Is It Finally Time For A Medicare Dental Benefit?


In 1958, the American Medical Association, the American Dental Association, and several other health professional organizations created the Joint Council to Improve the Health Care of the Aged, which pledged to oppose the creation of the program that would eventually become Medicare. In the years since the council’s defeat, Medicare has proven to be transformative, with enrollment in the program at age 65 resulting in better access to care and a reduction in racial health inequalities. .1 Yet organized medicine and dentistry’s historic opposition to Medicare has at least one current legacy: With the exception of some Medicare Advantage plans, Medicare still does not have dental coverage.

Current sources of dental coverage for adults in the United States.

In 1965, almost all older people could expect to lose all of their teeth eventually. Today, tooth loss is no longer a consequence of age but a structural injustice. Dentistry continues to operate on a fee-for-service model, with higher proportions of chargeable costs and higher financial barriers to access than other forms of health care. Additionally, most practice models focus on reconstructive care rather than preventative measures to maintain dental health.2 These factors contribute to inequalities in pain, edentulousness and unmet needs affecting low-income people, people of color and the elderly. Black and Latin Americans are two to three times more likely to have untreated tooth decay than white Americans, and low-income seniors are more than three times more likely to have lost all of their natural teeth. seniors with an income of 200% or more. of the federal poverty line (FPL).3 The main sources of dental coverage in the United States and their limits are listed in the table.

After decades of unsuccessful attempts to implement a Medicare dental benefit, the federal government is closer than ever to doing so. In 2019, the House of Representatives passed the Elijah E. Cummings Lower Drug Costs Now Act (HR 3), which included a proposal for Medicare coverage for dental, vision and hearing services, but the bill was unsuccessful. in the Senate. The dental benefit is expected to cost $ 238 billion in the first 10 years. A bill with similar provisions limited to dental care (HR 502 and S. 97) was introduced to Congress in 2021. President Joe Biden’s budget reconciliation program includes funding for a Medicare dental benefit, and in August 2021, the Centers for Medicare and Medicaid Services (CMS) appointed its first-ever Chief Dentist, whose role is to “guide CMS in advancing oral health” in various federal health programs, including Medicare .

The American Dental Association has offered support for a Medicare dental benefit only if it includes so-called means testing to restrict coverage to people with lower incomes (from assets, pensions, and incomes). at 300% FPL and only if dental coverage would be separate from Medicare Parts A, B, and D (that is, if Congress established a Medicare “Part T”). Beyond excluding many middle- and upper-income seniors who currently do not have dental coverage, we believe that a means-tested policy separate from other Medicare benefits would limit health gains. oral health for two reasons.

First, limiting a Medicare dental benefit to low-income beneficiaries would make it financially simple for most dentists to refuse to accept Medicare. Lack of acceptance by dentists has hampered Medicaid dental programs across the country. Nationally, only 43% of dentists accept Medicaid insurance or the Children’s Health Insurance Program (CHIP),4 This has resulted in low access rates and poor oral health outcomes, even in states whose Medicaid programs offer full adult dental benefits. Federally licensed health centers and other safety net providers that accept public insurance are already at full capacity and, without substantial private sector involvement, would find it difficult to meet the increased demand for newcomers. Medicare beneficiaries.

Second, a means-tested stand-alone Part T provision would perpetuate the separation of dentistry from the rest of the health care system. Although means testing has previously been offered as an option to lower Medicare costs and determine some premium costs for Medicare Part D beneficiaries, no other Medicare benefit is determined by income. Establishing a separately administered, means-tested Medicare dental program would maintain the financial and structural separation of dentistry and medicine, thereby precluding any innovation that might be made as part of the integration of medical care. and dental.

Fully integrated dental delivery could lead to capitation payment mechanisms that include both oral health and other health care services, as well as measures of oral health quality similar to those prescribed for other forms of Medicare reimbursed care. This type of centralization could help Medicare promote the integration of oral health into responsible care organizations and other health care delivery organizations, the development of quality-driven payment mechanisms, and the coordination of health care delivery. multidisciplinary care (for example, vaccination in dental offices or provision of preventive dental care). during primary care visits). The reach of Medicare offers an opportunity for change that could improve the quality and cost-effectiveness of health care. The scale of disruptive innovation in dental practice would be lost if benefits were limited to only a portion of Medicare beneficiaries and the administration of benefits remained siled.

The need for a Medicare dental benefit and the form that such benefit would take are not concerns limited to dentists. The medical system is already paying for the burdens associated with unmet dental needs. Each year, millions of patients, including many elderly people, present to emergency departments, hospitals and primary care offices for dental pain relief – visits that usually end with a directive to see a doctor. dentist, which many patients are unable to do. Untreated dental disease can lead to endocarditis, brain abscesses, and mediastinitis. Local and systemic inflammation caused by common periodontal infections has been associated with worsening diabetes and an increased risk of cardiovascular disease. Seniors with untreated dental problems have less nutritious diets and higher rates of depression and isolation than those with good dental health. But the main reason why access to dental care is crucial is that, even in the absence of other medical complications, dental problems are a preventable and far too common source of crippling disease.5

Especially in the face of opposition from organized dentistry, current Medicare dental insurance proposals may fail. Nonetheless, Democrats in Congress have expressed their commitment to establishing Medicare dental, vision and hearing benefits as necessary steps on the path to “Medicare for All.” Even if Medicare dental insurance is enacted, many challenges will remain. Congress and CMS should develop a dental coverage administration system, establish a fee schedule and begin registering dental providers. Health systems would need time to develop dental infrastructure to meet pent-up demand and to develop and refine integrated systems of care. With Medicare’s cost curve already a national concern, policymakers should determine what dental treatments would be covered and what forms of co-payment or coinsurance would be needed for beneficiaries. Even universal coverage of dental services would not guarantee the oral health of people in rural areas or low-income communities without accessible dental care. But we believe that none of these challenges should prevent the adoption of Medicare dental insurance.

The evolution of Medicare has had profound effects not only on the health of Medicare beneficiaries, but on all Americans. A Medicare dental benefit could transform the delivery of dental care to be more equitable, results-oriented and integrated with the rest of the health care system, but only if dentists are compelled to participate. We believe that the implementation of a universal dental benefit of Medicare is a health imperative and health equity imperative.

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