Orlando Harmon
In the United States, dental insurance is often seen as a luxury, while medical insurance is considered essential. This divide has created a disparity in access to dental care, with many people relying on Medicaid unable to receive dental treatment. While Medicare does not cover dental costs, and Medicaid covers few, states are required to provide dental benefits to children covered by Medicaid. States have the option to provide dental benefits to adults covered by Medicaid, but less than half provide comprehensive dental care. This divide between medicine and dentistry can be traced back to the early 1900s when oral health was not considered to be linked to overall health.
| Characteristics | Values |
|---|---|
| Dental insurance is seen as | A luxury |
| Medical insurance is seen as | Essential |
| Medicare covers | No dental costs |
| Medicaid covers | Few dental costs |
| Dental services for adults | Not included in Medicare, optional under Medicaid |
| Oral health | Widely thought to have little bearing on general health in the early 1900s |
| Dentists viewed their trade as | More craft than science |
| Medical-dental divide | Persists today |
| States are required to cover dental services for | People with Medicaid under the age of 21 |
| Dental services for children must include | Oral screening, but this does not substitute a dental examination from a dentist |
| States may choose whether to provide dental benefits to | Adult Medicaid-eligible populations |
| Less than half of states provide | Comprehensive dental care |
| States with separate CHIP programs may choose | A package of dental benefits that meets CHIP requirements or a benchmark dental benefit package |
| There are | No minimum requirements for adult dental coverage |
| Dental services covered by Medicare include | Dental ridge reconstruction, services to stabilize or immobilize teeth, dental splints, dental or oral examinations, and treatment for oral or dental infections |
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What You'll Learn
Dental insurance is seen as a luxury, not essential
In the United States, dental insurance is often considered a luxury rather than an essential part of healthcare. This perception has resulted in dental care being largely excluded from Medicare and optional under Medicaid. While dental symptoms can lead to severe health problems, dental insurance is often seen as a non-essential add-on to standard health insurance policies. This perception of dental insurance as a luxury item has contributed to the development of a two-tiered healthcare system, where those who can afford private dental treatment receive high-quality care, while those who rely on public healthcare may struggle to access even basic dental services.
Historically, the fields of medicine and dentistry in the United States were officially separated in the early 1900s, with dentists viewing their trade as more of a craft than a scientific discipline. At the time, oral health was not considered to have a significant impact on overall health, and efforts to integrate dentistry into medicine were resisted by dentists and dental organizations. This separation between medicine and dentistry has persisted and contributed to the perception of dental care as a luxury rather than a necessity.
The exclusion of dental coverage from Medicare and the optional nature of dental benefits under Medicaid have exacerbated health inequities in the United States. While Medicare does not cover most dental procedures, Medicaid has experienced reductions in dental coverage, with 12 million adults and children losing Medicaid dental coverage in a single year. Additionally, certain Medicaid waivers have positioned oral health care as a luxury that must be earned through healthy behavior requirements, further contributing to the perception of dental insurance as a non-essential benefit.
The lack of comprehensive dental insurance has led to a dental care crisis in the United States, with millions of Americans unable to afford basic dental procedures. Many individuals with dental insurance find that their coverage is inadequate, leading to skipped appointments and untreated dental issues. This crisis disproportionately affects low-income individuals, pregnant women, people with disabilities, veterans, rural communities, and racial and ethnic minorities, who already face barriers to accessing dental care.
The high cost of dental care in the United States has even driven some Americans to seek treatment in other countries, such as Mexico, Costa Rica, and India, where the cost of procedures is significantly lower. The situation has become so dire that Senator Bernie Sanders introduced a bill to expand Medicare, Medicaid, and the VA to provide comprehensive dental coverage to seniors, veterans, and low-income individuals, recognizing that dental care should be an essential benefit under the Affordable Care Act.
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States choose whether to provide dental benefits for adults
In the United States, dental insurance is treated differently for adults and children. While dental coverage for children is deemed essential, it is not considered a necessity for adults. States are required to provide dental benefits to children covered by Medicaid and the Children's Health Insurance Program (CHIP). However, states have the autonomy to decide whether to extend dental benefits to adults. This means that dental coverage for adults under Medicaid is not mandatory and is left to the discretion of each state.
The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit is a comprehensive child health program under Medicaid that ensures children have access to dental services. This program focuses on prevention, early diagnosis, and treatment of medical conditions. States are required to provide dental services to Medicaid recipients under the age of 21 as part of the EPSDT benefit. This includes oral screenings, dental examinations, and referrals to dentists as per the state's periodicity schedule. States must also ensure that dental services are provided at intervals that meet reasonable standards of dental practice and address any suspected illnesses or conditions.
While states have the flexibility to determine the extent of dental benefits provided to adult Medicaid enrollees, there are no minimum requirements for adult dental coverage. Most states provide at least emergency dental services for adults, but less than half offer comprehensive dental care. The decision to include or exclude dental benefits for adults in Medicaid is often influenced by budgetary constraints and state priorities. When states face financial pressures, adult dental services are often among the first cutbacks.
The separation of medicine and dentistry in the United States has a long history. Despite recognizing the importance of oral health, the American Medical Association (AMA) and other organizations have resisted the inclusion of dental coverage in health insurance policies. This has resulted in a medical-dental divide, exacerbating health inequities between those who can afford dental care and those who cannot. The exclusion of dental services from Medicare and the optional nature of dental coverage under Medicaid contribute to this disparity.
In recent years, there have been efforts to improve oral health care access and quality for individuals enrolled in Medicaid and CHIP. The Centers for Medicare & Medicaid Services (CMS) established the Oral Health Initiative (OHI) in 2010 to enhance preventive dental care for children. Since then, there has been an increase in Medicaid and CHIP enrollment among adults and children, state expansion of dental benefits for adults, and progress in dental quality measurement. These initiatives aim to address the challenges of accessing dental care, particularly for low-income adults, and to recognize the significance of oral health in overall well-being.
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Dentistry is separate from medicine
The separation between dentistry and medicine is a long-standing divide that has been described as unnatural and illogical. While dental health is widely acknowledged to be essential to overall health, it is often treated as a separate entity from medicine. This divide has created and exacerbated health inequities, with dental insurance being harder to obtain and dental problems being left untreated, sometimes leading to severe health complications.
Historically, the separation between dentistry and medicine can be traced back to the 18th and 19th centuries when medical schools began to exclude dentistry from their curricula. In 1840, the United States' first dental school was established after the University of Maryland School of Medicine rejected proposals to integrate dentistry into its medical program. This event, known as the “historic rebuff”, symbolically defined the relationship between medical and dental education and healthcare systems. Dentists began to establish their own schools and identities, separate from their medical counterparts.
Over time, dentistry came to be viewed as a trade or craft rather than a branch of medicine. In the early 1900s, oral health was widely believed to have little or no bearing on general health, and efforts to combine the fields were resisted by both dentists and physicians. This mindset persisted despite the recognition by some, including the Greek scholar Hippocrates, that oral health was integral to overall health.
The separation between dentistry and medicine has led to distinct education systems, physician networks, medical records, and payment systems. Dental records, for example, lack a commonly accepted diagnostic code language, making it challenging to integrate medical and dental records and conduct research on the connections between oral and overall health. This separation has contributed to a gap in understanding oral diseases and has influenced the approach to tooth decay, often treating it as a surgical problem rather than a preventable disease.
While the divide between dentistry and medicine has deep roots, there are efforts to integrate the two fields. Some clinics have embedded dentists and hygienists into clinical teams, providing comprehensive care that addresses the links between medical and dental health. Initiatives like these demonstrate the potential for deeper integration and a more holistic approach to patient care.
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Lack of minimum requirements for adult dental coverage
The separation between medicine and dentistry in the United States has a long history. In 1840, the country's first dental school opened after the University of Maryland School of Medicine rejected proposals to integrate a standardised dentistry curriculum. By the 1900s, oral health was widely believed to have little to no impact on general health, and dentists considered their trade more of a craft than a science. This divide between medicine and dentistry persists today.
In the 1920s, the Carnegie Foundation hired a biological chemist, William Gies, to report on dental schools, and he insisted on the impossibility of separating oral health from overall health. However, dentists were not convinced, and efforts to combine the fields were resisted. In the 1930s, President Franklin D. Roosevelt created the Interdepartmental Committee to Coordinate Health and Welfare Activities, which covered "minimum essential needs" and included emergency dental care. Despite this recognition of the importance of oral health, Medicare, established in 1965, covers no dental costs, and Medicaid covers few.
The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit is a mandatory service required under a state's Medicaid program. States are required to provide dental benefits to children covered by Medicaid, and dental services must be provided at intervals that meet reasonable standards of dental practice. However, there are no minimum requirements for adult dental coverage under Medicaid. States may choose whether or not to provide dental benefits to their adult Medicaid-eligible population, and while most states provide at least emergency dental services for adults, less than half provide comprehensive dental care.
This lack of minimum requirements for adult dental coverage under Medicaid contributes to health inequities between those who can afford dental care and those who cannot. It also highlights the ongoing challenge of integrating oral health into overall health care financing and policy.
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Dentists value pricing autonomy
In the United States, the fields of medicine and dentistry have been officially severed since the legislative advent of Medicare and Medicaid in 1965. This divide was entrenched much earlier, in the 1900s, when oral health was widely considered separate from overall health, and dentists viewed their trade as more of a craft than a science.
While dental insurance is often seen as a luxury, medical insurance is considered essential. This has created a health inequity between those who can afford dental care and those who cannot. Despite this, dentists have historically resisted efforts to combine the fields of medicine and dentistry, fearing a loss of pricing autonomy and an increase in clerical work.
In the context of Medicaid, states are required to cover dental services for people under the age of 21 as part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. However, states have the flexibility to determine what dental benefits are provided to adult Medicaid enrollees, and less than half of states provide comprehensive dental care for adults.
The separation of dentistry from medicine has resulted in a situation where dental services are not consistently covered by Medicaid, contributing to the perception of dental insurance as a luxury rather than a necessity. This further reinforces the autonomy of dentists over their pricing and practices, separate from medical insurance and healthcare systems.
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Frequently asked questions
Medicaid does cover some dental services, but it is up to each state to determine what dental benefits are provided to adult enrollees. While most states provide at least emergency dental services for adults, less than half provide comprehensive dental care.
States are required to cover dental services for people with Medicaid under the age of 21 as part of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit.
In the early 1900s, oral health was widely believed to have little to no bearing on general health. Even dentists, who viewed their trade as more of a craft than a science, resisted efforts to combine oral health with general health.
In 2023, an expert workgroup recommended that the Centers for Medicare & Medicaid Services (CMS) broaden its Oral Health Initiative (OHI) to work on oral health access, quality, and outcomes across the lifespan.
