Study: Cuts to Medicaid dental benefits led to increased emergency room use in California

Just another example of how cuts to health care funding simply shift the costs and endanger people’s health. This time it’s a study on the impact of eliminating adult dental coverage within the California Medicaid program. Not surprisingly, the cut resulted in a significant and immediate rise in people seeking help in hospital emergency departments.

While federal rules require Medicaid programs to cover children’s dental care, covering adult dental care is up to state policymakers. California lawmakers decided to stop offering dental care to adult Medicaid beneficiaries in 2009, which left more than 3 million low-income adults without dental coverage. To examine the impact of that decision, researchers examined data from the State Emergency Department Databases as well as California Medicaid enrollment and reimbursement data between 2006 and 2011. The study, which was published this month in Health Affairs, found that the benefit cut led to more than 1,800 additional dental emergency department visits per year. And the average yearly costs related to dental-related emergency department visits went up by 68 percent. Study authors Astha Singhal, Daniel Caplan, Michael Jones, Elizabeth Momany, Raymond Kuthy, Christopher Buresh, Robert Isman and Peter Damiano write:

Hospital emergency departments fill the role of a safety-net provider by attending to people who cannot obtain care, including dental care, in traditional primary care settings. However, hospital (emergency departments) and emergency personnel are generally not equipped or trained to diagnose and treat dental diseases effectively. As a result, the vast majority of patients who visit an (emergency department) with a dental problem do not receive definitive dental treatment. Instead, they receive only prescriptions for painkillers, antibiotics, or both.

Despite not providing definitive dental care, (emergency department) visits for dental problems are very expensive and, in the case of Medicaid enrollees, add to the state’s Medicaid expenditures. Hence, the original intent of reducing state Medicaid expenditures by limiting adult dental benefits could be partially counteracted by the additional expenses associated with increased (emergency department) visits for dental problems.

In studying the California experience between 2006 and 2011, researchers found nearly 122,000 emergency department visits for dental problems among more than 113,300 adult Medicaid enrollees. A month before state policymakers eliminated the dental coverage, records documented 42.4 dental emergency department visits per 100,000 adult Medicaid enrollees; after the policy change, the rate increased to 56.1 visits per 100,000 enrollees. The change translates to an increase of more than 32 percent. However, study authors found that the policy change didn’t affect all adult beneficiaries equally — young adults, members of racial and minority groups, and people living in urban communities shouldered a disproportionate burden of the impact.

Also, the rate of emergency department dental visits among adult Medicaid beneficiaries in small metropolitan and micropolitan communities (defined as a population between 10,000 and 50,000) had been in decline before the policy change. After the policy change, that decline either reversed or began to slow down. Overall, researchers found that the state Medicaid program spent about $2.85 million per year on emergency department dental visits after eliminating its adult dental coverage, compared to $1.6 million per year before the policy change.

Also, consider this comparison. The researchers noted that while emergency department dental visits were going up during the study period, emergency visits for other illnesses and conditions that can be effectively managed via outpatient care were on the decline. In other words, patients were showing up at the emergency room with dental issues that could have easily been treated or even prevented if they had had access to a dentist.

However, the researchers also noted that the significant increase in emergency department dental visits throughout the study period points to a larger dental access problem, noting that California is home to 80 designated dental health professional shortage areas. And even before the policy change, California’s Medicaid program offered especially low reimbursement rates for dentists. Still, researchers noted that emergency department visits only capture a fraction of the total cost of eliminating dental benefits, which California lawmakers partially restored in 2014. To calculate the full cost, they would also have to consider hospital admissions, care sought at other health settings and safety net clinics as well as losses in productivity due to untreated dental disease.

“These (emergency department) costs offer almost no benefit in terms of the actual resolution of the dental problem for the enrollees,” the study stated. “Policymakers should think of these costs in terms of cost-effectiveness rather than of cost savings per se.”

To request a full copy of the study, visit Health Affairs.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.

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