If Congress adds dental coverage to Medicare, should all seniors get it?

William Stork needs a tooth out. That's what the 71-year-old retired truck driver's dentist told him during a recent checkup.

That kind of extraction requires an oral surgeon, which could cost him around $1,000 because, like most seniors, Stork does not have dental insurance, and Medicare won't cover his dental bills. Between Social Security and his pension from the Teamsters union, Stork said, he lives comfortably in Cedar Hill, Missouri, about 30 miles southwest of St. Louis. But that cost is significant enough that he's decided to wait until the tooth absolutely must come out.

Stork's predicament is at the heart of a long-simmering rift within the dental profession that has reemerged as a battle over how to add dental coverage to Medicare, the public insurance program for people 65 and older — if a benefit can pass at all.

Health equity advocates see President Joe Biden's Build Back Better agenda as a once-in-a-generation opportunity to provide dental coverage to those on Medicare, nearly half of whom did not visit a dentist in 2018, well before the pandemic paused dental appointments for many. The rates were even higher for Black (68%), Hispanic (61%) and low-income (73%) seniors.

The coverage was left out of a new framework announced by President Joe Biden on Thursday, but proponents still hope they can get the coverage in a final agreement. Complicating their push is a debate over how many of the nation's more than 60 million Medicare beneficiaries should receive it.

Champions for covering everyone on Medicare find themselves up against an unlikely adversary: the American Dental Association, which is backing an alternative plan to give dental benefits only to low-income Medicare recipients.

Medicare has excluded dental (and vision and hearing) coverage since its inception in 1965. That exclusion was by design: The dental profession has long fought to keep itself separate from the traditional medical system.

More recently, however, dentists have stressed the link between oral and overall health. Most infamously, the 2007 death of a 12-year-old boy that might have been prevented by an $80 tooth extraction prompted changes to Maryland's version of Medicaid, the federal-state public insurance program for low-income people. But researchers have also, for example, linked dental care with reduced health care spending in patients with Type 2 diabetes. When the World Health Organization suggested delaying non-urgent oral health visits last year to prevent the spread of covid-19, the American Dental Association pushed back, with then-President Dr. Chad Gehani saying, "Oral health is integral to overall health. Dentistry is essential health care."

The ADA-backed Medicare proposal would cover only seniors who earn up to three times the poverty level. That currently translates to $38,640 a year for an individual, reducing the number of potential recipients from over 60 million people to roughly half that number. Medicare has never required means testing, but in a world where Congress is looking to trim the social-spending package from $3.5 trillion over 10 years to $1.85 trillion, the ADA presents its alternative as a way to save money while covering those who need a dental benefit the most. A Congressional Budget Office analysis estimated the plan to provide dental coverage to all Medicare recipients would cost $238 billion over 10 years.

Unlike the ADA, the National Dental Association is pushing for a universal Medicare dental benefit. The group "promotes oral health equity among people of color," and formed in 1913, in part, because the ADA did not eliminate discriminatory membership rules for its affiliates until 1965. Dr. Nathan Fletcher, chairman of NDA's board of trustees, said he was unsurprised to find his organization at odds with the ADA over this issue of Medicare coverage.

"The face and demographic of the ADA is a white male, 65 years old. Understand that those who make decisions for the ADA are usually the ones who have been in practice for 25 to 30 years, doing well, ready to retire," Fletcher said. "It looks nothing like the [patients] who we're talking about."

Research from the ADA's Health Policy Institute found cost as a barrier to dental care "regardless of age, income level, or type of insurance," but low-income older adults were more likely to report it as a barrier.

"It would be tragic if we didn’t do something for those low-income seniors," said Michael Graham, senior vice president of government and public affairs for the ADA.

Graham is critical of the design of the proposals in Congress for a universal Medicare dental benefit, noting that one includes a 20% copay for preventive services that could block low-income patients from accessing the care they would presumably be gaining.

"Something is better than nothing, but the something [with a copay] almost equals nothing for many seniors," Graham said.

Graham said the ADA backs covering 100% of preventive services for low-income Medicare recipients.

Of course, covering only low-income seniors presents its own questions, the biggest being: Will dentists even accept Medicare if they don't have to? Low-income patients often seek care at safety-net clinics that schedule out months in advance. Some dentists worry a Medicare benefit limited to low-income older adults would be easier to shun, pushing even more newly insured Americans into an already burdened dental safety net.

Fewer than half of dentists overall accept Medicaid, but more than 60% of NDA members do, according to Fletcher. The ADA worries the reimbursement rates and bureaucratic paperwork for a Medicare benefit will be similarly unappealing.

But Fletcher, who is dental director for a Medicaid insurance company in Washington, D.C., said participation in Medicaid varies widely across states — and, as with Medicaid, participation in any new Medicare dental program would largely depend on the benefit's design.

If the reimbursement rates for a Medicare benefit are high enough, Fletcher said, giving coverage to tens of millions of seniors could be quite lucrative for dentists. Ultimately, he said, dentists should have a choice in whether to accept Medicare patients, and all Medicare patients should be entitled to dental services since they paid into the program.

Dr. Nathan Suter, William Stork's dentist, sees adding a dental benefit for all seniors as the right thing to do.

A self-described "proud ADA member," Suter finds himself at odds with the organization, which has showered him with accolades. He was named Dentist of the Year by the affiliated Missouri Dental Association in 2019, and received one of the ADA's awards for young dentists in 2020.

"I, as an ADA member, think they should be at the table for me, making sure it’s as good a benefit as possible for all of my seniors," said Suter, who estimated at least 50% of patients at his House Springs, Missouri, practice are older adults.

But rather than push for a universal benefit, the ADA's well-funded lobbying operation is pushing against congressional Democrats' proposed plan to add dental coverage for all Medicare recipients. The organization has asked its members to contact their congressional representatives on the topic. Graham said more than 60,000 emails have been sent to Capitol Hill so far.

Suter sees the battle over whom to cover as a generational rift. As an early-career dentist, he prefers adding full dental coverage now so he can adapt his business model sooner. And the more seniors who get dental coverage, the more his potential client base expands. Dentists like him, still building their practices, are less likely to have time to be involved in the ADA's policymaking process, he said.

Caught up in it all are patients such as Stork, who said the possibility of dental coverage in Medicare is one reason he is holding off on the extraction, even though he knows a benefit is unlikely to be implemented for years, if at all.

Stork also knows the benefit might not cover a middle-class person like himself even if approved. Still, it sure would be nice to have when his tooth cannot wait any longer to come out.