Achieving Oral Health Care Equity Through Medicaid

Background

Lessons to be learned from the COVID-19 pandemic and the racial unrest seen in the United States include how limited government is and how many social inequities remain in health care. Institutions such as the Centers for Disease Control and Prevention and the National Institutes of Health haven’t been able to keep pace with the pandemic and are now overcompensating with opposing and sometimes short-lived directives. The disillusionment caused by these situations is further supported by parallels with the marginalization of poor and minority populations with respect to health care. Medicaid is an essential program that serves persons in poverty who experience dental disease, yet it suffers from poor administrative policies, problems with accessing care, and health care inequities compared to private dental insurance. Children’s oral health care access has been somewhat improved, but poor adults have no such improved oral health care equity. Steps should be taken to move closer to oral health care equity, with fundamental changes in Medicaid serving as the best way to restore hope for oral health care and trust in government among those who rely on Medicaid for their dental care.

Measures

Increase Dental Fees

Dentist participation in Medicaid is severely hampered by the low fees that are paid. If Medicaid continues to depend on a dental care system of private practice dentistry and other business models designed for fee-for-service compensation, equity won’t be obtained without increasing the fee structure to be competitive with what is in place for privately insured populations. Inadequate reimbursement for dental care affects operating room access, the financial viability of dental school graduates who carry a heavy burden of debt, the ability to employ case management for target populations, and the willingness of practitioners to enter the environments where care is needed. Often the fees have been in place for years and don’t reflect the increases in real costs for care.

In particular, pediatric dentists and oral surgeons have been unable to gain hospital and surgical center operating room access. The situation was exacerbated by the pandemic and will grow worse when the backlog of cases is addressed. Hospitals won’t be able to provide operating room access to dentists at current Medicaid facility fee reimbursement rates in many states. Today’s facility fee reimbursement to hospitals for dental care under general anesthesia is a fraction of what is reimbursed for general surgical procedures. Hospitals haven’t yet recovered from the financial cost of the pandemic. Young children with severe early childhood caries and adults with special needs are limited to receiving care in potentially less safe environments or have no care at all.

Fix What’s Broken

A disconnect exists between government and the people who depend on Medicaid for care. Exchanging the free-for-service system for a value-based system hasn’t worked well, as shown in California’s expensive experimentation with the plan. Managed care systems haven’t obtained any consistent improvement in equity either. Many minority Americans see ill-conceived medical experimentation as symbolic of the government’s approach to their health care. The system has produced higher rates of death from COVID-19 among people of color, vaccine hesitancy, and vaccine distribution plans that don’t consider the life expectancies of minorities. Among the plans that have succeeded is Michigan’s Healthy Kids Dental Program. It increased reimbursement and integrated Medicaid dental care into the private mainstream nearly 2 decades ago. It’s success is due to the fact that it was reparative, integrative, and confirmed the basic principles of minimal government and a strong private practice health care system.

Expand Adult Dental Medicaid

Some adults, many of whom were unemployed related to the pandemic, do not regularly seek dental care but will eventually require it. Those in poverty are often forced to come to hospital emergency departments for care. Medicaid is designed to address the situation but is failing currently. However, if benefits to seniors are added, many in the population who have had limited oral health care services throughout their lives and suffer from systemic illnesses can have access to care through Medicaid. In addition, children with special needs require Medicaid access to dental care to reach adulthood. Adding a robust adult Medicaid dental benefit would add about 1% to a state’s Medicaid budget.

Engage the Community

Segments of the population have been marginalized by leaders’ decisions on social issues that don’t consider the actual needs of the community. Putting the decision-making power into the hands of the community could encourage the actual people in the situation to come up with solutions and use experts for advice rather than direction. The large Medicaid community is diverse in its membership at its foundation, and its leaders should reflect that diversity in the provision of services. Decision-making processes should be equally shared by those who receive services, those who serve, and those who make Medicaid work. The glaring shortfall of the medical and dental care systems during the pandemic should focus decision makers on listening to those experienced with health care inequities, including patients, committed dental clinicians, and those actively involved in seeking social change to craft solutions that actually make a difference.

Medicaid Homestead Act

The differences between medicine and dentistry include their economies of scale, mandated quality assurance, and regulations, among other areas. As a result, entitlement care for dentistry is miles away from what is provided for medical care. The differences should translate to incentives that will encourage providers to join the Medicaid system. The use of unfair robotic audits, Medicaid credentialing and billing barriers, and disparaging comments about Medicaid patients by nonparticipating providers can negate the work of the American Dental Association Council on Advocacy for Access and Prevention’s Medicaid Provider Advisory Committee to coax future dentists in Medicaid participation. Rather than focus solely on reasonable fee structure, bolder actions are required, such as tuition payback based on Medicaid care participation, fee incentives for rural dental practices, increased fees tied to care in needy microenvironments and for special needs individuals, preferred prior authorization status, and fast-track credentialing, among other creative approaches. The review of Health Provider Shortage Areas currently conducted by the Health Resources and Services Administration offers the opportunity to pilot a homesteading of dental providers to care for Medicaid patients. Such bold actions could help to reduce the number of dental care deserts that exist.

Conclusions

The medical care system has been able to reach patients in the Medicaid system with innovative and strong programs to achieve health equity. It seems reasonable that focusing on Medicaid has the potential to advance equity in oral health care as well.

Clinical Significance.

Dentists need to join ranks to pursue the goal of oral health care equity for all children and adults. Changes to improve access to and participation in Medicaid programs offer a way to achieve the promise of oral health care equity for those being served. True equity in oral health care shouldn’t be a dream but rather an achievable goal shared by all dental practitioners.