The Cost of the GOP’s Medicaid Cuts: ER Bills for States and a Spiraling Oral Health Crisis

Dentist Dr. Tara Prasad thinks a lot about the logistics of homelessness — how difficult it is to brush your teeth when you don’t have a place to store a toothbrush, or how to protect a life-changing set of dentures when you’re sleeping and someone may steal your belongings. Prasad is the dental director at Boston Health Care for the Homeless Program, where she often sees patients who have delayed dental care for a long time. 

Prasad and oral health providers in several states are bracing for impact as the fallout of HR1, also known as the One Big Beautiful Bill Act, descends upon state legislatures. The budget law’s cuts to Medicaid — to the tune of over $900 billion over the next 10 years — are now being passed on to state legislatures. 

“This is a movie we’ve seen before,” said Alex Sheff, senior director of policy and government relations at the advocacy group Health Care for All Massachusetts. In lean times, optional Medicaid adult dental benefits have often been the first on the budget chopping block as states search for ways to make up for shortfalls. But history has shown that these cuts are a fool’s bargain, with dire consequences for both states’ budgets and their residents’ health.

Following the passage of HR1, Massachusetts state legislators originally proposed a $1,000 cap for dental benefits, which alarmed oral health providers and advocates. According to Dr. Prasad, over 25% of her patients’ care exceeded that cap — meaning they would be responsible for any costs over that amount. A new proposal from the state House of Representatives raised the proposed cap to $1,750. 

But the proposed cap is missing a critical piece: 15 other states currently cap dental benefits, but often with exemptions for specific kinds of care or procedures. Chief among these is dentures, which Prasad describes as “the light at the end of the tunnel” for many of her patients, who sometimes require invasive treatments and full-mouth extractions. While $1,750 is right around the typical cost for two arches of dentures, according to Prasad, most patients would need extensive care prior to receiving dentures, and would be on the hook for the cost if dentures are not granted an exemption — and she fears that many would not want to move forward with their treatment without the guarantee of coverage for dentures. 

“Dentures restore someone’s dignity, allow them to eat again without pain, enable patients to go to job interviews, reconnect with their families,” Prasad told TPM. There is currently no proposed exemption to allow Medicaid participants full coverage for dentures in Massachusetts, and MassHealth only covers dentures every seven years. 

The $1,750 cap is projected to save the state $35 million annually — but according to Melissa Burroughs, senior director of policy and advocacy at the national oral health nonprofit CareQuest Institute for Oral Health, caps like this are “a false financial trade-off.” 

Massachusetts is not alone; Colorado recently passed a $3,000 cap to adult dental benefits, and Virginia is considering a $2,000 cap. These measures would impact around 750,000 Medicaid participants in each state (Virginia legislators did not pass a budget before the end of the legislative session, and are now in a special session to do so before the new fiscal year begins in July). 

Idaho considered cutting its dental benefits altogether — something the state already did back in 2011, and has slowly built back since then. The state budget passed with holdbacks, preserving adult dental coverage for now. But the question of dental coverage cuts will likely return again in future legislative sessions. 

Several states have also enacted cuts to provider reimbursement rates to reduce costs following HR1, according to Burroughs. Nationally, as few as one in three dentists treat Medicaid patients, largely because they are reimbursed at far lower rates for those patients compared to patients with commercial insurance. 

In Massachusetts, nearly two million people — or one in three residents — are enrolled in MassHealth, the state Medicaid and CHIP program. About half of them would be subject to the new cap if it passes, experts estimate. 

“Anybody who has had the experience of having significant tooth pain knows how disruptive it can be, but it’s broader than that,” said Sheff. “It impacts our ability to eat, to speak, to sleep, to connect with other people, and participate fully in our lives.” Oral health is also connected to the overall health of a person and the population at large, he says. “It’s linked to improved chronic condition management. It’s linked to better pregnancy and surgical outcomes. It’s linked to better outcomes for recovery from substance use disorder, and even greater access to employment opportunities.”

Although reducing dental coverage may save states money in the short term, the cuts come with a steep price. 

“When benefits are cut, people don’t stop needing dental care. They just stop getting the dental care they need in a preventative setting or in a safe setting,” said Burroughs. “That’s when you see people showing up in emergency rooms for dental needs that could have been prevented. You see families that are pushed deeper into debt, or that their health outcomes are getting worse because they can’t get their dental needs addressed.”

The average cost of an emergency room visit for a non-traumatic dental concern (like an abscess or severe toothache) was $2,437 in 2022 in the U.S. When patients are unable to pay these hospital bills, those uncompensated care costs are often passed onto struggling hospitals; those costs may result in further strain on state budgets that support healthcare infrastructure, and in insurance carriers raising premiums on commercial plans, according to Burroughs. 

You don’t have to take Burroughs’ word for it — following the 2008 financial crisis, several states cut dental benefits to make up for budget shortfalls, and researchers have already analyzed the data for what happens when Medicaid adult dental benefits go away. One nationally representative survey found that eliminating medicaid adult dental coverage was associated with a 60% increase in dental uninsurance, and a 37% decrease in the proportion of people who visited a dentist in the past two years between 2010 and 2021. After Idaho eliminated its dental benefits in 2011, monthly emergency room costs for dental issues more than doubled by 2014. 

Pennsylvania limited its adult dental benefits in 2011 to save $19 million. But according to the Pennsylvania Coalition for Oral Health, the state and its residents now pay for over $35 million in emergency department visits for preventable dental issues annually, most of which could have been treated in a dental office. Those ER visits jumped 60% after 2010, and expensive inpatient hospitalization for oral diseases more than doubled from 2010 to 2016. 

Similarly, California Medicaid’s elimination of its comprehensive adult dental coverage in 2009 led to an immediate 68% increase in average yearly costs of emergency room visits for dental issues. Not only this, but “it also increased instances of severe dental infections, and some of them even leading to hospitalizations and fatalities,” said Sheff. 

According to Burroughs, California’s 2009 cuts also led to a drop in provider participation, and long-term impacts to healthcare infrastructure. “Even after those benefits were fully restored in 2018, the state still hasn’t been able to rebuild access to what it looked like before those initial cuts in 2009,” she said. The American Dental Association estimates that a single year without any Medicaid adult dental benefits would cost the U.S. nearly $2 billion.

“I would caution lawmakers, if I were to talk to them, about making short-sighted decisions purely based on financial perspectives,” said Prasad, “because ultimately patients will pay, the system will pay for delayed and prolonged care.” 

The irony of state legislatures repeating their own self-sabotaging history is not lost on Burroughs. “You’d think in states like Idaho or Massachusetts or California,” she said, “that they maybe would have learned some lessons from previous rounds of cuts.” But she acknowledges the impossibility of balancing state budgets in the face of a $1 trillion reduction to Medicaid. “They don’t have a lot of options, and they’re forced to make real trade-offs.”

Lower-income communities and medically vulnerable populations will see the biggest impact of changes to Medicaid coverage, as they are also the least likely to be able to afford costs that exceed any new caps. Safety-net providers, like rural hospitals, community health clinics, and federally qualified health centers — whose patient populations often experience more severe oral health issues due to limited access to preventative care — will bear the brunt of any coming austerity, through low Medicaid reimbursement rates, uncompensated care costs, and the complexities of enhancement fees. Millions of individuals are expected to lose their Medicaid as states begin to implement the work requirements of HR1. 

Prasad is concerned about the confusion that a new cap might sow among her patients, who have often been disenfranchised from healthcare.”One of our biggest concerns is that people will just truly not want to go to the dentist because of concerns about receiving a bill,” or fear that the services they need are no longer within reach, she said. She is also worried that patients will start putting off preventative care to avoid reaching the $1,750 cap, which could compromise their long-term oral health. 

Oral health providers who work with low-income populations know that delaying care isn’t trivial — in fact, it can be a matter of life and death. In 2011,  24-year-old Kyle Willis paid the steepest price of his country’s healthcare coverage system. With an aching tooth but no insurance, he put off an unaffordable tooth extraction and antibiotics, and died within two weeks when the infection spread to his brain.

Thinking about her patients, Prasad hopes she and her team can continue to make oral healthcare feel accessible, despite coverage instability. “I would want [my patients] to know that their oral health providers are still there to provide the services that they need, that they should not put off addressing infection, any concerns that they have about their oral health because of this cap,” she said. “Though it seems scary that there might be changes that are coming, our facility and other facilities that are committed to the communities that we serve will still be providing this essential care.”