35. Dental Insurance

Summary

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The Economics of Everyday Things – Episode 35: Dental Insurance

Host: Zachary Crockett (Freakonomics Network)
Guests: Dr. Pamela Maragliano Muniz (Dentist, Salem, MA), Brad Bolman (Medical Historian), Wendell Potter (Healthcare Activist, former Cigna executive)
Release Date: April 30, 2026

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Episode Overview

This episode unpacks the concept of dental insurance—exploring what it really covers, why it's so distinct from medical insurance, and the economic oddities that keep dental care separate from overall healthcare in the U.S. Host Zachary Crockett investigates dental insurance’s history, the real value it provides (or fails to), and what could change in the future, with perspectives from practitioners, historians, and industry insiders.

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1. The History: Why Are Teeth Treated Differently?

Key Segment: 03:02–08:48

• Dentistry began as a marginal, sideshow profession in the 1700s and 1800s, with practitioners performing in carnivalesque settings—sometimes pulling teeth while juggling or joking.

  • Brad Bolman (Medical Historian): “They were often these carnivalesque performers who would have little shows and moving performances while giving dental care to people. And partly the performances were designed to muffle the screams of people having their teeth pulled.” (03:34)

• In 1840, two dentists (Horace Hayden and Chapin Harris) were denied the chance to teach at a medical school. They responded by founding the first dental school, cementing the split between medicine and dentistry.

  • Bolman: “...we can trace the origins of the separation to basically two guys who are rejected from medical school?” (05:31)
  • Bolman: “That is right. And that's at least the story that dentists like to tell.” (05:38)

• Dentists ultimately developed an independent, professional identity, with their own schools and philosophies, and resisted being folded into broader public health programs even after World War II.

  • Bolman: “Dental practice in the mid-1900s is typically very different from medical practices. Dentists often work in their own small offices… an individualistic approach.” (07:26)

• The American Dental Association (ADA) fiercely lobbied to exclude dental coverage from major health programs such as Medicare. Their efforts succeeded—most federal programs don’t cover routine dental care.

  • Bolman: “The ADA fights a really vicious battle against including dental benefits within Medicare... Ultimately they win. Teeth are excluded from basic Medicare benefits.” (08:00)

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2. Dental Insurance Today: What Does It Really Mean?

Key Segment: 08:48–13:43

• It’s Not True Insurance:
  Most dental “insurance” just means prepaid, limited annual benefits—more like a “gift card” than risk pooling.

  • Dr. Maragliano Muniz: “Dental insurance is simply a gift card.” (08:44)
  • Dr. Maragliano Muniz: “I think the number one problem is the fact we call it insurance.” (02:55, 11:40)
  • Dr. Maragliano Muniz: “When something goes catastrophically bad, this insurance that you've paid for is there to support you in that. However, dental insurance does not operate that way.” (11:40)

• Most plans cover routine cleanings, X-rays, and—partially—procedures like fillings and crowns. But annual maximums (usually around $1,500) haven’t changed much in decades and are inadequate for dental emergencies.

  • Dr. Maragliano Muniz: “It's kind of the opposite approach as what insurance should be. You're getting a $1,500 gift card per year that doesn't really cover that much of your dental.” (13:43)
  • Dr. Maragliano Muniz (analogy): “Imagine you lost all your teeth…can you imagine if the insurance company’s like, 'We'll clean your windows and paint your siding.' And you're like, 'No, no, no, wait. My whole house burned down...' But that's what dental insurance is.” (12:43)

• Dental insurance provides, at most, a small discount for the generally healthy—but quickly caps out for anyone needing more extensive care.

  • Crockett (host): “When you sign up for dental insurance, you're paying for, at most, a small discount on your dental work over the next year.” (13:55)

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3. Economics for Insurers and Providers

Key Segment: 14:26–17:17

• Dental insurers can make high profits because they rarely pay out major claims. There’s also a notable absence of regulation on “medical loss ratios” (MLR) for dental plans—unlike in medical insurance, where 80% of premiums must go to patient care by law.

  • Wendell Potter (ex-insurance exec): “If you are selling this kind of insurance, you can see how profitable it can be because you're not providing very good coverage.” (14:26)
  • Potter: “In a medical insurance plan, you have, by law, a requirement that insurers spend at least 80%... There’s no such thing in dental care. So it's kind of the wild west out there for dental benefits.” (15:07)

• Exception: Massachusetts passed a ballot measure in 2022 requiring dental insurers to spend 83% of premiums on care, but outside that state, no such requirements exist. (15:24)

• For dentists, joining insurance networks boosts their patient base—but forces them to accept insurer-set prices, often resulting in significant write-offs on procedures.

  • Dr. Maragliano Muniz: “You can build a practice much faster when you participate in insurance plans... But there’s a trade off.” (16:05)
  • Dr. Maragliano Muniz: “Every insurance has their own fee schedule…by being in network, you have to write off contractually $500 on every single crown...” (16:37)

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4. Could Dental and Medical Ever Reunite?

Key Segment: 17:17–18:00

• There’s growing curiosity (and some optimism) about re-integrating dental with broader healthcare, but resistance—rooted in both profession and policy—is strong and slow to erode.
  • Bolman: “We're moving toward a world where these things are going to be merged somehow. That's the optimistic side... But you also see this really intense and long fight to keep dentistry and medicine separate.” (17:28)

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5. Alternatives: “Netflix for Cleanings” and Self-Pay

Key Segment: 18:00–18:46

• Some dental practices create their own in-house “membership plans,” where patients pay a monthly fee for preventative care—a model compared to Netflix.

  • Dr. Maragliano Muniz: “It's almost like Netflix. You pay a monthly fee and it covers all of your preventive visits and then you have a percentage off of any restorative visit that you have.” (18:06)

• Even critics of insurance, like activist Wendell Potter, personally opt-out and use these direct-pay plans.

  • Potter: “I am one of the people who pays an annual amount to my dentist for my care and I find that to be more cost effective. I do not have dental insurance myself. It's such a waste of money, in my view,” (18:25)

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Notable Quotes & Memorable Moments

• "Dentists were often these carnivalesque performers...designed to muffle the screams of people having their teeth pulled."
  – Brad Bolman, Historian (03:34)

• “Dental insurance is simply a gift card.”
  – Dr. Pamela Maragliano Muniz (08:44)

• “I think the number one problem is the fact we call it insurance.”
  – Dr. Pamela Maragliano Muniz (02:55, 11:40)

• “If you are selling this kind of insurance, you can see how profitable it can be because you're not providing very good coverage.”
  – Wendell Potter (14:26)

• “I am one of the people who pays an annual amount to my dentist for my care...I do not have dental insurance myself. It's such a waste of money, in my view,”
  – Wendell Potter (18:25)

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Timestamps: Segment Highlights

• [03:02] History of dentistry’s separation from medicine.
• [05:08] Baltimore rejection and founding of dental schools.
• [08:00] ADA and exclusion of dental from Medicare.
• [08:44] “Dental insurance is simply a gift card.”
• [12:43] Why dental insurance isn’t catastrophic.
• [14:26] Insurer profit model and lack of regulation.
• [15:24] Massachusetts’ new dental medical loss ratio.
• [16:05] Dentist practice-building via insurance networks.
• [17:28] Prospects for merging dental and medical coverage.
• [18:06] In-house membership plans: the “Netflix” model.

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Takeaway

Dental insurance in the U.S. is a historical outlier: structurally distinct from medical insurance, set up to act more like a limited-use coupon than true catastrophic coverage, and maintained by deep professional, financial, and policy inertia. Unless reforms (like Massachusetts's new MLR law) or creative new payment models become widespread, most Americans will continue to navigate a peculiar system where dental health remains, economically and practically, isolated from healthcare at large.

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Transcript

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[Dr. Pamela Maragliano Muniz]

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[Zachary Crockett (Narrator/Host)]

Dr. Pamela Maragliano Muniz never thought she'd end up fixing teeth for a living.

[Dr. Pamela Maragliano Muniz]

I thought I'd become, I don't know, a professional hockey player or something like that.

[Zachary Crockett (Narrator/Host)]

Her dreams of glory on the ice didn't pan out, and her father suggested dental hygienist school.

[Dr. Pamela Maragliano Muniz]

And I got right into dental hygiene school and who knew? I absolutely fell in love with it. I felt like I was finally going to school with a purpose for the first time. And I felt that if I was going to place my hands on another human, there's such a responsibility that comes with that.

[Zachary Crockett (Narrator/Host)]

Miragliano Muniz became a hygienist, but she didn't stop there. She completed her Doctor of Dental Medicine degree, became a dentist, and in 2014 bought her own practice in Salem, Massachusetts. She was excited to get to work, helping her patients and building her business, but she soon found herself spending much of her time navigating the complex rules of dental insurance plans.

[Dr. Pamela Maragliano Muniz]

For example, some plans only allow two dental hygiene visits a year, and sometimes it's twice within the calendar year. Doesn't matter really when it is, but then there's some that say, no, no, no, we we only allow two hygiene visits, but they have to be six months and a day apart. So you just have to kind of follow all of the rules of that plan.

[Zachary Crockett (Narrator/Host)]

In the course of sifting through the intricacies of these plans, Maragliano Muniz began to ask herself some fairly existential questions. What is dental insurance anyway? Why isn't it part of medical insurance? And what were her patients getting when they signed up for it? Eventually, she came to a realization.

[Dr. Pamela Maragliano Muniz]

I think the number one problem is the fact we call it insurance.

[Zachary Crockett (Narrator/Host)]

For the Freakonomics radio network, this is the economics of everyday things. I'm Zachary Crockett. Today, dental insurance, if you have medical insurance, you expect it to cover at least some of the cost of treatment when you have an illness or an injury, unless that illness or injury involves your teeth. What puts those enamel covered mouth nubs in a separate category from the rest of your body? The answer goes back a couple of centuries.

[Brad Bolman (Medical Historian)]

Dentists were in the 1700s and the 1800s. They were often these carnivalesque performers who would have little shows and moving performances while giving dental care to people. And partly the performances were designed to muffle the screams of people having their teeth pulled.

[Zachary Crockett (Narrator/Host)]

That's Brad Bolman. He researches the history of medicine at the Institute for Advanced study in Princeton, New Jersey. He says that in the 18th and 19th centuries, dentistry was sort of a weird profession.

[Brad Bolman (Medical Historian)]

A lot of the time, these dentists were somewhat itinerant. They would offer perhaps multiple services, so maybe teeth pulling and a haircut or something like that. The performances might include juggling. The dentists were often these larger than life impresario figures who would maybe pull your teeth while making jokes or giving lectures.

[Zachary Crockett (Narrator/Host)]

In the early 19th century, all of medicine started to professionalize and specialize, and dentists wanted in. But they had a bit of a PR problem.

[Brad Bolman (Medical Historian)]

For a lot of the medical profession, dentists are still seen as a barbaric little sideshow or something like that. You know, it's not the most prestigious kind of medicine that someone could practice. And in a sense, that's at the root of this historic rebuff.

[Zachary Crockett (Narrator/Host)]

The historic rebuff that Bowman is referring to took place in Baltimore around 1840.

[Brad Bolman (Medical Historian)]

You had these two dentists, Horace Hayden and Chapin Harris, who come to the medical faculty at the University of Maryland, and they say, we want to start teaching dentistry here. They're refused. And this moment really sets the foundation for these dual trajectories between medicine and dentistry.

[Zachary Crockett (Narrator/Host)]

So you're telling me that we can trace the origins of the separation to basically two guys who are rejected from medical school?

[Brad Bolman (Medical Historian)]

I think in a sense, that is right. And that's at least the story that dentists like to tell.

[Zachary Crockett (Narrator/Host)]

Hayden and Harris responded to that snub by founding the first dental school in the world in Baltimore. By 1900, the US had 56 more of them. Dental education was booming, and dentistry itself was changing, too.

[Brad Bolman (Medical Historian)]

During the period when these institutions are growing, you get some of the first widespread uses of anesthetics, which makes teeth pulling a slightly less painful endeavor. You start to get debates among dentists about what is the goal of dentistry, what should a dentist be doing? And then of course there's a natural development where tools get better. You get some early mechanical drills which allow for more effective response to dental maladies. So there's this widespread growth in dental practice in dental technique. But because of the separation, you really get this sense that being a dentist is something different than being a doctor.

[Zachary Crockett (Narrator/Host)]

Dentists evolved from carnival style performers into trained professionals doing valuable medical work. But that separation between dentistry and other forms of medicine persisted partly because dentists wanted to be in their own camp. Above all, they didn't want dental services to be included in medical insurance. Both doctors and dentists fought against proposals to institute government provided health insurance in the decades after World War II. The doctors got on board with the system of employer sponsored plans that cover most of us today. But the dentists didn't.

[Brad Bolman (Medical Historian)]

Dental practice in the mid-1900s is typically very different from medical practices. Dentists often work in their own small offices. They often own their practices rather than being part of a hospital or being part of a larger practice. So there's very much an individualistic approach and and ideology to a lot of dentists.

[Zachary Crockett (Narrator/Host)]

The American Dental association kept up the fight against state subsidized coverage.

[Brad Bolman (Medical Historian)]

So in 1964, Medicare is proposed and the idea is that it would cover basic healthcare across the board. That would include dentistry and dental visits. The ADA fights a really vicious battle against including dental benefits within Medicare. It's a key fight for the dentists and ultimately they win. Teeth are excluded from basic Medicare benefits,

[Zachary Crockett (Narrator/Host)]

while dentistry is mostly excluded from public insurance programs. There are now hundreds of companies offering private dental insurance policies to Americans. But are they really insurance policies?

[Dr. Pamela Maragliano Muniz]

Dental insurance is simply a gift card.

[Zachary Crockett (Narrator/Host)]

That's coming up.

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[Dr. Pamela Maragliano Muniz]

People in general need to understand and get a realistic view on what dental insurance is.

[Zachary Crockett (Narrator/Host)]

Again, that's Dr. Pamela Maragliano Muniz.

[Dr. Pamela Maragliano Muniz]

I think the number one problem is the fact we call it insurance. Because when you hear insurance, you think of, oh, I have homeowner's insurance, I have medical insurance, I have life insurance. So when something goes catastrophically bad, this insurance that you've paid for is there to support you in that. However, dental insurance does not operate that way. And so I think that patients think that, well, I have dental insurance. That should be the same as the way my medical insurance works. And it does not.

[Zachary Crockett (Narrator/Host)]

Medical insurance, like most things we refer to by the name insurance, works by pooling risk. In a given year, most of us will pay more for health insurance premiums than we get back in medical services. But a few people will need a lot of treatment and their insurance will pay out much more than their premiums cost. We accept that deal because even if we're healthy now, there's always the risk that we'll get sick. A dental insurance plan doesn't work like that.

[Dr. Pamela Maragliano Muniz]

Imagine you lost all of your teeth for some reason, or from a personal standpoint, say your house burns down. You contact your insurance company, and can you imagine if the insurance company's like, we'll clean your windows and paint your siding. And you're like, no, no, no, wait. My whole house burned down. I don't even have a house. I don't even have windows anymore. And they're like, well, we'll clean your windows and paint your siding. You're like, but that's not what I need. But that's what dental insurance is.

[Zachary Crockett (Narrator/Host)]

Dental insurance pays for routine treatment, cleaning, x rays, the stuff we should all be getting every year. If you have a cavity or need a crown or dentures, your dental insurance plan will cover some of that. But most dental plans have a maximum benefit of around $1,500 a year. That'll cover those cleanings. But it won't help if you have a dental catastrophe, an infection that causes an abscess, a badly cracked tooth, or any kind of mouth trauma.

[Dr. Pamela Maragliano Muniz]

It's kind of the opposite approach as what insurance should be. You're getting a $1,500 gift card per year that doesn't really cover that much of your dental.

[Zachary Crockett (Narrator/Host)]

In other words, when you sign up for dental insurance, you're paying for, at most, a small discount on your dental work over the next year.

[Dr. Pamela Maragliano Muniz]

Dental practices will work very hard to maximize whatever benefit the patient has. But it's important to understand that unless you are generally healthy and you just need dental hygiene visits, then you know you're really going to probably max out relatively quickly.

[Wendell Potter (Healthcare Activist)]

If you are selling this kind of insurance, you can see how profitable it can be because you're not providing very good coverage.

[Zachary Crockett (Narrator/Host)]

That's Wendell Potter. He used to be an executive at the insurance giant cigna. But after witnessing his share of horrors in the American healthcare system, he switched sides and became an activist.

[Wendell Potter (Healthcare Activist)]

I'm president of the center for health and democracy, which is a nonprofit organization dedicated to health care reform.

[Zachary Crockett (Narrator/Host)]

As Potter explains it, the other difference between medical and dental insurance has to do with what's called the medical loss ratio. That's the share of revenue that the insurer has to spend on medical care for policyholders.

[Wendell Potter (Healthcare Activist)]

In a medical insurance plan, you have, by law, a requirement that medical insurers spend at least 80% of what we pay in premiums that goes to medical care. There's no such thing in dental care. So it's kind of the wild west out there for dental benefits.

[Zachary Crockett (Narrator/Host)]

That might be starting to change. In Massachusetts, where Maragliano Muniz practices dentistry, voters approved a ballot measure in 2022 requiring dental insurers to spend at least 83% on care outside of Massachusetts, there are no requirements. So dental insurance works pretty well for insurance companies and not that great for patients. How does it work for dentists? Well, it faces them with a choice. They can sign up to become part of the insurer's network or stay out of network. Joining the network helps attract patients.

[Dr. Pamela Maragliano Muniz]

You can build a practice much faster when you participate in insurance plans. If you participate, you're on a list and it makes it a little bit easier for patients to find you. It's almost low hanging fruit for patients to find a dentist. They say, oh, I subscribe to this insurance. Let me find a dentist that's close to me. But there's a trade off.

[Zachary Crockett (Narrator/Host)]

If you're in an insurance network, the insurer gets to set the prices you charge its members.

[Dr. Pamela Maragliano Muniz]

Every insurance has their own fee schedule on what they feel your procedure is worth. Let's say a crown. They say, okay, our usual and customary fee for a Crown is say, $1,000, and they will pay 50% of $1,000. So say your crowns are $1,500. Just by being in network with this insurance plan, you have to write off contractually $500 on every single crown that you perform. You may accept three different fee schedules from three different insurance companies. It's just what it means to be in network with them.

[Zachary Crockett (Narrator/Host)]

So could dental insurance ever look more like medical insurance? Could it even become a part of your health plan? Historian Brad Bowman says, maybe people are

[Brad Bolman (Medical Historian)]

starting to wonder again why they don't have access to free dental care, or at least cheap dental. So my sense is that we're moving toward a world where these things are going to be merged somehow. That's the optimistic side of me. But then you also see this really intense and long fight to keep dentistry and medicine separate. So I think it won't be easy to transform some of these systems because there are a number of people who are fighting to keep this system in place.

[Zachary Crockett (Narrator/Host)]

In the meantime, dentists are trying to come up with better ways for patients to pay for care.

[Dr. Pamela Maragliano Muniz]

Some practices offer in house membership plans. It's almost like Netflix. You pay a monthly fee and it covers all of your preventive visits and then you have a percentage off of any restorative visit that you have.

[Zachary Crockett (Narrator/Host)]

Wendell Potter sees value in that approach.

[Wendell Potter (Healthcare Activist)]

I am one of the people who pays an annual amount to my dentist for my care and I find that to be more cost effective. I do not have dental insurance myself. It's such a waste of money, in my view,

[Zachary Crockett (Narrator/Host)]

For the economics of everyday things. I'm Zachary Crockett. This episode was produced by Julie Kanfer and Sarah Lilly and mixed by Jeremy Johnston. We had help from Daniel Moritz.

[Brad Bolman (Medical Historian)]

There are a lot of great dentists. I don't want to come out as an anti dentist figure right.

[Zachary Crockett (Narrator/Host)]

And I don't think you're coming across that way at all.

[Brad Bolman (Medical Historian)]

Okay, good. I loved my childhood dentist. He was a great guy.

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