“People in poverty have a higher incidence of disability, and people with disabilities are likely to live in poverty”—(Poverty and Disability, 2000, p. 1)
Medicaid and Medicaid Dentistry
In the mid-1960s, during the Congressional review of the then pending Medicare and Medicaid legislation, the American Dental Association opposed dental care for older citizens under the Medicare bill and lobbied for the inclusion of dentistry as a benefit under the proposed Medicaid legislation (Waldman, 1980). Medicaid (Title XIX of the Social Security Act) is the largest source of funding for medical and health-related services for America's poorest people (Social Security Administration, 2002). Under the Early and Periodic Screening, Diagnostic and Treatment component of the Medicaid Program (EPSDT), comprehensive coverage of all needed dental services is required for children and adolescents from birth up to age 21. Whereas general Medicaid eligibility poverty levels are established by individual political jurisdictions, the EPSDT program eligibility level is based on federal poverty standards. As a result, increased numbers of children have become eligible for services in those jurisdictions with general Medicaid poverty standards that are below the federal poverty level.
In addition, Title XXI of the Social Security Act (the State Children's Health Insurance Program—SCHIP) allows states to craft or expand an existing state insurance program to increase Medicaid eligibility to include a greater number of children who currently are uninsured. For the most part, these are low-income children who would not qualify for Medicaid coverage. Funds from SCHIP may be used to provide medical assistance to children during a presumptive eligibility period for Medicaid (Social Security Administration, 2002).
Dental services for adults, however, are classified as an “optional service” within the general Medicaid program. In addition, the fact that a state provides adult Medicaid dental services does not mean that all services are covered. A state may select the dental services it wishes to cover for adults. In some states coverage is comprehensive whereas in others, it is limited to the immediate relief of pain and infection (Social Security Administration, 2002).
In recent years, “States have invested considerable resources in addressing low dental provider participation in Medicaid and poor access to dental services” (Health Resources and Services Administration, 2001, p. 1). Although no state can be said to have a true “success story,” a number of states have had sizeable increases in Medicaid reimbursement fees (American Dental Association, 2003). For example, in New York State, in an out-of-court settlement in 2000, an agreement was reached that called for “$573 million in increased funding over the next four years for Medicaid dental fees” (Dental Society, 2000).
In 1998, $901 million was spent for almost 5 million recipients of Medicaid dental services (approximately $182 per individual—$77 per individual in terms of constant dollars removing the effects of inflation). In federal fiscal year (FY) 2000, including expenditures for SCHIP beneficiaries, $1.4 billion was spent for almost 5.9 million recipients of Medicaid dental services (approximately $258 per individual; $92 per individual in terms of constant dollars). Over time, average constant dollar expenditures for dental services, however, have not kept pace with the rate of inflation (see Table 1) (Centers for Medicare and Medicaid Services, 2003; Social Security Administration, 2002; U.S. Department of Labor, 2003).
As a result, despite the fact that private practitioners serve as the primary providers of dental services for lower income populations, significant numbers of private dental practitioners are unwilling to offer Medicaid dental services (Seale & Casamassimo, 2003). Indeed, “after years of enduring Medicaid's shortcomings, many dentists are washing their hands entirely of the program” (Schlossberg, 2004, p. 12). Most important, however, because of the limitations of adult Medicaid dental services in many states, children once eligible for dental services under the EPSDT program “age out” of dental care when they reach 21 years of age (Waldman & Perlman, 1997).
In addition, recent changes in national economics have impacted dramatically on state finances. Despite increases in the numbers of individuals adversely affected by the downturn in the economy, state governments have sought to limit increases in taxes while trimming budgets, particularly in areas in which spending is not required by federal and state legislation (e.g., adult Medicaid dentistry). For example, between 2000 and 2003:
The number of states that provided full Medicaid dental services to adults decreased from 14 to 4.
Including the District of Columbia, the number of states that provided no Medicaid dental services to adults increased from 6 to 7, with 8 additional states proposing to eliminate adult services.
Only New Mexico, New York, North Dakota, and Pennsylvania have provided the full range of adult Medicaid dental services since 2000 with no apparent current legislative efforts being made to modify these services. In addition, the full range of dental services has been provided in New Jersey; in 2003, however, efforts were made to eliminate all adult services (see Table 2) (Schneider & Schneider, 2003).
Need for Dental Services
No national studies have been conducted to determine the prevalence of dental diseases among various populations with mental retardation and other disabilities. Numerous local and regional reports, however, provide a general appreciation of the needs. The population with mental retardation and other disabilities has significantly higher rates of poor oral hygiene, gingivitis, and periodontitis than do members of the general population. Although there is wide range of caries (tooth decay) rates among people with disabilities, overall their rate is significantly higher than that of the general population (Acs, Shulman, Ng, & Chussid, 1999; Beck & Hunt, 1985; Waldman, Perlman, & Swerdloff, 1998; White, Caplan, & Weintraub, 1995). (For a more comprehensive discussion of dental needs and prevention of oral disease for children with mental retardation and other developmental disabilities, see Waldman, Perlman, and Swerdloff, 2001.)
Eliminating Dental Services
Hundreds of thousands of children and adults with mental retardation have or will “age out” of Medicaid dental services. The litany of reasons for dental practitioner nonparticipation in the Medicaid dental program (e.g., inadequate compensation, contentious paperwork, appointment no-shows) pales in the reality that increasing numbers of adults in need of services will not be eligible for care. As federal and state governments attempt to deal with the “red ink” of budget deficits and the demands for improvements in the Medicare and Social Security programs, it is all too easy to neglect needed but nonstatutory required health care services. Once again, the reality is that only New Mexico, New York, North Dakota, and Pennsylvania have provided the full range of adult Medicaid dental services since 2000 with no apparent current legislative efforts being made to modify these services. But what about the needs of those who have aged out of dental services in other jurisdictions, including hundreds of thousands of individuals with mental retardation? And what about the limited action taken by the dental profession in face of these realities?
There is a dearth of information in the dental field about (a) youngsters with mental retardation as they age out of Medicaid dental services and (b) adults who are eliminated from state Medicaid dental programs, including (a) the specific oral and general systemic consequences (e.g., need for emergency care, pain, suffering, inability to eat properly, and cardiac or other organ complications (Slavkin & Baum, 2000); (b) the type and extent of needed services; (c) the ability to secure needed care (from general and specialist practitioners); (d) the available locations for services and frequency of visits; and (e) services for individuals in community residency settings.
If dental professionals (and advocates for individuals with mental retardation) are to redirect government actions, there is a critical need to fill in the proverbial “blanks in our knowledge” about the consequences to individuals who have lost their Medicaid dental coverage. If we are to improve practitioner willingness to provide needed services, increased attention must be directed towards (a) increasing dental student preparation and appreciation of the abilities of individuals with mental retardation (Fenton, 1999; Wolff, Waldman, Milano, & Perlman, 2004); (b) emphasizing that many youngsters and adults with mental retardation reside in their communities and are members of families already being treated in many dental practices; and (c) encourage working relationships between dentists and physicians (comparable to the American Academy of Developmental Medicine and Dentistry), whose members seek to eliminate health disparities for individuals with mental retardation (Fenton, Hood, Holder, May, & Mouradian, 2003).
Authors:H. Barry Waldman, DDS, PhD (firstname.lastname@example.org) School of Dental Medicine, Stony Brook, NY 117940–8706, Professor of Dental Health Services, Department of General Dentistry, SUNY at Stony Brook, NY. Steven P. Perlman, DDS, Global Clinical Director, Special Olympics, Special Smiles, Associate Clinical Professor of Pediatric Dentistry, The Boston University Goldman School of Dental Medicine, 77 Broad St., Lynn, MA 01902