Dental Care Utilization Rate Highest Ever among Children, Continues to Decline among Working-Age Adults Authors: 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 From 2011 to 2012 dental care utilization increased among children and decreased among working-age adults. Changes in dental care utilization patterns from 2011 to 2012 represent the continuation of multi-year trends. Dental care utilization in 2012 was at its highest level among children and at its lowest level among working-age adults since the Medical Expenditure Panel Survey began tracking dental care use in 1996. Introduction 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 In the past decade, there have been significant changes in dental care use patterns among the U.S. population. Utilization among children has been increasing, due mainly to gains among lower income children. Among working-age adults, dental care use has been declining since 2003 for all income groups. 1,2 As a result, the gap in dental care utilization between low-income and high-income children has narrowed 3 while for adults it has widened. 4 The American Dental Association Health Policy Institute (HPI) has been tracking trends in dental care use 5 as well as key drivers of these trends, 6,7 through an ongoing comprehensive research program. In this research brief, we update previous research on dental care utilization patterns, using newly released data for 2012. Contact the Health Policy Institute for more information on products and services at hpi@ada.org or call 312.440.2928. 2013 American Dental Association All Rights Reserved. October 2014
Data & Methods We analyzed data from the Medical Expenditure Panel Survey (MEPS) that is managed by the Agency for Healthcare Research and Quality (AHRQ). We focused on the period 2000 to 2012, the most recent year for which data are available (data for 2012 were released in September 2014). The MEPS is recognized as the most reliable data source for dental care utilization at the national level. 8 We measured dental care utilization as the proportion of the population who visited a general practice (GP) dentist in the year. This is the most basic indicator of dental care utilization. It does not capture any information on measures such as the type of care received, the total amount of care received, or whether a treatment plan was completed. Nevertheless, it is an informative measure of whether the population is seeing the dentist. We examined trends in dental care utilization for children ages 2-18, working-age adults ages 19-64 and elderly adults ages 65 and older. For each age cohort, we analyzed trends in dental care utilization by household income and dental benefits status. We classified dental benefits into three categories: public, private and uninsured. Public dental benefits include those provided through Medicaid or State Children s Health Insurance Programs (SCHIP). Because pediatric dental services are a mandated benefit, 9 children enrolled in these programs were defined as having comprehensive dental benefits. Medicaid coverage of dental benefits for adults is optional and varies considerably by state. MEPS does not allow us to identify the state of residence, however. Thus, we simply identify adults covered by Medicaid as publicly insured even though the majority will have either no dental benefits at all or very limited benefits. Because Medicare does not provide dental benefits, persons who only had Medicare coverage were considered uninsured for dental care. We test 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 MEPS. Results Figure 1 shows trends in dental care utilization for children, working-age adults and the elderly. Among children, dental care utilization increased from 2000 through 2003 and remained steady through 2011. In 2012, children s dental care utilization increased to 47.6 percent, a noticeable uptick from 2011, and the highest level measured by the MEPS since the survey began in 1996. 10 This uptick was statistically significant at the 10 percent level. The overall increase in dental care utilization among children from 2000 through 2012 was statistically significant at the 1 percent level. Dental care utilization among working-age adults declined in 2012, continuing a multi-year trend. At 35.4 percent, dental care utilization among working-adults is at its lowest level since the MEPS began tracking dental care use in 1996. 11 The slight decline in dental care utilization among working-age adults from 2011 through 2012 was not statistically significant although the overall decline from 2003 through 2012 was statistically significant at the 1 percent level. From 2011 to 2012, dental care utilization remained steady among the elderly. In 2012, 42 percent of elderly Americans saw a GP dentist in the past year. Figure 2 shows dental care utilization rates for narrower age groups. The decline in utilization among working-age adults that occurred through 2011 continued to occur through 2012 among adults ages 2
19-34 and 50-64. There was a slight uptick in dental care utilization from 2011 (35.7 percent) to 2012 (36.1 percent) among adults ages 35-49, although this change was not statistically significant. The largest decline in dental care utilization during our period of study occurred in the 50 through 64 age group. All of the changes in from 2002 through 2012 were statistically significant. Figures 3 through 5 show dental care utilization rates for children, working-age adults and the elderly, respectively, according to household income level. For all income groups of children, dental care utilization increased from 2011 through 2012, although these changes were not statistically significant. Looking at the entire timeframe, among poor, defined as those living below the federal poverty level (FPL<10), near poor (100-20 FPL), and high-income children (40 + FPL), dental care utilization increased by a statistically significant margin from 2000 to 2012 (Figure 3). For working-age adults, dental care utilization held steady among the poor (FPL<10) from 2011 (19.3 percent) through 2012 (19.9 percent). For other income brackets, however, dental care utilization declined slightly from 2011 to 2012 but the changes were not statistically significant. The decline in dental care utilization from 2002 through 2012 was statistically significant for the 100-20 FPL, 200-40 FPL and 40+ FPL groups (Figure 4). Among the elderly, dental care utilization fell for the 100-20 FPL group from 31 percent in 2011 to 26.6 percent in 2012, a statistically significant change (Figure 5). For the poor (FPL<10), it fell 2.9 percentage points from 2011 through 2012, although this drop was not statistically significant. Figures 6 through 8 show dental care utilization rates for children, working-age adults and the elderly, respectively, according to dental benefits status. Among children with private dental benefits, the percentage with a dental visit increased from 56.8 percent in 2011 to 59.3 percent in 2012, a statistically insignificant change. In 2012 there was also a slight uptick in dental care utilization among children with public insurance and among children with no dental benefits, although these changes were also not statistically significant. From 2011 through 2012, dental care utilization declined 1.3 percentage points among working-age adults with private dental benefits, although this change was not statistically significant (Figure 7). It held steady among working-age adults with public insurance or no dental insurance. Among the elderly with private dental benefits, dental care utilization fell 2.2 percentage points from 2011 through 2012, a statistically insignificant change. However, dental care utilization fell 6.0 percentage points from 2011 through 2012 among the elderly with public insurance, a statistically significant change (Figure 8). 3
Figure 1: Percentage of the Population with a Dental Visit in the Year, 2000-2012 45% 35% 47.5% 47.2% 47.6% 46.1% 46.1% 46.2% 46.4% 46.2% 45.4% 44.2% 44.4% 42.4% 43.1% 42.5% 41.4% 42.3% 41.3% 41.7% 42.4% 42. 40.3% 40.9% 41. 40.6% 40.2% 38.9% 39.6% 40. 40.4% 39.6% 39.8% 39.3% 38.3% 38.2% 38.4% 37.9% 36.8% 36.1% 35.4% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Children 2-18 Adults 19-64 Adults 65 and older Source: Medical Expenditure Panel Survey, AHRQ. Notes: For children ages 2-18, changes were statistically significant at the 1% level (2000-2012) and at the level (2011-2012). Among adults ages 19-64, changes were statistically significant at the 1% level (2003-2011). For adults 65 and older, changes were significant at the 5% level (2000-2012). Changes from 2011 to 2012 among adults 19-64 and the elderly 65 and above were not statistically significant. Figure 2: Percentage of the Population with a Dental Visit in the Year for Select Age Groups, 2000-2012 7 2 42.4% 44.2% 46.1% 47.5% 44.4% 46.2% 45.4% 47.6% 31.5% 33.9% 34.3% 31.4% 31.6% 29.9% 30. 28.5% 42.4% 42.4% 41.8% 40.7% 37.9% 37.5% 35.7% 36.1% 44.1% 48.3% 47.1% 46.8% 46.4% 43.6% 42.9% 42.2% 38.3% 39.6% 40.4% 41.4% 41.3% 40.2% 42.4% 42. Children 2-18 Adults 19-34 Adults 35-49 Adults 50-64 Adults 65+ Source: Medical Expenditure Panel Survey, AHRQ. Notes: Changes for children were significant at the 1% level (2000-2012) and at the level (2011-2012). Changes for adults ages 65 and older were significant at the 5% level (2000-2012). Changes for adults 19-34, 35-49 and 50-64 were significant at the 1% level (2002-2012). Changes for adults 19-34, 35-49 and 50-64 from 2011 to 2012 were not statistically significant. 4
Figure 3: Percentage of Children Ages 2-18 with a Dental Visit in the Year for Select Income Groups, 2000-2012 7 2 26.5% 30.7% 33.5% 34.7% 33.5% 36.2% 34.8% 36.2% 31.4% 32.9% 34.7% 37.3% 35.7% 41.7% 38.1% 40.3% 44.7% 45.5% 47.4% 47.6% 45.4% 45.6% 47.3% 48.6% 55.4% 59.1% 61.1% 62.4% 57.8% 57.9% 58.5% 61.5% FPL<10 FPL 100 20 FPL 200-40 FPL 40 + Source: Medical Expenditure Panel Survey, AHRQ. Notes: Changes were significant at the 1% level for FPL<10 and FPL 100-20 (2000-2012) and at the 5% level for FPL 400+ (2000-2012). Changes from 2011 to 2012 were not statistically significant. Figure 4: Percentage of Adults Ages19-64 with a Dental Visit in the Year for Select Income Groups, 2000-2012 7 49.3% 54.2% 54.1% 53. 51.3% 50.6% 49.3% 48.7% 2 22.8% 21.5% 20.2% 19. 19.9% 19.1% 19.3% 19.9% 25.5% 25.5% 25.2% 22.1% 23.5% 22.8% 22.7% 20.6% 35.2% 36.4% 37.3% 35.8% 35.2% 34. 33.9% 33.4% FPL<10 FPL 100 20 FPL 200-40 FPL 40 + Source: Medical Expenditure Panel Survey, AHRQ. Notes: Changes were significant at the 5% level for FPL 200-40 and at the 1% level for FPL 100-20 and FPL 40 + (2002-2012). Changes from 2011 to 2012 were not statistically significant. 5
Figure 5: Percentage of Adults 65 and Older with a Dental Visit in the Year for Select Income Groups, 2000-2012 7 2 24.8% 24.3% 25.9% 24.8% 23.5% 29.6% 26.9% 24. 26.6% 29.3% 27.8% 27.8% 32.4% 30.1% 31. 26.6% 38.6% 38.3% 39.2% 40.2% 39.9% 33.1% 38.9% 41.7% 54.3% 54.5% 56.8% 57.3% 54.5% 55.5% 56.8% 56.9% FPL<10 FPL 100 20 FPL 200-40 FPL 40 + Source: Medical Expenditure Panel Survey, AHRQ. Notes: Changes were significant at the 5% level for FPL 100-20 (2011-2012). Changes for FPL<10, FPL 200-40 and FPL 40+ from 2011 to 2012 were not statistically significant. Figure 6: Percentage of Children Ages 2-18 with a Dental Visit in the Year by Dental Benefits Status, 2000-2012 7 51.4% 55.3% 57.1% 58.3% 56.1% 57.5% 56.8% 59.3% 2 30.6% 33.6% 36.6% 36.8% 36.6% 39.5% 38. 39.5% 29.6% 26.4% 26.7% 30.5% 22.9% 26.5% 25.2% 26.1% Private Public Uninsured Source: Medical Expenditure Panel Survey, AHRQ. Notes: Changes were significant at the 1% level for private and public (2000-2012). Changes from 2011 to 2012 were not statistically significant. 6
Figure 7: Percentage of Adults Ages 19-64 with a Dental Visit in the Year by Dental Benefits Status, 2000-2012 7 49.1% 52.5% 53.4% 52.3% 52.2% 51.6% 49.8% 48.5% 2 25. 23.7% 23.1% 23.6% 22. 18.8% 19.7% 20.5% 22.5% 22.8% 20.7% 19.2% 19.1% 17.6% 18. 18.3% Private Public Uninsured Source: Medical Expenditure Panel Survey, AHRQ. Notes: Changes were significant at the 1% level for private (2004-2012) and the uninsured (2000-2012). Changes were significant 5% level for public (2000-2012). Changes from 2011 to 2012 were not statistically significant. Figure 8: Percentage of Adults Ages 65 and Older with a Dental Visit in the Year by Dental Benefits Status, 2000-2012 7 56.5% 59.5% 61.8% 63.1% 63. 68.2% 69.1% 66.9% 2 35.3% 36.1% 36.2% 37.9% 37.6% 33.6% 35.2% 36.6% 14.4% 13.3% 18.7% 13.2% 13.6% 16.4% 19. 13. Private Public Uninsured Source: Medical Expenditure Panel Survey, AHRQ. Notes: Changes were significant at the 1% level for private (2000-2012). Changes were significant at the 5% level for public (2011-2012). Changes from 2011 to 2012 were not statistically significant for elderly adults with private dental insurance or no dental benefits. 7
Discussion In this brief, we updated findings from prior analysis on dental care utilization in the United States 12 using newly released 2012 data. We find that dental care utilization continues to decline among working-adults and is at its lowest level since the MEPS began measurement in 1996. Previous research demonstrates that one key reason behind this decline is that fewer working-age adults have private dental benefits 13 14 and many adults perceive financial barriers to dental care. 15 But we find that dental care utilization continues to decline for high-income adults and among those with private dental insurance, suggesting more than just affordability is at play. In fact, new research has shown that the biggest reason why privately insured individuals do not intend to visit a dentist in the next twelve months is because they perceive their mouth to be healthy. 16 Due to the Affordable Care Act (ACA), over 8 million adults could gain Medicaid dental benefits in 2014. 17 Through 2018, up to 9 million children could gain dental benefits through Medicaid, their parents employer health insurance policies or though the health insurance marketplaces. 18 These coverage expansions are likely to lead to increased demand for dental care. However, low reimbursement rates and 19 20 burdensome administrative processes in Medicaid 21 could potentially dissuade dental providers from participating in Medicaid programs, which may reverse the gains made by low-income children over the last decade and further increase access barriers for lowincome adults. The Health Policy Institute will continue to monitor the impact of the ACA and other market developments on dental care utilization patterns in the United States. Unlike adults, dental care use among children increased in 2012 and is at its highest level since the MEPS began tracking dental care use in 1996. The decade-long increase in dental care use among U.S. children is continuing and is being driven primarily by gains among poor and near-poor children. 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. 8
References 1 Nasseh K, Vujicic M. Dental care utilization continues to decline among working-age adults, increases among the elderly, stable among children. Health Policy Institute Research Brief. American Dental Association. October 2013. Available at: http://www.ada.org/~/media/ada/science%20and%20research/hpi/files/hpibrief_1013_2.ashx. Accessed September 24, 2014. 2 Vujicic M. Dental care utilization declined among low-income adults, increased among low-income children in most states from 2000 to 2010. Health Policy Institute Research Brief. American Dental Association. February 2013. Available at: http://www.ada.org/sections/professionalresources/pdfs/hprcbrief_0213_3.pdf. Accessed September 3, 2014. 3 Nasseh K, Vujicic M. Dental care utilization continues to decline among working-age adults, increases among the elderly, stable among children. Health Policy Institute Research Brief. American Dental Association. October 2013. Available at: http://www.ada.org/sections/professionalresources/pdfs/hprcbrief_1013_2.pdf. Accessed September 26, 2014. 4 Nasseh K, Vujicic M. The effect of growing income disparities on U.S. adults' dental care utilization. J Am Dent Assoc. 2014;145(5):435-42. 5 Nasseh K, Vujicic M. Dental care utilization continues to decline among working-age adults, increases among the elderly, stable among children. Health Policy Institute Research Brief. American Dental Association. October 2013. Available at: http://www.ada.org/~/media/ada/science%20and%20research/hpi/files/hpibrief_1013_2.ashx. Accessed September 24, 2014. 6 Vujicic M, Nasseh K. A decade in dental care utilization among adults and children (2001-2010). Health Serv Res. 2014;49(2):460-80. 7 Nasseh K, Vujicic M. Dental benefits continue to expand for children, remain stable for working-age adults. Health Policy Institute Research Brief. American Dental Association. October 2013. Available at: http://www.ada.org/~/media/ada/science%20and%20research/hpi/files/hpibrief_1013_3.ashx. Accessed September 26, 2014. 8 Macek MD, Manski RJ, Vargas CM, Moeller JF. Comparing oral health care utilization estimates in the United States across three nationally representative surveys. Health Serv Res. 2002; 37(2):499 522. 9 Medicaid.gov. Dental Care. Available at: http://www.medicaid.gov/medicaid-chip-program-information/by- Topics/Benefits/Dental-Care.html. Accessed September 26, 2014. 10 In 1996, dental care utilization among children ages 2-18 was 41.9 percent. Agency for Healthcare Research and Quality (AHRQ). MEPS HC-012: 1996 Full Year Consolidated Data File. September 2014. Available at: http://meps.ahrq.gov/mepsweb/data_stats/download_data_files_detail.jsp?cbopufnumber=hc-012. Accessed September 26, 2014. 11 In 1996, dental care utilization among adults ages 19-64 was 40.2 percent. Agency for Healthcare Research and Quality (AHRQ). MEPS HC-012: 1996 Full Year Consolidated Data File. September 2014. Available at: http://meps.ahrq.gov/mepsweb/data_stats/download_data_files_detail.jsp?cbopufnumber=hc-012. Accessed September 26, 2014. 12 Nasseh K, Vujicic M. Dental care utilization continues to decline among working-age adults, increases among the elderly, stable among children. Health Policy Institute Research Brief. American Dental Association. October 2013. Available at: http://www.ada.org/sections/professionalresources/pdfs/hprcbrief_1013_2.pdf. Accessed September 26, 2014. 13 Nasseh K, Vujicic M. Dental benefits continue to expand for children, remain stable for working-age adults. Health Policy Institute Research Brief. American Dental Association. October 2013. Available at: http://www.ada.org/~/media/ada/science%20and%20research/hpi/files/hpibrief_1013_3.ashx. Accessed September 26, 2014. 14 Vujicic M, Nasseh K. A decade in dental care utilization among adults and children (2001-2010). Health Serv Res. 2014;49(2):460-80. 9
15 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 2014. Available from: http://www.ada.org/~/media/ada/science%20and%20research/hpi/files/hpibrief_1014_2.ashx. Accessed October 6, 2014. 16 Yarbrough C; Nasseh K, Vujicic M. Key differences in dental care seeking behavior between Medicaid and non- Medicaid adults and children. Health Policy Institute Research Brief. American Dental Association. September 2014. Available at: http://www.ada.org/~/media/ada/science%20and%20research/hpi/files/hpibrief_0814_4.ashx. Accessed September 26, 2014. 17 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 2014. Available at: http://www.ada.org/~/media/ada/science%20and%20research/hpi/files/hpibrief_0214_1.ashx. Accessed September 26, 2014. 18 Vujicic M, Goodell S, Nasseh K. Dental benefits to expand for children, likely decrease for adults in coming years. Health Policy Institute Research Brief. American Dental Association. April 2013. Available at: http://www.ada.org/~/media/ada/science%20and%20research/hpi/files/hpibrief_0413_1.ashx. Accessed September 26, 2004. 19 US Government Accountability Office. Factors contributing the low use of dental services by low-income populations. Washington, DC: US Government Accountability Office; 2000. GAO/HEHS-00-149. Available at: http://www.gao.gov/assets/240/230602.pdf. Accessed September 26, 2014. 20 Decker SL. Medicaid payment levels to dentists and access to dental care among children and adolescents. JAMA. 2011;306(2):187-93. 21 Buchmueller TC, Orzol S, Shore-Sheppard LD. The effect of Medicaid payment rates on access to dental care among children. NBER Working Paper No. 19218. July 2013. Available at: http://www.nber.org/papers/w19218.pdf?new_window=1. Accessed September 26, 2014. Suggested Citation Nasseh K, Vujicic M. Dental care utilization rate highest ever among children, continues to decline among working-age adults. Health Policy Institute Research Brief. American Dental Association. October 2014. Available from: http://www.ada.org/~/media/ada/science%20and%20research/hpi/files/hpibrief_1014_4.ashx. 10