ACCESS TO ORAL HEALTH CARE IN THE U.S.

Jonathan Shenkin, DDS, MPH

Clinical Associate Professor of Health Policy, Health Services Research and Pediatric Dentistry

Boston University

Outline• US Dental Delivery• Trends in dental access• Decay rates in the U.S.• Dental crisis in the U.S.?—Adults!!• New Zealand vs the U.S.• The myth of Maine’s oral health• How can we improve oral health effectively in the US

US Dental Delivery System• For Children:

• Expanding number of children covered through private benefits and Medicaid

• Greatest increase in delivery of care has been to children with Medicaid

• For Adults:• Since recession, Medicaid cuts have resulted in more use of ERs• Declining use of dental services for those with private dental

benefits

Dental Care Use

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 201230%

35%

40%

45%

50%

42.4%43.1%

44.2%

46.1% 46.1% 46.2%47.5% 47.2%

44.4%

46.4% 46.2%45.4%

47.6%

38.9%

40.3% 40.9% 41.0% 40.6%

39.6% 39.3%39.8%

38.4% 37.9%36.8%

36.1%35.4%

38.3% 38.2%

39.6% 40.0%40.4%

42.5%41.4%

42.3%41.3% 41.7%

40.2%

42.4% 42.0%

Children 2-18 Adults 19-64 Adults 65 and older

Percentage of Children Ages 2-18 with a Dental Visit in the Year by Dental Benefits Status, 2000-2012

Private Public Uninsured0%

10%

20%

30%

40%

50%

60%

70%

51

.4%

30

.6%

29

.6%

55

.3%

33

.6%

26

.4%

57

.1%

36

.6%

26

.7%

58

.3%

36

.8%

30

.5%

56

.1%

36

.6%

22

.9%

57

.5%

39

.5%

26

.5%

56

.8%

38

.0%

25

.2%

59

.3%

39

.5%

26

.1%

2000 2002 2004 2006 2008 2010 2011 2012

Caries Prevalence in the Primary Dentition for Youths age 2-5 years

Total (20) Total (UA) <133% FPL(UA)

≥133% FPL(UA)

0

5

10

15

20

25

30

1988-1994 1999-2004 2011-2012

Total (20) Total (UA) <133% FPL(UA)

≥133% FPL(UA)

0

5

10

15

20

25

30

1988-1994 1999-2004 2011-2012

Dental Caries Prev (dft > 0) Untx Caries Prev (dt > 0)

Dye 2014

Adult Private Dental Benefits• Trend has resulted in higher deductibles• More plans have maximum annual allowable expenditures

of less than $1,500• More plans are requiring “in network” dentists with lower

reimbursement.• More out of pocket expenditures, with decline in dental

care utilization.

Percentage of Adults Ages 19-64 with a Dental Visit in the Year by Dental Benefits Status, 2000-2012

Private Public Uninsured0%

10%

20%

30%

40%

50%

60%

70%

49

.1%

25

.0%

22

.5%

52

.5%

23

.7%

22

.8%

53

.4%

23

.1%

20

.7%

52

.3%

23

.6%

19

.2%

52

.2%

22

.0%

19

.1%

51

.6%

18

.8%

17

.6%

49

.8%

19

.7%

18

.0%

48

.5%

20

.5%

18

.3%

2000 2002 2004 2006 2008 2010 2011 2012

Pew: A Costly Destination

“…830,590 visits to ERs nationwide in 2009—a 16 percent increase from 2006. For many low-income children, emergency rooms are the first and last resort because their families struggle to find a dentist who either practices in their area or accepts Medicaid patients.”

ER use in the US, 2006-2009

AHRQ, 2009

ER spending for Dental in Maine

Decay in NZ vs US

Before After

*NZ report notes that 17% of NZ children ages 5-11, have untreated decay in primary teeth. This is higher than in the US.

What’s the best Intervention?

Percent of Children with a Dental Visit in the Past Year, Commercially and Medicaid Insured

Main

e

Florida

Miss

ouri

New Y

ork

New J

erse

yIo

wa

Kansa

s

Califo

rnia

North

Car

olina

Utah

Virgini

a

Verm

ont

Illino

is

Alabam

a

South

Dak

ota

Mar

yland

Wes

t Virg

inia

Nebra

ska

Alaska

Wyo

ming

South

Car

olina

Arkan

sas

Kentu

cky

Ohio

Texas

Hawaii

0

20

40

60

80

Commercial (2009 and 2010 Average) Medicaid (2010)

Per

cen

tag

e

Maine’s Oral Health Stats• NOHSS-2012

• 3rd graders

Untreated decay-14.6% 2nd lowest in nation

Caries experience 32.7% Lowest overall in nation

Sealants 68.5% Highest in the nation

Dentists vs IPDHs in Rural Maine

Conclusions• How can we improve oral health in the US?

• Maintain and improve water fluoridation• Drastically improve oral health literacy• Improve patient navigation through CDHCs

• For children:

• Increased early preventive care• Improved Medicaid administration and financing• More use of evidence based sealant protocols

• For Adults:

• Fund adult dental Medicaid• Address declining quality of private dental benefits for adults• Fill the knowlege gap!

Your Text Here

Mean dmft/DMFT by age group, and village water fluoridation status, in five rural Alaska villages and the US, 2008

MMWR, Sept 2011