A bill introduced by the US senator Bernie Sanders would dramatically expand access to oral healthcare by adding dental benefits to Medicare and enhance them in Medicaid, public health insurance programs that together cover 115 million older and lower-income Americans.

Despite Americans’ reputation for the flashy “Hollywood smile”, millions struggle to access basic dental care. One in five US seniors have lost all their natural teeth, almost half of adults have some kind of gum disease and painful cavities are one of the most common reasons children miss school.

“Any objective look at the reality facing the American people recognizes there is a crisis in dental care in America,” Sanders told the Guardian in an exclusive interview. “Imagine that in the richest country in the world.”

Nearly 69 million adults and almost 7 million children lack dental insurance. For those who have insurance, costs are often opaque and high. Multi-thousand-dollar bills are so common that the nation’s largest professional organization for dentists, the American Dental Association (ADA), signed an exclusive partnership with a medical credit card company.

In 2019, more than 2 million Americans went to the emergency room for tooth pain, a 62% increase since 2014, and a crisis of affordability pushed an estimated 490,000 Americans to travel to other countries such as Mexico for lower-cost dental care.

“The issue of dental care is something we have been working on for years,” said Sanders. “It is an issue I think tens of millions of Americans are deeply concerned about, but it really hasn’t quite gotten the media attention it deserves.”

Sanders said he had seen how poor dental health can affect every aspect of a person’s life – he described constituents who cover their mouths when they laugh or have been turned down for jobs because of missing teeth.

Sanders said he recognized the importance of the issue by attending town halls in his home state of Vermont, “and learning how hard it is to get dental care, how expensive it is and [how] dental insurance [is] totally inadequate”.

“Having bad teeth or poor teeth is a badge of poverty,” said Sanders. “It becomes a personal issue, a psychological issue, an economic issue as well.”

Sanders’ bill expands dental coverage by adding comprehensive benefits to Medicare; incentivizing states to improve dental benefits through Medicaid; and providing dental benefits to veterans through the Veterans Administration.

Additionally, the bill would attempt to tackle some states’ dentist shortage by creating student loan forgiveness programs for dentists who practice in underserved areas, and increasing funding to non-traditional places to see dentists, including at community health centers and schools.

Expanding dental coverage is exceedingly popular – recent polls show 92% of voters support the proposal, including an overwhelming majority of Republicans. Sanders said his proposal was good policy and “very good politics”.

Sanders has also reportedly lobbied the Biden administration to make dental benefits in Medicare a part of the president’s re-election campaign. The Biden administration, for its part, has taken incremental steps to improve health insurance coverage of dental care through federal rule-making.

In one example, the Biden administration expanded dental benefits to some cancer patients on Medicare. Although analysts expect the rule to affect only a small number of beneficiaries, it is significant because Medicare has traditionally excluded dental benefits.

Despite popular support and the poor state of Americans’ dental health, Republican lawmakers and conservative thinktanks argue the proposal is “a solution in search of a problem”.

“With Medicare on track for insolvency in a little over a decade, we should also think about making that sustainable before adding programs to it,” the Republican senator Bill Cassidy of Louisiana said at a committee hearing on the bill last week.

The ADA has also opposed past efforts to add dental benefits to Medicare, arguing in part that the administrative burden of accepting Medicare would be too great for many dental practices.

“I don’t have to tell you that the insurance companies, the drug companies have zillions of lobbyists here in Washington,” said Sanders. He later added: “The function of our healthcare system is not to provide high-quality care, but to make huge profits for drug companies and insurance companies.”

In response to questions from the Guardian, a spokesperson for the ADA said: “There are many approaches needed to address access to oral health care in America. Multiple measures will be needed to make improvements.”

The group said it supported efforts to improve the workforce, but did not address Medicare benefits.

Because Republicans control the House of Representatives, Sanders does not expect his whole bill will move forward. However, he believes there is “progress” that can be made in a “piecemeal way” – in particular, benefits for military veterans and enhanced support for Medicaid dental benefits.

“Republicans don’t blink an eye on spending $900bn on the military, but when it comes to spending on quality care for Americans – that is not one of their priorities,” said Sanders.

This is not Sanders’ first attempt to expand dental care access in the US. In 2021, a proposal to add dental, vision and hearing benefits to Medicare was also overwhelmingly popular, favored by 84% of voters including a large margin of Republicans.

However, the large social and environmental bill that contained the proposal, the Build Back Better bill, died when Democrats failed to sway a key member of their caucus, the West Virginia Democrat Joe Manchin. Democrats eventually passed a pared-down bill, the Inflation Reduction Act, which stripped the health proposals.

“It is not just dental care,” said Sanders. “We have an entire healthcare system which is broken, it is dysfunctional. In terms of policy, dental care is healthcare.”