Aurice Barlow knows what happens when someone can't afford dental care.
"I see people walking the streets with toothaches, teeth hanging out of their mouths," said the former nurse's aide. At least 30 percent of the people in this city of 124,500 are impoverished.
"Nobody cares," she says.
Barlow is worried she'll now become one of them.
Washington is pouring $87 billion in federal stimulus money into the states to help maintain state-run Medicaid health care for the needy -- and to handle the expected surge in enrollment.
But Connecticut and other cash-strapped states say they still must slash spending on health care to cover massive budget deficits. At least 21 states have already restricted low-income children's and families' eligibility for health insurance or their access to services; at least 22 states and the District of Columbia are cutting services for low-income elderly or disabled patients.
Those considering Medicaid cuts are targeting benefits considered optional under federal rules -- such as adults' dental coverage, vision care and some therapy -- as well as cuts or freezes in Medicaid reimbursement. Some states are also looking to cut non-Medicaid or state-funded programs.
In Connecticut, where a budget agreement has not yet been reached, Gov. M. Jodi Rell wants to limit Medicaid dental benefits for adults to emergencies only, saving nearly $51 million over two years.
Barlow is one of about 193,000 people eligible for Connecticut's dental coverage. Out of work since 1998 and recently accepted for federal disability assistance, she dutifully visits the Charter Oak Health Center in Hartford for her twice-a-year cleanings and other dental needs, all paid by Medicaid.
If that coverage disappears, Barlow says she can't afford to pay for dental care on her own.
"I would go without I guess, brush my teeth the best I can," she said.
The Center on Budget and Policy Priorities in Washington, D.C., reports that at least 48 states have already addressed or still face budget shortfalls for the new fiscal year, which began in most states on July 1.
Judith Solomon, a senior fellow at the nonpartisan center, which focuses on budget issues regarding low- and moderate-income people, said the situation would be much worse if there were no federal stimulus money.
"But it certainly has allowed states to maintain eligibility and not make some cuts they probably would have," she said.
Oklahoma used the federal funds to increase its budget for Medicaid health care providers and Iowa expanded health care to tens of thousands of children. Officials in South Carolina restored some proposed cuts, such as daily meals for homebound people and support for autistic children.
The programs that do face cuts are diverse. And the reductions come at a time when the demand for government health care is expected to rise as the unemployment rate climbs and people lose their private health coverage.
-- Louisiana Gov. Bobby Jindal plans to shut down a mental health hospital in New Orleans by Sept. 1, consolidating its services with a suburban facility 35 miles away. Residents have filed a lawsuit to stop the closure.
-- Illinois plans to cut $40 million from a prescription drug program for about 200,000 low-income seniors and people with disabilities. About 150,000 of them will have to pay more out-of-pocket.
-- The Ohio Legislature sharply cut drug and alcohol addiction services and community-based mental health care.
-- Maryland's Medicaid cuts include rates paid to nursing homes, spending on hospital stays and an inflation adjustment for community health care providers.
-- Washington state cut about $255 million, more than 40 percent, from a state program that offers low-cost subsidized health insurance for the poor.
"While some things have been avoided, delayed, to meet these significant budget shortfalls, states are considering some pretty major cutbacks to the program," said Robin Rudowitz, a principal policy analyst at the Kaiser Family Foundation in Washington, D.C.
Many of the programs facing cutbacks or elimination were hard-won by advocates over the years.
Paul Gowins, an activist in Reno, Nev. lobbied his state for about 20 years to pay for personal care attendants for the disabled and elderly. He's relieved that Nevada lawmakers only cut attendants' pay from $18.50 to $17 hour, crediting federal stimulus money for helping offset the cost.
Gowins, a quadriplegic, gets five hours of help a day for bathing and other needs. He worries what will happen in December 2010, when the federal money ends.
"I anticipate as the economy keeps slowing down, as it is in Nevada, I expect in a year we'll be looking at cuts to those programs," he said. "There's no option."
Connecticut recently increased rates paid to dentists who serve needy adults under the Medicaid program that's at risk of being cut. That encouraged Dr. Jonathan Knapp of Bethel, Conn., and other dentists to begin accepting more of the adult patients.
The fees still don't cover his costs for those patients at his practice, but Knapp -- who participates in free Mission of Mercy dental clinics in the state -- said the Medicaid coverage for needy adults saves the state money. An untreated infection can be deadly, he said.
"Most of these folks will end up in emergency rooms if a tooth gets bad enough and it starts to abscess," said Knapp. Other states that have cut coverage have seen similar results, he added. "It's penny-wise and pound-foolish."
Mary Alford of Louisville, Ky., whose 23-year-old son Aaron is autistic and has a genetic disorder, receives Medicaid benefits for adult day care and other services. He was initially denied coverage for his occupational and speech therapy but she persuaded the state to cover some of the services, which allow her to keep her son at home and not in an expensive institution.
"It's a tough time for everyone, but there are many ways we could actually be helping these disabled folks in the community and help Kentucky's bottom line at the same time," she said.
Associated Press writers Joe Biesk in Frankfort, K; Brendan Riley in Carson City, Nev.; Curt Woodward in Olympia, Wash.; Jim Davenport in Columbia, S.C.; Christopher Wills in Springfield, Ill.; Julie Carr Smyth in Columbus, Ohio; Melinda Deslatte in Baton Rouge, La.; Tim Talley in Oklahoma City, Okla.; Brian Witte in Annapolis, Md.; and Mike Glover in Des Moines, Iowa contributed to this report.