As New Hampshire pushes off Medicaid adult dental benefit, experts fear wider implications
By Hadley Barndollar
Dentist Dr. Greg Fredette looks into a mouth and often sees the ravages of poor dental care: missing teeth, receding gums and cavities like tiny canyons.
Some patients are struggling single moms caught in a financial squeeze, habitually putting off their own dental care. Others are retirees who haven’t had adequate insurance since leaving the workforce.
“It’s not that these people don’t care about their health. It’s just at the end of the month, there’s no money left for them,” said Fredette, associate chief dental officer at Greater Seacoast Community Health in New Hampshire.
Fredette sees the results of “years of neglect” that could have been avoided with routine preventative care.
Poor dental health can ultimately lead to chronic diseases, and at worst, death. But care often falls by the wayside for many low-income people who lack insurance or don’t have a way of getting to the dentist’s office.
For adults on Medicaid in New Hampshire, dental coverage still remains elusive. Last week, Republican Gov. Chris Sununu signed the biennial state budget, and in doing so, scrapped funding for the state’s Medicaid adult dental benefit.
New Hampshire only provides emergency dental coverage to adults on Medicaid – not for preventative care or other major procedures, which are covered for children 18 and under. Across New England, Medicaid dental benefits vary widely from comprehensive, to limited, to emergency services only. Massachusetts, for example, just spent the last 10 or so years rebuilding its Medicaid adult dental benefit after gutting it post-recession.
With no federal mandate to require dental coverage for adults on Medicaid, states are allowed to scrap and restore funding as they please.
Dental issues can lead to chronic diseases
Poor dental health – particularly gum disease – has been linked to chronic diseases such as diabetes, heart disease and stroke. It can also cause pregnant women to suffer from preeclampsia, a potentially fatal complication characterized by high blood pressure, and their babies can be born at a low birth weight.
Neglected teeth can also get in the way of people trying to find a job.
Six out of 10 low-income adults who did not have Medicaid dental benefits reported they didn’t go on job interviews because of bad teeth or felt that their teeth cost them a job, according to a national survey by the American Dental Association. People without jobs ultimately add other financial burdens to states.
Many argue that investing in comprehensive dental care will ultimately save states money in the long run, but it can be a tough argument for some to swallow when considering the upfront costs alongside other state programs needing money.
Adding to the urgency are dental health problems exacerbated by the COVID-19 pandemic: most dentists nationally are now seeing major backlogs. In April, a dentist at the Richford Health Center in Richford, Vermont, said patients could not get an appointment with her until October, for example.
Seeing people who have gone a lifetime without dental care is “devastating,” said Dr. Kris Blackwelder, chair of the New Hampshire Dental Society’s Medicaid Advisory Committee.
New Hampshire is one of four states in the country that has expanded Medicaid, but still doesn’t have a dental benefit. It’s also among just 10 states, along with Maine in New England, that only cover emergency services.
“All we’ve ever done is extract teeth for adults, and there’s no type of treatment,” said Dr. Sarah Finne, Medicaid dental director for the state Department of Health and Human Services.
As a result, Blackwelder said, there is “pent-up need across a generation without an adult (dental) benefit” in New Hampshire.
Medicaid adult dental benefit removed from New Hampshire budget
In New England, according to the Center for Health Care Strategies’ rankings of Medicaid dental benefits state-by-state, Massachusetts, Connecticut and Rhode Island are all listed as extensive, while Maine and New Hampshire are emergency coverage only, and Vermont is limited.
In states without comprehensive Medicaid dental coverage, low-income residents will likely continue to face emergency room visits or last-resort tooth extractions as their only options, advocates say.
Before the pandemic, Sununu signed a bill that created a dental plan for adults on Medicaid, but it didn’t have funding. Despite unanimous approval by the Senate twice this year, New Hampshire House Republicans removed the proposed funding from the budget last month due to concerns of a state budget already squeezed by the pandemic.
Democratic state Sen. Cindy Rosenwald, who introduced the bill, said House Republicans “decided to turn their backs on over 120,000 Granite Staters who would have benefitted from the economic and social advantages of preventative dental care.”
The bill would have provided approximately $1.5 million for a partial year to start giving nearly 75,000 people dental insurance, and ultimately $7.45 million for a full year.
“A lot of us were very disappointed with the way things worked out this year,” said Finne, of the state’s DHHS. “But on a positive note, I think over the last four to five years, a tremendous amount of work has been done by oral health advocates across the state to really raise the awareness of how important oral health is to overall health. We can’t continue to keep separating the two and pretend they don’t have any relation to each other.”
Michael Auberbach, executive director for the New Hampshire Dental Society, cited bipartisan support for the adult dental benefit, and momentum to continue until the funding is ultimately signed into law.
Finne feels most legislators in New Hampshire understand the importance, “but they’re just not yet comfortable with the cost, and trying to understand where we might see savings down the line.”
Massachusetts stripped, then restored Medicaid dental funding
The Granite State’s neighbor to the south just spent the last 10 or so years rebuilding its dental care coverage for low-income people. After the Great Recession, coverage under MassHealth – Massachusetts’ Medicaid program – was stripped down to the bare minimum as a cost-savings measure.
In January, coverage was fully restored for adults ages 21-64 when the Massachusetts House and Senate overrode Gov. Charlie Baker’s veto of the budget line item for coverage of root canals and crowns.
“Those with MassHealth will no longer be forced to face a tooth extraction because it was the only course of treatment covered,” Health Care For All Massachusetts celebrated in a statement after the vote. “Having good oral health is critical to an individual’s ability to maintain a healthy diet, as well as their dignity and ability to work.”
Colin Reusch, senior adviser on oral health policy for national nonprofit Community Catalyst, said when Massachusetts cut Medicaid dental benefits, dental-related emergency room visits went up as much as 14%, “a huge cost to the health system and taxpayer.”
“There are savings to be had on the medical side when you’re offering comprehensive oral health benefits,” said Reusch.
He said his organization will soon release a research paper with the American Dental Association and Families USA detailing the impact on each state’s Medicaid program if Congress required comprehensive dental benefits. That savings nationally is estimated to be about $273 million.
Katherine Pelullo, of the Massachusetts Dental Hygienists’ Association, said the absence of a federal mandate for dental coverage “makes it easier for a state government to terminate coverage during periods of economic decline.” Medicare – the country’s health insurance program for people 65 or older – does not include dental coverage, she said.
The U.S. spends $2 billion per year on dental-related emergency room visits, Reusch said, and 80% of the problems could have been solved with preventative care. In New Hampshire, the state could save an estimated $2 million by diverting dental problems out of emergency rooms.
But simply the implementation of a Medicaid benefit is not the cure-all, said Dr. Laurie Rosato, chair of the New Hampshire Dental Society’s Council on Government Affairs. The benefit requires “care coordination” – the many steps in between a patient getting to a dental provider. That would include keeping people up to speed on their own dental health, tackling widespread systemic fear and anxiety around dental work, transportation, child care and more.
“We know by having the benefit in the long run will save the state money, but the most important thing is not just to give the benefit, but how the benefit is administered,” Rosato said.
Getting underserved people ‘out of pain’
Seacoast Periodontics and Dental Implants in Portsmouth, New Hampshire hopes to “help underserved people and get them out of pain” during a charity event in July , said office manager Luis Rodriguez.
It’s the second year the specialty dental office will offer free single-tooth extractions for people with limited finances. The event is scheduled for Friday, July 16, starting at 8 a.m. and going until the final patient is seen.
“We are looking to see if we see a drastic increase,” said Rodriguez. “There’s obviously a large unemployed population out there right now, and people who have lost benefits from their employers. And there’s people at the baseline who either don’t have insurance, or insurance that doesn’t cover enough to make them comfortable to come in.”
Rodriguez said the main focus for that day is to help people who are in immediate pain, with active infections or broken teeth, and cannot afford treatment. The dental office has spread the word through the local public housing authorities, senior centers, and Meals on Wheels programs.
What are the Medicaid dental benefits in each New England state?
New Hampshire and Maine’s Medicaid programs currently cover emergency dental services only for adults, but the Maine House and Senate recently advanced a celebrated bill that would expand that benefit in the Pine Tree State to preventive, diagnostic and restorative care.
In Massachusetts, Rhode Island and Connecticut, Medicaid adult dental benefits are considered comprehensive.
For example, Rhode Island covers two cleanings and two oral exams per year, complete root canal therapy, biopsies of oral tissue, and oral surgery when medically necessary, among other procedures.
Connecticut’s Medicaid program, called HUSKY Health, covers fillings, partial and full dentures, root canals, crowns and oral surgery, and other procedures.
In Vermont, the Medicaid dental benefit is limited to $1,000 per beneficiary per calendar year, but up to two visits for preventive services do not count towards the dollar limit.