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

Abstract

Oral Health in America and Subsequent Policy Challenges for Oral Health Equity Danny A. Kalash, DMD, MPH (bio) Key words Oral health, access to care, health disparities, health reform 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 [End Page 466] 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...