ObamaCare and Dentistry

ObamaCare will change the American healthcare marketplace in unintended ways. It will have notable impact on the dental field, through mandated pedodontic coverage. Few people enjoy visiting the dentist; however, dental care may become more problematic. Within a few years, private dental care with a trusted and known practitioner may be limited.

In the practice of medicine, a notable trend has been the movement of doctors toward employee status rather than owner/partner business practices. This relationship lessens the working hours that burden younger practitioner's families and provides economic stability at a lower salary. This changes the relationship between patient and doctor while reducing marketplace competition. Established and trusted relationships provide a sense of security for those undergoing difficult treatments. Similarly, in dentistry the trend has been toward larger practices. Most recent graduates of dental schools burdened with extremely high educational debt do not have the option for individual offices.

Employee-based practice creates ethical dilemmas for younger dentists. Larger corporate practices encourage dentists to maximize dental insurance benefits, rather than treat each patient as an individual. The ACA will accelerate this disturbing trend.

The ACA requires dental-care coverage for children through age 18. This expansion appears to be a good device for improving healthcare generally. Yet, as private health plans move in this direction, the cost of dental insurance for adults will increase. Dental insurance is usually an added policy. Fewer healthy adults will opt for this coverage as they face higher premiums due to mandated ACA coverage. Therefore, as adults who require more extensive and costly treatment make up a greater fraction of the pool, dental premiums will rise. This will result in fewer people with private insurance plans with extensive dental coverage.

Dental insurance is affordable because roughly 50% of those with active policies do not seek routine care. This may be due to fear, anxiety, lack of money for co-payments, or lack of time and interest. Dental insurance, unlike medical insurance, is rarely catastrophic and contains yearly maximums to limit insurance company losses. This restriction against overutilization, which could bankrupt any health care plan, is removed under ObamaCare. This will drive up the costs beyond early expectations, just as Medicare and Medicaid costs have skyrocketed.

Under ObamaCare, early estimates were that up to 8.5 million additional children would be receive dental coverage by 2018 under private or government insurance. Perhaps up to 4.5 million adults would qualify for dental coverage through added Medicaid rolls and 800,000 through health insurance exchanges under the ACA. Unfortunately, most states have reduced adult dental coverage under Medicaid due to soaring costs. Therefore, these estimates may not be valid. (Statistical information comes from the American Dental Association, which did not support ObamaCare since it did not provide dental coverage for adults and failed to address low dental reimbursement rates under Medicaid.)

The original Medicaid legislation mandated dental coverage for children, but gave the states an option for adults. The majority of newly-covered persons via exchanges will be through government insurance (Medicaid) because of enhanced eligibility. An estimated additional 2.5 million pediatric and 7.5 adult Medicaid dental visits will result. This will increase Medicaid spending for dentistry by $2.5 billion, further burdening taxpayers and increasing waiting periods for routine care. Medicaid coverage is restricted and prescribed by each state. Medicaid reimbursements are stagnant at low levels, so many dentists do not participate.

As the economy has created fewer jobs with benefits since 2008, there has been a reduction of almost 6% of all adults with private dental coverage from age 19-64. There has been an increase of 3% of the population covered under Medicaid as the employment market has provided more part-time jobs. Meanwhile, since 2007 adults over 65 have seen an increase in dental coverage under the Medicare Advantage program. As these premiums increase, due to reduced subsidy under ObamaCare, then this trend could reverse.

Dental visits for children have increased since 2000 owing to greater numbers of Medicaid-eligible families. Adult visits have declined during the same period because of lost private insurance benefits. Despite government insurance coverage, dental visits increase as families' income increases, growing steadily above the federal poverty level, reaching 50% at 400% of that amount and to 70% at higher incomes. Yet, since 2003, the percentage of adults and children visiting the dentist within the last year has declined in all income categories. Only senior visits have held steady over the past decade. Poorer people are three times more likely to seek dental care at hospital emergency rooms, though this is usually only palliative.

Reduction in national income has accompanied a diminution in the number of dental office visits and billings per visit. The initial appointment waiting period has declined from about 10 days in 2001 to 5 days in 2011. Per capita dental care spending increased until 2007, but has declined since then by almost .5%. Per capita spending is projected to be flat under most estimates through 2040. As profit margins erode, quality care could suffer. This trend further erodes the ability of smaller offices to survive.

The ACA has increased taxes, which will be counterproductive. These include a medical device excise tax of 2.3%. This tax will increase the cost of national dental care by an estimated $160 million annually. Flexible spending accounts are now limited to $2500 per year with a COLA. An increase of 0.9% on Medicare payroll taxes and additional 3.8% taxes on investment income on earnings above $200,000 per individual and $250,000 per couple will further burden small businesses. A tax credit for small businesses that provide health insurance for employees expires in 2016 increasing costs in future years.

Most dental offices are small businesses. Smaller businesses cannot manage higher expenses easily, eroding profit margins. This leads them to merge into larger groups. Individual care will be a casualty. Increased use of technology reduces affordability and increases the impersonal nature of care. Auxiliaries will be expected to perform more procedures previously undertaken by dentists. This will have adverse affects upon dental care.

As corporate practices become a larger portion of the marketplace their employee dentists (who earn less and are burdened by high educational debt) will be encouraged to maximize dental care. Lower national spending on dental health from 2008-2011, coupled with accelerated increases in practice costs has reduced dental incomes. Average age of dentists at retirement has increased by 4 years from 64.3 to 68.3 as economic and life-expectancy realities have affected savings and practice sales values. Office owners will face the employer burdens of ObamaCare by adjusting employee hours and benefits as have other businesses.

Public dental-health efforts since the 1950s have included fluoridation of water supplies which is associated with a reduction in dental decay and its subsequent sequella. These include lost teeth, infections that threatened general health, and expensive restorations. ObamaCare does nothing to encourage fluoridation in untreated communities.

Despite governmental efforts since the 1960s the utilization of dental services appears related to income and private insurance benefits. Economic prosperity provides the greatest hope for quality dental care. The government can provide a safety net, but it cannot guarantee that dental decay will managed adequately. Poorer persons are more likely to lose teeth and become edentulous despite government programs.

We may not recognize dental offices of the future. ObamaCare may accelerate the worst trends in healthcare by increasing the cost of care and limiting our choices. Our choice of dentist may be adversely impacted. This is not what we were promised.

Howard J. Warner is a practicing private office dentist, with hospital and public health experience. He is involved in dental society leadership and dental policy politics on the state and national levels.

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