Every morning she gets the chance, Andrea Hall Rodgers sings Raffi’s 1976 classic children’s song “Brush Your Teeth” to her son Ian at the bathroom sink as encouragement.

Ian Joya, 31, has intellectual disabilities. For him, tooth brushing can be painful, as he has had to go without oral health check ups for years at a time.

Around the time Joya turned 21, dental health insurance benefits were dropped from the state Medicaid plan that insures people with low incomes as well as people with disabilities.

Today, Joya is among more than 350,000 Hawaii adults with Medicaid insurance who have gone a decade without dental health coverage.

“We’ve had two cleanings since he turned 21, and that’s in 10 years,” Rodgers said. “We’re talking $4,500 for a deep cleaning, flossing and an exam. They’re not doing root canals.”

Andrea Hall Rodgers and Ian Joya

Andrea Hall Rodgers and her son Ian Joya, who is covered by Medicaid, have had to pay thousands of dollars out of pocket for his dental care.

Courtesy Andrea Rodgers

The Legislature this year will consider reinstating adult dental benefits to Med-QUEST, the Hawaii state division that oversees the federal Medicaid insurance program.

House Bill 2249 and its companion, Senate Bill 2459, are similar to a bill that failed last year in the House Finance Committee.

“By the end of the session, the funding for it had been whittled down to such a small amount, so we thought we’d come back this year,” said Sen. Russell Ruderman, who introduced SB 2459.

This session, both Senate and House bills seek a $7 million appropriation for diagnostic, preventive and restorative dental benefits added to Medicaid with the possibility of leveraging 50% more in federal matching funds. The ask represents less than 1% of the entire Department of Human Services budget of $3.6 billion.

The Hawaii Oral Health Coalition is making it one of its top legislative priorities this year, said Dr. Nicole Nakashima, a dentist and one of HOHC’s leaders as Hawaii Public Health Institute’s oral health and policy coordinator.

“From our point of view, it is a social justice issue but it’s also a wise investment for the state,” she said.

Hawaii is among a minority of states that only fund emergency dental services for adult Medicaid patients. Those emergency services are limited to pain relief, injuries, trauma and tooth removal. As a result, visits by Medicaid patients to the ER represent more than half of all emergency dental service visits in Hawaii.

Hawaii Med-Quest Administrator and Medicaid Director Dr. Judy Mohr Peterson said the division is supportive of the restoration of the adult dental benefit, as long as it fits in the DHS budget.

The Med-QUEST division plans to publish a more detailed report with cost estimates for various tiers of coverage this month, she said.

What a dental benefits package would look like is still up for discussion. There are different tiers of coverage, each with a different level of dental service offerings. Policy makers could end up customizing a new benefit, or perhaps one that covers a certain population such as only pregnant women or people with disabilities.

Last January, Medicaid insurers AlohaCare and Ohana Health Plan began to offer a basic dental package, which includes twice a year cleanings, a set of X-rays, fluoride, as well as one non-emergency extraction or filling.

In its first year, 2,212 AlohaCare members have utilized the free benefit, according to Paula Arcena, the executive vice president of external affairs for AlohaCare.

“We decided to offer the benefit because we knew there was a need,” she said. “The costs of caring for someone who is healthy versus unhealthy are dramatic.”

A Decade Without Dental

Dr. Anthony Kim, the dental director at Waimanalo Health Center and a member of the coalition, has witnessed how the oral health of the community has unraveled in the years since the benefit was dropped.

A significant number of patients at the health center — approximately 40% — are covered by Med-QUEST.

Almost overnight, regular patients stopped coming to see him, except for emergencies.

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Kim said in the years since, “countless” patients have sought help for painful abscesses, and a few of them had to be referred to a hospital. Nearly all of the cases could have been managed by regular teeth cleanings and basic fillings.

“The emergencies that we’re seeing are a result of years of decay or gum disease that go unchecked,” Kim said. “Unfortunately for the patients it becomes debilitating and it can permanently disfigure them.”

At Waimanalo, there has been a surge in urgent dental care visits since the benefit was dropped, mostly among the adult population with Medicaid insurance.

“We’re being swamped with walk-ins and we’re trying to deal with more acute specific issues,” Kim said. “The tragic part of this decade now is that the rise of urgent dental care is like a man-made epidemic. We basically created our own epidemic by putting up this barrier to care for those adults.”

‘Slammed’ Clinics

The story of Waimanalo Health Center echoes that of other dental clinics, especially in more rural areas.

“Our coalition members report that their clinics are slammed,” said Nakashima of the Hawaii Oral Health Coalition. “The wait to see a dentist is incredibly long. On some of our neighbor islands, you need to wait months and months in advance and that’s because the only coverage they can afford is at a federally qualified health center.”

Data shows an increasing reliance on emergency rooms for oral health care over the past decade, and the highest rates of ER visits for oral health care are on neighbor islands.

Residents of the North Shore of Oahu and from Kauai and Hawaii counties are more likely than urban residents to go to the emergency room for dental problems, according to data from Hawaii Oral Health: Key Findings report.

In addition, new data also outline how oral health inequities have consistently affected Native Hawaiian adults and children.

A 2017 study found Native Hawaiians had the largest proportion of excess tooth loss. And the rate of preventable emergency oral health visits for Native Hawaiians was 27.3%, more than 1.5 times greater than the 17.6% for non-Hawaiians.

Anthony Kim

Dr. Anthony Kim, the dental director at Waimanalo Health Center, says the bulk of his work load has shifted from regular check ups to urgent appointments.

Eleni Gill/Civil Beat

There are currently about 68,000 Native Hawaiians covered by Medicaid, according to Papa Ola Lokahi, the Native Hawaiian Health Board.

“Here in Waimanalo, with easily more than half of our patients being Native Hawaiian, it almost becomes personal,” Kim said. “Having a financial barrier has really impacted the outcomes. The thing that is most frustrating is that this is a winnable situation. With the proper access and the proper care, this is something that we could actually overcome.”

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