Impact of the Affordable Care Act Medicaid expansion on oral surgery delivery at community health centers: an observational study

Abstract

Background Unmet oral health needs routinely affect low-income communities. Lower-income adults suffer a disproportionate share of dental disease and often cannot access necessary oral surgery services. The Affordable Care Act (ACA) Medicaid expansion created new financial opportunities for community health centers (CHCs) to provide mission-relevant services in low-income areas. However, little is understood in the literature about how the ACA Medicaid expansion impacted oral surgery delivery at CHCs. Using a large sample of CHCs, we examined whether the ACA Medicaid expansion increased the likelihood of oral surgery delivery at expansion-state CHCs compared to non-expansion-state CHCs. Methods Exploiting a natural experiment, we estimated Poisson regression models examining the effects of the Medicaid expansion on the likelihood of oral surgery delivery at expansion-state CHCs relative to non-expansion-state CHCs. We merged data from multiple sources spanning 2012–2017. The analytic sample included 2054 CHC-year observations. Results Compared to the year prior to expansion, expansion-state CHCs were 13.5% less likely than non-expansion-state CHCs to provide additional oral surgery services in 2016 (IRR = 0.865; P = 0.06) and 14.7% less likely in 2017 (IRR = 0.853; P = 0.02). All else equal, and relative to non-expansion-state CHCs, expansion-state CHCs included in the analytic sample were 8.7% less likely to provide oral surgery services in all post-expansion years pooled together (IRR = 0.913; P = 0.01). Conclusions Medicaid expansions can provide CHCs with opportunities to expand their patient revenue and services. However, whether because of known dental treatment capacity limitations, new competition, or coordination with other providers, expansion-state CHCs in our study sample were less likely to provide oral surgery services on the margin relative to non-expansion-state CHCs following Medicaid expansion.

The Impact of the Affordable Care Act (ACA) on Oral Health in Low-Income Individuals

“…It is unclear why these pre-expansion states were less likely to give additional oral surgery than pre-non-expansion states. After the start of the ACA, expansion states were 8.7% less likely to provide supplemental oral surgery when compared to non-expansion states (Goldstein et al, 2021). These were unexpected results from the study since it was expected that more individuals would access these community health centers for low-cost dental care.…”

“…A new perspective was observed by Goldstein et al (2021) in a study that focused on how the Medicaid extension in dental coverage through the ACA impacted the prevalence of oral surgery procedures in community health centers. Often, low-income individuals are unable to access the required treatment for oral health diseases.…”

“…However, the ACA introduced financial support for low-income individuals who could go to community health centers for dental care located in their area. This would ultimately lead to more revenue for the health centers, and in turn would allow for more health care resources in low-income areas (Goldstein et al, 2021). The study combined data from 2054 community health centers, half in states that expanded dental coverage, and half in non-expansion states from 2012-2017.…”

“…One explanation is that the expansion-states community health centers had younger patients who did not require as extensive dental procedures compared to patients in non-expansion states. Another reason for the unexpected findings is that the expansion state's community health centers may have started prioritizing very complicated procedures to private dental offices that had the capacity, resources, and accepted Medicaid (Goldstein et al, 2021). Since individuals in non-expansion states would have no alternative dental care and could only go to community health centers, that is most likely why the use of oral surgery in community health centers increased.…”