Even with the Affordable Care Act in place, more than 100 million Americans still don’t have dental insurance.

The Affordable Care Act (ACA) brought health insurance coverage to millions of people last year who had never had it before. Not only did the sweeping changes put an end to exclusions for pre-existing conditions, but healthcare reform also designated 10 “essential benefits” that insurers must include in their plans, such as treatment for mental health problems and drug and alcohol abuse.

The idea was to provide coverage for things that could improve a person’s overall health at a relatively low cost. The theory? Keep people healthy by taking care of small problems before they become big, expensive ones.

So why does something as basic as dental care continue to take a back seat, even with the new emphasis on preventive medicine?

“The failure to value oral health and understand that the mouth is the gateway to the body has for too long impeded people’s ability to achieve good overall health,” Maxine Feinberg, a Cranford, New Jersey dentist, told Healthline. “This failure can negatively affect anyone, but it is particularly devastating to low-income people who lack dental coverage or who for other reasons don’t seek or receive regular care.”

According to the U.S. Centers for Disease Control and Prevention (CDC), about one-quarter of Americans 65 and older have lost their teeth. One-third have untreated tooth decay, even though poor dental health is linked to heart problems and other health concerns seniors already face, such as diabetes. Medicare, the federal program intended to keep seniors healthy, has never covered teeth cleanings, fillings, dental X-rays, or exams.

Almost 8,000 people in the United States die of oral and pharyngeal cancers every year, most of them elderly. But the problem is not limited to seniors. Children from lower-income families are twice as likely to have tooth decay. Mexican-American children are disproportionately affected.

“I believe that most Americans have access to the best dental care in the world,” Feinberg said. “But too many face barriers, often multiple barriers, to receiving care. People need help with other things in order to receive care, things like transportation, child care, or getting permission to miss work in order to get care.”

Feinberg took office as president of the American Dental Association (ADA) at its annual conference last week in San Antonio, Texas.

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The bottom line is that although healthy teeth are essential for good overall health, they have never really been considered a part of the body by many insurers and third-party payers. The U.S. Department of Health and Human Services (HHS) estimates that 108 million Americans lack dental insurance.

For children, dental coverage is an “essential benefit” under the ACA. That means that when selling insurance plans on state and federal exchange websites, insurers must make dental coverage available for people under 18 either as part of the health plan or as a separate plan. But nobody is required to buy it.

Medicaid, which provides health insurance to low-income people on the state level, must also offer dental benefits to children. “The problem with programs like Medicaid is that they vary from state to state in what they will cover, and most state Medicaid programs do not cover adult dental services,” Feinberg said. Connecticut, Maryland, and Michigan are among the top states for providing extensive Medicaid dental benefits, she added.

Last year, the Centers for Medicare and Medicaid Services released a report showing that dental care for children had improved during the previous five years in about half of U.S. states. Yet most states only use about 2 percent of their Medicaid budgets for dental care.

The ADA maintains a Washington office that lobbies lawmakers for more funding for dental care. They’re pushing for better community water fluoridation and tooth sealant programs. Safety nets for those who can’t afford dental care and better dental care for those serving in the military are also high priorities.

The Administration on Aging, part of the HHS, acknowledges the barriers to dental care that older Americans face and has several initiatives aimed at improving the situation. It operates a website intended to help seniors access dental services.

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Earlier this year, the ADA Policy Institute produced a study that shows which states offer adult dental benefits and how extensive the benefits are.

The CDC is hoping to promote good oral health by working with communities to strengthen local dental programs. The CDC provides funding to 19 states to help boost such programs.

Through events such as Missions of Mercy and Give Kids a Smile, dentists provide about $2.6 billion in free care per year. “But charity is not a healthcare system,” Feinberg said.

“Another possible source of lower-cost dental care is a dental school clinic,” she added. “Generally, dental costs in school clinics are reduced and may include only partial payment for professional services covering the cost of materials and equipment.”

However, this year alone, more than 181 million Americans won’t even visit a dentist, according to the ADA. In 2012, the CDC found that almost half of people over age 30 suffer from gum disease. More than 2 million people visited an emergency room in 2010 with dental pain, according to the National Hospital Ambulatory Medical Care Survey.

Clearly, there is a disconnect between the need for care and the ability to pay for it.

One emerging trend in dental care is the shift toward savings plans. Companies like :DentalPlans work with health insurers such as Aetna, Careington, and others to provide discounts on dental services. For as low as $135 per year, consumers can purchase plans that offer discounts on dental services. Members save up to 40 percent on services ranging from cleanings to orthodontics like braces.

Many employers don’t offer dental coverage, said Bill Chase, vice president of marketing for :DentalPlans. And many of those who do have raised their deductibles and employee contributions.

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:DentalPlans offers an online marketplace to bring insurers directly to consumers. This saves the insurers money on marketing costs and makes plans more affordable, Chase told Healthline. “We have a lot of lower-income individuals and families that are members. It’s the only way they’re going to be able to access dental care at all,” he said.

Chuck Misasi, senior vice president at Careington International, said the increasingly popular model of health insurance exchanges actually began with dental care. “The rest of healthcare is trying to replicate what [:DentalPlans and others] have done.”

Although most Americans still don’t see a dentist as often as they should, often because of high cost or lack of insurance, the pendulum is beginning to swing toward greater recognition of the importance of oral health.

“The good news is that with evidence mounting that problems like [gum] disease can affect other parts of the body, like the cardiovascular system, insurers, policymakers, the other health professions, and patients are looking at the mouth from the viewpoint of maintaining systemic health, rather than isolating — and undervaluing — healthy teeth and gums,” Feinberg said.

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