Every week, hygienist Joanne Puente sees patients at the People’s Health & Wellness Clinic in Barre who have not seen a dentist in years and come to her with severe tooth decay.
They are newly in recovery from opioid abuse or just out of prison. Or they are simply in pain, without savings and unable to find a dental practice with a sliding scale that is taking new patients.
Puente can offer free dental exams, cleanings and X-rays. But for crowns, tooth extractions and other treatments, she needs to refer patients to a dentist.
Lately it’s been those who have dental insurance who are actually the hardest to place, because that insurance is through Vermont Medicaid, Puente said.
Across all of central Vermont, only two dental practices will reliably accept her Medicaid referrals, and one only for emergency extractions. That’s a difficult fact to explain to patients.
“They’re reaching out for help. They finally have a chance to get to a dentist. They’ve got Medicaid,” Puente said. “But their mouths are totally, totally blown out. And there’s one dentist.”
Medicaid — the federally supported, state-administered program for children and low-income and disabled adults that has grown during the pandemic to cover one-third of all Vermonters — has not significantly raised its payments to dental providers for more than a decade. Over that same period, more and more practitioners stopped accepting new patients with the insurance.
That first issue — stagnant payment rates — is expected to be addressed with the start of the 2024 fiscal year on July 1. Both the state budget recommended by Gov. Phil Scott in January and the one approved by the Legislature on May 12 include $13.1 million to raise Medicaid dental payment rates by 50% across the board.
Legislators in the Democratic majority anticipate that Republican Gov. Scott will oppose their budget, which includes Medicaid rate increases for other health and human services providers, as well as new investments in child care and affordable housing. The details of the final approved budget are unlikely to be completely settled until a special session starting June 20.
However, the Medicaid dental rate increase is a shared priority and is expected to be enacted. The cost to the state would be an additional $5.7 million annually, with the remainder matched by federal Medicaid dollars.
Administrators and advocates alike hope the increase in payments will lead more private dental practices to open their doors to patients with Medicaid.
There has been a steady decline in the percentage of dentists across the state who accept new Medicaid patients, from around 70% in 2011 to 57% of primary care providers and 46% of providers in specialty care in 2019, according to the most recent census available from the Vermont Department of Health.
More recently, outreach in the fall of 2022 to the roughly 260 dental providers registered as participants in the Medicaid program found that most were not accepting new patients with the insurance, according to the Department of Vermont Health Access, which administers the program.
It’s clear at least one factor is that public rates were not keeping up with what private insurers were paying, said Andrea DeLaBruere, commissioner of the Department of Vermont Health Access. The increase would bring Medicaid rates up from roughly 49% of what Northeast Delta Dental pays providers to around 75%.
“When the department spoke with dentists, the answer across the board was this would really go a long way for us,” DeLaBruere said.
The challenge for providers who are not part of federally qualified health centers, which receive additional financial support to cover uncompensated care, is that current rates do not even cover the cost of materials for some procedures.
Creating a structure in which providers can at least break even is “a big step in the right direction,” said Patrick Gallivan, director of the Vermont State Dental Society. “We really hope this is going to have a direct impact on access to care, that more dentists will be interested.”
Several other changes are expected for Medicaid’s adult dental benefits.
First, adults on Medicaid currently face a cap on dental costs of $1,000 annually. Preventive care such as exams and cleaning do not count toward that total. New budget language increases that cap for all adults by 50%, to $1,500, to keep pace with the rate increase, and allows the Department of Vermont Health Access to increase the cap in a given calendar year if available funds allow.
Another bill the Legislature approved, H.206, lifts the cap entirely for specific groups of adults: those who are pregnant or within 60 days after giving birth and those who receive community-based services for developmental disabilities or severe mental illness.
Access to dental care is a big concern for people with developmental disabilities, most of whom are covered by Medicaid, said Kirsten Murphy, executive director of the Vermont Developmental Disabilities Council, a statewide policy and advocacy resource. That’s both because of a lack of providers who accept the insurance, and also because not many dentists and hygienists have training on how to provide treatment for people with special needs.
Not having a regular relationship with a provider can also result in less daily support for oral hygiene, she said. “All those things need to come together, you know, in order to support somebody with a significant intellectual disability to engage in good preventative care,” Murphy said.
So, in addition to the rate increase, lifting the cap will be helpful because the treatment needs can end up being complex and expensive, she said.
However, that ends up being true for many adults who are on Medicaid, said Vermont Legal Aid’s Mike Fisher, the state’s Health Care Advocate, which is why he argued this legislative session that the Department of Vermont Health Access should eliminate the cap altogether.
“We have such a crisis of people in real pain and they can’t find a dentist,” Fisher said, adding that access to dental care is one of the top issues about which people call his office for help. “People are really struggling,” he said.
Currently, an increase in the cap would not assist with the cost of dentures, something that 20 of Puente’s active patients need. Vermont Medicaid does not cover the cost of purchasing and fitting dentures, which can run upward of $3,000, except for people who are pregnant or under age 21.
This is particularly an issue for people struggling with opioid use disorder, as both the drug and its treatment have degenerative effects on teeth. “I can get these patients out of pain, I can get all their teeth taken out, but I can’t get dentures,” Puente said.
Fisher is also concerned that the rate increase may not make a significant dent in the problem, given the workforce challenges facing dental providers, along with most other health care sectors. The Department of Vermont Health Access would be required to report on the impact of the rate increases on access by January 2025.
Even people with private insurance, or those who can pay out of pocket, are waiting months for a checkup because of limited numbers of dentists and hygienists across the state. The Health Resources & Services Administration, an independent federal agency, considers every county in Vermont except for Chittenden and Franklin to be health professional shortage areas for dental care.
Addressing that challenge will require continued local efforts to train more providers, including dental therapists, who are advanced practice dental hygienists. The credential was created by law in 2016, but only one practitioner is currently licensed in the state.
Meanwhile, Puente and her colleagues at Vermont’s other four free dental clinics, along with the dental society, are anxious to get the word out about the coming rate increases, as soon as the budget passes.
“Our goal is to really encourage our members to re-look at taking Medicaid at their practice,” said Gallivan. “We’ve made a commitment to work with folks to promote this.”