A tale of two safety nets

Abstract

The mouth incontestably is an important part of the body, no matter what your age. But when you look at many public policies in the health sector of the United States, the importance of the oral cavity may not seem so obvious.Take Medicaid, for example. Dental benefits for children are mandatory. For adults, however, dental benefits are optional, and states can select the level of coverage to provide—one option being no coverage at all. Within the Affordable Care Act, pediatric dental services are one of 10 essential, required health benefits. For adults, dental care is not considered “essential” within the Act. Clearly, among policymakers, the status of the mouth changes with age.Of course, there could very well be sound economic, political or social reasons for this. For example, with limited resources, investments in children's oral care and disease prevention might be viewed as having the biggest bang for the buck in terms of lifetime gains in oral health and, therefore, should be prioritized. Whatever the reasons, it is important to take a hard look at the data to understand the impact of what are essentially two different safety nets when it comes to dental care—one for low-income children and one for low-income adults.The past decade has seen a steady increase in the rate of dental care utilization among low-income children in the United States. These gains have been widespread across the states. Between 2000 and 2011, state-level data from the federal Centers for Medicare & Medicaid Services indicate that dental care utilization among children enrolled in Medicaid increased in 47 of the 50 states. Some of these gains are quite remarkable.For example, just 15 percent of Medicaid-enrolled children in Oklahoma had a dental visit in 2000 compared with 44 percent in 2012. Texas improved from a utilization rate of 37 percent in 2000 to 59 percent in 2012—higher than the utilization rate for children with private dental benefits. The percentage of children who have no form of dental benefits has decreased steadily over the past decade, from 22 percent in 2000 down to 14 percent in 2011.Reforms within Medicaid programs—streamlined administrative processes, patient and provider outreach, and enhanced provider incentives—are key factors driving increased dental care use among children enrolled in Medicaid.For adults, we have a very different story. The past decade has seen a significant decrease in dental care utilization among low-income adults. The data suggest that this is due, at least in large part, to access issues and not the result, for example, of significant reductions in need for care. Emergency department visits for dental conditions have doubled in the past decade. More and more low-income adults are reporting that they cannot get dental care they need because of cost.The central question for the policy community is whether this tale of two safety nets—one for low-income children that has seen a decade of progress, the other for low-income adults that has not—is the right tale for America's oral health. Because adult dental care is not part of essential benefits under the Affordable Care Act, this question will continue to be answered primarily at the state level, at least for now. Thankfully, there is much experience to draw on.There is strong evidence that adult dental benefits within Medicaid affect utilization and access to care. The so-called “Romneycare” experience in Massachusetts shows that expanding dental benefits coverage through Medicaid and health insurance marketplaces—opportunities available to states under “Obamacare”—can greatly increase dental care use among adults. How to pay for this, of course, is always an issue. But that is for a future perspectives piece. The mouth incontestably is an important part of the body, no matter what your age. But when you look at many public policies in the health sector of the United States, the importance of the oral cavity may not seem so obvious. Take Medicaid, for example. Dental benefits for children are mandatory. For adults, however, dental benefits are optional, and states can select the level of coverage to provide—one option being no coverage at all. Within the Affordable Care Act, pediatric dental services are one of 10 essential, required health benefits. For adults, dental care is not considered “essential” within the Act. Clearly, among policymakers, the status of the mouth changes with age. Of course, there could very well be sound economic, political or social reasons for this. For example, with limited resources, investments in children's oral care and disease prevention might be viewed as having the biggest bang for the buck in terms of lifetime gains in oral health and, therefore, should be prioritized. Whatever the reasons, it is important to take a hard look at the data to understand the impact of what are essentially two different safety nets when it comes to dental care—one for low-income children and one for low-income adults. The past decade has seen a steady increase in the rate of dental care utilization among low-income children in the United States. These gains have been widespread across the states. Between 2000 and 2011, state-level data from the federal Centers for Medicare & Medicaid Services indicate that dental care utilization among children enrolled in Medicaid increased in 47 of the 50 states. Some of these gains are quite remarkable. For example, just 15 percent of Medicaid-enrolled children in Oklahoma had a dental visit in 2000 compared with 44 percent in 2012. Texas improved from a utilization rate of 37 percent in 2000 to 59 percent in 2012—higher than the utilization rate for children with private dental benefits. The percentage of children who have no form of dental benefits has decreased steadily over the past decade, from 22 percent in 2000 down to 14 percent in 2011. Reforms within Medicaid programs—streamlined administrative processes, patient and provider outreach, and enhanced provider incentives—are key factors driving increased dental care use among children enrolled in Medicaid. For adults, we have a very different story. The past decade has seen a significant decrease in dental care utilization among low-income adults. The data suggest that this is due, at least in large part, to access issues and not the result, for example, of significant reductions in need for care. Emergency department visits for dental conditions have doubled in the past decade. More and more low-income adults are reporting that they cannot get dental care they need because of cost. The central question for the policy community is whether this tale of two safety nets—one for low-income children that has seen a decade of progress, the other for low-income adults that has not—is the right tale for America's oral health. Because adult dental care is not part of essential benefits under the Affordable Care Act, this question will continue to be answered primarily at the state level, at least for now. Thankfully, there is much experience to draw on. There is strong evidence that adult dental benefits within Medicaid affect utilization and access to care. The so-called “Romneycare” experience in Massachusetts shows that expanding dental benefits coverage through Medicaid and health insurance marketplaces—opportunities available to states under “Obamacare”—can greatly increase dental care use among adults. How to pay for this, of course, is always an issue. But that is for a future perspectives piece.