I've Been Learning a Lot About Dental Care—What I'm Finding Is Weird

It was the summer of 2019. I was in Boston, and I had a cracked tooth. It was two months after starting my first job out of college.

I had a fever and was calling around to find a dental practice who would accept my dental insurance and could see me on very short notice.

After calling half a dozen offices, I finally found one that, thankfully, could fit me in later that afternoon.

The procedure cost $2,000.

Here’s the thing: at the time, I had dental insurance.

So, why did it cost so much?

What Does Dental Insurance Actually Do?

For dental insurance most yearly premiums range from $400 to $700. Cleanings are often fully covered.

For minor procedures, like fillings, the plans might pay 70% to 80%. For major procedures, such as crowns, the plans often pay about 50% of the cost.

One of the key points is that dental insurance typically has an annual maximum—this is the most the insurer will pay in a year, often between $1,000 and $2,000. Once you reach this limit, you are responsible for paying everything out-of-pocket.

This means dental insurance doesn't always protect you from high costs, especially if you need major work done.

While it can help you get discounted rates with network dentists, the coverage often isn’t as comprehensive as you might expect from medical insurance.

The system isn’t set up to protect you from financial risk in the same way other types of insurance (ideally) are, and for many people, the high costs still lead them to skip or delay treatments.

As well, insurance plans are subject to a variety of barriers, including waiting periods, extensive paperwork, treatment limitations, and annual maximums. These limit quality of care and are time consuming to navigate.

Dental is Oddly Not Considered Medical Care

About 50% of Americans get dental coverage through their workplace.

And around 47% Medicare beneficiaries, do not have dental coverage. And most state Medicaid programs don’t cover dental treatment for adults.

The U.S. healthcare system often overlooks dental care as a core component of overall health, even though research consistently shows that oral health is closely tied to general health.

A healthy mouth contributes to outcomes like better pregnancy health and a lower risk of heart disease. Yet, dentistry has long been treated as a separate and less integrated part of healthcare.

Now, the most effective way to avoid steep dental bills is through regular checkups and preventive care. Routine cleanings, x-rays, and exams help identify potential issues early, preventing them from escalating into costly emergencies.

Yet, without a clear pathway—either through insurance or alternative options—patients often forgo the dental care critical to their overall health.

The Impact of Insurance on Small Dentist Practices

Patients aren’t the only ones questioning whether insurance is truly worth it—dental offices can also face financial challenges when they choose to accept insurance.

For small practices with a large proportion of insured patients, being in-network can result in significant revenue loss.

This is because, the payments from dental insurance haven’t kept pace with inflation. As a result, solo practices who accept insurance are adopting one of two strategies:

1. Volume-based approach: Focus on seeing as many patients as possible, with a heavy reliance on hygienists to handle most of the labor, allowing the dentist to focus on essential procedures.

2. Growth strategy: Expand the practice in higher-income areas to attract private-pay clients.

As a result of the financial pressures, many dentists are selling their practices to larger groups or private equity firms, which are better equipped to manage the volume-focused model. In addition, they can benefit from vertical integration.

The Dental Membership Alternative

To support patients who prefer to avoid insurance or don’t have insurance, dental practices can offer membership plans. These plans typically involve an annual fee, granting patients a discount on services.

These membership plans have become increasingly popular in the dental industry due to the growing demand for alternatives to traditional insurance.

Consider this a similar approach to Direct Primary Care (DPC).

For instance, a patient might pay $450 annually and receive two cleanings, along with a 10–15% discount on treatment.

Unlike traditional insurance, these plans have no deductibles or limitations or waiting periods that can make individually purchased dental insurance unattractive.

Before joining a membership plan, patients should ask what the dentist charges for procedures so they know not just the discount but their actual out-of-pocket cost. In some cases, the membership plans are a viable option.

If you can afford it and don’t anticipate high costs, this seems like a good option, particularly if you are uninsured.

Price Transparency in Dentistry

So, is dental insurance helpful?

Here’s the thing: I don’t think anyone can assert this definitively.

It can vary based on the patient's dental needs, the dentist's office, and the insurance provider.

As well, patients should know upfront what their out-of-pocket expenses. This concept is currently foreign, which makes an apples-to-apples comparison of dental insurance versus out-of-pocket costs difficult.

We are seeing the same problem in non-dental settings, where people are not given the opportunity to see prices upfront, preventing the market from influencing the prices offered.

This is largely because prices aren’t determined by the market but are instead set through closed-room negotiations or by dental practices establishing non-market-influenced prices.

This means a dental practice can offer significantly higher prices than the practice down the street.

It appears that the price transparency movement has bypassed dental insurance altogether.

One of the things we need is a marketplace with upfront pricing in the dental space.

It's Time to Treat Dental Care as Essential Healthcare

Dental care must be considered medical care.

The reality is that the operational costs of dentistry are high—this is unavoidable. And dental practices deserve to get paid for their work.

To help do this, there needs to be greater shopability for those who can afford it, alongside the development of creative strategies for Medicare and Medicaid to reimburse dental care for those who cannot.

I emphasize "creative" because operational challenges make it unlikely that dental insurance will merge seamlessly with medical insurance. The two systems have entirely different billing structures, and transitioning to a medical billing model would be a daunting task, especially for smaller dental practices.

Additionally, dental insurance needs to better protect patients, and reimbursement rates for dental providers need to increase.

The time has come. Everyone deserves affordable and accessible dental care.