C. Everett Koop, the avuncular doctor with a fluffy white beard who served as the U.S. surgeon general during the Reagan administration, was famous for his work as an innovative pediatric surgeon and the attention he paid to the HIV-AIDS crisis.
As dentistry scholars, we believe Koop also deserves credit for something else. To help make the medical profession pay more attention to the importance of healthy teeth and gums, he’d often say: “You are not healthy without good oral health.”
Yet, more than three decades after Koop’s surgeon general stint ended in 1989, millions of Americans don’t get even the most basic dental services, such as checkups, tooth cleanings and fillings.
Americans who rely on the traditional Medicare program for their health insurance get no help from that program with paying their dental bills aside from some narrow exceptions. This group includes some 24 million people over 65 – about half of all the people who rely on Medicare for their health insurance.
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‘Medically necessary’ exceptions
When the Medicare program was established in 1965, almost all dental services were excluded due to the expense and vigorous opposition from associations that represent dentists out of fear that reimbursement rates would be markedly low compared to traditional insurance plans or out-of-pocket payment.
However, interest in including dental benefits in Medicare is on the rise at the Centers for Medicare and Medicaid Services, the federal agency responsible for the Medicare program, as well as many organizations that seek to provide dental benefits to all members of society.
The Biden administration initially considered the addition of comprehensive Medicare dental coverage as part of its proposed Build Back Better legislation, a broad US$1.8 trillion legislative package designed to fix problems ranging from child care costs to climate change, but failed to get enough support in Congress.
Dental coverage was eliminated from the version of the bill the House passed in 2021, in part due to cost concerns and resistance from organized dentistry due to the low reimbursement rates for medical care for patients with Medicare benefits.
In 2022, after the broader package was blocked in the Senate, the federal government added coverage for dental treatment that was designated as “medically necessary” for people with Medicare.
The list of circumstances that would lead patients to be eligible is short. Some examples include patients scheduled for organ transplants or who have cancer treatment requiring radiation of their jaws.
But we believe that dental care is necessary for everyone, especially for older people.
Chew, speak, breathe
While many working Americans get limited dental coverage through their employers, those benefits are usually limited to as little as $1,000 per year. And once they retire, Americans almost always lose even that basic coverage.
Given the importance of oral health for your overall health and quality of life, and increasing scientific understanding of the role of poor oral health in a wide array of chronic diseases, we believe that Medicare should include basic dental services.
A healthy mouth is essential for chewing, speaking and breathing. Being able to flash a good smile boosts self-esteem and helps maintain a sense of well-being.
Left untreated, dental diseases often result in infections that can cause severe pain. Poor oral health can lead to hospitalization and even death. Yet, routine oral care is frequently unavailable to many Americans.
Rich Americans with Medicare coverage are almost three times more likely to receive dental care compared to those with low incomes. And almost 3 in 4 low-income people over 65 don’t see a dentist in a typical year.
Connected to many serious conditions
Numerous epidemiological studies have associated atherosclerosis, a serious condition colloquially known as clogged arteries, cardiovascular disease and stroke, with periodontal disease – chronic inflammation of the bone and gum tissues that support the teeth.
Having diabetes makes you three times as likely to develop gum disease because diabetes compromises the body’s response to inflammation and infection. At the same time, treating diabetes patients for gum disease can help control their blood sugar levels. Researchers have found that when people with diabetes get preventive dental and periodontal care, their diabetes is better controlled and health care costs decline.
Poor oral health can also increase the risk of contracting pneumonia, especially for patients in hospitals and nursing homes. When patients see a dentist before entering the hospital, they’re less likely to get pneumonia during their stay.
There is also evidence that untreated dental problems may contribute to rheumatoid arthritis as well as Alzheimer’s disease and other cognitive impairments.
Chemo can damage your teeth
Many cancer treatments can damage teeth, especially for older adults.
As a result, Medicare has started to reimburse for dental bills tied to tooth decay or other oral conditions after they get chemotherapy or radiation treatment.
More than nice to have
The history of U.S. health care helps explain why Medicare generally won’t cover the cost of dental and gum treatment.
Doctors and dentists are educated separately, and doctors learn very little about dental conditions and treatments when they’re in medical school.
Most dental electronic health records aren’t linked to medical systems, hindering comprehensive care and delivery of dental care to those in need.
At the same time, medical insurance and dental insurance have evolved to serve very different functions. Medical insurance was designed specifically to cover large, unpredictable expenses, while dental insurance was intended to mainly fund predictable and lower-cost preventive care.
While protection from catastrophic medical costs has always been perceived as a necessity, coverage of dental services was conceived as a benefit that’s mostly nice to have.
But that’s an outdated idea disconnected from a large body of scientific evidence.
Medicare Advantage plans
Until Medicare expands coverage to include preventive dental services for everyone, alternative plans such as Medicare Advantage, through which the federal government contracts with private insurers to provide Medicare benefits, serve as a stopgap.
In 2016, only 21% of beneficiaries in traditional Medicare had purchased a stand-alone dental plan, whereas roughly two-thirds of Medicare Advantage enrollees had at least some dental benefits through their coverage. However, these plans vary greatly in the procedures that they cover.
The costs of this hole in Medicare coverage is high: 1 in 5 Americans with Medicare – including many with little disposable income – are spending at least $1,000 a year on dental care.
It seems that Dr. Koop was onto something – you can’t be healthy without good oral health. Adding basic dental benefits to Medicare would likely help many older Americans to live happier and healthier lives, and at the same time potentially reduce overall health care costs.
Frank Scannapieco is affiliated with The Task Force on Design and Analysis in Oral Health Research, and consults for the Colgate-Palmolive Company.
Ira Lamster is a member of the Santa Fe Group. He currently receives consulting fees from Colgate, and research support from the CareQuest Institute.
