Current Dental Coverage under ACA

The Affordable Care Act (ACA) offers a mixed approach to dental coverage:

  • Children under 18: Pediatric dental care is included as an essential health benefit, available either as part of a health plan or as a standalone option. Insurers must offer it on the Marketplace, but parents aren't required to purchase it.
  • Adults: Dental coverage isn't mandated by the ACA. Insurers decide whether to offer adult dental plans and what they'll cover, typically including a range of basic to major services, often with additional out-of-pocket costs.

On the Marketplace, dental plans come in two varieties:

  1. High-option plans: Higher monthly premiums but lower out-of-pocket costs at the dentist
  2. Low-option plans: Lower monthly premiums but potentially higher direct payments at the dentist's office

The costs can be substantial before benefits activate, especially with embedded plans that include a medical deductible. This cost barrier can lead many insured adults to skip necessary care, potentially resulting in poorer health outcomes over time.

Potential Changes in Dental Coverage

The future of dental coverage may see significant improvements for adult dental care. Recent legislative proposals suggest adult dental care could become an essential health benefit, potentially reshaping access to dental services.

Key proposals include:

  • The Comprehensive Dental Care Reform Act of 2024, proposing to add dental benefits to Medicare and Medicaid
  • The Department of Health and Human Services' Payment Parameters for 2025, suggesting states might have the option to classify routine adult dental health coverage as an essential health benefit

If adopted, these changes could provide consumers with protections similar to those for pediatric dental care, including:

  • Bans on annual and lifetime dollar limits
  • Reduced out-of-pocket costs
  • A more affordable dental care environment

As states consider their response, insurers are preparing for possible changes. If dental coverage becomes an essential health benefit, they may need to adjust their financial strategies, potentially restructuring plans with high deductibles and embedded plans to reduce financial strain on consumers.

Financial Barriers and Public Opinion

Financial barriers often present a significant challenge for many individuals seeking dental care. The KFF Consumer Survey reveals that more than one in four insured adults postpone necessary dental care due to high out-of-pocket costs.

Public support for expanding dental coverage is strong:

  • About nine in ten voters want dental benefits added to Medicare
  • This widespread backing spans across political lines
  • There's bipartisan agreement on the importance of dental care to overall health
"A lack of dental care can worsen other serious medical conditions, but without adequate coverage, millions of Americans go without the critical oral care they need." – Rep. Debbie Dingell, D-Michigan

Despite this strong public support, policymakers face challenges in implementing widespread reform. Aligning financial support structures, such as advanced premium tax credits, with new dental benefits requires careful planning and execution.

The political discussion, while acknowledging the need, often gets caught up in budget allocations and priorities. However, the fact remains that untreated dental problems can lead to more serious health complications, expanding the conversation beyond oral health to broader medical concerns.

Looking ahead, the potential restructuring of dental coverage could create a more inclusive future for adult care. Integrating dental benefits into essential health coverage offers hope, potentially easing financial burdens and improving access to necessary services. This change may finally address longstanding gaps in our healthcare system, promoting healthier smiles and overall well-being for everyone.

  1. Kaiser Family Foundation. KFF Consumer Survey of Consumer Experiences with Health Insurance. 2023.
  2. National Association of Dental Plans. Dental Plans Report. 2023.
  3. CareQuest Institute for Oral Health. Voter Poll on Dental Coverage. 2023.
  4. American Dental Association. Statement on Medicare Dental Coverage. 2024.