Editor’s note: Watch for research in the upcoming September issue of Health Affairs by these authors, Marko Vujicic and Kamyar Nasseh, on dental care utilization among poor adults after health reform in Massachusetts.
As the Surgeon General and the Institute of Medicine have clearly stated, oral health is a vital component of overall health. But when it comes to a major determinant of oral health — access to routine dental care — the Affordable Care Act (ACA) falls well short in all three of the ‘triple aims’: lowering costs, increasing access, and improving health outcomes, mainly when it comes to adults.
As a result, state governments now play an even more important role, as they have several critical policy levers at their disposal to pick up where the ACA left off. This is the main conclusion of research briefs from the American Dental Association’s Health Policy Resources Center that discuss the potential impact of the ACA on dental benefits, visits, and expenditures and the effect of Accountable Care Organizations on dental care financing and delivery, as well as offering a broader analysis of the shifting patterns of dental benefits for adults and children. The ACA has important implications for oral health, for adults more in terms of what it did not do as opposed to what it did.
The past decade has seen a significant decline in dental care utilization among adults and, particularly, poor adults. This has been driven in large part by a decline in private dental coverage as well as a scaling back of adult dental benefits within state Medicaid programs. The results have been worrying. More and more adults are experiencing financial barriers to dental care. The rate of hospital emergency room visits for preventable dental conditions has increased among adults, unnecessarily driving up cost to the health care system to the tune of up to $2 billion per year. Urgent action is needed to reverse these trends and, unfortunately, the ACA did not take the bold steps needed.
Impact of the ACA on Children and Adults
Under the ACA, pediatric dental services are an “essential health benefit” that all plans in the individual and small-group markets must offer. According to the American Dental Association’s Health Policy Resources Center, because of the ACA approximately 8.7 million children are expected to gain some form of dental benefits by 2018, an increase of 15 percent relative to 2010. This is expected to decrease the number of children who have no dental benefits by 55 percent.
By contrast, the ACA has a modest impact on adult dental benefit coverage. Although 17.7 million adults are expected to gain some level of dental benefits because of the ACA, almost all of this increase will be through Medicaid, which — depending on an individual’s state of residence — may offer emergency-only dental services, limited dental benefits, extensive dental benefits, or no dental benefits whatsoever. In fact, only 4.5 million additional adults are expected to gain extensive dental benefits through Medicaid. An additional 800,000 will gain private dental benefits through health insurance exchanges. Combined, this will reduce the number of adults without dental benefits by only about 5 percent relative to 2010.
The Dental Delivery System in Medicaid
With an influx of children with extensive dental benefits in Medicaid, and adults with mainly limited dental benefits, there is likely to be significant pressure on Medicaid providers within the dental care delivery system. Most state Medicaid programs have significant inefficiencies that pose an important constraint to increasing access to care for the poor, including administrative inefficiencies and low provider reimbursement for dental care. Unfortunately, these problems are not addressed in the ACA. The evidence is strong that reforming Medicaid, including ramping up patient outreach, streamlining administrative procedures, and paying providers closer to market rates can increase access to dental care. Such reforms are urgently needed if the increased demand — estimated at 10.4 million dental visits per year — is to be met.
The Role of Accountable Care Organizations
Accountable care organizations (ACOs) — via their ability to manage, coordinate and enhance oral and overall health through sophisticated information systems and economies of scale — may have the ability to bridge the gap between oral and general health care, potentially reducing overall health care costs. They also provide an opportunity to re-examine the role of dental care providers within the broader health care team. Generally, dental care is not part of the core services provided within existing ACOs. But this need not be the case going forward. Since dental care for children is an essential health benefit under the Affordable Care Act, there are some immediate opportunities to better coordinate dental and medical care with the pediatric population.
ACOs that focus on the Medicaid population present another opportunity, particularly in states that provide some level of adult dental benefits. In Oregon, for example, CCOs (equivalent to ACOs) must coordinate physical, mental, behavioral, and dental health care for people eligible for Medicaid or dually eligible for Medicare and Medicaid. CCOs will be required to publicly report on quality metrics, including those related to dental care.
But one key issue that is likely to heavily influence the extent that dental care is provided through an ACO framework is how dental care delivery is financed. Over 90 percent of dental spending in the United States is financed through private insurance and out-of-pocket payment. According to the National Association of Dental Plans, 99 percent of dental benefit plans are sold as stand-alone policies, separate from medical plans. Due to various factors, we believe this is unlikely to change in the coming years, and this weakens the financial incentives for ACOs to provide dental care.
Implications for Oral Health and Access to Dental Care
Despite the fact that the mouth is the gateway to the body and oral health is a key part of whole-body health, the ACA fails to address critical dental care access issues. Moreover, particularly when it comes to adults, it has actually increased the divide between dental and medical care delivery and financing, which is at odds with one of the key tenets of the ACA — better coordination of care. Even for children, where an expansion in dental benefits and reduction in the uninsured is expected, many critical issues are not specifically addressed by the ACA. These include improving the administrative process in Medicaid programs and adjusting reimbursement levels to providers so they are closer to market rates.
The issue of low provider reimbursement rates within Medicaid programs is certainly not unique to dentistry. Interestingly though, for many primary care services, the ACA explicitly addresses this issue by mandating temporary increases in Medicaid fees paid to physicians to Medicare rates. As a result, Medicaid physician primary care reimbursement rates are expected to increase by about 73 percent. Despite the fact that pediatric dental care is one of ten essential health benefits mandated by the ACA, no such reimbursement adjustment has been mandated for dental care services within Medicaid.
Policy Options and Opportunities Moving Forward
The bright spot is that state governments still have considerable opportunities to implement policies to improve the oral health of the population and, essentially, pick up where the ACA left off. The research is compelling that providing dental benefits to adults in Medicaid programs — in conjunction with adequate provider reimbursement, patient outreach, and simplified administrative procedures for patients and providers — increases access to dental care and reduces costly emergency room visits. A recent national analysis shows that adult Medicaid dental benefits increase the likelihood of a dental visit among low-income individuals by about 16 to 22 percent.
In addition, states such as Maryland, Virginia, and Connecticut increased dental utilization among children by implementing Medicaid reforms that streamlined administrative processes and increased provider reimbursement. In research in the upcoming September Health Affairs issue, we examine the changes in dental care utilization among poor adults after Massachusetts restored adult dental benefits in Medicaid and expanded dental benefits through its health insurance exchange in 2006.
States still have the option to mandate adult dental benefits in their individual and small-group markets, although to date no state has gone beyond the essential benefits mandated by the ACA, and this will be challenging fiscally due to the financing arrangements for optional dental benefits combined with the tough fiscal environment. However, we have recently shown that up to $2 billion is spent each year on emergency room visits for dental conditions. Redirecting these financial resources to expand dental benefits to poor adults through Medicaid programs could be a cost-effective strategy, although more analysis is needed. Moreover, one study found that the cost savings resulting from eliminating or reducing adult dental benefits are quite minimal.
Some states are exploring expanding the scope of practice of non-dentist personnel to address access to care and cost issues. The evidence base is very limited but there are some studies that examine issues such as the safety, quality, impact on oral health, as well as the economic aspects of this approach.
In addition, Accountable Care Organizations – particularly those that focus on Medicaid populations – are another opportunity for dental and medical providers to leverage the benefits that improved oral health brings to population health and overall health care costs.
Unless states act now, there is a real risk that the huge gains made by poor children in the last decade in terms of access to dental care and oral health will be eroded as these children turn into adults. In addition, policy makers could also focus more attention on the low-income and young adult population, who by far have experienced the largest decline in dental care utilization and the biggest increase in financial barriers. Fortunately, actions already taken by individual states provide a roadmap on how to move forward. America’s oral health is at stake.
Note: The views presented here are solely those of the authors and do not necessarily represent the views of the American Dental Association.
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