GAO

United States General Accounting Office

Report to Congressional Requesters

April 2000 ORAL HEALTH

Dental Disease Is a

Chronic Problem

Among Low-Income

Populations

GAO/HEHS-00-72

Page 1 GAO/HEHS-00-72 Oral Health in Low-Income Populations

Contents

Letter 3

Appendixes Appendix I: Scope and Methodology 22

Appendix II: State Data Tables 24

Appendix III: Comments From the Department of Health and Human

Services 29

Tables Table 1: Four National Health Surveys With Dental Data, 1988-97 6

Table 2: Percentage of Adults With Tooth Loss From Decay or Gum

Disease by Family Income 11

Table 3: Percentage of Selected Ethnic Groups With Untreated

Tooth Decay 12

Table 4: Number of States That Provide Dental Coverage for

Children and Adults 14

Table 5: Percentage of Residents Making a Dental Visit in 1996 by

Metropolitan Area and Income 19

Table 6: Percentage of Adults Who Made a Dental Visit in the

Preceding Year by Annual Family Income 24

Table 7: Medicaid Coverage of Adult Dental Care 26

Table 8: Percentage of Medicaid Fee-for-Service Recipients Who

Made a Dental Visit in the Preceding Year 28

Figures Figure 1: Percentage of Children With Untreated Caries by

Family Income 8

Figure 2: Restricted Activity Days per 100 Children Because of

Dental Problems by Family Income 9

Figure 3: Percentage of Adults With Untreated Caries by

Family Income 10

Figure 4: Percentage of Population Who Made a Dental Visit in the

Preceding Year:1977, 1987, and 1996 13

Figure 5: Percentage of Children Who Made a Dental Visit in the

Preceding Year by Family Income 15

Figure 6: Percentage of Children With at Least One Sealant by

Family Income 17

Figure 7: Percentage of Adults Who Made a Dental Visit in the

Preceding Year by Family Income 18
Contents

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Abbreviations

ADA American Dental Association

AHRQ Agency for Healthcare Research and Quality

BRFSS Behavioral Risk Factor Surveillance System

CDC Centers for Disease Control and Prevention

EPSDT Early and Periodic Screening, Diagnostic, and Treatment

HCFA Health Care Financing Administration

HHS Department of Health and Human Services

MEPS Medical Expenditures Panel Survey

NHIS National Health Interview Survey

NHANES III National Health and Nutrition Examination Survey III

SCHIP State Children's Health Insurance Program

SMRF State Medicaid Resource File
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United States General Accounting Office

Washington, D.C. 20548

Health, Education, and

Human Services Division

B-283914 Letr

April 12, 2000

The Honorable Jeff Bingaman

The Honorable Russell D. Feingold

United States Senate

The Honorable Thomas M. Barrett

The Honorable David R. Obey

House of Representatives

The dental health of most Americans has improved significantly since the

1960s. There is growing concern, however, that low-income and other

vulnerable populations continue to have high levels of dental disease.

Dental problems not only affect health and well-being but also contribute

to lower productivity in the workplace and increased absenteeism at

school. This continued vulnerability is a matter of concern to the federal

government and the states, which jointly fund Medicaid, a program that

pays for health care—including dental care—for low-income and disabled

persons. Gauging the extent of efforts to address the problem through

Medicaid and related programs has been difficult, because the

implementation of these programs differs from state to state. To explore

these issues in more depth, you asked us to report on (1) the dental health

status of Medicaid beneficiaries and other vulnerable populations and (2)

the extent to which these groups have dental coverage and use dental

services. At your request, we are also conducting a second study in which

we will identify major barriers to dental care and assess federal and state

efforts to overcome them.

To respond to your request, we analyzed dental health and data on the use

of dental health care from four national health surveys and surveyed

Medicaid and related programs state by state. We also analyzed Medicaid

payment data for dental services. Appendix I explains our methodology.

We conducted our work from October 1999 to February 2000 in accordance

with generally accepted government auditing standards.

Results in Brief Dental disease is a chronic problem among many low-income and

vulnerable populations. Our analysis of the most recent national health

surveys (1994-97) showed that relative to more affluent segments of the

population, low-income populations had a disproportionate level of dental
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disease. For example, poor children had five times more untreated dental

caries (cavities) than children in higher-income families, and poor adults

were much more likely to have lost six or more teeth to decay and gum

disease than higher-income adults. Minority populations also faced high

levels of dental disease. Dental problems result in pain, infection, and

millions of lost school days and workdays each year.

Although every state Medicaid program offers dental coverage for children

and most programs cover adults eligible for Medicaid, use of dental

services by low-income people is low. States are required to provide

comprehensive dental benefits for children enrolled in Medicaid, and the

State Children’s Health Insurance Program (SCHIP) provides variable but

often substantial levels of dental coverage to eligible low-income children

in all but two states. Adult dental services, although optional under

Medicaid, are covered to some extent in about two-thirds of the states. The

availability of coverage does not, however, bridge the income gap to

equalize the likelihood of visiting a dentist. For example, our analysis of

1995 Medicaid claims data showed that only 29 percent of enrolled adults

had visited the dentist in the preceding year, less than half the rate of

higher-income adults. National survey data also showed that in 1996 poor

children and adults visited the dentist at about half the rate of their higherincome counterparts—numbers that had stayed relatively unchanged since

1977.

Background Medicaid is the largest public program of health care insurance for lowincome people. As a joint federal and state program, it finances health care

coverage for about 40 million people, over half of whom are children.

Nationwide, combined federal and state expenditures were $177 billion in

1998. The states operate their Medicaid programs within broad federal

requirements and can elect to cover a range of optional populations and

services, thereby creating programs that differ substantially from state to

state. Despite this variation, some services are mandated under federal

law. For instance, in 1967 the Congress created the Early and Periodic

Screening, Diagnostic, and Treatment (EPSDT) service within Medicaid to

help ensure that children receive needed medical and dental care. Under

EPSDT, the states must provide comprehensive medical and dental

services for all enrolled children, even if the services are not normally

covered by a state’s Medicaid program. While EPSDT requires the states to

provide certain care for children, many services for adults, such as dental

care, are optional under state Medicaid programs.
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Although Medicaid covers low-income people, only about half of those

living in poverty were eligible for Medicaid in 1996, according to the

Congressional Research Service. This is largely because of eligibility

restrictions that make benefits available only to certain low-income

categories, such as families with children and the aged, blind, and

disabled.1 While the Congress expanded eligibility for pregnant women and

children several times beginning in 1984, the states can expand coverage to

these populations beyond federal requirements. To expand health

coverage to children whose families have incomes that are low, but not low

enough to qualify for Medicaid, in 1997 the Congress created SCHIP as title

XXI of the Social Security Act. In return for an enhanced federal matching

share, states can expand coverage to low-income children in families

earning up to 200 percent of the federal poverty level.2 To implement

SCHIP, the states have three options: They can expand their existing

Medicaid program, develop a separate SCHIP program, or do some

combination of both. Coverage of dental services is not mandatory for

children under SCHIP as it is in Medicaid, but if a state elects a Medicaid

expansion, it must offer the same comprehensive benefit package,

including dental services, that is required under EPSDT. By September

1999, nearly two million children were enrolled in the 53 operational

programs. Fifty-six states and territories had SCHIP programs that the

Health Care Financing Administration (HCFA) had approved; three had not

begun enrollment.

1

For example, by law, the states must provide Medicaid eligibility to pregnant women, to

infants, and to children up to age 6 whose family income is up to 133 percent of the federal

poverty level and children aged 6 to 15 whose family income is up to 100 percent of the

federal poverty level. Many adults do not qualify for Medicaid unless they are aged, blind, or

disabled.

2

Under Medicaid, the federal government will match a state’s contribution from 50 to 77

percent in fiscal year 2000, depending on the state’s average income level. Under SCHIP, the

states are eligible for an enhanced federal matching share of 65 to 84 percent. SCHIP allows

states with Medicaid incomes that already approach or exceed 200 percent of the federal

poverty level to expand eligibility to up to 50 percentage points above their existing

Medicaid eligibility standards.
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The federal government collects information on the nation’s dental health

through several nationwide health surveys. The surveys are designed for

different purposes and thus have different strengths and weaknesses. For

example, dental information in the Centers for Disease Control and

Prevention’s (CDC) National Health and Nutrition Examination Survey III

(NHANES III) included examinations that dentists performed. The survey

provided a representative sample of dental health nationwide, but the

results could not be narrowed to the state level. In contrast, data from

CDC’s Behavioral Risk Factor Surveillance System (BRFSS) can be

examined at the state level, but not all states have conducted the oral

health module, and the survey relies on self-reported data that are likely to

overlook some conditions such as untreated tooth decay. We examined

data from a combination of surveys conducted by CDC and the Department

of Health and Human Services’ (HHS) Agency for Healthcare Research and

Quality (AHRQ) in order to minimize individual survey limitations (see

table 1).3

Table 1: Four National Health Surveys With Dental Data, 1988-97

Note: Dental questions vary from year to year within surveys. We used the most recent survey data

available for our analyses.

Recognizing the importance of good oral health, HHS established oral

health goals as part of its departmentwide Healthy People 2000 initiative.

3

Formerly the Agency for Health Care Policy and Research (AHCPR).

Survey Data used in study Description

National Health and Nutrition

Examination Survey III (NHANES III),

CDC

1988-94 A nationally representative survey of the prevalence, trends, and

risk factors for selected diseases. Oral assessments were

conducted by dentist examiners.

National Health Interview Survey

(NHIS), CDC

1994 A broad, nationally representative survey that monitors trends in

illness and disability and tracks progress toward national health

objectives.

Medical Expenditures Panel Survey

(MEPS), AHRQ

1996 A nationally representative survey of health care use,

expenditures, sources of payment, and insurance coverage. Data

are collected through in-person, telephone, and mailed surveys.

Providers are contacted to verify and supplement reported events.

Behavioral Risk Factor Surveillance

System (BRFSS), CDC

1995-97 A state-based random telephone survey of the prevalence of major

behavioral risks associated with premature morbidity and mortality

among adults. Provides state-specific estimates.
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HHS set goals, such as reducing untreated caries in children and increasing

regular dental visits by adults, for the population in general and some

minority groups. Interim assessments showed that progress toward these

goals was mixed, with poor and minority groups being furthest from

reaching them. HHS established a new set of oral health goals in its

Healthy People 2010 initiative, announced in January 2000.

In April 1997, the Secretary of HHS commissioned the first Surgeon

General’s Report on Oral Health. Under the direction of the National

Institute of Dental and Craniofacial Research, the study will examine the

relationships between oral health and general health and well-being.

Highlights are expected to include the determinants of oral health, the

effects of oral health on daily living, leading-edge technologies, preventive

approaches, and community-based interventions to improve oral health.

The report’s publication is planned for spring 2000.

Oral health includes prevention or elimination of a number of diseases and

conditions that occur in the mouth, such as gum disease and oral cancer.

Many factors can affect an individual’s oral health, including personal

behavior such as oral hygiene and diet, as well as environmental factors,

such as community water fluoridation. We used tooth decay as a key

indicator for our work because it is the most common oral disease, data are

readily available, and it can be a sentinel condition for dental care.

Dental Disease Is a

Chronic Problem for

Low-Income People

Poor oral health afflicts many low-income and other vulnerable

populations. Analysis of key dental health indicators—including untreated

tooth decay and restricted activity days for children and untreated tooth

decay and tooth loss for adults—showed large disparities between lowincome groups and their higher-income counterparts. Many vulnerable

populations, including homeless people, minorities, and some rural

residents, face similar problems.

Low-Income Children Suffer

From Poor Dental Health

Tooth decay, the most common chronic childhood disease, is most

prevalent among poor children. About 25 percent of all children have

untreated caries in their permanent teeth. Eighty percent of untreated

caries in permanent teeth are found in roughly 25 percent of children who

are 5 to 17 years old, mostly from low-income and other vulnerable groups.

Left untreated, the pain and infection caused by tooth decay can lead to

problems in eating, speaking, and attending to learning.
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Our analyses of national survey data show that the prevalence of untreated

caries in the lowest income group was much greater than that in the highest

income group for children of all ages. For example, among children aged 2

through 5 who had family incomes below $10,000, nearly one in three had

at least one decayed tooth that had not been treated. In contrast, only 1 in

10 preschool children whose family incomes were $35,000 or higher had

untreated caries. As shown in figure 1, these income-based disparities

generally hold for untreated caries in both children’s primary (baby) teeth

and permanent teeth across all age groups.

Figure 1: Percentage of Children With Untreated Caries by Family Income

Source: NHANES III, CDC, 1988-94.
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Another key indicator of dental health is the number of missed activity

days, such as days of school or work, because of dental problems.4 Surveys

show that missed activity days are concentrated in low-income groups.

Poor children suffer nearly 12 times more restricted-activity days, such as

missing school, than higher-income children as a result of dental problems

(see figure 2).

Figure 2: Restricted Activity Days per 100 Children Because of Dental Problems by

Family Income

Source: NHIS, CDC, 1994.

Low-Income Adults Have

Poor Dental Health

Poor oral health and dental disease often continue from childhood into

adulthood because tooth decay and periodontal disease are progressive

4

A National Institute of Dental Research study of 1989 NHIS data found that children missed

about 52 million school hours (more than 8 million school days) and adults missed more

than 20 million work days because of dental treatment or problems in 1989. However,

missed days from dental problems alone cannot be disaggregated from the total. More

current estimates are not available
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and cumulative throughout life. Low-income adults have more untreated

caries and suffer from greater tooth loss because of decay or gum disease

than their higher-income counterparts. For example, among adults aged 19

to 64 who had family incomes of less than $10,000, nearly one in two had at

least one decayed tooth that had not been treated. In contrast, only one in

six adults whose incomes were $35,000 or more had untreated caries (see

figure 3).

Figure 3: Percentage of Adults With Untreated Caries by Family Income

Source: NHANES III, CDC, 1988-94.

Another important marker of dental health is tooth loss from decay or gum

disease. Left untreated, caries and gum disease eventually lead to tooth

loss. Our analysis of CDC survey data shows that low-income adults suffer

more severe tooth loss than their wealthier counterparts. For example,

adults in families earning less than $15,000 per year were more than 2-1/2
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times as likely to have lost six or more teeth from decay or gum disease as

adults in families earning $35,000 or more (see table 2).

Table 2: Percentage of Adults With Tooth Loss From Decay or Gum Disease by

Family Income

Note: Columns may not total 100 percent because of rounding.

Source: BRFSS, CDC, 1995-97.

Other Vulnerable

Populations Have Poor

Dental Health

The same characteristics of poor dental health can be seen in various

populations that are generally considered to be at higher risk for dental

problems or may have a disproportionate number of persons living in lowincome situations. Health surveys consistently show that minority groups

have higher levels of unmet dental health needs. Recognizing this disparity,

HHS has set specific goals for some minority groups as part of its

departmentwide initiatives. Further, in planning for its Healthy People

2010 initiative, HHS reported that minorities, particularly Native

Americans, experience significantly greater levels of untreated tooth decay

(see table 3).

Number of teeth lost Less than $15,000 $15,000-$34,999 $35,000 or more

None 34% 40% 51%

1-5 30 33 34

6 or more 34 25 13

Other or no response 2 2 1
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Table 3: Percentage of Selected Ethnic Groups With Untreated Tooth Decay

a

Data not statistically reliable.

Source: HHS, Healthy People 2010 Conference Report: Oral Health Survey of Native Americans,

Indian Health Service service areas, 1999; California data for Asian and Pacific Islander, 1994; all

other, NHANES III, CDC, 1994.

Among the most vulnerable low-income populations are homeless people.

For millions of homeless men, women, and children, maintaining personal

hygiene in general is a challenge, and finding a place to practice routine

good oral hygiene may be nearly impossible for some. Homeless persons

have more grossly decayed and missing teeth than even low-income

persons who live in stable housing. Homeless children are more likely to

never have visited a dentist. One-third of homeless families responding to a

1999 survey reported their children had never visited a dentist, and 17

percent reported that their children had needed to see a dentist in the

preceding year but were unable to do so.5 For homeless adults, the survey

found 54 percent had not seen a dentist in at least 2 years, and 46 percent

reported they needed to see a dentist in the preceding year but were not

able to do so.

The Use of Dental Care

by the Poor Is Low

Despite the Availability

of Coverage

While the states offer comprehensive dental coverage to most low-income

children and some adults, the use of dental care is low. In response to our

survey, state Medicaid agencies reported comprehensive dental coverage

for children but more limited coverage for adults. Our analysis of two key

markers of the use of dental care—the rate of dental visits in the past year

for children and adults and the use of sealants for children—showed that

Age in years

Group 2 to 4 6 to 8 15 35 to 44

Total 16% 29% 20% 27%

Native American 68 69 66 a

Asian and Pacific Islander 30 71 a a

African American 22 36 29 46

Mexican American 24 43 27 34

White 11 26 195 24

5

Interagency Council on the Homeless, Homelessness: Programs and the People They Serve

(Dec. 1999)
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low-income populations use dental services at a much lower rate than more

affluent groups. Our comparison of state Medicaid coverage for adults and

rates of dental visits showed a small increase in use as coverage increased.

National surveys have shown little improvement in the use of dental care

among low-income populations over the past two decades. In 1996,

persons in low-income groups made dental visits at about half the rate of

their higher-income counterparts, a finding similar to survey results in 1977

and 1987 (see figure 4).

Figure 4: Percentage of Population Who Made a Dental Visit in the Preceding

Year:1977, 1987, and 1996

Note: The federal poverty level for a family of four was $6,191 in 1977, $11,611 in 1987, and $16,036 in

1996.

Source: AHRQ unpublished data: National Medical Care Expenditure Survey, 1977; National Medical

Expenditure Survey, 1987; MEPS, 1996.
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Under Medicaid, Children

Have Comprehensive Dental

Coverage, but Adults’

Coverage Varies

Under EPSDT, all states are required to provide comprehensive dental

services to enrolled children. While the states have considerable flexibility

in the benefits packages they can offer under SCHIP, all but Colorado and

Delaware offer substantial dental coverage. Adult dental coverage is

optional under Medicaid, but about two-thirds of the states indicated that

they cover some dental services. However, many impose considerable

limitations. (See table 4.)

Table 4: Number of States That Provide Dental Coverage for Children and Adults

Source: GAO Jan. 2000 survey of 50 state Medicaid and SCHIP agencies and the District of Columbia.

Although the states offer comprehensive dental coverage to all enrolled

children and many adults, a significant gap exists between the number who

are eligible and the number who are enrolled. An estimated 4.7 million

uninsured children were eligible for Medicaid but not enrolled in 1996.

While comparable estimates are not available for adults, a 1999 HCFAsponsored study estimated that, nationwide, 46 percent of the persons who

were potentially eligible were not enrolled in Medicaid.

Most Poor Children and

Adults Do Not Receive

Regular Dental Care

Having poor oral health and armed with Medicaid or SCHIP dental

coverage, poor people might be expected to make substantial use of dental

services. However, they often do not receive the care they need. Our

analysis of national surveys shows that low-income children and adults do

not visit the dentist as often as their higher-income counterparts. A

separate analysis of Medicaid billing data for 1995 confirms the low use of

dental care in Medicaid’s fee-for-service programs in the 27 states where

data were available. We could not, however, determine from either the

survey or billing data the extent to which low use was the result of

individuals’ not seeking dental care or a lack of available dental services.

Category of services (typical service)

Children Adult

EPSDT SCHIP Medicaid

Emergency 51 49 42

Preventive (prophylaxis, sealants) 51 49 27

Diagnostic (clinical oral evaluations) 51 49 32

Routine restorative (amalgam, resin restoratives) 51 49 29

More complex (crowns, bridges, dentures) 51 43 30
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Most Children of Low-Income

Families Do Not Visit the Dentist

Regularly

National survey data from 1996 show that low-income children were largely

not receiving regular dental care. For example, about 36 percent of 6-to-18-

year-olds living at or below the federal poverty level had visited a dentist in

the preceding year compared with about 71 percent living in families with

incomes higher than 400 percent of the federal poverty level. At all ages,

children in the highest income group were about twice as likely to have

made a dental visit as children at or below the federal poverty level (see

figure 5).

Figure 5: Percentage of Children Who Made a Dental Visit in the Preceding Year by

Family Income

a

Data insufficient for the 101 to 200 percent category.

Note: The federal poverty level for a family of four was $16,036 in 1996.

Source: MEPS, AHRQ unpublished data, 1996.
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Although the large number of eligible recipients not enrolled in Medicaid or

SCHIP explains part of the absence of dental care, it is not the only reason.

Children enrolled in Medicaid, as a subset of all low-income children

described above, also show low use of dental care. We analyzed data from

HCFA’s State Medicaid Resource File to assess the extent to which

individual state Medicaid programs had been billed for dental care for

children. This analysis of 1995 data (the most recent available) from 27

state Medicaid programs showed that only about one in three children (34

percent) enrolled in Medicaid fee-for-service plans had visited the dentist in

the preceding year.6

Another indicator of the use of dental care by children is the use of sealants

on permanent teeth. Sealants are plastic-like coatings that can

dramatically reduce the likelihood of caries. HHS established a Healthy

People 2000 goal of having at least 50 percent of children with sealants on

permanent molars. Our analysis showed that none of the income groups

had achieved this goal and that the poorest children were furthest away.

For example, only 12 percent of children aged 6 to 14 living at or below the

federal poverty level had at least one sealant—roughly one-third the

incidence of children in higher-income families (see figure 6).

6

HCFA’s State Medicaid Resource File contains Medicaid fee-for-service information on

eligibility, billing claims, and utilization for states that participate in the Medicaid Statistical

Information System. Billing data are limited to the extent that they do not provide

information on provided services for which no reimbursement was sought. This analysis

does not include information on children who may have made a dental visit under a

managed care plan, because such data are not available.
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Figure 6: Percentage of Children With at Least One Sealant by Family Income

Source: NHANES III, CDC, 1988-94.

Most Low-Income Adults Do Not

Visit the Dentist Regularly

Low-income adults also make fewer visits to dentists than their higherincome counterparts. Adults living at or below the federal poverty level are

less than half as likely to have seen a dentist in the past year as adults

earning more than four times the poverty level (see figure 7).
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Figure 7: Percentage of Adults Who Made a Dental Visit in the Preceding Year by

Family Income

Note: The federal poverty level for a family of four was $16,036 in 1996.

Source: MEPS, AHRQ unpublished data, 1996.

Our analysis of Medicaid payment data also shows low utilization by

enrolled adults. Dental claims billed to Medicaid in 1995 for the 18 states

that cover adult dental services show that only 29 percent of adults

enrolled in Medicaid fee-for-service had visited the dentist in the preceding

year.7 In comparison, nationwide AHRQ data for 1996 showed that 44

percent of adults aged 19 to 64 had made a dental visit in the preceding

year. Our analysis was limited to fee-for-service encounters because

7

Of the 27 states that submitted billing data to HCFA in 1995, 9 did not cover adult dental

services or covered only emergency services. Our analysis was limited to adults who were

enrolled in Medicaid for a full year and who presumably had no other source of insurance.
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consistent and reliable data for Medicaid beneficiaries enrolled in managed

care plans were not available.

In general, residents of rural areas are slightly less likely to have visited a

dentist in the past year than urban residents. While access to dental care is

a persistent problem for residents of many rural areas, our analysis of

national data for all nonmetropolitan counties shows, in general, these

residents just slightly behind metropolitan area residents in dental visits

(see table 5).

Table 5: Percentage of Residents Making a Dental Visit in 1996 by Metropolitan Area

and Income

Note: The federal poverty level for a family of four was $16,036 in 1996.

Source: MEPS, AHRQ unpublished data, 1996.

The Use of Dental Services

Varies by State

The rates at which dental services are used vary significantly for all income

groups among the states. CDC survey data show that the proportion of

adults who made a dental visit in the preceding year ranged from a low of

33 percent in Arkansas to a high of 61 percent in Hawaii for those with less

than $15,000 annual family income.8 Higher income groups show similar

variations of between 66 and 83 percent. Within states, utilization was not

uniform among income groups. For example, Alaska had one of the higher

Area

Family income as a % of the federal poverty level

0-200% 201%-400% 401% or more

Central metropolitan counties 29% 43% 58%

Other metropolitan counties 29 49 57

Nonmetropolitan counties

adjacent to metropolitan areas 29 41 58

Nonmetropolitan counties not

adjacent to metropolitan areas 22 47 53

8

National data from AHRQ’s survey cannot be analyzed state by state. Instead, we used

CDC’s state-based BRFSS. Because the two surveys differ in their purpose, survey

questions, and protocols, they yield somewhat different results, but important trends and

disparities remain. Of note, MEPS gathers income and family size data that can be

expressed as a percentage of the federal poverty level. BRFSS gathers income data only in

broad categories that cannot be correlated with federal poverty levels.
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rates for the low-income group (55 percent) but one of the lower rates for

the highest income group (69 percent). Conversely, Kentucky had one of

the lowest rates for the low-income group (35 percent) but one of the

highest rates for the highest income group (79 percent). Appendix I

contains data for all 46 states that reported data from the optional BRFSS

oral health module.

To determine whether Medicaid coverage affected the variation among

states, we compared rates for the use of dental services for the 27 states

reporting Medicaid payment data. Our analysis of HCFA’s 1995 fee-forservice payment data showed wide variations between states for both

children and adults. For children enrolled in Medicaid, the proportion who

made a dental visit in the preceding year ranged from a low of 22 percent in

Delaware to a high of 58 percent in Vermont. By comparison, in states that

cover partial or full adult dental care under Medicaid, adults’ use of dental

care was generally much lower, ranging from less than 6 percent in

Colorado to 46 percent in Iowa. While Medicaid’s policy of mandatory

dental coverage for children and optional coverage for adults may explain

these differences, it does not explain the wide variation among states for

children. Appendix I contains data for all 27 states that submitted payment

data to HCFA in 1995.

Concluding Observations Dental disease is a chronic problem among low-income populations. Key

markers of dental health and the use of services for dental problems, such

as untreated caries and lost teeth, show that low-income populations bear a

disproportionate level of dental disease and make fewer dental visits.

Disparities exist despite coverage of dental services under Medicaid and

SCHIP programs. The poor oral health and relatively low use of dental care

even among Medicaid enrollees suggest that barriers other than access to

insurance coverage contribute to the problems faced by low-income

populations. Frequently cited barriers include a shortage of dentists in

some areas, unwillingness of dentists to participate in Medicaid, low

Medicaid reimbursement rates and the program’s administrative burden,

and unresolved patient education issues. In a subsequent report, we will

examine these barriers in more detail, as well as federal and state

initiatives to address them.

Agency Comments We provided a draft of this report to HHS for comment. HHS concurred

with our findings and reiterated its commitment to eliminating dental

access disparities and promote oral health, particularly for disadvantaged
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populations. It also delineated a wide array of initiatives that are planned

or under way by its various component agencies, including intra- and

interagency collaborative strategies, to help address concerns about oral

health disparities. HHS also provided technical comments, which we

incorporated where appropriate. HHS’s comments are included in full in

appendix III.

As we agreed with your offices, unless you publicly announce the report’s

contents earlier, we plan no further distribution of it until 14 days from the

date of this letter. We will then send copies to the Honorable Donna E.

Shalala, Secretary of HHS, and others who are interested. We will make

copies available to others upon request. This report was prepared under

the direction of Frank Pasquier, Assistant Director. Other individuals who

made key contributions include Rashmi Agarwal, Sophia Ku, Terry Saiki,

Stan Stenersen, and Kim Yamane. Please call me at (202) 512-7118 if you or

your staff have any questions.

Kathryn G. Allen

Associate Director, Health Financing

and Public Health Issues
Page 22 GAO/HEHS-00-72 Oral Health in Low-Income Populations

Appendix I

Scope and Methodology ApApenednxidexiIs

To determine the oral health status and use of dental care of Medicaid and

other low-income populations, we analyzed data by income group, age,

urban and rural locations, and insurance status from several nationally

representative health surveys, including

• National Health and Nutrition Examination Survey III (NHANES III),

Centers for Disease Control and Prevention (CDC), 1988-94;

• National Health Interview Survey (NHIS), CDC, 1994;

• Medical Expenditures Panel Survey (MEPS), Agency for Healthcare

Research and Quality (AHRQ), 1996; and

• Behavioral Risk Factor Surveillance System (BRFSS), CDC, 1995-97.

Data from the different surveys we examined produce somewhat different

results for similar questions.1 Differences in survey design, collection

methods, timing, and other factors affect survey results. Important trends

and disparities were, nevertheless, consistent across all four surveys.

Differences in survey design also affect our ability to compare results

between surveys. For example, some surveys ask for specific income levels

and family size and thus can be converted to federal poverty levels, while

others ask for income only in general categories that cannot be expressed

in terms of poverty level.

To determine which dental benefits were covered by state Medicaid and the

State Children’s Health Insurance Programs (SCHIP), we analyzed data

from the American Dental Association (ADA) and the Health Care

Financing Administration (HCFA). We also surveyed each state Medicaid

agency to complete and update data on dental coverage under state

Medicaid and SCHIP.

To assess available data on state Medicaid dental care for children and

adults covered by fee-for-service arrangements, we analyzed HCFA’s State

Medicaid Resource File (SMRF). This database provides summarized

information on Medicaid eligibility, claims, and utilization for states that

participate in the Medicaid Statistical Information System. To facilitate

research, HCFA has adjusted and reformatted the data and added service

and eligibility codes. The data are arranged in five separate research files:

Drug Claims, Inpatient Claims, Long-Term Care Claims, Other Ambulatory

1

See Mark D. Macek and others, “A Comparison of Dental Utilization Estimates From Three

National Surveys,” abstract, Association for Health Services Research, Washington D.C.,

June 28, 1999.
Appendix I

Scope and Methodology

Page 23 GAO/HEHS-00-72 Oral Health in Low-Income Populations

Claims, and Person Summary. Claims information is not available for

children and adults in Medicaid managed care arrangements, and reliable

data on health care services provided to managed care enrollees were not

available at the time of our review.

We used the Person Summary and the Other Ambulatory Claims files to

determine the percentage of children aged 0 to 18 and adults aged 19 to 64

who had received dental services in 1995. The Person Summary file

contains characteristics such as date of birth and dates of coverage for

each person covered by Medicaid during the year. The Other Ambulatory

Claims file contains records for dental services received. Our analysis was

limited to 1995 data from the 27 states that provided data to HCFA for that

year. According to HCFA officials, 1995 is the most recent year for which

reliable claims data are available.

We performed separate analyses for children aged 0-18 and adults aged 19-

64. We limited our analysis to children and adults for whom the data

indicated that they were covered by Medicaid for the entire year in order to

make sure that we did not include beneficiaries who may have switched to,

and received care from, a managed care plan during the year.

Other than making these control checks, we did not independently verify

the SMRF data because (1) HCFA’s process for modifying the data includes

quality control phases in which the data are analyzed with a number of

statistical tools and crosswalks and (2) the data originated at the state level

and the benefit of tracking them back to their source would not have

outweighed the considerable cost and staff resources that this would have

entailed. These data represent the most current and complete data

available on state-level billing within Medicaid fee-for-service programs.
Page 24 GAO/HEHS-00-72 Oral Health in Low-Income Populations

Appendix II

State Data Tables ApendxiI

Table 6: Percentage of Adults Who Made a Dental Visit in the Preceding Year by

Annual Family Income

State Less than $15,000 $15,000-$34,999 $35,000 or more

Alabama 43% 62% 77%

Alaska 55 67 69

Arizona 55 61 74

Arkansas 33 58 66

California 45 58 71

Colorado 43 56 73

Connecticut 46 65 81

Florida 51 62 74

Georgia 45 63 74

Hawaii 61 72 80

Idaho 42 57 75

Illinois 41 61 74

Indiana 48 58 74

Iowa 47 58 70

Kansas 45 55 76

Kentucky 35 56 79

Louisiana 40 57 72

Maine 38 58 77

Maryland 46 62 70

Massachusetts 54 60 73

Michigan 43 66 81

Mississippi 35 56 73

Missouri 42 56 70

Montana 53 63 75

Nebraska 44 65 80

Nevada 42 49 72

New Hampshire 49 67 80

New Jersey 53 61 78

New Mexico 45 63 77

New York 53 64 79

North Dakota 49 63 77

Ohio 43 61 83

Oklahoma 41 57 77

Oregon 54 64 77

Continued
Appendix II

State Data Tables

Page 25 GAO/HEHS-00-72 Oral Health in Low-Income Populations

Note: Dental data not available for Delaware, Minnesotta, North Carolina, and South Carolina.

Source: BRFSS, CDC, 1995-97.

Pennsylvania 48 61 79

Rhode Island 49 61 69

South Dakota 56 68 83

Tennessee 37 58 78

Texas 37 54 71

Utah 55 66 78

Vermont 55 64 77

Virginia 41 60 76

Washington 46 63 70

West Virginia 34 54 76

Wisconsin 60 66 78

Wyoming 51 60 70

State Less than $15,000 $15,000-$34,999 $35,000 or more

Continued from Previous Page
Appendix II

State Data Tables

Page 26 GAO/HEHS-00-72 Oral Health in Low-Income Populations

Table 7: Medicaid Coverage of Adult Dental Care

State Full Partiala Noneb

Alabama X

Alaska X

Arizona X

Arkansas X

California X

Colorado X

Connecticut X

Delaware X

District of Columbia X

Florida X

Georgia X

Hawaii X

Idaho X

Illinois X

Indiana X

Iowa X

Kansas X

Kentucky X

Louisiana X

Maine X

Maryland X

Massachusetts X

Michigan X

Minnesota X

Mississippi X

Missouri X

Montana X

Nebraska X

Nevada X

New Hampshire X

New Jersey X

New Mexico X

New York X

North Carolina X

North Dakota X

Continued
Appendix II

State Data Tables

Page 27 GAO/HEHS-00-72 Oral Health in Low-Income Populations

a

States do not cover particular services (preventive, diagnostic, restorative, or more complex), or they

impose other limitations on coverage, such as a $475 annual ceiling.

b

None or emergency services only.

Source: GAO survey of state Medicaid and SCHIP agencies, Jan. 2000.

Ohio X

Oklahoma X

Oregon X

Pennsylvania X

Rhode Island X

South Carolina X

South Dakota X

Tennessee X

Texas X

Utah X

Vermont X

Virginia X

Washington X

West Virginia X

Wisconsin X

Wyoming X

State Full Partiala Noneb

Continued from Previous Page
Appendix II

State Data Tables

Page 28 GAO/HEHS-00-72 Oral Health in Low-Income Populations

Table 8: Percentage of Medicaid Fee-for-Service Recipients Who Made a Dental Visit

in the Preceding Year

a

State does not provide dental coverage for adults or provides only emergency care.

Source: SMRF, HCFA, 1995.

State Children Adults

Weighted average 33.5% 29.0%

Alabama 29.1 a

Alaska 45.1 a

Arkansas 36.8 a

California 31.8 34.5

Colorado 32.4 5.6

Delaware 21.8 a

Florida 33.7 11.5

Georgia 36.2 a

Indiana 26.0 24.2

Iowa 47.9 45.7

Kansas 38.9 a

Kentucky 34.3 23.1

Maine 41.4 10.0

Michigan 39.4 30.6

Mississippi 32.0 a

Missouri 27.1 25.7

Montana 35.8 35.4

New Hampshire 56.1 a

New Jersey 33.8 28.2

North Dakota 37.2 35.3

Pennsylvania 38.4 22.6

Rhode Island 28.6 26.6

Utah 30.7 34.8

Vermont 58.3 42.7

Washington 35.0 31.9

Wisconsin 26.5 32.6

Wyoming 40.1 a
Page 29 GAO/HEHS-00-72 Oral Health in Low-Income Populations

Appendix III

Comments From the Department of Health

and Human Services ApendxiI
Appendix III

Comments From the Department of Health

and Human Services

Page 30 GAO/HEHS-00-72 Oral Health in Low-Income Populations
Appendix III

Comments From the Department of Health

and Human Services

Page 31 GAO/HEHS-00-72 Oral Health in Low-Income Populations
Appendix III

Comments From the Department of Health

and Human Services

Page 32 GAO/HEHS-00-72 Oral Health in Low-Income Populations
Appendix III

Comments From the Department of Health

and Human Services

Page 33 GAO/HEHS-00-72 Oral Health in Low-Income Populations
Appendix III

Comments From the Department of Health

and Human Services

Page 34 GAO/HEHS-00-72 Oral Health in Low-Income Populations
Appendix III

Comments From the Department of Health

and Human Services

Page 35 GAO/HEHS-00-72 Oral Health in Low-Income Populations
Appendix III

Comments From the Department of Health

and Human Services

Page 36 GAO/HEHS-00-72 Oral Health in Low-Income Populations
Appendix III

Comments From the Department of Health

and Human Services

Page 37 GAO/HEHS-00-72 Oral Health in Low-Income Populations
Appendix III

Comments From the Department of Health

and Human Services

Page 38 GAO/HEHS-00-72 Oral Health in Low-Income Populations
Appendix III

Comments From the Department of Health

and Human Services

Page 39 GAO/HEHS-00-72 Oral Health in Low-Income Populations
Appendix III

Comments From the Department of Health

and Human Services

Page 40 GAO/HEHS-00-72 Oral Health in Low-Income Populations
Appendix III

Comments From the Department of Health

and Human Services

Page 41 GAO/HEHS-00-72 Oral Health in Low-Income Populations
Appendix III

Comments From the Department of Health

and Human Services

Page 42 GAO/HEHS-00-72 Oral Health in Low-Income Populations
Appendix III

Comments From the Department of Health

and Human Services

Page 43 GAO/HEHS-00-72 Oral Health in Low-Income Populations
Appendix III

Comments From the Department of Health

and Human Services

(101888) Letr Page 44 GAO/HEHS-00-72 Oral Health in Low-Income Populations
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