Non-grandfathered plans for individuals and small employer groups with 100 or fewer employees have to provide essential health benefits, but larger employer groups do not, Graziano explains. However, if larger groups choose to provide such benefits, they cannot impose annual and lifetime dollar limits. 

“Adults could be the losers,” Graziano says. “Large group health plans don't have to provide essential health benefits, but if they do, they have to follow the rules. Therefore, the thought is that if it costs you to follow the rules in some places, you might pull back benefits to cut costs in places where you don't have to follow any rules—and in this case, that might mean eliminating or cutting back adult dental benefits.”

Moreover, if medical carriers also offer pediatric oral health coverage, small employers don't have to have other dental coverage that would cover adults, Graziano says. For large employer groups, the Affordable Care Act doesn't apply at all to dental and vision benefits if the benefits come from a separate insured policy. If dental is self-insured, it also doesn't apply if it's a separate election.

“My hunch is that a lot of employers are not going to be subject to the Affordable Care Act because in the traditional way health benefit plans are constructed, there is usually a separate election for a dental plan,” he says. “Some employers may reduce their dental and vision benefits, or shift them to voluntary benefits, in response to escalating plan costs. I am one of those people who do not believe that they will drop health care coverage altogether and force all of their employees over to the new exchanges. There is still too much competition for skilled employees.”

However, employees might decide to opt out of a dental plan for themselves, to afford a dental plan for their children, says Chris Pyle, spokesman for the Delta Dental Plans Association in Oak Brook, Ill.

“A small business may offer dental through a stand-alone carrier, but after reform is implemented and the small business decides they are going to continue to offer medical coverage outside of the exchange in the private market, the medical carrier that is going to provide coverage is going to have to include pediatric oral benefits as part of the package,” Pyle says. “So that means an employee would have duplicative coverage, and they just might drop the coverage for themselves and keep the coverage for their children, to save money.”

No fix in sight

Indeed, the National Association of Dental Plans estimates that up to 11 million Americans may drop dental coverage when their children are removed from their dental polices.

The trade group, as well as other groups such as the National Association of Insurance Commissioners, has been lobbying the U.S. Department of Health and Human Services to reinsert the ability of dental plans outside the exchanges to be able to cover the mandated pediatric oral care. Senator Debbie Stabenow (D-Mich.) had sponsored an amendment in the legislation to allow carriers both inside and outside the exchanges to satisfy the mandate. However, by the time the law was enacted, the outside exchange language was omitted.

“We've been working with HHS to make changes, as we believe they have the regulatory authority to do that, and they are still trying to decide if they do have that kind of authority,” Pyle says. “If HHS or the administration does not remedy this problem, we will have to look for other means of protecting the insurance market and ensuring that people who like their current coverage are able to keep it. Pursuing a legislative fix is certainly an option. Time is running out, though, so these fixes need to happen very soon.”

Meanwhile, there is still a great need for charitable oral health services, says Nicole Lamoureux, executive director for the National Association of Free and Charitable Clinics in Alexandria, Va.

“In fact, many are surprised to hear that even after full implementation of the ACA, there may be as many as 26 million people who are still without access to health insurance,” Lamoureux says. “Outrageously, many public insurance plans barely cover dental benefits and in 22 states, individuals with Medicaid have no dental coverage or may only have it available in emergency situations.”

Across the country, free and charitable clinics and other members of the safety net are providing access to much needed dental care for free or at a dramatically low cost, she says. Many such clinics that provide dental care have a waiting list because the demand for dental care is so high. Across the country, NAFC clinics have seen a 20 percent decrease in donations and a 40 percent increase in patient demand for services.

“While the Affordable Care Act is a first step toward access to health care for some, it is not a complete solution for primary care—with respect to dental care, it leaves great holes in care,” Lamoureux says. “Until effective reforms can be implemented, there are people in communities throughout this nation who are standing in the gap every day and filling the need as best they can. They are the men and women who provide their services at more than 1,200 free and charitable clinics across the country, as well as at other safety-net health care providers.”

Delta Dental Plans Association as well as its individual member companies financially support many nonprofit charitable oral health service providers, including Mission of Mercy, Pyle says.

Delta Dental recently purchased and gave Mission of Mercy an 18-wheel truck refurbished with medical equipment, to transport to dental care events around the country in local convention centers or other large arenas, he says.

“These events provide free dental services for whoever shows up and they typically draw about 2,000 people over two days,” Pyle says. “People will spend the night on the street in the cold and heat, to camp out in order to get out of pain.”

A need for more dentists

Moreover, there are a lot of areas in the country, federally designated as “health professional shortage areas,” that still do not have enough dentists to treat all of the people who reside there, he says. According to a June 2012 report by the Kaiser Family Foundation, more than 44 million Americans live in such areas.

Delta Dental is trying to attract dentists to those areas by offering incentives, such as helping to repay their student loans. For every year a dentist practices in an underserved area, Delta Dental provides a lump sum of money to help repay school loans.

“Sometimes they then choose to stay in those areas, because they learn to love the place and this helps them establish a practice,” Pyle says. “It's a very important service and it's helping to meet a significant need.”

While health reform mandates dental insurance for children either through employer plans or subsidies for parents to buy insurance, not all parents will take advantage of the benefits—without active encouragement, says Terry Dickinson, a Richmond, Va.-based dentist who also is executive director of the Virginia Dental Association.

“These folks simply don't have the necessary information to make better choices about what they eat or drink, how to properly clean their child's teeth and how to access and navigate the dental care system,” Dickinson says. “But the decisions on food and drink are also contingent on a lot of other factors. Some of these families have to make decisions about where the next meal is going to come from, the next tank of gas or the next pair of shoes. One significant negative financial event could put them in a desperate economic situation. So dentistry is pretty far down the list for them.”

To mitigate for these issues, the Virginia Dental Association, the state's Department of Medicaid Assistance Services and other stakeholder groups developed a program, Smiles for Children, for children of Medicaid receipts. Medicaid medical providers apply oral fluoride varnishes to these children during mandated well-baby visits, teach the parents about proper care of the teeth and gums and discuss dietary issues that would increase the risk of dental disease at an early age.  

“We've seen a dramatic increase in Virginia over the last few years of kids involved in this program,” Dickinson says. “The ultimate payoff comes in having healthier children at a lower risk of dental disease and a parent that is better educated in prevention of dental disease.” 

Katie Kuehner-Hebert is a freelance writer in Running Springs, Calif.