Talk Dental to Me

A trip to the dentist elicits a variety of reactions, ranging from irritation about time lost to severe anxiety about a dental procedure. These might seem like commonplace concerns, however for a vast majority of Americans, a trip to the dentist for an annual cleaning or toothache is out of reach.  Over the past decade, the number of total ED visits increased and the number of ED visits for dental conditions nearly doubled. Between 2000 and 2010, the number of dental ED visits increased from 1.1 million to 2.1 million. Various estimates of the cost to treat dental conditions in the ED range from $867 million to $2.1 billion.

The majority of dental-related ED visits are for non-traumatic conditions; most patients are discharged with either pain medication or antibiotics, rather than after a completed dental procedure. Data from the Nationwide Emergency Department Sample (NEDS) shows that the principle diagnosis for 41.8% of all ED visits for dental conditions are dental caries, a preventable and treatable condition with regular dental care. Non-traumatic dental conditions, such as dental caries, are better served in a dental office, which offers expertise in oral health and continuity of care.

Unfortunately, millions of Americans do not receive this necessary care, primarily due to lack of dental insurance, an inability to pay what insurance does not cover and a lack of dental providers. The 2008 National Health Interview Survey indicated that of 172 million Americans with private insurance coverage, 45 million (26%) lack dental insurance (more updated data is not currently available). And while some states offer comprehensive dental coverage under Medicaid for adults, most states offer limited coverage, emergency coverage or no coverage at all

In 2009, more than 16 million children who received Medicaid did not receive dental care, not even a routine exam. Even though Medicaid is required to cover dental insurance for children in all states, inaccessibility of providers, financial issues, and the harsh reality that many dentists do not accept Medicaid creates a situation of poor oral health care that continues throughout an individual’s entire life. Even for those adult Medicaid beneficiaries with dental coverage, no more than half of all dentists in 25 states accepted Medicaid in 2008.

Nearly 49 million individuals live in an area designated as a Dental Health Professional Shortage Area (DHPSA), an indication that simply having insurance coverage for dental care is not the same as having access to care. An estimated 9,600 new dental providers are necessary meet current demand for existing dental care needs. Even though more providers are critical to improving issues of access, projections show that reality will not even come close to this need. In 2019, estimates show that the U.S. could have 7,000 fewer dentists than in 2009, further compounding concerns about access to care.

In addition to access and insurance issues, the out-of-pocket costs for dental care prevent millions from seeking even routine and preventative care; these costs totaled $30.7 billion in 2008. Taken collectively, the issues of access to care, lack of or insufficient insurance coverage and inability to pay out-of-pocket costs push millions of individuals to a much more expensive care setting: the emergency department (ED).

The Affordable Care Act (ACA) significantly expands insurance coverage for millions of Americans, but does not address coverage for dental care. The lack of inclusion of dental insurance in the ACA perpetuates the access and financial barriers faced by individuals attempting to find dental care. While Medicaid is required to provide dental benefits for children and the ACA mandates the same standards for private insurance coverage. However, the ACA does not require dental benefits for adults receiving Medicaid or mandate coverage in exchange plans. Subsidies in the exchanges cannot be used for dental insurance, except when it is an “add-on” to an exchange plan.

In light of the numerous budget challenges facing states, few have taken steps to increase access to dental insurance and care. Nonetheless, Oregon has pioneered a new model that extends much needed dental coverage and improves access to care for its Medicaid population, a group that utilized the ED at much higher rates than those with private insurance for dental issues.  In 2011, Oregon enacted legislation to create a new payment and delivery structure known as a “Care Coordination Organization (CCO). The legislation created 16 regional CCOs around the state to deliver physical and behavioral health care to Medicaid enrollees under a single budget. The CCO program has just completed its first full year of implementation.

Oregon has set its CCOs apart from accountable care entities in other states by establishing them in statute, creating them as geographic entities and stipulating that they are responsible for the states’ Medicaid population. The authorizing legislation also explicitly recognizes dental care as a necessary heath service that must be covered. Each CCO is required to contract with all “dental care organizations” (DCOs) in their region. For example, the Portland CCO had to contract with eight DCOs to fulfill this provision. The legislation also set forward financial incentives to encourage collaboration between CCOs and DCOs, but the early economic success of these collaborations has also been helped by increased Medicaid enrollment due to the program’s expansion in the ACA.

While a recent report from the Oregon Health & Science University cited a high prevalence of ED visits for dental conditions in the state, health care officials have locally seen results. It is also important to note that the data in the report was collected prior to the implementation of the Oregon’s CCO/DCO collaboration. Even prior to the CCO/DCO implementation, some localities had noticed changes to ED utilization for dental care after dental providers started offering affordable care.  Creating an affordable care model is crucial to encouraging individuals to seek preventative care in a dental office. When, individuals receive dental care in the ED, there is little to be done except pain management and/or infection treatment.  According to a report in Oregon, 65% of patients who went to the ED for a dental issue were given pain medication and 57% received antibiotics. Prior to the CCO/DCO collaboration and the inclusion of expanded dental care, most adult Medicaid patients were covered only for extractions or temporary fillings; individuals would often not have a tooth removed because they could not afford permanent treatment.

While Medicaid coverage differs significantly between states, the federal government retains the ability to mandate coverage for aspects of care in all states. Senator Bernie Sanders (I-VT) and Representative Elijah Cummings (MD-7) introduced the Comprehensive Dental Reform Act of 2015. This legislation is the most comprehensive dental care legislation in Congressional history and would seeks to expand dental coverage to all individuals receiving coverage through Medicaid, Medicare and the Veterans Administration. It would also designate oral health care an essential benefit as defined under the ACA; this provision would require oral health care to be included in all insurance plans available on federal and state insurance marketplaces (also known as exchanges). This legislation was introduced in the previous Congress as well, however, yet again no movement on the bill is expected.

Oregon is an impressive leader in its commitment to oral health care for its adult Medicaid population, particularly in contrast to the political environment preventing the federal government from addressing this issue.  The Oregon CCO/DCO initiative is still in its infancy; however, early reports indicate that for individuals enrolled in an Oregon CCO, total ED visits for all conditions decreased by 22% from data collected in 2011, a possible sign of improved access to preventative and sick care in communities. It will take a few years for accurate data on dental care and the impact of its expansion in ED utilization in Oregon. Improving oral health care coverage and access is vital to overall physical health and could have significant implications for ED utilization, not only in Oregon but around the country.

Molly Benoit, Master of Public Health Candidate at the George Washington University, Urgent Matters Graduate Research Assistant