California lawmakers want better dental benefits under Medi-Cal

When Bobby Moske visited a community clinic with a toothache several years ago, he couldn’t find a dentist in Marin County who was willing to pay for a root canal with Medicaid.

The Marin Community Clinics referred the 75-year-old to a dentist about 20 miles away in San Francisco, but while he waited months for reimbursement, he developed a tooth decay and ended up having his tooth pulled.

It’s the sixth time in 10 years that Moske has lost a tooth due to poor dental care, he said. The peer behavioral health specialist wears dentures that must be removed at mealtimes, making eating a chore. He often has trouble mashing food between his gums, and he limits his diet to things he can chew easily. Nuts and steaks, for example, are off the table. Sitting down to eat with clients or coworkers can be awkward.

“I feel like I give the impression of being someone who doesn’t take care of myself, but I do take care of myself,” Moske said. “I try very hard. When I go out, I try not to smile.”

California is among a growing number of states that offer comprehensive dental benefits to adults covered by Medicaid, and some lawmakers want to include more cleanings, exams and implants in the social safety net program. But many dentists don’t accept Medi-Cal, the state’s Medicaid program, so new benefits would offer no guarantee that patients will get treatment.

The UCLA Center for Health Policy Research found that 21% of California dentists treated Medi-Cal patients of all ages, based on data from 2019 to 2021. Often, these dentists limit the number of Medi-Cal patients they treat, meaning that in a given year, only 15% of adults may receive dental care, said Elizabeth Mertz, a dentistry professor and medical sociologist at the University of California-San Francisco.

“The problem is that you have insurance that is useless,” Mertz said. “The government offers insurance, but almost no dentist accepts it.”

One of the bills currently moving through the California Legislature would expand Medi-Cal coverage of dental implants — artificial tooth roots that are implanted into the jawbone and support artificial teeth — and crowns, giving patients with chipped or missing teeth more options.

Currently, Medi-Cal only covers implants when “extraordinary medical circumstances are documented,” according to the state’s 2024 benefits guide. It’s unclear how many private dental plans cover implants, but preliminary research has shown that about half of people enrolled in a PPO plan nationwide have some type of coverage, said Mike Adelberg, executive director of the National Association of Dental Plans.

Under the bill introduced by Democratic Senator Aisha Wahab, Medi-Cal patients could be eligible for an implant if their dentist decides it is the best option for replacing a missing tooth.

“If you need an implant, you should be able to get it, especially our most vulnerable,” Wahab said. “The poorest of the poor in California deserve it.”

The Senate passed the bill unanimously in May. A vote in the Assembly Budget Committee is pending. Elana Ross, a spokeswoman for Democratic Gov. Gavin Newsom, declined to comment on the bill.

According to an analysis by the Centers for Disease Control and Prevention, four in 10 adults in the United States have had their permanent teeth extracted. The CDC also reports that older, low-income people are at higher risk of tooth loss, which can cause discomfort and affect eating and speaking. The solution may be prosthetic devices such as bridges and dentures or replacement teeth, but these can be costly, especially for those without insurance or in government programs with limited benefits.

While the alternatives may be more suitable for some patients, implants are “the standard of care,” says Sohail Saghezchi, director of the oral surgery training program at UCSF.

“They can’t eat everything they want, and often foods like fruits and vegetables are harder to eat,” he said.

The Department of Health Care Services, which oversees Medi-Cal, estimates that about 1.5 million implants would cost between $4 billion and $7 billion a year – a price that, in Wahab’s view, could be problematic since Newsom signed a state budget in June that addresses an estimated $46.8 billion deficit.

The cost of an implant varies widely. DHCS estimates it would reimburse dentists between $3,000 and $4,500 for each implant surgery. FAIR Health, a national nonprofit that estimates health care costs, reported that the average cost of a typical implant in California was about $4,000 to $4,800 between October 2022 and September 2023. Location also plays a role. In San Francisco, for example, an implant is more likely to cost $8,000, Saghezchi said.

“Reimbursement rates must cover the cost of providing the service,” said Alicia Malaby, a spokeswoman for the California Dental Association. “As with any Medi-Cal benefit, coverage doesn’t make sense if the state isn’t willing to fully invest in it to make sure people actually have access to the care they need.”

The California Dental Association, which does not support the current bill, has raised concerns about the invasiveness of implant surgery, which requires regular follow-up visits, and is supporting a bill that would require Medi-Cal to standardly cover two dental cleanings and exams per year for people 21 and older, rather than just one.

DHCS spokeswoman Leah Myers said the state has increased Medi-Cal reimbursements to dentists since Proposition 56 passed in 2016 and developed a web-based app to attract more dentists. More than 14,000 dentists — about 40% — were enrolled in the Medi-Cal program as of July, according to the latest figures from the Dental Board.

But for people like Moske, finding a dentist and getting the care they need seems impossible. In most parts of California, three out of four Medi-Cal patients ages 21 and older will not have had a dentist appointment by 2023, according to DHCS.

When Moske testified in favor of the implant law in June, he took out his dentures, held them up to show lawmakers, and opened his mouth.

“I’m here to show you something,” said Moske. “Please don’t be offended. These are the teeth I lost.”

After Moske finished his speech, Rep. Reggie Jones-Sawyer (D-Los Angeles) turned to his colleagues and removed his own dentures.

“I know exactly what you’ve been through,” he said. “I have dental insurance through the city of Los Angeles and the state of California, and I still had trouble covering the costs. Thank you for being brave enough to tell people.”

Molly Castle Work is a correspondent for KFF Health News covering health care in California. Reach her at [email protected], @mollycastlework