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RESEARCH AND PRACTICE |
The authors are with the Urban Institute, Washington, DC.
Correspondence: Requests for reprints should be sent to Genevieve M. Kenney, PhD, Urban Institute, 2100 M Street, NW, Washington, DC 20037 (e-mail: jkenney{at}ui.urban.org).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. We examined the ways in which levels of preventive dental care and unmet dental needs varied among subgroups of low-income children.
Methods. Data were drawn from the 2002 National Survey of America’s Families. We conducted bivariate and multivariate analyses, including logistic regression analyses, to assess relationships between socioeconomic, demographic, and health factors and receipt of preventive dental care and unmet dental needs.
Results. More than half of low-income children without health insurance had no preventive dental care visits. Levels of unmet dental needs among low-income children who had private health insurance coverage but no dental benefits were similar to those among uninsured children. Children of parents whose mental health was rated as poor were twice as likely to have unmet dental needs as other children.
Conclusions. Additional progress toward improving the dental health of low-income children depends on identifying and responding to factors limiting both the demand for and the supply of dental services. In particular, it appears that expanding access to dental benefits is key to improving the oral health of this population.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Expansions of public health insurance programs after enactment of the State Children’s Health Insurance Program (SCHIP) in 1997 led to increases in low-income children’s access to dental benefits. By 2000, all states had enacted some type of coverage expansion policy for children by expanding Medicaid, using a separate non-Medicaid program, or using some combination of these 2 strategies.8
Eligibility expansions under SCHIP have targeted low-income children whose family incomes are too high to qualify for Medicaid coverage. States are required to cover dental benefits under Medicaid but are not required to do so under separate SCHIP programs. However, most separate SCHIP programs include dental benefits. The only exceptions are Delaware (which has never included dental benefits); Colorado and Florida, both of which had phased in dental benefits as of 2002; and Texas, which included dental benefits in its program until 2003. Given that Medicaid and most SCHIP programs include dental benefits for children, the 2 major groups of low-income children who lack access to dental coverage are those who are not covered by insurance and who are covered by private insurance that does not include dental benefits.
There is evidence that, among both children in general and low-income children, lack of health insurance coverage is associated with decreased likelihood of visiting a dentist.4,6 Studies have indicated that children who do not have the recommended number of dental care visits are more likely to be Black or Hispanic, to be from families with low incomes, and to have a parent who did not attend college.1–4,7 Also, it has been shown that the risk of not receiving any dental care is lower among children aged 6 to 12 years than among preschool and adolescent children.1–4,7
In addition, studies have revealed that unmet dental needs vary according to race/ethnicity and that children with no dental insurance are more likely to have unmet dental needs than children with private or public insurance.9,10 Children from low-income families who are in fair or poor health have been shown to have more unmet dental needs than children in excellent or very good health, and children from families facing difficulties such as poor parental health and economic hardship have been shown to have more unmet dental needs.4,11
The purpose of our study was to assess how receipt of preventive dental care and the level of unmet dental needs vary across different subgroups of low-income children using data from the 2002 National Survey of America’s Families (NSAF). The observed patterns of care may suggest successful policies for improving the oral health of low-income children.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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The analysis presented here focused on 2 dimensions of dental care measured in the 2002 version of the NSAF: unmet dental needs and number of preventive dental care visits. The primary caregiver was asked whether, in the 12 months preceding the survey, the child had experienced delays in receiving or had failed to receive needed dental care, including orthodontia and emergency care. The caregiver was also asked how many times the child had visited a dentist or dental hygienist for a general dental examination, checkup, or cleaning during those 12 months. A variable was constructed from these questions indicating whether a child had a preventive dental care visit in the previous year. Because the NSAF provides no information on content or quality of visits, the fact that a child visits a dentist for preventive care does not necessarily imply that the recommended standards have been met; however, an absence of visits indicates that the recommended level of preventive care has not been received.
Bivariate and multivariate analyses, including logistic regression analyses, were used to assess the relationships between socioeconomic, demographic, and health factors and whether children visited a dentist for preventive care and had unmet dental needs. The factors examined were as follows:
We examined correlations among these different factors and found that most were not highly correlated with one another. One notable exception was parental mental health status, which was correlated with both parental health status (correlation coefficient = 0.29) and presence of a functional limitation (correlation coefficient = 0.24). The multivariate models also included control variables for the states that were oversampled in the survey. Also, we conducted exploratory multivariate analyses in which children imputed as being enrolled in separate SCHIP programs in the 3 states that had no dental benefits in 2002 or were still phasing in their dental benefits (Delaware, Florida, and Colorado) were compared with children enrolled in public programs including dental benefits (the imputation was based on income and other information reported about the child and his or her family in combination with the eligibility rules for SCHIP in these 3 states).
The results of the bivariate and multivariate analyses are presented in the form of descriptive statistics and adjusted odds ratios. We weighted responses to the interviews to estimate values appropriate to the nation as a whole. These weights adjusted for the complex design features associated with the sample. Sampling errors were calculated via replication methods appropriate to the survey design, including clustering within households.12
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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presents bivariate data on preventive visits and unmet dental needs. There was a strong association between dental insurance coverage and receipt of preventive care: low-income children who were uninsured were more than twice as likely as children with dental insurance to have received no preventive dental care (Figure 1). More than half (55.6%) of uninsured children from low-income families had not had a preventive visit during the previous year, while only 19.9% of children with private dental coverage and 24.3% of those with public dental insurance had not had a preventive visit. Low-income children with private health insurance but no dental benefits were more likely than those without health insurance to receive preventive dental care; only 27.7% of these children had not had a preventive dental care visit.
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Figure 2 presents data on receipt of dental care and extent of unmet dental needs according to parent mental health status. Children whose parents had poor mental health scores were significantly more likely than other children to have received no preventive dental care: 34.6% of low-income children whose parents had poor mental health scores had no preventive dental care visits in the past year, as compared with 27.0% of other children. Children of parents with poor mental health scores were more than twice as likely as other children to have unmet dental needs (16.0% vs 7.2%).
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Other characteristics were associated with whether low-income children received preventive care or had unmet dental needs. Children aged 6 to 12 years (25.6% with no visits) were more likely to have had a preventive dental care visit than children aged 13 to 17 years (31.4% with no visits) or 4 to 5 years (36.0% with no visits). About a third of children whose families had problems paying for food or rent had not had a preventive dental care visit, as compared with 26.0% of children whose families were not facing such economic hardship. Finally, low-income children with a parent who had completed high school or had a general equivalency diploma and those with a parent who had education beyond high school were more than 10 percentage points as likely to have received preventive dental care as children with a parent who had not completed high school.
Low-income children with functional impairments (14.2%) were more likely to have unmet dental needs than children without such impairments (8.8%). Children whose families were experiencing economic hardship were more likely to have unmet dental needs (13.2%) than children whose families were not having problems paying for food or rent (6.0%). Having a parent in fair or poor health was associated with a greater likelihood of unmet dental needs (12.2% vs 8.6%), and Black children were less likely to have unmet dental needs than White children (7.1% vs 11.2%).
Table 2 presents adjusted odds ratios, derived from multivariate logistic regression analyses, for no receipt of preventive dental care and for unmet dental needs. The multivariate findings were consistent with the bivariate results with a few exceptions (unless otherwise specified, the results described in the following were significant at P < .05). Low-income children with public coverage and those with private coverage that included dental benefits were more likely to have had preventive dental care visits and less likely to have had unmet dental needs than were uninsured children. In addition, children who had private coverage with dental benefits or public coverage were more likely to have had preventive dental care visits and less likely to have had unmet dental needs than were children who had private health insurance without dental benefits.
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The mental health of the child’s parent exhibited a strong association with both unmet dental needs and receipt of preventive dental care. Children whose parents had poor mental health scores were more likely to have unmet dental needs and less likely to have received preventive dental care. Likewise, low-income children whose families faced economic hardship were more likely to have unmet dental needs and less likely to have had a preventive dental care visit.
In contrast to the bivariate findings, the multivariate analyses indicated no significant associations between preventive dental care visits and ethnicity; however, children who were not US citizens were less likely to have had a preventive visit, and the association between Spanish-language interviews and receipt of preventive dental care was not significant at the 0.05 level (P = .072). In addition, no association was found between fair or poor overall health among either children or parents and unmet dental needs, and the association between presence of functional impairments among children and unmet dental needs was not significant at the 0.05 level (P = .054).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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First, by increasing families’ financial burden, lack of dental benefits appears to limit access to needed care among low-income children. Our results showed that more than half of uninsured low-income children did not have a dental checkup, and 13% had unmet dental needs. Privately insured low-income children without dental benefits were just as likely as uninsured children to have unmet dental needs. Moreover, children with public coverage were significantly more likely than privately insured children without dental benefits to receive preventive dental care and to have no unmet dental needs. In 2002, 17% of all low-income children had no insurance coverage, and another 9% had private health insurance coverage but no dental benefits. Improving the dental health of these low-income children is likely to depend on increasing their access to insurance that includes dental benefits.
Increasing participation in Medicaid and SCHIP among children who are already eligible could increase the rate at which low-income children are covered.13 While there is a high level of interest in Medicaid and SCHIP enrollment on the part of low-income parents with uninsured children,14 states have been reducing their spending on outreach in response to budget pressures.15 In addition, the dental needs of children who have private health insurance coverage but no dental benefits could be met by increasing access to Medicaid and SCHIP-covered benefits. Children with private insurance who meet the eligibility criteria for Medicaid are entitled to wrap-around coverage from Medicaid, including dental care. However, states may need to increase public awareness of the availability of this benefit if more children are to gain access to it.
The situation is more complicated among SCHIP-eligible children. Dental benefits are optional under separate SCHIP programs. While almost all SCHIP programs include dental benefits, Texas, with one of the largest SCHIP programs in the nation, dropped dental benefits in 2003. Under the SCHIP statute, children are barred from having both SCHIP and private coverage at the same time, which prevents eligible children with private coverage from receiving SCHIP dental benefits. Federal legislation must be passed before states can provide SCHIP dental benefits to eligible low-income children who have private health insurance coverage.
Second, other financial obstacles facing low-income families may affect children’s receipt of dental care. Families facing economic hardship, such as difficulties paying bills or buying food, appear to have greater difficulty meeting their children’s dental needs. The comprehensiveness of dental benefits and copayments may affect use of dental care among those families who have dental insurance but are facing other types of material hardship.
Third, the mental health status of a child’s parent appears to affect the extent to which the child’s dental needs are met. In this study, children whose parents had poor mental health scores were twice as likely as other children to have unmet dental needs and were less likely to receive preventive dental care. Other analyses (data not shown) indicated that only 22% of the parents with reported mental health problems had received any mental health services in the previous year. More research is needed to understand how mental health status may affect parents’ care-seeking behaviors and perceptions. Tending to the mental health needs of parents may be a prerequisite for improving the oral health of their children. Moreover, given the correlation between parents’ mental health status and their physical health, it may also be important to focus attention on the broader health care needs of parents.
Fourth, we found more gaps in receipt of dental care among children who were not US citizens even after control for insurance coverage and other socioeconomic factors; fewer than half of noncitizen children in low-income families had received any preventive dental care in the preceding year. If these differentials are to be narrowed, it may be necessary to target outreach efforts advocating preventive dental care to immigrant families.
Finally, it appears that adolescents are less likely than younger children to receive preventive dental care. Our results showed that nearly a third of children between the ages of 13 and 17 years did not receive preventive dental care. Adolescence can be a challenging period in which some young people begin to engage in higher risk behaviors.16 Many low-income adolescents receive only limited counseling on their health concerns.17 Having health care providers work with adolescents to understand the importance of preventive dental care may improve the dental health of adolescents.
Study Limitations
While efforts were made to ascertain the actual amount of dental care received by each child, these data were subject to potential bias. Caregivers may have reported more dental care than was actually received so as to not appear negligent. Thus, our data may understate the extent to which children fail to receive any, or minimum recommended levels of, dental care. In addition, because data on insurance coverage were self-reported, it was difficult to distinguish between Medicaid and separate SCHIP coverage.
There was also the potential for a lack of connection between our insurance coverage measures and dental outcomes, given that insurance coverage was reported at the time of the survey and dental care visits and unmet dental needs were reported for the 12 months preceding the survey. This discrepancy could have attenuated the relationships estimated between insurance coverage and receipt of care and unmet dental needs. Finally, our findings can be interpreted only as associations; we cannot establish causal links with these data or discuss potential selection concerns.
Conclusions
Our study focused on how the characteristics of children and their families may affect receipt of dental care among low-income children. Although identifying factors that prevent children from receiving dental care appears critical to achieving the objectives of Healthy People 2010, of equal importance is reducing factors that limit the supply of dental services to low-income children, including low provider reimbursement rates in the case of public insurance and a safety net that inadequately serves the uninsured.4,18 In all likelihood, further progress in improving the dental health of low-income children will depend on expanding both demand and supply.
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Acknowledgments |
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We wish to thank Burton Edelstein and Barbara Ormond for their helpful advice and comments on an earlier version of the article.
Human Participant Protection
No protocol approval was needed for this study.
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Footnotes |
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Contributors
G.M. Kenney developed the research topic, directed the data analysis, and led the writing. J.R. McFeeters and J.Y. Yee performed the data analysis and made significant contributions to writing. All of the authors helped to conceptualize ideas, interpret findings, and review drafts.
Accepted for publication February 15, 2004.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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2. Manski RJ, Moeller JF, Maas WR. Dental services: an analysis of utilization over 20 years. J Am Dent Assoc. 2001;132:655–664.
3. Watson MR, Manski RJ, Macek MD. The impact of income on children’s and adolescents’ preventive dental visits. J Am Dent Assoc. 2001;132:1580–1587.
4. Kenney GM, Ko G, Ormond BA. Gaps in Prevention and Treatment: Dental Care for Low-Income Children. Washington, DC: Urban Institute; 2000. Policy brief B-15.
5. US Department of Health and Human Services. Healthy People 2010 objectives. Available at: http://www.healthypeople.gov/document/html/objectives/21-12.htm. Accessed August 23, 2004.
6. Edelstein BL. Disparities in oral health and access to care: findings of national surveys. Ambulatory Pediatr. 2002;2(suppl 2):141–147.
7. Macek MD, Edelstein BL, Manski RJ. An analysis of dental visits in U.S. children, by category of service and sociodemographic factors, 1996. Pediatr Dent. 2001;23:383–389.[Medline]
8. Centers for Medicare and Medicaid Services. The State Children’s Health Insurance Program annual enrollment report: federal fiscal year 2001. Available at: http://www.cms.hhs.gov/schip/enrollment/schip01.pdf. Accessed August 23, 2004.
9. Waldman HB. More children are unable to get dental care than any other single health service. J Dent Child. 1998;65:204–208.
10. Newacheck PW, Hughes D, Hung Y, Wong S, Stoddard J. The unmet health needs of America’s children. Pediatrics. 2000;105:989–997.
11. Fairbrother G, Kenney G, Hanson K, Dubay L. How do stressful family environments relate to reported access and use of health care by low-income children? Med Res Rev. 2005;62:205–230.
12. Brick JM, Broene P, Ferraro D, Hankins T, Strickler T. 1999 NSAF Sample Estimation Survey Weights. Washington, DC: Urban Institute; 2000. Methodology report 3.
13. Dubay LC, Kenney GM, Haley JM. Children’s Participation in Medicaid and SCHIP: Early in the SCHIP Era. Washington, DC: Urban Institute; 2002. Policy brief B-40.
14. Kenney GM, Haley JM, Tebay AC. Familiarity With Medicaid and SCHIP Programs Grows and Interest in Enrolling Children Is High. Washington, DC: Urban Institute; 2003.
15. Hill IT, Stockdale HS, Courtot BM. Squeezing SCHIP: States Use Flexibility to Respond to the Ongoing Budget Crisis. Washington, DC: Urban Institute; 2004. Policy brief A-65.
16. Oral Health in America: A Report of the Surgeon General. Rockville, Md: National Institute of Dental and Craniofacial Research; 2000.
17. Shenkman E, Youngblade L, Nackashi J. Adolescents’ preventive care experiences before entry into the State Children’s Health Insurance Program (SCHIP). Pediatrics. 2003;112:e533–e541.
18. Abelson R. Dental double standards. New York Times. December 28, 2004:C1.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
0.05. 