This month, California’s top Republican lawmakers asked Gov. Jerry Brown (D) what may seem like an unusual request. They want to spend more money on the state’s Medicaid program that provides insurance services to low-income Californians.
Specifically, lawmakers want to pour $200 million into the state’s struggling Denti-Cal program, the state-run dental insurance program under Medicaid. The lawmakers were spurred to action by a damning report published in April. “[The] report reveals that ‘California’s Medicaid dental program is… broken, bureaucratically rigid, and unable to deliver the quality of dental care most other Californians enjoy,’” the lawmakers wrote in a letter to the governor.
“Fixing Denti-Cal is a priority for legislative Republicans,” they concluded.
At first glance, the California GOP’s enthusiasm to boost Medicaid funding seems out of character. Republicans are usually vocal opponents of expanding Medicaid with government dollars, citing the program’s runaway costs. Nineteen states still refuse to expand Medicaid coverage under Obamacare — almost all Republican controlled.
But California Republicans are perhaps not so different from conservative legislators in other states. Earlier this year, the same Missouri lawmakers who dug in their heels against Medicaid expansion extended dental benefits to nearly 300,000 Medicaid recipients. In 2014, Republican-controlled South Carolina did the same, using federal Medicaid dollars to cover 70 percent of the cost.
In fact, many of the states opposed to Medicaid expansion — including Wyoming, South Dakota, Nebraska, Kansas, and North Carolina — provide at least very basic dental benefits to their low-income residents. The Medicaid program does not require dental coverage, so these benefits are entirely optional.
These lawmakers view preventive dental care as a cost-saving measure. Missouri estimates that emergency dental room visits cost the state $17.5 million in 2013. Nationwide, dental emergency room visits cost an estimated two billion dollars per year, according to the American Dental Association.
“Receiving regular preventive care from dentists is the most effective way to avoid [expensive emergency room] visits for dental problems,” Missouri health officials said of fiscally conservative lawmakers’ decision to expand government health insurance.
In California, lawmakers are relying on the same logic.
“If people can’t get in with prevention, they eventually show up for more serious treatments,” California Sen. Dr. Richard Pan (D), a dentist himself, told a state oversight agency. “Now you have cavities that aren’t treated and you’re putting in a crown. Then they set up in the emergency room with an abscess and now you’re treating that. Then they have to have teeth extracted and then you’re talking about dentures and on and on. You start to cause this ball to roll.”
California is doing a poor job of stopping the ball. Denti-Cal’s woes are much the same as those of Medicaid nationwide: reimbursements are so low that doctors don’t want to participate in the program, leaving needy people without timely or accessible care. Of the 15 states that offer extensive dental coverage for low income adults, California is perhaps the most penny-pinching — paying dentists 35 percent of what other state-run dental programs pay their dentists, on average.
Dentists also complained to the state oversight agency that it takes months to register using the program’s offline, 40-page application. Worse, once they do register they have to deal with the program’s sensitive billing system.
“[Even] with experienced staff, the return rate on claims was 25 percent because maybe you left a box out, or didn’t process a fee somewhere, or didn’t have the exact word for the description for why you were treating that specific tooth,” Assemblymember Jim Wood, a former practicing dentist, told the state oversight agency.
Many dentists simply don’t want to deal with the program. 400,000 Californians live in counties that have no Denti-Cal providers at all or no dentists willing to accept new Denti-Cal patients. Consequently, just 38 percent of Denti-Cal-eligible children see a dentist annually.
The Affordable Care Act, also known as Obamacare, did not ultimately include adult dental coverage in Medicaid reform. Dental care was left largely untouched by the reforms, leaving state lawmakers to reform dental care for themselves.
One reform that has bipartisan support is for states to license mid-level dental hygienists to do teeth cleanings without a dentist’s permission. Most states require that dental hygienists be employed by dentists, which drives up the cost of tooth cleanings and prevents low income individuals from getting regular cleanings. Democratic lawmakers tried and failed to fold this reform into Obamacare in 2010. The conservative organization Americans for Tax Reform, headed by Grover Norqhuist, endorsed this reform as a tax-free alternative to Medicaid.
But Republicans in California see Medicaid as a solution, and they are working to improve its cost-effectiveness. Gov. Brown is expected to release his revised budget later today.
Cory Herro is an intern at ThinkProgress.