Wednesday September 12, 2012

On Sept. 6, Mark Larson, commissioner, Department of Vermont Health Access, and Robin Lunge, director of Health Care Reform, presented updated Plan Design Recommendations for the Vermont Health Benefit Exchange to the Green Mountain Care Board.

At an earlier presentation in August the same members of the Shumlin administration did not include dental benefits because it was felt the state could not afford to offer them in exchange plans. The loud voice of engaged Vermonters was heard and the GMC board asked the administration team to return with a plan for adult dental benefits. The GMC board is slated to vote on the benefits package for insurance plans offered in Vermont's new exchange on Sept. 20.

Thanks to citizen activism an adult dental benefit is now on the table. We all know too well how unaffordable and inaccessible dental care is for many of us. It has been an accepted fact of life that teeth are really not part of the human body when it comes to most insurance coverage or discussions of health care reform.

It's all about money. While there are some options for dental insurance, it is not as widely available as it should be and coverage runs from decent to minimal. As the GMC board crafts new benefit plans the hope was that they will add realistic dental benefits to the package.

That hope is slim if you consider one of the slides in the Sept. 6 presentation that stated, "Questions have been raised about the relationship of stand-alone dental to the board's authority on plan design. Under Vermont law, stand alone dental plans are not health benefit plans and therefore do not require Board's approval."

Of course, that does not mean that the board cannot offer benefits, but it does give a sense of historical context for the dental coverage issue. To their credit, they did analyze four different dental coverage options whose overall cost to the state would range from $17-$87 million. Those options would be: 1. two exams / cleaning per year; 2.preventive services; 3.preventive and restorative services; 4. preventive, restorative and major services.

What this all boils down to is the age-old battle of what the state can afford and how priorities are set for health care coverage. The mouth always falls to the bottom of the list. So the big question is, "Can Vermonters do anything to push for meaningful dental coverage in the new exchange benefit plans?"

We need to fight the next battle in the dental war. We must demand that the mouth be considered part of the human body and we must demand that if the board is to craft a benefits plan that they cannot leave out meaningful dental coverage

All of the cost analysis assumes that the board or the state has no control over the price of dental care. While that is true, that does not mean they cannot change things. As far as I know, no one in government has proposed that there be some sort of government regulation of dental prices. It would be a very tricky legal maneuver, but if a state plan is offered and dentists are included in the plan then, perhaps, there could be some sort of price control.

I suspect most dentists would run away from such a plan as fast as they could and simply rely on current free-market dentistry. They would have nothing to lose if they steer clear of state plans. But, if the majority of their patients eventually end up in private, state-regulated plans that provide dental coverage things could change.

Keep in mind that is it projected that 100,000 Vermonters will be enrolled in the exchange by 2014 and that the number will increase quickly in the following years.

If Vermont finally moves to a single payer plan, that plan would have the potential to change the way dental care is provided because most Vermonters would be covered under the plan. Including a basic level of preventive and restorative dental care in a single payer benefits plan could, for the first time, possibly give the state and its citizens enough leverage to change the dental status quo.

A dentist who finds that 70 percent of his patients are now covered under a single payer benefits plan will have to listen to those patients when they demand that he accept state payment which will, most likely, be less than the obscene prices now charged for fillings, and restorative work.

He can either find a new patient population or figure out how to keep his prices at a level that the state and most Vermonters can afford. It will not be easy to cause such a seismic shift in the provision of dental care.

Widespread single payer dental coverage could set off a revolution in dental care. It would force dental care providers to join the rest of the health care community as they all work toward more integrated delivery systems. It would also mean that teeth would finally be considered important enough to be part of the human body in the world of comprehensive insurance coverage.

Richard Davis is a registered nurse and executive director of Vermont Citizens Campaign for Health. He writes from Guilford and welcomes comments at rbdav@comcast.net.