Children’s health advocates and the state dental association hoped an audit last month criticizing the state’s handling of dental coverage for more than five million children might loosen the purse strings in Sacramento when budget time rolled around.
Gov. Jerry Brown (D) did not address dental problems in his budget proposal last week.
The cold shoulder seems particularly icy to dental advocates in light of last month’s report by the state auditor saying more than half the 5.1 million children covered by the state’s program for low-income families did not receive dental care last year.
“Gov. Brown’s proposed budget missed an opportunity to improve access to dental care for children by not addressing California’s inadequate Medi-Cal rates for dental providers, which are some of the lowest in the country,” said Jenny Kattlove, senior director at the Children’s Partnership, a national advocacy group based in Santa Monica.
“More than half of California’s children are enrolled in Medi-Cal, yet significant numbers of these children are not getting needed dental care,” Kattlove said.
A spokesperson for the Brown administration said Brown’s budget blueprint “includes sufficient funding for dental benefits for the Medi-Cal program.”
“The budget includes $1 billion in 2014-15 and $1.1 billion in 2015-16 total funds for Medi-Cal dental services,” said H.D. Palmer, deputy director of the California Department of Finance, in an email response to questions.
“The funding level in the governor’s budget is consistent with caseload projections and current benefit levels,” Palmer said.
Officials at the California Dental Association and children’s advocates disagree.
“CDA will continue to advocate with the administration and educate policymakers on the shortcomings of the Denti-Cal program, which fails to uphold the state’s obligation by law to ensure an adequate network of dental providers,” CDA officials wrote in an email responding to questions.
The CDA email went on to say:
“The program also fails to provide reasonable reimbursement rates, with California among the lowest in the nation. CDA is in discussion with legislative chairs to schedule hearings that would investigate the findings of the recent state audit and help improve the Denti-Cal program.”
Audit Points to Several Problems
In addition to the millions of children who had no dental care last year, the audit predicted California’s situation could get worse as enrollment in Denti-Cal, the oral health section of Medi-Cal, is expected to double as a result of Medi-Cal expansion. Denti-Cal enrollment, about 2.7 million now, is expected to grow to 6.4 million.
Advocates and dental experts say the paucity of Denti-Cal providers will be exacerbated by the state’s decision to reduce Medi-Cal reimbursement by 10%.
California’s Medi-Cal reimbursement rates, already among the lowest in the country, have not increased since 2000. California’s rates are about 35% of the national average, according to CDA statistics.
Pointing out that reimbursement was already so low that California dentists who treat Denti-Cal patients were scarce, the 10% cut will make them scarcer, advocates said.
Last month’s audit by state auditor Elaine Howle appears to support their contentions.
According to the audit, as many as five counties with at least 2,000 Denti-Cal children may have had no dentists participating in the program last year. The audit also found 11 counties in which no dentists were accepting new Denti-Cal patients and 16 counties appeared to have “insufficient” numbers of providers accepting new Denti-Cal patients.
Kattlove said the audit should guide state policy makers.
“Given these findings, we urgently need to incentivize dentists to participate in the program and serve low-income families,” Kattlove said.
“We are also disappointed that the budget does not include investments in preventive oral health programs, such as the successful California Children’s Dental Disease Prevention Program, which was defunded in 2009,” Kattlove added.
Reimbursement Not a New Issue
Nadereh Pourat, director of research at UCLA Center for Health Policy Research, said the number of California dentists willing to accept Denti-Cal patients and Denti-Cal reimbursements “is a perennial issue.”
“It’s always been a problem in California. We did an analysis in 2003 — a big survey of dentists in the state — and our estimate was that only about 40% of the dentists at that time were accepting Medi-Cal patients,” Pourat said.
“It’s such a hard nut to crack — how to improve access to oral health care for the Medi-Cal population,” Pourat said. “Continuity is an important factor for both patient and provider,” Pourat said.
“There is research that shows if you lower reimbursement and then bump it back up again, you don’t necessarily get a lot of people jumping back into it. I think making that business decision in their practices is hard for dentists and if they’re forced out like many of them were in 2009, not as many will come back to Medi-Cal when the program’s funding improves.”
California reduced its subsidized oral health coverage in 2009 to save money in a particularly bleak budget period. Many dental programs were reinstated in 2013 and 2014, but some dentists — especially those who treat children — did not return to the Medi-Cal fold.
“When you start to factor in the kinds of care and the level of reimbursement dentists get for different services, caring for children takes on a different aspect than caring for adults,” Pourat said. “With children, it’s primarily prevention services and the potential earnings for seeing a child would tend to be lower than seeing an adult. Those are the kinds of business decisions dentists are forced to make,” Pourat said.
Brown Budget Steers Coverage Toward Youth
Brown’s budget proposal includes policy initiatives aimed at increasing dental care for the youngest of Medi-Cal beneficiaries — children up to age three.
State officials hope to “expand the provider network of Medi-Cal dental services providers by allowing allied dental professionals to enroll as rendering providers,” Palmer said.
The budget also “proposes to amend Health & Safety Code to require dental referrals on children at least one year of age rather than three years of age,” Palmer added.
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