As states grapple with the economic impact of COVID-19 and focus on closing budget shortfalls, Medicaid programs will likely take center stage, since Medicaid typically accounts for the largest portion of a state’s budget — 20 percent on average. As such, states may consider eliminating optional benefits to reduce Medicaid expenditures.

Historically, the adult dental benefit is one of the first optional benefits that is eliminated during economic downturns. Recent proposals in California, Colorado, and Nevada to eliminate the adult dental benefit suggest that a similar dynamic could play out during the current recession. While these three states ultimately preserved the benefit, their proposals may be a bellwether for similar budget considerations in other states and the potential impact on adult dental services in Medicaid.

• A brief background on the adult dental benefit: While Medicaid programs are required to provide comprehensive dental coverage for child enrollees, states have broad flexibility when it comes to whether and how an adult dental benefit is implemented. As a result, Medicaid adult dental coverage varies by state and, in some cases, is limited to emergency services such as tooth extractions, or to specific populations such as pregnant women. Regardless of the comprehensiveness of a state’s benefit, adult Medicaid beneficiaries often experience barriers to accessing regular oral health care. Many Medicaid-enrolled adults also lack awareness of what dental services are available, as the benefit often changes based on the economic and political climate.
• How do oral health care provider shortages further compound the issue? Prior to the COVID-19 pandemic, Medicaid programs were already faced with a limited pool of participating oral health care providers and challenges recruiting new ones. Providers often cite Medicaid’s low reimbursement rate and high administrative requirements as reasons for not accepting Medicaid patients. Amid COVID-19, states could opt to further reduce provider reimbursement rates as a strategy for decreasing overall Medicaid spending, further compounding provider shortages. CARES Act funding does provide potential financial support for some oral health care providers, as it allows eligible providers to apply for a distribution of approximately two percent of their reported gross revenue from patient care on their most recent tax filing.
• Are we already seeing reductions in the adult dental benefit? While states have been trending toward a more comprehensive adult dental benefit in recent years, economic stressors may be impacting this progress. Some states, such as Colorado, are moving to reduce the benefit budget for fiscal year 2021, while other states are putting off planned investments in their oral health care program, such as increases to provider rates and coverage for pregnant women. However, no states have yet moved forward with a complete elimination of the adult dental benefit. As the fiscal year gets underway, it will be important to track COVID-related impacts to oral health care access and outcomes.
• Why does this matter? COVID-19 could worsen already tenuous access to oral health care services for Medicaid beneficiaries. Without a dental benefit, adults often delay care despite emerging or existing oral health conditions. Due to limited care options, beneficiaries that ultimately need treatment may seek care in the emergency department — or not at all. Oral health stakeholders have voiced concern around access during the pandemic, noting that COVID-19 exacerbates oral health disparities within the Medicaid population, especially among Black and Latino enrollees. The impact of poor oral care extends beyond health; it also can affect one’s ability to find and keep a job, which is especially salient in an economic downturn.
• What’s the bottom line? States are in a difficult situation when it comes to balancing their budgets, and Medicaid — a sizable portion of all state budgets — is often in the spotlight. In one analysis, implementing and maintaining an adult dental benefit is estimated to account for 0.4 to 2.1 percent of a state’s Medicaid spending. While reducing or eliminating the adult dental benefit can be one strategy to reduce expenditures, it can present significant risks for Medicaid beneficiaries’ access to oral health care and their overall health and wellbeing. These changes could also further amplify existing oral health provider shortages, and state Medicaid programs could see further reductions in provider networks as a result of these fiscal considerations.

What Else is Worth Watching?

• States are adopting policies to expand access to oral health care through teledentistry. As of August 2020, approximately half of all states have regulatory environments that may support the use of teledentistry. For example, North Carolina and West Virginia established teledentistry codes for Medicaid providers. Yet, some states, such as Oklahoma, considered but ultimately did not pursue teledentistry. In June, the Association of State and Territorial Health Officials examined ways, including teledentistry, to ensure safe access to oral health care amidst a pandemic. A recent article from the Elsevier Public Health Emergency Collection analyzes existing literature on teledentistry to understand how it can be used to complement or supplement in-person visits during the pandemic.
• Dentists may play a role in vaccinating against COVID-19. During public health crises, states can expand providers’ scope of practice so that a broader array of health care professionals can offer critically needed services, such as administering vaccines. During the 2009 H1N1 outbreak, for instance, New York issued an executive order allowing dentists and dental hygienists to administer seasonal and H1N1 flu vaccines. Oregon also enacted 2019 legislation authorizing dentists to administer vaccines. The JAMA Network explores ways the oral health care workforce may help in responding to COVID-19.