The Patient Protection and Affordable Care Act may have mandateddental insurance for children, but the new law does not addresscoverage for adults.

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In fact, experts say it could actually significantly disrupt thedental benefits market if employers drop coverage for their workersor workers opt out of duplicative plans for themselves to pay fortheir children's benefits.

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Meanwhile, charitable oral care is on the rise to address thecontinued need for adults without dental insurance or access todentists in underserved markets, as well as children whosefamilies—for whatever reason—don't take advantage of dentalinsurance.

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Children clearly gain from the new health care law, as thedefinition of “essential health benefits” encompasses pediatricservices, including oral and vision care, says Vincent Graziano,vice president and health practice manager for the Segal Company inBoston.

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Non-grandfathered plans for individuals and small employergroups with 100 or fewer employees have to provide essential healthbenefits, but larger employer groups do not, Graziano explains.However, if larger groups choose to provide such benefits, theycannot impose annual and lifetime dollar limits. 

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“Adults could be the losers,” Graziano says. “Large group healthplans don't have to provide essential health benefits, but if theydo, they have to follow the rules. Therefore, the thought is thatif it costs you to follow the rules in some places, you might pullback benefits to cut costs in places where you don't have to followany rules—and in this case, that might mean eliminating or cuttingback adult dental benefits.”

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Moreover, if medical carriers also offer pediatric oral healthcoverage, small employers don't have to have other dental coveragethat would cover adults, Graziano says. For large employer groups,the Affordable Care Act doesn't apply at all to dental and visionbenefits if the benefits come from a separate insured policy. Ifdental is self-insured, it also doesn't apply if it's a separateelection.

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“My hunch is that a lot of employers are not going to be subjectto the Affordable Care Act because in the traditional way healthbenefit plans are constructed, there is usually a separate electionfor a dental plan,” he says. “Some employers may reduce theirdental and vision benefits, or shift them to voluntary benefits, inresponse to escalating plan costs. I am one of those people who donot believe that they will drop health care coverage altogether andforce all of their employees over to the new exchanges. There isstill too much competition for skilled employees.”

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However, employees might decide to opt out of a dental plan forthemselves, to afford a dental plan for their children, says ChrisPyle, spokesman for the Delta Dental Plans Association in OakBrook, Ill.

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“A small business may offer dental through a stand-alonecarrier, but after reform is implemented and the small businessdecides they are going to continue to offer medical coverageoutside of the exchange in the private market, the medical carrierthat is going to provide coverage is going to have to includepediatric oral benefits as part of the package,” Pyle says. “Sothat means an employee would have duplicative coverage, and theyjust might drop the coverage for themselves and keep the coveragefor their children, to save money.”

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No fix in sight

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Indeed, the National Association of Dental Plans estimates thatup to 11 million Americans may drop dental coverage when theirchildren are removed from their dental polices.

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The trade group, as well as other groups such as the NationalAssociation of Insurance Commissioners, has been lobbying the U.S.Department of Health and Human Services to reinsert the ability ofdental plans outside the exchanges to be able to cover the mandatedpediatric oral care. Senator Debbie Stabenow (D-Mich.) hadsponsored an amendment in the legislation to allow carriers bothinside and outside the exchanges to satisfy the mandate. However,by the time the law was enacted, the outside exchange language wasomitted.

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“We've been working with HHS to make changes, as we believe theyhave the regulatory authority to do that, and they are still tryingto decide if they do have that kind of authority,” Pyle says. “IfHHS or the administration does not remedy this problem, we willhave to look for other means of protecting the insurance market andensuring that people who like their current coverage are able tokeep it. Pursuing a legislative fix is certainly an option. Time isrunning out, though, so these fixes need to happen very soon.”

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Meanwhile, there is still a great need for charitable oralhealth services, says Nicole Lamoureux, executive director for theNational Association of Free and Charitable Clinics in Alexandria,Va.

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“In fact, many are surprised to hear that even after fullimplementation of the ACA, there may be as many as 26 millionpeople who are still without access to health insurance,” Lamoureuxsays. “Outrageously, many public insurance plans barely coverdental benefits and in 22 states, individuals with Medicaid have nodental coverage or may only have it available in emergencysituations.”

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Across the country, free and charitable clinics and othermembers of the safety net are providing access to much neededdental care for free or at a dramatically low cost, she says. Manysuch clinics that provide dental care have a waiting list becausethe demand for dental care is so high. Across the country, NAFCclinics have seen a 20 percent decrease in donations and a 40percent increase in patient demand for services.

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“While the Affordable Care Act is a first step toward access tohealth care for some, it is not a complete solution for primarycare—with respect to dental care, it leaves great holes in care,”Lamoureux says. “Until effective reforms can be implemented, thereare people in communities throughout this nation who are standingin the gap every day and filling the need as best they can. Theyare the men and women who provide their services at more than 1,200free and charitable clinics across the country, as well as at othersafety-net health care providers.”

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Delta Dental Plans Association as well as its individual membercompanies financially support many nonprofit charitable oral healthservice providers, including Mission of Mercy, Pyle says.

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Delta Dental recently purchased and gave Mission of Mercy an18-wheel truck refurbished with medical equipment, to transport todental care events around the country in local convention centersor other large arenas, he says.

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“These events provide free dental services for whoever shows upand they typically draw about 2,000 people over two days,” Pylesays. “People will spend the night on the street in the cold andheat, to camp out in order to get out of pain.”

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A need for more dentists

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Moreover, there are a lot of areas in the country, federallydesignated as “health professional shortage areas,” that still donot have enough dentists to treat all of the people who residethere, he says. According to a June 2012 report by the KaiserFamily Foundation, more than 44 million Americans live in suchareas.

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Delta Dental is trying to attract dentists to those areas byoffering incentives, such as helping to repay their student loans.For every year a dentist practices in an underserved area, DeltaDental provides a lump sum of money to help repay school loans.

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“Sometimes they then choose to stay in those areas, because theylearn to love the place and this helps them establish a practice,”Pyle says. “It's a very important service and it's helping to meeta significant need.”

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While health reform mandates dental insurance for childreneither through employer plans or subsidies for parents to buyinsurance, not all parents will take advantage of thebenefits—without active encouragement, says Terry Dickinson, aRichmond, Va.-based dentist who also is executive director of theVirginia Dental Association.

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“These folks simply don't have the necessary information to makebetter choices about what they eat or drink, how to properly cleantheir child's teeth and how to access and navigate the dental caresystem,” Dickinson says. “But the decisions on food and drink arealso contingent on a lot of other factors. Some of these familieshave to make decisions about where the next meal is going to comefrom, the next tank of gas or the next pair of shoes. Onesignificant negative financial event could put them in a desperateeconomic situation. So dentistry is pretty far down the list forthem.”

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To mitigate for these issues, the Virginia Dental Association,the state's Department of Medicaid Assistance Services and otherstakeholder groups developed a program, Smiles for Children, forchildren of Medicaid receipts. Medicaid medical providers applyoral fluoride varnishes to these children during mandated well-babyvisits, teach the parents about proper care of the teeth and gumsand discuss dietary issues that would increase the risk of dentaldisease at an early age.  

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“We've seen a dramatic increase in Virginia over the last fewyears of kids involved in this program,” Dickinson says. “Theultimate payoff comes in having healthier children at a lower riskof dental disease and a parent that is better educated inprevention of dental disease.” 

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Katie Kuehner-Hebert is a freelance writer in RunningSprings, Calif. 

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Katie Kuehner-Hebert

Katie Kuehner-Hebert is a freelance writer based in Running Springs, Calif. She has more than three decades of journalism experience, with particular expertise in employee benefits and other human resource topics.