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Invited Commentary
Health Policy
September 30, 2021

Addressing Oral Health of Low-Income Populations—A Call to Action

Author Affiliations
  • 1University of Colorado Anschutz Medical Campus, School of Dental Medicine, Aurora
  • 2CareQuest Institute for Oral Health, Boston, Massachusetts
JAMA Netw Open. 2021;4(9):e2125263. doi:10.1001/jamanetworkopen.2021.25263

The study by Elani et al1 evaluates the association of Medicaid expansion with the utilization of adult dental services and variation in utilization across states. The authors used data from the National Health and Nutrition Examination Survey from 2009 to 2018, including over 7000 low-income adults in the study. They found that Medicaid expansion in states that included adult dental benefits was associated with increased access to dental care, reduced uninsured rate, and a reduction in the prevalence of untreated decayed teeth. In expansion states that did not have Medicaid adult dental benefits, the expansion was associated with a significant increase in the number of missing teeth. The authors concluded that states that included Medicaid dental benefits in their expansion may have offered a chance for low-income adults to retain their teeth and have a better quality of life. In comparison, the states that did not provide the Medicaid dental benefit may have pushed the low-income adults toward tooth loss and edentulism. Overall, they found that Medicaid coverage of adult dental services was associated with enhanced access to dental care and improved oral health for low-income populations.

Oral health is recognized as an essential component of the overall health and quality of life of individuals. Poor oral health can increase the risks associated with chronic diseases such as diabetes and heart disease.2 Furthermore, poor oral health has social repercussions and impacts employability and work presenteeism.3 Low-income adults are twice as likely to experience tooth decay and gum disease and have unmet oral health needs.4 Coverage for dental services under Medicaid is one of the few options for low-income adults to access and receive dental care. Without Medicaid adult dental coverage, low-income adults are left to seek care at emergency departments, which is an unsustainable and costly option. In addition, visiting the emergency departments does not promote optimal oral health, as patients are often given antibiotics and pain medication and not definitive treatment for their dental problem. In fact, uninsured adults are 3 times more likely to visit the emergency department for dental emergencies than privately insured adults.5

Medicaid adult dental coverage varies significantly across states. According to a report from the Center for Health Care Strategies, 3 states have no adult dental coverage, 11 have emergency dental services only, 15 have limited dental benefit, and 20 states and Washington, DC, have extensive coverage under Medicaid.6 State variation in coverage is related to state budgetary considerations. The Affordable Care Act’s Medicaid expansion has provided federal dollars to several states, such as California and Washington, to prioritize implementing an adult dental benefit under Medicaid. Other states have used innovative methods to fund adult dental coverage. For example, Colorado identified Unclaimed Property Trust as a source of financing the benefit.6

Like the article by Elani et al,1 other publications have provided evidence that Medicaid adult dental benefits were associated with greater probability of visiting the dentist yearly, positive oral health outcomes, and reduced unmet dental needs.7 Also, Medicaid expansion that includes adult dental benefits may have affected the type of treatments provided to the low-income population—comparing the kind of dental health services before and after implementation of Medicaid adult dental benefits in Colorado showed that the benefit was associated with increased tooth-saving procedures, including restorations, endodontic and periodontal treatments, and a downward trend in tooth extractions.8

The long-term benefits of expanding Medicaid adult dental benefits can help low-income adults establish a dental home and receive regular care. It can promote greater use of preventive approaches, helping to detect oral diseases earlier, which can help reduce the cost of treatments, reduce discomfort to the patient, and improve quality of life.9 Furthermore, the expansion of Medicaid adult dental benefits can reduce the rate of unmet dental needs for low-income adults. However, there are challenges in implementation, uptake, and sustainability of expansion of Medicaid adult dental benefits that can threaten its continuity. Providing coverage to low-income populations is not the same as giving them access to care. In the past several years, states have invested resources in expanding Medicaid adult benefits, but the care delivery capacity of a Medicaid dental practitioner network has remained unchanged. Historically, low Medicaid reimbursement rates and stigma of Medicaid participation have limited the number of dentists who accept publicly insured patients. However, dentists are more likely to take new Medicaid patients when the reimbursement rates are closer to their fees when patients do not miss appointments, and the claims approval process is faster.10 But with limited numbers of private dentists accepting Medicaid patients because of low reimbursement rates, the dental safety net clinics may be the only avenue for low-income adults to access dental care.

Lastly, some of the threats in uptake and continuity of the Medicaid adult dental benefit include the optional status of this coverage, decisions made at the state level, and the likelihood of reducing or eliminating the benefit due to state budget cuts in light of changing priorities and economic declines. To prevent these threats from reducing coverage, the dental and public health communities must maintain constant vigilance to changes in the benefit and work closely with state policymakers to highlight the importance of Medicaid adult dental benefits. It is imperative to have a concerted call to action for federal policy that mandates comprehensive, nationwide adult dental benefit as a permanent part of Medicaid. Such a mandate should include (1) Early and Periodic Screening, Diagnostic and Treatment (EPSDT) as a way to maintain consistency of access and practitioner participation; (2) a benefit that is extensive enough to promote oral health, better outcomes, and cost savings for dental and medical costs; and (3) data integration and interoperability to enable knowledge, quality improvement, and payment reform.

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Article Information

Published: September 30, 2021. doi:10.1001/jamanetworkopen.2021.25263

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Tiwari T et al. JAMA Network Open.

Corresponding Author: Tamanna Tiwari, MPH, MDS, BDS, Department of Community Dentistry and Population Health, University of Colorado Anschutz Medical Campus School of Dental Medicine, 13065 17th Ave, Room 104F Aurora, CO 80045 (tamanna.tiwari@cuanschutz.edu).

Conflict of Interest Disclosures: None reported.

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