PHE 610 Module 2 Financing Short Paper Example

Who Pays for Teeth: Dental Care Financing and Its Consequences in a Northern Plains State

[Student Name]

Southern New Hampshire University

PHE 610: Health Policy and Management

Module Two Short Paper

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Who Pays for Teeth: Dental Care Financing and Its Consequences in a Northern Plains State

Introduction

When the only dentist in our state's westernmost county retired, residents lost more than a convenient office. They lost the one practice within ninety miles that would see a patient on Medicaid. Where a service is located is only half of the access story; who pays for it, and how much, is the other half. This paper describes how dental care is financed in the United States and in a composite northern Plains state of about 900,000 people, explains how that financing shapes who receives care, and identifies the financing questions a policy analysis of the state's dental workforce will need to answer.

How Dental Care Is Paid For

Nationally, dental care is financed differently from almost every other part of health care. Hospital care is paid largely by private insurers, Medicare and Medicaid, with patients covering a small share directly. Dental care relies far more on direct payment by patients, and private dental plans usually carry annual maximums of one to two thousand dollars that have changed little in decades (Northridge et al., 2020). Traditional Medicare excludes routine dental care altogether, so most retirees lose dental coverage when they leave work.

Medicaid is the main public payer, but its obligations differ by age. Under federal law, states must cover comprehensive dental services for children enrolled in Medicaid. Adult dental benefits are optional, and states decide whether to offer none, emergency only, limited or extensive coverage. In our state, adult Medicaid covers emergency extractions and little else.

Table 1. Main Payers for Dental Care in the Study State

Consequences for Access

These arrangements push more cost onto patients for dental care than for any other service. Using national survey data, Vujicic et al. (2016) found that cost was a more common reason for going without needed dental care than for going without medical care, mental health care, prescription drugs or eyeglasses, and that this held across age, income and insurance groups. Among low-income adults, the share reporting unmet dental need because of cost was several times the share reporting unmet medical need.

Financing also shapes where people go when pain becomes severe. Adults without dental coverage turn to hospital emergency departments, which can prescribe antibiotics and pain medication but rarely treat the underlying tooth (Northridge et al., 2020). Our county hospital sees this pattern every week. The visit is billed to Medicaid or written off as uncompensated care, so the system pays for a dental problem without solving it. A patient may return three or four times with the same tooth, each visit costing more than the filling or extraction that would have ended the problem, and each one counted in hospital data as a medical rather than a dental encounter. Because those costs land in a different budget, they rarely appear in debates about dental coverage at all.

The burden is not evenly spread. Northridge et al. (2020) describe consistent gaps in dental use by income, race and ethnicity, rural residence and disability. In our state the three tribal nations face a double gap: the Indian Health Service is funded by annual appropriations rather than entitlement, and its clinics cannot recruit enough dentists to use the funds they have.

What Changing the Financing Does

Two financing levers have been studied closely. The first is adult Medicaid dental coverage. Decker and Lipton (2015) compared states that added or removed adult dental benefits and found that coverage increased the probability that low-income adults visited a dentist and reduced some measures of unmet need. Coverage alone, however, depends on dentists willing to accept it.

The second lever is what Medicaid pays. Buchmueller et al. (2016) showed that when states added adult benefits, dentists did respond by treating more publicly insured patients, but the response was larger where fees were higher and dentists were more numerous. In a state with few dentists and low fees, a new benefit may produce coverage on paper and little care in practice. Both levers therefore run into the workforce constraint that brought the state to this question in the first place.

There is also a budget question. Every dollar added to adult dental benefits or fees comes from a state general fund matched by the federal government at the state's regular matching rate, or at the higher expansion rate for adults in the expansion group. Legislators in our state have twice rejected a fee increase on cost grounds. A financing change that pays for itself, such as one that shifts care from emergency departments to cheaper settings, would be easier to pass, but the evidence that dental coverage reduces emergency spending enough to offset its cost is limited, and an honest analysis should say so.

Financing Questions for the Policy Analysis

Three financing questions follow for the policy analysis that will examine licensing dental therapists. First, could dental therapists bill Medicaid directly, and at what rate, so that their services are paid for rather than absorbed? Second, would tribal clinics be able to bill Medicaid at the federal encounter rate for therapist visits, as tribal programs in Alaska do, giving them a revenue stream to hire therapists? Third, would the state need to add or broaden adult dental benefits for a new provider type to reach adults at all, since a therapist who can fill teeth helps little if fillings are not covered? Financing will not settle the workforce question, but any workforce option that ignores who pays for its services is likely to fail.

Conclusion

Dental care in the United States is paid for mostly by patients and by benefit designs that stop at the edge of the mouth. In our state, emergency-only adult Medicaid coverage and low fees mean that the people with the greatest need face the highest costs and the fewest willing providers. Evidence shows that adding coverage and paying more can raise care, but only where providers exist to deliver it. That is why the next step in this course is a policy evaluation proposal focused on who may provide care, with financing built in from the start.

References

Buchmueller, T., Miller, S., & Vujicic, M. (2016). How do providers respond to changes in public health insurance coverage? Evidence from adult Medicaid dental benefits. American Economic Journal: Economic Policy, 8(4), 70-102. https://doi.org/10.1257/pol.20150004

Decker, S. L., & Lipton, B. J. (2015). Do Medicaid benefit expansions have teeth? The effect of Medicaid adult dental coverage on the use of dental services and oral health. Journal of Health Economics, 44, 212-225. https://doi.org/10.1016/j.jhealeco.2015.08.009

Northridge, M. E., Kumar, A., & Kaur, R. (2020). Disparities in access to oral health care. Annual Review of Public Health, 41, 513-535. https://doi.org/10.1146/annurev-publhealth-040119-094318

Vujicic, M., Buchmueller, T., & Klein, R. (2016). Dental care presents the highest level of financial barriers, compared to other types of health care services. Health Affairs, 35(12), 2176-2182. https://doi.org/10.1377/hlthaff.2016.0800