Dr. Bill Collins, a supporter of the Medicaid dental expansion, treats a patient at the Red Bird Mission dental clinic in Clay County. (Photo by Deborah Yetter)

At the Red Bird Mission dental clinic in Southeastern Kentucky, patients with few or no teeth now are eligible for dentures through an expansion of the state’s Medicaid dental services for adults.

“People are tickled to death,” said Dr. Bill Collins, the dentist at the United Methodist Church mission in a remote corner of Clay County. “We get patients who haven’t had teeth for 20 years.”

Dentures and other services newly covered by Medicaid have the potential to remake Kentucky’s image as a state of “toothless hillbillies,” said Collins, who has treated patients in the region for decades.

“I hate that image,” he said.

But a political fight in Frankfort over who has the power to enact the new benefits — that also expand vision and hearing services — could end the extra coverage advocates say is desperately needed.

Already the new benefits have started, stopped and started again amid a tussle between Republicans who control the General Assembly and Gov. Andy Beshear, a Democrat who enacted them Jan. 1.

Lawmakers have scheduled a hearing July 13 on the new benefits, but already expressed their disapproval at a meeting in May where Republicans said Beshear usurped their authority over the federal-state health plan for low-income individuals.

“I’m not necessarily opposed to doing this,” said Rep. Derek Lewis, R-London. “There’s a lot of people in my district that could benefit from this. But the process matters.”

Since lawmakers have the power to kill the expansion when they next meet in the 2024 legislative session, there’s no guarantee the benefits will last beyond this year.

That’s unfortunate in a state that ranks 49th in oral health and consistently ranks among the top states in the number of adults with no teeth, according to health advocates.

“We really wish that the governor’s office and the legislature, working together, could find a way to get this done instead of being adversarial,” said Dr. Stephen Robertson, executive director of the Kentucky Dental Association.

Samone Gist, a Louisville woman suffering from multiple dental problems, says she just wishes someone would establish consistent, accessible dental care for those including herself who rely on Medicaid for health coverage.

Even if it survives, expansion might not be enough unless Medicaid pays Kentucky dentists more

With demand high for dentures now that Kentucky’s Medicaid program has agreed to cover them for adults, Dr. Bill Collins, the dentist at Red Bird Mission dental clinic in Clay County, is providing them as fast as he can.

But the Medicaid reimbursement of $656 for dentures doesn’t cover the clinic’s base cost of $1,100, meaning the nonprofit clinic has to make up the difference from other sources, he said.

“We take Medicaid and try to help as many people as we can help,” Collins said.

Not all dental practices — many of them small businesses — can afford to do that, said Dr. Stephen Robertson, executive director of the Kentucky Dental Association.

“For an office to decide to participate in Medicaid, they have to agree to operate at a loss,” Robertson said.

Gov. Andy Beshear has tried to address the problem by directing Medicaid to pay for more adult dental services previously not covered by the federal-state plan. The future of that expansion, caught up in a partisan fight in Frankfort, is uncertain.

30 years without a raise

But should the expanded services survive, they may not be enough to address deeper problems in a system beset with a complicated reimbursement system where payment for the few services adults previously received hasn’t been increased for 30 years, Robertson said.

“What it really needs is a significant increase,” he said.

By contrast, Medicaid dental services for children received a boost in 1997 that advocates say has led to improved oral health and more regular treatment for kids.

Moreover, dentists must deal with a complex network of six separate managed care organizations,? known as MCOs, hired by the state to oversee health care for most of the 1.6 million Kentuckians enrolled in Medicaid.

They in turn subcontract with dental MCOs who negotiate rates with dentists and pay them, not always as much as the state Medicaid program recommends in its fee schedule. Also, rates may vary from one dental MCO to another.

Robertson said the dental association would like to see the MCOs required as part of their contract with the state, to use standard rates specified by the state Medicaid Department.

“That’s one of the things we are pushing for,” he said.

‘Gateway to everything’

So far, state officials have not required that to avoid conflict with rules from the federal government, which covers 70 to 80% of the state’s Medicaid costs, that require flexibility in managed care.

Kentucky also faces a shortage of dentists, especially in rural areas, and many do not take Medicaid because of the historically low reimbursements, Robertson said.

Robertson thinks all these problems have solutions, but it’s going to take a concerted effort in a state that ranks 49th in oral health and first in the rate of older adults with no teeth.

When it comes to overall health, “The mouth is the gateway to everything,” he said. “We’re for finding the best way to move forward.”

A shortage of dentists — especially those who accept Medicaid because of notoriously low reimbursement rates — makes it difficult to find an appointment, health advocates say.

Recently, Gist said she managed to get one decayed tooth pulled but has others that need treatment.

“I was in so much pain, it was unbelievable,” she said. “The pain is unbearable.”

Dental disease is linked to a host of health problems including infection, diabetes complications, heart disease and premature births — all significant health issues in Kentucky. It also is linked to addiction among those prescribed painkillers for dental abscess and decay, problems that too often send people to emergency rooms, advocates say.

Kentucky spends about $9 million a year in Medicaid funds on patients visiting the emergency room for dental pain, according to the Cabinet for Health and Family Services. In such cases, patients generally are prescribed antibiotics for infection and painkillers but don’t get dental care.

By contrast, the expansion of dental, vision and hearing benefits is expected to cost about $36.5 million a year, with $31 million covered by the federal government, which pays most of the state’s share of Medicaid. Beshear has said the state’s costs will be covered from savings in other areas in Medicaid.

Advocates argue that dental health, as well as good vision and hearing, also are essential in helping people get and keep jobs.

“Kentuckians need teeth. They need glasses. They need hearing aids,” said Cara Stewart, director of policy advocacy for Kentucky Voices for Health, a coalition of health groups. “It’s just a no-brainer.”

Gist, who recently attended a job-training program and is looking for work, agrees.

With bad teeth, “It’s embarrassing to do an interview or try to get a job,” she said. “It will definitely hold you back.”

There seems to be little dispute in Frankfort about the need for the expanded dental and other services for the 900,000 adults covered by Medicaid who could benefit.

But that’s where agreement ends.

‘We’re number one’

For decades, adults covered by Medicaid were eligible only for an annual cleaning and tooth extraction.

In a poor state where nearly 1.7 million people get care through the federal-state health plan, that led to inevitable results, said Robertson, the dental association executive.?

Kentucky consistently ranks at or near the top in the nation in the? number of adults with no teeth, a condition known as edentulism.

“When the only benefit you’ve got is to have a tooth removed, that’s what the outcome is going to be,” Robertson said, adding that a recent study ranked Kentucky first in the number of toothless, older adults.

“We’re number one,” he said.

So last October, citing the need, Beshear announced he was using executive authority to expand Medicaid dental, hearing and vision benefits for adults in the program.

Adults could get dentures, fillings, crowns and two checkups a year as well as eyeglasses and hearing aids.

Children enrolled in Medicaid — currently about 637,000 — already are eligible for a full range of dental, vision and hearing services.

The new adult benefits, introduced through emergency regulations, began Jan. 1.

But Republican lawmakers objected, saying the governor should have sought legislative approval for the changes.

They included Sen. Stephen West, of Paris, who sponsored Senate Bill 65 in the 2023 session to stop the new benefits.

“It was a huge change, really that should have been done through, we felt, through statute, through involving the legislature,” West said.

The bill passed in late March, stopping the new benefits after just three months, but it was amended to extend them until June 30 for people already getting services, such as dentures.

But on April 12, after the legislature adjourned and lawmakers left town, the Beshear administration issued a new set of emergency regulations to again provide the expanded dental, vision and hearing services.?

That restored the benefits but set up a new confrontation with Republicans who hold a supermajority in the General Assembly.

Groundhog Day

GOP lawmakers were swift to react, taking up the new version of the benefits at the May 9 meeting of the joint Administrative Regulatory Review Subcommittee, which examines regulations enacted by the administration.

They complained the new version looked much like the old version they had already rejected.

“I half expected Bill Murray to come to the table today because I feel like this is ‘Groundhog Day,’” said Sen. Damon Thayer, majority floor leader, referring to the movie where Murray plays a TV news personality caught in a time loop. “The same thing kept happening over and over again.”

Officials with the Beshear administration, including Medicaid Commissioner Lisa Lee, insisted the plan had been changed to meet legal requirements that prohibit offering regulations that already had been rejected.

Besides, Lee said, with Kentucky’s abysmal ranking in oral health, it’s time to break out of the groundhog mode.

Since 2014, after Kentucky expanded access to Medicaid under the Affordable Care Act to include more low-income adults, the state has moved from 47th to 43rd in overall health rankings.

“But we remain 49th in oral health care,” Lee said. “We have got to get something done here.”

Rep. Daniel Grossberg, a Louisville Democrat, agreed.

“Something has got to change,” he said. “We may be having an element of ‘Groundhog Day’ here but we’re living it over and over because neither side’s willing to give.”

Cabinet numbers show that the expanded benefits so far have resulted in dental, vision and hearing services for 196,000 individuals with about $12 million in payments to providers.

About 4,000 have received dental services including 2,500 sets of dentures.

But Republicans said that while they don’t necessarily dispute the need for those services, they fault the Beshear administration for failing to work with them.

“You kept coming back after we said no,” said Rep. Randy Bridges, of Paducah. “We said no. We said no. You don’t want no. You’re going to do what you dang well please.”

Committee co-chair Derek Lewis said benefits from the expansion isn’t the point.

“I think every single person on this committee would be in favor of expanded dental services,” Lewis said. “But our job on this committee is to protect the legislative process.”

The committee voted 5-2 to find the regulations “deficient,” with Democrats casting the two no votes.

But the legislature can’t actually block them until it meets again in session in 2024 and enacts legislation to do so.

That leaves the Beshear administration free to offer the expanded benefits through at least the end of the year.

‘Last bastion of small business’

Meanwhile, Kentucky needs to work on other problems plaguing dental services throughout the state, especially in rural areas, dental officials said.

Medicaid reimbursement rates for dental services have not increased for 30 years to the point where costs of dental care exceed what the program pays, Robertson said.

Of the state’s 3,200 licensed dentists, about 57% are signed up to treat Medicaid patients but many either don’t accept them or limit those they see because of low reimbursement, he said.

“People tend to forget dentists are the last bastion of small business in Kentucky,” Robertson said. “When you are asked to operate at a loss, that’s not a sound business plan.”

The state’s latest proposed regulations include increased reimbursements for dentists.

The state also doesn’t have enough dentists and other staff, such as dental hygienists, to meet demand.

Even federally-established community clinics, such as the Family Health Centers in Louisville, long considered the medical safety net, have extended waits for dental care and few openings for patients, said Melissa Mather, chief communications officers.

“There has been a significant atrophy in the dental safety net here in Louisville,” Mather said. “We desperately need dental staff.”

Collins, the Red Bird Mission dentist, agrees all those problems must be addressed.

But he said another concern is whether the legislature will even allow the expanded benefits to survive.

“I am for this Medicaid expansion big-time,” he said. “But when Jan. 1 hits, they’re going to come in here and stop it.”