Residents in rural America face major
difficulties in access, coverage, and geography that limit their ability to
obtain good oral health care. This is especially true for the rural elderly;
whose oral health is often worse than that of the rest of the nation. While
seniors nationwide would benefit from coverage improvements and better access
to timely and appropriate care to reduce tooth decay, tooth loss, and oral
disease, these barriers take an especially serious toll on rural seniors. Poor
oral health places a disproportionate burden on rural seniors, but there are
potential policy solutions and pending legislation to address these challenges.
The link between oral
health and overall health cannot be understated—particularly for the
elderly—and numerous policy changes are needed to ensure that health coverage
and care address oral health within the context of strong management of overall
health. For seniors in rural communities and across the nation, pending
legislation could begin to address these issues through expanded grant programs
and, critically, by adding dental coverage to Medicare. Improved access could
result if Congress appropriates sufficient funding for the Action for Dental Health Act,
which passed in December 2018, as well as for existing grant programs that
support community health centers and training of the oral health workforce.
Other already-introduced bills would add an oral health benefit to Medicare,
and these efforts could go a long way toward alleviating coverage disparities
for seniors and adults younger than age 65 who have disabilities.
Rural Seniors
Disproportionately Experience Barriers That Prevent Them From Getting Needed
Oral Health Care
Nearly one-quarter of residents of rural
areas are at least 65 years old. They face major barriers including the cost of
dental care, lack of coverage, and limited access to providers. An analysisof 2016
Behavioral Risk Factor Surveillance System (BRFSS) data found that 20 percent
of rural seniors have not seen a dentist or visited a dental clinic for more
than five years, compared to 14 percent of non-rural seniors. This disparity in
access to care has been evident for at least 10 years: From 2006 to 2016, rural
seniors were 33 percent to 40 percent more likely than non-rural seniors to
have had no dental care. Regardless of geography, seniors are becoming less
likely to have all of their teeth pulled due to decay or gum disease over time.
However, in 2016, one in five (20 percent) rural seniors reported having all
their teeth pulled by the time the survey was completed, compared to one in
seven (14 percent) non-rural seniors. Nearly 23 percent of rural seniors have
had six or more teeth, but not all, of their teeth pulled.
Poor Oral Health
Exacerbates Other Health Problems Common In Rural Areas
Unmet oral health needs can exacerbate other
health problems that are common in rural areas. Studies show strong links between
oral health and diabetes, a disease with much higher rates of death in
rural areas than in more urban locations. Oral health treatment, including
scaling and cleaning, can ward off oral
health problems that often are associated with diabetes. Rural seniors also
have high rates of obesity and heart disease, conditions that are linked to gum
infection. Poor oral health, including pain, bleeding, and lack of dentition,
makes eating difficult. As a result, many people favor foods that are easy to
chew and swallow but often lack nutritional value and are high in cholesterol
and fat, worsening all associated conditions. In surveys, self-rated
poor oral health is linked to low levels of self-rated general health,
self-esteem, and life satisfaction among seniors.
It Can Be Particularly
Difficult To Find Dental Providers In Rural Areas
About 66 percent of the
nation’s dental health professional shortage
areas are in rural or partially rural communities. The National Advisory Committee on
Rural Health and Human Services lists a plethora of reforms
that are necessary to make significant differences in access to oral health
care in rural areas. Major challenges include raising capital, attracting
dentists to rural areas, and the large number of dentists expected to
retire in the near future.
Addressing provider shortages will require measures including expanded coverage
to ensure reimbursement; enhanced recruitment and retention; investment in
rural health centers that provide care; and workforce solutions, including
involving the full range of dental practitioners.
Medicaid Dental
Benefits Can Address Some Barriers, But Seniors Need Additional Coverage
Solutions
States can improve the situation for rural
adults, including seniors, by providing adult dental care within Medicaid
coverage, an option available to all states. However, whether states provide
that coverage to adults
at all, and whether that coverage is comprehensive or limited to emergency
extractions and pain relief, varies considerably.
For example, in West
Virginia, Medicaid’s adult oral health benefit covers only emergency services:
extracting up to two problematic teeth per year, draining abscesses, performing
biopsies, and removing oral tumors. West Virginia Medicaid does not cover
dental exams for adults, so those who need oral health clearance before undergoing
heart surgery or beginning chemotherapy may join a waiting list at the one
dental school in the state that provides that service. Limiting coverage in
this way makes it difficult for people to get the care they need—when they need
it.
Medicaid coverage of adult oral health care
fluctuates over time in different states and is tied to state budget decisions.
Cutbacks and coverage fluctuations pose additional challenges and barriers to
care. Proposals to block grant Medicaid or to impose per capita caps or work
requirements would likely cause more states to cut adult oral health coverage.
In California, Medicaid
provided no adult dental coverage from 2009 to 2014. The state has gradually
restored coverage and, as of 2018, provides a fairly comprehensive benefit.
However, the nine-year gap in coverage affected rural dental care and oral
health.
A study on the elimination of optional adult dental
Medicaid benefits in California documented the challenges that
rural dental providers faced in addressing Medicaid cuts. Some shifted their
practices to primarily serving pregnant women and children, for whom coverage
was not eliminated; many others mainly performed extractions as a way to
mitigate adults’ dental pain. Even with the staggered restoration of adult
dental coverage after 2014, it is clear that seniors needed additional
care—such as periodontal services, root canals, and dentures—that was not
restored to Medicaid until 2018. For rural seniors, the consequences of these
gaps in coverage, as well as other barriers to coverage and care, can be seen
in California BRFSS data from
2016. These data reveal that, as of 2016, 15 percent of seniors residing in
rural California ZIP code areas had all of their teeth pulled due to decay or
gum disease, compared to 8 percent of non-rural seniors. Moreover, oral
health screening data
revealed that in 2016, older adults in rural California counties who had lost
all their teeth were half as likely to have dentures compared to their urban
counterparts. The proportion of California rural seniors with no teeth grew
larger from 2008 to 2016, reflecting a lack of care during the period when
California Medicaid was not covering adult dental services (Note 1). Even with full Medicaid coverage
restored, rural residents may have to travel long distances to receive
extensive care, such as root canals, that are not offered by a local clinic.
Funding The Action For
Dental Health Act Will Help Bring Clinics And Dental Professionals To
Underserved Rural Areas
The Action for Dental Health Act authorized
grant programs that could provide more care in underserved communities. It is
still up to Congress to appropriate funds to make these grants viable. When
funded, the act could provide grants and contracts to state, county, tribal,
and local officials or stakeholders to reduce geographic and cultural barriers
to dental services in such shortage areas and to establish dental homes for
both adults and children. The act includes new initiatives to improve
prevention and increase public awareness about oral health; it also provides
new and continuing grants for innovative programs in underserved communities.
For the first time, those programs could include an explicit focus on
establishing dental homes for the elderly and individuals with disabilities,
including those living in long-term care facilities. While these types of grant
programs have the potential to foster incremental change, a sustainable oral
health care system for rural seniors will require additional policy changes.
Medicare Coverage Of
Oral Health Could Make Care Truly Available And Affordable
As explained in a recent white paper by
leaders in the health and oral health fields, adding an oral health benefit to
Medicare Part B would have a number of advantages as the best policy vehicle to
help seniors afford and obtain oral health coverage and care. The white paper
explains that Medicare could offer affordable comprehensive oral health
coverage to everyone who relies on the program for health coverage. The white
paper also shows the base premium increase for a Part B oral health benefit at
about $14.50 per month. This model is broadly affordable because of Medicare
mechanisms that make its services available and affordable to the Medicaid
population (typically, seniors with incomes below about 73 percent of
the federal poverty level, or about $9,200 annually) and those just above the
poverty line through the Qualified Medicare Beneficiary (QMB) program. Full
Medicaid and QMB beneficiaries, with low assets and incomes up to about $12,700
for an individual in 2019, would not be charged deductibles, coinsurance, or
premiums for dental care. Medicare beneficiaries with low assets and incomes up
to about $17,100, who do not pay Medicare Part B premiums, would not pay a
premium for dental care. Moderate- and higher-income seniors pay a deductible
and 20 percent coinsurance for Medicare Part B services, with no copayment for
preventive services.
Including such coverage within Medicare Part B
also draws on existing systems to support fair reimbursement and provider
participation. Medicare Part B has mechanisms that set and update fee schedules
and adjust them by region. Physicians widely accept Medicare. Although
establishing payment rates for dental professionals will take time, Medicare
could enjoy wide participation among dental professionals, going a long way
toward bringing providers into rural communities.
Several bills before Congress would add oral
health coverage to Medicare. Rep. Lucille Roybal-Allard’s (D-CA) bill (H.R. 576) would remove
language from the Medicare statute that currently excludes coverage for dental
care, eyeglasses, and hearing aids. Rep. Lloyd Doggett’s (D-TX) bill (H.R. 1393) adds dental,
vision, and hearing coverage to Medicare by removing the exclusion and details
what these benefits would look like. Sen. Ben Cardin’s (D-MD) bill (S. 22) proposes a
Medicare dental and oral health benefit that includes coverage for diagnostic,
preventive, restorative, and other necessary care within Medicare Part B.
Forthcoming bills are expected to also help seniors who are eligible for full
Medicaid and for the Qualified Medicare Savings Program by increasing federal
Medicaid matching funds for oral health services. These bills stimulate needed
discussion of ways to address glaring disparities impacting oral health and,
concomitantly, the overall health and well-being of seniors and people with
disabilities. Adding an oral health benefit to Medicare and increasing the
number of dental providers in shortage areas could make a significant
difference in the health of rural seniors.
Note 1
Authors’ analysis of 2008–16 Behavioral Risk
Factor Surveillance System data for California using the identical methodology
as in this fact sheet.
https://www.healthaffairs.org/do/10.1377/hblog20190501.797365/full/
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