Medicare has excluded dental (and vision and hearing) coverage since its inception in 1965.

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The biggest adversary for dental coverage to all Medicare beneficiaries is the American Dental Association (ADA).

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William Stork needs a tooth pulled. That’s what the dentist told the 71-year-old retired truck driver during a recent evaluation.

That type of extraction requires a maxillofacial surgeon, which could cost around $ 1,000 because, like most seniors, Stork doesn’t have dental insurance and Medicare won’t cover dental bills. Between Social Security and his Trunks union pension, Stork says, he lives comfortably in Cedar Hill, Missouri, about 30 miles southwest of St. Louis. But that cost is high enough that you’ve decided to wait until tooth extraction is absolutely necessary.

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William Stork, who lives in Missouri, needs to have a tooth extracted but does not have dental insurance and Medicare will not cover dental bills. So for now he does not intend to do so. Joe Martinez / KHN

Stork’s situation is at the center of a long-standing rift within the dental profession that has resurfaced as a battle to add dental coverage to Medicare, the public insurance program for people 65 and older. , if a profit can be added.

Health equity advocates see President Joe Biden’s Build Back Better agenda as a unique opportunity to provide dental coverage to those with Medicare, who represent nearly half of those who did not visit a dentist in 2018. , long before the pandemic canceled dental appointments for many. Rates were even higher for black (68%), Hispanic (61%), and low-income (73%) seniors.

The cover fell outside of a new framework announced by President Joe Biden, but proponents still hope to get the cover in a final deal. To complicate the process, there is a debate about how many of the more than 60 million Medicare beneficiaries in the country should receive it.

Advocates for coverage for all Medicare beneficiaries face an adversary that you might think unlikely: the American Dental Association (ADA), which backs an alternative plan to provide dental benefits only to low-income Medicare beneficiaries.

Medicare has excluded dental (and vision and hearing) coverage since its inception in 1965. That exclusion was by design – the dental profession has long struggled to stay separate from the traditional medical system.

More recently, however, dentists have emphasized the link between oral and general health. What’s worse is that, in 2007, the death of a 12-year-old boy that could have been prevented with an $ 80 tooth extraction sparked changes in Maryland’s version of Medicaid, the federal and state public insurance program for low-income people. But researchers have also linked, for example, dental care to reducing health care spending for patients with type 2 diabetes. When the World Health Organization last year suggested delaying non-urgent oral health visits to prevent spread of COVID-19, the American Dental Association rejected it, and then-President Dr. Chad Gehani stated, “Oral health is an integral part of general health. Dentistry is an essential health care ”.

The ADA-backed Medicare proposal would cover only seniors who earn up to three times the poverty level. That currently translates to $ 38,640 a year for one person, reducing the number of potential beneficiaries from more than 60 million people to about half that number. Medicare has never required proof of income, but in a world where Congress seeks to cut the social spending package over 10 years from $ 3.5 billion to $ 1.85 billion, the ADA presents its alternative as a way to save money while covering those who need more a dental service. An analysis by the Congressional Budget Office estimated that the plan to provide dental coverage to all Medicare beneficiaries would cost $ 238 billion over 10 years.

Unlike the ADA, the National Dental Association (NDA) is pushing for a universal dental Medicare benefit. The group “promotes equity in oral health among people of color” and was created in 1913, in part, because the ADA did not eliminate discriminatory membership rules for its members until 1965. Dr. Nathan Fletcher, president of the NDA’s board of trustees says he was not surprised to see his organization disagreeing with the ADA on this issue of Medicare coverage.

“The face and demographics of the ADA is that of a 65-year-old white male. Understand that the decision makers for the ADA are generally those who have been in practice for 25 to 30 years, are doing well, and are close to retirement, ”says Fletcher. “It looks nothing like the [pacientes] of which we are speaking ”.

Research from the Health Policy Institute of the American Dental Association found that cost is a barrier to dental care “regardless of age, income level, or type of insurance,” but low-income older adults are more likely to report it as a barrier.

“It would be tragic if we didn’t do something for those low-income seniors,” says Michael Graham, senior vice president of government and public affairs for the ADA.

Graham is critical of the design of proposals in Congress for a universal Medicare dental benefit, noting that one includes a 20% copayment for preventive services that could prevent low-income patients from accessing care they presumably would be receiving. .

“Something is better than nothing, but something [con un copago] It amounts to almost nothing for many older people, ”says Graham.

Graham says the ADA supports 100% coverage of preventive services for low-income Medicare beneficiaries.

Of course, covering only low-income seniors presents its own questions, the most important of which is: Will dentists accept Medicare if it is not necessary? Low-income patients often seek care at safety net clinics that are scheduled months in advance. Some dentists worry that a Medicare benefit limited to low-income seniors is easier to evade, pushing more newly insured Americans into an already burdened dental safety net.

Overall, less than half of dentists accept Medicaid, but more than 60% of NDA members do, Fletcher says. The ADA is concerned that reimbursement fees and red tape for a Medicare benefit are just as unappealing.

But Fletcher, who is a dental director for a Medicaid insurance company in Washington, DC, says that participation in Medicaid varies widely between states and, as with Medicaid, participation in any new Medicare dental program would depend largely on it. profit design measure.

If the reimbursement rates for a Medicare benefit are high enough, Fletcher explains, providing coverage to tens of millions of seniors could be quite lucrative for dentists. Ultimately, he says, dentists should have the option of accepting Medicare patients, and all Medicare patients should be entitled to dental services because they paid for the program.

Dr. Nathan Suter, William Stork’s dentist, believes adding a dental benefit for all older adults is the right thing to do.

Suter, who describes himself as a “proud member of the ADA,” finds himself at odds with the organization, which has showered him with praise. He was named Dentist of the Year by the Missouri Dental Association in 2019 and received one of the ADA Awards for Young Dentists in 2020.

“I, as a member of the ADA, I think they should be at the table for me, making sure that it is the best possible benefit for all my seniors,” says Suter, who estimated that at least 50% of patients in his practice in House Springs, Missouri, are older adults.

But instead of pushing for a universal benefit, the ADA’s well-funded lobbying operation is pushing against the plan proposed by Congressional Democrats to add dental coverage for all Medicare beneficiaries. The organization has asked its members to contact their representatives in Congress on the issue. Graham says more than 60,000 emails have been sent to the Capitol so far.

Suter sees the battle over who to cover as a generation gap. As a dentist early in your career, you prefer to add full dental coverage now so you can adapt your business model sooner. And the more seniors get dental coverage, the more your potential customer base expands. Dentists like him, who are still developing their practices, are less likely to have time to participate in the ADA policy-making process, he says.

Caught up in all of this are patients like Stork, who says the possibility of dental coverage in Medicare is one of the reasons he’s delaying extraction, although he knows that a benefit is unlikely to be rolled out in the next few years, if it is. that they do.

Stork also knows that the benefit might not cover a middle-class person like him, even if approved. Still, it would be nice to have it when your tooth can’t wait any longer to be extracted.

KHN (Kaiser Health News) is the newsroom of KFF (Kaiser Family Foundation), which produces in-depth journalism on health issues. Along with Policy Analysis and Surveys, KHN is one of KFF’s top three programs. KFF is a nonprofit organization that provides health information to the nation.

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