Oral Health: Dental Disease Is a Chronic Problem Among Low-Income
Populations (Letter Report, 04/12/2000, GAO/HEHS-00-72).

Pursuant to a congressional request, GAO provided information on the:
(1) dental health status of Medicaid beneficiaries and other vulnerable
populations; and (2) extent to which these groups have dental coverage
and use dental services.

GAO noted that: (1) dental disease is a chronic problem among many
low-income and vulnerable populations; (2) GAO's analysis of the most
recent national health surveys (1994-1997) showed that relative to more
affluent segments of the population, low-income populations had a
disproportionate level of dental disease; (3) for example, poor children
had five times more untreated dental caries (cavities) than children in
higher-income families, and poor adults were much more likely to have
lost six or more teeth to decay and gum disease than higher-income
adults; (4) minority populations also faced high levels of dental
disease; (5) dental problems result in pain, infection, and millions of
lost school days and workdays each year; (6) although every state
Medicaid program offers dental coverage for children and most programs
cover adults eligible for Medicaid, use of dental services by low-income
people is low; (7) states are required to provide comprehensive dental
benefits for children enrolled in Medicaid, and the State Children's
Health Insurance Program provides variable but often substantial levels
of dental coverage to eligible low-income children in all but two
states; (8) adult dental services, although optional under Medicaid, are
covered to some extent in about two-thirds of the states; (9) the
availability of coverage does not, however, bridge the income gap to
equalize the likelihood of visiting a dentist; (10) for example, GAO's
analysis of 1995 Medicaid claims data showed that only 29 percent of
enrolled adults had visited the dentist in the preceding year, less than
half the rate of higher-income adults; and (11) national survey data
also showed that in 1996 poor children and adults visited the dentist at
about half the rate of their higher-income counterparts--numbers that
had stayed relatively unchanged since 1977.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-00-72
     TITLE:  Oral Health: Dental Disease Is a Chronic Problem Among
	     Low-Income Populations
      DATE:  04/12/2000
   SUBJECT:  Dental services
	     Health care programs
	     State-administered programs
	     Disadvantaged persons
	     Dental insurance
	     Health surveys
IDENTIFIER:  Medicaid Program
	     State Children's Health Insurance Program
	     Early and Periodic Screening, Diagnosis, and Treatment
	     Program
	     National Health and Nutrition Examination Survey III
	     CDC Behavioral Risk Factor Surveillance System

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GAO/HEHS-00-72

Appendix I: Scope and Methodology

22

Appendix II: State Data Tables

24

Appendix III: Comments From the Department of Health and Human Services

29

Table 1: Four National Health Surveys With Dental Data, 1988-97 6

Table 2: Percentage of Adults With Tooth Loss From Decay or Gum
Disease by Family Income 11

Table 3: Percentage of Selected Ethnic Groups With Untreated
Tooth Decay 12

Table 4: Number of States That Provide Dental Coverage for
Children and Adults 14

Table 5: Percentage of Residents Making a Dental Visit in 1996 by
Metropolitan Area and Income 19

Table 6: Percentage of Adults Who Made a Dental Visit in the
Preceding Year by Annual Family Income 24

Table 7: Medicaid Coverage of Adult Dental Care 26

Table 8: Percentage of Medicaid Fee-for-Service Recipients Who
Made a Dental Visit in the Preceding Year 28

Figure 1: Percentage of Children With Untreated Caries by
Family Income 8

Figure 2: Restricted Activity Days per 100 Children Because of
Dental Problems by Family Income 9

Figure 3: Percentage of Adults With Untreated Caries by
Family Income 10

Figure 4: Percentage of Population Who Made a Dental Visit in the Preceding
Year:1977, 1987, and 1996 13

Figure 5: Percentage of Children Who Made a Dental Visit in the
Preceding Year by Family Income 15

Figure 6: Percentage of Children With at Least One Sealant by
Family Income 17

Figure 7: Percentage of Adults Who Made a Dental Visit in the
Preceding Year by Family Income 18

ADA American Dental Association

AHRQ Agency for Healthcare Research and Quality

BRFSS Behavioral Risk Factor Surveillance System

CDC Centers for Disease Control and Prevention

EPSDT Early and Periodic Screening, Diagnostic, and Treatment

HCFA Health Care Financing Administration

HHS Department of Health and Human Services

MEPS Medical Expenditures Panel Survey

NHIS National Health Interview Survey

NHANES III National Health and Nutrition Examination Survey III

SCHIP State Children's Health Insurance Program

SMRF State Medicaid Resource File

Health, Education, and
Human Services Division

B-283914

April 12, 2000

The Honorable Jeff Bingaman
The Honorable Russell D. Feingold
United States Senate

The Honorable Thomas M. Barrett
The Honorable David R. Obey
House of Representatives

The dental health of most Americans has improved significantly since the
1960s. There is growing concern, however, that low-income and other
vulnerable populations continue to have high levels of dental disease.
Dental problems not only affect health and well-being but also contribute to
lower productivity in the workplace and increased absenteeism at school.
This continued vulnerability is a matter of concern to the federal
government and the states, which jointly fund Medicaid, a program that pays
for health care--including dental care--for low-income and disabled persons.
Gauging the extent of efforts to address the problem through Medicaid and
related programs has been difficult, because the implementation of these
programs differs from state to state. To explore these issues in more depth,
you asked us to report on (1) the dental health status of Medicaid
beneficiaries and other vulnerable populations and (2) the extent to which
these groups have dental coverage and use dental services. At your request,
we are also conducting a second study in which we will identify major
barriers to dental care and assess federal and state efforts to overcome
them.

To respond to your request, we analyzed dental health and data on the use of
dental health care from four national health surveys and surveyed Medicaid
and related programs state by state. We also analyzed Medicaid payment data
for dental services. Appendix I explains our methodology. We conducted our
work from October 1999 to February 2000 in accordance with generally
accepted government auditing standards.

Dental disease is a chronic problem among many low-income and vulnerable
populations. Our analysis of the most recent national health surveys
(1994-97) showed that relative to more affluent segments of the population,
low-income populations had a disproportionate level of dental disease. For
example, poor children had five times more untreated dental caries
(cavities) than children in higher-income families, and poor adults were
much more likely to have lost six or more teeth to decay and gum disease
than higher-income adults. Minority populations also faced high levels of
dental disease. Dental problems result in pain, infection, and millions of
lost school days and workdays each year.

Although every state Medicaid program offers dental coverage for children
and most programs cover adults eligible for Medicaid, use of dental services
by low-income people is low. States are required to provide comprehensive
dental benefits for children enrolled in Medicaid, and the State Children's
Health Insurance Program (SCHIP) provides variable but often substantial
levels of dental coverage to eligible low-income children in all but two
states. Adult dental services, although optional under Medicaid, are covered
to some extent in about two-thirds of the states. The availability of
coverage does not, however, bridge the income gap to equalize the likelihood
of visiting a dentist. For example, our analysis of 1995 Medicaid claims
data showed that only 29 percent of enrolled adults had visited the dentist
in the preceding year, less than half the rate of higher-income adults.
National survey data also showed that in 1996 poor children and adults
visited the dentist at about half the rate of their higher-income
counterparts--numbers that had stayed relatively unchanged since 1977.

Medicaid is the largest public program of health care insurance for
low-income people. As a joint federal and state program, it finances health
care coverage for about 40 million people, over half of whom are children.
Nationwide, combined federal and state expenditures were $177 billion in
1998. The states operate their Medicaid programs within broad federal
requirements and can elect to cover a range of optional populations and
services, thereby creating programs that differ substantially from state to
state. Despite this variation, some services are mandated under federal law.
For instance, in 1967 the Congress created the Early and Periodic Screening,
Diagnostic, and Treatment (EPSDT) service within Medicaid to help ensure
that children receive needed medical and dental care. Under EPSDT, the
states must provide comprehensive medical and dental services for all
enrolled children, even if the services are not normally covered by a
state's Medicaid program. While EPSDT requires the states to provide certain
care for children, many services for adults, such as dental care, are
optional under state Medicaid programs.

Although Medicaid covers low-income people, only about half of those living
in poverty were eligible for Medicaid in 1996, according to the
Congressional Research Service. This is largely because of eligibility
restrictions that make benefits available only to certain low-income
categories, such as families with children and the aged, blind, and
disabled.1 While the Congress expanded eligibility for pregnant women and
children several times beginning in 1984, the states can expand coverage to
these populations beyond federal requirements. To expand health coverage to
children whose families have incomes that are low, but not low enough to
qualify for Medicaid, in 1997 the Congress created SCHIP as title XXI of the
Social Security Act. In return for an enhanced federal matching share,
states can expand coverage to low-income children in families earning up to
200 percent of the federal poverty level.2 To implement SCHIP, the states
have three options: They can expand their existing Medicaid program, develop
a separate SCHIP program, or do some combination of both. Coverage of dental
services is not mandatory for children under SCHIP as it is in Medicaid, but
if a state elects a Medicaid expansion, it must offer the same comprehensive
benefit package, including dental services, that is required under EPSDT. By
September 1999, nearly two million children were enrolled in the 53
operational programs. Fifty-six states and territories had SCHIP programs
that the Health Care Financing Administration (HCFA) had approved; three had
not begun enrollment.

The federal government collects information on the nation's dental health
through several nationwide health surveys. The surveys are designed for
different purposes and thus have different strengths and weaknesses. For
example, dental information in the Centers for Disease Control and
Prevention's (CDC) National Health and Nutrition Examination Survey III
(NHANES III) included examinations that dentists performed. The survey
provided a representative sample of dental health nationwide, but the
results could not be narrowed to the state level. In contrast, data from
CDC's Behavioral Risk Factor Surveillance System (BRFSS) can be examined at
the state level, but not all states have conducted the oral health module,
and the survey relies on self-reported data that are likely to overlook some
conditions such as untreated tooth decay. We examined data from a
combination of surveys conducted by CDC and the Department of Health and
Human Services' (HHS) Agency for Healthcare Research and Quality (AHRQ) in
order to minimize individual survey limitations (see table 1).3

Table 1: Four National Health Surveys With Dental Data, 1988-97

           Survey              Data used              Description
                               in study
                                            A nationally representative
 National Health and                        survey of the prevalence,
 Nutrition Examination Survey 1988-94       trends, and risk factors for
 III (NHANES III), CDC                      selected diseases. Oral
                                            assessments were conducted by
                                            dentist examiners.
                                            A broad, nationally
                                            representative survey that
 National Health Interview                  monitors trends in illness and
 Survey (NHIS), CDC           1994          disability and tracks progress
                                            toward national health
                                            objectives.
                                            A nationally representative
                                            survey of health care use,
                                            expenditures, sources of
 Medical Expenditures Panel                 payment, and insurance
 Survey (MEPS), AHRQ          1996          coverage. Data are collected
                                            through in-person, telephone,
                                            and mailed surveys. Providers
                                            are contacted to verify and
                                            supplement reported events.
                                            A state-based random telephone
                                            survey of the prevalence of
 Behavioral Risk Factor                     major behavioral risks
 Surveillance System (BRFSS), 1995-97       associated with premature
 CDC                                        morbidity and mortality among
                                            adults. Provides state-specific
                                            estimates.

Note: Dental questions vary from year to year within surveys. We used the
most recent survey data available for our analyses.

Recognizing the importance of good oral health, HHS established oral health
goals as part of its departmentwide Healthy People 2000 initiative. HHS set
goals, such as reducing untreated caries in children and increasing regular
dental visits by adults, for the population in general and some minority
groups. Interim assessments showed that progress toward these goals was
mixed, with poor and minority groups being furthest from reaching them. HHS
established a new set of oral health goals in its Healthy People 2010
initiative, announced in January 2000.

In April 1997, the Secretary of HHS commissioned the first Surgeon General's
Report on Oral Health. Under the direction of the National Institute of
Dental and Craniofacial Research, the study will examine the relationships
between oral health and general health and well-being. Highlights are
expected to include the determinants of oral health, the effects of oral
health on daily living, leading-edge technologies, preventive approaches,
and community-based interventions to improve oral health. The report's
publication is planned for spring 2000.

Oral health includes prevention or elimination of a number of diseases and
conditions that occur in the mouth, such as gum disease and oral cancer.
Many factors can affect an individual's oral health, including personal
behavior such as oral hygiene and diet, as well as environmental factors,
such as community water fluoridation. We used tooth decay as a key indicator
for our work because it is the most common oral disease, data are readily
available, and it can be a sentinel condition for dental care.

Poor oral health afflicts many low-income and other vulnerable populations.
Analysis of key dental health indicators--including untreated tooth decay
and restricted activity days for children and untreated tooth decay and
tooth loss for adults--showed large disparities between low-income groups
and their higher-income counterparts. Many vulnerable populations, including
homeless people, minorities, and some rural residents, face similar
problems.

Tooth decay, the most common chronic childhood disease, is most prevalent
among poor children. About 25 percent of all children have untreated caries
in their permanent teeth. Eighty percent of untreated caries in permanent
teeth are found in roughly 25 percent of children who are 5 to 17 years old,
mostly from low-income and other vulnerable groups. Left untreated, the pain
and infection caused by tooth decay can lead to problems in eating,
speaking, and attending to learning.

Our analyses of national survey data show that the prevalence of untreated
caries in the lowest income group was much greater than that in the highest
income group for children of all ages. For example, among children aged 2
through 5 who had family incomes below $10,000, nearly one in three had at
least one decayed tooth that had not been treated. In contrast, only 1 in 10
preschool children whose family incomes were $35,000 or higher had untreated
caries. As shown in figure 1, these income-based disparities generally hold
for untreated caries in both children's primary (baby) teeth and permanent
teeth across all age groups.

Figure 1: Percentage of Children With Untreated Caries by Family Income
Source: NHANES III, CDC, 1988-94.

Another key indicator of dental health is the number of missed activity
days, such as days of school or work, because of dental problems.4 Surveys
show that missed activity days are concentrated in low-income groups. Poor
children suffer nearly 12 times more restricted-activity days, such as
missing school, than higher-income children as a result of dental problems
(see figure 2).

Figure 2: Restricted Activity Days per 100 Children Because of Dental
Problems by Family Income
Source: NHIS, CDC, 1994.

Poor oral health and dental disease often continue from childhood into
adulthood because tooth decay and periodontal disease are progressive and
cumulative throughout life. Low-income adults have more untreated caries and
suffer from greater tooth loss because of decay or gum disease than their
higher-income counterparts. For example, among adults aged 19 to 64 who had
family incomes of less than $10,000, nearly one in two had at least one
decayed tooth that had not been treated. In contrast, only one in six adults
whose incomes were $35,000 or more had untreated caries (see figure 3).

Figure 3: Percentage of Adults With Untreated Caries by Family Income
Source: NHANES III, CDC, 1988-94.

Another important marker of dental health is tooth loss from decay or gum
disease. Left untreated, caries and gum disease eventually lead to tooth
loss. Our analysis of CDC survey data shows that low-income adults suffer
more severe tooth loss than their wealthier counterparts. For example,
adults in families earning less than $15,000 per year were more than 2-1/2
times as likely to have lost six or more teeth from decay or gum disease as
adults in families earning $35,000 or more (see table 2).

Table 2: Percentage of Adults With Tooth Loss From Decay or Gum Disease by
Family Income

 Number of teeth lost Less than $15,000  $15,000-$34,999  $35,000 or more
 None                 34%                40%              51%
 1-5                  30                 33               34
 6 or more            34                 25               13
 Other or no response 2                  2                1

Note: Columns may not total 100 percent because of rounding.

Source: BRFSS, CDC, 1995-97.

The same characteristics of poor dental health can be seen in various
populations that are generally considered to be at higher risk for dental
problems or may have a disproportionate number of persons living in
low-income situations. Health surveys consistently show that minority groups
have higher levels of unmet dental health needs. Recognizing this disparity,
HHS has set specific goals for some minority groups as part of its
departmentwide initiatives. Further, in planning for its Healthy People 2010
initiative, HHS reported that minorities, particularly Native Americans,
experience significantly greater levels of untreated tooth decay (see table
3).

Table 3: Percentage of Selected Ethnic Groups With Untreated Tooth Decay

                            Age in years
 Group                      2 to 4  6 to 8  15   35 to 44
 Total                      16%     29%     20%  27%
 Native American            68      69      66   a
 Asian and Pacific Islander 30      71      a    a
 African American           22      36      29   46
 Mexican American           24      43      27   34
 White                      11      26      195  24

aData not statistically reliable.

Source: HHS, Healthy People 2010 Conference Report: Oral Health Survey of
Native Americans, Indian Health Service service areas, 1999; California data
for Asian and Pacific Islander, 1994; all other, NHANES III, CDC, 1994.

Among the most vulnerable low-income populations are homeless people. For
millions of homeless men, women, and children, maintaining personal hygiene
in general is a challenge, and finding a place to practice routine good oral
hygiene may be nearly impossible for some. Homeless persons have more
grossly decayed and missing teeth than even low-income persons who live in
stable housing. Homeless children are more likely to never have visited a
dentist. One-third of homeless families responding to a 1999 survey reported
their children had never visited a dentist, and 17 percent reported that
their children had needed to see a dentist in the preceding year but were
unable to do so.5 For homeless adults, the survey found 54 percent had not
seen a dentist in at least 2 years, and 46 percent reported they needed to
see a dentist in the preceding year but were not able to do so.

of Coverage

While the states offer comprehensive dental coverage to most low-income
children and some adults, the use of dental care is low. In response to our
survey, state Medicaid agencies reported comprehensive dental coverage for
children but more limited coverage for adults. Our analysis of two key
markers of the use of dental care--the rate of dental visits in the past
year for children and adults and the use of sealants for children--showed
that low-income populations use dental services at a much lower rate than
more affluent groups. Our comparison of state Medicaid coverage for adults
and rates of dental visits showed a small increase in use as coverage
increased.

National surveys have shown little improvement in the use of dental care
among low-income populations over the past two decades. In 1996, persons in
low-income groups made dental visits at about half the rate of their
higher-income counterparts, a finding similar to survey results in 1977 and
1987 (see figure 4).

Figure 4: Percentage of Population Who Made a Dental Visit in the Preceding
Year:1977, 1987, and 1996
Note: The federal poverty level for a family of four was $6,191 in 1977,
$11,611 in 1987, and $16,036 in 1996.

Source: AHRQ unpublished data: National Medical Care Expenditure Survey,
1977; National Medical Expenditure Survey, 1987; MEPS, 1996.

Adults' Coverage Varies

Under EPSDT, all states are required to provide comprehensive dental
services to enrolled children. While the states have considerable
flexibility in the benefits packages they can offer under SCHIP, all but
Colorado and Delaware offer substantial dental coverage. Adult dental
coverage is optional under Medicaid, but about two-thirds of the states
indicated that they cover some dental services. However, many impose
considerable limitations. (See table 4.)

Table 4: Number of States That Provide Dental Coverage for Children and
Adults

                                               Children
 Category of services (typical service)                     Adult Medicaid
                                               EPSDT  SCHIP
 Emergency                                     51     49    42
 Preventive (prophylaxis, sealants)            51     49    27
 Diagnostic (clinical oral evaluations)        51     49    32
 Routine restorative (amalgam, resin
 restoratives)                                 51     49    29
 More complex (crowns, bridges, dentures)      51     43    30

Source: GAO Jan. 2000 survey of 50 state Medicaid and SCHIP agencies and the
District of Columbia.

Although the states offer comprehensive dental coverage to all enrolled
children and many adults, a significant gap exists between the number who
are eligible and the number who are enrolled. An estimated 4.7 million
uninsured children were eligible for Medicaid but not enrolled in 1996.
While comparable estimates are not available for adults, a 1999
HCFA-sponsored study estimated that, nationwide, 46 percent of the persons
who were potentially eligible were not enrolled in Medicaid.

Having poor oral health and armed with Medicaid or SCHIP dental coverage,
poor people might be expected to make substantial use of dental services.
However, they often do not receive the care they need. Our analysis of
national surveys shows that low-income children and adults do not visit the
dentist as often as their higher-income counterparts. A separate analysis of
Medicaid billing data for 1995 confirms the low use of dental care in
Medicaid's fee-for-service programs in the 27 states where data were
available. We could not, however, determine from either the survey or
billing data the extent to which low use was the result of individuals' not
seeking dental care or a lack of available dental services.

Most Children of Low-Income Families Do Not Visit the Dentist Regularly

National survey data from 1996 show that low-income children were largely
not receiving regular dental care. For example, about 36 percent of
6-to-18-year-olds living at or below the federal poverty level had visited a
dentist in the preceding year compared with about 71 percent living in
families with incomes higher than 400 percent of the federal poverty level.
At all ages, children in the highest income group were about twice as likely
to have made a dental visit as children at or below the federal poverty
level (see figure 5).

Figure 5: Percentage of Children Who Made a Dental Visit in the Preceding
Year by Family Income
aData insufficient for the 101 to 200 percent category.

Note: The federal poverty level for a family of four was $16,036 in 1996.

Source: MEPS, AHRQ unpublished data, 1996.

Although the large number of eligible recipients not enrolled in Medicaid or
SCHIP explains part of the absence of dental care, it is not the only
reason. Children enrolled in Medicaid, as a subset of all low-income
children described above, also show low use of dental care. We analyzed data
from HCFA's State Medicaid Resource File to assess the extent to which
individual state Medicaid programs had been billed for dental care for
children. This analysis of 1995 data (the most recent available) from 27
state Medicaid programs showed that only about one in three children (34
percent) enrolled in Medicaid fee-for-service plans had visited the dentist
in the preceding year.6

Another indicator of the use of dental care by children is the use of
sealants on permanent teeth. Sealants are plastic-like coatings that can
dramatically reduce the likelihood of caries. HHS established a Healthy
People 2000 goal of having at least 50 percent of children with sealants on
permanent molars. Our analysis showed that none of the income groups had
achieved this goal and that the poorest children were furthest away. For
example, only 12 percent of children aged 6 to 14 living at or below the
federal poverty level had at least one sealant--roughly one-third the
incidence of children in higher-income families (see figure 6).

Figure 6: Percentage of Children With at Least One Sealant by Family Income
Source: NHANES III, CDC, 1988-94.

Most Low-Income Adults Do Not Visit the Dentist Regularly

Low-income adults also make fewer visits to dentists than their
higher-income counterparts. Adults living at or below the federal poverty
level are less than half as likely to have seen a dentist in the past year
as adults earning more than four times the poverty level (see figure 7).

Figure 7: Percentage of Adults Who Made a Dental Visit in the Preceding Year
by Family Income
Note: The federal poverty level for a family of four was $16,036 in 1996.

Source: MEPS, AHRQ unpublished data, 1996.

Our analysis of Medicaid payment data also shows low utilization by enrolled
adults. Dental claims billed to Medicaid in 1995 for the 18 states that
cover adult dental services show that only 29 percent of adults enrolled in
Medicaid fee-for-service had visited the dentist in the preceding year.7 In
comparison, nationwide AHRQ data for 1996 showed that 44 percent of adults
aged 19 to 64 had made a dental visit in the preceding year. Our analysis
was limited to fee-for-service encounters because consistent and reliable
data for Medicaid beneficiaries enrolled in managed care plans were not
available.

In general, residents of rural areas are slightly less likely to have
visited a dentist in the past year than urban residents. While access to
dental care is a persistent problem for residents of many rural areas, our
analysis of national data for all nonmetropolitan counties shows, in
general, these residents just slightly behind metropolitan area residents in
dental visits (see table 5).

Table 5: Percentage of Residents Making a Dental Visit in 1996 by
Metropolitan Area and Income

                                     Family income as a % of the federal
 Area                                poverty level
                                     0-200%    201%-400%       401% or more
 Central metropolitan counties       29%       43%             58%
 Other metropolitan counties         29        49              57
 Nonmetropolitan counties adjacent
 to metropolitan areas               29        41              58
 Nonmetropolitan counties not
 adjacent to metropolitan areas      22        47              53

Note: The federal poverty level for a family of four was $16,036 in 1996.

Source: MEPS, AHRQ unpublished data, 1996.

The rates at which dental services are used vary significantly for all
income groups among the states. CDC survey data show that the proportion of
adults who made a dental visit in the preceding year ranged from a low of 33
percent in Arkansas to a high of 61 percent in Hawaii for those with less
than $15,000 annual family income.8 Higher income groups show similar
variations of between 66 and 83 percent. Within states, utilization was not
uniform among income groups. For example, Alaska had one of the higher rates
for the low-income group (55 percent) but one of the lower rates for the
highest income group (69 percent). Conversely, Kentucky had one of the
lowest rates for the low-income group (35 percent) but one of the highest
rates for the highest income group (79 percent). Appendix I contains data
for all 46 states that reported data from the optional BRFSS oral health
module.

To determine whether Medicaid coverage affected the variation among states,
we compared rates for the use of dental services for the 27 states reporting
Medicaid payment data. Our analysis of HCFA's 1995 fee-for-service payment
data showed wide variations between states for both children and adults. For
children enrolled in Medicaid, the proportion who made a dental visit in the
preceding year ranged from a low of 22 percent in Delaware to a high of 58
percent in Vermont. By comparison, in states that cover partial or full
adult dental care under Medicaid, adults' use of dental care was generally
much lower, ranging from less than 6 percent in Colorado to 46 percent in
Iowa. While Medicaid's policy of mandatory dental coverage for children and
optional coverage for adults may explain these differences, it does not
explain the wide variation among states for children. Appendix I contains
data for all 27 states that submitted payment data to HCFA in 1995.

Dental disease is a chronic problem among low-income populations. Key
markers of dental health and the use of services for dental problems, such
as untreated caries and lost teeth, show that low-income populations bear a
disproportionate level of dental disease and make fewer dental visits.
Disparities exist despite coverage of dental services under Medicaid and
SCHIP programs. The poor oral health and relatively low use of dental care
even among Medicaid enrollees suggest that barriers other than access to
insurance coverage contribute to the problems faced by low-income
populations. Frequently cited barriers include a shortage of dentists in
some areas, unwillingness of dentists to participate in Medicaid, low
Medicaid reimbursement rates and the program's administrative burden, and
unresolved patient education issues. In a subsequent report, we will examine
these barriers in more detail, as well as federal and state initiatives to
address them.

We provided a draft of this report to HHS for comment. HHS concurred with
our findings and reiterated its commitment to eliminating dental access
disparities and promote oral health, particularly for disadvantaged
populations. It also delineated a wide array of initiatives that are planned
or under way by its various component agencies, including intra- and
interagency collaborative strategies, to help address concerns about oral
health disparities. HHS also provided technical comments, which we
incorporated where appropriate. HHS's comments are included in full in
appendix III.

As we agreed with your offices, unless you publicly announce the report's
contents earlier, we plan no further distribution of it until 14 days from
the date of this letter. We will then send copies to the Honorable Donna E.
Shalala, Secretary of HHS, and others who are interested. We will make
copies available to others upon request. This report was prepared under the
direction of Frank Pasquier, Assistant Director. Other individuals who made
key contributions include Rashmi Agarwal, Sophia Ku, Terry Saiki, Stan
Stenersen, and Kim Yamane. Please call me at (202) 512-7118 if you or your
staff have any questions.

Kathryn G. Allen
Associate Director, Health Financing
and Public Health Issues

Scope and Methodology

To determine the oral health status and use of dental care of Medicaid and
other low-income populations, we analyzed data by income group, age, urban
and rural locations, and insurance status from several nationally
representative health surveys, including

ï¿½ National Health and Nutrition Examination Survey III (NHANES III), Centers
for Disease Control and Prevention (CDC), 1988-94;

ï¿½ National Health Interview Survey (NHIS), CDC, 1994;

ï¿½ Medical Expenditures Panel Survey (MEPS), Agency for Healthcare Research
and Quality (AHRQ), 1996; and

ï¿½ Behavioral Risk Factor Surveillance System (BRFSS), CDC, 1995-97.

Data from the different surveys we examined produce somewhat different
results for similar questions.9 Differences in survey design, collection
methods, timing, and other factors affect survey results. Important trends
and disparities were, nevertheless, consistent across all four surveys.
Differences in survey design also affect our ability to compare results
between surveys. For example, some surveys ask for specific income levels
and family size and thus can be converted to federal poverty levels, while
others ask for income only in general categories that cannot be expressed in
terms of poverty level.

To determine which dental benefits were covered by state Medicaid and the
State Children's Health Insurance Programs (SCHIP), we analyzed data from
the American Dental Association (ADA) and the Health Care Financing
Administration (HCFA). We also surveyed each state Medicaid agency to
complete and update data on dental coverage under state Medicaid and SCHIP.

To assess available data on state Medicaid dental care for children and
adults covered by fee-for-service arrangements, we analyzed HCFA's State
Medicaid Resource File (SMRF). This database provides summarized information
on Medicaid eligibility, claims, and utilization for states that participate
in the Medicaid Statistical Information System. To facilitate research, HCFA
has adjusted and reformatted the data and added service and eligibility
codes. The data are arranged in five separate research files: Drug Claims,
Inpatient Claims, Long-Term Care Claims, Other Ambulatory Claims, and Person
Summary. Claims information is not available for children and adults in
Medicaid managed care arrangements, and reliable data on health care
services provided to managed care enrollees were not available at the time
of our review.

We used the Person Summary and the Other Ambulatory Claims files to
determine the percentage of children aged 0 to 18 and adults aged 19 to 64
who had received dental services in 1995. The Person Summary file contains
characteristics such as date of birth and dates of coverage for each person
covered by Medicaid during the year. The Other Ambulatory Claims file
contains records for dental services received. Our analysis was limited to
1995 data from the 27 states that provided data to HCFA for that year.
According to HCFA officials, 1995 is the most recent year for which reliable
claims data are available.

We performed separate analyses for children aged 0-18 and adults aged 19-64.
We limited our analysis to children and adults for whom the data indicated
that they were covered by Medicaid for the entire year in order to make sure
that we did not include beneficiaries who may have switched to, and received
care from, a managed care plan during the year.

Other than making these control checks, we did not independently verify the
SMRF data because (1) HCFA's process for modifying the data includes quality
control phases in which the data are analyzed with a number of statistical
tools and crosswalks and (2) the data originated at the state level and the
benefit of tracking them back to their source would not have outweighed the
considerable cost and staff resources that this would have entailed. These
data represent the most current and complete data available on state-level
billing within Medicaid fee-for-service programs.

State Data Tables

Table 6: Percentage of Adults Who Made a Dental Visit in the Preceding Year
by Annual Family Income

Continued

     State     Less than $15,000  $15,000-$34,999  $35,000 or more
 Alabama       43%                62%              77%
 Alaska        55                 67               69
 Arizona       55                 61               74
 Arkansas      33                 58               66
 California    45                 58               71
 Colorado      43                 56               73
 Connecticut   46                 65               81
 Florida       51                 62               74
 Georgia       45                 63               74
 Hawaii        61                 72               80
 Idaho         42                 57               75
 Illinois      41                 61               74
 Indiana       48                 58               74
 Iowa          47                 58               70
 Kansas        45                 55               76
 Kentucky      35                 56               79
 Louisiana     40                 57               72
 Maine         38                 58               77
 Maryland      46                 62               70
 Massachusetts 54                 60               73
 Michigan      43                 66               81
 Mississippi   35                 56               73
 Missouri      42                 56               70
 Montana       53                 63               75
 Nebraska      44                 65               80
 Nevada        42                 49               72
 New Hampshire 49                 67               80
 New Jersey    53                 61               78
 New Mexico    45                 63               77
 New York      53                 64               79
 North Dakota  49                 63               77
 Ohio          43                 61               83
 Oklahoma      41                 57               77
 Oregon        54                 64               77
 Pennsylvania  48                 61               79
 Rhode Island  49                 61               69
 South Dakota  56                 68               83
 Tennessee     37                 58               78
 Texas         37                 54               71
 Utah          55                 66               78
 Vermont       55                 64               77
 Virginia      41                 60               76
 Washington    46                 63               70
 West Virginia 34                 54               76
 Wisconsin     60                 66               78
 Wyoming       51                 60               70

Note: Dental data not available for Delaware, Minnesotta, North Carolina,
and South Carolina.

Source: BRFSS, CDC, 1995-97.

Table 7: Medicaid Coverage of Adult Dental Care

Continued

        State         Full  Partiala  Noneb
 Alabama                              X
 Alaska                               X
 Arizona                    X
 Arkansas                             X
 California           X
 Colorado                   X
 Connecticut          X
 Delaware                             X
 District of Columbia                 X
 Florida                    X
 Georgia                              X
 Hawaii                               X
 Idaho                      X
 Illinois                   X
 Indiana              X
 Iowa                 X
 Kansas                               X
 Kentucky                   X
 Louisiana                  X
 Maine                X
 Maryland                             X
 Massachusetts        X
 Michigan             X
 Minnesota            X
 Mississippi                          X
 Missouri                   X
 Montana                    X
 Nebraska                   X
 Nevada                               X
 New Hampshire                        X
 New Jersey           X
 New Mexico           X
 New York             X
 North Carolina             X
 North Dakota         X
 Ohio                       X
 Oklahoma                             X
 Oregon                     X
 Pennsylvania         X
 Rhode Island               X
 South Carolina                       X
 South Dakota               X
 Tennessee                            X
 Texas                                X
 Utah                       X
 Vermont                    X
 Virginia                   X
 Washington           X
 West Virginia                        X
 Wisconsin            X
 Wyoming                              X

a States do not cover particular services (preventive, diagnostic,
restorative, or more complex), or they impose other limitations on coverage,
such as a $475 annual ceiling.

b None or emergency services only.

Source: GAO survey of state Medicaid and SCHIP agencies, Jan. 2000.

Table 8: Percentage of Medicaid Fee-for-Service Recipients Who Made a Dental
Visit in the Preceding Year

 State            Children  Adults
 Weighted average 33.5%     29.0%
 Alabama          29.1      a
 Alaska           45.1      a
 Arkansas         36.8      a
 California       31.8      34.5
 Colorado         32.4      5.6
 Delaware         21.8      a
 Florida          33.7      11.5
 Georgia          36.2      a
 Indiana          26.0      24.2
 Iowa             47.9      45.7
 Kansas           38.9      a
 Kentucky         34.3      23.1
 Maine            41.4      10.0
 Michigan         39.4      30.6
 Mississippi      32.0      a
 Missouri         27.1      25.7
 Montana          35.8      35.4
 New Hampshire    56.1      a
 New Jersey       33.8      28.2
 North Dakota     37.2      35.3
 Pennsylvania     38.4      22.6
 Rhode Island     28.6      26.6
 Utah             30.7      34.8
 Vermont          58.3      42.7
 Washington       35.0      31.9
 Wisconsin        26.5      32.6
 Wyoming          40.1      a

a State does not provide dental coverage for adults or provides only
emergency care.

Source: SMRF, HCFA, 1995.

Comments From the Department of Health and Human Services

(101888)

Table 1: Four National Health Surveys With Dental Data, 1988-97 6

Table 2: Percentage of Adults With Tooth Loss From Decay or Gum
Disease by Family Income 11

Table 3: Percentage of Selected Ethnic Groups With Untreated
Tooth Decay 12

Table 4: Number of States That Provide Dental Coverage for
Children and Adults 14

Table 5: Percentage of Residents Making a Dental Visit in 1996 by
Metropolitan Area and Income 19

Table 6: Percentage of Adults Who Made a Dental Visit in the
Preceding Year by Annual Family Income 24

Table 7: Medicaid Coverage of Adult Dental Care 26

Table 8: Percentage of Medicaid Fee-for-Service Recipients Who
Made a Dental Visit in the Preceding Year 28

Figure 1: Percentage of Children With Untreated Caries by
Family Income 8

Figure 2: Restricted Activity Days per 100 Children Because of
Dental Problems by Family Income 9

Figure 3: Percentage of Adults With Untreated Caries by
Family Income 10

Figure 4: Percentage of Population Who Made a Dental Visit in the Preceding
Year:1977, 1987, and 1996 13

Figure 5: Percentage of Children Who Made a Dental Visit in the
Preceding Year by Family Income 15

Figure 6: Percentage of Children With at Least One Sealant by
Family Income 17

Figure 7: Percentage of Adults Who Made a Dental Visit in the
Preceding Year by Family Income 18
  

1. For example, by law, the states must provide Medicaid eligibility to
pregnant women, to infants, and to children up to age 6 whose family income
is up to 133 percent of the federal poverty level and children aged 6 to 15
whose family income is up to 100 percent of the federal poverty level. Many
adults do not qualify for Medicaid unless they are aged, blind, or disabled.

2. Under Medicaid, the federal government will match a state's contribution
from 50 to 77 percent in fiscal year 2000, depending on the state's average
income level. Under SCHIP, the states are eligible for an enhanced federal
matching share of 65 to 84 percent. SCHIP allows states with Medicaid
incomes that already approach or exceed 200 percent of the federal poverty
level to expand eligibility to up to 50 percentage points above their
existing Medicaid eligibility standards.

3. Formerly the Agency for Health Care Policy and Research (AHCPR).

4. A National Institute of Dental Research study of 1989 NHIS data found
that children missed about 52 million school hours (more than 8 million
school days) and adults missed more than 20 million work days because of
dental treatment or problems in 1989. However, missed days from dental
problems alone cannot be disaggregated from the total. More current
estimates are not available

5. Interagency Council on the Homeless, Homelessness: Programs and the
People They Serve (Dec. 1999)

6. HCFA's State Medicaid Resource File contains Medicaid fee-for-service
information on eligibility, billing claims, and utilization for states that
participate in the Medicaid Statistical Information System. Billing data are
limited to the extent that they do not provide information on provided
services for which no reimbursement was sought. This analysis does not
include information on children who may have made a dental visit under a
managed care plan, because such data are not available.

7. Of the 27 states that submitted billing data to HCFA in 1995, 9 did not
cover adult dental services or covered only emergency services. Our analysis
was limited to adults who were enrolled in Medicaid for a full year and who
presumably had no other source of insurance.

8. National data from AHRQ's survey cannot be analyzed state by state.
Instead, we used CDC's state-based BRFSS. Because the two surveys differ in
their purpose, survey questions, and protocols, they yield somewhat
different results, but important trends and disparities remain. Of note,
MEPS gathers income and family size data that can be expressed as a
percentage of the federal poverty level. BRFSS gathers income data only in
broad categories that cannot be correlated with federal poverty levels.

9. See Mark D. Macek and others, "A Comparison of Dental Utilization
Estimates From Three National Surveys," abstract, Association for Health
Services Research, Washington D.C., June 28, 1999.
*** End of document. ***