It is no secret that Medicare, the nation’s largest health care program for older adults and individuals with disabilities does not provide dental coverage as part of its “basic Part B outpatient package”. This is because when Medicare was established the goal was to provide care to treat illness and disease, not prevent or control normal aging processes (Freed, Potetz, Jacobson, & Neuman, 2019). This means coverage for assessment, diagnostic, prevention and treatment of dental needs is extremely limited or nonexistent for our older adults at a time when it is needed most.
As a primary care practitioner, encounters for oral and dental pain are a common chief complaint. Addressing dental care access is important as poor oral hygiene, tooth decay and loss impact physiologic health and overall nutrition. Mastication issues impede absorption and nutritional status which impact quality of life and lead to physical decline. Poor oral hygiene increases the risk of abscess and infection which can lead to sepsis. Oral bacterium has also been found to spread from the oral cavity systemically which increases cardiovascular and valve disease, activates the inflammatory cascade and can lead to stroke, myocardial infarction and increased mortality (Damle, 2018; Harvard Medical School, 2018). Gingivitis and Periodontal diseases have also been linked to gastric and pancreatic cancers.
Inpatient part A coverage is sometimes authorized based on the “incident and integral to” rule. For example, when surgery is performed to remove a tumor of the jaw, removal of teeth and examination of the oral cavity is covered. However, replacement and follow up for reconstructive and tooth replacement under Part B is not (Freed, Potetz, Jacobson, & Neuman, 2019). This means those who qualify for Medicare need to either purchase an individual dental policy or look at Advantage care programs during enrollment or reenrollment to cover preventative and restorative dental services. The sad truth is even when people purchase standalone coverage or participate in an Advantage care program, coverage and reimbursement is minimal compared to the actual cost of the coverage. There are often high deductibles and co-pays with these plans. According to the Centers for Disease Control and Prevention (CDC) in 2017 nearly 35 percent of adults over 65 had not seen a dental provider within the past 12 months or more (2019). Those at or below the poverty level constituted the majority of non-visits. Cost and coverage was reported to be the primary reason for this population in contrast to time constraints reported by adults aged 18-55 (Yarbrough, Nasseh & Vujicic, 2014).
There have been numerous attempts to amend this Medicare limitation. The latest attempt was heard in the House late last year. As of December 13th 2019, the Bill H.R.1393, otherwise referred to as the Medicare Dental, Vision, and Hearing Benefit Act of 2019, was passed by the House of Representatives and is currently in line to be voted on in the Senate this year. This Bill would include coverage for recipients with Medicare part B for preventative dental, vision and hearing services. It also includes provisions for treatment and some coverage for devices like hearing aids. Since this bill covers Dental, Hearing and Vision services, it expands a Medicare recipients’ ability to see a specialist without obtaining a referral from a primary practitioner (PCP) as well. One of the biggest limitations of this bill is addressing the added cost associated with coverage. As Medicare covers almost 61 million adults over the age of 65, obviously the fiscal ramifications abound. The payment proposal is primarily based off renegotiating pharmaceutical drug prices and pooling the savings back into Medicare’s bucket. This Cost shifting plus inclusion of co-payments and deductibles are similar to current Part B practices. This sounds promising, but is it enough to entice our Senate and can we provide enough support to advocate for our elderly? Only time will tell.
Centers for Disease Control and Prevention. (2019). Dental Care Among Adults Aged 65 and Over, 2017. Retrieved from https://www.cdc.gov/nchs/products/databriefs/db337.htm
Damle S. G. (2018). Health Consequences of Poor Oral Health?. Contemporary clinical dentistry, 9(1), 1. doi:10.4103/ccd.ccd_106_18
Freed, M., Potetz, L., Jacobson, G. & Neuman, T. (2019, Sept. 18). Policy options for improving dental coverage for people on Medicare. Henry J. Kaiser Family Foundation. Retrieved from https://www.kff.org/medicare/issue-brief/policy-options-for-improving-dental-coverage-for-people-on-medicare/
Harvard Medical School. (2018, April). Gum disease and the connection to heart disease. Retrieved from https://www.health.harvard.edu/diseases-and-conditions/gum-disease-and-the-connection-to-heart-disease
Medicare Dental, Vision, and Hearing Benefit Act of 2019, H.R. 1393, 116th Congress, 2019-2020. Retrieved from https://www.congress.gov/bill/116th-congress/house-bill/1393/text
Yarbrough, C., Nasseh, K., & Vujicic, M. (2014). Why adults forgo dental care: Evidence from a new national survey. Retrieved from https://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_1114_1.ashx
Dental Policy and Health Advocacy 