Steve Lockard got two cavities filled this summer. He also has new dentures to replace missing teeth.
While routine care for most people, it’s the first non-emergency dental care the 47-year-old house painter has received in about 15 years and only became possible when he became eligible for MaineCare dental coverage in July. He had to travel about an hour from his home in Moscow to the Community Dental Clinic of Waterville, but it was worth it.
“Before, I was always embarrassed to smile, but now I can smile. I just have that extra confidence now,” Lockard said.
But Lockard is one of the fortunate ones, and he knows it.
Maine already had too few dentists. And with more than 220,000 people having just become eligible for the MaineCare benefit, demand is soaring.
Jess Falero of Portland is one of the thousands of people who also became eligible for MaineCare benefits but can’t get in to see a dentist.
“Either dentists don’t have openings or they don’t accept MaineCare,” Falero said. “It has been 100% frustrating.”
Falero is suffering from two cracked teeth and multiple cavities. And while it’s nice that MaineCare has a dental benefit, the 25-year-old community activist said, the continued lack of access to care will result in poor health for many people.
“Democracy is notoriously very slow, but the need is notoriously very urgent,” Falero said.
Part of the reason is that the overall supply of dentists, dental hygienists and other staff is stagnant or declining, according to the Maine Dental Association.
The U.S. Bureau of Labor Statistics shows that in 2019 – before the pandemic – Maine had 590 dentists in general practice, declining to 510 in 2021, the latest year statistics are available.
Another part of the problem is that a large number of those dentists do not accept MaineCare patients because the program’s reimbursement rates are so low.
The state lists about 40 dental practices that accept MaineCare patients, although the Maine Dental Association said there are likely more practices that will at least accept some MaineCare patients. Some dentists have a cap on the number of such patients.
In some cases, patients could have to travel hours to reach a dentist willing to see a new MaineCare patient.
Reimbursements for MaineCare dental work have improved by about 70% with the adult dental expansion, but dentists are still only paid about two-thirds of what private insurance pays.
It’s not clear how many of the newly eligible patients are trying, and failing, to find a dentist.
Based on the experience of other states, about 3o% of the 220,000 newly eligible adults are expected to use the dental benefit and seek care. That amounts to about 70,000 more people who could be trying to find an open dentist’s chair.
The adult MaineCare benefit is “a great win for us and an achievement for us and the state of Maine,” said Melissa Watson, operations director for Community Dental, which has offices in Portland, Biddeford, Farmington and three other locations in the state. Despite the similar name, it is a different practice than Waterville’s Community Dental. “The downside of it is there’s no additional providers throughout the state of Maine.”
Advocates say access issues are real, but the system needs to be given time to absorb new patients.
“Something we’ve neglected for so long can’t be fixed overnight,” said Kathy Kilrain del Rio, advocacy and program director for Maine Equal Justice, a progressive group that lobbied for years for the law. Maine is now one of 37 states offering the adult dental benefit for Medicaid, called MaineCare in the state.
Dentists who do see MaineCare patients are reporting being bombarded with calls for appointments and have to turn them down because there’s not enough capacity.
“The demand right now for dental services is just so high,” said Dr. Kailee Williams, Lockard’s dentist. “It’s frustrating for patients calling and there’s nowhere to go.”
Williams said when the benefit opened up in July, they were flooded with new patient requests, and within a month had to stop accepting new patients. They will try to work some new patients in if there’s a cancellation, but it’s difficult and demand is much higher than the slots available, Williams said.
Lockard said he was able to get care at Community Dental because he had previously received emergency care there. Under the old MaineCare rules, those with the insurance could only get dental care if there was an emergency, such as needing a tooth pulled. Lockard said he only has about 1/3 of his natural teeth, and the rest are dentures, because he went many years without dental insurance.
Therese Cahill, executive director of the Maine Dental Association, said even before adding the MaineCare dental benefit, supply was not meeting demand. And the pandemic only led to more staff shortages and delays in getting care.
“Finding someone who is taking new patients is increasingly challenging,” Cahill said. “It’s been a longstanding problem, but the light has shined pretty brightly on it since the pandemic.”
Cahill said as the rollout continues, she’s hoping more dentists will agree to take on MaineCare patients, and that efforts to expand the workforce, such as graduating students into dental careers, will accelerate.
For now, staffing is a large obstacle, said Kate Hopkins, CEO of Community Dental. Part of the clinic’s mission is to serve MaineCare patients, but Hopkins said they have a 25% vacancy rate among dentists and 21% among hygienists, leaving them short-staffed while demand ramps up.
In fact, staff shortages led to an announcement Friday that Community Dental would be closing two of its locations this November – in Rumford and Monson.
Watson, the chief operating officer of Community Dental, said that despite improved reimbursement rates that were tied to the dental expansion – rates increased to where now MaineCare reimbursement is 67% of the revenue practices get from private insurance – it is still a financial disincentive to accept MaineCare.
“The idea that a lot of private practices would jump on this feels very unlikely,” Watson said. “Why would you add a less-paying service, and quite frankly a whole new way of billing, to your practice?”
Watson said programs that the state offers on loan forgiveness for those with dental careers are helpful, but could be improved to be more robust to help spur recent graduates to practice in Maine. Williams, for instance, said she has $500,000 in student loan debt to pay off.
Jeanne Lambrew, Maine’s health and human services commissioner, said the situation is similar to the overall MaineCare expansion in 2019. It will take time to build out the adult dental benefit, but the pieces are in place to improve access, she said. Part of it will be increased awareness and word-of-mouth as more dentists take on new MaineCare patients and find that the improved reimbursements can make the numbers work.
“We do think more dental providers are interested in serving MaineCare patients. We’re hopeful the combination of expanded access, the comprehensive dental benefit and higher reimbursement rates increase the number of dental providers in Maine,” Lambrew said. “It may take some time to get the supply to meet the demand.”
Lambrew said there are a number of programs in Maine that use federal funding to boost the health care workforce, including in the dental field.
The dental benefit is expected to cost the MaineCare program $45 million a year. Maine is now one of 37 states that offer adults some form of non-emergency dental coverage.
At the University of New England, the only dental school in Maine, the number of dental graduates will increase from 64 this year to 74 in fall 2023.
“This will mean more dental students treating patients across rural and underserved regions of northern New England, and ultimately, more licensed dentists in Maine,” said Nicole Kimmes, interim dean of the UNE College of Dental Medicine.
Kimmes said a loan forgiveness program for students who stay in Maine – sponsored by Delta Dental insurance – and an externship rotation for fourth-year students that immerses students “in rural and underserved communities for 10-12 week rotations” are keeping some graduates in the state.
Williams, the Waterville dentist, said the workforce shortage stemming from the pandemic has set back efforts to expand capacity.
“During COVID-19, we lost facilities. We lost providers,” Williams said. “Many places that came back, came back at a lower capacity. Some decided to stop practicing altogether.”
The 2020 shutdowns meant that all but the most urgent oral care was delayed, so when dental practices reopened, it took many months to catch up with their existing patients. And now there’s added demand.
Dr. Genko Stanilov, a dentist and dental director for Community Dental, said he hopes other dentists will start accepting at least some MaineCare patients.
“My message is to please give it a chance and hopefully they will see they can implement it in their practice,” Stanilov said.
Del Rio, the Maine Equal Justice advocate, said it’s important to remember that advocates lobbied for several years to get the dental benefit for adults with MaineCare, and there will be growing pains.
“There are people who are now getting access to care who couldn’t before,” del Rio said. “Over time, providers will come on board who aren’t there yet.”