Coi Vanover, a retired coal miner, waits for free dental services in the early morning on July 22, 2017 in Wise. Hundreds of Appalachia residents waited through the night for the annual Remote Area Medical (RAM), clinic for dental, vision and medical services held at the Wise County Fairgrounds in western Virginia. The county is one of the poorest in the state, with high number of unemployed and underinsured residents. (Photo by John Moore/Getty Images)
Lisa Coles had a tooth infection.
But she couldn’t afford treatment. So, for nearly a decade, she suffered through terrible toothaches, relying on heating pads and Advil to make it through the worst of the pain. Twice, she borrowed $50 from family members to visit a dentist in her home county of Goochland. But without money to pay for a procedure, the treatment was always the same: a prescription for antibiotics that Coles also struggled to afford.
Not that it mattered when she paid for the medication. The infection always came back. By the time she broke down and saw an oral surgeon — one who agreed to let her set up a payment plan — the infection had spread. She had eight teeth extracted when she was still in her 30s.
“One tooth was so bad that they had to take some of the bone out,” said Coles, now 50. “It was awful. I never want to go through that again.”
It’s the type of situation that makes dental health advocates cringe: a simple problem that spirals into a major medical issue. But it’s a concern for the more than 670,000 adults enrolled in Virginia’s Medicaid program, which doesn’t cover basic dental care.
“The only mandated service in Medicaid right now is emergency extraction,” said Sarah Bedard Holland, CEO of the advocacy group Virginia Health Catalyst. “So, if things get bad enough that a tooth has to be removed, they’ll cover it. But they’re not required to cover any services that would maintain that tooth.”
That’s made a proposal to expand adult dental services under Medicaid a number-one priority for Virginia’s “dental safety net” — the coalition of nonprofits and providers that connect low-income patients with free or subsidized treatment. Both Del. Mark Sickles, D-Fairfax, and Sen. George Barker, D-Fairfax, proposed spending about $34 million in state dollars over the next two years to fund a comprehensive dental benefit.
But the future of the proposal is far from clear. While Barker’s amendment made it into the Senate’s proposed budget, Sickles’ was excluded from the House budget. “We just didn’t think we had the resources to cover it, period,” he said.
The Senate amendment would leverage millions more in federal subsidies to extend the dental benefit, Sickles added. Under the program’s current funding formula, the federal government pays 50 percent of costs for Medicaid’s “base” population — adults who enrolled before Virginia expanded the program in 2019 — and 90 percent of the expansion population.
In total, the state anticipates spending more than $125 million to implement dental coverage. Over the next week, lawmakers from both chambers will have to negotiate to decide whether the dental benefit will be included in the state’s final two-year budget.
“It’s been considered for many years, but there are also many competing health priorities,” said Karen Kimsey, director of the state’s Medicaid program. “This year, for instance, maternal health has been a big focus. And those competing priorities are why we still haven’t seen this benefit extended in Virginia.”
Experts say cost is a major factor in a state that spent years fighting Medicaid expansion. Many Republicans still blame the decision for a rise in Medicaid spending during the first year of expanded enrollment (though state experts said broader coverage didn’t contribute to the rise in costs).
As lawmakers negotiate the budget, oral health advocates are working to convince them that dental benefits would save money for the state. A report from the American Dental Association Health Policy Institute estimates that Virginia would save nearly $14 million by the third year of implementation, based on an anticipated reduction in dental-related emergency room visits and reduced medical costs for Medicaid patients with diabetes and coronary artery disease.
“Every time a Medicaid enrollee goes to the emergency room for tooth pain, Medicaid is billed, even though they’re very unlikely to treat the problem,” Bedard Holland said. A 2019 report from the state’s Department of Medical Assistance Services found that nearly 16,000 Medicaid beneficiaries visited the emergency department nearly 19,000 times for dental issues.
The problem is that emergency rooms rarely have dentists or oral surgeons on call. “At most, patients will get pain management or a prescription for antibiotics and be told to see a dentist,” said Tara Quinn, the executive director of the Virginia Dental Association Foundation.
The hope is that extending Medicaid coverage to dental services will connect more patients with appropriate care — reducing overall health care costs. The same is true for patients with co-existing conditions, including diabetes, which can be complicated by poor oral health.
Quinn said gum disease can make it harder for the body to regulate blood sugar levels. Research has also linked it to an increased risk for diabetes, cardiovascular disease and stroke, according to a fact sheet from Virginia Health Catalyst.
Virginia Medicaid does cover comprehensive dental services for pregnant women and patients younger than 21. But adults are almost primarily limited to a patchwork of dental clinics operated throughout the state. Over the last several years, their numbers have grown to 96, said Debbie Oswalt, executive director of the Virginia Health Care Foundation. But that still leaves about half of Virginia’s 133 localities without a safety net dental provider.
Access to dental care can be life-altering for patients, Quinn said. Coles, for example, was finally able to get comprehensive treatment through GoochlandCares, a low-cost health clinic that opened a new consolidated facility in 2016. After five years of catch-up services — including fillings and a root canal — she now goes every six months for preventive cleanings.
Quinn can still remember a patient who came through VDAF’s Donated Dental Services program. The 54-year-old man had been on dialysis for 27 years and needed comprehensive dental services to clear him for a kidney transplant in August of 2018.
The program provided more than $3,000 worth of care, including a root canal, two partial dentures and tooth restoration. The end result was rewarding, she said — but she’d rather expand access to regular preventive care.
“The hope is for less people to need our programs,” Quinn said. “That we wouldn’t have to exist because everyone would have access to comprehensive medical care.”
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