Medicaid: Concerns Remain about Sufficiency of Data for Oversight of Children's Dental Services
Published: 2007-05-02T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The 31 million children enrolled in Medicaid are particularly vulnerable to tooth decay, which, if untreated, may lead to more serious health conditions and, on rare occasion, result in death. Congress established a comprehensive health benefit for children enrolled in Medicaid to cover Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, which include dental services. The Centers for Medicare & Medicaid Services (CMS) is responsible for oversight of these services. States are responsible for administering their state Medicaid programs in accordance with federal requirements, including requirements to report certain data on the provision of EPSDT services. GAO was asked to address the data that CMS requires states to submit on the provision of EPSDT dental services and the extent to which these data are sufficient for CMS oversight of the provision of these services. This testimony is based on reports GAO issued from 2000 through 2003. GAO updated relevant portions of its earlier work through interviews conducted in April 2007 with officials from CMS; state Medicaid programs in California, Illinois, Minnesota, New York, and Washington (states contacted for GAO's 2001 study or referred to GAO by another official); and national health associations. GAO also reviewed relevant literature provided by officials from CMS and other organizations.
section_title: What GAO Found
paragraphs: CMS requires states to report annually on the provision of certain EPSDT dental services through form CMS 416. The CMS 416 is designed to provide information on state EPSDT programs in terms of the number of children who receive child health screening services, referrals for corrective treatment, and dental services from fee-for-service providers and under managed care plans. Data captured on dental services include the number of children receiving any services, any preventive services, and any treatment services. The CMS 416s, however, are not sufficient for overseeing the provision of dental and other required EPSDT services in state Medicaid programs. We reported in 2001 that not all states submitted the required CMS 416s on time or at all. CMS 416s that states did submit were often based on incomplete and unreliable data. States faced challenges getting complete and accurate data, however, particularly for children in managed care. According to agency officials, CMS has taken steps since our 2001 report to improve the data. For example, CMS has conducted reviews of some states' EPSDT programs that included assessments of states' CMS 416 data. CMS officials said that 11 states' EPSDT programs had been reviewed since 2002. CMS has also required since 2002 that states collect data on utilization of dental and other required EPSDT services from managed care plans. State and national health association officials told us that these data have improved over time. But concerns about the CMS 416 remain. Concerns cited by state and national health association officials we contacted included inconsistencies in how states report data, data inaccuracies, and problems with the data captured that preclude calculating accurate rates of the provision of dental and other required EPSDT services. Further, the usefulness of the CMS 416 for federal oversight purposes is limited by the type of data currently requested. First, rates of dental services delivered to children in managed care cannot be identified from the data. Second, the data captured do not address whether children have received the recommended number of dental visits. And third, the data do not illuminate factors, such as the inability of beneficiaries to find dentists to treat them, which contribute to low use of dental services among Medicaid children.

section_title: Letter
paragraphs: I am pleased to be here today as you examine the Centers for Medicare &  Medicaid Services’ (CMS) oversight of dental care for the 31 million  children from low-income families enrolled in the Medicaid program,  including the significant number of children covered by managed care.  Medicaid is the joint federal-state program that provides health care  coverage for certain low-income individuals. According to the Centers for  Disease Control and Prevention, tooth decay is one of the most common  chronic infectious diseases among U.S. children: 28 percent of children  aged 2 to 5 have had decay in their primary (baby) teeth, about 50 percent  by age 11. Untreated tooth decay may result in pain, dysfunction, and  other problems that may lead to more serious health conditions and, on  rare occasion, result in death. Low-income children—such as those  enrolled in Medicaid—are estimated to be twice as likely to have untreated  tooth decay as children in families with higher incomes.
In 1967, Congress established a comprehensive health benefit for children  enrolled in Medicaid to cover Early and Periodic Screening, Diagnostic,  and Treatment (EPSDT) services. In 1989, Congress further defined  EPSDT services to specifically include dental services. As the agency  responsible for overseeing the administration of states’ Medicaid  programs, CMS has an important role in ensuring that states comply with  federal requirements, including that each state report annually to CMS on  certain aspects of dental and other EPSDT services. Despite the known  prevalence of tooth decay in the Medicaid population, recent CMS  estimates of the provision of dental services, based on state reports to  CMS, indicate that only about one-third of Medicaid children received a  dental service in fiscal year 2005.
My remarks today will address the data that CMS requires states to submit  on the provision of EPSDT dental services and the extent to which these  data are sufficient for CMS oversight of the provision of EPSDT dental  services for children enrolled in Medicaid. My testimony is based on  reports we issued from 2000 through 2003, an assessment of CMS’s  reporting requirements and state-submitted reports obtained from CMS in  April 2007, and a review of selected CMS reports on EPSDT services and  of related literature in April 2007. Our past work on the data CMS requires  states to submit focused on the broad range of required EPSDT services,  including dental services, but did not focus specifically on dental services  data. We have supplemented these findings with information from our past  work on oral health, including factors contributing to low use of dental  services by low-income populations. We also updated relevant portions of  our earlier information through interviews conducted in April 2007 with  officials from CMS and state Medicaid programs in California, Illinois,  Minnesota, New York, and Washington—states we contacted in our earlier  work or which were referred to us by an official from a national health  association who considered the states’ experiences to be relevant to our  current work. We interviewed officials from national health associations,  including the Children’s Dental Health Project, Medicaid/SCHIP Dental  Association, the National Academy of State Health Policy, the National  Oral Health Policy Center, and the George Washington University Medical  Center for Health Services Research and Policy. All of our work was  conducted in accordance with generally accepted government auditing  standards.
In summary, CMS collects annual data from states for purposes of  overseeing the delivery of dental and other required EPSDT services. Each  year, states must submit EPSDT reports known by the form on which they  are submitted, the CMS form 416. The CMS 416 report (hereafter called the  CMS 416) is designed to capture data such as the number of children who  received any dental service, a dental preventive service, or a dental  treatment service. CMS has indicated that the CMS 416 is used to assess  the effectiveness of state EPSDT programs to determine the number of  children provided child health screening services, referred for corrective  treatment, or receiving dental services.
The CMS 416s, however, are not sufficient for overseeing the provision of  dental and other required EPSDT services in state Medicaid programs. We  reported in 2001 that not all states submitted the required CMS 416s on  time or at all. CMS 416s that states did submit were often based on  incomplete and unreliable data. States faced challenges getting complete  and accurate data, however, particularly for children in managed care.  According to agency officials, CMS has taken steps since our 2001 report  to improve the data. For example, CMS has conducted reviews of some  states’ EPSDT programs that included assessments of states’ CMS 416  data. CMS officials said that 11 states’ EPSDT programs had been  reviewed since 2002. CMS has also required since 2002 that states collect  data on utilization of dental and other required EPSDT services from  managed care plans. State and national health association officials told us  that these data have improved over time. But concerns about the CMS 416  remain. Concerns cited by state and national health association officials  we contacted included inconsistencies in how states report data, data  inaccuracies, and problems with the data captured that preclude  calculating accurate rates of the provision of dental and other required  EPSDT services. Further, the usefulness of the CMS 416 for federal  oversight purposes is limited by the type of data currently requested. First,  rates of dental services delivered to children in managed care cannot be  identified from the data. Second, the data captured do not address  whether children have received the recommended number of dental visits.  And third, the data do not illuminate factors, such as the inability of  beneficiaries to find dentists to treat them, which contribute to low use of  dental services among Medicaid children.
We discussed the key findings of our testimony with CMS officials and  obtained from them technical corrections, which we incorporated as  appropriate. CMS commented on our earlier reports upon which our  testimony is primarily based.
subsections: section_title: Background
paragraphs: Medicaid is one of the largest programs in federal and state budgets. In  fiscal year 2005, the most recent year for which complete information is  available, total Medicaid expenditures were an estimated $317 billion. The  estimated federal share that year was about $182 billion. States pay  qualified health providers for a broad range of covered services provided  to Medicaid beneficiaries, and the federal government reimburses states  for their share of these expenditures. The federal matching share of each  state’s Medicaid expenditures for services is determined by a formula  defined under federal law and can range from 50 percent to 83 percent.  Each state administers its Medicaid program in accordance with a state  plan, which must be approved by CMS. Medicaid is an open-ended  entitlement program, under which the federal government is obligated to  pay its share of expenditures for covered services provided to eligible  individuals under each state’s federally approved Medicaid plan.
States have considerable flexibility in designing their Medicaid programs,  including certain aspects of eligibility, covered services, and provider  payment rates. But under federal law, states generally must meet certain  requirements for what benefits are to be provided, who is eligible for the  program, and how much these beneficiaries can be required to pay in  sharing the cost of their care. States are required, for example, to cover  certain services under their state plans, such as physician, hospital, and  nursing facility services, as well as EPSDT services for beneficiaries under  the age of 21.
subsections: section_title: EPSDT Services
paragraphs: EPSDT services are designed to target health conditions and problems for  which children are at risk, including obesity, lead poisoning, dental  disease, and iron deficiency. EPSDT services are also intended to detect  and correct conditions that can hinder a child’s learning and development,  such as vision and hearing problems. For many children, particularly those  with special needs related to disabilities or chronic conditions, EPSDT  services can help to identify the need for, and make available, essential  medical and support services.
State Medicaid programs are required to cover EPSDT services for  Medicaid beneficiaries under 21. These services are defined as screenings,  which must include a comprehensive health and developmental history, a  comprehensive unclothed physical exam, appropriate immunizations,  laboratory tests (including a blood-lead assessment), and health  education. Other required EPSDT services include    dental services, which must include relief of pain and infections,  restoration of teeth, and maintenance of dental health;    vision services, including diagnosis and treatment for vision defects, and    hearing services, including diagnosis and treatment for hearing defects,  and hearing aids; and   services necessary to correct or ameliorate physical and mental illness  discovered through screenings, regardless of whether these services are  covered under the state’s Medicaid plan for other beneficiaries.
Although state Medicaid programs must cover EPSDT services, states have  some flexibility in determining the frequency and timing of screenings,  including the provision of dental services. Federal law requires states to  provide dental services at intervals that meet reasonable standards of  dental practice, and each state determines these intervals after consulting  with recognized dental organizations. Each state must also develop  dental periodicity schedules, which contain age-specific timetables that  identify when dental examinations should occur.
section_title: Medicaid Delivery and Financing
paragraphs: States generally provide Medicaid services through two service delivery  and financing systems—fee-for-service and managed care. Under a fee-for- service model, states pay providers for each covered service for which  they bill the state. Under a managed care model, states contract with  managed care plans, such as health maintenance organizations, and  prospectively pay the plans a fixed monthly fee, known as a capitated fee,  per Medicaid enrollee to provide or arrange for most medical services.  This model is intended to create an incentive for plans to provide  preventive and primary care to reduce the chance that beneficiaries will  require more expensive treatment services in the future. However, this  model may also create a financial incentive to underserve or deny  beneficiaries access to certain services.
State Medicaid agencies use a variety of delivery and payment approaches  to provide dental services under Medicaid. These include (1) paying  managed care plans with which they have contracts to cover or arrange  for the provision of dental services; (2) “carving out” or not requiring the  provision of dental services from the group of services provided by  managed care plans and paying dentists on a fee-for-service basis; or   (3) carving out the dental services and paying specialized dental managed  care plans to provide Medicaid dental benefits, giving the managed care  dental plan flexibility in managing the program in exchange for a capitated  payment to cover dental services. According to the American Dental  Association, 18 states and the District of Columbia used one or more  managed care dental plans to provide Medicaid dental benefits in 2004.
Much of the Medicaid population is covered by some form of managed  care, and consequently Medicaid managed care plans often provide  EPSDT services. In 1991, 2.7 million beneficiaries were enrolled in some  form of Medicaid managed care. According to CMS statistics, this number  grew to 27 million in 2004—a tenfold increase—after the Balanced Budget  Act of 1997 (BBA) gave states new authority to require certain Medicaid  beneficiaries to enroll in managed care plans. CMS estimates that in 2004,  about 60 percent of Medicaid enrollees received benefits through some  form of managed care.
section_title: CMS Requires States to Report Annually on Provision of EPSDT Dental Services through the CMS 416
paragraphs: CMS requires states to report annually on the provision of EPSDT dental  services through the CMS 416, the agency’s primary tool for overseeing the  provision of dental services to children in state Medicaid programs. The  CMS 416 is used to report a range of EPSDT services. CMS implemented  the CMS 416 to comply with the Omnibus Budget Reconciliation Act of  1989 (OBRA), which required that the Secretary of Health and Human  Services establish state-specific annual goals for children’s participation in  EPSDT services. OBRA and implementing regulations mandated state- established periodicity schedules for health, dental, vision, and hearing  screenings and related services. CMS initially required states to provide  only one type of dental-related data: the dental assessments provided. This  requirement was expanded in 1999 to collect more detailed data.
According to CMS, the CMS 416 is used to assess the effectiveness of state  EPSDT programs in terms of the number of children who are provided  child health screening services, referrals for corrective treatment, and  dental services. Child health screening information is used to calculate the  provision of health screenings and states’ progress in meeting an   80 percent screening participation goal. For dental services, the CMS 416  captures, by age group, the total number of eligible children  receiving any dental services, receiving any preventive dental services (each child is counted only once  even if more than one preventive service is provided), and receiving dental treatment services (each child is counted only once even  if more than one treatment service is provided).
CMS officials told us in April 2007 that CMS had not established a  participation goal or other standard that states are expected to meet  specifically for the provision of dental services. CMS officials told us they  calculate state and national ratios only for child health screenings and  participation.
The CMS 416 also requires states to report the number of individuals  eligible for EPSDT services who are enrolled in managed care at any time  during the reporting year. States are required to report information on all  EPSDT dental services provided to children, regardless of whether those  services are provided under a fee-for-service or managed care  arrangement.
section_title: Quality of CMS Data on EPSDT Dental Services Has Improved, but Data Have Limited Usefulness for Oversight
paragraphs: We have issued a number of reports that highlighted various problems in  the delivery of EPSDT dental services and with the reporting of dental and  other required EPSDT services provided. Problems we found in 2001 with  the CMS 416 reporting included states not submitting CMS 416s on time or  at all and states submitting reports that were not complete because of  challenges they faced collecting accurate data. In our 2001 report, we  recommended that CMS work with states to improve EPSDT reporting and  the provision of EPSDT services. According to agency officials, CMS has  taken steps to improve the CMS 416 data. However, state and national  health association officials continue to cite concerns about the data’s  completeness and sufficiency for purposes of overseeing the provision of  dental and other required EPSDT services.
subsections: section_title: State CMS 416s Are Not Always Submitted or Complete
paragraphs: Some states have submitted their CMS 416s late, and others have not  submitted the CMS 416s at all. Further, states that did submit reports may  have provided incomplete data because of challenges in collecting the  data. Therefore, the reports cannot be used to provide national estimates  of the provision of dental and other required EPSDT services to children in  Medicaid or to assess every state’s progress in providing services. We first  reported this problem in July 2001. States were required to submit their  fiscal year 1999 CMS 416 reports by April 1, 2000. But as of January 2001,  15 states had not submitted their reports, and another 15 states’ reports  had been returned by CMS because they were deficient. As of April 2007,   7 states had not submitted their CMS 416s for fiscal year 2005 (due to CMS  by April 1, 2006), and another 2 states had submitted reports, but CMS  considered them deficient and was working with the states to improve  their reports. We estimate that these 9 states account for 20 percent of all  children enrolled in Medicaid nationwide.
Another long-standing concern with the CMS 416s submitted by states has  been the completeness of the data on dental and other required EPSDT  services used to compile the reports. Our July 2001 report found that  states faced challenges collecting data on EPSDT services from both fee- for-service providers and managed care plans. Under the fee-for-service  approach, providers bill the state for each EPSDT service they deliver.  Thus, data on EPSDT services are often collected by the state as part of  the payment process. Most of the states we examined for our 2001 report  had some difficulty obtaining complete and accurate data from fee-for- service providers—for example, due to coding or system issues. States  faced more extensive problems obtaining data from capitated managed  care plans. Unlike fee-for-service arrangements, when capitated managed  care plans pay their participating providers a flat fee per beneficiary  regardless of services provided, the providers do not need to submit  information on each service provided in order to receive payment. Thus  plans have had difficulty reporting on the provision of specific EPSDT  services separately as required by states.
section_title: CMS Has Taken Steps to Improve Quality of the Data, but Concerns Remain
paragraphs: CMS officials have reported taking several actions in response to our 2001  recommendation that the Administrator of CMS improve EPSDT  reporting. CMS reported, for example, that it had started assessing states’  CMS 416s as part of periodic focused reviews conducted by CMS regional  offices. We reported in 2001 that CMS regional office reviews of states’  EPSDT programs had been helpful in highlighting policy and process  concerns, as well as innovative state practices. Since 2002, according to  CMS in April 2007, the agency had conducted focused reviews in 11 states.  These reviews have evaluated, among other things, state data collection  and reporting, including the extent to which the state develops its CMS 416  in accordance with instructions and uses the data to measure progress and  define areas for improvement. During these reviews, CMS found  deficiencies, such as incorrect coding and incomplete data. CMS made  specific recommendations to the states that would improve the reliability  of the state-generated CMS 416 data.
Another step CMS has taken that has improved the quality and  completeness of the data states can use to compile their 416s was to  require states to gather encounter data from Medicaid managed care plans.  The BBA and implementing regulations require states that contract with  managed care plans to implement a quality assessment and improvement  strategy that included procedures for monitoring and evaluating the  quality and appropriateness of services provided under the contracts.  States are also required to ensure that managed care plans maintain a  health information system and report encounter data. CMS also  developed a protocol for states’ use for validating encounter data. Officials  from several states and national health associations we contacted in  preparation for this hearing generally said that, although problems remain,  the quality and completeness of the underlying data, such as managed care  encounter data, that states used to prepare the CMS 416, had improved  since 2001. CMS officials indicated a number of efforts were underway to  evaluate other quality and outcome measures of dental services provided  to children enrolled in Medicaid. For example, one measure CMS is  considering is the Quality Compass developed by the National Committee  for Quality Assurance that provides plan-specific, comparative, and  descriptive information for use as a health plan benchmarking tool.
But despite these improvements, officials from states and from national  health associations remain concerned that the CMS 416s are unreliable for  developing national estimates of the provision of dental and other required  EPSDT services and therefore insufficient for oversight purposes.  Although some officials cited some uses of the CMS 416, for example, as a  set of basic indicators of the extent to which children use dental services  over time, the officials cited several different problems.
Inconsistent data collection. Citing differences in how states collected  data on dental EPSDT services, an April 2005 National Oral Health Policy  Center report stated that comparing the number of children receiving  services over time or examining the rate of dental utilization across states  should be done with caution. The Center’s director provided several  examples. For instance, some states inappropriately reported oral health  assessments conducted in group settings, such as those performed by  nurses or other non-dentist health providers in schools, as dental  examinations. Likewise, some states inappropriately reported oral health  assessments provided by hygienists as dental examinations. According to  the director, such assessments should not be considered dental  examinations.
Coding inconsistencies and anomalies. CMS 416s may not accurately  reflect the provision of dental and other required EPSDT services,  according to an official from the National Academy for State Health Policy  speaking about research she had done in 2002 and 2004. States have  reported that discrepancies exist between managed care plans and state  Medicaid agencies in the definitions of ESPDT services. Similarly, we  reported in 2001 that states faced such issues in collecting CMS 416 data  for the range of EPSDT services that might be provided during a  comprehensive office visit. For example, providers in Florida were  required to use a specific EPSDT code and a claim form to document the  components of EPSDT services they provided. However, according to  state officials, providers often chose to use other codes instead. According  to the officials, some providers submitted claims under a comprehensive  office-visit code for a new patient that paid a higher rate than an EPSDT  screening, or used other comprehensive office-visit codes that required  less documentation. Specific to dental EPSDT services, the George  Washington University Medical Center reported in December 2003 that  several Medicaid program representatives said that it was difficult to  separate specific provided services in EPSDT data reported by managed  care plans to determine the provision of dental screening services because  providers did not always bill for those services separately.
Changes in beneficiary eligibility. Gaps in children’s eligibility for  Medicaid and movement of children between Medicaid and other health  insurance plans may also cause problems in accurately determining the  extent that Medicaid children received dental and other required EPSDT  services. One official told us that interrupted Medicaid eligibility,  accompanied by the implementation of the State Children’s Health  Insurance Program, has also caused problems in the data on the number  of children eligible for services. As children move between health  insurance programs as their program eligibility changes, officials reported  that it becomes difficult to maintain an accurate count of Medicaid-eligible  children. Without an accurate count, an accurate rate of the provision of  the dental and other required EPSDT services to eligible children cannot  be calculated.
section_title: CMS 416s Have Limitations for Oversight Purposes
paragraphs: The type of data collected on the CMS 416 has limited usefulness for  purposes of oversight, as officials from states and national health  associations have noted. Many officials from national health associations  told us that the CMS 416 did not provide enough information to allow CMS  to assess the effectiveness of states’ EPSDT programs. One official who  works with many state Medicaid agencies told us that states do not  generally use the CMS 416 to inform their monitoring and quality  improvement activities, but instead rely on other sources of data. Some  state officials reported using the CMS 416 data, but noted that they  supplement the data with additional information.
The limitations noted generally fell into three categories. First, while states  report the total number of children enrolled in managed care plans, dental  and other required EPSDT services delivered to managed care enrollees  are not reported separately from fee-for-service enrollees. Consequently,  the data captured by the CMS 416 cannot be used to specifically monitor  the provision of dental and other required EPSDT services under either  fee-for-service or managed care arrangements.
Second, the information captured by the CMS 416 is limited to summary  statistics, such as age group, eligibility, state requirements, and services  delivered, and does not provide information that would illuminate whether  children have received the recommended number of visits for dental and  other required EPSDT services. For example, a concern raised by a  national health association official was that the CMS 416 did not provide  information about whether eligible children had received the number of  biannual preventive dental visits that are required by the state or  recommended by the American Academy of Pediatric Dentistry. Because  each child is counted only once each fiscal year, regardless of the number  of dental services or preventive dental services the child received that  year, the data do not reflect the total number of dental appointments each  child had in any given year.
Third, CMS 416s do not contain information that would illuminate any of a  number of factors that may contribute to low use of dental and other  required EPSDT services among children enrolled in Medicaid. Our 2001  report found that children’s low utilization of EPSDT dental and other  services could have been attributed to program-related matters, such as  limited provider participation in Medicaid or inadequate methods for  informing beneficiaries of available services. In addition, some  beneficiary-related factors, such as changing eligibility status or language  barriers, could have limited utilization of services. Also, our 2000 report on  factors contributing to low utilization of dental services by Medicaid and  other low-income populations found that the primary contributing factor  among low-income persons with coverage for dental services was  difficulty finding dentists to treat them. Dentists generally cited low  payment rates, burdensome administrative requirements, and such patient  issues as frequently missed appointments as the reasons why they did not  treat more Medicaid patients. Additional, more specific information  would be needed to supplement the information collected in the CMS 416  to further understand these factors.
section_title: Concluding Observations
paragraphs: Millions of low-income children enrolled in Medicaid should have access  to important services to treat dental disease, as intended by Congress in  mandating the coverage of and reporting on the provision of EPSDT dental  services. Services to identify and treat tooth decay—a chronic problem  among low-income populations and a preventable disease—are critical for  ensuring that the nation’s children and adolescents are healthy and  prepared to learn. Unfortunately, as we reported in 2001 and 2003, data for  gauging Medicaid’s success in providing these important services to  enrolled children are unreliable and incomplete. CMS and states have  taken a number of steps to improve the data, but problems persist.  Moreover, concerns have been raised that the reported data on EPSDT  dental services have limited utility for determining how to improve  children’s access to these services. Strengthening the safety net for  children in Medicaid will require additional efforts to gather more  complete and reliable information on the delivery of dental and other  ESPDT services.
Mr. Chairman, this concludes my prepared remarks. I would be pleased to  respond to any questions that you or other members of the Subcommittee  may have at this time.
section_title: GAO Contacts and Acknowledgments
paragraphs: For future contacts regarding this testimony, please contact James C.  Cosgrove at (202) 512-7118 or at cosgrovej@gao.gov. Contact points for  our Offices of Congressional Relations and Public Affairs may be found on  the last page of this testimony. Katherine Iritani, Assistant Director; Emily  Beller; Terry Saiki; and Timothy Walker made key contributions to this  statement.
section_title: Appendix I: CMS Form 416
section_title: Related GAO Products
paragraphs: Medicaid and SCHIP: States Use Varying Approaches to Monitor  Children’s Access to Care. GAO-03-222. Washington, D.C.: January 14,  2003.
Medicaid: Stronger Efforts Needed to Ensure Children’s Access to Health  Screening Services. GAO-01-749. Washington, D.C.: July 13, 2001.
Oral Health: Factors Contributing to Low Use of Dental Services by Low- Income Populations. GAO/HEHS-00-149. Washington, D.C.: September 11,  2000.
Oral Health: Dental Disease Is a Chronic Problem Among Low-Income  Populations. GAO/HEHS-00-72. Washington, D.C.: April 12, 2000.
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