Community Efforts to Expand Dental Services for Low-Income People

Issue Brief No. 122
July 2008
Laurie E. Felland, Johanna Lauer, Peter J. Cunningham

Inadequate oral health among low-income populations is increasingly recognized as a major health care challenge. Primary obstacles to obtaining dental services include low rates of dental insurance coverage, restricted dental benefits through public insurance programs, and a shortage of dentists willing to treat low-income patients, based on findings from the Center for Studying Health System Change's (HSC) 2007 site visits to 12 nationally representative metropolitan communities. Communities across the country are striving to deliver more dental services to low-income residents. In addition to state-level efforts aimed at boosting dentist participation in Medicaid and the State Children's Health Insurance Program (SCHIP), hospitals, community health centers, health departments, dental schools, and other organizations are working to broaden dental care access. Some initiatives concentrate on fundamental preventive services while others pursue more wide-ranging dental treatment. A large number of these community programs depend on expanding the pool of dental professionals who serve low-income populations. Without greater engagement from the dental community and state and federal policy makers, however, many low-income individuals will likely continue to go without dental care and bear the resulting health consequences.

Low-Income People Lack Dental Coverage and Care

Awareness of the significance of oral health has expanded since the U.S. Surgeon General's 2000 report, which drew attention to the widespread prevalence of poor oral health among low-income groups and emphasized that oral health is integral to overall well-being. [1] Research indicates an apparent connection between certain oral infections and a number of systemic medical conditions, including heart disease, lung disease, stroke, and premature births. Furthermore, abscessed teeth can lead to severe infections and even death, as vividly illustrated in 2007 by the widely reported case of Deamonte Driver, a Maryland boy who died when a tooth infection spread to his brain.

The absence of dental care is the primary driver of oral health problems, with low-income individuals and certain racial and ethnic minorities encountering particularly significant barriers to treatment. Data from the Agency for Healthcare Research and Quality's 2004 Medical Expenditure Panel Survey (MEPS) shows that roughly 40 percent of people living in poverty — those with incomes at or below $21,200 for a family of four in 2008 — went without dental coverage during the year, compared to about a quarter of people earning more than four times the poverty level. The 2005 MEPS reveals that approximately a quarter of people living in poverty had a dental visit during the year, whereas more than half of those with incomes above 400 percent of the poverty level did. Similarly, about a quarter of Hispanics and blacks visited a dentist during the year, in contrast to nearly half of whites.

HSC's 2007 site visits to 12 communities (see Data Source) revealed that dental care ranks among the most difficult health care services for low-income people to access, primarily because of the challenge of locating dentists who accept public insurance or offer charity care. Further barriers for low-income individuals may include limited awareness of the connection between dental health and overall health, as well as perceptions that dental care is more of a luxury than a necessity. [2] As one community health center respondent put it, "If you weren't raised to get your teeth cleaned, you won't do it."

Because of these barriers to care, many low-income individuals forgo preventive dental treatment or delay seeking help for oral health problems until an infection or other urgent condition develops. When treatment does occur, diseased teeth are frequently extracted rather than restored.

State Medicaid and SCHIP Policy Affects Dental Coverage

State Medicaid and SCHIP policy has a substantial influence on access to dental services at the community level. Although states are mandated to provide comprehensive dental coverage to children enrolled in Medicaid, dental coverage for children in SCHIP and for adult Medicaid enrollees remains optional. While the majority of states include some degree of dental coverage through SCHIP, Medicaid coverage for adults differs greatly from state to state and is frequently limited to emergency services, with the scope of coverage often rising and falling along with state budgets. In 2006, when state budgets were in relatively good shape, Florida began providing limited dental coverage for Medicaid adults, and Massachusetts added two cleanings and exams per year on top of existing emergency dental treatment coverage for adults.

Even when Medicaid and SCHIP offer dental coverage, low reimbursement rates frequently discourage dentist participation. Although Michigan restored a previous cut in routine dental services for adults in 2006, dentist participation had dropped substantially, leaving only 15 percent of dentists in the state willing to accept adult Medicaid patients. [3] A Lansing respondent noted, "Patients thought they were going to get care, but they couldn't because no one would see them."

Higher payments that approach private insurance rates or dentists' usual charges have contributed to increased participation by dentists in several communities, including Little Rock, Phoenix, and Syracuse. While New York's 250 percent increase in dental reimbursement rates initially showed little effect, it eventually encouraged a few private dental practices in Syracuse to participate; notably, a dental practice chain focused on treating Medicaid and SCHIP children opened two locations in Syracuse. New Jersey — which has historically maintained some of the lowest Medicaid payment rates in the country — recently raised reimbursement for children's dental services by 350 percent, bringing Medicaid rates in line with private rates, though the effect of this change has yet to be fully assessed.

In addition to raising reimbursement rates, streamlining administrative processes such as claims processing has been shown to help improve dentist participation in Medicaid and SCHIP and enhance access to care for enrollees. [4] To achieve this, some Medicaid programs, including Michigan's Medicaid program for children, have contracted with commercial dental insurance plans. [5] However, adequate payment remains essential: Florida's managed care pilot for children's dental services led to a significant decline in dentist participation and utilization of care because capitated payments were low relative to the previous fee-for-service rates. [6]

Despite these changes, other challenges that low-income people face, such as keeping appointments, reportedly contribute to some dentists' reluctance to treat them. [7] As one Syracuse respondent remarked, "The reimbursement increases were still not encouraging dentists to accept Medicaid patients. It turns out it was more of an issue of having the 'unwashed' in the waiting room, problems scheduling and noncompliant patients."

Significant Gaps in the Dental Safety Net

Low-income patients unable to find private-practice dentists willing to treat them often seek care from safety net providers. Yet, the safety net for dental care is considerably less developed than the safety net for medical care more broadly, and few dental providers specifically focus on serving low-income populations. Moreover, dental care has not traditionally been a central focus of general safety net providers — public and not-for-profit hospitals, community health centers, free clinics, and local health departments — and their capacity remains limited.

Hospital emergency departments (EDs) function as de facto dental care providers. ED directors in Lansing, Miami, and Seattle, in particular, reported high demand for dental services. The Emergency Medical Treatment and Labor Act (EMTALA) requires ED staff to screen and stabilize all patients, including those presenting with dental conditions, though most EDs lack the staff or equipment to deliver dental services and are generally restricted to providing pain relief. However, some EDs in Syracuse, northern New Jersey, and Boston benefit from having dental residents on call through their hospitals' oral surgery or general practice dental residency programs.

Although some hospitals operate dental clinics staffed by dental residents or volunteer dentists, the services available are often limited. As a Boston hospital CEO stated, "There is infinite demand for dental services. Every Tuesday we have people lining up to have their teeth pulled." While some hospitals are expanding their dental clinics, others are questioning whether they should continue to provide dental care, especially as other types of residency programs and services generate more revenue. Seattle's public hospital recently scaled back its general dentistry clinic after determining those services fell outside the hospital's core mission. [8]

Community Efforts to Expand Dental Services

Numerous communities are actively working to broaden dental services for low-income people. These initiatives range from providing preventive care — including cleanings, X-rays, fluoride treatment, and sealants to prevent tooth decay — to filling cavities and delivering other restorative services, and in some instances, offering rehabilitative services such as orthodontics and periodontics. Funding support for these services and participation from dental students and professionals are essential to these efforts.

Preventing dental problems. A number of communities deliver preventive care and general dental education to schoolchildren, since such programs are relatively inexpensive compared with the cost of addressing future dental problems, and providing services at school eliminates some of the barriers associated with scheduling appointments. For instance, students from a Cleveland dental school offer preventive care at local elementary schools, while the county health department in Miami runs a dental van that visits schools. In Syracuse, community advocates are pushing to re-establish the county's school-based preventive dental program, which was discontinued following a cut in state funding.

Communities frequently depend on dental hygienists to support their preventive programs. Hygienists are less costly and generally more available than dentists, partly due to recent expansions of training programs. [9] A growing number of states now permit dental hygienists to deliver certain preventive services to low-income people in public facilities without the direct supervision of a dentist. For example, community activists in Arizona successfully lobbied to change licensure laws so that hygienists could provide preventive treatments to low-income children without supervision. [10]

Still, preventive programs require resources to treat dental problems discovered during examinations. Directors of the Cleveland school-based program have sought to address this challenge by partnering with local dental societies to compile a list of dentists willing to provide follow-up treatment. [11] However, community programs that coordinate physicians and dentists volunteering their services for low-income people generally have limited capacity. Through such a program in Little Rock, the wait for a dental appointment reportedly stretches to several years. While advocates in some communities, such as Miami, propose advanced training for hygienists or other dental personnel to perform certain restorative treatments, state and national dental associations are largely opposed to such expansions in scope of practice, citing safety concerns. [12]

Providing comprehensive services. Federally qualified health centers (FQHCs) and other community clinics are increasingly offering dental services, encompassing preventive, restorative, emergency, and in some cases, rehabilitative care. These health centers are particularly important providers for racial and ethnic minorities and immigrants. With federal grant support, the volume of dental services provided by FQHCs grew 85 percent between 2000 and 2005; by 2006, approximately three-quarters of FQHCs provided preventive dental care. [13] Health centers or community clinics in half of the 12 communities reported increasing capacity — for example, by opening new dental clinics, expanding clinic sessions, and/or hiring new dental staff over the preceding few years. FQHCs receive enhanced Medicaid reimbursement, which helps generate the revenues needed to support these expansions.

However, health centers report that the expansions to date do not come close to matching the level of need, and waits for appointments remain long. Respondents in northern New Jersey and Seattle indicated that the wait for an adult to see a dentist is often two to three months, even for extractions of diseased teeth. As a health center respondent from Indianapolis explained, "We have three [patient treatment chairs]. I could probably double those and still not have enough capacity." Yet, federal dental expansion grants to FQHCs have declined in recent years.

Recruitment challenges also impede further expansion of dental capacity because health centers and community clinics frequently cannot offer competitive compensation. Although health centers receive dentists from the National Health Service Corps, which places dentists in underserved areas in exchange for student loan repayment, approximately 40 percent of urban health centers have reported that it is very difficult to recruit dentists. [14] Health centers in Little Rock, Syracuse, and northern New Jersey reported significant problems recruiting dentists.

Developing community collaborations. Paralleling their role in preventive efforts, dental schools are partnering with health centers to enhance training opportunities for students while simultaneously expanding dental services for low-income people. Training in community clinics typically allows students to treat more low-income patients than they would in dental school clinics. [15] Health centers in Lansing, Indianapolis, and Phoenix have such arrangements with local dental schools. Dental students have had a particularly notable impact on access in Phoenix, where two new dental schools have an explicit commitment to serving the community.

Although lacking a dental school in the area, Greenville recently established a dental program through an expansive partnership with the technical college (which trains dental assistants and hygienists), the FQHC, a local hospital, and corporate and foundation support. The initiative raised more than $1.6 million to care for 3,000 Medicaid and uninsured patients in its first year. Care is delivered through the FQHC's fixed dental practice and a fully equipped mobile unit donated by the hospital, which brings dental professionals to churches, schools, and other community locations. Students and faculty provide preventive services in exchange for training space, and three dentists employed by the health center provide restorative services. The health center's enhanced Medicaid payments are expected to help sustain the program over time.

Implications

Community efforts to address the dental service needs of low-income residents face a steep challenge because the demand for services far outstrips available resources. Policy makers could explore a number of options to improve dental care access through both public and private providers.

Further state efforts to improve Medicaid and SCHIP payment rates and reimbursement processes could help expand the number of dentists willing to treat low-income people. Recent improvements in dentist participation in some communities could erode if public payment rates are not adjusted as private fees rise. [16] However, state spending on dental services is threatened by competing priorities and the economic downturn at the time, along with declining tax revenue in many states. Policy makers also might examine whether targeted incentives to large dental practices that specialize in meeting the particular needs of low-income patients — as seen in Syracuse — could help expand access in a cost-effective manner.

Additional National Health Service Corps dentists, dental expansion grants for FQHCs, and other federal efforts could help build community capacity. Prompted by the death of Deamonte Driver, several pieces of federal legislation aimed at improving dental access, particularly for children, were under consideration at the time of publication. One measure called "Deamonte's Law" would attempt to increase the number of pediatric dentists and expand community health center dental capacity. Additional proposals include providing grants to states to improve Medicaid and SCHIP dental programs, offering tax credits to dentists who treat low-income children, and establishing a working group of representatives from federal health and human service agencies to coordinate resources and identify best practices for oral health programs.

Collaboration among policy makers, safety net providers, national and state dental associations, and dental schools could help address gaps in the dental workforce. For instance, the Robert Wood Johnson Foundation and The California Endowment are funding an initiative to help dental schools recruit more minority and low-income students and to place more dental students and residents in community clinics. [17] Additionally, the debate continues about the level of care hygienists should be permitted to provide without dentist supervision, and whether other non-dentist professionals could safely fill cavities and extract teeth; such training programs are developing in Minnesota and Alaska. [18]

Moreover, the overall supply of dentists warrants examination, since the number of practicing dentists has not kept pace with the growing population. [19] Although the dental workforce is expected to expand with the development of several new dental schools — with some schools emphasizing training students in community settings — it remains uncertain whether the supply of future dental graduates will meet the rising demand for dental care. [20] Furthermore, without incentives for new dentists to treat Medicaid and SCHIP enrollees and low-income uninsured people, it is unlikely that an increased supply of dentists alone will significantly improve dental care access for these vulnerable groups.

Notes

1. U.S. Department of Health and Human Services (HHS), Oral Health in America: A Report of the Surgeon General, Rockville, Md. (2000).

2. Ibid.; Kelly, Susan E., et al., "Barriers to Care-Seeking for Children's Oral Health Among Low-Income Caregivers," American Journal of Public Health, Vol. 95, No. 8 (August 2005).

3. "Share of Michigan Dentists Who Accept Medicaid Drops," The Michigan Daily (March 14, 2006).

4. Borchgrevink, Alison, Andrew Snyder and Shelly Gehshan, Increasing Access to Dental Care in Medicaid: Does Raising Provider Rates Work? Issue Brief, California HealthCare Foundation, Oakland, Calif. (March 2008).

5. Eklund, Stephen A., James L. Pittman and Sarah J. Clark, "Michigan Medicaid's Healthy Kids Dental Program: An Assessment of the First 12 Months," Journal of the American Dental Association, Vol. 134, No. 11 (November 2003).

6. Community Voices Miami, "Understanding the Impact of Florida's Medicaid Pre-Paid Dental Pilot," Oral Health Issue Brief No. 2, Miami, Fla. (August 2006).

7. U.S. Department of Health and Human Services (HHS), Office of the Inspector General. Children's Dental Services Under Medicaid: Access and Utilization, San Francisco, Calif. (1996).

8. Song, Kyung M., "Harborview Scales Back Outpatient Dental Clinic," The Seattle Times (Nov. 1, 2007).

9. American Dental Hygienists' Association, "Access to Care Position Paper" (2001) www.adha.org/profissues/access_to_care.htm (Accessed Feb. 29, 2008).

10. Arizona State Dental Hygienists' Association, "Achievements" (2006) www.asdha.org/page-21.aspx (Accessed Nov. 1, 2007).

11. Lalumandier, James A., and Kay F. Molkentin, "Establishing, Funding, and Sustaining a University Outreach Program in Oral Health," Health Affairs, Vol. 23, No. 6 (November/December 2004).

12. Berenson, Alex, "Boom Times for Dentists, But Not for Teeth," The New York Times (Oct. 11, 2007).

13. National Association of Community Health Centers, Health Center Fact Sheet (2006).

14. Rosenblatt, Roger A., et al., "Shortages of Medical Personnel at Community Health Centers: Implications for Planned Expansion," Journal of the American Medical Association, Vol. 295, No. 9 (March 1, 2006).

15. Bailit, Howard, et al., "Dental Safety Net: Current Capacity and Potential for Expansion," Journal of the American Dental Association, Vol. 137, No. 6 (June 2006).

16. Borchgrevink (2008).

17. Pipeline, Profession & Practice: Community-Based Dental Education, Fact Sheet, www.dentalpipeline.org (Accessed April 23, 2008).

18. Berenson, Alex, "Dental Clinics, Meeting a Need With No Dentist," The New York Times (April 28, 2008).

19. Berenson (Oct. 11, 2007).

20. Bailit, Howard, and Tryfon Beazoglou, "Financing Dental Care: Trends in Public and Private Expenditures for Dental Services," The Dental Clinics of North America, Vol. 52, No. 2 (April 2008).

Data Source

Approximately every two years, HSC conducted site visits to 12 nationally representative metropolitan communities as part of the Community Tracking Study to interview health care leaders about the local health care market, how it had changed, and the effect of those changes on people. The communities are Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y. The sixth round of site visits was conducted between February and June 2007 with 453 interviews. This Issue Brief is based on responses from state Medicaid executives and other policy makers, community health centers, safety net hospital executives and emergency department directors, local health department officials, consumer advocates, and other knowledgeable market observers.

Sources and Further Reading

CDC Oral Health Program — Federal data and resources on oral health disparities, prevention strategies, and community water fluoridation programs.

National Institute of Dental and Craniofacial Research (NIDCR) — NIH institute funding research on oral health conditions, with data on dental care access and oral health disparities among underserved populations.

Medicaid.gov: Dental Care Benefits — CMS overview of Medicaid and CHIP dental coverage requirements for children and optional adult dental benefits by state.

KFF: Dental Care in Medicaid — Analysis of Medicaid dental benefits, provider participation rates, and state-level variation in dental coverage for low-income populations.

AHRQ Medical Expenditure Panel Survey (MEPS) — National survey data on dental care utilization, insurance coverage, and out-of-pocket expenditures referenced throughout this study.

Robert Wood Johnson Foundation — Funder of HSC research and dental workforce pipeline initiatives aimed at expanding community-based dental education and minority recruitment.