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85 million Americans lack dental coverage. Fixing that requires more than just money.

Regular Wonkblog readers know that poor access to dental care is a national problem. By one estimate, 85 million Americans lack dental coverage. Tooth problems are leading causes of school absence, missed workdays, and emergency department use.

Dental access problems are most acute among adults. These are important for kids, too. The National Bureau of Economic Research recently released a nice working paper on this topic: “The effect of Medicaid payment rates on access to dental care among children.” The authors, Thomas Buchmueller, Sean Orzol, and Lara Shore-Sheppard, examined 2001-2010 changes in Medicaid payment rates and private dental fees. These authors then related these payment changes to children’s receipt of dental care.  (Buchmueller and Orzol are former colleagues at the University of Michigan.) It’s an important topic, since Medicaid dental fees are notoriously low. Indeed these fees have slipped relative to the private sector in recent years. Buchmueller, Orzol and Shore-Sheppard construct a weighted fee index to capture the overall generosity of Medicaid in dental care. By 2010, the mean value of Medicaid on this measure was down to about 51 percent of private fees.

Accounting for steady differences across states and for national trends, these authors find that increased Medicaid reimbursement rates were associated with greater receipt of pediatric dental care among Medicaid recipients. Such policies presumably induce more dentists to take Medicaid. This is an important finding, consistent with prior research, not to mention basic economic principles.

But Buchmueller and colleagues add a troubling wrinkle, which deserves attention. They find that the behavioral impact of raising Medicaid reimbursement rates is disappointingly small. Because dentists’ willingness to participate in Medicaid isn’t very sensitive to reimbursement rates, moving Medicaid rates closer to parity with private providers would be somewhat costly, yet would not greatly increase children’s use of dental services.

In particular, these authors estimate that raising Medicaid pediatric dental rates to 85 percent of private fees would increase utilization by about 9 percent among Medicaid recipients. Ninety percent of the additional spending associated with the rate increase would be used to pay dentists more for visits that would have occurred anyway, under the lower fee schedule. The authors calculate that such a Medicaid rate increase would cost the program about $219 for each additional dental visit brought about by the new policy. That’s not especially cost-effective.

It’s reasonable to ask why the supply of Medicaid dental services seems so insensitive to price. This partly reflects the reality that price is only one barrier in the Medicaid world. Many dentists don’t like dealing with the program’s billing process. Their offices are not especially accessible to Medicaid recipients. Medicaid recipients have a reputation of having higher no-show rates, and aren’t always viewed as the world’s most profitable or attractive market segment.

Findings may also reflect this paper’s specific methodology. Its statistical approach relates state-specific changes in dental utilization to state-specific changes in reimbursement rates. This is a smart and standard approach, but it is generally better at tracking the impact of price jumps and dips than it is at capturing long-term changes. A state which credibly announces that Medicaid reimbursement will be permanently set at 85 percent of private rates would probably see larger utilization increases than the current paper predict. As Buchmueller told me, “If fees increase and stay high for a long time, you’d see bigger behavioral changes, and on both sides of the market.” Dentists will make different decisions about whether to book Medicaid recipients for appointments. Patients will also learn that they have new options.

Still, this working paper’s overall argument is compelling. There are good reasons to raise Medicaid reimbursement, not least to fairly pay providers for their work. Yet raising fees just addresses one barrier that patients confront, and only one reason many dentists spurn the Medicaid population. It seems sensible to consider other complementary, potentially more cost-effective strategies to increase dental access. The American Dental Association (ADA) presents some useful options here.

One might also expand services provided by mid-level providers known as dental therapists. These providers have more extensive training than dental hygienists, and are qualified to fill teeth and perform other basic tasks traditionally performed by dentists. Buchmueller and colleagues note Minnesota legislation providing dental therapists with greater professional autonomy.

Dental therapists’ permitted scope of practice is a contentious issue across the states. Not surprisingly, the ADA “remains unequivocally opposed to proposals for these so-called ‘midlevel providers,’ believing that adding lesser-trained ‘surgeons’ to the workforce has the potential to erode the superlative quality of American dental care.” Yet mid-level providers have practiced in many countries for decades. A literature review conducted by Elizabeth Phillips and (my former student) Luke Shaefer finds that the quality of work performed by dental therapists compares favorably with that of dentists performing the same tasks.

Other options deserve attention, too. Expanding dental residencies and the overall dental workforce would help. Government at all levels could also expand direct public provision of basic dental services, for example by expanding dental clinics located in Federally Qualified Health Centers (FQHCs) and other facilities in high-need communities. Specialized clinics now serve individuals with HIV/AIDS and for the homeless. The Affordable Care Act included $11 billion in new funds between 2011 and 2015 to support FQHCs. Expanded dental care was one component of these efforts. More could be done.

Some readers might balk at such proposals. Expanded direct provision of dental services smacks of a second-tier dental system. This reaction is understandable, but it’s mistaken. There is nothing inherently wrong with specialized public services for low-income people or for vulnerable populations with particular needs. By providing basic services, public clinics could serve patient populations which otherwise have limited contacts with the health-care system. These sites could thus provide a venue for other important health and social services that are rarely provided within the private dental sector. Such clinics might also amass scale economies required to maintain low unit costs, and thus provide a cost-effective path to expanded coverage and care.

More to the point, America already has an embarrassingly segmented dental-care system. We just haven’t owned up to it, or accepted the responsibilities that come with this reality. Oral health received embarrassingly little attention during the fight for health reform. Dental services weren’t included in Medicare. Adult dental care remains an optional Medicaid service. Children on Medicaid and CHIP enjoy limited options -- though at least they are covered. Raising Medicaid reimbursement rates would help this group, though Buchmueller and colleagues suggest that the practical results may prove disappointing.

Given that we’ve chosen to build this tiered dental-care system, the least we can do is to build its lower tiers to actually work. We should think more creatively and honestly about how this can be done.

Harold Pollack is the Helen Ross professor at the School of Social Service Administration and co-director of the Crime Lab at the University of Chicago. He is a nonresident fellow of the Century Foundation.