By Rick Valachovic, DMD, MPH, Clinical Professor and Director of the NYU Dentistry Center for Oral Health Policy and Management

November 19, 2021 was disappointing for many oral health advocates. That’s the day Medicare dental benefits were stripped from the Build Back Better Act, which Democrats were striving to advance through the U.S. House of Representatives. It’s likely that even more provisions of the bill will be scaled back if it passes at all, but the fact that it contained dental benefits for as long as it did is something to celebrate. Finally, there appeared to be a consensus that all government programs should cover dental care.

This broad acknowledgement constitutes a major step forward. The disagreement lies in how to pay for dental care and how a dental benefit should be designed. At the heart of the debate lies an undeniable fact: Dental care, as currently provided, is expensive. This explains why so many older adults avoid routine and even urgent care, and why many in Congress are hesitant to add dental benefits to the Medicare program.

One way to reduce the cost of a Medicare dental benefit would be to target it at beneficiaries with the greatest financial need. The American Dental Association (ADA) suggested this last year when it proposed restricting any Medicare dental benefit to seniors earning up to three times the poverty rate (less than $39,000 a year). Such a restriction would reduce the number of people receiving the benefit by roughly half.

The ADA also called for situating dental benefits in a new Medicare program rather than in Medicare’s medical coverage, Part B. The association mobilized its members and other dentists to send 60,000 emails to Congress. This action “helped ensure that the proposed Part B benefit was not included in the Build Back Better package passed by the House,” ADA President Cesar Sabates, DDS, told ADA members.

Far from all dentists, including me, were pleased by this outcome. The Wall Street Journal published a letter to the editor that I wrote about the issue.  William Giannobile, DDS, DMSc, dean at the Harvard School of Dental Medicine, and Lisa Simon, MD, DMD, fellow in oral health and medicine integration, provided a well-argued rebuttal to the ADA position last month in the New England Journal of Medicine.

“Beyond excluding many middle- and higher-income older adults who currently lack dental coverage, we believe a means-tested policy that is distinct from other Medicare benefits would restrict advances in oral health for two reasons,” they wrote. “First, limiting a Medicare dental benefit to low-income beneficiaries would make it financially straightforward for most dentists to refuse to accept Medicare.” They went on to point out that fewer than half of dentists currently accept patients insured through Medicaid or the Children’s Health Insurance Program (CHIP). This places an undue burden on safety-net providers, who are already at capacity and desperately need private practices to pitch in.

Lisa and Will also believe a means-tested, stand-alone benefit “would perpetuate dentistry’s separation from the rest of the healthcare system….” As I wrote last month, this separation lies at the root of many of our oral health challenges. It also hinders some of the advancements in health care delivery that policymakers and health care innovators have been seeking: a healthier population, a better patient experience, and lower health care costs. We can’t reach these goals unless we provide care in a way that acknowledges the link between oral and overall health.

Adding a dental benefit to Medicare is highly popular with older adults and with advocacy organizations, including the American Heart Association, Families USA, and AARP, whose policy director called a means-tested dental benefit “a nonstarter” for the association. The American Dental Education Association, my old stomping grounds, the American Dental Hygienists’ Association, and the National Dental Association (NDA), are also on record supporting a universal dental benefit. Dentists in Congress take a different view.

“Here’s the challenge that we see with the current Medicare legislation,” Rep. Drew Ferguson, (R-GA), said during a September event hosted by The Hill. “We see it as an empty promise to seniors.” As a dentist who spent two decades practicing in a rural, economically depressed community, he said his biggest fear is that providers won’t take part in the program. “Dentists can’t stay in business losing money under…what we anticipate CMS (the Centers for Medicare and Medicaid Services) will do with this,” he said.

A September NDA statement also raised the issue of reimbursement, stressing the organization’s support for a “model and strategy that will attract an adequate provider network.” Ferguson and the NDA have a point. The reimbursement rates for dental services offered through state Medicaid programs attract fewer than half of U.S. dentists to participate. A notable exception are NDA members, 60% of whom take part, the organization’s president told NPR. But as Will and Lisa argue, a standalone dental benefit for low-income Americans would likely make Ferguson’s fear a self-fulfilling prophecy, encouraging dentists who don’t accept Medicaid patients to reject all Medicare-insured patients as well. A universal dental benefit, on the other hand, would give dentists access to an economically mixed and expanded customer base.

From where I sit, these disagreements reflect a growing generational divide. Older dentists accustomed to high incomes and clinical independence may well shy away from accepting Medicare reimbursement rates for their services, but the younger generation of dentists and dental students understand that the dental care economy is shifting. The growth of per-capita dental expenditures has slowed in the past decade, and since 2006, private practice incomes have declined. While there is rampant dental need among un- and underinsured people, the need for restorative care among working-age adults has fallen overall as a consequence of community water fluoridation, widespread use of fluoride toothpaste and varnish, and routine care for those with dental insurance. Many dental schools have picked up on these trends and are preparing their students to practice in areas of growing demand — the Medicaid population and children who received dental benefits through CHIP and as an essential benefit enshrined in Affordable Care Act-compliant insurance plans.

My sense is that younger dentist’s strong sense of social responsibility, well documented among millennials and the rising Gen Z, will translate into their pursuit of the opportunity to serve Medicare beneficiaries. In October, Kaiser Health News quoted one such dentist, Nathan Suter, DDS, a self-described “proud ADA member,” calling on the association to make sure a Medicare dental benefit is “as good a benefit as possible for all of my seniors.” Suter practices in rural Missouri, and roughly half of his patients are older adults.

Like Will and Lisa, I see a universal Medicare dental benefit as “a health and health equity imperative” as well. Our profession needs to serve everyone who would benefit from the care we provide, not just those patients for whom cost is no barrier. It may be a while before Congress approves a Medicare dental benefit, but I’m confident the day will come, and when it does, it will bring us closer to fulfilling that obligation.