COLUMBUS, Ohio – Disabled and unable to work, David Kuehl put off dental care for six years until he became eligible for Medicaid. Only then did he have several damaged teeth removed to ward off the infections he's prone to as a hemophiliac.
But adult dental coverage is optional under Medicaid (search), and many states, including Ohio, are considering pulling the dental programs from their budgets as they face stagnant revenue and soaring health care costs.
The National Governors Association (search) said its top priority this year is reforming Medicaid, the joint federal-state health care program for the poor that serves about 44 million people nationwide.
"What's a word bigger than catastrophe?" said Barb Edwards, deputy director of Ohio's Medicaid program, describing the state's financial woes if the program's growth isn't slowed.
Kuehl, of Buckland in western Ohio, said he couldn't have afforded the $20,000-plus in treatment — which included a hospital stay — without Medicaid, which covered everything. And as a hemophiliac (search), he is subject to uncontrolled bleeding from even minor injuries or infections.
"Not only is it a financial burden, but it would also put my life at risk," the 48-year-old former maintenance worker said.
In the past three years, several states reduced adult dental coverage under Medicaid for budget reasons, including Michigan, Minnesota and Utah. In California, Connecticut, New Jersey and other states, intense lobbying by dentists blocked similar moves.
The number of states with comprehensive dental benefits for adults under Medicaid dropped to seven in 2004, down from 14 in 2000, according to the American Dental Association (search).
In 2003, Minnesota added a $500 cap to dental services that don't include major procedures like extractions, saving about $1 million a year, said Brian Osberg, the state's assistant commissioner of health care.
As a result, some patients are choosing to have all their teeth pulled and replaced by dentures — which Medicaid still covers — rather than the less invasive procedures they can't afford, said Richard Diercks, executive director of the Minnesota Dental Association (search).
The change was necessary because of budget problems, and the cap was better than no dental coverage at all, said Minnesota Rep. Tim Wilkin.
Advocates for the poor say reducing the benefits would hurt the needy and cost states more in the long run because patients may seek more costly emergency treatment.
Dentists and others also argue that poor dental health can lead to additional health problems, including diabetes, strokes and premature births.
"It is really foolish to not provide those preventative and acute care programs for adults, because some of the most expensive conditions are exacerbated by oral health problems," said Shelly Gehshan, a program director with the National Conference of State Legislatures (search).
At stake in Ohio is about $28 million from the state and $42 million in matching federal funds. The money covers everything from routine office visits — at costs starting at an average of $45 — to major surgery.
About 247,000 Ohio adults on Medicaid, or about 31 percent, used a dental service at least once during 2003.
The potential loss comes at a time when access to dental care is considered by the Ohio Health Department as one of the state's top unmet medical needs.
The dental coverage survived budget cutting two years ago, but Gov. Bob Taft and lawmakers say they need to look for savings everywhere in a spending plan already facing a $5 billion deficit.
The Republican governor warned last fall that increases in Medicaid, which could account for up to 40 percent of state spending over the next two years, must be slowed.
Reductions in dental funding are being watched closely by community health centers.
"Almost every state we're aware of that was providing dental for adults as an optional service has dropped it or is thinking about it," said Roger Schwartz, state affairs director for the National Association of Community Health Centers (search).
In North Carolina, lawmakers tried unsuccessfully in 2002 to reduce funding to the state's dental program. Dentists fear the state may try again.
"Adults need to be able to get a job, they need to be able to be healthy," said Dr. Cynthia Bolton, a dentist in Reidsville, N.C. "You certainly can't interview well for a job if you don't have your teeth."