On this episode, three guests join the podcast to discuss oral health care coverage under Medicaid, why coverage varies from state to state, and how two states took on the challenge of providing oral health care to adults.
Oral health care for children is required in every state under Medicaid or the Children’s Health Insurance Plan. But dental coverage for adults is optional. And while nearly every state provides some level of coverage for adults, what is covered and who is covered varies widely from state to state and even within states.
Our first guest on this podcast is Ian Hedges, the director of Medicaid and Medicare program policy for the American Dental Association. Hedges explained how oral health care affects overall health and why different levels of coverage for adults under Medicaid can lead to higher costs later on for health complications that arise from neglected oral health issues. One study found that untreated oral health conditions can lead to health complications that cost the U.S. about $45 billion each year in lost productivity.
Our other guests are Sen. Evan Vickers, a Republican of Utah, and Sen. Malcom Augustine, a Democrat from Maryland. Senators Vickers and Augustine explained how their states have approached broadening coverage for adults covered by Medicaid, the challenge in assembling a group of providers that will accept Medicaid reimbursement and some of the particular problems in providing care to those with low incomes and those living in rural areas.
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Ed: Hello and welcome to “Our American States,” a podcast from the National Conference of State Legislatures. I’m your host, Ed Smith.
IH: There is well documented evidence showing that poor oral health does not only have effects on your overall health, but it can play a determinant role of whether someone to be gainfully employed.
Ed: That was Ian Hedges, the director of Medicaid and Medicare program policy for the American Dental Association. Hedges is one of my guests on this episode looking at oral health care coverage under the Medicaid program. He is joined by Senator Evan Vickers, a Republican of Utah, and Senator Malcolm Augustine, a Democrat from Maryland. Oral health care for children is required for every state under Medicaid or the Children’s Health Insurance Plan, but dental coverage for adults is optional. And while nearly every state provides some level of coverage for adults, what’s covered and who’s covered varies widely from state to state and even within states. Hedges explained how oral health care affects overall health and why different levels of coverage for adults can lead to higher costs later on for health complications that arise from neglected oral health issues. One study found that untreated oral health conditions can lead to health complications that cost the U.S. about $45 billion each year in loss productivity.
Senator Vickers and Augustine explained how their states have approached broadening coverage for adults, the challenge in assembling a group of providers who will accept Medicaid reimbursement and some of the particular problems in providing care to those with low incomes and those living in rural areas.
Here is our discussion starting with Ian Hedges.
Ian, welcome to the podcast.
IH: Thank you so much, Ed for having me.
Ed: So Ian, just to get started, I wonder if you could tell listeners a little bit about your role at the American Dental Association.
IH: Yes. So, I am the director of Medicaid and Medicare program policy at the American Dental Association so I work on educating our members and other dentists about becoming dental providers for patients that utilize public benefits. I also work with our state association and federal advocacy team to ensure these programs meet the oral health needs of the patients we serve without putting undue burden on the providers. And finally, I work very closely with the ADA’s health policy institute on research around Medicaid and access to care for vulnerable populations.
Ed: Ian, as you probably know, our audience is largely state lawmakers, state legislative staff, others interested in state policy. With that in mind, could you talk a little bit about how oral health contributes to overall health and why it’s a policy area legislators should care about.
IH: We know that there are systemic connections to overall health when oral health is not addressed. There is research that suggests heart disease, clogged arteries and stroke might be linked to the inflammation infection that oral germs can cause. Many people also do not realize this, but periodontitis or what we know as gum disease among pregnant women has been linked to premature birth and low birth weights. So, there is well documented evidence showing that poor oral health does not only have effect on your overall health, but it can play a determinative role on whether someone can be gainfully employed. And I’m not only come from this as a policy wonk, but as someone who formally operated a community health center with safety net medical, dental and behavioral health clinics. And constantly we had patients with diabetes were being treated at our medical clinic and the doctors would say well frankly you need new teeth because even if you had programs to help with food insecurity or received incentives for purchasing healthier foods it is not going to help your diabetes if you do not have enough healthy teeth to chew fruits or vegetables. And we also know that patients with substance abuse conditions and when someone is going down a pathway of recovery, you need a new beginning on a second chance and how is someone going to be able to get that when your smile does not bring you the confidence to improve your life or help you get a job that improves your situation. So, without oral health treatment, many patients become stuck with these physical conditions and socioeconomic circumstances. And looking back you know the reason I became invested in oral health because it almost seemed like the magic bullet that would improve people’s circumstances dramatically. I remember numerous stories of patients who were working part-time fast-food jobs making $12 to $13 per hour doing odd jobs. But as soon as they got a new smile or even getting cavities treated in their front teeth, many of them would not have to utilize our clinic anymore because they got a $24 to $25 per hour customer service job with benefits. And those stories I think just underscore that oral health not only plays a huge role in health care, but in someone’s wellbeing.
Ed: Ian, access to oral health care varies widely across the U.S. and across different populations and can you share a little bit about why that is.
IH: Well, what we do know is again the adult Medicaid dental benefit is really in a patchwork across the United States in what level of coverages are offered, but the ADA Health Policy Institute has actually done a survey of Medicaid beneficiaries. And more than 45% said they cannot access dental services because they are not covered by their state Medicaid program or they cannot afford to pay the out-of-pocket costs for non-covered services. I think the other issue that determines access across states is provider administrative burden ridden and reimbursement. We have to remember that dentists do not operate like many physicians that work in settings with a building or credentialling department. Many dentists practice in small, individual or group practices in which the dentists have to often take the burden of doing the credentials or reexamined claim denials. And frankly do not have the hours to spend going back and forth on reliable systems from roaming or credentialing in the denial just to get cents on the dollar. So, I can really attest that is an issue among dentists. But one is provider participation is affected by reimbursement again. Eighty percent of dentists say they do not want to participate in Medicaid because of low reimbursement and so we have to remember that dentists are not asking Medicaid to match their fees, but we need to make it so that they are not having to essentially have a burdensome workload that’s going to burn them out to make up for the losses that occur when servicing Medicaid beneficiaries.
TM: 07:08
Ed: So, Ian as I understand it, there is a number of factors that can drive up the overall cost of oral health such as emergency room visits and inadequate preventative care. Can you walk us through some of these costs and how states can alleviate them for individuals as well as for the state coffers.
IH: Yeah. We know that a presence of an adult Medicaid dental benefit provides a tremendous amount of cost savings. We estimate that the adult Medicaid dental benefit as it stands in 42 states and the District of Columbia today is providing almost 1.9 billion dollars in cost savings annually. And these cost savings come from the fact that the Medicaid programs with adult benefits spend a lot less when doing prevention, extractions or restorations as opposed to patients without a benefit having to go to the emergency room for untreated dental infection because emergency room visits on average for dental condition is $2,380 almost as opposed to the tens of hundreds of dollars it costs to treat those conditions in a dental office. We also know too that the treatment of gum disease is less expensive compared to cardiovascular disease in the long term or keeping babies in the hospital due to premature birth or low birth weight which can be caused again by poor gum hygiene. And so that 1.9 billion dollars in cost savings is huge, but it is not even inclusive of increased economic activity that is integrated from the benefit. So, the 88-health policy institute released a report called what happened if the adult Medicaid dental benefit goes away. And we actually looked at what happened at states that previously had an extensive limited adult dental benefit then took it away due to budgetary constraints and we found that in the state of California when this benefit was only gone for six years it led to an estimated loss of nearly 4,500 jobs and over half a billion dollars in economic activity.
Ed: Ian, looking at the big picture, what do you think some of the biggest challenges the oral health industry faces in meeting the demand for care and what sort of solutions are being explored?
IH: In the oral health industry, it has to be inclusive of not only just the solo providers, but state Medicaid programs, the payers of managed care organizations and Medicaid and dental support organizations. I think one of the challenges we found among the officiaries when we talked with them for our research is when you compound a lack of knowledge or improvement in their dental benefit or provider availability transportation issues and overall care anxiety, patients are not going to be able to access this benefit. So, some of the solutions we believe to make a great impact are making sure that payers who are implementing the EPSDT or the early periodic screening and diagnostic treatment benefit for child wellness screenings are also reminding parents or following up with them about dental visits and incorporating that because MCO’s often have to make sure that children are getting those within their benefit year.
I think another solution is dental support organizations are growing in the United States. They are kind of the Aspen Dental, Midwest Dentals and what we are finding is that when these providers are actually or when these organizations want to participate in Medicaid, the cost of being Medicaid providers is a lot less to them because of economy’s scale. They are able to also network different providers in different areas if they don’t have availability and they also do have quality outcome programs incorporated in their organizations that make sure that their patients are getting great health care. So and we have learned too that more dentists who are going to work for these dental support organizations are more likely to be Medicaid providers. So, I would say there are a couple of solutions that we have been exploring in meeting those challenges as well as talking to our state legislators and strengthening the adult benefits as well as the administration of them.
Ed: So, Ian, I do a lot of podcasts on a wide range of policy issues and I think this question is one I ask almost everybody and that’s about workforce. When you think about the challenges in the workforce area in the health care field, how does this relate to oral health and into Medicaid particularly and I think you were just alluding to that a little bit about where we get these providers to be able to bring these services to people who are on Medicaid.
TM: 12:08
IH: Well first I think there are talks of expanding the type of professionals who can enter the oral health workforce in order to solve access issues. And I would personally say that the dividends in return on investment into that area has not shown a significant improvement and in some cases had to be retracted. But rather than add an entirely new category of providers as a nation, I think it is better for us to focus on training more hygienists and assistants because I can tell you when I was an administrator at these clinics, it was really hard for us to hire the best hygienists and assistants that keep our clinics going, getting dental professionals where they are most needed and helping underserved patients seeking care and being able to connect with dentists for treatment.
Ed: Well Ian, thank you so much. This is I think as you suggested a not very well understood area and one, I think of great importance for legislators and staff to understand and I appreciate you explaining it. Thanks very much and take care.
IH: Thank you.
Ed: I will be right back after this short break with Senator Evan Vickers and Senator Malcolm Augustine.
TM: 15:52
Senator Vickers, Senator Augustine, welcome to the podcast.
EV: Thank you.
MA: Thanks for having us.
Ed: So, we are talking today about oral health coverage for people who are covered under Medicaid. I talked with Ian Hedges from the American Dental Association about why oral health care is important health care picture and with you Senators, I wanted to discuss what your experience has been in the legislature. And Senator Vickers, let me start with you. In 2024, Utah passed legislation requiring your department of health and human services to seek a waiver from the centers for Medicare and Medicaid services to expand dental services to Medicaid eligible adults 21 and over who previously were ineligible. And I wonder if you can talk about how that legislation came about in Utah and why it was an important thing for you to see passed.
EV: Yeah, well thank you. Yeah, it’s been a critical element in providing coverage for Medicaid patients especially in the dental area. We started out with a program with a managed care program to talk to deal with children with pediatrics and with pregnant mothers. And then we have this traditional Medicaid program primarily for dental patients. We saw a consistent habit coming out of it that practitioners continued to refuse to take Medicaid patients just because of the low reimbursement, those types of things. The dental school at the University of Utah, previous to that we did not have a dental school but they are celebrating their 10th anniversary now. Once they got involved, they started taking over taking a role that they tried to provide better coverage and see if they couldn’t build up a network of providers. So, they started out small. They used their endowment to that they originally had at the dental school to provide coverage for the blind and disabled and those that were suffering under substance abuse. They used the endowment for the match and then any work that they did by their students they were able to get reimbursement through Medicaid and so they could kind of cover the match with that. And then they started building a provider network whereby they could provide a higher reimbursement. So obviously they had to get a waiver you know through Medicaid to do that and they were able to provide a higher reimbursement to those patients. They expanded that a couple of years later to include elderly and then as you mentioned in 24, we were able to go to all adults that were not previously covered under another program. What the dental school has been able to do is they have been able to go throughout the provider networks throughout the state and buildup a network where they would accept the you know Medicaid patients. They would get a higher reimbursement. It really doesn’t cost the state anything because they are using their endowment and whatever reimbursement they are getting at the school to cover the match. So, it’s been a really good positive thing. We are now over 400 providers that are participating in the program and it’s been a real positive thing. Like all other primary care, if you can take care of a patient at the lower-level entry challenges then you could prevent it from escalating into something that turns in a very serious and very expensive to the state later on. It’s a pretty good program.
Ed: Yeah, I’ve certainly that that these things the delayed oral health care can often lead to more serious health care problems. And Senator Augustine, let me ask you about the tragic death of 12-year-old Deamante Driver back in 2007 and I know this sparked some action in Maryland to increase oral health services. I wonder if you can share why that was such a seminal moment and also why that was an important impetus for this action in Maryland.
MA: Well, thank you so much Ed. I think that anytime we lose the life of a child, it really touches us in an emotional way particularly if that loss of life was preventable. And this was an absolutely preventable loss of life that with just basic dental care, we would have been able to save young Deamante’s life. And that touched the hearts of the people of our state and really moved us in a direction to really improve and expand dental coverage for children. And that really was impetus to for us to do that in order for us to really save some lives and improve dental care for young people at that time.
Ed: And Senator, let me stick with you for a minute. What has gone on in Maryland in terms of trying to address the oral health needs?
MA: Sure. Now while we address the oral health needs of our children after the tragic loss of Deamante’s life were behind, quite frankly, as it related to adult Medicaid recipients in our state who as one of the few states that did not offer a comprehensive dental care plan so we realized that this was actually costing us a significant amount of money. A significant number of our emergency room visits were patients who were there for dental services. And so, in 2022, we put forward legislation to create a comprehensive dental benefit for Maryland adult Medicaid patients and we were able to pass that. Now there is a significant investment by our state in order to that, but we felt like it made sense to do so as an obvious dental indicator of other conditions and so we felt that it would help us as a preventive measure in addition to a matter of dignity for our adult Medicaid patients.
Ed: Senator Vickers, you alluded to this before, but I think probably every public policy podcast that I do the issue of workforce comes up and you talked about working with the University. I wonder what advice you would give your colleagues in other states specifically about that workforce issue. It sounds like it has worked out well there in Utah. How would you just suggest approaching the higher education facilities, the dental schools, that kind of thing and how that works with them. Why it works out for them.
TM: 24:18
EV: It has been a unique challenge. As I mentioned you know we have many dentists who refused to take any kind of Medicaid patients or any new Medicaid patients certainly was limiting the accessibility for patients throughout especially into the rural areas. So, we were finding it was becoming a real challenge for us in Utah and I think each state can be creative and be new you know and they can look at it their own individual assets and challenges they might have. With us, the dental school worked with the dental association and then with Medicaid to kind of create kind of a triangular or trijective kind of approach to reach out to providers and find out what procedures needed to be enhanced that the reimbursement needed to be enhanced in order to rise it to a level that they could make a profit on it and they worked through that, worked through that study as we slowly built this up. As I mentioned, we started out with blind and disabled and substance abuse and the elderly. Now we are just ready now we received the full go ahead on the waiver so we can start into the whole complete adult population at least if there are those that aren’t covered in another method. And so, the dental school and the dental association has taken the lead on that reaching out individually one by one. You know if the provider is across the state working with them. We also added a little bit of an enhancement. We with the dental school, the state provides we specifically provided three scholarships for rural students and one of the stipulations is that once they graduate then they start into practice, they have to be willing to accept Medicaid. We kind of worked around this at a number of different angles, but the bottom-line is you got to get the reimbursement the providers up to a level that they can afford to take a patient. Then if you can do that and then get that network going then obviously you’ve got access for the patient. And it’s challenging. It’s challenging for any patient, but especially a lower income patient if they’ve got to drive a long ways or you know they might just get frustrated and say awe the heck with it you know and then that’s when it leads to some real serious things and they end up in an emergency room. And that leads to a significant increase in cost and also a significant increase in their mental and medical health care so.
Ed: Yeah, this issue of travel and the cost of it just the difficulty for it especially for people with low incomes I hear that a lot around health care issues. Senator Vickers, let me just stick with you as we wind up here and I would like to ask both of you just generally what would your advice be to your colleagues around the country just in trying to address this problem. It sounds like Utah has taken kind of a tiered approach here. Any other suggestions you have for other legislators around the country as they look at this issue.
EV: Sure. Obviously the first thing is to evaluate. You know work with whoever your resources are. For us, it was Medicaid. It was the dental association, dental school. We started doing some evaluations and see where we could be beneficial. And then get creative. You know states are kind of incubators of creativity and each state is going to be a little different. You know what works in Utah may or may not work in another state. And we are a little smaller. We don’t have as many dental schools. At the same token, you know maybe that model works. But first evaluate and then look at and start asking some questions you know why aren’t providers taking Medicaid cases. That’s what we did is we kind of went through the process and found a lot has to do with reimbursement. And once you identify the challenges, then start looking for some creative solutions and that’s what happened with us. You know I mentioned that we have a managed care model for pediatrics and pregnant mothers. We have actually recently done an evaluation on that and it appears now that if we can move that population into this provider group that we are working through the dental school with, we can save the state about 20 million dollars a year. So, it’s kind of an ongoing evaluation you know but it started with us it started small and now it’s built up, but. So, I would say yeah evaluate, identify and then get creative.
Ed: Senator Augustine, I think Senator Vickers makes a great point which is that and certainly it’s been my experience that if you know one state, you know one state. Everybody’s situation is different. So how about from the Maryland perspective. What would you tell your colleagues around the country. What kind of lessons have you learned?
EV: I would say that it is important as the Senator said to look within and to understand the values of your state and what you prioritize and what you find to be important and follow that and that is the place that we start from. We are trying to identify the best and highest use of our resources and I would suggest that other states do the same. They find the things that matter to them the most that they believe that the care of the folks and the benefits of oral health and the dignity of a smile which you could tribute again. You talk about workforce. A person is obviously going to feel better about going to work if they are comfortable opening their mouth and being able to really contribute. You think that those things are important. You do everything you can to maximize the resources that you have in your state in this regard and that would be my suggestion. That’s what we have done here in Maryland. It’s why we expanded this. We find it to be an excellent investment and that would be my advice.
Ed: Well, I’ve certainly heard this issue that good oral health helps promote personal dignity as well as helping people giving them a leg up when they go to apply for a job. And I want to thank both of you gentlemen so much. I think this is a somewhat overlooked area of health care and I think it is an important one to bring some attention to so thanks both of you and take care.
EV: Thank you.
MA: Thank you.
Ed: I’ve been talking with Ian Hedges from the American Dental Association, Senator Evan Vickers of Utah and Senator Malcolm Augustine of Maryland about the challenges and opportunities for providing adult oral health care under Medicaid. Thanks for listening.
TM: 31:18
You can check out all the podcasts from the National Conference of State Legislatures by searching for NCSL podcasts wherever you get your podcasts. This podcast “Our American States” dives into some of the most challenging public policy issues facing legislators. On “Across the Aisle” host Kelley Griffin tells stories of bipartisanship. Also check out our special series “Building Democracy” on the history of legislatures.