What dentists need to know about Graham-Cassidy

Experts have criticized the latest Republican U.S. healthcare bill, which would change the way state Medicaid programs are funded. The ADA cautioned that some of the bill's provisions could reverse recent advances made in improving pediatric dental utilization.

Gary L. Roberts, DDS, president of the ADA. Image courtesy of the ADA.

The Graham-Cassidy bill is the latest effort from U.S. Senate Republicans to repeal and replace the Patient Protection and Affordable Care Act (ACA). It addresses healthcare regulation mainly by putting states in charge of their own requirements and implementation, but the ADA and American Academy of Pediatric Dentistry (AAPD) have strongly criticized some of the provisions, stating that the proposed changes to Medicaid funding will be detrimental to Americans who rely on the program.

"We believe provisions in the current proposal introduced by Sens. Lindsey Graham and Bill Cassidy will be detrimental to Medicaid programs and the vulnerable Americans who rely on them for healthcare and coverage," wrote ADA President Gary L. Roberts, DDS, and AAPD President James Nickman, DDS, in a letter to leading lawmakers.

So how does Graham-Cassidy differ from the ACA? And, perhaps more important, what provisions are likely to affect you and your patients?

Major changes to Medicaid

Graham-Cassidy was written by Republican U.S. Sens. Bill Cassidy, MD (R-LA), and Lindsey Graham (R-SC). The bill seeks to give states more control over healthcare policy. However, if the bill is not passed by September 30, Senate rules change and more than a simple majority will be needed to pass healthcare legislation.

The biggest, and perhaps most criticized, change from the ACA will be how state Medicaid programs are funded. Instead of matching funds for qualified expenditures like the current program, this proposal will cap how much money states receive for Medicaid through block grants. The grants are designed to give states more flexibility in the way they administer their healthcare programs, according to a press release from Sen. Cassidy. The hope is that states that rely heavily on the federal match, including New York and California, will streamline their Medicaid programs.

James Nickman, DDS, president of the AAPD.

However, the bill's approach to Medicaid has been widely criticized by experts and public health organizations, including the ADA and AAPD. In their letter to lawmakers such as Senate Majority Leader Mitch McConnell (R-KY), Drs. Roberts and Nickman defended the Medicaid program and noted that its expansion has helped to increase dental care utilization rates among publicly insured children.

"The Medicaid program's importance to Americans' oral health cannot be overstated," they wrote. "Under the current structure and financing system, Medicaid provides a significant foundation for children to achieve optimal oral health through preventive efforts and routine care."

Drs. Roberts and Nickman specifically pointed to the current requirement for children to have dental coverage through early periodic screening diagnosis and treatment as one of the drivers behind the uptick in utilization rates.

"To that end, we are concerned that proposed fundamental changes to Medicaid funding could put the nation's overall oral health at risk," they wrote. "While we support state flexibility and innovation, we also believe states should follow statutory guidelines when designing their Medicaid benefit programs because without such guidelines care can and may be reduced or eliminated entirely."

Nadereh Pourat, PhD, director of research, UCLA Center for Health Policy Research.

Dental health policy expert Nadereh Pourat, PhD, director of research at the University of California, Los Angeles (UCLA) Center for Health Policy Research, agreed that changes to Medicaid would likely result in fewer children and adults receiving dental care. By turning Medicaid funding into block grants, states will likely reduce optional benefits, including adult dental coverage, and also make cuts to provider payments, which may result in fewer dentists and doctors accepting Medicaid patients, she told DrBicuspid.com.

"It is unlikely that adult dental benefits would remain in any state," she said. "Lack of coverage is directly correlated with delays in care, even for those in the middle class. So you could expect patients to show up with more advanced dental disease and opt for less costly procedures, such as extractions, due to unaffordability."

The bill does have one provision that mentions states with a Medicaid waiver will be required to provide assistance for noncosmetic dental services. However, what that exactly means is unclear. It has been suggested that the section implies protections for some dental care provided by Medicaid but without the same emphasis on prevention and early periodic screening diagnosis and treatment. It is also unknown whether the provision would apply to adults.

"It does not specifically mention dental services for adults but seems to imply an overwrite of what is mandatory and optional," Dr. Pourat said. "If this bill indeed requires states to offer adult dental, then the only option available to states is to cut the number of beneficiaries and provider payments in order to provide any care given the cap on total Medicaid funding."

DrBicuspid.com attempted to contact the bill's co-authors to clarify this provision on multiple occasions. Sen. Cassidy's office did not respond, while an automated email from Sen. Graham stated that he only responds personally to inquiries from South Carolinians.

Regulating private and public insurance markets

Because Graham-Cassidy leaves the vast majority of healthcare legislation to the states, it cuts the federal individual and employer mandates, as well as some of the consumer protections under the ACA.

While some states may try to keep their programs as close to the ACA as possible, others may drastically change the rules for health insurers, such as by adding a work requirement to Medicaid or eliminating cost sharing that helps to protect people with pre-existing conditions from paying substantially more for health insurance.

For dentistry, there is particular concern that some states will rewrite the 10 essential health benefits mandated by ACA, which currently require all health insurers to provide comprehensive pediatric dental coverage.

"Similar to the Medicaid program, significant oral health improvements in recent years have been achieved in the private market as well," Drs. Roberts and Nickman wrote in their letter. "While pediatric dental benefits are an essential health benefit, the most significant coverage gains in the marketplace have been among adults. We are concerned that proposed changes to private dental plan offerings and private health insurance financing could undo these improvements."

Graham-Cassidy also expands the use of health savings accounts (HSA), which allow people to set aside money, tax-free, for healthcare costs. The ADA has previously supported the expanded use of HSAs, since many people use them to pay for dental care, but the association did not specifically mention HSAs in its letter to Congress and instead urged the legislators to reject the provisions that change Medicaid funding.

"We encourage you and your colleagues to reject the proposed changes to Medicaid funding and seek alternatives that will ensure continuity of coverage and continued access to oral health services for the vulnerable Americans," Drs. Roberts and Nickman concluded. "Please utilize our organizations as resources and look forward to working with you to ensure that our nation's children and low-income, working families can continue to benefit from measurable improvements in oral healthcare and access to dental coverage."