ObamaCare and dentistry: The Affordable Care Act stirred up plenty of controversy, but dental professionals should stay focused on how it affects their livelihood

The Affordable Care Act stirred up plenty of controversy, but dental professionals should stay focused on how it affects their livelihood

BY Lisa Dowst-Mayo, RDH, BSDH

The Affordable Care Act (ACA), sometimes known as "ObamaCare," is a complex federal law that was signed into law on March 23, 2010 by President Obama. Confusion among health-care providers is common as many of the ACA provisions are just beginning to take form. This article will provide a basic overview of the ACA and highlight its potential impact on dentistry.

The ACA is expected to bring health insurance coverage to 30-34 million previously uninsured Americans.1,2 It is no secret that an increase in health-care providers will be needed to attend to this population. These patients' health-care needs are expected to be greater, as they previously had limited access to medical and dental care due to lack of insurance coverage. It has been said that the ACA will change every aspect of health care, from insurance to delivery of care by providers.²

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The current health-care workforce will be dramatically affected by the ACA. For example, the United States currently reports a shortage of primary care physicians, and demand for their services will only increase.³ The government is promoting the expansion of medical midlevel providers' scope of practice to help meet the new demands on the health-care workforce. This piqued my interest as a dental hygienist; being a midlevel provider myself, I am left wondering what impact the ACA will bring to my own profession.

The ACA and dentistry

Adults in the United States are not required to obtain dental insurance coverage like they are medical, which they must purchase or otherwise be subject to a penalty. In the current language of the ACA, dental coverage is only required for children.⁴ Pediatric oral health coverage is a required benefit in all ACA-compliant plans.^4,5 However, as a 2013 New York Times article points out, pediatric dental care is handled differently than medical care on federal and state exchanges: "These plans are often sold separately from medical insurance, and dental coverage for children eventually became optional. People shopping on the exchanges are not required to buy it and do not receive financial support for buying it."⁵ The dental plans can be embedded into a medical plan or sold separately as a stand-alone benefit.⁵ Pediatric dental insurance was envisioned as a mandatory benefit when the ACA was proposed and was intended to supply dental benefits to roughly three million children by the year 2018; however, this vision was not carried to completion by the time the ACA became law in 2010.5

According to an August 19, 2013 post on the ADA website, "About 17.7 million adults could gain some sort of dental coverage through the ACA. However, given that many states have only limited or emergency dental benefits through Medicaid, only 4.5 million adults will gain extensive dental benefits through Medicaid. About 800,000 adults will gain dental benefits through the health insurance exchanges."⁶ Basic Medicare plans do not cover dental services; however, supplemental plans can be purchased by the beneficiary for an additional cost. Dental practitioners in private practice may want to explore these plans to determine if they wish to accept them. In states where dental hygienists are able to practice autonomously from a dentist, this ACA population may be worth tapping, as other private practitioners may not wish to accept these types of plans.

A February 2012 report for the U.S. Senate addressed the need to expand Americans' access to oral health care.⁷ Below are some of its key findings:

Sadly, reading these statistics did not surprise me. Many dental providers are aware of the access-to-care issues in the populations they serve. Statistics like these call for politicians to investigate ways to expand the current dental workforce. Enhancing the scope of practice for dental midlevel providers, just as in medicine, is of interest in many state congresses and on many senate floors.

The number of Americans who will gain dental benefits under the ACA is modest (80,000) compared to those who will gain medical insurance (30-34 million). As dental professionals, we know how important oral health is to total-body health and wellness. While the ACA attempts to address health-care system issues, it is not perfect. It does not expand access to oral health care as extensively as it extends access to medical care. According to the Centers for Medicare and Medicaid Services, in 2013 approximately 50% of Americans had some sort of dental insurance (private or public); 47.1% of all dental service expenditures were out-of-pocket expenses, while medical expenditures were 13.7% out-of-pocket.⁸ As indicated by these statistics, the future of oral health services in America needs to be addressed, and the ACA did not appropriately allot for such services.

ACA highlights

The following bullet points contain basic highlights of the ACA that are starting to impact the health-care and insurance fields dramatically.²

Mandate that every American have an approved level of health insurance or pay a penalty.²

Health insurance regardless of medical history or employment status.²

Insurers must offer policies to anyone who applies and renew policies without regard to the health status of the insured and to eliminate preexisting condition limitations.²

1. More than 47 million people live in places where it is difﬁcult to access dental care.
2. About 17 million low-income children received no dental care in 2009.
3. Low-income adults are almost twice as likely as higher-income adults to have gone without a dental checkup in the previous year.
4. There were over 830,000 visits to emergency rooms across the country for preventable dental conditions in 2009-a 16% increase from 2006.
5. Almost 60% of kids age 5-17 have cavities, making tooth decay ﬁve times more common than asthma among children of this age.
6. Nearly 9,500 new dental providers are needed to meet the country's current oral health needs.
7. There are more dentists retiring each year than there are dental school graduates to replace them.

Expanded access to Medicaid. It is estimated that 16 million individuals will become eligible for Medicaid due to changes in eligibility requirements.²

Extensive new requirements on the health insurance industry, such as provisions and regulations to the risk adjustments in individual and small-group health insurance markets.^9,10Risk assessments are a mechanism insurance companies use to protect themselves against unpredictable losses.³ Certain risk assessment methods have previously prevented individuals from obtaining insurance policies. Through changing the way private insurance companies utilize risk assessments, the ACA will slow annual premium increases. In years to come, through lower cost sharing and premiums, more low- to moderate-income employees should be able to afford insurance for themselves and their dependents. When more Americans have basic health insurance, their health and wellness will improve. This will lower overall health spending across the nation as people begin to use more preventive services and less expensive acute emergency services.

Numerous regulations on the practice of health care such as the establishment of medical/health homes. A medical home, as established by the ACA, sets forth provisions for health-care providers in maintaining and improving a person's total body health and wellness. Medical homes are being piloted through Medicare and Medicaid and they were envisioned to include oral health services. They help establish an interdisciplinary approach to treating a person's behavior and meeting his or her mental and physical health-care needs.¹¹ To be eligible for health home services, Medicaid and Medicare beneficiaries must have at least two chronic conditions (e.g., asthma, diabetes, heart disease, obesity, psychological condition, substance abuse disorder), one chronic condition and be at risk for another, or one serious and persistent mental health condition.¹²

While the medical home concept shows a step in the right direction for providing more consistent, intimate patient care, the funding and financial aspects to the concept seem inconsistent. According to Berenson, Devers, and Burton, few studies have documented how the decision to become a medical home affects a practice's finances.¹¹ Furthermore, studies have shown dramatic variances in the revenue of practicing physicians; revenues ranging from $720-$91,146 per year have been reported. There does not appear to be predictable spending or savings, and one has to consider the risk primary care physicians undertake when they choose to take on patients as part of a medical home concept. Altruistically, many health-care providers would be thrilled to practice medicine in a medical home fashion; however, financially they may not be able to if they do not possess the correct technology and equipment required for this type of program.

It will be interesting to see the impact the ACA has in the years to come, especially in the expansion of midlevel health-care providers. The current health-care workforce will have to change to meet the demands of this new influx of patients into the medical and dental worlds. The ACA relies heavily on the concept of the patient-centered medical home model and free preventive care.⁶ However, both models require enough health-care providers to deliver these services. RDH

LISA DOWST-MAYO, RDH, BSDH, graduated magna cum laude with a degree in dental hygiene from Baylor College of Dentistry in 2002. She is currently pursuing a master's in Health-care Administration from Ohio University. She is a full time professor at Concorde Career College in the dental hygiene department where she teaches clinical sciences, board review, special needs and pharmacology. She is a published author and national speaker and can be contacted at lisamayordh.com.

References

1. Anderson A. The impact of the Affordable Care Act on the health care workforce. The Heritage Foundation Backgrounder. March 18, 2014;2887:1-20.
2. Manchikanti L, Caraway DL, Parr AT, Fellows B, Hirsch JA. Patient Protection and Affordable Care Act of 2010: Reforming the health care reform for the new decade. Pain Physician. 2011;14:E35-67. http://www.painphysicianjournal.com/2011/january/2011;14;E35-E67.pdf.
3. Barton PL. Understanding the U.S. Health Services System. 4th ed. Chicago, IL: Health Administration Press; 2010.
4. Affordable Care Act dental coverage. ObamaCare Facts. http://obamacarefacts.com/dental-insurance/dental-insurance/. Accessed April 9, 2015.
5. Saint Louis C. A gap in the Affordable Care Act. The New York Times. December 16, 2013. http://www.nytimes.com/2013/12/17/health/a-gap-in-the-affordable-care-act.html?_r=1. Accessed April 9, 2015.
6. Affordable Care Act, dental benefits examined. ADA News. http://www.ada.org/en/publications/ada-news/2013-archive/august/affordable-care-act-dental-benefits-examined. Published August 19, 2013. Accessed April 9, 2015.
7. Chairman Bernard Sanders Subcommittee on Primary Health and Aging. U.S. Senate Committee on Health, Education, Labor & Pensions. Dental Crisis in America: The Need to Expand Access. http://www.sanders.senate.gov/imo/media/doc/DENTALCRISIS.REPORT.pdf. Published February 29, 2012. Accessed April 9, 2015.
8. Historical National Health Expenditure Data. Centers for Medicare & Medicaid Services. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html. Accessed April 9, 2015.
9. Cordova A, Eibner C, Vardavas R, Boyles J, Girosi F. Modeling employer self-insurance decisions after the Affordable Care Act. Health Serv Res. 2013;48:850-65. doi:10.1111/1475-6773.12027.
10. Pope GC, Bachofer H, Pearlman A, et al. Risk transfer formula for individual and small group markets under the Affordable Care Act. Medicare Medicaid Res Rev. 2014;4:mmrr2014-004-03-a04. doi: 10.5600/mmrr.004.03.a04.
11. Berenson RA, Devers KJ, Burton RA. Will the patient-centered medical home transform the delivery of health care? Timely Analysis of Immediate Health Policy Issues. http://www.urban.org/uploadedpdf/412373-will-patient-centered-medical-home-transform-delivery-health-care.pdf. Published August 2011. Accessed April 9, 2015.
12. Kaiser Family Foundation. Medicaid's new "health home" option. http://kff.org/health-reform/issue-brief/medicaids-new-health-home-option/. Published January 2011. Accessed April 9, 2015.