Rita Sokolowski has been living with no top teeth and a denture that doesn’t fit for the past four years. In July of 2009 when the state eliminated most adult dental services under the Medi-Cal dental program called Denti-Cal, Sokolowski and an estimated 3 million other Californians lost virtually all of their dental benefits as a result of budget cuts.

“I’ve lost a lot of my confidence. It’s very degrading and humiliating. It’s harder to talk to people without making sure you don’t smile too hard,” said the 67-year old retired teacher and school administrator who lost her teeth to a violent attack. She now cares full time for her 95-year-old mother in Santa Cruz.

But in May of 2014 Sokolowski and millions like her will have their Denti-Cal benefits largely restored through a provision of the state budget.

“We’re thrilled we’ve got at least a partial reinstatement and hopefully we can build from there,” said Lindsey Robinson, a dentist in Grass Valley and president of the California Dental Association.

Carmela Castellano-Garcia, President and chief executive officer of the California Primary Care Association, which represents the state’s non-profit community clinics and health centers, called it “a robust restoration.”

The restoration of adult Denti-Cal was part of Assembly Bill 82, a bill added onto the 2013-2014 budget and supported by Senator Darrell Steinberg (D-Sacramento) and Senator Bill Monning (D-Carmel).

They toured one of the massive free dental clinics that the California Dental Association (CDA) and its foundation organizes twice a year in different cities. More than 2,000 patients stand in line overnight, some of them in wheel chairs, to get cleanings, fillings, extractions and dentures. CDA reports that one in three Californians do not have access to dental care.

At the CDA clinic in the San Jose Convention Center in May more than 1,658 volunteers provided $1.6 million in dental services to about 2,000 patients.

While Denti-Cal reinstatement is good news for patients, community clinics and federally funded health centers, there is a long road to restoring dental care to low-income people.

One of those is the Aug. 14 announcement by the California Department of Health Care Services (DHCS) that it will begin implementing a provision of AB 97, passed in 2011, requiring a 10 percent reduction in Medi-Cal provider payments. The California Medical Association (CMA) and others filed a lawsuit to stop the cuts and a district court ruled in favor of CMA. But the 9th Circuit Court of Appeals reversed that. Dental providers will see those cuts start on Sept. 5 of this year. And the cuts will be retroactive to June 1, 2011.

These cuts may make it difficult to find a dentist that accepts Medi-Cal, especially when 1.4 million more people will qualify for the coverage starting in January, when health care reforms kick in.

California already has one of the worst Medicaid reimbursement rates in the country. Only four states have a lower reimbursement rate, said René Mollow, deputy director of health-care benefits and eligibility for the California Department of Health Care Services. Medi-Cal is the California version of Medicaid.

Given the low rates and onerous reimbursement process, many private dentists have decided they can’t afford to take Denti-Cal patients. The California Medical Association reports that 56 percent of Medi-Cal patients have difficulty finding a doctor.

“Even if they had not cut reimbursement by 10 percent, it would be difficult to get providers to come back, not knowing when the rug will be pulled out from under them again,” Robinson said.

DHCS reports there are approximately 15,000 providers taking Denti-Cal outside of the federally qualified and community health clinics. That’s up from 14,000 prior to the reduction in Denti-Cal benefits, Mollow said.

The California Association of Rural Health Clinics has sued DHCS and on July 5th won a ruling from the 9th Circuit Court of Appeals that the state law which eliminated adult dental, podiatry, optometry and other services conflicts with the Medicaid Act. DHCS has requested a rehearing. If the Association prevails, the state would have to retroactively pay for services, Castellano-Garcia said.

Many county and federally-funded clinics have been on unstable financial footing for years now.

“We’ve been charging adult patients, but at a fraction of the actual cost of providing services. But it was increasingly unsustainable,” said Dorian Seamster, director of patient services and quality improvement for Salud Para la Gente, a federally qualified health center (FQHC) in Watsonville. FQHCs are safety net organizations receiving federal funding and obligated to serve people regardless of their insurance or ability to pay.

Salud has had to prioritize patients.

“If you have an infection, we will treat that, but getting a root canal may not be possible. We will pull a tooth, but cannot cover the cost of getting the tooth replaced,” Seamster said.

Some clinics didn’t make it. At least three FQHCs in Humboldt, Colusa and Orange counties have closed due to Denti-Cal cuts, Castellano-Garcia said.

“For me and my clinic, it was a $2 million hit,” said Dr. Ariane Terlet, chief dental officer of La Clinica de la Raza Inc. based in Oakland. La Clinica is an FQHC, so while it receives significantly more Medi-Cal and Denti-Cal compensation than a private provider does for the same procedures, most of its patients are uninsured, Terlet said.

“We’re required to have a safety net, we’re not required for it to work well,” Terlet said.
“We have not financially recovered from the hit yet. The next few months will determine who gets laid off. In 27 years we haven’t had layoffs. It’s really tough.”

When the safety nets don’t have the funding to provide preventive care and treat problems before they escalate, people end up in the emergency room. Oakland-based Highland Hospital, a public hospital operated by the Alameda Health System, saw a big increase in emergency room visits between 2007 and 2009.

“The hospital was wondering what was going on,” said Anthony Mock, director for the hospital’s emergency dental clinic and chief of general dentistry for Alameda Health System. In 2007 the emergency room had 2,400 emergency dental visits. That jumped 50 percent to 3,600 in 2009 and 75 percent to 4,196 last year. In 2011 there was a 96 percent increase compared to 2007.

Mock says this partial reinstatement of Denti-Cal doesn’t go far enough. It doesn’t cover partial dentures or periodontal work like deep cleanings or surgeries.

“Maybe providers will over treat to make full dentures,” he said. “It means they will take out a lot of good teeth as well.”

“Denti-Cal reimbursement is not good, but it’s better than nothing at this point,” Terlet said. “Now if you have Medi-Cal and walk into the ER with a broken tooth they have to pull it.” With partial Denti-Cal reinstatement in May those teeth can be fixed, she said.

Getting more doctors to take Denti-Cal will be a huge factor in how many patients can actually use their benefits. The Denti-Cal program has been streamlining its enrollment and claims processes and is doing a lot of provider outreach and training, said Mollow of DHCS.

“We recognize the value of dental services, it was a very difficult decision that had to be made by both the administration and the legislature in response to the significant fiscal challenges the state has,” she said. She said the state estimates it saved $189.6 million in fiscal year 2009/2010 and $221.7 million in 2010/2011.

But with the Denti-Cal cut the state also lost $134.5 million of federal matching funds, stated a 2009 report funded by the Dental Health Foundation, the Oral Health Access Council and the California Primary Care Association.

On the ground the state’s fiscal challenges translate into scenarios like this year’s effort by Salud and other clinics and county agencies. They jointly rented a bus for 200 county residents, some of them toothless, to go to CDA’s free dental clinic in San Jose at 5 a.m. Once there, they stood in line at to get their teeth fixed, pulled or replaced.

And those were the lucky ones.