Medicaid adult dental benefits are shamefully — and dangerously — inadequate in most states

In the middle of the night, you’re jolted awake by a throbbing pain in your mouth that is radiating down your neck and behind your eyes. Earlier in the week, it was just a small toothache, but now over-the-counter remedies can’t even begin to address the excruciating pain.

Knowing you will not be able to get any sleep tonight, let alone concentrate on work tomorrow, you head to the emergency room, where they suspect you have an infection inside of your tooth or an abscess. That could be deadly, but the ER doctor is not equipped to provide dental treatment. All they can do is prescribe medication for your pain and infection, which can’t address the root of the problem.

This toothache will go on to cause months of health issues, mental anguish, and costly out-of-pocket expenses. You already have Type 2 diabetes, and the active infection is making your blood sugar even more difficult to control. But you can’t just head to the dentist, because your minimum wage job does not provide dental insurance, and you live in a state that does not provide comprehensive, adult dental benefits through Medicaid. Even with antibiotics from the ER, you face the possibility of the infection recurring, a potentially life-threating risk unless you can get dental treatment to fix the true problem.

All of this could have been avoided if you had access to preventive oral health care.

For too long, oral health has existed apart from systemic health, even though evidence shows a strong connection between the two. And because health insurance policies treat the mouth as separate from the rest of the body, access to affordable oral health care remains out of reach for many low-income individuals, people with disabilities, communities of color, and Tribal and rural communities.

According to data from CareQuest Institute for Oral Health, where I am CEO and president, 77 million adults in the U.S. lack dental benefits. Medicaid dental coverage for adults is one of the few options available for low-income families who are seeking oral health care. Yet 47 state Medicaid programs do not offer dental benefits sufficient to maintain optimal oral health.

Now, as the Covid public health emergency comes to an end, an estimated 14 million people are expected to lose their access to oral health care.

Congress needs to act. By ensuring extensive adult dental benefits for all state Medicaid programs, Congress can promote positive health outcomes, address health inequities, and curb health care costs. It just needs to take these three straightforward steps to make this a reality:

1. Designate dental services as a mandatory benefit category for all Medicaid-enrolled adults.

As of now, states are required to provide preventive and medically necessary comprehensive health care services for children under age 21 enrolled in Medicaid and the Children’s Health Insurance Program, including dental care. However, there is no corresponding dental care requirement for adult Medicaid enrollees. Adult dental coverage is optional under state Medicaid programs, and many states provide no, little, or emergency-only coverage.

Even when a state does provide adult dental coverage, the benefits are always at risk of reduction or elimination, especially during economic downturns when states face budget pressures. This patchwork approach creates uncertainty among patients and providers, reduces access, and impacts health outcomes.

To close this gap, Congress can designate dental services as a required benefit category for all Medicaid-enrolled adults. This statutory policy change would ensure that all states offer comprehensive oral health coverage, eliminating the extreme variation across states. For instance, a Medicaid recipient in New Mexico can get one cleaning a year, periodontal care, and dentures. But right across the border in Texas, that same Medicaid enrollee would only receive dental coverage in emergency situations.

Requiring dental services in Medicaid would also reduce or eliminate the need for states, providers, and enrollees to differentiate between eligibility categories for the purposes of covering dental services. This would further reduce uncertainty for people who may currently only have access to dental care during pregnancy or 60 days postpartum and may also serve to reduce the state administrative burden of differentiating benefits for separate categories of Medicaid enrollees.

2. Establish a baseline of comprehensiveness for adult dental services in Medicaid

Further, Congress can and should also establish a baseline of comprehensiveness for adult dental services in Medicaid. The current statutory definition of Medicaid dental services can be amended to address the full range of oral health conditions, specifying categories of services as necessary.

CareQuest Institute’s Rubric for Assessing the Extensiveness of State Medicaid Adult Dental Benefits provides an important starting point for this work. The rubric defines an extensive Medicaid adult dental benefit, outlines the specific service categories necessary to constitute that benefit, the specific procedures to be covered within each service category, and specific frequency to be covered.

According to the rubric, an extensive dental benefit is one that “provides coverage for a range of dental procedures considered adequate for the prevention of disease and promotion of oral health; the restoration of oral structures to health and function; and the treatment of emergency/urgent conditions for the largest group of Categorically Needy Medicaid adult dental beneficiaries.”

To meet this definition, coverage of specific procedures and services, including allowed frequency, is required in eight service categories: diagnostic, preventive, restorative, endodontic, periodontal, prosthodontic, and extraction services and annual benefit maximum.

Categories of procedures outlined in the rubric encompass specific services that are critical to maintaining lifelong oral health.

3. Look to states that have comprehensive Medicaid adult dental coverage

Some states already offer comprehensive adult dental benefits through their state Medicaid programs, which should serve as a blueprint for a national model. Due to inaction at the federal level, some states have acted to strengthen their Medicaid programs by adding adult dental coverage. While it’s a piecemeal approach that would be better addressed at the national level, there are some valuable lessons to gather from states that have made this a priority.

According to the Medicaid Adult Dental Coverage Checker, which displays the results of the 2020 Rubric, Alaska, Washington, D.C., Nebraska, and Wisconsin all offer extensive benefits. They provide a dental benefits package that includes coverage for a robust array of services — diagnostic, preventive, restorative, endodontic, periodontal, prosthodontic, and extractions.

Other states more recently extended benefits through the dedicated work of state community advocates and policymakers. For instance, Maine went from providing only emergency coverage to passing a law effective July 2022 that granted more than 200,000 Medicaid adult beneficiaries access to extensive dental coverage, proving that closing this coverage gap is possible if there is a will to do so.

While states often face barriers in finding the budget to expand these benefits, doing so has undeniable economic benefits. Dental coverage significantly reduces costly emergency department visits for dental conditions. Dental-related ED visits nationwide cost an estimated $2.1 billion per year, but nearly 79% of those visits could’ve been addressed in a dental office, saving up to $1.7 billion per year.

No one should have to go through months of ongoing health issues and mental stress due to oral health problems. When people have access to oral health care, it can have a positive impact on overall health and well-being, including educational achievement, economic stability, and mental health, and can be instrumental in managing chronic diseases including diabetes and heart disease.

If we want to meaningfully improve health outcomes, especially for our most vulnerable populations, we need Congress to take action now.

Myechia Minter-Jordan, M.D., MBA, is president and CEO of CareQuest Institute for Oral Health.