'They kept saying 'no' to what would fix it'
Karen Wadsack stores her collection of broken teeth inside a tiny box. She considers each tooth essential evidence of a system that’s failed her.
For the past eight years, the 68-year-old Sacramento woman has been fighting the California Department of Health Care Services for appropriate dental treatment. During that time, she has lost 15 teeth.
How many left? She sticks a finger in her mouth and counts: nine.
She wants to save them. She probably can’t.
Low-income seniors with Denti-Cal are losing teeth, suffering infections and accruing thousands of dollars of debt to pay for an array of treatments not covered by the state-funded dental insurance for the poor.
In truth, these seniors are lucky to have any coverage. Medicare – the federal insurance program for seniors – does not cover dental care. Dental benefits for many adults on Medi-Cal, which provides health coverage for low-income Californians, disappeared completely for five years, between 2009 and 2014. Many other states’ Medicaid programs do not provide adult dental benefits.
Still, critics of the program say the coverage that was brought back in California is sorely inadequate. Today, adult Medi-Cal patients can get a root canal on a front tooth, but not a back tooth. They can get full dentures, but not partial dentures.
“It’s either you should kill it or fund it,” said Paul Downey, chairman of the California Commission on Aging. “Now it’s in a limbo where it’s not useless, but it’s close to useless.”
A scathing report published by a state watchdog agency last spring described a poorly funded program with some of the nation’s lowest reimbursement rates, burdensome paperwork, restrictive rules and too few providers. The addition of millions of new patients under the Affordable Care Act only served to exacerbate those problems, the Little Hoover Commission said. The report noted that only a quarter of the state’s dentists accept Medi-Cal.
“Overall, it appears that the current Denti-Cal creates high levels of havoc in the lives of people it is supposed to help,” the report concluded.
Wadsack is one of the minority of seniors who actually saw a dentist through Medi-Cal last year. An analysis of state data shows that less than a quarter of eligible California seniors – and less than 19 percent of eligible younger adults – saw a dentist through Medi-Cal in 2015-2016.
In Sacramento County, where Wadsack lives, the numbers are even lower. While some managed care plans in the county that handle Denti-Cal patients are on par with state averages, overall only about 20 percent of the county’s 44,000 eligible seniors – and less than 17 percent of younger adults – saw a dentist through Medi-Cal. One plan, Access Dental, saw only 8 percent of enrolled adults.
Some benefits restored
Anastasia Dodson, acting chief of the Medi-Cal dental services division of the Department of Health Care Services, contends that the network of participating dentists is adequate, and says the restoration of some benefits has addressed the most urgent dental needs of adults with Medi-Cal.
Dodson adds that the state’s utilization rates are on par with the national average – although reports show national rates are dropping among seniors.
“Overall, while we still want to keep improving, we’ve come pretty far in the past few years,” she said.
Some lawyers, clinicians and advocates tell a different story. They describe seniors going deep into debt to pay for basic dental services that aren’t covered by Medi-Cal – or simply suffering without needed care. Tooth decay, gum disease, pain and tooth loss abound, they say.
“Typically what happens is the older adults will often only do that which is covered by Denti-Cal,” said Dr. Susan Hyde, director for dentistry for the University of California, San Francisco’s Multidisciplinary Geriatrics Fellowship. “If they cannot afford it, it doesn’t get done.”
Dental infections often exacerbate chronic health conditions, including heart disease and diabetes. A study published this spring in the Journal of the American Geriatrics Society says poor oral health is the biggest contributor to malnutrition among the elderly.
Unable to chew, Wadsack mostly subsists on smoothies and purees these days. She says she has lost 20 to 30 pounds this year alone. Embarrassed and ill, she rarely goes out in public.
Back when she worked as a bookkeeper in Redding, Wadsack paid out of pocket for her dental care. In 2001, she got severe whiplash after a bus accident and ended up on Medi-Cal. She says she is grateful for the care she has received through the program, but is “bowled over” by her inability to save her teeth.
In spring 2009, Wadsack said she went to a dentist to get stainless steel crowns on three of her teeth. After the dentist put on what Wadsack thought were permanent crowns, he took X-rays to send Medi-Cal for billing purposes, she said. She assumes he must then have removed the crowns and replaced them with temporary crowns. When she asked, he promised her pain would soon let up.
Instead, Wadsack said her teeth continued to decay and break. That July, the state — facing major budget challenges — dropped most adult Denti-Cal benefits. The following month, Wadsack landed in the hospital with meningitis. The likely culprit, a nurse told her, was an infection in the head or mouth. Wadsack began taking the first of dozens of courses of antibiotics to keep her dental infections in check.
In December 2009, Medi-Cal agreed to send her to a second dentist for evaluation. That dentist told her the first dentist had performed faulty work. He warned that other fillings would start to fall out soon. Although adult Denti-Cal was suspended, the state authorized payment to fix the three teeth. But the dentists Wadsack approached said pre-fabricated stainless steel crowns would no longer work on her damaged teeth.
Medi-Cal refused to cover the porcelain-fused crowns she required. In 2010, and again in 2013, they denied her requests, saying that type of crown was no longer a covered benefit.
Eventually, the initial three teeth fell out, and her bottom front teeth cracked. She lost an expensive bridge she’d paid for years earlier. A few months ago, she lost tooth #15 – a top front incisor.
“My option now is, I win the lottery, or I have all my teeth pulled and get dentures,” she said. She has a swallowing disorder, and worries that poorly fitting dentures might cause her to choke.
John Tan, an attorney for the nonprofit Legal Services of Northern California, inherited Wadsack’s case in 2012. “The whole thing frustrates me,” he said. “The whole thing makes me sad.”
This year, the debate about how to fix the Denti-Cal program has gained traction in the state Legislature. Last November, California’s voters approved Proposition 56, a $2 a pack tax on cigarettes. Most of the revenue – estimated at $1.2 billion dollars this year – was intended to help improve Medi-Cal programs.
Anthony Wright, executive director of Health Access, a statewide patient advocacy coalition that helped campaign for Proposition 56, said his organization is pushing for the restoration of the remaining adult dental benefits that were not brought back in 2014. He described the current lack of coverage for services such as rear root canals and partial dentures as “ridiculousness.”
His organization also wants to see an increase in payments to Denti-Cal providers. The state’s Denti-Cal program provides some of the lowest reimbursement rates in the country – often less than half the national average – and a fraction of what those dentists receive from private insurance. Many refuse to participate because of that.
Dr. Rodney Bughao, who treats developmentally disabled patients in hospitals around the Sacramento region, said most of his patients have Denti-Cal. The rates have stagnated over the years, he said, while payment delays, costs and regulations have increased.
“It creates a lot of pressure to make ends meet,” he said.
Bughao is considering no longer accepting the insurance, although he hates to do so because so many of his patients are in such dire situations.
“It’s very frustrating, because we have so many people who want and need this kind of care,” he said.
Assemblyman Brian Maienschein, R-San Diego, recently introduced legislation proposing that $200 million of the Proposition 56 funds be used to double Medi-Cal reimbursement to dental providers for the 15 most common prevention, treatment and oral evaluation services.
“These rates have to go up,” he said. “If they don’t go up, we’re going to see the status quo – which is disastrous – or worse.”
Rene Mollow, deputy director of health care benefits and eligibility for the state Department of Health Care Services, expressed skepticism that improving reimbursement rates alone will draw more dentists to the program. She and Dodson instead emphasized the importance of outreach campaigns, collaboration with safety net clinics, an expanded role for registered dental hygienists and increased use of tele-dentistry.
But Alicia Malaby, a spokeswoman for the California Dental Association, cited statistics showing a significant improvement in access to care for Medicaid beneficiaries in Connecticut and Texas after those states increased provider reimbursement rates.
All involved note that threatened federal cuts to Medicaid cast a shadow over different efforts to increase utilization – and, in fact, could again pose an existential threat to the adult Denti-Cal program.
As troubled as the current system is, many patient advocates acknowledge there’s something worse than having Denti-Cal: not having it.
Cynthia Morla, dental manager for the Sacramento Native American Health Clinic in midtown Sacramento, said that when the adult benefits were cut, many patients’ only option was to extract infected teeth.
“There were so many people who were in pain, there were so many people who needed so much more treatment than just an extraction,” she said.
This past January, the clinic doubled its dental chairs – going from seven to 14. They also added providers. Many of the seniors who come through the doors haven’t been to the dentist for years, she said.
“They’ve kind of lost hope,” Morla said. “We try to give that back.”
For some of these patients, the clinic can offer dentures that let them smile for the first time in years, or root canals to alleviate their pain.
Karen Wadsack, though, is just resigned.
She gazed at her box of teeth, lamenting that she’ll likely add nine more before too long. All for the failure to fix those first three.
She sighed. “We’re at the end of the road on this.”
Wiener writes for the Center for Health Reporting at the USC Schaeffer Center for Health Policy & Economics. Research for the story was supported by the Gary and Mary West Foundation.