Medicaid expansion means new oral health benefits for hundreds of thousands of people. Will NC dentists step up?

Author: Anne Bryce

When North Carolina expands Medicaid this month, giving more than 500,000 people access to government-subsidized health care, these new recipients may get even brighter smiles.

The state’s Medicaid program provides comprehensive oral health benefits such as daily cleanings, exams and other preventive services. Care considered “medically necessary” includes some oral surgeries, periodontal care, dental restorations, denture fittings and implants, with full replacement every 10 years and partial replacement every 5 years.

However, when new Medicaid recipients try to schedule a dental appointment, some of those new smiles may turn into grimaces: Only about 45% of North Carolina dentists accept Medicaid patients. Additionally, many dentists do not accept new Medicaid recipients.

Oral health care providers and advocates say there are several reasons why so few providers are accepting new patients on the Medicaid list. One problem, they say, is that reimbursement rates have remained static for 15 years.

“The North Carolina Medicaid dental provider network is in serious crisis,” Frank Courts, chairman of the North Carolina Dental Association’s Oral Health and Prevention Committee, said in a recent letter to the editor published in Neuse News and other publications. wrote in. “…due to the COVID-19 pandemic and resulting inflation, the actual cost of providing dental care is significantly higher than Medicaid reimbursement rates and is the same as it was in 2008.”

For years, dentists have been trying to remind insurance companies and others in the health care industry of the importance of the connection between oral health and systemic health.

Research shows that poor oral health can negatively impact conditions such as heart disease, stroke, diabetes, pregnancy and dementia.

“The people of North Carolina deserve an oral health care system that contributes to their overall health,” Kautz added. “State leaders have a responsibility to find ways to adequately fund dental care for Medicaid recipients. Achieving this goal will save the state money in the long run and lead to a healthier, more productive population.”

Zachary Brian, associate professor and director of the Dental Community Service Program at the University of North Carolina at Chapel Hill’s Adams School of Dentistry, told NC State Health News in a phone interview this week that he is The current situation is “ecstatic”. One of 40 states expanding Medicaid benefits.

“Policy is being developed slowly and may take longer than we want,” Bryan said. “At the end of the day, this should be cause for celebration.”

how we got here

Republicans leading the state Senate and House of Representatives have resisted expansion for a decade despite Democratic Gov. Roy Cooper’s vigorous campaign.

Republican Senate leader Phil Berger, R-Eden, changed his mind and told the Senate in 2022 that expanding Medicaid was “the right thing to do.” His shift toward expansion also comes after the Biden administration put billions of dollars in federal incentives on the table.

That year, however, the House did not fully agree, in part because the proposal came with other health care policy changes.

In 2023, the House and Senate agreed to pass the change but attached the expansion to approval of a state budget that contained policies and changes that Cooper did not support.

Still, Cooper allowed the budget to become law without his signature, and enrollment of new Medicaid beneficiaries began on Dec. 1.

Now, Bryan and other oral health providers are working to ensure new Medicaid enrollees receive their full benefits.

Examine the challenges

Even if all dentists accepting Medicaid patients did so, it would not be enough to provide care for the projected increase of 600,000 people. Additionally, there are fewer dental offices and dentists in rural areas than in the state’s cities and suburbs.

For decades, North Carolina ranked last among states in the nation for the number of dentists per 10,000 people.

In 2001, North Carolina ranked 47th with only 4.2 dentists per 10,000 residents, according to a report compiled by the Cecil Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill. By 2013, North Carolina had risen to 44th in the nation with 4.8 dentists per 10,000 people, and four years later, the state ranked 37th nationally. In 2022, the state had 5.6 dentists per 10,000 people, ranking 24th nationally. The national average is 6.1 dentists per 10,000 inhabitants.

All but six of the state’s 100 counties are classified as dental health professional shortage areas, according to a map created by the Center for Rural Health Information based on data from the federal Department of Health and Human Services.

Health Professional Shortage Areas: Dental Care, By County, 2023 – North Carolina
Credit: Rural Health Information Center, data provided by: HRSA

Where suppliers are in short supply

Dental nurse shortages also exist in parts of the six counties of Cabarrus, Chatham, Davie, Mecklenburg, Wake and Union, but not across the entire county. Condition.

However, for the other 94 counties, this designation means they do not have enough oral health professionals to meet the needs of the entire county.

This may mean that these counties have geographic, transportation, and economic challenges that make oral health services difficult to access.

However, Medicaid expansion could play an important role in changing that.

Bryan, who teaches dental students, said many in his class said they wanted to take on Medicaid patients when they started working, but they questioned whether they could afford it. According to the American Dental Education Association, the average debt burden for 2022 dental school graduates nationwide is $293,000.

A movement is underway across the country to lower student loan interest rates and provide refinancing opportunities for dental school graduates. There is also a push for more loan forgiveness programs.

Bryan would like to see policymakers discuss different types of programs that could be used to entice more dentists fresh out of school to start working in rural areas, where they might stay for more than a year or two.

ready to speak

Dentists and hygienists have wanted to have a healthy debate about Medicaid reimbursement rates for years, said Steve Klein, vice president of the North Carolina Oral Health Partnership. Lately, though, there has been a reluctance to take too drastic measures, in part because they don’t want to jeopardize expansion efforts.

There are other discussions taking place within the industry.

In 2022, the North Carolina Oral Health Partnership launched the Oral Health Transformation Initiative in partnership with the North Carolina Institute of Medicine and the Duke Endowment. (Revealed: Duke University endowment sponsors NC Health News coverage of children’s health issues.)

Over the past year and a half, a working group composed of members from diverse backgrounds in oral health care and other aspects of medicine has met to develop recommendations for policymakers and legislators in 2024 and beyond.

Klein said the report could be released as early as January and could address a topic that has long troubled oral health providers in the state. That said, when North Carolina moves from a fee-for-service Medicaid system to a managed care system overseen by private insurance companies in 2022, oral health care is not included in the transition.

Many dentists want to keep it that way, but some are willing to discuss it.

“Across the country, we are seeing a movement to reshape the health care delivery system in many ways,” Michelle Reese, associate director of the North Carolina Institute of Medicine, said in a video announcing the initiative. As North Carolina has moved toward managed care for primary care and behavioral health services, we believe it is our responsibility to educate the consumer and provider community thoroughly about the current oral health landscape and make recommendations based on our analysis of other states to date. Practices and lessons learned to date in the rollout of Medicaid managed care in North Carolina.

legislator’s perspective

Sen. Gale Adcock, a Cary Democrat who is a nurse practitioner and a former member of the committee, said whether a move to managed care was among lawmakers’ recommendations, the proposal Any recommendations need to involve dentists and oral health providers in discussions. task force.

If lawmakers are encouraged to create new loan forgiveness programs, increase Medicaid reimbursement rates or change the way oral care is administered in the system, she expects any proposals to address the problem will have to be multi-pronged.

It’s like trying to help any patient who comes to her.

“My experience when trying to solve any problem is that it’s never just one thing,” Adcock said. “North Carolina covers more Medicaid services than any other state. I have to believe we can solve this problem.”

Adcock may find allies among lawmakers such as Rep. Tim Reed (R-Greenville), who is an emergency room doctor when not in the Legislature.

We need to connect the head and mouth to the rest of the body, Reed said during a recent panel discussion at the annual meeting of the North Carolina Institute of Medicine. We need to find a way to reconnect them because they are all interconnected. So I think that’s definitely some work that needs to be done.

Poor oral health can have an impact on your entire body.

It may also interfere with someone’s employability. If they worry about smiling and exposing tooth or gum problems, they may not come across as attractive or friendly during interviews, leading employers to pass on capable employees, Adcock said.

“Poor oral health leads to poor physical health,” Adcock added. “We really separate the head from the body in the way we deliver care. We do the same thing with mental health. They’re all connected. Everything is tied together.”

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