William Stork needs a tooth. That’s what the 71-year-old retired truck driver’s dentist told him during a recent check-up.

This type 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 will not cover his dental bills. Between Social Security and his Teamsters Union pension, Stork says he can live comfortably in Cedar Hill, Missouri, about 30 miles southwest of St. Louis. But this cost is significant enough that he decides to wait until the tooth absolutely has to come out.

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

A unique opportunity

Health equity advocates see President Joe Biden’s Build Back Better program as a unique opportunity to provide dental coverage to those on Medicare, nearly half of whom have not visited. a dentist in 2018 – long before the pandemic interrupted dental appointments for a lot of people. Rates were even higher for black (68%), Hispanic (61%) and low-income (73%) seniors.

Coverage was excluded from a new framework announced by President Joe Biden on Thursday, but supporters are still hoping they can get the cover in a final deal. To further complicate their push, there is a debate over how many of the country’s more than 60 million Medicare beneficiaries should receive it.

Advocates of dental coverage for anyone on Medicare find themselves facing an unlikely opponent: the American Dental Association, which supports an alternative plan that would offer dental benefits only to low-income Medicare beneficiaries.

Medicare has excluded dental (and visual and hearing) coverage since its inception in 1965. This exclusion was intentional: the dental profession has long fought to separate itself from the traditional medical system, in order to preserve the autonomy of the field.

Dental care and health are inextricably linked

More recently, however, dentists have emphasized the link between oral health and overall health. More infamously, the 2007 death of a 12-year-old boy that could have been prevented with an $ 80 tooth extraction led to changes in Maryland’s version of Medicaid, the federal state’s public insurance program. for low-income people. But researchers also, for example, linked dental care to reduced health care costs in patients with type 2 diabetes. When the World Health Organization suggested delaying oral health visits. -dental elective last year to prevent the spread of COVID-19, the American Dental Association pushed back, with Dr. Chad Gehani, president of the organization at the time, saying, “Oral health is integral to overall health. Dentistry is essential health care.

The ADA-backed Medicare proposal would only cover seniors who earn up to three times the poverty level. This currently translates to $ 38,640 per year for an individual, reducing the number of potential beneficiaries from over 60 million people to about half that number.

Medicare has never required means testing, but in a world where Congress seeks to cut social spending 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 profit the most. A Congressional Budget Office analysis estimated that the plan to provide dental coverage to all Medicare beneficiaries would cost $ 238 billion over 10 years.

Research Finds Cost Is A Barrier To Dental Care

Unlike the ADA, the National Dental Association is pushing for a universal dental benefit of Medicare. The group “promotes equity in oral health among people of color” and was formed in 1913, in part because the ADA only eliminated discriminatory membership rules for its affiliates. in 1965. Dr. Nathan Fletcher, chairman of the board of directors of the NDA, said he was not surprised to find his organization at odds with the ADA on this issue regarding Medicare coverage.

“The face and demographics of ADA is a 65 year old white male. retirement, ”Fletcher said. said. “It doesn’t look like the [patients] we’re talking about. “

Research by the ADA’s Health Policy Institute found that cost was a barrier to dental care “regardless of age, income level or type of insurance,” but low-income seniors were more likely to report it as an obstacle.

Why Some Oppose a Universal Dental Medicare Benefit

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

Graham criticizes the design of Congressional proposals for a universal dental benefit for Medicare, noting that one includes a 20% co-payment for preventative services that could prevent low-income patients from accessing the care they would get. otherwise.

“Something is better than nothing, but the something [with a copay] means next to nothing for a lot of seniors, ”Graham says.

The ADA supports 100% preventative services for low-income Medicare beneficiaries, he says.

Would Most Dentists Take Medicare Patients?

Of course, only covering low-income seniors has its own questions, the most important of which is: will dentists even accept Medicare if they don’t have to? Low-income patients often seek dental care at safety clinics that plan months in advance. Some dentists fear that a limited Medicare benefit to low-income seniors will be easier to avoid, pushing even more newly insured Americans into an already overburdened dental safety net.

Overall, less than half of American dentists accept Medicaid, although more than 60% of NDA members do, according to Fletcher. The ADA is concerned that the reimbursement rates and red tape for a Medicare benefit will also be unattractive to many of its members.

But Fletcher, who is the dental director of a Medicaid insurance company in Washington, DC, says participation in Medicaid varies widely from state to state – and, as with Medicaid, participation in any new dental program. Medicare would largely depend on the design of the benefit.

If reimbursement rates for a Medicare benefit are high enough, Fletcher says, providing coverage to tens of millions of seniors could be very lucrative for dentists. Ultimately, he says, dentists should have the choice of whether or not to accept Medicare patients, and all Medicare patients should be entitled to dental services, since they have paid into the program.

A generational divide in the profession

William Stork’s dentist Dr. Nathan Suter sees adding dental insurance for all seniors to be the right thing to do.

A self-proclaimed “proud member of the ADA,” Suter finds himself at odds with the organization, which showered him with praise. He was named Dentist of the Year by the Affiliate Dental Association of Missouri in 2019 and received one of the ADA Awards for Young Dentists in 2020.

“As a member of the ADA, I think they should be at the table for me, making sure it’s as good a benefit as possible for all of my seniors,” says Suter, who believes that at least 50% of the patients in his practice in House Springs, Missouri, are seniors.

But rather than lobby for universal benefit, the well-funded ADA lobbying operation opposes the plan proposed by Congressional Democrats to add dental coverage for all Medicare beneficiaries. The organization has asked its members to send e-mails to representatives of Congress on the subject; over 60,000 emails have been sent so far, Graham says.

Suter sees the battle over who to cover as a generational divide. As an early-career dentist, he prefers to add full dental coverage now so he can adapt his business model sooner. And the more seniors who benefit from dental coverage, the more its potential clientele grows. Dentists like him, who continue to grow their practice, are less likely to have the time to get involved in the ADA’s policy-making process, he says.

Patients like Stork, who say the possibility of dental coverage in Medicare is one of the reasons he’s withholding the tooth extraction he needs, even though he knows a benefit is unlikely to happen. be implemented before years, if at all.

Stork also knows that the benefit might not cover a middle class person like him, even if it is approved. Still, it would definitely be nice to have when her tooth can’t wait to come out.

Kaiser Santé news is a national, editorially independent program of the Kaiser Family Foundation and is not affiliated with Kaiser Permanente.