First of all, what is a health care system? Sometimes called a health system, it is an organization of people, institutions, and resources that deliver health care services to meet the health needs of groups of people. They can occur in specific settings such as homes, educational institutions, workplaces, public places, communities, hospitals, and clinics. They also include efforts to address the things that impact health, such as access to healthy food, mental health, and poverty.

Oral health is related to the health of the rest of the body (systemic health) and likewise, the health of one’s body affects their oral health. Unfortunately, dental care and medical care are mostly separate in the U.S (as well as in other parts of the world). Dental care is much less available to those communities that have the highest rates of dental disease due to its high fees which places an “undue burden of dental disease on the most vulnerable Americans who face barriers to accessing dental care”^[1]. Since poor oral health can affect systemic health, the costs of lack of dental care can increase the costs of medical care.

In this module, you will learn about the various oral health care systems that exist in the United States. Then, you will be able to utilize your knowledge to explore Washington’s state health insurance. Lastly, we will discuss the problematic issues that arise when patients with dental problems go to a hospital emergency room rather than a dentist for care.

Preferred Provider Organizations(PPO)

This type of plan allows patients to pay less if the provider is within the plan’s network. Additionally, enrollees may use out-of-network doctors, hospitals, and providers without a referral at an additional cost^[2].

Health Maintenance Organizations(HMO)

This type of plan limits coverage to doctors who have a contract with the HMO and out-of-network coverage is restricted except in an emergency. Additionally, HMO enrollees are usually required to live or work in the service area to be eligible for coverage. However, HMOs offer more integrated care encompassing various health types of health professionals such as dental and therapy. In this regard, HMOs tend to focus on prevention and wellness^[2].

Medicare

Medicare is a national health insurance program for people in the U.S. regardless of income who are age 65 or over and certain younger people with disabilities. This program is financed through Federal government expenditures and through payroll taxes from people throughout their working careers^[3]. Additionally, Medicare is split into four parts that cover different services and have different costs. While Medicaid is a welfare assistance program that varies across states, Medicare is a Federal health insurance program that is mostly the same everywhere around the U.S.

It is important to remember that Medicare only covers dental care that results in a hospital stay (Part A or B), but does not cover routine dental care like dental examinations, fillings, dentures, or regular dental cleanings. Regular dental care would otherwise be covered if the individual elects to include dental coverage in their Part C Medicare Advantage plan. More information about Medicare Dental Coverage can be found here.