By Anne Blythe
When North Carolina expanded Medicaid this month to give more than half a million people access to government-subsidized health care, those new beneficiaries could gain even brighter smiles.
The state’s Medicaid program offers comprehensive oral health benefits such as routine cleanings, exams and other preventative services. Care deemed “medically necessary” includes some oral surgeries, periodontal care, tooth restoration, denture fittings and placements — with complete replacements every 10 years and partial replacements every five years.
Some of those new smiles might turn into grimaces, though, when the new Medicaid beneficiaries try to get a dental appointment: Only about 45 percent of North Carolina’s dentists accept Medicaid patients. Furthermore, many of those dentists are not accepting new Medicaid beneficiaries.
Oral health care providers and advocates say there are myriad reasons for the paucity of providers welcoming new patients on the Medicaid rolls. A big one, they say, is that the reimbursement rate has remained the same for 15 years.
“The North Carolina Medicaid dental provider network is in serious crisis,” Frank Courts, chair of the North Carolina Dental Society Council on Oral Health and Prevention, wrote in a letter to the editor published recently in Neuse News and other publications. “…With the Covid pandemic and resultant inflation the actual cost of providing dental care is significantly higher than Medicaid reimbursement rates, which are at the same level as in 2008.”
For years, dentists have tried to remind insurers and others in the health care industry of the importance of recognizing the connection between oral and systemic health.
Poor oral health can have a negative impact on such conditions as cardiac disease and stroke, diabetes, pregnancy and dementia, research shows.
“The people of North Carolina deserve an oral health care system that contributes to their overall health,” Courts added. “It is incumbent on state leaders to find ways to adequately fund dental care for Medicaid recipients. Accomplishing this will save state funds in the long run and result in a healthier and more productive population.”
Zachary Brian, associate professor and director of the Dentistry in Service to Community program at the UNC Adams School of Dentistry in Chapel Hill, said this week in a phone interview with NC Health News that he is “over the moon” that North Carolina is now one of the 40 states with expanded Medicaid benefits.
“Policy is slow, it can take longer than we want,” Brian said. “At the end of the day, this should be celebrated.”
How we got here
Republicans leading the state Senate and House of Representatives resisted expansion for a decade, despite an all-out campaign by Democratic Gov. Roy Cooper.
Senate leader Phil Berger, a Republican from Eden, had a change of heart and told his chamber in 2022 that expanding Medicaid was the “right thing to do.” His shift on expansion also took place after the Biden administration put billions of dollars in federal incentives on the table.
That year, though, the House was not fully on board, in part because of other health care policy changes attached to the proposal.
In 2023, both chambers agreed to adopt the change but attached the expansion to approval of the state budget, a document that contained policies and changes that Cooper did not support.
Nonetheless, Cooper let the budget become law without his signature, and enrollment of new Medicaid beneficiaries began on Dec. 1.
Now Brian and other oral health providers are working to make sure that new Medicaid enrollees are able to get the full benefits.
Looking at challenges
Even if all the dentists who accept Medicaid patients do so, that would not be enough providers to care for the 600,000 people expected to be added to the rolls. Furthermore, there are fewer dental practices and dentists in rural areas than in the more urban and suburban parts of the state.
For several decades, North Carolina ranked in the bottom half of states across the country for the number of dentists per 10,000 people.
In 2001, according to a report compiled by the Cecil G. Sheps Center for Health Services Research at UNC Chapel Hill, North Carolina had only 4.2 dentists for every 10,000 residents, putting it in 47th place. By 2013, North Carolina had risen to 44th in the country with 4.8 dentists per 10,000, and four years later the state was ranked 37th in the country. In 2022, the state notched in at 24th in the country with 5.6 dentists per 10,000 people. The national average was 6.1 dentists for every 10,000 residents.
Of the state’s 100 counties, all but six are dental care Health Professional Shortage Areas, according to a map created by the Rural Health Information Hub with data from the federal Department of Health and Human Services.
Where provider shortages are
Portions of those six counties — Cabarrus, Chatham, Davie, Mecklenburg, Wake and Union — have shortages of dental care providers, too, just not across the entire county.
For the 94 other counties, though, the designation means they don’t have enough oral health professionals to meet the needs of the entire county.
That can mean there are geographic, transportation and economic challenges in those counties that make oral health care unattainable.
Medicaid expansion, though, could play a large role in changing that.
Brian, who teaches dental students, says many in his classes say they would like to take Medicaid patients when they start working, but they question whether they will be able to afford to. The average debt burden for dental school graduates across the country in 2022 was $293,000, according to the American Dental Education Association.
There is a movement nationally to reduce student loan interest rates for dental school graduates and to offer refinancing opportunities. Additionally, there is a push for more loan forgiveness programs.
Brian would like to see policymakers discuss different kinds of programs that could be used to entice more dentists just getting out of school to start in rural areas where they might stay for more than a year or two.
Ready to talk
Steve Cline, vice president of the North Carolina Oral Health Collaborative, said dentists and hygienists have wanted to open a healthy debate about Medicaid reimbursement rates for years. Recently, though, there has been a reluctance to be too heavy handed, in part because they did not want to jeopardize expansion efforts.
There have been other discussions going on in the profession.
In 2022, the North Carolina Oral Health Collaborative partnered with the North Carolina Institute of Medicine and The Duke Endowment to launch the Oral Health Transformation Initiative. (Disclosure: The Duke Endowment sponsors NC Health News to cover children’s health issues.)
For the past year and a half, a task force with members from varied backgrounds in oral health care and other aspects of medicine met to develop recommendations for policymakers and legislators in 2024 and beyond.
That report could be released as soon as January, according to Cline, and it could touch on a topic that has long roiled the state’s oral health providers. Namely, when North Carolina moved from a fee-for-service Medicaid system in 2022 to a managed care system overseen by private insurers, oral health care was not included in the transformation.
Many dentists would like it to stay that way, but some are open to discussion.
“Nationally, we see a movement in remodeling our health care delivery system in many ways,” Michelle Ries, associate director of the North Carolina Institute of Medicine, said in a video announcing the initiative. “As North Carolina has moved to managed care for primary health care and behavioral health services, we believe we owe it to the consumer and provider communities to thoroughly look at the current landscape for oral health and make recommendations based on an analysis of what other states are doing and lessons learned from the rollout of Medicaid managed care so far in North Carolina.”
Lawmakers’ perspectives
Whether moving to managed care is or is not one of the recommendations for lawmakers, whatever is brought forward needs to bring dentists and oral health providers to the table, said Sen. Gale Adcock, a Cary Democrat and nurse practitioner who was a member of the task force.
If lawmakers are encouraged to foster new loan forgiveness programs, increase the Medicaid reimbursement rate or change how oral health care is managed in the system, she expects that any proposal to fix things will have to be multi-pronged.
It’s similar to trying to help any patients who come to her.
“It’s been my experience in trying to solve any problem, is that it never is just one thing,” Adcock said. “North Carolina covers more Medicaid services than any other state. I have to believe we can solve this problem.”
Adcock might find allies across the aisle in lawmakers such as Rep. Tim Reeder (R-Greenville), who is an emergency room physician when he’s not at the legislature.
“We need to connect the head and the mouth to the rest of the body,” Reeder said during a recent panel discussion at the NC Institute of Medicine annual meeting. “We need to figure out a way to reconnect them because they’re all interrelated. And so I think that that’s some of the work that needs to be done for sure.”
Poor oral health can have an impact on the whole body.
It also can interfere with someone’s ability to get employment. If they are worried about smiling and exposing problems with their teeth or gums, they might not come across as engaging or friendly in an interview, leading an employer to pass on a capable worker, Adcock said.
“Bad oral health causes bad physical health,” Adcock added. “We really have severed the head from the body in how we provide care. We’ve done the same for mental health. They’re all connected. It’s just all tied together.”
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It is likely that NC Medicaid dental fees are abysmally low. I was a Medicaid consultant before I retired and I believe that every state I worked in had extremely low dental reimbursement. Apparently the State Dental Association has less lobbying clout than the Medical Association, which in turn has less clout that the Hospital lobby. Given the postion of the NC Republicans it may be hard to raise those fees to an acceptable level.
Medicaid expansion concerns me. Where will our people access dental care? Our local FQHCs can’t do it alone! Private dental practices aren’t interested. Help!
What about prevention? Increase Public Health Dental Hygiene positions! Put them BACK in needy counties to serve children and families!
What about finding a way to address the severe shortage of dental hygienists? In our area of western North Carolina there is great need for more of those service providers and, as mentioned in the previous comments, the work they do toward prevention is vital to good dental health.