Michigan’s Medicaid Problem

The likelihood that someone receives preventive dental care, such as a routine checkup at a dentist’s office, varies with personal income. For instance, only 44 percent of adults in Michigan with less than $20,000 in reported income visited a dentist in 2012. But 72 percent of adults with a household income between $35,000 and $49,999 visited a dentist that year and 86 percent of adults in households with incomes above $75,000 did.[43] This is one of the fundamental challenges of trying to expand access to dental care.

One contributing factor to this problem is that Medicaid does a poor job of helping low-income families get dental care. Michigan uses a “fee-for-service” funding model that relies on Medicaid reimbursing dentists for services they provide Medicaid-eligible patients. But Medicaid reimbursement rates are very low — having not increased since the 1990s — and too few dentists opt to enroll in the Medicaid program. In fact, only 10 percent of dentists in Michigan had Medicaid claims of $10,000 or more in 2008. And six counties in Michigan did not have a single dentist enrolled in Medicaid’s fee-for-service reimbursement program.[44]

Fortunately, efforts have been underway to make it easier for low-income families to receive dental services, especially for children. Delta Dental of Michigan, a large dental insurance provider, partnered with the state of Michigan to create a program called Healthy Kids Dental. Under this arrangement, Delta Dental reimburses dentists who provide services to Medicaid-eligible children. Delta Dental is able to give higher reimbursement rates for dentists than Medicaid (although not equal to their customary rates). Participating dentists do not have to enroll in Medicaid’s program to get reimbursed. They can apply for a reimbursement like they would for any other patient covered by a private dental insurance plan.[45]

This program has made significant improvements to low-income children’s ability to gain access to dental care. In 1999, only 8 percent of children who were eligible for Medicaid benefits received a preventive dental service. In 2013, that figure had increased to 36 percent and Healthy Kids Dental is now available to children in every county in Michigan.[46] That’s important progress for sure, but it still lags the national average, where 39 percent of Medicaid-eligible children receive preventive dentist services annually.[47]

Despite this effort, 64 percent of low-income children are not seeing a dentist on a regular basis, potentially creating higher health care costs in the future. As noted earlier, it is estimated that dental care provided by a hospital’s emergency department costs about five times more than what a similar service would cost at a dental provider.[48]

Emergency room visits for oral health issues is a real problem in Michigan. Recall that the Anderson Economic Group study (commissioned by Delta Dental) found that there were over 7,000 emergency room visits related to oral health issues, all of which were for preventable conditions, and 1,000 of these patients needed to be hospitalized as a result of their condition. This situation creates millions of dollars of extra emergency room and hospitalization costs that could have easily been prevented with the appropriate dental care needed to avert these types of emergencies.[49]

Adding a midlevel dental provider could help more low-income families in Michigan get dental care. Dental therapists would make it easier and less costly for dentists to expand their practices, especially their capacity to provide routine and preventive care — care that helps reduce future health-related costs. Instead of being limited to having to hire a second dentist to enlarge their practice, dentists could expand on a smaller scale by hiring a dental therapist. Since a dental therapist will not cost as much as a second dentist, this will allow dentists who would not otherwise be able to afford expanding their practice to do so. This will benefit low-income families, because they are potential clients for new business for dentists. And more dentists expanding their practices means better access to more affordable dental care.

A second reason why dental therapists may help low-income families is that offices that employ them might be more open to accepting Medicaid’s reimbursement rate. They also might be more likely to take part in the Healthy Kids Dental program. Midlevel providers may be better able to provide care at the lower reimbursement rates offered by Medicaid and Health Kids Dental. If this is the case, more dentists might be willing to expand their services for Medicaid-eligible populations.

Further, if dentists find that hiring dental therapists makes it feasible to expand their practice, the market for dental services will become more competitive. That could lead to lower prices, benefitting all consumers of dental services, but low-income ones the most, especially those who currently cannot afford any dental care. In a 2010 survey of parents of third-graders in Michigan, the two most common reasons cited for why third-graders had not visited a dentist were lack of insurance and affordability.[50]

At least one group of professionals who are very knowledgeable about the dental markets agree with this assessment. A survey of deans of dental schools published in 2013 by three Michigan professors found that three-fourths of respondents thought that midlevel providers would “improve access to care for the underserved.” More than half these deans agreed that the dental profession should include new midlevel practitioners.[51]