The thing about dental insurance is that it isn’t really insurance — it’s more like a half-helpful discount plan with a maximum. And once you reach the maximum, you’re on your own, often to the tune of hundreds and thousands of dollars. As though going to the dentist needed to be less fun.

In the realm of all things health care, dental exists as a sort of overlooked stepchild. The American medical system doesn’t really consider dental care an essential service, despite mounds of evidence linking a healthy mouth to the well-being of the rest of the body, from better pregnancy outcomes to a healthier heart. Dentistry has always been siloed off.

Dental coverage has been off in its little — largely unregulated — corner, too. According to the American Dental Association, one-third of adults aged 19 to 64 don’t have any benefits at all. (For comparison, just 8.4 percent of Americans lack health insurance.) Many patients put off dental care and cite cost as the main reason they don’t go to the dentist — including those who are insured.

Even if you do have dental benefits, they’re often less than beneficial. Insurers may cover 100 percent of a cleaning or a checkup, but once you get into other more complicated services, they start to cover less, so patients have to pick up some or much of the cost. Plans have annual maximums ranging between, say, $1,000 to $2,000, after which the insurance covers nothing.

“When you look at the dental insurance model, it doesn’t protect the patient from financial risk. It’s the opposite,” said Marko Vujicic, chief economist and vice president of the Health Policy Institute at the American Dental Association. “Once the benefit runs out, the $1,400 or whatever it is, all of that financial burden is on the patient. So it protects the insurer, they’re limited on their exposure.”

Imagine being told your health insurer will only pay for 50 percent of your heart bypass surgery, and that it only covers $10,000 of all your health services each year. That would be considered unacceptable in this day and age. But that’s what would happen if I needed a crown — my insurance covers half, and it only pays out $1,500 total all year. My dentist screwed up on a filling last year. It didn’t take long before I hit my limit.

None of this is to say you should nix dental insurance and just go it alone. Insurers are often able to get patients better prices for services than patients would get on their own, and a $1,500 help on dental costs isn’t nothing. It’s just hard not to look at the landscape and wonder whether it can’t be better.

Your mouth is definitely part of your body, and yet that’s not how America treats it

To back up a bit and then some, dentistry was for centuries performed by barber surgeons, which is pretty much what it sounds like — the guy who cut your hair also pulled your rotten tooth (and did a lot of procedures you’d probably prefer your hairdresser not get into anymore). Dentistry wasn’t recognized during the establishment of medical schools in the US in the 1700s and 1800s. Eventually, the country’s first dental school was founded in 1840.

“From the beginning of the modern era, there has been debate about dentistry’s proper place in the wider health system, but what has evolved is clear: Dental education, regulation, and practice are isolated from the rest of health care,” wrote Elizabeth Mertz, associate director of research at Healthforce Center at the University of California, San Francisco, in a 2016 paper on the dental-medical divide.

In the 1960s and 1970s, she notes, consumers largely paid their own dental costs, while most of the public had some sort of hospital or surgical insurance for medical care. A prepaid dental plan should incentivize dental visits, since it at least covers some of the costs. But it became a valid business model for insurers only after they realized that not everyone would take advantage of the benefit — people and employers would pay for the insurance but not necessarily go.

So today, America’s got a system where we separate out dental care into its own separate little realm. We then do the same with dental insurance and treat it like it serves a different purpose.

“Medical is structured to help you most when you’re sickest,” said Michael Adelberg, executive director of the National Association of Dental Plans, a trade group representing dental insurers. “Dental insurance is focused more on preventative care and helping people — many of whom are not naturally inclined to go to the dentist — get to the dentist by being most generous on preventative care and regular checkups.” Even though, again, having dental insurance doesn’t always equate to taking those biannual recommended trips to the dentist.

Medicaid and Medicare, designed in the 1960s, excluded dental services from coverage and continue to do so.

Dental isn’t included in regular Medicare, except for in specific circumstances where it’s considered part of some other medical procedure (like certain cardiac or organ transplant procedures). While 90 percent of Medicare Advantage plans offer some sort of dental coverage, the quality of that coverage can vary greatly. Patients often don’t realize the limitations on those add-on plans when signing up, so they think they’ve signed up for a robust service and ultimately all they’ve got covered are cleanings. “You have to read the fine print of the plan,” said Michelle Rosenberg, director of the Government Accountability Office’s health care team.

States are required to cover dental for all children in Medicaid. Most states offer at least emergency dental services for adults, but many don’t offer much beyond that. The Affordable Care Act declared pediatric dental care an essential health benefit (though it’s a little complicated, depending on the state), but it didn’t do much for adults. Untreated dental issues can result in some scary negative consequences, including gum disease and undiagnosed oral cancers.

Because dentistry isn’t governed as an essential service, there are a bunch of patient protection regulations that don’t apply, Vujicic explained. “Under the Affordable Care Act, we protected consumers from health care costs, we said you can’t be denied care because of pre-existing conditions, there’s a limit to how much a family is going to pay out of pocket each year for their medical care, it doesn’t matter how sick you get,” he said. “All of those things don’t apply in the dental world, because it’s not regulated as a core service. So we have a little bit of a Wild West when it comes to what type of insurance is out there.”

There are no heroes here, nor are there clear-cut villains

Study after study shows Americans with and without insurance forgo dental visits and treatments because it’s so expensive. That decision can wind up being even more costly — hundreds of thousands of people land in the ER each year because of often preventable dental conditions, costing, by one estimate, $2 billion.

There’s plenty of evidence that moving away from the status quo on dentistry and dental benefits would be a positive development for patients. One study found that low-income people who gained access to dental coverage through Medicaid did start to go to the dentist more. Another found that embedding dental coverage in medical plans (in this specific case for children) reduced costs for beneficiaries.

So what’s stopping change? There’s not a lot of political energy around addressing dental benefits, and when there is, there’s plenty of resistance among those who prefer the status quo.

“Organized dentistry itself has actively and expensively campaigned to keep things the way they are,” said Lisa Simon, a dentist and physician at Brigham and Women’s Hospital and Harvard Medical School. “There have been plenty of opportunities for dental insurance to be, more recently, integrated into Medicare and Medicaid in various ways, and those who have been vociferously opposed by many dentists.” Simon noted that many dentists still work in private practice with their own offices and tend to accept public insurance at low rates, if at all. “[They] tend to be very reactionary in any attempts to update the insurance industry,” she added.

In 2021, the ADA fought against a proposal from Democrats to provide dental coverage for all Medicare recipients under President Joe Biden’s Build Back Better agenda, arguing the focus should be on low-income seniors, not everyone.

“As an association, we’re not against it, it’s a question of how it’s structured,” said Mark A. Vitale, dentist based in New Jersey and the former chair of the council of government affairs at the American Dental Association. He said introducing dental benefits for everyone over 65 could be “cost prohibitive” for the federal government and noted that there are structural differences between the Medicare system and dentistry. “We use different codes, different qualifiers, different types of fee schedules.”

“The [ADA] is a trade group that defends the interests of its members who are private practice dentists who have done very well under the current system and have perceptions that Medicare may increase their administrative burden or provide lower reimbursement that they’re not interested in participating in,” Simon said.

The White House eventually dropped the plan as part of a broader decision to pare back the package.

The dental insurance industry is lightly regulated and on many measures would like things to remain that way. One recent battle has been over medical loss ratios (MLR), which measures how much of the revenue insurers get from premiums goes toward medical claims and improving care quality compared to, for example, administrative fees. The ACA required health insurers to keep their MLR to 80/20, but it didn’t touch dental.

In 2022, voters in Massachusetts said yes on a ballot initiative that would make dental insurers spend at least 83 percent of premiums on caring for and improving care for patients. Dentists are keen on MLR rules. Dental insurers and the NADP, which represents them, not so much. They argue low-premium products like dental insurance naturally have a higher percentage of their operating costs eaten up by costs that are fixed. “My industry views the application of a medical-level medical loss ratio on any low-premium products, without considering the fundamental economic differences of medical and dental, as just kind of silly,” Adelberg said.

One common theme here is that all parties involved would like more money in their pockets.

Some dentists also note that insurance maximums haven’t gone up in recent decades, even though the price of dentistry has. “Forty years ago, $1,500 bought you a lot of dentistry,” said Vitale. “Today, $1,500 doesn’t buy you a lot of dentistry. My question to the insurance carrier is why haven’t you increased the benefit level?”

The result of all of this is that going to the dentist — and paying for it — can be really hard to navigate

When people are picking out dental insurance plans, what they need to understand, really, is that it’s not insurance. Richard Manski, chair of dental public health at the University of Maryland’s School of Dentistry, said to think of it more like Amazon Prime — you hand the company money, and in return they go out into the marketplace, find sellers (in this case, providers), and try to get you deals that are better than what you would get in your own. “When you buy dental insurance, and you buy the kind of dental insurance where the dentist is part of a network, that means the dentist has agreed to a set pricing for all these procedures,” he said. “So even if the insurance company didn’t pay a dime for anything, you’re already getting back a really valuable service, which means you don’t have to negotiate with the dentist.”

Indeed, if you’ve got a painful tooth infection or something, you’re probably not in the position to talk discounts with the doc.

There are ways to strategize around dental care and insurance. If a patient hits their annual max, they can consider moving certain procedures to the following year. People can also try to decipher ahead of time whether dental insurance is even worth having. Say someone’s never had a cavity, just goes twice a year for a cleaning and checkup — the cost of that might be less than the insurance premium. Or maybe the insurance they’re offered doesn’t pay much or anything on more complex issues, anyway.

“I give talks on why you don’t need dental insurance to go to the dentist,” Vitale said. “Offices today will have office loyalty plans, they’ll have various financing modalities available.” He also noted people can try to negotiate discounts with their dentists, which, as mentioned, your mileage may vary on that one.

This scenario where people are supposed to try to anticipate what sort of care they’ll need and essentially hope it isn’t too much is far from ideal. It’s not realistic to expect people to try to do their own health care math, said Simon, “because it requires a level of such sophistication in terms of understanding health care pricing, health care access, and all these other things, which makes it super inequitable.” If English is someone’s second language, or they’re working multiple jobs, or the bus ride to the dentist is really long, deciphering the basics of insurance and whether it’s worth the financial burden is even harder to do. “That’s why one of the things that is so bad about the way our dental ‘insurance system’ works is that it’s really unjust for most people,” Simon said. “For anyone, but it works the worst for the people who need the most help.”

It’s worth noting that patients can also have a hard time deciphering what procedures they really even need at the dentist — some offices recommend the basics, it can feel like others suggest doing everything under the sun. (The Invisalign push at some dentists is real.) “The consumer has an obligation to press their provider and say to them, ‘Is this necessary?’” Manski said. “Patients should be much more involved in their caretaking decisions.”

Of course, all of this is easier said than done. Most people don’t have the time or energy to be gaming out their dental care or dental insurance, nor should they. From a patient perspective, it’s not hard to look at this and wonder whether there isn’t a better way to approach oral health in America than the way we do now. The thing is, a lot of that would require legislation and a different regulatory framework.

That might mean congressional action to expand dental coverage in Medicare and Medicaid. It’s something the dental community would likely resist, though Manski said he believes there’s some sort of deal both sides can probably “live with.” One could also envision ACA-like requirements that, for example, get rid of maximums on dental insurance and protect consumers from high costs. Dental, perhaps one day, could be covered as part of everyday medical insurance — once the country stops treating people’s teeth like some separate bodily entity.