Summer 2016

The State We’re In

ADA paints a mixed picture of oral health care in America

By Helene Ragovin

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Illustration: Dan Page

Some good news: The number of children from low-income families in the U.S. who are seeing the dentist is on the rise. In some states, just as many children covered by Medicaid are receiving dental care as those with private insurance.

When it comes to adults, though, the trends are not as encouraging. The gap in dental care between adults with private insurance and those on Medicaid is far wider than it is for children. And in much of the country, fewer adults with private dental benefits are seeking oral health care.

Those conclusions are contained in a sweeping state-by-state analysis released by the American Dental Association’s Health Policy Institute in late 2015. The findings are sure to contribute to discussions among dental professionals and policymakers on issues such as increasing access to care and expanding the dental workforce.

Ninety-five percent of American adults say they want to maintain good oral health.

Marko Vujicic, chief economist and vice president of the Health Policy Institute and an author of the report, explained the findings during a webinar broadcast at the School of Dental Medicine in January. “We hope this can change the fundamental conversation of what we mean by oral health,” said Vujicic, a visiting professor at Tufts. Among the other key findings was that an overwhelming majority of American adults—95 percent—agreed that they want to maintain good oral health.

The report covers a wide range of topics, such as dental visits, knowledge about oral health, community water fluoridation and Medicaid reimbursement rates. It offers recommendations on a nationwide level.

The Role of Medicaid

First among them is introducing proven reforms into Medicaid. From 2000 to 2013, the percentage of Medicaid children across the country who had been to the dentist increased from 29 percent to 48 percent—in some states, the increase was as much as fivefold. The states with the largest gains, the report says, introduced measures such as broad outreach to recipients and providers, higher reimbursements to providers and streamlined administrative procedures that made it easier for dental offices to file for reimbursement.

The key is “getting the right dentists at the right times in the right places.”

Vujicic presented a graph that plotted, by state, the number of Medicaid-participating dentists against the number of Medicaid-enrolled children who visited the dentist. For the most part, there was little correlation between the two—North Dakota, for example, had a high per capita number of Medicaid providers, but low rate of Medicaid children who went to the dentist. “Why is that?” Vujicic asked. “Do [the providers] have appointments available? Are they in the right geographic area?” The key, he said, is “getting the right dentists at the right times in the right places.”

And that, Vujicic says, touches on the question of whether access-to-care issues can be addressed by training more dental care providers, or by more strategic use of the existing workforce. “I feel like we need to move the conversation,” he said.

Team-Based Care

The data suggest that fundamental changes are ahead for dentistry, says Mark Nehring, the Delta Dental of Massachusetts Professor and chair of public health and community service at Tufts School of Dental Medicine. “The traditional dental practice—namely, a place you have to get in your car and drive to and make some effort for an appointment—is difficult for many patients,” he says—and not just for the poor. The decline in dental visits by middle-age people with private insurance also indicates that the current “work-week, business-hour” office model isn’t as accessible as one might think, he says.

Some of the same approaches that have contributed to the increase in children receiving dental care—expanded school-based and mobile care, for instance—could also be adapted for adults, Nehring suggests. He mentions dental facilities based at large employers, or mobile offices that visit workplaces or retirement communities, especially those integrated with primary care and that are focused on prevention.

“The current system of care is evolving to one that’s team-based,” he says. And the more convenient this comprehensive care can be, the more likely people will be to take advantage of it.

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