Story Produced by New Hampshire Bulletin
Julie Hilliard faces two significant challenges every time her son Cameron, 30, needs basic dental care.
His intense fear of medical procedures, triggered by his severe intellectual disability, autism, and epilepsy, requires restraints, anesthesia, and treatment in an operating room, even for a cleaning. But before Hilliard can book that appointment, she must find a grant to cover what can be a $5,000 bill because Cameron’s Medicaid does not include preventative care.
“What’s covered in New Hampshire is they will go in and pull the tooth out,” said Hilliard, of Claremont. “They won’t even clean the other teeth while they are in there.”
One anesthesiologist proposed a solution, telling Hilliard she should have all her son’s teeth pulled and be done with it. “He could even learn to eat steak with no teeth,” Hilliard recalls him saying.
Federal law requires that all children on traditional and expanded Medicaid receive free preventative and emergency dental care and restoration of their teeth. New Hampshire is one of 10 states that provide only emergency dental benefits for adults, according to the American Dental Association. That means the state will cover a tooth extraction for the approximately 85,000 adults on traditional and expanded Medicaid in New Hampshire but none of the preventative care to avoid that extraction.
For the third straight year, lawmakers are working to change that.
A Senate bill that had unanimous support in that chamber this year will be back. And a scaled-back version of House Bill 103, which was retained last session over cost concerns, will head to the full House in January with near-unanimous support from the same committee that retained it. As reworked last week, the bill would provide expansive preventative care for adults with the addition of a co-pay for those with incomes above 100 percent of the federal poverty level and a limit on who gets dentures coverage.
The cost is estimated at about $27.5 million, $20 million of it paid for by the federal government, which covers half the cost of dental expenses for traditional Medicaid recipients and 90 percent of the cost for those on expanded Medicaid.
“I think there is good reason to believe it will pass,” said Rep. Jess Edwards, an Auburn Republican who, like others in his party, was uncomfortable last session with the price tag and absence of a co-pay. “If we only get half of the Republicans to vote for it, it’s going to pass pretty handily.”
What looks like broad support, however, doesn’t guarantee success. This benefit has died at the finish line before.
In 2019, Gov. Chris Sununu signed a bill directing the Department of Health and Human Services to create a plan for providing broad dental benefits for adults. The department convened a working group of health care advocates and Delta Dental, which has been a strong advocate of expanding adult benefits beyond only emergency situations.
Two years later, plan in hand, lawmakers brought forward new legislation for adult dental benefits with overwhelming support from the House and Senate. Lawmakers heard from people like Tim McKernan, the director of policy and advocacy for ABLE NH.
McKernan, of Pembroke, grew up getting dental care under his mother’s insurance plan. When he moved to California in his 20s, he had little money and no dental insurance. A painful wisdom tooth was making it difficult to go to work, but McKernan put off care knowing he couldn’t afford it.
When someone told him about a free dental clinic, he waited there all day in hopes of getting an appointment. He did and went home with the wisdom tooth out and without a bill. “It was just the sense of vulnerability and uncertainty and not knowing if I was going to be taken care of or what was going to happen to me,” he said. “I knew dental infections were dangerous and could lead to death.”
When the bill reached Gov. Chris Sununu’s desk in July 2020, the state was four months into the pandemic. Sununu vetoed it, citing concerns about spending $11 million when the state was navigating economic uncertainty. In his veto message, Sununu said he supported the concept and hoped more work would produce an affordable and sustainable plan: “If so, we can implement a benefit at such a time as the state has the financial resources to do so in a responsible, cost-effective manner.”
Gail Brown, director of the New Hampshire Oral Health Coalition, remembers that day well.
Brown had begun her advocacy for adult dental benefits nearly two decades earlier and spent those first years educating lawmakers of both parties about the connection between poor oral health and dozens of other illnesses, from heart disease and birth complications to Alzheimer’s and osteoporosis. With leadership from Sen. Jeb Bradley, a Wolfeboro Republican, Brown and fellow advocates called it a big win when lawmakers came to see oral health as overall health. She was devastated to see the bill vetoed.
“It was like someone pulling your heart out because we had worked together for so long,” Brown said. “There was bipartisan, unanimous support in the Senate. There was overwhelming support in the House. To have it not happen, it was just like having a hole in your heart.”
Dental benefits returned in 2021, with bills introduced in the Senate and House.
During the Senate’s public hearing, 255 people signed in to support the bill, and one to oppose it. The bill passed the Senate 24-0. The House bill saw similar overwhelming support – 131 in favor, seven opposed – but was retained in committee. An unexpected, last-minute disagreement over the cost of expanding the dental benefit couldn’t be resolved before the session ended.
Rep. Keith Ammon, a New Boston Republican, was among those seven to oppose the House bill. He said in an email last week that he supports the amended version because it includes cost-sharing and a more stringent requirement on Health and Human Services to provide a legislative oversight committee an annual report on the utilization of benefits, participation of dental providers, and other indicators of program effectiveness. “Better reporting helps ensure program costs don’t become unsustainable,” he said.
Ammon also said he thought the original bill was too expensive and not sustainable. “The amendment strikes a better balance between making sure the most vulnerable receive dental care and respect for those who pay for dental care out-of-pocket,” he said.
The limit on denture care and addition of a co-pay could be a tough sell to some lawmakers and oral health advocates who’ve worked for more than a decade on this issue.
Dentures will be covered only for nursing home residents, adults with developmental disabilities or acquired brain disorders, and Medicaid recipients who receive medical and other services at home under the federal Choices for Independence program. Adults receiving expanded Medicaid services for substance abuse would not be included unless they fell into one of those categories.
Edwards said the co-pays of 5 to 10 percent of a dental bill would provide benefits to those who most need but can least afford them, while also keeping taxpayers in mind.
“It’s out of respect for taxpayers who don’t get free dental insurance,” he said. “You may have an option to pay for dental insurance, but it’s not free. So, although a Medicaid beneficiary would not be paying at the same rate as a taxpayer on a commercial program, we thought it was important to let the taxpayer know that the medical beneficiary is also paying for a similar benefit.”
Rep. Joe Schapiro, a Keene Democrat who sits on the House’s Health, Human Services, and Elderly Affairs Committee, was reluctant to support the amended version. During his years as a social worker and psychotherapist, Schapiro saw clients who suffered greatly because they could not afford dental care. He recalled one, a single mom on Medicaid, whose benefits covered her children’s dental care but not her own. She was paying for root canals and caps with a credit card and dental plans, which often come with high-interest rates.
Schapiro is concerned even a small co-pay of 5 percent to 10 percent of a service, the maximum allowed by Medicaid, will be beyond the reach of some and lead them to forgo dental care.
“My concern is that it doesn’t save a lot of money and that it will reduce utilization,” he said. “What we want to do is improve public health and have these people going for the most important thing, which is preventative service, and then restorative service, and then go out and get dentures so they can get jobs and get off Medicaid.”
The compromise is a step in the right direction, he said, but a tough one to take.
“I had to really struggle whether to agree to a cost-share, which in principle I don’t think is a good idea,” he said.
When the committee holds a public hearing on the amended bill, Hilliard will likely be back to tell Cameron’s story and make a strong case for expansive dental benefits.
“Cameron has no speech and mentally he functions at a 2-year-old level. He has no understanding of what we are doing for him,” she said. “He is completely helpless. It is unconscionable that this is at all an acceptable dental practice – to just pull his teeth out one by one until he has none. And this is what they consider ‘care.’”
This story was reproduced with permission under NH Bulletin’s Creative Commons license.