Medicaid now covers adult dental care - but there aren't enough dentists

Apr. 8—Chloe Bertrand, 23, of Mont Vernon is non-verbal and has developmental disabilities. With assistance, she runs Chloe's Shredding Shack, her own data destruction business.

As of this month, she has a new health-preserving and cost-saving option: dental insurance through Medicaid — a godsend for adults who can't afford to pay for oral health care. Some have delayed tooth and gum treatment for months or years. For others, tooth loss has become an inevitable sign of aging. Bertrand is fortunate: for two years her parents have footed her dental bills.

"This is a monumental positive turn of events for our state," said Jennifer Bertrand, Chloe's mother, who for 10 years advocated for New Hampshire's Medicaid plan to cover comprehensive dental care for adults. "It's going to help individuals like Chloe stay healthy and productive during their adult lives."

Endorsed by the state legislature with bipartisan support and signed into law by Gov. Chris Sununu last summer, the freshly-minted Medicaid expansion, known as the New Hampshire Smiles Program, is rolling out as a way to guarantee oral health care to financially and medically vulnerable people, including those with developmental disabilities.

Carrie Duran of Wolfeboro is a single mom with a part-time job and three daughters. Her youngest, age 12, has Down syndrome. The expansion will benefit Duran now — her daughter later. "It means I can actually go to the dentist for the first time in I don't want to say how many years."

In 2021 Duran used COVID relief funds to pay for cleaning, X-rays and an exam that cost $450 at a Wolfeboro dentist's office, which gave a $2,100 estimate for follow-up work on a previous root canal and fillings for new cavities. With her limited budget and no dental insurance, the price she was quoted became invisible ink on a wish list.

"For so many of us, any extra funds go to care for our kids and not ourselves," she said. "I don't think lack of access to affordable dental care should hold us back from taking care of ourselves. Now I have a partner in health care and can make myself a priority."

On April 1, dental checkups, routine cleanings, fillings, X-rays, limited gum treatment, tooth extractions and other oral surgeries became covered procedures for residents ages 21 and older through New Hampshire Smiles, capping decades of lobbying by advocates, professionals and patients who wanted the insurance to extend beyond children to adults at any age.

"Doing the adult dental Medicaid program is the most significant initiative in my 27-year career at Delta Dental," said Tom Raffio, president and CEO of Northeast Delta Dental, who has advocated for it since he moved to New Hampshire in 1994. Northeast Delta Dental administers the plan with DentaQuest, which processes claims. He said it goes a long way to solving a fundamental problem: "You can't have good overall health without oral health."

According to the New Hampshire Department of Health and Human Services, roughly 35 states offer dental coverage for adults through state Medicaid plans, including recent additions New Hampshire and Maine.

An estimated 120,000 adults with New Hampshire Medicaid now can get preventative and problem-solving care from roughly 75 dentists at 60 offices across the state. Advocates hope the census will increase with education, time and interest.

On April 1, two mobile dental care units in Colebrook and Concord served 48 adults. The clinics will return to Colebrook on April 29 and to Northeast Delta Dental in Concord on April 30, offering first-time and follow-up appointments to Medicaid-insured adults. There are no plans yet for clinics in other locations. State dental health advocates are watching as the program unfurls.

"Many of these adults have been searching for help and it hasn't been available," said Dr. Sarah Finne, Medicaid dental director at the New Hampshire Department of Human Services. Chronic health problems make preventive dental care critical to well being, she said. Research has shown that regular tooth and gum care and cleanings improve blood sugar control for people with diabetes, and the inflammation that causes gum disease is linked to the inflammation in cardiac conditions.

"One of the really important parts of this benefit is (dental) care management," said Finne. Every member will go through a risk assessment, she said, and transportation will be provided for those who need help getting to appointments.

Enough providers?

A question now is will there be enough dentists, dental assistants and hygienists to provide the dental care?

According to the American Dental Association, there were 201,922 dentists in the U.S. in 2021. In 2020, 16.3% of dentists nationwide were 65 or older, up from 11.3% 10 years earlier. According to the ADA, the number of dentists age 55 and older who left the workforce increased sharply in 2021.

There are just under 800 practicing dentists across New Hampshire, the state's chapter of the American Dental Society reports.

Dr. David Staples had a family dental practice in Dover for 35 years and now serves as board chair of Delta Dental Plan of New Hampshire. He said a dearth of dentists here and nationwide is making dental services harder to find as older professionals retire and too few are entering fast enough to fill the gap. COVID aggravated workforce shortages in dentistry, including in small towns and rural areas.

"There's a tsunami of need within New Hampshire now," Staples said.

Many federally-qualified health centers, which often include dentistry and serve Medicaid patients, have lost staff to higher-paying private practices, he said. Those may be tight on staff and unable or reluctant to add patients — including those with Medicaid, whose care is reimbursed at lower rates than private insurance pays.

Goodwin Community Health in Somersworth, where Staples serves as board secretary, had four dentists over a year ago, then lost three. Dental care is currently provided by one full-time dentist and an occasional part-timer whose position is in flux.

Adding dentists to serve New Hampshire Healthy Smiles patients "may be slow going for a while," Staples said. "If everyone takes a few patients it will go a long way to improving the health of the state. We have some very sick people with terrible teeth and no jobs who need a lot of dental work. Medicaid dental coverage couldn't come at a better time. Now the problem is finding enough dentists who will accept Medicaid."

That's a problem for Chloe Bertrand and Carrie Duran. Right now no Wolfeboro dentists accept Medicaid, said Duran, and she must find a way to pay out of pocket or cast a much wider net.

Jennifer Bertrand raves about the high-quality care her daughter received at a family practice in Derry, when her dental work was covered by Medicaid until she turned 21. But that office recently told Bertrand it won't serve adults with Medicaid. Friends referred her to a practice in Nashua where practitioners are sensitive to people with phobias related to teeth and touch such as Chloe Bertrand, who needs professionals versed in special needs, who can work slowly and take extra time when necessary. But that practice is not participating in New Hampshire Smiles until it gets answers to questions about benefits.

When contacted by phone on Thursday, two dental practices in Manchester that are on the New Hampshire Smiles roster were not aware that adult services are now covered.

Education is needed, said Bertrand. "I know it's not perfect and it's going to take time. But together we can make this a reality."

To entice more Granite State dentists to care for adult patients on Medicaid, New England Delta Dental is offering $1,000 to each office that signs up. Medicaid fees have been increased for several procedures, said Raffio.

"We know we have to get way more dentists and we will. We're trying all strategic and creative ways," he said. "On day one, we provided a path to get an oral surgeon. Our goal is whether you have Medicaid or private insurance, you're treated exactly the same."