We Have a Dental Care Crisis. Medicare for All Could Solve It.

Guaranteed dental coverage would finally put an end to the deep inequities in U.S. oral health.

Natalie Shure July 11, 2019

Everyone should be provided with free dental care. (Photo by Tom Kelley/Getty Images)

Over an ear­ly Sep­tem­ber week­end in 2017, some 850 vis­i­tors showed up to the Uni­ver­si­ty of Mary­land (UMD) bas­ket­ball are­na in Col­lege Park. But the atten­dees weren’t there to watch a game, they came to receive free den­tal care through Mis­sion of Mer­cy, which holds sim­i­lar events across the coun­try to pro­vide one-off den­tal ser­vices to any­one who needs them.

Dental inequality is even more extreme in America than inequality in other areas of healthcare.

Many of the atten­dees queued up in the UMD gym were there not for rou­tine tooth-clean­ings, but instead were suf­fer­ing from severe den­tal prob­lems requir­ing inter­ven­tions like painful extrac­tions. As Mary­land den­tist Dr. Jacob Nix explained, these treat­ments were like­ly long over­due, but had been put off because the patients had no access to den­tal care. I doubt that many of them had been wait­ing on that day just to save a few dol­lars,” said Nix.

As debates over health­care reform have tak­en cen­ter stage dur­ing the 2020 Demo­c­ra­t­ic pri­ma­ry, oral health has received sig­nif­i­cant­ly less atten­tion. But with near­ly one-third of non-elder­ly adults lack­ing den­tal cov­er­age — and Medicare for All bills in the House and Sen­ate includ­ing pro­vi­sions for den­tal care — the incor­po­ra­tion of oral health into a broad­er vision for uni­ver­sal health­care is emerg­ing as a dis­tinct social jus­tice issue.

If the silo­ing of health and den­tal care in the Unit­ed States now feels like a giv­en, it’s by no means nat­ur­al. The sep­a­ra­tion began back in 1840 at the Uni­ver­si­ty of Mary­land-Bal­ti­more, not far from where hun­dreds of work­ing-class peo­ple would receive den­tal pro­ce­dures in a gym­na­si­um near­ly two cen­turies lat­er. When two founders of the then-recent­ly formed Amer­i­can Soci­ety of Den­tal Sur­geons were alleged­ly refused per­mis­sion to teach den­tistry at the UMD-Bal­ti­more med­ical school, they estab­lished their own instead, begin­ning a tra­di­tion that per­sists today.

While both den­tists and med­ical doc­tors adamant­ly opposed nation­al health insur­ance plans dur­ing the Tru­man admin­is­tra­tion in the 1940s, med­ical insur­ance became a stan­dard ben­e­fit for work­ers and was expand­ed to more mar­gin­al­ized pop­u­la­tions through the enact­ment of Med­ic­aid and Medicare in the 1960s. Mean­while, den­tal cov­er­age remained rel­a­tive­ly lim­it­ed. While the pas­sage of CHIP in 1997 and the Afford­able Care Act in 2010 even­tu­al­ly expand­ed basic den­tal cov­er­age to most chil­dren, broad swaths of the Amer­i­can pub­lic still go with­out ade­quate den­tal care.

As a result, den­tal inequal­i­ty is even more extreme in Amer­i­ca than inequal­i­ty in oth­er areas of health­care. Twice as many chil­dren lack den­tal cov­er­age as con­ven­tion­al health cov­er­age. Some 800,000 ER vis­its a year stem from den­tal issues, many of which could be avoid­ed with rou­tine man­age­ment. More Amer­i­cans report finan­cial bar­ri­ers for den­tistry than any oth­er type of health­care. Those who do have den­tal cov­er­age are hard­ly spared: most plans cap annu­al ben­e­fits at around $1500 — an amount eas­i­ly exceed­ed by a sin­gle den­tal emer­gency — and near­ly 50 per­cent of den­tal care nation­wide is paid for out-of-pocket.

Those dis­par­i­ties in access have a pro­found impact. As per­fect teeth have become a cod­ed class mark­er, some 30 per­cent of low-income adults avoid smil­ing with their teeth. But the issue runs even deep­er. I think there’s this per­cep­tion that it’s just aes­thet­ic,” explained Meg Booth, Exec­u­tive Direc­tor of the Children’s Den­tal Health Project. We have to dis­pel this notion that oral health is only about the appear­ance of your teeth. It’s actu­al­ly about dis­ease, and the rest of your body.”

Indeed, poor oral health has been linked to heart dis­ease, Alzheimer’s and oth­er seri­ous ail­ments. In her 2017 book Teeth: The Sto­ry of Beau­ty, Inequal­i­ty, and the Strug­gle for Oral Health in Amer­i­ca, jour­nal­ist Mary Otto tells the sto­ry of 12-year-old Dea­monte Dri­ver, whose untreat­ed toothache even­tu­al­ly devel­oped into a dead­ly infection.

Poor oral health has also been linked to poor school per­for­mance and absen­teeism among chil­dren. This dan­ger­ous sta­tus quo high­lights just how odd it is that teeth have been arbi­trar­i­ly sequestered from oth­er body parts when it comes to Amer­i­can health­care. As San­ta Fe, New Mex­i­co den­tist Dr. Daniel Bor­rero put it, We have teenagers who are devel­op­ing gum dis­ease and we ask them, Do your gums bleed when you brush?’ And they say, yes.’ But if your fin­gers were bleed­ing, you wouldn’t just say that casually!”

While includ­ing den­tal care in a Medicare for All sys­tem would deliv­er more patients, the cur­rent sys­tem of deny­ing den­tal care pro­vides plen­ty of mon­ey. On aver­age, den­tists make near­ly as much as physi­cians, while typ­i­cal­ly work­ing few­er and more pre­dictable hours. Sim­i­lar­ly, den­tists are more like­ly to have auton­o­my over their jobs and work in inde­pen­dent prac­tices, where­as physi­cians are increas­ing­ly employed by con­sol­i­dat­ing health­care com­pa­nies. Few­er than 40% of den­tists cur­rent­ly accept Med­ic­aid, and the pro­fes­sion leans con­ser­v­a­tive.

It’s no sur­prise, then, that the pow­er­ful Amer­i­can Den­tal Asso­ci­a­tion (ADA) oppos­es Medicare for All, and stands as a for­mi­da­ble ene­my in the fight for uni­ver­sal health­care. As Maine leg­is­la­tor Richard Mal­a­by said of the ADA to the Wash­ing­ton Post, I put their pow­er right up there with the NRA…dentists do every­thing they can to pro­tect their inter­ests — and they have money.”

While Physi­cians for a Nation­al Health Pro­gram is com­prised of some 20,000 doc­tors sup­port­ing Medicare for All, few (if any) den­tists are mem­bers. While Bor­rero sup­ports sin­gle-pay­er health­care and Nix describes him­self as open to it,” they both strug­gled to think of many col­leagues who embraced the idea — as did oth­ers in the den­tal pro­fes­sion whom I spoke to for this sto­ry. The excep­tion was den­tal students.

Per­son­al­ly I feel that if you are more inter­est­ed in accu­mu­lat­ing exces­sive wealth than in pro­tect­ing the health of your com­mu­ni­ty, then you prob­a­bly should­n’t be in any type of health care in the first place,” one den­tal stu­dent explained, who asked not to be iden­ti­fied in order to speak can­did­ly. I feel like sin­gle pay­er is a far more equi­table solu­tion than expect­ing den­tists to nego­ti­ate with insur­ance com­pa­nies for what they can charge patients. Every­one needs teeth!”

If den­tal stu­dents are more like­ly to join a coali­tion of sin­gle-pay­er sup­port­ers than their more expe­ri­enced pro­fes­sion­al coun­ter­parts, they’ll be in good com­pa­ny. As Meg Booth tells it, over a decade after she began work­ing on the issue of access to ade­quate den­tal care, it’s final­ly begin­ning to coa­lesce as a major polit­i­cal issue: I think kids’ groups, and Medicare groups, and social jus­tice groups at the grass­roots lev­el are all try­ing to edu­cate the pub­lic on a more fun­da­men­tal lev­el that oth­er peo­ple besides den­tists care about this,” she said. She’s hope­ful they’re becom­ing vocal, con­spic­u­ous con­stituents for uni­ver­sal den­tal care: There are peo­ple who see the impact in their com­mu­ni­ties and states.”

Natal­ie Shure is a Los Ange­les-based writer and researcher whose work focus­es on his­to­ry, health, and politics.
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