For the dental insurance industry, the upcoming November elections are among the most important in recent history. Depending on the outcome, the Affordable Care Act (ACA) could be affected significantly, which in turn could reduce access to oral health care for millions of Americans.

What’s going on with the ACA?

The future of the ACA is in question. In the case of California v. Texas, scheduled to be heard before the United States Supreme Court on November 10, the court will decide whether the law should be struck down, and which elements may or may not be saved.

A previous Insider Update article looked at how the upcoming Supreme Court nomination might affect the fate of the ACA. We’ll now consider the potential impact of the upcoming elections.

The upcoming election: What could happen?

On November 3, U.S. voters will decide whether to reelect President Donald Trump, a Republican, or replace him with former Vice President Joe Biden, a Democrat. They’ll also decide who will fill many United States Senate and House of Representative seats. Three outcomes are possible: 

  • A clean sweep by the Democrats. Democrats gain control of the White House and Senate, and retain control of the House.
  • A partial sweep by the Democrats. Democrats gain control of the White House and retain control of the House, but Republicans keep control of the Senate.
  • A return to status quo. Republicans keep the White House and Senate, and Democrats retain control of the House.

Current polling data strongly suggests that Democrats will retain the House, so a Republican sweep is unlikely.

How could a Democratic sweep affect the dental insurance industry?

A clean sweep for the Democrats, not surprisingly, would likely preserve and strengthen the ACA, regardless of the Supreme Court’s decision on California v. Texas, said Jeff Album, Vice President of Public & Government Affairs for Delta Dental.

“With Democrats controlling all three branches, Congress can quickly restore almost anything the Supreme Court might strike down, and do so long before the court’s decision becomes effective,” Album said.

Beyond the ACA, industry experts predict a clean sweep could lead to many other outcomes relevant to the dental industry:

  • Medicare could become available to people younger than 65, which could open new Medicare Advantage (MA) markets in which dental is often offered.
  • A dental benefit could be added to Medicare Part B, or as separate Part “T” (for teeth). Depending on the extent of the benefit provided, a Part B dental benefit could create or eliminate opportunities for dental insurers. A comprehensive Part B benefit could replace the private dental coverage purchased by millions of Medicare beneficiaries today, give growth to dental as a part of Medi-Gap policies, and eliminate employer-sponsored retiree dental plans. However, a Part B dental benefit limited to only preventive care could create opportunities for insurers to offer supplemental benefits plans. A Part B dental benefit would also require that all Medicare Advantage plans provide at least the same set of dental benefits, which would result in these plans receiving larger payments from the U.S. Centers for Medicare & Medicaid Services (CMS). About a third of MA plans today don’t offer dental.
  • A “public option” could be created. While the Biden campaign hasn’t offered many details, a public option is conceptually a federal health insurance program to be offered on state Health Insurance Exchanges as an alternative to private plans. It would likely be subsidized for lower income Americans, and partially or fully paid by enrollees who currently don’t qualify for subsidies. While dental coverage isn’t guaranteed to be a benefit for anyone other than children, an intriguing possibility is that it could be made available on a voluntary basis.
  • The public option might even entail automatic enrollment for low-income people into an existing Medicaid managed care or Medicaid fee-for-service plan.
  • Balance billing, or “surprise billing,” by out-of-network providers could become regulated by federal law, but it’s unclear how this might affect dental benefits, if at all.

How about a partial Democratic sweep?

A partial sweep, with a Republican-controlled Senate able to prevent legislation beginning in the House from reaching the president, would likely thwart a public option, strengthening the ACA or adding dental coverage to Medicare. However, a Biden White House could preserve the ACA as it currently exists, and eliminate through executive order moves by the prior administration to weaken it.

“Dramatic change is unlikely,” Album said.

Paired with an unfavorable Supreme Court ruling, however, a partial sweep could spell trouble for the ACA, Album said.

“It makes recovering from an adverse Texas decision in the Supreme Court much harder because the Senate Republicans may support many of the cutbacks an adverse SCOTUS decision could cause,” Album said. “And should the Supreme Court strike the ACA entirely, it’s hard to imagine Democrats and Republican agreeing on replacement.”

And what if we maintain status quo?

Should the country continue with a Republican president and divided Congress, the outcome of California v. Texas is uncertain.

A ruling that either leaves the ACA in place, or finds that the law’s individual mandate can be eliminated while leaving the ACA otherwise intact, means little change. But a ruling that the ACA is inseverable from the mandate means millions will lose coverage they have today, with Congress likely unable to respond.

Album predicts that a Republican White House would probably continue to work through executive orders to weaken the ACA and make ACA-non-compliant alternatives more widely available.

The worst-case scenario for the ACA occurs if federal funding for the program is eliminated. As many as 2 million people with Exchange-based dental benefits in the Exchanges could lose that coverage. For insurers, the risk is most acute for those with sizeable managed Medicaid and Exchange business.

“Marketplace changes could be profound,” Album said.