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Delaware sinks teeth into problem of low income dental care

Linwood Worthington’s parents always made sure he received regular dental care while he was growing up.  But when he became an adult, he discovered that the dental insurance that came with his job didn’t go very far. Moreover, when he became unemployed after relocating to Delaware in 2005, he learned that his Medicaid benefits excluded dental altogether.  His teeth suffered.  But then a friend told him about Hope Medical Clinic in Dover which offers free non-emergency treatment and consultations to low-income adults.

There, Worthington got the care he needed to maintain a healthy mouth.  “I’m very grateful,” said the 43-year-old Dover resident.  “Now I’m smiling away.”

Lack of Dental Care for Adults on Medicaid in Delaware

States are required to cover dental for children in their Medicaid programs but coverage for adults is optional.  Delaware is one of about a half dozen states that does not extend even minimal dental benefits to adult Medicaid recipients.  Coverage stops at age 21. “It’s a disgrace,” said Dr. Thomas Conaty, past president of the Delaware State Dental Society and member of its legislative council. “And let’s put the problem where it is—it’s in our state.”

The lack of service to this population has serious health and economic consequences. Dental caries (tooth decay), now considered an infectious disease, has reached epidemic proportions among the poor of all ages, according to a 2000 report on oral health by the U.S. Surgeon General.  Poor oral health has been linked to a variety of medical conditions, including diabetes, heart disease and adverse pregnancy outcomes. 

Dental disease has devastating personal consequences as well, including pain, impaired eating, speech difficulties and lost work days.  Moreover, adults with visible dental caries are less likely to gain employment than those with healthy smiles, according to the Surgeon General’s report.

Treating dental disease early prevents the need for more expensive services later. Indeed, when low-income individuals experience a dental emergency, they head to the hospital where care is more palliative than curative.  “It costs three to four hundred bucks and it doesn’t treat the problem,” said Dr. Gary Colangelo, chair of the Delaware Oral Health Coalition.  “When you have to have a tooth pulled, you have to have it pulled and I don’t know of too many emergency room doctors that do extractions.”

Low-income and Medicaid-eligible adults can access preventive care at federally qualified health centers and other clinics where dentists in private practice donate their time.  Nemours offers care to persons 65 and over who meet eligibility requirements. But these efforts pale in comparison to the need they must serve. “It’s a growing problem,” said Dr. Thomas Mercer, dental director at the Hope Medical Clinic in Dover.  “I don’t think the other clinics that are doing what we’re doing are able to keep up with it either.  Dental disease is a rampant problem.”

Dr. Carmelina D’Arro, dental director at Henrietta Johnson Medical Center in Wilmington, confirms his observations.  “We have patients coming from a two-hour radius and we’re seeing rampant decay,” she said.  “We’ll have a line of patients outside the clinic on most days with emergencies.”

And although these facilities provide care at a greatly reduced cost, it is often beyond the reach of the working poor whose budgets are already strained by the sour economy.

“When people have limited resources, they set priorities, and unfortunately, patients who have limited financial resources probably see their oral issues and their dental issues as low priority until they get into trouble,” said Dr. Edwin Granite, chair of the Department of Oral and Maxillofacial Surgery and Hospital Dentistry at Christiana Care Health System.  Granite says Christiana Care’s clinic counted over 11,000 dental visits last year.

Efforts to Add Dental Benefits to Adult Medicaid Coverage

Experts agree that while dental clinics provide a much-needed service, they are not the best way to treat the low-income adult population.  Indeed, a 2003 report by Families USA found that states could provide the same service at a 50-70 percent discount through Medicaid.

“I think that Medicaid is really the solution we need to hammer home,” said Dr. Brian McAllister, board member of the Delaware Institute for Dental Education and Research or DIDER.  “Clinics are not efficient.  They have a purpose but a dental office is run to be efficient.  If it’s not efficient, it’s not profitable.”

The dental community has made several attempts over the past few years to get the dental benefit extended to adult Medicaid recipients but recent efforts have fallen victim to the foundering economy.

“We’ve not had that history (of providing dental coverage for adults) so I think getting geared up to start with a major cost effort is what’s precluded us from doing so,” said Dave Michalik, chief of policy and planning for the state Division of Medicaid and Medical Assistance.

Colangelo feels legislators don’t appreciate the economic value of extending benefits.  “You can get long-term cost savings,” he said. “That’s a difficult policy for politicians to understand because they can only think until the next election and when your payoff is going to be 15-20 years down the road, they kind of glaze over.”

Conaty believes it’s just hard to advocate for adults.  “It’s easy to advocate for children because everybody wants to help the kids,” he said. “But it’s a much harder job to sell this for adults.  We’ve been trying four or five years in a row to do it.”

Delaware sinks teeth into problem of low income dental care
Click the image to view a breakdown of care provided for Medicaid-elgible Delaware children

If and when Medicaid dental benefits get extended to adults, the dental community stands ready to accommodate the new entrants.  The state has attracted many new practitioners through its mandatory one-year residency program at Christiana Care and DIDER’s arrangement with Temple University’s dental school to reserve a certain number of slots for Delaware residents.  In addition, DIDER’s loan repayment program has brought more dentists to Sussex County, lifting it from its federally underserved status.

Delaware also boasts strong provider participation and reimbursement rates. Two-thirds of the state’s 400 dentists provide dental benefits to Medicaid-eligible children, receiving 80 percent of their usual fees for services.  Nationally, a 2010 Government Accountability Office (GAO) report found that in 25 of 39 reporting states, fewer than half of dentists saw any Medicaid patients.  And a recently released report from the Pew Center on the States finds Delaware is one of only five states nationally that reimburse at over 70 percent of the usual fee for service.

“The infrastructure is there,” said McAllister.

Improving Utilization of Dental Services by Medicaid-Eligible Children

The lack of progress in providing adult dental benefits stands in marked contrast to the state’s accomplishments with children.  In addition to private practitioners, children can access care at various dental clinics throughout the state, including eight run by the Division of Public Health solely for their benefit.

“A child who has Medicaid eligibility really shouldn’t have a problem getting an appointment on a regular basis,” said Dr. Greg McClure, dental director for the Division of Public Health and founder of the Delaware Oral Health Coalition.

Indeed, nearly 40,000 Medicaid-eligible children accessed some type of dental service, giving the state a 41 percent utilization rate, just above the national average, according to a 2010 report from the Centers for Medicare and Medicaid.  The state has also reinstated its dental sealant program, targeting schools with high percentages of low-income students.

The dental community would like to see a higher utilization rate but barriers remain.

“People on Medicaid have other concerns,” said McClure.  “Transportation might enter into it.  A lot of people just don’t put a value on dental care and that’s one of the things we’re trying to address through a number of initiatives.”

Those initiatives include the “Tooth Troop,” which engages caregivers in local community organizations and “Give Kids a Smile,” an annual one-day volunteer initiative to give kids’ free dental screenings.

“I think we are making progress,” said McClure.  “When I look at what it was ten years ago—no community clinics, relatively little Medicaid participation other than through our Division of Public Health—it’s a tough thing to do, but we continue to work on it.”