American Journal of Public Health | May 2008, Vol 98, No. 5876 | Research and Practice | Peer Reviewed | Brickhouse et al.
RESEARCH AND PRACTICE
Effects of Enrollment in Medicaid Versus the State
Children’s Health Insurance Program on Kindergarten
Children’s Untreated Dental Caries
| Tegwyn H. Brickhouse, DDS, PhD, R. Gary Rozier, DDS, MPH, and Gary D. Slade, DDPH, PhD, BDSc
visits, timeliness in obtaining care, and unmet
In North Carolina, SCHIP is a separate
program administered by Blue Cross and
Blue Shield of North Carolina (BCBSNC). At
the time of this study, SCHIP in North Car-
olina reimbursed dental providers at rates
comparable to those of private insurance,
whereas Medicaid reimbursed at rates of
44% to 62% of usual fees. Providers submit-
ted Medicaid claims and negotiated settle-
ments through the Department of Medical
Assistance, a governmental agency, whereas,
for their patients with SCHIP (with the non-
profit company BCBSNC), providers submit-
ted and negotiated claims just as they did for
their privately insured patients. Medicaid and
SCHIP provided a similar set of dental bene-
fits, including preventive, diagnostic, and
The implementation of SCHIP in North
Carolina appears to have improved access to
dental care for children with low incomes.
On the basis of caregivers’ reports, the num-
ber of school-aged children who received
dental services increased from 47% in the
year before enrollment to 64% in the year
after enrollment, and perceived unmet dental
needs decreased from 43% to 18%, respec-
tively.10In an analysis of reimbursement
claims, Brickhouse et al. documented a 20%
greater use of dental services among pre-
school-aged children enrolled in SCHIP than
among those enrolled in Medicaid.1 1
With this investigation, we extend our on-
going evaluation of the effects of enrollment
in public insurance on North Carolina children
and are the first, to our knowledge, to directly
examine the impact of SCHIP on clinically
determined tooth decay and compare it to
The State Children’s Health Insurance Pro-
gram (SCHIP), created by Congress in 1997,
expanded eligibility for public dental insurance
to children of the working poor and has grown
to include more than 5 million children.
SCHIP has provided states with the flexibility
to experiment with new health care delivery
models that may overcome long-standing ob-
stacles to low-income populations obtaining
dental care.1Currently, 18 states operate
separate SCHIP programs, 12 offer Medicaid
expansions, and 20 have combination pro-
grams.2Furthermore, the implementation of
SCHIP had a spillover effect on Medicaid in
some states that led to simplification of their
enrollment processes and thus increased en-
rollment in Medicaid.3Information about the
effects of SCHIP on children’s access to dental
services is just beginning to emerge.4,5
There have been only 3 studies, all using
data from the National Health Interview Sur-
vey (NHIS), that have considered the impact
of SCHIP at the national level. Wang et al.
found that for children with low incomes,
those with either Medicaid or SCHIP were
less likely to have unmet needs for dental
care by 8% and more likely to have had a
dental visit within the last 12 months by
23% than were those who were uninsured.6
Davidoff et al. found that SCHIP expansions
increased the probability of a dental visit
among children with chronic conditions by
4.5% and decreased unmet treatment needs
The third study, by Duderstadt et al., found
that children whose family incomes were con-
sistent with SCHIP eligibility and who were
insured for a full year visited the dentist
about as often as did children with private in-
surance.8State-specific studies of SCHIP’s ef-
fects have found favorable results for a num-
ber of self-reported indicators, including usual
source of dental care, any number of dentist
Objectives. We compared levels of untreated dental caries in children en-
rolled in public insurance programs with those in nonenrolled children to de-
termine the impact of public dental insurance and the type of plan (Medicaid vs
State Children’s Health Insurance Program [SCHIP]) on untreated dental caries
Methods.Dental health outcomes were obtained through a calibrated oral screen-
ing of kindergarten children (enrolled in the 2000–2001 school year). We obtained
eligibility and claims data for children enrolled in Medicaid and SCHIP who were
eligible for dental services during 1999 to 2000. We developed logistic regression
models to compare children’s likelihood and extent of untreated dental caries ac-
cording to enrollment.
Results. Children enrolled in Medicaid or SCHIP were 1.7 times (95% confidence
interval [CI]=1.65, 1.77) more likely to have untreated dental caries than were
nonenrolled children. SCHIP-enrolled children were significantly less likely to have
untreated dental caries than were Medicaid-enrolled children (odds ratio [OR]=0.74;
95% CI=0.67, 0.82). According to a 2-part regression model, children enrolled in
Medicaid or SCHIP have 17% more untreated dental caries than do nonenrolled
children, whereas those in SCHIP had 16% fewer untreated dental caries than did
those in Medicaid.
Conclusions. Untreated tooth decay continues to be a significant problem for
children with public insurance coverage. Children who participated in a separate
SCHIP program had fewer untreated dental caries than did children enrolled in
Medicaid. (Am J Public Health. 2008;98:876–881. doi:10.2105/AJPH.2007.111468)
May 2008, Vol 98, No. 5 | American Journal of Public HealthBrickhouse et al. | Peer Reviewed | Research and Practice | 877
RESEARCH AND PRACTICE
TABLE 1—Descriptive Statistics of Dental Caries in Kindergarten Children, by Dental
Insurance Enrollment: North Carolina, 2000–2001
of Dental Cariesa
of Dental Cariesa
Note. SCHIP=State Children’s Health Insurance Program.
aAt least 1 decayed tooth.
bThe predicted probability of dental caries adjusted for covariates (length of enrollment,utilization,missing or filled teeth,
race,and public provider ratio).
cNo dental caries or missing or filled teeth.
dAt least 1 missing or filled tooth.
that of Medicaid. Health status is an important
indicator of the effectiveness of policies to im-
prove access to care.12We sought to answer 2
questions. First, is the number of untreated
dental caries different among children enrolled
in public insurance plans from those not en-
rolled? Second, what is the impact of the type
of public insurance plan (Medicaid vs SCHIP)
on the number of untreated dental caries?
Study Design and Data Sources
We used a retrospective cohort design to
compare the prevalence of untreated dental
caries among students enrolled in kinder-
garten from September 2000 through May
2001 who had been enrolled in public insur-
ance the previous year (October 1999 to
September 2000) with those who had not
been enrolled during that period. The main
exposure variable was program enrollment
(nonenrolled, SCHIP, or Medicaid) obtained
from Medicaid and SCHIP enrollment and re-
imbursement claims files. The outcome vari-
able for untreated dental caries was the num-
ber of decayed primary teeth (i.e., baby teeth)
for each child; we obtained this from the
North Carolina Surveillance of Dental Caries
The Medicaid and SCHIP enrollment files
provided the enrollment status for each child.
These files also provided demographic informa-
tion about each enrolled child (date of birth,
gender, race, and county of residence) and en-
rollment status for every month during the 12
months. Duration of enrollment was controlled
in the analysis by the use of a variable consist-
ing of the number of months enrolled in
each plan during the 12-month study period.
The Medicaid and SCHIP dental claims files
(1999–2000) contained all paid dental claims
for an enrolled child and provided a usable
measure of dental services utilization.
The NCSoDC system provides annual pub-
lic health surveillance of dental caries of al-
most all kindergarten students in the state.
Oral health professionals who receive annual
training and standardization collect informa-
tion from open-mouth dental screenings.13,1 4
The reliability of these professionals compared
with standard examiners was determined in a
separate study to be good to excellent (mean
κ=0.86).15The NCSoDC indicators used for
our study were the numbers of decayed, miss-
ing, and filled primary teeth, which together
represent the lifetime caries experience for a
child. We included only molars in the treated-
by-extraction category because anterior teeth
may have been exfoliated naturally and their
inclusion would inflate this estimate of caries
experience. We used the variable of missing
and filled teeth to control for a child’s lifetime
experience of dental treatment, which in-
cludes the child’s expressed demand for den-
tal care. The number of dental caries for each
child was considered separately as the pri-
mary outcome variable and represented un-
treated dental caries.
We manually matched kindergarten stu-
dents in the NCSoDC with the Medicaid and
SCHIP enrollment or claims files, using a
computer program developed to match the
child’s first and last names, age, and county.
The resulting data set was supplemented with
county-level provider characteristics created
from the Medicaid and SCHIP dental claims
files along with the metropolitan status (met-
ropolitan vs rural) of the county in which the
We quantified summary statistics and
comparisons among exposure groups as pre-
dicted probabilities of dental caries. We de-
veloped multivariate regression models to
compute adjusted estimates of the relation
between a child’s public insurance enroll-
ment status and untreated dental caries. The
first analysis of effect included the entire
sample; the second was limited to those with
We used a 2-part regression model (logistic
and ordinary least squares) to estimate the
differences in actual levels of the outcome
(untreated dental caries) and to compare en-
rolled versus nonenrolled children and SCHIP
versus Medicaid.16The first analysis in the
2-part model used a logistic regression model
to predict the probability of a child having
any untreated dental caries. The second part
of the model used ordinary least squares re-
gression to predict the number of teeth with
untreated dental caries, conditional on there
being untreated carie present. The models
contained the same covariates. The marginal
effects of the plans were calculated from the
2-part model with methods proposed by
Duan et al.1 7Both logistic regression models
were adjusted for gender (girl vs boy), race
(Black, Hispanic, American Indian, and other
vs White), insurance use (dental claims vs no
claims), missing and filled teeth, length of
enrollment (months), and the ratio of dental
providers providing care to children enrolled
in Medicaid or SCHIP (5–10 per 1000 and
>10 per 1000 vs <5 per 1000). We esti-
mated statistical calculations and marginal
effects using Stata 9.0.18
American Journal of Public Health | May 2008, Vol 98, No. 5878 | Research and Practice | Peer Reviewed | Brickhouse et al.
RESEARCH AND PRACTICE
TABLE 2—Percentages and Means (SE)
of Untreated Dental Caries in
Kindergarten Children (n=23936)
Enrolled in SCHIP or Medicaid: North
Untreated tooth decay,a% (SE)
Decayed teeth,mean (SE)
Missing and filled teeth,a% (SE)
Dental claim,a% (SE)
Length of enrollment,
Ratio of public dental care
Note.SCHIP=State Children’s Health Insurance Program.
aYes or no.
TABLE 3—Unadjusted Results of the 2-Part Regression Model Predicting Untreated Dental
Caries in Kindergarten Children Enrolled in Medicaid or SCHIP: North Carolina, 2000–2001
Logistic Regression Modela
b (SE)OR (95% CI)OLS model,b b (SE)
Nonenrolled children (Ref)
Note.OR=odds ratios; CI=confidence interval; OLS=ordinary least squares; SCHIP=State Children’s Health Insurance Program.
aPart 1 of regression model.At least 1 decayed tooth.
bPart 2 of regression model; results conditional on part 1.Extent of decay for at least 1 tooth.
cEnrolled children have 17% more untreated dental caries than do nonenrolled children.
dThe marginal effect of moving a child from Medicaid to SCHIP would be 11% fewer untreated dental caries.
For the sample of children screened (n=
79731), descriptive statistics measuring den-
tal caries are displayed in Table 1. Approxi-
mately 85% of enrolled kindergarten chil-
dren were screened according to the North
Carolina Department of Public Instruction
(94350 average daily membership from
2000 to 2001); 30% (n=23936) of these
children were publicly insured by either
SCHIP (10%) or Medicaid (90%). Overall,
kindergarten children had a mean of 0.73
(SE=0.01) untreated dental caries per child.
Twenty-three percent had 1 or more dental
caries, and these children had a markedly
higher mean number of dental caries per
child (dental caries=3.15; SE=0.02) than
did the overall sample.
Among children enrolled in public insur-
ance, 30% had untreated dental caries, with
an overall mean of 0.90 (SE=0.01) per child.
Medicaid-enrolled children had the highest
percentage and largest mean number of un-
treated dental caries (31%; dental caries=
0.98; SE=0.01) followed by SCHIP-enrolled
children (24%; dental caries=0.74;
SE=0.04) and nonenrolled children (20%;
dental caries=0.63; SE=0.01). During the
study period, the mean enrollment time in
public insurance was 10 months, with 35%
having dental claims. Twenty-three percent of
enrolled children had 1 or more missing or
filled teeth. Additional summary characteris-
tics of the children enrolled in public insur-
ance programs are displayed in Table 2.
Kindergarten children enrolled in public in-
surance programs were 1.71 (95% CI=1.65,
1.77) times more likely to have untreated dental
caries than were nonenrolled children, whereas
SCHIP-enrolled children were less likely (odds
ratio [OR]=0.74; 95% confidence interval
[CI]=0.67, 0.82) than were Medicaid-enrolled
children to have untreated dental caries (Table
3). As noted in Table 1, the base case probabili-
ties of having untreated dental caries for a
nonenrolled child and enrolled child were 20%
and 30%, respectively. The marginal effects sug-
gest that if a child changed from Medicaid to
SCHIP, he or she would have 11% fewer un-
treated dental caries.
Children Enrolled in Public Insurance
Summary statistics for the predicted
probabilities of untreated dental caries in
the enrolled population, adjusted for regres-
sion model covariates, are also presented in
Table 1. Among children enrolled in public
insurance, 30% had untreated dental caries,
with an overall mean of 0.96 (SE=0.01) per
child. Medicaid-enrolled children had the
highest percentage and largest mean number
of untreated dental caries (36%; dental
caries=1.19; SE=0.05) followed by SCHIP-
enrolled children (24%; dental caries=0.92;
Table 4 presents the parameter estimates
for the final 2-part regression model for chil-
dren enrolled in 1 of the public insurance
programs. Again, children enrolled in SCHIP
were significantly less likely to have any
untreated dental caries than were those
enrolled in Medicaid (OR=0.73; 95%
CI=0.66, 0.82). The marginal effects sug-
gest that if children changed from Medicaid
to SCHIP, they would have 16% fewer un-
treated dental caries.
Our investigation, to our knowledge, is the
first to examine the effectiveness of SCHIP
in meeting the dental treatment needs of en-
rolled children. The strengths of this study
include its large sample size and linkage of
dental health status from a statewide surveil-
lance system with public insurance adminis-
trative files containing claims and enrollment
data. This approach provided key health sta-
tus elements that are rarely available in stud-
ies of the effectiveness of public insurance at
the population level.
May 2008, Vol 98, No. 5 | American Journal of Public HealthBrickhouse et al. | Peer Reviewed | Research and Practice | 879
RESEARCH AND PRACTICE
TABLE 4—Adjusted Results of the Final 2-Part Regression Model Predicting Untreated Dental
Caries in Kindergarten Children Enrolled in Medicaid or SCHIP: North Carolina,2000–2001
Variables Logistic Regression Model,a b (SE) OLS Model,bb (SE)
Length of enrollment,mos
Dental claims (yes)
Missing and filled teeth
Ratio of public providers
Note. OLS=ordinary least squares; SCHIP=State Children’s Health Insurance Program.
aPart 1 of regression model.At least 1 decayed tooth.
bPart 2 of regression model; results conditional on part 1.Mean number of dental caries for individuals with at least 1
untreated decayed tooth.
cThe marginal effect of moving a child from Medicaid to SCHIP would be 16% fewer untreated dental caries.
The 3 primary findings concern the effect
of SCHIP enrollment on the unmet dental
treatment needs of North Carolina’s kinder-
garten children, the burden of untreated den-
tal caries in this population that is associated
with being enrolled in Medicaid compared
with the SCHIP program, and the effect of
public insurance overall on unmet dental
treatment needs in children.
The most important finding is the effect
on young children’s unmet dental needs of
the SCHIP program, which began relatively
recently, compared with Medicaid, which has
been in existence for almost 40 years. The
separate SCHIP program in North Carolina
reduces more untreated dental caries than
does Medicaid. Marginal effects suggest there
would be a 16% improvement if children
with sociodemographic characteristics similar
to those enrolled in Medicaid were moved
into SCHIP (Table 4).
As of 2005, enrollment penetration is
high for Medicaid programs. It is possible that
larger gains in access to dental care could be
made by improving the effectiveness of the
public insurance programs themselves rather
than focusing on enrolling more children in
those programs. In their national study of
SCHIP effectiveness, Wang et al. concluded
that improving public insurance programs’
effectiveness regarding access and use of
dental services by children already enrolled
may be more important than increasing en-
The comparison of untreated dental caries
of children enrolled in public insurance pro-
grams with those of children of the same age
who were not enrolled provides an assess-
ment of the total effect of public insurance
on dental health outcomes. This comparison
is important because federal guidelines re-
quire Medicaid to provide access to dental
care for children enrolled in Medicaid equal to
that of other children in their communities.19
Although this effect could not be explored
beyond a descriptive analysis because we did
not have important information such as insur-
ance status for those not enrolled in Medicaid
or SCHIP, we found that children enrolled in
public insurance programs have more un-
treated dental caries than do children who
are not enrolled. The prevalence and severity
of dental caries were greater in children en-
rolled in public insurance than in those not
enrolled. This difference in extent of un-
treated disease appears to be of clinical and
public health significance because of the
large number of children enrolled in these
public programs nationwide. Children living
in poverty continue to have serious levels of
untreated dental caries.20
Our study had 2 primary limitations. First,
we did not randomly assign study participants
to enrollment status, and thus, selection bias
or other contributions to lack of equivalence
of study groups could affect results. There
are barriers beyond dental coverage that af-
fect low-income children’s access to dental
care that we did not measure, such as ethnic-
ity, overall health and caregivers’ income, ed-
ucation, access to transportation, and dental
Because our design was nonrandomized
and because enrollment in Medicaid or
SCHIP is voluntary, any observed effects of a
health plan on untreated dental caries could
have been confounded by self-selection.
Poor oral health status may independently
increase use of dental services and therefore
reduce the amount of untreated disease and
bias the effect of insurance coverage. Con-
versely, parents who are diligent about pre-
vention of dental disease in their children
may be more likely to enroll their children
in public insurance.
Although various analytic approaches have
been developed for dealing with problems of
selection bias, these techniques generally re-
quire additional measures (e.g., instrumental
variables) that can be used to predict enroll-
ment but that do not affect the outcome of in-
terest.21We were unable to undertake more-
formal statistical modeling of self-selection bias,
because there were no unambiguous markers
that we could have used as instrumental
variables. Because we did not have good in-
strumental variables for the multivariate
American Journal of Public Health | May 2008, Vol 98, No. 5880 | Research and Practice | Peer Reviewed | Brickhouse et al.
RESEARCH AND PRACTICE
analysis, we relied on the use of as many con-
trol measures as possible to try to mitigate
any problems of selection bias.
To quantify any selection bias that may
have existed, we used a stratified analysis to
compare Medicaid and SCHIP enrollees
across 4 strata defined by cross-classifying 2
indicators of dental treatment history. One in-
dicator was use of dental care services during
the study period (i.e.,≥1claim). The other in-
dicator was missing or filled teeth as mea-
sured by the dental screening, which distin-
guished between children who had evidence
of past treatment for dental caries and those
who did not. Probabilities of untreated dental
caries were calculated using predicted proba-
bilities from the final logistic regression
model, which also adjusted for age, race, and
availability of dental providers. We estimated
that SCHIP produced absolute reductions in
the probability of dental caries from 3% (for
SCHIP children with utilization who had no
missing or filled teeth) to 7% (in those with
utilization who had 1 or more missing or
filled teeth); this confirmed that our results
were not solely caused by selection biases.
A second limitation was that children en-
rolled in Medicaid or SCHIP may have ob-
tained dental care not reimbursed by Medic-
aid during the time they were enrolled in
public insurance. Children enrolled in Medic-
aid or SCHIP also may be enrolled in other
public programs, such as WIC (Special Sup-
plement Nutrition Program for Women, In-
fants, and Children) and Early Head Start or
Head Start, that have dental components
that are not measured.22,23
SCHIP has played an important role over
the past 10 years in reducing the number of
uninsured children in America and providing
a crucial safety net for families in a time of
declining employer-based dental insurance.
Recent studies of SCHIP show increased use
of dental services and reduced self-reported
unmet dental needs for established en-
rollees.24We provided additional evidence
that SCHIP also can improve clinically deter-
mined oral health status. It is unknown at this
time how the Deficit Reduction Act of 2005
will affect children’s access to dental care and
what the effects will be of actions taken by
Congress during reauthorization legislation of
the SCHIP program in 2007.25Nevertheless,
both instances provide opportunities to national
and state legislators, and Medicaid programs
themselves, to improve the effectiveness of pub-
lic insurance in low-income children’s gaining
access to and using dental care.
Currently, SCHIP provides states with the
opportunity to creatively expand health insur-
ance for children in low-income families and
experiment with innovative programs. The re-
imbursement and administrative improvements
of SCHIP compared with Medicaid affected
the outcome, with SCHIP enrolled children in
North Carolina having fewer untreated dental
caries than Medicaid enrolled children. The
findings highlight the importance of using
lessons learned from the effects of a separate
SCHIP program in improving access to dental
care among low-income children.
About the Authors
At the time of the study, Tegwyn H. Brickhouse was a PhD
candidate in epidemiology and resident trainee in dental
public health at the School of Public Health, University of
North Carolina, Chapel Hill. R. Gary Rozier is with the De-
partment of Health Policy Analysis and Administration,
University of North Carolina, Chapel Hill. Gary D. Slade
is with the Australian Research Centre for Population Oral
Health, University of Adelaide, Adelaide, Australia.
Requests for reprints should be sent to Tegwyn H.
Brickhouse, DDS, PhD, Assistant Professor, Pediatric
Dentistry, Virginia Commonwealth University School of
Dentistry, 521 N. 11th St, Woods Bldg 317, Richmond,
VA 23298-0566 (Phone: 804-827-2699, Fax: 804-
827-0163, e-mail: firstname.lastname@example.org).
This article was accepted August 24, 2007.
All authors participated in the origination, design, data
analysis, and interpretation of the study. T.H. Brickhouse
wrote the first draft of the article, and R.G. Rozier and
G.D. Slade contributed to subsequent versions.
This research was funded in part by Agency for Health-
care Research and Quality (grant 1-R03-HS11514–01),
Maternal and Child Health Bureau (grant 5-T17 MC
00015), Health Resources Services Administration
(grant D13HP30002), and the National Institute for
Dental and Craniofacial Research (grants 1-T32-DE–
07191 and 1K22-DE–016084–01).
The authors recognize Rebecca King, DDS, MPH,
Paul Buescher, PhD and the staff at the North Carolina
State Center for Health Statistics and the North Carolina
Oral Health Section for their help in obtaining the data.
Human Participant Protection
The institutional review board at the University of
North Carolina, Chapel Hill, School of Public Health
approved the protocol for this investigation.
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