Spring 2015

Maze of Questions

Five years after the passage of health-care reform, its impact on dentistry remains muddled 

By Gail Bambrick

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Illustration: Blair Kelly

When the Affordable Care Act took shape, there was optimism that its inclusion of dental coverage for children and teens among its essential benefits would, indeed, widen access to oral health care for more youngsters.

Five years after the passage of the landmark health-care reform law, however, it is still not known how many more pediatric patients will find their way to dentists’ chairs. Other key aspects of the law, known as ACA or Obamacare, that affect dentistry also remain in flux—namely, how many low-income adults will gain dental benefits through the federal Medicaid program and what effect the contentious medical device tax, intended to help fund the ACA, will have on the cost of dental care if the tax withstands ongoing congressional attempts to repeal it.

The law’s impact on the dental profession depends on these and other moving targets, says Marko Vujicic, chief economist and vice president of the Health Policy Institute at the American Dental Association and a visiting assistant professor at Tufts School of Dental Medicine. Or, as the journal Pediatric Dentistry Today put it in an article last year: “Expect more pediatric patients to have dental insurance, potentially fewer adults with dental coverage and plenty of confusion.”

“This is a seminal moment for the U.S. health-care system, and dentistry must chart a new course and a new vision for the profession in this shifting environment.” —Marko Vujicic, ADA

Elements of the ACA, enacted in 2010, have been phased in over the past five years. As one of the act’s “10 essential benefits,” coverage for dental care for children under age 19 must be offered on state and federal health-care exchanges. However, parents and guardians are not mandated to purchase this coverage for their kids—or for themselves.

The ACA is facing yet another hurdle as the U.S. Supreme Court considers the King v. Burwell case, which challenges the insurance subsidies provided to individuals in the 34 states with federally run health-care exchanges. A ruling is expected in June.

Coverage for Children

So what does this all mean for the dental profession?

Despite the uncertainties, many parents and guardians are expected to purchase dental coverage for their children, while other young people will qualify for expanded coverage under Medicaid, says Vujicic. The ACA requires states to provide dental benefits to children covered by Medicaid and the Children’s Health Insurance Program (CHIP), which provides low-cost health coverage to children in families whose income is too high to qualify for Medicaid.

“We originally estimated that approximately 8.7 million children could gain some form of dental benefits by 2018, an increase of 15 percent relative to 2010,” he says. “But given what we have seen during implementation in the first year, the actual number will be much less.”

Meanwhile, “adult dental care is not considered ‘essential’ under the ACA. As a result, coverage remains optional—both within Medicaid programs and for individuals shopping for health insurance in the marketplaces,” says Vujicic. According to the ADA, up to 8.3 million adults could gain at least limited dental benefits through Medicaid expansion, while to date, a little more than 1 million adults have purchased a dental plan through the health-insurance marketplaces.

Today, about 187 million Americans have some form of dental insurance provided either by their employers or public programs such as Medicaid and CHIP, according to the National Association of Dental Plans. That leaves about 130 million who have to pay for dental care out of pocket—or go without care. This becomes problematic if the cost of dental care increases—something the medical device tax may precipitate, says Vujicic.

A Contentious Tax

The 2.3 percent tax, which took effect in 2013, covers materials and components used to make many dental products and restorations. It also covers nitrous oxide and oxygen delivery systems, and X-ray and other diagnostic equipment, including imaging and sensors, cone-beam CT, caries detection devices, handpieces and CAD/CAM machines—essentially anything dentists use that is designated as a Class I, Class II or Class III dental device by the Food and Drug Administration.

The tax is expected to generate $26 billion between 2015 and 2024, according to the Center on Budget and Policy Priorities, an independent policy research organization. But opponents of the tax argue it will raise health-care costs and kill innovation in the medical device industry.

Repealing the tax is a priority of the Republican-led Congress. In 2013, the Republican majority in the House voted to get rid of the tax, but the measure did not gain support in the Democrat-controlled Senate. Earlier this year, new legislation for repeal was introduced in the Senate. Five Democratic senators and four Republicans signed onto the bill, authored by finance committee chairman Orrin Hatch, R-Utah. While President Obama had threatened to veto previous attempts to repeal the tax, he has said he will consider this latest bipartisan effort.

Repealing the medical device tax is a priority of the Republican-led Congress.

If the tax is not repealed, Vujicic says, dentists could be in the position of passing increased costs for diagnostic equipment and other materials on to their patients.

The cost of care, for patients and providers, remains at the center of the debate. Stand-alone dental plans offered through state and federal exchanges have out-of-pocket maximums, known as OOPs. For example, all federal insurance exchanges have a $700 annual OOP per child (capped at $1,400 for two or more children) for plans that cover only dental care. State and federal exchanges also offer “embedded” dental plans, in which a single policy covers both medical and dental care. These may carry one annual deductible for medical and dental care combined.

“Longer term, it is vital for [all those assessing the future of the ACA] to understand how changes in dental insurance coverage affect access to care and, ultimately, oral health,” Vujicic wrote in an August 2014 article published by the ADA’s Health Policy Institute. “More broadly,” he says, “this is a seminal moment for the U.S. health-care system, and dentistry must chart a new course and a new vision for the profession in this shifting environment.”

Gail Bambrick can be reached at gail.bambrick@tufts.edu.

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