Older woman receiving dental care

Medicare—the U.S. government’s health insurance program for adults 65 and over, as well as people of all ages with disabilities—currently covers cancer screenings, mental health services, and appointments with specialists from allergists to urologists. But what about a visit to the dentist? Surprisingly, most dental services are not covered by Medicare, despite the fact that older adults are at increased risk for dental problems, including gum disease and tooth loss.

Older adults “currently access dental care benefits in a piecemeal fashion,” according to a paper by NYU College of Dentistry researchers published earlier this year—perhaps finding coverage through employer benefits, Medicaid, or buying a supplemental insurance plan. However, the Kaiser Family Foundation found that nearly half of Medicare beneficiaries have no dental coverage, and have not been to the dentist in the past year.

But this lack of federal dental coverage could change as U.S. lawmakers consider expanding Medicare to include dental, vision, and hearing benefits. While the proposed expansion would be expensive—the Congressional Budget Office estimates that covering dental under Medicare would cost taxpayers $238 billion over 10 years—it is popular among Americans, would increase access for millions of older adults, and could reduce the substantial out-of-pocket costs that older adults incur for dental care.

“Cost is the major barrier that keeps people from visiting the dentist,” says  Richard Valachovic, clinical professor at the NYU College of Dentistry and director of the NYU Dentistry Center for Oral Health Policy and Management. “Making dental care more accessible to the 62 million older adults and people with disabilities covered under Medicare has the potential to improve our country’s overall health, given the well-documented connection between oral health and the health of the rest of the body.”

Prior to joining NYU, Valachovic was the president and CEO of the American Dental Education Association (ADEA), where he was involved in advocacy efforts that were successful in improving access to dental care, including ensuring that kids’ oral health services were an essential health benefit in the Affordable Care Act and the expansion of dental benefits in Medicaid and the Children's Health Insurance Program.

Richard Valachovic

Richard Valachovic

NYU News spoke with Valachovic about the proposed Medicare expansion and what it would mean for those eligible.

Why is dental insurance separate from medical or health insurance?

Medical insurance began during the 1940s as a way for employers to create incentives beyond a base salary for recruiting employees.  Insurance premiums that were paid by employees were considered tax-free under IRS regulations. In general, medical insurance is based on a risk sharing model for a group or groups and assumes that covered individuals are mostly healthy and need insurance to cover unexpected health events.

The concept of a dental benefit started in the 1950s as a supplement to medical insurance. But at that time, dental diseases were quite prevalent in the U.S. population and using a risk sharing model was not financially feasible. In fact, the term “dental insurance” is a misnomer as there are annual maximum payments, usually $1,000 to $2,000, with considerable deductibles and copayments, along with pretreatment reviews required for many procedures.

How accessible, and important, is dental care for those who rely on Medicare?

Access to dental care for older adults is probably the most challenging of any age cohort, and this is particularly true for the Baby Boomer generation. These individuals grew up at a time of limited access to community water fluoridation or other preventive dental practices that are available today. As a result, many of them have either chronic dental conditions that emerged over a lifetime or have had dental procedures in the past that now need replacement or alternative restoration.

This is complicated by a couple of additional concerns. Older adults often face a reduction in their incomes upon retirement, making the cost of dental care even more out of reach. Others are surprised to learn that Medicare does not cover dental care after having had access to dental benefits through their employers during their careers.

How have dental schools helped to offset these issues for older adults?

Dental schools like the NYU College of Dentistry play a huge role in serving the needs of individuals with access to care challenges, both by providing care and training the next generation of dentists. The clinical facilities within dental schools provide a critical safety net for many of these patients—there are more than 300,000 patient encounters a year just at NYU Dentistry. The fees charged for dental care within the teaching clinics in dental schools are generally around 50 percent of those charged by dentists in the local area.

What would the proposed expansion of Medicare change about dental coverage for older adults?

The current legislation that is being considered by Congress and the Biden Administration would provide comprehensive dental benefits through the Medicare program. It would be similar to other employer-provided dental insurance programs. This would mean that Medicare eligible individuals would be covered in part for routine preventive care, such as cleanings and X-rays, and restorative dental services, such as fillings and crowns.

There are a number of important outcomes that would result from this program. Of course, everyone—no matter what their age—wants to be able to smile without embarrassment, and social interactions can depend on a person’s facial appearance. But good oral health is more than just a smile. Teeth are needed to chew food to prepare for digestion. The mouth is part of the human body and inflammation from dental diseases can spread to the rest of the body, with relationships documented between such conditions as gum disease and cardiovascular disease, stroke, and diabetes.

Why are dentists and professional organizations divided on whether Medicare should cover oral health?

A survey of a random sample of dentists conducted with support of the American Dental Association in 2018 found that more than 71 percent agreed that Medicare should include comprehensive dental benefits. However, some dentists and organizations oppose the proposal.

The majority of dental care in the United States is provided in small private practices, often with just one or two dentists. The financial model for the success of these practices is challenging given the costs of the facility, dental staff, equipment, and supplies. Like other small business owners, dentists are concerned about the sustainability of their operation when faced with proposals that are not yet well-defined, such as a dental Medicare benefit, which will impact that business model.