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. 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. 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. 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). 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. 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. 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. 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. 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. 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. 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.

Summary: 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. 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.