Californians on Medicaid dental program are about to get full coverage back, but dentists who will see them are scarce

Smiling broadly to show off her new teeth, a woman at a free dental clinic in Coachella Valley earlier this year stood up and shouted a thank you to the volunteers who had just given her new partial dentures.

“She was making so much noise that people several rows over in the dental area had to stop and look up to see what was going on,” said Paul Congdon, whose wife, Pamela, founded California CareForce, the organization that hosted the clinic. When the woman saw the new teeth filling the gaps in her smile, her speechlessness turned into an outpouring of gratitude, Congdon recalled.

Other Californians may soon see similar benefits when they visit their dentists. Beginning January 1, California’s Department of Health Care Services will restore full dental coverage, which was previously cut in 2009 amid the state budget crisis. The coverage expansion, building on a partial restoration of benefits in 2014, will provide services to approximately 13.5 million adults with Medi-Cal, California’s Medicaid program. However, the impact of the restored benefits may be limited by an ongoing lack of dental providers who accept Denti-Cal insurance, likely forcing some low-income Californians to continue relying on volunteer services for dental care.

The restored Denti-Cal benefits will add gum disease treatments such as deep cleanings, as well as partial dentures, root canals for back teeth, and other procedures. The coverage expands on current Denti-Cal services, which include cleanings, X-rays, fillings, and full dentures.

“(If) you have a benefit for fillings or restorative work and you don’t treat gum disease, that’s kind of like fixing a roof on a burning building,” said John Luther, chief dental officer for Western Dental. He said that the added benefits mark a significant improvement in low-income dental services, particularly for patients who previously received fillings or other basic dental work, but then faced the prospect of losing their teeth to gum disease.

Around half of California adults age 45 to 64 have had a permanent tooth extraction as a result of gum disease or tooth decay, according to a recent California Department of Public Health report. The report also found that black and Latino adults in California were more likely to have had teeth extracted due to gum disease or tooth decay than other ethnic groups, and that minority groups with less education and income tended to have fewer dental visits than other groups. 

Luther said the state’s expansion of Denti-Cal benefits could help more patients access dental care, keeping them from seeking it in emergency rooms. The most recent data from the California HealthCare Foundation shows that emergency room visits for preventable oral conditions numbered over 80,000 in 2007 — 45 percent more visits than for diabetes. Besides providing only temporary relief for dental problems, emergency room visits are also more expensive. An American Dental Association research brief found that the average charge for an emergency department treat-and-release dental visit for adults on Medicaid in 2012 was $690, far higher than treatment from a dental provider.

Western Dental, which treats over 1 million Denti-Cal visits a year, is bracing for a potential “huge influx” of patients after the New Year, Luther said. 

But the restored coverage is only a part of the solution for many Medi-Cal enrollees. The state’s low reimbursement rates prevent many dentists from accepting Denti-Cal patients, making it hard for patients to find a dentist.

According a 2014 California State Auditor report, the 2012 reimbursement rates for the 10 most common dental procedures was only about one-third of the national average. The same report found that in 2013, 11 California counties had no dental providers accepting new Denti-Cal patients, and 16 counties had too few Denti-Cal providers to care for the volume of patients.

“It is very difficult for some dentists, smaller practices, to treat patients and even break even at those rates,” said Luther. “To just say, ‘Well, you have benefits now, it’s easy to find a dentist,’ that isn’t always the case.”

The California Department of Health Care Services announced in June that it would raise many reimbursement rates for providers by 40 percent for one year, funded by revenues from the Proposition 56 tobacco tax passed in 2016. The Centers for Medicare and Medicaid Services approved the supplements in November, but it’s unclear whether they will ultimately increase access to dental care for Medi-Cal beneficiaries. 

Meanwhile, other organizations have sprung up to fill the gaps in care. California CareForce, which ran the Coachella clinic, was founded in 2011 to provide free dental, vision, and medical services to underserved Californians. Jason Sullivan-Halpern, the organization’s clinic program manager, says that they hold approximately two to five clinics a year, with medical professional volunteers treating around 1,500 to 2,000 patients at each event.

Sullivan-Halpern said that many of the patients, the majority of whom are adults, come just for dental services. The clinics often perform tooth extractions, fillings, and X-rays, but also sometimes offer more involved services such as dentures. He said many patients can access general medical care but not dental services.

“There are people who are completely uninsured but they’ve been able to rely on us coming back every year,” Sullivan-Halpern said.

Luther praised volunteer clinics, but said that they are not sufficient. He pointed again to low reimbursement rates as one of the biggest barriers keeping more dentists from treating the Denti-Cal population.

“It’s one thing not to get rich on Medicaid patients, but … doctors and dentists have to be able to cover their costs and run a business in order to treat these patients at a sustainable level,” he said. “Treating one or two Denti-Cal patients isn’t going to make the difference, you’ve got to be able to make a living treating a fair number of them in the communities.”

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