“How Do You Not Include Dental Care in Overall Health?”

October 4, 2021

Nathan Fletcher, DDS, is the dental director at AmeriHealth Caritas District of Columbia, a Medicaid insurance company. He is chairman of the Board of Trustees and past president of the National Dental Association (NDA) and former NDA executive director.  

Dr. Fletcher is also former co-owner of Fletcher & Fletcher Dental Baltimore, MD, a role he held from 1996 – 2020.  He graduated from Howard University College of Dentistry in 1987. In addition to making decisions for dental policies for 130,000 Medicaid recipients, he now spends a lot of his time mentoring younger people inside and outside of the profession.   

His work with the NDA provides a unique look into the underserved communities Dr. Fletcher aims to help. Drawing from those experiences and through that lens, Dr. Fletcher shared his thoughts on Congress’s ongoing work that could add dental coverage to Medicare.   

What’s your view on adding dental coverage to Medicare? 
I support adding dental coverage to Medicare to provide oral health care to individuals who have paid into a system to provide for their overall health care. Oral health care is part of overall health care, as we see with diabetes, heart disease, lung conditions, and gastrointestinal conditions. Gum disease is the most common cause for the most inflammation in the body in adults, which affects heart disease and other conditions. And it’s preventable.  

The senior population is the hidden underserved when it comes to dental care. Those on fixed income are often not able to afford even basic preventive services without assistance. And that doesn't include dentures to get proper nutrition and avoid GI problems.

Unfortunately, some of the larger dental organizations oppose the addition of a dental benefit for all Medicare beneficiaries. It is unfortunate, but I do believe that we will make the health of US citizens our top priority. 

From what you’ve seen, do other providers across the country support the legislation? 
The NDA has surveyed its members and found close to 2/3 take Medicaid. The communities they serve are those that are often underserved when it comes to health care services many take for granted. That includes seniors. It is my belief that these same providers will accept Medicare for the same reasons they take Medicaid.  

The NDA, along with several other clinical organizations, signed a joint letter in support of Part B on September 29, 2021. The letter states, “This will ensure that ALL Medicare beneficiaries have equitable access to an oral health benefit that is integrated into our current Medicare system.” 

It is astounding to me that it has been purported that the administration of Medicare dental services would pose some difficulties in managing dental coverage under Part B. The Centers for Medicare and Medicaid Services (CMS) manages dental services for Medicaid right now. This same government agency could easily add management of dental services for Medicare with its goals to address health equity in the health disparities that underlie the health system and to increase access to health care as part of its mission. The proposition by some that would be a burden seems disingenuous to me. 

Are there patients you’ve seen that crystallize the need for this change? 
You can pick a senior anywhere who could tell a story of neglect due to cost. There are any number of stories of patients who cannot afford routine dental care to include preventive services due to retirement or disabilities. When we consider that many have paid into the Medicare program every day, it's hard to say that they don't deserve dental care.  

Let’s imagine legislation passes. What looks different in the oral health industry?  
In a few years, you’ll be able to quantify the reduction in health care costs for a diabetic population, for example. There may be a quantifiable reduction in heart conditions of those who see their dentist regularly. And the industries’ profile would reflect a better image than it does now, with the negative perceptions of dentists. Overall health care would improve for the citizens who are paying every day for health care services right now.  

How could this legislation change individual practices?  
I took Medicaid patients when I was in private practice. I participated in a loan repayment program, as well, although I took Medicaid patients prior to participation. It fulfilled the dual purpose of service and business. If the reimbursement rates are reasonable, I believe that more dentists will participate than do currently.  

There will always be the segment of the dental profession who will not take anything except fee-for-service, depending on the region and surrounding environment. In areas where insurance is prevalent and underserved populations exist in high numbers, there will be those who will provide the services. 

Why are some in the dental industry against this legislation? 
I believe that those against this proposition feel it is an infringement on their "right" to do business outside of government intervention. There are those in the profession who provide service to the community and the priorities of others that are different. My opinion is that the face of the profession does not relate to those of underserved groups. The NDA has advocated for undeserved groups since its inception 108 years ago. Meanwhile, African American dentists weren't allowed to join professional organizations for more than a hundred years. When they did, the impediments of true members still made it hard to join. The interests of the NDA are different in that respect.   

But I do have to add that reimbursement should allow a reasonable business to be profitable and thrive. Maybe not to have that vacation home but to allow for student loan repayment and a comfortable life. 

Why is this a needed change for our country?  
The change this would bring is in line with changing health care policies, such as the Affordable Care Act, to truly address the health care of the nation. How do you not include dental care in overall health? Research has shown a diabetic patient who visits the dentist twice a year saves at least $2,000 in physical health costs annually. Those savings could be spent on dental care. For the average patient, the cost of preventive services would help reduce the overall health care costs in the nation.

Editor's note: Share your voice and tell Congress to strengthen Medicare by adding oral health coverage. 

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