Mass. could be the birthplace of a dental revolution. Here’s why.

After voters overwhelmingly approved Question 2, which requires dental insurers to spend more on patient care, dentists in other states are planning similar campaigns.

Dentists nationwide are planning a push to require dental insurance plans to pay a set amount toward patient care, after a resounding win at the ballot box in Massachusetts last month.Carlin Stiehl for The Boston Globe

The battle over Question 2 on November’s ballot essentially began as a showdown between a disgruntled orthodontist and a well-connected dental insurer.

By the time Election Day arrived, it had become so much more than that. Maybe even the start of a revolution.

Dentists from around the country poured money into the campaign, helping generate more than $9.5 million for the cause. The opponents spent almost as much after other insurance companies joined Delta Dental of Massachusetts to block it.

The roughly $18 million in spending underscores the high stakes: Question 2 will impose financial reporting rules for dental insurers in Massachusetts and require them to devote at least 83 percent of premiums they collect to patient care, or rebate the difference.

Now, the overwhelming support for the measure — 72 percent of Massachusetts voters were in favor — has emboldened dentists in other states to embark on their own campaigns. The Question 2 legislation was considered the first of its kind to become state law. If industry chatter is any indication, it won’t be the last.

Take a look at Oklahoma, whose state association was one of 49 to contribute to Question 2. After the big win here, the Oklahoma Dental Association is gearing up for its own bill, which would impose an 85-percent loss ratio on dental plans in that state.

“The dentists in Oklahoma are thrilled about what happened in Massachusetts,” executive director Lynn Means said. “It might be one of the most precedent-setting things to happen in dental benefits in decades. ... It is because Massachusetts was so successful that we feel confident about filing this bill.”

Like many in her industry, Means said dental plans are more like gift cards than insurance coverage; in an emergency, dental patients can quickly max out. Call them “dental benefits,” she said, not insurance. If these plans have to meet loss ratios, like those imposed nationwide by Obamacare on health plans, she said, it would represent an “existential shift” for the insurers but also prompt stronger coverage for consumers.

The Connecticut State Dental Association is also planning to push for an 85-percent ratio, though executive director Kathlene Gerrity expects resistance, especially because her state is home to many of the country’s biggest insurance companies. The Question 2 victory, she said, gives her group more confidence. “Certainly what happened in Massachusetts has put more wind in our sails,” Gerrity said.

Question 2 came too late for dentists in Maine. They tried to get a similar measure passed in the state Legislature but ran into resistance from insurers and their lobbyists. Maine lawmakers adopted a ratio reporting requirement this year, but no minimum threshold or refund mandate. Therese Cahill, head of Maine’s dental association, said her group was an early contributor to the Massachusetts fight. Maine was close to something similar. Now, she said, Maine dentists want to honor the legislators’ work and give the state’s new reporting rules time to play out, before pressing for additional reforms.

Dr. Andrew Tonelli worked on milling a crown for his patient, Paul Convey, with the help of dental assistant Sharon Tavares at Dental Health Concepts in North Reading, Mass. in October. Carlin Stiehl for The Boston Globe

In Massachusetts, though, the voters have spoken: State insurance regulators will need to write the rules to make the loss-ratio mandate a reality by this time next year.

It all started with Dr. Mouhab Rizkallah, an orthodontist who has long tangled with state regulators over Medicaid reimbursement rates. (He remains locked in a court battle over this issue with Attorney General and Governor-elect Maura Healey.) Rizkallah also owns a number of apartment buildings in communities around Boston, helping provide the resources to launch a ballot question. Last year, he spent $500,000 of his own money for signature gatherers to collect enough names. After Rizkallah began receiving modest contributions from colleagues this year, the real breakthrough for Question 2 came when the American Dental Association pledged $5 million in September and encouraged its members to donate as well. Rizkallah ended up contributing about $2 million this year, too.

Chad Olson, the ADA’s director of state government affairs, said there’s a reason that 49 state associations contributed: They see an opportunity to change the paradigm. Olson expects most will take it up with their respective legislatures rather than pursuing ballot questions (in part because two dozen states don’t even allow such initiatives). Nevada, he said, is the only place with a dental loss ratio threshold already on the books, at 75 percent. But it apparently doesn’t have enough, um, teeth. Dentists there will ask legislators to adopt a refund requirement, like the one that proved popular in Massachusetts.

Needless to say, the insurers don’t seem pleased with the turn of events. Delta Dental underwrote most of the opposition campaign, kicking in roughly $6 million. Several others — Sun Life, MetLife, Guardian, Principal — chipped in, too. They argued Question 2 would hurt, not help, consumers by driving up the cost of doing business, possibly prompting insurers to raise premiums or leave Massachusetts. Many employers may drop the benefit entirely, leading more people to go without dental care, said Jack Dolan of the American Council of Life Insurers. Dolan’s blunt forecast: “Under the Massachusetts scenario, everyone, including dentists, loses.”

He notes that health insurance premiums can average more than $700 a month, or 15 times more than premiums for dental insurance. That leaves the dental plans with a much smaller margin to spend on administrative functions.

Most plans in Massachusetts are below the 83 percent. As a result, the National Association of Dental Plans said it can point to one probable outcome: Premiums go up, while reimbursements to dentists increase at an even faster pace, without any tangible improvements in patient care. Given the nuances of insurance reform, the NADP hopes for more success negotiating with legislators than by waging war with TV ads and sound bites. The insurance industry fully expects a nationwide push by the dentists.

So does Rizkallah. During an emotional victory speech on Election Night at the Fairmont Copley Plaza hotel, Rizkallah promised that Question 2 “will now ricochet to every state in the country.” Rizkallah plans to ask Congress to create a federal standard, by removing a dental plan exemption from the Obamacare requirement. Meanwhile, the ADA sees a state-by-state approach as a more practical strategy.

Either way, Rizkallah’s crusade has sparked a fire that will be tough for the insurance industry to put out.

That’s often how a revolution starts: one passionate person, with a cause that can win the hearts of many.