Massive Massachusetts win helps set stage for future insurance reform

ADA, state dental societies focus on establishing medical loss ratios in other states

Celebration: Dentists from Massachusetts celebrate the signing of the Question 2 ballot measure in early December. Seated is Massachusetts Secretary of State William Francis Galvin. From left to right are Kevin Monteiro, MDS executive director; Mouhab Rizkallah, D.D.S., author of the ballot question; Richard J. Rosato, D.M.D., trustee, ADA First District; Meredith A. Bailey, D.M.D., MDS president; Abdul Abdulwaheed, D.M.D., MDS vice president; and Patricia Brown, D.M.D.

A dental insurance reform victory in Massachusetts achieved via public ballot is spurring advocates across the country to pursue legislation to institute a medical loss ratio for dental plans in their states, while the ADA explores similar reform at the federal level.

"The Massachusetts victory was a watershed moment for patients and dentistry, setting a precedent that could herald future change for dental insurance across the country," said ADA President George R. Shepley, D.D.S. "It's a shining example of where we can go in our future endeavors in dental insurance reform and what we can do to help our patients."

The Massachusetts measure establishes what is known as a medical loss ratio - a minimum percentage of premium dollars collected by an insurance company that must be spent on actual patient care and not on administrative costs such as salaries and marketing.

The new measure in Massachusetts, signed into law in early December, requires the state's insurance carriers to spend at least 83% of premium dollars on patient care and also contains a key provision that does not allow carriers to raise premiums egregiously. The measure also requires transparency on the part of dental insurance companies to disclose projected medical loss ratio for dental plans, file the following year's group product base rates by July, and release other specified financial information. It authorizes the commissioner of the Massachusetts Division of Insurance to approve or disapprove of any product rates, which includes premium increases beyond dental's consumer price index.

All the provisions taken together make the Massachusetts law unique and groundbreaking, and the ADA, working with state societies, is looking to support similar measures in other states, ensuring the win in the Bay State won't be the last.

How it began
Dental insurance reform has long been a goal of organized dentistry and its members.

One passionate dentist - orthodontist Mouhab Rizkallah, D.D.S., an ADA member from Somerville, Massachusetts - seized the opportunity to push forward medical loss ratio in his state. Motivated by exasperated dental patients and the lack of transparency in dental plans, Dr. Rizkallah sought to change the status quo to help both patients and dentists by authoring the Massachusetts measure - known as Question 2 - and worked to get it on the 2022 ballot. He also formed the Committee on Dental Insurance Quality, which comprised dentists and patients advocating for reform. In addition to Dr. Rizkallah, other dentist members of the committee included Patricia Brown, D.M.D., Andrew Chase, D.M.D., Robert Petrosino, D.M.D., Laura Rizkallah, D.M.D., and Abdul Abdulwaheed, D.M.D.

"I realized around 2010 that a dental MLR law would change the dental insurance company paradigm from 'insurers make more by paying less for patient care' to 'insurers make more by paying more for patient care,'" explained Dr. Rizkallah, who said he personally contributed $2.8 million. "The data showed this change would shift [billions] annually from ridiculous insurance administrative [and] contribution expenses to real patient care. Since insurance lobbyists have repeatedly obstructed all dental MLR bills from becoming law, I decided to side-step lobbyists with the nation's first dental ballot question."

Even before it was placed on the ballot, Dr. Rizkallah explained there was strong opposition from the insurance companies. They filed two lawsuits aimed at knocking Question 2 off of the ballot. In one suit, the insurers sued to change the state's official  voter information guide description of Question 2, written by Committee on Dental Insurance Quality member Dr. Brown. Ultimately, the Massachusetts Supreme Court justices unanimously rejected both challenges.

"What may surprise readers is that I was thrilled each time I heard the insurers were suing my ballot," Dr. Rizkallah said. "I knew it would help me activate Massachusetts dentists and simultaneously educate voters."

Massachusetts Dental Society supports Question 2
In addition to the Committee on Dental Insurance Quality, the Massachusetts Dental Society was also in favor of getting a medical loss ratio in dentistry. Since 2006, the state's major medical insurers have been held to an 88% medical loss ratio standard and the state's dental leaders were looking for something similar in dentistry. The dental society had also previously supported a medical loss ratio reporting bill in the state legislature that never gained traction.

"Not having a medical loss ratio for dental insurance was unfair to patients who deserve to have most of their premium dollars spent on the dental care they need," said Meredith A. Bailey, D.M.D., MDS president.

After gaining support from dentists, dental team members and patients across the state, the Massachusetts Dental Society reached out to the ADA for support as leaders from both organizations realized Question 2 provided a unique opportunity to benefit patients nationwide. Together they formed the Massachusetts Dental Care Providers for Better Dental Benefits committee.

"We wanted to work together on this important issue to help ensure that dental patients across Massachusetts can get the care and improved dental benefits they deserve," said Andrew S. Tonelli, D.M.D., co-chair, MDS Government Affairs Committee. "This type of reform is long past due."

Drs. Bailey and Tonelli noted that dentists and patients weren't the only ones calling for change. In an editorial the Boston Globe said, "this issue has come before the legislature a number of times in the past decade, but lawmakers failed to act - including on the bare minimum of  requiring more transparency from dental insurers. That's ultimately why voters should vote yes: to put pressure on lawmakers to finally take on the very real failures of the dental insurance industry to properly serve consumers."

ADA contributes millions to campaign
In September, the ADA shared its support of the initiative with ADA members by announcing a $5 million commitment to the campaign. That significant donation was followed by contributions from nine national dental specialty organizations and 49 state dental societies as well as hundreds of dentists from across the country.

In the end, the Massachusetts Dental Care Providers for Better Dental Benefits campaign raised more than $7.5million, which included an additional half-million dollars contributed by the ADA. Question 2 passed overwhelmingly, with more than 72% of Massachusetts' voters voting in favor of the measure.

"Dental patients deserve the same consumer protections as medical patients," Dr. Bailey said. "Massachusetts' voters recognized the importance of accountability and transparency when it came to the spending of their premium dollars, with 'Yes on 2' earning a majority of votes in each of the commonwealth's 351 cities and towns. We are hopeful that the better dental benefits Massachusetts patients will soon experience will spread across the country."

"Dentistry is always better when we are united together to benefit the profession and the patients we serve," Dr. Shepley said. "The Committee on Dental Insurance Quality, the Massachusetts Dental Care Providers for Better Dental Benefits Committee and everyone who contributed achieved a remarkable victory with the passage of Question 2."

What's next
When asked where he hopes the Massachusetts win goes from here, Dr. Rizkallah said he intends to push for a federal medical loss ratio in dentistry just like there is in medicine.

The victory is already sparking reform efforts in other states. Three states, Connecticut, Nevada and Oklahoma, have already announced intentions of pursuing similar bills.

"The dentists in Oklahoma are thrilled about what happened in Massachusetts," said Oklahoma Dental Association Executive Director Lynn Means. "It might be one of the most precedent-setting things to happen in dental benefits in decades."

Based on feedback from state dental societies, the ADA expects medical loss ratio bills to be filed in as many as 20 states in the next legislative session and the Association will continue to support these efforts, as well as pursue national opportunities for this reform.

"When more premium dollars are spent on dental care, it means that our patients are getting real value from their plans and getting access to the care they need," Dr. Shepley said. "The Massachusetts victory showed that patients want this reform in a big way. As their dentists, we can do nothing less than offer our full support."

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