As a primary care physician, I am constantly reminded of the connection between good oral health and a good life.

Oral disease can lead to serious health conditions, including heart disease, blood clots, brain infections and diabetes. But just as importantly, missing teeth and toothaches can make it hard for adults to maintain good nutrition, and can be an impediment to securing and retaining employment. Seniors who have lost all their teeth due to a lack of dental care over their lifetime have self-reported lower quality of life and higher rates of depression. Children with untreated cavities often perform poorly in school.

We need to learn more about oral health’s role in chronic disease. Initial studies are promising.  For example, one study showed that periodontal treatment for diabetes patients led to a 40 percent reduction in inpatient admissions and a corresponding reduction in annual health care costs. Other studies have found that periodontal disease increases the ten-year mortality rate for people with chronic kidney disease by nine percent and that oral hygiene problems are linked to incidence of aspiration pneumonia in older patients. Further studies are needed to confirm these findings and investigate additional connections between oral health and overall health.

But even as we work on the science linking oral health to overall health, there is no excuse for leaving people across our country without access to care from dental professionals. Every day, I see suffering caused by a lack of preventive and restorative dental care, especially for people living in rural communities, people of lower socio-economic status, and members of ethnic groups including African Americans, American Indians and Alaska Natives. Due to a combination of lack of insurance and a provider shortage, care remains inaccessible to people of many backgrounds. One out of every 50 emergency department visits are generated by acute dental pain – and that number is increasing.

The good news is that there exists a part of the solution to this oral health crisis that should give everyone a reason to smile – it stands to make people healthier, dentists better off financially and teeth cleaner and more sound. A new category of highly-trained professionals, dental therapists, can and should join dental teams to perform routine and preventive services in a role similar to that of physicians’ assistants in medicine. Our health care system is increasingly moving toward a team-based approach to provide the best care to patients and it would be a mistake for dental practices not to follow the same approach. There’s little doubt: the time for a national surge of dental therapists has arrived.

Matthew Tobey, MD, MPH, Instructor of Medicine, Harvard Medical School,
Associate Director, Massachusetts General Hospital Fellowship Program in Rural Health Leadership

This post is part of a Community Catalyst blog series describing different perspectives on dental therapists at work. Dental therapists are highly trained oral health practitioners who work within dental teams similar to the way in which physicians’ assistants work within medical teams. Along with providing education and preventive services, they are able to

Racial and ethnic health disparities persist in our nation and health care system. Compared to their white counterparts, people of color are more likely to be without health insurance. They often receive poor quality care and experience worse health outcomes. The causes of these disparities are complex and interrelated, and include social and economic determinants (such as income level, education, and living conditions in homes and neighborhoods) as well as racial biases and structural racism within the health care system and society. The Affordable Care Act (ACA) included a number of provisions to address health disparities including anti-discrimination requirements, essential health benefits and essential community providers—all aimed at more equitably providing coverage and access to needed care, but it did not eliminate all disparities. We still have far to go in eliminating health disparities but the GOP replacement plan, the American Health Care Act (AHCA) would be a giant step in the wrong direction that would further harm vulnerable populations.

Despite the growing fears and mounting opposition from many communities across the country to the dismantling of the ACA, the Trump administration and Republicans in Congress are determined to push through their vision of health care. The AHCA will undo the extraordinary progress we have made over the past six years. As Richard (RJ) Eskow, Contributor to the Huffington Post, rightly puts it, this bill is “an assault on people of color,” as it would “cut programs that disproportionately help people of color while providing tax cuts for the wealthy that disproportionately help white people.” According to the analysis released by the Congressional Budget Office (CBO) on March 13, as many as 24 million people would lose their health care coverage by 2026, and people of color would be among the hardest hit. Below are three ways the AHCA harms people of color.

1. Massive cuts in Medicaid would cause millions of people of color to lose coverage

Medicaid plays an important role helping to fill some of the gaps in private coverage, as people of color are more likely than whites to be in low-income, low-wage jobs that provide limited access to employer sponsored insurance (or if offered, require employee premium contributions that are too expensive and beyond their reach). However, one of the most outrageous aspects of the House Republican repeal bill is its deep cut of 880 billion dollar cut in federal funding for Medicaid over ten years. This is due to the reduction in federal funding for Medicaid expansion and conversion of the program to a per capita cap. Such a significant reduction in funding would put at least 14 million low-income Medicaid enrollees at serious risk of becoming uninsured and losing access to the care they need.

A rollback of Medicaid expansion would cause, for instance, as many as 1.5 million Blacks to lose coverage; similarly at least 440,000  American Indians and Alaska Natives would become uninsured; and the vast majority – 3.3 million – of women of color would be at risk of losing Medicaid expansion coverage and access to reproductive care services. Many people of color who face serious physical and/or mental health problems, including being overweight or obese, having diabetes or cardiovascular disease and experiencing frequent mental distress or substance use disorders would have efforts to treat and prevent these conditions undermined by the loss of coverage. For children of color, capping Medicaid means denying them access to important preventive services (including but not limited to preventive and developmental screenings and chronic care management for health conditions such as diabetes or asthma) provided at school-based clinics. A Medicaid per capita cap would exacerbate disparities in health outcomes between white children and children of color. Capping Medicaid funding will result in lower provider rates, reduced access to care predominately in communities of color and low-income communities, and separate and unequal health care systems.

2.  Marketplace coverage will cost people more as subsidies and cost-sharing benefits decrease dramatically

In addition to Medicaid coverage loss, approximately 12.2 million people – 30 percent of those are people of color – who are currently enrolled in the marketplace would find coverage unaffordable and would see their out-of-pocket costs significantly increase due to a decrease in financial assistance. According to the Center for American Progress, virtually everyone would experience an average cost increase of $3,174 in 2020 if the House Republican repeal bill passed into law; those with income below 250 percent of the federal poverty line would see their costs increase by $4,815; and the impact would be severe for older individuals age 55 through 64 as they would be forced to pay five times more than younger adults. People of color, especially Blacks and Latinos, would more likely fall into the lower-income range than their white counterparts. This financial impact would erode their financial stability – many of them have already struggled with medical bills. Facing financial burdens, many would forego needed treatments or medications, which would further deteriorate their health outcomes.

3.  Eliminating the Prevention and Public Health Fund Would Cut Supports to Low-income and Vulnerable Communities

Furthermore, the House Republican repeal bill would eliminate the Prevention and Public Health Fund (PPHF), which would directly affect everyday Americans and their families. On average, people of color experience shorter life spans, higher infant mortality rates and higher prevalence of many chronic conditions compared to whites. Much of the PPHF have granted to low-income and vulnerable communities, like West Bronx in New York as well as many other communities across the country, to expand preventive health programs such as diabetes awareness classes, infectious disease research, toxic lead eradication, mental health and vaccination efforts, and community bike plans. According to the Centers for Disease Control and Prevention, PPHF dollars have proven successful improving physical activity and childhood immunizations, lowered hospitalizations for preventable conditions, and increased prenatal care visits in their target communities. Eliminating PPHF would make the fight to close the racial health gap even harder.

We must continue to be loud and united!

Community Catalyst and the Health Equity Leadership and Exchange Network recently hosted a webinar in which Daniel Dawes, author of 150 Years of ObamaCare, and Dara Taylor of Community Catalyst discussed the impact of the AHCA on health equity and strategies we can use to protect our care and combat health disparities. The presentation can be found here. Some of the strategies shared were that, first and foremost, it is essential for us to work toward addressing systemic racism and to explicitly name it as “a cause of poor health.” Secondly, data collection is an effective tool to identify health disparities. We should work with state and local government agencies across sectors, health care providers and community leaders to collect as much health data as possible. In addition to race, ethnicity, sex, language and disability status, we should collect information related to gender identity, sexual orientation and income level to help answer research questions, test hypotheses and evaluate outcomes that lead to reducing and eliminating health inequities.  Lastly but not least, whenever possible, let’s make sure to elevate the voices of the people who will be affected in communities of color. Nothing is more powerful than hearing stories of how the ACA has positively improved health outcomes and provided financial security for millions of Americans. We must continue to work together in advocating against Republican repeal efforts that threaten to strip coverage away from millions of people and fails to advance health equity.

In the middle of the night, in an effort to save their flawed health care bill, Republicans released a number of amendments to the American Health Care Act (AHCA) that would dramatically impact the ability of low-income children, including millions of children with disabilities, to access health care. AHCA’s original language changed Medicaid financing to a per capita cap financing scheme that would harm children and families and burden state budgets. The bill would also eliminate coverage for certain low-income school aged children and deny them access to important preventive services including vision, hearing and dental. The amendments House Republicans released last night add insult to injury by offering states the option of a block grant (an option that includes a financial incentive for states) and permitting states to impose a work requirement that could apply to some parents – even those with young children.

Medicaid is a multi-generational program set up to protect our most vulnerable consumers at any stage in their lives including infants, toddlers and school-aged children. Roughly half of the 73 million enrolled in Medicaid around the country are kids and almost 60 percent of children with disabilities rely on Medicaid for coverage and access to necessary health services. Under the current Medicaid program, children have special protections to make sure they have access to the health care they need. These protections include no cost-sharing and access to a comprehensive benefit package known as Early Periodic Screening, Diagnosis and Treatment (EPSDT), which provides the full range of services children need to help them develop and grow.

The original language in AHCA would roll back eligibility for children ages six to 18 from 133 percent of the Federal Poverty Level (FPL) to 100 percent of FPL. The amendments would exacerbate this eligibility rollback by allowing states to implement a block grant. A block grant, like the one House Republicans are proposing, would significantly decrease the amount of funding available to states and would not keep pace with increases in medical spending or eligibility needs. Because of this massive cut in federal funding, states would be forced to cut benefits, roll back eligibility, increase cost sharing, and deny children comprehensive preventive care they need to stay healthy. This bill gives states permission to make such changes, reversing the Medicaid program’s longstanding commitment to protecting low-income children. Children with special health care needs will be at particular risk for benefit cuts and cost sharing increases. Their more complex health care needs make them a target as states look for places to make cuts and find savings in the new capped funding environment. 

These changes would have significant negative long-term impacts on kids health outcomes. Studies show that children who have access to continuous health services lead healthier, more productive lives over the long term. For example, EPSDT helps very young children (0-3 years) access screenings and treatment they need during these critical years for brain development. The House Republican proposal does not require states that choose a block grant to cover EPSDT, putting access to these critical services at risk.

The combination of the eligibility rollback and state’s ability to reduce benefits will also negatively impact school-aged children. Children of color will disproportionately be hurt. For black children whoare six times more likely to attend a high-poverty school than their white peers, Medicaid is a lifeline that can help students access eligible health services inside school walls. These services include, but are not limited to, mental health services, substance use disorder screening and chronic care management (such as diabetes and asthma care). For children with disabilities, the risk, too, is great. Many school-aged children with disabilities require health services in school in order to participate and thrive.

AHCA was already a huge step backwards for children's health and these amendments do nothing to increase access to health care or improve the health of children. In fact, they will only lead to further coverage losses and reverse the progress made since the passage of the Affordable Care Act. They are merely political ploys to try and win over the votes of members of Congress who are on the fence about passing this deeply flawed bill that would strip coverage from millions of Americans.

 

I would venture to guess that congressmen Paul Ryan and Joe Kennedy don't agree on too much, but one thing they do appear to agree on is that the ineptly named American Health Care Act (aka Trumpcare) is first and foremost a bill about cutting taxes. Ryan trumpeted the bill as a $1 trillion tax cut and seemed entirely unfazed by the fact that the beneficiaries of the tax break were overwhelmingly the richest households and big drug and insurance corporations. Meanwhile, Rep. Kennedy denounced the bill as "a tax cut wrapped up as health care" and called it "an act of malice rather than mercy" in a statement that went viral on YouTube.

And the Congressional Budget Office (CBO) has made it crystal clear who would pay for that tax cut: working families and especially older adults and people with disabilities. CBO projects that should AHCA become law, 24 million people would lose their health insurance – that's 80 percent of the number projected to lose coverage with a full repeal of the ACA. The financial assistance that makes coverage affordable for people who lack employer-sponsored insurance would be cut almost in half and would be restructured in a way that provides more assistance for the middle class but dramatically scales back help for people with more modest incomes.

Promises Made, Promises Broken

Ironically, the biggest losers under Trumpcare are the voters who provided President Trump with critical support during the election. For example, A 60-year-old person with an income of $30,000 would see her or his assistance shrink by an average of $6,000 per year. Many Trump supporters are now nervous that their coverage will be taken away, but in the face of all evidence to the contrary, some still cling to the hope that their candidate will not abandon them.  (Adding insult to injury for older adults, Trumpcare undermines Medicare's financial stability, despite Trump’s repeated promises not to cut the program. And the President’s budget called for eliminating federal funding for the meals on wheels program, among many other domestic program cuts.)

However, the greatest damage of Trumpcare may not be to the non-group insurance market, but to the Medicaid program. Notwithstanding his campaign promises, the legislation that Trump is backing "1,000 percent" would cut $880 billion in federal support for Medicaid. Cutting Medicaid would apparently fulfill a dream Paul Ryan has had ever since he was attending college keg parties… But the consequences for children and families, people with disabilities and seniors, should his dream become a reality, are serious. Capped funding would put states in a financial straightjacket, making it harder for them to meet the growing need for long-term services and supports or to respond to a disease outbreak like Zika or address the opioid addiction epidemic. Trumpcare would also force most states to abandon the recent expansion of Medicaid to more low-income adults.

Things Will Get Worse Before They Get Better

Not satisfied with inflicting all of these coverage losses, the most conservative members of the House are trying to make the bill even worse, and seem to be succeeding, at least for now. As the bill made its way through the Budget Committee, the committee took non-binding votes in favor of a more rapid phase-out of Medicaid funding for the 31 states that expanded the program under the ACA, making eligibility for non-disabled adults contingent on work and giving states more power to eliminate benefits or services for Medicaid beneficiaries. It is likely that some or all of these ideas will get converted into amendments in the House Rules committee where the bill is heading later this week before it goes to the floor.

While House leaders are trying to project confidence, the fate of the legislation in the House (let alone the Senate) is still unclear. Many of the most far-right members of the Republican House are still not on board. At the same time, changes meant to appease them could force some of the party's more moderate members – especially those in districts carried by Hillary Clinton – to think twice before voting to support a bill that would increase costs and cut coverage for thousands of their constituents. Many are unhappy with being asked to take a tough vote for a bill that could die or get substantially reworked in the Senate, and some have come out in opposition. Speaker Ryan is trying to keep these members on board by providing some additional help to older adults, but whether this will be enough to secure passage for the legislation in the face of opposition from health care providers, governors and concerned constituents remains to be seen.

On top of the uncertainty surrounding Medicaid expansion and Medicaid funding stemming from GOP Affordable Care Act (ACA) repeal efforts, HHS Secretary Tom Price and CMS Chief Seema Verma’s recent letter to governors adds another layer of change and uneasiness. This letter affirms the new administration’s intent to use Section 1115 Medicaid waivers to cut key consumer protections that have made Medicaid a vital, comprehensive source of health and financial security to millions of low-income Americans.

Concerning Waiver Directions

Strong evidence demonstrates that Medicaid is efficient and cost-effective – and that the ACA’s coverage expansion has had a positive effect on state budgets and enrollees’ health. Nevertheless, the Price-Verma letter gives states the green light to move towards Medicaid policy provisions that could lead to loss of coverage and access to care, and potentially hurt state budgets, such as:

  • Cost-sharing requirements. Studies show Medicaid beneficiaries lose coverage and experience barriers to care when states impose premiums and copayments. An evaluation of Indiana’s most recent waiver suggests beneficiaries who are subject to copayments likely have higher use of the emergency department (ED) as a result. Collecting premiums and copayments has shown to be inefficient and costly.
  • Eliminating non-emergency medical transportation (NEMT). Medicaid beneficiaries are more likely than those privately insured to have health care access barriers and NEMT helps bridge that gap. NEMT helps Medicaid expansion enrollees access critical care and treatment including behavioral health services, preventive health services and substance use treatment.
  • Copayments for non-emergent use of the ED. Copayments do not reduce unnecessary use of the ED, financially burden Medicaid consumers and fail to address larger systemic health care access issues.
  • Waiving presumptive eligibility and retroactive coverage. These provisions facilitate access to care and important protections for both enrollees and the providers that serve them, especially when there are delays in the application and enrollment process.
  • Support for work requirements. The letter stops short of explicitly saying it will approve work requirements, but includes language that strongly encourages states to impose training or work programs. Work requirements would be onerous on beneficiaries (most of whom are already in working families) and costly for states to administer.

We are troubled by a few other aspects of the letter. First, HHS’ intention to expedite waiver approvals and extensions may roll back important public input and evaluation requirements that have supported a fair and transparent waiver approval process. Second, a willingness to approve state waiver requests that replicate approvals in other states is troubling, since 1115 waivers are meant to be temporary demonstrations to test different approaches to providing Medicaid services. HHS should assess the impact of a waiver provision on access to care for beneficiaries in a single state, before approving it across the board.

Finally, the letter expresses an incorrect view that childless adults are not “vulnerable” and do not fit in with the mission of the Medicaid program. In fact, these low-income adults have experienced a historic lack of access to affordable health care, fluctuating income and language and cultural barriers, and thus, are appropriately served by Medicaid. Covering more adults under Medicaid has benefitted state budgets, consumer health and hospitals. Rolling back these gains would be detrimental.

Trump HHS Commits to Combatting Opioid Epidemic, But There’s a Catch

Medicaid is a critical source of coverage for adults with substance use disorders (SUD). For instance, almost 500,000 individuals (most who were previously uninsured) in Ohio have received  treatment for mental illness or substance misuse under the state’s expansion of Medicaid. HHS’ letter commits to continuing the important work begun in the Obama administration to enhance Medicaid services for SUD and improve access to comprehensive substance abuse treatment. For instance, HHS plans to continue the Medicaid Innovation Accelerator Program that provides technical assistance to states in enhancing SUD services. We hope that HHS continues the previous administration’s explicit support of waivers that contained a specific set of evidence-based measures including Screening, Brief Intervention and Referral to Treatment (SBIRT), integration with primary care, recovery support services, and medication-assisted treatment. Of course, the proof of HHS’ commitment will be in what state proposals they eventually support.

However, HHS Secretary Price’s support of ACA repeal and cutting federal Medicaid payments is at odds with the letter’s promise to address opioid addiction. The latest ACA repeal bill would jeopardize an estimated 1.3 million Americans with substance use disorders or mental illness who have received treatment through Medicaid expansion.

Allowing States to Assess Their Own Compliance on Home and Community-Based Services

The letter also says the administration will give states more time and say in implementing regulations ensuring that long-term services and supports are appropriately provided to people in their homes or communities. Allowing individual states to assess their own compliance could open the door to services that are less responsive to consumer needs and preferences.

Keeping an Eye on Medicaid

The upside to this letter is that none of the harmful waiver provisions listed can take place unless the states themselves choose to pursue such avenues. However, we do anticipate that this is just the first of many regulations and guidances HHS will produce that could undermine consumer protections in Medicaid. We intend to track these developments and provide more resources that equip advocates to push back. Stay tuned!