Oral Health Disparities in the U.S. and COVID-19

Policymakers have struggled to close the gap between those who regularly go to the dentist and those who don’t.

by Arielle Kane, Director of Health Care at PPI

This week I went to the dentist for the first time since the outbreak of SARS-CoV-2. Obviously I was nervous to go. I knew the dentist would be in head-to-toe PPE so that didn’t worry me. My concern was that another patient would be mouth breaking into the same space for an hour and that their aerosols would drift over to my open mouth.

If you know me personally, you’ll know that I don’t delay dental care. When I worked for Deloitte, I went to the dentist three times a year for cleanings (because they covered it). But I hadn’t been to the dentist since October — eons in my book.

I know that delayed dental care is the number one reason for avoidable emergency visits. I know that poor oral health is a huge class divide — affecting health outcomes and employment opportunities.

Yet even though we know all of this, policymakers have struggled to close the gap between those who regularly go to the dentist and those who don’t.

There multifaceted barriers to accessing care:

• The first is coverage. More than 114 million Americans lack dental health coverage, roughly four times the number of people who lack regular health insurance. And that number has likely grown because of the 5.4 million people who have lost their insurance during the pandemic. People without dental coverage include almost two-thirds of Medicare enrollees, a quarter of children, and 40 percent of adults under the age of 65.
• The second is provider shortages. There are some rural areas where even if you did have health insurance that covered oral health services, you would be hard pressed to find a dentist to serve you. Roughly 45 million Americans live in a dental health shortage area.
• The final one is cultural. Because oral health has long been separated from physical health, people view it as secondary. People need help navigating existing resources and overcoming individual barriers to care. For example, a lack of awareness of dental benefits, how to find a quality dentist, and oral health literacy all prevent people from seeking treatment.

States have long acted as the “laboratories of democracy” piloting innovative policy solutions that, if proven successful, can be scaled. Oral health is no different. The federal government has an opportunity to learn from the states and increase access to dental health services through a multipronged approach.

Coverage: Medicaid covers dental benefits for children, but states are not required to cover dental services for adults. Though some states cover preventative services, many only cover emergency dental services. If Medicaid took the $520 million that it spends annually on dental ED visits and invested it in upfront oral health services, it would cover roughly one million dental visits. But even with coverage, barriers to accessing care remain. The data show that in states which expanded dental coverage to adults with Medicaid, emergency dental visits remained high (even in urban areas with lots of dentists). This suggests there are other barriers, than coverage, to accessing care.

Provider shortages: There are a number of policy initiatives to address provider shortages. Thirty three states and the District of Columbia provide dental loan repayment to push graduating dental students into underserved areas. In some very remote areas, such as Alaska, where it would take years to recruit dentists to small, isolated communities, policymakers created a two-year training program for “dental health therapists” to help fill in provider gaps. But before more states create these new programs, they need to accurately understand the barriers to access care within their borders. If no one can pay for dental services, putting more dentists in an area won’t get people the care they need. Furthermore, because HRSA has long used county boundaries to measure provider shortage areas, it can create artificial borders and over estimate the number of people living in shortage areas. HRSA, the agency that defines health provider shortage areas (HPSAs), is currently accepting ideas on how to best update the HPSA designation. According to the GAO, in 2005 more than 30 programs used federal HPSA designations to allocate funding and resources.

Cultural barriers: Oftentimes communities don’t need more dentists but rather, people need help finding and navigating the existing oral health resources and overcoming individual barriers to care. Roughly 80 percent of community health centers clinics offer free or discounted dental services to people who need them. Unfortunately, many potential patients often don’t know that dental care is readily available at these facilities and delay care until it is so painful they end up at the ED. States have developed pilots with a new type of health worker: a community dental health coordinator (CDHC). They help patients better access dental care and navigate the health care system. Based on the community health worker model, where workers help patients bridge the gap between clinical and community services, CDHCs provide community-based prevention, care coordination, and patient navigation to connect people with available services in their community. They can work for health centers, private dental practices and schools to better connect patients with the care they need. They may be able to perform some preventative services such as sealants and fluoride applications, as their state licensing laws allow, but they are not mid-level providers and must work under the supervision of a dentist.

Anyone who has a silver bullet to improve oral health in the U.S., is offering snake oil. It’s a complex problem that will take a holistic approach to address. However, it is solvable and states have demonstrated many innovative ways to improve access to oral health services.

COVID-19 fact of the week:. My dentist did take my temperature upon entry to the office. However, they clearly didn’t take it seriously. When I asked what the thermometer read, she said 92 degrees but that she didn’t feel like doing it again. Furthermore, the form I had to fill out to confirm I had no Covid-19 symptoms was pre-filled out to expedite the process — not exactly encouraging an honest response. However, no Covid-19 cases have been linked to the dentist office to date.