California lawmakers appear to be realizing that cutting dental care services out of its Medicaid program was not only unwise, but has exacerbated health care problems for the state’s most underserved individuals and communities – people who struggle to make ends meet on low-incomes and African Americans who have long been discriminated against in the health care system.
As lawmakers know or should know, oral health is critical to overall health and well-being. Recent studies show an association between oral infections and diabetes, heart disease, stroke, and adverse pregnancy outcomes. Oral health affects the ability to speak and chew, which can affect socialization and employment opportunities. Medi-Cal covers more than 13 million people in the state and is an important source of health coverage In 2016, only 44.5 percent of children on Medi-Cal received any dental service and in 2015, only 37 percent received a preventive dental service. Less than half of all pregnant women received dental care during pregnancy. Racial and socioeconomic disparities in oral health persist in California. For example, African American adults have much higher rates of tooth extraction for gum disease or decay and Latinx and low-income children experience much higher rates of tooth decay (treated and untreated) than other children.
Recognizing these problems, California lawmakers are taking some steps towards improving access to dental care. First, the state passed the California Healthcare, Research and Prevention Tobacco Tax Act of 2016 (Proposition 56), increasing the tobacco tax and allocating thirty million dollars annually to improving oral health, including as supplemental payments for Denti-Cal providers. In a Little Hoover Commission (an independent state oversight agency) hearing on March 22, DHCS testified that from 2013-2017, the number of Denti-Cal billing providers decreased by eight percent (with a 1.5 percent increase in 2016-2017). This is particularly troubling in light of the partial restoration of Dent-Cal adult benefits in 2014. Yet DHCS’s stated goal is to increase the number of Denti-Cal providers by ten percent over the next four years.
California has taken three other steps to improve dental care access: The Dental Transformation Initiative (DTI), full restoration of adult dental benefits in Medi-Cal, and the California Oral Health Plan.
Dental Transformation Initiative (DTI)
California’s Medi-Cal 2020 Waiver (1115 renewal) included the DTI, which allocates funds to improve children’s oral health. It creates provider incentives for increasing the proportion of preventative services they provide for children on Medi-Cal and creates three types of pilot programs in select counties. While a step in the right direction, only one piece of this initiative is currently available statewide and there is no clear path for broadening the pilot programs. The statewide goal of increasing children’s access to preventive services by ten percent over five years, if accomplished, would still leave more than half of children in Medi-Cal without any preventive dental services and would fall far short of California meeting its federal EPSDT obligations. Further, DTI only focuses on children’s dental care and does not improve adult Denti-Cal access. While the program’s 2016 annual report indicated some improvements in one of the pilot programs and in the number of preventive services for children, there is no path yet established for broadening the reach of these efforts.
Adult Dental Restoration
The state’s 2017-2018 budget included a complete restoration of adult dental benefits under full-scope Medi-Cal, which went into effect on Jan. 1. Among the benefits restored are partial dentures; partial denture adjustments, repairs, and relines; periodontics (scaling and root planing); rear root canals; laboratory processed crowns; and implants. This benefit restoration did not affect the annual $1,800 soft cap in Denti-Cal. There are, however, still are too few Denti-Cal providers to meet the need for those services even if now covered.
Oral Health Plan
Recently, the state released the California Oral Health Plan for 2018-2028. This plan is not specific to Denti-Cal, but there is some overlap given that the overarching objective is to improve the oral health of all Californians. The California Department of Public Health, in collaboration with DHCS and other stakeholders, developed the plan. The ten-year plan includes five goals, and many objectives and strategies for improving oral health. These goals aim to increase access to dental care and reduce oral health disparities by making changes to dental care delivery systems and payment structures, educating providers and patients, expanding community-clinical linkages, and collecting and effectively using data.
Phase one of the plan focuses on improving existing programs and services like access to fluoridated water, and on data collection and analysis, at both the local health department and state levels. Meetings will start in June and there will be an opportunity for stakeholders and local health departments to provide feedback and share best practices. The plan sets out important goals and a number of promising strategies, but is lacking in detail about the timeline and priorities for implementation.
The state’s efforts to improve access to dental care for low-income Californians are a step in the right direction and show a commitment to making oral health a priority. It is yet not clear, though, how effective they will be, and how long it will take to make a dent in the problem.
Many promising efforts and innovative approaches are being rolled out slowly in pilot programs and one-by-one in local health departments and communities, but there is no plan for expanding the scale of successful programs to have a greater impact on access. With all the changes moving forward for the Denti-Cal program, it is an opportune and critical time for progressive health care advocates to take action. It is imperative that advocates get involved in this process and make clear to state decision-makers what needs to be prioritized in fixing the Denti-Cal program so that those most in need are able to access dental services.