A yellow dentist chair, in an empty dental office.

Barriers to Dental Care Abound for Individuals with Developmental Disabilities

In early May, a New York Times article profiled the N.Y.U. College of Dentistry’s Oral Health Center for People with Disabilities. As the Times article describes, the new facility establishes an important point of service for people with developmental disabilities in New York City. It also creates a much-needed pipeline for dentists skilled in treating this special population.

The need for improved access to dental care for people with developmental disabilities is great. People with developmental disabilities are often less able to care for their teeth, leading to a higher burden of disease, and this population sometimes requires special services, such as general anesthesia, not offered during routine care. Some conditions can involve inherently higher risk of oral disease. Individuals with Down syndrome, for instance, often experience decreased saliva production, which can lead to cavities and mucosal changes. Poor oral health, in turn, is linked to a host of serious health conditions, including cardiovascular disease and endocarditis. Unfortunately, a shortage of trained dentists and specialized facilities has meant that many people with developmental disabilities have not been receiving adequate care when it matters.

While the Oral Health Center for People with Disabilities is an important step towards improving access to care in New York City, major barriers remain elsewhere. Many people with developmental disabilities are dual-eligible, meaning that they are insured under both Medicare and Medicaid. But routine dental services are not covered under Medicare, and coverage of dental care under Medicaid is spotty for adults. (Children’s dental services are covered under Medicaid and CHIP.) Because states are not required to provide dental coverage to adults under Medicaid, policies vary considerably. While patients with developmental disabilities in New York benefit from extensive dental coverage, patients in other states may not be so fortunate.

Indeed, a handful of states—including Alabama and Delaware—provide no dental coverage for Medicaid beneficiaries. Some states cover only emergency services, and others provide limited coverage for dental services, with spending caps and constraints on covered procedures. Fewer than half of states provide extensive coverage for dental services under their Medicaid program. These dental benefit policies can vary wildly over time, with states slashing coverage when budgets are tight. And because dental benefits are discretionary, states may provide benefits to members of some categories of Medicaid beneficiary while excluding people with disabilities from full coverage. Conversely, some states—including Tennessee—provide dental coverage for adults with developmental disabilities while excluding beneficiaries from other categories.

Even in those states where beneficiaries with disabilities receive coverage, too few providers accept Medicaid patients. A recent article in Salon examines the Denti-Cal system in California as an example. Californians have long complained about the public dental insurance program, and only one fifth of providers in the state accept Medicaid patients. As a result, the Medicaid population remains underserved, in spite of the state’s extensive coverage. People with disabilities have been particularly hard-hit by insufficient access. Twenty-two percent of developmentally disabled patients insured under Denti-Cal received a dental service over a three-year span, compared to 32 percent of Denti-Cal beneficiaries overall. The state recently implemented a new tobacco tax to increase payment to dentists who provide services to Medicaid patients, but it remains unclear how the supply of providers will change as a result.

Academic dental institutions like the one recently opened at N.Y.U. play a central role in providing care to Medicaid patients in many states. However, as some of these institutions have begun putting caps on the number of new Medicaid patients, even this dental safety net cannot be a reliable source of care. Until states begin paying more for Medicaid dental services, simplifying the administrative process for reimbursement, and widening access to insurance coverage, patients with developmental disabilities will continue to receive insufficient dental services.

 

Alexandra Slessarev is a 2018-2019 Petrie-Flom Center Student Fellow. 

Alexandra Slessarev

Alexandra Slessarev

Alexandra Slessarev graduated from Harvard's joint JD/MPH program in 2019, and she will be clerking for Judge Ronald Lee Gilman on the 6th Circuit beginning in August 2019. Her Petrie-Flom fellowship paper was entitled "Curbing Pharmaceutical Detailing Practices in the Opioid Era." Alex's public health research interests include maternal and reproductive health, state-level Medicaid implementation, and the intersection of health and the environment. Prior to starting her dual-degree program, Alexandra spent a year working as a research assistant at the Bixby Center for Global Reproductive Health at the University of California, San Francisco, where she worked on several projects related to long-acting reversible contraception provision and education.

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