Healthcare Debates: Should Health Insurance Cover Dentistry?

Despite the systemic separation between medicine and dentistry, there is a consensus between dental and medical professionals that oral health and overall health are interconnected.

According to the Mayo Clinic, oral health can contribute to conditions like endocarditis, cardiovascular disease, pregnancy/birth complications, and pneumonia. In the reverse, conditions like diabetes, HIV/AIDS, osteoporosis, and Alzheimer’s can negatively affect oral health.

From a zoomed out perspective, it’s estimated that over 100 systemic diseases and more than 500 medications impact the mouth—especially in older populations. Lack of access to oral healthcare can also result in cavities, and in children, it can result in sinus infections, ear infections, weakened immune systems, school absenteeism, and even death.

There is a relationship between lack of dental coverage and financial cost as well. Lack of insurance coverage for dentistry results in the delay of dental care, creating more expensive and extensive issues for patients down the road. For example, a section of the Medicaid population who received preventive dental care had lower medical costs for seven chronic health conditions (diabetes, heart disease, etc.) than those without preventive care by a margin of 31 percent to 67 percent. In 2016, 2.2 million visits to the emergency room were for dental reasons, many of which could’ve been prevented by routine dental care.

The impact of lack of dental care on the population in the United States extends beyond health and money and into everyday well-being. Physiological functions like speech, smiling, and chewing—functions all mediated by oral health—contribute to factors like self esteem, quality of life, and social standing. In the United States, teeth have become a marker of wealth, and the state of one’s teeth can either open or limit economic and social opportunities. Poor oral health, teeth that don’t conform to aesthetic standards of perfection, or missing teeth can actually drive those who are poor deeper into poverty because they are considered “less employable” than those who have aesthetically intact teeth. There is also social stigma associated with poor teeth, where those with “bad teeth” are stereotyped as uneducated or intellectually delayed.

While the Affordable Care Act did mandate dental coverage for children, one in ten still have no benefits. About one in every three adults in the U.S. hold no coverage as well. Considering the benefits to having dental care and the linkages between oral health and overarching health, this article explores why dental care isn’t covered by health insurance—and whether or not integration should occur.

To truly understand whether or not health insurance should cover dentistry, it is first important to understand why these two health-promoting fields operate independently of one another.

Two-hundred years ago, barber-surgeons—the “dentists” of the day—practiced tooth removal and repair as a mechanical challenge, offering dentistry alongside services like haircuts, leeching, and cupping. While the linkage between teeth and health has been present throughout ancient history, it wasn’t a part of the cultural conversation at the time. In 1840, when the first dental college was opened by self-trained dentists who understood there was much more to dentistry than just repair and extraction, there was an opening for the two fields to integrate,

However, antiquated ideas about dentistry as incidental persisted in medical schools of the time, and the request to integrate dentistry into medicine was denied because of cost. In the cycles of attempts to integrate the two systems over the subsequent years, the impact of this rebuff resulted in a culture of dentistry fiercely attached to professional autonomy and dominion over healing the mouth.

This historical moment also resulted in a cultural ideation of dentists and doctors as separate, as demonstrated by a New York appellate court decision rendered nearly 100 years later. The medicine-fueled metaphor of the body as a machine, treatable in distinctive parts without deep consideration of the whole somatic system, also helped to keep this separation between the mouth and the rest of the body alive.

Despite the legitimization of dentistry as a profession and the contemporary acceptance of the links between oral and overall health, the two health-promoting systems remained separate—including in the realm of insurance coverage.

Despite the commonly understood link between oral and overall health—and despite the merging medical consciousness that everything in the body is interconnected—the separation that plagues the professions also plagues insurance coverage.

Part of this separation stemmed from how health insurance came into being in the United States. As a result of a post-World War II wage freeze, health coverage, largely unavailable before the war, became a way to incentivize, reward, and keep employees healthy enough to continue working. Dental care was not seen as an essential means to any of these ends, and so was historically excluded from most medical benefits. Medicare adopted this stance, and in not offering dental, most private insurances followed suit.

Fast-forward to today and much of the reason why dental and medical benefits are separate is because that’s the way it’s always been. Megalithic institutions like medicine, dentistry, and insurance continue to practice in the traditional historical legacy because change is hard.

Another reason why dental is not included in health insurance is because of the inherent nature of health insurance. Ultimately, the purpose of health insurance is to pool money in order to protect patients from financial bankruptcy in the face of emergencies, urgent care needs, major health issues, or rare health considerations, which can incur devastating costs in the most expensive healthcare system on earth.

This reality of health insurance leads to two interconnected reasons why dental isn’t included in medical insurance: the threat to the fiscal solvency of insurance companies and the possibility of inflated healthcare premiums. The hallmarks of dental care are prevention and maintenance. If the pooled money collected for healthcare were utilized to cover typical dental care, insurance companies would lose fiscal solvency because they would be paying for services too often. To mediate for this cost, healthcare premiums would rise, negatively impacting the consumer.

As it stands, most consumers don’t opt into dental coverage because they don’t want to pay higher premiums for care of this kind.

This reluctance to pay higher premiums for dental care is also why current standalone dental insurance tends to be bare bones in nature. Dental insurance, unlike health insurance, is specifically catered toward prevention and maintenance.

According to the National Association of Dental Plans (NADP), standalone dental insurance generally covers 100 percent of preventive care, 80 percent of basic services, and 50 percent of major procedures. With yearly premiums ranging from $170 to $680, deductibles of $50 to $100, and an annual benefit maximum of $1,500 per year (i.e., the most that the insurance will pay out per year), standalone dental insurance is a gamble for some.

Those with good oral health who are only getting cleanings twice per year may lose money by opting in to dental insurance. Those experiencing struggles with oral health or with catastrophic oral health issues not covered by medical insurance may find that the out-of-pocket expenses are still quite high, making premiums less than worthwhile.

Despite the historical legacy of separation, the convergence of medical and dental insurance are in the sights of all stakeholders. As more citizens come to understand the importance of oral health both on physiological and social levels, the desire for dental coverage is here.

According to the American Dental Association (ADA) 93 percent of adults 50 years or older want dental coverage included in Medicare. Consumers are on board for the switch, and so too are many providers who understand that the mouth and the rest of the body aren’t separate. Some medical and dental providers are beginning to shift the way they practice, integrating dentistry into medicine and vice versa. As more providers see the responsibilities of dentists and doctors merge, overlap, and work in concert, insurance companies may have to adapt to keep up with this reality.

In the eyes of 96 percent of healthcare executives, the convergence of health and dental insurance is either already happening or will happen eventually. The bundling of insurance happening in other arenas (e.g., auto, home, and life bundles) is extending into health insurance. Fifty-one percent of private insurances already offer pediatric dental insurance in a bundle with health insurance, 22 percent offer full adult dental bundled into health, and 50 percent offer health insurance bundled with a standalone dental insurance managed by a subsidiary.

One-hundred percent of payers plan to offer dental benefits in the future, and 98 percent plan to bundle these benefits together when offered. While bundling standalone dental with health insurance is not offering dental coverage within the scope of health insurance, it is one step further down the path of integration.

In the United States, it appears that we are in a cultural epoch where we are examining the unconsciously reproduced cycles of historical ignorance and deciding whether or not they still serve us as a people. Based on our emerging understanding that the body is not a machine but a fully interconnected system, the evolving viewpoint that dentistry and medicine aren’t separate, and the changing consumer tide regarding desire for dental insurance, it seems that we are ready to break the cycle of seeing oral health as less important than somatic health. Tack on the part of the Affordable Care Act that attempts to make preventative care in the United States more accessible, and it seems obvious that medical insurance should cover dentistry.

However, when one looks at this issue from the inherent nature of health insurance, it’s not as straightforward. If insurance is supposed to be a safety net for catastrophe, then including dental coverage in health insurance only makes sense in cases where the dental work needed occurs at a fiscally catastrophic level.

Whether health insurance should cover dentistry then comes down to one’s viewpoint on the purpose of health insurance. If health insurance is seen as a safety net to protect patients from financial catastrophe, then it doesn’t make sense that it would cover all of dentistry. With most dental work existing within the realms of prevention and maintenance, it doesn’t fit within the penumbra of the true purpose of health insurance.

If health insurance is about creating a system of health where everyone has access to services to keep them healthy and whole, then including dentistry into health insurance is both intuitive and obvious.

Therefore, to truly answer the question, “Should health insurance cover dentistry” one must first answer the question, “what is the true purpose of health insurance?”