From one side of the U.S. to the other, dental benefits for adults are being eyed for reduction or elimination as states struggle with the ongoing effects of the recession and burgeoning enrollment in Medicaid.
Medicaid enrollment grew by 8.5% in fiscal year 2010, and while states got $87 billion in economic stimulus funds to help cope, they were also barred from placing new limits on eligibility. So to contain costs, many states have been cutting back on optional benefits, including adult dental services, according to an annual 50-state survey of Medicaid budgets released September 30 by the Kaiser Commission on Medicaid and the Uninsured.
Adult dental benefits are always vulnerable in hard times, said Diane Rowland, the commission's executive director.
"Dental services for children are not an option for state cuts," Rowland said. "It's adult dental that is one of the first benefits to be cut."
And as the effects of the economic downturn wear on, other states continue to mull limits.
"Virtually every state that we work with has looked at the issue of adult dental," said Kevin Klein, vice president of dental management for DentaQuest, which oversees Medicaid dental services in 24 states and the District of Columbia. "They are all struggling. It's a challenge for all of them."
DentaQuest recently drew fire for cutting back on the number of dentists serving Medicaid patients in Idaho, where it provides care as a subcontractor for Blue Cross. Reducing a network to keep only the most efficient providers is one more way of balancing increased demands with limited resources, Klein said. Other options include reducing fees for doctors and cutting benefits to adults.
"These are government programs, taxpayer-funded," Klein said. "People don't want to pay more in taxes. It's a difficult challenge."
'We're bleeding red ink'
Often, adult dental services are among the first things to go. Until 2009, California provided a range of dental services to adult Medicaid beneficiaries. Then, faced with a massive budget shortfall, the state Legislature reduced optional adult Medicaid benefits, including podiatry, optometry, psychology, and dental.
— Beth Truett, president, Oral Health
America
"We were in the midst of a $60 billion deficit," said Tony Cava, spokesperson for the California Department of Health Care Services. "We couldn't change eligibility. Reimbursement rate changes went to court."
Now the only dental services that remain for poor adults in California are treatments to relieve pain and infection, such as tooth extraction. "Optional benefits are just what they are -- optional," Cava said.
In Hawaii, adult Medicaid dental benefits have served as a reliable economic indicator for years. In 1996, in the midst of a statewide economic downturn blamed on shrinking real estate investment and dwindling tourism and sugar cane industries, Hawaii cut the restorative and preventive care it had been offering to its adult Medicaid beneficiaries. In 2006, when the economy improved, the benefits were restored. But in 2009 they were cut again.
"We're bleeding red ink," said Toni Schwartz, a public information officer for Hawaii's Department of Human Services. "We had to go back to emergency treatments only."
Adults enrolled in the state's welfare program still receive preventive and restorative services, Schwartz noted. "Our director has said that when things get better she'd like to restore the benefits."
In Washington state, cuts that the state Medicaid director described as "devastating" are expected to end adult dental benefits, along with hospice, vision, and hearing services, in 2011.
"Our intention was to preserve a healthy mouth but pare back on the benefit," said Jim Stevenson, communications director for the Washington State Department of Social and Health Services. "This fall our governor ordered an across-the-board cut for all state agencies. We have submitted all our optional programs to the state Legislature."
And in Arizona, adult dental care under Medicaid, which was already limited to emergency treatment for pain and infection, was completely eliminated as of October 1.
With other Medicaid services in the state -- including specified organ transplants -- also marked for elimination, it was hard to argue the case for dental care with the Legislature, Arizona Dental Association Executive Director Kevin Earle admitted.
"We're just a little piece of this," he said. "It's a shame."
But the decision to cut adult emergency dental benefits was the wrong one, even from an economic standpoint, Earle remains convinced.
"The state is being penny-wise and pound-foolish," he said. "A $70 extraction would be much less of an investment than having a patient present to an emergency room with an acute infection."
State by state
Others have also questioned the wisdom of such cuts.
"When states are in financial trouble, it may seem like an easy solution to cut Medicaid adult dental benefits," said Oral Health America President and CEO Beth Truett. "But we underestimate the cost of the burden of oral disease to health and well-being as well as budgets. As a country, are we saying that those who rely on Medicaid dental benefits are a group who can do without them?"
Yet state by state, the axe continues to fall. In Minnesota, the state Legislature also enacted a number of reductions in dental services for adults on Medicaid last year, along with other reductions made to balance the state budget. The cuts have hurt, according to a spokesperson for the Minnesota Department of Human Services.
"We have heard concerns from both providers and enrollees," she said. "Unfortunately, the significant budget shortfall forced officials to make cuts in some services, rates for many types of providers, and many other areas."
In Massachusetts, benefits were sharply pared on July 1 of this year. The state eliminated all adult dental services considered restorative, rehabilitative, and/or beyond basic preventive care for beneficiaries of MassHealth, the state Medicaid program. But adults who receive their care at community health centers (CHCs) can continue getting treatments, said Julia Hurley, a department of public health spokesperson.
"CHCs are able to bill the Health Safety Net for the restorative treatment they provide, including those services that were eliminated on July 1," she said. Developmentally disabled adults will continue to receive comprehensive care, she added.
Other states are trying other ways to hold onto at least some benefits. In Ohio, adult dental visits have been reduced from twice a year to once a year.
"We thought it would have less of an impact on access to limit visits rather than to reduce fees. Adults can still expect a range of preventive services," said Benjamin Johnson, a spokesman for the Ohio Department of Job and Family Services.
The challenge never goes away, he added.
"All we do is balance financial realities with getting the needed services to our customers so they can have the care they need," Johnson said.
Positive news
And yet, even in these trying times, a few states have managed to restore and extend benefits. On September 28, Michigan reinstated funding to support adult Medicaid dental benefits for the 2011 fiscal year. After the state eliminated the benefit in 2009 to save $5 million, a disabled woman suffering from severe periodontitis died. Some blamed her death on the cut in benefits.
And Arkansas, which formerly offered only emergency dental benefits to adults, recently began offering preventive, restorative, and even denture-related care, up to a $500 annual limit to adult beneficiaries.
Sheena Olson, assistant director of the Arkansas Department of Human Services Division of Medical Services, is aware her state is bucking the national trend.
"Everybody is cutting back and we are adding," Olson noted. But the benefits seemed important and the state found a way, using tobacco tax money, to fund them, she said. The program has gotten an overwhelming response, Olson added.
"People who have been desperate for some care are getting it," she said.
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