There is no doubt that families are much better off than they were before the Affordable Care Act (ACA) was enacted. Young adults, the most likely age group to be uninsured, can stay on their family’s health plan. Children with cancer will no longer exceed their annual limit on costs or max out their lifetime benefits. Asthmatic children can no longer be denied coverage due to a pre-existing condition. And millions of parents will have improved health and greater economic security having gained health coverage, many for the very first time.

Yet no law is perfect, and that is definitely the case when it comes to pediatric dental benefits.

Health leaders wisely included pediatric services — and specifically oral health — among the Essential Health Benefits (EHB) that must be covered by both qualified health plans (QHPs) in the marketplace and new plans sold in the private insurance market. But the ACA fails to consistently deliver oral health benefits by allowing QHPs to skip dental services if stand-alone dental plans are available in the marketplace.

For this reason, families will almost always pay extra premiums for separate dental coverage, and dental cost-sharing doesn’t count toward a child or family’s annual out-of-pocket maximum. These additional costs may cause low-income families to forego dental coverage altogether.

Before I suggest some potential solutions for this problem, consider a state-focused study that provides a sobering example of how affordability shapes coverage.

The additional financial burden of separate dental coverage was highlighted in a recent study that my colleague Martha Heberlein and I conducted in looking at the dismantling of the Arizona Children’s Health Insurance Program (CHIP), known as KidsCare.

Arizona froze KidsCare enrollment in early 2010. Although the program was temporarily reinstated in May 2012, 14,000 Arizona children lost their KidsCare coverage on January 2014. Assuming these families are not locked out of financial assistance in the marketplace (the “family glitch”), they should qualify for both premium subsidies and cost-sharing reductions. Our analysis looked at the health care needs of three children and what their cost-sharing would be in three of the lowest-cost Silver QHPs.

In two of the three plans we studied, dental benefits were not covered by the QHP. These plans cost an extra $300 in premiums per child, plus any deductibles and co-payments. In fact, for the two generally healthy children studied, dental premiums and cost-sharing accounted for 55 – 87% of their total out-of-pocket expenditures. This is much less affordable than the CHIP coverage that Arizona once offered.

There are multiple ways for policymakers to address this issue:

• Requiring all QHPs to cover dental benefits is one option and one that would not necessarily lock stand-alone dental issuers out since medical plans could team up with dental plans to offer an integrated benefit package.
• Perhaps more politically realistic would be a requirement that marketplaces combine premiums and cost-sharing so that families are not penalized when a QHP does not provide all the essential health benefits that children are entitled, by law, to receive.

We have made great progress in improving children’s oral health over the past decade. Without fulfillment of the ACA’s promise of dental benefits for kids, we are missing out on a tremendous opportunity to further those gains.