Pediatric dental care, long a concern of children’s health advocates, is poised to get a major boost with each of the Democratic health reform proposals.
“The silver lining of all this heated debate, for children at least, is that in almost every conversation, in every version of a bill, there’s some provision for children’s oral health,” said Amir Moursi, chair of the department of pediatric dentistry at New York University’s College of Dentistry.
Yet in a surprising twist, some insurance industry experts worry that the legislation may create unintended consequences and disruptions for adult and family dental coverage.
While he calls the children’s benefit “an unbelievable mark of progress,” Jeff Album, the vice president for public and government affairs for Delta Dental insurance company, fears that adults and employers may drop their dental coverage because of the legislation’s treatment of dental plans and taxation of insurance benefits.
A Surgeon General’s report on oral health, released in May 2000, found:
- Tooth decay is the single most common chronic childhood disease and is five times more common than asthma.
- More than half of all children aged 5 to 9 have at least one cavity or filling. More than three quarters of all those who are 17 years old have a cavity or filling.
- Poor children have twice as many cavities as children with more resources and their disease is more likely to be untreated.
- For each child without medical insurance, there are at least 2.6 children without dental insurance.
- Children lose more than 51 million school hours because of dental problems.
Many dental experts say the proposed mandate for children’s coverage addresses a serious need, one that gained national attention in 2007 when Deamonte Driver, a 12-year-old Maryland boy who lacked access to dental care, died after bacteria from an abscessed tooth spread to his brain. Currently, about twice as many children are without dental coverage as those without medical insurance.
Furthermore, pediatric dental issues represent children’s most common unmet health care need, according to the Surgeon General’s first report on oral health in 2000. It found that tooth decay is the single most common chronic childhood disease, five times more common than asthma and seven times more common than hay fever.
The report described dental disease as a “silent epidemic” that created significant social, financial and health burdens disproportionately affecting low-income, minority and rural populations. It also said research suggests intriguing associations between chronic oral infections and diabetes, stroke and heart and lung disease.
Dental coverage lags for adults, too, despite significant gains in the past 20 years. According to the most recent information from the Agency for Healthcare Research and Quality, in 2004 54 percent of Americans had private dental coverage, 12 percent had coverage through government programs such as Medicaid and 35 percent had no dental coverage. Dental industry estimates suggest that the number of insured has increased only slightly since then.
Adult coverage, however, is not mandated in the reform proposals.
All the major bills in Congress require that pediatric dental care be included in the coverage guaranteed to anyone purchasing insurance through the government-sponsored marketplace for health plans, also called an insurance exchange or gateway. The House bill also calls for that benefit to be extended to the private market, including employer-provided plans, in five years.
One of the issues for legislators was what plans would be considered qualified to provide the children’s pediatric dental benefit. Currently, 97 percent of dental coverage comes from stand-alone plans that are separate from medical health insurance.
Decoupling Dental From Medical Insurance
Initially all the bills called for pediatric dental care to come from plans that also offer medical insurance. But the Senate Finance Committee’s bill and the House bill have been amended to allow stand-alone dental insurance companies to provide that coverage. Dental insurance experts said, however, it is not clear if those amendments will survive in the full House and Senate.
But Jim Crall, a professor of pediatric dentistry at the University of California at Los Angeles, said it is important that reform take into consideration how the dental industry works now so that the changes can be implemented smoothly and not lead to problems for families that have dental insurance. “Otherwise,” he said, “we’re going to end up with a hollow promise.”
For example, dental insurers are worried that if Congress goes forward with proposals to tax high-cost, or Cadillac, insurance plans, some of those plans may ditch their adult dental coverage to help keep the overall premiums below the tax threshold.
Album said dental insurers also fear that parents may be less likely to buy the stand-alone coverage for themselves if their children have coverage that comes as part of comprehensive medical insurance package.
According to a 2008 survey by the Kaiser Family Foundation, 44 percent of employers that offer health benefits also offer or contribute to dental coverage. (KHN is a program of the foundation.)
Some dental experts suggest that securing the pediatric benefit in the overhaul package should be the top priority and that more narrow issues, such as the best means to provide the coverage, should be addressed later.
Burt Edelstein, the founding director of the Children’s Dental Health Project, stressed that the inclusion of dental experts in the board overseeing the insurance exchange would help to make sure important delivery issues are addressed.
The House has already recognized the need for an oral health expert to sit on any health benefits advisory committee, while Rep. G. K. Butterfield, D-N.C., has called for a federal study on the need for affordable adult dental coverage.
Edelstein said getting the dental benefit is important and advocates on the issue should not focus on concerns “that could in any way cause the dental benefit to be revisited” and stripped from the proposals.
Many of the current concerns are caused by the dental industry’s unique history and structure. Dentistry’s separation from medical care makes integration a formidable task.
Dentists are trained separately from doctors while dental insurance developed much later than medical insurance with a different set of diagnostic code, billing system and benefit structure. As such, dental contracts are generally created separately from medical ones and people often consider dental insurance to be more elective than medical, according to dental experts.
This separation can cause problems for patients, such as when serious dental needs require work in a hospital’s operating room. In such instances, it’s often unclear whether dental or medical insurance will cover the costs.
The Tragedy of Deamonte Driver
The case of Deamonte Driver illustrates the medical dangers of untreated dental problems. Driver and his brother had erratic dental care because their Medicaid coverage would sometimes lapse and their mother had difficulty finding a dentist who would accept Medicaid payments.
Driver’s death led to congressional hearings that showed how children face many difficulties in accessing care despite Medicaid’s requirement that states provide pediatric dental services. It also helped prompt the inclusion of eight specific pediatric dental provisions in the law signed last February that reauthorizes the Children’s Insurance Health Program (CHIP), which covers poor children whose family incomes are too great to qualify for Medicaid.
A Government Accountability Office report released last month found that such barriers, which include extensive bureaucracy, low dental reimbursement rates and shortages of dentists who will take Medicaid reimbursements, still exist.
Medicaid rates vary by state, but a 2008 study found that dental reimbursements are often 30 to 50 percent of the usual and customary fees charged locally. The dentists got paid as little as $15 to see a Medicaid patient. The study was published by the National Academy for State Health Policy.
The GAO report found that the number of children on Medicaid getting dental care has improved in recent years, but is still low. The number has grown from 27 percent in 2000 to 35 percent in 2007, and only one state reported a rate above 50 percent.
Allen Finkelstein, chief dental officer at AmeriChoice, suggested that the paucity of dentists accepting Medicaid may be because “we don’t reward physicians and dentists for prevention.”
Finkelstein considers Driver’s death a wake-up call for policymakers to use a more holistic approach to health care and suggests integrating medical and dental care in simple ways, such as having a dental visit be part of a child’s immunization record or having physicians do fluoride varnishes.
He points out that AmeriChoice, which provides both dental and medical care, already reimburses physicians who put fluoride on children’s teeth.
“You really have to imbed dentistry with medicine. … We have to change the way we think,” said Finkelstein, who considers the pediatric dental benefit a move to greater integration. “It’s an adjustment phase, but it’s a wonderful start.”
Related resource: The Children's Dental Health Project's side-by-side comparison of dental provisions in the proposed legislation