Why Medicare won’t pay for your dental care, and what you can do instead

March 31--Maine is widely recognized for its lobsters, its granite coastline and inland forests, and its oldest-in-the-nation population. With a low birth rate and a median age in 2016 of 44.5 years, the population here is aging rapidly, with an estimated 22 percent of Mainers reaching age 65 or older by 2030.

That demographic reality presents a number of challenges to the Pine Tree State, but among them is providing access to dental care for an aging population of baby boomers and seniors, many of whom live on low or fixed incomes. This problem is especially pronounced when considering the high prices of dental procedures and the fact that federal Medicare coverage doesn't include dental benefits.

"We see a tremendous unmet need here," said Dr. Bart Eisenbarth, chief dental officer at Penobscot Community Health Care in Bangor. The community health clinic is one of several in Maine that offer discounted dental services on a sliding schedule.

"We have people who drive two hours to get to this facility," Eisenbarth said. "The financial component is a real roadblock."

The need for healthy, pain-free teeth is as basic as being able to chew your food and as complex as supporting the management of chronic illness like diabetes and heart disease. And yet, basic preventive care and disease treatment are out of reach for many older Mainers.

A pricey necessity

For those who can afford it, private dental insurance typically covers preventive care such as cleanings and X-rays but is of little value for restorative work such as fillings, crowns and bridges. MaineCare, Maine's state-administered Medicaid program for low-income residents, provides almost no dental coverage for adults, though children fare much better.

Medicare, the public health plan for Americans aged 65 and older, considers only a few dental procedures "medically necessary," although some privately managed -- and more expensive -- Medicare Advantage plans provide a more generous dental benefit.

The retail cost of dental and oral health care services varies widely, from practice to practice and from one geographic region to another. But according to one consumer website, a standard cleaning typically costs between $70 and $200. Dental X-rays can cost $250 or more. Filling a cavity can cost hundreds of dollars, while more complicated restorations like crowns and bridges often run in the thousands. A root canal procedure to save a damaged tooth can cost a few hundred dollars up to several thousand.

The importance of dental care as we age is huge. Healthy teeth and gums are critical for enjoying the the kind of healthy, high-fiber diet we should all be eating. They're also important for communicating clearly and for looking and feeling our best.

Untreated tooth decay and periodontal disease is not just painful and unsightly. It is also linked to serious systemic illness, including heart disease, diabetes, dementia and stroke. In addition, oral disease can delay or even prevent treatment for other conditions, such as organ transplant, chemotherapy, heart valve replacement and orthopedic joint replacement.

According to a 2013 report from the Maine Center for Disease Control and Prevention, 51 percent of all Maine adults in 2011 had lost at least one permanent tooth, and 8 percent had lost all their permanent teeth. Among adults 65 and older, 21 percent had lost all their permanent teeth. Within the 65-and-older group, rates of tooth loss were significantly higher among smokers, adults with diabetes, Mainers who had not graduated from high school and those living in poverty.

Medicare's omission

In 1965, when Medicare was passed into law, the average life expectancy for American men was about 67. For women, it was 74. Dentistry was an emerging science then, says one Maine expert, and it was common for people to have lost most or all of their teeth by the time they turned 50.

"Over half of the people Medicare was designed to benefit were already edentulous, and people were living not very long past the age of enrollment," said Dr. Jonathan Shenkin, a past vice president of the American Dental Association who practices pediatric dentistry in Augusta. "So the idea of including a dental care benefit in Medicare was not even on the radar."

Now, though, more than 50 years later, much has changed. Dentistry has evolved into a sophisticated specialty practice dedicated to preserving the health and function of teeth, gums and other oral structures across the lifespan.

Importantly, Shenkin said, medical science now recognizes the impact of good dental care and oral hygiene on overall health, particularly as we age. That growing body of evidence could provide the impetus to add a dental benefit to taxpayer-funded Medicare, he said, and interest is growing nationwide in doing just that.

Promoting a Medicare dental benefit

Led by the nonprofit, nonpartisan Center for Medicare Advocacy, a coalition of more than 70 medical specialty groups and other professional organizations, including the American Dental Association, has signed onto a "community statement" urging Congress to explore options for expanding evidenced-based coverage to Medicare recipients.

Among the groups endorsing the proposal is the senior advocacy organization AARP.

"This has been our policy for many years now," said AARP's senior legislative representative, Andrew Scholnick. "Older Americans certainly rely on Medicare to provide health care coverage, but Medicare doesn't really consider the mouth as part of the body."

The group also supports adding Medicare coverage for eyeglasses, hearing aids and related medical care.

Scholnick said work must focus on identifying an expanded definition of medical necessity and determining reimbursement rates that will make participating as a Medicare provider an attractive option for dental professionals. In addition, he said, the group aims to raise awareness and build support among policymakers and the general public.

"The lack of oral care is a big problem for millions of older Americans," Scholnick said. But, he added, "there is no hard and fast timeline" for making a change.

Existing resources

While advocates and policymakers in Washington take the long view, resourceful Mainers must look closer to home for affordable care. Here are some options:

-- Check out the nearest publicly funded community health clinic, several of which, like PCHC in Bangor, offer sliding-fee services ranging from cleanings and extractions to more complicated interventions.

-- In Portland, the University of New England provides sliding fee care at the UNE Oral Health Center and the separate UNE Dental Hygiene Clinic.

-- The nonprofit Community Dental clinics operate in Rumford, Lewiston, Farmington, Portland, and Biddeford and advertise "affordable" rates.

-- Inexpensive dental cleanings and disease screening are available in Bangor through the University of Maine at Augusta dental hygiene program.

-- The American Dental Association's Donated Dental Services program is run by the Colorado-based Dental Lifeline Network. About 170 Maine dentists volunteer in the program, but long wait lists mean applications are being accepted only in some areas of the state.

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