The future of dental coverage: Will Congress pull out the rug?

What will happen to dental coverage under the Donald J. Trump presidency and 115th Congress? Colin Reusch, senior policy analyst for the Children's Dental Health Project, shares an update on the outlook for the Affordable Care Act (ACA), Medicaid, and the Children's Health Insurance Program (CHIP).

We're a little more than a month into the Trump presidency and the 115th Congress, and it is clear that both are focused on making major changes to the health-care system, including repealing and replacing (or, at least, repairing) the Affordable Care Act (ACA). (1) Exactly what shape those changes will take remains uncertain, but it is likely that oral health will be significantly impacted.

This push for change in Washington, DC, comes in the wake of enormous progress in recent years, during which we have seen oral health and dental coverage emerge as crucial components of Medicaid, the Children's Health Insurance Program (CHIP), and the ACA’s health insurance marketplaces.

Since 2000, when the surgeon general issued a report calling tooth decay a “silent epidemic,” the rate of children without dental insurance has been cut in half. (2) In addition, millions of adults now have access to affordable, comprehensive dental benefits, largely through public coverage options like Medicaid. Children enrolled in Medicaid or CHIP are more likely to receive dental services than they were in earlier years. (3)

Furthermore, since CHIP’s 2009 reauthorization and the ACA’s enactment in 2010—both of which recognized oral health’s importance—we’ve seen a reduction in the prevalence of tooth decay among children and a decline in visits to the emergency room for oral health problems. Only a few weeks ago, new research showed that an increase in the portion of children with dental coverage has been accompanied by a decline in unmet dental needs. (4)

Nonetheless, the future of dental coverage is precarious. The ACA remains a prime target, there is talk of converting Medicaid into a block grant or otherwise changing how state Medicaid programs are funded, and, unless Congress takes action, federal funding for CHIP runs out this fall. Right now, Congress’s attention is focused on the ACA.

By mid-February, only two Republican proposals for replacing the ACA had been publicly announced. Both of them would place decision-making power in the hands of states while rolling back benefit protections, including the establishment of children’s dental coverage as an essential health benefit.

Of the two proposed plans for replacement, the Patient Freedom Act is the only one that would allow states to retain some components of the ACA. (5) However, the act offers no guidance on what should be included in children’s coverage. In other words, pediatric dental coverage wouldn’t necessarily make the cut, so to speak. Although the act could enable states to preserve the “essential health benefits” of the ACA, the proposal would reduce federal funding and could therefore mean less financial support for families to buy dental coverage that might otherwise be unaffordable.

The other proposed plan, the Obamacare Replacement Act, does not ensure that consumer protections would endure, nor does it sustain incentives for maintaining comprehensive dental benefits. (6) For example, insurers might no longer be required to abide by the ACA rule that prevents them from setting annual or lifetime caps on the benefits they pay for once deductibles are met. Suffice it to say, much is at stake if the ACA is repealed without a robust replacement.

While the ACA is the focus of attention for members of Congress and health reporters, oral health professionals and children’s advocates also should keep a close eye on Medicaid and CHIP. Together, these two programs cover an estimated 43 million children. (7) As a matter of fact, the ACA helped connect more children with Medicaid and CHIP coverage by creating a simpler method for determining family income that is compatible with the method used to calculate eligibility for subsidies to buy plans offered on the ACA marketplaces. This approach has streamlined the enrollment process.

Unfortunately, the future of Medicaid and CHIP is up in the air. President Trump and some congressional leaders have discussed converting the Medicaid program to a block grant or instituting per-capita caps—structural changes that could threaten the stability and quality of coverage for children and families. (8) For now, no specific proposal has been introduced. Federal funding for CHIP ends after September, and states could be forced to tighten eligibility rules accordingly. CHIP fills a crucial gap, covering children whose families earn too much to qualify for Medicaid but too little to afford the typical medical and dental premiums.

Measures to change Medicaid’s funding or other aspects could be directed at the adults enrolled in the program—or at those who became newly eligible through ACA-enabled Medicaid expansions. Even under this scenario, dental coverage for millions of adults could be at risk. (2) This kind of approach could also erect a barrier to children’s access because the increase in adult coverage is strongly associated with improved coverage for kids. (9) In fact, we saw the largest increases in post-ACA child Medicaid and CHIP enrollment in states that also expanded Medicaid for adults.

Although the situation in Washington, DC, may look very polarized, it would be a mistake for Americans to assume their members of Congress have made up their minds about the future of coverage. We believe many members in both parties would appreciate hearing the perspectives of dental professionals, parents, and others. There are signs that a number of Republicans who have criticized the ACA in the past want to proceed with caution.

Referring to Americans who gained coverage through the ACA, Rep. Tom MacArthur (R-NJ) recently told his colleagues, “We’re telling those people that we’re not going to pull the rug out from under them, and if we do this too fast, we are, in fact, going to pull the rug out from under them.” (10) We couldn’t agree more.

References

1. Greenwood M. Pence reaffirms plans to 'repeal and replace' ObamaCare. The Hill. http://thehill.com/policy/healthcare/317688-mike-pence-gop-will-still-repeal-replace-obamacare. Published February 2, 2017.
2. Nasseh K, Vujicic M. Dental Benefits Coverage Rates Increased for Children and Young Adults in 2013. http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_1015_3.ashx. American Dental Association Health Policy Institute research brief. Published October 2015.
3. Mann C. Update on CMS Oral Health Initiative and Other Oral Health Related Items. Baltimore, MD: Centers for Medicare & Medicaid Services, US Dept of Health and Human Services; 2014:1-7. https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-07-10-2014.pdf.
4. Yu ZJ, Elyasi M, Amin M. Associations among dental insurance, dental visits, and unmet needs of US children. J Am Dent Assoc. 2017;148(2):92-99.
5. Cassidy, Collins Introduce Comprehensive Obamacare Replacement Plan [news release]. Senator Susan Collins; January 23, 2017. https://www.collins.senate.gov/newsroom/cassidy-collins-introduce-comprehensive-obamacare-replacement-plan.
6. The Obamacare Replacement Act, S 222. https://www.paul.senate.gov/imo/media/doc/ObamacareReplacementActSections.pdf.
7. Burwell SM; US Dept of Health and Human Services. 2015 Annual Report on the Quality of Care for Children in Medicaid and CHIP. https://www.medicaid.gov/medicaid/quality-of-care/downloads/2015-child-sec-rept.pdf. Published February 2016.
8. LaRochelle R. The GOP plan to fund Medicaid through block grants will probably weaken it. Washington Post website. https://www.washingtonpost.com/news/monkey-cage/wp/2017/01/18/republicans-want-to-fund-medicaid-through-block-grants-thats-a-problem/?utm_term=.6c10d583a9a4. Published January 18, 2017.
9. Alker J, Chester A; Georgetown University Health Policy Institute Center for Children and Families. Children’s Health Insurance Rates in 2014: ACA Results in Significant Improvements. http://ccf.georgetown.edu/wp-content/uploads/2015/10/ACS-report-2015.pdf. Published October 2015.
10. Pear R, Kaplan T. In Private, Republican Lawmakers Agonize Over Health Law Repeal. New York Times website. https://www.nytimes.com/2017/01/27/us/politics/affordable-care-act-republican-retreat.html?_r=1. Published January 27, 2017.

Editor's note: This article first appeared in the Apex360 e-newsletter. Apex360is a DentistryIQ partner publication for dental practitioners and members of the dental industry. Its goal is to provide timely dental information and present it in meaningful context, empowering those in the dental space to make better business decisions. Visit the Apex360 home page here, and subscribe to the Apex360 e-newsletter here.

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