An Oral Health Equity Agenda For The Biden Administration

Featured in Health Affairs Blog, on February 23, 2021. Contributing authors Melissa Burroughs, Danny A. Kalash, Colin Reusch, Ifetayo B. Johnson, Kata M. Kertesz.

COVID-19 has demonstrated the need to address weaknesses in our nation’s health care system, as well as underlying structures that perpetuate inequities in health. Oral health is a critical, but frequently forgotten, part of this equation. Despite bipartisan recognition of America’s oral health crisis, policy makers repeatedly fail to address oral health as a core component of our health care system or to adopt a comprehensive oral health policy agenda centered on equity. The Biden-Harris administration is now uniquely positioned to make significant progress toward America’s oral health priorities while simultaneously addressing our country’s structural barriers and health disparities.

During the COVID-19 pandemic, oral health has carried important implications for both health and health care. Americans disproportionally impacted by COVID-19 are also more likely to suffer from poor oral health, which conversely puts people at greater risk for COVID-19 complications. Ventilator-related pneumonia has been strongly implicated among individuals with poor oral health. Moreover, when oral health care is out of reach, many people turn to expensive emergency department settings for dental relief—further straining already limited hospital capacity.

In addition to pandemic risks, longstanding evidence shows that poor oral health harms our physical, mental, and economic well-being. A recent survey of middle-age adults revealed that nearly four in ten had dental problems within the past two years that caused pain, difficulty eating, and missed work. Nearly one in six children have untreated tooth decay, which obstructs school success and healthy development. Children of color are disproportionately harmed and have higher rates of tooth decay due to systemic racial inequities.

Americans are roughly four times more likely to lack dental insurance than medical insurance, with the greatest rates of uninsurance among racial and ethnic minorities. Without policy change to help people achieve oral health, we eventually strain the health care system and economy.

What follows are important administrative actions and legislative opportunities that can better ensure the oral health, health, and economic well-being of all Americans.

Extend Medicare Coverage For Medically Necessary Oral Health Care

Chronic diseases disproportionately affect Medicare beneficiaries and result in significant expenditures for our federal government. Oral health status has been shown to be a risk factor for numerous chronic diseases, and untreated oral diseases can preclude, delay, or jeopardize numerous medical treatments.

However, most Medicare beneficiaries do not receive oral health care even as it is medically necessary to successfully manage their Medicare-covered diseases. In fact, Medicare coverage extends to the treatment of all microbial infections except for those originating from the teeth or periodontium. There is simply no medical justification for this exclusion, especially in light of the broad agreement among health care providers that such care is integral to the medical management of numerous diseases and medical conditions.

The absence of medically necessary oral health care heightens risk for and severity of preventable medical complications. To avoid these harms, we urge the new administration to exercise its existing statutory authority to extend Medicare coverage more broadly to oral health care that is integral to covered medical treatment. Such evidence-based coverage would reduce the risk of medical complications and lower the resulting financial burden on Medicare and taxpayers, as well as on beneficiaries.

Integrate Dental Coverage In Medicare Part B

Traditional Medicare explicitly excludes coverage for dental services, except under limited circumstances. It does not cover routine preventive dental care, nor minor or major restorative treatment. Medicare coverage is currently restricted to dental services that are related to a covered medical procedure. Medicare also covers inpatient hospital care resulting from dental-related complications but not the cost related to dental care itself.

As a result, the majority of adults who rely on Medicare continue to have no form of dental coverage, although Medicare Advantage plans frequently offer dental coverage. In recent surveys, nearly half of all Medicare beneficiaries did not visit the dentist, with higher rates among racial and ethnic minorities, and adults with low income or from rural settings. In addition, numerous barriers make it more difficult to access a dentist, including dental health provider shortages, transportation, and out-of-pocket expenses.

Federal policy makers can fill this coverage gap and ensure our nation’s older adults and people with disabilities can get the care they need by adding comprehensive oral health coverage to Medicare Part B. The House-passed Elijah E. Cummings Lower Drug Costs Now Act (HR 3) offers a strong, bipartisan framework for improving Medicare oral health coverage, although the proposed benefit should be strengthened further and grounded in health equity.

Stabilize State Medicaid Programs And State Budgets

As states continue to weather the economic downturn and struggle through reduced revenue, they will inevitably be forced to make budget cuts. The recession of the late 2000s provides an important example of how many states are likely to reduce or terminate dental coverage for adults on Medicaid when faced with financial pressure.
While this coverage was previously protected under the “Maintenance of Effort” provision in the Families First Coronavirus Response Act, the Centers for Medicare and Medicaid Services (CMS) issued an interim final rule on November 2, 2020, allowing these benefits to be slashed. We urge the new administration to reverse this rule immediately. The administration can also work with Congress to make two crucial updates to the federal Medicaid matching rate (FMAP):

• Increase FMAP funding for Medicaid as part of any COVID-19 relief legislation, by at least 12 percent.
• Increase FMAP funding for adult dental services, by at least 5 percent.

Taken together, these supports would allow state Medicaid programs to maintain coverage and respond to anticipated demands in the months ahead. In the future, it is also our hope that Congress will pass legislation that makes oral health coverage a permanent part of Medicaid coverage for both children and adults. This will ensure that states do not cut this critical care the moment state budgets experience strain.

Appoint Oral Health Leaders Throughout Federal Government

As the Biden administration continues to nominate health experts for key federal positions, it is critical that the administration recruits advisers with oral health expertise as well as creates high-level roles specifically dedicated for oral health. Oral health experts can lead in population-based dentistry, oral health surveillance, policy development, community-based disease prevention and health promotion, and maintenance of our dental safety net.

Many federal agencies, including CMS, the Health Resources and Services Administration, the Centers for Disease Control and Prevention, and the Department of Veteran Affairs, play a critical role in American’s oral health. Despite federal oversight of numerous public dental programs, activities, and budgets, agencies maintain a glaring lack of oral health experts. Over the past decade, only two federal agencies carried a chief dental officer or equivalent at any point: CMS and the Office of the Surgeon General. In contrast, eight federal agencies currently retain a chief medical officer or equivalent.

Although oral health is closely tied to systemic health, it must be formally recognized as a specialized area that requires unique expertise. To promote effective oral health executive, legislative, or regulatory actions, as well as subsequent implementation and evaluation, oral health experts are urgently needed in key positions across federal government.

Engage Oral Health Providers To Fight COVID-19 While Improving Access To Dental Care

The Biden-Harris administration has a unique opportunity to engage the oral health workforce to help stop the spread of COVID-19, while also working with Congress to increase access to oral health care. In particular:

Use Oral Health Providers As Part Of A Comprehensive COVID-19 Vaccine Strategy

This moment presents a critical opportunity to integrate dental and medical care. As the nation releases COVID-19 vaccines, dental providers can play a vital role in efficient vaccine administration. This capacity should be part of a comprehensive vaccine distribution strategy.

Invest In Oral Health Infrastructure

Federal policy makers must provide immediate support to state health departments and oral health programs by establishing an oral health infrastructure fund. This fund would allow states to respond to crisis-related oral health needs. This may include providing direct safety-net care to uninsured individuals and collecting relevant data. It could also support investments in telehealth technology to safely reach patients, including the more than 65 million individuals living in dental professional shortage areas.

Expand The Dental Workforce

Expanding oral health coverage should be coupled with policies that ensure equitable access to oral health providers. To help meet demand, the administration should advance policies that end scope-of-practice restrictions, facilitate licensing across state lines, and allow for the deployment of dental professionals in community-based settings and existing touchpoints for marginalized communities. Additionally, it should support policies that include additional provider types such as dental therapists, advanced practice dental hygienists, and community health workers and coordinators.

Include Comprehensive, Affordable Oral Health Coverage For Everyone

Our nation’s current crises have highlighted both health and oral health inequities that undermine the ability of millions of people across the United States to lead healthy, productive, and dignified lives. Oral health outcomes remain an entrenched marker of health disparities among communities of color, vulnerable age groups, and underserved geographic regions.

The Biden-Harris administration can make meaningful progress toward ending oral health disparities and helping every person achieve optimal oral health. We urge the administration and Congress to ensure that comprehensive, affordable oral health coverage and improved access to oral health care are a part of any major health care reforms, whether through the proposed Public Option in the Affordable Care Act’s health care Marketplaces, or expansions to Medicaid, Medicare, or Veterans Administration benefits.