Dental visits have been found to be more scarce among children with lower family incomes.^2,3 Access to a dental examination for Medicaid-eligible children has been improved by federal and state programs but remains worse than for those whose family incomes are above poverty (a family income at or above 201 percent of the FPL).⁴ Both groups, poor and near-poor, are considered to be at high risk of experiencing poor oral health¹ and are similar in terms of having had "any" dental visit⁵—a visit for either routine dental examinations, restorative procedures, emergency care or preventive services or a combination thereof. Historically, the near-poor population was not covered by federal-state programs and, thus, was unable to afford care. In light of the expanded eligibility criteria of the State Children’s Health Insurance Program, or SCHIP,⁶ as of 1997, which largely includes the near-poor population, access to dental care for both groups should be monitored to measure the program’s impact.

Access to care and utilization of dental services are difficult to measure. Access to care pertains to the availability of and accessibility to health care providers.⁷ Utilization is related to the patients’ (or their families’) knowing how to use the available resources effectively.⁷ Generally, the percentage of the population having made any dental visit in the past year is used as a measure of dental care utilization. The problems with this measure are that it usually includes all types of dental visits and that it assumes that all visits are similar, therefore masking differences between levels of care for at-risk and non–at-risk population groups. For example, one may examine any visit in poor and nonpoor groups and find no difference but, when looking more carefully, find that one of the groups had more preventive visits and the other more emergency visits. This would translate into greater treatment needs in one of the groups, with implications for policy and resource allocation, although they appeared comparable originally. Thus, the dental visits made for any reason should be monitored separately from those made for preventive reasons.

Dental primary prevention visits are intended to monitor oral health and to prevent disease before it occurs. If early carious lesions are detected, these can be reversed and controlled in a timely way (secondary prevention). By contrast, emergency treatment only eliminates pain or infection and neither addresses primary prevention for children at higher risk nor has an impact on future caries. Preventive visits, therefore, may be a better health indicator for a population.

In this article, we present an analysis of data from the 1996 Medical Expenditure Panel Survey, or MEPS,⁸ which provided baseline data for Healthy People 2010⁹—namely, for the Healthy People 2010 Objective 21-12: "To increase the proportion of children and adolescents under age 19 years at or below 200 percent of the federal poverty level who received any preventive dental service during the past year." For Healthy People 2010, a baseline of 20 percent was identified via preliminary analysis of the 1996 MEPS (children and adolescents younger than 19 years of age who were at or below 200 percent of the FPL and received any preventive dental service during the previous year). The target for this Healthy People 2010 objective was set at 57 percent (children and adolescents younger than 19 years of age at or below 200 percent of the FPL who should receive any preventive dental service during a year, measured against data from the preceding year). This article examines the Healthy People 2010 baseline data for Objective 21-12 and explores the impact of income on preventive dental visits among a representative sample of U.S. children and adolescents younger than 19 years of age.

	METHODS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
The 1996 MEPS is the most recent in a series of nationally representative health surveys of the U.S. community-based population that is sponsored by the Agency of Healthcare Research and Quality. The MEPS provides data on health care expenditures, use and payment source, along with socioeconomic and demographic characteristics and health insurance status.⁸ The 1996 MEPS included a subsample of 10,500 households selected to participate in the 1995 National Health Interview Survey.⁸

Data for the 1996 MEPS were collected as personal interviews by trained personnel using computerized survey instruments during the last three quarters of 1996 and during the first quarter of 1997. Poverty levels were determined using the ratio of total family income (adjusted by family size and composition) to the applicable poverty line. For this study, we used the following income categories:

– poor—income at or below 100 percent of the FPL, which is an annual income of approximately $16,500 for a family of four;

– near-poor—income ranging from 101 percent to 200 percent of the FPL;

– middle or high income—income 201 percent of the FPL or greater.

Patients’ race and ethnicity information was coded in categories of non-Hispanic black, Hispanic and non-Hispanic white, which in this analysis included very small numbers of other population groups (Asian or Pacific Islanders, American Indians, Aleuts and Eskimos). Age group categorization was based on Healthy People 2010 baseline requirements for setting objectives (age groups of 0 to 5 years, 6 to 11 years and 12 to 18 years).

This analysis focuses on children’s and adolescents’ use of preventive dental care. Specifically, we provide national estimates for visits in which preventive dental procedures (such as dental prophylaxis and fluoride and sealant applications) were completed for subjects in each of several socioeconomic and demographic categories. If multiple procedures of different types were completed during a single visit—for example, a preventive procedure and a restorative procedure—both types of procedures were reported. Multiple procedures of the same type reported during a single visit were recorded as a single procedure type. For example, a reported visit including only sealant applications would be counted similarly to a visit with both a prophylaxis and sealant applications.

We computed percentage estimates and standard errors reported here using the software package SUDAAN,¹⁰ taking into account the complex sampling design of MEPS. Additionally, we completed a multiple logistic regression analysis to adjust poverty levels by race and ethnicity, age group and sex. Furthermore, we explored interaction terms for poverty levels by race and ethnicity.

	RESULTS

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There were 23,230 participants in the 1996 MEPS, representing approximately 268 million noninstitutionalized United States civilians. Of these, 42 percent (n = 6,595) were younger than 19 years of age. Approximately one-half of the participating children were female (48.2 percent), 15.5 percent were non-Hispanic black and 14.9 percent were Hispanic. Table 1 shows the distribution of the sample population and numbers represented by demographic characteristics.

View larger version (38K): [in this window] [in a new window]   Figure 1. Percentage distribution of children with preventive dental visits by poverty status and racial/ethnic background, 1996. All confidence intervals of the percent estimates were significant at the P < .01 level. The sample represents 75 million children younger than 19 years of age. Based on information from Cohen.8

View this table: [in this window] [in a new window]   TABLE 2 PERCENTAGE DISTRIBUTION OF U.S. CHILDREN AND ADOLESCENTS AGED YOUNGER THAN 19 YEARS WHO HAD A PREVENTIVE* DENTAL VISIT, BY POVERTY STATUS AND SELECTED POPULATION CHARACTERISTICS, 1996.

	DISCUSSION

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

The strength of the data source is that MEPS data provide nationally representative estimates and include data elements that describe specific preventive dental visits. For instance, MEPS data describe the amount of preventive dental visits detailed for children in each of several demographic and socioeconomic categories. MEPS data also served to establish a baseline for rates of preventive dental care utilization for the U.S. population for use in the Healthy People 2010 objective-setting process.⁸ Relevant to our discussion is the fact that these MEPS 1996 data provide a preintervention baseline for possible changes brought about by SCHIP.

The finding that the distribution of preventive dental visits did not differ between poor and near-poor children, but that the distribution in both of those groups differed significantly from that among children with middle or high incomes, is notable. Children identified as poor in this study are those eligible for Medicaid coverage. However, in 1997, the eligibility for health benefits to those in the near-poor category was expanded through SCHIP (rather than Medicaid).⁶ One must note, however, that the actual eligibility level for SCHIP and the services included in each program vary from state to state.

It is important to evaluate estimates of dental care utilization by looking at FPL poor and near-poor categories separately and to monitor future trends in access to care by these two groups, particularly in states that do not provide similar amounts of access for them. Here we examined preventive visits rather than all visits, and we found that both poor and near-poor groups had similar low levels. No other studies have found differences by income^2,5; however, these studies looked at any visit, and comparisons are complicated by the fact that the near-poor group was grouped entirely⁵ or partially² with the poor group.

Data regarding all pediatric dental visits recorded in the 1996 MEPS have been reported,¹¹ including emergency and orthodontic care visits, using a combined low income of 0 to 200 percent of the FPL. Since dental visits for primary prevention are more desirable than those for secondary and tertiary prevention, we believe it is important to monitor numbers of both dental visits for any reason and dental visits for preventive care. Future studies of the utilization of both primary and secondary dental services should be conducted to assess results of the introduction of SCHIP benefits and other federal demonstration or intervention programs.

Overall, the proportion of children who had had preventive visits was unexpectedly low for all children and adolescents younger than 19 years of age. This finding was particularly unexpected, given that coverage for pediatric dental services has been required under Medicaid’s comprehensive Early and Periodic Screening, Diagnostic, and Treatment services, which were amended to be more explicit in 1989 and have been part of the Medicaid program for more than three decades.⁷ Furthermore, the proportions of children younger than 6 years of age who had had preventive visits also were unexpectedly small, as performance standards of Head Start programs, usually pertaining to children aged 3 to 5 years in the poor category, require compliance with oral health examinations and rendering of the required treatment.¹²

This small proportion of children younger than 6 years of age who had preventive visits may be a reflection of a large number of children younger than 3 years of age in the MEPS database for whom preventive dental visits are not anticipated, given the Head Start focus on children aged 3 to 5 years. About 50 percent of the children in this age category (younger than 6 years of age) were younger than 3 years of age (n = 1,020). Thus, the overall (all income levels combined) proportion of children aged 3 to 5 years (a portion within the age group of children younger than 6 years of age) who had had a preventive visit amounted to less than the 31.7 percent of the whole age bracket who had had a preventive visit. Although the American Academy of Pediatric Dentistry recommends that children have their first dental examination at 1 year of age or within six months of the eruption of the first tooth, the dearth of providers available to see these younger groups provides a barrier to compliance with this recommendation.¹³ Also, there is a lack of public awareness of the need to bring children to the dentist early in life.

It is hoped that SCHIP dental benefits will improve children’s access to and use of dental care in the future. However, SCHIP’s success in terms of access to care depends on whether dental providers participate in the program. Its success in terms of utilization depends on eligible patients’ enrolling in and using the services covered. Likewise, according to the definition in the report of the U.S. Department of Health and Human Services inspector general on children’s dental services under Medicaid,⁷ utilization assumes that the patients (or their families) know how to use the available resources effectively; therefore, education of the populations eligible for the Medicaid and SCHIP programs regarding how to enroll and access the system is essential for the success of these programs.

This analysis focused on children who may be eligible for either Medicaid or SCHIP, rather than children actually enrolled in these programs. Enrollment in these federal and state programs is an indicator of access to and utilization of care among the poor and near-poor that needs future evaluation. Enrollment may be an intermediate indicator of actual utilization of dental services—that is, an indicator of the population’s knowledge of its eligibility for the services and of how to access the system (at least for the medical services component).

Figure 2 illustrates this concept using local data from the state of Maryland (Centers for Medicare and Medicaid Services, formerly known as Health Care Financing Administration, unpublished data, 1996).¹⁴ Only 18,000 children used dental services (the top of the pyramid), representing 16.7 percent of the "eligibles" (the base of the pyramid) and 30.9 percent of the medical services recipients already enrolled in Medicaid (the middle of the pyramid). Thus, the dental component of Medicaid missed rendering primary preventive oral health care services to 40,100 (69 percent) children who were Medicaid enrollees and medical services recipients (of the 58,100 in the middle of the pyramid). Furthermore, nearly 50,000 additional children were completely missed by both the medical and dental components of Medicaid—that is, 46 percent of the "eligibles" (from the base of the pyramid) received neither medical nor dental services.

View larger version (45K): [in this window] [in a new window]   Figure 2. Enrollment as an intermediate step in the utilization of dental services: Medicaid example using data for Maryland children aged 1 through 5 years, 1996. Based on information from the Centers for Medicare and Medicaid Services, formerly known as the Health Care Financing Administration.14

The findings we present in this report raise awareness of the low levels of utilization of preventive dental care among U.S. children and adolescents younger than 19 years of age (20 percent combined), particularly in prospect of the aforementioned Healthy People 2010 target of 57 percent. Oral health disparity issues are at the center of the national agenda for health. Even though the expanded eligibility criteria for SCHIP have increased the proportion of the population eligible for health benefits, increasing financial eligibility alone has been found unlikely to sufficiently improve low-income children’s access to care.^16,17

For the Healthy People 2010 targets for preventive visits for children to be achievable, the dental profession must find a way to set up broad-based cooperative efforts. These efforts are necessary to achieve several goals:

– the preparation of the work force needed to provide care for these population groups—given that a dearth of Medicaid- and SCHIP-enrolled dentists has been identified as an important barrier¹³;

– outreach to these population groups using valid primary preventive strategies such as school-based programs^18,19;

– the use of oral health promotion and prevention programs that combine parental educational interventions with regular preventive care,²⁰ placed on site within federal early childhood programs²¹;

– the integration of oral health care with general health care programs²² and with primary health care provided by pediatricians.¹⁸

Most importantly, parental education should include content on how to enroll children (and pregnant women) in Medicaid and SCHIP and how to access the services available to them. As it was said at the 2000 Surgeon General’s Conference on Children and Oral Health, our job now is to turn eligibility for Medicaid and SCHIP into enrollment.²³ Additionally, other care alternatives, such as incorporating group (or individual) primary care case management programs with opportunities for oral health preservation by dental care providers in federal primary care programs, have been advocated.^18–20,24 The dental profession has the responsibility to increase the numbers of dentists in the system who are appropriately trained and available to care for these children^13,25 and to reach these children with dental primary care services.

	CONCLUSION

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
This analysis provides baseline information for future follow-up of SCHIP’s impact. Future analyses of national utilization data on dental visits for preventive and for any type of dental care will serve to determine if the dental profession has been successful in improving access to care and utilization for the poor and near-poor child and adolescent populations.

View larger version (121K): [in this window] [in a new window]   Dr. Watson is a research assistant professor, Department of Pediatric Dentistry, Baltimore College of Dental Surgery, University of Maryland, 666 W. Baltimore St., Baltimore, Md. 21201-1596, e-mail "mwatson{at}umaryland.edu". Address reprint requests to Dr. Watson.

View larger version (127K): [in this window] [in a new window]   Dr. Manski is a professor, Department of Oral Health Care Delivery, Dental School, University of Maryland, and a visiting scholar, Center for Cost and Financing Studies, Agency for Healthcare Research and Quality, Rockville, Md.

View larger version (155K): [in this window] [in a new window]   Dr. Macek is an assistant professor, Department of Oral Health Care Delivery, Baltimore College of Dental Surgery Dental School, University of Maryland.