A long-shot bid to expand health care benefits for seniors is beginning to gain attention as part of Democrats’ signature health care bill, which the House is expected to vote on Thursday.
Speaker Nancy Pelosi and committee leaders are aiming to use savings from the drug bill to add dental, hearing and vision benefits to Medicare. Democrats say the legislation could result in $500 billion in savings over a decade, based on guidance they received from the Congressional Budget Office.
Despite increasing evidence that dental, vision and hearing care are critical to long-term health, House Democrats hoping for enactment would have to overcome reservations from some Republicans, as well as high-powered provider and health insurance groups wary of increasing the federal government’s influence.
If Democrats are successful, the bills would plug critical holes in the federal health program for seniors. While older adults are more likely to need things like dentures, hearing aids and glasses, Medicare currently covers only certain dental and hearing services under extreme circumstances, such as inpatient dental procedures or cochlear implants, and nothing related to eye exams for glasses or contacts.
Mounting evidence shows that oral, hearing and vision health have ties to chronic conditions. Multiple studies link periodontitis to diabetes and heart disease, for example, while eye exams can identify conditions like diabetes and high cholesterol. Hearing loss, meanwhile, is linked to dementia and Alzheimer’s.
An expansion would knock down an age-old barrier. Shawn Gremminger, senior director of federal relations for the Families USA advocacy group, said that barbers also once acted as dentists — people went to get a shave, a haircut and a tooth pulled.
“The lack of coverage in Medicare is a product of 1965,” he said, referring to the year Medicare was created. “But the way that dental care has always been considered separate really does date back to the 1800s.”
Some providers, such as dentists, are reluctant to accept payments through the original fee-for-service Medicare program, which they predict would be too low.
The change would also intrude on a corner of the Medicare market reserved for private insurance companies that offer additional benefits through comprehensive Medicare Advantage private plans or supplemental “Medigap” plans.
“On the one hand, the MA plans would lose a powerful distinguisher from original Medicare,” said Mike Adelberg, leader of Faegre Baker Daniels’ health care practice and former director of the federal Centers for Medicare and Medicaid Services Insurance Programs Group. “On the other, MA plans would likely receive additional funds to provide these services and could use existing money for new distinguishers like meals and transportation.”
The Better Medicare Alliance, which advocates for Medicare Advantage plans, suggested that it would be unnecessary to expand benefits and noted that nearly all beneficiaries could join private plans with additional benefits.
“Medicare Advantage beneficiaries — projected to be 40% of eligible beneficiaries — already enjoy additional benefits not available in Traditional Medicare, at no extra cost to the federal government or enrollees,” Allyson Schwartz, president and CEO of the Better Medicare Alliance, said in a statement.
Other groups, such as the National Association of Dental Plans, the National Association of Vision Care Plans, the American Council of Life Insurers, the International Hearing Society and the American Optometric Association, endorse the idea.
“This is something that we think is important for all Americans, but especially seniors,” NAVCP Executive Director Julian Roberts said.
Bills expanding benefits for dental care, hearing aids and vision benefits were approved by both the Ways and Means Committee and the Energy and Commerce Committee by voice vote in October. But while Republicans support the ideas, they oppose their inclusion in Pelosi’s polarizing drug pricing bill, which would require government negotiation of drug prices. The Senate hasn’t discussed a similar benefit expansion.
Medical providers’ views
Some provider groups appear open to the expansion, while some are more cautious.
The American Optometric Association says that current Medicare policy is counterproductive because it only covers eye exams when an underlying issue is found, which means seniors pay for their own routine care. “While a noticeable change in vision can be a sign of an issue somewhere else in the body, current Medicare policy deters seniors from seeing their eye doctor on an annual basis for a comprehensive eye exam,” the group said in a statement.
Audiologists, who conduct hearing tests, fittings and other procedures associated with hearing aids, also see promise in Medicare coverage — with caveats.
University of Pittsburgh professor Catherine Palmer, president-elect of the American Academy of Audiology, emphasized that Medicare would need to reimburse the full suite of services required for hearing aids. That includes measurements within an individual’s ear to ensure a proper output level, as well as ongoing care such as maintenance and reprogramming.
“This is specialized work that requires specially educated individuals and needs to be reimbursed accordingly,” she said.
The American Dental Association, along with the vast majority of doctor organizations, ardently opposed Medicare during its creation in the 1960s, even though dental services were largely excluded.
Attitudes within the ADA have changed, although concerns about payment rates are still high.
An “elder care workgroup” is working on a strategy to present to lawmakers, according to an email President Chad Gehani sent members in November, assuming the ADA House of Delegates approves the plan next fall.
“The question is not, ‘should we do something,’” Gehani wrote. “The question is, ‘how do we do it.’”
ADA lobbyists are making the rounds on Capitol Hill after sending a letter to committee leaders that proposed alternative policy options, like creating a separate optional benefit for dental services or incorporating coverage for low-income seniors into state Medicaid programs.
“We question whether this latest proposal adequately addresses the needs of seniors in the most appropriate and equitable way,” the group said in a statement. “Any solution must provide appropriate care for the most vulnerable elderly and guarantee a robust provider network.”
Dentists are wary of Medicare because of their experience with Medicaid, which they say offers reimbursements that are less than the cost of providing services. The ADA said the average state Medicaid reimbursement in 2016 for adult dental services was around 37 percent of the fees that dentists charged.
The legislation in Congress wouldn’t set the reimbursement rates. Instead, Medicare would set a fee schedule the way it does for services it currently covers — a process that could allow dentists to push for more generous rates.
New Jersey Democratic Rep. Jeff Van Drew, a dentist who was elected to Congress in 2018, supports adding dental coverage but says ensuring a fair reimbursement rate will be crucial. Otherwise, he fears it could discourage dentist participation and force Medicare patients to rely on federally qualified health centers.
“That’s a concern because you want patients to be able to go to their own dentist,” he told CQ Roll Call.
And there are questions about how generous the benefit will be for patients. The current bill would cover 80 percent of basic services, like cleanings and tooth extractions, with the patient paying 20 percent. That’s the same cost-sharing structure as for most outpatient Medicare services. But for more intensive services, like crowns and root canals, Medicare would phase in cost sharing of 50 percent by 2029.
Some members are unhappy with the burden on patients, but Van Drew, who hails from a conservative district, said Congress needs to mind the federal budget and called the current proposal adequate.
“They may not get implants. They’re not going to get veneers, I’ll tell you right now,” he said. “But at least they could get some basic stuff.”