PHE 610 Module 6 Reform Legislation Short Paper Example

What the Affordable Care Act Did and Did Not Do for Teeth

[Student Name]

Southern New Hampshire University

PHE 610: Health Policy and Management

Module Six 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.

What the Affordable Care Act Did and Did Not Do for Teeth

Introduction

Signed in 2010, the Affordable Care Act changed American health coverage more than any law since Medicare and Medicaid were created. Most analyses ask what it did for insurance coverage, hospital finances or premiums. This paper asks a narrower question with direct relevance to our state's dental shortage: what did the law do for teeth? The answer is that it did something for children, much less for adults and nothing for older Americans, and the reasons say a great deal about how reform legislation is built and fought over.

What the Law Changed

Two provisions reached dental care. The first was Medicaid expansion, which opened the program to low-income adults, up to 138 percent of poverty,, and Washington picked up nearly all of the bill for that new group. Congress wrote expansion as a requirement. Two years later the Supreme Court, in NFIB v. Sebelius, held that states could not lose their existing Medicaid funds for refusing it, which turned expansion into a state choice. Expansion added adults to Medicaid, but because adult dental benefits in Medicaid are optional, whether new enrollees gained dental coverage depended entirely on each state's benefit package.

The second provision designated pediatric services, including oral and vision care, as one of ten essential health benefits that plans sold in the individual and small-group markets must cover. In practice this meant children could get dental coverage through marketplace plans, either embedded in a medical plan or through a stand-alone dental plan, though families were not always required to buy it.

What the Law Left Out

The law's dental gaps are as notable as its provisions. Adult dental care was not made an essential health benefit, so marketplace plans had no obligation to cover it. The law made no change to Medicare's exclusion of routine dental care, leaving most adults over 65 without dental coverage at the age when tooth loss and gum disease are most common. And it did nothing to expand the dental workforce beyond modest grant programs. The ACA did include a demonstration program for alternative dental providers, but Congress never funded it.

These omissions reflected the law's politics. Coverage expansion had to be paid for, and every added benefit raised the cost estimate that drove the debate. Dental care, long separated from medicine in schools, licensing and insurance, was easy to leave on the edge of a bill already fighting for votes.

The consequences show up in the data our program sees. Since expansion, the number of adults in our state with a Medicaid card has grown by roughly 60,000, yet the share of those adults with a dental visit in a year has barely moved, because their benefit covers only an extraction once a tooth is beyond saving. Older residents are in a similar position from the other direction: they leave employer dental plans at retirement and enter a Medicare program that will pay for a hospital admission caused by a dental abscess but not for the filling that would have prevented it. In both cases the law expanded coverage for the body and stopped at the mouth.

Evidence on Effects

Did coverage improve health? A review by Sommers et al. (2017) weighed the Oregon Medicaid lottery alongside quasi-experimental studies of expansion. Their reading was that insured people get more care, face fewer catastrophic bills and rate their own health better, and that a growing body of work points to lower death rates, while results for particular clinical measures such as blood pressure remain mixed. Those findings are about medical coverage; they do not automatically extend to dental care, which Medicaid may not cover.

Wehby et al. (2019) examined dental care directly. Comparing states before and after expansion, they found that expansion increased dental visits among low-income adults, but the gains were concentrated in states that offered generous adult dental benefits and had more dentists per capita. In states with limited or emergency-only benefits, or with few dentists, expansion produced little change in dental use. The law, in other words, could only amplify what each state's own benefit design and workforce already allowed.

Two cautions apply to this evidence. Studies of expansion compare states that chose to expand with states that did not, and those states differ in politics, income and health systems in ways that statistical methods can reduce but not eliminate. And most studies measure visits rather than oral health itself, so we know more about whether people saw a dentist than about whether their teeth were saved. Even so, the pattern in Wehby et al. (2019) is consistent with the finding that dentists respond to coverage only where there are dentists to respond.

The Politics That Still Shape Choices

Oberlander (2020) describes the ACA's first decade as a ten years' war marked by partisan polarization, repeated repeal attempts, litigation and uneven state implementation. That war reached our state directly. Its legislature declined expansion for six years before voters approved it by ballot measure, and the compromise that followed held adult dental benefits to emergency extractions to limit cost.

The legacy shapes today's options in three ways. First, any proposal to broaden adult dental benefits will be judged against an expansion that legislators did not choose and still resent paying for. Second, because expansion adults now hold Medicaid cards, a workforce change such as dental therapists could reach them quickly if benefits were broadened. Third, because federal funds cover nine of every ten dollars spent on the expansion group, adding dental benefits for those adults costs the state far less per person than adding them for traditional enrollees.

Implications for the Policy Analysis

The ACA shows that coverage is necessary but not sufficient. It extended Medicaid to tens of thousands of adults in our state, yet their coverage stops at emergency extractions and there are few dentists to accept it. The dental therapy bill addresses the workforce half of that problem. The final policy analysis should treat benefit design and workforce as linked: licensing therapists without covering the care they provide would repeat the ACA's lesson in reverse.

References

Oberlander, J. (2020). The ten years' war: Politics, partisanship, and the ACA. Health Affairs, 39(3), 471-478. https://doi.org/10.1377/hlthaff.2019.01444

Sommers, B. D., Gawande, A. A., & Baicker, K. (2017). Health insurance coverage and health: What the recent evidence tells us. New England Journal of Medicine, 377(6), 586-593. https://doi.org/10.1056/NEJMsb1706645

Wehby, G. L., Lyu, W., & Shane, D. M. (2019). The impact of the ACA Medicaid expansions on dental visits by dental coverage generosity and dentist supply. Medical Care, 57(10), 781-787. https://doi.org/10.1097/MLR.0000000000001181