Medicaid: Extent of Dental Disease in Children Has Not Decreased, and Millions Are Estimated to Have Untreated Tooth Decay
Published: 2008-09-23T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: In recent years, concerns have been raised about the adequacy of dental care for low-income children. Attention to this subject became more acute due to the widely publicized case of Deamonte Driver, a 12-year-old boy who died as a result of an untreated infected tooth that led to a fatal brain infection. Deamonte had health coverage through Medicaid, a joint federal and state program that provides health care coverage, including dental care, for millions of low-income children. Deamonte had extensive dental disease and his family was unable to find a dentist to treat him. GAO was asked to examine the extent to which children in Medicaid experience dental disease, the extent to which they receive dental care, and how these conditions have changed over time. To examine these indicators of oral health, GAO analyzed data for children ages 2 through 18, by insurance status, from two nationally representative surveys conducted by the Department of Health and Human Services (HHS): the National Health and Nutrition Examination Survey (NHANES) and the Medical Expenditure Panel Survey (MEPS). GAO also interviewed officials from the Centers for Disease Control and Prevention, and dental associations and researchers. In commenting on a draft of the report, HHS acknowledged the challenge of providing dental services to children in Medicaid, and cited a number of studies and actions taken to address the issue.
section_title: What GAO Found
paragraphs: Dental disease remains a significant problem for children aged 2 through 18 in Medicaid. Nationally representative data from the 1999 through 2004 NHANES surveys--which collected information about oral health through direct examinations--indicate that about one in three children in Medicaid had untreated tooth decay, and one in nine had untreated decay in three or more teeth. Projected to 2005 enrollment levels, GAO estimates that 6.5 million children aged 2 through 18 in Medicaid had untreated tooth decay. Children in Medicaid remain at higher risk of dental disease compared to children with private health insurance; children in Medicaid were almost twice as likely to have untreated tooth decay. Receipt of dental care also remains a concern for children aged 2 through 18 in Medicaid. Nationally representative data from the 2004 through 2005 MEPS survey--which asks participants about the receipt of dental care for household members--indicate that only one in three children in Medicaid ages 2 through 18 had received dental care in the year prior to the survey. Similarly, about one in eight children reportedly never sees a dentist. More than half of children with private health insurance, by contrast, had received dental care in the prior year. Children in Medicaid also fared poorly when compared to national benchmarks, as the percentage of children in Medicaid who received any dental care--37 percent--was far below the Healthy People 2010 target of having 66 percent of low-income children under age 19 receive a preventive dental service. Survey data on Medicaid children's receipt of dental care showed some improvement; for example, use of sealants went up significantly between the 1988 through 1994 and 1999 through 2004 time periods. Rates of dental disease, however, did not decrease, although the data suggest the trends vary somewhat among different age groups. Younger children in Medicaid--those aged 2 through 5--had statistically significant higher rates of dental disease in the more recent time period as compared to earlier surveys. By contrast, data for Medicaid adolescents aged 16 through 18 show declining rates of tooth decay, although the change was not statistically significant.

section_title: Letter
paragraphs: In recent years, concerns have been raised about the adequacy of dental  care for low-income children. Attention to this subject became more acute  due to the widely publicized case of Deamonte Driver, a 12-year-old boy  who died as a result of an untreated infected tooth that led to a fatal brain  infection. Deamonte had health coverage through Medicaid, a joint federal  and state program that provides health care coverage, including dental  care, for millions of low-income children. Even though Deamonte was  entitled to dental care from his Medicaid managed care organization,  Deamonte’s family had experienced significant difficulties in obtaining  needed dental care, including finding a dentist in their Maryland  neighborhood who would accept Medicaid patients.
May 2007 and February 2008 congressional hearings investigated the  effectiveness of federal oversight of state Medicaid dental programs by the  Department of Health and Human Services’ (HHS) Centers for Medicare &  Medicaid Services (CMS), the agency that oversees state Medicaid  programs at the federal level. Concerns raised at the hearings about low- income children’s oral health, including the extent that children in  Medicaid experience dental disease and receive dental care, are not new.  Our reports dating back to 2000 highlighted the problem of chronic dental  disease and the factors that contribute to low use of dental care by low- income populations, including children in Medicaid.
You asked us to examine two aspects of children’s oral health: the extent  to which children in Medicaid experience dental disease and the extent to  which they receive dental care. You also asked us to assess how these  conditions have changed over time. This report presents information from  national health surveys on key indicators of the oral health status of  children in Medicaid, specifically, the rate of dental disease and their  receipt of dental care, and changes in these indicators over time. To  determine the extent to which children in Medicaid experience dental  disease, we analyzed data from a survey conducted by HHS—the National  Health and Nutrition Examination Survey (NHANES). NHANES— administered by the Centers for Disease Control and Prevention’s (CDC)  National Center for Health Statistics—obtains nationally representative  information on the health and nutritional status of the U.S. population  through direct physical examinations, including dental examinations, and  interviews. The dental examinations include a dentist’s assessment of  tooth decay and the presence of dental sealants, and the interviews  include questions on various health and demographic characteristics,  including information on insurance status. We grouped NHANES survey  data from 1999 through 2004 (the most recent data based on direct oral  examinations by dentists available) in order to include a sufficient  number of examinations to provide a reliable basis for assessing the extent  of dental disease in the Medicaid population of children aged 2 through  18. To assess how the rate of dental disease experienced by children in  Medicaid has changed over time, we compared NHANES data from 1999  through 2004 with NHANES data from 1988 through 1994. We analyzed  results from three different groups based on their health insurance status:  children with Medicaid, children with private health insurance, and  uninsured children. The group of children with private insurance included  both children with dental coverage and children without dental coverage,  while the group of uninsured was children who had neither health  insurance nor dental insurance.
To assess children’s receipt of dental care, we analyzed data from another  HHS survey, the Medical Expenditure Panel Survey (MEPS). MEPS— administered by HHS’s Agency for Healthcare Research and Quality  (AHRQ)—obtains nationally representative information on Americans’  health insurance coverage and use of health care, including information on  receipt of dental care, such as how often participants see a dentist and  whether they have experienced problems accessing needed dental care.  Our MEPS analysis was based on surveys conducted in 2004 and 2005 (the  most recent data available); to assess how receipt of dental care has  changed over time, we compared the data from 2004 and 2005 with the  earliest available MEPS data, from 1996 and 1997. We analyzed the MEPS  data using the same three insurance groups we used for the NHANES data.  To estimate the number of children in each Medicaid category with a given  condition, we applied certain proportions from NHANES or MEPS data to  an estimate of the 2005 average monthly Medicaid enrollment of children  aged 2 through 18 (20.1 million children). Similar to NHANES, the  Medicaid category included children enrolled in the State Children’s  Health Insurance Program (SCHIP) for the later time period (2004 through  2005 for MEPS). To assess the reliability of NHANES and MEPS data, we  spoke with knowledgeable agency officials, reviewed related  documentation, and compared our results to published data. We  determined these data to be reliable for the purposes of this report.  Appendixes I and II contain more information on our NHANES and MEPS  analyses. Finally, we obtained information on oral health and the Medicaid  population from CDC and from dental associations and experts including  the Children’s Health Dental Project and the Medicaid/SCHIP Dental  Association. This work was conducted in accordance with generally  accepted government auditing standards from December 2007 through  September 2008.
subsections: section_title: Background
paragraphs: In 2000, a report of the Surgeon General noted that tooth decay is the most  common chronic childhood disease. Left untreated, the pain and  infections caused by tooth decay may lead to problems in eating, speaking,  and learning. Tooth decay is almost completely preventable, and the pain,  dysfunction, or on extremely rare occasion, death, resulting from dental  disease can be avoided (see fig. 1). Preventive dental care can make a  significant difference in health outcomes and has been shown to be cost- effective. For example, a 2004 study found that average dental-related  costs for low-income preschool children who had their first preventive  dental visit by age 1 were less than one-half ($262 compared to $546) of  average costs for children who received their first preventive visit at age 4  through 5.
The American Academy of Pediatric Dentistry (AAPD) recommends that  each child see a dentist when his or her first tooth erupts and no later than  the child’s first birthday, with subsequent visits occurring at 6-month  intervals or more frequently if recommended by a dentist. The early initial  visit can establish a “dental home” for the child, defined by AAPD as the  ongoing relationship with a dental provider who can ensure  comprehensive and continuously accessible care. Comprehensive dental  visits can include both clinical assessments, such as for tooth decay and  sealants, and appropriate discussion and counseling for oral hygiene,  injury prevention, and speech and language development, among other  topics. Because resistance to tooth decay is determined in part by  genetics, eating patterns, and oral hygiene, early prevention is important.  Delaying the onset of tooth decay may also reduce long-term risk for more  serious decay by delaying the exposure to caries risk factors to a time  when the child can better control his or her health behaviors.
Recognizing the importance of good oral health, HHS in 1990 and again in  2000 established oral health goals as part of its Healthy People 2000 and  2010 initiatives. These include objectives related to oral health in children,  for example, reducing the proportion of children with untreated tooth  decay. One objective of Healthy People 2010 relates to the Medicaid  population: to increase the proportion of low-income children and  adolescents under the age of 19 who receive any preventive dental service  in the past year, from 25 percent in 1996 to 66 percent in 2010.
Medicaid, a joint federal and state program which provides health care  coverage for low-income individuals and families; pregnant women; and  aged, blind, and disabled people, provided health coverage for an  estimated 20.1 million children aged 2 through 18 in federal fiscal year  2005. The states operate their Medicaid programs within broad federal  requirements and may contract with managed care organizations to  provide Medicaid benefits or use other forms of managed care, when  approved by CMS. CMS estimates that as of June 30, 2006, about   65 percent of Medicaid beneficiaries received benefits through some form  of managed care. State Medicaid programs must cover some services for  certain populations under federal law. For instance, under Medicaid’s  EPSDT benefit, states must provide dental screening, diagnostic,  preventive, and related treatment services for all eligible Medicaid  beneficiaries under age 21.
section_title: Dental Disease and Inadequate Receipt of Dental Care Remain Significant Problems for Children in Medicaid
paragraphs: Children in Medicaid aged 2 through 18 often experience dental disease  and often do not receive needed dental care, and although receipt of  dental care has improved somewhat in recent years, the extent of dental  disease for most age groups has not. Information from NHANES surveys  from 1999 through 2004 showed that about one in three children ages 2  through 18 in Medicaid had untreated tooth decay, and one in nine had  untreated decay in three or more teeth. Compared to children with private  health insurance, children in Medicaid were substantially more likely to  have untreated tooth decay and to be in urgent need of dental care. MEPS  surveys conducted in 2004 and 2005 found that almost two in three  children in Medicaid aged 2 through 18 had not received dental care in the  previous year and that one in eight never sees a dentist. Children in  Medicaid were less likely to have received dental care than privately  insured children, although they were more likely to have received care  than children without health insurance. Children in Medicaid also fared  poorly when compared to national benchmarks, as the percentage of  children in Medicaid ages 2 through 18 who received any dental care—  37 percent—was far below the Healthy People 2010 target of having   66 percent of low-income children under age 19 receive a preventive  dental service. MEPS data on Medicaid children who had received dental  care—from 1996 through 1997 compared to 2004 through 2005—showed  some improvement for children ages 2 through 18 in Medicaid. By  contrast, comparisons of recent NHANES data to data from the late 1980s  and 1990s suggest that the extent that children ages 2 through 18 in  Medicaid experience dental disease has not decreased for most age  groups.
subsections: section_title: National Survey Data from 1999 through 2004 Show That One in Three Children in Medicaid Had Untreated Tooth Decay
paragraphs: Dental disease is a common problem for children aged 2 through 18  enrolled in Medicaid, according to national survey data (see fig. 2).  NHANES oral examinations conducted from 1999 through 2004 show that  about three in five children (62 percent) in Medicaid had experienced  tooth decay, and about one in three (33 percent) were found to have  untreated tooth decay. Close to one in nine—about 11 percent—had  untreated decay in three or more teeth, which is a sign of unmet need for  dental care and, according to some oral health experts, can suggest a  severe oral health problem. Projecting these proportions to 2005  enrollment levels, we estimate that 6.5 million children in Medicaid had  untreated tooth decay, with 2.2 million children having untreated tooth  decay involving three or more teeth.
Compared with children with private health insurance, children in  Medicaid were at much higher risk of tooth decay and experienced  problems at rates more similar to those without any insurance. As shown  in figure 3, the proportion of children in Medicaid with untreated tooth  decay (33 percent) was nearly double the rate for children who had private  insurance (17 percent) and was similar to the rate for uninsured children  (35 percent). These children were also more than twice as likely to have  untreated tooth decay in three or more teeth than their privately insured  counterparts (11 percent for Medicaid children compared to 5 percent for  children with private health insurance). These disparities were consistent  across all age groups we examined.
According to NHANES data, more than 5 percent of children in Medicaid  aged 2 through 18 had urgent dental conditions, that is, conditions in need  of care within 2 weeks for the relief of symptoms and stabilization of the  condition. Such conditions include tooth fractures, oral lesions, chronic  pain, and other conditions that are unlikely to resolve without professional  intervention. On the basis of these data, we estimate that in 2005,   1.1 million children aged 2 through 18 in Medicaid had conditions that  warranted seeing a dentist within 2 weeks. Compared to children who  had private insurance, children in Medicaid were more than four times as  likely to be in urgent need of dental care.
The NHANES data suggest that the rates of untreated tooth decay for  some Medicaid beneficiaries could be about three times more than  national health benchmarks. For example, the NHANES data showed that  29 percent of children in Medicaid aged 2 through 5 had untreated decay,  which compares unfavorably with the Healthy People 2010 target for  untreated tooth decay of 9 percent of children aged 2 through 4.
section_title: National Survey Data from 2004 through 2005 Showed That Nearly Two in Three Children in Medicaid Did Not Receive Dental Care in the Previous Year
paragraphs: Most children in Medicaid do not visit the dentist regularly, according to  2004 and 2005 nationally representative MEPS data (see fig. 4). According  to these data, nearly two in three children in Medicaid aged 2 through 18  had not received any dental care in the previous year. Projecting these  proportions to 2005 enrollment levels, we estimate that 12.6 million  children in Medicaid have not seen a dentist in the previous year. In  reporting on trends in dental visits of the general population, AHRQ  reported in 2007 that about 31 percent of poor children (family income  less than or equal to the federal poverty level) and 34 percent of low- income children (family income above 100 percent through 200 percent of  the federal poverty level) had a dental visit during the year. Survey data  also showed that about one in eight children (13 percent) in Medicaid  reportedly never see a dentist.
MEPS survey data also show that many children in Medicaid were unable  to access needed dental care. Survey participants reported that about   4 percent of children aged 2 through 18 in Medicaid were unable to get  needed dental care in the previous year. Projecting this percentage to  estimated 2005 enrollment levels, we estimate that 724,000 children aged 2  through 18 in Medicaid could not obtain needed care. Regardless of  insurance status, most participants who said a child could not get needed  dental care said they were unable to afford such care. However,   15 percent of children in Medicaid who had difficulty accessing needed  dental care reportedly were unable to get care because the provider  refused to accept their insurance plan, compared to only 2 percent of  privately insured children.
Children enrolled in Medicaid were less likely to have received dental care  than privately insured children, but they were more likely to have received  dental care than children without health insurance. (See fig. 5.) Survey  data from 2004 through 2005 showed that about 37 percent of children in  Medicaid aged 2 through 18 had visited the dentist in the previous year,  compared with about 55 percent of children with private health insurance,  and 26 percent of children without insurance. The percentage of children  in Medicaid who received any dental care—37 percent—was far below the  Healthy People 2010 target of having 66 percent of low-income children  under age 19 receive a preventive dental service.
The NHANES data from 1999 through 2004 also provide some information  related to the receipt of dental care. The presence of dental sealants, a  form of preventive care, is considered to be an indicator that a person has  received dental care. About 28 percent of children in Medicaid had at least  one dental sealant, according to 1999 through 2004 NHANES data. In  contrast, about 40 percent of children with private insurance had a sealant.  However, children in Medicaid were more likely to have sealants than  children without health insurance (about 20 percent).
section_title: Comparison of Past and Recent Survey Data Suggests That the Rate of Dental Disease in Children in Medicaid Is Not Decreasing, although the Receipt of Dental Care Has Improved Somewhat in More Recent Years
paragraphs: While comparisons of past and more recent survey data suggest that a  larger proportion of children in Medicaid had received dental care in  recent surveys, the extent that children in Medicaid experience dental  disease has not decreased. A comparison of NHANES results from 1988  through 1994 with results from 1999 through 2004 showed that the rates of  untreated tooth decay were largely unchanged for children in Medicaid  aged 2 through 18: 31 percent of children had untreated tooth decay in  1988 through 1994, compared with 33 percent in 1999 through 2004 (see  fig. 6). The proportion of children in Medicaid who experienced tooth  decay increased from 56 percent in the earlier period to 62 percent in more  recent years. This increase appears to be driven by younger children, as  the 2 through 5 age group had substantially higher rates of dental disease  in the more recent time period, 1999 through 2004. This preschool age  group experienced a 32 percent rate of tooth decay in the 1988 through  1994 time period, compared to almost 40 percent experiencing tooth decay  in 1999 through 2004 (a statistically significant change). Data for  adolescents, by contrast, suggest declining rates of tooth decay. Almost 82  percent of adolescents aged 16 through 18 in Medicaid had experienced  tooth decay in the earlier time period, compared to 75 percent in the latter  time period (although this change was not statistically significant). These  trends were similar for rates of untreated tooth decay, with the data  suggesting rates going up for young children, and declining or remaining  the same for older groups that are more likely to have permanent teeth.  According to CDC, these trends are similar for the general population of  children, for which tooth decay in permanent teeth has generally declined  and untreated tooth decay has remained unchanged. CDC also found that  tooth decay in preschool aged children in the general population had  increased in primary teeth.
At the same time, indicators of receipt of dental care, including the  proportion of children who had received dental care in the past year and  use of sealants, have shown some improvement. Two indicators of receipt  of dental care showed improvement from earlier surveys:    The percentage of children in Medicaid aged 2 through 18 who received  dental care in the previous year increased from 31 percent in 1996 through  1997 to 37 percent in 2004 through 2005, according to MEPS data (see   fig. 7). This change was statistically significant. Similarly, AHRQ reported  that the percent of children with a dental visit increased between 1996 and  2004 for both poor children (28 percent to 31 percent) and low-income  children (28 percent to 34 percent).
The percentage of children aged 6 through 18 in Medicaid with at least one  dental sealant increased nearly threefold, from 10 percent in 1988 through  1994 to 28 percent in 1999 through 2004, according to NHANES data, and  these changes were statistically significant. The increase in receipt of  sealants may be due in part to the increased use of dental sealants in  recent years, as the percentage of uninsured and insured children with  dental sealants doubled over the same time period. Adolescents aged 16  through 18 in Medicaid had the greatest increase in receipt of sealants  relative to other age groups. The percentage of adolescents with dental  sealants was about 6 percent in the earlier time period, and 33 percent  more recently.
The percentage of children in Medicaid who reportedly never see a dentist  remained about the same between the two time periods, with about   14 percent in 1996 through 1997 who never saw a dentist, and 13 percent in  2004 through 2005, according to MEPS data.
More information on our analysis of NHANES and MEPS for changes in  dental disease and receipt of dental care for children in Medicaid over  time, including confidence intervals and whether changes over time were  statistically significant, can be found in appendixes I and II.
section_title: Concluding Observations
paragraphs: The information provided by nationally representative surveys regarding  the oral health of our nation’s low-income children in Medicaid raises  serious concerns. Measures of access to dental care for this population,  such as children’s dental visits, have improved somewhat in recent  surveys, but remain far below national health goals. Of even greater  concern are data that show that dental disease is prevalent among children  in Medicaid, and is not decreasing. Millions of children in Medicaid are  estimated to have dental disease in need of treatment; in many cases this  need is urgent. Given this unacceptable condition, it is important that  those involved in providing dental care to children in Medicaid—the  federal government, states, providers, and others—address the need to  improve the oral health condition of these children and to achieve national  oral health goals.
section_title: Agency Comments
paragraphs: We provided a draft of this report for comment to HHS. HHS provided  written comments which we summarize below. The text of HHS’s letter,  including comments from CMS, CDC, and AHRQ, is reprinted in   appendix III. HHS also provided technical comments, which we  incorporated as appropriate. In commenting on the draft, CMS  acknowledged the challenge of providing dental services to children in  Medicaid, as well as all children nationwide, and cited a number of  activities undertaken by CMS in coordination with states, such as  completing 17 focused dental reviews and forming an Oral Health  Technical Advisory Group. CDC commented that trends in dental caries  vary by age group and for primary versus permanent teeth. CDC also noted  that beginning in 2005, trained health technologists conducted basic  assessments of caries experience. We revised our report to further clarify  the differing trends by age groups and to acknowledge the assessments  performed by health technologists. We did not analyze the data by both  age and dentition (primary versus permanent teeth) due to small sample  sizes; we note that the trends for the youngest and oldest age groups in the  Medicaid child population that we identified are consistent with those that  CDC found in the general population by age and dentition.
AHRQ commented that agency staff had completed a Chartbook that  summarizes dental use, expenses, dental coverage, and changes from 1996  and 2004 for the general population that was not cited and referenced in  our report, and indicated it was unclear why the same analytical approach  was not followed for the determination of public coverage status. In  technical comments, AHRQ noted that their reported findings are  generally comparable to GAO’s findings. We revised our report to cite  AHRQ’s findings on dental services for children and to further describe  our methodology. Regarding our determination of public coverage status,  we did not use AHRQ’s analytical approach that describes “public  coverage” because the focus of this report was on children covered by  Medicaid. AHRQ’s approach did not distinguish Medicaid from other types  of public coverage.
We are sending copies of this report to other interested congressional  committees and to the Secretary of HHS. We will also make copies  available to others upon request. In addition, the report will be available at  no charge on the GAO Web site at http://www.gao.gov.
If you or your staffs have any questions regarding this report, please  contact me at (202) 512-7114 or cosgrovej@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on the  last page of this report. Key contributors are listed in appendix IV.
section_title: Appendix I: NHANES Analysis
paragraphs: The National Health and Nutrition Examination Survey (NHANES),  conducted multiple times since the early 1960s by the Department of  Health and Human Services’ (HHS) National Center for Health Statistics of  the Centers for Disease Control and Prevention (CDC), is designed to  provide nationally representative estimates of the health and nutrition  status of the noninstitutionalized civilian population of the United States.  NHANES provides information on civilians of all ages. Prior to 1999, three  periodic surveys were conducted. Since 1999, NHANES has been  conducted annually. For this study, we examined data from 1999 through  2004 and data from 1988 through 1994. We did not analyze any NHANES  data after 2004 because, beginning in 2005, NHANES surveys do not  include examinations by dentists for tooth decay, dental sealants, and  most other oral health conditions.
Our analysis of NHANES data focused on the oral examination of children  ages 2 through 18. As part of an overall physical examination, dental  examiners inspect children’s mouths and collect data on the number and  condition of teeth and the condition of gums. To analyze these data, we  considered three categories of children, based on their health insurance  status as reported by their parents or guardians on the interview section of  the survey: children with Medicaid, children with private health insurance,  and children without health insurance. These categories include more  than 90 percent of children who were given dental examinations as part of  NHANES. We do not present results for children with other forms of  government health insurance, such as TRICARE or Medicare, and we do  not present results for children whose parents or guardians provided no  information on their health insurance status (about 1.5 percent of children  fell into this category). For the 1999 through 2004 time period, the  Medicaid category includes some children enrolled in the State Children’s  Health Insurance Program (SCHIP); we estimate that about 85 percent of  the children for that time period were enrolled in Medicaid with the  remainder enrolled in SCHIP. To assess the reliability of NHANES data,  we interviewed knowledgeable officials, reviewed relevant  documentation, and compared the results of our analyses to published  data. We determined that the NHANES data were sufficiently reliable for  the purposes of our engagement.
Using the NHANES data, we analyzed the percentage of children with  untreated tooth decay, the percentage of children who had experienced  tooth decay, the percentage of children with tooth decay in three or more  teeth, and the percentage of children with dental sealants (see tables 1  through 5). We also analyzed the dental examiner’s recommendation for  care as the basis for determining whether a child had an urgent need for  dental care. For each of these measures, we estimated the percentage,  with 95 percent confidence intervals (that is, there is a 95 percent  probability that the actual number falls within the lower and upper limits  of our estimates), of children in each of the three insurance categories  using raw data and appropriate sampling weights. We also used standard  errors to calculate if changes from the 1988 through 1994 time period to  the 1999 through 2004 time period were statistically significant at the 95  percent level. To estimate the number of children in the Medicaid category  with a given condition, we multiplied the calculated percentage by an  estimate of the 2005 average monthly enrollment of children ages 2  through18 in Medicaid (20.1 million children). We estimated the 2005  average monthly enrollment of children ages 2 through 18 in Medicaid  using CMS statistics, by age group, for children ages 1 through 18 (we  reduced this number to account for children age 1 using Census data).
Our analysis of the NHANES data was conducted in accordance with  generally accepted government auditing standards from December 2007  through September 2008.
section_title: Appendix II: MEPS Background and Analysis
paragraphs: The Medical Expenditure Panel Survey (MEPS), administered by HHS’s  Agency for Healthcare Research and Quality (AHRQ), collects data on the  use of specific health services—frequency, cost, and payment. We  analyzed results from the household component of the survey, which  surveys families and individuals and their medical providers. Our analysis  was based on data from surveys conducted in 1996 through 1997 and 2004  through 2005. We used the 1996 through 1997 data because they were the  earliest available and we used the 2004 through 2005 data because they  were the most current available.
The household component of MEPS collects data from a sample of  families and individuals in selected communities across the United States,  drawn from a nationally representative subsample of households that  participated in the prior year’s National Health Interview Survey (a survey  conducted by the National Center for Health Statistics at the Centers for  Disease Control and Prevention). The household interviews feature  several rounds of interviewing covering 2 full calendar years. MEPS is  continuously fielded; each year a new sample of households throughout  the country is introduced into the study. MEPS collects information for  each person in the household based on information provided by one adult  member of the household. This information includes demographic  characteristics, health conditions, health status, use of medical services,  provider charges, access to care, satisfaction with care, health insurance  coverage, income, and employment. We analyzed responses to questions  on the use of dental care as well as responses to questions on the difficulty  accessing needed dental care. As with the National Health and Nutrition  Examination Survey (NHANES) data, we analyzed results from children  aged 2 through 18 and divided children into three categories on the basis  of their health insurance status. Similar to NHANES, the Medicaid  category included children enrolled in the State Children’s Health  Insurance Program (SCHIP) for the later time period (2004 through 2005  for MEPS). The privately insured category included children with private  health insurance, some of whom had dental coverage and others who did  not, while the uninsured category comprised children who had neither  health insurance nor dental insurance.
To determine the reliability of the MEPS data, we spoke with  knowledgeable agency officials and reviewed related documentation and  compared our results to published data. We determined that the MEPS  data were sufficiently reliable for the purposes of our engagement.
We analyzed data according to four different questions asked by the MEPS  survey (see tables 6 through 9). The questions asked (1) whether the child  had seen or talked to any dental provider in a given time period; (2) how  often the child got a dental checkup; (3) whether the child had trouble  accessing needed dental care; and (4) if the respondent answered yes to  the third question, then what the reasons were for having trouble  accessing needed dental care. Using sampling weights, we estimated the  percentage of children in each category as well as a lower and upper limit  of this percentage, calculated at the 95 percent confidence interval. We  also used standard errors to calculate if changes from the 1996 through  1997 time period to the 2004 through 2005 time period were statistically  significant at the 95 percent level.
To estimate the number of children ages 2 through 18 in Medicaid not  receiving dental care in the previous year, we calculated the percentage  that had not received dental care in the previous year (62.6 percent) and  applied this percentage to an estimate of the 2005 average monthly  enrollment of children ages 2 through18 in Medicaid (20.1 million  children). We estimated the 2005 average monthly enrollment of children  ages 2 through 18 in Medicaid using CMS statistics, by age group, for  children ages 1 through 18 (we reduced this number using Census data to  account for children age 1).
Our analysis of the MEPS data was conducted in accordance with  generally accepted government auditing standards from December 2007  through September 2008.
section_title: Appendix III: Comments from the Department of Health and Human Services
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: Staff Acknowledgments
paragraphs: In addition to the individual named above, Katherine M. Iritani,   Assistant Director; Susannah Bloch; Alex Dworkowitz; Erin Henderson;  Martha Kelly; Ba Lin; Elizabeth T. Morrison; Terry Saiki; Hemi Tewarson;  and Suzanne Worth made key contributions to this report.
section_title: Related GAO Products
paragraphs: Medicaid: Concerns Remain about Sufficiency of Data for Oversight of  Children’s Dental Services. GAO-07-826T. Washington, D.C.: May 2, 2007.
Medicaid Managed Care: Access and Quality Requirements Specific to  Low-Income and Other Special Needs Enrollees. GAO-05-44R.  Washington, D.C.: December 8, 2004.
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.
Medicaid Managed Care: Challenge of Holding Plans Accountable  Requires Greater State Effort. GAO/HEHS-97-86. Washington, D.C.:   May 16, 1997.