Legislative leaders and Gov. Jerry Brown (D) agreed on a budget plan this week that restores partial funding for dental services in Medi-Cal, California’s Medicaid program.
Northern California legislators and dental providers have been at the forefront of a campaign over the past four years to get dental coverage for Medi-Cal adults restored. For many advocates and stakeholders, this week’s budget news was considered a partial victory. Although not the complete restoration of $131 million sought, the state plans to spend about $16.9 million this fiscal year and $77 million next year on dental coverage. The money will provide preventive care, dental restorations and full dentures for adult beneficiaries of Medi-Cal.
Restoring adult coverage in Denti-Cal was considered a priority for California Senate President Pro Tempore Darrell Steinberg (D-Sacramento).
“Dental care is so essential to physical health and employability,” Steinberg said. “The current alternatives are gum disease and use of hospital emergency rooms at the expense of taxpayers, which is unacceptable.”
Lindsey Robinson, a pediatric dentist in Grass Valley and president of the California Dental Association, called the agreement “a significant achievement in the effort to restore all adult Denti-Cal services and a step in the right direction to address the oral health care crisis facing millions of Californians.”
Budget Woes Led To Denti-Cal Cuts
In 2009, California eliminated nonemergency dental benefits from its Medicaid program as a way to save more than $100 million annually. Nearly three million adults lost coverage for cleanings, exams, gum treatment, crowns, root canal procedures, dentures and fillings.
There are a few exceptions: Women age 21 and older who are pregnant and those who live in licensed skilled nursing facilities or licensed intermediate care facilities still can access basic dental care through Medi-Cal.
After the cuts were implemented, adult dental expenditures decreased from $114 million in the second quarter of 2009 to $14.2 million during the same time period a year later, as reported in a 2011 issue brief from the California HealthCare Foundation, “Eliminating Adult Dental Benefits in Medi-Cal.” CHCF publishes California Healthline.
Use of adult dental services fell from 35% of Medi-Cal beneficiaries in 2008-2009 to 12% in 2009-2010, according to the brief.
Community Steps In
Recognizing the access issues resulting from cuts in coverage in 2009, the California Dental Association launched semi-annual, two-day free dental clinics throughout the state.
At one such free clinic in San Jose last month, 1,700 dental professionals and volunteers provided $1.6 million in charitable dental services — including an estimated 2,300 tooth extractions and 11,000 dental procedures – to 2,200 patients, according to CDA officials.Â
“The number of patients highlighted the enormous problem we have in California in providing preventive dental care to our population,” said Ken Wallis, secretary of CDA and a solo practitioner in Santa Clara.
Wallis, who does not regularly treat Denti-Cal beneficiaries, said he considers the clinics — called CDA Cares — an opportunity to offer pro bono services.Â
It was a CDA Cares event last year in Sacramento that moved Steinberg to push for dental coverage. Steinberg said he was overwhelmed by the number of people lined up around the block for dental care, many with advanced oral disease.
Looking back at the state’s budget cuts over the past five years, Steinberg said elimination of adult dental services stands out for him the most.
Hospitals Support Basic Dental Care
Highland Hospital in Oakland, part of Alameda Health System, offers adult dental services through its main dental clinic and drop-in emergency dental clinic, which coordinates with the hospital’s emergency department to provide surgery coverage for dental problems resulting from trauma and life-threatening infections.
Averaging 35 patients a day, up from 25 before 2009, clinic staffers check vital signs, perform X-rays, make diagnoses and provide treatment. Some patients wait up to five hours to be seen, clinic officials said.
According to hospital officials, dental visits to the emergency department doubled between 2007 and 2011 and dental emergencies in the clinic increased by 70% between 2008 and 2011, the most recent statistics available.
Anthony Mock, chief of general dentistry for Alameda Health System and director of the dental clinic at Highland Hospital, said the immediate increase in utilization of both the emergency department and the emergency clinic was due to elimination of funding for adult preventive dental care in July 2009, and possibly a decrease in providers taking Denti-Cal patients.
He estimated that if adult dental services were reinstated, the hospital could save $2 million in the emergency department and $1.7 million a year in its drop-in clinic. “And we could prevent urgent care needs from developing into emergency care,” he said.
Discounted Fee-for-Service Promotes Oral Health
Dentist Ariane Terlet treats low-income adults in her private practice in Berkeley and at La ClÃnica de La Raza, a community health center serving residents in three East Bay counties. Terlet is La ClÃnica’s chief dental officer.
La ClÃnica’s Oral Health Initiative, funded by the John Muir/Mt. Diablo Community Health Fund, provides dental screenings and oral health education at health fairs, schools, senior centers and other community sites. About 35% of La ClÃnica’s patients are Medi-Cal beneficiaries and almost all the rest are uninsured, according to Clinica officials. Patients pay on a sliding fee scale based on income.
Terlet said she is “cautiously optimistic” about the recovery of the budget dollars for adult dental care, especially in light of the bipartisan vote to restore the services last month in the Senate budget committee. Even a step toward reinstating benefits on a limited basis would suit her for now.
She recommended the state establish the position of a state dental director to ensure that California takes advantage of federal funding that could support adult dental care.
Leaving Money on the Table
“We are simply leaving federal dollars in Washington,” Steinberg said.
The state lost out on approximately $134 million in federal funding when it cut Denti-Cal benefits, according to some analysts. A 2009 report funded by oral health advocates, Â “Eliminating Medi-Cal Adult Dental: Costs and Consequences” showed that with a multiplier effect, the cut to adult dental care cost the state more than $500 million, including loss of jobs, wages and business activity.
“The one-to-one matching federal dollars could provide basic dental benefits to three million low-income parents, seniors and people with disabilities and an additional one million adults without children at home who are newly eligible for coverage under the Affordable Care Act in 2014,” said Anthony Wright, executive director of Health Access, a not-for-profit consumer advocacy group.
“Restoring dental services for adults could further promote economic recovery,” Wright said. “Eliminating benefits has an impact on finding jobs, financial security and overall health.
“When you realize that the state has cut more than $15 billion worth of services over the past four years, the $131 million for adult dental care is only a small fraction,” he said.
Further, Wright said, “The state is being penny-wise, penny-foolish without the services, causing adults to show up in the emergency department for more expensive procedures.”
According to a report from the Pew Center on the States, more Americans are turning to hospital emergency departments  for routine dental problems — a choice that often costs 10 times more than preventive care.
In 2007, more than 83,000 people visited California hospital emergency departments for preventable dental conditions, according to the California HealthCare Foundation.
Terlet said the use of emergency departments for exacerbated dental problems that result in teeth extraction is akin to a patient going into an emergency department with a broken arm, and the only option is amputation. She noted that extractions without the benefit of restorative dental procedures can influence employability.
“We are now seeing the aftermath of four years of neglecting the oral health of adults,” she said.
Lower Reimbursement Enhances Problem
Despite restoration of funding, access to care will be a problem, advocates predicted. The Legislature’s 2010 decision to reduce all Medi-Cal reimbursements by 10% could make it cost-prohibitive to serve patients, according to dentists and advocates.
The lower reimbursement has not yet been implemented, but the 9th U.S. District Court of Appeals ruled that state officials can push through reductions retroactive to July 2011.
“It will be difficult for dentists to provide care at such low rates, resulting in fewer Denti-Cal participants,” Wallis said. “We need more group dental practices which will make it more cost-effective to serve Medi-Cal patients.”
“Combine lower reimbursement with an already underfunded program, and dentists will lose money before anyone even walks through the door,” said Carrie Gordon, vice president of public policy for CDA.