Biting Into Medicaid: What Happens When States Cut and Expand Medicaid Dental Benefits?

When States Cut Adult Dental Coverage, Access and Utilization Drop Sharply

The most immediate effect of eliminating Medicaid adult dental coverage was a large increase in the share of people without any dental insurance at all. This is not surprising, as most low-income adults cannot afford private dental insurance. After state cutbacks, the share of people without dental insurance increased by 60 percentage points. When people lost coverage, they also received less care and had more financial risk. For instance, individuals experienced a 37 percentage-point decrease in the likelihood of having a dental visit in the prior two years and a 20 percentage-point increase in the likelihood of having any out-of-pocket dental spending. Importantly, some of these effects persisted for up to eight years in the study, suggesting that a coverage cut is not merely a short-term disruption, and often does not immediately resolve when budgets improve. One reason may be that cuts reduce provider participation and disrupt patient–dentist relationships; rebuilding networks and reestablishing routine preventive care can take years. Administrative issues and reduced trust in the stability of coverage may also slow recovery.

When States Expand Dental Coverage, Access and Utilization Increase

Expanding adult dental benefits was associated with meaningful gains. The share of adults without dental insurance fell by 41 percentage points, the share who had a dental visit in the prior two years increased by 22 percentage points, and the likelihood of any out-of-pocket dental spending fell by 37 percentage points.

Our key insight comes from comparing the two policy changes. For the outcomes tied to coverage, dental visits, and out-of-pocket spending, the changes associated with eliminating adult dental benefits were significantly larger than the changes observed when dental coverage was added. In other words, cutting adult dental services from Medicaid is not simply the reverse of expanding them.

Many Beneficiaries Did Not Know Their Dental Coverage Changed

Beneficiaries are often unaware of the change in status of their dental coverage. After states eliminated adult dental benefits, the share of people who incorrectly described their dental coverage status increased by 12 percentage points. After states expanded benefits, the share of people who were unaware of changes in their benefits increased by 33 percentage points. This is significant. When benefits are cut and patients don’t realize it, they risk unexpected out-of-pocket costs. In addition, when benefits expand and they again don’t realize it, the policy can’t deliver on its promise of enhanced access to services. Coverage expansions improve access most when beneficiaries can confidently use the benefit and when providers can verify it easily at scheduling.

This pattern is not unique to dental coverage. Medicaid research often reveals a gap between reality and what beneficiaries experience or understand, particularly when communication is unclear and coverage is difficult to verify at the point of care. Studies show that the perception of coverage may drive health care use even more than a person’s actual coverage status.

What Can Policymakers Do?

Adult dental benefits provide meaningful financial protection and help maintain access to essential care for low-income adults. Policymakers should consider the following recommendations:

• Treat dental cuts as major health coverage changes. Dental care is health care. The effects on insurance coverage, dental visits, and out-of-pocket spending are large and can persist for years. Because oral health is linked to chronic disease management, infection prevention, and overall well-being, changes to adult dental benefits should be considered part of core health coverage policy.

• Do not assume benefit restorations fully undo earlier cuts. Because the consequences of cuts are larger than the gains from expansions, cycling benefits on and off can leave lasting reductions in access even after benefits resume.

• If benefits change, communication must be part of the policy. Whether a state is cutting or expanding adult dental coverage, beneficiary awareness should be treated as a core implementation goal.

If policymakers want to protect access to dental care while managing Medicaid costs, adult dental benefits should not be treated as a go-to option for cuts. Frequent benefit changes may appear reversible in the short term, but for beneficiaries, they can produce long-term setbacks that are harder and slower to repair.