Affordable Care Act 10-year anniversary: Oral health wins and losses

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March 23 marked the 10-year anniversary of the signing of the Patient Protection and Affordable Care Act (ACA). Dental public health expert Nadereh Pourat, PhD, spoke with about some of the oral health wins and losses from the biggest U.S. healthcare overhaul in 50 years.

One of the most important oral health provisions in the ACA was that dental benefits were declared an essential health benefit for children, noted Pourat, director of research at the University of California, Los Angeles (UCLA) Center for Health Policy Research.

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

"We generally know that kids who have insurance coverage have better access to care," she said.

Data from the ADA Health Policy Institute back that assertion. Increasing access to dental benefits for children led to improvements in pediatric dental coverage, dental visits, and affordability gaps.

In 2015, only 10% of U.S. children didn't have any form of dental coverage, the lowest that percentage had ever been. At the same time, more children visited the dentist, and the rates of untreated caries dropped for children from all income groups.

But for adults, dental benefits were not considered an essential health benefit under the ACA. In the past decade, more adults in the U.S. have dental benefits, but fewer adults are seeing the dentist, often for citing financial reasons.

"That was the missed opportunity," Pourat said. "That we did not consider dental benefits as an essential benefit for adults."

Although dental benefits were not considered essential, adults still saw some oral health benefits under the law. The ACA enabled people who were self-employed or working in jobs that didn't offer dental benefits to purchase dental coverage through the state insurance exchanges. It also removed barriers to insurance for people with preexisting conditions, helping them to access public or private insurance.

"The advantage of the ACA is that it improved the ability to purchase coverage," she said.

However, just because people had access to insurance, doesn't mean that the coverage was affordable -- a common criticism of the ACA. Many individuals and families continue to suffer from an affordability gap, in which they make too much money to qualify for medical and/or dental insurance through Medicaid but also too little to qualify for ACA subsidies that help them afford plans on the exchanges.

"There's a whole group of people being left behind," Pourat said. "Those who make just above the qualification for Medicaid but don't make enough to buy their own plans."

Furthermore, just because a dental plan is on a state exchange doesn't mean it has quality coverage. Unlike medical plans, dental plans don't have standardization. This means that people can easily burn through the maximum allowed coverage for the year, she noted.

"Dental benefits are just restrictive," Pourat said. "You don't get as much as you want. If you need one crown and a root canal, it could wipe out all of your dental benefits for the year."

What's next for the ACA?

In the end, the ACA produced some mixed results, and its legacy may be short-lived. The U.S. Supreme Court is set to hear another major challenge to the law, and policymakers from both sides of the aisle have talked about wanting the ACA repealed, rewritten, expanded, or replaced.

"So much depends on who is going to be in power and what direction we end up taking," Pourat said.

When rethinking the ACA, future lawmakers will have to contend with dentist reimbursement rates, public versus private insurance, and quality of dental care. But those discussions can't and won't happen if oral health isn't on people's minds.

And in some ways, it feels like we're going back to 10 years ago. In the coming months and years, policymakers will have to decide all over again whether oral health is important enough to add to any new law -- and if so, whether that coverage should extend to some or all Americans.

"The big problem is you need to get people in the door," Pourat said. "Once they're in the door, you can figure out how to improve things."

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