study found that about $1 billion in annual emergency department spending was attributed to dental conditions, and 30 percent of emergency department visits for dental problems were made by people enrolled in Medicaid.

Other states that have proposed imposing work requirements as a condition of Medicaid eligibility include Arizona, Arkansas, Indiana, Kansas, Maine, New Hampshire, North Carolina, Utah and Wisconsin. Of these, only North Carolina and Wisconsin offer extensive dental benefits, while Arkansas, Indiana and Kansas offer limited benefits. (The definition of “limited” varies by state, but in all such states benefits are capped at $1,000 per year and cover less than 100 of 600 recognized dental procedures.) Maine, New Hampshire and Utah offer emergency-only benefits. Arizona offers none.

Though emergency-only coverage is less than ideal, it is better than nothing, as documented in a recent study based on Oregon’s Medicaid experiment. The study used a random lottery to offer some low-income adult residents eligibility for Medicaid. At the time of the study, Oregon offered dental coverage only for emergencies..

The study found that one year after the lottery, Medicaid coverage meant more people got dental care (largely through emergency department use), and the percentage of people reporting unmet dental needs fell to 47 percent from 61 percent. It also doubled the use of anti-infectives, which are used to reduce gum infections. Another study, published in the Journal of Health Economics, found that Medicaid dental coverage increased the chances that Medicaid-eligible people had a dental visits by as much as 22 percent.

It’s an accident of history that oral care has been divided from care for the rest of our bodies. But it seems less of an accident that the current system hurts those who need it most.


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