The Patient Protection and Affordable Care Act's 10 essentialhealth benefits have given brokers and agents plenty to chew onduring the law's implementation. While those benefits are intendedto improve care covered under health plans across the nation, theyhave been shown to drive up the cost of some plans—a side effectlargely unknown to many new plan purchasers thanks to the law'ssubsidies—and has led to cases of coverage incongruity. Forexample, men are now required to pay for prenatal care. Childlessindividuals are required to pay for pediatric care. And people whodon't take pills have to pay for prescription coverage.

But even with all those covered areas, there's a glaringomission, especially for workers who've been receiving health carebenefits for years. PPACA doesn't cover adult dental care, and theomission has garnered sharp criticism from benefits professionals,health care officials and dentists across the nation. “[PPACA] is amissed opportunity, and we have a long way to go in ensuring accessto oral health for all Americans,” says Marko Vujicic, managingvice president of the American Dental Association's Health PolicyResearch Center. “This is especially true for adults, who haveexperienced greater financial barriers to dental care in recentyears.”

Sure, there's a mandate for pediatric dental care, but there'sno mandate for adults to get coverage—even though a recent study bythe ADA showed that 40 percent of lower-income adults believe PPACAwill help them get dental care. And while the ADA also estimatesthat 5.3 million adults are expected to get dental care under PPACAfrom expansions of dental benefits in Medicaid states, it won'thappen for everyone.

“With PPACA, you're going to find employees very confused overthe rules around the dental benefit,” says Dani Fjelstad, presidentof Wellpoint Dental in Minneapolis. “They're going to ask questionslike, 'If I don't have it through my medical carrier, do I need toget it on my own? Am I going to be penalized? And, gee, I'm anadult, why do I have to have the pediatric coverage?' No matterwhat kind of press is out there and how good the insurancecompanies explain it, I just think it's going to be confusing.”

A shift to voluntary

Many American workers, though, will face a choice. Thanks toPPACA, dental coverage now essentially becomes a voluntarybenefit—a separate line item that employees will have to decidewhether to keep or not. That's in contrast to the past few decades,when dental coverage was packaged with medical coverage as part ofan employee's benefits. The shift could affect dental benefits in anumber of ways. Some benefits brokers and agents are advising theirclients to separate medical and dental. Dental could see a slide inbusiness, some industry watchers say, but there are alsofactors—such as dental's affordability—that could keep thebenefit's usage stable. Also, fewer people taking dental coveragecould mean higher expenses in the future. Employees could make lesseffort at preventative care or decline the benefit altogether,which could result in more expensive claims for more invasiveprocedures. Less time in a dentists' chair also means fewer chancesfor dentists to detect some diseases or medical conditions. Someeven say the of Americans' oral health could even decline. Industryinsiders agree that only time will tell for any scenario to playout.

It isn't clear why adult dental coverage was left out of PPACA,but industry sources say it could range from the law's overall costto people simply disliking trips to the dentist. “They're trying tobring it under budget,” says Wayne Emery, executive vice presidentof employee benefits for Toledo, Ohio-based Hylant. “If they wouldhave added it to PPACA, it would have added to the overall cost.Down the road, I think it will be added—it's a matter of economics.Plus there are still a significant number of people that arepetrified of the dentist. And PPACA wouldn't make those people wantto go to the dentist.”

Benefits brokers and agents, as well as dental providers, havebeen working with their clients—both large and small—since thelaw's passage to develop strategies to continue providing dentalcoverage to employees in the midst of the changing regulatoryenvironment.

The options

Options run the full spectrum. Some employers are offering plansthat ask employees to shoulder more of the cost through higherdeductibles. Others are moving to a self-funded model while a fewothers are referring employees to exchanges or the federalmarketplace. Some industry sources say some employers are eventaking the wait-and-see approach.

“Most of my groups are separate so they're not tied to oneanother,” says Susan Rider, human capital consultant and accountexecutive for Gregory & Appel of Indianapolis. “We've probablybeen going down the voluntary route for dental and vision over thepast four years, meaning the employee is picking up the premium.The other trend in mid-to-large size groups is self-funding. Theyknow their exposure, so they figure out the annual maximum and theyself-fund, but there are many still in networks.

“We don't have any clients that went into the exchange, theydon't want to be a guinea pig,” Rider adds. “Every one of them hassaid we're going to wait a year and see what happens. Our agencyhas access to a couple of private marketplaces, so those thataren't eligible or are smaller, there are options out there, butour employer groups don't want to be the first one to pull thetrigger.”

One thing brokers and agents can count on, though, is that theirclients will look to them for a way to navigate through PPACA'simplementation, which hasn't been easy, Fjelstad says.

“We have been planning for years, but the rules have changedalong the way,” he says. “The laws were written in general, andthen the guts were defined on the fly. They've been changing at thefederal level; then while a state can follow the federal rules,they also have the liberty to make their changes. So you've got allof that going on. You have all of this variability going on. Myview is that is going to lead to a ton of administrative work.”

Still, there are plenty of reasons for employers to continueoffering—and employees to continue paying for—dental coverage. Manydentists notice early warning signs of major disease or medicalconditions during routine cleanings or other procedures, and earlydetection can mean reduced overall medical costs. Not to mentionthe overall state of the nation's oral health could be affected,too.

“What can be diagnosed through good oral care? Diabetes,” Ridersays. “Pregnant women are encouraged to have cleanings four times ayear. If we're funding health care through the marketplace,theoretically, we would want those folks to be healthy to offsetclaims, and we would want to diagnose through good oral care, too.People are even diagnosed with high blood pressure through eyeexams.

“When you go to places like Europe, the government is coveringsome benefits and the public has to purchase the rest. If they needa crown, they're just stuck with it,” Fjelstad says. “ManyEuropeans forgo the benefit as long as they can and it leads tomuch worse general oral health. There's a reason Europeans say youcan tell an American by their good teeth. In Britain, the bus pullsup twice a year and you get what you need. What happens is that'swhere it starts and ends. It's interesting how they have thiscoverage provided and in general you see their oral health isn't asgood.”

The Positives

While the overall outlook on dental coverage under PPACA remainssomewhat murky, some brokers and agents are seeing a few positives.Even though employees are now forced to add the cost of dentalcoverage to their overall financial calculus, many brokers andagents continue to see employees who find value in carrying thecoverage. And now that employees are paying for the benefit, ittranslates to a more engaged group of clients.

“Most employees continue to take dental,” Emery says.“Participation is still pretty high. Most people—particularly thosewith families—are scared of unknown expenses. And if you go twice ayear, most plans cover it. Most people are scared of getting that$1,000 bill and not being able to pay for it with cash or out ofpocket. [Dental coverage] is still pretty reasonable. You can get afamily dental plan for under $100 a month from most groups. Afamily of four or five—if they all go twice a year—visits are goingto come to a thousand dollars or more.”

“More people are engaged in getting dental care,” Rider says.“To me, that's important. Now that they're paying more for thepremium, they're going to use the benefit. And I think whether it'snegative or positive, I think they're hearing things about healthcare reform that prompts them to ask questions. And if you askquestions, you become more educated.”

Uninsureds say exchanges are problematic

Although the administration has been adamant the exchanges underthe Patient Protection and Affordable Care Act are working betternow a few months in, consumers are telling a different story.

Fifty-nine percent of uninsured Americans reported having anegative experience with the new health exchanges in December,according to the latest Gallup numbers. Comparatively, 39 percentsaid they had a positive experience.

Only 7 percent reported a “very positive” experience, while 29percent had a “very negative” experience.

Those numbers are only a slight improvement from October andNovember, when the exchanges were especially plagued with technicalproblems.

Gallup figures are based on Dec. 1-29 tracking interviews withmore than 1,500 uninsured Americans, including roughly 450 who havevisited an exchange website.

Among those uninsured Americans who have visited an exchange, 24percent say they went to a federal exchange, 20 percent to a stateexchange, 17 percent to both, and 37 percent are unsure.

Gallup also found only 26 percent of uninsured Americans hadvisited an exchange, up 6 percent since November.

Researchers noted, though, that number may be skewed ifproportionately more visited near the end of the month to meet thedeadline for having insurance coverage effective Jan. 1.

Still, that number is not ideal.

A prior Gallup poll found that less than half of uninsuredAmericans who plan to get insurance say they will do so through anexchange, perhaps opting instead to take an employer-sponsored planor get covered on a family member's plan. Additionally, roughly 30percent of uninsured Americans say they are more likely to foregoinsurance and pay the penalty than to sign up for insurance.

Americans still have until March to enroll in coverage and notpay a penalty.

Overall, researchers say that, although the administration saidthe exchanges' major technical problems are resolved, the pollindicates otherwise.

“The update suggests the website fixes have not dramaticallyimproved the customer experience for uninsured Americans seekinghealth insurance to comply with requirements of the Affordable CareAct,” Gallup researchers noted.

“The fact that most uninsured Americans who have visited theexchanges report a negative experience is problematic, particularlygiven the Obama administration's efforts to improve the federalsites,” they concluded. “If uninsured Americans continue to havebad experiences with the exchanges, it could hinder the Obamaadministration's goal to insure as many Americans as possible.”

—Kathryn Mayer