But officials with the Centers for Medicare and Medicaid Services have said it could take in the range of three to five years to implement new dental benefits, six people said. The lengthy timeline threatens to diminish the political upside of the new benefits, which Democrats have seen as an immediate and tangible improvement in voters’ lives they could present to the public in the 2022 and 2024 elections. One person characterized the prediction of five years as CMS’s “worst case scenario" timeline.
Health officials have raised several potential hurdles to quick allocation of the new Medicare benefits. CMS has told senior Democrats that it will take time to vet thousands of new dentists before including them in the Medicare system, a process that could prove cumbersome and administratively difficult. CMS also has to devise a new pricing system for reimbursing dentists for the new Medicare procedures and products. These challenges will be greater given that CMS will be simultaneously tasked with expanding vision and hearing care for millions of American seniors and those with disabilities.
A CMS spokesperson said the agency regularly offers technical assistance to lawmakers on the Hill, but does not comment on the specifics of those conversations. The agency will work with Congress to implement whatever legislation is passed, the spokesperson added.
The White House, Congressional Democrats, and officials with the Department of Health and Human Services are currently working to see what they could do to expedite implementation of the dental care, the people said.
A White House spokeswoman declined to comment, but a Democrat familiar with the negotiations said Democrats intend to provide a benefit that offers seniors financial assistance next year for dental, vision and hearing care while the formal benefits are set up.
One option may involve working with private dental companies with access to better data, three of the people said. Another option could involve a temporary stopgap measure — such as sending out funds to seniors through a program comparable to a voucher — as federal agencies work to permanently overhaul Medicare, the three people said. It is unclear how seriously either option is being pursued.
“It’s going to be a real challenge to speed this up,” one person involved in the discussions said.
Mike Monopoli, vice president at the nonprofit CareQuest Institute for Oral Health, said it is crucial that policymakers do not disrupt the dental benefits of those who already have them through Medicare Advantage, a private health program that contracts through traditional Medicare, during the initial implementation phase. A majority of the 26 million seniors with Medicare Advantage have dental insurance, but the coverage is often capped. Citing conversations with the administration and Congressional lawmakers, Monopoli also said policymakers are working to try to deliver the new benefits as soon as possible to people with chronic diseases or who are immunocompromised.
CMS announced on Monday that it has named Natalia Chalmers — a pediatric dentist and public health expert — the agency’s first-ever “chief dental officer."
“Medicare is complicated, and this will take some time to come together,” Monopoli said. “We have to take into consideration everything already happening as we move toward more equitable dental coverage for all those served by Medicare.”
The timing of the benefits has clear political ramifications. The midterm elections loom next November. A person familiar with the White House’s thinking denied the matter had to do with the elections but acknowledged they want the funding allocated quickly.
The White House Domestic Policy Council and officials in the Department of Health and Human Services have been involved in the discussions to expedite the benefits. Senate Budget Chair Bernie Sanders (I-Vt.) has helped spearhead the push for expanding Medicare as part of the reconciliation package. Congressional Democratic leadership is also at the center of the budget negotiations.
The challenge in expanding Medicare benefits reflects the broader administrative hurdles awaiting the administration and Congressional Democrats as they seek to enact a $3.5 trillion spending plan that would transform multiple facets of the safety net, revamp the tax code, and strive to stop climate change. Such was the case for the $1.9 trillion stimulus plan passed in March, with — for instance — billions in state aid remaining unspent months after its approval.
Democrats’ sprawling reconciliation package includes a number of measures that could take well beyond the 2022 midterm elections to translate into clear improvements in voters’ lives. The plan aims to expand early education, community colleges, and paid family medical leave — policies that could take time for the federal government to stand up. The reconciliation package faces an uncertain path through a narrowly divided Congress and will require the support of all Senate Democrats, including moderates concerned about its price-tag. Biden’s $1 trillion bipartisan infrastructure bill will also take years, or decades, to upgrade the nation’s public works in many cases.
“This is a health equity issue, it’s an affordability issue, but it’s unrealistic to expect CMS to turn on a dime and implement a brand new benefit with a whole new category of providers within a year or even a year or two,” said Tricia Neuman, who leads the Kaiser Family Foundation’s work on Medicare policy.
About half of Americans ages 65 to 80 lack dental insurance, according to University of Michigan researchers, and older voters tend to vote in higher numbers than the general population. Sanders’ office has said that half of Medicare recipients have not seen a dentist over the past year. Some swing-state senators — such as Sen. Robert P. Casey Jr. (D-Pa.), the chair of the Senate panel on aging – have already taken to touting the potential expansion.
“There’s an awful lot of folks on the left who think this can really play well with the electorate in the next election and they’ll be disappointed if they can’t get the program up and running as quickly as they’d hoped,” said Jim Manley, who served as an aide to former Senate Majority Leader Harry M. Reid (D-Nev.), of the push to expand Medicare.
The nonpartisan Congressional Budget Office projected in an analysis of a House bill in 2019 similar to the measures currently being debated that it could take half of a decade to implement the dental benefits.
Lawmakers are still in the throes of hashing out exactly what a dental benefit in Medicare will look like, as they work to write their pieces of Biden’s massive social spending bill by mid-September.
One major trade lobby, the American Dental Association, is pushing for an income limit on who can access the benefits, arguing it should extend only to those earning up to 300 percent of the federal poverty line, or roughly $38,000 for an individual.
“If you have scarce federal resources, and you want to get the most bang for the buck, then you’re going to treat those low-income seniors that do not have the money to go to the dentist, and that’s who we want to focus on,” said Michael Graham, the association’s senior vice president for government and public affairs.
But others, such as health care advocacy group Families USA, argue everyone with Medicare should be able to access the benefit, and means-testing it would create complexities for both patients and the federal government. Shortages in the number of dentists could make the program harder to launch. Polling of dentists has found severe staff shortages. Public health experts have warned about “dental deserts” that mean poorer parts of the country — including rural areas; inner-cities; and tribal territories — do not have an adequate supply of dentists.
Wendell Potter, a health insurance reform advocate and former insurance executive, said it was “extraordinarily important" for CMS to roll out the new benefits efficiently. But he noted the administration will face challenges in trying to ensure dentists participate in the new program, given that Medicare is expected to pay lower reimbursement rates.
“There’s a significant shortage of dentists and if they revolt it could pose a big challenge,” Potter said. “I think that’s precisely what CMS will be challenged with — finding an adequate supply of dentists to meet the demand.”