Missouri’s thin dental safety net stretched in the middle of the Medicaid expansion

At the Access Family Care clinics in southwest Missouri, the next available dental appointment is next summer. Northwest Health Services, headquartered in St. Joseph, is booked for May. The waiting time is a little shorter at CareSTL Health in St. Louis – about six weeks.

Approximately 275,000 Missourians are recently eligible this year for Medicaid, the federal state public health insurance program for low-income people, and they may also be covered for dental care. Missouri voters approved the expansion of the program in 2020, the latest of 39 states to do so as part of the Affordable Care Act, but policies delayed implementation until Oct. 1. Adults earning up to 138% of the federal poverty level – about $ 17,774 a year for one person or $ 24,040 for a family of two – can now receive coverage.

But one big question remains: Who will treat these newly insured dental patients?

Only 27% of Missouri dentists accept Medicaid, according to government data, one of the lowest rates in the country. Many of them work at so-called safety net clinics, such as Access Family Care, Northwest Health Services and CareSTL Health. Such clinics receive federal funding to serve uninsured patients on a sliding scale and experienced a huge demand for dental services before the expansion.

The reason so few Missouri dentists accept Medicaid is simple, according to Vicki Wilbers, executive director of the Missouri Dental Association: The state program pays dentists extremely poorly compared to private insurance or what a dentist could charge a patient who pays cash. To increase the burden, Wilbers said, dentists who accept Medicaid often have to deal with the state plus private insurance companies that administer Medicaid through a program known as managed care.

“You have more people on the rolls, you still have no increase in reimbursement rates,” Wilbers said. “And it’s troublesome.”

Still, coverage for these new patients can be life-changing.

Only 37% of adults in the state with incomes below $ 15,000 a year saw a dentist in 2018 compared to 76% of adults earning over $ 50,000, according to a state report. A study by the American Dental Association found that 53% of the low-income population of Missouri have difficulty chewing, 43% avoid smiling because of the condition of their mouths, and 40% experience pain.

“I just don’t think those stories are told enough,” said Steve Douglas, a spokesman for Access Family Care in Neosho.

Douglas described a patient at the clinic who believes that his hitherto unsuccessful search for higher-paying work has been hampered by the appearance of his teeth.

“We hope that with the Medicaid expansion we can get him care,” Douglas said. “He wants to save some of his teeth and not go for full dentures.”

About 62% of Missouri adults earning less than $ 15,000 a year have lost at least one tooth due to caries or gum disease, and 42% of people 65 and older in that income area have lost them all, according to the state report. For Missourians earning over $ 50,000, these rates are 34% and 8%, respectively.

Part of the backlog of dental care at Access Family Care, which offers dental care at five locations around southwestern Missouri, is due to the pandemic. The clinic laid off all 95 dental staff in March 2020 before gradually rebuilding to full capacity. As with dental practice across the country, many of their patients are now coming to have the dental work done, which they delayed earlier due to fear of exposure to coronavirus.

But central to the high demand is an overall need for more providers. Nearly 1.7 million Missourians live in a federally designated area of ​​shortage of dentists, one of the highest levels of unmet need in the country. It would take an additional 365 dentists to fill that void, at least one additional dentist for every 10 already practicing in the state.

“We could easily hire four more dentists and still have high demand,” Douglas said.

His clinic, Access Family Care, has actually hired two new dentists to start in 2022. To cope with the dental treatment until then, however, it had to temporarily stop seeing new patients.

In St. Louis had Dr. Elena Ignatova, director of dental care at CareSTL Health, scheduled 18 patients a recent Wednesday in November. About a quarter of them were insured through Medicaid.

By 10 a.m., she had cast a mold of a patient’s mouth to fit dentures, referred another to an oral surgeon for root canal treatment, and prepared a fourth-year dental student to extract a Medicaid patient’s remaining teeth. In Missouri, Medicaid covers simple adult tooth extractions, but not root canals or crowns.

“We are removing teeth because the second treatment is too expensive and they can not afford it,” Ignatova said. “Then it can take years for those patients to come up with the money for dentures.”

Ignatova is booked into February, but the clinic is still taking walk-ins for dental emergencies. She is also working her way through a waiting list of 39 patients, who may show up quickly if a cancellation or no-show opens a place in her schedule.

There is easily enough demand for another dentist, but Ignatova said they are still working on hiring the dental assistants and hygienists needed to reopen the school-based clinics for children they ran before the pandemic. The hiring is underway, but it is going slowly. As with many health facilities, she and others said, President Joe Biden’s vaccine mandates have added an additional barrier to recruiting and retaining staff.

One clinic that does not see a bottleneck of dental patients, however, is the KC Care Health Center in Kansas City. Kristine Cody, the clinic’s vice president of oral health services, said a new patient could be seen there in about a week. The Kansas City region benefits from having the University of Missouri-Kansas City School of Dentistry, which offers reduced-cost care to patients at the clinic where its students are trained, plus several other safety net clinics.

KC Care also added two dentists and extended its clinical hours in anticipation of Medicaid expansion.

“I just hope people will use it,” Cody said.

Kaiser Health NewsThis article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, an impartial health policy research organization unrelated to Kaiser Permanente.

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