In December, Health Affairs published a thematic issue on oral health, a first for the journal. With the timing of that issue and the presidential inauguration upon us, it is the perfect time to discuss Obamacare, Trumpcare, and your mouth.
The Mouth Separated from the Body
The dental-medical divide—the systemic separation of nearly all aspects of medical and dental care—began a century ago, and health care policy has historically reinforced it. In terms of coverage, dental care for adults is not an essential health benefit under the Affordable Care Act (ACA). Dental care for adults is an optional benefit in Medicaid, and Medicare does not cover routine dental care. In contrast, dental care for children is a mandated benefit in Medicaid and CHIP and an essential health benefit under the ACA. Most notably, however, dental care for all age groups is financed and delivered separately from medical care through dental-only insurance plans and dentist offices that are largely siloed from the rest of the health care system.
Given the approach to oral health in state and federal health care policy, it ought to be no surprise that children, especially low-income children, are seeing steady improvements in oral health, access to dental care, and dental care use, while adults are seeing increasing rates of unmet dental care needs and rising emergency room visits for oral conditions. It is also unsurprising that financial barriers to dental care are more severe than for any other health care service and dental care is less readily available compared to medical care within federally qualified health centers and accountable care organizations.
The Affordable Care Act and Dental Care
Though the ACA reinforced the status quo approach of maintaining separate medical and dental care financing and delivery systems, there have been some interesting lessons learned worth highlighting.
The inclusion of children’s dental care as an essential health benefit under the ACA has had major implementation challenges. This is largely due to the fact that dental insurance plans are offered alongside medical plans and there is no mandatory purchase. As a result, dental insurance coverage for children has not expanded much under the ACA.
Navigating the dental coverage options in the health insurance marketplace can be very difficult for consumers. Information on key components of dental insurance plans is lacking in the vast majority of states. Consumers are highly confused because basic information on dental coverage is missing or incorrect. This makes it impossible for consumers to make well-informed choices.
Embedding dental coverage within medical insurance benefits consumers. For example, about one out of three medical plans on Healthcare.gov includes child dental coverage. The incremental premium associated with embedding children’s dental coverage within medical plans is much lower than dental insurance premiums, and key aspects of coverage (e.g. first-dollar coverage for preventive services and coinsurance rates) are similar between embedded and dental-only plans. In a new paper in Pediatrics, we show that total financial outlays for dental care for child beneficiaries are lower, on average, under medical plans that include dental coverage compared to dental-only plans.
Medicaid expansion has improved access to dental care for low-income adults, allowing over 5 million adults to gain dental coverage. This has led to a decline in cost barriers to dental care for low-income adults and a modest increase in dental care utilization.
Expanded dependent coverage has also improved access to dental care for young adults. Although dental care was not subject to the expanded dependent coverage provision of the ACA, dental insurance coverage for young adults expanded anyway through a “spillover” effect. This reduced financial barriers to dental care and increased dental care utilization for this age group.
Dental Care Under ‘Repeal and Replace’
The Trump administration plans to remove many of the key provisions of the ACA and implement alternatives to address key health care challenges. Some parts of Trumpcare are unlikely to impact the dental care world. For example, dental coverage for adults is not subject to the individual mandate and is a voluntary purchase under Obamacare. But other parts are relevant, namely Medicaid reform.
Medicaid and CHIP have driven tremendous gains in oral health. Unmet dental care needs have declined for low-income children, narrowing the gap with high-income children. Dental care use rates among Medicaid children have increased in 49 out of 50 states since 2003, narrowing the gap with privately insured children. These positive developments stem mainly from the fact that Early and Periodic Screening, Diagnosis, and Treatment coverage includes a broad, comprehensive basket of dental care services, and both Medicaid and CHIP have limited or no cost-sharing provisions for children’s dental care. Moving Medicaid to block grants is likely to worsen financial protection for low-income children and potentially increase uninsured rates.
Health savings accounts (HSAs) may be more widespread under Trumpcare, but the impact of HSAs on dental spending has not been studied. On the one hand, they might “crowd in” dental spending by allowing consumers to finance dental care out of pre-tax dollars. On the other hand, they could “crowd out” dental spending if the high-deductible medical plans they are typically paired with lead to higher out-of-pocket medical spending. Based on studies of HSAs, the healthy and wealthy are likely to benefit most.
Policy Priorities for Oral Health
Evidence points to several policy priorities that should be preserved or implemented in order to enhance access to dental care and promote oral health in state and federal policy going forward.
First, preserve Medicaid and make CHIP a mandatory program. These programs have been instrumental in improving children’s oral health. Second, provide comprehensive adult dental benefits within Medicaid. Low-income adults face the most severe dental care affordability challenges of any age and income group. The fiscal impact of adding an adult dental benefit in Medicaid is estimated to be about 1 percent of total state Medicaid spending. This does not include potential fiscal offsets in reduced emergency room spending, reductions in medical costs among beneficiaries with chronic diseases such as diabetes, and improved employment prospects associated with better oral health.
Third, promote dental insurance transparency so consumers can make informed choices; consumers are frustrated with the lack of navigable information to compare plans. Fourth, promote key provisions for medical plans that include dental benefits. Embedding dental benefits within medical insurance, at least for children, would significantly expand dental coverage rates, ease affordability challenges, and likely increase dental care use. However, for this to happen, there are important conditions that need to be met. These include defining a core set of dental care services eligible for first-dollar coverage and establishing deductible and out-of-pocket arrangements that do not limit access to dental care. Finally, promote maximum flexibility for eligible dental services within HSAs. If the use of HSAs expands, it is important that the broadest array of dental care services be included in the set of eligible services.
There is major change ahead for the U.S. health care system. How the mouth will be treated remains to be seen.
The views are the author’s and do not necessarily represent those of the American Dental Association.