Dental care has traditionally been financed and delivered separately from medical care. This is despite the Surgeon General’s report in 2000 that emphasizes the importance of oral health to whole body health. Now, new data show the consequences of the approach taken in U.S. health care policy to oral health.
Medicaid Children Seeing Big Gains in Access to Dental Care
The American Dental Association Health Policy Institute (HPI) recently launched The Oral Health Care System: A State-By-State Analysis. This first-of-its-kind data repository brings together data from multiple sources related to oral health and is meant to serve policy makers and researchers. One of the most significant findings from these data is that access to dental care has been increasing steadily among Medicaid children for more than a decade.
Nationally, the percent of Medicaid children who visited a dentist within the past twelve months went from 29% in 2000 to 48% in 2013, the most recent year for which data are available. What is striking is that the trend is remarkably widespread across states, with all but one state experiencing gains over this time frame. As a result, the gap in dental care utilization between Medicaid- and privately-insured children has been shrinking steadily. In fact, it narrowed in every single state for which we have data between 2005 and 2013 (see figure below). There are two states – Hawaii and Texas – where there is actually a “reverse gap”: children enrolled in Medicaid are more likely to visit a dentist than children who have private dental benefits. Moreover, this progress has all been happening during a time when the number of children enrolled in Medicaid and the Children’s Health Insurance Program (CHIP) has been rising steadily. In 2013, nearly four out of ten children in the U.S. were enrolled in Medicaid or CHIP compared to two out of ten in 2000.
Title of Figure: Gap in Dental Care Utilization Between Medicaid-Enrolled Children and Children with Private Dental Benefits, 2005 and 2013
Source: Vujicic M, Nasseh, K. Gap in dental care utilization between Medicaid and privately insured children narrows, remains large for adults. Health Policy Institute Research Brief. American Dental Association. December 2015. Available from:
Trends for Adults Are Much Different
In contrast, the trends for adults are very different. The gap in dental care use between Medicaid- and privately-insured adults is much wider than it is for children and has actually increased in several states in recent years. Adults – especially Millennials – are nearly three times more likely than children to report avoiding dental care they need because of cost. In fact, one out of four low-income adults report that they have avoided dental care they needed in the past year due to financial reasons.
Dental care presents affordability challenges to adults to a much greater degree than any other type of health care service. Emergency room visits for dental conditions in the U.S. are on the rise, a trend that is being driven entirely by young adults. Even among adults with private dental benefits, dental care use is declining in most states and the number one reason adults with private dental benefits do not visit the dentist is cost.
The barriers to dental care that adults face are leading to some troubling physical, social, and emotional effects. New data show that more than one out of three low-income adults say they avoid smiling and 17 percent report difficulty doing usual activities because of the condition of their mouth and teeth. Nearly one out of four low-income adults and 14 percent of all adults report that their oral health issues have led them to reduce participation in social activities.
Where Do We Go From Here?
Looking forward, policymakers and the research community ought to focus on three things to address some of the key challenges facing the U.S. oral health care system.
First, there needs to be a continued and sustained focus on implementing evidence-based policies when it comes to access. The states with the largest gains in access to dental care among Medicaid children over the past decade are those that implemented comprehensive, multi-pronged reforms. For example, Connecticut, Texas, and Maryland reformed their Medicaid programs by focusing on provider and Medicaid beneficiary outreach, provider reimbursement increases,innovations in care delivery models, and streamlined administrative procedures and saw remarkable improvements. It is important to note that the improvements in access to dental care in these three states, as well as others, did not involve any major increase in the number of dental care providers. In fact, there is strong evidence that there is significant excess capacity in the dental care system today. Nationwide, one out of three dentists report they are “not busy enough and can see more patients” suggesting that policymakers ought to focus on interventions that leverage existing unused capacity.
Second, there need to be a rethink of how oral health is defined and measured. The current focus of many government agency data collection efforts, for example,is to measure the presence and severity of dental disease and the frequency and type of dental care services people use. There is very little emphasis, in contrast, on measuring the contribution of oral health to physical, social, and emotional well being. These are the ultimate outcomes of interest that any dental care delivery system ought to be designed around. The new measures of oral health status recently developed by HPI are a significant advancement in this area but are meant to be a starting point for others, including the Centers for Disease Control and Prevention and the Agency for Healthcare Research and Quality, to build on. A robust oral health status measurement system would also enable a shift toward outcomes-based delivery and reimbursement models, a critical future direction in health care in the United States.
Third, policy makers need to reconsider how dental care for adults is handled in state and federal policy. Within Medicaid, adult dental benefits are optional and most states provide only basic coverage. Under the Affordable Care Act, dental care for adults is not considered “essential” and thus, dental benefits coverage is not part of the individual mandate. Implementing a comprehensive dental benefit for Medicaid adults in the 22 states that currently lack one is estimated to cost $1.6 to $1.8billion per year. The estimated state portion of this bill translates to about 1 percent of total Medicaid spending. Compare this to the $1.6 billion spent each year on hospital emergency room visits for dental conditions, one third of which is paid for by Medicaid. Newly published research from the NBER suggests that the dental care system has the capacity to absorb the spike in demand for dental care arising from large-scale expansions of dental benefits to Medicaid adults. There are also numerous state experiences to draw on that serve as good practices in managing adult dental benefits in Medicaid. Beyond Medicaid, insurers are approaching dental benefits for children and adults differently within the health insurance marketplaces. While more and more private medical insurance plans in the health insurance marketplaces are covering dental benefits for children, there are far fewer options for adults. This is despite the fact that dental care is a high priority among adults, especially young adults,who are shopping for health insurance.
As a former U.S. Surgeon General said, “you can’t be healthy without good oral health.” There is emerging evidence that oral health is related to conditions outside of the mouth, like diabetes, pregnancy, and even mental health. Health care policy in the United States clearly emphasizes the importance of oral health for children. It might be time to reconnect mouth and body for adults.
Marko Vujicic is the Chief Economist and Vice President of the Health Policy Institute at the American Dental Association. Prior to joining the American Dental Association, he was Senior Economist with The World Bank in Washington D.C. where he directed the global health workforce policy program. He was also Labor Economist at the World Health Organization in Geneva, Switzerland.
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Excellent analysis, Marko. The point you made that I would like to emphasize is that the supply of dentists is not the problem. There is measurable unused capacity in many dental offices for a few reasons.
First, the supply of dentists in the U.S. has increased and is expected to continue to do so as more dental schools open and the baby boomers are slower to retire. Second, as you point out, adults perceive that dental care is too costly, however that is just a perception. Routine, preventative care is affordable for most budgets, it just has to be valued as much as other costs. If patients delay routine care because “nothing hurts” then they will find themselves with more costly options to restore health. I think some public education would be beneficial here (e.g. routine check up cost every six months compared to six months of a cell phone bill).
So if the supply of dentists isn’t the problem, I would argue the issue is distribution and demand. I already spoke of demand in the prior paragraph. By distribution I don’t just mean having dentists in more remote parts of the country. I also mean increasing incentives for dentists to take private and public benefit plans. Better reimbursement and less red tape should strongly encourage dentists to incorporate these plans into their practices.
The omission of adult dental coverage in the ACA is not for lack of trying but, at the time, it simply wasn’t politically feasible to include it as an essential health benefit. Keep in mind that many compromises were made in order to make the law passable. Still, as Marko alluded to, it might have become a reality had the dental community as a whole agreed to pursue an adult benefit but historically some segments of the community have sought to remain outside of the constraints of government programs, so to speak.
As for why children’s dental coverage isn’t part of the individual mandate, that has more to do with the fact that dental insurance has historically been separate from health coverage and dental plans are considered excepted benefits for the purposes of most market reforms. The individual mandate explicitly excludes these excepted benefits, stating only that people must have health coverage.
Luckily, some states have been able to address the latter issue by establishing standard plan designs that integrate dental coverage into health plans, ensuring that every child who enrolls in a health plan automatically receives dental benefits without having to pay an additional premium.
First, congrats to ADA, HPI and to Marko for a continuing, frequent series of wonderful reports, commentaries, research papers, etc that bring evidence to discussions about oral health and access to care. One only wishes that dentists would use more evidence to base their actions and decisions on such things as dental therapists and other innovative solutions to the access problems. But, on to other important issues raised in this commentary.
First,with respect to the increases in utilization across the country for Medicaid enrolled children, it should be noted that for some of these states, the improvements only came after lawsuits against the states to improve reimbursement and fixing administrative barriers. MORE STATES OUGHT TO LOOK AT THE LAWSUIT APPROACH,, albeit, not doing much good yet in Florida right now. Second, the trends for adults are indeed shocking. COSTS are the key factor and the decreasing numbers of adult visits are probably a key factor in the alarming increase in Hospital ED visits for preventable dental conditions. We could probably reduce the costs of such care on a per capita basis if we had dental therapists- the evidence is clear in Minnesota and in Alaska. But, “you know who” is blocking this in many states!!!!!!!
A comments about the “excess capacity” issue. Yes, dentists may have excess capacity but, will they use this capacity to exercise their professional and moral obligations to help those in need (in return for which they get a monopoly on dental care); prior history says they will not see these Medicaid and other low income patients. But they could if they hired dental therapists.
I applaud the efforts to develop self reported oral health state measurements. However, my concern is that self reported measures do not address the NEEDS of those who cannot currently access the system- this is the old “need versus demand” argument the ADA uses to say we do not have shortages. We also should support the DQA quality measures which get closer to the real need of underserved patients.
Finally, a plea to make sure the data we collect is accurate if we plan to use it for making decisions. For example, a recent HPI report stated that about 30% of Florida dentists participate in the medicaid program- we know that number is really much closer to 8%. We know this data is hard to get and verify but it is critical that we use the best data we can.
Finally, I truly want to thank Dr. Vujicic and his team at the ADA HPI for their work over the past few years. The above comments are not meant to criticize him or the HPI reports- please keep up the quality work you are doing. Rather, they are a plea to 1) continue working hard to get the right data so we can make better decisions and 2) a plea to the ADA and member dentists to use data rather than emotion and fear to make decisions about access solutions.
Great post. I especially agreed with the second point on measurement. As soon as we better understand the true price we are paying for a lack of dental care, the easier the financial argument can be made for shifting and refocusing our resources.
This is a shrewd analysis and great commentary. One of the critical facets of the health care industry’s collective move toward “value” is in recognizing the myriad health determinants that have often been overlooked in various clinical settings. The shift of the risk dollar to the locus of care should start driving greater clinical and economic alignment between traditional care settings and additive institutions like behavioral health, post-acute and dental. Oral health plays a fundamental role in ameliorating health disparities. Recognizing this will drive improved patient outcomes and economic efficiency.
John –
I was not around at the time, but the ACA negotiations around dental care were very superficial and somewhat shortsighted in my view. In fact, had it not been for very strong advocacy efforts among key groups, dental coverage for children would not have even made it into the essential health benefit package. I think a lot of this has to do with legacy and history and the oral health community – payers, providers, consumer groups – did not exactly approach Congress with a united front. But that is all in the past and there is actually quite a bit of innovation happening in some states on how they are approaching dental benefit redesign post-ACA. Check out the latest here:
http://www.ada.org/en/science-research/health-policy-institute/publications/webinars/taking-stock-of-the-pediatric-dental-benefit-mandate-under-the-aca
On your second point, the Health Policy Institute is working on new measures of self-reported oral health. You can get a sense of what we are envisioning at http://www.ada.org/statefacts We are measuring how the condition of the mouth and teeth affect day to day function, self-esteem, and job prospects.
Marko
Marko
It does seem odd, particularly given what we now know about the ways our oral health influences our overall health. Given the emphasis on prevention in the ACA, this seems a strange omission. Any insight or theories on what happened during the ACA negotiations?
Meanwhile your comments on measurement are very interesting. Can you tell us a bit more about how you plan to quantify oral health? And what could we theoretically learn from low scores?
/ j