Why do I need separate dental insurance?
October 25, 2010 10:44 AM   Subscribe

Why did our (admittedly flawed) health insurance system develop in such a way that excludes dentistry from covered services?

Why do I have to have separate dental insurance? My teeth are just as much a part of my body as my lungs or my kidneys are. Why are dental services not covered by regular health insurance?

To be clear: I have dental "insurance" provided through my employer, the same way I get my health insurance, but it's a different policy/different terms/different plastic card.

I just don't understand why it's not all one thing.
posted by mccxxiii to Health & Fitness (28 answers total) 9 users marked this as a favorite
Dentists aren't doctors. They're a separate provider category; they're schooled and licensed separately, they keep separate practices, etc.
posted by ThePinkSuperhero at 10:58 AM on October 25, 2010

Yeah, but health insurance (often) covers services from psychologists, who are also schooled and licensed separately.
posted by bubukaba at 11:01 AM on October 25, 2010

Because dental insurance doesn't exist.

You just get a discount that's good for the first two fillings and a couple of cleanings a year.

That's pretty much why Flexible Spending Accounts were invented.

(Every time I need dental work done, I exhaust my "insurance" in the first visit or two. That's why I don't even call it insurance. It's totally just a discount.)
posted by phoebus at 11:02 AM on October 25, 2010 [1 favorite]

Partially because a lot of dental expenses go on things that are regular and predictable maintenance. It is ridiculous to have insurance to pay for regular teeth cleaning, because it is regular. It would be like insuring to cover your monthly rent. Also the majority of dental procedures are a lot less expensives than other medical procedures, yes there are exceptions, but most are pretty cheap.
posted by atrazine at 11:03 AM on October 25, 2010

Even fillings really, such a large majority of the adult population will need one or more fillings that it doesn't make sense to develop an actuarial insurance system for it.
posted by atrazine at 11:05 AM on October 25, 2010

Response by poster: Fair enough. But cardiologists aren't chiropractors, and both of *those* specialists get paid the same way through my insurance company. If Aetna can establish a billing-and-reimbursement process with both of those offices, why can't they with a dental practice?

Do the insurance companies reject the idea, or do the dental practices reject the idea?

How did we get where we are with that? I think I am actually asking a question about the history of healthcare policy, so let me hear from some wonks out there ... :)
posted by mccxxiii at 11:07 AM on October 25, 2010

phoebus is exactly correct: Dental insurance does not exist under the currently-accepted definitions of the word insurance, dental and exist. At best you get a stipend that can only be used to apply to certain percentages of certain procedures. Routine filling? 85% Routine filling with modern materials (i.e., not composite?) 65%. Cleaning? Free! Second cleaning in a year? Not free!

I believe the term for this is joke or racket or both.
posted by Civil_Disobedient at 11:09 AM on October 25, 2010 [1 favorite]

Best answer: The long answer to this involves the separate evolution of dental practice from medicine, from the earliest days of barber-surgeon-dentists and itinerant tooth-drawers.

Medicine has always looked askance at dentistry as its less-reputable cousin. Dental practitioners have been associated with shady, lower-class forms of charlatanism for at least 500 years.

(It's also worth noting that surgeons used to have this image problem, too. The doctor was the sophisticated, educated guy who made the diagnosis; then he hired the surgeon, a blue-collar "mechanical" practitioner, to actual do the operations, and, conveniently, take the blame if/when the patient died).

At such time as dentistry endeavored to become a respectable profession (in Europe around the 17th Century), it had to do so from within. Individual dentists wrote treatises and textbooks; they trained apprentices; invented and made their own instruments and enlisted help from craftspeople like metallurgists, jewelers and ivory workers. Slowly but surely, dentistry evolved in parallel with medicine.

Even so, medicine never wanted to absorb dentistry, nor did dentistry desire to be overtaken by the medical establishment. Something of a respectful distance has been maintained between the two professions ever since. It's only been in very recent years that university medical schools have begun to partly subsume the dental schools into "medical" education; this has more to do with administrative consolidation than a true adoption of dentistry by the medical profession.

The division between medical and dental insurances is just another reflection of this very long and strained relationship.
posted by overeducated_alligator at 11:18 AM on October 25, 2010 [9 favorites]

phoebus wrote: "Because dental insurance doesn't exist."

That's simply not true. When I had dental insurance, it paid for 100% of scheduled cleanings and intake fees, 80% of most procedures, and 50% on crowns and other prostheses. In combination with the lower negotiated fees, it saved me a crap ton of money, even though it had something like a $2500 or $3500 a year payout limit.

I presume they pay for the regular cleanings so that they don't have to pay for more expensive stuff down the road, same as how most health insurance pays 100% for yearly checkups and gyno exams for women. As for why it's a completely separate thing, I can't say.

Ironically, I have yet to have a medical procedure that cost even half of what some of my dental procedures have cost me. Abscess draining: $350 — Root canal by endodontist: $800 — Crown for that tooth: $600 — Surgical extraction of two wisdom teeth: $900 (at least I got some fun "twilight" anaesthesia, which I have a vague memory of)

Granted, a regular filling is only like $125, but that's more equivalent to a simple office visit with an MD. Takes about the same time, anyway.
posted by wierdo at 11:20 AM on October 25, 2010 [1 favorite]

Best answer: Chiropractors are health practitioners covered by health insurance because of Wilk v. Am. Medical Ass'n, 895 F.2d. 252 (7th Cir. 1990), which held that the AMA excluding chiropractic from the definition of medicine and prohibiting licensed physicians from doing business with them constituted a restraint of trade in violation of federal antitrust laws. Before that, the AMA classified them as quacks and considered dealings with them to be breaches of professional ethics. Once that classification was removed, there was sufficient demand by consumers of chiropractic care to get it covered by health insurance.

The reason dental insurance doesn't exist in the same way as health insurance is basically because there isn't really demand for dental insurance, largely for the reasons described above, i.e. most people need dentists on some basic level, but the need for physicians is so much greater that there isn't the same systemic demand for dental work as there is for the rest of it.

Also, dentists aren't stupid: health insurance pays pennies on the dollar, depending on the nature of the care provided and the insurer paying the bill. Hospitals and doctors can generally expect to recover somewhere between 10% and 40% of what they actually bill. That, to put it mildly, is no way to run a business. So dentists haven't been very quick to get themselves on that train.
posted by valkyryn at 11:23 AM on October 25, 2010

In terms of the history though, overeducated_alligator nails it: the two professions grew up independently and established independent professional organizations, though there is some recent move towards bringing dentistry under the traditional physicians' umbrella.
posted by valkyryn at 11:25 AM on October 25, 2010

The only slightly snarky answer is "because dentists, viewed collectively, are bastards."*

The slightly less flaggable version is that dentistry is a distinct profession with a distinct guild culture that has consistently rejected attempts to be drawn under the umbrella of general health insurance or universal provision. This even extends to the NHS in Britain, where the governing body for dentistry negotiated a separate deal in the 1940s, and where in certain parts of the country, it's now extremely difficult to find a dentist who takes on NHS patients.

Dentistry also has an identity problem, especially in the US, where there's a core oral health element, but also a large and hugely profitable cosmetic element more closely bound up to the core business than, say, cosmetic surgery to general practice.

There's also a structural difference in the way dentistry functions: as this brief assessement of the American system notes, an medical industry composed of "bungalow solo private practices in the nation's suburbs" is not set up for wider goals of improving oral health. It's also not set up ideally for an insurance-based system.

* A pop culture anecdote: Barry, Rachel's ex in Friends, is an orthodontist, as opposed to a neurologist or some other medical specialist. Making him a dental professional is a shorthand to shape his character.
posted by holgate at 11:31 AM on October 25, 2010

As a data point: in the Netherlands we have sort-of universal health care (we have mandatory health insurance), but dental care is exempt as well. You have to buy dental insurance seperately and it is relatively expensive and often even impossible to get insurance that covers the expensive things (most insurance companies have a cap of about 2000 euro's for even the most expensive policy which requires a dental exam that says there are no pre-existing conditions, which means that if you need more than one crown or for example have periodontitis you are out of luck). I know that people say that dental care is less expensive than, say, cancer treatment, but it is not that hard at all to have treatments cost thousands of euro's and that is still a lot of money for most people.

This was not always the case. When I was a child dental care was covered under the general universal health care program, provided that you went to the dentist every six months. So at least here there are no historical reasons. Also, like you said: other disciplines like psychologists ARE covered by insurance and they are possibly even more distinct from medical health than dentistry.

I get some of the arguments that are mentioned here, but at the same time, it is weird to me that a broken tooth is not insured, whereas a broken toe is. Both are not all that expensive, both are somewhat equally (un)preventable.

The argument that I sometimes here is that teeth aren't that important. You can just extract a teeth for very little money. I think that there is more and more evidence that dental health is important for general health so perhaps the thinking about this may change. I often hear from dentists that so many dental problems are preventable and that that is a reason against universal coverage, but I think the same goes for many general health topics as well and they are still covered by insurance.
posted by davar at 11:34 AM on October 25, 2010

That's simply not true. When I had dental insurance, it paid for 100% of scheduled cleanings and intake fees, 80% of most procedures, and 50% on crowns and other prostheses. In combination with the lower negotiated fees, it saved me a crap ton of money, even though it had something like a $2500 or $3500 a year payout limit.

The confusion arises because of the byzantine American healthcare system which means that even the cash price of "insured" and "un-insured" procedures are different. It may be called Insurance, but it's really more of a co-operative with negotiating power. The reason that it isn't properly described as "insurance" (At least when it comes to dental cleanings) is that these are scheduled procedures. There is no point pooling risk when the outcome (everyone has a dental cleaning a year) is known in advance. When it comes to crowns it's a little more complicated because the schedule on which people will require them is not predetermined.

Basically, anything that is scheduled and covered by an insurance provider is not actually "insured", even if the insurance plan covers it.
The comparison is with insurance for cars, accidents are covered, oil changes are not. Except that some insurance plans might offer free oil changes at partnered dealerships (with complex kickback deals on the back-end).
posted by atrazine at 11:37 AM on October 25, 2010

My dentist doesn't accept dental insurance. Which is fine with me because I don't have dental insurance. He told me it is because a) he would have to hire someone to deal with all the paperwork and b) he would be forced to take more patients than he wants.
posted by interplanetjanet at 11:38 AM on October 25, 2010

Post-non-preview, overeducated_alligator's summary is excellent. And in fairness to non-bastard dentists, the profession's decisions over the past 70 years have reflected a rational self-interest, particularly in the American context of fragmented and insufficient provision. If the people for whom the basic oral health aspect of dentistry matters most aren't likely to walk through your door anyway, because the up-front costs remain prohibitive, then you build your industry with the patient/customer base you have.
posted by holgate at 11:44 AM on October 25, 2010

This isn't exactly what you asked, but it is likely that your regular health insurance covers dental services resulting from accidental injury. That is, if I get in an accident and my teeth get knocked out, my health insurance pays for restorative services.
posted by massysett at 11:44 AM on October 25, 2010

Here's a reason that relates to why we have insurance for anything. Insurance is a way to pay for unexpected, catastrophic expenses. You insure your house against fire, your stuff against burglars, your car against accidents and liability to others. And you have medical insurance because you could potentially get hit with something that costs tens or hundreds of thousands of dollars. You have auto expenses against unexpected catastrophic costs; you can't buy insurance to cover automobile maintenance and normal repairs. Dental expenses are more like auto repair costs than like auto wreck costs.

If medical care had no more upside expense risk than dental care, nobody would sell it and nobody would need it. You might have medical savings accounts to even out the cash outflows, but you would not have insurance (and coverage, rather than insurance, could still be a job benefit just like, say, free parking). Dental care is really 90 percent prevention and maintenance, plus the occasional hit for services that max out at a few grand. In the scheme of things, until recently it has not been seen as a risk worth insuring against, because at the time when medical insurance was becoming the norm with large employers post WWII, putting virtually every kid through orthodontics was not the norm, and having the occasional filling or crown done was not all that costly. Insuring against those minor costs didn't occur to anyone. Since then, however, there's been a steady upward creep in the value and acquisition cost of a nice smile, along with considerable inflation in the cost of dental services and the fanciness of their equipment, so as a result, there's a bit more demand for dental coverage these days. The quandary for employers is that buying it for everyone is pretty expensive, and offering it as an option with a stiff co-pay means that only those with bad teeth sign up, which doesn't work well as an insurance risk proposition.
posted by beagle at 12:13 PM on October 25, 2010 [2 favorites]

Dentistry also has an identity problem, especially in the US, where there's a core oral health element, but also a large and hugely profitable cosmetic element more closely bound up to the core business than, say, cosmetic surgery to general practice.

In fairness, this is not completely excluded from some practices under the medical side of the aisle. More often than not a dermatologist's office is going to be shilling some or a lot of various product. While some of it may be things like sunscreen which are in the health interest of the patient, often they're just highly overpriced versions of the same thing you can get over the counter.

Anyone who does cosmetic surgery is somewhat similar; deviated septums are medical. New boobs (usually) are not. The mix of insurance-covered medical necessities alongside vanity products with higher profit margins is a growing trend; it's not the purview of the dentist anymore.

My point doesn't address the why - others have done that - but I think it does indicate that this separation shouldn't continue. I don't know what regulatory hurdles need to be overcome but I wonder if the health care legislation won't provide an impetus to see these merge.
posted by phearlez at 12:18 PM on October 25, 2010

(make that "you have auto insurance against unexpected..." in my first paragraph.)
posted by beagle at 12:44 PM on October 25, 2010

Best answer: Hi, health policy wonk here! Looking at the origins of health insurance in the United States goes a long way towards explaining why dental benefits aren't typically covered in health plans (nor, for that matter, are vision benefits). So, here's a (somewhat short!) history of health insurance in the U.S.:

In 1929, Baylor University Hospital began offering teachers in the Dallas area up to 21 days of hospital care for $6 per person. Other hospitals--many of which were facing slumping revenue in the face of the Depression--followed suit in offering "pre-paid" hospital benefits, and in this way the Blue Cross plans were born. Note that these plans only covered the costs of hospitalization, and not the cost of the doctor who would come to visit you in the hospital. Ten years later, a few state medical societies (California and Michigan being the first) bucked the national AMA--which opposed any form of pre-paid health benefits as a threat to the income of physicians--and formed pre-paid medical plans, which became the Blue Shield plans. These medical plans paid for the costs of visiting a doctor, but not the cost of hospital care. Thus, from the very beginning hospital plans and medical plans were separate products, and nothing else was covered. (This worked okay, though, because there was barely anything else available in terms of medical care--no fancy biologic drugs, no ambulatory surgical centers, no rehabilitation centers to mend broken hips--just hospitals and individual doctors.)

In the days before WWII, less than one-fifth of the population had either hospital insurance or medical insurance. In the period at the end of the war and immediately afterwards, unions and employers began using hospital and medical plans as a fringe benefit as a way to get around pay caps imposed by the war effort, and as a way to avoid payroll taxes. At this point, the percentage of the population covered by one or the other type of plan increased to over 60%, and commercial indemnity insurers began to get into the game. However, commercial insurers still offered hospital benefits and medical benefits as separate things, and a union or employer had the option of selecting one or the other or both. Lots of people were covered only by hospital plans, and had to continue to pay out-of-pocket for doctor's bills. However, as more and more people were covered by both hospital and medical plans, often invisibly through their union's or employer's HR bargaining and bundling, it became an expected standard for "health insurance" to cover both hospital and medical/doctor benefits. The Blue Cross and Blue Shield plans in many states merged, commercial indemnity insurers offered plans that covered both, and we start to get close to modern insurance; the rise of PPOs, HMOs, and "managed care" in the 1980s completed the transition.

You can see the effect of this traditional split betwen hospital and medical insurance even today. Note that Medicare--the federal program offering health benefits to those over 65 or who are permanently disabled--has hospital insurance (Part A, which eligible people are automatically enrolled into and for which no premiums are due) and medical/doctor insurance (Part B, which is optional for eligible people and requires the payment of a monthly premium). Up until fairly recently it was not uncommon for "health insurance" to include only hospital and medical benefits, but no prescription drug coverage; as medicine has shifted towards treating more and more chronic diseases through pharmacological methods, a prescription drug benefit has become an expected part of a health insurance plan, and the public programs followed, with Medicare starting to offer an optional, premium-based prescription drug benefit (Part D) only in 2003.

Dental benefits (and vision benefits) are not yet covered by "comprehensive" health insurance plans because there isn't an expectation among employees or people buying insurance on the private market that this would be included. Looking at how prescription drugs went from being a "frills" sort of benefit to a core health insurance benefit is instructive; it wasn't until we had pharmacological treatments as the first-line treatment for a lot of common chronic illnesses like diabetes and high blood pressure and heart attacks that it became an expected benefit. I'm skeptical that we'll see that happen for dentistry, for all the reasons that people note above, but you never know.

If you're interested in the history of health care and health insurance in the United States, I can't recommend Paul Starr's The Social Transformation of American Medicine highly enough. Much of my answer above is cribbed from that book, which is the definitive history of how we got where we are today (or at least through 1982).
posted by iminurmefi at 12:49 PM on October 25, 2010 [19 favorites]

beagle has it right. medical insurance is, at root, about risk spreading. dental insurance is, at root, about cost spreading. the acceptability of cost-spreading as a legitimate purpose of insurance is a relatively recent phenomenon.
posted by thesmophoron at 12:56 PM on October 25, 2010 [1 favorite]

Response by poster: +eleventy-million for iminurmefi!!

and bonus points for explaining the origins of Blue Cross/Blue Shield, which is something else I've always wondered about.
posted by mccxxiii at 1:01 PM on October 25, 2010

More often than not a dermatologist's office is going to be shilling some or a lot of various product.

I was actually going to mention dermatology, but deleted it, thinking that I'd cast aspersions at enough parts of the medical profession for one post. [checks vital signs]

iminurmefi's post is excellent, but as davar notes upthread, the separate status of dental and optical coverage isn't confined to the US, with its idiosyncratic history of health provision and funding: even France's top-rated universal system reflects this, as la S├ęcu offers very limited dental coverage to working adults, while complementary insurance through a mutuelle comes with fairly low reimbursement caps.
posted by holgate at 1:27 PM on October 25, 2010

That's simply not true. When I had dental insurance [...] even though it had something like a $2500 or $3500 a year payout limit.

There's the rub. I have never seen dental "insurance" without a ludicrously-low payout cap. I challenge anyone in the U.S. to show me a plan that doesn't have one.
posted by Civil_Disobedient at 2:27 PM on October 25, 2010

atrazine wrote: "The confusion arises because of the byzantine American healthcare system which means that even the cash price of "insured" and "un-insured" procedures are different."

No, what I had really was insurance, with detailed explanations of benefits and the whole 9 yards. They had a negotiated rate, like health insurers, that they would pay their part of, just like health insurance. For example, a one surface filling at my dentist is around $125. The negotiated rate my insurer had with my dentist was $78 and change for that particular service. I'd pay around $16 out of pocket for said service, while the insurance would pay for the other $62.

The total cost of the plan between the employer and employee paid portions was around $750 a year, as I recall. (as opposed to the health plan, which was around $12000 a year for an employee and spouse) So yeah, it's insurance and was regulated as such. They get away with the low caps because anything caused by traumatic injury will be covered by one's health insurance. (which may end up getting the money from someone else's insurer, if it was someone else's fault)

I'm aware of the "this is not insurance" dental "plans" that are just negotiated discounts off rack rate, but that's not what I'm talking about.
posted by wierdo at 2:46 PM on October 25, 2010

For example, a one surface filling at my dentist is around $125.

It must be really sweet to live in a part of the country where a filling costs $125. The last time I got a one surface filling at a dentist, it was $325. A cleaning at most dentists I shopped at around where I live and worked was upwards of $200 by itself. With the insurance cap of $1500 that most of us get, any work at all, crowns, multiple fillings, eat that $1500 really quickly.

Maybe you live in a state that regulates dental insurance like health insurance. Lucky you. I live in the San Francisco Bay Area. Things are really expensive here, so that "insurance" is pretty much just a discount. That's why most of us pay for flexible spending accounts. Because I'm not canceling my trip to Yellowstone this year because Dr. Yachtsman found a gum-line cavity.
posted by phoebus at 12:40 AM on October 26, 2010

phoebus, in exchange for your extra money, you get to not live in wehategovernmentville. But yeah, if you're paying $1500 a year for a plan with a yearly benefit cap of $1500, that's not insurance.
posted by wierdo at 6:02 AM on October 26, 2010

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