A Call for Adult Dental Benefits in Medicaid and Medicare

Abstract
Elderly (65 years and older) and low-income adults in the United States are often unable to afford dental care or dental insurance. While some states offer public assistance (Medicaid) dental benefits to qualifying low-income adults, many such programs provide only emergency or limited treatment. There are no Medicare dental benefits available for the elderly except in extremely limited circumstances, leaving most elderly individuals to choose among options such as costly private insurance plans, often paying out of pocket while on a limited or fixed income, or forgoing dental care altogether. The inability to obtain dental care can result in progression of dental disease, leading to a diminished quality of life owing to dental pain, infections, loss of function, and exacerbation of comorbidities affecting overall health. Including a sufficient dental benefit for elderly and low-income adults through established public option pathways can alleviate this cost and health burden for some of our most underserved and vulnerable populations.

Relationship to Existing APHA Policy Statements
Several existing APHA policy statements address oral health disparities among specific adult populations, access to other aspects of health care, and health promotion and disease prevention for aging adults. This policy statement fills a gap by describing barriers to oral health care among elderly and low-income adults, the health consequences of lack of dental care access, and the financial and health benefits for these populations if action steps are patterned after existing successful public health care programs. While a previous APHA policy statement called for state Medicaid funding for community members with intellectual and developmental disabilities, this is the first statement to address inclusion of dental benefits in state and federal health insurance/assistance programs for all individuals eligible for Medicare and Medicaid. This policy statement also is the first to address the heterogeneity among existing state dental Medicaid policies and laws.

• APHA Policy Statement 20161: Access to Integrated Medical and Oral Health Services
• APHA Policy Statement 201011: Reforming Primary Health Care: Support for the Health Care Home Model
• APHA Policy Statement 20018: Establishment of a Medicare Prescription Drug Benefit
• APHA Policy Statement 20002: Reducing the Incidence of Blindness, Lower Extremity Amputation, and Oral Health Complications in Minority Populations Due to Diabetes
• APHA Policy Statement 20109: Health Literacy: Confronting a National Public Health Problem
• APHA Policy Statement 200911: Public Health’s Critical Role in Health Reform in the United States
• APHA Policy Statement 20023: Support of Healthy Aging through Health Promotion and Prevention of Disease and Injury
• APHA Policy Statement 200117: Support the Framework for Action on Oral Health in America: A Report of the Surgeon General
• APHA Policy Statement 20064: Support for the Alaska Dental Health Aide Therapist and Other Innovative Programs

Problem Statement
Oral health is an integral part of overall health. Both elderly and low-income adult populations need preventive and restorative oral health services and therefore require oral health care coverage and access to those services. Such coverage should be made available by including or expanding dental benefits in state and federal health insurance/assistance programs for all Medicare- and Medicaid-eligible adults.

Working-age adults and the elderly have less access to dental care than any other health care service, including prescription drugs, medical care, vision care, and mental health care.[1] In 2017, 9.5% of Americans were unable to access dental care owing to cost, the highest proportions of whom were working-age adults and the elderly.[2] Only 7% of those with private health insurance were unable to access needed dental care due to cost, as compared with 18.3% of those covered by Medicaid and 27.2% of those with no insurance coverage.[2]

Among adults 19 to 64 years of age, 59.0% have private dental benefits, 7.4% have dental benefits through Medicaid, and 33.6% have no dental benefits.[3] Adults 65 years or older are the least likely of any age group to have dental benefits, with only 34% having any type of dental benefit.[3] Studies have shown that uninsured populations and Medicaid beneficiaries are the groups most likely to make dental emergency department visits.[4,5] While 50% of dentate working-age adults have private dental insurance,[6] less than 30% of seniors 65 years or older have private dental benefits.[7]

Oral health coverage and Medicaid-eligible adults: Low-income adults qualify for Medicaid, which is a joint federal-state public assistance program that is primarily state run while following federal guidance.[8] Nationally, Medicaid provides health care benefits for 20% of Americans of all ages who qualify on the basis of income.[9] While states are required to provide comprehensive dental benefits to all children enrolled in Medicaid, states determine what level (if any) of dental benefits to provide for adult Medicaid participants.[10] Not all states offer adult Medicaid dental benefits. Few states offer comprehensive adult dental care benefits, and others offer emergency-only dental benefits under specific circumstances to relieve pain.[10] In 2019, three states did not provide any dental coverage, 11 provided only emergency services such as tooth extraction, and 16 provided limited dental coverage that paid for services up to $1,000 annually.[10] Medicaid adult benefits vary within states over time,[11] adding confusion and uncertainty about dental care availability.

The prevalence of untreated dental decay among U.S. working-age adults has risen in the past 25 years.[12] Nearly one quarter of U.S. adults 20 to 64 years of age have untreated tooth decay.[13] The prevalence varies widely by race/ethnicity, with nearly 40.8% of non-Hispanic Black and 38.2% of Mexican American adults presenting with untreated tooth decay, as compared with 20.6% of non-Hispanic White adults.[13] Similarly, those who are below 200% of the federal poverty level and are less educated have a 40% or higher prevalence of untreated dental decay than their wealthier and more educated counterparts.[13] In 2013 to 2016, 47.9% of uninsured U.S. adults 35 to 44 years old had untreated dental decay, while 40.1% of Medicaid beneficiaries and 18.5% of those with private insurance in that age group had untreated decay.[14] During the same time period, 88% of 45- to 64-year-old uninsured adults reported a history of permanent tooth loss due to dental decay or periodontal disease, as opposed to only 64.6% of privately insured patients.[15] Thirty-three percent of U.S. low-income elderly adults have untreated dental decay, in comparison with only 9% of higher-income elderly adults.[13] Older racial/ethnic minority adults with Medicaid dental benefits face several barriers in accessing dental care, including difficulty affording copayments, difficulty in finding transportation to a dental office, and challenges in understanding their coverage.[16] 

Access to dental care among Medicaid-enrolled adults can be limited as a result of the types of Medicaid dental benefits offered by the state; also, it is indirectly impeded by low levels of reimbursement to dentists. With some state Medicaid adult dental plans reimbursing at less than 30% of dentists’ usual and customary fees,[17] there may be little incentive for dentists to participate, forming another barrier to low-income adults’ access to dental care. These inconsistent and fluctuating state-to-state levels of dental benefits and provider reimbursement fees can lead to further disparities in access to dental care among Medicaid recipients according to their state of residence. 

Oral health coverage and Medicare-eligible adults: Medicare is a federal health insurance program that provides health care coverage to the disabled, dialysis patients, and individuals 65 years or older.[8] Few of these Medicare beneficiaries are given dental benefits as part of basic Medicare.[8] Fifty-nine percent of adults 19 to 64 years old have employer-sponsored dental insurance benefits,[3] many of whom lose those dental benefits at retirement or when they qualify for Medicare at 65 years of age. There is only limited availability of dental benefits for a narrowly defined portion of the Medicare population; this potentially leaves the dentally uninsured elderly who live on a limited or fixed income to use their savings to finance their dental care, as only 33% of elderly adults have any form of dental benefit.[3] Nearly two thirds of Medicare beneficiaries do not have dental coverage, half have not been to a dentist in the past year, and one of five who report visiting a dentist spent more than $1,000 out of pocket.[18] While other forms of optional insurance such as Medicare Advantage plans can potentially provide a dental benefit, coverage comes at a cost, caps are sometimes in place, and not all plans offer restorative dental benefits.[18] As a result, nearly 70% of low-income and one half of middle-income elderly individuals cite cost as a reason for not visiting the dentist.[19] Only one in four low-income Medicare beneficiaries visit a dentist annually, as compared with approximately three in four high-income Medicare patients.[20] 

Forty-two percent of adult Medicare beneficiaries taking part in a 2019 study reported oral symptoms associated with severe periodontitis, tooth loss, or unaddressed caries.[21] Compounding this problem, about 80% of older adults have at least one chronic health condition, and 68% have at least two chronic conditions.[22] Many of these chronic health conditions require multiple prescription medications, which can reduce the quantity and quality of saliva and subsequently increase the risk for dental decay. Increased age and infirmity can reduce the manual dexterity needed to perform effective oral hygiene, and a lack of mobility can hamper transportation to dental offices for care.

Americans are also living longer, which can add to the financial burden of dental care. People are retaining their teeth longer[13] but are less likely to have private dental benefits as they age.[6,7] While the overall population increased by 4% between 2007 and 2017, the number of elderly in the United States grew by 34%.[23] Thirty-five million Americans are 65 years or older, and that population is expected to double by 2050, while the 85-year-old population is the fastest-growing age group in the United States.[24] Americans 65 years of age are expected to live on average nearly 20 additional years.[23] As our population and its needs evolve, our policies and provisions should evolve to accommodate those changes. 

Oral health and affordability: Cost has been reported to be the main barrier to accessing dental care in adult populations,[25] which could potentially be alleviated for the most underserved and vulnerable populations by providing dental benefits in public assistance (Medicaid) and public insurance (Medicare) programs. Financial concerns are the most frequently cited barriers to dental care among low-income working-age adults and seniors.[25] The Affordable Care Act designates pediatric dental benefits as essential health benefits, yet adult oral health care is considered optional.[26] In 2016, only 11% of total health care expenditures were paid out of pocket, as compared with 40% of dental expenditures.[27]

Lack of access to affordable dental care has driven some low-income adults and the elderly to hospital emergency departments as a last resort to relieve their dental pain and infection. Young adult women make up the largest percentage of the 2 million annual visits to emergency departments for dental treatment.[28] Medicaid and Medicare beneficiaries and the uninsured population account for nearly 80% of all dental visits to emergency departments, suggesting limited access to dental care among these groups.[29] Unfortunately, most hospital emergency departments are not equipped to provide dental treatment, resulting in palliative care through antibiotics and pain medications without the underlying dental problem being addressed. As a result, repeat patients account for nearly 40% of dentally driven emergency department visits,[28] creating a cycle of costly emergency department visits and prescriptions and possibly fueling dependency on pain medications. The direct cost of each of these palliative emergency department visits can be $1,500 or more, while definitive oral health care at a dental office could be considerably less expensive.[28] Indirect costs of dental-related emergency department visits and dental disease due to limited dental care access and coverage include a loss of productivity[30] and the burden of travel for those living significant distances from an emergency department.[31]

Additional consideration should be given to specific populations such as lesbian, bisexual, gay, and transgender people and people experiencing homelessness. These groups are more likely to be impoverished than the general U.S. population[32] and are thus less likely to have access to dental care or be able to afford out-of-pocket dental costs. In addition, there are more than 10 million Americans with disabilities who qualify for Medicaid benefits,[33] along with more than 8 million people with disabilities who are enrolled in Medicare.[34] The types of health care covered and the extent of dental benefit coverage in these public programs can have a profound effect on the quality of life and health of such populations. 

Evidence-Based Strategies to Address the Problem
Providing adult dental benefits for Medicaid and Medicare recipients could help improve access to dental care among low-income and elderly adults. Research has shown that low-income adults are more likely to visit a dentist if they have Medicaid dental benefits.[35,36] States with adult Medicaid dental benefits have been found to have 12.9% more dental visits than states without those benefits. In addition, provision of adult Medicaid dental benefits is associated with improved oral health status.[36] Adults in states with Medicaid dental coverage have been shown to have less untreated decay than those in states without the added dental benefit.[36] The addition of dental benefits may yield overall health care savings.[37,38]

Research has shown negative economic and health effects of discontinuing adult Medicaid dental benefits. There was a 2% increase in dental-related emergency department visits during the first year after Massachusetts discontinued offering adult Medicaid dental benefits, along with a 14% increase the following year.[39] Adults 55 years or older and minorities in that Medicaid-enrolled population showed the greatest increase in dental-related emergency department visits of any age group,[39] underscoring the potential impact of dental benefits on access to care among vulnerable populations. California saw a more dramatic 32% increase in dental-related emergency department visits after discontinuing Medicaid dental benefits.[40] Currently, only 19 states provide comprehensive dental benefits for their adult Medicaid population, while 16 states provide limited dental benefits[10]; as a result, many low-income adults and seniors in the United States face barriers to accessing dental care and a reduced likelihood of achieving good oral health.  

Medicare recipients at all income levels who have dental insurance are nearly twice as likely as beneficiaries without dental insurance to have an annual dental visit.[20] Only 27% of low-income Medicare beneficiaries lacking dental insurance have an annual dental visit, as compared with 65% of low-income Medicare beneficiaries who have dental insurance.[20] Having dental insurance coverage has been associated with an increase in dental spending relative to lacking coverage, indicating increased access to dental care and the value of dental benefits to elderly adults.[20] Multiple studies have analyzed the feasibility of incorporating dental benefits into Medicare, demonstrating that doing so could improve access to dental care among elderly adults.[18,20,41,42] Research has shown that adults who cannot afford dental care have a high prevalence of dental problems, which can increase disability-adjusted life-years.[21] Providing affordable dental care may improve quality of life among adults and may be a good societal investment.[43]

In addition to providing coverage, competitive reimbursement to Medicaid and Medicare dental providers can help ensure availability of an adequate workforce to meet the demand for care. Low reimbursement for Medicaid dental care has been cited in the past by dentists as a barrier to participation in public programs.[44] Some states found an increase in children’s dental care utilization when Medicaid dental care reimbursement was increased to make it more competitive with private insurance reimbursement, which suggests a similar approach is indicated for adult services.[45,46]  

Opposing Arguments/Evidence
One challenge related to including adult dental benefits in Medicaid and Medicare is ensuring that the dental workforce can accommodate the increased volume of patients.[36] One study showed that the supply of dentists per capita is expected to grow through 2037.[47] In addition, alternative dental workforce models such as advanced practice dental hygienists, dental therapists, and community dental health coordinators are increasingly being used in a number of states to increase access to dental care. In 2019, 42 states allowed dental hygienists to practice in community settings without a dentist on-site, up from 28 states in 2008, thereby increasing the potential for dental workforces in traditionally underserved locations.[48] Teledentistry can also offer access to dental care in rural areas, physically distanced locations, or other situations in which Medicaid and Medicare recipients are unable to physically attend a dental office to access care for consultations and referrals.[49]

Another concern is that there could be a rise in Medicaid and Medicare dental spending due to increased utilization of dental benefits.[36] While this is to be expected to an extent, one large-scale study showed that insurance participants who used oral health benefits had lower net medical costs than participants who received no dental care.[50] While each of these two groups showed medical savings, medically noncompliant patients who received dental care had higher medical cost savings than medically compliant patients.[50] Reduced medical costs among patients with conditions such as diabetes and cardiovascular disease relative to costs among control patients also have been reported following periodontal therapy.[37] Irrespective of medical cost savings, statistical modeling has estimated that providing dental benefits for Medicaid and Medicare patients potentially could save $520 million in Medicaid funds by avoiding dental emergency department visits.[51] These and other potential savings could largely offset costs of adding Medicaid and Medicare dental benefits. 

Concerns about costs can also be considered from a social justice perspective. Oral health has been recognized worldwide as a basic human right.[52,53] When balancing costs with fulfilling human rights within an environment of scarce resources, giving priority to those who are worse off relative to others can help reduce health disparities.[54] Providing dental benefits to Medicaid- and Medicare-eligible beneficiaries can help reduce health disparities and align policies with the human rights perspective. 

Alternative Strategies
No alternative strategies are being offered. This call is for a specific action for which we do not see a more reasonable and affordable alternative.

Action Steps
APHA recommends the following action steps:

1. Congress should remove the exclusion of dental benefits from Medicare.
2. The federal government should mandate comprehensive dental benefits for Medicare beneficiaries.
3. The federal government should amend the Affordable Care Act to include dental care for adults as an essential health benefit.
4. The federal government should ensure that the oral health research agenda is expanded and adequately supported to evaluate cost-effective access to dental care solutions for evolving subpopulations.
5. The federal government should support and expand national oral health surveillance to enable identification of health disparities and evolving oral health problems.
6. State government agencies should provide comprehensive dental benefits for Medicaid-enrolled adults.
7. State government agencies should provide adequate Medicaid dental reimbursement rates to ensure widespread provider participation.
8. State government agencies should allow and expand diverse and alternative dental workforce provider models to meet the oral health care needs of low-income and elderly adults. 
9. Non-governmental entities and other stakeholders should advocate for, support, and sustain efforts toward including adult dental benefits in Medicaid and Medicare.

References
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