By Anne Blythe
When North Carolina started enrolling more people in the expanded Medicaid program almost 15 months ago, hundreds of thousands of low-income people became eligible for an array of dental services.
But that didn’t mean dentists across the state started welcoming the new Medicaid beneficiaries onto their chairs. Nearly 60 percent of North Carolina dentists don’t accept Medicaid patients, and many of those who do aren’t taking on new patients with the government subsidized insurance plan.
The problem is, many oral health care providers say, that the state reimbursement rate for dental patients on Medicaid insurance plans is 34 cents on the dollar. That’s the same as it was in 2008.
That could change if a bill introduced Feb. 4 in the state House of Representatives gains traction. Republican representatives Brian Biggs, the house deputy majority whip from Trinity, Donny Lambeth of Winston-Salem, Larry Potts of Davidson County, and Tricia Cotham of Charlotte sponsored House Bill 60.
The “An Act To Modernize Medicaid Dental Rates” would increase the rate from 35 percent of the average dental charges in 2023 to 46 percent.
The potential catch? The bill comes with a $52 million price tag — recurring funds that would have to be included in the next state budget. State dollars would be matched with $95 million from the federal government promised as part of the North Carolina Medicaid expansion agreement established during President Joe Biden’s administration.
President Donald Trump and Republicans in Congress, though, could put some of those funds in jeopardy through budget cuts to pay for tax breaks.
The bill sponsors laid out their case for the rate increase in their proposed legislation: “good oral health is vital to good overall health, and untreated oral health conditions negatively affect overall health and have associations with chronic disease.”
A peek inside the mouth can offer a glimpse of those chronic diseases that affect other parts of the body, such as the kidneys and heart. It also can provide hints about Alzheimer’s disease and even mental illness, the bill sponsors add.
“(T)he failure to adjust reimbursement rates to account for increasing inflation and costs over the last fifteen years has resulted in reduced dental provider participation in Medicaid,” the bill states. “(R)egular preventative dental care is the most cost effective method available to prevent minor oral conditions from developing into more complex oral and physical health conditions that would eventually require emergency and palliative care.”
The bill adds that “it’s in the best interest of the state” to raise reimbursement rates.
Sense of optimism
That’s music to the ears of oral health care advocates who have been lobbying for change for years.
“We’re hopeful 2025 will be the year we see a meaningful increase,” Jim Goodman, executive director of the North Carolina Dental Society, told N.C. Health News in an email. “However, it’s important to understand that the increases proposed in HB60 are not a windfall for dentists.”
While the proposal would bring reimbursement rates in this state up to nearly 46 percent of the overall average fees and more in line with neighboring states, Goodman added, North Carolina dentists still would be providing a significant discount for Medicaid patients.
“We’ve reached a tipping point in NC,” Goodman said. “There are more Medicaid recipients in the state than ever before, but the current system does not provide enough reimbursement to ensure dentists can afford to serve these patients.”
Medicaid expansion went into effect on Dec. 1, 2023, and 628,681 additional adults ages 19 to 64 have been enrolled in the program as of early February, according to a state Department of Health and Human Services dashboard.
In July 2024, former Gov. Roy Cooper issued an update on the expansion program that he advocated for throught most of his two terms — over the objections of many Republican lawmakers who stood firmly against it for years. During the first seven months, expanded Medicaid covered more than $28.6 million in claims for dental services, according to the news release.
“Low rates, coupled with rising student loan debt, higher wage demands of dental staff, and soaring overhead costs have made it nearly impossible for dentists to treat these patients,” Goodman told NC Health News. “Good oral health is systemic to good overall health. When patients don’t have access to routine and emergent dental care there are negative effects to daily life and to the state via emergency room visits which are far more costly.”
Federal budget unknowns
As North Carolina lawmakers look to increase the reimbursement rate, the U.S. House of Representatives has started pushing a federal budget through Congress that calls for a $2 trillion reduction in federal spending, partly to offset the cost of tax cuts.
The New York Times reported that the budget, not yet finalized in the House or approved by the Senate, could become law without cuts to Medicaid, but finding that large of a spending reduction without touching the social safety net program would be difficult.
The Democratic-leaning Center for American Progress issued a Feb. 24 release that breaks down the potential $880 billion in Medicaid and Children’s Health Insurance Program, or CHIP, cuts by congressional districts. North Carolina’s 14 districts, according to the center, are looking at more than $25 billion in funding losses over a nine-year window, and those numbers do not capture Medicaid expansion data.
Jay Ludlam, director of Medicaid for North Carolina, put the total potential loss closer to $27 billion during a legislative Joint Health and Human Services Appropriations Committee on Feb. 26.
“We continue to work alongside state and federal partners to understand and provide information on what potential federal funding cuts to Medicaid would mean,” a DHHS spokesperson wrote in an email to NC Health News on Thursday. The cuts that would span 10 years “would have impact on local, regional and state economies, especially rural areas,” the spokesperson added.
The budget for the state Department of Health and Human Services has relied on the federal government for a large part of its Medicaid budget. It pays 65 percent of the cost for Medicaid recipients who don’t fall into the expansion category, according to KFF. That goes up to 90 percent of the cost for the 628,681 mostly low-income workers added to the enrollment rolls because they fall within the parameters of the expanded benefit.
After being swayed to support Medicaid expansion, in part because of the federal dollars available, Republican legislative leaders included a statutory prompt that could end the program if those funds diminish.
So far, though, some state lawmakers on powerful health and budget committees are taking a wait-and-see approach while ambiguity reigns on the details of the federal spending plan still being hammered out in Washington.
More wait-and-see
Steve Cline, a dentist who is vice president of the North Carolina Oral Health Collaborative, is hesitant to overly celebrate the introduction of the state legislation. His organization has been lobbying for the rate increase, in part, to help overcome an oral health care provider shortage not only in rural areas, where the need is most prevalent, but in urban and suburban areas as well.
“In a nutshell, I’m guardedly optimistic,” Cline told NC Health News. “I think people are hearing the importance of the dental needs in a genuine way but, as always, there will be competing needs for the funds — especially in this unclear federal landscape.”
The North Carolina Dental Society surveyed its more than 3,900 member dentists last year, according to Goodman, about their willingness to take Medicaid patients. They let the organization know that low reimbursement rates were the biggest barrier to treating them, Goodman said. When asked if reimbursement rates were raised to better reflect market rates, “members were more highly likely to participate in Medicaid,” the chief executive added.
Goodman pointed to Virginia as evidence of the benefits.
After North Carolina’s northern neighbor increased its reimbursement rate for dentists by 30 percent in 2022 with an additional 3 percent increase two years later, the number of Medicaid providers increased by 20 percent from their low three years earlier, he said.
“The NC Dental Society, and pretty much every dental related group that I’m aware of in NC, fully supports HB60,” Goodman said. “The fact that this bill has bipartisan support demonstrates that lawmakers understand the crisis in North Carolina and the need to increase Medicaid reimbursement rates to improve access to quality and affordable dental care.”
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