When I was growing up, I didn’t know that scheduling biannual dental appointments was commonplace. Due to the economic recessions of the 2000s, my family’s income was shaky for many years, and even after the Great Recession, we moved around repeatedly for work. Most of the time we didn’t have the stability to attend regular medical appointments due to our health insurance’s high deductible — under which there are typically significant out-of-pocket payments — let alone go to the dentist, which wasn’t covered by our insurance. When I started attending regular dental appointments in middle school, I was dazzled by the experience. But we still don’t have dental insurance and instead pay for appointments with no help. Thus, if our financial situation were to again turn bleak, we would drop the appointments once more.
General medical opinion considers oral health to be a vital part of public health. Poor oral health is correlated with worse bodily health and quality of life and disproportionately disadvantages marginalized communities. Yet the lackluster dental care covered by both public and private health insurance policies perpetuates the perception that dental care and non-dental care are inherently separable. Dental care is unaffordable for many Americans and insurance plans frequently fail to cover important operations. Comprehensive dental care must be fully covered by both public and private health insurance policies if we hope to promote the health of all Americans.
Poor oral health can contribute to numerous illnesses and conditions, including cardiovascular disease, pneumonia and complications with pregnancy and birth. And the relationship between oral and non-oral bodily health works both ways. For example, diabetes and gum disease worsen each other in a positive feedback loop, and conditions such as HIV/AIDS, osteoporosis and Alzheimer’s disease lead to dental decline. Despite the potentially severe effects of neglecting oral health, the lack of access to primary dental care discourages people from engaging the medical system until an emergency occurs, resulting in both medical and financial consequences.
Financial obstacles add to these disincentives. Dental spending makes up less than 4.5% of health care expenditures yet constitutes a large part of patient spending: An astronomical 44.2% of dental bills were paid out of pocket, as opposed to 10.3% of physician costs, which are largely covered by insurance plans. Recent research indicates that the expensive nature of dental care prevents medically insured individuals from fulfilling their treatment needs.
While the federal Medicaid program helps to ease some of the economic burden of oral health care from low-income individuals and families, it still falls short. Although Medicaid is supposed to cover dental care for all children, fewer than half of children who qualify actually receive dental care. Furthermore, adult dental care depends on state Medicaid policy. In 2016, 15 states provided extensive adult dental benefits, but 13 only provided dental coverage for emergency care or pain relief and four states provided no dental benefits. But even if a state offers substantial dental care, individuals are limited by whether they can find dental professionals in their communities. Fewer than half of U.S. dentists participate in the Medicaid dental program due to low reimbursement. As a result, dentists tend to set up businesses in affluent areas where residents can afford better insurance or can pay for procedures out of pocket. As a result, the poorest areas of the United States offer little to no access to dental care — over 50 million Americans live in communities with a federally designated shortage of dental professionals.
Medicare, which insures those who are 65 and older or have disabilities, also offers insufficient dental coverage. The program doesn’t cover primary dental services — “care, treatment, removal or replacement of teeth or structures directly supporting teeth”— necessary for installing dentures and removing diseased teeth. Furthermore, while it covers surgeries necessary for “non-dental” procedures, Medicare will not pay for dentures or any other type of appliance necessary for taking care of the mouth post-operation. Medicare’s insufficiencies in dental coverage are particularly egregious due to the heavy burden of oral diseases on older populations.
While the separation of dental and non-dental medical care in health care policy disproportionately harms marginalized communities covered by Medicaid and Medicare, a much larger group can feel the consequences. Of civilian workers who received medical insurance through work in 2018, like my family, only 44% received dental coverage as well, leaving the rest uninsured for dental care. The dental uninsured rate is four times higher than the medically uninsured rate, with some 74 million Americans having no dental coverage in 2016. Even those who can purchase separate dental insurance don’t receive all the coverage they need. For example, many private dental insurance plans don’t cover major dental procedures, which can be pricey. Though dental insurance companies cover preventative care, regular dental maintenance does not completely eliminate the risk of dental emergencies.
All of these factors add up to a clear image of dental care in the United States: inaccessible and unacceptable. As medical journalist Mary Otto put it, “Due to economic deprivation, geographic isolation, age, disability and lack of dental coverage, an estimated one-third of the population faces significant difficulties getting access to the autonomous, insular and privatized system that provides most of the dental care in this country.”
Addressing disparities in dental care could, in turn, improve dental coverage for everyone. The Medicare and Medicaid Dental, Vision and Hearing Benefit Act, introduced to the U.S. Senate Aug. 5, would greatly expand the breadth of dental care covered by the Medicare and Medicaid programs. This legislation could be the first step in shifting attitudes around dental health, but as of now, the bill has a 3% chance of passing, according to predictions by machine learning prediction firm Skopos Labs. For real progress to be made, dental health must be considered inseparable from non-dental health at all levels. It is time to move past antiquated insurance structures so that we can focus on advancing the health of all Americans, regardless of their socioeconomic status.