As the COVID-19 storm rages, health care providers have had to navigate the virus’ formidable waves, finding the safest way to continue working. For oral health professionals, who face an especially high risk of exposure to the virus, finding the best course has required dentists, oral surgeons, orthodontists and others to make serious adaptations.
The Centers for Disease Control and Prevention offered specific guidance for dental settings to help slow the spread of the disease. The recommendations sought to balance the need to control the rate of infection with the need to provide emergency or necessary routine care. Patients, however, generally chose to stay at home and put their dental care on hold for the first few months of the pandemic. This put many small clinics in danger of closing.
Like other businesses between March and June, the oral health profession faced tough financial and service-delivery challenges because of the virus. In June, however, the American Dental Association (ADA) reported a substantial rebound in patient visits, though still fewer than pre-pandemic levels.
Teledentistry, Coverage and Access
With social distancing and stay-at-home mandates, one oral health care practice became critical: teledentistry, which allows professionals to avoid the risks of in-person encounters by using technology to diagnose and refer patients. All 50 states have addressed telehealth since the pandemic began. Over the last several years, 23 states have specifically authorized the use of teledentistry.
The ADA issued guidance in early May on the reimbursement process for teledentistry services to encourage their use during the pandemic. State health agencies in Arizona and North Carolina issued guidance to help providers understand new state or federal laws and regulations regarding billing, eligibility requirements and authorized technologies.
The New Jersey Legislature voted to require private and public insurance plans to cover telehealth services. Maine lawmakers made recommendations on telehealth coverage by private insurers. And Alaska’s governor extended his emergency executive orders facilitating the expanded use of telehealth.
Reaching the Underserved
Public dental coverage for adults may decrease due to state revenue declines, which have been projected to range from less than 5% to more than 20%. Facing large budget reductions in the years after the 2008-09 recession, state legislatures had to make difficult decisions. Several chose to eliminate some Medicaid dental benefits. Whether that will happen during the current crisis is unknown.
Public dental coverage can be a tool to reach vulnerable and underserved communities in need of care. But projected budget reductions may require the elimination of some services, including adult Medicaid dental benefits. While some benefits may be cut, there are also success stories about adding coverage for vulnerable populations without affecting the budget. In 2018, the Utah Legislature enacted House Bill 435 to provide dental services to people who qualify for the state Medicaid Health Coverage Improvement Program and receive treatment for a substance use disorder.
The University of Utah School of Dentistry covers the state’s costs for providing dental work under Medicaid. The program has now served about 9,000 patients. Utah removed the Medicaid adult oral health benefit after the 2008-09 recession, but in the following years the legislature, executive branch and oral health providers worked to reestablish coverage for Medicaid enrollees who are blind, disabled, elderly or diagnosed with substance use disorders. The Medicaid substance abuse program is an opportunity for enhanced training for dental students. Patients in the program benefit as well, with higher rates of drug abstinence and a faster return to normal life activities than those not in the program.
Preventive Care for Children
The virus could exacerbate existing challenges and disparities related to children’s dental health as well. Based on COVID-19 case counts or projections, pediatric dentists may be limited to fewer patient visits than usual—and only about half of U.S. children see a dentist each year in normal circumstances. Reductions in routine care could lead to greater tooth decay, which is currently the leading chronic disease in children, though it is highly preventable.
Although oral health coverage for children is guaranteed under Medicaid, state lawmakers still look for effective, noninvasive strategies to improve preventive care for kids—especially when they do not increase costs. Dental sealants, the development of fluoride treatments and additions to the oral health workforce have all been shown to reduce the need for procedures that are more painful and that can spread COVID-19 by allowing virus particles into the air.
School-based health centers can provide a range of innovative services, including oral health, as they adapt to the challenges of COVID-19. State legislatures often determine the amount and allocation of school-based health center funding.
States are responding to the coronavirus with approaches that fit their unique circumstances and challenges. How oral health care fits into larger health or budget discussions will vary by state. It may be encouraging to note that while 97% of dental practices closed following the onset of the pandemic in March, 90% had reopened by June. While the pandemic’s waves rise and fall, they will continue to test the health system’s resolve and ability to meet the needs of its communities.
Erik Skinner is a policy associate in NCSL’s Health Program.
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