Issue 1/May 2004 Use of Dental Care Among Alabama’s Uninsured: Results from Alabama’s 2002 Household Survey THE POLICY CONTEXT SURVEY METHODS In the wake of deteriorating state budgets and rising health In the summer of 2002, the Alabama Department of care expenditures, state legislators are pursuing strategies to Public Health was awarded a State Planning Grant contain health care spending, particularly in Medicaid. (SPG) from the Health Resources and Services States have enacted incremental reforms in the absence of a Administration (HRSA) to study health insurance national approach to cost control, including restrictions on coverage issues in Alabama.1 Under Alabama’s SPG, eligibility and benefits, provider payment rate reductions, the State Health Access Data Assistance Center and beneficiary cost-sharing requirements. (SHADAC) and the University of Minnesota’s Center for Survey Research in Public Health conducted a Dental benefits are often the first benefit to be cut, in part survey of Alabaman households to determine how because states are not required to offer dental care to adults health insurance coverage varies among different under Medicaid or to children under the State Children’s population groups, what barriers to accessing coverage Health Insurance Program (SCHIP) in order to be eligible exist among the uninsured, and how these barriers affect for federal matching funds. Between 2002 and early 2004, residents as they attempt to access the health care 16 states either eliminated or restricted adult dental system in Alabama. coverage in their Medicaid programs (Smith et al., 2002, 2003, 2004). One unique feature of this survey is a section that focused on respondents’ access to, and receipt of, Whether such reductions have a meaningful impact on the preventive dental care. Survey respondents were asked a overall health of low-income populations and/or state series of questions on dental coverage, treatment, and budgets is a matter of some debate. Some, citing well- barriers to receiving care, shown in Figure 1 below. documented barriers to dental access among Medicaid recipients, would argue that dental coverage is often Figure 1: Dental Access Questions, Alabama’s 2002 underutilized and less cost-effective than other medical Household Survey services that make up the state Medicaid benefit set. Others counter that restricting dental benefits is short- sighted as individuals who do not receive preventive dental care will require more costly treatment or will utilize the emergency room for more serious oral health problems that might have been avoided. While state-specific data necessary to evaluate investments in dental access is scarce (Gehshan et al., 2002), a recent DENTAL COVERAGE AND INSURANCE STATUS survey of households in Alabama provides important insights about dental access issues, as well as about the According to the Alabama survey, 11.2% of the state’s relationship between the receipt of dental care and health population lacks health insurance coverage. This insurance coverage status. The State Health Access Data uninsurance rate is lower than the U.S. average of Assistance Center (SHADAC) developed its State Data 15.2% (U.S. Census Bureau Current Population Survey, Series to highlight unique information collected by state 2003) and reflects Alabama’s relatively high public household surveys to inform health policy. program coverage rates, especially for children. Compared to 25.7% of the U.S. population (U.S. Census Figure 3: Percent of Alabamans Who Received Dental Bureau, Current Population Survey, 2003), this survey Care Services in Last 12 Months, by Health Insurance found that 31.4% of Alabamans are covered through public Coverage Status health insurance programs.2 Figure 2 suggests that having health insurance is positively associated with having coverage that pays for dental care. The overwhelming majority (97%) of individuals who lack health insurance coverage also lack insurance that pays for dental care. While a small percentage (3%) of the uninsured reported having dental coverage, some individuals responding yes to this question may have done so in error, or because they receive free care from dental clinics in the state. Most (77%) individuals with private health insurance coverage also have insurance that covers dental expenses, compared to about half (49%) of those who are publicly Figure 4 shows that whether uninsured, publicly-insured, insured—either through Medicare, Medicaid, or Alabama’s or privately-insured, individuals with dental coverage are Children’s Health Insurance Program (CHIP). This result more likely to receive care from a dentist’s office or dental makes intuitive sense because Alabama does not provide clinic than those without dental coverage. dental coverage to adults on Medicaid, but does provide dental coverage to children enrolled in Medicaid or CHIP. Figure 4: Likelihood that Alabamans With and Without Dental Coverage Will Receive Dental Care, by Health Figure 2: Percent of Alabamans Who Have Insurance Insurance Coverage Status that Pays for Preventive Dental Care, by Health Insurance Coverage Status BARRIERS TO DENTAL ACCESS The literature points to multiple barriers that may influence access to dental services, particularly among high-risk DENTAL TREATMENT AND INSURANCE STATUS groups such as immigrants, Medicaid and SCHIP This survey found that uninsured Alabamans are less likely beneficiaries, and other low-income families. Potential to have access to dental care than those with insurance. barriers in a state may include: Figure 3 illustrates that 30% of uninsured Alabamans • a shortage of dentists, or geographic disparity in the received dental care in the last year, compared to 50% and availability of dentists; 70% of publicly- and privately-insured Alabamans, • a shortage of dentists willing to treat low-income or respectively. disabled clients; • an inadequate safety net infrastructure for dental services; SURVEY RESPONDENTS WHO RECEIVED • inadequate reimbursement (e.g., through Medicaid) for DENTAL CARE dental services; • public program administrative hurdles; and/or Figure 6 shows that among those who did access dental • failure among public program beneficiaries to keep care, Alabamans without dental coverage are more likely to appointments (Gehshan et al., 2002). have problems finding a convenient dental office than individuals with dental coverage. 15% of Alabamans who SURVEY RESPONDENTS WHO DID NOT RECEIVE received dental care without dental coverage had trouble DENTAL CARE finding a convenient dental office, compared to 10% of individuals with dental coverage. To help discern barriers to care, the survey asked individuals who had not received dental care to identify the reason why Figure 6: Percent of Alabamans Who Received Care Who they had not. Response options included: (1) “dental care is Had a Problem Finding a Convenient Dental Office, by too expensive,” (2) “did not need dental care during 12 Dental Coverage Status month period,” (3) “I don’t have insurance that covers dental care,” (4) “not important,” (5) “child is too young to need dental care,” (6) “dentist does not accept insurance,” (7) “no dentist in my area,” (8) “dentist is not accepting new patients,” and (9) “other”. Figure 5 illustrates that Alabamians without dental coverage who had not seen a were more than five times as likely to cite cost as the main reason—32% said they had not seen a dentist due to cost, compared to only 6% of those with dental coverage. People with coverage who had not seen a dentist were more likely to report that they did not need dental care. This group was also more likely to say that dental care is unimportant or that their children are With respect to health insurance status, uninsured too young to see a dentist. Alabamans are twice as likely as public program recipients, and almost four times as likely as those with private Figure 5: Main Reasons Alabamans Did Not Receive insurance, to have problems finding a convenient dental Dental Care, by Dental Coverage Status office when seeking dental care. Thirty percent of uninsured Alabamans who received dental care, compared to 15% of publicly-insured and 8% of privately-insured individuals, reported having trouble finding a convenient dental office. IMPLICATIONS FOR STATE HEALTH POLICY In comparison to those with public or private health insurance, Alabamans who lack health insurance coverage are: (1) less likely to have dental coverage that pays for preventive care, (2) less likely to receive dental treatment, (3) more likely to have a problem finding a convenient dental office if they have had care, and (4) more likely to cite cost as a barrier to getting care. These findings underscore the likely consequences of dropping dental coverage benefits, either by private employers or by states as they attempt to contain health care expenditures in their Medicaid and SCHIP programs. (Dasanayake et al., 2002; Mofidi et al., 2002; and One can speculate that publicly- or privately-insured Mouradian et al., 2000), the results of Alabama’s 2002 individuals who lose their dental benefits will come to survey suggest that perhaps more fundamental to the resemble survey respondents who lacked dental coverage in policy goal of increasing oral health among low-income terms of their dental health care seeking behaviors. That is, populations is maintaining investments in public coverage they will be less likely to receive dental care services, and for dental care services. more likely to find dental care too expensive or to have problems finding a dental office. Researchers at the State Health Access Data Assistance Center at the University of Minnesota have developed and fielded This is particularly problematic for those who believe that the Coordinated State Coverage Survey (CSCS), a survey promoting access to routine, preventive dental care is an instrument used to determine state-level insurance coverage important objective. While much has been written about rates. The State Data Series is a collection of policy briefs state strategies to reduce access barriers for Medicaid- informed by the analysis of unique survey data collected in insured children and adults who have dental benefits states that have used the CSCS. SOURCES Alabama State Planning Grant, Interim Report, Year 1. August 2003. Montgomery, Alabama: Alabama Department of Public Health. Dasanayake, Ananda P., Yufeng Li, Sangeetha Wadhawan, Katharine Kirk, Janet Bronstein, and Noel K. Childers. Disparities in dental service utilization among Alabama Medicaid children. Community Dentistry and Oral Epidemiology, 2002; 30: 369-76. Gehshan, Shelley, and Tara Straw. Access to oral health services for low-income people: policy barriers and opportunities for intervention for The Robert Wood Johnson Foundation. October 2002. Washington, D.C.: National Conference of State Legislatures. McRae, James A., and Thomas R. Fields. Perspectives of dentists and enrollees on dental care under Minnesota health care programs. May 2002. St. Paul, MN: Minnesota Department of Human Services. Mofidi, Mahyar, Gary Rozier, and Rebecca S. King. Problems with access to dental care for Medicaid-insured children: what caregivers think. American Journal of Public Health, January 2002; 92(1): 53-58. Mouradian, Wendy E., Elizabeth Wehr, and James J. Crall. Disparities in children’s oral health and access to dental care. Journal of the American Medical Association, November 2000; 284(20): 2625-2631. Smith, Vernon, Eileen Ellis, Kathleen Gifford, Rekha Ramesh, and Victoria Wachino. Medicaid spending growth: results from a 2002 survey. September 2002. Washington, D.C.: Kaiser Commission on Medicaid and the Uninsured. Smith, Vernon, Rekha Ramesh, Kathleen Gifford, Eileen Ellis, and Victoria Wachino. States respond to fiscal pressure: state Medicaid spending growth and cost containment in fiscal years 2003 and 2004. September 2003. Washington, D.C.: Kaiser Commission on Medicaid and the Uninsured. Smith, Vernon, Rekha Ramesh, Kathleen Gifford, Eileen Ellis, Victoria Wachino, and Molly O’Malley. States respond to fiscal pressure: a 50-state update of state Medicaid spending growth and cost containment actions. January 2004. Washington, D.C.: Kaiser Commission on Medicaid and the Uninsured. U.S. Census Bureau, Current Population Reports. Health insurance coverage in the United States: 2002. Issued September 2003. U.S. Census Bureau, Current Population Reports. Health insurance coverage in the United States: 2002. Issued September 2003. (Endnotes) 1 Information on HRSA State Planning Grants can be found on at http://www.statecoverage.net/hrsa.htm. 2 We make the comparison between state survey estimates and and the CPS to illustrate general differences between Alabama and the nation as a whole, not to make precise comparisons. CPS tends to provide higher estimates of the uninsured than estimates based on state survey data. The key reasons for this difference are outlined in the SHADAC Issue Brief, “State Health Insurance Coverage Estimates: Why State-Survey Estimates Differ from CPS”, available at www.shadac.org.