By Paul S. Casamassimo, DDS, MS, contributing writer

March 6, 2013 -- Michelle Andrews' recent National Public Radio (NPR) report (January 15, 2013), "Law Expands Kids' Dental Coverage, But Few Dentists Will Treat Them," addresses one of the two major obstacles to improved access to pediatric oral healthcare: inadequate financing.

The continued parsing of the Patient Protection and Affordable Care Act (ACA) reveals that there are many more obstacles to the realization of affordable oral healthcare for children in the U.S. Some are obvious, and some lurk just beyond the recognition of those hoping that the ACA will mean an end to dental disease in U.S. children.

Paul Casamassimo, DDS, MS
Paul Casamassimo, DDS, MS.

Medicaid reimbursement for dental care across the country is woefully inadequate. In some states, reimbursement has declined. In many others, such as Ohio, it has remained static for a dozen years. That alone would not necessarily doom dentist participation, but, in many cases, the initial reimbursement rates began well below what dentists need to charge the general public and the insured.

Often, criticism is exchanged between the dental profession and child advocates about Medicaid reimbursement and dentists' willingness to care for Medicaid-supported children at reimbursements well below their typical fee. However, the reality of the inadequacy of Medicaid reimbursement as it relates to safety net dental programs caring for the poor brings this inequity into clearer focus. Today, across the U.S., safety net dental programs are failing or at risk because the cost of providing dental care has increased while Medicaid reimbursement has not.

In the healthcare world, cost-shifting is a reality, but for safety net programs -- which ironically depend upon Medicaid revenues to allow them to care for the uninsured -- that ability has largely disappeared. Even government-supported dental programs that have seen public largesse evaporate in response to the recession are in jeopardy without a sizable increase in Medicaid reimbursement rates. Medicaid expansion without reimbursement increases may simply just put more people in cars and on the phone searching for dental care.

Ironically unifying trend

Andrews' story on NPR reported accurately about the unknown but worrisome risk for pediatric dental benefits in the health insurance exchanges. Families may be expected to provide out-of-pocket payments for dental services under the exchange system.

This has to be put into context with what middle-class families are experiencing as a result of the recession. It has been 15 years since the typical middle-class family experienced a true increase in real income. Add to that changes in tax regulations that have led to a thousand or more dollars in the typical family's tax burden for 2013 and subsequent years. Any additional out-of-pocket payment for healthcare will likely be at the expense of oral health, because the mouth has long been considered an organ onto its own from the standpoint of health coverage.

Little public or policy attention has been paid to an ironically unifying trend for both dentists and patients: growing debt. New dentists graduate with about $200,000 in educational debt, on average. Cumulative educational debt for college and additional higher education is destined to surpass credit card debt and has been called the next U.S. financial crisis.

The debt upon entering dental practice for the overwhelming majority of dentists drives practice choices, including participation in Medicaid. For a meager few, debt relief opportunities for shortage area practice bring care where it is needed. The proposed increase in dental schools and new workforce models carry with them the specter of educational debt and the likelihood that these providers will be reluctant to serve the poor.

Recent lay press has pointed to the continuing consumer debt and the reality that many of today's middle-class adults will die in debt. The ability and willingness of middle-class patients to take on any additional nonemergent healthcare costs, such as dentistry, may be questioned.

As has been suggested by child advocates, the inclusion of pediatric oral health benefits may be more form than substance, although there is hope that with further clarification and guidance, the integrity of the law's intent will be realized.

Clash of cultures

Another gorilla is a clash of cultures, professional and socioeconomic. There is a chasm between the goals and values of mainstream dental care and of those who need it most, the poor. In addition, governmental solutions are slow, unwilling, or unable to recognize the often overwhelming social obstacles facing the poor and, more recently in the lingering recession, the middle class. While recent attention given to emergency department visits for dental pain focuses on financial and access difficulties, less often -- if at all -- is underlying cultural and poverty-related oral health literacy addressed. Some discrepancy in oral healthcare relates to lack of knowledge, differing life priorities, and cultural values and not just inability to find care resources or pay for care.

The dental profession may be ill-prepared to take on additional newly insured children under the ACA, not only because of the financial inadequacies in reimbursement, but because of social factors that tend to permeate many health-related behaviors, not just oral health. Repeated surveys of dentists caring for Medicaid clients include "patient characteristics" in the top three reasons provided for lack of their participation. Despite that, reimbursement for care-management costs related to oral health to agencies or providers remains spotty at best.

Government's disconnect from, or unwillingness to, address real problems in healthcare is best illustrated by a recent report of the National Academy of Sciences, which pointed out the failure of the food stamp program to provide healthy diets to recipients. Such a huge disconnect does not inspire hope that the ACA will bring oral healthcare to the poor!

In the present, this cultural divide piggybacks with reimbursement insufficiency to present the ACA with formidable obstacles to improved oral health in the short term. In the long term, any hope of reaching an outcomes-based reimbursement system to replace fee-for-service, which is the vision of many oral health planners, seems a pipe dream unless the financial and social aspects of healthcare reform are more adequately addressed.

Ray of light

However, a ray of light can be found in a recent survey of pediatric dental practice by the ADA's Survey Center. The report indicates that about a fifth of a typical pediatric dental practice is made up of patients with governmental coverage -- coincidentally, the same percentage of children across the U.S. who live in poverty.

Most children in the U.S. are cared for by general dentists, but the youngest and most vulnerable often can't be and so rely on pediatric dentists to address their dental problems. Years of Title VII funding and Pediatric GME to children's hospital-based dental residencies have increased the number of pediatric dentists in practice and may ultimately have as great an impact on access to care for the newly insured as the ACA. Some authors have already suggested that the increased "treatment" increments of the primary dentition caries index in very young children are the result of this improved access.

The ACA presents hope for improved oral health for those who need it most. It is important that its provision for universal dental access for children be seen in the greater context of ongoing financial and cultural challenges. Now that we passed it, it is time to read it, fix it --- and make it work.

Dr. Paul Casamassimo is currently president-elect of the Ohio Dental Association and director of the American Academy of Pediatric Dentistry Oral Health Policy Research Center. He received his dental degree from Georgetown University in 1974 and a Master of Science and certificate in pediatric dentistry from the University of Iowa in 1976. He has taught at the University of Iowa College of Dentistry and the University of Colorado Denver School of Dental Medicine, and is currently chair of the division of pediatric dentistry at the Ohio State University College of Dentistry and chief of dentistry at Nationwide Children's Hospital. He is the former editor in chief of the AAPD and its journal, Pediatric Dentistry, and a past president of AAPD.

The comments and observations expressed herein do not necessarily reflect the opinions of, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.

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Copyright © 2013

Last Updated kk 3/6/2013 4:13:54 AM

9 comments so far ...
3/6/2013 7:20:46 PM
Buckeye DDS
Your article is absolutely correct.  Quality care in 2013 and beyond, can not be provided with fees that were last raised in Ohio on 01-01-2000.  Bad patient behavior (broken appointments, not following post op & oral hygiene instructions, emergency oriented visits & ignoring preventive visits, smoking, high fructose diets, etc.) has never been addressed by the Medicaid program.  ACA will NOT improve oral health unless we start thinking outside of the box & make radical changes to the current Medicaid policies & improve the fees to keep pace with inflation. 

3/7/2013 1:45:48 PM
I respect Dr Casamassimo's perspectives & his sincere convictions to assist disadvantaged children. However, I see the Medicaid problems as FAR worse.
I don't see this current broken Medicaid system as viable, in any current structure, as today exists. The only means to make children's dental Medicaid viable w/ it's current fee structures, is w/ rampant fraud & abuses. That's exactly what we see.
We see hoards of children placed in physical restraints, uneducated parents signing off on "joke" informed consents, parents denied access to witness their children's care, & needless round-housing w/ steel crowns & pulpotomies. Non-dentist corporate managers push our junior professional colleagues for production quotas & bonuses, based on corporate production schedules, most commonly found in retail sales, not healthcare.
Let's openly face the facts. The US taxpayer is fiscally tapped out. Regualtors cannot or will not enforce Medicaid rules & regs. Medicaid fee schedules will NEVER be close to the costs of providing appropriate care. Fraud is seemingly openly invited.
So, let's totally scrap the current system. It costs too much. It invites fraud. It corrupts our recent grads. It demeans our profession. Disadvantaged children get hurt.
Let's design a system taxpayers can afford & provides honest services. Let's have a true safety net program. Let's have reasonable fees, but that means severe elimination of services, which are today provided (but only theoretically provided properly). What's that mean?
We would provide emergency care. We would provide care for dental abscesses (exodontia, I&D, etc.) We would provide preventive services. We would eliminate most orthodontic services. We would eliminate many restorative services, inclusive of steel crowns (which is nearly the ONLY restorative service many dental Medicaid providers generate). We would have tough & real oversight of dental Medicaid fraud & abuses.
Further, recent dental grads often graduate w/ $200-300K in student loan debt. This is NOT dischargeable in a bankruptcy. Student loan forgiveness of $5-15K per year, for working in underserved public health clinics is PATHETIC. This needs to be in to $30-60K range. If this doesn't happen, we'll soon see "dental therapists" providing a 2nd tier level of care.
Michael W Davis, DDS
Santa Fe, NM

3/7/2013 2:09:55 PM
There are about 14,000 dentists in Texas. There are estimates that perhaps 10% of them are actively treating Medicaid children. Texas spent about $1,400,000,000 in Medicaid dental services in 2012. That's $1,000,000 per dentist. That's not enough to adequately treat our poor children? Are you kidding?

3/7/2013 2:46:40 PM
Dear Mr Moriarty,
Those numbers are totally unsustainable. The vast majority of Texas dentists did NOT participate in Medicaid, because the viable business models for dental Medicaid involved fraud & abuses. So, is that a round-about way of saying many (most?) private Medicaid dental providers in Texas, engaged fraud & abuses. YES! The Texas dental Medicaid system is out-of-control for fraud, waste, & abuses.
The ACA is anticipated to expand the theoretical coverage for children's dental Medicaid, by 25-33% of new enrollees. Our current system is in breakdown mode already. So, w/out repairing (or better- scrapping the old, & creating an improved system), we're going to balloon-out a failed system. What will ensue? POP!
Further, the initial years of the expanded healthcare provided by ACA will be totally paid for by federal, not state-matching money. Thats bogus printed money, from the feds! We already borrow 40 cents of every dollar the feds spend. This is unsustainable. This bubble will burst.
When a bubble pops, like the US housing & banking crisis circa 2008, people get hurt. No, it won't be Wall Street investment bankers getting hurt. We not only won't criminally prosecute them, we always bail them out, whether Republicans or Democrats are in office. Those getting screwed over will be the poor & middle class. The sad thing is, all of this is preventable.
I agree w/ you, in that there is adequate funding at some level, for a highly viable dental safety net. There is money available!!!
However, the current dental Medicaid system will squander those moneys to crooks, be they individual dishonest dentists, ignorant corporate managers of dentists, or scamming investment bankers.
Michael W Davis, DDS
Santa Fe, NM

3/8/2013 11:27:01 AM
Politically engineered crisis deserves a politically engineered solution. [:)]
Medicaid Expansion: States Must Meet Obamacare Standards To Get Full Federal Funding
Put more people on medicaid and herd the sheep to Walmart..I believe that is the Jim Cramer said once "Buy, buy, buy..."