International Journal of Dentistry The use of PDC is also predicted by the child’s age at his/her ﬁrst PDV, and it has been proven that the younger the child’s age at the ﬁrst PDV, the more likely he/she utilizes more PDV in the future [5]. Up-to-date well-child care visits can promote PDC among Medicaid-enrolled children because families are inﬂuenced and encouraged to seek PDC in the medical oﬃce [37]. 6.2. Meso Level (Community and Organization). Communi- ties play huge role in improving PDC access through out- reach Medicaid-eligible beneﬁciaries and educate them about the beneﬁts they generate by maintaining their PDC. Convenient transportations and quality of general education provided are also community level factors that could lead to minimize dental health disparities [20]. The number of dentists and the type of dental provider who participate in Medicaid are important inﬂuencing factors in accessing and utilizing PDC [5, 19]. Since the majority of dentists 84% do not participate in government-sponsored programs such as Medicaid [20], there is a huge need to increase their partic- ipation in Medicaid and increase dentist-to-population ratio. Referral partnership between community resources and medical and/or dental oﬃces has great impact on connecting Medicaid-eligible children to receive appropriate PDC. In addition, the collaboration between medical and dental oﬃces should be promoted in order to fully utilize PDC available [37]. It is important for communities to step up their education for Medicaid-eligible beneﬁciaries on how to enroll and access the health and dental care systems [27]. 6.3. Macro Level (Government). Medicaid itself sounds very promising and convincing in decreasing PDC disparities among the U.S. children as a whole. Unfortunately, there are many policies and administrative details within Medicaid that have negatively aﬀected the access to PDC and decreased the utilization level among Medicaid-eligible children. Med- icaid contributing factors include amount of reimburse- ments, explanations and communication for denied dental claims, claims processing time, paperwork, and complexity of ﬁlling dental claims [7, 23]. Furthermore, the child’s age at which Medicaid dental beneﬁts end can be a limitation of utilizing PDC as it is the case in North Carolina [37]. Lastly, assigning dental case mangers for Medicaid beneﬁciaries may reduce the number of broken appointments [24]. Mangers can identify potential barriers, solve them, and educate cli- ents about PDC [35]. 7. Outcome Issues related to eﬀectiveness, eﬃcacy, and equity will be pre- sented in the next part. Outcome evaluation is the sixth sec- tion before the conclusion of this paper. 7.1. Eﬀectiveness. The variety between diﬀerent states in the way they implement and interpret Medicaid has great ef- fect on the way beneﬁciaries appreciate Medicaid or not. While Oregon State and Washington State Medicaid-enrolled beneﬁciaries have a positive feedback about Medicaid, ben- eﬁciaries from North Carolina, Alabama, and Connecticut 5 are not happy with the current Medicaid program. For example, through implementing the Access to the Baby and Childhood Dentistry (ABCD) that targets Medicaid-enrolled children in Washington State, ABCD is found to be positively eﬀective in providing at least one PDV for high number of Medicaid children [34]. ABCD dentists receive clinical and behavior trainings, and their reimbursements is expanded; in addition, beneﬁciaries are reached through ABCD and are referred to ABCD dentists by pediatricians and family physicians [34]. On the other side, Medicaid children in Connecticut complain about access to not only PDC, but to most dental care services [28]. The case is not much diﬀerent in Georgia and Alabama where the majority of Medicaid children are less likely to receive PDC [30]. In general, only few Medicaid- eligible children received at least single PDC [7]. Among those who received PDC, only few receive dental treatments [29]. 7.2. Eﬃciency. The argument that Medicaid saves money through PDC is not an easy argument. The total dental dollar amounts reimbursed for Medicaid-enrolled children in 2002 range from $19,113 to $72,614 [32]. Seventy-nine percent of Medicaid-eligible children receive PDC and have the least dental expenses. On the other hand, Medicaid children with high dental expenses and more dental problems consume 64% of Medicaid money, and they only represent 9% of the total Medicaid-enrolled children [32]. Medicaid children who receive PDC at early stage have fewer dental-related expenses than those who start dental care at a later time. The average dental cost for each Medicaid child who receives early PDC is only $263 during 5 years [5]. Although the children who receive PDC usually have little dental expenses, the dollar amount saved is consumed by children with more dental problems and high expenses. Medicaid needs to increase the number of children who receive PDC and decrease the percentage of children with high dental expenses in the same time. Medicaid can reach the objective of saving money from PDC through better outreach, get children see dentists as early as possible, increase the number of dentists who partic- ipate in Medicaid, and provide easy PDC access to Medicaid- eligible children. Overall, Medicaid needs to increase the amount of money assigned for PDC reimbursements as it is shown to be the most inﬂuencing factor for dentists to partic- ipate in Medicaid. Increasing the amount of reimbursements can help Medicaid-enrolled children in having a convenient access to PDC and better utilization of the services. 7.3. Equity. Equity is about equal access to PDC. Medicaid program plays huge role in reducing oral health disparities among U.S. children. Children with either private or public dental coverage are more likely to access and utilize more PDC than their peers who lack dental coverage. Unfortu- nately, the shortage in the number of dentists who participate in Medicaid and other factors related to Medicaid-eligible beneﬁciaries have huge impacts on not reaching the goal of eliminating access disparities to PDC [5, 7, 19, 20, 23, 32, 37].