Policy Brief Analysis

To: Bob Cook-Deegan

From: Abd-Manaaf Bakere
Date: July 18, 2023
Re: Policies to Implement to Increase access to dental care

Problem Statement: What type of policy should be implemented to increase access to dental care?

Background:
Maintaining good dental hygiene is crucial as we rely on our mouths for various daily activities throughout our lives. From breathing and speaking to consuming food and beverages, our oral health significantly impacts our overall well-being. This is particularly true for the elderly population, where neglecting proper dental care can lead to an increased risk of gum pain and gum disease, resulting in difficulties with eating, dry mouth affecting speech, and compromised eating habits. Furthermore, poor dental health among the elderly can have cosmetic implications, affecting self-esteem. Research has also established a correlation between periodontal disease and other health complications such as heart issues, strokes, diabetes-related complications, and respiratory problems^1. According to a recent report by the CDC, approximately 47.2% of adults aged 30 years and older have some form of periodontal disease, with the prevalence increasing with age, affecting 70.1% of adults aged 65 years and older^2.

The oral health of Americans has shown improvement over time, but significant challenges. remain, particularly for low-income families. Limited access to oral health care perpetuates a cycle of poverty and compromised overall health. Children from low-income families are more likely to suffer from tooth decay and less likely to visit the dentist, leading to untreated decay affecting more than 9.6 million kids^3. The consequences of untreated tooth decay extend beyond pain and anxiety, as it can cause malnourishment and make children vulnerable to bullying. Moreover, dental issues contribute to missed school hours, with 34 million hours lost annually^3.

Landscape:

Dental insurance coverage remains a significant concern in the United States, with one in three Americans lacking dental insurance. The primary deterrent for adults in seeking dental care is the high cost associated with it^4. For individuals without insurance, routine dental cleanings can cost nearly $200, while extensive treatments like braces can quickly accumulate into thousands of dollars. It is important to note that health insurance and dental insurance are separate in the US, and public insurance programs such as Medicaid and Medicare either provide limited coverage or do not cover dental care at all. Public officials have a crucial role in considering the inclusion of dental care within Medicaid and Medicare. Expensive private dental insurance policies typically offer coverage in three categories: preventive care (such as regular exams, cleanings, and X-rays) with 100% coverage, basic services (including fillings and simple extractions) with 80% coverage, and major services (such as root canals, bridges, crowns, dentures, and implants) with 50% coverage.

The American Dental Association highlights several reasons why individuals are not able to access necessary dental care. The primary reason, affecting 11.4% of people, is the inability to afford the costs associated with dental treatment. Additionally, 3.0% of individuals face the obstacle of insurance plans that do not cover necessary procedures, while 1.2% simply choose not to allocate funds towards dental care. Fear or dislike of dentists is another common deterrent^4. Although less prevalent at less than 1%, other factors such as being too busy, unable to take time off work, expecting the issue to resolve on its own, inconvenient office hours, distant dental offices, or receiving contrary recommendations from other dentists also contribute to the problem^4. It is evident from these challenges that a collaborative effort involving community leaders, government officials, public health professionals, healthcare providers, and social service providers is necessary to address these issues. These stakeholders should focus on improving oral health care financing, strengthening the oral health workforce, and removing barriers to accessing dental services.

Policy Options

1: A federal policy mandate requiring Medicaid and Medicare to include coverage of dental services is crucial. It is particularly important to add a dental benefit to Medicare Part B^5. Currently, almost half of the Medicare population, which amounts to 24 million beneficiaries, lack any dental coverage whatsoever^5. Additionally, dental services are currently optional under Medicaid^1. By mandating dental coverage within these programs, millions of individuals, especially vulnerable populations, will have improved access to essential oral healthcare. This step would address a significant gap in healthcare coverage and contribute to overall improved oral health outcomes for Medicare and Medicaid beneficiaries.

Advantages: While enrollment in Medicare Part B is voluntary, the vast majority of beneficiaries who are entitled to Part A are also enrolled in Part B. Medicaid on the other hand, is the most common form of public insurance, covering more than 86 million people each year. This policy would establish appropriate standards of preventive and restorative oral health care to which everyone living in US to have reasonable access. Including dental services in Medicaid and Medicare promotes the integration of oral health care with primary and overall healthcare. This integration can lead to better coordination of care, improved communication among healthcare providers, and a more holistic approach to patients’ well-being.

Disadvantages: Including dental services in Medicaid and Medicare coverage would require additional funding from the federal government. The cost of providing comprehensive dental care to a large population could strain the budget and potentially lead to increased taxes or reduced funding for other healthcare areas^5. Furthermore, the inclusion of dental services under Medicaid and Medicare coverage might result in increased demand for dental care, potentially leading to overutilization of services. Without appropriate utilization management, this could strain the healthcare system, increase costs, and delay care for those in need. Furthermore, it is worth noting that some healthcare institutions still do not accept Medicaid insurance, posing a barrier to access for those covered by these programs.

2: Policy that increase the numbers of oral health professionals who can deliver high standards of oral healthcare^6. Need to increase federal and state funding to dental schools and oral health professional training programs. To increase access to oral health care, states can play a vital role by authorizing both traditional and non-traditional providers to deliver dental services. Traditional providers such as dentists, dental hygienists, and dental assistants can continue to offer their

expertise. Additionally, non-traditional providers like primary care physicians, pharmacists, community health workers, and social workers can be trained and empowered to contribute to a robust and comprehensive oral health care system^6.
Advantages: This collaborative approach would leverage the skills and resources of various healthcare professionals, enabling them to work together in addressing the oral health needs of underserved populations, especially low-income families.

Disadvantages: It will potentially increase healthcare expenditures, which are already high. The absence of universal health insurance can indeed present challenges to collaborative efforts. Increasing the overall numbers of oral health professionals may not address the issue of maldistribution. Certain regions, particularly rural and underserved areas, may still face shortages even with an overall increase in professionals. Encouraging professionals to practice in these underserved areas may require additional incentives and support.

3: State policy to expand the scope of services allowed for oral health providers^6. States policy can enable them to perform a broader range of procedures, increasing their capacity to meet the needs of patients. States have the power to enhance access to dental care by implementing workforce-related legislation, regulations, and procedures. These measures can be effective in improving the availability of oral health services for underserved populations.

Advantages: Relaxing supervision requirements can allow dental hygienists and other non-dentist providers to work more independently, extending their reach to areas with limited access to dental care. Expanding teledentistry services can leverage technology to connect patients with oral health providers remotely, particularly in rural or underserved areas. Granting more providers, the authority to write prescriptions can streamline the process of obtaining necessary medications for dental treatments. Encouraging authorized dental providers to practice at federally qualified health centers can further improve access, as these centers often serve low-income individuals and communities with limited resources.

Disadvantages: Different oral health providers may have varying levels of training and education. Expanding their scope of practice without adequate standardization and oversight can result in inconsistent quality of care across providers. Expansion often requires changes in regulatory frameworks, licensure requirements, and professional scopes of practice^6. These changes can be complex and time-consuming, requiring careful consideration of potential risks, consensus- building among stakeholders, and adjustments to legal and regulatory systems.

4: State policy that aims to educate patients and the general public about the importance of oral hygiene, preventive measures, and regular dental care^1. This will need an integration into school curriculum and public awareness campaigns.
Advantages: Incorporate oral health education into school curricula at various levels, starting from primary education. This ensures that children receive early education on proper oral hygiene practices and understand the importance of maintaining oral health. Encourage healthcare providers, including primary care physicians and pediatricians, to incorporate oral health education into their practice. Provide training and resources to ensure they can effectively communicate oral health information to patients and emphasize the importance of regular dental visits. Disadvantages: Education alone may not guarantee behavior change. Despite receiving information about oral hygiene and preventive measures, individuals may not always translate that knowledge into consistent practices. Some individuals may struggle to adopt new habits or prioritize oral health due to various factors, including competing priorities, cultural beliefs, or lack

of resources. Language and literacy levels, cultural beliefs, practices, and attitudes, can influence the effectiveness of educational programs. If materials are not provided in multiple languages or presented in a way that is easily understood by diverse populations, some individuals may not fully comprehend or engage with the educational content.

Policy Recommendation

Including dental services in Medicaid and Medicare coverage ensures that a larger population, particularly low-income individuals, and seniors, has access to essential oral health care^5. This can help address existing disparities in dental care access and reduce barriers to treatment for vulnerable populations. By providing coverage for dental services, the federal policy mandate can contribute to improved overall health outcomes. Timely prevention, diagnosis, and treatment of oral health issues can help prevent or manage systemic conditions such as cardiovascular disease, diabetes, and respiratory infections. Early detection and treatment of oral health issues can prevent the progression of diseases, reduce emergency room visits related to dental problems, and minimize the need for expensive interventions. Lastly Extending dental coverage to Medicaid and Medicare aligns with principles of equity and social justice, ensuring that individuals have equal access to necessary healthcare services, regardless of their income or age.

References

1.Center for Health Care Strategies. “Medicaid adult dental benefits: an overview.” Fact Sheet. January 2018. Available from: https://www.chcs.org/media/Adult-Oral-Health-Fact- Sheet_011618.pdf. Accessed July 17, 2023.

2.Division of Oral Health, National Center for Chronic Disease Prevention and Health Promotion. “Basics of Oral Health.” Last Reviewed: January 4, 2023. Available from: https://www.cdc.gov/oralhealth/basics/index.html

3. National Center for Health Statistics. “Prevalence of Total and Untreated Dental Caries Among Youth: United States, 2015–2016” Published by CDC on July 25, 2018. https://www.cdc.gov/nchs/products/databriefs/db307.htm

4.Niodita Gupta, Marko Vujicic. “Main Barriers to Getting Needed Dental Care All Relate to Affordability.” Published by The Health Policy Institute, American Dental Association. Available from: https://www.ada.org/-/media/project/ada-organization/ada/ada- org/files/resources/research/hpi/hpibrief_0419_1.pdf

5.Meredith Freed, Lisa Potetz, Gretchen Jacobson, and Tricia Neuman. “Policy Options for Improving Dental Coverage for People on Medicare.” Published By KFF on Sep 18, 2019. Available from: https://www.kff.org/medicare/issue-brief/policy-options-for-improving-dental- coverage-for-people-on-medicare/

6.US Department of Health and Human Services. “Using Law and Policy to Promote the Use of Oral Health Services in the United States.” Published by Office of Disease Prevention and Health Promotion (OSHA). Available from: https://health.gov/our-work/national-health- initiatives/healthy-people/healthy-people-2020/healthy-people-2020-law-and-health-policy/oral- health