Dental insurance is not the usual kind of subject for a ballot question, but it is this year in Massachusetts.
Health insurance is regulated by state medical loss ratio guidelines. That means health insurers have to prove to overseers yearly that they're spending patients' premiums in a way that regulators deem responsible. There's no current similar regulation of dental insurance in the Bay State.
That's what Dr. Mouhab Rizkallah, the chair of the Committee on Dental Insurance Quality, aims to change. He urges a "yes" vote on Question 2. And representing the Committee to Protect Access to Quality Dental Care — opposed to the ballot question — is former state Sen. James Welch.
Carrie Healy, NEPM: Doctor, are voters the best people to decide how to regulate something as complicated as the dental insurance industry? Shouldn't this be left to lawmakers who can take testimony and then carefully craft a law?
Mouhab Rizkallah, dentist: You know, I think every ballot question in the past has had that kind of question asked. But in fact, in this particular case, this proposed law has actually gone before the Legislature. And because of the deep pockets of dental insurance companies, they cause these proposals that do become bills to stagnate in committee. And they actually never get out of committee, so they never get voted [on]. In 2015 and then 2019, a similar law never made it out of committee.
We have bypassed the lobbying tactics of dental insurance companies by bringing it straight to the voters who know the problem, feel it every day, and want to solve it.
James, this question needed tens of thousands of signatures to get onto the ballot. Why shouldn't people get a say in how their dental premiums are spent?
James Welch, former state senator: Well, certainly respect the process, and respect to the voters and their ability to make decisions on difficult priorities. And this question is — certainly falls into that category. The voters not only get to decide — have the right to decide, but they also have the right and the expectation to be provided with valid information to help them make the decision on such a complicated issue.
Unfortunately, the proponents of this ballot question really didn't do much research before putting the ballot question on the ballot, and collecting the signatures. And unfortunately, the voters are left with not a lot of valid information, and valid research, to help make their decision. We've provided good research that shows why it shouldn't be passed. But unfortunately, the proponents just put the ballot question on the ballot without doing any research whatsoever.
Doctor, you have support from dental and oral health organizations far and wide. In what way would setting a minimum threshold of monthly premiums that insurers spend on patient care change the way that dental insurance looks and works for the voter?
Rizkallah: Carrie, I do want to respond for a moment to what he said. In fact, we do have plenty of data that supports our law and the figures in our law. And I would say that Mr. Welch's description of a study that they have provided, I would like to make sure is fact-checked — how they have labeled their study as an independent study, and they've written that to the voters and the Red Book. But in fact, I'm looking at that study, and it says, "Commissioned by the National Association of Dental Plans" on the front of the study, so it's not independent.
How would monthly premiums — the amount that is spent on this patient care — change?
Rizkallah: Thank you. Not only would monthly premiums go down, because that egregious waste would be stopped and redirected to patient care — monthly premiums would go down. But even more than that, which is really the meat of the matter, is co-pays would go down. So when a person walks up to the front desk receptionist at their wonderful dentist's office and is asked to open their wallet or purse, and make a payment as a co-pay because they have insurance, their co-pay is going to be dramatically lower when the kind of waste we are talking about [is lessened].
So you're saying that there's an amount of money that's going to be transferred. James, what do you have to say about this?
Welch: The ballot question says nothing about what the doctor just said. The only guarantee that the ballot question, should it pass, would happen, would be that dentists would get paid more money. The reality is the "No on 2" campaign is really trying to focus on how this impacts consumers. And as a legislator — as the chair of health care finance for six years — we always looked at three main questions when you talk about health care policy. The first one: How will it impact costs for consumers? Second: How will it impact access for consumers? And thirdly: How will it impact the quality of health care that the consumers are going to receive?
When you ask all three of those questions. and all you have to do is just scratch a little bit at the surface on this question, on this policy, and you realize that [on] all three of those questions, this proposal fails.
I'm a little confused. There are many who say that dental insurance — an opponent to this measure is Delta Dental of Massachusetts. So, James, they've put more than $4 million into this opposition campaign. We should disclose here that they're also an underwriter of NEPM. Some recent advertising that Delta Dental is using directly links dental health to overall health. So, James, if oral health is a key predictor of overall health, how do you justify not using a medical loss ratio law to regulate dental insurance?
Welch: Well, dental insurance and health insurance are very similar in many cases. And of course, oral health is very important to overall health, the system of dental and traditional health care are different. And there's two main reasons why they're different, and why you really can't apply the medical loss ratio for traditional health care to dental loss ratio for dental care. The big one, to me, is always the fact that traditional health care is mandated. There's an individual mandate, business mandate, government mandate. There's no mandate for dental care in the ACA, for example. And that is a huge difference that can't be ignored. You have to —
Rizkallah: What's the difference? I don't know..
Welch: What is the difference?
Rizkallah: Yes.
Welch: When insurance plans change, or there's a mandate put on an insurance plan or put on an individual — when there's a change, they have to to reevaluate what they provide and how they provide it. And when they do that, sometimes there's going to be certain plans that change. Unfortunately, maybe plans are going to offer less benefits. Maybe employers are going to think twice about what type of benefits they want to provide to their employees.
OK, we're going to move on. I want one answer from the doctor — who is a stakeholder in this, as dentists stand to see either increased rates, increased patient visits, or both if this passes. You've sued the state; you've been sued by the state regarding MassHealth billing. How do you dispel this notion that this campaign is about self-interest?
Rizkallah: Oh, it's — here's what happens: When patients do better, doctors will do better. And the way that doctors do better is by providing quality service to patients.
Our patients want care. And there is no question that when when the patient's funding becomes available — the studies show very clearly — when a patient's funding becomes higher from their insurance company, their oral health improves. When patients can get better services — because they can afford the services, because the insurance companies are not scamming them out of the money and giving the money away to their parent company — that money now goes back to patients' wallets so that patients get a chance to make a decision if they want treatment. If they want treatment, then they will improve their oral health, and doctors will make more. But that is —
We are going to move on to closing statements. James, we're going to start with you. Why should people vote "no"? You have 30 seconds.
Welch: Consumers need to ask themselves three basic questions: How will this impact me in regards to costs? How will this impact me in regards to access? And how will it impact me in regards to the overall quality of care? When voters scratch at the surface on this question, they'll realize very quickly, costs will go up, access will go down, and there's absolutely no guarantee that quality of care will improve.
Doctor, why should people vote “yes”? 30 seconds.
Rizkallah: Carrie, what Jim just said is completely false. Currently, insurance companies are scamming patients out of fair coverage in their dental insurance. Question 2 solves this in two ways. First, their outrageous waste and scams get stopped and redirected to patient care so the patients will have lower out-of-pocket costs, such as lower co-pays and lower premiums.
Secondly, if Question 2 passes, dental insurance companies will be required to disclose to consumers what the true payout value is of their insurance plan. Buyers of insurance, whether a business buying for their insurance, their employees or individual consumers, will know the true value of the plan that they are buying.
Here to fact-check and provide some perspective on ballot Question 2 is Matt Murphy of the State House News Service.
We're going to jump right in and start with that report that voters can see quoted in the ballot question guide published by the secretary of the commonwealth. That's the Milliman research study. That is or is not an independent report?
Matt Murphy, SHNS: Well, it is true that report was commissioned by the National Association of Dental Plans. Milliman does this kind of work. In this case, it is the most comprehensive we've seen to date, but it was paid for by the industry.
This issue has come before lawmakers previously. Can you briefly catch us up?
Murphy: Yeah, this proposal has been filed in various forms before the Legislature, before. And in all cases, lawmakers have looked at this, they've grappled with some of the issues, but they've been unable to come to any sort of resolution, which is how we find ourselves here today with lawmakers allowing this to proceed to the ballot.
[It's] a very complicated issue and one that we often see on Beacon Hill take a lot of time to come to any fruition. And often times, proponents just lose their patience and proceed to the ballot, which is what we're seeing this year.
And a version of this was introduced in 2021 by Rep. Puppolo and — that was killed off?
Murphy: That was sent to a study which is basically the Legislature's way of saying we don't know what to do with this at this time, and we're going to push this off, and we'll continue to have this debate.
The two sides here have very differing views about what the impact on the dental insurance market would be in Massachusetts. And that is probably why you're seeing lawmakers unable to reach any sort of conclusion, and handle this on their own.
Anything jump out at you?
Well, I did hear during this debate, former Sen. Welch talking about how the medical loss ratios that are applied through the ACA to your traditional health insurance, much different than the dental insurance. And in some respects, he is correct there. What we're hearing opponents say is the dental insurance market is so much smaller than the broader medical insurance market, there's not as many subscribers to spread administrative costs over, which is why the impact would be far different.
Another thing that jumped out: When the doctor talked about premiums going down, there's a number of ways insurers could handle this question should it pass. Without a medical loss ratio applied to dental insurance anywhere else in the country, just how the insurance industry would respond to this is a big unknown. And some say it could cause small carriers to leave the market entirely.
Disclosure: Delta Dental of Massachusetts, referenced in this report, is an underwriter of New England Public Media. Our newsroom operates independently of the station’s fundraising department.
