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Editor’s Note: This article is part of a Health Affairs Forefront series on Racism and Health, published in conjunction with the February issue of Health Affairs Journal. Read other posts in the series on the Racism and Health landing page.
Over two decades ago, in 2000 the first Surgeon General’s Report on Oral Health placed oral health at the forefront of national health priorities. Specifically, this report attributed racial oral health inequities to inadequate dental care access. In 2003, a national call to action centered on increasing access to care by improving Medicaid provider reimbursement rates, dental student loan repayment, and research funding.
In 2007, Deamonte Driver, a 12-year-old African American boy from Maryland, died “for want of a dentist” as bacteria from a tooth infection spread to his brain. Driver’s death spurred changes to oral health policies, such as dental benefits’ inclusion as an essential benefit for children in the Affordable Care Act and a strengthened oral health safety net for children.
Since then, preventive dental care has generally improved for children. Yet, access to preventive dental care remains an issue for minoritized children, as well as working-age adults and older adults. Medicare and many state Medicaid programs lack comprehensive dental benefits for beneficiaries, contributing to existing racial oral health inequities. Strategies to diversify the dentist workforce have resulted in few gains for historically underrepresented minority (URM) groups.
Now, years after the Surgeon General’s call to action, Black, Hispanic, and American Indian/Alaska Native populations continue to bear a disproportionate burden of oral diseases. The workforce does not reflect the racial demographics of the country. And policy decisions about oral health still seem to center on the financial interests of some providers but not the communities at highest risk for oral health complications. We still need better policies to move the United States from its current status quo: Oral health equity requires attention to racial equity.
Evidence around systemic racism and health lags behind other social sciences that have demonstrated racial inequities in incarceration, housing opportunities, and banking practices for BIPOC communities. However, the role of systemic racism in health care is clear, notably in maternal morbidity and mortality.
While racial inequities have been observed in population oral health and attributed to dental care access, the oral health literature has not been explicit in categorizing racial inequities as evidence of dentistry’s role in systemic racism. This reticence could hinder development and implementation of interventions that explicitly target systemic racism to improve population oral health.
Access to health care is an important factor in a population’s oral health. However, access to health care is just one factor in social determinants of health that are strongly linked to racism and oppression. Racial equity in oral health relies on recognition that interventions must reach beyond efforts to improve access to dental care. While addressing access to dental care is important, advancing racial equity in oral health requires systems-level interventions that largely center on population-level health, such as targeting oral health behaviors including dietary intake, toothbrushing, or smoking.
To be sure, multi-level interventions to address the other social determinants of health must acknowledge that whole-person health includes oral health. Integration of medicine and dentistry is imperative, as oral health can reflect the status of systemic diseases such as diabetes. Interprofessional practice with value-based care payment models must be a part of the equity equation.
Dental coverage varies greatly from state to state, across the age span. This variability contributes to racial inequities in oral health. The Affordable Care Act (ACA) included dental care as an essential health benefit for children. However, this inclusion has not resulted in significant or sustained gains in coverage or use for children of color. In a comparison of pre- and post-ACA periods—2011–2013 and 2014–2015—authors estimated that among children likely to be affected by the ACA, there was a significant increase in the proportion of children with private dental insurance but no increase in annual dental visits. Authors noted the inability to determine what percentage of children of color lacked dental insurance.
From a policy perspective, unclear data may under- or over-represent the true nature of the problem for children of color.
Dental coverage for working-age adults with low incomes also varies from state to state. As states have expanded Medicaid under the ACA, dental coverage for low-income adults increased. However, gaps in coverage persist in 12 states, which provide emergency-only or no dental benefit for adults. Six of those states (Texas, Alabama, Mississippi, Tennessee, Georgia, and Florida) have not expanded their Medicaid programs following the ACA, despite high percentages of historically marginalized populations of color that typically experience a disproportionate burden of dental diseases. While access to dental insurance has improved, there has been no significant increases in use of adult preventative or treatment services.
Dental coverage for adults older than age 65 is even worse. Despite calls from advocates, Medicare continues to ignore oral health as essential to systemic health. Gaps in dental coverage leaves too many older adults to suffer from tooth loss and untreated dental caries, and worsening inequity for Black and Hispanic older adults living below the federal poverty level. Nearly half of all Medicare beneficiaries lack dental insurance, and among these beneficiaries, non-Hispanic Black and Hispanic older adults have higher rates of not having an annual dental visit compared to non-Hispanic White older adults.
A 2012-13 national survey reported that despite representing 30 percent of the general population, underrepresented minorities comprised only 9 percent of the dental workforce. Recent data from the American Dental Association Health Policy Institute paints a sobering picture: Data from 2005 to 2020 show an overrepresentation of White and Asian individuals with less pronounced growth in the dentist workforce among Black and Hispanic individuals. The data are incomplete with no results for American Indian/Alaska Native dentists, which is concerning given the large need for dentists to provide care to American Indian/Alaska Native communities.
Diversity in the dental workforce is an important component of efforts to mitigate systemic racism. While 43 percent of all dentists participate in Medicaid or CHIP, there is a stark difference by race/ethnicity with more than half of Black (63 percent) and Hispanic (51 percent) dentists compared to White dentists (39 percent) participating. A study using 2012 survey data showed that URM dentists are not only severely underrepresented, but that they care for a disproportionate share of URM patients. On average, Black dentists practice in counties that are approximately 30 percent Black. Black patients also comprise approximately 45 percent of all patients that Black dentists treat. Similar patterns are observed for Hispanic and American Indian/Alaska Native dentists.
Now is the time to bend the arc toward oral health equity by targeting systemic racism. Here’s how:
Such systems will allow for timely referrals of patients in need of everything from diabetes monitoring and prenatal care to tobacco cessation support and HPV vaccinations. The integrated nature of systemic and oral health should be reflected in a connection through coordinated electronic health systems between health care providers across medicine and dentistry.
The cost of dental education is a burden for Black, Hispanic, and American Indian/Alaska Native dentists who may have incurred educational debt from their undergraduate training. Student loan forgiveness programs should support these providers, alleviating their debt and freeing them to practice in communities where they are most needed. The Health Resources and Services Administration along with private dental philanthropy should provide opportunities for student loan forgiveness and scholarships for predoctoral and postdoctoral training. Additionally, the Commission on Dental Accreditation and the American Dental Education Association should lead the way in creating workforce opportunities.
Just as racism directly affects communities’ access to safe water, healthy food, or public transportation, systemic racism is also at work in dental education settings where there are few Black, Hispanic, and American Indian/Alaska Native faculty or executive leaders. Addressing systemic racism in dental educational settings requires the inclusion of Black, Hispanic, and American Indian/Alaska Native students, faculty, and staff, especially in historically White institutions. The Commission on Dental Accreditation should strengthen its standards around humanistic education. Moreover, the American Dental Education Association should work to create dental education settings that support belonging and antiracist learning spaces.
To ensure the oral health workforce represents the populations bearing the greatest burdens from disparities, dental schools should eliminate legacy admissions. Likewise, all pre- and post-doctoral programs should practice holistic admissions policies and enlist the guidance of organizations such as the National Dental Association, the Hispanic Dental Association, and the Society of American Indian Dentists to improve equity. The Commission on Dental Accreditation should strengthen its standards in ways that support diversity in dental education.
Whereas previous generations suffered significant tooth loss as they aged, today older adults are keeping their teeth. Yet, under Medicare they don’t have the coverage necessary to care for them. What is more, many older adults have systemic conditions that require the services and coordination of both medical providers and oral health providers. Only by including access to dental coverage in Medicare benefits, can we ensure they have access to the services and whole-person care necessary to maintain their overall health.
All adults covered by Medicaid should receive comprehensive dental benefits provided under reimbursement models similar to those in private insurance. The Centers for Medicare and Medicaid Services should support state policies that provide such benefits.
Policy makers should prioritize timely data on dental insurance coverage, dental care use, and burden of disease while ensuring it tracks key demographics such as age, race, and ethnicity. This approach will help researchers to better understand how new and ongoing policies and programs affect historically underrepresented minorities.
Value-based care payment should be used to incentivize population-level oral health and prevention. By tying reimbursement to positive outcomes, payers will not only motivate health systems to collect the relevant data, they will also drive innovation and improvement in care.
Systemic racism is a driver behind many social determinants of health, even if models of social determinants often exclude racism completely. Researchers have more work to do to build evidence for this connection and to inform even more specific recommendations for how to mitigate oral health inequities.
We have known for decades that racial inequities in oral health exist. Yet, policy changes to improve access alone have been insufficient. To improve oral health and reduce oral health inequities, we must continue addressing systemic racism.
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