Abstract

Excerpted From: Jessica L. Millward, Inherited Health: A Targeted Medicaid Reform to Redress Generational Health Disparities, 55 Seton Hall Law Review 699 (2025) (215 Footnotes) (Full Document)

“I said 'Don't be embarrassed about your bad teeth, look at your grandma! I have bad teeth too.”’ As my client, Ms. Byron, and I waited for a small claims hearing, she relayed the story of her teenage grandson's tooth extraction. Her grandson, Jeremiah, presented with a swollen cheek earlier in the week, and both grandson and grandmother thought it was a sports injury. The swelling increased and Jeremiah was in immense pain, so Ms. Byron took him to the emergency room. He was diagnosed with a tooth abscess in a molar, provided some immediate antibiotics and pain medication, and told to visit a nearby dental school for an emergency extraction. The dentist extracted the molar two days later, and the dentist took the opportunity to lecture the teenager on dental health and the importance of regular cleanings. From what I gathered from our conversation, the teenager felt embarrassed by the events. Due to a storm of financial, legal, and health issues in the family, Jeremiah's Medicaid coverage had recently lapsed. But even before the coverage lapsed, he did not have regular dental visits.

Ms. Byron took quick action because she was educated about dental abscesses. She remembered the 2007 death of Deamonte Driver, a twelve-year-old boy who lived in neighboring Prince George's County, Maryland. Deamonte died of an abscessed tooth and a consequential brain infection in 2007. Like Ms. Byron and her grandson, Deamonte was Black. His death was publicized throughout the region and calls to action were made. The Maryland Medicaid program was reformed, and a mobile dental clinic bearing Deamonte's name now serves the region. In the past twelve years, accesto dental health services for children in low-income families has improved; but utilization has not caught up to that of higher-income peers. In 2015, only 22 percent of Medicaid-insured children received all required dental services over a two-year period.

The predominant systems providing health care coverage for low-income individuals are perpetuating health-harming inadequacies of care on an intergenerational basis. These inadequacies of care create health disparities that “are the result of subordination, not accident, genetics, or individual choice .... These [individuals] ..., however, are vulnerable to poor health and premature death not for biological reasons, but for political and social ones.” Using a “confrontational incrementalism” framing proposed by Wiley, McCuskey, Lawrence, and Brown, this paper explores pathways for reconstructive reform of the Medicaid program while recognizing the present reality that prevents a full reform of the medical system in the United States. It does so by looking at two spaces--Medicaid coverage and Medicaid eligibility--where Medicaid policies that are intended to promote children's health fail to do so because adequate coverage is not provided to adults.

First, mandates for health coverage differ between children's Medicaid and adult Medicaid. These differences mean that children receive more access to care than adults. Children's Medicaid mandates access to dental coverage, while coverage categories are optional for adults. The result is that adults may pass on diseases to children in their care because the adults have not had the opportunity to receive adequate treatment. Additionally, adults who cannot access the same medical care as their children often do not have access to health knowledge that promotes healthy behaviors, like the importance of frequent doctors' visits. This paper explores the specific coverage gap of Medicaid dental coverage. Dental coverage is a useful space to explore the consequences of unequal and unaligned intergenerational health coverage. If caregivers have poor dental health, it puts children's dental health at risk.

Second, different Medicaid eligibility standards result in mixed coverage for children and adults living in the same household and sharing the same income, which also makes acquisition and transfer of health-promoting behaviors more difficult. Because of policy decisions that increased eligibility for children while continuing fiscal austerity for adults, children may have coverage while adults remain without coverage or with limited coverage.

While America grapples with the reality of its health care system, a short-term solution is to align Medicaid benefits and income-eligibility standards for children and adults so that individuals within the same household and supported by the same income sources can all access insurance. To ensure that children's health is protected, Medicaid must provide parallel coverage standards between all adults and children. This means that services for adults that are currently optional to states, like dental coverage, must be made mandatory for states. This also means that states should capitalize on the Patient Protection and Affordable Care Act's (hereinafter Affordable Care Act or ACA) Medicaid expansion to ensure coverage of low-income adults.

Medicaid is failing to protect children's health by failing to adequately cover caretakers. Although Medicaid provides coverage for discrete periods in life, such as childhood and pregnancy, it often limits coverage of services. When dental service is limited, for example, disease originating in the mouth can transmit unchecked from the mouth to other areas of the body. This unchecked bacterial transmission can undermine whole-body health over the course of a person's lifetime and across generations. The current health system operates under an isolated assumption that intervention during high-risk periods in an individual's life, like childhood or pregnancy, is sufficient. In fact, health is affected by care over an individual's lifespan, consistent education, and access to care for entire households.

[. . .]

Intergenerational health transmission provides an opportunity to reconceptualize our health care delivery systems, promote health equity within Medicaid, and break the socioeconomic and race-based chain of passing poor health between generations due to subjugation and subordination. Dental health and access to care provide a prime example of how health and health behaviors pass between generations and how individuals of color and individuals living in low-income households experience disparities in health. Dental health also exemplifies how childhood health impacts lifelong health and the ability to engage in education, which then, of course, impacts the ability to obtain wealth as an adult.

Health education alone, without consistent, multigenerational access to health care, is not enough. Returning to Ms. Byron--she knew about the severity of tooth abscess because a child close to her community died. She knew about the utility of going to the dentist. But, much like Deamonte Driver, she and her family struggled with accessing the dentist due to the patchwork of Medicaid dental coverage in her household. Access to dental health care or health care overall should not be a privilege that comes only to those with wealth. It should be a basic standard of care that is afforded to all. But, given the current political climate and the backlash against the ACA, we must turn to a thoughtful and incremental reform that challenges the structure of the system while maintaining the current Medicaid framework.

Targeted reform is possible within the existing Medicaid system. That reform must turn to intergenerational health and immediately to dental health. This particular targeted reform would be a step towards redressing systemic failures of the health care system and would serve as a reparation to historically subjugated groups.

Assistant Professor of Law, University of Idaho College of Law.