Chances are you know someone who has struggled to access dental care. It is a nationwide crisis that, according to the American Dental Association, is only projected to worsen. The need for accessible dental care is most urgent in rural areas and for vulnerable populations. This problem was recently covered in a National Public Radio story that cited “a quarter of Americans went without dental care they needed in 2014 because they couldn't afford it.” Wouldn’t it be nice if there was a solution that would increase access to care that a wide range of stakeholders could agree upon? Well there is – expanding the number of dental therapists providing care.

Dental therapists are early intervention and prevention dental professionals who are specially trained to provide a limited scope of services under the supervision of a dentist. In leading edge states, it has been demonstrated that licensure of dental therapists can garner bipartisan support from both lawmakers and the public.

Just this past June, legislation was passed in Vermont that authorized dental therapists to be trained and practice in the state. On a recent Community Catalyst webinar, “Dental Therapy: A Bipartisan Solution to Expanding Dental Access,” Vermont State Senator Jeanette K. White (D) and State Representative Paul Dame (R) spoke about how they saw the bill as a unique opportunity for advocates and legislators across the political spectrum to come together to address an issue that will really make a difference in the health of Vermonters. Sen. White approached it from the perspective of universal health care and the concern that medical care is often “cut off at the neck,” excluding mental health, dental and eye care. She praised the licensure of dental therapist as an opportunity to begin to reintegrate dental care for all the state’s citizens. Rep. Dame saw it more as a cost-effective and free-market-oriented solution that can address the problem of inadequate access by creating decent-paying jobs in the new profession, while still allowing dentists to have full control over their practice. “If someone had been practicing in Minnesota as a dental therapist for five years and they decided to move to Vermont, why should we make it illegal for them to practice?”

But bipartisan support for dental therapists isn’t limited to Vermont: it exists nationally, as well. Results from a recent poll conducted for Americans for Tax Reform found  “79 percent of likely voters support the creation of mid-level providers that could perform dental care services such as basic extractions and hygiene plans,” and that the support “extends across all key demographic groups including men and women of all ages, Republicans, Independents, Democrats, white, and Hispanic voters. The support for such a process extends across a wide swath of Americans, regardless of political affiliation, ethnicity or gender.” Furthermore, it was the number one health issue on the Progressive Agenda in 2014 and is even supported by the Koch brothers – two influential conservative activists who support a free-market agenda. 

Dental therapy isn’t a new solution to accessing dental care – it is only fairly new to the United States, and it is clear that Americans believe this is a solution that works for everyone. In a time of such contentious political gridlock, it is refreshing to have advocates and lawmakers from both sides of the aisle coming together to address the needs of the communities they serve and improve access to oral health care for those that need it most.

As the race for the White House tightens, a number of stories over the past week have cast a bright light on how the election outcome could shape future health care policy. On the one hand, the contours of the next wave of health reform that would build on the Affordable Care Act’s foundation are emerging. On the other hand, Medicaid waiver proposals from several states plus debates on the future direction of health reform that are swirling within the political right-wing paint a disquieting picture of where health policy might go should "anti-ACA" candidates prevail.

California Dreaming

New data from the Census Bureau underscores both the success of the ACA and the need for additional action. In particular, the Census data corroborate the recent findings from the Centers for Disease Control that thanks to the ACA, the proportion of the U.S. population lacking health insurance is smaller than it has ever been in history. At the same time, high out-of-pocket spending is spiking and health costs still drive too many households into poverty.

And it now seems clear that no county will go without any available insurer and some carriers who threatened to pull out may be having a change of heart. However, in the long run it will be impossible to hold insurers accountable for either premiums or other policies affecting coverage and cost (such as benefit design) if regulators are constantly worrying about market exit.

What these recent stories illustrate is that despite the great progress we have seen, more needs to be done to ensure quality affordable coverage is available to all. We are seeing steps to address this "unfinished business" at both the state and national level.

Consider two recent developments in California. The state recently passed legislation that would extend protection to consumers against surprise out-of-network bills, a growing problem in the context of the narrow networks that are becoming commonplace on the ACA marketplaces and beyond. They are also moving to fill a gap created in the ACA by the ban prohibiting undocumented immigrants from obtaining Marketplace coverage. This was ill-considered policy adopted for reasons of "optics," but since undocumented immigrants are not eligible for premium tax credits (a whole different story) there is nothing gained from excluding them from marketplace coverage.

On the federal level we are seeing a renewed push for a public option that would enhance choice and reduce premiums on the marketplaces. Members of Congress are also taking aim at price gouging by the drug industry with new bipartisan calls for increased scrutiny of excessive price increases. While these federal initiatives face tough sledding – even if the election outcome is favorable to health reform – the very fact there is a renewed push for progressive reform is a step in the right direction.

Dark as a Dungeon

On the other hand, we see a starkly different vision in the Medicaid waiver proposals from Ohio (recently rejected) and Kentucky (still pending). What would states do with the kind of "flexibility" that is promised in the House Republican "Better Way" ACA repeal/replace proposal? Apparently, at least some, if not most would create new barriers to coverage -- including higher premiums, higher cost-sharing and arbitrary coverage lockouts -- that would force many back into the ranks of the uninsured and undermine financial protection for those who do manage to hold on to coverage. These proposals are likely only the tip of the iceberg of what we would see since they are being put forward in the context of the current state entitlement to federal matching funds -- a commitment that Congressman Ryan and the House leadership are intent on eliminating.

The agenda embodied in the so-called “Better Way” proposal is deeply unpopular with the American people. Even in Speaker Ryan’s home district, consumers seem more interested in expanding coverage while providers worry about the disruption and spiking uncompensated care costs that would accompany a rollback of the ACA.

But as problematic as the House proposals are, the reality could be even worse. Observers on the "conventional right" are already warning against what they see as a nascent effort by the far-right to enact "repeal" without "replace.” While such an approach might seem politically irrational, it is these very same irrational forces that forced a government shutdown and the resignation of Speaker Boehner. While political backlash would likely follow from a coverage rollback and the ensuing financial disruption, this is cold comfort for the millions who would lose coverage -- especially since it would take years to reassemble the political alignment that was necessary to pass the ACA (not to mention Medicaid) in the first place.

So we are in a strange moment. Even as the evidence mounts that the ACA has improved access to care and financial security for millions, these gains hang by a slim margin if current polls are an accurate predictor of the electorate on November 8. All elections have consequences, but some have more than others. For health care, it is hard to imagine higher stakes.

Third in a series addressing implicit bias in health care

Implicit bias among health care providers is a key factor contributing to racial and ethnic health disparities. Since implicit biases are automatic and subconscious associations that are expressed through attitudes and stereotypes, they can influence judgements and discriminatory behavior toward particular groups of people. This is dramatically apparent in treatment for drug and alcohol problems for people of color and in how our society repeatedly fails at providing treatment at potential points of intervention.

Individuals with drug and alcohol addiction encounter bias throughout their many points of contact within the criminal justice and health care systems, two of the main systems that serve as potential points for providing treatment. This bias is compounded when racial dynamics come into play, and we see these potential points of intervention turned into missed opportunities in a way that disproportionately affects people of color.

Pointing People in the Direction of Treatment, Not Jail

One point of potential intervention is when individuals with substance use disorders come into contact with law enforcement. Recently released data by National Survey on Drug Use and Health continues to support the pattern of White Americans using illegal drugs at a slightly higher rate than Black Americans. Ideally, people needing treatment and encountering law enforcement would be referred to treatment or other services. However, Black Americans are far more likely to be arrested for drug possession than White Americans with the result that “nearly 80 percent of people in federal prison and almost 60 percent of people in state prison for drug offenses are black or Latino.” An investigation in California revealed disproportionate criminalizing of people of color with substance use disorders. The findings show how racial biases create a system that punishes addiction for one subset of people and encourages access to treatment for another.

Another potential point of intervention is within the health care system. When individuals with substance use disorders have interactions within a hospital, mental health clinic or at a doctor’s office, their race matters. Studies looked at how mental health providers treated Latino and White adolescents who also had substance use disorders. The providers were less likely to refer Latino adolescents to substance use treatment than Whites.

Implicit bias also interferes with doctors’ ability to accurately assess their patients’ needs because of doctors’ assumptions about who is likely to be addicted to drugs. Studies on pain management show that Black and Hispanic patients are less likely to receive opioids pain medicine for equivalent levels of pain than Whites. Researchers hypothesized that this was partly due to some doctors’ false belief that Blacks are more likely to misuse drugs and less likely to feel pain. Other research finds that doctors tend to empathize less with patients of races different from their own, a problem exacerbated by the fact that only about 4 percent of the country’s practicing physicians are black.

Implicit bias is a complex problem that is not easily identified with studies and data even when it appears evident from the personal stories our advocates have collected. It is further complicated due to the fact that it is driven by the subconscious and subliminally reinforced throughout society. Often conversations surrounding bias and race are met with resistance from those with power and privilege, but addressing implicit bias within health care settings is not meant to be a personal affront on the character of any individual provider. Addressing implicit bias is an indictment of the systems in place that continue to fail those vulnerable populations who feel its impact the most.

So, what’s next?

Building and maintaining awareness around implicit bias is the first step. Our society needs to act. Community Catalyst is working to address implicit bias as well as overt discrimination. Our Center for Consumer Engagement in Health Innovation is focusing on advancing health equity as one of its priorities. Our Substance Use Disorders Project advocates for better health services and community supports to address substance use disorders and help people lead healthier lives. Community Catalyst looks forward to working with all its partners to tackle this issue and achieve equity.

Read our other Implicit Bias Blogs:

• Seeing Providers as Partners to Tackle Discrimination and Implicit Bias in Health Care

• Community Catalyst Looks Inward and Outward in Observance of Minority Health Month

Last week, the Centers for Medicaid and Medicare Services (CMS) rejected Ohio’s “Healthy Ohio” Medicaid waiver proposal, which included provisions that would have undermined health coverage for many low-income Ohioans. Among other changes, the state requested permission to require low-income Ohioans to pay premiums into health savings accounts or else have their health coverage suspended. In their announcement, CMS noted its concern “that these premiums would undermine access to coverage and the affordability of care, and do not support the objectives of the Medicaid program.” Ohio’s Department of Medicaid estimated the waiver’s provisions would result in 126,000 low-income Ohioans losing their coverage.

For over a year, our partners at UHCAN Ohio directed a targeted, grassroots campaign elevating the voices of low-income Ohioans from across the state to protect Medicaid expansion. UHCAN mobilized hundreds of consumers through conference calls, webinars, and community presentations to express their concerns about Healthy Ohio. Through their community presentations alone, UHCAN was able to reach over 600 community members and collaborate with over 70 community and faith-based organizations. Advocates spread the word about Healthy Ohio’s provisions, their impact on low-income Ohioans and opportunities to shape the waiver process. Nearly 1,000 comments were submitted during the state public comment period alone, overwhelmingly in opposition to Healthy Ohio. By ensuring that Ohio Medicaid beneficiaries retain their health coverage, CMS’s decision to reject Healthy Ohio strengthens advocates’ efforts to reduce health disparities experienced by low-income communities of color.

CMS’s decision also sends a strong signal to other states with outstanding waiver proposals that would restrict and threaten Medicaid coverage opportunities. Kentucky Governor Matt Bevin’s recently proposed waiver includes lock-out periods and other requirements that would roll-back the progress made by the state’s successful Medicaid expansion program. Our partners at Kentucky Voices for Health and their grassroots supporters are weighing in during the federal comment period to express concerns on the negative impact Gov. Bevin’s waiver proposal would have on the 430,000 Kentuckians receiving health coverage because of Medicaid expansion.        

The outcome in Ohio shows that consumer activism plays an important role in waiver decisions. Strong backing from consumer groups helps CMS resist state efforts to institute barriers to access and care for Medicaid beneficiaries. Other states facing similar proposals should take notice that raising the voices of those affected is necessary and important. Ultimately, consumer health advocates, their coalition partners and their supporters will need to continue to play a pivotal role weighing at all stages of the waiver process to ensure the consumer voice is heard and to shape the narrative around waiver proposals negatively impacting low-income people.

Over the last year, I have had the opportunity to serve on behalf of Community Catalyst on the Health Care Transformation Task Force - a consortium of patients, payers, providers and purchasers working to accelerate the pace of U.S. health care delivery system transformation and inspire a greater focus on person-centered care.

Since Community Catalyst’s founding, our work and investment in meaningful consumer engagement has made it clear to us that it is fundamental to transforming the health care system. Over the years, we have learned an immense amount through our work with low-income populations, seniors, people with disabilities and advocates on the ground, and were tasked with ensuring that those voices and interests were represented through our participation on the Task Force.

The result of seven months of collaboration and discussion among the members of the Advisory Group for Consumer Priorities, which I co-chaired, recently culminated in a new multi-stakeholder, consensus-based framework, “Addressing Consumer Priorities in Value-Based Care: Guiding Principles and Key Questions.”  As one of the members tasked with representing consumers and consumer advocates, I am pleased that the recommendations made by the Advisory Group were fully endorsed by the diverse membership of the entire Task Force and are present in the final white paper.

The resulting document should raise eyebrows: this is a big deal. The Task Force is comprised 42 member organizations and individuals, which includes representation from six of the nation’s top 15 health systems and four of the top 25 health insurers, as well as leading national organizations representing employers, patients and their families, and the policy community.

This white paper should open the door for consumers and consumer advocates to have an increasingly meaningful seat at the table for discussions about value-based, people-centered care. In assessing their own consumer engagement efforts, plans, providers and payers agreed to examine the following six principles:

1. Include patients/consumers as partners in decision-making at all levels of care. For example, are patients/consumers included as integral partners in all aspects of health care decision-making at every level, from system-level reform design to point-of-care decisions?
2. Deliver person-centered care. For example, are patients/consumers and those who support them at the center of the care team?
3. Design alternative payment models (APMs) that benefit consumers. For example, do APMs achieve cost-savings only through improvements in health and health care and ensure beneficiary rights and protections?
4. Drive continuous quality improvement. For example, do the health care transformation policies and practices drive continuous quality improvement?
5. Accelerate use of person-centered health information technology. For example, do alternative payment and care delivery models accelerate the effective use of person-centered health information technology?
6. Promote health equity for all. For example, does the health care delivery system and payment reform model promote health equity and seek to reduce disparities in access to care and in health outcomes for all?

We have seen - over and over again - how meaningful consumer engagement in public health care reform has reaped dividends. In Massachusetts, consumer advocates drove adjustments to One Care, the Massachusetts dual eligible program, to provide more accurate rates for the complex care management and service needs of low-income adults with disabilities. In Ohio, advocates shaped the State Innovation Model on Patient-Centered Medical Homes to include Patient and Family Advisory Councils, community health workers and collaboration with community-based organizations. And in California the collection of data, driven by consumer advocates, will illuminate health disparities to promote greater health equity.

And now we are seeing proactive measures and the explicit endorsement of the need for meaningful consumer engagement from private purchasers, payers and providers.

The next steps are to bring these practices from the white paper to reality through our new Center for Consumer Engagement in Health Innovation in its mission is to bring the consumer experience to the forefront of health innovation in order to deliver better care, better value and better health for every community, particularly vulnerable and historically underserved populations.

Consumer advocates will play an equally important role as we work to engage health plans to invest time and resources to support meaningful patient and family advisory roles, to ensure purchasing contract provisions that emphasize patient-reported outcomes and to push proactive efforts to understand and address health disparities to create a better way to better health. For everyone.