Rethinking Oral Health Policy Across the Lifespan

Over the past two decades, public policies expanding dental coverage for children have helped reduce untreated tooth decay, particularly among those from lower-income families. But adults have seen far less progress, and disparities in oral health among older Americans have continued to widen.

For Dr. Marko Vujicic, PhD, chief economist and vice president of the Health Policy Institute and chief of international relations at the American Dental Association, the contrast offers an important lesson: improvements in oral health depend not only on advances in dental care, but also on the policies that determine who can access it.

Speaking at Columbia University College of Dental Medicine's Dean's Distinguished Lecture Series, Building Bridges for Oral Health Research, Vujicic examined these disparities and the policy changes needed to address them. His lecture, "Evidence-Based Policy Making in Oral Health: What Research is Missing?" also explored how academic researchers could produce evidence to help guide those decisions.

Drawing on findings from the Oral Health in America report, Vujicic pointed to the role of federal policies in expanding dental coverage for children. Medicaid and the Children's Health Insurance Program (CHIP) establish comprehensive pediatric dental benefits, and the Affordable Care Act recognizes pediatric dental care as an essential health benefit. Approximately 93 percent of American children now have some form of dental coverage.

Adults and older Americans face a much less consistent system. States have broad discretion over adult dental benefits under Medicaid, and private insurance plans vary considerably in what they cover. Medicare Advantage plans also illustrate how dental coverage does not always translate into affordable care.

An analysis by Vujicic's team of more than 5,000 Medicare Advantage plans illustrated the problem. Although 98 percent offered some dental coverage, only 35 percent covered checkups without out-of-pocket payments. Just 8 percent met the researchers' criteria for comprehensive coverage.

"The mouth doesn't disconnect the body at 19, right? Or at 65," Vujicic said.

Cost remains a significant barrier to dental care, particularly for adults and older Americans. National data show that Americans perceive dental care as more financially difficult to access than other health services. He argued that these barriers cannot be addressed simply by asking patients to pay more out of pocket.

Growing research on the connections between oral health and conditions such as diabetes, cardiovascular disease, and dementia has brought greater attention to dentistry's role in overall health. He also pointed to work through the World Economic Forum examining how poor oral health affects employment, productivity, and educational outcomes.

Vujicic identified three areas where policy reform could help advance oral health: expanding comprehensive dental coverage, strengthening connections between dentistry and the broader health care system, and shifting incentives toward prevention rather than treatment.

Building on the framework established for children, he suggested expanding comprehensive dental benefits for adults and older Americans through public and private insurance programs.

But expanding dental coverage alone will not resolve the challenges patients face when dental and medical care operate separately.

"It's very hard to leverage that mouth-body connection when dentistry is on an island from the rest of healthcare," he said.

To illustrate what integration could look like, Vujicic described a patient newly diagnosed with diabetes who would automatically receive an oral health evaluation as part of their care. Such an approach would require coordinated referrals, connected health records, provider networks, and insurance benefits that make dental treatment accessible.

He also questioned a reimbursement system that largely rewards treating dental disease after it develops. Shifting those incentives, he suggested, could encourage greater investment in preventing disease in the first place.

For Vujicic, making these changes will require research that policymakers can use to evaluate their potential benefits.

"We need to have some type of way to make research much more actionable for policymakers, customized to their local setting," he said.

Academic medical centers such as Columbia could help generate that evidence. Vujicic proposed the possibility of a large-scale study in which patients diagnosed with diabetes are routinely referred for comprehensive dental care, with no out-of-pocket costs or annual benefit limits. Following those patients over several years could help researchers determine how expanded access affects health outcomes, medical spending, employment, and overall well-being.

The lecture also prompted a lively discussion about how academic researchers define and measure the impact of their work. Dr. Rena D’Souza, who leads the Dean's Distinguished Lecture Series, emphasized the need to consider the broader factors that influence oral health.

"There is a need to keep pace with the complexity of the problems academic clinicians and researchers seek to solve," D’Souza said. "For example, oral health is shaped by housing, education, employment, nutrition, commercial influences, transportation, insurance coverage, and public policy."

D’Souza argued that these factors should play a more central role in population health research. "These forces are not merely contextual variables but should be at the center of population health research and not at its periphery," she said.

She also pointed to Columbia Dental's capacity to contribute to this work through its integrated Epic health record system, which could provide valuable data for future research.

Vujicic acknowledged that expanding coverage, changing reimbursement, and bringing dentistry into closer alignment with medicine would require difficult decisions. But he emphasized that the choices made now could determine the direction of dental care for years to come.

"This is a real fork in the road for the profession," he said.