© Picasa Drs. David Miller and James Fitzgerald, along with a dental student resident, talk to a patient at the Interfaith Dental Center in Brooklyn. Most of the center’s patients are enrolled in Medicaid, which pays for nearly all of their care. In much of the rest of the country, Medicaid either offers no adult dental coverage or very limited benefits. (Picasa)

NEW YORK – At the Interfaith Dental Center in Crown Heights, Brooklyn, people with dental pain can walk into a ground floor office off Bedford Avenue and get treated without an appointment. They might have to wait in a packed waiting room. But if they’re in the door by 5 p.m., a dentist will see them.

Residents in this low- to middle-income neighborhood likely don’t realize how lucky they are. The majority of Americans have to travel miles to see a dentist who takes their insurance, particularly if they’re covered by Medicaid. Many dental patients with private insurance cannot afford to pay their share of the bill.

Federal law requires state Medicaid programs to include dental care for children, and the Affordable Care Act extended that requirement to private insurers. But the federal health law did little for adults: While premium tax credits were made available to help low-income people purchase health insurance, the subsidies cannot be used to purchase dental coverage except as an add-on to health coverage. No new dental benefit requirements were included for adults covered by Medicaid.

“The ACA was a big flop when it comes to adult dental coverage,” said Dr. Jonathan Shenkin, vice president of the American Dental Association (ADA).

Even so, some states have stepped up coverage for at least some adults on Medicaid. Virginia added a dental benefit for pregnant women in March. Colorado introduced limited adult dental coverage for the first time last year. Also last year, California, Illinois, Massachusetts and South Carolina reinstated benefits that had been cut in the years since the recession began in 2007. Indiana began offering expanded adult dental benefits this year.

Shenkin acknowledged the federal health law’s provision allowing young adults to stay covered by their parents’ insurance until age 26 has helped. Fewer young adults are showing up in emergency rooms with dental pain, according to an April ADA survey. About 1.4 million Americans have purchased dental coverage on health insurance exchanges since January 2014 when the law took full effect. “But overall, we’ve seen no real improvement in the quality of adult dental coverage for decades,” he said.

It’s not just a Medicaid problem. Employer-sponsored insurance typically caps coverage at $1,500 per year, the same level as 30 years ago when dental insurance was first offered. Medicaid dental coverage has had even lower spending caps in most places. States vary widely when it comes to adult dental benefits, but on average, Medicaid dental coverage has declined since the recession.

“Adult dental benefits are caught in a pendulum swing of contraction in fiscal downturns and expansion when fiscal pressures go away,” said Andrew Snyder, dental expert at the National Academy of State Health Policy. “That’s been the story for a long time. I don’t know that there was ever a time when adult dental was really great.”

Although the ACA does not make Medicaid dental coverage mandatory for adults, it gives states that have chosen to expand Medicaid a potential financial incentive to include dental benefits.

Under the ACA, the federal government pays the entire health care bill for all newly enrolled adults with incomes below 138 percent of the federal poverty level ($16,243 for an individual) through 2016. After that, the federal share gradually decreases to 90 percent in 2020 and beyond. As a result, officials in a few states are considering dental coverage for the first time or reinstating coverage cut during the last recession.

New York and 14 other states have nearly comprehensive coverage, 16 states and the District of Columbia offer limited coverage, and 14 states cover only emergency dental care. Alabama, Arizona, Delaware, Maryland and Tennessee offer no adult dental coverage.

Another barrier to dental care for low-income adults is the relatively low reimbursement rates offered by state Medicaid programs. Extensive paperwork and oversight also limit the number of dentists willing to take Medicaid patients. (The ACA calls for even more intensive oversight and audits.) The result is poor access to preventive care for low-income people on Medicaid in much of the country, ultimately resulting in higher overall costs.

The problem is not limited to Medicaid. Most employer-sponsored insurance pays for only a portion of the cost of an annual checkup and a few fillings. For moderate-income people who need more extensive restorative work, out-of-pocket expenses can be unaffordable. In a recent survey, nearly four out of 10 respondents said they or a family member had put off seeing a dentist because of concerns about out-of-pocket expenses.

Americans spend as much to treat dental disease — almost all of it preventable — as on the treatment of all cancers combined, according to DentaQuest, a research and advocacy organization and administrator of dental insurance plans, including Medicaid.

Patchwork of Funding

New York has offered comprehensive dental coverage for adults in Medicaid for as long as anyone can remember. But the fees it pays dentists are among the lowest in the country — only 37 percent of what private insurance pays.

Still, New Yorkers, particularly those living in the populous southern half of the state close to New York City have better access to dental care than most people in the country. The biggest reason is the state requires dental students to complete a year of postgraduate residency to become certified. To do that, they must provide full-time dental care wherever they can find patients.

That requirement adds about 900 dentists to the state’s workforce at any given time, all of them on salary and eager to work on Medicaid enrollees and other low-income patients, said Dr. David Miller, who heads the Interfaith Dental Center. (Delaware is the only other state that has a similar dental residency requirement.)

In Crown Heights, Miller said his clinic also benefits from its affiliation with Interfaith Medical Center, which is about a mile away. The staff there includes grant writers who have brought in federal, state and local money to help provide the services most in demand in the community. Adult dental care is a top priority, he said.

Miller said his clinic is part of Interfaith’s integrated medical system. Dentistry is not separate, it’s a collaboration with the emergency department, anesthesia and internal medicine. “Our patients are being well taken care of,” Miller said. “We couldn’t do it on Medicaid alone.”

As president-elect of the New York dental association, Miller said he’s concerned that the statewide enrollment of dentists in Medicaid’s provider network is stagnant. New York has begun a transition to managed care for dentistry and other health care services that he anticipates will present even more challenges for dentists who serve Medicaid patients, especially small practices.

Under Medicaid managed care, all dental practices will have to negotiate separately with each insurance plan if they want to serve Medicaid patients. “If you’re not a big entity with lots of practices and lots of specialties, you have a lot less to bring to the table. Managed care companies are trying to find one-stop shopping,” Miller said.

Health and Cost Savings

Medical research shows that poor oral health results in increased risk for diabetes, breathing disorders, cardiovascular disease and poor pregnancy outcomes such as preterm births and stillbirths. It also affects eating, speaking and self-esteem, as well employability.

Low-income adults are 40 percent less likely than those with higher incomes to have seen a dentist in the last year, according to the Center for Health Care Strategies, which provides research and technical assistance to state Medicaid programs. More than 40 percent have untreated tooth decay, and one-third of those 65 or older have lost all of their teeth. People with disabilities and elders who live in a nursing facility are at even greater risk of dental disease.

Lack of regular dental care also drives up costs. Unlike diabetes, hypertension and other chronic diseases that affect millions of people, dental disease affects everyone. With regular preventive care, most oral health problems can be avoided or curtailed. Without it, people end up in emergency rooms, often with problems that are more expensive to treat, Shenkin explained.

A recent study showed that California’s decision to end its dental program in 2009, which had covered 3.5 million low-income adults, resulted in a 68 percent increase in costs for emergency department use for dental pain.

“I think the important point here is although the Medicaid dental benefit for adults is optional, savings derived from dropping the benefit are somewhat eaten up by the increased costs from adults seeking dental care in hospital emergency departments,” author Astha Singhal wrote in the journal Health Affairs.

Lack of Continuity

Many Americans aren’t aware of the importance of oral health. With a scarcity of dentists, particularly in rural areas, transportation can also be an issue.

Too many people think they don’t need to go to a dentist unless they’re in pain, said Stacey Chazin, senior program officer at the Center for Health Care Strategies. At that point, they often have nowhere to go but emergency rooms, she said.

Once they see a dentist and learn more about oral health, people tend to go in for regular check-ups, she said. But maintaining continuity of care can be difficult when state Medicaid programs shrink or withdraw dental coverage from one year to the next.

Fluctuations in Medicaid benefits also affect dentists’ willingness to go to the effort of registering as a Medicaid provider. “It’s no way to build a relationship with the dental community,” said Matt Salo, executive director of the National Association of Medicaid Directors.

Because adult dental care is optional, states have to justify it financially, he said. So far, there are no standard quality measures for dental health, and most studies project savings over too long a time frame for states to warrant the added expenditure in any given budget year.

That may be changing, though. According to Salo, state Medicaid agencies are becoming more interested in improving the health of their overall populations. Increased recognition that dental health is an important component of health and economic mobility may spur more states to include dental benefits, particularly in expansion states where many of the new adults coming into the Medicaid system have untreated dental conditions, he said.

In the few states that have expanded adult dental coverage so far, it’s too early to know how much of a difference it will make in improving oral health and saving on Medicaid spending, Chazin said. “Folks need to know about it and enroll. They need to be educated about it and find a provider. It will take at least a year or two.”