Column: Five Million People Just Got Access to Root Canals in Your State. Will You be Their Endodontist? 

By Dr. Brandon Barnett

When Walton Meredith needed a root canal on #30; there was a silver lining. After all, he lived in a state that offered robust Medicaid coverage for dental treatment. But Walton would soon learn a hard truth. While coverage was broad; only a mere 17% – 31% of dentists in his home state actively accepted Medicaid. (1)

National expenditures on dental procedures increased by $3 billion USD from 2019-2021 alone ($10 billion USD, if you count spending from COVID-19 related government relief programs); accompanying an increase in dental spending in the US year by year over the past several decades. Shockingly though, the percentage of working-age adults who visit a dentist annually has stayed more or less the same during the same timeframe. (2) And more than a third of working-age adults; nearly 71 million Americans, go entirely without dental visits annually. (3) The number of untreated caries in adults, and other oral health diseases have also remained largely unchanged in the past 20 years.

Where did things go wrong? Part of the problem stems from a classic lack of Medicaid dental coverage for adults. Only half of all state insurance plans offer some form of adult dental coverage, and when states face budget constraints, adult dental services are among the first to be cut. (4) Medicaid also handles dental care for adults and children differently. The Affordable care act mandates comprehensive dental care coverage for children. Indeed 90% of children are now covered by some form of dental insurance. (5) With this coverage the dental community has seen direct improvements in oral health care especially in minority and socioeconomically disadvantaged children. But inexplicably, for adults, dental care is not considered essential.

In New York, measures are being undertaken to remedy this. A class action lawsuit from 2018 settled in May of 2023 against the State Health Department of New York  (Ciaramella et. al. v. Bassett) which claimed thousands of low-income New Yorkers were denied medically necessary dental treatment. (6) Previously, root canals were denied to those with more than four pairs of occluding posterior teeth, outright. The settlement in this lawsuit would end this practice; allowing root canals in all cases where it is deemed medically necessary i.e. for a documented medical condition precluding an extraction, for critical abutment teeth and for maintaining balanced occlusion. These changes go into effect January 31st, 2024, reversing the usual precedent in which treatment covered by Medicaid skews towards removal of otherwise salvageable teeth; and expanding dental coverage to 5 million New Yorkers.

In general, we know that expanded Medicaid coverage leads to increased access to dental care, a decreased prevalence of untreated carious teeth, and improved oral health related behaviors. (7) But an increase in Medicaid coverage means little for people like Walton whose dentists choose to opt out of Medicaid. For him and many others, coverage and access are not the same. Furthermore, practitioners and endodontists not already taking Medicaid have little incentive to modify their practice models to accommodate a Medicaid shift. Preauthorizations, delayed payments, eligibility verification, limited treatment options, and compliance with Medicaid regulations are just the tip of the iceberg. New endodontists, haunted by the specter of six–sometimes seven-figure student debt, are especially hesitant when considering the diminutized reimbursement relative to private insurance. Expanded coverage is important, but without increased provider participation and fundamental changes to how Medicaid dentistry is administered, concerns arise that more access may only overburden an already stressed Medicaid system. Despite this, the decision in Ciaramella et. al. v. Bassett gives a reason for optimism. It has the potential to open the door for other states with limited or emergency dental coverage to broaden their Medicaid offerings, potentially even incorporating root canals, as the general public becomes more aware of the importance and medical necessity of saving teeth. Just five months after the ruling in New York the Pennsylvania legislature introduced a bill that would reinstate dental care within their state Medicaid program, a component that was eliminated back in 2011. (8) Expanded dental coverage including root canals is on the horizon for Medicaid. For now, our endodontic training programs and many hospital/clinical facilities nationwide are ready to meet the future head-on. Will residents and new practitioners find Medicaid participation more appealing in the future? Only time will tell. What we do know is that the success of such an endeavor will undoubtedly hinge on dynamic policy innovation from members of the dental community. It may or may not be feasible; but like in nonsurgical retreatments, sometimes you only know how bumpy the road is once you start to cross it.

 

1. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/hpi/hpi_dentist_participation_medicaid_webinar_slides.pdf?rev=ca757c4dac654900b7eb1cbac2990fa3&hash=06C1E0E05A7BBF00AE9566D90BC27036
2. “Nidcr Oral Health Disparities and Inequities Research Think Tank Summary.” National Institute of Dental and Craniofacial Research, www.nidcr.nih.gov/grants-funding/grant-programs/health-disparities-research-program/think-tank. Accessed 25 July 2023.
3. Oral health in america: Advances and challenges, A report from the national institutes of health:Section 3A: Oral health across the lifespan: Working-age adults. . 2021.
4. https://www.kff.org/wp-content/uploads/2013/01/8105_es.pdf
5. https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/hpi/marko_vujicic_senate_oral_health_testimony.pdf?rev=8c22366568914e39b3ca4149043fabe9&hash=8D2231B53D02E807CC87C791C5B65A28
6. https://legalaidnyc.org/wp-content/uploads/2023/05/LAS-Willkie-and-Freshfields-Secure-Historic-Settlement-Requiring-New-York-State-to-Provide-Expanded-Dental-Coverage-to-Low-Income-Residents-.pdf
7. Elani HW, Kawachi I, Sommers BD. Dental Outcomes After Medicaid Insurance Coverage Expansion Under the Affordable Care Act. JAMA Netw Open. 2021;4(9):e2124144. doi:10.1001/jamanetworkopen.2021.24144
8. https://www.legis.state.pa.us/cfdocs/billInfo/billInfo.cfm?sYear=2023&sInd=0&body=H&type=B&bn=1417