Dental hygienists are critical to preventing and treating oral health issues at the individual and community levels. However, the effectiveness of oral health programs and access to care are deeply influenced by policies that govern health care delivery. Policies shape oral health care, identify barriers to care, and provide opportunities for dental hygienists to advocate for better policies to reduce health disparities.
The relationship between policy, public health programs, and access to dental care is complex but essential for improving oral health outcomes across populations.
The Burden of Poor Oral Health
Oral diseases, including dental caries, periodontal disease, and oral cancer, are among the most prevalent chronic conditions worldwide. Despite advancements in oral health care, millions of individuals still suffer from untreated dental problems, especially among low-income and underserved populations.1,2
According to the Centers for Disease Control and Prevention (CDC), oral diseases disproportionately affect vulnerable groups, including children, older adults, racial and ethnic minorities, and those living in rural areas. These populations often face barriers that hinder access to timely and affordable dental care.2
While there is a federally supported National Institute of Dental and Craniofacial Research and federally qualified health centers with dental services in the United States, each state is responsible for its oral health care policies. Funding for dental care is primarily out-of-pocket, as only 29.2% of older adults have dental health insurance, and this percentage declines with age.3
The burden of poor oral health care extends beyond physical discomfort. It can also lead to significant social, emotional, and economic consequences. Individuals with poor oral health are more likely to experience difficulties with eating, speaking, and social interaction. Additionally, oral health problems are associated with other chronic conditions, such as diabetes and cardiovascular disease, making them a public health priority.4,5
The Role of Health Policies in Access to Care
Health policies and the regulations, laws, and guidelines that determine how health care services are delivered, funded, and accessed play a crucial role in shaping oral health care systems, influencing everything from allocating resources to regulating health care providers. Like dental hygienists, oral health policymakers understand that health policy is vital for advocating for policies that expand access to care and reduce barriers to treatment.4,5
Health policies that can influence access to care include:
- Funding: Government funding determines the availability of resources for public oral health programs, such as school-based dental programs or community fluoridation projects.5 From 2018 to 2024, the CDC funded 20 state health departments with about $370,000 per year to reduce dental caries, oral health disparities, and other chronic diseases that coexist with poor oral health.5,6
- Insurance coverage: Policies that govern Medicaid, Medicare, and private insurance coverage dictate whether people can afford preventive and therapeutic dental services.7
- Workforce regulations: Scope-of-practice laws regulate what dental hygienists and other professionals can do, impacting the efficiency and reach of oral health programs.4,7
Barriers to Oral Health Care Access
Cost, provider shortages, lack of insurance, and geographical barriers prevent people from accessing needed dental care, particularly among underserved populations. Many people lack dental insurance or the financial resources to pay for dental care, leading to delayed treatment.4
While Medicaid and Medicare provide coverage for certain dental services, many people still face limited benefits or out-of-pocket costs that deter them from seeking care.7
In rural or low-income areas, there is often a need for more dental providers, including dental hygienists, who are critical to delivering preventive services.8 People in rural areas also may have to travel long distances to access dental care, which can be a significant deterrent.7
Policies Affecting Oral Health Care
Policies and programs impact oral health care delivery, particularly for underserved populations. These include Medicaid, Medicare, the Patient Protection and Affordable Care Act (ACA), federally qualified health centers, the National Health Service Corps, and state practice acts.7,9
Medicaid and Medicare
Medicaid and Medicare are critical safety net programs that provide health care coverage for millions of Americans. Medicaid is the most common form of public insurance, covering more than 86 million people annually.7
Many states provide limited dental coverage for adults. As of 2019, only 12 states cover emergency dental services through Medicaid, while 34 states cover services beyond emergency care. Four states offer no dental benefits.7
States must cover oral health services for children under age 21 who are eligible for Medicaid.7 However, reimbursement rates for dental services under Medicaid are often low, which leads many dental providers, including dental hygienists, to opt out of the program. As a result, individuals who rely on Medicaid may face challenges accessing dental care.4
Medicare, the federally funded program for older adults and individuals with disabilities, provides minimal dental benefits. This lack of coverage for routine dental care for older adults is a major issue, as poor oral health in older adults is associated with systemic conditions such as heart disease and diabetes.3
The Patient Protection and Affordable Care Act (ACA)
The ACA expanded access to health care for millions of Americans, including some provisions that affect oral health care. Under the ACA, pediatric dental care is considered an essential health benefit, which means insurance plans in the Health Insurance Marketplace must include coverage for children’s dental services. However, adult dental benefits are not mandated, leaving many adults without comprehensive coverage.3,9,10
National Health Service Corps (NHSC)
The NHSC is a federal program that helps to address health care provider shortages by offering loan repayment and scholarships to health care professionals, including dental hygienists, who agree to work in underserved areas. This initiative is vital for reducing provider shortages in rural and underserved communities where access to dental care is often limited.9
As of November 8, 2024, 59 million Americans were living in 7,062 health professional shortage areas (HPSA) with a need for at least 10,126 dental health practitioners.11
Federally Qualified Health Centers (FQHCs)
FQHCs are community-based organizations that provide comprehensive health care services, including dental care, to underserved populations, regardless of their ability to pay. These centers receive federal funding to support their operations and are required to offer services on a sliding fee scale based on income. FQHCs are an important avenue for dental hygienists to provide care in underserved areas, and policies that support these centers are crucial for improving oral health access.9
State Practice Acts and Workforce Regulations
State practice acts govern the scope of practice for dental hygienists, determining what services they can provide and under what supervision. In some states, dental hygienists are allowed to practice independently in certain settings, such as public health clinics or schools. In contrast, they work under general, direct, or indirect supervision in other states. These regulations directly affect the ability of dental hygienists to expand their role in public health programs and to serve populations that face significant barriers to dental care.7
States can increase access by authorizing traditional and nontraditional providers to provide dental care. Dentists, dental hygienists, and dental assistants can work alongside nontraditional providers, primary care physicians, pharmacists, community health workers, and social workers to create a comprehensive oral health system.7
State policies also affect reimbursement for dental services. In some states, Medicaid reimbursement rates for dental services are very low, which can deter providers from accepting Medicaid patients. Advocacy for policy changes that increase reimbursement rates or allow dental hygienists to provide more services independently could improve access to care for underserved communities.4
Opportunities for Advocacy
Dental hygienists are uniquely positioned to advocate for policies that improve access to oral health care and reduce health disparities, such as:
- Advocate for expanded coverage for dental services under Medicaid and Medicare, particularly for older adults and adults with lower socioeconomic status.
- Work to expand the scope of practice in the state legislature, including advocating for laws that allow dental hygienists to practice independently or in collaborative practice models.4
- Join the American Dental Hygienists’ Association (ADHA) to participate in advocacy efforts, raise awareness about oral health policy issues, and engage with lawmakers on issues that affect the profession and public health.
- Raise awareness about the importance of integrating oral health into broader public health policies, particularly programs that address chronic disease prevention and health disparities.
Healthy People 2030 encompasses 15 initiatives related to oral conditions that dental hygienists can advocate for, including:12
- Reduce the proportion of people who can’t get the dental care they need when they need it.
- Increase the use of the oral health care system.
- Increase the proportion of people with dental insurance.
- Increase the proportion of low-income youth who have a preventive dental visit.
- Increase the number of states and DC with an oral and craniofacial health surveillance system.
- Increase the proportion of people whose water systems have the recommended amount of fluoride.
- Increase the proportion of oral and pharyngeal cancers detected at the earliest stage.
- Reduce the consumption of added sugars by people aged 2 years and over.
- Increase the proportion of children and adolescents with dental sealants on one or more molars.
- Reduce the proportion of children and adolescents with active and untreated tooth decay.
- Reduce the proportion of children and adolescents with lifetime tooth decay.
- Reduce the proportion of adults with active or untreated tooth decay.
- Reduce the proportion of adults aged 45 years and over who have lost all their teeth.
- Reduce the proportion of adults aged 45 years and over with moderate and severe periodontitis.
- Reduce the proportion of older adults with untreated root surface decay.
In Closing
Public policies are essential drivers of oral healthcare access and quality, and dental hygienists are integral to advocating for policy changes that reduce barriers to care. By understanding the impact of key policies, dental hygienists can become powerful advocates for improving oral health outcomes.
With strategic advocacy, dental hygienists can help shape policies that ensure all individuals have access to affordable dental care, improving public health and reducing oral health disparities.
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References
- Oral Health. (2024, November 6). World Health Organization. https://www.who.int/news-room/fact-sheets/detail/oral-health
- Health Disparities in Oral Health. (2024, May 15). Centers for Disease Control and Prevention. https://www.cdc.gov/oral-health/health-equity/index.html
- Jiang, C.M., Chu, C.H., Duangthip, D., et al. Global Perspectives of Oral Health Policies and Oral Healthcare Schemes for Older Adult Populations. Frontiers in Oral Health. 2021; 2: 703526. https://doi.org/10.3389/froh.2021.703526
- Oral Health and America: Advances and Challenges. (2021). National Institute of Dental and Craniofacial Research. www.ncbi.nlm.nih.gov/books/NBK578297/
- Bastani, P., Jafari, A., Ha, D.H. The Mutual Relationship of the Policymakers, Providers, and the Community on the Children’s Oral Health; New Windows for More Discussions. Archives of Public Health. 2023; 81: 69. https://doi.org/10.1186/s13690-023-01073-8
- Historical Oral Health Program Funding. (2024, August 12). Centers for Disease Control and Prevention. https://www.cdc.gov/oral-health-funded-programs/funding/historical-funding-for-oral-health-programs.html
- Oral Health. (2021, November 24). Office of Disease Prevention and Health Promotion. https://odphp.health.gov/our-work/national-health-initiatives/healthy-people/healthy-people-2020/healthy-people-2020-law-and-health-policy/oral-health
- Oral Health in Rural Communities. (2024, August 2). Rural Health Information Hub. https://www.ruralhealthinfo.org/topics/oral-health
- Committee on Integrating Primary Care and Public Health; Board on Population Health and Public Health Practice; Institute of Medicine. (2012, March 28). Primary Care and Public Health: Exploring Integration to Improve Population Health. Policy and Funding Levers. National Academies Press. https://www.ncbi.nlm.nih.gov/books/NBK201597/
- Health Benefits and Coverage: Dental Coverage in the Marketplace. (n.d.). U.S. Centers for Medicare and Medicaid Services. https://www.healthcare.gov/coverage/dental-coverage/
- Health Workforce Shortage Areas. (2024, November 9). Health Resources and Services Administration. https://data.hrsa.gov/topics/health-workforce/shortage-areas
- Oral Conditions. (n.d.). Office of Disease Prevention and Health Promotion. https://odphp.health.gov/healthypeople/objectives-and-data/browse-objectives/oral-conditions
