Closing the Gap: A Conversation on Oral Health, Equity, and Aging

Claire Altman, Blog Editor, spoke with Samantha Morales, Senior Policy Advocate at Justice in Aging, about a gap in our health care system: oral health coverage for older adults.

Justice in Aging is a national organization that uses the power of law to fight senior poverty by securing access to affordable health care, economic security, and the courts for older adults with limited resources. Below, Morales walks us through the policy landscape, the equity issues, and what population health researchers should know about oral health for older adults.

This interview has been edited and condensed for blog-friendliness.

Claire: Let’s start with the basics. Why doesn’t Medicare cover dental care, and how does that gap actually work in practice?

Samantha: The Medicare program is limited, but the Centers for Medicare and Medicaid Services (CMS) have allowed for some coverage — despite the statute that prohibits Medicare coverage of routine and comprehensive dental care — of medically necessary dental services to be covered under Medicare Part A or B when these dental services are inextricably linked to a Medicare-covered medical service.

For example, a Medicare enrollee who needs to get open-heart surgery, and their provider has informed them that if they have any type of infection, it could be very dangerous. CMS now allows Medicare participants who need cardiac valve replacement surgery to get dental services to address oral infection or pain. They’re allowed to see a dentist, and then Medicare will cover those services. Those are called medically necessary dental services because they are inextricably linked to the clinical success of the covered procedure.

Despite this coverage, gaps persist because you have many more people who may not meet the medically necessary dental criteria for Medicare coverage. CareQuest Institute for Oral Health has come out with a number: And that’s really where we see concerns with overall health outcomes, because the research is not new in terms of the bi-directional link between oral health and overall health, especially for folks with chronic conditions. That’s really what we’ve tried to uplift at Justice in Aging in our oral health work — in our fact sheets covering oral health care access for nursing facility residents and protecting Medicaid for low income older adults and people with disabilities, and in our FAQs about adding a dental benefit to Part B, and other publications such as our oral health blog uplifting the need for oral health coverage in Original Medicare.

Even though we’ve had some successes with Medicare covering medically necessary dental services, we’re really trying to push Medicare to expand that coverage. For example, as part of a coalition of national organizations that form the Consortium for Medically Necessary Oral Health Coverage, Justice in Aging supported the nomination to CMS of diabetes-associated retinopathy and nephropathy and hospital-acquired pneumonia (NVHAP) as conditions to be considered for further expansion of Medicare coverage of medically necessary dental services. Currently, Medicare enrollees diagnosed with end-stage renal disease (ESRD) who are receiving dialysis treatments can receive dental services related to preventing infection, and Medicare will cover that. Other Medicare enrollees who do not meet the criteria for medically necessary dental coverage via Medicare are out of luck, even though they may have serious chronic conditions, such as dementia and other conditions where their oral health impacts their overall health.

Claire: You’ve described oral health as more than a clinical issue. In fact, you see it as an access-to-justice and equity issue.

Samantha: You’re absolutely right. We try to really uplift what lack of access to oral health care means for the most vulnerable populations of people — older adults who are low-income, who are from communities of color, who are institutionalized in nursing facilities — and what lack of access to oral health care means to these folks who are dealing with multiple chronic conditions, and how that impacts their overall health when managing those conditions.

Through our oral health work, whether it’s a focus on California or nationally, we uplift the importance of protecting Medicaid adult dental benefits, and discuss how securing health insurance coverage is not enough. Our fact sheet explains how institutionalized older adults — people living in nursing facilities who have both Medicare and Medicaid, and comprehensive dental benefits through Medi-Cal, California’s Medicaid program — are still struggling to access the dental benefits they already have.

We need to think creatively about how to get hard-to-reach populations access to care, as an equity issue.  Mobile dental clinics can come to the nursing facility, but how can we integrate oral health care within primary care? We try to uplift medical-dental integration as championed by our national partners, like Community Catalyst, Families USA, and the CareQuest Institute for Oral Health. Access to care must also address how people get the care they need when they’re in rural communities or in institutionalized spaces like nursing homes.

Claire: Which populations of older adults are hardest hit by this coverage gap — by race, income, immigration status, geography?

Samantha: All of these groups. The lowest-income older adults who cannot afford private dental insurance are the hardest hit. Typically, these are folks dually enrolled in the Medicare and Medicaid programs— and hopefully their state has expanded Medicaid adult dental benefits as many states have. With the passage of the Budget Reconciliation Act of 2025 (H.R. 1) and the significant cuts to state Medicaid funding, many states are now dealing with fiscal constraints that place Medicaid adult dental benefits at risk.

Communities of color are hardest hit as well. The CDC shows higher percentages of Black and Mexican American older adults in the U.S. who are not getting access to dental care or oral health care presenting with higher percentages of caries, and many more older adults who are Black or Mexican American are losing more of their permanent teeth. The CDC has a lot of great data already published that we incorporate in our fact sheets. And KFF also has done an amazing amount of work and research that’s publicly accessible, that we’ve utilized.

There’s also really wonderful research on older adults who have more than one chronic condition — especially true for older adults in nursing facilities. Nursing home residents with more than one chronic condition have much higher percentages of caries and other oral health problems compared to those without chronic conditions. Older adults with dementia, for example, have poorer oral hygiene scores.

We uplifted research from Dr. Natalia Chalmers, who was the first CMS chief dental officer until she departed last year, focused on oral health among nursing home populations. The Center for Oral Health in California has also come out with important research on institutionalized older adults throughout the state, and disparities when it comes to rural versus urban access.

IAPHS: What should population health researchers understand about the downstream effects of poor oral health or limited access to oral health care?

Samantha: Researchers are already making the case that oral health impacts overall health and demonstrating it with data.

But I’d encourage a focus on quality-of-life outcomes. The Center for Oral Health report that I referenced earlier does a great job of incorporating quality-of-life outcomes. In our work, we try to do this by uplifting stories and lived experiences.

There is research demonstrating how access to oral health care for people with diabetes can help mitigate their chronic condition, and reduce health care costs. In addition to this, there is also the isolation that comes with oral health infections — what happens when you can’t eat properly. Without comprehensive oral health care coverage, low-income older adults who lose their permanent teeth will likely be unable to afford dentures or prosthesis. This can impact their intake of nutritious foods and can cause serious impacts on their health if they suffer weight loss. Additionally, there is a mental health effect when people can’t connect to their communities because they might be embarrassed, or not feel well due to dental pain.

Claire: What do you see as the most promising policy levers right now — Medicare dental benefits, state Medicaid expansion, managed care requirements? Where’s the momentum?

Samantha: In the Medicare space, it’s not just protecting medically necessary dental services that are already part of the program, but expanding that — making sure that list grows to include Medicare enrollees diagnosed with diabetes, for example — but also thinking beyond that: What about adding a dental benefit to Medicare Part B?

We released a statutory analysis in 2019 that we’re building on now, making the case for how Congress can incorporate a dental benefit in Medicare, and how we already have the infrastructure in Part B to make this happen. We’re shifting to think not just defensively, but to provide proposals to expand coverage — especially thinking about the midterms and changes that might create a landscape supporting expansion.

It’s the same with Medicaid — we want to protect Medicaid adult dental benefits, mitigate the impacts of H.R. 1 and also think through how to expand coverage to make it more feasible for states given the current budgetary constraints.

We are doing two things at once: protecting and defending existing coverage in Medicare and Medicaid, and also building on ideas of expanding coverage within both programs, to ensure Medicare enrollees — including dually eligible people enrolled in both programs — can have access to comprehensive health coverage that includes oral health care.

On Medicare Advantage, which is often marketed as covering the dental benefits that Original Medicare doesn’t:

Medicare enrollees face many challenges in Medicare Advantage (MA) plans when trying to access dental benefits.

At Justice in Aging, we’re uplifting how there’s a lack of transparency when it comes to dental benefits in Medicare Advantage. While MA plans are often sold as providing dental, research from KFF demonstrates that access to plan supplemental dental benefits can be challenging due to plan rules and restrictions. Additionally, MA plans often do not provide comprehensive dental benefits. For these reasons, we are really trying to make the case that we need to work on expanding oral health coverage within Original Medicare to uplift all Medicare enrollees.

Claire:  How do nursing facility residents’ oral health needs differ from community-dwelling older adults, and what are the systemic barriers specific to that setting?

Samantha: We’ve done a lot of work around this — uplifting the lived experiences of older adults in nursing facilities and their lack of access to oral healthcare, and what that does to people.

Isolation is a problem—some providers aren’t equipped to go there. Unfortunately, nursing facility staff are dealing with so many other fires that the oral health piece just gets pushed to the background. There aren’t enough dental providers willing to go to nursing facilities, or enough mobile dental clinics to come to them. The transportation piece is big — there’s often not enough resources to provide transportation to residents to go see a provider in the community. And for people with disabilities who are homebound, it’s not always easy to move them, because they may have chronic conditions that don’t allow for a safe transfer. There are also not enough dental providers who are trained and equipped to provide services to individuals with certain cognitive conditions.

The other piece is nursing facility staff expressing discomfort providing oral health care, even though that’s often part of their responsibilities — especially when it comes to residents with dementia, memory loss, or other cognitive conditions that may cause behavioral issues. Nursing facility staff are often not sufficiently trained to address these issues.

When considering solutions to address the challenges, it is a conflation of multiple things. There has to be more training when it comes to working with a geriatric population. I often hear from experienced experts working in this field about the need to reframe dental services and access to care —for example, thinking about creative models that decenter the traditional dentist office with auxiliary dental professionals with an expanded scope of work that allows for them to practice in nursing facilities and provide preventive care early, so a dental problem doesn’t become a bigger issue requiring more invasive and costly care.

Community Catalyst has been doing a lot of work and research around dental therapists and their ability to reach hard to reach populations. In California, registered dental hygienists in alternative practice (RDHAP) can go out into nursing facilities. Other states are looking into it or have already expanded auxiliary dental professionals and their scopes of practice.

And as I mentioned, there’s work being done on medical-dental integration — the CareQuest Institute for Oral Health has been publishing and doing research around that as well.

We’re also thinking, for example, about how primary care providers such as nurse practitioners who are already seeing patients in nursing facilities can be trained to apply silver diamine fluoride (SDF) or other minimally-invasive care that does not require a dentist.

Community health workers (CHWs) in California are able to provide oral health education and navigation services under the Medi-Cal program. This could serve as a model for other states.