The federal government says Minnesota is failing to provide adequate dental care to low-income children and risks losing funding.
Some dentists say they can't afford to provide care for patients on government programs. Minnesota is among the states with the lowest reimbursement rates.
Mike Flynn is the only dentist in the small southeastern Minnesota town of Lewiston. He's been fixing teeth for 38 years. Half of his 1,200 patients are covered by state programs.
"At this point in time, the viability of my practice is dependent on either getting a higher reimbursement or limiting my practice," Flynn said in between appointments.
Limiting his practice means refusing any new Medicaid patients. Minnesota's reimbursement rate of 27 percent doesn't come close to covering the cost of treating patients, Flynn said.
"It's one thing to volunteer, but it's another thing to subsidize everybody that comes in your office," he said.
Many Minnesota dentists limit the number of patients on government programs, or refuse to accept any Medicaid patients.
Access is a problem for children and adult Medicaid patients, but the federal focus is on care for children.
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In an April 26 letter to the state, the U.S. Department of Health and Human Services pointed out that just 37 percent of children on Medical Assistance in Minnesota got preventive dental care in 2015, and 62 percent of the participants reported having been told that a dentist was not taking new patients covered by the program.
Nationally, 46 percent of children on Medicaid got preventative dental care, according to the Centers for Medicare and Medicaid.
Noting that such figures could place Minnesota out of compliance with federal rules, regulators told state officials that they must devise an improvement plan within 90 days.
"It's a dignity issue, it's a human rights issue," said Michael Helgeson, CEO of Apple Tree Dental, a nonprofit that had 60,000 dental appointments at six locations around the state last year.
"It's not right for young children to get up in the morning and have painful broken teeth and miss school and not be able to concentrate in school because they can't get the dental care they need," added Helgeson, who believes Minnesota needs to at least double its dental reimbursement.
One of the highest reimbursement rates for dental care is in North Dakota, at 63 percent.
But more money hasn't solved the dental access problem, said Shawnda Schroeder, a professor at the University of North Dakota's Center for Rural Health.
She says distance and lack of awareness of the importance of dental health keep patients from care they need.
"We're not going to be able to say, well, let's increase Medicaid reimbursement and now all of our oral health needs have been addressed," said Schroeder. "We also can't just say let's provide transportation to a dentist and all of our needs are addressed. It's a much bigger issue."
Minnesota officials say until dentists are properly paid, it's hard to talk about innovative solutions to improve dental access.
"I do think that we are at a critical juncture," said Nathan Moracco, assistant commissioner at the Department of Human Services. "I think dentists that are participating are doing everything they can to stay within the program, but I believe that their resources are extremely strained and they may have to start making decisions about whether to participate in the Medicaid program."
Gov. Mark Dayton has recommended a 54 percent increase in dental reimbursement. Moracco anticipates the state Legislature will approve a smaller increase. It's not clear if either will do enough to satisfy the federal government.