Aaron Isle knows what it’s like to have a severe toothache but not to have the money to get it treated.
The 38-year-old Baltimore man works in the restaurant industry, sometimes as a server, sometimes as a bartender or manager. His current job offers no medical benefits, so he depends on the state’s Medicaid program for health insurance, but Maryland provides little or no dental coverage for adults.
“I’ve had to cancel appointments or reschedule them — sometimes just suffer through the pain until I can afford to get it taken care of,” Isle said in an interview at Baltimore’s Chase-Brexton Health Care, a nonprofit clinic where he receives dental care.
Isle is one of more than 700,000 Medicaid-eligible Marylanders — roughly 13 percent of the population — whose insurance will cover an emergency room visit to treat oral infections or pain, but not the cost of dentistry to prevent or fix the underlying problems. Health care advocates from across the state traveled to Annapolis Wednesday to urge the General Assembly session to close what they call a glaring coverage gap in Maryland’s medical safety net for low-income adults.
About two dozen dentists, patients and advocates appeared before the Senate Finance Committee to support legislation that would require the state to expand its Medicaid coverage to include at least a limited dental benefit to adults. They urged lawmakers to look beyond the estimated costs of launching the program and to focus on the money the state could save by reducing costly emergency room visits and preventing more serious health problems.
The legislation, sponsored by Sen. Thomas M. “Mac” Middleton, is the product of a multi-year push by the Maryland Dental Action Coalition, an advocacy group representing dentists and other health advocates.
Last year, the group helped pass legislation authorizing the governor to put money in the state budget for adult Medicaid dental care. Gov. Larry Hogan did not do so in next year’s budget.
This year the coalition wants to make it a spending mandate. Hogan has consistently opposed such mandates.
“Despite what certain members of the legislature might believe, passing a bill that mandates new services does not automatically create the funds to provide them,” Hogan spokesman Doug Mayer said. “Senator Middleton’s bill will not create these funds either.”
Advocates say they want to elevate the quality of Maryland’s dental care for low-income adults in the same way it was improved for children covered by Medicaid over the past decade.
The state’s overhaul of children’s dental care was driven by the death in 2007 of Deamonte Driver, a 12-year-old Prince George’s County boy who died when an untreated tooth abscess spread to his brain. His mother had been unable to find a dentist to perform an $80 tooth extraction. His death put Maryland in a poor national spotlight and helped shame legislators into shoring up care for children.
“We are virtually a model for the nation in terms of oral care for children,” said Mary Backley, executive director of the dental coalition. “It’s time for us to step up and do the same for adults.”
Maryland ranks in the bottom third of Medicaid dental care for adults, according to the Center for Health Care Strategies, a New Jersey-based advocacy group.
Maryland is one of 14 states the center classifies as offering only emergency care services. Under Middleton’s legislation, Maryland would join another 17 states that offer limited dental services.
Middleton, who chairs the finance committee, pointed to an estimated average of more than 500 cases a year in which patients go to emergency rooms with dental conditions so severe they must be admitted for medical care.
“There’s greater cost if these people show up in the emergency and need to be admitted,” the Charles County Democrat said. “It’s significant.”
Maryland has up-to-date statistics on the cost of emergency room care for dental problems because legislation Middleton sponsored last year called for a study of the issue. When the report came in last month, it showed that those inpatient admissions cost $9,274 on average, for a total of $4.6 million a year.
The study by DentaQuest Institute put the cost of dental-related emergency room visits at an average of almost $30 million a year from 2013 to 2016.
Natalia Chalmers, research director for DentaQuest, said her study of the outcomes of those visits yielded a more disturbing statistic: She found 15 cases during those four years in which adults died after being admitted to hospitals with severe oral health conditions.
“We had 15 Deamonte Drivers,” she said. “Adults.”
Witnesses told lawmakers Wednesday that the demand for adult dental care overwhelms the availability of pro bono services.
Deacon James Nalls, Catholic Charities’ outreach director for the Washington Archdiocese, said his organization sponsors a Mission of Mercy event each year to provide free dental care at the University of Maryland, College Park. He said people begin lining up about midnight.
His job, he said, is to go out at about 6:30 a.m and tell about half of the roughly 1,000 patients that they won’t receive treatment.
“I shouldn’t have to do it,” Nalls told the Senate panel. “Please put me out of business.”
Supporters said proper dental care has consequences far beyond teeth and gums.
“Oral health is health,” said Harry Goodman, the former chief of dental health for the state health department. “It affects adults, not just in their mouths but in systemic health.”
Dentists say poor dental health can be related to diabetes, cancer, heart disease, rheumatoid arthritis and premature births.
Brooks Woodward, director of the dental clinic at Chase-Brexton, said the best emergency rooms can do for dental conditions is to provide antibiotics and painkillers. He said Chase-Brexton has an unofficial policy of limiting such prescriptions to three refills to avoid contributing to the pervasive problem of opioid addiction in Maryland.
Athena Haniotis said years of poverty and homelessness left her with a backlog of root canals and crowns that she can’t afford. The 39-year-old Baltimore woman has had teeth extracted she might have saved if she’d had the money to fix them. And she recalls having a broken tooth and no insurance to cover it.
“I remember being rolled up in a ball on the floor and wanting to put my head through the floor because I was in so much excruciating pain,” she said.
When she’s gone to the ER for dental problems, she said, she’s had trouble getting pain treatment.
“They kind of look at you as if you’re trying to obtain the prescriptions to abuse,” she said.
The price tag of coverage remains a barrier to expansion.
The Hogan administration sent no witnesses to testify Wednesday, but Mayer told The Baltimore Sun the Maryland Department of Health estimated that adding adult dental coverage to Medicaid would cost an additional $50 to $160 million a year, including federal funds. He noted that lawmakers haven’t identified a funding source for the expanded benefit.
The Department of Legislative Services puts a different cost on the expanded benefit. Noting that the federal government would match the cost of mandated benefits with two dollars for each one provided by the state, it puts the tab for the state at $15.1 million for six months beginning in January 2020, rising to $34.6 million a year three years later.
Mayer said the health department questions the legislative estimates.
Middleton said his bill might be “a little bit premature,” and that an expansion might require a more extensive cost-benefit analysis. He indicated a willingness to work with the Hogan administration on a long-term plan to add a dental benefit but also signaled that if the governor isn’t prepared to negotiate, the spending mandate could pass.
“It’s my gut feeling that the benefit outweighs the cost and we’re probably already paying for it anyway,” he said. “I’m just hopeful we can do something this year.”