Seniors Deserve a Medicare Dental Benefit Without Strings Attached

The connection between oral health and overall health is increasingly clear, but you wouldn’t know it looking at the federal government’s Medicare program. Medicare, which provided health insurance for more than 62 million U.S. retirees and people with disabilities in 2020, does not include dental coverage — except in very limited circumstances.

Overall, according to a 2019 study by the Kaiser Family Foundation (KFF), 47 percent of Medicare beneficiaries do not have dental coverage. While some Medicare beneficiaries have a dental benefit through optional, add-on Medicare Advantage plans (with additional premiums and co-pays), the scope of coverage is often extremely limited. For much of the older adult population in the United States, oral health care services are simply unaffordable.

A Public Health Emergency

The lack of Medicare dental coverage and high out-of-pocket costs facing older U.S. adults with oral health needs represent a true public health emergency. Forty-seven percent of Medicare beneficiaries did not have a dental visit in the last year, according to the same KFF study. The impact is especially disproportionate for marginalized communities, with the percentage without a dental visit climbing to 68 percent for Black beneficiaries, 61 percent for Hispanic beneficiaries, and 73 percent for low-income beneficiaries. Other at-risk populations are similarly affected. Among Medicare beneficiaries in fair or poor health, for example, the number is 63 percent.

The consequences are as devastating as they are preventable. A study by KFF of the 2016 Medicare Current Beneficiary Survey (MCBS) found that among all Medicare recipients living in the community, “18 percent have some difficulty chewing and eating solid foods due to their teeth.” This includes 29 percent of low-income recipients and 33 percent of recipients with disabilities under age 65. Oral health conditions are also common among the Medicare population: over 14 percent of older U.S. adults have untreated dental decay (caries), and 68 percent have periodontal disease (gum disease).

Various studies have linked periodontal disease to systemic health problems like diabetes, heart disease, kidney disease, and cancer. Dr. Lisa Simon and Dr. William Giannobile said it well in a recent opinion piece appearing in the New England Journal of Medicine: “The key reason that 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 disabling disease.”

That reality is especially true for older adults. “Growing evidence shows that poor oral health can worsen health conditions disproportionately impacting older individuals such as diabetes and cardiovascular disease — conditions that Medicare does cover,” the National Dental Association stated in a September letter calling for the expansion of Medicare to include a dental benefit.

A Historic Opportunity

In the decades since Medicare’s establishment in 1965, advocates have continually pushed for expanding the program to include dental, hearing, and vision benefits. However, current political realities mean that reform is perhaps closer than ever before. Powerful interest groups nevertheless threaten to dramatically scale back or derail the proposed change.

“Means-Testing” for Medicare Dental Benefits: A Costly Mistake

Despite not necessarily opposing a dental Medicare benefit altogether, some interest groups are applying the brakes. Rather than make dental coverage universal for all Medicare recipients, some have endorsed a model in which Medicare dental benefits would be available only to beneficiaries whose incomes are 300 percent or less of the federal poverty level (FPL), equating to roughly $38,000 per year for an individual.

To be clear: this would be a mistake. “Means-testing” has never been used with other health coverage under Medicare and would represent a step in the wrong direction if applied to a new dental benefit.

An Inequitable, Potentially Destabilizing Solution

By means-testing dental Medicare benefits, oral health care would remain out of reach for millions of working and middle-class older adults. That’s because out-of-pocket costs for dental care would still exceed many individuals’ available discretionary income, even for those earning more than 300% FPL. After all, KFF reports that out-of-pocket spending on dental care was $874 on average for Medicare beneficiaries using dental services in 2018 and that one in five Medicare beneficiaries using dental services spent more than $1,000 out-of-pocket. Many seniors, the majority of whom live on fixed incomes, simply cannot afford the out-of-pocket costs associated with routine, preventive dental care, to say nothing of more costly restorative or surgical procedures.

Beyond this inequity, however, means-testing dental benefits could potentially threaten the sustainability of the broader Medicare program. Max Richtman, president and CEO of the National Committee to Preserve Social Security and Medicare, noted in a recent op-ed that “If means-testing results in Medicare becoming increasingly unfair to higher-income beneficiaries, they may opt-out and purchase their policy on the private market. The departure of higher-income beneficiaries, who tend to be younger and healthier, would weaken the risk pool, putting additional strain on Medicare’s finances.” Further, as Richtman writes, applying the first-ever means-test to a Medicare benefit would set a dangerous precedent for future means-testing of other coverages.

Moreover, applying a means test to Medicare dental benefits would likely result in a situation in which a majority of private practice dentists decline to participate. We’ve seen this happen with Medicaid and the Children’s Health Insurance Program (CHIP). By limiting the potential pool of new patients, means-testing a Medicare dental benefit would similarly and significantly reduce the financial incentive for private practice dentists. According to the ADA Health Policy Institute (HPI), only 43 percent of dentists nationwide participate in Medicaid or CHIP, dramatically limiting access to care and fueling health disparities among disadvantaged populations. A means test applied to Medicare would almost certainly compound the problem.

The Bottom Line

Dental coverage under Medicare is sorely needed, but to make Medicare dental benefits anything but universal diminishes the message that public health-minded dentists have fought so hard to advance: that oral health is overall health. It also threatens to deepen inequities and deny care to at-risk populations that need it most. Congress should act now to expand Medicare to include dental coverage and reject misguided attempts to impose means-testing on potential beneficiaries.

Dr. Zachary Brian is the Director of North Carolina Oral Health Collaborative (NCOHC) and VP of Impact, Strategy, and Programs for its parent organization, the Foundation for Health Leadership & Innovation (FHLI).


Pregnancy and Oral Health: Postpartum Care

Changes may be coming to help pregnant women in North Carolina access the care they deserve.

Have you heard of Medicaid for Pregnant Women (MPW)? For those in North Carolina with incomes up to 196 percent of the federal poverty level, people can access Medicaid services for the duration of a pregnancy through the MPW program, and they retain access to medical services for 60 days postpartum (after birth).

While the MPW program offers important services at a time when people need reliable access to care, the range of benefits and time constraints are simply not enough.

For example, oral health services unfortunately don’t extend into the postpartum period at all.

Pregnancy is a busy time for anyone. It is especially busy when you have limited access to resources—financial and otherwise. Between preparing a home for a new baby, attending pregnancy classes, going to regular checkups, and more, things like dental care can easily go by the wayside.

Just as it is during the rest of a person’s life, but especially during pregnancy, oral health care is not a luxury. It is absolutely essential.

Hormone imbalances that result from pregnancy make expecting mothers especially susceptible to tooth decay and gum disease, as does vomiting from morning sickness—stomach acid is not friendly to your mouth.

And the negative impacts of poor oral health stem beyond the parent-to-be. For example, research into the oral-systemic connection has found that gum disease is related to low birthweight in newborns.

Fortunately, there is hope for an expansion of services, allowing women to retain all MPW benefits for a full 12 months postpartum. While an extension of benefits even longer than one year would certainly be even better for new mothers—the first year after birth isn’t a particularly relaxing period of time—a 12-month expansion would mark a big step in the right direction.

Earlier in 2021, Senators Jim Burgin, Joyce Krawiec, and Kevin Corbin filed Senate Bill 530, extending MPW benefits 12 months postpartum. While that bill has stalled in committee, its contents appear to be up for negotiation in the 2021 budget.

An early version of the 2021 budget included the full 12-month postpartum MPW expansion. The most recent update cut that section of the bill, but that does not mean all hope is lost.

There are legislators in the majority party who appear to have taken on this issue, and as negotiations continue, NCOHC will keep a close eye on MPW expansion in the state budget.

Stay up-to-date by joining us as a North Carolinian for Change, and take a moment to learn more about the policy options on the horizon. One of NCOHC’s fantastic interns during the 2021 summer, Hannah Archer, wrote this policy brief outlining MPW expansion and policy implications.

NCOHC is a program of the Foundation for Health Leadership & Innovation. To get involved, find out more information, and to stay up to date, head over to NC4Change to sign up for our newsletter and see what events and other opportunities are on the horizon.


PFAS: An Oral Health Perspective

From pizza boxes to shampoo, and even some dental floss, PFAS (per-and polyfluoroalkyl substances) are everywhere. These “forever chemicals” are so widespread that it is virtually impossible to avoid exposure. While they have been commercially used since the 1940s, the scientific community is just beginning to learn about the adverse health effects that PFAS exposure can cause.

PFAS are a group of manmade chemicals widely used in a variety of industries. The story of PFAS calls to mind the history of asbestos. While we are aware of the danger that asbestos poses today, decades of prior use exposed many to adverse health effects, and its ubiquity has made removing the substance from everyday life a difficult and still incomplete, task.

In 2016, North Carolina became the center of attention after a joint study published by scientists from North Carolina State University, the University of North Carolina at Charlotte, the EPA, and other local agencies shed light on PFAS pollution in the Cape Fear River.

The Chemours Company, a spin-off of DuPont, had been releasing PFAS pollutants into the Cape Fear River for decades.

More recently, Pittsboro and other communities along the Haw River in North Carolina have been added to the high exposure list.

The most-studied PFAS chemicals, PFOA and PFOS, have been linked to low infant birth weight, immune system deficiencies, multiple forms of cancer, thyroid hormone disruption, and they can negatively impact the liver and kidneys.

To underscore just how serious and widespread PFAS contamination is, an agreement reached by the Southern Environmental Law Center and the Chemours Company in 2018 includes the “largest fine ever levied by the North Carolina Department of Environmental Quality,” $12 million on top of funding for studies regarding the health impacts of PFAS chemicals.

From an environmental health perspective, PFAS are a nightmare. They were given the name “forever chemicals” because of their durability. They are so persistent that the EPA simply states that the chemicals don’t break down in the human body or in the natural environment.

From a public health perspective, PFAS pollution also underscores the importance of integrated care, especially when managing a health crisis.

It isn’t obvious at first glance that oral health providers have any significant role to play in responding to PFAS contamination. There are no known direct oral health impacts, after all.

However, one of the recommendations for anyone living in an area impacted by PFAS pollution is to install a water filter, specifically a reverse osmosis two-stage filter. Reverse osmosis filters remove around 99 percent of PFAS chemicals, a great preventive step for anyone in an impacted area. Unfortunately, those filters also remove fluoride from drinking water.

Preventing the negative health impacts of PFAS pollution is priority number one. But down the line, it would be tragic for tooth decay and gum disease to emerge as an adverse side-effect.

From simply adding discussion of water filtration devices to dental health questionnaires, to potentially boosting supplemental fluoridation programs in areas heavily impacted by PFAS contamination, dental providers have an important role to play.

NCOHC had the pleasure of working with Dr. Kelly Bailey as she completed her public health practicum for the UNC Gillings School of Global Public Health during the summer of 2021. Dr. Bailey created this toolkit to help the dental community better understand PFAS contamination and the role that oral health providers can play in helping impacted communities remain healthy, from head to toe.

NCOHC is a program of the Foundation for Health Leadership & Innovation. To get involved, find out more information, and to stay up to date, head over to NC4Change to sign up for our newsletter and see what events and other opportunities are on the horizon.