Dental debate leaves out kids

Former Texas Gov. Rick Perry joined nearly two dozen other lobbyists in Tallahassee at the start of this year's legislative session on a mission to change Florida's dental care program for poor children.

Florida is among the worst states in the country when it comes to ensuring the dental health of these children from low-income families, providing care to barely one-third of those eligible.

But that wasn't the focus of these lobbyists' efforts. Instead, they worked with state lawmakers to once again change its flailing children's Medicaid dental program. That program is lucrative, with a pot of about $250 million set aside each year for insurance companies managing dental care for 4 million people who rely on Medicaid for their health care. Under current state rules, insurance companies that cover the care are paid a flat rate per month and get to keep any money left over, whether needy children get dental care or not.

On Monday, state lawmakers passed a bill that would change how the program is administered, and which companies get paid — but the change wouldn't do anything that could move the number of children covered closer to the national average of 46 percent.

The current system is run by medical insurers, and dental insurers are trying to elbow their way back into the picture, as they were a few years ago.

Now, the bill will go to Gov. Rick Scott, who is familiar with the measure, thanks to lobbying from Perry.

The proposed change is the latest twist in Florida's effort to run its Medicaid health care program for the poor through a managed care system. Supporters say the bill would make it more effective by first studying the existing system, and then changing it to try a new approach that could potentially help more children receive dental care. But national experts say simply changing the structure of the program is not enough to improve it.

Health consequences

In Sarasota and Manatee counties, respectively, 20,370 and 27,252 children from infants to age 17 were enrolled in Medicaid. Statewide, the numbers jump to about 2 million children, or roughly half the children in the state.

Without proper dental care from the time children sprout their first tooth, they can be set up for a lifetime of tooth decay and cavities, which, when left untreated, leads to pain and infection that can spread throughout the body.

In 2014, only 32 percent of Medicaid-enrolled children received any oral health care, according to Florida data submitted to the federal government. That same year, dental emergencies forced 163,906 patients into hospital emergency department and cost $234.4 million, mostly in taxpayer-subsidized uncompensated care, according to research by a University of Florida team.

The bill that sailed through the Legislature this year requires the state to study the current Medicaid dental care system, which has medical insurance companies providing dental care for their members, and present the results of the study to lawmakers next year.

After reviewing the study, lawmakers could decide to keep the integrated system, but if they do nothing, the dental and medical care would be split between two industries.

While health advocates are concerned about yet another change to the Medicaid program, they're hopeful that the study will give a clear picture of the state of kid's oral health care.

“We are excited about having a study, and then as long as the data is there, we trust an informed decision would be made,” said Dr. Jolene Paramore, a practicing dentist in Panama City and second vice president of the Florida Dental Association.

No health advocacy groups have spoken publicly in favor of or in opposition to the bill.

History of managed care

For the handful of lawmakers opposed to the bill, concerns stem from the state's recent transformation of the Medicaid program.

In 2005, Florida began transitioning some small groups of Medicaid members to managed care plans, and separate prepaid dental health plans. At that time, just 20 percent of Medicaid-enrolled children saw a dentist, according to data submitted by the Florida Agency for Healthcare Administration to the federal government.

As the Medicaid managed care program rolled out across the state, more people were moved into separate dental plans, which built insurance networks of approved dentists willing to see Medicaid patients. Two dental insurance companies, the Fort Lauderdale-based MCNA Dental and Boston-based Dentaquest, dominated the market.

By 2011, the state had changed directions. Instead of a Medicaid program that divided medical and dental care between two different insurance systems, lawmakers opted for an integrated system, where medical and dental benefits were offered by medical insurance companies only.

Officials made that move partially based on an outside consultant's report, which concluded that “Florida Medicaid's fragmented, complex system makes it difficult to improve value for patients and taxpayers.”

When the law creating the integrated Medicaid system passed in 2011, the percentage of children receiving oral health care had climbed to 24.1 percent, still well below the national average that year of 46 percent of kids who received some dental care, according to federal data.

Currently, the Medicaid program pays insurance companies a flat rate for each child enrolled, meaning the companies get paid whether children see a dentist or not. If the insurance companies have money left over at the end of the month, they get to keep it. Under the proposed system, the state could write contracts to require companies to make sure a certain number of children get dental health care, but those details are still to be worked out.

Politics of dental care

Almost as soon as the system cut out dental insurance companies in 2011, the companies began working on getting back into the market.

To ensure passage this year, MCNA Dental hired 20 lobbyists, including Perry, who met with Scott to endorse the bill.

The CEO of MCNA Dental, Jeffery Feingold, is a personal friend of Perry and his company was the single-largest donor to Perry's failed 2016 presidential campaign committee, donating $37,800. Perry now works for MCNA Dental as the company's chief strategy officer.

MCNA has also heavily supported the bill's Senate sponsor and incoming Senate president Joe Negron's political committee Treasure Coast Alliance with donations of $85,000 over the past three years, including a $25,000 donation just a few weeks before the 2016 legislative session began on Jan. 12, according to state campaign finance records.

MCNA Dental also gave seven $500 donations and one $1,000 donation to House sponsor Jose Felix Diaz over four years.

Negron has also received $119,500 since 2009 in donations from the medical insurance companies which oppose the bill. Negron said this proves he is concerned about policy, not about donations.

“I file bills based on what I think is the best public policy, not based on things that happen when we're not in session,” Negron said. “My goal is to have as many children as possible receiving dental we deliver services does matter.”

Rep. Diaz and MCNA Dental did not respond to repeated requests for comment.

National trends?

Nationally, more than half the states operate their Medicaid dental and medical programs separately, and some states that use these two-part systems have high dental access rates for children. But the program structure doesn't have much to do with quality, said Andy Snyder, project director at the National Academy for State Health Policy in Washington, D.C.

Snyder said funding is key, along with whether the program works collaboratively with dentists and whether the program is a priority for state lawmakers.

For instance, when Connecticut changed its Medicaid program to provide dental benefits separately, the state also picked dental care as an area of focus and priority, Snyder said. The state put more resources into the system, raised reimbursement rates for dentists and focused on making sure more kids received oral health care. In 2014, the state had one of the highest utilization rates in the country — 63 percent of Medicaid-enrolled children received oral health care that year.

“They've had success, but there's been a lot of work put in,” Snyder said. “It's not merely due to changing the administrative set up of the program.”

In the Florida debate over which system is better, neither side has much data to stand on. Because the Medicaid dental program has flipped back and forth between fee-for-service, prepaid, managed care and now potentially back to prepaid, not enough time has passed under any one system to prove conclusively which one actually works the best.

One of the lead detractors of the bill, Sanford Republican Rep. Jason Brodeur, voiced that frustration in a committee hearing in early February.

“Now, 18 months after we've got it (the integrated system) going, we want to go back again,” Brodeur said, while outlining his concerns about the legislation.

Because of the study requirement and the possible need for a vote during next year's legislative session, the millions of Medicaid members would not see a change until early 2019.

Supporters of the potential change are hopeful that the study, which must be produced to the legislature by December 2016, will at least provide an accurate picture of what's happening in children's dental health care in the state.

“It is an unbiased report that we can look at as a legislative body in order to make a decision,” Diaz said during debate on the bill. “This body is smart enough to make decisions based on numbers.” 

[This story was originally published by Herald-Tribune.]