While often seen as a health care afterthought, forgoing dental work can have serious long-term consequences: reduced ability to speak, reduced ability to eat healthy foods — not to mention reduced confidence in one’s appearance. Gum disease can lead to heart attacks, strokes, and more severe diabetes.
According to the AARP, about one in five Americans age sixty-five or older have untreated cavities, and two in three have gum disease; 50 percent of people over age fifty-five wear dentures, which require routine maintenance. Gum tissue naturally recedes as you age, exposing roots to decay, and a lifetime of crunching and grinding wears away tooth enamel.
But surely Medicare, the United States’ national health plan for those sixty-five and older, covers all of that, right?
Wrong. Nearly 70 percent of older Americans currently have no form of dental insurance. Coverage for routine oral health services, including cleanings and cavities, much less extensive procedures like root canals, have never been part of traditional Medicare.
The good news is that could change under the $3.5 trillion budget reconciliation proposal in Congress, the outline of which the House recently passed. The plan would expand Medicare to include dental coverage as well as vision and hearing, and also lower the eligibility age to sixty. While it may not be Medicare for All, there’s a reason Bernie Sanders — currently chair of the Senate Budget Committee — has been championing the plan. It would be a huge victory in the fight for Medicare for All.
Under the current system, Medicare supplemental private plans, which cost $200 per month on average, offer some coverage. So do the mostly for-profit Medicare Advantage plans. But they have small provider networks and coverage limits. Private dental insurance is notoriously skimpy even compared to private medical health insurance. For expensive procedures, insurance typically covers only 50 percent of the cost. The same is true of so-called “discount plans” that contract with groups of dentists.
As one Medicare beneficiary told the AARP: “I send my dentist on a major vacation at least twice a year… I have had bone grafts twice. $40,000. Braces, crowns, and 1/2 implant. I need $2,000 to finish the tooth. I still have major work to be done. Last year I spent $10,000 and that is with insurance.”
Federal lawmakers declined to include dental coverage when they first established the Medicare program in 1965. They’ve had fifty-six years to remedy that mistake. Instead, they’ve deferred to the market — enabling profit-making insurance companies to sell supplemental plans and, in 1982, creating Medicare Advantage, which delivers Medicare benefits through a private insurer and now covers 40 percent of Medicare beneficiaries.
Extending dental coverage would therefore be a huge win for health justice — even the widely touted Canadian health system doesn’t provide dental coverage. Yet corporate Democrats in the House and Senate are already pushing back. Seeing the sparse benefits and high out-of-pocket costs of private dental insurance as something to emulate, moderate Democrats propose covering a minimal percentage of benefit costs or means-testing the program so only lower-income Medicare beneficiaries would qualify.
The political dynamic is familiar. Given the opportunity to take on the care-denying, profit-driven health insurance industry, the Democrats who front for them parse public benefits — undermining the universality that would make the public program stronger politically, while maintaining a role for their patrons to profit at our expense.
The priority for the House Democratic leadership is to give subsidies to commercial insurers through the Affordable Care Act (ACA), expand Medicaid that relies on for-profit HMOs, and then expand Medicare. They propose funding it all with the savings achieved from negotiating drugs prices through Medicare. This, too, would make for a weaker expansion. Prescription drug savings are not enough to cover these priorities. In fact, using savings from public Medicare for the profits of private insurers shows neoliberalism is alive and well.
Another reflection of the House Democratic leadership’s twisted priorities is their plan to postpone implementation of dental benefits until 2028, seemingly to limit the amount spent on dental benefits so more money is available for ACA subsidies. Not only would this divert savings achieved from Medicare drug price negotiations away from Medicare — thereby undermining political support from seniors in the short term — deferring benefits so far into the future would undercut support for the expansion itself.
Getting the plan design and timeline right means getting the politics right. The plan to defer dental benefits is a clear signal that we must push for a high-benefit, comprehensive program that helps seniors now and puts us on the path to Medicare for All.
Dentists are also fighting the Medicare expansion. Unlike most doctors today, dentists have individual or small group practices and run their businesses as they wish, charging what the market will bear. A big, universal public program that limits their prerogative to do so is a threat — so their trade association, the American Dental Association, is lobbying against the inclusion of dental.
But it is the large health insurance companies, so used to feeding at the public trough of an increasingly privatized Medicare, that stand to lose the most and who are fighting the hardest. The private companies that run Medicare Advantage plans like to use dental (and vision and hearing) benefits to attract enrollment — inadequate dental coverage is a financial boon for them.
The health of seniors and the future of traditional Medicare hangs in the balance. As Sanders says, this fight, including lowering the eligibility age, is about stopping the continuing incursion of commercial insurance into Medicare and beating back the pharmaceutical companies. Lowering drug costs to beneficiaries and improving benefits is politically popular. The more prescription drugs are covered, the more money — initially estimated at $450 billion in the stand-alone bill, HR 3 — there is available to expand Medicare benefits and eligibility. The savings shouldn’t be funneled into the overflowing coffers of private insurance companies.
We cannot separate our teeth from the rest of our bodies. We cannot let the market imperative for profits separate us from the services essential to our health. That’s what at stake in the fight over dental benefits in Medicare — and the ongoing fight for Medicare for All.