There are reasons dental and vision care are not included under health insurance policies here in the United States. There are not good reasons. But there are reasons. In terms of dentistry, these reasons date back to the days when dentists were more of a one-stop shop for pulling painful teeth and sending folks on their way. Dentists weren’t considered medical doctors. For a while, they couldn’t get into medical school if they tried. In fact, as covered over at The Atlantic, there were points when barbers provided dental care.
Clearly, we’ve come a long way. But the way our health care system and insurance companies handle dental care hasn’t, and our confusing health insurance systems definitely play a role. Per a 2021 consumer research study by Value Penguin, about one-third of American adults don’t go to the dentist at least once per year. For folks in the lower income brackets, that number increases to about 50%. Of folks who do get to the dentist annually, about one-quarter go once per year (as opposed to the often recommended twice per year), one-third do go every six months, and less than 10% go more than twice per year.
And sure. It's a running joke that no one likes going to the dentist. But it’s a safe bet that we’d all go a lot more regularly (and before things got bad in our mouths) if we could actually afford it. And yet: capitalism.
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So, how does insurance work today? If you receive Medicaid, a minority of states cover dental care, including things like cleanings, root canals, and crowns. If you receive Medicaid while pregnant or while you’re under 18, your dental services are supposed to be covered. But not every dentist accepts Medicaid patients. And states are allowed to decide if they extend dental Medicaid coverage to adults.
So, in many states, if you’re covered under Medicaid, you have to sift through confusing paperwork and qualifications in order to avoid steep costs for things like fillings, extractions, and X-rays. It’s legitimately confusing! Unsurprisingly, many folks simply try to mitigate discomfort at home until they end up in an urgent care clinic or emergency room.
It’s important to recognize where dental insurance stops short of being equivalent to medical insurance. Even if you have dental insurance, it likely has a deductible and a relatively low maximum. Some folks argue that dental insurance is supposed to be more about prevention—if you go to your biannual cleanings, for example, you can catch issues before they get so bad you need tens of thousands in work. Brush and floss! And, sure. But we all know dental health is not always so simple.
We can’t control our genetics, for one thing. And not everyone has access to regular check-ups, and even if they do, associated costs can spiral. Costs of dental care can be very, very high, unless you are able to access treatment at, say, a community clinic or a dental school. The fact of the matter is that people do rub a gel on their gums and hope for the best… even when the best can lead to middle-of-the-night emergencies and tons of bills.
In speaking to NBC News in an interview, Dr. Gary Glassman, an endodontist based in Canada, gave journalist Nicole Spector a sobering example. Glassman estimated that each year, about 50,000 people will be diagnosed with oral cancer. Glassman estimated that about 10,000 of those folks will likely die, but “if caught really early [these things] can be better treated, before they spread and metastasize.”
One person who might spot oral cancer early? The dentist!
And cancer isn’t the only thing. Plenty of research points to the connection between things like periodontal infections (otherwise known as gum disease) and cardiovascular disease, premature labor and low birth weight (when found in pregnant people), diabetes, and of course, nutritional issues based on chewing. (Raw vegetables can be a healthy snack, but try getting yourself to eat carrots and broccoli instead of mashed potatoes when you have tooth pain...)
It’s safe to assume more people would get—or at least try to get—regular preventative dental care (like cleanings) if insurance covered it. There are still access issues, especially for folks who live in rural areas or live with certain disabilities. But the only real reason dental care isn’t covered under our current system is archaic. And people of all incomes deserve better when it comes to both their physical and emotional health.
Why emotional? Well. Teeth are, sadly, a status symbolizer here in the U.S. And sure, this can mean things like having the “perfect” smile for photos or social media fame. But it’s not just about having a Hollywood smile. It’s also about, well, all the ways people in the “real” world, from potential employers to dates, might read “bad” or “poor” teeth as signs that someone is lazy, irresponsible, or… poor. It’s a class signifier. People shouldn’t hold that against anyone, but they do. And this can be especially important to remember for marginalized folks who face discrimination even with the “perfect” smile.
My coworker, Jessica Sutherland, who serves as the Managing Editor of Community Content here at Daily Kos, sat down with me for a brief virtual interview on dental care and her personal experiences with classism and dentistry.
“I’ve got a terminal degree, a good job, and a comfortable life, but always felt like my teeth were the giveaway of the deep poverty I escaped,” shares Sutherland, a writer and editor in her 40s who grew up in Ohio and has since relocated to California. “It’s been less than a month since my restoration was finished, and I still don’t smile like I used to. I’m still adjusting to my newest fake teeth. Even if people might not notice my restored teeth, they’ve definitely noticed the black ones, the broken ones, and the missing ones throughout my life.”
Now, what’s the deal with vision insurance? For a long time, vision care has been regarded similarly to dental care. If you get regular preventative care and protect your eyes (say, by wearing goggles or sunglasses when needed), you should find out if you need glasses or have cataracts within enough time to catch them early. But, again, genetics. Not to mention freak accidents! Not to mention, again, access and cost.
About half of American adults don’t opt into vision insurance and about 40% of those who don’t get a yearly eye exam say cost is the main barrier, per a 2016 survey. But you can, for example, get your eye exam without insurance if you pay out of pocket, similar to getting your teeth cleaned without dental insurance.
I have had terrible vision since I was a small child. I truly don’t remember ever seeing well, even as a little kid. I’ve gotten LASIK (paid for out of pocket) as an adult and am really satisfied with it. But for literal years, I actually wore a former partner’s glasses because we had a similar prescription and I couldn't afford to go to the eye doctor. I couldn’t find a community clinic or a school with reduced rates. So I dealt with headaches and hoped for the best. (Note: I do not recommend this approach!)
If you have Medicare, you can often see an ophthalmologist (who is a medical doctor) for serious issues like cataracts or glaucoma. Generally, though, the person you’ll see first is an optometrist (an “eye doctor” who is not a medical doctor) for your yearly vision exam. The optometrist is likely who writes your prescription and keeps track of its changes over the years. The optometrist is likely who refers you to an ophthalmologist as needed. An ophthalmologist is often who you’d need to see for surgery, in the case of cataracts or injuries.
But in many cases, even if you receive Medicare, you’re paying out of pocket for glasses or contact lenses. This is likely why retailers like Warby Parker and Zenni (among others) are so popular today—it’s a whole lot less expensive than what you’re likely to find at your local eye doctor. So people get the prescription and get themselves to the discount retailer.
Now, similar to dental health, we know that our vision impacts the rest of our body. And, quite literally, our life! Poor vision can impact our mental health, especially in terms of depression, loneliness, and loss of social life. On a literal day-to-day level, poor vision can also affect our abilities to perform daily tasks, like walking or driving a car. And yet vision insurance became a thing in the 1950s and has stayed (generally) separate from health insurance ever since.
It’s also worth remembering that while we know eyesight can worsen as we age, many folks who retire no longer have access to their previous employer-based health insurance or don’t have the same income coming in. Worsening vision while aging while potentially having a lower or limited income is legitimately frightening, especially if you live alone or are a caretaker for your spouse or others. We can count this as one of the many, many areas where our society fails older folks.
Capitalism makes it all too easy to believe that health issues are the fault of the individual. Just brush more, just wear glasses when you drive at night, and just eat fresh food instead of processed. And while these points aren’t bad or wrong, they’re far from the full picture. And, sadly, they’re all too often rooted in privilege.
“Brushing and flossing will only take people so far if they have teeth prone to decay,” Sutherland points out. “I was and am meticulous about my oral hygiene, but once a cavity starts, if you can’t get cared for swiftly, more problems will follow. It’s a speed game.”
Sutherland is right—health is a speed game, and we should all have safe, affordable, and accessible health care for all parts of our bodies, including our teeth and eyes, as a matter of routine. Too many people can only get help when it’s an emergency—or when it’s too late. And in one of the richest countries in the world, that’s simply shameful. We all deserve better.
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