One More Look at Medicare and Why a Dental Benefit Is Still Needed for All

Elisa M. Chávez, DDS

ABSTRACT

Medicare was originally envisioned to include oral health care. But the opposition to its inclusion prevailed, and nearly 60 years since its enactment, older Americans struggle to afford needed dental care. An opportunity came and went to include provisions for oral health care in Medicare with the Affordable Care Act and most recently in the Build Back Better Act. The need and benefit of regular oral health care for older adults has been demonstrated time and again. There has been strong support from advocates for older adults and their families, including many medical and dental professional groups and patients themselves. Yet, there was not enough support to surmount resistance to the financial, social and professional investment that is required to get older and disabled Americans the resources they need to improve their access to care and maintain good oral health. And so there remains a known gap in our health care system that will continue to present a barrier to achieving the best outcomes for patients in both dentistry and medicine.

Keywords: Aging, dentistry, oral health, health policy, disparities, Medicare, vulnerable patients

The concept of integrating medical and dental care in America is not novel. In 1932, the inclusion of dental care as part of a comprehensive health plan was considered by then Secretary of the Interior Ray L. Wilbur, MD. 1 President Harry Truman sought a national health plan in 1945 that would provide for routine health care such as doctor and hospital visits, laboratory services, nursing and even dental care. Then in the early 1960s, President John F. Kennedy called for a health program specifically to support seniors after a study revealed more than half were without health insurance at the time. [2] This is interesting in light of 2016 data showing 62.7% of adults aged 65 and older lacked dental insurance. 3 In 1965 under President Lyndon B. Johnson, Medicare was enacted, but without dental benefits. Both the American Medical Association (AMA) and the American Dental Association (ADA) were opposed to Medicare. The ADA prevailed, and ultimately oral health care was left out of Medicare. [4] In 1966, some 19 million older adults signed up for Medicare in the first year. In 1972, Medicare was extended to individuals under age 65 if they had a long-term disability or end-stage renal disease. The 1980s saw expansion in home health and hospice care benefits. Medicare Part C or Medicare Advantage (MA) plans introduced in the 90s offered addon benefit coverage through a managed care program, rather than the traditional Medicare fee for service. Now about 42% of all Medicare enrollees are in an MA plan. These MA plans take the place of both Part A and Part B for people who choose to enroll. In 2003, Medicare Part D was added as an option to purchase in addition to Medicare or integrated with an MA plan to help cover prescription drug costs. Prior to this time, only about a quarter of older American’s had insurance to cover drug costs. By 2019, nearly threequarters of enrollees had a drug benefit and about 90% of MA plans included Part D. [2] The Patient Protection and Affordable Care Act of 2010 implemented many reforms in Medicare aimed at reducing costs and improving outcomes, but provisions for dental care for older adults were not among these reforms. [2,5,6]

What Medicare Covers and How

Medicare is primarily funded by federal dollars and is available to all Americans age 65 and older and some adults younger than 65 who are disabled. There are 6.4 million enrollees in California, the most of any state. Medicare is administered on a federal level and income is not a consideration for enrollment. Medicaid uses means testing to determine eligibility and is funded by federal and state funds but is administered by each state. As such, states can determine if or what benefits they will provide as well as reimbursement structures and rates. Rates for Medicare tend to be higher than rates for Medicaid, and there is a higher physician enrollment as a result. 7 While some states provide adult dental benefits in Medicaid, these benefits are not guaranteed and are not a reliable source of oral health care coverage for older adults. California is one of only 19 states that provide extensive dental coverage for adults who qualify for Medicaid, but these benefits are also vulnerable each year as the annual state budget is established. [8]

Medicare is paid for through two trust fund accounts held by the U.S. Treasury. These funds can only be used for Medicare. [9]

■ Part A is funded by the Social Security’s Federal Hospital Insurance (HI) Trust Fund and helps cover inpatient hospital stays, stays in skilled nursing facilities, hospice and home health care as well as program administration costs. Part A is funded by payroll taxes, income taxes paid on Social Security benefits and interest earned on the trust fund investments, so enrollees do not pay a premium for this coverage. Medicare spending projections fluctuate with time. It has been projected that the Medicare Part A trust fund asset level was expected to be depleted by 2026 and that future claims would have to be covered predominantly by payroll taxes, which may be inadequate. [9,10]

■ Part B is funded by the Supplementary Medical Insurance (SMI) Trust Fund. These funds come from general revenue authorized by Congress and enrollee monthly premiums. Part B helps cover the costs for outpatient care, including some preventive services and tests, physician’s services, medical equipment, clinical laboratory services and some other services for all enrollees. Medicare beneficiaries pay a Part B premium to the Social Security Administration. Although Part B services are the same for all beneficiaries regardless of income, low-income beneficiaries who qualify for Medicaid receive subsidies for Part B at no extra cost ($0 premium). For most services, Medicare pays 80% of the cost (using an established fee schedule) and patients have a 20% copay. There are no limits on outof-pocket payments for enrollees. 8 However, enrollees can purchase supplemental health insurance (Medigap) to traditional Part A and Part B to help reduce the out-ofpocket costs for copays, coinsurance and previously for deductibles. These Medigap plans are different from MA plans and they are not available for persons with MA plans, only traditional Medicare. For persons who qualify for Medicaid, Medicaid covers those gaps in traditional Medicare coverage. States can use Medicaid funds to cover Medicare premiums and cost sharing for beneficiaries whose income is ≤ 100% of the federal poverty level (FPL). Some states have expanded Medicaid eligibility to include individuals and families up to 138% of the FPL. The FPL in 2020 was an annual income of $12,880 for one person and $17,420 for a family of two. In 2019, ~12% of Medicare beneficiaries were at 100% or below the FPL and another ~20% were below 200%. 11 The average out-of-pocket costs in 2016 were $5,806 for supplemental insurance and uncovered medical and long-term care costs, but they could be much higher for persons without this Medigap insurance. [10]

■ Part C allows Medicare recipients to select to receive their Part A and Part B covered services via a managed health care plan (known as Medicare Advantage) rather than accessing them through the traditional fee-for-service providers who participate in Medicare.

o MA enrollees usually pay the Part B premium in addition to their MA premium.

o MA plans must provide at a minimum the same benefits provided under traditional Medicare, but they can offer additional coverage at additional cost. The plans may charge beneficiaries a premium in addition to their Part B premium and can establish different copay arrangements with patients. They may offer extra coverage above what is required under Part A and Part B such as prescription drug coverage, dental, vision, hearing and wellness programs, but they are not required to provide a specific package of benefits beyond what is currently provided through traditional Medicare. Federal regulation requires MA plans to establish a limit on out-of-pocket spending for beneficiaries. In 2021, this limit was $7,550 for in-network care and $11,300 for out-of-network care. This out-of-pocket limit does not exist in traditional Medicare and thus the availability of Medigap (supplemental plans) to traditional Medicare. These limits do not apply to Part D, which is discussed below. [11]

o While dental plans are now widely available in MA plans, they also vary widely. In 2020, ~74% of MA enrollees paid for a dental plan, some of which included only preventive care. Every MA plan can establish its own set of benefits and rates and most plans mirror traditional dental plans, including an annual dollar cap on the benefit. If a dental benefit were provided in Part B, MA plans would need to include at least the same benefit for anyone who chooses an MA plan. [10]

Plans must provide at a minimum the same benefits provided under traditional Medicare.

■ Part D is also funded by SMI and provides prescription drug coverage to both traditional and MA enrollees who wish to enroll. Part D is offered by distinct Medicare Prescription Drug Plans or MA plans, each of which establishes their own drug formulary and enrollees’ cost-sharing like premiums and deductibles, but they must provide at least a standard benefit that is established by Medicare. 10 States must use Medicaid funds to cover Medicare Part A and Part B premiums and cost sharing for beneficiaries whose income is at or below 100% of the FPL.

Dental Benefits in Medicare Now [12]

The exclusion of dental care in Medicare is specified in Section 1862 (a)(12) of the Social Security Act: “where such expenses are for services in connection with the care, treatment, filling, removal or replacement of teeth or structures directly supporting teeth, except that payment may be made under part A in the case of inpatient hospital services in connection with the provision of such dental services if the individual, because of his underlying medical condition and clinical status or because of the severity of the dental procedure, requires hospitalization in connection with the provision of such services.” This provides only for the cost of the hospital services, not the providers or any dental procedures that are provided in the hospital.

The Centers for Medicare & Medicaid Services (CMS) acknowledges that the exclusion is not based on value nor necessity of the care but is limited by the structures, in this case: “Structures directly supporting the teeth means the periodontium, which includes the gingivae, periodontal membrane, cementum of the teeth and the alveolar bone (i.e., alveolar process and tooth sockets).” Even in cases where another procedure is covered, such as surgery to excise a tumor, any subsequent dental care, such as replacement of dentition that was removed at the same time the tumor was removed, is not covered. There are two exceptions to the dental exclusions:

■ The extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease.

■ An oral or dental examination performed on an inpatient basis as part of comprehensive workup prior to renal transplant surgery or performed in a rural health center (RHC) or federally qualified health center (FQHC) prior to a heart valve replacement. Note that this refers to just the examination, not the subsequent dental treatment.

MA plans currently serve about 45% of Medicare beneficiaries in California and about 39% nationally. 14 These plans voluntarily offer dental benefits to attract patients to their plans and there are no requirements for what these plans must provide. 13,14 Benefits provided through Part B in the fee-forservice traditional Medicare program would establish a minimum level of coverage that MA programs must include in their policies. 13 If dental benefits were added to Part B, MA plans could provide more extensive coverage at an additional cost for persons who want more coverage, but they could not provide less than Part B, which would establish it as a basic benefit for all enrollees.

The Legislative Road So Far

There has been much discussion and anticipation of a dental benefit in Medicare in recent years and months. Even before the pandemic, recognition was growing about the disparities in oral health care for older adults as a group with additional disparities related to race, ethnicity, income and disability. 14 Approximately half of Medicare enrollees did not have a dental visit prior to the pandemic — often skipping care due to cost. 15 And disparities exist along racial and ethnic lines as well; 68% of Black beneficiaries and 61% of Hispanic beneficiaries did not have a dental visit in 2018. 15 Individuals with disabilities experience an additional level of risk for oral disease and difficulty accessing care. Fourteen percent of enrollees are under age 65 with a disability that qualifies them to receive Medicare. 11 A third of all enrollees require help with one or more activities of daily living such as eating, bathing, dressing, walking, doing chores or managing their money or medications. Three percent require assistance to the extent that they are in long-term care. And 12% of enrollees are age 85 and older, a population that continues to grow rapidly. Approximately two-thirds of all enrollees live with two or more chronic conditions such as diabetes and cardiovascular and pulmonary diseases, all of which have been associated with poor oral health 15 (FIGURE 1). Persistent and chronic poor oral health poses a risk to overall health and well-being. 16–19 And further, the conditions themselves and the medications used to manage diseases such as these that are common in older adults also place oral health at risk, becoming a circular issue. In the absence of regular preventive oral health care, dentition and oral health can break down with both chronic and acute consequences. [20]

Since 2015, 26 legislative bills were drafted with the aim of including a dental benefit in Medicare. Some of the most recent and most widely known bills are H.R.3, the Elijah E. Cummings Lower Drug Costs Now Act, and H.R.5376, the Build Back Better Act of 2021. The Build Back Better plan called for dental, vision and hearing coverage to be added to Medicare at an estimated cost of $238 billion over 10 years to include preventive and screening services such as oral exams, cleanings and X-rays, major treatments such as crowns and root canals and dentures. The savings from the other provision of this bill to reduce the cost of prescription medications were projected to pay for the cost of these added benefits, along with patient premiums and co-pays. 21 The plan would provide coverage to all enrollees through Part B — alongside other outpatient health care services such as primary and specialty physicians, physician assistants, nurse practitioners, chiropractors, clinical social workers, physical therapists, occupational therapists, speech language pathologists, clinical psychologists and others. [13,22]

As noted by a letter to legislators from the Medicare Oral Health Coalition (established through advocacy efforts of Families USA), this legislation to include dental care in Medicare had the support of many diverse organizations including formal coalition member groups and others such as dental professional organizations, advocacy groups for older adults, consumer groups, social service and social justice groups and older adults themselves. (Letter: Medicare Oral Health Coalition, September 2021.) Some groups that signed support were American Association of Retired Persons, American Association for Dental, Oral and Craniofacial Research, American Association of Public Health Dentistry, American Board of Dental Public Health, American Dental Hygienists’ Association, American Geriatrics Society, American Heart Association, American Medical Student Association, Association of State and Territory Dental Directors (ASTDD), CareQuest Institute for Oral Health, Center for Medicare Advocacy, Families USA, Justice in Aging, National Association of Chronic Disease Directors, National Council on Aging, National Dental Association, National Interprofessional Initiative on Oral Health, National Kidney Foundation and many other national, state and grassroots groups. They were among many supporters and an estimated 9 in 10 voters who support a Part B dental benefit to be included with the rest of their health care benefits. These groups collectively advocated for full coverage of preventive benefits and 20% copay and 80% coverage for more complex services, except for those in poverty whose copays would be covered by Medicaid.

Opposition to a Benefit in Part B

There were also several groups and individuals opposed to adding a Medicare dental benefit to Part B for a variety of political, financial, ideological and professional reasons. Just as in 1965, the ADA was an important and ardent voice in opposition to the proposed Part B benefit for all enrollees in 2021. The leadership also voiced its position in a letter to legislators that included concurrence from the Academy of General Dentistry, American Academy of Oral and Maxillofacial Pathology, American Academy of Oral and Maxillofacial Radiology, American Academy of Periodontology, American Association for Women Dentists, American Association of Endodontists, American Association of Oral and Maxillofacial Surgeons (AAOMS), American Dental Education Association (has since clarified their position in support of a Part B benefit), American Student Dental Association and Society of American Indian Dentists. (Letter Sept. 1, 2021.) This was followed by a letter in which most of the state dental associations, though notably not the California Dental Association, also expressed agreement with the ADA’s position and suggested that most dentists would be unlikely to enroll as providers. The concerns expressed included the potential for low reimbursement rates that would not adequately address the high overhead costs of dental practice, deterirng dentists from enrolling and resulting in inadequate access to care, such as occurs in many state Medicaid programs that provide dental benefits. Further, there was concern that there would be an “undue burden on dentists” to meet the administrative, regulatory and compliance issues that would be required by Medicare in order to participate as part of a national system of care and that most dentists are not currently prepared to meet the requirements.

In response to these concerns, the ADA proposed a dental benefit outside of Part B — “Part T” — and also proposed restricting coverage to persons who live below 300% of the FPL ($38,640 for one person). (Letter Sept. 9, 2021, Klemmedson and O’Loughlin.) Using income to determine benefit qualification, which is known as means testing, as proposed by the ADA, is how Medicare is structured. However, benefits in Medicare are not determined or restricted based on income status; everyone who receives Medicare is eligible for the same set of benefits. Where the Medicare Part B framework does consider income is to determine premiums; some people pay no premiums and people who earn more pay a higher Part B premium. 14

Some concerns that have been expressed about the ADA proposal include: A new administrative structure would need to be created within Medicare, possibly extending the time to implementation in addition to additional cost to administer the program; a new Part T with new rules could potentially cause confusion among beneficiaries who are already accustomed to managing Part B; a benefit outside Part B could perpetuate coverage gaps, much like occurred with Medicare Part D for prescription drugs; a Part T would not result in establishing any minimum of required benefits that are available through MA plans for an additional cost to older adults; and if dental care is not included along with all other outpatient medical services for all Medicare enrollees, it reinforces the perception that oral health care is not as important as other health care services that are provided for older and disabled adults through Medicare. 13

While persons with higher incomes may have certain advantages in access to care, it is important to remember that Medicare was enacted to protect older adults and adults who are disabled by making sure they have adequate resources to meet their health care needs. Financial resources do not prevent neglect and financial abuse by individuals caring for them. 24 In the absence of guaranteed benefits through Medicare, older adults who become cognitively or physically disabled and rely on others to help them access appropriate care may be denied even basic medical and dental care as well as necessary care. Caregivers could be seeking to preserve financial resources that would otherwise be available for their own expenses or passed on to them after the death of the individual, or they could deplete the resources that the dependent adult might have otherwise used for health care. 25 Some basic level of guaranteed dental benefits for all Medicare enrollees is an important safeguard for older Americans who are most at risk.

Some stakeholders have also expressed concerns that reimbursements will be inadequate or will be set and controlled by physicians rather than dentists. Part B already includes fee-setting schedules to accommodate a wide range of outpatient services and could presumably accommodate a distinct and separate process for dentistry, setting adequate reimbursement levels based on dentists’ input. 26 Adequate reimbursement will be needed for a large proportion of dentists to accept Medicare and for patients to receive the care they need. If dentists don’t enroll, then access will not have been improved. Therefore, the profession must be engaged and included to ensure that appropriate rates are established to encourage dentist participation and good experiences for both providers and patients.

In 2019, CDA formed a Medicare task force, of which I am a member, to examine these issues and concerns and develop educational resources for its members as well as prepare the organization to respond should congress become active on this issue. The task force acknowledged that adequate reimbursement will be needed for a large proportion of dentists to accept Medicare and for patients to receive the care they need, noting that if dentists don’t enroll, then access will not have been improved. The task force concluded that the profession must be engaged and included to ensure that appropriate rates are established to encourage dentist participation and that the program is designed so it works well for both patients and providers. 21

Some basic level of guaranteed dental benefits for all Medicare enrollees is an important safeguard for older Americans who are most at risk.

Some dental providers, such as oral and maxillofacial surgeons, are already enrolled as Medicare providers. The ADA and the AAOMS have recently expressed concern not for the reimbursement amounts but that claims for biopsies required for diagnosis in the oral region may have been denied altogether on the basis of the pre-existing exclusion for dental care. (Letter Sept. 21, 2021, Klemmedson and Tiner.) The removal of the express exclusion of dental care in Medicare Part B could immediately resolve the potential for issues such as these for those who are already Medicare providers and open the door for other general and specialty providers to provide and be reimbursed for similar procedures, improving access to care and early diagnosis of diseases and conditions that can range from issues related to quality of life to those that are life threatening. 14

The Argument for a Benefit in Part B

As noted above, the addition of a dental benefit is highly popular among older Americans themselves and organizations who advocate on behalf of older adults, adults with disabilities and their families. Grassroots and professional organizations have been vocal and persistent supporters of a robust dental benefit in Medicare Part B since the first bills to include a benefit were drafted. These groups support the elements contained in the legislative framework that was under consideration in the Build Back Better bill. AARP’s letter supporting a Part B dental benefit stated that Medicare Advantage dental coverage is “inconsistent, and not nearly robust enough,” adding that, “Medicare should cover the entire person — from head to toe … People want these services and are often surprised when they learn Medicare does not cover them.” 23 A universal dental benefit would cross all socioeconomic, racial and ethnic lines and immediately create the potential to reduce the disparities in care that became so apparent during COVID-19. These disparities have been repeatedly demonstrated in regard to oral health and access to care for older adults in particular during the pandemic but also pre-pandemic. 14 This broad-based advocacy set the table for oral health care to be included in Medicare.

Older adults have at once diverse and distinctive oral health needs that must be addressed in health care. Even before there is a benefit, there has already been much speculation that the coverage would be inadequate and that persons who most need care won’t be served. But individuals who need care are not getting it now; coverage as it currently stands in Medicare and options for coverage outside of Medicare are inadequate to meet even the basic oral health needs of most older adults who rely on Medicare. 14 Not only are they lacking financial resources, but they are also lacking important cues about the importance of oral health care as a component of successful aging. Other health care providers may not consider the importance of oral health care if they are not prompted to make a referral as part a comprehensive health program. Patients who get referrals can’t follow up if they don’t have the financial means. They are missing one more opportunity for an encounter with another health professional who can reinforce healthy habits that preserve oral health as well as general health. Common risk factors in areas such as nutrition, preventive behaviors and self-care are relevant to both oral and systemic chronic diseases. One more touchpoint in the system through dentistry can mean improved access to vaccinations and reminders to see health care providers for routine examination and diagnostic procedures. Medicare enrollees are missing opportunities to receive treatment for diseases — oral and systemic — at early stages, because they are missing out on basic and routine preventive and restorative oral health care that is currently disjointed from the rest of primary care. 27

A dental benefit in Medicare that is accessible to all and stands alongside other preventive care provided through Medicare is an important step toward increasing public awareness of the importance of oral health, addressing the oral health needs of older adults and deconstructing long-held ageist views that associate deteriorating oral health as inevitable in old age. While persons with higher incomes tend to have better health literacy, that is still not a guarantee that their oral health literacy is adequate and that they understand the full value of oral health as a part of health and wellbeing. By failing to include a universal dental benefit in Medicare, not only are opportunities for direct care lost, but also opportunities to signal and reinforce the importance of oral health care. A dental benefit in Part B would raise oral health care to the same level of importance as the other health needs that are included. Inclusion of a meaningful benefit available to all enrollees would also create an opportunity for oral health measures to be included in a national health care system and develop best practices that advance both dentistry and medicine. 27

Who Is in Need and What Kind of Care Is Needed

A dental benefit package must meet the unique oral health needs of older adults. From individuals with good oral health and low risk to others with extreme risk of oral disease and poor oral health, appropriate preventive and restorative care can reduce inflammation, treat disease, stabilize oral health, restore basic function or maybe save a life. 20,27 FIGURE 2 represents just a few scenarios in which health and oral health collide in older adults in a way that can be disfiguring, debilitating and disheartening for the millions without resources and access to appropriate dental care.

These are common scenarios that describe the people who lack adequate resources and access to oral health care. This is the kind of care that is needed and the conditions that will go untreated because they are expressly excluded from Medicare benefits. Left untreated, an eminent decline in oral health looms along with a broad range of implications for the health and well-being of such individuals. 20,27

The Road Ahead

Since 2015, seven bills have been put forth in the Senate and 19 in the House aimed at adding a dental benefit in Medicare. In this moment, it is difficult to know if this represents inevitability or futility. Now it appears this effort is on a path toward nothing as an element of the Build Back Better Act, except for some provisions for oral health literacy initiatives as the proverbial and nominal nod to the importance of oral health. A national oral health literacy campaign is important, but it cannot take the place of direct care for persons who have been without and are in need or at risk. Much can and should be done at home and in the community to preserve oral health, but this is not enough to ensure that older Americans can age successfully, with grace and dignity, and to mitigate the impact of such widespread neglect on public health.

As a profession, dentistry has long espoused that oral health is integral to general health and more recently hailed oral health care as essential care. Yet, nearly 60 years after the advent of Medicare, dentistry has not collectively and definitively said “yes, oral health is important enough that every older adult should receive oral health benefits through Medicare.” The failure to say these words and to agree on this point — as the primary advocates for oral health and oral health care — must have some impact on what the public and legislators think is important and how they will ultimately advocate and legislate. Dentistry can’t continue to have it both ways when 64 million older and disabled Americans are lucky to have it any way at all when it comes to oral health care. Numerous studies have shown that for older adults in particular, oral health is inextricably linked to systemic health. 28 Yet once again we are poised to wait for the next opportunity, for the next fiscal projection and proposal, for the social, political and professional will to remedy the nextto-nothing in essential oral health care coverage that exists now for older adults. Whether we view Medicare favorably or unfavorably, as individuals, as professionals or as organizations, Medicare has made a positive difference to older Americans for decades, across the country and across class, race, ethnicity and gender. Yet in this moment, the failure to realize a dental benefit in Medicare remains a missed and elusive opportunity for the profession to join the rest of health care and lend our expertise from the inside, rather than from the sidelines, in an integrated effort toward successful aging for older Americans.

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THE AUTHOR, Elisa M. Chávez, DDS, can be reached at echavez@pacific.edu.