Mind the Gap: Bridging the Oral Health Divide for More Affordable and Accessible Coverage

Our country’s affordability crisis is hurting everyday Americans’ access to health care and health coverage. That is just as true for oral health care as it is for other kinds of medical care. Approximately 72 million, or about a quarter of adults in this country lack dental insurance. And even among those adults who do have dental coverage, high out-of-pocket costs often mean they don’t get the care they need. As advocates, patients, and families sound the alarm about crushing health care costs, and as states are dealing with the fallout from Republican health care cuts going into effect, oral health cannot be left out of the conversation.

Millions Still Lack Access to Coverage

Oral health care is key to overall health and wellness, employment opportunities, economic stability, and social connectedness, and without this coverage millions remain vulnerable to high costs and harms to their physical, mental, and economic well-being. Yet for too many families, access to oral health coverage remains out of reach.

Traditional Medicare offers no comprehensive dental benefits. And while Medicaid is required to cover pediatric dental care, adult coverage is optional for states, creating wide variation in access depending on where you live. That variation may only grow as states look to cut benefits as a direct result of the massive Medicaid cuts included in last year’s Republican budget reconciliation bill, H.R. 1.

Even within private coverage, gaps in dental coverage remain. While the Affordable Care Act (ACA) required marketplace plans to cover pediatric dental as an essential health benefit, adult dental coverage was left out. And, despite the fact that most employer-sponsored plans offer some form of dental benefit, roughly 17 million adults who get medical insurance either through the individual marketplace or their employer, still lack oral health coverage.

Access to dental coverage is even more challenging for states that rely on the federal marketplace given that families are not permitted to purchase a stand-alone dental plan without first purchasing medical insurance. This creates additional and unnecessary barriers for a person who might not get dental insurance through their employer, has Traditional Medicare but needs dental insurance, or someone who is otherwise uninsured but may want dental insurance.

Additionally, the failure by Congress to extend the enhanced premium tax credits has exposed consumers and patients to the full cost of marketplace plans, pushing some people out of coverage altogether. For those that were able to remain in the marketplace, financial choices and tradeoffs to afford additional dental coverage just got even more difficult.

High Costs Even If You Have Coverage

Even for those who do have access to dental coverage, the cost of dental care is exorbitant, forcing millions to struggle with affording the out-of-pocket costs. Although benefits vary, private plans typically cover 100 percent of preventive care, such as regular check-ups and cleaning; 80 percent of basic services, like filling cavities and pulling teeth; and 50 percent of extensive work, such as root canals, bridges, and crowns. While preventive care is covered without cost-sharing, dental procedures can be very costly, and the average out of pocket spending can be as high as $887 per person who goes to the dentist. Additionally, many dental plans also have an annual maximum — typically between $1,000 and $2,000 — meaning the plans will stop paying for care once the patient hits that ceiling.

The ACA established important consumer protections to ensure health coverage is truly comprehensive — but dental coverage was largely left out of those safeguards. Applying similar standards to dental plans, including requiring insurers to spend a meaningful share of premiums on actual patient dental care, would greatly improve access to comprehensive care.

Oral Health Can’t Be Excluded from Efforts to Make Health Care More Affordable

As Congress continues to debate how to improve health care — and specifically private and employer-sponsored insurance — affordable and accessible oral health care must be on the agenda. And as states look to minimize harms caused by federal inaction on premium tax credits and Medicaid budget cuts, they should not make short-sighted cuts to dental benefits that will only expose more people to the devastating impacts of our health care affordability crisis.