Each of the key national health proposals calls for expanding coverage of pediatric dental care, long a concern of children's health advocates.
"The silver lining of all this heated debate, for children at least, is that in almost every conversation, in every version of a bill, there's some provision for children's oral health," said Amir Moursi, chair of the department of pediatric dentistry at New York University's College of Dentistry.
Yet in a surprising twist, some insurance industry experts worry that the legislation may create unintended consequences and disruptions for adult and family dental coverage.
While he calls the children's benefit "an unbelievable mark of progress," Jeff Album, the vice president for public and government affairs for Delta Dental insurance company, fears that parents may drop their dental coverage since their children will already be covered. He also worries that proposals to tax high cost plans may cause some adults or employers to drop dental benefits.
Many dental experts say the proposed mandate for children's coverage addresses a serious need, one that gained national attention in 2007 when Deamonte Driver, a 12-year-old Maryland boy who lacked access to dental care, died after bacteria from an abscessed tooth spread to his brain. Currently, about twice as many children are without dental coverage as those without medical insurance.
Furthermore, pediatric dental issues represent children's most common unmet health care need, according to the Surgeon General's first report on oral health in 2000. It found that tooth decay is the single most common chronic childhood disease, five times more common than asthma and seven times more common than hay fever.
The report described dental disease as a "silent epidemic" that created significant social, financial and health burdens disproportionately affecting low-income, minority and rural populations.
Dental coverage lags for adults, too. Despite significant gains in the past 20 years, still 35 percent having no dental insurance. Adult coverage, however, is not mandated in the health overhaul proposals.
All the major bills in Congress require that pediatric dental care be included in the coverage guaranteed to anyone purchasing insurance through the government-sponsored marketplace for health plans, also called an insurance exchange or gateway. The House bill also calls for that benefit to be extended to the private market, including employer-provided plans, in five years.
One of the issues for legislators was what plans would be considered qualified to provide the children's pediatric dental benefit. Currently, 97 percent of dental coverage comes from stand-alone plans that are separate from medical health insurance.
Initially all the bills called for pediatric dental care to be handled by plans that also offer medical insurance. But the Senate Finance Committee's bill and the House bill have been amended to allow stand-alone dental insurance companies to provide that coverage. Dental insurance experts said, however, it is not clear if those amendments will survive in the full House and Senate.
Jim Crall, a professor of pediatric dentistry at the University of California at Los Angeles, said it is important to take into consideration how the dental industry works now so that changes can be implemented smoothly and not lead to problems for families that have dental insurance. "Otherwise," he said, "we're going to end up with a hollow promise."
For example, dental insurers are worried that if Congress goes forward with proposals to tax high-cost, or Cadillac, insurance plans, some of those plans may ditch their adult dental coverage to help keep the overall premiums below the tax threshold.
Also, Album said parents may be less likely to buy coverage for themselves if their children get dental benefits as part of comprehensive medical insurance package.
Still, some dental experts suggest that securing the pediatric benefit in the overhaul package should take priority over more narrow issues, such as the best means to provide the coverage, should be addressed later.
Burt Edelstein, the founding director of the Children's Dental Health Project, stressed that advocates should not focus on issues "that could in any way cause the dental benefit to be revisited" and stripped from the proposals.
Many of the current concerns are caused by the dental industry's unique history and structure.
Dentists are trained separately from doctors while dental insurance developed much later than medical insurance with a different set of diagnostic code, billing system and benefit structure. As such, dental contracts are generally created separately from medical ones and people often consider dental insurance to be more elective than medical, according to dental experts.
The Tragedy of Deamonte Driver
The case of Deamonte Driver, illustrates the medical dangers of untreated dental problems. Driver and his brother had erratic dental care because their Medicaid coverage would sometimes lapse and their mother had difficulty finding a dentist who would accept Medicaid payments.
Driver's death led to congressional hearings that showed how children face many difficulties in accessing care despite Medicaid's requirement that states provide pediatric dental services. It also helped prompt the inclusion of eight specific pediatric dental provisions in the law signed last February that reauthorizes the Children's Insurance Health Program (CHIP), which covers poor children whose family incomes are too great to qualify for Medicaid.
A Government Accountability Office report released last month found that barriers — including extensive bureaucracy, low dental reimbursement rates and shortages of dentists who will take Medicaid reimbursements — still exist.
Medicaid rates vary by state, but a 2008 study found that dental reimbursements are often 30 to 50 percent of the usual and customary fees charged locally. The dentists got paid as little as $15 to see a Medicaid patient. The study was published by the National Academy for State Health Policy.
Allen Finkelstein, chief dental officer at AmeriChoice, which provides both dental and medical care, considers Driver's death a wake-up call for policymakers to use a more holistic approach to health care.
"You really have to imbed dentistry with medicine," he said. "We have to change the way we think."