I began my professional career as a pediatric dentist in the inner city of Boston, Massachusetts. At that time, the community water supply in the city was not fluoridated, and I noticed a stark contrast between the dental health of the children that I treated who were from the wealthier suburbs with access to fluoride and who had parents with sophisticated health literacy skills and those children from the inner city who were not so fortunate. Children in these vulnerable populations as young as two years of age would present with extensively decayed teeth that required multiple extractions. They would then have to wait until their permanent teeth erupted to be able to chew properly and smile without hesitation. The same situation could arise in their adolescent years with similar consequences to the pain they suffered, the social and economic implications of not having an aesthetic smile, and the impact on their overall health and well-being. I now serve as the president and chief executive officer of the American Dental Education Association, which represents the individuals and institutions in the academic dental community. My perspective has become much more focused on the dental health of the U.S. population and the impact that the academic preparation of future dentists and dental hygienists will have on addressing the oral health needs of the people in our country as well as the rest of the world.
The Current Debate About Medicaid Coverage
One of the major deterrents to accessing appropriate preventive and restorative dental services has always been the cost of dental care.1 The availability of commercial dental insurance is most commonly provided through employers, with Medicaid coverage being one of the few options that many, who are not employed or who are underemployed, have to pay for dental care.2 Often lost in the recent political debates over the future of health care and the role of government funding is the impact that reductions in Medicaid would have on access to dental care for vulnerable populations. Currently, Medicaid covers dental benefits for children and has optional dental benefits for adults, and about 54 million adults and children have dental coverage through Medicaid.3 Nearly all the proposals put forth by the current Congress and Administration to modify the Affordable Care Act (ACA) would repeal Medicaid expansion, which in just the first year has extended dental coverage to nearly 16 million people and provided nearly $50 billion to participating states.4 Despite initial reluctance among many governors to accept the new Medicaid funding, 31 states and the District of Columbia eventually chose to take part, and several more states were on the cusp of applying for waivers to design their own Medicaid expansion programs before the November 2016 election.4
The Value of Good Oral Health, and Individual and Societal Consequences of Poor Oral Health
Poor oral health affects the lives of individuals of all ages, and the impact of poor oral health accumulates from childhood through the end of life.5 Tooth decay, clinically known as dental caries, remains the most chronic condition among children and adolescents, being four times more common than asthma among teens.6 By age 5, nearly a quarter of all children have experienced a dental cavity, and by the adolescent years, that number doubles.7 Furthermore, one out of every two American adults age 30 or older has periodontal disease, and this prevalence rate increases to over 70% in adults age 65 or older.8
Because dental caries and periodontal disease are progressive, chronic conditions, the oral health problems that impact children continue into adulthood, affecting academic performance, employability and annual earnings, military readiness, overall health care costs, and general health status and well-being. Dental diseases and conditions are often a consequence of poor diet and lack of hygiene, which are often associated with poverty and could be addressed with more social support for families.9 Children in dental pain are more likely to miss school and do not perform as well academically as those who are pain free.10 Good oral health may also increase an individual’s annual earnings, and lower-income individuals who receive necessary dental care are more likely to be successful at their jobs than those who do not receive necessary dental care.11 Additionally, a little-known historical note shows the critical value of oral health on national security.12 One of the most common reasons for medical deferments from the military draft from the Civil War through the Vietnam War was not having enough teeth or some other dental condition.13 In fact, the term “4-F” for medical deferments came from the inability of potential recruits to open a gun powder cartridge because they did not have four front teeth with which to do so.14 More recently, in 2012, almost two-thirds of new U.S. Army recruits were “not immediately deployable because of a significant dental issue.”15 Further, the economic impact of untreated oral conditions has an impact on the health care system overall. The cost of dental care remains an unsurmountable challenge for many Americans. Adults are more likely to cite cost as a barrier to dental care than they are to cite cost as a barrier to medical care, vision care, or prescription drugs.2 Relatedly, between 2008 and 2010, 4 million Americans went to the emergency room for dental-related problems at a cost of $2.7 billion dollars.16
Impact of the ACA on Dental Coverage
A remarkable change in this approach to seeking dental care through hospital emergency rooms occurred after the introduction of the ACA, which includes pediatric oral health services among the 10 “essential health benefits” that private insurers are required to include in policies they offer through the new health exchanges. That is, after the ACA was introduced, the number of dental-related hospital emergency room visits declined, most likely as a result of access to enhanced dental coverage through Medicaid and the Children’s Health Insurance Program (CHIP).17 In addition, more than 5 million adults gained access to dental benefits as part of the Medicaid expansion from 2009 through 2015, and over the same time frame the percentage of children without dental coverage has been cut in half.17
Consequences of Cutting Back Medicaid Funding
As the current Congress and Administration move forward with health care reform, the importance of maintaining the already limited funding for dental services, especially for vulnerable populations, must be recognized for the impact that it can have on maintaining overall health and success over the course of an individual’s entire life. The ACA and other legislation has had a clear impact on improving the accessibility of dental care to these populations.18 Almost all of the proposals that are currently being considered to modify the ACA include reductions in Medicaid spending, either directly by the federal government and/or through enhanced state control over Medicaid spending. For example, though H.R. 195 has extended CHIP for six years (through fiscal year 2023) without any changes to the coverage provisions, there is a change to the funding level beginning in fiscal year 2020.19 This and other limitations (e.g., funding on a per capita basis or via block grants) to federal support for Medicaid will eventually increase the pressure on states to cut costs, and dental care is usually one of the first benefits on the chopping block.20 If this happens, all of the gains that have been realized as a result of the Medicaid expansion would be diminished or lost, with a significant impact on the overall health, well-being, and success of those who will suffer the consequences of a lack of access to dental care.
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