Nationally, Medicaid programs provide crucial access to dental and oral health services. Yet, as these benefits are not federally mandated, coverage is not standard state-by-state.

Although required to provide dental benefits for children covered under Medicaid and the Children’s Health Insurance Program (CHIP), including services is considered ‘optional’ for adults. Therefore, great variation exists among states, with some providing an extensive oral health benefit package, some providing coverage for only emergency dental services, and a small handful continuing to provide no dental coverage of any kind.

Fifty-one percent of patients rank oral health as their top health concern, yet from 2013 to 2016 about one in five working-age adults did not receive needed dental care. Expensive out-of-pocket costs for dental care can be prohibitive, especially for low-income families who spend 10x more on their dental care than wealthier families.

Without dental coverage or the inability to afford care, many adults postpone treatment until their condition becomes too painful to endure. This means adults need more expensive and extensive oral care than they would if they had seen a dentist earlier in the disease process. In fact, some adults could avoid the pain and urgency altogether because their oral health issue could have been entirely prevented with regular dental care.

Emergency departments (EDs) are seeing patients for oral health problems even though most EDs are not equipped to provide dental treatment. Instead, patients are treated for pain or possible infection without treatment for the underlying condition. Every 14 seconds nationwide, adults visit an ED for a dental condition and these (often unnecessary) visits cost the health care system approximately $2.4 billion.

Additionally, poor oral health contributes to higher risk for the development of diabetes, cardiovascular disease, stroke, adverse mental health outcomes, and other conditions. The cost of care and treatment for these oral-health related chronic conditions are expensive and come with additional costs that are borne by state Medicaid budgets.

Adult Medicaid dental benefits are often the first service targeted for reductions or elimination in efforts to save money, especially in difficult economic times. In many states this means that the adult dental benefit coverage has fluctuated over time; sometimes they are robust, other times are extremely limited. Particularly during and leading up to the recession experienced in the late 2000s, many Medicaid programs have reduced or eliminated dental benefits offered to their adult members.

Changes to Medicaid Dental by State

Arizona cut its already limited dental benefit for elderly and developmentally or physically disabled adults enrolled in its Arizona Long Term Care System (ALTCS) program in 2006, leaving only the emergency dental benefit offered to the non-elderly, non-disabled population. In 2009, this benefit was also eliminated. It took two phases to restore all these benefits, the first in 2016 with funding included in the FY2017 state budget, which limited the per-member, per-year benefit for ALTCS members to $1,000. The second phase came in 2017 with the same $1,000 per-member, per-year emergency benefit restored for all adults.

California and Hawaii eliminated Medicaid coverage of non-emergency dental services for adults in 2009. Like Arizona, California also restored benefits in two phases: in 2014 a limited benefit that included preventive and restorative care and full dentures was restored. In 2018, additional services, including periodontal treatment, root canals, and partial dentures were restored. In Hawaii, however, advocates are currently pursuing the restoration of a limited benefit.

Under a restructuring of their Medicaid adult dental benefits in 2018, both Connecticut and Idaho capped benefits at $1,000 per-member, per-year.

In 2011, Idaho limited dental benefits for adults ages 21 and older to emergency services only. Comprehensive dental benefits for adults with disabilities and/or other special health care needs were restored in 2014. And in 2018, the state restored a limited and prevention-focused benefit to all non-disabled adults.

Illinois restricted Medicaid adult dental services to emergency services only as part of the 2012 Save Medicaid Access and Resources Together (SMART) Act, which reduced budgets by $1.6 billion. Shortly thereafter, the state restored limited coverage for pregnant women and, in 2014, as part of a broader package reversing several SMART Act cuts, they restored dental benefits to all adult members. Preventive services were added to the adult benefit package for the first time in the program’s history in 2018.

Significantly limiting its dental benefit to cleanings, extractions and oral surgery in 2010, Massachusetts has pursued incremental restoration of services in the FY2013, 2014 and 2015 state budgets. Most recently, the FY2019 budget restored periodontal services.

Missouri limited coverage of dental services in 2005 to specifically cover trauma of the mouth, jaw, or teeth as a result of injury or medical condition for most adults. More extensive coverage remained in place for adults who were pregnant, blind, or in nursing homes. In 2016, all adults gained back expanded coverage, including diagnostic services, preventive services, restorative services, periodontal treatment, oral surgery, extractions, pain evaluation and relief, infection control, and general anesthesia.

Drastically reducing the Medicaid adult dental package in 2012, Pennsylvania left most adults in the program with limited benefits primarily covering x-rays, cleanings, fillings, and extractions. Advocates continue to pursue the restoration of a full adult dental benefit.

South Carolina eliminated its adult emergency dental benefit in 2011 and limited remaining benefits to cover trauma, transplants, and oncology treatment. Lawmakers reinstated emergency coverage in 2014. In December 2014, federal funding provided in the FY2015 budget enabled expanded benefits, adding cleanings, fillings, and extractions to a maximum benefit of $750 per-member, per-year.

Utah eliminated a broad array of dental services in 2009, leaving most adult recipients with only an emergency dental benefit. New 2016 legislation provided dental services for blind and disabled adults. Similar legislation came in 2019, expanding coverage for adults ages 65 and older.

The State of Washington eliminated comprehensive dental benefits in 2011 and left Medicaid enrollees with emergency dental services only. Six months later, full dental coverage was restored for pregnant women, enrollees with disabilities, and those residing in long-term care facilities. In January 2014, the state restored comprehensive dental benefits for all adults enrolled in the Medicaid program.

Drastically reducing the Medicaid adult dental package in 2012, Pennsylvania left most adults in the program with limited benefits primarily covering x-rays, cleanings, fillings, and extractions. Advocates continue to pursue the restoration of a full adult dental benefit.

Advocacy at local, state, and national levels has been crucial in the restoration and enhancement of dental benefits to adults. Amplifying messages and providing data that resonates with policy makers remain a key component of advocacy efforts. The most common messages used center around the importance of oral health in overall health, highlighting the pain and complications of untreated dental disease, and the societal impact and costs of poor oral health and lack of coverage, including rising emergency department costs.

Oral Health Care is Essential to Overall Health and Well-Being

Poor oral health is connected to higher risk for diabetes, cardiovascular disease and stroke, complications in pregnancy and childbirth, adverse mental health outcomes, and other conditions that are costly to treat.

When left untreated, oral infections, cancers and other diseases that start in the mouth will spread throughout the body, causing serious and lifelong issues, and in some cases, death. What’s more, research shows the average medical cost of treating patients with multiple chronic conditions is lower when a Medicaid program includes preventive oral health coverage.

Diabetes and the gums

Periodontal (gum) disease is a chronic bacterial infection of the gums and supporting structures -- including the bone -- that surround the teeth. It can affect blood glucose control and contribute to diabetes progression. Those with diabetes are up to three times more likely to develop periodontal disease, partially due to increased susceptibility to infections. Untreated dental disease results in pain, infection, poor nutrition, and can limit social interactions, including employment opportunities.

In the U.S., half of adults ages 30 and over suffer from periodontal disease and more than 30 million Americans (9.4%) have diabetes.

Oral Cancers

Oral and throat cancers start in the mouth or in the region behind the oral cavity. The number of people dying from oral cancer each year is about the same as those dying from skin or cervical cancer. Without regular access to dental care, oral cancer often goes undetected until it is too late. An estimated 53,000 people will be diagnosed with oral or oropharyngeal cancer in 2019.

Heart Disease and the mouth

Oral cancer and heart disease are connected, as the bacteria from the mouth travels to other parts of the body through the blood stream. When they reach the heart, the bacteria attach to any damaged area and cause additional inflammation. This results in endocarditis, an infection of the inner lining of the heart. Other conditions like atherosclerosis (clogged arteries) and stroke are also linked to inflammation caused by oral bacteria. In 2017, 6.4% of all U.S. adults ages 18 and older had cardiovascular disease, including more than 16 million Medicaid-enrolled adults (53%) with a history of cardiovascular disease.

Preterm Birth and Oral Health

Women with better oral health before and during pregnancy have more positive birth outcomes than those who don’t. Pregnant women with gum disease are up to eight times more likely to suffer premature birth.

One in ten babies are born prematurely each year. The average cost of medical care for a premature or low birth-weight baby in the first year of life is $49,000, compared to $4,551 for care of a newborn without complications. And more than 18% of preterm low birth weight babies can be attributed to the pregnant woman’s gum disease. Given that Medicaid pays for 43 percent of all live U.S. births, improving oral health in this population is particularly important.

Lack of Medicaid Adult Dental Benefits Increases Dental-Related Emergency Department Visits

Nationally, studies show that reducing or eliminating Medicaid adult dental benefits leads to significant increases in dental-related ED visits. Conversely, when dental benefits are implemented or reinstated, the use of preventive services increase and ED visits for non-traumatic dental conditions decreases. Without access or referral to definitive care following an ED visit, many patients will have to return to the ED for additional care. Not only is this cycle untenable for hospitals, health care costs, and the patient, but untreated chronic dental conditions can become life-threatening and even lead to inpatient admission.

Since restoration of benefits in 2018, California has experienced a rise in the percentage of adults visiting a dentist annually and receiving preventive dental services.

In Hawaii, the state paid $4.8 million for 1,691 adults to treat preventable oral health conditions in the ED during 2012 alone.

In FY2016, adults in Maryland made 42,327 ED visits for chronic dental conditions, with an average charge of $537 per visit, totaling $22.7 million. Medicaid paid for 53% of those visits; Medicaid participants only account for 15% of the total adult population in the state.

Data from Missouri shows that 350,000 adults now have access to the range of services restored in 2016. This correlates to a 44% drop in ED usage for non-traumatic dental conditions, as well as a drop in associated opioid prescriptions and inpatient hospitalizations.

Oral Health Coverage Supports Work, Increases Employability

Oral health coverage supports an individual’s ability to work and increases employability. Oral disease is directly responsible for 164 million lost work hours each year in the U.S. Twenty-nine percent of low-income adults report the appearance of their mouth and teeth affect their ability to interview for a job.

As states continue seeking innovative approaches to provide dental and oral health benefits, policymakers have a fiscal responsibility to understand the far-reaching implications of budget choices. Dental benefits are often the first adjunctive service struck from constrained state budgets. But through the tireless work of advocates and interest groups, the positive momentum in 2019 will continue through the next decade.

Maintaining focus on improving oral health benefits will only result in healthier populations, increased provider and patient satisfaction, and improved oral and overall health outcomes – not to mention reduced costs, mortality and disability.