Oral Health in America and Subsequent Policy Challenges for Oral Health Equity

The National Institutes of Health recently released only the second nationwide account of oral health in American history, Oral Health in America: Advances and Challenges, after a 20-year follow-up to the seminal report of 2000, Oral Health in America: A Report of the Surgeon General. The original report was a groundbreaking and comprehensive examination of oral health across the United States, and the first to systematically characterize the state of U.S. oral health, detail its numerous challenges, and establish a framework of action for the public, policymakers, and health care providers to improve population oral health. Although the resulting strategies and approaches led to important national progress, many of our nation's oral health challenges remain unaddressed or unresolved.¹

Since the original report, an evolving America has witnessed notable improvements in certain areas of oral health. However, gains achieved have been glaringly unequal across social groups. Many of the oral health disparities prominently identified two decades ago persist or have worsened today.¹ Consequently, America's disparate burden of oral disease continues to fall sharply along race and class lines—mirroring critical trends and patterns observed in general health.¹ Unless our context of oral health inequities is thoughtfully weighed, federal and state policies and practices will continue to be incomplete and ineffective. This includes the differential and relative contribution of social, political, and commercial determinants on oral health. The U.S. oral health care system has yet to meaningfully remedy starkly different experiences in Americans' oral health care access and oral health outcomes.

Structural racism and its role as a root cause of many oral health inequities has slowly gained recognition across America. Each of its resulting harms discriminate against people of color, create barriers throughout the lifespan, and limit opportunities—making it difficult to achieve or maintain oral health. This cycle perpetuates social disadvantages and leads to conditions that impair oral health or limit access to resources and opportunities that promote oral health, leaving certain groups at higher risk for dental diseases and unmet needs. Discriminatory policies and laws embedded in oral health financing and coverage create a two-tier system of segregated care featured across models and settings of oral health delivery.¹ Barriers to accessing essential care preclude timely and continual preventive services or appropriate treatment of critical needs. Moreover, the nationwide maldistribution of dentists and exceedingly low participation in public insurance plans is worsened by lack of workforce diversity, constraints in licensure portability, and limits to oral health care team services or member expansion.¹

Challenges to the U.S. Oral Health Care System

This context is significant as the U.S. stubbornly maintains a siloed and highly fragmented oral health care system. As the U.S. upholds a system purposefully designed to serve American groups differently, can it sincerely expect equitable outcomes? In fact, the underlying structure of dental care finance is a primary reason oral health disparities persist. The U.S. created a delivery system altogether inadequate to support its marginalized and underserved populations—who are unable to equally access available care, utilize care for equal need, or obtain equitable care outcomes.^1,2 Furthermore, consequences of the historical separation between dentistry and medicine linger in Americans' health and health care system - including the perception among policymakers and the public that oral health is non-essential, propagating federal and state policy neglect.

America's dental financing model and subsequent patchwork of public and private dental insurance remains deliberately separated from medical insurance.² This presents unique burdens for diverse populations to access care while diminishing its value—isolating oral health care from the overall health care system. It should come as no surprise that almost a quarter of all Americans still live without any form of dental insurance.¹ If available, dental insurance plans notably differ in scope, breadth, and quality—particularly through burdensome eligibility requirements, narrow benefits provided, and limited availability of participating dentists—effectively creating gaps in coverage that keep patients underinsured or uninsured.¹ In comparison with medical insurance, dental insurance burdens patients with greater out-of-pocket expenses. In fact, financial barriers play a larger role in access to dental care than to any other type of health care.²

Delivery of dental care in the U.S. continues to function predominantly as a fee-for-service payment model, incentivized by service volume. Clinical practice models emphasize restorative and surgical procedures over preventive methods to attain or preserve oral health.^1,2 As dentistry slowly adopts alternative payment models, the profession will reach an important crossroad concerning whether it serves mainly as primary care providers or surgical specialists. The resulting tension will redirect dentistry's purpose and approaches away from post-disease treatment towards prevention, regular maintenance, early interventions, and appropriate referrals while holding promise to lower costs, improve outcomes, and increase patient satisfaction. Such a change should further cement oral health into a universal definition of primary health and health care. Additionally, the integration of oral and primary care can better support person-centered care alongside core benefit packages that include dental care coverage among our public payer systems. This also encourages a natural system shift towards pay-for-performance programs, use of quality measures, and population-based payments.

However, lack of quality performance measures to assess the U.S. oral health care delivery system hinders any potential to address oral health disparities. Without meaningful indicators and nationally representative data it will not be possible to measure, monitor, improve, or incentivize quality to build a more equitable oral health system. Over the past several years the Centers for Medicaid and Medicare Services made important steps to assess dental access and utilization of preventive services.^1,2 However, broader progress in dental quality measurement remains impeded by constraints in infrastructure and capacity, as well as the affordability, availability, and granularity of data including patient-level oral health status or oral health care outcomes.^1,2 Dental quality measures have also yet to be evaluated alongside population health measures, without which one is unable to understand or target oral health determinants for improved outcomes.

Policy Lessons and Options for Population Oral Health

Through the Affordable Care Act (ACA), America reached an important milestone while simultaneously missing a vital opportunity, when it mandated dental care as an essential health benefit for children but critically not adults. In the years since the ACA's implementation, diverging impacts between beneficiaries—particularly among social groups—have been striking. In 2015, the percent of Americans without dental insurance was 12% for children—compared to 28% for working-age adults and 68% for seniors.^3,4 During this same period, children from low-income racial and ethnic minority families experienced the greatest improvements across several oral health indicators, in sharp contrast to adults.⁴ This benefit has proven to support oral health access and outcomes and should be mirrored as a framework to design and implement an adult mandatory dental benefit.^5,6

Despite evidence that coverage and expansion of dental benefits improves oral health and reduces inequity, the Medicare Dental Benefit Act of 2021 was not included in the Build Back Better legislative package. This setback signifies another lost opportunity to develop a truly equitable, quality-driven, and integrated dental delivery system. Furthermore, other policy options including legislation that requires states to provide comprehensive dental benefits for Medicaid adults remain stalled. These exclusions further risk the health, quality of life, and economic stability of already vulnerable Americans with the heaviest burdens on racial and ethnic minorities and rural or tribal communities. Together, these policy imperatives remain our most necessary and fundamental steps toward reducing and eliminating oral health disparities. See Box 1 for a distillation of current federal and state challenges to oral health equity in the United States.

All Americans should be unencumbered by oral disease and able to fully achieve their aspirations. This starts by centering equity and justice as we reform the design and implementation of the U.S. oral health care system. Without mutually reinforcing policy actions that close dental coverage gaps, integrate oral health, and address social

Box 1. CURRENT FEDERAL AND STATE CHALLENGES TO ORAL HEALTH EQUITY IN THE UNITED STATES

Barrier	Challenge
Structural	Separation of oral health care from health care financing, insurance, payment, and delivery systems.
	Variable rules of eligibility, processes of enrollment, and maintenance of coverage that hinder and limit access to oral health care.
Political	Inconsistent political interest, motivation, or commitment to enact or reform oral health policies or programs.
	Disconnect between population disease burden, oral health needs, and regard by policymakers.
Financial	Insufficient allocation of federal or state funding for oral health coverage and programs, subject to discretionary spending, and vulnerable to budget cuts.
	Inadequate equity-based incentives, including equity-based pay-forperformance to understand, measure, and improve oral health system performance.
Institutional	Inequitable design and implementation of oral health policies that unjustly pose burdens to access care for certain population groups.
	Disconnect between federal and state coordination of policies and actions that aim to address oral health disparities.
Analytical	Lack of nationally representative oral health data for all racial and ethnic minorities, particularly population subgroups.
	Limited infrastructure or capacity to collect or utilize meaningful quality measures and metrics.

context, the country will again find widening disparities according to race, income, and age over the next decades. Locked in a cycle that perpetuates disadvantages and marginalization, Americans would continue to be at a loss of personal security, prosperity, and dignity when deprived of oral health.