Medicaid: Extent of Dental Disease in Children Has Not Decreased
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, by insurance status, from two nationally representative surveys of the Department of Health and Human Services (HHS): the National Health and Nutrition Examination Survey (NHANES) and the Medical Expenditure Panel Survey (MEPS). This statement summarizes the resulting report being released today, Medicaid: Extent of Dental Disease in Children Has Not Decreased, and Millions Are Estimated to Have Untreated Tooth Decay (GAO-08-1121). In commenting on a draft of the report, HHS acknowledged the challenge of providing dental services to children in Medicaid, and cited the agency's related activities.
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: I am pleased to be here today as you further examine concerns related to  the adequacy of dental services for children in Medicaid. My testimony will  provide a summary of our report for the subcommittee, which you are  releasing today, entitled Medicaid: Extent of Dental Disease in Children  Has Not Decreased, and Millions Are Estimated to Have Untreated Tooth  Decay. This report provides information following the May 2007 and  February 2008 subcommittee hearings investigating concerns related to  the provision of dental services to children in Medicaid. These hearings  investigated the circumstances of Deamonte Driver, a 12-year-old boy with  Medicaid coverage who did not receive timely and needed dental care and  who died as a result of an untreated infected tooth that led to a fatal brain  infection. As you know, Medicaid—the joint federal and state program that  provides health care coverage for millions of low-income individuals— provides comprehensive dental coverage for enrolled children. 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. GAO reviews conducted in the late 1990s  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.
Our new work examined 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. We also assessed how these conditions  have changed over time. Our work provides 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.
In carrying out this work, we analyzed data from a survey conducted by  the Department of Health and Human Services (HHS)—the National  Health and Nutrition Examination Survey (NHANES). NHANES, which is  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. 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 how receipt of dental care has changed over time, we also  analyzed data from another HHS survey, the Medical Expenditure Panel  Survey (MEPS). MEPS is administered by HHS’s Agency for Healthcare  Research and Quality (AHRQ). MEPS 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  changes in receipt of dental care over time, we compared the data from  2004 and 2005 with MEPS data from 1996 and 1997. We analyzed the MEPS  data using the same three insurance groups as 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). 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. The work for  our report was conducted in accordance with generally accepted  government auditing standards from December 2007 through September  2008. A detailed explanation of our methodology is included in the report.
In summary, dental disease and inadequate receipt of dental care remain  significant problems for children in Medicaid. Nationally representative  survey data from 1999 through 2004 indicate that about one in three  children aged 2 through 18 in Medicaid had untreated tooth decay, and one  in nine had untreated decay in three or more teeth. Projecting the survey  results to the 2005 average monthly Medicaid enrollment of 20.1 million  children, we estimate 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 who have private health  insurance; children in Medicaid were almost twice as likely to have  untreated tooth decay.
Survey data from 2004 and 2005 showed that only about one in three  children in Medicaid aged 2 through 18 had received dental care in the  prior year; about one in eight children reportedly never sees the 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 aged 2 through 18 who received any dental care—  37 percent—was far below HHS’s Healthy People 2010 target of having   66 percent of low-income children under age 19 receive a preventive  dental service in the prior year.
Survey data on Medicaid children’s receipt of dental care showed some  improvement over time. For example, comparison of survey data from  1988 through 1994 to more recent data from 1999 through 2004 showed  that 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. However, over the same  time periods, dental disease in the overall Medicaid population aged 2  through 18 did not decrease, although the data suggest the trends vary  somewhat among different age groups. Younger children—those aged 2  through 5—had statistically significant higher rates of dental disease in the  more recent time period examined as compared to earlier surveys. By  contrast, data for adolescents—children in Medicaid aged 16 through 18— show declining rates of tooth decay, although the change was not  statistically significant.
In commenting on a draft of our report, HHS provided comments from  three component agencies: CMS, CDC, and AHRQ. 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. CDC commented that trends in dental  caries (tooth decay) vary by age group and for primary versus permanent  teeth. We revised our report to further clarify the trends by age group and  added information on CDC’s findings in the general population. AHRQ  commented that its own work on dental use, expenses, dental coverage,  and changes had not been cited and sought additional clarification on the  methodology used to analyze the data. We revised our report to cite  AHRQ’s findings on dental services for children and to further describe  our methodology. A full copy of HHS’s written comments can be found in  our report.
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 that 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  early and periodic screening, diagnostic, and treatment (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. 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 but less than or  equal to 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 (27 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 comments we received from HHS on a draft of the report  and our response, more detailed data tables, and confidence intervals can  be found in the report released today.
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. As you know, we have ongoing work for the  subcommittee examining state and federal efforts to ensure that children  in Medicaid receive needed dental services. We expect to report to the  subcommittee on our findings and any recommendations in spring 2009.
Mr. Chairman, this concludes my prepared remarks. I will be happy to  answer any questions that you or other members of the Subcommittee  may have.
section_title: GAO Contacts and Acknowledgments
paragraphs: For information regarding this testimony, please contact Alicia Puente  Cackley at (202) 512-7114 or cackleya@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on the  last page of this statement. Katherine Iritani, Assistant Director; Sarah  Burton; and Terry Saiki made key contributions to this statement.
section_title: Related GAO Products
paragraphs: Medicaid: Extent of Dental Disease in Children Has Not Decreased, and  Millions Are Estimated to Have Untreated Tooth Decay. GAO-08-1121.  Washington, D.C.: September 23, 2008.
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.
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