Minnesota Dental Clinic Shows the Daily Economic Benefits of Dental Therapy

Welcome to a new Community Catalyst blog series describing different perspectives on dental therapists at work. Dental therapists are highly trained oral health practitioners that work with dental teams similar to the way physicians’ assistants work with medical teams. Along with providing education and preventive services, they are able to perform common dental procedures such as filling cavities and, in limited cases, removing decayed teeth.

Dental therapists have been practicing in the U.S. for more than 10 years. They have improved access to dental care for underserved communities in Alaska since 2005 and in Minnesota since 2011. Vermont and Maine recently authorized them to work in those states. Oregon and Washington have hired dental therapists as part of demonstration projects within tribal communities, and nearly a dozen more states are considering authorizing the providers.

As Executive Director of Children’s Dental Services, a clinic that provides dental care to children from low-income families in Minneapolis, I have to balance the huge need for subsidized dental care with the need to keep our clinic financially solvent so it can stay open.

In 2009, members of the Minnesota legislature approved the licensure of dental therapists, highly trained mid-level professionals who can perform routine and preventative services through team-based care, often compared to the way physician assistants work in medicine.

When the bill passed, dental therapists were touted as a cost-effective way to increase access to dental care and our clinic was one of the first to put them to work in our state. It turned out to be a wonderful decision – both for our young patients and the financial stability of our clinic.

We use a team-based approach. Dentists supervise our dental therapists and because they are paid less than dentists our clinic is able save over $60,000 each year. That savings goes directly back into serving our patients. This had a significant impact to our bottom line during the recession allowing us stay open when other clinics were being forced to close.

But it is not all about saving money. Our dental therapists have provided care to more than 18,000 patients, decreasing our wait time for appointments by two weeks, and increasing overall patient time with the provider by 10 minutes. Furthermore, we’ve been able to extend our reach to remote parts of the state increasing dental access to those most in need.

In addition to these care delivery improvements, we are now using dental therapists as part of our emergency room diversion program helping to reduce the number of people seeking dental care in the E.R, which is saving the state money.

I cannot imagine our clinic operating without these critical members of the dental care team. For us, they have proven to be a financially viable solution for making sure that low-income, uninsured and underinsured kids in our state have access to high-quality dental care.

Sarah Wovcha joined Children's Dental Services as Executive Director in January of 2001. She holds a Juris Doctorate from the University of Minnesota Law School and a Master of Public Health degree from the She was one of the first employers of dental therapists in the state of MN.

Yesterday, House Republican leadership released another "replacement plan," the Obamacare Repeal and Replace Policy Brief and Resources. After nearly seven years, Republicans continue to call for replacement of the Affordable Care Act but have yet to put forward a plan that offers any clarity to consumers, let alone the same protections and coverage gains currently available under the Affordable Care Act (ACA). The announcement of yet another messaging document masquerading as a replacement plan continues that trend. Once again, in spite of much fanfare and self-congratulation, House Republicans still failed to present agreed-upon legislative language. The white paper released yesterday includes only high-level descriptions on some possible aspects of replacement while leaving key details missing.

Despite Republican protestations, the ACA has greatly improved the affordability of coverage available to consumers. The ACA has provided low- and moderate-income individuals and families with hundreds of billions of dollars in tax cuts to help make health insurance more affordable. And a majority of consumers using Healthcare.gov have been able to find plans with premiums below $100 after taking into account financial assistance.  Although most marketplace enrollees like their coverage, the main thing people want from health reform is lower out-of-pocket costs.

Yet instead of building on the current law, Republicans keep on releasing proposals that would undermine the coverage gains we have made under the ACA, leave families with fewer benefits and higher out-of-pocket costs, and dismantle Medicaid’s critical safety net. Rather than a detailed consensus for specific legislation, the Obamacare Repeal and Replace Policy Brief simply reiterates a grab-bag of recycled Republican policy ideas that fail to provide true protection for consumers.

For example, the tax credits offered under the Republican plan would not be adjusted based on income. Under this proposal, a family earning $150,000 would get just as much help as a family earning $25,000. People with fewer resources would likely get far less help affording premiums than they get today, which essentially amounts to a tax increase for these families and would likely put coverage out of reach for them. The proposal also encourages use of health savings accounts to supplement high-deductible health plans and the establishment of high-risk pools to aid individuals with pre-existing conditions. None of these policies makes coverage more accessible or affordable to low-income consumers and in reality would increase out-of-pocket costs when consumers can least afford it.

The GOP plan would also dismantle the Medicaid program as we know it. Their proposal to phase out Medicaid Expansion would reverse the progress made under the ACA to extend health insurance to low-income adults. And the proposal to cap and slash federal funding through per capita caps and block grants would push massive costs onto states and erode the health care safety net, putting coverage at risk for tens of millions of children, older adults and people with disabilities.

The Republican leadership's continued reliance on concept papers and rhetoric – instead of real proposals backed by concrete numbers and analysis – shows just how far they are from having a plan that can deliver on the promises they have made to replace the ACA with something that is both better and cheaper. Ultimately, these plans are a distraction from the real issue at hand – whether Congress will vote for a reconciliation bill that takes coverage away from millions and raises costs for millions more without any consensus on what, if anything, will come next.

As the timeline for an Affordable Care Act (ACA) repeal bill continues to slip, many writers have written some variant of the idea that technical challenges with how to repeal the Individual Responsibility Requirement (IRR) without undermining the ban on pre-existing condition exclusions are a key stumbling block. Strictly speaking, this is not correct. It is not that Republicans cannot figure out an alternative to the IRR. Some combination of auto enrollment provisions and a late-enrollment penalty might be an adequate substitute given that the ACA requirement is somewhat porous to begin with.

There’s Still No Agreement…

The bigger problem is they cannot agree among themselves on with what or even whether to replace the ACA. Some want to continue down the original path of repeal now and replace later (and later could mean MUCH later--maybe never). Others want to wipe out most of the federal protections but essentially allow states that want to keep the ACA to ‘kinda sorta’ do that. Still others want to inject a "down payment on replace" into the initial repeal bill, which, of course, opens up fresh controversies over what should be in that down payment.

And controversy there will be. Based on previous policy statements and information on what House Republicans are vetting with the CBO, the policies that will likely emerge from the House include: high-risk pools; increased reliance on high deductible plans and Health Savings Accounts; changes to the ACA insurance tax credits that will make coverage less affordable for low-income people; and elimination of the guarantee of federal matching funds to states for Medicaid expenditures.

But There Are Dozens of Unanswered Questions

Implementing each of these policies requires many complex decisions. Consider high-risk pools. They were common before the ACA, but have never worked well in the past because inadequate benefits, high cost-sharing, high premiums, and enrollment caps have made them a poor vehicle for providing coverage to their primary market, which is composed of high-risk people with modest incomes. If Congress seeks to return to a reliance on pools, will they implement policies in an effort to overcome these historic shortcomings? For example, what benefits would be covered by high-risk pools? How much above market would premiums be for enrollees? Under what circumstances could insurers send people to the pool--would people need to be rejected first before they could access pool coverage? Would enough funding be available to keep premiums affordable, benefits robust and enrollment open, or would the new policy simply replay the shortcomings that have plagued past failed pools?

Capping Medicaid funds is, if anything, an even more complex undertaking. How would caps be calculated? How would they be adjusted over time? What, if anything, would states be allowed to do that they cannot do now to stay within the federal caps? Would the amount each state gets just be a reflection of past decisions made by states (which could disadvantage states that have been more aggressive at trying to reduce Medicaid spending), or will they reflect some more empirical standard? Would the federal matching formula remain essentially the same under the cap or would states be able to pull state dollars out of the system without losing federal funds, thereby increasing health system cuts? And, of course, there is the question of what will happen to the states that expanded Medicaid (and, for that matter, those that didn't)?

People Don't Like What's On the Republicans' Health Policy Menu

The common thread that unites all of these ideas is that they would increase costs and undermine access for people who are poorer and sicker. Just how badly would be determined by the other health policy debate that is roiling the ranks of Republicans: how much, if any, of the revenue raised by the ACA would remain to pay for benefits and how much is going to be spent on tax cuts for the wealthy. But it is no wonder that, with a policy menu that boils down to fewer people covered, higher cost-sharing, fewer jobs, more financial instability for health care providers and higher costs for state government, Republicans are not anxious to unveil their plans before the President's Day recess. In fact, many are doing everything they can to avoid the questions that are coming at them from angry constituents. Some may hope, given that many people don't know that the ACA and Obamacare are the same thing, they can confuse the public and escape accountability for undermining access and affordability. Those who don't want to see our health care system take a giant step backwards will have to make sure that doesn't happen.

One of the most shameful failures of our public safety net system is when structural harm goes unaddressed. The lead crisis in Flint, Michigan remains a painful reminder of when blind commitment to cost savings results in irreversible harm for an entire generation of children and families. The city of Flint is a low-income, majority black community—and it does not go unnoticed that this low-income, majority community of color, is the recipient of cost cutting efforts. The lead crisis in Flint – a crisis that is ongoing and will be for years to come—highlights the importance of public health and equitable infrastructure investment as a clear path to improving health outcomes and advancing health equity. Despite the high profile reporting on Flint, over 4 million children in the U.S.  live in homes with high levels of lead. This is heartbreaking – and unacceptable. States and communities are not without tools to demand and require lead exposure prevention programs and abatement in homes, in schools and in our water systems to ensure healthy living conditions for low-income children and families.

Cindy Mann, the former head of Medicaid at the Centers for Medicare and Medicaid Services, and her colleagues at Manatt recently highlighted a key tool in this battle: the Children’s Health Insurance Program (CHIP). Within the CHIP program, there is an opportunity for states to use a portion of their CHIP funds for a Health Services Initiative (HIS). As outlined in Manatt’s brief, it does not require a CMS waiver, it does not need to be a statewide effort and it does not require that only Medicaid- and CHIP- enrolled children benefit from the initiative. It does require a state to demonstrate need, meet program requirements that communicate how it will meet the needs of the targeted group and the program must have a clear timeline. Mann and her colleagues note that a majority of states have not yet taken up this opportunity—and have room in their CHIP budgets to do so.

Thanks to the Affordable Care Act (ACA), states are able to draw down a CHIP enhanced match through September 2019. While access to this enhanced match remains unclear beyond September (CHIP needs to be refunded by September 2017), there is opportunity now for states to address the needs of low-income communities. Advocates can play an important role in highlighting this opportunity for key decision makers and communities.  

We know that children’s health and wellness requires more than access to health insurance coverage. Children’s health is shaped by their surrounding environment—clean drinking water, stable and safe housing, nutritious foods and nurturing caregivers and community. All of these basic needs when knit together, blanket children with health opportunity. We know that for many children, this is not their reality and that the systems that serve them continue to struggle to identify needed resources, coordinate their work and reach the most vulnerable families. CHIP remains a key tool in helping states not just increase access to coverage and care but also create a healthier environment.

America’s rust belt has been struggling with an opioid epidemic for the last two decades that has taken the lives of thousands of people and brought national attention to the indiscriminate way it has harmed so many families. In states such as Kentucky, Ohio and West Virginia, three of the five states with the highest rates of death due to drug overdose, it is easy to see the real consequences ahead if repeal of the Affordable Care Act (ACA) occurs. The expansion of coverage through the ACA and its provision of life-saving services have been essential strategies for combating this epidemic.

A number of recent reports capture the benefits of substance use coverage provided through the ACA nationally and in these states, and what repeal would mean for those with opioid addictions. Overall, repeal could eliminate coverage for up to 2.8 million Americans with a substance use disorder, including about 222,000 with an opioid disorder.

According to a recent report from The Foundation For A Healthy Kentucky, prior to the implementation of the ACA approximately 585,000. Kentuckians lacked coverage for substance use treatment mainly because they did not have access to any form of health insurance. The combination of Medicaid expansion, private insurance tax credits and requirements for coverage of substance use disorders treatment, all included in the ACA, enabled 320,000 uninsured people to get covered and another 300,000 who were already insured to get access to better coverage of substance use treatments. This gave the people of Kentucky a real fighting chance to combat the opioid epidemic.

Similarly, in neighboring Ohio, the misuse of powerful opioids, such as heroin, fentanyl and prescription painkillers, continue to drive up the state’s overdose deaths. The ACA has helped people get treatment. Thirty thousand Ohioans with substance use disorders are currently covered through the Marketplace according to a recent report from experts at Harvard University and New York University. In addition, Medicaid expansion greatly expanded access to substance use treatment. An additional report from the Department of Health and Human Services found that 75 percent of expansion enrollees who sought care for problematic use of drugs and alcohol reported improved access to care, and 83 percent reported improved access to prescription medications. ACA repeal would cut in half the state’s funds for evidence-based Medication Assisted Treatment (MAT), the most effective treatment for opioid addiction, and care that can make all the difference for Ohioans battling opioid addiction.

In Kentucky, Medicaid pays for between 35-50 percent of all MAT. Since Kentuckians gained access to treatment through the Medicaid expansion in 2014, use of alcohol and drug treatment services grew by more than 700 percent. Research shows that many of the new enrollees had been previously uninsured and therefore had limited, if any, access to treatment until 2014. Substance use treatment services also increased for adults enrolled in traditional Medicaid, increasing by more than 300 percent in the same time period. Individuals whose options for treatment had been limited prior to the ACA were not only enrolling in health coverage, they were also using life-saving treatment options.

States with the highest overdose rates in the nation, such as West Virginia and Kentucky, which in 2015 ranked first and third in overdose death rates, will see their uninsured rates nearly triple if the ACA is repealed. This points to the real life consequences losing coverage will have in communities trying to get ahead of this epidemic. Two weeks ago, one city in West Virginia had 26 overdoses in the span of four hours, reminding us that what we need now more than ever is access to coverage, harm reduction servicesand treatment.

Though we are still in the midst of the opioid epidemic, these recent studies confirm that the ACA made considerable headway in treating opioid disorders. If Congress repeals the law, it is hard to imagine that the coverage and treatment gains will be sustained. Instead of repealing the ACA and constructing additional hurdles for people to jump over, Congress should focus on what has proven to work. They should build on that success and protect our care.