A couple of years ago, I found out that I needed to have a few cavities filled followed by a root canal. Luckily, I have dental insurance, I thought to myself, so this ought not to be a major financial burden. Unfortunately, I would come to find out that dental insurance plays by a different set of rules and regulations compared with health insurance. Despite the insurance coverage I had, which the dentist told me was one of the better plans on the market, I found myself paying hundreds of dollars for necessary care. While this nearly 4-figure surprise bill was extremely upsetting, I was fortunate enough to be able to pay it and get the care I needed. But I couldn’t help but wonder how this system is impacting less financially stable members of US society. This led me to further explore some of the complexities of the US health care and insurance systems.
While Georgetown’s motto is Cura personalis, care for the whole person is not the mantra of your health insurer. This is apparent to anyone who has attempted to use their health insurance card when buying glasses or a hearing aid, or when getting a cavity filled. None of the costs of these services are covered by a primary health insurance plan, and instead are paid through separate insurance programs or out of pocket. It’s intuitively ridiculous that we, as a society, have labeled certain body parts to be left behind from the purview of primary health insurance coverage.
Focusing on the highlighted example of dental care, deep fault lines between medicine and dentistry are seen. Dentistry is professionally separate from medicine with 2 distinct educational pathways. This schism is historically complicated, but it includes the hubris of doctors rejecting dentistry from inclusion in medical curricula in the 1800s.1 This led to the creation of the first dental college at the University of Maryland, which solidified the chasm between dentistry and medicine.
Unfortunately, our bodies do not respect this distinction. Problems with our teeth and gums can spread and affect the rest of the body. This is best highlighted by the famous and tragic case of Deamonte Driver, a 12-year-old Maryland resident who died of a neurological infection in 2007 that was caused by an untreated dental infection.2 In the richest country in the world, this sort of tragedy should never occur.
While this example highlights the worst outcomes of untreated dental problems, less extreme outcomes can still be quite terrible. Many people experience severe dental pain that goes unaddressed, and others will lose their teeth completely, leaving them with a broken smile that can affect them in profound ways. For example, people with missing teeth are more likely to be passed over in job interviews, further perpetuating cycles of poverty that likely contributed to the loss of teeth in the first place.2 Others will be unable to focus at work or school due to nagging and constant pains in their mouths. Overall, underprivileged populations are disadvantaged and hurt as a consequence of a lack of access to dental care, resulting in further health inequity.
With the separation of medicine and dentistry in mind, I turn back to insurance to explore how this separation manifests in access to care. Medicare, the nation’s public insurance program aimed at serving senior citizens, does not cover dental care. Medicaid, the nation’s public insurance program aimed at serving low-income individuals, leaves the decision to cover dental care up to individual states, except for children who are always provided coverage.2
Many low-income adults either have no dental coverage or very limited coverage for a small number of dental procedures.2 Further, despite the fact that children covered through Medicaid are entitled to dental care, many still go without that care. This is because Medicaid pays much less for dental procedures compared with private insurers, leading many dentists to either not accept Medicaid or limit the number of Medicaid patients they accept.2 Deamonte Driver was caught in this situation.
This leaves private dental insurance companies for those who are lucky enough to access a plan through their job or are financially able to pay premiums out of pocket. However, even if you have private dental insurance, you will find that the insurance company only pays a certain percentage for most procedures. Unlike deductibles, the insurer will only pay a percentage of every procedure, usually between 50% and 80%, and the patient pays the rest of the burdensome costs. Moreover, dental insurance has annual and lifetime maximums. This means that in a given year if your dental care goes above a certain amount, you have to pay the rest.3 This was a common practice for medical insurance as well, until the Affordable Care Act (ACA) made this illegal in most cases. However, the ACA did not alter this for dental insurance.
So let’s consider a hypothetical example of a patient who needs to have a root canal. This procedure can easily cost $1500, and if you have insurance that covers 50%, you pay $750. If by chance you need a second root canal in the same year, then you’ll soon hit your annual $1000 maximum, paying the additional $1250 out-of-pocket. This would bring your total out-of-pocket costs for the 2 procedures to $2000, while the insurer paid $1000. While better than no assistance, dental insurance in its current form can still allow for significant financial hardships.
There is no easy solution to these issues. Should dentistry join medicine as a specialty starting with training? Historically, there have been challenges with training dentists, which have forced dental schools, including Georgetown’s, to close.4,5 Thus, any thought of combining these fields is one filled with hurdles and should be a long-term discussion for health care professionals to undertake. However, there are more immediate solutions that can help. For now, we should insist that the government require dental coverage under medical health insurance. This is quite a lofty goal, but there are more manageable changes we should demand in the pursuit of that ultimate goal. We should ensure that, when dental is covered by public insurance programs, the dental coverage is competitive with private insurers so that dentists don’t refuse to treat those patients. We should also expand the ACA to cover dental care so that the more egregious insurance practices, including annual and lifetime limits, are barred from dental insurance. Overall, we need to seek solutions that will bridge the arbitrary gap between dental care and medical care to do what is best for the whole person. Cura personalis should guide us in this regard.