Overview
Dental care is essential to prenatal and maternal health, but oral health coverage is often inaccessible for low-income women. This issue brief discusses the importance of comprehensive oral health care during pregnancy; explains the status of dental coverage for pregnant women under Medicaid, the Children?s Health Insurance Program (CHIP), and the Affordable Care Act (ACA); and recommends strategies to expand dental coverage for lowincome adult pregnant women.
Background
Pregnant women are especially vulnerable to developing oral health problems, which, if left untreated, can lead to serious complications and negatively affect fetal development. Yet pregnant women with lower household incomes are significantly less likely to seek dental care.1 Further, women who have lower incomes, are enrolled in Medicaid, or belong to a racial or ethnic minority are half as likely to obtain dental care compared to higher-income, privately insured Caucasian women.2
This disparity in maternal dental health is due in part to the limited dental coverage for lowincome adult pregnant women enrolled in public insurance programs. Although pregnant women enrolled in Medicaid and CHIP are entitled to ?pregnancy-related services,? dental care is not explicitly included as a pregnancy-related service, and federal Medicaid law leaves dental care for adult enrollees as a state option.3 CHIP requires coverage of dental care for youth, including pregnant youth, but not for adult women.4 Moreover, the Affordable Care Act (ACA) provides some opportunities for adult dental coverage.5 Yet state advocates will need to monitor and provide input throughout their state?s ACA implementation process to ensure that health plans cover at least some dental care for adults.
Notably, Medicaid and CHIP must provide youth enrollees with dental services.6 In addition, under the ACA, qualified health plans, Basic Health Program plans, and Medicaid benchmark coverage must cover pediatric dental care.7 Still, advocates should monitor their state?s Medicaid and CHIP programs and their state?s health care reform implementation process to ensure youth enrollees receive dental services.
Discussion
Oral Health Care is Essential to Maintaining a Healthy Pregnancy
Oral diseases are among the most prevalent and preventable health conditions affecting women in the United States.8 Pregnant women, in particular, are susceptible to oral diseases due to issues that may include fluctuating hormonal balances during pregnancy, an increased diet of sugary food from food cravings, vomiting during morning sickness, and the limited attention paid to oral health issues during pregnancy.9 Tooth decay, for example, is often aggravated by hormonal imbalance and a reduced immune response. If left untreated, it can develop into serious conditions such as oral abscess (severe oral infection) or facial cellulitis (a painful bacterial skin infection).10
Medical research has also shown that untreated oral infection can adversely affect fetal and child development.11 Pregnant women who have periodontitis (infection in the gums) are much more likely to have oral bacteria and inflammatory markers in amniotic fluid than pregnant women who did not suffer from periodontitis.12 Periodontitis has also been linked to intrauterine growth restriction, lower placental blood flow, premature delivery, and low birth weight.13 Even after birth, oral infection can be passed from mother to child through kissing, sharing utensils, and breastfeeding, placing children at risk of developing oral health problems.14
To mitigate oral health problems during pregnancy, the American Academy of Pediatric Dentistry, the California Dental Association, and the New York State Department of Health recommend that oral health providers assess pregnant women for dental hygiene habits and provide them with dental care throughout their pregnancies.15 In addition, pregnant women who become aware of their oral health needs during pregnancy are more likely to establish improved lifelong oral care habits for themselves and their children.16 Therefore, increasing pregnant women?s access to oral health care may help reduce future occurrences of oral health conditions and prevent them for their children.
Dental Coverage under Medicaid, CHIP, and the ACA
a. Medicaid
Under federal Medicaid law, adult dental care is not a mandatory service.17 As a result, many state Medicaid programs do not provide comprehensive dental coverage to adult enrollees.18 For example, in 2010, three states did not provide adults with any dental coverage, and twelve states provided only emergency or acute dental care.19
However, the majority of states extend some form of dental coverage to at least one group of adult enrollees (such as pregnant women or individuals with disabilities).20 Most often, states use a Medicaid § 1115 demonstration project to provide adult enrollees with oral health care services. These demonstration projects provide states with flexibility to modify their Medicaid programs to meet their health care goals, such as expanding coverage for certain populations or services. For instance, Oregon provides dental coverage to the vast majority of enrollees through a § 1115 project.21
While the Medicaid Act does not explicitly require states to provide dental services to adult pregnant women enrollees, states, at a minimum, must cover pregnancy-related services.22 Pregnancy-related services include services for the ?treatment of conditions or complications that exist or are exacerbated because of the pregnancy? and services necessary for the ?diagnosis, illnesses, or medical conditions which might threaten the carrying of the fetus to full term or the safe delivery of the fetus,? such as prenatal, postnatal, and delivery services.23 Accordingly, adult pregnant women enrolled in a Medicaid program that does not generally provide (or severely restricts) dental care for adults could still potentially receive necessary oral health care services as pregnancy-related services if the need for dental care impacts their pregnancies.
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