Access to dental care is critical for advancing oral and overall health. Oral health problems are associated with many other chronic conditions and good oral health can improve physical, mental and economic wellbeing. Unfortunately, access to affordable, quality, culturally respectful dental care remains out of reach for millions, particularly Black and brown communities, low-income populations and other marginalized groups. A myriad of policy factors both contribute to existing inequities and present opportunities to address them – Medicare does not include a comprehensive dental benefit and Medicaid dental benefits are optional for adults; almost 70 million people live in areas without enough dental providers; two-thirds of dentists don’t see any Medicaid patients and white dentists are significantly less likely to do so.
As 2022 comes to a close, we offer a retrospective on positive developments as well as opportunities to improve access to dental care and oral health.
Improving the Oral Health Workforce
At the state level, advocates continue to push efforts to increase the number of providers and expand access to providers who represent the language and culture of their patients. In 2022, Colorado became the 13th state to authorize dental therapists to practice in at least some settings and Skagit Valley College in Washington became the second dental therapy education program to receive accreditation. Also in Colorado, a waiver was approved to implement the state’s public option. In addition to improving access to affordable coverage, the Colorado Option requires a provider network that is culturally responsive and representative of the communities it serves. As a private plan, the Colorado Option does not currently cover adult dental care, highlighting the importance of efforts at the federal level to add adult dental to the ACA’s list of essential health benefits.
On the federal level, the Health Resources and Services Administration’s Advisory Committee on Training in Primary Care Medicine and Dentistry released a report calling for additional funding and support to grow dental therapy and improve access to oral health. The report bolstered ongoing efforts calling for Congress to support states and Tribes seeking to expand their dental workforce by not continuing to block funding for an ACA program that would offer grants to colleges, health systems, tribal organizations and clinics to train or employ dental therapists.
Advancing Dental Coverage
As with the past several years, 2022 brought significant progress on Medicaid adult dental benefits at the state level. Several states, including Hawaii, Kansas, Kentucky and New Hampshire, expanded their existing benefits to cover additional services. In Kansas, this included coverage of silver diamine fluoride, a medicine that can prevent and stop the spread of cavities, representing important progress toward minimally invasive care. Additionally, Maine and Maryland now have comprehensive dental benefits for all adults enrolled in Medicaid. Other states, like Tennessee and [Louisiana](https://ldh.la.gov/news/dentalexpansion#:~:text=Louisiana Medicaid is expanding its,Waiver or the Supports Waiver.), added dental benefits for specific populations – in Tennessee, pregnant people now have dental coverage up to one year post-partum and in Louisiana some adults with intellectual or developmental disabilities have access to Medicaid dental benefits.
Improving Access to Care
The COVID-19 public health emergency led many states to implement telehealth policies to ensure continued access to care. These efforts spotlighted the increased accessibility that telehealth options provide and several states codified COVID-19 telehealth policies so they continue to be available long-term. For example, New Mexico, North Carolina and Texas all passed legislation defining and/or outlining requirements for teledentistry practice. Additionally, Maine authorized use of teledentistry in 2021 and rulemaking was finalized this year. The Pennsylvania Medicaid program also began paying for teledentistry services in 2022 and Oklahoma passed legislation allowing some dentists to practice teledentistry.
Additional states have adopted other innovative approaches to improve access to needed oral health services in both public and private programs. In Oregon, legislation was passed that will create a new program to offer premium assistance for dental coverage for veterans whose incomes are too high to qualify for Medicaid, but who otherwise do not have access to dental benefits. Connecticut submitted a Medicaid 1115 waiver to provide wraparound services, including dental coverage, to low-income adults and parents (up to 175% FPL) through the state’s health insurance marketplace. And Massachusetts voters approved a ballot measure in the recent midterm election requiring dental insurance companies to spend at least 83% of premium costs on patient care. This measure aligns dental insurance with what health insurance companies are already federally required to do and makes Massachusetts the first state to institute such requirements for dental plans.
2023 and Beyond
This progress is exciting, but peoples’ ability to pay for and access care shouldn’t be dependent on where they live. Both Congress and administrative officials have opportunities to institute solutions at the federal level that would standardize and guarantee dental coverage for adults similarly to how it’s already provided to children. Several options include:
- Congress should pass legislation to make adult dental benefits a mandatory Medicaid coverage category. Advocates, including Community Catalyst, pushed for this to be included in the Build Back Better Act. While it wasn’t included in the final package, as Congress looks to the next session they could capitalize on state-level momentum by standardizing and mandating coverage for adults with Medicaid.
- Congress should pass legislation adding a comprehensive dental benefit to Medicare. 2022 also brought a CMS rule change that expanded the limited circumstances under which Medicare will cover “medically necessary” dental care. While this is important progress, CMS’s proposal is narrow and there is only so much that can be done within its rulemaking authority. Regular dental care remains largely uncovered for millions of older adults and people with disabilities covered by Medicare, and Congress should address this through legislative action.
- Congress should eliminate the ban on use of health workforce grant funding for dental therapy programs in FY2023 and fully fund the alternative dental health care provider demonstration grant program.
- On the private insurance end, the secretary of Health and Human Services, who is required to periodically review and update the ACA’s essential health benefits (EHB), should use that authority to add adult dental to the EHB package for all marketplace plans. This policy change would also help improve access to dental coverage in states expanding Medicaid and in innovative state coverage efforts like the Basic Health Program.
Lastly, oral health must be considered as a key component to closing the coverage gap in the 12 states that still have not expanded Medicaid through the ACA. Dental care presents the greatest cost barriers to any health care services and is consistently reported by community members as a top concern. And research shows that when Medicaid expansions include dental, health outcomes and job prospects are improved. Without the inclusion of dental benefits, the Medicaid coverage gap will remain open.