Caring for older Americans’ teeth and gums is essential but Medicare generally doesn’t cover it

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Author: Frank Scannapico, University at Buffalo and Ella Langster, Stony Brook University (State University of New York)

C. Everett Koop, an avuncular doctor with a shaggy white beard who served as U.S. Surgeon General during the Reagan administration, was known for his work as an innovative pediatric surgeon. Known for his work and attention to the HIV/AIDS crisis.

As a dental scholar, we believe Koop deserves praise in other ways as well. In an effort to bring more attention to the importance of healthy teeth and gums in the medical community, he often said, “Without good oral health, you cannot be healthy.”

Yet more than three decades after Koop's tenure as Surgeon General ended in 1989, millions of Americans lacked access to even the most basic dental services, such as exams, cleanings and fillings.

With some rare exceptions, Americans who rely on traditional Medicare plans for their health insurance get no help from the plan when it comes to paying their dental bills. This group includes about 24 million people over age 65—about half of all people who rely on Medicare for health insurance.

“Medically Necessary” Exception

When the Medicare program was established in 1965, nearly all dental services were excluded due to high costs and strong opposition from associations representing dentists concerned about significantly lower reimbursement rates compared with traditional insurance plans or out-of-pocket costs.

However, interest in including dental benefits in Medicare is rising from the Centers for Medicare and Medicaid Services, the federal agency responsible for the Medicare program, and from many organizations that seek to provide dental benefits to all members of society.

The Biden administration initially considered comprehensive Medicare dental coverage as part of its proposed “Build Back Better” legislation, a sweeping $1.8 trillion legislative package that would address issues from child care costs to climate change. , but failed to gain sufficient support in Congress.

Dental coverage was eliminated in the version of the bill passed by the House in 2021, in part due to cost concerns and resistance from organized dentistry because of lower medical reimbursement rates for patients with Medicare benefits.

In 2022, the federal government increased coverage for dental treatments designated as “medically necessary” for Medicare patients after the Senate blocked a broader package.

There are few circumstances that would cause a patient to qualify. Some examples include patients scheduled for organ transplants or patients undergoing cancer treatment who require radiation therapy to their jaws.

But we believe dental care is necessary for everyone, especially seniors.

chew, talk, breathe

While many working-class Americans receive limited dental coverage through their employer, these benefits are typically limited to $1,000 per year. Once they retire, Americans almost always lose basic coverage.

Given the importance of oral health to your overall health and quality of life, and the growing scientific understanding of the role of poor oral health in many chronic diseases, we believe that health insurance should cover basic dental services.

A healthy mouth is essential for chewing, speaking and breathing. Being able to smile brightly can boost self-esteem and help maintain a sense of well-being.

If left untreated, dental disease often leads to infection, which can cause severe pain. Poor oral health can lead to hospitalization and even death. Yet many Americans often lack access to routine oral care.

Wealthier Americans with health insurance are almost three times more likely to receive dental care than low-income people. Nearly three-quarters of low-income people over 65 would not visit a dentist in a typical year.

associated with many serious conditions

Many epidemiological studies have linked atherosclerosis (a serious disease commonly known as clogged arteries), cardiovascular disease and stroke to periodontal disease (chronic inflammation of the bone and gum tissue that supports teeth).

Having diabetes triples your likelihood of developing gum disease because diabetes impairs the body's response to inflammation and infection. At the same time, treating gum disease in people with diabetes can help control their blood sugar levels. Researchers found that when people with diabetes receive preventive dental and periodontal care, their diabetes is better controlled and medical costs decrease.

Poor oral health also increases the risk of contracting pneumonia, especially for hospital and nursing home patients. When patients see a dentist before entering the hospital, they are less likely to develop pneumonia during their stay.

There is also evidence that untreated dental problems can lead to rheumatoid arthritis, Alzheimer's disease and other cognitive disorders.

Chemotherapy can damage your teeth

Many cancer treatments can damage teeth, especially in older adults.

As a result, Medicare has begun reimbursing dental expenses related to tooth decay or other oral disease after receiving chemotherapy or radiation treatments.

It's better to have than to have

The history of U.S. health care helps explain why Medicare often doesn't cover the cost of dental and gum treatments.

Doctors and dentists are educated separately, and doctors learn little about dental diseases and treatments while in medical school.

Most dental electronic health records are not connected to the healthcare system, hindering the delivery of comprehensive care and dental care to those who need it.

Meanwhile, medical insurance and dental insurance have evolved into distinct functions. While medical insurance is designed to cover large, unpredictable expenses, dental insurance primarily funds preventive care that is predictable and less costly.

While protection against catastrophic medical expenses has always been considered a necessity, coverage for dental services is considered one of the best benefits.

But this is an outdated idea disconnected from a wealth of scientific evidence.

Medicare Advantage Plans

Alternative programs such as Medicare Advantage (the program through which the federal government contracts with private insurance companies to provide Medicare benefits) can serve as a stopgap measure until Medicare expands coverage to cover preventive dental services for everyone .

In 2016, only 21% of traditional Medicare beneficiaries purchased a stand-alone dental plan, while about two-thirds of Medicare Advantage beneficiaries received at least some dental benefits through their insurance. However, the procedures covered by these plans vary widely.

The costs of this gap in Medicare coverage are high: One in five Americans with Medicare—including many with little disposable income—spends at least $1,000 a year on dental care.

Dr. Koop seems to be right – you can't be healthy without good oral health. Adding basic dental benefits to Medicare could help many older Americans live happier, healthier lives while potentially lowering overall health care costs.



Frank Scannapieco, Professor and Department Chair, Oral Biology, University at Buffalo; Ira Lamster, Clinical Professor, Periodontology and Endodontics, Stony Brook University (SUNY)

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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This article Taking care of older Americans’ teeth and gums is important, but health insurance often doesn’t cover it appeared first on Ohio Capital Magazine.

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