Ensuring an adequately sized dental workforce

Factors Influencing Demand for Dental Services: Population, Demographics, Disease, Insurance B. Alex White, D.D.S., Dr.P.H. Dr. White is Unit Chief, Public Health Dentistry, School of Dental Medicine, East Carolina University. Direct correspondence and requests for reprints to him at School of Dental Medicine, East Carolina University, 1851 MacGregor Downs Road, Greenville, NC 27834; 252-737-7041; whiteben@ecu.edu. Keywords: dental workforce, dental services, patient populations, demographics, economics Ensuring an adequately sized dental workforce with the skills necessary to meet the needs of current and future patient populations is difficult. Educators, professional associations, policymakers, commissions, foundations, and others strive to balance these needs against the projected workforce supply. 1-5 Population-level measures of disease provide important guidance. These measures alone, however, limit our understanding of the complexities of this task. Changing demographics and economic circumstances, for example, have significant influence on the need and demand for care and on our ability to predict future workforce requirements. 6 To understand better these influences on need and demand over time, a model illustrating these relationships is useful. One such model is shown in Figure 1. While other articles in this issue present more sophisticated economic models, the approach outlined here emphasizes the components of demand that will be impacted by changing demographic, economic, and health-related influences. It begins with need, represented by the oval. The level of need for dental care can be estimated from two perspectives. When viewed through the eyes of clinicians, need may be identified according to certain norms or set standards. Data from epidemiological studies are used to assess the extent and severity of dental diseases within populations, from which estimates of need can be made. These estimates of normative need tell us how much care is required if we were Figure 1. Factors influencing and relationships between need and demand for dental care 996 Journal of Dental Education Volume 76, Number 8

to treat active disease today. It does not mean that patients necessarily know the specifics of the care they need, that they want the care, that they will seek out that care, that they can afford care, or that they will accept recommended treatment. Patients have a different viewpoint about need. From their perspective, need equates with want: measuring how much someone wants dental care and the health outcomes associated with that care tells us the magnitude of need. Social interaction, function, aesthetics, relief from pain and infection, tooth retention, and prevention of future disease are examples of the benefits that patients may value. The higher the value, the greater the want, increasing the likelihood that someone will demand dental services. Demand the shaded center area grows out of the need for care and includes interactions with the resources available to pay for care and a willingness to buy that care. If someone wants care, has or has access to resources, and is willing to pay, that person will demand care. If the workforce supply is adequate, that demand should result in provision of dental care. This article reviews recent trends in population size, growth rate, and sociodemographic characteristics; oral health status and the desire for care; performance of the overall economy; and pri- vately and publicly financed dental benefits. Other factors also influence need and demand; these four areas, however, are most significant. Population Factors The U.S. population is growing, aging, moving, diversifying, and living longer (Table 1). Between 1970 and 2010, for example, the population increased in size by 51.3 percent, reaching 310 million people. 7-9 By 2050, 129 million more people will live in the United States, a 41.5 percent increase. 10 Western and southern states continue to grow faster than states in the Northeast or Midwest. Between 1970 and 2010, populations in western and southern states increased by 13.8 percent and 14.3 percent, respectively, while northeastern and midwestern states grew by 3.2 percent and 3.9 percent, respectively. Between 2000 and 2010, six states Arizona, California, Florida, Georgia, North Carolina, and Texas grew by more than 1,000,000 each. Today, one in four people live in one of the three most populous states, and one in two people live in the nine most populous states. In contrast, about 26 percent live in the thirty-two least populous states and the District of Columbia. Table 1. Selected sociodemographic characteristics of U.S. population, 1970, 2010, and 2050 1970 2010 2050 Population Growth Global population (in millions) 3,696.2 6,895.9 9,606.1 Percent change from prior period (%) 86.6% 39.3% U.S. population (in millions) 205.1 310.2 439.0 Percent change from prior period (%) 51.3% 41.5% U.S. population as a percent of global population (%) 5.5% 4.5% 4.6% Geographic Characteristics Persons living in urban areas (%) 73.6% 80.7% Persons per square mile 57.5 87.4 124.1 Persons living in the South (%) 30.9% 37.1% 39.4% Persons living in the West (%) 17.1% 23.3% 24.3% Age Characteristics Persons under 5 years (%) 8.4% 6.8% 6.4% Persons 65 years and over (%) 9.8% 13.0% 20.2% Median age (years) 28.3 36.9 39.0 Percent change from prior period (%) 30.4% 5.7% Life expectancy (years) 70.8 78.3 83.1 Percent change from prior period (%) 10.6% 6.1% Racial and Ethnic Characteristics Non-Hispanic white (%) 87.7% 64.8% 47.2% African American (%) 11.1% 12.9% 13.0% Hispanic or Latino (%) 4.7% 16.0% 30.2% August 2012 Journal of Dental Education 997

Between 2010 and 2030, projections show that ten states will experience a net population growth of one million or more; three states California, Texas, and New York will increase by more than eight million each. The U.S. population is also aging. 11,12 By 2050, more than 40 million people will be sixty-five years old or older, about one in every five people (Figure 2). The estimated population median age increased from 28.3 years in 1970 to 36.9 years in 2010, and it is projected to increase to 39.0 years by 2050. 8 Life expectancy is also increasing, rising from 70.8 years in 1970 to 78.3 years in 2010; by 2050, it will reach 83.1 years. The proportion of persons born outside the United States is increasing (Figure 3). 13 In 2010, about 13 percent of the population 40 million people were born outside the United States, the highest level in nearly a century. About 29 percent were born in Mexico, about 28 percent in Asia, and about 12 percent in Europe. By 2050, the percentage of foreign-born persons will increase to 19 percent, or about 83.4 million people. This is the highest percentage since before 1850. More than one-half of the foreign-born population live in four states: California, New York, Texas, and Florida; more than one-fourth live in California alone. In 2010, more than one in four residents of California and more than one in five residents of New York and New Jersey were foreign- born. One-half of all foreign-born persons were between eighteen and forty-four years of age. Onethird of foreign-born persons arrived in the United States since 2000, and nearly two in three arrived since 1990. Relative to the native-born, foreign-born persons are more likely to be married, to have larger households, to speak languages other than English (Figure 4), to have lower levels of educational attainment (30 percent have not completed high school), and higher levels of participation in the labor force. Foreign-born women are more likely to have had a child in the past twelve months. International immigration will also have an impact on overall population growth. By 2027, estimates indicate that more than half of total U.S. population growth will be due to net international immigration rather than natural growth (births minus deaths). The population is becoming more diverse, particularly more Hispanic. 11,12,14 As a percentage of total population, the white, non-hispanic population is steadily shrinking dropping from 69.1 percent in 2000 to 61.7 percent in 2010. By 2050, the Census Bureau projects that the non-hispanic white population will represent less than half about 46 percent of the total U.S. population, about 207 million people. The proportion of Hispanics will increase from about 17 percent in 2010 to 30 percent in 2050, or about 132 million people. The proportion of African Americans is projected to remain at about Figure 2. Percent distribution, number, and relative size of U.S. population by age group, 1970, 2010, and 2050 998 Journal of Dental Education Volume 76, Number 8

Figure 3. Foreign-born persons as a percentage of total U.S. population, 1850 2010 Figure 4. Percent distribution of persons five years of age and older by language spoken at home and English-speaking ability, 2010 13 percent over this time period, reaching about 57 million people in 2050. Other population characteristics that impact the value of dental care and the ability to pay for that care include education, income, and poverty status. Educational attainment has risen since 1970, when about 52 percent of adults twenty-five and older had completed high school and about 11 percent had completed college. 8,9 By 2010, 87 percent had completed high school and about 30 percent completed college. During the 1970 2010 period, median household income rose by only $5,679 to $49,445 (2010 dollars). 15 In 2010, 15.1 percent of the population 46 million people, a record number lived in poverty (Figure 5). (In 2010, the Federal Poverty Level [FPL] was $10,830 for one person and $22,050 for a family of four. These levels were slightly higher in Alaska and Hawai i.) Unemployment reached 9.6 percent in 2010 the highest level since the early 1980s. August 2012 Journal of Dental Education 999

Figure 5. Percent distribution by poverty status, health insurance coverage, and employment status, 1970 2010 Health and Disease Factors Over the past fifty years, most Americans have experienced significant improvements in oral health. 16,17 In 1963 65, for example, 54 percent of boys and 48 percent of girls ages six to eleven years were caries-free in their permanent dentition; by 1999 2004, these percentages increased to 81 percent and 77 percent, respectively. For all age groups, the mean number of decayed, missing, and filled teeth (DMFT) has declined. Periodontal diseases and tooth loss, including total tooth loss, have declined. More people are living longer and are keeping more of their teeth longer. We have come to understand the chronic nature of most oral diseases, and risk assessment and disease management are increasingly part of what we do. Some segments of the population have improved less than others, particularly the poor, racial and ethnic minorities, those born outside the United States, disabled persons, and the elderly. Significant numbers of the U.S. population have untreated dental caries (Figure 6). 18 Almost 20 percent of children two to five years of age (2.8 million), 7.6 percent of children six to eleven years of age (1.8 million), and 19.6 percent of adolescents twelve to nineteen years of age (6 million) have untreated decay. Among adults twenty to sixty-four years of age, about 25 percent have untreated decay (39.7 million), and among those sixty-five years or older, 18.2 percent (5.8 million) have untreated decay. The prevalence of untreated decay has declined for all age groups except for the very young. Among two-to-five-year-olds, increases were seen among white, non-hispanic children as well as among children in families with incomes at 100 percent or more of the FPL. Global measures of dental caries in twelveyear-old adolescents show significant differences by region. 19 From 2004 to 2011, the global mean DMFT increased from 1.61 to 1.67, about 4 percent. However, the mean DMFT decreased from 2.43 in 1980 to 1.67 in 2011, a drop of 45 percent. Of note are differences by geographic region. In 2011, the mean DMFT ranged from 1.2 among children in Africa to 2.4 among children in the Americas. In Southeast Asia, mean DMFT was 1.87. In 2001 the most recent year when data are available children in Mexico had a DMFT of 2.0. Use of dental sealants is increasing, preventing caries in millions of U.S. children. 17 Forty years ago, few if any children had sealants. Between 1988 94 and 1999 2004, the proportion of children six to eleven years of age with sealants increased from 22 percent to 31 percent. Among adolescents aged twelve to nineteen, the prevalence increased from 18 percent to 38 percent. In 1999 2004, 7.3 million children and 11.7 million adolescents had one or more sealants. 1000 Journal of Dental Education Volume 76, Number 8

Figure 6. Percent distribution of persons by presence of untreated dental decay and age group, 1971 2009 Measures of periodontal diseases have improved. 17 The prevalence of periodontal diseases and of moderate to severe periodontitis has declined among adults in all age groups. Edentulism continues to decline as well. Between 1988 94 and 1999 2004, the percentage of persons twenty to sixty-four years of age who were edentulous dropped from 6.1 percent to 3.8 percent, or about 5.9 million adults. Among persons sixty-five years and older, there were an estimated 8.7 million edentulous people, reflecting a drop in prevalence from 34 percent to 27 percent between 1988 94 and 1999 2004. In 2009, about 264,400 men (65 percent) and women (35 percent) were alive who had a history of cancer of the oral cavity and pharynx. 20 In 2012, an additional 40,000 people will be diagnosed with this disease; the median age at diagnosis is about sixty-two years. About 70 percent of new cases will occur in men, with an incidence rate of 16.1 cases per 100,000. This year about 7,800 men and women will die from this cancer. The overall five-year relative survival for 2002 08 was 61.5 percent. Black men (37.2 percent) and women (53.0 percent) have lower survival rates than white men (62.9 percent) and women (64.1 percent). Recent national surveys have included questions about perceived need for care and the ability to access services in response to that need. In 2010, when participants were asked if they needed dental care in the past twelve months and could not get that care because of cost, 13.5 percent said yes. 18 Since 1997, this proportion has increased in all sociodemographic groups. For example, among those whose income level was less than 100 percent FPL, this proportion increased by 57 percent; for those whose income was between 100 percent and 199 percent FPL, it increased by 59 percent (Figure 7). Surveys also have asked participants to assess their own oral health and the condition of their teeth and mouths. 17 In 1988 94, among persons twenty to sixty-four years of age, about 34 percent perceived their oral health to be fair or poor. By 1999 2004, this proportion increased to about 39 percent, or 60.1 million people. Social and behavioral health determinants, such as income, ethnicity, and smoking status, increase the likelihood that participants reported their condition to be fair or poor. In each of these groups, more people reported fair or poor conditions in 1999 2004 than in 1988 94 (Figure 8). Among persons sixty-five years and older, 38.4 percent about 12 million people reported their oral health as fair or poor. More people are living with one or more chronic conditions. 18 Among those forty-five to sixtyfour years of age, one in five (21 percent) reported two or more chronic health conditions in 2009 10. Among those below 100 percent of the FPL, one in three reported two or more conditions (Figure 9). The August 2012 Journal of Dental Education 1001

Figure 7. Percent distribution of persons, by income level, reporting that they needed dental care in past twelve months and could not get it because of cost, 1997, 2000, and 2010 Figure 8. Percent distribution of persons twenty to sixty-four years of age who perceived the condition of their teeth and mouth to be fair or poor, by selected sociodemographic characteristics for 1988 94 and 1999 2004 Since 1970, the annual percent change in GDP has slowed (Figure 10). 21 The U.S. economy experienced seven recessions in the past forty years, the longest two lasting eighteen months and sixteen months. Services account for nearly 70 percent of total GDP value, while goods now represent less than 20 percent (Figure 11). The value of government activities has remained relatively constant at about 15 percent. Another indicator of economic performance is the Consumer Price Index (CPI), which reflects inflation as experienced by consumers in their dayprevalence is increasing fastest among those living with incomes 400 percent or more of FPL. Economic Factors Several measures are useful in assessing the performance of the U.S. economy. Gross Domestic Product (GDP) is perhaps the most familiar. GDP measures the value of final goods and services produced in the United States in a given period of time. 1002 Journal of Dental Education Volume 76, Number 8

Figure 9. Prevalence of (and percent change in) self-reported presence of two or more chronic conditions among persons forty-five to sixty-four years of age by income level, 1999 2000 and 2009 10 Figure 10. Annual percent change in gross domestic product, disposable personal income, and consumer price indexdental in the United States, 1970 2010 to-day living expenses. Since 1970, the CPI for dental services grew until the early to mid-1980s and has trended downward since then, reflecting a similar pattern as that for GDP (Figure 10). Consumers who purchase dental services have seen slower rates of increase in the prices paid for care. Disposable personal income (DPI) is another key economic indicator used to gauge the overall state of the economy. It measures the amount of money that households have available for spending and saving after income taxes have been accounted for (Figure 10). More resources should increase the demand for dental care. The annual percentage change in DPI tracks closely with the GDP and, like the GDP and the CPI-Dental, has trended downward since the 1970s. State and federal governments continue to run significant budget deficits (Figure 12), and this trend is projected to continue through 2060. 22,23 In 2000, total debt reached $5.66 trillion, about $20,120 for every man, woman, and child in the United States. By 2010, total debt climbed to $14 trillion, about $45,426 per capita. One-third of federal expenditures is made with borrowed money. By 2027 just fifteen years from now projections indicate that outstanding federal debt will exceed the entire U.S. GDP. August 2012 Journal of Dental Education 1003

Figure 11. Shares of gross domestic product by type of product, 1970 2010 Figure 12. Federal and state/local governments operating balances as a percentage of gross domestic product, 2005 60 Dental Benefit Factors Dental benefits public or private increase use of dental services by reducing the financial barriers that prevent access. In 1970, few people had dental benefits; with rapid growth in the 1970s and early 1980s, more and more people were covered through their employers. Since then, however, the proportion of full-time employees who participate in a dental benefit program through their employers has declined to an overall rate of 37 percent in 2011 (Figure 13). 24,25 More than 165 million people have private dental benefits. Full-time employees, workers in larger firms, and workers in goods-producing firms are more likely to participate in dental benefit programs. However, trends suggest that participation rates are declining in all sectors (Figure 14), and the annual percent change in number of covered lives has slowed. 26 The number of employers who offer any health benefits declined from 66 percent in 1999 to 60 percent in 2011. 27 Changes are also occurring in publicly financed dental benefit programs. During the past decade, the annual percent change in the number of Medicaid and CHIP beneficiaries declined until the recession of 2007 09 (Figure 15). 28 States are required to provide dental benefits to children covered by Medicaid and the Children s Health Insurance Program (CHIP). Since adult dental services are optional, most states provide for emergency dental services; few states offer comprehensive adult dental care. 1004 Journal of Dental Education Volume 76, Number 8

Figure 13. Percentage of full-time employees participating in dental benefit programs, 1980 2010 Figure 14. Percentage of employees participating in dental benefit programs by selected employment characteristics, 2011 With the passage of the Affordable Care Act (ACA), more than 30 million people currently without health benefits will be covered. 29 The federal government will provide subsidies to states for persons with incomes up to 133 percent FPL. The ACA also extends the CHIP program for low-income populations. Health exchanges will be established, allowing individuals and small businesses to purchase coverage, and subsidies will be provided to those with incomes less than 400 percent FPL. Millions of Americans currently uninsured will have health benefit coverage. In addition, through defined essential health benefit packages, there will be a required minimum coverage that includes pediatric oral health services. This proposed expansion comes with significant costs for state and federal governments. Aside from any legal issues, budget constraints and growing debt levels will have a major impact on implementation efforts. Discussion The face of the U.S. public is changing. An older, larger, and more diverse population will reflect different oral health needs and expectations regarding dental care, will have different levels of resources to pay for dental care, and will be different in their willingness to pay for dental care. With this evolution, there is likely to be a growing proportion in poor health, with higher incidences of certain chronic health conditions and less access to health insurance and health services. August 2012 Journal of Dental Education 1005

Figure 15. Annual percent change in number of Medicaid beneficiaries (total and dental) and CHIP beneficiaries by year, 2001 09 Today, the proportion of Hispanics in the population is increasing rapidly; this growth is concentrated in a few states, creating new challenges in those areas. Hispanics are more likely to work in sectors that are less likely to offer dental benefits and to face cultural and language issues when seeking care. The majority of Hispanics perceive their oral health condition as fair or poor, and one in five need care and cannot get it because of cost. Growing numbers of Hispanics who need and want care set the stage for increases in the demand for dental care. Elders who represent a growing number of people and an increasing proportion of the population have significant levels of untreated disease and tooth loss, report the longest time interval since their last dental visit of any other age group, live on fixed incomes, and have higher levels of chronic conditions and disabilities that affect oral and overall health. On average, dental care for elders is more costly than it is for other age groups. Since dental benefits are typically employment based, few elders have private coverage; many states do not include adult dental benefits in their Medicaid programs. Millions of elders either pay for care out-of-pocket or go without care. The United States faces daunting economic and budgetary challenges. Performance of the general economy impacts the budgets and resources of everyone: individuals, families, and communities; local, state, and federal governments; nonprofit organizations; and small and large businesses. It also influences many components of the demand model: more unemployment means fewer people will have access to dental benefits, and their willingness to spend resources on dental care will decline. The dental workforce is a fundamental part of a future with better oral health and less oral health disparities. Yet when everything is changing, how does one plan to have the right practitioner with the right skills in the right place at the right time doing the right things in the right way to the right people twenty years from now? And who determines what is right? As with most complex challenges, there likely is no single solution or right answer, and no single entity deserves all the credit or blame. Workforce changes are not quick fixes that can be made in isolation. Aligning the future dental workforce with this new picture of the American public will not be easy. However, if we are to continue our progress in improving the public s oral health and reducing oral health disparities, there are few, if any, other options. REFERENCES 1. The complexities of national health care workforce planning. Washington, DC: Bipartisan Policy Center, 2011. 2. Brown LJ. Dental workforce strategies during a period of change and uncertainty. J Dent Educ 2001;65(12):1404 16. 3. Board of Health Care Sciences. The U.S. oral health workforce in the coming decade: workshop summary. Washington, DC: Institute of Medicine, 2009. 4. Health Resources and Services Administration, U.S. Department of Health and Human Services. Oral health workforce. At: www.hrsa.gov/publichealth/clinical/oralhealth/workforce.html. Accessed: May 23, 2012. 5. Mertz EA, Finocchio L. Improving oral healthcare delivery systems through workforce innovations: an introduction. J Public Health Dent 2010;70(Suppl S1):S1 S5. 6. Bureau of Health Professions. The physician workforce: projections and research into current issues affecting supply and demand. Washington, DC: Health Resources and Services Administration, Department of Health and Human Services, 2008. 1006 Journal of Dental Education Volume 76, Number 8

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