Approximately one-third of Americans remained without dental insurance in 2014 despite coverage gains—particularly for nonelderly adults—from the implementation of the Affordable Care Act (ACA). Dental uninsurance rates were highest for those over the age of 65 (62%), and lowest for those under 18 years old (11%). Approximately 35% of nonelderly adults lacked dental coverage.1
For many, having insurance is a financial necessity for seeking treatment, especially for preventative care and disease maintenance. Left untreated, oral disease can quickly escalate from a local issue to a holistic concern. It can severely undermine personal health and well-being, with increased risks of medical comorbidities (e.g., heart and lung disease, stroke, and diabetes), chronic pain, sleep deprivation and nutritional deficiency. It also can result in appearance issues that can be detrimental to employment prospects and retention.2
Although the ACA Boosted Dental Coverage, Many Still Forgo Care Due to Costs
The ACA bolstered dental coverage, directly and indirectly, through several provisions. Pediatric dental care was added as an Essential Health Benefit (further strengthening already robust Medicaid and CHIP coverage for children), state Medicaid programs were allowed to expand coverage at enhanced federal payment rates for low-income nonelderly adults (up to 138% of the federal poverty level (FPL)), and parental health insurance was required to cover children up to age 26.
Though Medicaid expansion and dependent-coverage provisions targeted medical care, nearly all Medicaid expansion states extended their base populations’ dental benefits to their new expansion populations, and increases in young adult private market medical coverage were closely tied to increases in dental coverage.3 (The robustness of state Medicaid dental benefits, however, continued to vary considerably, with one-quarter of “dental-coverage states” only offering emergency service coverage, continuing to leave many “covered” individuals financially exposed.4)
However, in 2015, more than one in five (21%) low-income Americans still reported forgoing needed dental care due to cost—a rate four times higher than that for high-income earners—though data suggest ACA-related coverage gains may have alleviated financial vulnerability for some (Figure 1).5 Cost as a barrier for the lowest-income earners (making less than the FPL) fell by nearly a third (30%) between 2010 and 2015, and declined 28% for those making between 100% and 200% of the FPL. Rates for all income categories improved from highs experienced during the Great Recession, as economic conditions improved.
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Dental Visits Increased With Coverage Gains Though Challenges Remain
Dental visits also rose with coverage levels, though gains were more muted, potentially indicating challenges with provider availability.6 According to the 2017 American Dental Association’s “Support of Dentists” survey, slightly more than a third of general dental practices (36%) accepted Medicaid patients in 2015, and Medicaid patients comprised only 9% of the overall dental patient population. A June 2017 study in Health Affairs suggests that while Medicaid expansion may have increased oral health coverage, access, counterintuitively, may have declined as the limited number of Medicaid-accepting dental practitioners faced increased demand.