Article

Income-based disparities in a yearly dental visit in US adults and children: Trend analysis 1997 to 2016

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Abstract

Objectives To determine how income-based disparities in a yearly dental visit (the Healthy People 2020 Leading Health Indicator for Oral Health) changed since legislation to expand dental coverage and to compare disparity trends in children and adults. Methods We analyzed Medical Expenditure Panel Survey (MEPS) 1997-2016 to determine yearly dental visit rates for US children and adults by family income. We determined measures of income disparity, including the Slope Index of Inequality (SII) and the Relative Index of Inequality (RII) and examined trends in yearly dental visit, SII, and RII using joinpoint regression. Results Income-based disparities, absolute and relative, narrowed over time for children. Steady upwards trends in yearly dental visit rates were observed for poor and low-income/poor children and no joinpoint was identified that corresponded to legislation expanding dental care coverage for lower income children. Relative income-based disparities in yearly dental visit rates widened for adults over 20 years. After declining for 14 years, yearly dental visit rate increased for poor adults from 2013 to 2016 suggesting a possible positive effect in adult dental care use trends following enactment of the Affordable Care Act. Conclusion In 1997, US children and adults had similar levels of income-based disparity in yearly dental visits, but by 2016, they differed markedly. Trends in income- based disparities in yearly dental visit rate narrowed for children but widened for adults. There are lessons from the expansion of dental care coverage for children that could be applied to improve access to dental care for adults.

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... 8,9 Greater use of dental visits is associated with lower disparities in untreated caries. 10 Recent studies showed that the gap in dental visits among American children has narrowed in the past 3 decades, 11 and disparities among young children also have declined. 12 It remains unknown whether such trends have occurred in developing countries. ...
... ,11 The narrowing disparities in dental visits might have been related to the changes in policy, the health system and individual factors. First, this reduction may be partly due to an implemented oral health programme in Beijing, China. ...
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Objectives Little is known about children's oral health disparities and their changes in developing countries. This study aimed to measure rural-urban and maternal education-related disparities in dental visits and untreated caries among Chinese children, and to describe their changes between 2005 and 2015. Methods The 12-year-old children's oral health data were from the 3rd (2005) and 4th (2015) oral health surveys in Beijing, China. Rural-urban disparities and maternal education-related disparities in dental visits and untreated caries were measured. The slope index of inequality (SII) and a relative index of inequality (RII) were applied to reflect the absolute and relative disparities respectively. These were estimated using a generalized linear regression model. Results Data were analysed from 388 children in 2005 and 1926 children in 2015. The proportion of 12-year-old schoolchildren who visited the dentist was 24.0% in 2005 and 36.0% in 2015. Untreated caries prevalence in 2005 and 2015 was 20.9% and 16.2% respectively. Rural-urban disparities in dental visits narrowed between 2005 and 2015 (SII: −10.75 to −3.30, RII: 0.55 to 0.87), and maternal education-related disparities in dental visits also decreased during this decade (SII: −18.52 to −8.49, RII: 0.38 to 0.65). These changes were statistically significant. For disparities in untreated caries, only maternal education-related disparities in untreated caries in 2015 were found. The SII and RII were 6.39% (95% CI: 1.65, 11.13) and 1.57 (95% CI: 1.13, 2.20) respectively. The change in disparities in untreated caries was not statistically significant for rural-urban disparities (P = .319) or maternal education-related disparities (P = .501). Conclusions These findings indicate that in Beijing, China, disparities in children's dental visits narrowed between 2005 and 2015. However, maternal education-related disparities in dental visits and in untreated caries were still apparent, suggesting that policies to improve children's oral healthcare utilization equality should target the children with less-educated mothers.
Article
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Dental caries is the most common chronic disease among youth aged 6-19 years. Untreated caries can cause pain and infections. Monitoring prevalence of untreated and total caries (untreated and treated) is key to preventing and controlling oral diseases. This report presents the prevalence of total and untreated caries in primary or permanent teeth among youth aged 2-19 years for 2015-2016, and trends from 2011-2012 through 2015-2016. All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.
Article
Background: Except for a small increase in caries prevalence in young children from 1999 through 2004, the prevalence of pediatric caries in the United States has remained consistent for the past 3 decades. Methods: The authors used data from the National Health and Nutrition Examination Survey (NHANES) (from 1999 through 2004 and from 2011 through 2014) to ascertain changes in caries prevalence in youth aged 2 to 19 years. The authors evaluated changes in the prevalence of caries experience, untreated caries, and severe caries (3 or more teeth with untreated caries) in the primary, mixed, and permanent dentition according to poverty status. Results: Untreated dental caries in the primary dentition decreased (24% versus 14%) for children aged 2 to 8 years regardless of poverty status from the period from 1999 through 2004 to the period from 2011 through 2014. Severe caries in primary teeth decreased between the period from 1999 through 2004 and the period from 2011 through 2014 for 2- to 8-year-olds (10% versus 6%). Among preschool-aged children in families with low incomes, caries experience decreased from nearly 42% to 35%, and untreated caries decreased from 31% to 18%. Furthermore, there were significant reductions in the number of carious dental surfaces and significant increases in the number of restored dental surfaces. Overall, there was little change in the prevalence of caries in older children and adolescents. Conclusions: The prevalence of caries in primary teeth in preschool-aged children has improved in the previous decade in the United States; however, the prevalence of having no caries experience in permanent teeth in children and adolescents remains unchanged. Practical implications: Although the oral health status of young children has improved in the previous decade, few changes have occurred for many older children and adolescents.
Article
The Affordable Care Act is improving access to and the affordability of a wide range of health care services. While dental care for children is part of the law's essential health benefits and state Medicaid programs must cover it, coverage of dental care for adults is not guaranteed. As a result, even with the recent health insurance expansion, many Americans face financial barriers to receiving dental care that lead to unmet oral health needs. Using data from the 2014 National Health Interview Survey, we analyzed financial barriers to a wide range of health care services. We found that irrespective of age, income level, and type of insurance, more people reported financial barriers to receiving dental care, compared to any other type of health care. We discuss policy options to address financial barriers to dental care, particularly for adults.
Article
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Article
Among adults aged 20-64, 91% had dental caries and 27% had untreated tooth decay. Untreated tooth decay was higher for Hispanic (36%) and non-Hispanic black (42%) adults compared with non-Hispanic white (22%) and non-Hispanic Asian (17%) adults aged 20-64. Adults aged 20-39 were twice as likely to have all their teeth (67%) compared with those aged 40-64 (34%). About one in five adults aged 65 and over had untreated tooth decay. Among adults aged 65 and over, complete tooth loss was lower for older Hispanic (15%) and non-Hispanic white (17%) adults compared with older non-Hispanic black adults (29%). All material appearing in this report is in the public domain and may be reproduced or copied without permission; citation as to source, however, is appreciated.
Article
Objective The authors conducted a study to measure the gap in dental care utilization between poor and nonpoor adults at the state level and to show how the gap has changed over time. /st> The authors collected data from the 2002, 2004, 2006, 2008 and 2010 Behavioral Risk Factor Surveillance System prevalence and trends database maintained by the Centers for Disease Control and Prevention to measure differences in dental care utilization between poor and nonpoor adults. Poor adults are defined as those at or below the federal poverty threshold. The authors estimated a series of linear probability models to measure the dental care utilization gap between poor and nonpoor adults, while controlling for potentially confounding covariates. /st> In 12 states (Arkansas, California, Florida, Georgia, Illinois, Indiana, Nebraska, Ohio, Oklahoma, South Carolina, Texas and Washington), the gap in dental care utilization between poor and nonpoor adults grew from 2002 through 2010. The remaining states had a stable utilization gap from 2002 through 2010. The study results show that four states (Alaska, Massachusetts, Minnesota, New York) and the District of Columbia had a smaller gap in dental care utilization in 2010 than that in other states. /st> At the state level, poor adults face greater access barriers to dental care than do nonpoor adults. As states limit dental coverage through Medicaid, poor adults are at greater risk of experiencing poor oral health outcomes. Practical Implications In states that are experiencing increasing inequality in dental care utilization between poor and nonpoor adults, policymakers may wish to explore alternative approaches that could address this situation.
Article
To decompose the change in pediatric and adult dental care utilization over the last decade. 2001 through 2010 Medical Expenditure Panel Survey. The Blinder-Oaxaca decomposition was used to explain the change in dental care utilization among adults and children. Changes in dental care utilization were attributed to changes in explained covariates and changes due to movements in estimated coefficients. Controlling for demographics, overall health status, and dental benefits variables, we estimated year-specific logistic regression models. Outputs from these models were used to compute the Blinder-Oaxaca decomposition. Dental care utilization decreased from 40.5 percent in 2001 to 37.0 percent in 2010 for adults and increased from 43.2 percent in 2001 to 46.3 percent in 2010 for children (p < .05). Among adults, changes in insurance status, race, and income contributed to a decline in adult dental care utilization (-0.018, p < .01). Among children, changes in controlled factors did not substantially change dental care utilization, which instead may be explained by changes in policy, oral health status, or preferences. Dental care utilization for adults has declined, especially among the poor and uninsured. Without further policy intervention, disadvantaged adults face increasing barriers to dental care.
Article
Although Medicaid removes most financial barriers to receipt of dental care among children and adolescents, Medicaid recipients may not be able to access dental care if dentists decline to participate in Medicaid because of low payment levels or other reasons. To describe the association between state Medicaid dental fees in 2 years (2000 and 2008) and children's receipt of dental care. Data on Medicaid dental fees in 2000 and 2008 for 42 states plus the District of Columbia were merged with data from 33,657 children and adolescents (aged 2-17 years) in the National Health Interview Survey (NHIS) for the years 2000-2001 and 2008-2009. Logit models were used to estimate the probability that children and adolescents had seen a dentist in the past 6 months as a function of the Medicaid prophylaxis fee and control variables including age group, race, poverty status, and state and year effects. The effect of fees on children with Medicaid relative to a control group, privately insured counterparts, served to separate Medicaid's effect on access to care from any correlation between the Medicaid fee or changes in fees by state and other attributes of states. Whether a child or adolescent had seen a dentist in the past 6 months. On average, Medicaid dental payment levels did not change significantly in inflation-adjusted terms between 2000 and 2008, although a difference existed for some states, including in 5 states plus the District of Columbia, where payments increased at least 50%. In 2008-2009, more children and adolescents covered by Medicaid (55%, 95% confidence interval [CI], 53%-57%) had seen a dentist in the past 6 months than did uninsured children (27%, 95% CI, 24%-30%), but fewer than children covered by private insurance (68%, 95% CI, 67%-70%). Changes in state Medicaid dental payment fees between 2000 and 2008 were positively associated with use of dental care among children and adolescents covered by Medicaid. For example, a $10 increase in the Medicaid prophylaxis payment level (from $20 to $30) was associated with a 3.92 percentage point (95% CI, 0.54-7.50) increase in the chance that a child or adolescent covered by Medicaid had seen a dentist. Higher Medicaid payment levels to dentists were associated with higher rates of receipt of dental care among children and adolescents.
Article
Children from low-income families face barriers to preventive dental care (PDC) and are disproportionately affected by dental caries. The Access to the Baby and Childhood Dentistry (ABCD) program of Washington State is targeted to Medicaid-insured children <6 years of age to improve their access to PDC. To test the hypothesis that residing in an ABCD county improves the likelihood of receiving PDC and, to compare PDC use among young, Medicaid-insured children in Washington to national statistics. We extracted 2003 Washington Medicaid dental claims for continuously enrolled children <or=6 years of age. Multivariable analysis was performed to identify variables independently associated with >or=1 preventive dental visit (PDV) in 2003. For national comparison, we used the 2003 Medical Expenditure Panel Survey (MEPS). Among Medicaid-insured children <or=6 yrs of age from WA counties with ABCD program, 45% had at least 1 PDV compared with 36% from non-ABCD counties (P < .001) and 37% of US children with continuous private insurance (P < .001). There were significantly higher adjusted odds of a PDV for children from ABCD counties relative to non-ABCD counties (odds ratio: 1.30 [95% confidence interval: 1.05-1.60]). We confirmed our hypothesis that residing in an ABCD county was associated with a higher likelihood of having >or=1 PDV in 2003. We also found that significantly more children in established ABCD counties received PDC compared with privately insured US children. These findings provide additional evidence that the ABCD program reduces disparities in dental care access among young, Medicaid-insured children in Washington and point to the importance of expanding the ABCD program to other states.
Article
To determine if children eligible for coverage by the State Children's Health Insurance Program (SCHIP) and Medicaid Programs were more likely to receive preventive dental visits after implementation of the SCHIP policy, retrospective cross-sectional analysis was done from the 1996-2000 Medical Expenditure Panel Surveys (MEPS) data. We linked the individual level data from the MEPS to state-level information on program eligibility. Using logistic regression models that adjust for the complex survey design, the association between SCHIP implementation and receipt of preventive dental care was examined for children aged 3-18 with family incomes < or =200% of the Federal Poverty Line (FPL). Children who were eligible for SCHIP/Medicaid coverage in their respective states were more likely to have received preventive care three years after SCHIP implementation than children with similar eligibility profiles prior to SCHIP implementation. SCHIP has successfully increased the proportion of eligible children receiving preventive dental care among children in families with incomes less than or equal to 200% FPL. Our findings indicate, however, that SCHIP needed time to mature before detecting significant effects on national level.
Article
Insurance coverage can reduce financial barriers that constitute a significant deterrent to obtaining medical and dental care, especially for children who reside in low-income households. We present baseline information on the codistribution of medical and dental coverage among US children according to sociodemographic characteristics before the enactment of the State Children's Health Insurance Program (SCHIP). Data for 27,059 children 0-17 years old from the 1995 National Health Interview Survey (NHIS) were analyzed to examine the distribution of medical and dental insurance coverage by sociodemographic characteristics. Prevalence estimates and adjusted odds ratios with 95 percent confidence intervals were calculated using SUDAAN. Overall, 14.1 percent children were uninsured for medical care and 36.4 were uninsured for dental care; thus, there were 2.6 times as many children uninsured for dental than for medical care. Near-poor and Hispanic children were most likely to be without medical or dental coverage. Near-poor children were more likely to be uninsured for dental care than for medical care (43.8% vs 22.5%). Our findings, coupled with previous reports, suggest that the most serious problem concerning lack of dental insurance is among near-poor children. SCHIP has the potential to address dental coverage among near-poor children.
Article
The authors sought to describe the proportion and characteristics of U.S. children with dental insurance and to assess the relationship between dental insurance and preventive dental care (PDC). The authors used the National Survey of Children's Health, designed to represent all U.S. children. Outcomes of interest were dental insurance status and at least one PDC visit in the previous year. Seventy-seven percent of U.S. children had dental insurance; of these, 29 percent had public dental insurance. Overall, 16.3 million children lacked dental insurance, 2.6 times the number of children who did not have medical insurance. Children uninsured for dental care were less than half as likely to have received PDC. Among children without dental insurance, 3 million were potentially eligible for public dental insurance and 8 million had private medical insurance but no dental insurance. While the majority of children younger than 3 years had dental insurance, few received PDC (for example, 76 percent of 2-year-olds had dental insurance but less than one-quarter had received PDC). Race/ethnicity was an important modifier in the relationship between insurance coverage and PDC. African-American children, regardless of dental insurance type, were significantly less likely than white children to have received PDC. Dental insurance, whether public or private, is associated with the receipt of PDC. However, disparities in PDC disproportionately affect young children and black and multiracial children, even those with dental insurance. Despite recent increases in the number of children with dental insurance, 2.6 times as many children did not have dental insurance compared with those who had medical insurance. The authors offer recommendations to increase the availability of dental insurance to U.S. children.
Article
To provide national estimates of implementation effects of the State Children's Health Insurance Program (SCHIP) on dental care access and use for low-income children. The 1997-2002 National Health Interview Survey. The study design is based on variation in the timing of SCHIP implementation across states and among children observed before and after implementation. Two analyses were conducted. The first estimated the total effect of SCHIP implementation on unmet need for dental care due to cost in the past year and dental services use for low-income children (family income below state SCHIP eligibility thresholds) using county and time fixed effects models. The second analysis estimated differences in dental care access and use among low-income children with SCHIP or Medicaid coverage and their uninsured counterparts, using instrumental variables methods to control for selection bias. Both analyses controlled for child and family characteristics. When SCHIP had been implemented for more than 1 year, the probability of unmet dental care needs for low-income children was lowered by 4 percentage points. Compared with their uninsured counterparts, those who had SCHIP or Medicaid coverage were less likely to report unmet dental need by 8 percentage points (standard error: 2.3), and more likely to have visited a dentist within 6 or 12 months by 17 (standard error: 3.7) and 23 (standard error: 3.6) percentage points, respectively. SCHIP program type had no differential effects. Consistent results from two analytical approaches provide evidence that SCHIP implementation significantly reduced financial barriers for dental care for low-income children in the U.S. Low-income children enrolled in SCHIP or Medicaid had substantially increased use of dental care than the uninsured.
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