A Decade in Dental Care Utilization among Adults and Children (2001–2010)

Oral health is a critical component of overall health. Oral health has been shown to be associated with cardiovascular disease, diabetes, and certain cancers, although the nature of the link is still not fully understood (Fitzpatrick and Katz 2010; Simpson et al. 2010; Teeuw, Gerdes, and Loos 2010; Azarpazhooh and Tenenbaum 2012; Lockhart et al. 2012). It has also been linked to health care costs, labor productivity, and wages (Cigna 2010; Glied and Neidell 2010). Along with prevention and good oral hygiene, a key driver of oral health is routine dental care (Institute of Medicine [IOM] 2011a,b2011b). Recent years have seen a sharp increase in emergency room use for dental care, largely for preventable conditions that could have been avoided with routine dental care at considerably lower cost (The Pew Center on the States 2012; Wall 2012). Several studies have shown that the last decade has brought significant changes in utilization of dental care among the US population. Two recent studies based on data from the National Health Interview Survey (NHIS) (Kenney et al. 2012; Wall, Vujicic, and Nasseh 2012) show that the percent of the adult population with a dental visit in the last 12 months has been declining since the early 2000s. The trend is particularly pronounced for low-income adults (Wall, Vujicic, and Nasseh 2012). A key finding in both studies (Kenney et al. 2012; Wall, Vujicic, and Nasseh 2012) is that the downward trend was established well before the recent economic downturn. Among children, however, the trend in utilization of dental care is different from adults. The percent of children with a dental visit in the last 12 months increased from 74.2 percent in 2000 to 78.7 percent in 2010 (Kenney et al. 2012). Among poor children, the increase was much larger. For children below the federal poverty line, the utilization rate of dental care increased from 62 percent in 2000 to 71 percent in 2010 (Wall, Vujicic, and Nasseh 2012). A number of factors appear to be contributing to the observed pattern of dental care utilization in the past decade. There has been widespread improvement in state Medicaid and Children Health Insurance Programs (CHIP). In the late 1990s and early 2000s, a number of states took dramatic steps to improve access to dental care among children covered by Medicaid and CHIP. Numerous states employed a variety of approaches, including raising reimbursement rates (Greene-McIntyre, Finch, and Searcy 2003; Hughes et al. 2005; Borchgrevink, Snyder, and Gehshan 2008; Centers for Medicare and Medicaid Services [CMS] 2011a; Decker 2011), revamping administrative structures and processes (Greene-McIntyre, Finch, and Searcy 2003; Hughes et al. 2005; Borchgrevink, Snyder, and Gehshan 2008; CMS 2011a), and conducting outreach and education to both providers and patients (Greene-McIntyre, Finch, and Searcy 2003; Borchgrevink, Snyder, and Gehshan 2008; CMS 2011a). CMS data show a clear record of improved children's access to dental care in Medicaid/CHIP programs. Approximately 40 percent of children in Medicaid received a dental service in 2009, reflecting a nearly 50 percent increase over the 27 percent of children who received a dental service in 2000. These improvements occurred during a period when the number of children enrolled in Medicaid/CHIP grew from 23 to 33 million (CMS 2011b). This achievement was supported by significant increases in funding for children's dental services within Medicaid programs. Between 1990 and 2010, Medicaid dental expenditures grew from $756.1 million to $7.4 billion or from 2.4 to 7.1 percent of total dental expenditures (CMS 2012). The last decade has seen widespread reductions in adult dental benefits within Medicaid programs as well as in employer-sponsored dental benefits (American Dental Association [ADA] 2012a). Due to fiscal constraints, numerous states (CA, IL, IN, MD, MA, MI, MN, MO, MT, NJ, PA, SD, TN, UT, and WA) decreased dental benefits coverage for adults within Medicaid since 2002 (Wall, Nasseh, and Vujicic 2013). Although states are required to cover dental services for low-income children in Medicaid under the Early and Periodic Screening, Diagnostic, and Treatment benefit, Medicaid coverage for dental services for adults is optional (Medicaid.gov Undated). Availability of dental benefits has an important impact on utilization of dental care (Brown et al. 2009). Changes in provider behavior might also account for some of the trends in dental care utilization. Since 2000, there has been an increase in provider participation in public programs. The most recent data from the American Dental Association indicate that nationally, the percentage of patients on public assistance who visit private practice dentists has increased from 4.7 percent in 2000 to 7.0 percent in 2009 (ADA 2012b). Some authors have also suggested that new care delivery models have emerged that take advantage of economies of scale and are able to treat patients at lower average cost. These models may be able to treat more Medicaid patients despite the fact that Medicaid programs typically pay well below market fees (Edelstein 2012; Winegarden and Arduin 2012). In this article, we examine trends in the utilization of dental care among the U.S. population from 2001 to 2010 and identify the relative importance of various factors in explaining the trends. Specifically, we use econometric analysis to decompose the change in utilization of dental care for both children and adults that is due to changes in demographic factors (age, education, marital status, race, region, and gender), family income, dental benefits status, and overall personal health status. To our knowledge, this is the first study that attempts to quantify the relative contribution of various factors in explaining the pattern of dental care utilization over this period. Our results show different utilization patterns for children and adults, and a different set of factors driving these patterns. We discuss the policy implications, particularly in light of an aging population, changing demographics, and continued fiscal austerity within state Medicaid programs. The downward trend in adult utilization—particularly among the disadvantaged—is troubling and could signal continued challenges in the future when providing dental care to this group.