Oral Health Care for All
Even before COVID-19 disrupted the economy, more than 74 million Americans lacked access to dental coverage, and more than 45 million Americans lived in areas lagging in dental services. Black, brown and low-income adults, as well as people living in rural areas, are disproportionately affected and far more likely to face barriers.
On December 10, several leading voices on oral health gathered for POLITICO’s virtual event, “Closing America’s Oral Health Care Gap” presented by DentaQuest, an oral health care company dedicated to improving the oral health of all, to unpack these challenges and identify possible solutions.
Elizabeth Gianini, senior vice president of government relations at DentaQuest, said that unmet dental needs and lack of routine care can lead to serious health conditions.
“Poor oral health increases risks, costs and worsens outcomes for far too many chronic diseases, including diabetes, asthma, hypertension and depression,” she said. Dental problems also result in lost hours from work and school and bear an emotional toll: When someone is uncomfortable with their smile, it could impact their social life, career opportunities and more.
Addressing these health disparities calls for system-wide changes, said Gianini. In an approach called the “Three Domain Framework to Innovating Oral Health Care,” the DentaQuest Partnership for Oral Health Advancement has outlined solutions that emphasize expanding Medicaid and Medicare coverage; increasing the use of teledentistry to reduce costs and improve access; and focusing on value-based care approaches, such as integrating medical and dental care and improving prevention through minimally invasive techniques that address issues before they require costly surgical interventions.
Gianini and other oral health leaders believe that these solutions are crucial to addressing inequities and building a better health system that benefits all people.
Meeting patients where they are
For many people, scheduling a dental cleaning and check-up is a routine step in their health care habits, such as an annual wellness visit to the doctor. But that’s not true in all communities.
“In the United States in particular, people are more likely to have poor oral health if they're from low-wealth communities, if they're uninsured or if they are members of racial and ethnic minority groups. Also, immigrants in rural populations because they have suboptimal access to oral health care,” said event panelist Charles Moore, M.D., who is chief of otolaryngology with Grady Health System, founder of HEALing Community Center and director of the Emory Urban Health Initiative.
Black adults are 22 percent less likely than white adults to have had a routine dental visit in the past year and 68 percent more likely to have an unmet dental need. Latino adults are 52 percent more likely than white adults to report having difficulty performing at work due to poor oral health. Four-in-ten Black and Latino adults reside in one of the 14 states where Medicaid’s adult dental benefits don’t cover any services or cover emergency-only care. And people living outside of cities are also at a disadvantage: 43 percent of Americans live in rural areas that lack access to dental care.
These problems result in massive losses in productivity. According to the Centers for Disease Control and Prevention, more than 320 million hours of work and school are lost annually for dental care in the United States, and nearly one-third of those hours are for emergencies or unplanned care. Again, there’s a disparity by race and ethnicity, with communities of color bearing more of the burden.
COVID-19 has further exacerbated those inequities. Because of the pandemic’s economic impact, dentists’ offices have closed; people have lost their jobs, and with them, their dental insurance; and many are delaying dental visits because of health and safety concerns. Plus, children who would normally receive preventive dental care in a school setting have largely been going without care during the pandemic.
Ann Battrell, who is CEO of American Dental Hygienists' Association, said COVID-19 has underscored the need to meet people where they are. “The traditional dental practice is just one of those mechanisms to provide care, so we really have to focus on how we are going to bring oral health care to these populations and not expect that it's always about coming to a dental practice,” said Battrell, speaking on the panel.
Teledentistry, which allows patients and dentists to connect virtually, is one way of addressing that. Early in the pandemic, as shelter-in-place orders took hold in much of the country, teledentistry visits increased by 50 percent.
Richard Valachovic, who also sat on the virtual event panel, is a visiting scholar at NYU College of Dentistry and former CEO of the American Dental Education Association. He said that teledentistry has long been practiced in rural settings. Its rapid adoption during COVID-19 demonstrated the benefits it can offer a broad range of populations, including Medicare and Medicaid beneficiaries, the uninsured, underserved and rural populations, people with urgent needs and others.
“I think that we need to take advantage of this moment of the pandemic to try to sustain this, as opposed to letting this opportunity go,” he said.
The panelists agreed that integrating dental and medical care is another important step forward. In some settings, nurse practitioners and physician assistants are now being trained to screen for potential oral health issues, so that they can make referrals for patients. And at integrated practices like HEALing Community Center, which Moore founded, staff remind patients to keep up with both preventive dental and medical services, which are all carried out under the same roof. When they check in at the front desk for a doctor’s appointment, for example, they might be encouraged to schedule a cleaning. That, said Battrell, makes health care more convenient for people like busy moms, or those who don’t have regular access to transportation.
“You can lessen that prevalence of missed appointments and whatnot if they're going one place to receive care, not three different places,” she said.
Additionally, any type of health concern impacts the entire person, said Valachovic. “The mouth is a part of the body. Inflammation in the mouth is inflammation just like anywhere else in the body. And so, we have to stop thinking, ‘Oh, you have your medical care and your dental care and your medical insurance and your dental insurance.’ We need to be integrated in many more ways than we already are.”
Around 33 million Americans lack health insurance coverage. At least twice as many lack oral health coverage. Changing that begins with expanding Medicare and Medicaid.
“We must first address the fact that in 14 states, Medicaid fails to provide access to comprehensive dental benefits for low-income adults, and a recent Centers for Medicare & Medicaid Services (CMS) rule will make it easier for states to cut those benefits,” said Gianini. “Likewise, Medicare does not cover dental care at all, leaving 44 million seniors nationwide without access to benefits. These inequities have very real consequences for far too many people.”
Medicare does not cover dental care at all, leaving 44 million seniors nationwide without access to benefits. These inequities have very real consequences for far too many people.
Valachovic pointed out that many people receive dental coverage through their workplace. When they retire or leave their jobs and start on Medicare, they lose that benefit, often for the first time in their lives. That can be dangerous, because the risk for a number of dental problems, including cancer and other diseases, increases with age, said Moore.
“Oral cavity cancers are more common as we mature, and that's something that our dental colleagues, our primary care physicians, everyone can be aware of and that we can educate all of our patients on,” he said. “Without that coverage, it's more likely that those types of things, in addition to what most people think of as traditional dental care, will be missed.”
While adults on Medicaid face barriers to dental care in many states, all states are required to provide dental visits to children covered by Medicaid and the Children's Health Insurance Program (CHIP); and under the Affordable Care Act, pediatric dental coverage is considered an essential health benefit. Because of that, Valachovic said there’s been an increase in child visits to dental offices in recent years. However, obstacles remain, including an insufficient number of dentists who provide Medicaid services and inconsistent reimbursement levels across different states. Valachovic hopes that in coming years, policymakers will address these gaps and expand access for those who need it most.
Working towards something to smile about
Improving access to oral health care is important on a community level as well as an individual level. While statistics paint a stark portrait of the health conditions, health disparities and inequities that make up the problem, behind those numbers lies another asset that’s impossible to measure: the value of a smile.
“We can talk about all the issues related to cavities and gum disease and so on and so forth, but if you don't have a smile, it's difficult for you to get employment. It's difficult for you to have social interactions. A whole variety of other factors are at play here, and so that's why having access for kids and adults remains something very important,” said Valachovic.
Throughout the dental industry, experts hope that fall-out from the pandemic will lead to positive systemic change. “As we move forward, hopefully COVID will be an impetus for the dental team to continue being elevated and integrated into the overall health care workforce, and not this separate specialty that is not considered part of the health care team,” said Da-Nell Pedersen, who is director of clinical programs at Arizona Alliance for Community Health Centers.
Bob Russell, who is public health dental director for the state of Iowa, believes that these candid conversations are important, and transformation is eminent. “Dentistry is evolving. By adopting models of both treatment and coverage that put the patient at the center of the equation, we can start to close the oral health care gap,” he said.
Arriving at a lasting solution will demand a collaborative effort, at all levels. “State and federal leaders, as well as health care industry experts must be catalysts for this kind of change if we're to achieve healthier communities,” said Gianini. “Together, we can make change.”