Missouri Medicaid began covering teeth cleanings, and almost no other routine dental work, for adults a few years ago.
But the bill for the dentist actually peering in your mouth to check teeth and gums went to the patient.
While some dentists wrote off the cost of the dental exam, many patients just stayed away from the dental chair and the potential bills it represented.
That changed July 1, when routine dental exams for adults were added to the state’s Medicaid coverage.
Health experts said it is a significant step in the state’s multiyear effort to improve dental access — and to boost overall health, beyond cavities, molars and gums.
“I was doing cartwheels when I heard that they were going to cover that,” said state Director of Oral Health Dr. Jacqueline Miller.
The move came less than a decade after Missouri restored limited adult dental benefits under MO HealthNet, the state’s Medicaid plan. And two years after it significantly increased the rates the plan pays dentists.
Although MO HealthNet still doesn’t cover expensive services like dentures and crowns, the state has gone from being one of the worst in the country for dental access two years ago to a model for other states.
In 2023, an additional 50,000 Medicaid recipients in Missouri got dental benefits. And 184 new dental offices began accepting Medicaid.
“We’ve seen changes in other states based on what has happened in Missouri,” said Dr. Aaron Bumann, a pediatric dentist in Liberty who serves as a public policy advocate for the Missouri Academy of Pediatric Dentistry. “That’s positive peer pressure.”
Inequities in access
For decades, public health experts complained that too many Americans couldn’t afford to see a dentist. Skipping checkups, they said, could put their overall health in peril.
In 2000, then-U.S. Surgeon General David Satcher commissioned a report that warned about who could and couldn’t get dental care. Twenty years later, a follow-up report from the National Institutes of Health said the same problems persisted.
“Oral health care has not been, and is not,” the report said, “equitably available across America.”
Low-income Americans are more likely to have untreated dental problems, which can spiral into bigger health and social issues. Even when people had dental insurance, they often put off or skip dental care because of the high out-of-pocket costs.
A 2023 KFF survey found that was true for 38% of adults on Medicaid, 37% of adults who got insurance through the Affordable Care Act marketplace, 26% of those covered by Medicare and 25% of adults with employer-sponsored insurance.
More than shiny white teeth
“There’s this general kind of belief for some people that dental isn’t actually health care,” said Gary Harbison, executive director of the Missouri Coalition for Oral Health. People think “it’s maybe more about white, shiny, straight teeth.”
But science is increasingly clear that oral health care is critical to overall health.
“It’s a mistake to let it go and think, ‘That is an extra. I’ll take care of it later,’” Harbison said.
In addition to uncovering cavities before they grow into serious dental problems, regular dental exams can reveal cancer diagnoses and symptoms of other serious conditions like diabetes and heart disease. Lack of oral health care can also affect mental health, experts said.
“You can’t be healthy without having good oral health,” said Dr. Megan Krohn, executive director of dental services for Swope Health. “It’s a right. As we fight for having health care access for all, part of that needs to be oral health care access also.”
Swope Health, a community health center that gets federal aid to serve as a safety net for uninsured patients, operates clinics that provide dental and other health care services in both Missouri and Kansas. The contrast in access in the two states is stark, Krohn said.
For one thing, Kansas has not expanded Medicaid, leaving nearly 250,000 adults in the state without any health care coverage. Missouri voters passed Medicaid expansion in 2020, bringing some 275,000 more Missourians onto the rolls the following year. That strained the dental providers who accepted the state’s Medicaid.
Jessica Emmerich, dental Medicaid facilitator with the Missouri Coalition for Oral Health, said in 2022 the state had 700 dental providers for 1.3 million Medicaid participants.
“We needed more dental providers to get on board,” she said.
Reimbursement rates are key
The state bumped the reimbursement rate it pays Medicaid providers in 2022 from around 30% to 80% of the usual and customary rate, or the same as private insurance.
Before the rate increase, Bumann said, “the reimbursement rates didn’t cover overhead, so dentists didn’t participate.”
Now the state has more than 1,000 providers who take Medicaid. Getting dentists to accept Medicaid benefits is key to expanding access, experts said.
Kansas reimbursement rates still hover around 35%.
“It’s hard to convince and encourage dentists to provide coverage under that program,” said Kevin Robertson, executive director of the Kansas Dental Association.
With low reimbursement rates and without Medicaid expansion, many Kansans rely on free dental care or places that cut rates for low-income patients. But that typically means waiting weeks or months for appointments.
Vibrant Health, a community health center in Kansas, can’t keep up with the demand it sees for dental care, said Dr. Anthony Jimenez, Vibrant’s vice president of dental services. The clinic is working to hire a fifth dentist, but that won’t begin to meet the need, he said.
“As soon as we hire this person,” Jimenez said, “their schedule would be full almost immediately.”
Since the changes to Missouri’s Medicaid coverage, 60% of patients who come to Swope Health’s dental clinics are covered by Medicaid, while 40% are uninsured. On the Kansas side, Krohn said, 85% of patients are uninsured.
States decide on dental coverage
States are required to pay for dental care for people younger than 21 enrolled in Medicaid. But for now, they can decide how to handle adult coverage. Traditionally, dental coverage has been seen as an add-on that many states decide not to spend money on.
Missouri reinstated limited adult dental coverage through Medicaid in 2016. At the time, coverage for dental cleanings, a one-time exam and a few other services like X-rays and fillings, were added. But not exams in following years. The gap meant many went without care.
But preventive care is vital in dentistry, experts said. Major dental problems can most often be prevented if caught early, which is why regular screenings — like the ones MO HealthNet is now covering — are crucial.
“You can fix a small cavity with just a filling,” Jimenez said. “But by the time the patient is aware of it, by the time it’s keeping them up at night, at that point it’s a much bigger problem.”
Changes like the ones in Missouri may begin to move the needle so more people get help sooner.
“The fact that we’re starting to see more coverage for adults is a huge win,” said Dr. Steven Haas, dean of the University of Missouri-Kansas City School of Dentistry. “It’s a very big win.”
And more change could follow. Just this spring, the Centers for Medicare and Medicaid Services said states could designate routine dental benefits for adults an essential health benefit, a service that must be covered under the Affordable Care Act.
