If Congress adds dental coverage to Medicare, should all seniors get it?

By Bram Sable Smith,

Kaiser Health News

William Stork needs a tooth. That’s what the 71-year-old retired truck driver’s dentist told him during a recent check-up.

This type of extraction requires an oral surgeon, which could cost him around $1,000 because, like most seniors, Stork doesn’t have dental insurance and Medicare won’t cover his dental bills. Between Social Security and his Teamsters union pension, Stork said, he lives comfortably in Cedar Hill, Missouri, about 30 miles southwest of St. Louis. But this cost is significant enough that he decides to wait for the tooth to come out absolutely.

Stork’s predicament is at the heart of a longstanding split within the dental profession that has resurfaced as a battle over how to add dental coverage to Medicare, the public insurance program for people with 65 and older – if such a benefit can pass at all.

Health equity advocates see President Joe Biden’s Build Back Better program as a once-in-a-generation opportunity to provide dental coverage to people on Medicare, nearly half of whom didn’t see a dentist in 2018 , long before the coronavirus pandemic suspended dental appointments. for many. Rates were even higher for black (68%), Hispanic (61%) and low-income (73%) seniors.

The coverage was left out of a new framework announced by President Joe Biden on Thursday, October 28, but supporters say they still hope to secure the coverage in a final deal. Complicating their push is a debate over how many of the nation’s more than 60 million Medicare beneficiaries should receive it.

The champions for covering everyone on Medicare find themselves up against an unlikely adversary: ​​the American Dental Association, which backs an alternative plan to give dental benefits only to low-income Medicare beneficiaries.

Medicare has excluded dental coverage (as well as vision and hearing) since its inception in 1965. This exclusion was intentional: the dental profession has long fought to separate itself from the traditional medical system.

More recently, however, dentists have emphasized the link between oral health and overall health.

The 2007 death of a 12-year-old boy that could have been prevented with an $80 tooth extraction, for example, prompted changes to Maryland’s version of Medicaid, the federal state’s public insurance program. for low income people. But researchers have also linked dental care to reduced healthcare costs in patients with type 2 diabetes. When the World Health Organization suggested delaying non-emergency oral health visits last year to prevent the spread of COVID-19, the ADA pushed back.

“Oral health is an integral part of overall health,” ADA President Dr. Chad Gehani said at the time. “Dentistry is essential health care.”

The ADA-backed health insurance proposal would only cover seniors who are up to three times the poverty level. This currently translates to $38,640 per year for an individual, reducing the number of potential beneficiaries from over 60 million people to about half that number.

Medicare has never required a means test, but in a world where Congress is seeking to cut the social spending package from $3.5 trillion over 10 years to $1.85 trillion, the ADA introduced its alternative as a way to save money while covering those who need a dental benefit the most. A Congressional Budget Office analysis estimated that the plan to provide dental coverage to all Medicare beneficiaries would cost $238 billion over 10 years.

Unlike the ADA, the National Dental Association is pushing for a universal Medicare dental benefit. The group “promotes equity in oral health among people of color” and formed in 1913, in part because the ADA only eliminated discriminatory membership rules for its affiliates. in 1965. Dr. Nathan Fletcher, chairman of the board of the NDA, said he was not surprised to find his organization at odds with the ADA on this issue of Medicare coverage.

“Understand that those who make decisions for the ADA are generally those who have been practicing for 25 to 30 years, who are doing well, ready to retire,” Fletcher said, noting that ADA members are for the most older white men. They are “nothing like the (patients) we are talking about”.

Research from the ADA’s Health Policy Institute found that cost was a barrier to dental care “regardless of age, income level, or type of insurance,” but low-income seniors were more likely to report it as an obstacle.

“It would be tragic if we did nothing for these low-income seniors,” said Michael Graham, senior vice president of government and public affairs for the ADA.

Graham criticized the design of proposals to Congress for a universal Medicare dental benefit, noting that one includes a 20% co-payment for preventive services, which could prevent low-income patients from accessing the care they need. they would be expected to get.

“Something is better than nothing,” Graham said, “but the something (with a copayment) equals almost nothing to many older people.”

The ADA, Graham said, supports 100% coverage of preventive services for low-income Medicare beneficiaries.

Of course, covering only low-income seniors presents its own questions, the most important being: will dentists even accept Medicare if they don’t have to?

Low-income patients often seek care at security clinics that plan months in advance. Some dentists say they fear a Medicare benefit limited to low-income seniors will be easier to avoid, pushing even more newly insured Americans into an already overburdened dental safety net.

Less than half of dentists accept Medicaid globally, but more than 60% of NDA members do, Fletcher said. The ADA said the reimbursement rates and paperwork for a Medicare benefit could be equally unattractive.

But Fletcher, the dental director of a Medicaid insurance company in Washington, D.C., said Medicaid uptake varies widely from state to state — and uptake of any new Medicare dental programs would largely depend on part of the service design.

If reimbursement rates for a Medicare benefit are high enough, Fletcher said, providing coverage for tens of millions of seniors could be very lucrative for dentists. Ultimately, he said, dentists should have a choice whether or not to accept Medicare patients, and all Medicare patients should be eligible for dental services since they paid into the program.

Dr. Nathan Suter, William Stork’s dentist, believes that adding a dental benefit for all seniors is the right thing to do.

Suter, a self-proclaimed “proud member of the ADA”, finds himself at odds with the organization.

“As a member of the ADA, I think they should be at the table for me,” Suter said, “making sure it’s as good a benefit as possible for all of my seniors.”

But the ADA’s lobbying operation opposes congressional Democrats’ proposed plan to add dental coverage to all Medicare beneficiaries. The organization asked its members to contact their congressional representatives on the matter. More than 60,000 emails, Graham said, have been sent to Capitol Hill so far.

Suter, for his part, sees the battle over who to cover as a generational divide. As an early career dentist, he prefers to add comprehensive dental coverage now so he can adapt his business model more quickly. And the more seniors there are who benefit from dental coverage, the more its potential clientele expands. Dentists like him, who are still building their practices, are less likely to have time to be involved in the ADA’s policy-making process, he said.

Patients such as Stork, who said potential Medicare dental coverage was one of the reasons he was waiting for the extraction, even though he knows a benefit is unlikely to be implemented before years, if at all, and if it occurs, may not cover him or other middle-income seniors.

Still, he said, it would be nice to have when his tooth can’t wait to come out.

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