In 2024, CMS announced new policies intended to expand access to dental services though Marketplace plans, creating an opportunity for states to impact oral health directly and broader outcomes indirectly. Poor access to preventive and routine dental services has severe consequences, financially and  in personal and population health. Most directly, untreated dental problems lead to emergency department visits.   In the longer term, poor oral health is a known contributor to widespread and costly chronic conditions. Periodontal disease leads to higher rates of hypertension, diabetes, and dementia, as well as adverse birth outcomes. The burden of these conditions is disproportionately born by low-income communities, so poor oral health contributes to and magnifies disparities by income, race, ethnicity, and urban/rural residence. The inequity in access to dental care also exacerbates economic disparities broadly. Low-income households spend more out of pocket on dental services due to lack of coverage. Moreover,  individuals with untreated dental problems are less likely to be hired, and more likely to miss work, leading to lost income. Preventing these sequelae through improved oral health depends heavily on coverage of routine and preventive dental care. 

While federal Medicaid rules require coverage of routine preventive dental care for children, each state determines whether to cover dental services for adults.  Nearly all states cover emergency dental services for adults, and a majority offer some additional dental coverage beyond emergency services for adults.   Still, only one-fifth of adult Medicaid enrollees received any dental service in the last year.  The rate varies depending on state policy, with states offering extensive coverage having a rate more than five-fold higher than states with no coverage, and 2.5 times higher than states with emergency-only coverage (see chart).  Medicaid dental coverage is a lever available to states seeking to promote oral health, population health, and health equity.  

Data Source: KFF analysis of the T-MSIS Research Identifiable Files (2021) and National Academy for State Health Policy (NASHP) State Tracker, Updated October 2022

Dental services are also a valuable avenue for patient engagement.  Educating dental providers and patients about post-procedure opioid use is an effective prevention strategy for opioid use disorders (OUD).  Providing dental services for individuals with diagnosed substance use disorders (SUD) has been found to increase retention in SUD treatment, especially for populations affected by housing instability and other unmet health-related social needs.  

States are increasingly recognizing Medicaid dental coverage as an opportunity to improve population health and reduce disparities. All states now provide comprehensive dental coverage for pregnant members as a strategy to improve birth outcomes and address disparities in maternal health. Some states have included dental coverage in plans targeting adults with SUD and unmet health-related social needs (HRSNs), in order to engagement in both dental care and SUD treatment in this historically hard-to-engage population. CMS has introduced measures related to oral exams, fluoride application, and dental sealants into the Child Core Set. States can also incorporate adult dental quality measures into Medicaid Managed care.   

The relationship of dental care and SUD treatment is highly relevant for justice-involved individuals; incarcerated individuals have higher rates of untreated tooth decay and periodontal disease, as well as SUD.  As states begin providing pre-release and re-entry Medicaid services, dental care may be synergistic with behavioral health services, leading to increased stability in this population. 

Medicaid coverage for dental services is cost effective for states, as routine treatment avoids ED visits and reduces chronic disease.  In order to promote oral health more broadly, states can combine expanded Medicaid coverage with requirements for Marketplace-based coverage. The recent Executive Order allows states to list dental services as an essential health benefit, which would extend coverage not only to Medicaid members, but to all enrolled in Marketplace plans, allowing states to have a larger impact through dental coverage. For maximum effect, states may need to employ complementary strategies to address provider shortages, such as tele-dentistry, mid-level licensing, and community clinics. There is current evidence that tele-dentistry in particular can facilitate dental referrals and treatment planning and improve access for rural communities.  

Oral health sits upstream of chronic disease, impacting maternal health, behavioral health, rural health, and vulnerable populations generally.  This allows states to enhance their population health strategy across the board by targeting access to dental services.  

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