S.B. NO.














relating to medicaid benefits.





     SECTION 1.  The legislature finds that oral disease is a significant health problem among many Hawaii residents, affecting their overall health and well-being.  Since 2010, Hawaii has received a failing grade of "F" in three oral health report cards published by the Pew Center on the States due to multiple policy and systems issues in the State that have left the oral health of Hawaii's families and children worse than the rest of the nation.

     The legislature further finds that Hawaii has the lowest proportion of residents with access to the benefits of fluoridated drinking water in the United States (eleven per cent vs. seventy-five per cent nationally in 2012).  In addition, dental benefits for medicaid-enrolled adults were eliminated in 2009, and, as a result, adults in medicaid seek services in the emergency room more frequently.

     The legislature also finds that COVID-19 has greatly impacted dental care and oral health access in the State.  COVID-19 has led to the closure and reduced hours of dental practices except for emergency and urgent services, exacerbating challenges to connect patients to dental care.  A consequence of the pandemic is that a large number of patients have put off dental visits and timely treatment for their already critical dental needs.  Limited care options, coupled with the loss of income and employer-sponsored health benefits, will lead to increased care being sought in the emergency department, worsening oral health disparities within the medicaid population, particularly among native Hawaiian and Pacific Islander enrollees.

     The legislature further finds that lack of access to dental coverage and oral health care is a health and social justice issue.  In 2009, the State terminated all preventive and restorative dental care services for adult medicaid recipients and replaced it with emergency room services limited to pain relief, injuries, trauma, and tooth removal and extraction.  The lack of preventive and restorative dentistry services for adult medicaid beneficiaries increases potential health care complications for individuals living with chronic diseases such as diabetes and heart disease.  These complications can all lead to increased disability and death.

     The legislature also finds that public and commercial insurance coverage are far less available and adequate for dental care than for medical care in Hawaii.  State-mandated employer medical insurance and publicly supported medicaid and medicare programs offer robust medical dental coverage with limited out-of-pocket payment.  In contrast, commercial dental coverage comes with significant co-pays, is not mandated by Hawaii's Prepaid Health Care Act, and is not a covered benefit for adults under the Affordable Care Act, medicare, or medicaid.

     The department of health's Hawaii Oral Health: Key Findings report issued in 2015 revealed that among low-income adults aged eighteen and over, fifty-one per cent had experienced tooth loss compared to thirty-two per cent of higher income adults, and only fifty-two per cent of the lower income group had made an annual dental visit compared to eighty-two per cent of those with higher incomes.  In addition, Hawaii fails to meet national recommendations for dental care for women during pregnancy, as only forty-one per cent of pregnant women obtain an annual dental visit.  The rate for those covered by medicaid is even lower at twenty-seven per cent, a rate likely depressed by the lack of dental benefits.

     Nationally, studies have shown that reducing or eliminating medicaid adult dental benefits has led to significant increases in dental-related emergency room visits and associated costs.  In 2012 alone, Hawaii medicaid paid $4,800,000 for 1,691 adult emergency room visits for preventable oral health problems.

     The legislature additionally finds that in Hawaii, a disproportionate number of adult medicaid beneficiaries ages twenty-one and older utilize emergency dental services.  While these adult medicaid beneficiaries represent twenty-five per cent of Hawaii's population, they represent fifty-six per cent of all emergency dental services.  Just over three thousand emergency room visits for acute oral health conditions occurred in 2016, totaling more than $17,000,000 in direct costs, a total that has more than doubled since 2007.  Data also indicated that rural residents of the State, primarily from the north shore of Oahu and the islands of Kauai and Hawaii, were more likely than urban residents to go to the emergency room for dental problems.

     Finally, the legislature believes that there is a greater need for investment in public health and in prioritizing the well-being of individuals most vulnerable to the impacts of COVID-19.  A September 2020 report from the DentaQuest Partnership for Oral Health Advancement found that COVID-19 patients who rely on mechanical ventilation to survive were more susceptible to ventilator-associated pneumonia, which is the second most common hospital-acquired infection and the leading cause of hospital-acquired infection deaths among critically ill patients.  However, patients are twenty-two per cent less likely to develop ventilator-associated pneumonia if they have received preventive dental care within three years of being placed on ventilation, according to the study.

     Recent analysis suggests that investing in dental benefits for medicaid-enrolled adults will, in the long term, lead to reductions in medical costs financed by medicaid.  A February 2020 research brief authored by the American Dental Association's Health Policy Institute and the Hawaii med-QUEST division estimates the cost of reinstating coverage in Hawaii and provides three possible options:

     (1)  Option 1 ($7,800,000 per year or $3.32 per enrollee) covers a basic package of diagnostic, preventive, and restorative services;

     (2)  Option 2 ($19,900,000 per year or $8.45 per enrollee) covers the basic package plus core prosthodontic services; and

     (3)  Option 3 ($36,200,000 per year or $15.37 per enrollee) is a further expansion to a more robust set of prosthodontic services.

All three options cover periodontal services.  The research brief estimates potential medical care cost savings of $1,900,000 to $5,300,000 per year attributable to a reduction in emergency department visits for dental conditions and reduced medical care costs among medicaid beneficiaries with diabetes and coronary artery disease, as well as pregnant women.

     It has been twelve years since the State removed all but emergency medicaid adult dental benefits.  The legislature finds that it is in the best interest of the State and its residents to expand access to care by restoring dental benefits to adult medicaid enrollees.

     Accordingly, the purpose of this Act is to appropriate funds to restore diagnostic, preventive, and restorative dental benefits to adult medicaid enrollees.

     SECTION 2.  There is appropriated out of the general revenues of the State of Hawaii the sum of $           or so much thereof as may be necessary for fiscal year 2021-2022 and the same sum or so much thereof as may be necessary for fiscal year 2022-2023 to restore diagnostic, preventive, and restorative dental benefits to adult medicaid enrollees; provided that the department of human services shall obtain the maximum federal matching funds available for this expenditure; provided further that the department of human services shall pursue all funding sources known to the State, including private grants, prior to expending any general revenues appropriated pursuant to this Act.

     The sums appropriated shall be expended by the department of human services for the purposes of this Act.

     SECTION 3.  This Act shall take effect on July 1, 2021.








Report Title:

Adult Dental Benefits; Medicaid; Appropriation



Appropriates funds to restore diagnostic, preventive, and restorative dental benefits to adult medicaid enrollees, provided the department of human services obtains maximum federal matching funds available and purses all funding sources, including private grants, prior to expending any general fund appropriations.




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