As far as ballot questions go, proponents say it should be pretty straightforward: Ensure the bulk of dental insurance premium costs find their way into patient’s mouths.

Opponents contend the measure, ballot question 21-13, will increase premium costs, reducing consumer choice and blocking access to dental insurance for the state’s most vulnerable residents, especially children.

The question, if the signatures presented to Secretary of State William Galvin July 6 are certified, would ask voters to approve a measure requiring dental insurers to spend 83% of insurance premiums on patient care, and if the funds go unspent, the overage would be rebated to subscribers.

Staff in Galvin’s office are in the process of examining the submitted paperwork, said a spokesperson for the secretary. The process is painstaking, but should be completed by mid-July.

What’s an aggregate medical loss ratio?

In Massachusetts, 88% of medical health insurance premiums must be used for treatment, otherwise, it is returned to the subscriber as a rebate. This is called an annual aggregate medical loss ratio.

Extending it to dental insurance just makes sense, proponents claim.

Both sides had it out in the shadow of the Massachusetts State House July 6 when they championed their cause at a noontime rally.

Dianne Morad, a lobbyist working with the ballot question committee, said during the press conference that some large dental insurance carriers spend as much as 40% of what they collect in premiums on “executive salaries, bonuses and other administrative expenditures” rather than on patient care.

“A yes vote would help fix a broken system in which insurance companies benefit from denying claims and limiting coverage,” Morad said.

Proponents of the measure traded dental anecdotes: The routine cleaning that revealed the need for fillings? Not covered. The removal of impacted wisdom teeth that would be borne by a health insurance provider, but only if the medically-necessary surgery were performed in a hospital rather than an outpatient setting.

Kudos, said Joseph Giannino dryly, noting hospitals do not routinely perform those oral surgeries.

Tooth pain does not ‘go away’

“Tooth pain doesn’t go away, it has to be addressed,” Giannino said, remarking that many illnesses do resolve themselves, regardless of medical interventions, citing the common cold as an example.

Sen. Harriette Chandler (D-1st Worcester) has proposed a bill (S.632) that echoes what could be included as a ballot initiative in November.

Dental health is essential to overall health, according to the Massachusetts Dental Society (MDS). According to their informational flyers, “oral health plays a very important role in overall health” with many systemic illnesses indicated by oral health symptoms. Plaque, periodontal (gum) disease, missing teeth, all contribute to other conditions, including lung issues (COPD), heart disease and stroke.

Women suffering from periodontal disease who are pregnant are more likely to deliver prematurely, according to the MDS. And low-birth weight babies are more likely to have breathing problems, anemia, jaundice (yellowing of the skin from liver issues), developmental delays and even congestive heart failure. Issues with teeth and gums can indicate diabetes and osteoporosis, a condition that affects some 10 million Americans, 8 million of them women..

Giannino said that unless the bulk of premium costs is redirected to patient care, families with minimal policies or living on the economic margins could forgo care until oral care issues become emergencies.

The Board of Trustees at MDS, a professional association representing some 5,000 member dentists, has endorsed the measure. The group, dedicated to the professional development of its members through education, advocacy and advancement of professional standards, has been advocating for dental insurance reform for years.

The American Dental Association endorses the measure

“As an advocate for dental care for all Massachusetts residents, the MDS endorses the Massachusetts Medical Loss Ratios for Dental Insurance Plans Initiative and encourages Massachusetts residents to pass it in November,” said Dr. Meredith Bailey, the organization’s president. “Patient dollars should be required to be spent in support of their oral health, and patients deserve visibility into how much of their dental insurance premiums are paying for care as opposed to administrative costs,”

Bailey noted the American Dental Association (ADA) is also in support of passage of the November ballot question. California, Bailey said, has already approved a similar measure after finding that only 76% of premium dollars were assigned to patient care.

Included in the measure is the requirement that dental insurers disclose the projected medical loss ratio for their plans. It also requires them to anticipate the groups base-rates and file those anticipated charges by July. The measure also puts the approval of base rates squarely in the hands of the state Commissioner of the Massachusetts Division of Insurance.

The Committee to Protect Access to Quality Dental Care, which is a coalition of dental plans, health plans, life insurers and trade associations organized in opposition to the initiative, said it is concerned the measure would drive up health care costs for consumers and small businesses.

“The proponents of this ballot question are not being straight with the voters,” according to a statement issued by the committee. “What they aren’t telling you is that their anti-consumer proposal will increase costs for Massachusetts families and employers — a nearly 40% premium increase in one recent study — and can result in thousands of residents being denied access to much-needed dental care.”

A study commissioned by National Association of Dental Plans, looking at the costs and benefits of the proposal found that most of Massachusetts dental insurers allocate between 60%  and 79% of premiums to patient care; depending on the size of the company, with smaller companies allocating fewer dollars while larger companies allocate more. The remainder of premiums charged is used, in part, for administrative costs.

The study by the Milliman Research group found that the proposal would impact companies with a smaller pool of clients as the administrative costs of insuring patients is shouldered by fewer clients. Also, the cost of fulfilling the 83% mandate, coupled with the cost of rebates would tax company revenue.

Opponents predict jumps in premiums

Opponents content that a yes vote on the ballot question in November could drive some dental insurance providers out of Massachusetts.

“With consumer prices soaring to all-time highs, the Commonwealth doesn’t need this added regulation that will only increase costs and decrease choice for patients across the state,” according to a statement by the opposition committee.

The study predicts that premiums could increase by 38%, jumping from $35 permonth to $50.

That would be painful to consumer pocketbooks.

However, Morad said that at least one large Massachusetts provider has the same number of millionaires on its board as the state’s largest health insurer; Blue Cross Blue Shield.

“And these insurance providers are designated as non-profits,” Morad said.