Obamacare Dental Reversal Pits Insurers Against Consumer Groups

The Trump administration’s proposal to block states from establishing adult dental services as an essential health benefit under the Affordable Care Act is prompting support from insurers and pushback from public interest groups.

The Centers for Medicare & Medicaid Services originally prohibited routine adult dental care from being labeled an essential benefit under the ACA, because dental plans are typically offered as an additional standalone benefit. But the CMS dropped the prohibition in 2024, allowing states to include adult dental care for plans beginning in 2027.

The agency is now considering removing it again under a proposed rule released last month. Insurers celebrated the move, saying it will help lower premiums. But public health groups point to the fact that more than one-quarter of Americans don’t have dental care, and argue standalone plans lack additional protections offered for essential benefits—such as cost-sharing caps.

“There’s a very real affordability impact for people who have coverage that is compliant with the essential health benefits requirements,” said Colin Reusch, director of policy at health advocacy group Community Catalyst.

Public health groups celebrated when the Biden administration removed the prohibition. Oral health is increasingly linked to other chronic conditions, with studies indicating that some bacteria found in the mouth can lead to higher risk for Alzheimer’s disease. People with diabetes also have higher risk of gum disease.

“What every study after study had demonstrated was finally being incorporated into policy and reflecting what medical professionals across the board already knew,” said Yehuda Sugarman, director of government affairs for the International Association for Dental Research.

Dental care has long been considered an ancillary benefit, although coverage has increased in recent years. Thirty-six states now offer exchange plans that include dental benefits, according to the American Dental Association.

Comprehensive data are limited, but dental coverage remains much lower than medical enrollment overall. Numbers show that 2.5 million people were enrolled in standalone dental plans in 2024, according to Georgetown University’s Center on Health Insurance Reforms, compared to 21.4 million people with medical plans. Those numbers exclude enrollees in medical plans that include dental, however.

No states had applied to incorporate dental in their essential benefits, but several had started to consider it, said JoAnn Volk, founder of Georgetown’s CHIR.

“Certainly there was interest in at least having the option of doing this,” she said.

Insurer Opposition

The dental insurance industry—which largely offers standalone plans—roundly supported the Trump administration’s proposed reversal.

The ACA requires exchange insurers to cover pediatric dental but—unless a state requires—it doesn’t have to be embedded in the medical plan if standalone options exist. Delta Dental Plans Association wrote that the current regulation “misaligns the delivery of pediatric and adult dental services, which will cause confusion to consumers and providers.”

Blue Cross Blue Shield Association said standalone plans are better suited to handle enrollment churn that destabilizes the system, saying people often enroll in a dental plan to treat years of deferred care before dropping it.

“Standard dental plans manage this risk through annual benefit limits; however, these limits disappear if adult dental becomes an essential health benefit,” BCBSA spokesperson Jennifer Martinez said in a statement. “Premiums will go up as a result at a time when people are already struggling to afford care.”

But American Dental Association Senior Vice President of Government and Public Affairs Jim Schulz countered that assertion.

“Based on the enrollment data the ADA has seen, enrollment numbers have been rather consistent and do not necessarily reflect the enrollment/rapid cancellation experience some dental insurers may allege,” he said in a statement.

Adult dental plan premiums average around $25 a month, according to Reusch. But coverage varies from plan to plan, and is typically capped around $1,500. Patient cost-sharing can also reach 50% for procedures such as root canals.

Categorizing dental as an essential benefit would ban coverage limits and help standardize plans, but insurers also noted that it could subject dental care to deductibles. Many dental plans offer first-dollar coverage.

Lack of affordability is what drives pent-up demand, said Melissa Burroughs, senior director of policy and advocacy at CareQuest Institute for Oral Health.

“That’s why it’s so important that we figure out how to fill these gaps,” she said.

Pros and Cons

Several states considered adding dental to their essential benefits package when the Biden administration dropped the prohibition, though none ultimately applied.

Kentucky came close, but abandoned the proposal in favor of four other benefits, including fertility preservation and expanded speech therapy. Dental was the most expensive by far, with an estimated cost of more than $15 per member per month.

Priscilla Easterling, director of outreach and enrollment for Kentucky Voices for Health, said the state’s view was that the expected premium increase wasn’t justified by the level of coverage when compared to standalone plans. But simplifying everything under one plan would have been a “game changer” in helping address Kentucky’s access issues, she said.

“All pieces of our body should be covered under one health insurance plan,” she said, “and it should not have to be so piecemeal as it is right now.”

The Kentucky Department of Insurance did not respond to a request for comment.

States also had to consider the policy’s political staying power, since ACA rules often change based on which party controls the White House. But oral health is even more important in the current environment, Burroughs said. She pointed to efforts to remove fluoride from public water systems and Republicans’ recent cuts to Medicaid.

“Now more than ever, we really need policies that improve access to dental coverage and dental care,” she said.