DEPARTMENT Health Policy

Impact of Affordable CareAct on Children’s OralHealth: States Hold the Key

Karen G. Duderstadt, PhD, RN, CPNP

Dental caries is themost commonchronic disease ofchildhood, and thelargestconcentration ofdental cariesoccurs in children

KEY WORDSAffordable Care Act, children, oral health, access to care,dental

Lack of access to dental care for children has contrib-uted to the inequality in oral health in the United States.Children living in low- and middle-income families areparticularly vulnerable to barriers in receiving quality,affordable oral health care services. Currently, 42% ofchildren aged 2 to 11 years and half of children aged12 to 15 years have dental caries (Centers for DiseaseControl and Prevention, 2011). Dental caries is themost common chronic disease of childhood, and the

Section EditorKaren G. Duderstadt, PhD, RN, CPNPUniversity of California—San FranciscoSchool of Nursing, Family Health CareSan Francisco, California

Eileen Fry-Bowers, PhD, JD, RN, CPNPLoma Linda UniversityLoma Linda, CA

Karen G. Duderstadt, Clinical Professor, Department of FamilyHealth Care Nursing, School of Nursing, University of California

San Francisco, San Francisco, CA.

Conflicts of interest: None to report.

Correspondence: Karen G. Duderstadt, PhD, RN, CPNP,

Department of Family Health Care Nursing, School of Nursing,

University of California San Francisco, 2 Koret Way, Box 0606N411Y, San Francisco, CA 94143-0606; e-mail: karen.

duderstadt@nursing.ucsf.edu.

J Pediatr Health Care. (2014) 28, 565-567.

0891-5245/$36.00

CopyrightQ 2014 by theNationalAssociationofPediatricNurse

Practitioners. Published by Elsevier Inc. All rights reserved.

http://dx.doi.org/10.1016/j.pedhc.2014.08.014

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largest concentration of dental caries occurs in childrenfrom low-income families with limited access to pediat-

from low-incomefamilies with limitedaccess to pediatricdental services.

ric dental services.More than 14 millionchildren living in low-income families didnot see a dentist in2011 (Department ofHealth and HumanServices [DHHS], 2014),and a recent survey ofparents showed that42% of uninsured chil-dren had not beento the dentist withinthe past year (Bloom,Cohen, & Freeman,2012). Most oral dis-ease, especially in chil-

dren, is largely preventable, and good oral health carein childhood impacts the child’s life course and overallhealth outcomes.Pediatric oral health care services are included in

the Affordable Care Act (ACA) as one of 10 essentialbenefits, with the goal of reducing inequality in ac-cess to dental care for children living in low- andmiddle-income families to improve oral health out-comes. As with many provisions within the ACA,the impact of the revision lies in the interpretationand implementation of the legislation across thestates. This article will review the ACA provision ofincreasing access to oral health care for children,the impact of oral health on the overall health of chil-dren, the current shortage of the pediatric dentalworkforce, and the role of pediatric primary care pro-viders, including nurse practitioners, in filling the cur-rent gap in the workforce and helping to meet theincreased demand for pediatric dental care createdby the ACA.

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BOX. Ten categories of Affordable Care Actessential health benefits

Affordable Care Act Essential Health Benefits mustinclude serviceswithin at least the following 10 categories:� Ambulatory patient services� Emergency services; hospitalization� Maternity and newborn care� Mental health and substance use disorder services,including behavioral health treatment

� Prescription drugs� Rehabilitative and habilitative services and devices� Laboratory services� Preventive and wellness services� Chronic disease management� Pediatric services, including oral health care andvision care

Insurance policies must cover these benefits to becertified and offered in the federal and state Health

Insurance Marketplace. States expanding their Medicaidprograms alsomust provide these benefits to children andfamilies newly eligible for Medicaid.

ACA AND ORAL HEALTH CAREThe ACA has the potential to significantly reduce thenumber of uninsured children without access to dentalcare. Pediatric oral health care was included as one ofthe 10 essential health benefits to be offered throughthe federal and state health insurance exchanges (seeBox). Individual and small-group health plans mustoffer dental benefits for children younger than 19 years.If the ACA provisions were fully implemented, approx-imately 8.7 million children would be expected to gainsome form of dental benefits by 2018, and the numberof children without dental benefits would be reducedby 55% (Nasseh, Vujicic, & O’Dell, 2013).

Medicaid is currently the largest provider of dentalbenefits, covering 32 million children living in low-income families. Part of the expected increase in dentalbenefits would come through the expansion ofMedicaid eligibility for 3.2million childrennot currentlyenrolled, which includes access to dental care as part ofcovered benefits (Nasseh et al., 2013). The other poten-tial increases in dental health benefits for children is apotential 3 million children who would gain benefitsthrough the state health insurance exchanges and anadditional 2.5 million children projected to gain dentalcoverage through the employer-sponsored mandate.

Although the number of states expanding Medicaideligibility is increasing, currently 21 states1 have chosennot to participate in Medicaid expansion under theACA, and three states (Indiana, Pennsylvania, and Ver-mont) are debating the expansion decision (KaiserFamily Foundation, 2014). Implementation of theemployer mandate has also been deferred. States notparticipating in the Medicaid expansion provision andthe challenge to implementation of the employermandate will significantly impact access to dental carefor children living in low- and middle-income families.

Although pediatric oral health care was included inthe ACA as an essential health benefit, it does notrequire consumers to buy stand-alone pediatric dentalinsurance as part of state health insurance exchanges,nor does it offer subsidies to help consumers pay for pe-diatric dental insurance. These shortfalls in the ACAprovisions will affect uptake of pediatric dental bene-fits. However, each state can exercise significant controlover expanding access to pediatric dental care amongtheir populations because the ACA requires dental ben-efits to be offered for everyone younger than 19 years,whether through Medicaid expansion or the statehealth insurance exchanges. States such as Maryland,Virginia, and Connecticut have streamlined administra-tive procedures and are paying dentists closer tomarketrates for providing services to Medicaid patients. This

1Alabama, Alaska, Florida, Georgia, Idaho, Kansas, Louisiana,Maine, Mississippi, Missouri, Montana, Nebraska, North Carolina,

Oklahoma, South Carolina, South Dakota, Tennessee, Texas,

Virginia, Wisconsin, and Wyoming.

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approach by the states has increased access to dentalcare for children, along with ramping up patientoutreach to increase uptake of pediatric dental benefits(Nasseh et al., 2013). Despite the DHHS Oral HealthInitiative 2010 recognizing oral health as integral tooverall health, oral health care services are still consid-ered a separate entity in health care financing (DHHS,2014).

IMPACT OF ORAL HEALTH ON OVERALLHEALTHChildren without access to dental care often have poororal hygiene anddental decay.Decayed teeth can causeoral abscesses, ear infections, and infection in sinusesand the brain if untreated in young children. In middlechildhood, decayed teeth have an impact on chewingand nutrition and sleep habits and contribute to poorspeech articulation, missed school days, and poorschool performance (American Academy of PediatricDentistry [AAPD], 2014). The cost of treatment of mod-erate to severe early childhood caries ranges from$10,000 to $25,000 per child for children who need tobe anesthetized. It is estimated that the Medicaid pro-gram spends between $100 and $400 million annuallyfor treatment of early childhood caries in children(AAPD, 2014).The oral health of parents and caregivers also signif-

icantly impacts children’s oral health, because a pri-mary factor contributing to early dental decay inchildren is the transmission of the bacteria Strepto-coccusmutans from the parent. Many parents and care-givers do not understand the importance of children’soral health and do not follow good dental practices.

Journal of Pediatric Health Care

Pediatric health care providers often do not pass on toparents the recommendation of the importance of es-tablishing a dental home by the first birthday (AAPD,2014). This gap in parental knowledge and in pediatricpractice continues to have an impact on the oral healthoutcomes of children.

SHORTAGE OF PEDIATRIC DENTISTSCurrently, there is a national workforce shortage of pe-diatric dentists to fill the demand for pediatric oralhealth care services, and increasing access to qualifiedpediatric dental services requires tackling the work-force issue. A 2011 Institute of Medicine report ad-dressed the need for improved access to oral healthcare and directed the Health and Human Resourcesand Services Administration (HRSA) to develop a planto integrate oral health services into primary care toaddress the gap between general health and oral health(Institute of Medicine of National Academies, 2011).HRSA’s report Integration of Oral Health and PrimaryCare Practice recommends a fundamental systemchange to expand the scope of practice of current pedi-atric primary care providers, including nurse practi-tioners, to incorporate oral health care services(DHHS, 2014). The recent recommendation from theU.S. Preventive Services Task Force (USPSTF)concurred with the recommendation that providersincorporate oral health care into primary carepractice, including the application of fluoride varnishfor children younger than 5 years (USPSTF, 2014).

Integration of oralhealth in primarycare promises toincrease access topreventive dentalcare services,particularly foryoung childrenliving in low-incomefamilies.

Integration of oralhealth in primary carepromises to increaseaccess to preventivedental care services,particularly for youngchildren living inlow-income families.However, this recom-mendation will requireincreasing the skillset of pediatric pri-mary care providers,including nurse practi-tioners, to provide pre-

ventive services for children, and application offluoride varnish will require further training of thehealth care workforce. The provision of preventivedental care services does provide the potential forincreased reimbursement for community clinics, whichwill likely will serve a large percentage children andfamilies gaining coverage through the ACA provisions.

ADVOCACY FOR ORAL HEALTHProviding improved access to oral health care servicesthrough the ACA is the first important step in reducing

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the inequality in oral health. However, further reformof the ACA is needed to set standards for what dentalbenefits arecoveredand toprovide feweradministrativebarriers for dental providers. Also, providing assistancewith subsidies for dental insurance would increase ac-cess to preventive services and contribute to lowerhealth care costs related to untreated dental disease.States are leading the way in mandating and providingdental benefits to children living in low- and middle-income families and are modeling provisions that havethe potential to influence national oral health policy.The role of pediatric health care providers as advo-

cates for improved oral health policy is also key toincreasing state uptake of pediatric oral health as anessential health benefit. Integrating improved preven-tive dental services into primary care practice linksoral health to overall child health, and discussing theimportance of dental benefits with families and assist-ing them in seeking access to current information abouthealth insurance exchanges will contribute to access topediatric dental care.Pediatric health care providers who work with chil-

dren living in low- andmiddle-income families withoutaccess to dental care have a critical role in advocatingfor improved access to dental benefits in the states asthe rollout of the ACA continues.

REFERENCESAmerican Academy of Pediatric Dentistry. (2014). The state of little

teeth. Retrieved from http://www.aapd.org/assets/1/7/State_of_Little_Teeth_Final.pdf

Bloom, B., Cohen, R. A., & Freeman, G. (2012). Summary health sta-tistics for U. S. children: NHIS, 2011. Vital Health Statistics,

10(254), 1-80.Centers for Disease Control and Prevention. (2011). Oral health:

Preventing cavities, gum disease, tooth loss, and oral cancers.At a glance, 2011. Retrieved from http://www.cdc.gov/chronicdisease/resources/publications/aag/doh.htm

Department of Health Human Services. (2014). Integration of oral

health and primary care. Washington, DC: Health and HumanResources and Services Administration.

Institute of Medicine of National Academies. (2011). Improving access

to oral health care for vulnerable and underserved populations.Retrieved from http://iom.edu/Reports/2011/Improving-Access-to-Oral-Health-Care-for-Vulnerable-and-Underserved-Populations.aspx

Kaiser Family Foundation. (2014). Status of state action on the

Medicaid expansion decision. Retrieved from http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

Nasseh, K., Vujicic, M., & O�Dell, A. (2013). Affordable Care Act ex-

pands dental benefits for children but does not address critical

access to dental care issues (Health Policy Resources CenterResearch Brief). Retrieved from http://www.ada.org/�/media/ADA/Science%20and%20Research/Files/HPRCBrief_0413_3.ashx

U. S. Preventive Services Task Force. (2014). Prevention of dental

caries in children from birth through 5 years of age. Retrievedfrom http://www.uspreventiveservicestaskforce.org/uspstf/uspsdnch.htm

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