Comprehensive dental care is the most important benefit extension to Medicare since the addition of prescription drugs in 2006. It is important that we get the right results.
Medicare is our country’s health insurance program for the elderly.
The current problem is that Medicare only covers “medically necessary” care. Examples are a dental exam before an organ transplant or a broken jaw after a car accident. For wealthier retirees, who can afford premiums, Medicare Advantage pays for exams, cleanings, and other treatments like fillings, crowns, and dentures.
Built into the Medicare program is a myth and a sad truth.
Myth: The mouth doesn’t matter. Try telling this to someone who has a toothache that pierces their brain. Or those who mash their food because they can’t afford dentures. Anyone who has had a dental problem knows that the mouth is inextricably linked to overall health and well-being.
The unfortunate truth: dental care in America is a privilege. In 2019, 30 percent of Medicare beneficiaries were on a Medicare Advantage plan (although not all plans have full dental coverage); 16 percent were insured by a private employer; and 8 percent thanks to dual enrollment in Medicaid. The latter figure is overestimated because dental coverage for adults in Medicaid is spotty, most states providing emergency care only.
Thus, 70 percent of the elderly are without full dental coverage.
Why is this important?
Not having coverage means missing annual checkups, which allows dentists to diagnose and treat disease early and patients to benefit from preventive care. This means having to rely on emergency services, which are ill-equipped to provide definitive dental treatment. Research has shown how costly and inefficient it’s for taxpayers. It also means relying on free clinics.
On a recent research trip, I met an older man with cavities who has been on a waiting list since 2019 to see a dentist.
Millions of seniors in America are silently and desperately suffering from the after-effects of dental disease, in part because Medicare has ruled out dentistry.
How can we do it right?
The American Dental Association, which represents its 160,000 member dentists, has ideas for Medicare that are largely aimed at protect dentists.
Our country’s Medicaid program, which provides low-income children with full benefits and adults with optional dental benefits, provides important lessons for Medicare reform.
First, to separate is not equal. Creating a separate program for low-income Medicare beneficiaries would widen the gap between the haves and have-nots, leaving millions of people to continue to struggle to find accessible and affordable care.
Comprehensive dental benefits should be fully integrated into Medicare Part B because described in the legislation in force. All Medicare beneficiaries would be eligible. Degressive premiums and co-payments should be part of a single program to ensure fairness.
Second, traditional reimbursement systems are prohibitive. Funding of Medicaid dental programs through fee-for-service has not been sustainable because it encourages overtreatment. Some states have turned to managed care to control costs, but this leads to rationed care, undertreatment, and dissatisfied beneficiaries.
Medicare administrators could consider other strategies. Oregon Coordinated Care Organizations is a model for integrating dentistry into the healthcare system with cost management, quality maintenance and sustainability in mind.
Third, dental care is important, but other factors, including behaviors, are essential for long-term oral health. Two of these behaviors include removing added sugar from the diet and brushing with fluoride toothpaste. My own research shows that sugary drinks lead to cavities in children enrolled in Medicaid. The dental care system fails to manage behavior.
Congress should allocate funds to develop programs for Medicare registrants that encourage and encourage optimal oral health behaviors. Medicare’s evidence-based diabetes prevention program promotes healthy eating and exercise. When combined with comprehensive benefits, behavioral programs can lead to healthier beneficiaries with fewer dental needs, resulting in cost savings. This is the kind of general impact we should be aiming for when overhauling Medicare benefits.
Seniors on Medicare are entitled to full dental benefits and Congress can achieve this in ways that ensure equity, sustainability and impact.
Donald L. Chi, DDS, PhD., Is professor of dentistry and public health at the University of Washington.