Earlier this year, 69-year-old Aneita McCloskey needed her two front teeth filed down and capped.
“They were kind of worn down and they were also getting little tears and cavities,” she recalls.
Without dental insurance, McCloskey is on the hook for the full $2,400 cost of the procedure. She was given 18 months to pay it before she gets charged interest. That’ll be hard to do on her fixed income.
In years past she would have had to wait to see the dentist again until she could afford it.
But in early April, McCloskey sat in a dental chair at COMTREA, a community health center in Hillsboro, Mo., while a hygienist confirmed her treatment plan to get a tooth pulled and a cavity filled.
For the first time in 11 years, Missouri Medicaid was going to pay to have her teeth fixed. The state approved temporary funding to provide dental coverage this year.
Now, that funding is in jeopardy as Missouri’s Medicaid agency goes back and forth with the federal Centers for Medicare and Medicaid Services. It’s the latest in a series of setbacks that are keeping about 282,000 Missouri Medicaid recipients without dental coverage.
And it’s a demonstration of how difficult it can be for the 22 states that don’t fully cover dental care to start providing it.
A ‘Tidal Wave’ of New Patients
Missouri’s adult dental benefit was funded this fiscal year through a one-time tax amnesty for delinquent taxpayers. The amnesty raised just $35 million of an expected $60 million, and for months it wasn’t clear there would be any coverage at all.
Then in January, the state announced the benefit would indeed be funded, pending approval from the Centers for Medicare and Medicaid Services. Approval was expected to come in April, for coverage that ends with the fiscal year on June 30.
When the temporary funding-window was announced, Nathan Suter, the dental director at COMTREA, started to prepare for what he describes as a “tidal wave” of new patients.
The three clinics Suter oversees are among the only dental practices in Jefferson County, Mo., that accept Medicaid. But even though they offer a sliding scale fee, Suter knows most Medicaid patients won’t go to the dentist without dental insurance.
“When you live on a fixed income, and have social security, and only have $700 a month to live off of, even a $30 filling is going to be too much.”
So he’s trying to reach as many as he can of the 9,000 people in the county who qualify for the new benefit. Throughout the state, there are roughly 282,000 adults who were slated to receive dental coverage through Medicaid.
“We’re scheduling out into June already,” Suter says. He knows this might be the one chance in a long time for many patients to get urgent problems fixed.
“People are really trying to get in because they have this opportunity to get things taken care of.”
Suter worked with the social workers at COMTREA to find the Medicaid patients already in their system to get their cases prioritized. In February he got a grant to bring in more dental hygienists to start prescreenings. By March there was so much interest in dental care from Medicaid patients Suter added extra hours to all three of his clinics—two evenings a week and half days two Saturdays a month.
Even so, Suter says COMTREA is “solidly booked up, and getting in as a new patient is difficult.”
Preventative Care vs Emergency Care
How Missouri got to this point is a long story.
The dental benefit was initially cut back in 2005 as part of a broader set of cutbacks to state’s Medicaid program. Across the country, adult Medicaid dental benefits have been a common target for state legislatures trying to save money over the past decade, particularly in times of economic hardship.
There are “quite startling, negative consequences,” however, when states stop offering dental insurance to Medicaid patients says Marko Vujicic, chief economist of the American Dental Association.
“You do see less low-income adults going to the dentist for routine care,” he says. “You also see a spike in emergency room visits for dental conditions, which I think everyone agrees is not an appropriate setting for treating dental pain.”
Those trips to the ER are expensive. Americans spent $1.6 billion on them in 2012 alone. And even though many of those patients will still have to see a dentist anyway, someone still has to foot the bill for the ER. For adults, the single biggest payer is Medicaid.
In Missouri in 2013, for example, there were nearly 58,000 ER visits for dental complaints totaling $17.5 million in charges. $5.7 million of that was billed to Medicaid. This is a big reason states are starting to invest again in preventative dental care: to fix dental problems before they become emergencies, and before they become expensive.
Missouri lawmakers tried to do that in 2014, adding funding for adult Medicaid dental benefits to the state budget for the fiscal year 2015. But to balance the budget, Missouri’s governor Jay Nixon withheld the funding for that benefit, so it never took effect.
For fiscal year 2016, the state legislature funded it again, this time tying it specifically to money raised from the tax amnesty. But even that funding is now in jeopardy.
The night of Aneita McCloskey’s appointment in early April, Suter noted they were still waiting for the dental benefit to be “officially turned on.”
“We’re kind of going on luck or wish,” he said half jokingly, “but we’re pretty assured” Missouri’s Medicaid will start paying providers.
But the federal government has to approve the new dental coverage and Missouri’s Department of Social Services—which houses the Medicaid program—recently found out it needed to provide clarification before it can get that approval.
Waiting for that could take up to another 90 days from April 7, basically the entire time the benefit is funded. Indeed it might not be approved until the fiscal year ends and Missouri Medicaid can no longer spend money from the tax amnesty funds.
“It’s bizarre,” Suter says. “If [the federal government] is going to take another 90 days to respond, the [temporary] window is gone. What do you do with those millions of dollars in the budget to get this taken care of?”
State officials have been unable to provide clear answers. In response to that question, Ryan Burns, director of communications for the State of Missouri Office of Administration said only, via e-mail, “We anticipate CMS to approve the Missouri state plan amendment well before the conclusion of [fiscal year 2016].”
That approval hasn’t happened yet, leaving dentists like Suter who are willing to provide care for low-income patients, in doubt as to whether they will be reimbursed.
“It makes us pretty nervous that if it goes much further than this, I’m going to have to have patients start paying out of pocket in the hope that we can reimburse them,” Suter says.
There are two ways those reimbursements will happen and they’re both uncertain.
If and when federal approval does come, Rebecca Woelfel, director of communications for the state’s Department of Social Services, said, via email, providers like Suter “would be paid for services they provided back to January 1, 2016.”
After June 30, though, those costs cannot be covered by the one-time tax amnesty funds. Instead, they’d have to be paid for out of next year’s state budget, which does include dental Medicaid benefits. But those still may not be approved.
Governor Nixon withheld the dental benefit funds two years ago. And he has until May 6 to act on this current budget. That could decide whether dentists like Suter will get paid at all for providing treatment to low-income Missourians.
“It was the right thing to do to start seeing these patients,” he says. “We’re just hoping that the state and federal government come through on what they’ve been promising.”
UPDATE: On Friday May 6, Missouri Governor Jay Nixon signed the Missouri state budget containing the dental benefit. Nixon theoretically could still withhold the money for dental coverage. Later the same day, Missouri’s Medicaid program also officially posted billing codes for dental services, presumably having received approval from the Centers for Medicare and Medicaid.
This story was produced by Side Effects Public Media, a reporting collaborative focused on public health.