Next Level Benefits » Dental care and insurance costs too much. ACA rule could change thatNext Level Benefits

Even when she had a massive infection and grueling pain from a cracked tooth, Nicole Sutton could not get a dentist to provide timely care.

Sutton, a single mother based in Tampa, Florida, could only get herself on a waitlist where she got in line to see one of the few dentists who take Medicaid, the government insurance for low-income families. She visited a hospital emergency room and a federally funded community health center, but those appointments only yielded prescriptions for antibiotics and pain pills. Neither offered to treat her dental crisis.

It wasn’t until she secured a loan from a friend that she could afford to see a specialist and an oral surgeon who extracted her tooth in an emergency procedure. Both demanded cash upfront.

It took months to clear the infection and return to health. The protracted dental episode two years ago exposed Sutton to the lurking disaster millions of Americans face because they don’t have robust dental insurance that guarantees access to oral care. A solution from the federal government may be forthcoming, which could have made a huge difference for Sutton.

The Affordable Care Act extended health insurance to tens of millions of Americans, through federal and state marketplaces that sell subsidized health insurance and Medicaid expansion adopted by all but 10 states.

But President Barack Obama’s signature 2010 health care law excluded dental coverage for adults. The health law required states to offer pediatric dental care as an essential health benefit for ACA plans.

In a move last month that received little fanfare, the Biden administration finalized a rule that would give states the option of adding adult dental insurance coverage as part of their Affordable Care Act plans.

In another attempt to bolster dental coverage, Sen. Bernie Sanders, I-Vt., on Friday introduced the Comprehensive Dental Care Reform Act of 2024, a bill that would expand dental coverage through Medicare, Medicaid and the Veterans Administration and increase the number of dentists, dental hygienists and dental therapists nationwide.

The deficit in dental coverage is immense: Nearly 69 million U.S. adults did not have dental insurance or access to routine oral health care last year, according to a survey by the nonprofit CareQuest Institute for Oral Health. Millions more lost dental insurance last year when states began to unwind Medicaid coverage for people who signed up during the COVID-19 pandemic.

People who don’t have coverage often wait before seeking care, and minor infections turn into life-threatening ordeals, advocates say. Those who rely on safety net programs such as Medicaid or community health centers that are federally qualified often end up on wait lists and struggle to get timely dental appointments. Only 1 in 3 U.S. dentists agree to take care of Medicaid patients. Even fewer dentists see a lot of Medicaid patients.

Dentists can limit which insurance plans they take and require uninsured patients to pay cash upfront. Others steer patients to credit-card-style companies that extend credit with high interest rates. Under the arrangement, dentists get paid immediately, and patients get bills and face high-interest penalties if they don’t pay the balance during a grace period of several months.

Advocates like Melissa Burroughs, director of public policy at CareQuest Institute for Oral Health, aim to level the playing field, making dental care accessible to all.

“For far too many people in this country, oral health care is unaffordable and out of reach,” Burroughs said. “And that’s largely because there are very significant gaps in insurance.”

Under Biden’s rule, states have until 2025 to decide whether to mandate that insurers cover dental benefits for adults. The dental benefits would not take effect until 2027. No states have publicly signaled yet that they intend to require ACA dental benefits in 2027, however, advocates say the new rule could represent a significant expansion of dental insurance, which gets less scrutiny than medical insurance for hospital, doctor and pharmacy bills.

Sanders has rallied for dental reforms for more than a decade. In 2022, the senator unsuccessfully pushed for Medicare to provide comprehensive dental coverage for older Americans. During a hearing Thursday of the Senate Health, Education, Labor and Pensions Committee he chairs, Sanders said tens of millions of American adults either can’t afford or are unable to get necessary dental care. The hearing featured testimony from dentists, advocates and academics who discussed the depths of the challenge of providing nationwide oral care access.

“This is an issue we do not discuss enough,” Sanders told the committee. “It is a crisis issue.”

Advocates cheered the renewed attention to dental health insurance. The Biden rule is “pretty monumental” because it could pave the way for more robust dental coverage, said Colin Reusch, senior adviser for oral health policy at Community Catalyst, a health advocacy organization.

Reusch said about a half dozen states have previously explored the possibility of adding adult dental benefits, but, he said, it’s too early to say whether any would consider adding coverage under the Biden rule.

Americans are more likely to skip dental care because of the cost than to forego other types of health care such as costly doctor visits or prescriptions.

Dental coverage and access is “one of the places where people face significant affordability barriers,” Reusch said. “In fact, dental coverage presents a higher out-of-pocket burden compared to just about any other category of health care.”

New York City native Shaena Morris became accustomed to top-notch medical and dental care as a child and young adult. She took diligent care of her teeth, getting routine cleanings and checkups.

But when she moved to Florida with her family a decade ago, she could no longer count on timely appointments or access to care.

When her gums became inflamed after the birth of her first child, one dentist recommended a $4,000 deep cleaning that her dental insurer, Medicaid, would not cover. Now a resident of Dania Beach, Florida, Morris has cycled on and off of a public health insurance program as her household income has changed. Even when she’s on Medicaid, she often cannot get timely appointments or coverage of dental specialists that she needs.

Beyond dealing with pain and discomfort, she feels her inconsistent dental care has harmed her career as a cosmetologist doing hair and makeup for the likes of Paris Hilton. She believes her clients and managers have noticed her dental problems. She ultimately walked away from a profession she’d been in for nearly two decades because of what limited dental care did to her oral health.