Approaches for Improving Oral Health Outcomes for Low-Income Americans
November 15, 2018 | ASTHO Staff
Poor oral health is considered a health disparity for low-income children and adults; it has significant impacts on the overall health and well-being especially for those who are vulnerable. Dental illnesses significantly increase the risk of chronic health conditions, may result in missed days of work and school, negatively affect employability, and increase use of expensive acute care. A recent study found that, over the span of three years, dental-related hospital emergency department visits cost taxpayers $2.7 billion. Of those studied, thirty percent were Medicaid-enrolled adults, and more than 40 percent were uninsured. According to an American Dental Association survey, approximately one-third of Americans who have income lower than 138 percent of federal poverty level struggle to get employed because of the condition of their mouth and teeth while only 15 percent of people whose income is above 400 percent of the poverty level experience such an issue. States can utilize a variety of approaches to mitigate this issue for low income Americans.
Impact of Medicaid on Access to Oral Health Services
State Medicaid programs are mandated to provide comprehensive dental coverage for Medicaid-enrolled children, but are not required to offer dental coverage to Medicaid‐enrolled adults. For Medicaid-enrolled adults there is an uneven patchwork of dental care coverage (as shown in Table 1) that impacts access to dental services.
Table 1. State Medicaid Coverage of Adult Dental Benefits to the Medicaid Base Beneficiary Population
| Dental Benefits Category | Offered to Medicaid Base Population |
|---|---|
| No dental benefits (3 states) | AL, DE, TN |
| Emergency-only (14 states) | AZ, FL, GA, HI, ID, ME, MD, MS, NV, NH, OK, TX, UT, WV |
| Limited (17 states) | AR, CO, LI, IN, KS, KY, LA, MI, MN, MO, NE, PA, SC, SD, VT, VA, WY |
| Extensive (17 states) | AK, CA, CT, DC, IA, MA, MT, NJ, NM , NY, NC, ND, OH, OR, RI, WA, WI |
Beyond the issue of coverage for oral health services, there is also the element of available providers oral health providers that complicates access in many jurisdictions. Many dental providers do not accept Medicaid coverage, and nearly 49 million people are living in over 5,000 dental health professional shortage areas (HPSAs) across the country. HPSAs are geographic regions, populations, or facilities that are lacking sufficient healthcare providers; in this sample, the insufficient providers are dentists.
States have used Medicaid Section 1115 Research and Demonstration Waivers (demonstrations) to improve dental care. For example, California used a Medicaid demonstration to develop its Dental Transformation Initiative, with the goals to increase dental care access and address the specific oral health needs of children by providing incentive payments to dental providers for achieving state-defined targets. States have also used demonstrations to create programs that allow beneficiaries to “earn” dental health benefits by fulfilling various program requirements. Iowa’s Dental Wellness Plan is one such example where adult enrollees were incentivized to seek preventative dental care by providing additional dental services if they maintained a regular check-up schedule.
State Strategies to Improve Oral Health Outcomes
States are in prime positions to improve oral health for their populations through a variety of programmatic and policy levers:
Primary Care Integration
Primary care medical providers can be an effective part of a state's strategy to improve oral health for participants. These providers can and should be made aware of Medicaid and CHIP coverage policies for oral health services, such as fluoride varnish. States are in the process of leveraging already existing healthcare transformation efforts, such as electronic health records implementation and optimization, to incorporate dental care and highlight the importance of screening for oral health in primary care (and particularly pediatrician's) offices. Some states have also simply co-located both primary care and dental care in the same physical location as a method to improve access to care (such as has been accomplished in Colorado).
Alignment with Population Specific Services
Oral health programs or pilots can also be aligned with current services provided by the state for increasing access to oral health services for specific populations. In 2013, New Hampshire created a pilot program held at local Women, Infants, and Children (WIC) sites to integrate preventative oral health care for low-income women and children into existing safety net programs. It included a weekly dental clinic at each WIC site at which dental hygienists and dental assistants provided preventative care and referred participants to local Medicaid-enrolled dental providers for follow-up care.
Workforce Innovation
States can also explore the role that mid-level dental care providers may play in expanding access to oral health care. A 2014 evaluation on the impact of dental therapists by the Minnesota Board of Dentistry and Department of Health found that dental therapists can expand access to care for underserved populations and improve clinics' and dental offices' efficiency. More states are considering legislation and other proposals to authorize such providers. For more information about scope of practice for oral health practitioners, ASTHO and the National Conference of State Legislatures maintain a website tracking scope of practice for these mid-level providers, and other types of practitioners.
Care Delivery Innovations
Advances in telehealth can also be promising avenues for improving access to oral health care. For example, Alaska has leveraged telehealth to address its oral health needs. Given the lack of access to oral healthcare that is affecting the state's rual residents, the state established the practice of mid-level oral health providers known as dental health aide therapists (DHATs). Telehealth (specifically live videoconferencing) allows DHATs to connect with supervising dentists in hub locations who are then able to provide professional oversight and supervision virtually. Since DHATs began working in the state in 2004, 45,000 Alaska Natives now have regular access to dental care.
Poor oral health can easily compound the effects of preexisting conditions and aggravate already fragile socioeconomic well-being, both at the individual and population levels. However, oral health care delivery and services can be improved through innovations in programming, financing, and workforce training. Using the population health framework, states can make significant strides towards improving their population's overall health by improving dental care access and delivery.