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The Gap Between Dental and Medical Coverage

Most consumers dread a visit to the dentist’s office, even for an annual cleaning, but an annual dental visit is arguably as important as a primary care visit. Clinical studies show that the increase in number of oral health issues is associated with higher mortality.

Some versions of the Build Back Better legislation included provisions for expansion of Medicare benefits to mandate dental benefits, along with incremental vision and hearing benefits. However, without widespread bipartisan support and the Congressional Budget Office’s estimate of a $238B price tag for dental care expansion, President Biden’s framework was ultimately trimmed down to include only expanded hearing benefits. 

The regulation of dental benefits merits deeper analysis, particularly with the Centers for Medicare and Medicaid Services' (CMS) hiring of the agency’s first-ever Chief Dental Officer, Dr. Natalia Chalmers, last year. This appointment reflects CMS’s broader objective to increase access to affordable dental care since traditional health insurance benefits limit or exclude coverage of dental care. 

Access to affordable dental services varies widely across sources of insurance coverage (i.e., government vs. employer-sponsored). Notably, dental care was omitted from the list of Essential Health Benefits in the Affordable Care Act. Comprehensive dental coverage for adults is not mandated in Medicaid, traditional Medicare, or on the state exchanges. However, comprehensive dental coverage is mandated for children covered by Medicaid and through the state exchanges. Nearly half of Medicare beneficiaries do not have dental coverage, and most of those with coverage access it through Medicare Advantage supplemental benefits. In Medicaid, states vary widely on the levels of coverage available to adult beneficiaries (i.e., no coverage, emergency coverage, limited coverage, and comprehensive coverage). Additionally, just 63% of employers offering dental coverage contribute to their employee’s costs. Therefore, most adults, regardless of coverage source, are required to purchase dental coverage on a pre-tax, but out-of-pocket (OOP), basis.

Recent National Health Expenditure data released by CMS illuminates key differences regarding patient responsibility for services rendered by dentists and physicians. In 2020, 37.4% of dental expenditures were paid for OOP and 7.2% of physician expenditures were paid for OOP (Figure 1). These data also highlight the coverage disparity between private and public health insurance, with just 1.8% and 8.9% of expenditures attributed to Medicare and Medicaid, respectively, as compared to 55.3% attributed to private insurance, despite Medicare and Medicaid beneficiaries accounting for 36.2% of the U.S. population.

Dental and Physician Services

The uneven distribution of expenditures by coverage source is reflective of the overall state of dental health inequity. Data from the Centers for Disease Control and Prevention shows that “the prevalence of untreated [tooth] decay was almost 40% to 50% among adults who were non-Hispanic black, Mexican American, or poor and near-poor combined; who had a high school education or lower; and who were current smokers. Prevalence among these groups was about twice that of adults who were non-Hispanic white or not poor, who had more than a high school education, and who had never smoked.”

Ultimately, payment is policy, and addressing the inequitable distribution of dental care will require more expansive insurance coverage. As new entrants such as Tend begin to offer individuals more choice for how and where they receive dental care, consumers will expect more from the healthcare system. Paying OOP for dental work, which consumers will increasingly define as medical care, is much less likely if consumers are accustomed to having some degree of financial support (i.e., insurance) when financing medical care. With recent increased funding and focus on oral healthcare research coinciding with CMS’s new C-suite role, it is likely that the historically divided medical and dental care payment systems will converge. Similar to the dental coverage provided to Medicare beneficiaries through Medicare Advantage, it is also possible that companies with capitated primary care models will expand coverage to include dental benefits, given the clear impact of oral health status on overall physical health. The question to consider is whether Walmart will be the price-setter in oral care as they now are in primary care.

Thanks to Katie Patton for her research support.

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