As policymakers consider proposals to slash successful community programs including Medicare and Medicaid, older Americans and their families continue to face barriers to necessary health care, including access to dental coverage and services. A new report from Oral Health America highlights this growing dental crisis for older Americans. According to the report, lack of affordable dental coverage options, provider shortages, and lack of preventive programs in communities across the country are creating serious hardship for older adults. Policy options to improve access and coverage, combined with community outreach and education, would strengthen public health while mirroring overall health care reform efforts to improve care, improve health, and lower long-term costs by investing in preventive care.
Older Americans Lack Dental Coverage
Despite improvements in oral health for the general population in the past 50 years, older Americans still face high risk of oral disease. The problem is likely to grow as the baby-boomer generation enters retirement: only 2% of boomers who retire do so with access to dental insurance benefits through their former employers or private market dental plans.
Lack of dental insurance is a major access barrier to dental care for older adults. Nearly 70% of older Americans currently have no form of dental insurance. Older adults with dental insurance are 2.5 times more likely to visit the dentist on a regular basis. Private insurance, however, remains costly, while coverage for low-income adults on Medicaid is optional for states and limited in those that do offer it. Forty-two percent of states provide no dental benefit or only emergency coverage through adult Medicaid. In states where dental coverage is provided through the adult Medicaid program, getting dental care can still be a challenge for beneficiaries due to low reimbursement rates and provider shortages.
In addition, coverage for routine dental care under Medicare – the largest health insurance provider for individuals over 65 – is virtually nonexistent. Less than 1% of dental services are covered by Medicare. In addition, because the services are not covered under Medicare, Medigap insurance, purchased by beneficiaries to supplement Medicare coverage and assist with out-of-pocket costs, does not cover dental services.
For older individuals living on fixed or low-incomes, the high cost of dental care deters those who lack insurance coverage from seeking needed treatment. A recent survey revealed that older individuals who earn less than $35,000 a year consider cost as the main factor in deciding whether to seek care. In the same survey, more than half making less than $35,000 reported not visiting a dentist routinely because they lack insurance or cannot afford the costs associated with seeking care. Two-thirds in the same income group said that if faced with the need for common dental procedures such as a crown, implant, or bridge, they would be unable receive the procedure due to cost. Older Americans in poverty are more than 60% more likely to have lost all of their teeth compared to those with higher incomes.
Differences in race, income, and disability status also impact older Americans when it comes to oral health and dental care. Poor oral health disproportionately occurs among racial and ethnic minorities, and also in older adults with physical and intellectual disabilities and those who are homebound or institutionalized. Older African-American adults are nearly twice as likely to have periodontitis (gum disease) than their white counterparts.
Lack of accessible, affordable dental coverage can lead to adverse health outcomes. Data shows, for example, that certain oral conditions including periodontal disease can increase risk for heart attacks and strokes. Conversely, many chronic health conditions can contribute to oral health problems, leading to further complications like those above.
The lack of coverage in the largest public insurance programs (Medicare and Medicaid) leaves individuals with few options for accessing needed care. Emergency room visits for dental-related issues among adults over 65 rose from 1 million in 1999-2000 to 2.3 million in 2009-2010. As overall health care system reforms aim to emphasize primary and preventive care and deter costly emergency care, dental care remains neglected by policymakers at a time when the need for attention is greater than ever.
The report highlights several policy solutions to address the dental crisis facing older Americans. Chief among them are the need for expanded coverage in Medicare and Medicaid. Further, adult dental coverage and services should be deemed as "essential health benefits" under the Affordable Care Act to expand access to services for those under 65. The report argues that states need a legal mandate for providing oral healthcare in Medicaid to ensure broad coverage and more equitable provider payment. In addition, the lack of dental coverage in Medicare must be addressed to effectively confront the growing challenge faced by older Americans.
Legislation to enact these policy proposals has been introduced in Congress, and includes:
- The Comprehensive Dental Reform Act of 2013: Introduced by Senator Sanders and Schatz in the Senate, and Representatives Cummings and Schakowsky in the House, this landmark legislation is the most comprehensive dental care legislation in American history. It extends comprehensive dental coverage to all individuals covered by Medicare, Medicaid, and the Veterans Administration, and would include oral health as an essential benefit as defined under the Affordable Care Act. 
- Special Care Dentistry Act of 2011: While this legislation has not been reintroduced in the current session of Congress, it would have extended dental services to millions of individuals by requiring states to provide oral health services to aged, blind, or disabled people under the Medicaid program. The federal government would cover 100% of the cost of this expansion.
Strengthening community education and outreach and addressing provider payment and shortage issues are critical to addressing the dental crisis faced by older Americans and people with disabilities. The lack of dental coverage in Medicare and Medicaid, and the expense of private insurance options remain barriers to needed care. Solutions that address oral health and access to dental care must be a part of efforts to improve and modernize Medicare and Medicaid. The Center for Medicare Advocacy has fought for expanded dental coverage for Medicare beneficiaries, and continues to advocate for policy changes that improve access to affordable care for older people and people with disabilities. Instead of cutting Medicare, Medicaid, and other critical health care programs serving our nation's most vulnerable individuals, policymakers should work to improve public health and modernize our largest insurance programs by expanding coverage and benefits, including comprehensive dental care.
 Oral Health America, State of Decay: Are Older Americans Coming of Age without Oral Healthcare?, available at http://www.toothwisdom.org/action
 CNN, "Dental crisis could create 'State of Decay'",
 Centers for Medicare and Medicaid Services, Chronic Conditions Among Medicare Beneficiaries, 2012 Chartbook, available at http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/Downloads/2012Chartbook.pdf.
 Oral Health America, State of Decay.
 Legislation available at http://thomas.loc.gov/cgi-bin/bdquery/z?d113:s1522:.
 Legislation available at http://thomas.loc.gov/cgi-bin/bdquery/z?d112:hr1606:.
 Center for Medicare Advocacy, Fournier v. Leavitt, more at http://cma.benfredaconsulting.com/fournier-v-leavitt/.