William Stork needs a tooth out. That's what the 71-year-old retired truck driver's dentist told him during a recent checkup.

That kind of extraction requires an oral surgeon, which could cost him around $1,000 because, like most seniors, Stork does not have dental insurance, and Medicare won't cover his dental bills. Between Social Security and his pension from the Teamsters union, Stork says, he is able to live comfortably in Cedar Hill, Mo., about 30 miles southwest of St. Louis.

But that $1,000 cost is significant enough that he has decided to wait until the tooth absolutely must come out.

Stork's predicament is at the heart of a long-simmering rift within the dental profession that has reemerged as a battle over how to add dental coverage to Medicare, the public insurance program for people 65 and older — if a benefit can pass at all.

A once-in-a-generation opportunity

Health equity advocates see President Biden's Build Back Better agenda as a once-in-a-generation opportunity to provide dental coverage for those on Medicare, nearly half of whom did not visit a dentist in 2018 — well before the pandemic paused dental appointments for many people. The rates were even higher for Black (68%), Hispanic (61%) and low-income (73%) seniors.

The coverage was left out of a new framework announced by Biden on Thursday, but proponents still hope they can get the coverage in a final agreement. Complicating their push is a debate over how many of the nation's more than 60 million Medicare beneficiaries should receive it.

Advocates of dental coverage for everyone on Medicare find themselves up against an unlikely adversary: the American Dental Association, which is backing an alternative plan that would give dental benefits only to low-income Medicare recipients.

Medicare has excluded dental (and vision and hearing) coverage since its inception in 1965. That exclusion was by design: The dental profession has long fought to keep itself separate from the traditional medical system in order to preserve the field's autonomy.

Dental care and health are intertwined

More recently, however, dentists have stressed the link between oral and overall health. Most infamously, the 2007 death of a 12-year-old boy that might have been prevented by an $80 tooth extraction prompted changes to Maryland's version of Medicaid, the federal-state public insurance program for people with low incomes. But researchers have also, for example, linked dental care with reduced health care spending among patients with Type 2 diabetes.

When the World Health Organization suggested delaying nonurgent oral health visits last year to prevent the spread of COVID-19, the American Dental Association pushed back, with Dr. Chad Gehani, the organization's president at the time, saying, "Oral health is integral to overall health. Dentistry is essential health care."

The ADA-backed Medicare proposal would cover only seniors who earn up to three times the poverty level. That currently translates to $38,640 a year for an individual and would the number of potential recipients from more than 60 million people to roughly half that number.

Medicare has never required means testing, but in a world where Congress is looking to trim the social-spending package from $3.5 trillion over 10 years to $1.85 trillion, the ADA presents its alternative as a way to save money while covering those who need a dental benefit the most. A Congressional Budget Office analysis estimated the plan to provide dental coverage to all Medicare recipients would cost $238 billion across 10 years.

Research finds cost a barrier to dental care

Unlike the ADA, the National Dental Association is pushing for a universal Medicare dental benefit. The group, which "promotes oral health equity among people of color," was formed in 1913, in part, because the ADA did not eliminate discriminatory membership rules for its affiliates until 1965. Dr. Nathan Fletcher, chairman of NDA's board of trustees, says he was unsurprised to find his organization at odds with the ADA over Medicare coverage.

"The face and demographic of the ADA is a white male, 65 years old. Understand that those who make decisions for the ADA are usually the ones who have been in practice for 25 to 30 years, doing well, ready to retire," Fletcher says. "It looks nothing like the [patients] we're talking about."

Research from the ADA's Health Policy Institute found cost as a barrier to dental care "regardless of age, income level, or type of insurance," but low-income older adults were more likely to report it as a barrier.

Why some oppose a universal Medicare dental benefit

"It would be tragic if we didn't do something for those low-income seniors," says Michael Graham, senior vice president of government and public affairs for the ADA.

Graham is critical of the design of the proposals in Congress for a universal Medicare dental benefit, noting that one includes a 20% copay for preventive services that could block low-income patients from getting access to the care they would otherwise be gaining.

"Something is better than nothing, but the something [with a copay] almost equals nothing for many seniors," Graham says.

The ADA backs covering 100% of preventive services for low-income Medicare recipients, he says.

Would most dentists take Medicare patients?

Of course, covering only low-income seniors presents its own questions, the biggest being: Will dentists even accept Medicare if they don't have to? Low-income patients often seek their dental care at safety-net clinics that schedule out months in advance. Some dentists worry that a Medicare benefit limited to low-income older adults would be easier to shun, pushing even more newly insured Americans into an already burdened dental safety net.

Overall, fewer than half of U.S. dentists accept Medicaid, though more than 60% of NDA members do, according to Fletcher. The ADA worries the reimbursement rates and bureaucratic paperwork for a Medicare benefit will be similarly unappealing to many of its members.

But Fletcher, who is dental director for a Medicaid insurance company in Washington, D.C., says participation in Medicaid varies widely across states — and, as with Medicaid, participation in any new Medicare dental program would largely depend on the benefit's design.

If the reimbursement rates for a Medicare benefit are high enough, Fletcher says, giving coverage to tens of millions of seniors could be quite lucrative for dentists. Ultimately, he says, dentists should have a choice in whether to accept Medicare patients, and all Medicare patients should be entitled to dental services, since they paid into the program.

A generational rift in the profession

Dr. Nathan Suter, William Stork's dentist, sees adding a dental benefit for all seniors as the right thing to do.

A self-described "proud ADA member," Suter finds himself at odds with the organization, which has showered him with accolades. He was named Dentist of the Year by the affiliated Missouri Dental Association in 2019 and received one of the ADA's awards for young dentists in 2020.

"I, as an ADA member, think they should be at the table for me, making sure it's as good a benefit as possible for all of my seniors," says Suter, who estimates that at least 50% of the patients in his practice in House Springs, Mo., are older adults.

But rather than push for a universal benefit, the ADA's well-funded lobbying operation is pushing against congressional Democrats' proposed plan to add dental coverage for all Medicare recipients. The organization has asked its members to email congressional representatives on the topic; more than 60,000 emails have been sent so far, Graham says.

Suter sees the battle over whom to cover as a generational rift. As an early-career dentist, he prefers adding full dental coverage now so he can adapt his business model sooner. And the more seniors who get dental coverage, the more his potential client base expands. Dentists like him, still building their practices, are less likely to have time to be involved in the ADA's policymaking process, he says.

Caught up in it all are patients such as Stork, who says the possibility of dental coverage in Medicare is one reason he is holding off on the tooth extraction he needs, even though he knows a benefit is unlikely to be implemented for years, if at all.

Stork also knows the benefit might not cover a middle-class person like himself even if approved. Still, coverage sure would be nice to have when his tooth cannot wait any longer to come out.

Kaiser Health News is a national, editorially independent program of the Kaiser Family Foundation and is not affiliated with Kaiser Permanente.

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