By this time next year, about half of California's children -- roughly five million -- will get dental care through Medi-Cal, California's Medicaid program.
Or maybe they won't.
A new issue brief from The Children's Partnership suggests California's Medicaid system may not be up to the task.
"California's Medi-Cal dental system is already struggling to serve children and is unprepared for what's to come," said Wendy Lazarus, founder and co-president of The Children's Partnership. "California's kids deserve real access to quality dental care -- not a false promise of it," Lazarus said in a statement accompanying the brief, "Fix Medi-Cal Dental Coverage: Half of California's Kids Depend On It."
Two significant changes under way now will mean an increase of about 25% in the number of children eligible for Medi-Cal dental coverage.
Expansion of coverage through the Affordable Care Act -- as well as California's decision to shift about 863,000 kids from one kind of subsidized care to another -- will add more than a million kids to the Medi-Cal system.
California is ending Healthy Families, the state's Children's Health Insurance Program and shifting to managed Medi-Cal.
The increase will mean an unprecedented percentage of California kids will be eligible for federally subsidized dental coverage.
Pay Raise Not Likely
The issue brief makes several specific recommendations, urging state officials to make policy decisions now that will pave the way for expansion later:
- Simplify and streamline enrollment processes for both beneficiaries and providers;
- Expand the scope of practice for mid-level providers, such as dental hygienists and dental assistants, who could provide care in regions with fewer dentists;
- Increase the use of teledentistry;
- Strengthen state leadership in oral health through the creation of a statewide ofﬁce of oral health; and
- Raise Medi-Cal reimbursement rates for dentists.
Dental leaders in California express varying levels of support for those ideas -- ranging from strong support for reducing bureaucratic hurdles to a lukewarm response to expanding mid-level providers' scope of practice.
The recommendation that dentists like the most -- raising reimbursement rates -- is probably the least likely to happen.
"We're not expecting any changes in reimbursement rates for dentists treating Medicaid kids," said Ray Stewart, executive director of the California Society of Pediatric Dentistry.
"In fact, they actually may squeeze providers even more just as they have in medicine. They've issued their 10% cut -- take it or leave it. We expect them (state officials) to do everything they can to ratchet down reimbursement to providers."
Lindsey Robinson, president of the California Dental Association and a pediatric dentist in Grass Valley, said California's reimbursement rates make it difficult for dentists to embrace the Medi-Cal system.
"We share these concerns, understanding that it impacts many dentists' ability to participate in the program. We know California's Medi-Cal program has among the lowest reimbursement rates in the nation -- approximately 30 cents on the dollar -- which actually results in situations where it costs dentists to provide care," Robinson said.
"While CDA has raised these concerns with policymakers, the Department of Health Care Services has made it clear that an increase in reimbursement rates is not being considered at this time."
If a pay raise isn't on the table, an argument could be made that the other recommendations for improving the system and recruiting dentists become more important.
Jenny Kattlove, director of Strategic Health Initiatives for The Children's Partnership, said, "We need a multi-pronged approach to meeting the dental care needs of California's children. There simply are not enough dental providers in areas where underserved children live."
"One of the solutions is to bring dental care to children where they are, such as school and Head Start sites. We also need to look at new workforce models and the use of technology to bring care to where the children are. Finally, we need the leadership of a dental director to develop and implement a statewide approach to improve the oral health of the state's children," Kattlove said.
In a written response to questions for this story, a DHCS official said the department is working on improving the system and considering the possibility of enrolling mid-level practitioners as Medi-Cal providers.
"Improving the performance of these programs is a top priority, and we are constantly exploring ways we can enhance both access and the quality of dental care provided. Over the last year, we have worked closely with stakeholders to streamline and improve dental provider enrollment process. Recently, we unveiled a new Preferred Provisional Provider process that lets applicants certify to specific criteria and be enrolled for treatment purposes while the credentialing of their application is completed."
DHCS officials said state officials are "looking at the role of dental hygienists and dental assistants in Denti-Cal and researching the criteria for their enrollment as providers."
On the likelihood of a pay raise for Medi-Cal dentists, DHCS officials said: "Increasing provider reimbursement rates is a budget issue and would need to be reviewed in light of the current fiscal environment and the potential fiscal impact on the program."
Example of Bureaucratic Frustration
Stewart recounted a story from his Northern California practice that he said illustrates "some of the road blocks and barriers dentists face in dealing with Medi-Cal."
"We opened a new office about five years ago roughly 20 miles from our existing two offices in Salinas. The third was in the Monterey Peninsula -- a town called Seaside. We have eight pediatric dentists and three general dentists all approved as Medi-Cal providers in Salinas. But when we wanted them to be able to see patients in Seaside, it took the state more than a year to approve the same 11 people as providers in Salinas," Stewart said.
"The state organization is archaic and the ways they accredit and approve providers just doesn't make sense. They should make it as easy as possible to become a Medi-Cal provider," Stewart said.
CDA President Robinson said state officials are trying to improve the process.
"We know the DHCS is conducting provider outreach efforts to encourage current Healthy Families providers to become Denti-Cal providers if they are not already and to encourage current Denti-Cal providers to serve more patients. They're also communicating with all licensed dentists to encourage their enrollment in the program to serve new beneficiaries. We're told that DHCS is expediting enrollment for providers and helping to ensure the application process goes as smoothly as possible. CDA supports all of these efforts and is in regular contact with the department on its implementation," Robinson said.
Bill To Explore New Tier of Dental Provider Stalled
Neither Robinson nor Stewart are enthusiastic about the idea of training a new mid-level tier of dental professional to help in underserved parts of the state.
"As far as expanding the roles of dental hygienists and dental assistants to provide care, California currently has one of the most highly trained dental workforces in the nation," Robinson said.
"Dental hygienists, who work in public health programs, and advanced trained dental assistants, who under a dentist's supervision are able to complete basic dental restorations, are able to greatly expand access to dental services in California. What California is missing is an infrastructure that supports the deployment of this workforce to reach the populations in need," Robinson added.
The California Legislature last year considered a bill aimed at improving dental care for underserved children. SB 694, by Sen. Alex Padilla (D-San Fernando Valley), would have created a statewide office of oral health that would help California get federal money for subsidized dental programs. It would have also launched a project to train a new level of oral health care professional in California -- people less educated than dentists but with enough training to perform some dental procedures.
The bill established the framework for a study -- probably about three years long -- but it did not spell out the details of how the new tier of providers would be trained or what levels of procedures they'd be able to deliver.
The bill died in committee last summer amid worries that a new state-level dental bureaucracy would cost the state too much money.
A new version of the bill may be introduced in the current legislative session.