Dr. Scott Miller knows exactly what it costs to fit a patient with dentures, place a crown or extract a tooth. A standard, non-surgical extraction costs $92.39.
Recently, Miller treated a patient who needed 23 teeth removed. The extractions alone would cost more than $2,000. The patient also needed dentures.
Under a line item in Gov. Glenn Youngkin’s final budget proposal, that patient would not be able to complete the full treatment plan in a single year.
Language in the former governor’s proposed budget, introduced in December, imposes a $2,000 annual spending limit on dental services for adults enrolled in Medicaid. Currently, there is no cap for Medicaid dental services.
When a patient reaches the $2,000 threshold, Virginia Medicaid would stop covering additional dental care until the benefit renews the following year. Patients would either have to pay out of pocket or delay care.
Virginia started offering separate dental benefits under Medicaid in 2005, but the coverage largely focused on children and pregnant women. In 2021, the state expanded the program to include all adults, extending coverage to about 750,000 Virginians.
Miller founded the Appalachian Highlands Community Dental Center, a nonprofit dental clinic in Abingdon that provides low-cost dental care to uninsured, underinsured and Medicaid patients across Southwest Virginia.
Since opening in 2020, the clinic has grown into the region’s largest adult Medicaid dental provider. Demand continues to outpace capacity. The clinic now has a waitlist of about 3,000 people, and the facility is expanding in order to accommodate more patients.
“We see a lot of patients that have delayed their care for decades sometimes. They’ll come in and they’ll have a lot of decay,” Miller said.
In some cases, the teeth are damaged beyond repair, and the only treatment option is to remove them.
More than 70% of Miller’s patients rely on Medicaid for dental coverage. Many of his patients are coal miners or members of mining families. Some are recovering from opioid or methamphetamine addiction. Others earn slightly too much to qualify for Medicaid but still cannot afford dental insurance, so they rely on the clinic’s sliding-fee scale.
Del. Rodney Willett, D-Henrico County, introduced a budget amendment to remove the cap, but he said the proposal is unlikely to advance this year due to the number of health care priorities that need attention.
“Between the health care related items that the governor did not fund in his budget and the impacts of HR.1 [the federal spending bill], it’s hundreds of billions of dollars in shortfall,” Willett said. “We have a lot of people to take care of.”
Sen. Todd Pillion, R-Washington County, said he is working to remove the line item from the budget while the General Assembly is still in session. As a pediatric dentist in Bristol, he sees many patients who use Medicaid.
“We were fortunate in Virginia to expand into adult dental Medicaid benefits several years ago. We’ve seen great results with that, and we want to continue those results,” Pillion said.
The legislature adjourns on Saturday.
For dentists like Miller, the proposed limit could force difficult choices in the exam room. Treatment plans that typically require several procedures can easily exceed $2,000. Providers say the cap could leave patients with partially completed care.
The cap could also have a chilling effect on the number of dentists who accept Medicaid, Pillion said, further limiting access for patients.
Choosing between incomplete and delayed care
Miller’s patient who needed their 23 remaining teeth pulled suffered from several abscesses — painful infections in the teeth. The treatment plan was to remove all of the teeth and then fit the patient with dentures.
Removing all 23 teeth cost $2,124.97 — already exceeding the proposed cap. Dentures would cost another $1,800.
In cases like this, Miller said the cap would force dentists to choose between incomplete or delayed care.
One option would be to leave a few infected teeth in place and wait until the following year to remove them. Another option would be to extract all of the teeth but postpone dentures until the next benefit cycle.
Miller said he could attempt a partial solution, such as placing crowns on a few remaining teeth. But a single crown costs $669, which would leave enough money to cover a partial denture for the bottom, but not to create the upper dentures.
“Once patients start treatment, a dentist has an obligation to try to preserve the patient’s oral health and complete that treatment plan. This cap won’t allow us to do that,” Miller said.
Dentures aren’t just cosmetic, he added. They restore about 25% of a patient’s chewing ability. Without them, patients have almost no ability to chew, Miller said. Dentures allow people to eat a wider variety of foods, too, such as fruits and vegetables and proteins.
People who don’t have teeth or can’t chew properly are more likely to eat soft foods that could be higher in sugars and carbohydrates, Miller said. This can lead to other chronic conditions like diabetes and obesity.
Southwest Virginia already faces a shortage of dentists
Access to dental care in Southwest Virginia is already limited.
Many dentists in Virginia have historically declined to accept Medicaid because reimbursement rates were too low, Miller said. Providers lost money when treating Medicaid patients.
A 2022 report from the Virginia Board of Dentistry found that only 12% of dentists in the state accepted Medicaid. That same year, the General Assembly voted to increase reimbursement rates by about 30%.
The next year, 22% of dentists accepted the public insurance, and in 2024, that increased to 23%, the board found.
Miller said more dentists in Southwest Virginia began enrolling as Medicaid providers after reimbursement rates increased. The proposed cap, however, could reverse that progress.
“With this limit, I’m afraid we’re going to lose the ones we’ve recruited,” Miller said.
His clinic serves a 14-county region where there are only about 29 dentists per 100,000 residents, according to Miller. Nationally, the average is closer to 60 dentists per 100,000 people, according to the American Dental Association.
Pillion added that more dentists in Virginia have enrolled to accept Medicaid in recent years, but the proposed cap could cause some to scale back their participation and make it harder to recruit new ones.
Lawmakers might address the cap next year
Miller believes that a higher cap could solve the problem. If the state increased the limit to $4,000 but allowed patients to use the benefit over two years, dentists could complete treatment plans without raising the overall annual spending.
Once a patient receives dentures, he said, they typically do not need major dental work again right away.
Sen. Mark Peake, R-Lynchburg, and Sen. Chris Head, R-Botetourt County, who both sit on the Senate Health Committee, said Wednesday that they were unaware of the provision, adding that line items can be overlooked in budget packages that stretch hundreds of pages.
Pillion and Willett noted that it is a tight budget year for Virginia, and lawmakers face difficult budget choices after several health initiatives went unfunded.
“In this case, that was an easy way to get a few dollars back in savings,” Willett said.
During budget shortfalls, states can limit or end optional coverage groups. Federal law requires states to cover certain groups or services, such as dental and vision screenings for young children and coverage for families with very limited incomes. Adult dental benefits, however, are optional, according to the Commonwealth Fund, a private foundation that supports independent research, grants and policy analysis focused on improving health care.
According to Willett’s amendment request, removing the cap would cost the state about $9.9 million from the General Fund in 2027 and $13.7 million in 2028.
If the amendment fails during budget negotiations this year, Willett said he plans to revisit the issue during the 2027 General Assembly session.
One year from now, Miller expects difficult decisions at his clinic. He will need to take on new patients, while others may be forced to pause treatment and return to the clinic’s already growing waitlist.
The clinic also operates as a training site for dental residents across Virginia. Next year, Miller expects eight new doctors to rotate through the program — learning their profession while navigating treatment plans they may not be able to complete.
