Health care reform continues to be in the forefront of policy discussions at the state and federal levels. In 2019, the U.S. health sector costs are projected to amount to $3.8 trillion.1 Nearly one-fifth of the U.S. economy is directly or indirectly associated with the health care sector. Federal and state governments heavily regulate health care delivered through the private sector, including by imposing mandates. Expenditures are expected to continue to rise for the foreseeable future.
Although dentistry accounts for just 4% of total national health expenditures, dentists are heavily impacted by the changing regulatory environment and increased administrative burdens.2 In addition, debates around expanding access to dental care too often fail to take into consideration significant differences between the oral health payment and delivery systems and the medical systems.
The Academy of General Dentistry (AGD) advocates for the interests of general dentists, both as an organization and in partnership with other dental associations. As clinicians, we advocate for the best interests of our patients and oppose third-party interference with the doctor-patient relationship. This paper outlines specific priorities that the AGD considers essential in its advocacy related to health care reform. The AGD believes that health care reform should:
- Be market-based and foster competition;
- Be based on a dental prevention/dental home model for oral health care;
- Reduce administrative burdens;
- Address state-level reforms; and
- Encourage healthy lifestyles, good oral health habits and personal responsibility.
MARKET-BASED SOLUTIONS–FOSTERING COMPETITION
The AGD supports market-based approaches to health care reform that build on the strengths of the current system. Any health care reform effort also must include relief for providers from administrative burdens.
Consistent with this principle, the AGD opposes the establishment of a single-payer health care system. A pure single-payer health care system would eliminate the private plans covering nearly 173 million people, the same plans with which so many Americans are satisfied.3 Any change should encourage competition that reduces costs and provides more consumer choice. Potential innovations warranting further exploration include allowing small businesses to form associations to buy insurance, providing a way for individuals to join these associations and allowing the purchase of health insurance across state lines. Careful consideration must be paid to ensuring innovations do not inadvertently increase administrative burden on providers.
Repealing Private Health Insurers’ Antitrust Exemption
The AGD supports efforts to repeal the antitrust exemption enjoyed by health insurers provided under the 1945 McCarran-Ferguson Act. Under the exemption, health insurers may share data and other information to help set rates. In the present era of dominant insurers, the McCarran-Ferguson Act exemption distorts the health insurance market, reduces transparency and undermines competition. If the antitrust exemption is repealed for private health insurers, they would be subject to applicable federal laws against bid-rigging, price-fixing and market allocations, among others.
Increase Contribution Caps to Health Accounts
The AGD supports increasing the maximum allowable contributions to flexible spending accounts (FSAs), health savings accounts (HSAs) and health reimbursement accounts (HRAs) and also supports changes that would allow families to carry over FSA contributions from year to year.4 Currently, carryover is limited to HSAs and HRAs.
Employees can use pretax dollars to fund FSAs and HSAs to pay for medical and dental expenses not paid by insurance. Consumers participating in these tax-advantaged accounts can evaluate the spending of their health care dollars and engage in more informed decisions. Because dental benefit plans are so limited in their coverage, this is especially important to help finance oral health care needs.
The AGD supports current law that eliminates exclusions for preexisting conditions.
Funding of Reform: No Provider Taxes
The issue of funding any health care reform is complex and beyond the scope of this paper. The AGD opposes any new specific tax on dental services.5
Current Government Programs: Dental Care
Between Medicaid, the Children’s Health Insurance Program (CHIP), and the inclusion of children’s dental care as an essential benefit in the Patient Protection and Affordable Care Act (ACA) exchange plans, dental coverage for children has increased significantly.6 However, coverage does not necessarily translate to access or utilization of care.
Fewer than half of the dentists in the United States participate in Medicaid. Lagging reimbursement and administrative burdens are major factors. While reimbursement levels vary by state, they are significantly lower than private-payer reimbursements.7 Other barriers to access and utilization include transportation issues, lack of oral health literacy, and fear and/or anxiety.8
Any expansion of present programs must address these barriers directly and be restructured to enhance dentist participation by ensuring reasonable reimbursement for dentists and relief from administrative burdens.
The elderly can be particularly at risk for oral health problems. The population of patients over 65 years of age is diverse; their interests, resources and needs vary widely. Recognizing this diversity is key in terms of considering approaches to dental care. Considerations include treatment planning and increasing oral health literacy later in life.
The AGD opposes efforts to expand access by adding a dental benefit to Medicare.9 Since it was enacted, the Medicare program (Part A and Part B) has included a specific blanket exclusion of dental services with limited exceptions as defined by the Centers for Medicare & Medicaid Services.10
U.S. Department of Veterans Affairs, Veterans Health Administration
The AGD supports broad-based reform for the U.S. Department of Veterans Affairs (VA),Veterans Health Administration (VHA). Previous wait times for appointments were unacceptable. Excessive bureaucracy and lack of integration of electronic health records within with the Department of Defense are often cited as needed transformations for the agency. The VAMISSION Act may provide appropriate solutions, particularly for rural residents. Veterans must be afforded a social and health care support system to attend to their evolving needs.
SUPPORT ORAL HEALTH PREVENTION MODEL
Many oral health problems can be prevented by exercising good health habits, such as tooth brushing, flossing between the teeth and routine visits to the dentist. However, only 5% of health care spending overall is allocated to prevention practices.11
Oral Health Literacy
Increasing oral health literacy is one of the greatest challenges and opportunities for the future and should be a priority in health care reform. If individuals, especially caretakers of children and members of at-risk populations, are educated about good self-care and encouraged to visit the dentist for preventive services, then individual oral health and the overall health of the population should improve. This will reduce costs associated with the need for more complex treatment and emergency room visits.
Data indicate that costs associated with non-traumatic emergency room visits for dental procedures may exceed $1.7 billion per year.12 Moreover, medical intervention in patients with newly diagnosed Type 2 diabetes is positively associated with lower health care costs.13
The Dental Home
The AGD strongly supports incorporating the dental home model as part of any health care reform. The dental home model is built around the core principle of the prevention of future oral health problems and, potentially, future medical problems. Dental homes provide patients with education (oral health literacy), prevention, treatment, referrals (if needed) and follow-up care.
In a dental home, general dentists or pediatric dentists are the gatekeepers of oral health care. They are also well-equipped to alert the patient to potential systemic conditions, such as Type 2 diabetes, prediabetes and high blood pressure. Optimally, establishment of a dental home begins at the eruption of the first tooth or no later than 12 months of age.
Dental procedures that are surgical and/or irreversible must be performed by a licensed dentist. Other staff members play critical roles in the advancement of oral health literacy as well as navigating patient access to preventive services based on individual needs.
Health Plan Accountability: ERISA Reform
The Employee Retirement Income Security Act of 1974 (ERISA) is a complex federal law that was designed to provide uniform regulation of employee health care benefit and pension plans. However, it includes a provision that specifically exempts self-insured health plans from complying with state laws that “relate to” insurance. Courts have determined that ERISA preempts state laws providing patient protections and provider fairness and that state laws cannot be enforced against these plans.14 Sixty percent of Americans receive coverage from self-insured, employer-provided plans.
To increase accountability, the AGD supports efforts to amend the federal law to remove the exemption and require self-insured health plans to comply with these state laws.
The AGD supports ongoing state-level efforts to reform the professional liability system. In addition, the AGD supports “Good Samaritan” laws that provide protection to health care professionals crossing state lines to assist in the aftermath of natural disasters.
Water fluoridation is the adjustment of the levels of fluoride that occur naturally in water to an optimal level to prevent tooth decay. Fluoride helps prevent tooth decay by making teeth more resistant to acids derived from bacteria in the mouth (as well as certain foods and drinks) that attack enamel.
The AGD encourages state and local governments to provide effective levels of fluoride in public water systems to reduce the prevalence of dental caries in their population.
Challenge Certificate of Need Restrictions
State certificate of need (CON) laws are contradictory to free-market principles and should be repealed. They require health care providers to obtain permission from state regulators to develop or expand a health care facility or to purchase regulated devices or technologies. Over 30 years of data demonstrate that CON laws fail in all goals intended to benefit the health care market, such as ensuring access to care in rural communities, restraining the cost of care, safeguarding charitable care for those unable to pay, providing adequate supply of health resources and improving the quality of care.15
Prevention through good oral health habits, a healthy lifestyle and exercising personal responsibility are critical for maintaining oral health and overall health. While there are many variables in a healthy lifestyle, lowering sugar consumption and eliminating tobacco use are two of the most important for good oral health.
The AGD supports efforts to educate the public on the importance of nutrition on health in general and oral health in particular. This includes limiting the consumption of sugar. Sugars in beverages and starchy foods such as bread, beans, fruit, potatoes and many others interact with bacteria in the mouth to form acids that can eat away at tooth enamel and lead to caries. Over time, a lowered pH in the mouth creates an environment where bacteria infiltrate the enamel of the tooth and can cause a carious lesion. A diet high in sugar and other carbohydrates also increases the likelihood of obesity, diabetes, heart disease, increased cholesterol and high blood pressure.16
The AGD supports efforts to decrease and ultimately eliminate the use of tobacco as well as ongoing Food and Drug Administration (FDA) regulation of nicotine levels in electronic nicotine delivery systems.17
OTHER AREAS OF NEEDED REFORM
Student Debt Relief
The Higher Education Act of 1965 [Public Law 89-329] was intended to strengthen the educational resources of our colleges and universities and to provide financial assistance for students in post-secondary and higher education. The AGD believes that addressing the issue of student debt is critical to a well-functioning graduate education system and overall health care system.
Support Student Loan Relief
In 2019, student loan debt totals $1.49 trillion in the United States. Recently, graduate and professional degrees have seen larger increases in student loan indebtedness. In 2015–16, graduate students, including those pursuing professional degrees, accounted for 38% of the amount of federal loans but 17% of the number of students.18,19,20 For dental school graduates who pursue general dentistry residencies, student loan debt is high and compounded by the fact that students must pay interest on their dental school loans while in residency. The interest continues to compound even when the student qualifies for deferment or forbearance due to an inability to make the payments.
The AGD supports a range of legislative efforts to provide student loan relief. The AGD will support legislative proposals on a case-by-case basis depending on the merits.
Support Dental Faculty Loan Payment Program
The AGD supports the Health Resources and Services Administration (HRSA) Title VII Health Professions Faculty Repayment Program. Under this program, dentists employed as a full- or part-time faculty member at a general, pediatric or public health dentistry program for at least two years are eligible for up to $20,000 in government assistance annually in paying the principal and interest of their student loans.
Providing interest accrual relief during residencies could offer options for dentists to work in underserved areas or join faculty and research positions at universities.
The AGD supports common sense solutions to bringing pharmaceutical prices down, including efforts to carefully examine new drug approvals in relation to patent duration, which determines when a drug becomes generic.
Pharmacy Benefit Managers (PBM)
Concerns with third-party PBMs include a lack of transparency, market consolidation and failure to pass along lower costs to consumers. The AGD supports the realignment of PBMs to increase transparency and put the interests of patients as the foremost consideration.
1Centers for Medicare & Medicaid Services (CMS). National Health Expenditure Projections 2018-2027. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/ForecastSummary.pdf (Accessed Aug. 19, 2019)
2CMS. National Health Expenditures2017 Highlights.; https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/highlights.pdf (Accessed Aug. 19, 2019)
3According to a recent Gallup poll, most Americans (69%)3 rate their own health coverage as excellent or good with 80% rating their health care quality as excellent or good. https://news.gallup.com/poll/245195/americans-rate-healthcare-quite-positively.aspx (Accessed Aug. 19, 2019)
4Ebeling, A. IRS Announces 202 Health Savings Account Limits. Forbes, May 29, 2019. https://www.forbes.com/sites/ashleaebeling/2019/05/29/irs-announces-2020-health-savings-account-limits/#40dd288f3f3c (Accessed Aug. 19, 2019) For 2020, the IRS allows Health Saving Account contribution limits of $3550 for an individual and $7100 for a family.
5The AGD supports the permanent repeal of the 2.3% medical device excise tax imposed by the Patient Protection and Affordable Care Act (ACA) [Public Law 111-148].
6The Patient Protection and Affordable Care Act (ACA) [Public Law 111-148]. https://www.govinfo.gov/content/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf (Accessed Aug. 19, 2019)
7Fontana, J, Lewis, C, Carver, T. Medicaid Adult Dental Reimbursement. Milliman, May 2019. http://assets.milliman.com/ektron/medicaid-adult-dental-reimbursement.pdfhttps://catalyst.nejm.org/cause-crises-whole-health-whole-person/
8Oral health literacy is defined as the capacity to obtain, process, and understand basic health information and services needed to make appropriate oral health decisions. Healthy People 2010: Understanding and Improving Health. Washington, DC: US Department of Health and Human Services; 2000.
9The AGD believes Medicare cannot sustain the inclusion of dental benefits. Market innovations should include the ability for seniors to obtain dental benefits in a competitive market. AGD Policy on Dental Benefits for the Medicare Population. https://www.agd.org/dental-practice-advocacy-resources/advocacy-resources/key-federal-issues/medicare (Accessed Aug. 19, 2019)
10CMS. Medicare Dental Coverage. https://www.cms.gov/Medicare/Coverage/MedicareDentalCoverage/index.html (Accessed Aug. 19, 2019)
11Jonas, WB, Schoomaker, E, Marzolf, JR, Gaudet, T. Finding the Cause of the Crises: Opioids, Pain, Suicide, Obesity, and Other Epidemics. NEJM Catalyst, May 15, 2019. https://catalyst.nejm.org/cause-crises-whole-health-whole-person/ (Accessed Aug. 19, 2019)
12Wall, T, Nasseh, K. Vujicic, M. Majority of Dental-Related Emergency Department Visits Lack Urgency and Can be Diverted to Dental Offices. ADA Research Brief. August 2014. https://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_0814_1.ashx (Accessed Aug. 19, 2019)
13Nasseh, K, Vujicic, M, Glick, M. The Relationship between Periodontal Interventions and Healthcare Costs and Utilization. Evidence from and Integrated Dental, Medical, and Pharmacy Commercial Claims Database. Health Economics 26:519-527. https://onlinelibrary.wiley.com/doi/epdf/10.1002/hec.3316 (Accessed Aug. 19, 2019)
14Gerth, JE. United States: Can State Prompt Pay Statutes be Enforced Against Self-Funded ERISA Health Plans? The 11th Circuit Says No. http://www.mondaq.com/unitedstates/x/294664/employment+litigation+tribunals/Can+State+Prompt+Pay+Statutes+Be+Enforced+Against+SelfFunded+ERISA+Health+Plans+The+11th+Circuit+Says+No (Accessed Aug. 19, 2019) (Accessed Aug. 19, 2019)
15Mitchell, MD. Certificate of Need Laws. Mercatus Center, George Mason University, April 17, 2017. https://www.mercatus.org/publications/certificate-of-need-laws-goals (Accessed Aug. 19, 2019)
16AGD Sugar & Heath Consequences https://www.agd.org/dental-practice-advocacy-resources/advocacy-resources/agd-policies (Accessed August 19, 2019)
17The negative oral health consequences of using combustible cigarettes is well documented and it contributes to cancer and other serious diseases. Furthermore, research indicates that youth who have used electronic nicotine delivery systems are more likely to take up combustible cigarettes. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on the Review of the Health Effects of Electronic Nicotine Delivery Systems; Eaton DL, Kwan LY, Stratton K, editors.
Washington (DC): National Academies Press (US); 2018 Jan 23.
18Baum, S, Steele, P. How Much Students Borrow. Urban Institutes. https://www.urban.org/sites/default/files/publication/95626/graduate-and-professional-school-debt.pdf (Accessed August 19, 2019)
19The average educational obligation for an indebted dental school graduate was $285,184 in 2019. American Dental Education Association. (ADEA) https://www.adea.org/data/