By Anne Blythe
This might not be something on the tip of your tongue in everyday conversation, but it’s important — especially when it comes to thinking about overall health.
Your mouth is where the digestive process begins. It also is a key part of your respiratory system.
Those things might seem obvious to many. So why, oral health care providers ask, is what’s inside the mouth — teeth and gums, for starters — treated as less essential when it comes to insurance and other health care benefits?
The American Dental Association explained why that should not be the case in a letter from its leadership earlier this month to Chiquita Brooks-LaSure, the administrator of the federal Centers For Medicare and Medicaid Services (or CMS).
The Jan. 4 correspondence was prompted by the announcement late last year that more adults could get dental coverage on the Affordable Care Act, or ACA, marketplace if a proposed rule change takes effect.
CMS has proposed lifting a ban that prohibits states from including adult dental services as one of the 10 Essential Health Benefits in ACA-compliant and marketplace plans.
The change would take effect in 2025, but states would have the ultimate say. As proposed, states would not be required to include dental services, but they no longer would be prohibited from including such health care as essential for adults.
Pediatric dental services are considered essential benefits. So are services for primary care, substance abuse and ambulatory care.
“(W)e believe this proposal would incentivize States to add routine non-pediatric dental services,” the 414-page proposal states.
Adding such services as an essential benefit, according to the proposed rule change, would give states the ability “to work to improve adult oral health and overall health outcomes, which are disproportionately low among marginalized communities such as people of color and people with low incomes.
“Lack of dental insurance remains one of the primary barriers to accessing dental care, and this proposed policy would help mitigate this barrier.”
The mouth and the body
Oral surgeons, dentists and hygienists have been on a crusade in recent years to do away with the notion that oral health is not inextricably linked to overall health.
“(U)ntreated oral health conditions can increase risk for and complicate the management of other chronic conditions,” the rule change proposal states. “For example, studies have shown that periodontal disease and tooth loss are strongly associated with heart health, and oral health care can reduce the risk for cardiovascular disease, atrial fibrillation, and heart failure.”
Further research indicates that people being treated for substance use disorder more consistently stick with a treatment plan — inside a facility and after they’re discharged — if they’re getting comprehensive oral health care, according to the federal government.
Having a healthy smile can play a part in employment prospects, as well, the federal agency added.
“Approximately 30 percent of low-income adults in the U.S. and nearly 60 percent of Medicaid beneficiaries without access to dental coverage report that the appearance of their mouth and teeth limits their ability to interview for a job,” the rule change material states.
Medicaid dental benefits
Those points have been made in North Carolina too.
In December, after as many as 600,000 people gained access to expanded Medicaid health care coverage, they also became eligible for oral health care benefits.
The state’s Medicaid program offers routine cleanings, oral health exams and other preventative services through a comprehensive oral health benefits package.
The problem is, only about 45 percent of North Carolina dentists accept Medicaid patients. And many of those dentists are not accepting new Medicaid beneficiaries — leaving a coverage gap across the state.
In lobbying for more dentists to consider treating more Medicaid beneficiaries, oral health care advocates said that providing preventative care could keep people with extreme pain from infected gums and crumbling teeth out of emergency rooms. Such care also could be beneficial in improving the mental well-being and economic viability for people with healthy gums and teeth.
“The people of North Carolina deserve an oral health care system that contributes to their overall health,” Frank Courts, chair of the North Carolina Dental Society Council on Oral Health and Prevention, wrote in a letter published in Neuse News. “It is incumbent on state leaders to find ways to adequately fund dental care for Medicaid recipients. Accomplishing this will save state funds in the long run and result in a healthier and more productive population.”
Incremental progress
It’s not clear whether there would be a widespread impact in North Carolina if adult dental services become an essential health benefit in Affordable Care Act marketplace insurance plans.
Nearly a million North Carolina residents will have health care coverage this year under individual insurance plans from the Affordable Care Act marketplace. Others receive coverage through their jobs or state and federal programs such as Medicaid or Medicare.
How do North Carolinians get their health insurance?
- From their employer – 46.5%
- Individual coverage – 7.5%
- Medicaid – 18.6%
- Medicare – 15.7%
- Uninsured – 9.4%
- Military (VA, TRICARE) – 2.4%
— Source, KFF, 2022 data.
In 2020, approximately 110 million Americans had private dental coverage, according to the Centers for Medicare and Medicaid Services. Nearly 91 percent of them got their dental benefits through their employer or organizations such as AARP, the federal agency added.
When developing essential health benefits in the early days of the Affordable Care Act, federal officials put a lot of stock in what was being offered by employers. Dental insurance plans often were offered as extras by employers, therefore oral health care generally was excluded as an essential in federal marketplace plans.
In their letter to the federal government supporting the essential health benefit change, the leaders of the American Dental Association stressed the importance of specifying necessary oral care services.
They suggested including diagnostic, preventative, emergency and restorative care. Additionally, the ADA suggested including oral and maxillofacial surgery, pulpal and root canal therapy, gum and oral tissue treatment, dentures and other prosthodontics, and orthodontics.
Any such marketplace plans should allow dependent children to remain on their parents’ plans until they are 26 years old.
The national dental association also asked for consumer protections to cover plans sold on federal and state marketplace plans.
“The ADA would support stronger policies with regards to reasonable assurance to ensure individuals and small groups both inside and outside the marketplaces include an offer of adult dental benefits for consumers,” the letter states.
Medicare already shifting what’s ‘necessary’
For North Carolina residents who receive Medicare — the program that covers older adults and many people with disabilities — the wait for more dental coverage won’t be as long.
The Biden administration announced late last year that it had modified Medicare payment policies to clarify the interpretation of “medically necessary dental services.”
Coverage has been expanded to include any dental or oral exams before organ transplant surgery and heart valve replacement procedures, according to KFF, an organization that tracks health policy research.
This year, Medicare will cover dental treatments needed after radiation, chemotherapy and treatments related to head and neck cancers.
Even with such changes, dental service coverage under Medicare remains very limited, KFF reported.
“While these rules modestly expand the types of dental services that are covered under Medicare, they do not represent a broad expansion of Medicare coverage of dental services, such as coverage of routine preventive services including exams and x-rays, or coverage of more extensive services, including root canals and dentures, for all people on Medicare,” KFF analysts wrote in its discussion points.
“Absent a broader expansion of dental coverage under Medicare, people on Medicare who do not have another comprehensive source of dental coverage will continue to face relatively high out-of-pocket costs, particularly if they need extensive dental care that is unrelated to other covered medical services,” KFF concluded.
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