AJPH PERSPECTIVES

implant is $4000 or more if bone Oral Health and Aging graft and anesthesia are needed. For the large segment of seniors fi See also Borrell, p. S6. who live on xed incomes, this is unaffordable. Seniors below 150% of the federal poverty level Oral diseases and conditions embarrassment and a loss of Medicare Advantage plans that are three times as likely to report that are associated with aging self-esteem contributing to do offer dental coverage provide unmet dental needs compared concomitantly result in an in- loneliness and social isolation. minimal benefits. According to with those with incomes over creased need for preventive, re- More than half (53%) of se- the Medicare Rights Center, 300% of the federal poverty level. storative, and periodontal dental niors have moderate or severe most beneficiaries do not realize Complicating this situation care. This is particularly true of . There is in- that dental services are not cov- are overall and regional shortages seniors aged 65 years and older creasing evidence of the associa- ered and express concern about of dental practitioners willing to who are economically disadvan- tion of periodontal disease with how to access and afford needed treat seniors. More than 60% of taged, who are members of chronic conditions including di- dental services. Under Medicaid, states have substantial provider abetes, heart disease, and stroke. states have the option of pro- racial/ethnic minority groups, shortages and racial/ethnic di- Oral health conditions among viding adult dental coverage. As and who are institutionalized, versity of providers is lacking. disabled, or homebound. seniors with chronic conditions a consequence, four states do not fi Only six percent of dentists are Nearly 19% of seniors no are often exacerbated by use of offer a dental bene t and 15 states 7 6 racial/ethnic minorities. longer have any natural teeth. medications. About 400 com- offer emergency-only coverage. Loss of teeth increases with age monly used medications can Access is further hampered be- and varies by race/ethnicity.1 cause dry , which heigh- cause 80% of dentists do not ac- – tens the risk of oral disease.3 cept Medicaid because of low According to 2011 2012 data ADDRESSING THE reported by the National Center reimbursement rates. for Health Statistics, adults aged Upon retirement, seniors of- NEEDS 75 years and older (26%) were ten lose their dental insurance. To address the oral health twice as likely to be edentulous as Only two percent of retirees needs of seniors, a multiyear, DENTAL INSURANCE 7 those aged 65 to 74 years (13%). COVERAGE retain dental coverage. With multipronged approach is supplemental dental insurance, needed. This includes tackling Non-Hispanic Blacks (29%) About one half of seniors do fi the coverage cap on claims gen- two cultural norms: First, we were signi cantly more likely to not go to the dentist.4 More than erally ranges from $1000 to must challenge the concept that be edentulous compared with one in five Medicare beneficiaries $1500 per year and has not oral health care is optional rather Hispanics (15%) and non- have not visited a dentist in five increased in 30 years. than an integral part of health Hispanic Whites (17%). A Mas- years.5 Cost is the major reason care. Second, we cannot yield to sachusetts survey revealed that why seniors do not seek or utilize the ageist view that accepts less- 34% of seniors in nursing homes dental care. Approximately 70% than-optimal oral health or asserts have urgent and major dental of older Americans lack dental 2 that seniors should be resigned to health needs. insurance. The remainder are SYSTEM BARRIERS TO losing their teeth and living with loss has multiple im- covered through employer- CARE oral disease. pactsonhealthandwell-being. sponsored plans, Medicaid, or Many seniors incur high out- A successful approach Seniors who have lost all or self-purchased supplemental of-pocket dental expenses. For encompasses the following most of their teeth often end insurance. example, the average cost of an components: up avoiding fresh fruits and For its 55 million beneficia- vegetables—basic elements of ries, traditional Medicare does a healthy diet. Relying on soft not cover routine dental care. ABOUT THE AUTHOR Carol Raphael is a senior advisor at Manatt Health Solutions and chair of the Long Term foodsthatareeasilychewable Medicare Part A (hospital in- Quality Alliance, New York, NY. results in a decline in nutrition surance) covers very limited Correspondence should be sent to Carol Raphael, Manatt Health Solutions, 7 Times Square, and health. In addition to “medically necessary” benefits 22nd Floor, New York, NY 10036 (e-mail: [email protected]). Reprints can be ordered “ ” fi at http://www.ajph.org by clicking the Reprints link. pain and dif culty speaking, related to certain dental services This editorial was accepted March 30, 2017. often leads to provided during a hospital stay. doi: 10.2105/AJPH.2017.303835

S44 Editorial Raphael AJPH Supplement 1, 2017, Vol 107, No. S1 AJPH PERSPECTIVES

1. A vigorous education campaign population of older adults Salon; September 29, 2016; Arlington, that will get this issue on the who are retaining more of VA. fi public’s radar screen. The cam- their teeth and have multiple 5. Oral health and Medicare bene cia- ries. Coverage, out-of-pocket spending, paign must demonstrate why chronic conditions that re- and unmet need. Washington, DC: society should care about this quire multiple medications. Kaiser Family Foundation; 2012. issue and how it would benefitif In addition, new delivery 6. Medicaid adult dental benefits: an theseissueswereaddressed. models are needed to address overview. Hamilton, NJ: Center for Health Care Strategies Inc; 2015. 2. A broad and potent coalition the needs of the homebound 7. State of decay. Are older Americans that builds broad support and long-term-care pop- coming of age without oral healthcare? particularly among credible ulations in nursing homes and Chicago, IL: Oral Health America; 2013. groups with no financial stake assisted living sites. Mobile in the outcome. It should technology, tele-dentistry, include national stakeholders, adoption of oral health teams, collaborators, and champions and integration with geriatric in executive and legislative and primary care offer op- branches. portunities for significant 3. A set of financially and po- improvements in care de- litically feasible options that livery models. includes a set of essential benefits and supports quality care and value-based out- comes with the additional CONCLUSIONS goal of reducing costs. A re- cent study by Avalere (2016) The population of older adults for the Pacific Dental Services is growing and is increasingly Foundation estimated the cost diverse. Dental practice and and savings of a new Medicare dental systems can and should be Part B benefit covering the transformed to ensure the oral initial and ongoing treatment health of all seniors. Focusing on fi of periodontal disease for the oral health of seniors bene ts beneficiaries with diabetes, not only those who are seniors coronary artery disease, or today, but also seniors in the stroke. It concluded that this future. new benefit would generate a net savings for Medicare of Carol Raphael, MPA, MEd $63.5 billion from 2016 to 2025. 4. At the same time, it may REFERENCES be advisable to work with 1. Dye BA, Thorton-Evans G, Li X, private-sector insurers and Iafolla TJ. Dental caries and in – providers establishing risk- adults in the United States, 2011 2012. NCHS data brief, no 197. National based coordinating entities Center for Health Statistics. 2015. Avail- such as accountable care or- able at: https://www.cdc.gov/nchs/data/ ganizations. These organiza- databriefs/db197.pdf. Accessed March 9, 2017. tions would have more fl fi 2. A path to expanded dental access in exibility in bene t design Massachusetts. Philadelphia, PA: Pew and in applying the results of Charitable Trusts; 2015. retrospective claims research 3. Oral health for older Americans. demonstrating the link Centers for Disease Control and Pre- vention. 2006. Available at: https://www. among oral health, peri- cdc.gov/oralhealth/publications/ odontal disease treatment, and factsheets/adult_oral_health/adult_older. medical costs in practice htm. Accessed January 3, 2017. environments. 4. Manski R. Access to oral care and the impact of retirement. Lecture presented 5. New models of delivery are at: Expanding Oral Healthcare for needed to treat the increasing America’s Seniors: A Sante Fe Group

Supplement 1, 2017, Vol 107, No. S1 AJPH Raphael Editorial S45