Recently, the New England Journal of Medicine published “Oral Health for All — Realizing the Promise of Science,” authored by some of the most respected officials in dentistry and medicine, including the U.S. Surgeon General. They declared the pressing need to address the “global public health threat” of inequitable dental care. With a surprisingly populist title, it was refreshing for a public health dentist to see a clear stance being taken and a call to action on such a prestigious platform.
Yet, two days prior to publication, President Joe Biden gave the State of the Union Address without mentioning dental health, even though adding dental coverage to Medicare was the top priority among voters during the final negotiations of the Build Back Better Agenda with more than 80 percent public support.
So, if the top medical and dental professionals of the country, the public at large, and many politicians acknowledge the issue, what or who keeps us from addressing it head-on?
A quick look into the past provides a bit of perspective. As the original legislation responsible for Medicare was being crafted, the American Dental Association (ADA) lobbied against its inclusion and has worked to maintain its autonomy from government-funded programs ever since.
Fifty years later in 2021, the ADA, coordinating with a group of allied organized dentistry groups, wrote in opposition of including dental care in Medicare Part B, specifically, and offered a counter-proposal, including a means-tested program to offer care to the lowest-income seniors. Despite this, more dental organizations than ever before lobbied in favor of the proposal, including the National Dental Association and Hispanic Dental Association.
The ADA’s counter-proposal of creating a separate plan that would serve seniors up to 300 percent above the federal poverty level sounds generous, but it would equate to about only $40,770 of yearly income, leaving millions still without crucial coverage. Oddly enough, one of the strongest complaints about the dental benefit in Plan B was that dentists are unwilling to work with administrative burdens; however, one of the most salient critiques of means testing is that it is more expensive and less effective than universal programs due to more of these burdens.
Throughout this lobbying spree, the ADA sent a litany of “Action Alert” emails asking its 161,000 members, myself included, to write to their legislators. However, six months later and after their victory of dental coverage being omitted from the final iteration of Build Back Better, my most recent email from the organization consisted of a list of “ADA endorsed” products ranging from waiting room TVs to luxury vehicles.
Not an advocacy email in sight.
Moving past the failure of the Build Back Better Agenda, there have been administrative steps made to acknowledge and explore ways to alleviate oral health disparities. In the past year, the Center for Medicaid and Medicare Services has hired its first-ever Chief Dental Officer, Natalia Chalmers DDS, PhD, to examine possible improvements of delivery of dental care through the agency.
Just a few months ago, The National Institute of Dental and Craniofacial Research, a division of the National Institutes of Health, released a monumental 800-page report titled “Oral Health in America: Advances and Challenges” outlining the current landscape and proposed policy suggestions. One of the proposals suggests using dental therapists. These mid-level providers can perform a limited number of low-risk dental procedures such as extractions, treatment of basic cavities, and cleanings to address the oral health needs of communities, particularly Black and Latinx communities.
The ADA has never gone on record supporting these providers.
To start the year of 2022, the American Medical Association Journal of Ethics released an issue titled, Inequity Along the Medical/Dental Divide edited by Lisa Simon, MD, DMD. In a note, she states that “the professionally entrenched view that what’s in patients’ mouths is somehow isolated from what’s going on in the rest of their bodies is one all clinicians need to resist, since this view can be a source of harm, particularly among vulnerable patients and communities.”
Not a week goes by where I scroll through my timeline on Twitter and see someone comment on this separation of the mouth from the body reflected in our health care system, and in most cases, it’s a young and financially struggling person of color expressing their valid concerns. Through posts like these, I am constantly reminded of the work that is required of us — dentists, policymakers, and advocates — to address this public health threat.
We must reframe the concept of oral health in American society. Routine care of our mouths should not be a luxury or an optional insurance add-on. More people are unable to afford dental care than other types of health care. Dentistry as a profession focuses entirely too much on the profits that can be made from aesthetic and implant dentistry. What good are the advances in the technology and services a dentist can offer if they’re only available to a select few?
The evidence base has been built now – there is no denying the importance of oral health to systemic health. It is time to reconsider our collective approach to improving access and understand the political and financial barriers we face to achieve our goals. The ADA, while some members and leaders of the organization share many of the same sentiments as local and state advocates, must step up to support marginalized communities. The mouth is undeniably a site for justice to be achieved, and the work is cut out for us all to create a more equitable dental care delivery system.
Richard Rodriguez is a dentist.
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