Oral health is an important component of overall health for all US residents, particularly older adults. Oral health problems are common in this population, given that most systemic diseases are manifested in the mouth. Left untreated, oral health problems can result in serious, painful, and costly complications.
A nationally representative survey of 1039 adults aged 65 to 80 years, conducted in December 2019 by the University of Michigan National Poll on Healthy Aging (NPHA), found that in the past 2 years, 20% of older adults had experienced dental pain, while an equal percentage reported problems with eating and chewing. Nearly half of older adults (46%) were missing teeth but did not have dentures or implants, and more than 1 in 4 (27%) were embarrassed by the condition of their teeth.
Despite this, 20% had delayed or forgone care in the past 2 years, and 19% reported that it had been at least 5 years since their last preventive dental visit. There were notable disparities in oral health and dental care utilization by income, race/ethnicity, and health status. For example, while 25% of all older adults rated their oral health as fair or poor, more than 40% of those who had annual household incomes of $30 000 or less, were black or Hispanic, or reported fair or poor mental or physical health rated their oral health as fair or poor.
Prior research has demonstrated that financial reasons, including cost and lack of insurance coverage, are the main barriers to dental care. In this poll, 34% of adults aged 65 to 80 years said they considered not going to the dentist because of the cost.
One contributor to cost-related barriers to dental care may be the limited availability of affordable dental care options. Dental schools and community health centers are the main recommended sources for low-cost care but are not available in many communities. The federal Administration on Community Living has identified innovative programs to address oral health among older adults, but many of these are limited in their reach.
The December 2019 NPHA found that 53% of older adults currently have dental coverage. Although this is higher than coverage rates documented by other sources, it remains among the lowest of any age group. Among those with dental coverage, the most common sources included employers (27%), Medicare Advantage plans (26%), retiree health plans (22%), and individually purchased plans (19%). About 3 in 5 Medicare Advantage plans offer dental coverage, and among those with dental insurance through Medicare Advantage, 72% said dental coverage was a factor in choosing their plan.
The popularity of dental coverage through Medicare Advantage points to a key opportunity to improve access to dental coverage through traditional Medicare. Traditional Medicare does not cover dental care except in very limited circumstances. When people retire, many lose employer-sponsored dental coverage, which limits coverage options for older adults.
While the exclusion of dental care from Medicare may have made sense when Medicare was enacted in 1965, this is no longer the case. At that time, tooth loss was considered an inevitable part of aging, for which few treatments were available. Today, advancements in dental and medical care mean that people are living longer and with more natural teeth. Moreover, the costs of dental care have increased. A Kaiser Family Foundation analysis found that among Medicare enrollees who received dental services, nearly 1 in 5 spent more than $1000 on their care in 2016. Altogether, these dynamics mean that more older adults need—and face difficulties affording—necessary dental care.
The December 2019 NPHA found that most US adults aged 65 to 80 years (93%) support adding a dental benefit to Medicare. When asked if they would favor the additional benefit even if they would have to pay more, most (59%) still supported it; this support did not vary based on currently having dental insurance, but it was lower among those with an annual household income of $30 000 or less and those who reported fair or poor physical or mental health.
Other results from the NPHA suggest that a Medicare dental benefit may be popular not only among adults aged 65 to 80 years but also among adults approaching Medicare eligibility age. A September 2017 NPHA report on dental care among adults aged 50 to 64 years found that while 72% had dental insurance, 51% did not know how they would get it at age 65 years or older and 16% thought they could rely on traditional Medicare for it. This report also showed lower rates of dental care utilization and higher rates of forgone care among adults aged 50 to 64 years than among those in the December 2019 NPHA survey of adults aged 65 to 80 years, which is similar to other research. A potential explanation is that people may be waiting to address untreated dental problems until they have Medicare, even though traditional Medicare does not cover dental services.
Six bills have been introduced in the 116th Congress that would add a dental benefit to Medicare. Other efforts to address expanded dental coverage include a 2018 letter from 28 US Senators to the US Secretary of Health and Human Services and the Administrator for the Centers for Medicare & Medicaid Services to encourage the expansion of Medicare coverage to medically necessary dental care. There have been additional efforts to incorporate dental coverage into various federal health reform proposals. The December 2019 NPHA suggests that such steps would be popular among older adults and could yield improvements in both their oral and overall health.
Corresponding Author: Erica Solway, University of Michigan Institute for Healthcare Policy and Innovation, 2800 Plymouth Rd, Ann Arbor, MI 48109 (email@example.com).
Conflict of Interest Disclosures: Dr Solway reported receiving grants from the AARP during the conduct of the study. Dr Kullgren reported receiving salary support for the University of Michigan National Poll on Healthy Aging from AARP and the Institute for Healthcare Policy and Innovation at the University of Michigan; receiving support from the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service outside the submitted work; receiving consulting fees from SeeChange Health, HealthMine, and the Kaiser Permanente Washington Health Research Institute outside the submitted work; and receiving honoraria from the Robert Wood Johnson Foundation, AbilTo, the Kansas City Area Life Sciences Institute, and the American Diabetes Association outside the submitted work.
Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
Additional Information: We acknowledge the contributions of Preeti Malani, MD, MS, MSJ, Matthias Kirch, MS, and Dianne Singer, MPH (University of Michigan).
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