More than 8 million low-income adults will become eligible for dental benefits this year, according to a new ADA analysis of the Patient Protection and Affordable Care Act (ACA). But expanded Medicaid coverage doesn't guarantee increased access to dental care, the report noted.
The February report by the ADA Health Policy Resources Center noted that the increase is caused by two key aspects of the ACA: expanded Medicaid eligibility and increased enrollment efforts.
Expanded Medicaid coverage includes about 2.9 million adults who will be eligible for extensive benefits and an additional 5.4 million who could get limited benefits.
In the nine states that are expanding Medicaid eligibility and also providing extensive dental benefits, the report predicts there will a significant increase in demand for dental care among low-income adults.
"In these states, policymakers ought to ensure that the enabling conditions are in place to ensure the Medicaid population can access dental care," wrote the report authors Cassandra Yarbrough, MPP; Marko Vujicic, PhD; and Kamyar Nasseh, PhD.
If the rest of the states also expanded Medicaid eligibility, it would further increase the number of adults with Medicaid dental benefits by 2.7 million. But if the states would enhance their current dental benefits for adults on Medicaid, the impact would be far greater, the report noted.
Dental coverage
Routine dental care is among the basic drivers of oral health, and dental insurance is a key factor in enabling people to access dental care. In fact, people with private dental insurance are more than twice as likely to have annual dental exams compared with those without benefits, studies show. However, the percentage of adults who visit a dentist has been declining since the early 2000s. Also, the percentage of nonelderly adults with private dental insurance also has declined, balanced by an increase in the number of nonelderly adults enrolling in Medicaid, the report noted.
Adult Medicaid dental benefits vary significantly since such benefits are optional for the state. Some states offer benefits similar to private dental insurance, while other states provide no dental care. Adult Medicaid dental benefits have eroded since 2002, with some states scaling back dental benefits; others have eliminated them.
Source: The Henry J. Kaiser Family Foundation. Notes: Based on the Census Bureau's March 2012 and 2013 Current Population Survey. All graphics courtesy of the American Dental Association.ACA impact
Before the ACA, the states varied in which low-income adults were eligible for Medicaid. The ACA tries to standardize Medicaid coverage for low-income nonelderly adults by expanding Medicaid eligibility. As originally proposed, the states had to provide full Medicaid benefits to adults ages 19 through 64 with incomes up to 133% of the federal poverty level. However, a 2012 U.S. Supreme Court ruling made Medicaid expansion optional.
The states that expanded Medicaid will get 100% reimbursement to cover newly eligible people until 2016, when it is decreased to 90% in 2020. The states will continue to get current levels of federal funding for those who were eligible for Medicaid prior to the new law, whether they chose Medicaid expansion or not.
Regardless of whether states expand Medicaid eligibility, studies show that Medicaid enrollment will increase. While the states that expanded Medicaid will enroll newly eligible adults, the ADA researchers predict that all the states will also experience a "woodwork effect," in which uninsured people realize they are eligible for Medicaid under the pre-ACA eligibility rules and apply for benefits. The effect is enhanced by streamlined enrollment procedures, increased visibility of Medicaid options, and the individual mandate requiring Americans to have health insurance, according to studies.
Although the states aren't required to provide dental benefits to adults on Medicaid, many states currently offer dental benefits ranging from emergency care to extensive dental treatment. As a result, the ACA will have an impact on the number of adults with Medicaid-provided dental benefits, the report authors stated.
Yarbrough C, Vujicic M, Nasseh K. More than 8 Million Adults Could Gain Dental Benefits through Medicaid Expansion. Health Policy Resources Center Research Brief. American Dental Association. February 2014.As of January 1, 26 states including the District of Columbia have expanded Medicaid eligibility. Of these, nine provide extensive adult dental benefits, 11 provide limited care, five provide emergency care, and one (Delaware) does not provide any benefits. Among the states that have not expanded Medicaid, three provide extensive adult dental benefits, nine provide limited care, 11 provide emergency care, and two don't provide any dental care.
The report noted that the states that expanded Medicaid are also the ones that tend to provide extensive adult dental benefits. In the states that expanded Medicaid, an estimated 9.1 million currently uninsured adults will become eligible for Medicaid as a result of the ACA, according to the report. This includes an estimated 6.5 million adults who will be newly eligible due to expanded Medicaid and 2.6 million who will learn they are eligible through the woodwork effect. Of these 9.1 million adults, 2.7 million are in states that provide extensive adult dental care. An additional 4.9 million are in states that provide limited adult dental care.
The report pointed out that more than 800,000 adults would have gained extensive Medicaid dental benefits if their state had opted to expand Medicaid eligibility, and an additional 1.9 million would have gained limited dental benefits.
Medicaid enrollment
About 20 million working age adults were enrolled in Medicaid in 2012, according to a Kaiser Foundation study. Based on recent studies, 6.5 million uninsured adults will be newly eligible for Medicaid this year. An additional 4.4 million uninsured adults are already eligible for Medicaid and may enroll through expanded enrollment and outreach efforts from the ACA (woodwork effect). If both of these groups enroll in Medicaid, 10.9 million more adults will be in the program in 2014.
The ADA report estimates that the ACA could expand Medicaid dental benefits to 8.3 million adults, with an estimated 2.9 million gaining extensive dental benefits and 5.4 million gaining limited dental benefits. And an additional 2.5 million people are expected to gain emergency dental benefits.
The ACA's Medicaid reforms are expected to reduce the number of low-income adults who lack at least limited dental benefits by up to 35%, based on Kaiser Foundation studies.
The ADA report noted these policy implications:
There will be a significant increase in demand for dental care among Medicaid adults in certain states. The largest increases are expected to be in the nine states that are expanding Medicaid eligibility and provide extensive adult dental benefits (CT, IA, NM, NY, ND, OH, OR, RI, WA).
Expanded coverage does not guarantee increased access to and utilization of dental care. "It is important that policymakers put in place the enabling conditions to ensure the expansion population can access care," the report authors noted. Studies show this includes expanded outreach to Medicaid beneficiaries and dental care providers, improved provider incentive structures -- including streamlined administrative procedures and adjusted fees -- and innovative practice models.
There is uncertainty on how the Medicaid expansion funding arrangement will impact the way states handle voluntary benefits such as adult dental care.
Dental benefits for average adults on Medicaid will probably increase in 2014.
The federal government will fund approximately 93% of the cost of the Medicaid expansion through 2022, even for optional benefits such as adult dental care, as long as they were in place in 2014, the report noted. The issue is how the states will finance the remaining 7%, the researchers emphasized.
"If states adopt an approach of looking to nonmandated services for cost savings and program cuts, then some optional benefits could be at risk of being 'crowded out,' " the researchers stated. "On the other hand, if the Medicaid expansion actually results in net cost savings, then some voluntary benefits may actually be 'crowded in.' "
A recent study estimated that the states could see savings ranging from $26 billion to $52 billion between 2014 to 2019 due to Medicaid expansion.
Emergency room visits for dental conditions have doubled over the past decade, which cost the healthcare system up to $2 billion per year, with young adults accounting for the most cases, ADA studies show.
Providing extensive dental benefits to Medicaid-enrolled adults increases dental care use, prevents the onset of more serious and costly oral health conditions, and can reduce emergency room visits for dental problems, the report noted. And insurance studies show that improved oral health and access to dental care also can reduce medical costs.
The report noted that California and Washington have recently restored some adult Medicaid dental benefits that were previously cut. And Colorado has added adult dental care to their Medicaid program for the first time in an effort to reduce ER costs from dental problems.
Conclusion
On a positive note, the report noted that only five states are planning to decrease Medicaid dental reimbursement rates this year, while 13 states are planning to raise reimbursements.
"These are positive developments that will contribute to America's oral health," the report concluded.
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