NEW YORK, U.S.: A proposal to expand Medicare could have provided millions of older Americans with free access to dental treatment, had President Joe Biden’s “Build Back Better” budget reconciliation bill not been watered down before being submitted to the House. Proposed changes to the insurance scheme included the provision of dental, vision and hearing benefits and had been dubbed a once-in-a-generation opportunity by health equity advocates. The American Dental Association (ADA) lobbied against including a dental benefit in Medicare and instead says it supports an income-tested dental benefit for seniors.
Medicare was established in 1965 as the U.S. Government’s insurance scheme for adults aged 65 years and over and people with certain disabilities from all age groups. Writing in the New England Journal of Medicine in October, Boston researchers pointed out that, whereas edentulism was expected by older adults in the mid-1960s as a consequence of age, it was nowadays a consequence of structural injustice. According to the Kaiser Family Foundation, 24 million Medicare beneficiaries (close to half of all those ensured through the scheme) did not have dental coverage in 2019. Around 47% of all Medicare beneficiaries had not visited a dentist within the past year, and this percentage was higher among those who were black (68%), Hispanic (61%) or had low incomes (73%).
The proposed expansion of Medicare would have provided beneficiaries with coverage of routine preventive care, such as cleanings and radiographs, and restorative services, such as fillings and crowns—similar to dental care that is provided to employees through employer-affiliated insurance programs. But not all Americans agreed with the proposed changes, and the House of Representatives on Nov. 5 approved a pared back version of Biden’s infrastructure bill that effectively shelved any major changes to Medicare.
“Older adults often face a reduction in their incomes upon retirement, making the cost of dental care even more out of reach”
– Dr. Richard Valachovic, NYU
Dr. Richard Valachovic, clinical professor at the New York University (NYU) College of Dentistry, said in an interview published by NYU that extending dental coverage to Medicare beneficiaries could improve systemic health in the U.S., but that some dentists and health organizations opposed it. “The majority of dental care in the United States is provided in small private practices, often with just one or two dentists. The financial model for the success of these practices is challenging given the costs of the facility, dental staff, equipment, and supplies. Like other small business owners, dentists are concerned about the sustainability of their operation when faced with proposals that are not yet well-defined, such as a dental Medicare benefit, which will impact that business model,” Dr. Valachovic commented.
A 2019 poll conducted by Families USA and YouGov found that 70% of likely voters supported the addition of oral health coverage to Medicare and that majority support for the proposal transcended political affiliations and demographic markers such as age, race, gender and religion. An earlier poll, conducted in 2018 by Oral Health America with support from the ADA, found that 71.2% of dentists agreed that Medicare should include comprehensive dental coverage.
The White House stripped Medicare dental benefits from the infrastructure bill on Oct. 28, but proponents of the changes had hoped that they would be reincluded at a later date. The ADA said in a press release on Oct. 29 that it had told U.S. dentists that it would “continue to lobby against the inclusion of a Medicare Part B dental benefit and for ADA policy that seeks to provide oral health care for poor and low-income seniors.” It explained that it had for months urged lawmakers not to include a Medicare dental benefit in the spending package, owing to the fact that it would not benefit low-income seniors who most require dental care.
The ADA outlined its opposition to the changes in August, stating that changes to Medicare should be income tested. It said that any expansion of Medicare should “include a range of services necessary to achieve and maintain oral health for beneficiaries whose income is up to 300% of the federal poverty level (FPL)” and be “sufficiently funded and efficiently administered to ensure access to care.”
The association said that it is estimated that “meeting the needs of beneficiaries up to 300% of the FPL covers about 47% of the older adult population. This would provide meaningful coverage to most seniors who presently do not visit a dentist because they cannot afford it.”
The need for dental care among older US adults will increase
Dr. Valachovic said that cost is the major barrier that prevents people from visiting dental clinics and that increasing accessibility to dental care for older adults and people with disabilities “has the potential to improve our country’s overall health, given the well-documented connection between oral health and the health of the rest of the body.”
He said that many older U.S. adults had not had access to water fluoridation earlier in life and, as a result, often experienced chronic dental conditions, or they had undergone dental procedures in the past that now needed replacement or restoration. Older adults, he added, are one of the most challenging groups to get into the dental chair. “This is complicated by a couple of additional concerns,” Dr. Valachovic explained. “Older adults often face a reduction in their incomes upon retirement, making the cost of dental care even more out of reach. Others are surprised to learn that Medicare does not cover dental care after having had access to dental benefits through their employers during their careers.”
The Congressional Budget Office had estimated that the cost of the proposed changes to Medicare over a ten-year period would be around $358 billion—just a few billion U.S. dollars shy of the nominal gross domestic product of the Philippines in 2020, according to World Bank data.
According to NYU researchers, changing U.S. demographics will only increase the need for dental care among older adults. By 2030, close to 80 million Americans (20% of the adult population) will be aged 65 years or older and will retain more teeth and require more intensive dental care, according to a scoping review conducted by NYU researchers earlier this year.
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