Adding dental benefits to Medicare

Comprehensive dental care is the most important benefit expansion to Medicare since prescription drugs were added in 2006. It is important we get it right.

Medicare is our nation’s health insurance program for older adults.

The current problem is that Medicare covers only “medically necessary” care. Examples are having a dental exam before an organ transplant or getting a fractured jaw fixed after a car accident. For wealthier retirees, who can afford premiums, Medicare Advantage pays for checkups, cleanings, and other treatments like fillings, crowns, and dentures.

Embedded within the Medicare program is a myth and an unfortunate truth.

Myth: The mouth is unimportant. Try telling this to someone with a brain-piercing toothache. Or to those who puree their foods because they cannot afford dentures. Anyone who’s had a dental problem knows the mouth is inextricably linked to overall health and well-being.

Unfortunate truth: Dental care in America is a privilege. In 2019, 30 percent of Medicare beneficiaries were in a Medicare Advantage plan (though not all plans have comprehensive dental coverage); 16 percent were insured through a private employer; and 8 percent through dual enrollment in Medicaid. The last number is overstated because dental coverage for adults in Medicaid is spotty, with most states providing emergency care only.

Thus, 70 percent of older adults are without comprehensive dental coverage.

Why does this matter?

Not having coverage means missing yearly checkups, which allow dentists to diagnose and treat diseases early and for patients to benefit from preventive care. It means having to rely on emergency departments, which are ill-equipped to provide definitive dental treatment. Research has shown how costly and inefficient this is to taxpayers. It also means depending on free clinics.

On a recent research trip, I met an older man with cavities who’s been on a waitlist since 2019 to see a dentist.

Millions of older adults in America suffer silently and hopelessly from the sequelae of dental diseases, in part, because Medicare has excluded dentistry.
How can we get it right?
The American Dental Association, which represents its 160,000 member dentists, has ideas for Medicare that are largely aimed at protecting dentists.

Our country’s Medicaid program, which provides low-income children with comprehensive benefits and adults with optional dental benefits, provides important lessons for Medicare reform.

First, separate is not equal. Creating a separate program for low-income Medicare beneficiaries would deepen the divide between haves and have-nots, leaving millions continuing to struggle to find accessible and affordable care.

Comprehensive dental benefits should be fully incorporated into Medicare Part B as outlined in current legislation. All Medicare beneficiaries would be eligible. Sliding-scale premiums and copays should be part of a single program to ensure equity.

Second, traditional reimbursement systems are cost prohibitive. Funding Medicaid dental programs through fee-for-service has been unsustainable because it incentivizes 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’s Coordinated Care Organizations is a model of how dentistry can be integrated into the health system with an eye on managing costs, maintaining quality, and ensuring sustainability.

Third, dental care is important but other factors, including behaviors, are critical for long-term oral health. Two such behaviors include cutting added sugar from the diet and brushing with fluoride toothpaste. My own research shows that sugar sweetened beverages lead to cavities in Medicaid-enrolled children. The dental care system fails to address behaviors.
Congress should appropriate funds to develop programs for Medicare enrollees that encourage and incentivize optimal oral health behaviors. The evidence-based Medicare Diabetes Prevention Program promotes healthy diet and exercise. When combined with comprehensive benefits, behavioral programs can lead to healthier beneficiaries with fewer dental needs, which translates to cost savings. This is the type of broad impact we should aim for when redesigning Medicare benefits.

Older adults in Medicare are entitled to comprehensive dental benefits and Congress can make it happen in way that ensures equity, sustainability, and impact.

Donald L. Chi, DDS, PhD., is professor of dentistry and public health at the University of Washington.