BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: AJR 30
AUTHOR: Pan
AMENDED: April 9, 2012
HEARING DATE: June 6, 2012
CONSULTANT: Bain
SUBJECT : Medicare: dental care.
SUMMARY : Memorializes the President and Congress to enact
appropriate legislation that would add comprehensive,
preventative dental care coverage to Medicare benefits.
Existing federal law:
1.Establishes the Medicare program to provide various medical
services to adults ages 65 and older, individuals under age 65
with disabilities, and individuals with end-stage renal
disease.
2.Prohibits payments from being be made under Medicare Part A
(hospital services) or Medicare Part B (physician services)
for any expenses incurred for specified items or services.
Excluded items include expenses for services in connection
with the care, treatment, filling, removal, or replacement of
teeth or structures directly supporting teeth.
3.Permits payments under Part A in the case of inpatient
hospital services in connection with the provision of dental
services if the individual, because of his underlying medical
condition and clinical status or because of the severity of
the dental procedure, requires hospitalization in connection
with the provision of such services.
This resolution:
1.Memorializes the President and Congress to enact appropriate
legislation that would add comprehensive, preventative dental
care coverage to Medicare benefits.
2.Makes various finding regarding dental care for individuals
ages 65 and older, including the following:
a. National Health Interview (NHI) surveys from 1997 to
2009 found 24 to 30 percent of persons 65 years of age and
older were edentulous (without teeth);
b. NHI surveys also found that during that period only 17
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AJR 30 | Page 2
to 24 percent of older edentate persons, compared to 69 to
73 percent of older dentate persons, had a dental visit in
the past year;
c. Medicare does not currently provide for most dental
care;
d. Senior citizens often cannot afford the out-of-pocket
costs of dental care;
e. A study done in March 2005 by the State University of
New York, University at Buffalo's School of Dental
Medicine found that cost was a major factor in senior
citizens not obtaining dental care;
f. Covering medical illnesses that are directly
correlated with poor dental health can be a significant
expense for Medicare;
g. Many of the diseases correlated with dental health are
preventable and could be avoided or mitigated through
better dental care; and
h. Including dental coverage in Medicare benefits will
lower the program's medical expenses as well as improve
the quality of life of senior citizens.
3.Resolves that the Chief Clerk of the Assembly transmit copies
of this measure to the President and Vice President, the
Speaker of the House of Representatives, the Majority Leader
of the Senate, the Chair of the Senate Special Committee on
Aging, and each Senator and Representative from California in
the Congress of the United States.
FISCAL EFFECT : This resolution is keyed non-fiscal.
PRIOR VOTES :
Assembly Health: 13- 5
Assembly Floor: 51- 25
COMMENTS :
1.Author's statement. According to the author, the elimination of
dental benefits from Medi-Cal since 2009 has meant that adults who
are over 65 and can't afford proper dental care are not getting
preventative treatment resulting in more emergency visits. Many of
the diseases correlated with dental health are preventable and can
be avoided or mitigated through proper dental care.
2.Medicare and dental coverage. According to the Centers for
Medicare and Medicaid Services (CMS), which administers the
Medicare program, the dental exclusion from Medicare coverage was
established as part of the initial program. In establishing this
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exclusion, Congress did not limit the exclusion to routine dental
services but instead included a blanket exclusion of dental
services. CMS states Congress has not amended the dental exclusion
since 1980, when it made an exception for inpatient hospital
services when the dental procedure itself made hospitalization
necessary.
CMS states Medicare will currently pay for dental services that are
an integral part either of a covered procedure (e.g.,
reconstruction of the jaw following accidental injury), or for
extractions done in preparation for radiation treatment for
neoplastic diseases involving the jaw. Medicare will pay for oral
examinations, but not treatment, preceding kidney transplantation
or heart valve replacement, under certain circumstances. Such
examinations would be covered under Part A if performed by a
dentist on the hospital's staff, or under Part B if performed by a
physician. Some Medicare Advantage plans cover dental services
voluntary.
3.Prior legislation. ABx4 5 (Evans), Chapter 20, Statutes of 2009,
eliminated Medi-Cal coverage of a number of Medi-Cal benefits that
are optional for states to provide under federal law, effective
July 1, 2009, to achieve budget savings. One of the optional
benefits eliminated from Medi-Cal coverage was adult dental
services. Following the enactment of ABx4 5, only the following
persons continue to receive dental services through Medi-Cal:
a. Pregnant women, if it is part of their pregnancy-related
care or for services to treat a condition that may cause
problems in pregnancy.
b. Children or young adults who are 20 years old and
younger and receive full-scope Medi-Cal.
c. People who live in a licensed nursing home such as a
Skilled Nursing Facility, Intermediate Care Facility (ICF),
ICF for the Developmentally Disabled and Sub-Acute Facility.
d. People needing dental treatment that can be provided by
a physician.
4.Surgeon General's report. In 2003, the federal government
released "Oral Health In America: A Report of the Surgeon
General," which made the following findings:
a. Twenty-three percent of 65- to 74-year-olds have
severe periodontal disease (measured as 6 millimeters of
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periodontal attachment loss). (Also, at all ages, men are
more likely than women to have more severe diseases, and
at all ages, people at the lowest socioeconomic levels
have more severe periodontal disease.)
b. About 30 percent of adults 65 years and older are
edentulous, compared to 46 percent 20 years ago. These
figures are higher for those living in poverty.
c. Oral and pharyngeal cancers are diagnosed in about
30,000 Americans annually; 8,000 die from these diseases
each year. These cancers are primarily diagnosed in the
elderly. Prognosis is poor. The 5-year survival rate for
white patients is 56 percent; for blacks, it is only 34
percent.
d. Most older Americans take both prescription and
over-the-counter drugs. In all probability, at least one
of the medications used will have an oral side effect -
usually dry mouth. The inhibition of salivary flow
increases the risk for oral disease because saliva
contains antimicrobial components as well as minerals
that can help rebuild tooth enamel after attack by
acid-producing, decay-causing bacteria. Individuals in
long-term care facilities are prescribed an average of
eight drugs.
e. At any given time, 5 percent of Americans ages 65
and older (currently some 1.65 million people) are living
in a long-term care facility where dental care is
problematic.
f. Many elderly individuals lose their dental insurance
when they retire. The situation may be worse for older
women, who generally have lower incomes and may never
have had dental insurance. Medicaid funds dental care for
the low-income and disabled elderly in some states, but
reimbursements are low. Medicare is not designed to
reimburse for routine dental care.
1.Medicare financial solvency. While dental care is an important
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issue to the health of seniors, the long-term financial
viability of Medicare continues to be an ongoing issue. Each
year the Trustees of the Social Security and Medicare trust
funds report on the current and projected financial status of
the two programs.
The Trustees project that Medicare costs (including both
Hospital Insurance �HI] and Supplemental Medical Insurance
�SMI] expenditures, more commonly known as Part B) will grow
substantially from approximately 3.7 percent of GDP in 2011 to
5.7 percent of GDP by 2035, and will increase gradually
thereafter to about 6.7 percent of GDP by 2086. The Trustees
state the HI fund again fails the test of short-range
financial adequacy, as projected assets are already below one
year's projected expenditures and are expected to continue
declining. The Trustees project that the HI Trust Fund will
pay out more in hospital benefits and other expenditures than
it receives in income in all future years, as it has since
2008. The projected date of HI Trust Fund exhaustion is 2024,
the same date projected in last year's report, at which time
dedicated revenues would be sufficient to pay 87 percent of HI
costs. The Trustees project that the share of HI expenditures
that can be financed with HI-dedicated revenues will decline
slowly to 67 percent in 2045, and then rise slowly until it
reaches 69 percent in 2086. The HI 75-year actuarial imbalance
amounts to 36 percent of tax receipts or 26 percent of program
costs.
The Trustees project that SMI, which pays doctors' bills and
other outpatient expenses, and Part D, which provides access
to prescription drug coverage, will remain adequately financed
into the indefinite future because current law automatically
provides financing each year to meet the next year's expected
costs.
2.Support. This resolution is sponsored by the California Senior
Legislature, which states that a major factor in senior
citizens not obtaining dental care is financial and, even if
cost is not an issue, about 30 percent of older adults face
difficulties in getting to a dental office because they may be
frail, homebound, or live in nursing homes. The sponsor
maintains that it would be a worthwhile investment for
Medicare to include dental coverage because many of the
diseases associated with poor dental health in older adults
are preventable and could be avoided or mitigated through
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access to routine dental care. Health Access California writes
in support that Medicare, which keeps seniors healthy across
the country, could remove cost as a significant barrier to
seniors seeking dental care by including dental care as part
of its benefit package.
SUPPORT AND OPPOSITION :
Support: California Senior Legislature (sponsor)
American Federation of State, County and Municipal
Employees, AFL-CIO
Health Access California
Oppose: None received.
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