At a May 16 hearing of the U.S. Senate Health, Education, Labor & Pension Committee, experts made the case for adding comprehensive dental coverage to Medicare and Medicaid insurance.
In her written testimony, Lisa Simon, M.D., D.M.D., an associate physician at Brigham and Women’s Hospital in Boston, said that working as a dentist in a community health center “broke my heart. The wait for my services routinely exceeded four months, and I was often forced to extract teeth I could have saved because of insufficient Medicaid funding.”
Simon eventually went to medical school to work on the crisis in oral health from both sides of the aisle. “Through medical school, I practiced dentistry at the Suffolk County Jail, where I had multiple patients tell me that the only good thing to happen to them since being incarcerated was that they finally got to see a dentist,” she said.
She noted that Medicare has been barred from providing a dental benefit since 1965, causing substantial harms to seniors and people with disabilities. “This must be reversed. Fewer than half of Medicare beneficiaries see a dentist each year; when they do, they spend more than $1,000 out-of-pocket on their care.”
Patients delay dental care due to cost more than any other healthcare service.
Dental plans are often a draw for beneficiaries to choose Medicare Advantage, and dental benefits are the most advertised supplemental benefit MA plans offer. Though 98% of Medicare Advantage beneficiaries are enrolled in a plan that reportedly offers a dental benefit, Simon said her research has shown they have equivalently low rates of dental access and equally high out-of-pocket costs. “Medicare Advantage is not the solution,” Simon said.
Simon said that the Congressional Budget Office estimated that a universal Medicare dental benefit would cost $23.8 billion per year, less than the cost to Medicare of the single discontinued Alzheimer’s drug Aduhelm (aducanumab). This estimate does not take into account the potential cost savings that would stem from reductions in pneumonia hospitalizations, fewer complications of cancer treatment, lower rates of frailty and malnutrition, and the long-term benefits of preventive care.
Turning to Medicaid, Simon said that the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit confirms that children with Medicaid or CHIP have dental coverage, but this protection disappears the moment they become adults. Dental benefits for adults are currently determined at the state level, with broad variability. Four states cover no dental care, and only eight cover enough care to be considered comprehensive. “When states do not have a dental benefit, Medicaid programs still pay the price in preventable emergency department visits for dental problems. Moreover, adult dental care is persistently threatened in times of budget shortfall due to its ‘optional’ nature,” she added.
Simon noted that organized dentistry has repeatedly lobbied against these changes to coverage. “Its lobbying protects the financial interests of dentists as small-business owners, not the oral health of patients and communities.”
Overall, dentistry has been unable, or unwilling, to change itself to serve the needs of more Americans, Simon said. “Change will need to come from outside. Both my medical and dental patients have asked me the same question: why is dentistry so separate? Why is it so hard for me to access and afford dental care? I tell them that there is no good reason. There is no good reason why we live in a country where low-income Americans are 16 times more likely to lose all their teeth than their wealthier neighbors. It simply isn’t fair. My patients deserve better. Our country deserves better.”
Myechia Minter-Jordan, M.D., M.B.A., president and CEO of the CareQuest Institute for Oral Health, also provided written testimony. She described how she had previously served as chief medical officer and CEO of the Dimock Center, one of the largest community health centers in Massachusetts.
During her time at Dimock, she witnessed the devastating consequences of oral disease on children who were part of the Head Start/Early Head Start program. The severity of disease that these young participants were experiencing — some as young as three years old — meant that these children were sedated with anesthesia to perform the level of restorative care needed to remove tooth decay and halt the progression of the disease. “That was a moment of reckoning for me. It was unacceptable that a preventable disease was impacting our children in this way. This experience is what ultimately led me to my work at CareQuest Institute,” Minter-Jordan said.
The fact that dental coverage and care remain largely separate from medical has had a profound impact on affordability and access to services, she explained. Millions of people across the country cannot access the oral health care they need, most often because they cannot afford it. In fact, dental care is the number one medical service skipped due to cost, even more than prescription drugs.
Nearly 70 million adults and nearly 8 million children in the United States do not have dental insurance. This is partly because traditional Medicare doesn’t cover dental services except under very specific and extreme circumstances. As a result, half of all Medicare enrollees don’t have dental coverage, meaning nearly 25 million older Americans and people with disabilities lack access to this critical form of healthcare. Around the same number of Medicare enrollees haven’t visited a dentist in 12 months. While people who have Medicare Advantage may get some dental coverage, the benefits can vary widely from plan to plan, and they may come with limited provider networks, Minter-Jordan said.
The lack of dental coverage options exacerbates the national oral health crisis and forces many people to forgo critical dental care, leading to deep inequities in access and outcomes, she explained. “Addressing these gaps is a critical and foundational step to realizing a health system that prioritizes prevention, bolsters the oral health workforce, integrates medical and dental care, and improves the exchange of health information between medical and dental providers.”
