The lack of timely and appropriate access to dental care for low-income children and adults is one of the most overlooked problems of California's health care system. It can also be life-threatening when not addressed.

The challenges facing California policymakers will become more substantial as the state embarks on a massive expansion of Medi-Cal, the state's public insurance program for the poor.

California is readying itself to significantly expand its Medi-Cal dental program starting next year as part of President Barack Obama's signature health care law and the state's ambitious plan to transition more than 875,000 children out of the Healthy Families program into Medi-Cal.

This will result in roughly half of California's children receiving dental care through a Medi-Cal managed plan. With these extensive changes looming, this year will be pivotal to shape the future of dental care for children in California.

Two recently released reports highlight the significant challenges facing children's oral health in California and the need for state policymakers to implement innovative ways to meet these challenges.

"Without Change It's The Same Old Drill: Improving Access to Denti-Cal Services for California Children Through Dentist Participation" by my consulting firm examined the state's Medi-Cal dental fee-for-service program and the extent that private dentists participate in the program. The other, "Fix Medi-Cal Dental Coverage: Half of All California Kids Depend Upon It" from the Children's Partnership, raised alarms about the impact that newly enrolled children will have on the state's strained dental care system.

Both studies illustrate how California faces a continuing challenge of achieving and maintaining enough dentists willing to accept Medi-Cal, and offer clearly demonstrated solutions for responding. But who is listening?

The state is moving to expand dental coverage and access for individuals – adding more people into a delivery system that already isn't meeting existing needs – while at the same time planning to cut the fees paid to dental providers. You can't have it both ways if the goal is to see that kids get dental care.

California has an adequate number of dentists, at least in urban areas, according to the state. However, the first study found that less than 25 percent of family dentists participate in Medi-Cal, down 40 percent since 2003. Why? Ninety-seven percent of dentists who don't accept Medi-Cal said the number one reason is the inequitable reimbursement rates – California's rates are the 49th lowest in the nation.

Unlike large health care systems that can shift costs to help cover no-pay and low-pay patients, dentists, who typically practice solo or with a partner, cannot as a small business afford to sustain a practice with Medi-Cal's unreasonably low reimbursement rates coupled with burdensome enrollment and claims submission processes. "I'd rather see a kid for free than bother with Medi-Cal," responded one of the recently surveyed dentists.

Rate cuts are clearly not the way to recruit and incentivize additional providers, especially in serving a high-risk and sometimes challenging patient population. Persistent low fees – on top of planned provider rate decreases – will likely result in a continuing shrinkage of the private practice dental provider network in California.

Increasing investments in the program is difficult during tight fiscal times, but some states have shown it is possible to make improvements with limited dollars. States that have increased dentists' participation in public programs have maximized the extent to which their Medicaid requirements and utilization mirror those of commercial insurance.

The goal of the state's Medi-Cal dental program is to provide a system of dental care for children who depend on Medi-Cal to meet their dental care needs. But the status quo is not working. Last year, half of the children with Medi-Cal dental benefits did not see a dentist. We need bold action.

The perfect storm is approaching. The state needs to partner with the dental profession and other stakeholders to put all options on the table and implement solutions to the challenges facing the system. California children deserve no less.

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