The Patient Protection and Affordable Care Act's 10 essential health benefits have given brokers and agents plenty to chew on during the law's implementation. While those benefits are intended to improve care covered under health plans across the nation, they have been shown to drive up the cost of some plans—a side effect largely unknown to many new plan purchasers thanks to the law's subsidies—and has led to cases of coverage incongruity. For example, men are now required to pay for prenatal care. Childless individuals are required to pay for pediatric care. And people who don't take pills have to pay for prescription coverage.

But even with all those covered areas, there's a glaring omission, especially for workers who've been receiving health care benefits for years. PPACA doesn't cover adult dental care, and the omission has garnered sharp criticism from benefits professionals, health care officials and dentists across the nation. “[PPACA] is a missed opportunity, and we have a long way to go in ensuring access to oral health for all Americans,” says Marko Vujicic, managing vice president of the American Dental Association's Health Policy Research Center. “This is especially true for adults, who have experienced greater financial barriers to dental care in recent years.”

Sure, there's a mandate for pediatric dental care, but there's no mandate for adults to get coverage—even though a recent study by the ADA showed that 40 percent of lower-income adults believe PPACA will help them get dental care. And while the ADA also estimates that 5.3 million adults are expected to get dental care under PPACA from expansions of dental benefits in Medicaid states, it won't happen for everyone.

“With PPACA, you're going to find employees very confused over the rules around the dental benefit,” says Dani Fjelstad, president of Wellpoint Dental in Minneapolis. “They're going to ask questions like, 'If I don't have it through my medical carrier, do I need to get it on my own? Am I going to be penalized? And, gee, I'm an adult, why do I have to have the pediatric coverage?' No matter what kind of press is out there and how good the insurance companies explain it, I just think it's going to be confusing.”

A shift to voluntary

Many American workers, though, will face a choice. Thanks to PPACA, dental coverage now essentially becomes a voluntary benefit—a separate line item that employees will have to decide whether to keep or not. That's in contrast to the past few decades, when dental coverage was packaged with medical coverage as part of an employee's benefits. The shift could affect dental benefits in a number of ways. Some benefits brokers and agents are advising their clients to separate medical and dental. Dental could see a slide in business, some industry watchers say, but there are also factors—such as dental's affordability—that could keep the benefit's usage stable. Also, fewer people taking dental coverage could mean higher expenses in the future. Employees could make less effort at preventative care or decline the benefit altogether, which could result in more expensive claims for more invasive procedures. Less time in a dentists' chair also means fewer chances for dentists to detect some diseases or medical conditions. Some even say the of Americans' oral health could even decline. Industry insiders agree that only time will tell for any scenario to play out.

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 cost to people simply disliking trips to the dentist. “They're trying to bring it under budget,” says Wayne Emery, executive vice president of employee benefits for Toledo, Ohio-based Hylant. “If they would have 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 are petrified of the dentist. And PPACA wouldn't make those people want to go to the dentist.”

Benefits brokers and agents, as well as dental providers, have been working with their clients—both large and small—since the law's passage to develop strategies to continue providing dental coverage to employees in the midst of the changing regulatory environment.

The options

Options run the full spectrum. Some employers are offering plans that ask employees to shoulder more of the cost through higher deductibles. Others are moving to a self-funded model while a few others are referring employees to exchanges or the federal marketplace. Some industry sources say some employers are even taking the wait-and-see approach.

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

“We don't have any clients that went into the exchange, they don't want to be a guinea pig,” Rider adds. “Every one of them has said we're going to wait a year and see what happens. Our agency has access to a couple of private marketplaces, so those that aren't eligible or are smaller, there are options out there, but our employer groups don't want to be the first one to pull the trigger.”

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

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

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

“What can be diagnosed through good oral care? Diabetes,” Rider says. “Pregnant women are encouraged to have cleanings four times a year. If we're funding health care through the marketplace, theoretically, we would want those folks to be healthy to offset claims, and we would want to diagnose through good oral care, too. People are even diagnosed with high blood pressure through eye exams.

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

The Positives

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

“Most employees continue to take dental,” Emery says. “Participation is still pretty high. Most people—particularly those with families—are scared of unknown expenses. And if you go twice a year, 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 of pocket. [Dental coverage] is still pretty reasonable. You can get a family dental plan for under $100 a month from most groups. A family of four or five—if they all go twice a year—visits are going to 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 the premium, they're going to use the benefit. And I think whether it's negative or positive, I think they're hearing things about health care reform that prompts them to ask questions. And if you ask questions, you become more educated.”

Uninsureds say exchanges are problematic

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

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

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

Those numbers are only a slight improvement from October and November, when the exchanges were especially plagued with technical problems.

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

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

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

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

Still, that number is not ideal.

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

Americans still have until March to enroll in coverage and not pay a penalty.

Overall, researchers say that, although the administration said the exchanges' major technical problems are resolved, the poll indicates otherwise.

“The update suggests the website fixes have not dramatically improved the customer experience for uninsured Americans seeking health insurance to comply with requirements of the Affordable Care Act,” Gallup researchers noted.

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

—Kathryn Mayer

Instant Insights /

Dental&rsquo;s big shift

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