2013 conference. The Impact of Policy on Oral Health Care Delivery. whitepaper. Peter C. Damiano, DDS, MPH. September 12 & 13, 2013 Washington, D.C.

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1 Oral INSTITUTE Health FOR IOHWA.ORG Education & Collaboration Resource for Advancing Innovation in Oral Health Care 2013 conference September 12 & 13, 2013 Washington, D.C. The Impact of Policy on Oral Health Care Delivery whitepaper Peter C. Damiano, DDS, MPH Director, University of Iowa Public Policy Center; Professor, Department of Preventive and Community Dentistry Writer Designer: Gavin James gjamesdesign.com

2 keynote speaker Peter C. Damiano, DDS, MPH Director, University of Iowa Public Policy Center; Professor, Department of Preventive and Community Dentistry The Affordable Care Act: The Short and Longer Term Implications for Oral Health As a professor of dentistry and director of the Public Policy Center at the University of Iowa, Dr. Peter Damiano has spent many years researching ways to improve access to quality dental care. With health care reform rolling out, a host of new challenges and opportunities are at the forefront. At the 2013 Institute for Oral Health conference, Dr. Damiano shared important insights on what we can expect with the Affordable Care Act (ACA) and how it may impact the dental profession. The drivers of health care reform While there may be heavy debate on how to reform our health care system, the need to do so is overwhelmingly clear: at $3 trillion each year, our nation s health care costs are out of control, nearly 10 times our spending since Those costs are considerably out of balance with overall consumer demand, with the majority of expense going toward a relatively small percentage of high-risk populations. Meanwhile, millions of American s have little or no access to affordable insurance, making the ability to receive health or dental care out of reach. An estimated 50 million people are uninsured and 25 million are underinsured, and those numbers are increasing as more employers are dropping coverage. As a result, we have a system overburdened by too much consumer demand and too few resources in the workforce, which often means quality suffers and the health of our nation suffers. This is a significant problem to solve. The opposing priorities Dr. Damiano cautioned there is a difference between the discussion on reform vs. how the ACA will get implemented. A key complication is the opposing perspectives from the two leading political parties. Many democrats focus on the lack of access to care, seeing it as a crisis requiring urgent, sweeping change. In contrast, republicans tend to be less concerned about access, and more focused on driving down costs. Dr. Damiano offered some insights on these issues: ሁCosts ሁ - Currently, the Congressional Budget Office states the cost of reform will total $940 billion in the first 10 years. While this sounds like a huge sum, the cost-shifting of the ACA is designed to reduce the federal deficit by $124 billion over the next 10 years, and reduce it by $1.2 trillion in the decade after that. However, it will take a number of years to determine whether we are achieving those savings. How are we financing the ACA? To help roll out health care reform, the government is drawing on a number of new taxations such as the Medicare payroll tax on investments for families with incomes over $250,000. Another tax is the upcoming 2014 health insurance company net premium tax, which is expected to increase costs per policy by about %. Yet some carriers are claiming this tax may cause them to increase premiums by 10-20%, so the real impact on consumers remains to be seen. IOH 2013 Conference The Impact of Policy on Oral Health Care Delivery 2

3 ሁCoverage ሁ - As of May 2013, reports estimate the ACA will provide coverage to drive about 24 million people into private insurance available on the marketplace. Another 13 million people are expected to access public insurance, most of them single adults who will become eligible for Medicaid. With shifts away from employer-sponsored plans and many adjustments as reform gets implemented, we will likely see these numbers shift as well. Where are we now? ACA policies already in place To prepare for the current wave of plan enrollment underway for the general public, over 50 policies of the Affordable Care Act have already been put in place. Some highlights include: ሁ ሁ Improving pediatric health - New provisions provide better coverage for children, such as including those up to age 26 on their parent s insurance. This is expected to increase access for about million young people until they transition into adult coverage. Additionally, insurance plans can no longer restrict coverage based on pre-existing conditions. ሁ ሁ Promoting prevention - The ACA supports free coverage for preventive services on all new health plans, free preventive care for seniors in Medicare, and free preventive care for women s health. Another prevention-oriented policy that established a $15 billion Prevention and Public Health fund is not faring so well, with money being cannibalized for other purposes. This is counterproductive to reducing costs, as having public health resources available to support healthier lifestyles in high risk populations can reduce their need for costly care. For those with chronic illnesses such as diabetes, behavioral changes that drive better systemic and oral health are typically not available in a hospital or traditional medical office, and need to be nurtured in places where these people interact everyday ሁ ሁ Controlling costs - Policies have been enacted to stem the rising cost of premiums with periodic reviews to assess and justify increases, and state reporting on cost trends to determine if plans with unjustified premium increase should be removed from a state s insurance marketplace. Additionally, we will soon see the introduction of Accountable Care Organizations (ACOs), which focus on improving health care quality while slowing down cost increases. Originally focused on Medicare, ACOs are spreading into Medicaid and private insurance plans in some states. (To learn more about ACOs, check out our whitepaper based on Dr. Martin Lieberman s presentation at the 2013 IOH Conference.) What s ahead? ACA in 2014 and beyond One of the biggest changes being talked about is the Medicaid expansion. It eliminates a key access barrier by removing eligibility categories such as those for pregnant women and seniors, and now focuses only on income level. As of July 2013, most west coast and east coast states are moving forward with the expansion, but much of middle America and the southeast are not implementing these changes to Medicaid. (source: kff.org) Furthermore, the controversial mandate for uninsured individuals to obtain coverage will begin in In preparation for that, we are seeing the onset of health insurance marketplaces, rebranded from the previously term exchanges. These entities provide online enrollment for regulated qualified health plans that meet state standards. It is expected the primary audience will be the uninsured, or those whose employer dropped coverage, or those with inadequate coverage. IOH 2013 Conference The Impact of Policy on Oral Health Care Delivery 3

4 Understanding the marketplace There are multiple models for the health insurance marketplaces for individual buyers. As of March 2013, there will be 18 state-based marketplaces (mostly on the west and east coast), 26 federally facilitated (mostly in middle America and the southeast), and 7 partnerships in a handful of midwest states. (Source: Pewstates.org) Yet another type of marketplace is the Small Business Health Options Program to provide lower cost options for businesses with fewer than 50 employees. This channel offers reasonable flexibility with optional coverage, and the opportunity to choose a plan on their own or work with a broker. Within each state marketplace, buyers can choose from a variety of qualified health plans (QHPs), which cover the essential benefits such as emergency services, hospitalization, maternity care, prescriptions and lab work, and preventive services. QHPs also cover pediatric care, which is one of the only areas where oral health is represented in the ACA. Premium costs are expected to be the same as they would be outside the marketplace, but costs will vary by state and the level of coverage. Ostensibly, there will be a limit on out-of-pocket expenses, yet that policy has been delayed until In a recent study of Iowa consumers who will likely need to purchase insurance through a marketplace, cost was the most important factor. Furthermore, ongoing confusion about coverage and the impact of ACA changes is leaving many people uncomfortable with the do-it-yourself online enrollment system. Fortunately, the government is stepping up to train navigators who will help consumers understand the plan choices, and find the appropriate plan to meet their needs. There will also be certified application counselors available at community sites such as public health clinics, hospitals, and libraries. Most studies are showing that the uninsured are relatively healthy; however, about 1/6th of this population are high risk with multiple chronic conditions. Worth noting is that, when Dr. Damiano s research team asked a sampling of people if they had any long-term illnesses that had lasted at least three months, dental tooth or mouth problems were the number one chronic issue. The oncoming impact for dentistry The Medicaid dental expansion will bring challenges to the dental workforce as an anticipated 13 million new enrollees may seek dental care. All children under age 19 will gain comprehensive dental coverage, many of whom were already eligible for care, but the raised awareness of the ACA may prompt more families to seek dental services. A bigger impact may come from the new crop of adults who become eligible for Medicaid dental benefits. With respect to the health insurance marketplace, dental coverage is fairly limited. On paper, the ACA mandates dental care as an essential benefit for children; however, in implementation many children will still not have dental coverage because it will often be available only in stand-alone dental plans, which are optional and may not be affordable for many families. Adults may face the same issue in many states, if dental coverage is not included with their overall health plan. The good news is that reform is driving changes in the health care delivery system to provide greater opportunities to integrate dentistry with primary care: IOH 2013 Conference The Impact of Policy on Oral Health Care Delivery 4

5 ሁ ሁ State Health Information Networks - In these collaborative venues, primary care providers can share electronic health records to integrate dentistry, pharmacy, and other disciplines for managing a more holistic patient profile. While there remains concern about confidentiality and other issues, these networks could provide a meaningful step forward to include oral health as a key part of managing overall health. ሁ ሁ Health homes - This new approach to holistic health care engages resources across communities to partner on improving a patient s overall health. For example, beyond medical management, diabetic patients could benefit from guidance on nutrition, fitness, and oral health. These supporting services can be critical in helping people better control their condition and avoid complications. If we really are going to get a handle on both improving the quality of care and reducing costs, health homes are a great way to do that. We ll see how successful the inclusion of dentistry is as we move forward. Dr. Damiano On a final note, Dr. Damiano offered that we will likely see dental education evolve as health care reform takes hold. New models of care delivery and coverage will prompt new approaches to education such as clinical training focused on quality outcomes as a driver for reimbursement, guidance on how to integrate dentistry into health homes, and programs to support new roles such as dental therapists, designed to expand capacity while reducing costs. Reform is complicated and challenging; yet it may also be a great motivator for innovation, which is key to the future of dentistry. IOH 2013 Conference The Impact of Policy on Oral Health Care Delivery 5