Fewer Americans Forgoing Dental Care Due to Cost

Fewer Americans Forgoing Dental Care Due to Cost Authors: Thomas Wall, M.A., M.B.A.; Kamyar Nasseh, Ph.D.; Marko Vujicic, Ph.D. The Health Policy Institute (HPI) is a thought leader and trusted source for policy knowledge on critical issues affecting the U.S. dental care system. HPI strives to generate, synthesize, and disseminate innovative research for policy makers, oral health advocates, and dental care providers. Key Messages The percentage of the population reporting cost as a barrier to receiving needed dental care fell in 2013. This decline is now in its third year, reversing the increase that occurred from 2000 to 2010. The largest decrease in cost barriers to dental care was among adults ages 21-34. The percentage reporting cost barriers declined from 17.1 percent in 2012 to 14.8 percent in 2013. Despite improvements in affordability over the last few years, cost still remains the most critical barrier to obtaining needed dental care. Who We Are HPI s interdisciplinary team of health economists, statisticians, and analysts has extensive expertise in health systems policy research. HPI staff routinely collaborates with researchers in academia and policy think tanks. Contact Us Contact the Health Policy Institute for more information on products and services at hpi@ada.org or call 312.440.2928. Introduction The ADA Health Policy Institute is leading a comprehensive research program on access to dental care, including closely monitoring the percentage of the U.S. population reporting cost as a barrier to dental care. 1 Studies have shown that affordability is the most common reason many segments of the U.S. population avoid or delay receiving dental care they need. 2,3,4 Research has also shown that cost barriers are higher for dental care compared to other healthcare services. 5 In this research brief, we use newly released data to update our previous analysis of cost barriers to dental care through 2013. We analyze cost barriers to dental care by age and by household income. 2013 American Dental Association All Rights Reserved. October 2014

Data & Methods We used data from the National Health Interview Survey (NHIS). 6 This survey, conducted annually, is nationally representative of the civilian noninstitutionalized U.S. population. The family core component collects information on every member of a sample household, including information on demographics, health characteristics and insurance coverage. The interviewed sample in 2013 consisted of 104,520 individuals. One adult and one child (ages 0-17) per household were randomly selected for the sample adult and sample child components. We compared cost barriers for five categories of health care services: (1) dental care, including check-ups (2) medical services, (3) mental health services, (4) prescription drugs and (5) eyeglasses. The dependent variable in the analysis was a binary variable based on the response to the following question: During the past 12 months was there ever a time when you needed [health care service] and didn t get it because you could not afford it? We examined trends in cost as a barrier to dental care for children ages 2-20, three non-elderly adult age groups (21-34, 35-49 and 50-64) and elderly adults ages 65 and older. We also reported results for nonelderly adults by four levels of household income as defined in the NHIS: (1) less than 100% of the Federal Poverty Level (FPL), (2) 100-199% of the FPL, 200-399% of the FPL and (4) 400% of the FPL and higher. We tested for statistical significance across time using a chi-squared test. Our point estimates and statistical inferences take into account the complex survey design of the NHIS. Results Figure 1 shows the percentage of the population reporting cost as a barrier to obtaining needed dental care, medical care, prescription drugs, mental health services and eyeglasses. The trends over time were similar for all five services a fairly steady increase from 2000 to 2010, followed by a decrease from 2010 to 2013. Changes from 2000 to 2010 and from 2010 to 2013 were statistically significant. Changes between 2012 and 2013 for all health care services were not statistically significant. Figure 2 shows that from 2000 to 2010, the percentage of population who experienced cost barriers to dental care increased among all age groups, with the notable exception of children. From 2010 to 2013 cost barriers to dental care declined among both children and working-age adults. The percentage of adults ages 21-34 reporting cost as a barrier to dental care fell from 17.1 percent in 2012 to 14.8 percent in 2013, the largest decrease of any age group. All of these changes were statistically significant. In 2013, young adults ages 21-34 were just as likely as adults 35-64 to report cost barriers to dental care. Young adults are no longer the age group with the highest level of cost barriers to dental care. Figure 3 shows trends for adults 21-64 broken down by household income level. From 2000 to 2010, the percentage who could not obtain needed dental care due to cost increased among all income groups. From 2010 to 2013, it declined among all income groups. Both of these changes over time were statistically significant. However, changes from 2012 to 2013 were not statistically significant. 2

Figure 1: Percentage of the Population Who Needed But Did Not Obtain Select Health Care Services during the Previous 12 Months Due to Cost, 2000-2013 16% 14% 12% 10% 8% 6% 4% 2% 0% Prescription Drugs Dental Care Mental Health Services Eyeglasses Medical Source: National Health Interview Survey, National Center of Health Statistics. Notes: Changes from 2000 to 2010 for all services were statistically significant at the 1% level. Changes from 2010 to 2013 for all services were statistically significant at the 1% level. Changes from 2012 to 2013 were not statistically significant. 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 25% Figure 2: Percentage of the Population Indicating Cost as a Barrier to Receiving Needed Dental Care by Age Group, 2000-2013 20% 20.3% 15% 10% 5% 11.5% 10.0% 7.1% 6.7% 14.8% 14.8% 14.1% 6.4% 5.8% 0% 3.4% 3.9% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2 to 20 21 to 34 35 to 49 50 to 64 65 + Source: National Health Interview Survey, National Center for Health Statistics. Notes: Changes from 2000 to 2010 for age groups 21-34, 35-49, 50-64 and 65 + were statistically significant at the 1% level. Changes from 2010 to 2013 for age groups 2-20, 21-34 and 35-49were statistically significant at the 1% level. Change from 2010 to 2013 for age group 50-64 was statistically significant at the 5% level. For adults ages 21-34, the change from 2012 to 2013 was statistically significant at the 1% level. For other age groups, changes from 2012 to 2013 were not statistically significant. 3

Figure 3: Percentage of the Adults Ages 21-64 Indicating Cost as a Barrier to Receiving Needed Dental Care by Household Income, 2000-2013 35% 30% 25% 30.1% 24.5% 20% 15% 10% 5% 17.4% 19.1% 10.7% 4.0% 13.5% 5.4% 0% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 FPL<100% FPL 100-199% FPL 200-399% FPL 400%+ Source: National Health Interview Survey, National Center for Health Statistics. Notes: Changes from 2000 to 2010 were statistically significant at the 1%level for all income groups. Changes from 2010 to 2013 were statically significant at the 1% level for all income groups except for < 100% FPL which was statistically significant at the 10% level. Changes from 2012 to 2013 were not statistically significant. Discussion The percentage of the U.S. population reporting cost barriers to dental care continues to decrease, with young adults experiencing the most significant decline. While a full analysis of the underlying causes driving this improvement in the affordability of dental care is beyond the scope of this research brief, we offer some possible explanations. One important factor contributing to the overall decline in cost barriers to dental care could be changes in the actual cost of dental care. A recent analysis shows that dental care prices have grown at much lower rates in recent years and have increased less than the price of other health care services. 7 Policy changes at the national level that occurred between 2010 and 2013 may have contributed to the decline in access barriers due to cost. Maintenance of Effort (MOE) provisions enacted under the Affordable Care Act (ACA), which end for adults in 2014 and for children in 2019, helped to preserve ongoing coverage in Medicaid and CHIP. 8 The policy change could have reduced the percentage of low-income adults and children with cost barriers to dental care. The ACA s expanded dependent coverage provision is likely to have played a role in improving affordability of dental care for young adults. Since September 2010, the ACA has allowed young adults to remain on their parents private health insurance until age 26. 9 Although this policy does not apply directly to private dental benefits, a recent study reported that relative to the pre-reform period, private dental benefits coverage among adults 19-25 increased in 2011 and 2012 as a result of the reform. 10 This dental benefits spillover effect also led to an increase in dental care utilization 4

and a decrease in cost barriers to dental care among young adults. While the improvements in affordability of dental care observed in the past few years are encouraging, cost still remains the most important reason for avoiding or delaying needed dental care. 11,12 Looking forward, up to 8.7 million children are expected to gain dental benefits by 2018 as a result of the ACA. 13 Up to 8.3 million adults are eligible to gain Medicaid dental benefits due to the Medicaid expansion. 14 In addition, through April 19, 2014 about 1.1 million adults and 88,000 children obtained private dental coverage through stand-alone dental plans in the new health insurance marketplaces, with an unknown number gaining dental coverage through private medical insurance. 15 Adults ages 26-34 were by far the most likely age group to purchase dental benefits in the marketplaces. 16 This expansion of dental benefits coverage could further improve the affordability of dental care, although there is considerable uncertainty at this stage in the type of dental benefit plans being purchased in the health insurance marketplaces as well as the readiness of Medicaid programs in many states to absorb an influx of new beneficiaries. 17 Problems such as administrative burdens and low reimbursement rates may limit the number of dental providers that accept Medicaid. 18 Recent studies show that reforming Medicaid, including increasing reimbursement rates closer to market levels, is associated with an increase in dental care utilization. 19,20 The Health Policy Institute will continue to monitor barriers to needed dental care in the coming years. This Research Brief was published by the American Dental Association s Health Policy Institute. 211 E. Chicago Avenue Chicago, Illinois 60611 312.440.2928 hpi@ada.org For more information on products and services, please visit our website, www.ada.org/hpi. 5

References 1 Wall T, Nasseh K Vujicic M. Financial Barriers to Dental Care Declining after a Decade of Steady Increases. Health Policy Institute Research Brief. American Dental Association. September 2013. Available from:http://www.ada.org/~/media/ada/science%20and%20research/hpi/files/hpibrief_1013_1.ashx. Accessed August 5, 2 Bloom B, Simile CM, Adams PF, Cohen RA. Oral health status and access to oral health care for U.S. adults aged 18-64; National Health Interview Survey, 2008. National Center for Health Statistics. Vital Health Stat 10(253). 2012. 3 Brown T, Finlayson T, Fulton B, Jahedi S. The demand for dental care and financial barriers in accessing care among adults in California. CDA Journal. 2009;37(8). 4 Wall T, Nasseh K, Vujicic M. Most important barriers to dental care are financial, not supply related. Health Policy Institute Research Brief. American Dental Association. October Available from: http://www.ada.org/~/media/ada/science%20and%20research/hpi/files/hpibrief_1014_2.ashx. Accessed October 8, 5 Wall T, Nasseh K Vujicic M. Financial Barriers to Dental Care Declining after a Decade of Steady Increases. Health Policy Institute Research Brief. American Dental Association. September 2013. Available from:http://www.ada.org/~/media/ada/science%20and%20research/hpi/files/hpibrief_1013_1.ashx. Accessed August 5, 6 National Center for Health Statistics. National Health Interview Survey, 2013. Public-use data file and documentation. Available at: http://www.cdc.gov/nchs/nhis/quest_data_related_1997_forward.htm#2013_nhis. Accessed August 5, 2014, 7 Wall T, Nasseh K Vujicic M. Financial Barriers to Dental Care Declining after a Decade of Steady Increases. Health Policy Institute Research Brief. American Dental Association. September 2013. Available from: http://www.ada.org/~/media/ada/science%20and%20research/hpi/files/hpibrief_1013_1.ashx. Accessed August 5, 8 The Kaiser Commission on Medicaid and the Uninsured. Medicaid Enrollment: June 2012 Data Snapshot. August 2013. Available at: http://kff.org/medicaid/issue-brief/medicaid-enrollment-june-2012-data-snapshot/. Accessed August 5, 9 Leonard Davis Institute of Health Economics. The Effects of the ACA s Under-26 Mandate: What Do We Know? June Available at: http://ldi.upenn.edu/voices/2014/06/18/the-effects-of-the-aca-s-under-26-mandate-what-do-weknow. Accessed August 5, 10 Vujicic M, Yarbrough C, Nasseh K. The Effect of the Affordable Care Act's Expanded Coverage Policy on Access to Dental Care. Med Care. 2014;52(8):715-719. 11 Wall T, Nasseh K, Vujicic M. Most important barriers to dental care are financial, not supply related. Health Policy Institute Research Brief. American Dental Association. October Available from: http://www.ada.org/~/media/ada/science%20and%20research/hpi/files/hpibrief_1014_2.ashx. Accessed October 8, 12 Bloom B, Simile CM, Adams PF, Cohen RA. Oral health status and access to oral health care for U.S. adults aged 18-64; National Health Interview Survey, 2008. National Center for Health Statistics. Vital Health Stat 10(253). 2012. 13 Nasseh K, Vujicic M, O Dell A. Affordable Care Act expands dental benefits for children but does not address critical access to dental care issues. Health Policy Institute Research Brief. American Dental Association. April 2013. Available from: http://www.ada.org/~/media/ada/science%20and%20research/hpi/files/hpibrief_0413_3.ashx. Accessed August 5, 14 Yarbrough C, Vujicic M, Nasseh K. More than 8 Million Adults Could Gain Dental Benefits through Medicaid Expansion. Health Policy Institute Research Brief. American Dental Association. February Available from: http://www.ada.org/~/media/ada/science%20and%20research/hpi/files/hpibrief_0214_1.ashx. Accessed August 5, 15 Yarbrough C., Vujicic M., Nasseh K. Update: Take-Up of Pediatric Dental Benefits in Health Insurance Marketplaces Still Limited. Health Policy Institute Research Brief. American Dental Association. May Available from: 6

http://www.ada.org/~/media/ada/science%20and%20research/hpi/files/hpi%20research%20brief%20- %20Update%20Takeup%20of%20Pediatric%20Dental%20Benefits.ashx. Accessed August 5, 16 Vujicic M, Yarbrough C. Young adults most likely age group to purchase dental benefits in health insurance marketplaces. Health Policy Institute Research Brief. American Dental Association. August Available from: http://www.ada.org/~/media/ada/science%20and%20research/hpi/files/hpibrief_0814_3.ashx. Accessed August 14, 17 Yarbrough C, Vujicic M, Nasseh K. Health Insurance Marketplaces Offer a Variety of Dental Benefit Options, but Information Availability is an Issue. Health Policy Institute Research Brief. American Dental Association. March Available from: http://www.ada.org/~/media/ada/science%20and%20research/hpi/files/hpibrief_0314_1.ashx. Accessed October 6, 18 Government Accountability Office. 2000. Oral Health. Factors Contributing the Low Use of Dental Services by Low- Income Populations. GAO/HEHS-00-149. Available from: http://www.gao.gov/assets/240/230602.pdf. Accessed October 8, 19 Decker SL. Medicaid payment levels to dentists and access to dental care among children and adolescents. JAMA. 2011;306(2):187-93. 20 Nasseh K, Vujicic M. The impact of Medicaid reform on children s dental care utilization in Connecticut, Maryland and Texas. Health Serv Res. Forthcoming 2015. Suggested Citation Wall T, Nasseh K, Vujicic M. Fewer Americans forgoing dental care due to cost. Health Policy Institute Research Brief. American Dental Association. October Available from: http://www.ada.org/~/media/ada/science%20and%20research/hpi/files/hpibrief_1014_6.ashx. 7