Impact of Health Policy

Millions of Americans are struggling with preventable dental diseases in an era when interventions to eradicate these diseases exist. The burden of poor oral health is not borne equally across the United States. Alarming disparities exist among Americans from racial and ethnic minority groups and those with low incomes. For example, approximately 29% of African-American children who live at or below the poverty line have untreated caries, compared with 17% of all US children. Additionally, approximately 40% of African-American working adults have untreated caries, compared with 25% of all US working adults.¹

Access to dental care and other interventions that promote, protect, maintain, and/or restore oral health are critical to addressing the oral health crisis in the US. Unfortunately, those who experience untreated dental disease are also more likely to experience barriers to accessing care. While approximately 79% of adults with an income greater than $50,000 have visited a dentist or dental clinic in the past year, the proportion of adults utilizing dental services drops to nearly half (42.8%) for those with incomes less than $15,000.²The cost and availability of dental care are cited as major barriers to access.

Health policies—defined as the decisions, plans, and actions undertaken to achieve special health care goals within a society—play an important role in access to care. While many policies impact access, those with the largest impact generally focus on removing barriers to care (eg, cost, availability, and accessibility) or regulating the health system to enhance the quality and safety of care (eg, professional regulation).

As dental hygiene professionals, we strive to provide the highest level of care to our patients. It is also our professional duty to remain informed about the state of oral health in the US and understand how we can contribute to improving oral health for all Americans, not just our patients. This article reviews the role of key health policies on access to care to educate dental hygienists about opportunities for advocacy (Table 1).

POLICIES AFFECTING ACCESS

For many Americans, the cost of dental care is prohibitive. Dental insurance offsets this cost for those who have it, but one-third (33.3%) of Americans do not have any form of insurance for dental care.³ Those who are uninsured bear the full cost of dental services, and many, especially those with low incomes, are forced to forego oral health care services until they have an acute need. Many in this situation seek high-cost care in their local emergency departments. In fact, 2.18 million dental visits were made to emergency departments in 2012, with a cost of $1.6 billion.⁴ Expansion of dental insurance represents policy focused on addressing cost as a barrier to access.

Some social insurance programs—such as Medicaid and state-administered insurance for low-income children and adults—provide dental insurance for a segment of the population. Not all social insurance programs, however, cover dental care. Currently, there are no minimum requirements for adult dental coverage within state Medicaid programs. This has led to disparities in dental coverage among low-income adults across state lines. Additionally, Medicare, the federal social insurance program for disabled Americans and those age 65 and older, offers minimal dental benefits, excluding preventive or restorative care. The demand for comprehensive dental services among American older adults is likely to grow in the coming decades. As a result of lifelong access to dental care, a large number of Americans aging into Medicare have retained many of their teeth. However, as policies currently exist, they may lose dental coverage as they transition to Medicare.

Expanding health insurance alone is not enough. While the oral health community has made great strides in recognizing oral health as integral to overall health, the structure of health insurance programs does not reflect this principle. The US recently expanded health insurance coverage for Americans through the Patient Protection and Affordable Care Act (ACA). The ACA identified 10 “essential health benefits” as critical. Dental care was included among the essential benefits for children, but not for adults.⁵

Overcoming the barrier of cost is not enough to ensure access. In order for access to occur, dental providers have to be available and their services be accessible to the populations in need of dental care. Shortages of oral health professionals limit availability of dental services in many rural and low-income urban communities. As of June 30, 2016, nearly 50 million Americans were living in designated dental health professional shortage areas.⁶ In order to address these shortages, the federal government administers programs such as the National Health Service Corps—a scholarship and loan repayment program—which provides incentives for dental professionals in exchange for practicing in a community that is recognized as underserved. Additionally, federally qualified health centers (FQHCs)—comprehensive primary health care organizations—are an important part of the dental safety net in many underserved communities. As part of the requirements to receive federal funding, FQHCs must provide dental care to their patients, either directly or through collaboration with community dental providers. This type of policy fosters an environment in which the provision of dental services is supported by the health system and such services are easily accessible for health center patients.

State policies that regulate the practice of and reimbursement environment for health professionals also impact the availability of dental services. Variations in state practice acts for the dental hygiene profession translate into varying practice environments and directly impact the provision of and access to care within a state.⁷ Some states have adopted practice acts that enable dental hygienists to practice without the direct supervision of a licensed dentist in all or selected settings (generally public health or rural settings). In these states, dental hygienists can integrate into nontraditional health-care settings, open their own clinics, or provide care in mobile or school-based settings. States with more restrictive practice acts do not afford dental hygienists the same opportunities for extending dental care into new and nontraditional settings.

In addition to regulating existing dental professionals, some states are expanding the availability of care by creating new provider types. While still small, the number of states that have adopted the midlevel oral health practitioner is increasing. These new providers offer an expanded scope of services (most often preventive and some restorative care) and consider enhancing access to care part of their professional missions.

Ensuring that a sufficient number of providers is available to serve the overall population is not enough to address the gross disparities that exist in oral health. Dental professionals must also be accessible to the populations in need, particularly to those low-income populations most affected by oral health disparities. In order to ensure accessibility to dental services for patients covered by Medicaid, providers must be enrolled as state Medicaid providers. In 25 of 39 states that responded to a survey completed by the Association of State and Territorial Dental Directors, only half of the dentists treated patients covered by Medicaid in the previous year.⁸ Dentists cite low reimbursement rates, administrative burden in Medicaid enrollment, and patient behaviors as reasons for low participation.⁹ Research has shown that higher reimbursement rates are associated with Medicaid acceptance among providers, increasing the accessibility of dental providers to patients covered by Medicaid.^9–11 Increasing reimbursement alone will not solve this issue. Currently only 18 states have adopted statutory or regulatory language permitting Medicaid programs to directly reimburse dental hygienists. Direct reimbursement is critical to support dental hygienists in their efforts to expand access to care. Practice acts affording greater independence must be coordinated with reimbursement policy to ensure sustainable models.

CHARGE TO DENTAL HYGIENE PROFESSIONALS

As dental hygienists, we partner with our patients in supporting and maintaining their oral health, and we have a responsibility to promote oral health beyond our dental chair. We can do this first by seeking out information and becoming educated about the state of oral health in our communities and nation. We can impact oral health in our broader community through advocating for policies that improve individuals’ access to care and our collective ability to meet the oral health needs of Americans.

From Perspectives on the Midlevel Practitioner, a supplement to Dimensions of Dental Hygiene. October 2016;3(10):24-27.