What’s Next for Oral Health in Medicare? A Former Congressman Explains.

Congress is working on significant legislation — including adding dental coverage to Medicare — that could improve the lives of millions of Americans. So, what happens next? And how did we end up in this situation where we’re trying to expand dental coverage for people who need it most? 

Chet Atkins served as Congressman for the 5th District of Massachusetts from 1985 – 1993 and was a member of the House Appropriations Committee and the House Ethics Committee. Before that, he served in the Massachusetts House of Representatives and the State Senate for more than 10 years. He knows his way around legislation and budgeting, and he’s passionate about improving our oral health and overall health systems. We asked Chet a few questions about this moment, something he calls, “literally, a once-in-a-lifetime opportunity.”

Let’s start at the beginning. Why isn’t oral health covered under Medicare?

Health coverage has been a central issue in American politics going back to 1912 when Teddy Roosevelt first proposed coverage. Harry Truman proposed it after that, but it wasn’t until 1965 that Medicare was signed into law by Lyndon B. Johnson. In 1965, that legislation was a terrible fight — one of the great political fights of the 20^th century. While dentists were qualified as health care providers, the legislation and subsequent regulations covered only an extremely limited set of dental procedures. When we look at those covered procedures today, they seem irrationally limited in the context of today’s health care delivery.

And that’s part of the historical separation between medicine and dentistry?

Yes, it isn’t based in science or clinical evidence. It’s based in politics and in the historical circumstances surrounding medical and dental education and training. Over time, study after study has shown the importance of integrating oral health care with all other health care coverage. Oral health is a central driver of overall health outcomes. And oral health coverage, particularly oral health prevention, leads to significant savings in the health care system. More than $1 billion is spent every year on ED visits that are related to a lack of oral health care. There is now widespread recognition of two things: One, our health care system is flawed because of this lack of integration; two, we understand that lack of oral health coverage has a disproportionate impact on underserved populations. Health disparities are far greater in oral health because of this lack of coverage.

Can you pinpoint a few of those disparities?

There have been a number of studies from groups like the Kaiser Family Foundation that show 1 in 5 seniors have untreated tooth decay, 70% of seniors have gum disease, and 27% of Black seniors have experienced complete tooth loss. The potential savings and improvements in health outcomes are increasingly clear and compelling.

When did the momentum for our current moment begin?

After the Affordable Care Act passed in 2010, members of Congress started to look at Medicare to include coverage of hearing, vision, and dental. Senator Bernie Sanders (I-Vermont) offered legislation in 2015 to include a dental benefit in Part B. In 2019, the House passed legislation that expanded Medicare Part B to include a dental and vision benefit. Senators Sanders and Senator Ben Cardin (D-Maryland) have made this a top priority for the Budget Committee. In the current Congress, there’s overwhelming support among House Democrats and we’ve seen a growing number of senators (including Majority Leader Senator Chuck Schumer (D-NY)) sign on.

Let’s jump to now. What’s next for this legislation?

The current situation is that the Senate had divided infrastructure into two bills: hard infrastructure (things like bridges, roads, and dams) and human infrastructure (things like health care (including dental benefits in Medicare), daycare, early childhood education). A bipartisan group of Senators, on Wednesday, voted to begin work on hard infrastructure. Once the Senate passes that bill, the Senate plans to address human infrastructure. For almost all matters, the Senate requires 60 votes to pass legislation. The one exception to this is a process called reconciliation, which requires only 51 votes. The reconciliation process begins in the Senate Budget Committee, which Senator Sanders chairs. And the Senate Budget Committee has now agreed on a $3.5 trillion human infrastructure bill with non-binding instructions, which encourages the Senate Finance Committee to pass legislation to cover Medicare Part B to include a dental, vision, and hearing benefit. The Budget Committee allocates a sum of money to Senate Finance, which will have the last say on how they spend that money, so the key players right now for Medicare Dental expansion are the Democratic members of the Senate Finance Committee who will make the ultimate decision about which priorities get funded. While these instructions are not binding, it is highly likely that the Senate Finance Committee will accept the Senate Budget Committee instructions and pass the expanded Medicare coverage through the Senate Finance Committee for inclusion in a budget reconciliation package. That package would be considered by the full Senate. 

What, specifically, would be covered if this legislation passes?

While the language has not been drafted in the Senate, it appears from previous House action that the language will be something like the following, “services that are necessary to prevent disease and promote oral health, restore oral structures to health and function, and treat emergency conditions.” In general terms, it means Medicare Part B would cover regular preventive care (cleanings, x-rays), minor work (fillings), and major work (crowns, root canals, dentures). It would cost $238 billion over 10 years. It would cover 2 out of 3 Medicare recipients who don’t have supplemental coverage for dental right now, 1 in 2 seniors who haven’t seen a dentist in last year, and 1 in 7 seniors who have lost all their teeth.

What can oral health advocates and stakeholders do to show their support for this?

The challenge for oral health advocates will be to make sure that dental coverage is included in the final negotiation. There are far more funding demands for reconciliation than there is financing available. This is reflecting the adage that the legislative process is akin to trying to fit 10 pounds of sausage into a 2-pound sausage skin. Something is going to be left on the butcher shop floor and we need to make sure dental care isn’t what’s left there.

That’s memorable imagery! So, contacting legislators is the best next step?

Yes! Personal contact — personal emails and letters — are the most effective advocacy. The important message is a thank you for your support and an emphasis on how important expanded coverage will be, particularly with stories about individual experiences with people lacking coverage. The legislative process is sometimes driven by numbers but mostly driven by narrative. We need to tell stories about what happens when seniors do not have access to coverage. Every Senator has a dentist and a dental hygienist. The Senators understand the importance of oral health in their own lives. The key is to engage them, to let them know this is important and that this needs to happen now. This is literally a once-in-a-lifetime opportunity. We are right on the 2-yard line of making this a reality and we need to use every ounce of persuasion we have.