ISSN 2691-7475 Health Policy Brief July 2020 Despite Insurance, the Poorest Adults Have the Worst Access to Dental Care Nadereh Pourat and Maria Ditter SUMMARY: Oral health is critical for overall access to timely dental care. We found that low- health and well-being, yet it is not considered income California adults were less likely to have an essential health benefit for adults under had timely dental visits, more likely to have had the Patient Protection and Affordable Care visits for dental problems, and less likely to have Act. Long-standing income disparities in had private dental insurance than their higher- oral health have been documented and are income counterparts. We also found that dental linked to lower rates of dental insurance and insurance alleviated some, but not all, income subsequent limited access to oral health care. disparities in access. These findings highlight We examined pooled data from the 2017 and the importance of considering dental health 2018 California Health Interview Surveys to as an essential health benefit and of ensuring assess whether there were income and dental parity in dental benefits, among other potential insurance disparities among California adults, policy solutions for reducing disparities in and, if so, whether such disparities included dental coverage and access. ‘‘ Dental services are not an essential health benefit under the ACA and are O ral health is an integral component of overall health.1 Evidence indicates that oral health depends on timely care that includes oral health education, preventive services, and early detection and treatment of dental problems.1 However, evidence also indicates that low-income under the Patient Protection and Affordable Care Act and are not covered by public programs such as Medicare. Adult dental benefits are optional for Medicaid (Medi-Cal in California), and California is one of 35 states that include this benefit.4 Most dental insurance policies have an annual cap on not covered by adults have poorer oral health, which benefit amounts, as well as restrictions on public programs is potentially linked to lack of dental coverage of some services.5,6 Medi-Cal has ’’ such as Medicare. insurance.2 Like health insurance, dental insurance lower provider reimbursement levels and a lower rate of provider participation than private dental insurance.7 Private insurance promotes access to care by reducing financial may also have high levels of cost sharing on barriers to access.3 However, dental insurance specific services, which may contribute to is different from health insurance in several reduced dental visits.8 respects. For one thing, private dental insurance is offered less frequently than health Access to dental care is measured by visits to insurance by employers. Without premium dental providers to receive preventive care and sharing from employers, dental insurance dental treatment. Healthy People 2020 set the premiums are less affordable to lower-income target for this access indicator as at least one populations. In addition, dental services are dental visit per year for 49% of the population not considered an essential health benefit by 2020.9 The frequency of visits varies by 2 UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 1 Timeliness of Dental Visits by Federal Poverty Level (FPL), Adults Ages 18 and Older, California, 2017–2018 6% 13% 17% 14% More than 5 years ago or never 23% 13% 24% More than 1 year and up to 5 years ago 6 to 12 months ago 17% 18% Up to 6 months ago 67% 47% 41% 0%–138% FPL 139%–249% FPL At or Above 250% FPL (6.97 million) (5.11 million) (17.49 million) Sources: 2017 and 2018 California Health Interview Surveys ‘‘ Our aim was to assess whether income disparities in access to dental dentist recommendations, which are based on the oral health of individuals. Most dental insurance policies and Medi-Cal cover up to two preventive visits per year. This policy brief examines timeliness of and reasons for dental visits among California Low-Income Californians Have Less Timely Dental Visits Than Higher-Income Individuals There is no single requirement for frequency of dental visits, as the need for care is highly dependent on individual risk factors. However, the American Dental Association recommends care exist, and adults by income and insurance coverage. a minimum of one annual visit, and most We pooled data from the 2017 and 2018 what potential California Health Interview Surveys (CHIS) survey data examine this frequency.10 CHIS respondents reported on how long it had role dental to obtain the most recent available data on been since they had had a dental visit, which insurance oral health access for California adults. Our allowed us to examine both variations in aim was to assess whether income disparities might have in in access to dental care exist among California annual visits and the time intervals between visits. We found that these indicators varied addressing these adults, and, if such disparities exist, what by income (Exhibit 1). Among low-income disparities. ’’ potential role dental insurance might have in addressing these disparities. adults (0%–138% FPL), we found that 41% had had a dental visit less than six months ago, and 18% had had a visit 6–12 months ago. We used the federal poverty level (FPL) Combined, 59% of low-income adults (data to measure income, identifying California not shown) had visited a dentist in the last adults with incomes at or below 138% FPL year. In contrast, 67% of those with incomes ($17,237 for a single person and $35,535 for above 250% FPL ($31,225 for a single person a household of four) as those whose incomes and $64,375 for a household of four) had had were lowest and were consistent with Medi- a visit less than six months ago, and 13% had Cal eligibility criteria. UCLA CENTER FOR HEALTH POLICY RESEARCH 3 had a visit 6–12 months ago. Combined, 80% of adults with the highest incomes had had a Last Dental Visit for Specific Problem by Exhibit 2 Federal Poverty Level (FPL), Adults Ages 18 dental visit last year. and Older, California, 2017–2018 Low-Income Californians Visit Dentists 41% More Frequently Than Higher-Income 35% Adults for Dental Problems CHIS respondents were asked whether their last dental visit was for preventive care, a 23% specific problem, or both. We examined whether low-income adults (0%–138% FPL) had visited dentists for specific problems (including those who had visited for both preventive and specific problems) at a different rate than that of higher-income adults. We found that 41% of low-income 0%–138% FPL 139%–249% FPL At or Above adults had visited a dentist for specific (6.59 million) (4.95 million) 250% FPL problems, compared to 23% of adults with (17.28 million) incomes at or above 250% FPL (Exhibit 2). Sources: 2017 and 2018 California Health Interview Surveys Medi-Cal Is the Dominant Form of Dental at or above 250% FPL had private dental Coverage Among Low-Income Adults insurance, and 8% had Medi-Cal (a small We identified adults with private dental share of higher-income populations received insurance, Medi-Cal, and no dental insurance Medi-Cal under specific circumstances, and examined types of coverage reported including high medical expenses). Data also by income. Sixteen percent of low-income showed that a smaller proportion of low- adults (0%–138% FPL) had private dental income adults (20%) had no dental insurance insurance, and 64% had Medi-Cal (Exhibit 3). compared to those with incomes at or above In contrast, 69% of those with incomes 250% FPL (24%). Type of Dental Insurance by Federal Poverty Level (FPL), Adults Ages 18 and Older, Exhibit 3 California, 2017–2018 20% 24% 30% 8% 36% 64% 69% Uninsured Medi-Cal 34% Private 16% 0%–138% FPL 139%–249% FPL At or Above 250% FPL (6.97 million) (5.11 million) (17.49 million) Sources: 2017 and 2018 California Health Interview Surveys Note: Private dental insurance may include a small proportion with military or other publicly funded coverage. 4 UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 4 Timeliness of Dental Visits by Dental Insurance and Federal Poverty Level (FPL), Adults Ages 18 and Older, California, 2017–2018 12% 15% 19% 14% 21% 20% 19% 16% 73% 17% 57% 61% 56% 48% 43% 41% 36% 28% Private Medi-Cal Uninsured Private Medi-Cal Uninsured Private Medi-Cal Uninsured 0%–138% FPL 139%–249% FPL At or Above 250% FPL (4.14 million) (3.23 million) (14.05 million) 6 to 12 months ago Up to 6 months ago Sources: 2017 and 2018 California Health Interview Surveys Note: Private dental insurance may include a small proportion with military or other publicly funded coverage. ‘‘ Having a higher income was significantly associated with more visits ... for Dental Insurance Improves Timeliness of Dental Visits, but Income Disparities Remain When we examined the joint relationship of type of insurance coverage with timeliness of visits by income, we found that having a higher income was significantly associated 56% of low-income adults (0%–138% FPL) had had a visit within the past six months, compared to 73% of those with incomes at or above 250% FPL. Among uninsured adults, 28% of low-income adults had had a dental visit within the past six months, compared to 57% of those with incomes at or above 250% both privately with more visits within the past six months FPL. Among adults with Medi-Cal coverage, insured and for both privately insured and uninsured adults (Exhibit 4). Among privately insured adults, however, the timeliness of dental visits did not significantly increase by income. uninsured adults. ’’ UCLA CENTER FOR HEALTH POLICY RESEARCH 5 Last Dental Visit for Specific Problem by Federal Poverty Level (FPL) and Dental Insurance, Exhibit 5 Adults Ages 18 and Older, California, 2017–2018 43% 43% 38% 39% 32% 31% 28% 27% 20% Private Medi-Cal Uninsured Private Medi-Cal Uninsured Private Medi-Cal Uninsured 0%–138% FPL 139%–249% FPL At or Above 250% FPL (6.59 million) (4.95 million) (17.28 million) Sources: 2017 and 2018 California Health Interview Surveys Note: Private dental insurance may include a small proportion with military or other publicly funded coverage. Dental Visits for Specific Problems Are Least Common Among Privately Insured Adults, but Income Disparities Persist We analyzed the data to determine whether rates of dental visits for a specific problem varied by type of dental insurance and income 43% of the Medi-Cal and uninsured groups. Among those with incomes at or above 250% FPL, these rates were lower for those with private insurance (20%) or Medi-Cal (32%) and those who were uninsured (28%). Implications and Policy Recommendations ‘‘ Low-income adults are more likely to have had a visit for a dental ’’ (Exhibit 5). Overall rates for visits due to a specific problem declined significantly for We found that a higher percentage of problem. high-income individuals, irrespective of type California adults had had a dental visit in of insurance. However, results also indicated the last year than the Healthy People 2020 that privately insured adults in all income target of 49%. However, we found income groups visited dentists for a specific problem disparities in timeliness of visits, with significantly less often than adults who had low-income adults more likely than high- Medi-Cal or who were uninsured. These rates income adults to have had a visit for a dental also varied by income. Among low-income problem. Furthermore, we found that among adults (0%–138% FPL), 31% of those who those who were uninsured, low-income were privately insured reported having visited adults (0%–138% FPL) had the lowest rates a dentist for a specific problem, compared to of dental visits compared to their higher- 6 UCLA CENTER FOR HEALTH POLICY RESEARCH ‘‘ Low-income adults have less access to dental services for preventive income counterparts. Also, we found that although most low-income adults had dental insurance because of enrollment in Medi-Cal, this advantage did not translate into better or more timely access to dental visits for this group compared to those with incomes at or above 250% FPL. Similarly, Medi-Cal Policies are also needed to address the limited role of Medi-Cal in reducing income disparities in access to dental services. In addition, policies should be established that promote higher reimbursement rates for dental services, along with financial and nonfinancial incentives to encourage care and early coverage did not reduce the likelihood of better participation of dentists in Medi- diagnosis of dental visits for specific problems for low- Cal. Financial incentives have been used ’’ income adults. Our findings were consistent successfully by Medi-Cal to promote access problems. with other studies that found more public to dental care of children.13 California dental coverage, infrequent dental check- Proposition 56 provided supplemental ups, fewer dental visits, and higher unmet payments for several dental services under need for dental treatment among low- Medi-Cal during fiscal years 2017–18 and income adults compared to higher-income 2018–19. However, the continuation of these populations.11, 12 payments is in question due to the financial impact of COVID-19 on the state budget. Collectively, our findings imply that low- The data in this brief were unlikely to have income adults (0%–138% FPL) have less captured the impact of these payments access to dental services for preventive care on access to dental care among Medi-Cal and early diagnosis of problems, which beneficiaries. in turn leads to missed opportunities to promote better oral health among this The impact of COVID-19 is likely to include population. Policies are needed that promote significant changes in dental coverage the availability of affordable dental insurance associated with loss of employment-based for adults. Such policies should involve insurance. The economic recession associated inclusion of dental services as an essential with the virus is also likely to lead to health benefit, regulation of premiums, cutbacks in coverage of adult dental care, standardization of dental benefits and cost which is an optional Medi-Cal benefit. These sharing, and parity between dental and changes are likely to exacerbate the income medical benefits. disparities highlighted in this brief. UCLA CENTER FOR HEALTH POLICY RESEARCH 7 Data Source and Methods Endnotes We pooled 2017 and 2018 California Health 1 U.S. Department of Health and Human Services. 2000. Oral Health in America: A Report of the Surgeon General. Interview Survey (CHIS) data for these analyses. Rockville, Md.: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Income was measured based on the total annual Research, National Institutes of Health. https://www.nidcr. nih.gov/sites/default/files/2017-10/hck1ocv.%40www.surgeon. income of a household divided by the number of fullrpt.pdf individuals in the household and reported as a 2 Sanders B. 2012. Dental Crisis in America—The Need to percentage of the federal poverty level. We considered Expand Access. Washington, D.C.: U.S. Senate Committee those who had had Medi-Cal insurance at any time on Health, Education, Labor, & Pensions. https://www. sanders.senate.gov/imo/media/doc/DENTALCRISIS.REPORT. during the past year to have had dental insurance, pdf regardless of their response to the question on 3 Manski RJ, Schimmel Hyde J, Chen H. 2016. having dental insurance. Among the remainder of Differences Among Older Adults in the Types of Dental Services Used in the United States. Inquiry: The Journal respondents, we identified those who had had dental of Health Care Organization, Provision, and Financing insurance and those who had lacked any dental (Sage Journals). Vol. 53. https://journals.sagepub.com/doi/ insurance. Some Medi-Cal beneficiaries—particularly full/10.1177/0046958016652523 those whose income was above 138% FPL—may 4 DHCS. 2019. Restoration of Adult Dental Services. Sacramento, Calif.: California Department of Health Care have had limited-scope Medi-Cal, although this data Services. https://www.dhcs.ca.gov/services/Pages/Restoration_ may be underreported. Adult_Dental.aspx 5 Cohens K. 2017. Denti-Cal for Adults. Fact Sheet. Author Information Justice in Aging. https://www.justiceinaging.org/wp-content/ uploads/2017/02/Denti-Cal-for-Adults.pdf Nadereh Pourat, PhD, is associate director of the 6 Vujicic M, Buchmüller T, Klein R. 2016. Dental UCLA Center for Health Policy Research and Care Presents the Highest Level of Financial Barriers, director of the center’s Health Economics and Compared to Other Types of Health Care Services. Health Affairs 35(12): 2176-2182. https://www.healthaffairs.org/ Evaluation Research Program, a professor of health doi/full/10.1377/hlthaff.2016.0800 policy and management at the UCLA Fielding 7 Ku L. 2009. Medical and Dental Care Utilization and School of Public Health, and a professor at the Expenditures Under Medicaid and Private Health Insurance. Medical Care Research and Review (Sage UCLA School of Dentistry. Maria Ditter, Dr.med, Journals) 66(4):456-471. https://journals.sagepub.com/ MPH, is a research analyst at the UCLA Center for doi/10.1177/1077558709334896 Health Policy Research. 8 ADA. 2012. Breaking Down Barriers to Oral Health for All Americans: The Role of Finance. Chicago, Ill.: American Dental Association. https://www.ada.org/~/media/ADA/ Funder Information Publications/ADA%20News/Files/7170_Breaking_Down_ This policy brief was supported by a generous grant Barriers_Role_of_Finance.pdf?la=en from the California Wellness Foundation (contract 9 Healthy People 2020. Data table: “Children, adolescents, and adults who visited the dentist in the past year by The California Health number 2018-230). total.” Rockville, Md.: Office of Disease Prevention and Health Promotion, U.S. Department of Health and Interview Survey (CHIS) Acknowledgments Human Services. https://www.healthypeople.gov/2020/data/ covers a wide array of Chart/5028?category=1&by=Total&fips=-1 health-related topics, The authors would like to thank Julian Aviles and 10 ADA. 2013. American Dental Association Statement on including health insurance Andrew Juhnke for their assistance with statistical Regular Dental Visits. Chicago, Ill.: American Dental Association. https://www.ada.org/en/press-room/news- coverage, health status analysis, and Tiffany Lopes and Venetia Lai for releases/2013-archive/june/american-dental-association- and behaviors, and access their editing and production support. The authors statement-on-regular-dental-visits to health care. It is based also thank Jayanth Kumar, DDS, MPH; Shannon 11 Berchick ER, Barnett JC, Upton RD. 2019. Health on interviews conducted Conroy, Phd, MPH; Earl Lui; and Todd Hughes for Insurance Coverage in the United States: 2018. Current Population Reports. Washington, D.C.: U.S. Census continuously throughout their helpful comments on this brief. Bureau. https://www.census.gov/content/dam/Census/library/ the year with respondents publications/2019/demo/p60-267.pdf from more than 20,000 Suggested Citation 12 Kramarow EA. 2019. Dental Care Among Adults Aged 65 and Over, 2017. NCHS Data Brief. Centers for Disease California households. Pourat N, Ditter M. 2020. Despite Insurance, the Control and Prevention. https://www.cdc.gov/nchs/products/ Poorest Adults Have the Worst Access to Dental Care. databriefs/db337.htm CHIS is a collaboration Los Angeles, Calif.: UCLA Center for Health Policy 13 Harrington M, Felland L, Peebles V, et al. 2019. between the UCLA Center Research. Evaluation of the Dental Transformation Initiative: Interim Evaluation Report. Ann Arbor, Mich.: Mathematica. for Health Policy Research, https://www.dhcs.ca.gov/provgovpart/Documents/DTI-draft- California Department of Interim-Evaluation-Report-v2.pdf Public Health, California Department of Health Care Services, and the Public Health Institute. For more information about CHIS, please visit chis.ucla.edu. UCLA CENTER FOR HEALTH POLICY RESEARCH 10960 Wilshire Blvd., Suite 1550 Los Angeles, California 90024 The UCLA Center for Health Policy Research is part of the UCLA Fielding School of Public Health. The analyses, interpretations, conclusions, and views expressed in this policy brief are those of the authors and do not necessarily represent the UCLA Center for Health Policy Research, the Regents of the University of California, or collaborating organizations or funders. PB2020-5 Copyright © 2020 by the Regents of the University of California. All Rights Reserved. Editor-in-Chief: Ninez A. Ponce, PhD Phone: 310-794-0909 Fax: 310-794-2686 Email: chpr@ucla.edu healthpolicy.ucla.edu Read this publication online