How Well Is CHIP Addressing Oral Health Care Needs and Access for Children? Lisa Clemans-Cope, PhD; Genevieve Kenney, PhD; Timothy Waidmann, PhD; Michael Huntress, MA; Nathaniel Anderson, BA From the Health Policy Center, The Urban Institute, Washington, DC The authors declare that they have no conflict of interest. Address correspondence to Lisa Clemans-Cope, PhD, Health Policy Center, The Urban Institute, 2100 M St, NW, Washington, DC 20037 (e-mail: [email protected]). Received for publication November 3, 2014; accepted February 17, 2015.
ABSTRACT OBJECTIVE: We examine how access to and use of oral and
to being uninsured, CHIP enrollees did better across nearly all oral health measures. Compared to being privately insured, CHIP enrollees were more likely to have dental benefits, to have a usual source of dental care, and to have had a dental checkup/cleaning, but they were more likely to have trouble finding a dentist and less likely to say that their child’s teeth were in excellent/very good condition. CONCLUSIONS: Enrolling eligible uninsured children in CHIP led to improvements in their access to preventive dental care, as well as reductions in their unmet dental care needs, yet the CHIP program has more work to do to address the oral health problems of children.
dental care under the Children’s Health Insurance Program (CHIP) compared to private coverage and being uninsured in 10 states. METHODS: We report on findings drawn from a 2012 survey of CHIP enrollees in 10 states. We examined a range of parentreported dental care access and use measures among CHIP enrollees. Comparisons of the experiences of established CHIP enrollees to the experiences of newly enrolling children who had been uninsured or privately insured were used to estimate the impacts of CHIP on children’s oral health and dental care. RESULTS: Most children enrolled in CHIP had a usual source of dental care and had received a dental checkup or cleaning in the past year, and most over age 6 had had sealants placed on their molars. In addition, parents of most CHIP enrollees were aware that CHIP covered dental benefits, and most reported not having trouble finding a dentist to see their child. Even so, 12% of CHIP enrollees had unmet dental care needs. Compared
KEYWORDS: access and use of health care; CHIP; dental services; impacts of health insurance coverage; oral health; public health insurance; unmet dental needs
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with separate CHIP plans to provide dental coverage, all children covered by CHIP had coverage for dental services.2 For children who would be eligible for CHIP based on income but who are enrolled in private coverage with limited or no dental benefits, CHIPRA included a provision allowing states with separate CHIP plans to provide supplemental dental coverage. Thus, low-income children who lack access to dental coverage are generally either uninsured children or privately insured children without either private dental benefits or supplemental dental coverage through CHIP. Several studies have examined receipt of dental services among low-income children by age, race/ethnicity, and other characteristics of children and their parents. Previous research has shown that being uninsured is associated with a decreased likelihood of visiting a dentist for children overall and for low-income children.3 Low-income children with no dental insurance are also more likely to have unmet dental needs compared to low-income children with private or public dental insurance.4 Previous research has also demonstrated that children with lower family incomes, those whose parents are black, and those who have a parent
Dental disease is common and preventable among children. The Children’s Health Insurance Program (CHIP) includes pediatric dental coverage. Relative to privately insured children, children enrolled in CHIP have better access to dental benefits and are more likely to have a usual source of dental care and a preventive dental visit, but the condition of their teeth is worse and they have more trouble finding a dentist.
ORAL HEALTH IS an important component of children’s overall health and well-being. Despite recent progress in pediatric oral health care, poor oral health is common among children, and dental caries (tooth decay) is the most common childhood disease.1 Expansions of public health insurance programs after enactment of the Children’s Health Insurance Program (CHIP) in 1997 led to increases in access to dental benefits for low-income children (those in families with incomes at or below 200% of the federal poverty level). After the enactment of Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), which included a provision requiring states ACADEMIC PEDIATRICS Copyright ª 2015 by Academic Pediatric Association
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with less than a college education are less likely to have the recommended number of dental visits and more likely to have postponed dental care.5 Low-income children ages 6 to 12 years are more likely to have had a preventive dental care visit than those who are preschool age (4 to 5 years) or adolescents (13 to 17 years).4 An analysis of 4 national health surveys with data spanning 2003 to 2007 showed that children who were uninsured or publicly insured had a decreased likelihood of any dental care, a decreased likelihood of preventive dental care, and a higher likelihood of delayed dental care compared to privately insured children.6 Other research has shown that ensuring access to oral health and dental services remains a concern for children enrolled in public coverage, as manifested by differences in the rates of preventive and dental treatment services across geographical areas, despite the availability of dental benefits and recent efforts to improve the quality of oral health care for these children.7,8 Here we present evidence on a wide range of outcomes related to the receipt of oral and dental care for children in CHIP compared to those with no insurance and those with private coverage in 10 states. Selected oral and dental health care access and use measures were based on parental report, including perceptions of whether their child has dental benefits; their access to a usual source of dental care; their access to dental providers; the use of dental-related services; the presence of unmet dental health needs; and the condition of their child’s teeth. The analysis was conducted as part of an independent, comprehensive evaluation of CHIP mandated in the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) and conducted by Mathematica Policy Research and its partner, The Urban Institute, on behalf of the secretary of the US Department of Health and Human Services and overseen by the Office of the Assistant Secretary for Planning and Evaluation.9 This is one in a series of articles in this supplement that report on findings from a large 10-state household survey of CHIP enrollees and disenrollees conducted as part of the evaluation. The observed patterns of care may suggest opportunities for improving the oral health of low-income children enrolled in CHIP.
METHODS SURVEY DATA The data for this study were drawn from a telephonebased survey of parents of 12,197 CHIP enrollees and disenrollees in 10 states fielded by Mathematica Policy Research from January 2012 through March 2013 as part of the CHIPRA-mandated evaluation of CHIP. The states included were Alabama, California, Florida, Louisiana, Michigan, New York, Ohio, Texas, Utah, and Virginia. These states were selected because they utilize diverse approaches to providing health insurance coverage for children, represent various geographic areas (including a mix of more rural and more urban states and a variety of races/ethnicities), and each contains a significant portion
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of uninsured children. In 2012, CHIP enrollees in these states represented approximately 57% of CHIP enrollees nationally.10 We used state eligibility and enrollment files to construct the sample frame for each state and randomly selected children (18 years or younger) in 3 strata in each state: 1) established enrollees (children who had been enrolled in CHIP for 12 or more consecutive months at the time of sampling), 2) recent enrollees (children who had been enrolled in CHIP for exactly 3 consecutive months, preceded by a gap in public coverage of at least 2 months, at the time of sampling), and 3) recent disenrollees (children who were disenrolled from the program for exactly 2 months, at the time of sampling, and who were previously enrolled for at least 3 months before the month of disenrollment). Recent CHIP enrollees who transferred from Medicaid or who returned to CHIP after a short gap in public insurance coverage (3 months or less) were excluded from the sampling frame for 2 reasons. First, parents of such CHIP enrollees are often unaware of these coverage transitions and therefore are not able to reliably describe health care experiences before their (re)enrollment in CHIP. Second, because their coverage history reflects a period of public coverage, these children do not represent a useful comparison group for assessing how CHIP differs from private or no insurance coverage. The final survey data included responses from parents of 5518 established enrollees, 4142 recent enrollees, and 2537 disenrollees. The overall survey response rate was 51% for established enrollees, 46% for recent enrollees, and 43% for recent disenrollees. The survey included a wide range of questions related to the sampled child’s current and prior health insurance, health status and needs, and health care use and experiences, many of which were adapted from other large surveys relevant to children’s health. Additional details on the survey, including the questionnaire, are available elsewhere.11 The study was reviewed and approved by the New England Institutional Review Board (NEIRB 12-200). STUDY DESIGN We compared the experiences of established enrollees who had been on the program for at least 1 year to the preenrollment experiences of recent CHIP enrollees. Established enrollees were asked about their experiences during the last 12 months of enrollment, while recent enrollees were asked about their experiences during the 12 months before their enrollment in CHIP. We focused our analyses on comparisons between established enrollees and 2 subgroups of recent enrollees: first, recent enrollees who were uninsured for 5 to 12 months before enrollment, and second, recent enrollees who were privately insured for 12 months before enrollment. (The children who had private insurance may or may not have had dental benefits included in their private coverage.) We used the previously uninsured children to compare CHIP to being uninsured and the children previously insured by a private plan to consider how outcomes differ under CHIP versus private coverage.
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DEPENDENT VARIABLES Five major types of outcome indicators are examined across each analytic group, with all outcomes based on parents reported perceptions of their child’s dental care in the past year: 1) oral health based on the condition of their child’s teeth (excellent or very good vs good, fair, or poor), 2) use rates for different types of dental services, 3) unmet dental needs, 4) perceptions of adequacy of access to dental providers, and 5) presence of and access to a usual source of dental care. Use of dental services is measured as any service use of a particular type during the past year. In addition, to assess parental perception of dental benefits, this analysis also included parental reports of whether their child had dental benefits or coverage for dental services; although all children covered by CHIP have dental coverage, not all parents are aware of these benefits. INDEPENDENT VARIABLES Our key explanatory variable was the insurance status of enrollees during the 12-month recall period. We also included potentially confounding variables, including child’s gender, age, and race/ethnicity; primary language and number of children in the household; parents’ highest education level, employment status, and citizenship; and geographical location at the time of sampling (through a series of state-region dummies). STATISTICAL ANALYSES We used binary dependent variables and estimated linear probability models to generate regression-adjusted differences between established CHIP enrollees and recent enrollees who were previously uninsured and who were previously covered by private insurance. We also conducted a number of sensitivity analyses to address possible unobserved differences between recent and established enrollees. We considered different subsets of established enrollees who were more likely to have been uninsured or privately insured before entering the program. We also considered various subgroups of recent enrollees on the basis of their reasons for enrolling and past service use in case their use of health care services during the year before enrollment was atypically high or low. Finally, we tested the sensitivity of our results to including different geographic control variables in the model, which address possible confounding due to differences in local health care markets. The results presented here are robust to these alternative specifications.12 All analyses used survey weights generated to account for the complex, multistage sampling design of the survey and nonresponse bias.11
RESULTS CHARACTERISTICS OF ESTABLISHED AND RECENT CHIP ENROLLEES Established CHIP enrollees in the 10 study states represent a diverse population of children primarily living in low-income households with working parents (Online Appendix Table 1). Over half of the enrollees (54%) are Hispanic, reflecting the large Hispanic populations in
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several large sample states. A large majority of enrollees live in households with incomes less than 150% of the federal poverty level (69%) and with at least one working parent (87%). CHIP enrollees are generally healthy, but over one-fourth have at least 1 special health care need, and 7% of enrollees had fair or poor parent-reported overall health. The sociodemographic and health characteristics of established CHIP enrollees vary significantly across the 10 states in this study. Compared to established CHIP enrollees, previously uninsured recent enrollees tended to be younger and have lower income, and were more likely to be Hispanic. Compared to established enrollees, recent CHIP enrollees coming from private insurance tended to be younger, to be in better health, and to have more educated parents and higher incomes; they were also more likely to be non-Hispanic white and have parents who are US citizens. As noted above, our models controlled for these potentially confounding differences between the treatment and comparison groups. ORAL HEALTH OUTCOMES BASED ON PARENTAL REPORTS CHIP ENROLLEES The key outcomes for this analysis were the oral and dental health characteristics of the CHIP sample. Over 90% of parents of CHIP-covered children reported that their children had dental health benefits (Table). Only slightly fewer said that they had no trouble finding a dentist who would see their children (89%) and that their child had a usual source of dental care (87%); almost three quarters (72%) said that scheduling appointments with the child’s usual source of dental care or another dentist was easy. However, only 38% of the places named were reported to be accessible at night or on weekends. Most CHIP enrollees (84%) had a preventive visit to a dentist in the past year, exceeding the targets in Healthy People 2020.13 Parents of 37% of children with a preventive dental visit reported that the dentist recommended follow-up treatment. Of those receiving such a recommendation, only 68% had a dental procedure during the past year, suggesting that nearly one-third of CHIP enrollees who needed follow-up care did not receive it. Sealants to reduce the risk of pit and fissure cavities in primary and permanent teeth susceptible to plaque retention are recommended for children younger than 6.14 Slightly over half (54%) of CHIP enrollees over age 6 were reported to have had dental sealants placed on their molars, exceeding the targets in Healthy People 2020.13 Only half of CHIP enrollees (52%) were reported to have teeth in excellent/very good condition. Because parents tend to overreport that their child’s dental health is good, this is probably an overestimate.* In addition, 12% of
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* Sanzone et al.15 found that parental reports of preventive oral health behaviors is influenced by the effects of social desirability bias, a form of response bias in which individuals misrepresent self-reported behaviors by overreporting behaviors considered socially desirable and underreporting undesirable ones. Although we do not present findings related to parental reports of the condition of children’s teeth, it is possible and likely that poor outcomes on this measure may also be underreported.
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Table. Parental Perceptions of Dental Benefits, Access to and Use of Dental Care, and Unmet Needs of Children in CHIP Compared to Uninsured or Privately Insured Children, 2012 (10-State Pooled, Regression-Adjusted Differences) Weighted Percentage or Percentage Point Difference (SE) Percentage Point Difference Between CHIP and Other Coverage (Regression Adjusted)
Characteristic Parental perception of dental benefits Has dental benefits or coverage for dental services Access to care based on parent reports Had usual source of dental care Usual source of dental care has or night or weekend hours Provider accessibility based on parent reports No trouble finding a dentist Usually/always easy to get appointments with dental provider Service use based on parent reports Any dental visit for checkup or cleaning Dentist recommend additional or follow-up treatment Dental procedure, such as having a cavity treated or a tooth pulled Ever had dental sealants placed on back teeth (molars; if age >6 y) Dental sealants placed at dentist’s office Dental sealants placed through a school program DK/Ref where dental sealants placed Unmet needs based on parent reports Dental care (if age >12 mo) Any unmet need Parental perception of child’s oral health Excellent or very good Good/fair/poor DK/Ref
Percentage of CHIP Versus Private CHIP Enrollees in 10 CHIP Versus Uninsured Insurance Before States (Unadjusted)† Before Enrollment‡ Enrollment§ 91.5 (0.5)
67.1 (2.3)**
14.7 (2.1)**
87.2 (0.7) 37.7 (1.0)
38.2 (2.6)** 3.4 (3.6)
6.8 (2.0)** 7.5 (3.1)*
88.6 (0.6) 72.0 (0.9)
7.8 (2.3)** 18.2 (3.1)**
4.9 (1.8)** 2.6 (2.6)
84.0 (0.7) 36.8 (1.0) 67.8 (1.5) 54.1 (1.0) 97.0 (0.5) 2.7 (0.9) 0.4 (0.2)
38.6 (2.6)** 2.4 (3.9) 4.0 (5.7) 13.4 (3.0)** 4.6 (2.8) 4.9 (2.7) 0.3 (0.2)
5.3 (2.1)* 4.9 (3.1) 0.9 (5.7) 1.9 (3.2) 0.4 (1.3) 0.1 (1.3) 0.3 (0.2)
11.6 (0.6) 24.3 (0.8)
12.1 (2.3)** 11.9 (2.5)**
0.4 (1.9) 2.9 (2.4)
52.4 (0.9) 47.6 (0.9) 0.1 (0.0)
8.0 (2.6)** 8.0 (2.6)** 0.1 (0.0)
7.1 (2.6)** 7.1 (2.6)** 0.2 (0.2)
CHIP indicates Children’s Health Insurance Program; DK/Ref, don’t know or refused to answer. Notes: The regression-adjusted differences derived from multivariate regression models control for age, sex; race/ethnicity and language groups, more than 3 children in the household, highest education of any parent, parents’ employment status, parent citizenship, and local area or county. Sample sizes differ across outcome indicators due to differences in response rates and survey skip patterns. “No out-of-pocket costs” includes those who indicated out-of-pocket costs but then said they had no problem paying, or later indicated they paid $0 in out-ofpocket costs. Values are statistically different from CHIP enrollees at the *P ¼ .05 or **P ¼ .01 level. †CHIP enrollees are those continuously enrolled in CHIP for at least 12 months at time of sampling. ‡Uninsured children had 5 or more months without any coverage in the past 12 mo. §Privately insured children had 12 mo of private coverage in the past 12 mo. Source: 2012 Congressionally Mandated Survey of CHIP and Medicaid Enrollees and Disenrollees. Survey states included Alabama, California, Florida, Louisiana, Michigan, New York, Ohio, Texas, Utah, and Virginia.
CHIP enrollees were reported to have had an unmet dental care need. Dental care was the most frequently cited unmet health need reported in the CHIP survey, a result consistent with prior studies.16,17 Although there were similar patterns across subgroups for most outcomes, there were several significant differences in the dental experiences among subgroups of CHIP enrollees (data not shown). Younger children (ages 1 to 5 years old) were less likely to have had a dental checkup or cleaning than older children (69% for younger children vs 89% for children ages 6 to 12, and 84% for children ages 13 to 18 years old). Children with a special health care need were more likely to have unmet dental needs compared to children with no special health care need (16% vs 10%). Hispanic children in families speaking mainly Spanish were less likely than those speaking mainly English or non-Hispanic white children to have teeth reported to be in excellent/good condition (35% for Hispanic children in families speaking mainly Spanish vs 59% and
67% for the other 2 groups, respectively). Finally, children whose resident parent did not complete high school were considerably less likely to have teeth reported to be in excellent/good condition than children with bettereducated parents (36% vs 57%). CHIP ENROLLEES COMPARED TO UNINSURED CHILDREN According to parental reports, children enrolled in CHIP had better access to dental benefits and care than the preCHIP experiences of the children who had been uninsured before enrolling (Table). Comparisons are based on regression-adjusted demographic and socioeconomic differences that control for observed differences between the 2 groups. Online Appendix Table 2 provides unadjusted estimates of uninsured children. The parents of uninsured children were 67 percentage points less likely to report that the child had dental coverage compared to the parents of CHIP enrollees. In addition, the parents of uninsured children appeared to have lower
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awareness of the need for dental care among children, as these parents were 8 percentage points more likely to report that their child does not need a dentist (data not shown). CHIP enrollees were 38 percentage points more likely than uninsured children to have a usual source of dental care. The parents of CHIP enrollees were 18 percentage points more likely to report that scheduling appointments with the child’s usual source of dental care was usually easy compared the parents of uninsured children. Receipt of preventive services was more common among CHIP enrollees compared to uninsured children, with CHIP enrollees 38 percentage points more likely to have had a dental checkup/cleaning in the past year. No significant difference between CHIP and uninsured was detected in the proportions recommended for additional follow-up treatment or in the proportions of those with recommended follow-up treatment who had a subsequent visit. CHIP enrollees over age 6 were 13 percentage points more likely to have had dental sealants placed on their molars compared to their uninsured counterparts. CHIP enrollees were also 12 percentage points less likely than uninsured children to be reported as having unmet dental needs and 8 percentage points more likely to have teeth reported to be in excellent/very good condition. CHIP ENROLLEES COMPARED TO PRIVATELY INSURED CHILDREN According to parental reports, children in CHIP tended to have better access to dental benefits and care than children with private insurance (Table). Online Appendix Table 2 provides unadjusted estimates of privately insured children. The parents of CHIP enrollees were 15 percentage points more likely to report having dental benefits compared to parents of privately insured children. However, the parents of CHIP enrollees were 5 percentage points more likely to have trouble finding a dentist to see their child. Even so, CHIP enrollees generally had better access to dental care than privately insured children—they were 7 percentage points more likely to have a usual source of dental care and 8 percentage points more likely to have access to their usual source of dental care in the evenings or on weekends. CHIP enrollees were also 5 percentage points more likely than privately insured children to have had a dental visit or checkup in the past year. Yet the percentage of children reported to have teeth in excellent or very good condition was 7 percentage points higher for privately insured children than for CHIP enrollees. There was no difference in reported unmet need for dental care between the 2 groups.
DISCUSSION Analysis of the 10-state CHIP sample indicated that covered children had considerable access to oral and dental care in 2012. Most had a usual source of dental care, most had a dental checkup or cleaning in the past year, and most of children over age 6 had sealants placed on their molars. In addition, most parents of CHIP enrollees were aware
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that CHIP covers dental benefits, and most did not report having trouble finding a dentist who would see their child. Even so, about 1 in 8 CHIP enrollees had unmet dental needs, and many did not get follow-up dental treatment that had been recommended by a dentist. Another indication of unmet oral health needs among CHIP enrollees was that nearly half were reported to have teeth in less than excellent/very good condition. Further research is needed to understand the factors that impede access to follow-up dental treatment for these children, which may well affect the condition of their teeth. Among children with a special health care need, the relatively high share with unmet dental needs suggested that these children face additional barriers to care relative to other children in CHIP. This is a particularly serious problem because children with a special health care need are at increased risk for oral diseases throughout their lifetime, and there may be a lack of trained providers willing to accept them as patients.18,19 The findings from the comparison analysis showed that children covered by CHIP are much more likely than uninsured children who later enroll in CHIP to have a usual source of dental care, are much more likely to have had a dental checkup in the past year, and are much less likely to have an unmet need for dental care. These findings provide strong evidence that enrolling eligible uninsured children in CHIP will to lead to improvements in their access to preventive dental care, as well as reductions in their unmet dental care needs. Our findings comparing CHIP enrollees with privately insured children who later enroll in CHIP indicated that children covered by CHIP had better dental benefits and access to care; were more likely to have a usual source of dental care; were more likely to have a dental checkup/ cleaning; and were less likely to have an unmet need for dental care. However, parents of children in CHIP were more likely to report having trouble finding a dentist to see their child than were parents of privately insured children. Moreover, although children covered by CHIP appeared to have somewhat greater access to dental care along a number of different measures, compared to children with private coverage, nearly half were reported to have problems with the condition of their teeth. The share of children reported to have problems with the condition of their teeth was nearly as high among the comparison group of privately insured children. This suggests that Medicaid and CHIP could be doing more to address gaps in dental benefits for privately insured children who are eligible for CHIP, as authorized under CHIPRA. It provides further impetus for conducting research to understand the factors that impede access to follow-up dental treatment for such children. These findings are consistent with expectations based on differences between CHIP and private coverage. On the one hand, CHIP’s broader dental benefit packages and lower cost sharing relative to private dental coverage should reduce both financial and nonfinancial barriers to care, and may enhance access. On the other hand, to the
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extent that CHIP reimbursement rates to providers are lower than those of commercial plans,20,21 dentists may be less likely to accept these publicly insured children as new patients compared to privately insured children, which could lead to CHIP enrollees having more problems finding dentists who will accept them compared to children with private dental coverage. This study has 2 key limitations. First, our estimates relied on parental reports of dental care and oral health; they did not verify the receipt of dental care or the assessment of oral health. Previous research has demonstrated the validity of self-reported dental care.22 However, our estimates could be subject to reporting error. Second, despite performing sensitivity analyses, estimates comparing CHIP experiences to uninsured or privately insured experiences may not be indicative of intrinsic differences that are due to possible unobserved differences between CHIP enrollees and the comparison groups. Despite the potential limitations, the findings presented here provide information about children’s access to and use of dental care in CHIP and comparisons to privately insured children. Both CHIPRA and the Affordable Care Act (ACA) include opportunities to expand dental coverage to children who lack access to these benefits. Inclusion of pediatric oral health benefits in the ACA’s Essential Health Benefits requires states to offer some pediatric dental benefits in all nongrandfathered plans in the individual and small group markets inside and outside the state and federally facilitated marketplaces; or stand-alone pediatric dental policies in the state and federally facilitated marketplaces. The comprehensiveness of these benefits is largely left to state discretion, however. The ACA also requires that some pediatric preventive dental benefits, when covered by a nongrandfathered private and employer-sponsored plan, be provided at no out-of-pocket cost. Concerns remain, however, that high premiums, limited benefits, and high cost-sharing requirements associated with the stand-alone pediatric dental plans may combine to put dental coverage out of the reach of many of the targeted low-income families. In addition, federal subsidies for marketplace coverage do not apply to stand-alone pediatric dental plans in at least some states. Even apart from affordability concerns for families, the evidence reported here indicates that addressing the oral health problems of children enrolled in CHIP will likely require more aggressive and effective implementation of outreach and education policies. Potential improvements in pediatric dental health may come from providing more anticipatory guidance to parents with young children on oral health issues so that problems can be avoided.23 This includes promoting good oral health through changes in children’s diets and oral hygiene practices, particularly among the youngest children. In addition, policies that increase access to dental services for those enrolled in CHIP through community health centers, school-based health centers, and private providers will likely support further improvements in oral health. Ultimately, oral health problems are preventable in children, and these findings indicate that CHIP programs are providing critical access to
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dental care but have more work to do in improving oral health.
ACKNOWLEDGMENTS This research was supported by the US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, under contract HHSP23320095642WC/HHSP23337021T. The views expressed in this report are those of the authors and do not necessarily represent those of the US Department of Health and Human Services, the Office of the Assistant Secretary for Planning and Evaluation, the Urban Institute, or Mathematica Policy Research.
SUPPLEMENTARY DATA Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.acap.2015.02.009.
REFERENCES 1. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, Md: Health and Human Services; National Institutes of Health; National Institute of Dental and Craniofacial Research; 2000. 2. Edelstein BL. Putting teeth in CHIP: 1997–2009 retrospective of congressional action on children’s oral health. Acad Pediatr. 2009; 9:467–475. 3. Kenney GM, Ko G, Ormond BA. Gaps in Prevention and Treatment: Dental Care for Low-Income Children. Washington, DC: Urban Institute; 2000. Policy Brief B-15. 4. Kenney GM, McFeeters JR, Yee JY. Preventive dental care and unmet dental needs among low-income children. Am J Public Health. 2005; 95:1360–1366. 5. Yu SM, Bellamy HA, Kogan MD, et al. Factors that influence receipt of recommended preventive pediatric health and dental care. Pediatrics. 2002;110:e73. 6. Romaire MA, Bell JF, Huebner CE. Variations in children’s dental service use based on four national health surveys. Pediatrics. 2012; 130:e1182–e1189. 7. US Department of Health and Human Services. The Department of Health and Human Services 2013 Annual Report on the Quality of Care for Children in Medicaid and CHIP. Washington, DC: US Department of Health and Human Services. Available at: http:// www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/ Quality-of-Care/Downloads/2013-Ann-Sec-Rept.pdf; 2013. Accessed March 17, 2015. 8. Borck R, Vine M, Crall J, et al. Improving oral health care delivery in Medicaid and CHIP: a toolkit for states. Available at: http://www. medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/ Downloads/Oral-Health-Quality-Improvement-Toolkit-for-States. pdf; 2014. Accessed March 17, 2015. 9. Harrington M, Trenholm C, Smith K, et al. CHIPRA 10-State Evaluation: Evaluation Design Report. Princeton, NJ: Mathematica Policy Research. Washington, DC: Urban Institute; 2011. 10. Henry J. Kaiser Family Foundatation. Number of children ever enrolled in the Children’s Health Insurance Program. Available at: http://kff.org/other/state-indicator/annual-chip-enrollment. Accessed March 17, 2015. 11. Smith K, Ingels J, Barrett K, et al. Methods for the 2012 Survey of Medicaid and CHIP Enrollees and Disenrollees. Report submitted to the US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Washington, DC: Mathematica Policy Research; 2014. 12. Clemans-Cope L, Kenney GM, Waidmann T, et al. How well CHIP and Medicaid are addressing health care access and affordability for children. In: Harrington M, Kenney GM, Smith K, et al., eds. CHIPRA Mandated Evaluation of the Children’s Health Insurance Program: Findings from the 2012 Survey of CHIP and Medicaid Enrollees and Disenrollees. Report submitted to the US Department of Health
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22.
23.
MACPAC Contractor Report.. Available at: http://www.urban.org/ publications/1001629.html, 2012;1. American Academy of Pediatric Dentistry. Symposium on lifetime oral health care for patients with special needs. Pediatr Dent. 2007; 29:92–152. American Academy of Pediatric Dentistry. Guideline on Management of Dental Patients with Special Health Care Needs. 2012. Reference Manual 35(6). Available at: http://www.aapd.org/media/Policies_ Guidelines/G_SHCN.pdf. Accessed March 17, 2015. Shirk C. Oral health checkup: progress in tough fiscal times? NHPF Issue Brief. 2010;1–18. Buchmueller TC, Orzol S, Shore-Sheppard LD. The effect of Medicaid payment rates on access to dental care among children. Cambridge, Mass: National Bureau of Economic Research; 2013. NBER Working Paper 19218. Gilbert GH, Litaker MS. Validity of self-reported periodontal status in the Florida dental care study. J Periodontol. 2007;78(7 suppl): 1429–1438. American Academy of Pediatric Dentistry. Guideline on Infant Oral Health Care. Revised 2014. Reference Manual 35(6). Available at: http://www.aapd.org/media/Policies_Guidelines/G_infantOralHealth Care.pdf. Accessed March 17, 2015.
ABSTRACT OBJECTIVE: We examine how access to and use of oral and
to being uninsured, CHIP enrollees did better across nearly all oral health measures. Compared to being privately insured, CHIP enrollees were more likely to have dental benefits, to have a usual source of dental care, and to have had a dental checkup/cleaning, but they were more likely to have trouble finding a dentist and less likely to say that their child’s teeth were in excellent/very good condition. CONCLUSIONS: Enrolling eligible uninsured children in CHIP led to improvements in their access to preventive dental care, as well as reductions in their unmet dental care needs, yet the CHIP program has more work to do to address the oral health problems of children.
dental care under the Children’s Health Insurance Program (CHIP) compared to private coverage and being uninsured in 10 states. METHODS: We report on findings drawn from a 2012 survey of CHIP enrollees in 10 states. We examined a range of parentreported dental care access and use measures among CHIP enrollees. Comparisons of the experiences of established CHIP enrollees to the experiences of newly enrolling children who had been uninsured or privately insured were used to estimate the impacts of CHIP on children’s oral health and dental care. RESULTS: Most children enrolled in CHIP had a usual source of dental care and had received a dental checkup or cleaning in the past year, and most over age 6 had had sealants placed on their molars. In addition, parents of most CHIP enrollees were aware that CHIP covered dental benefits, and most reported not having trouble finding a dentist to see their child. Even so, 12% of CHIP enrollees had unmet dental care needs. Compared
KEYWORDS: access and use of health care; CHIP; dental services; impacts of health insurance coverage; oral health; public health insurance; unmet dental needs
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with separate CHIP plans to provide dental coverage, all children covered by CHIP had coverage for dental services.2 For children who would be eligible for CHIP based on income but who are enrolled in private coverage with limited or no dental benefits, CHIPRA included a provision allowing states with separate CHIP plans to provide supplemental dental coverage. Thus, low-income children who lack access to dental coverage are generally either uninsured children or privately insured children without either private dental benefits or supplemental dental coverage through CHIP. Several studies have examined receipt of dental services among low-income children by age, race/ethnicity, and other characteristics of children and their parents. Previous research has shown that being uninsured is associated with a decreased likelihood of visiting a dentist for children overall and for low-income children.3 Low-income children with no dental insurance are also more likely to have unmet dental needs compared to low-income children with private or public dental insurance.4 Previous research has also demonstrated that children with lower family incomes, those whose parents are black, and those who have a parent
Dental disease is common and preventable among children. The Children’s Health Insurance Program (CHIP) includes pediatric dental coverage. Relative to privately insured children, children enrolled in CHIP have better access to dental benefits and are more likely to have a usual source of dental care and a preventive dental visit, but the condition of their teeth is worse and they have more trouble finding a dentist.
ORAL HEALTH IS an important component of children’s overall health and well-being. Despite recent progress in pediatric oral health care, poor oral health is common among children, and dental caries (tooth decay) is the most common childhood disease.1 Expansions of public health insurance programs after enactment of the Children’s Health Insurance Program (CHIP) in 1997 led to increases in access to dental benefits for low-income children (those in families with incomes at or below 200% of the federal poverty level). After the enactment of Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), which included a provision requiring states ACADEMIC PEDIATRICS Copyright ª 2015 by Academic Pediatric Association
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with less than a college education are less likely to have the recommended number of dental visits and more likely to have postponed dental care.5 Low-income children ages 6 to 12 years are more likely to have had a preventive dental care visit than those who are preschool age (4 to 5 years) or adolescents (13 to 17 years).4 An analysis of 4 national health surveys with data spanning 2003 to 2007 showed that children who were uninsured or publicly insured had a decreased likelihood of any dental care, a decreased likelihood of preventive dental care, and a higher likelihood of delayed dental care compared to privately insured children.6 Other research has shown that ensuring access to oral health and dental services remains a concern for children enrolled in public coverage, as manifested by differences in the rates of preventive and dental treatment services across geographical areas, despite the availability of dental benefits and recent efforts to improve the quality of oral health care for these children.7,8 Here we present evidence on a wide range of outcomes related to the receipt of oral and dental care for children in CHIP compared to those with no insurance and those with private coverage in 10 states. Selected oral and dental health care access and use measures were based on parental report, including perceptions of whether their child has dental benefits; their access to a usual source of dental care; their access to dental providers; the use of dental-related services; the presence of unmet dental health needs; and the condition of their child’s teeth. The analysis was conducted as part of an independent, comprehensive evaluation of CHIP mandated in the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) and conducted by Mathematica Policy Research and its partner, The Urban Institute, on behalf of the secretary of the US Department of Health and Human Services and overseen by the Office of the Assistant Secretary for Planning and Evaluation.9 This is one in a series of articles in this supplement that report on findings from a large 10-state household survey of CHIP enrollees and disenrollees conducted as part of the evaluation. The observed patterns of care may suggest opportunities for improving the oral health of low-income children enrolled in CHIP.
METHODS SURVEY DATA The data for this study were drawn from a telephonebased survey of parents of 12,197 CHIP enrollees and disenrollees in 10 states fielded by Mathematica Policy Research from January 2012 through March 2013 as part of the CHIPRA-mandated evaluation of CHIP. The states included were Alabama, California, Florida, Louisiana, Michigan, New York, Ohio, Texas, Utah, and Virginia. These states were selected because they utilize diverse approaches to providing health insurance coverage for children, represent various geographic areas (including a mix of more rural and more urban states and a variety of races/ethnicities), and each contains a significant portion
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of uninsured children. In 2012, CHIP enrollees in these states represented approximately 57% of CHIP enrollees nationally.10 We used state eligibility and enrollment files to construct the sample frame for each state and randomly selected children (18 years or younger) in 3 strata in each state: 1) established enrollees (children who had been enrolled in CHIP for 12 or more consecutive months at the time of sampling), 2) recent enrollees (children who had been enrolled in CHIP for exactly 3 consecutive months, preceded by a gap in public coverage of at least 2 months, at the time of sampling), and 3) recent disenrollees (children who were disenrolled from the program for exactly 2 months, at the time of sampling, and who were previously enrolled for at least 3 months before the month of disenrollment). Recent CHIP enrollees who transferred from Medicaid or who returned to CHIP after a short gap in public insurance coverage (3 months or less) were excluded from the sampling frame for 2 reasons. First, parents of such CHIP enrollees are often unaware of these coverage transitions and therefore are not able to reliably describe health care experiences before their (re)enrollment in CHIP. Second, because their coverage history reflects a period of public coverage, these children do not represent a useful comparison group for assessing how CHIP differs from private or no insurance coverage. The final survey data included responses from parents of 5518 established enrollees, 4142 recent enrollees, and 2537 disenrollees. The overall survey response rate was 51% for established enrollees, 46% for recent enrollees, and 43% for recent disenrollees. The survey included a wide range of questions related to the sampled child’s current and prior health insurance, health status and needs, and health care use and experiences, many of which were adapted from other large surveys relevant to children’s health. Additional details on the survey, including the questionnaire, are available elsewhere.11 The study was reviewed and approved by the New England Institutional Review Board (NEIRB 12-200). STUDY DESIGN We compared the experiences of established enrollees who had been on the program for at least 1 year to the preenrollment experiences of recent CHIP enrollees. Established enrollees were asked about their experiences during the last 12 months of enrollment, while recent enrollees were asked about their experiences during the 12 months before their enrollment in CHIP. We focused our analyses on comparisons between established enrollees and 2 subgroups of recent enrollees: first, recent enrollees who were uninsured for 5 to 12 months before enrollment, and second, recent enrollees who were privately insured for 12 months before enrollment. (The children who had private insurance may or may not have had dental benefits included in their private coverage.) We used the previously uninsured children to compare CHIP to being uninsured and the children previously insured by a private plan to consider how outcomes differ under CHIP versus private coverage.
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DEPENDENT VARIABLES Five major types of outcome indicators are examined across each analytic group, with all outcomes based on parents reported perceptions of their child’s dental care in the past year: 1) oral health based on the condition of their child’s teeth (excellent or very good vs good, fair, or poor), 2) use rates for different types of dental services, 3) unmet dental needs, 4) perceptions of adequacy of access to dental providers, and 5) presence of and access to a usual source of dental care. Use of dental services is measured as any service use of a particular type during the past year. In addition, to assess parental perception of dental benefits, this analysis also included parental reports of whether their child had dental benefits or coverage for dental services; although all children covered by CHIP have dental coverage, not all parents are aware of these benefits. INDEPENDENT VARIABLES Our key explanatory variable was the insurance status of enrollees during the 12-month recall period. We also included potentially confounding variables, including child’s gender, age, and race/ethnicity; primary language and number of children in the household; parents’ highest education level, employment status, and citizenship; and geographical location at the time of sampling (through a series of state-region dummies). STATISTICAL ANALYSES We used binary dependent variables and estimated linear probability models to generate regression-adjusted differences between established CHIP enrollees and recent enrollees who were previously uninsured and who were previously covered by private insurance. We also conducted a number of sensitivity analyses to address possible unobserved differences between recent and established enrollees. We considered different subsets of established enrollees who were more likely to have been uninsured or privately insured before entering the program. We also considered various subgroups of recent enrollees on the basis of their reasons for enrolling and past service use in case their use of health care services during the year before enrollment was atypically high or low. Finally, we tested the sensitivity of our results to including different geographic control variables in the model, which address possible confounding due to differences in local health care markets. The results presented here are robust to these alternative specifications.12 All analyses used survey weights generated to account for the complex, multistage sampling design of the survey and nonresponse bias.11
RESULTS CHARACTERISTICS OF ESTABLISHED AND RECENT CHIP ENROLLEES Established CHIP enrollees in the 10 study states represent a diverse population of children primarily living in low-income households with working parents (Online Appendix Table 1). Over half of the enrollees (54%) are Hispanic, reflecting the large Hispanic populations in
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several large sample states. A large majority of enrollees live in households with incomes less than 150% of the federal poverty level (69%) and with at least one working parent (87%). CHIP enrollees are generally healthy, but over one-fourth have at least 1 special health care need, and 7% of enrollees had fair or poor parent-reported overall health. The sociodemographic and health characteristics of established CHIP enrollees vary significantly across the 10 states in this study. Compared to established CHIP enrollees, previously uninsured recent enrollees tended to be younger and have lower income, and were more likely to be Hispanic. Compared to established enrollees, recent CHIP enrollees coming from private insurance tended to be younger, to be in better health, and to have more educated parents and higher incomes; they were also more likely to be non-Hispanic white and have parents who are US citizens. As noted above, our models controlled for these potentially confounding differences between the treatment and comparison groups. ORAL HEALTH OUTCOMES BASED ON PARENTAL REPORTS CHIP ENROLLEES The key outcomes for this analysis were the oral and dental health characteristics of the CHIP sample. Over 90% of parents of CHIP-covered children reported that their children had dental health benefits (Table). Only slightly fewer said that they had no trouble finding a dentist who would see their children (89%) and that their child had a usual source of dental care (87%); almost three quarters (72%) said that scheduling appointments with the child’s usual source of dental care or another dentist was easy. However, only 38% of the places named were reported to be accessible at night or on weekends. Most CHIP enrollees (84%) had a preventive visit to a dentist in the past year, exceeding the targets in Healthy People 2020.13 Parents of 37% of children with a preventive dental visit reported that the dentist recommended follow-up treatment. Of those receiving such a recommendation, only 68% had a dental procedure during the past year, suggesting that nearly one-third of CHIP enrollees who needed follow-up care did not receive it. Sealants to reduce the risk of pit and fissure cavities in primary and permanent teeth susceptible to plaque retention are recommended for children younger than 6.14 Slightly over half (54%) of CHIP enrollees over age 6 were reported to have had dental sealants placed on their molars, exceeding the targets in Healthy People 2020.13 Only half of CHIP enrollees (52%) were reported to have teeth in excellent/very good condition. Because parents tend to overreport that their child’s dental health is good, this is probably an overestimate.* In addition, 12% of
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* Sanzone et al.15 found that parental reports of preventive oral health behaviors is influenced by the effects of social desirability bias, a form of response bias in which individuals misrepresent self-reported behaviors by overreporting behaviors considered socially desirable and underreporting undesirable ones. Although we do not present findings related to parental reports of the condition of children’s teeth, it is possible and likely that poor outcomes on this measure may also be underreported.
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Table. Parental Perceptions of Dental Benefits, Access to and Use of Dental Care, and Unmet Needs of Children in CHIP Compared to Uninsured or Privately Insured Children, 2012 (10-State Pooled, Regression-Adjusted Differences) Weighted Percentage or Percentage Point Difference (SE) Percentage Point Difference Between CHIP and Other Coverage (Regression Adjusted)
Characteristic Parental perception of dental benefits Has dental benefits or coverage for dental services Access to care based on parent reports Had usual source of dental care Usual source of dental care has or night or weekend hours Provider accessibility based on parent reports No trouble finding a dentist Usually/always easy to get appointments with dental provider Service use based on parent reports Any dental visit for checkup or cleaning Dentist recommend additional or follow-up treatment Dental procedure, such as having a cavity treated or a tooth pulled Ever had dental sealants placed on back teeth (molars; if age >6 y) Dental sealants placed at dentist’s office Dental sealants placed through a school program DK/Ref where dental sealants placed Unmet needs based on parent reports Dental care (if age >12 mo) Any unmet need Parental perception of child’s oral health Excellent or very good Good/fair/poor DK/Ref
Percentage of CHIP Versus Private CHIP Enrollees in 10 CHIP Versus Uninsured Insurance Before States (Unadjusted)† Before Enrollment‡ Enrollment§ 91.5 (0.5)
67.1 (2.3)**
14.7 (2.1)**
87.2 (0.7) 37.7 (1.0)
38.2 (2.6)** 3.4 (3.6)
6.8 (2.0)** 7.5 (3.1)*
88.6 (0.6) 72.0 (0.9)
7.8 (2.3)** 18.2 (3.1)**
4.9 (1.8)** 2.6 (2.6)
84.0 (0.7) 36.8 (1.0) 67.8 (1.5) 54.1 (1.0) 97.0 (0.5) 2.7 (0.9) 0.4 (0.2)
38.6 (2.6)** 2.4 (3.9) 4.0 (5.7) 13.4 (3.0)** 4.6 (2.8) 4.9 (2.7) 0.3 (0.2)
5.3 (2.1)* 4.9 (3.1) 0.9 (5.7) 1.9 (3.2) 0.4 (1.3) 0.1 (1.3) 0.3 (0.2)
11.6 (0.6) 24.3 (0.8)
12.1 (2.3)** 11.9 (2.5)**
0.4 (1.9) 2.9 (2.4)
52.4 (0.9) 47.6 (0.9) 0.1 (0.0)
8.0 (2.6)** 8.0 (2.6)** 0.1 (0.0)
7.1 (2.6)** 7.1 (2.6)** 0.2 (0.2)
CHIP indicates Children’s Health Insurance Program; DK/Ref, don’t know or refused to answer. Notes: The regression-adjusted differences derived from multivariate regression models control for age, sex; race/ethnicity and language groups, more than 3 children in the household, highest education of any parent, parents’ employment status, parent citizenship, and local area or county. Sample sizes differ across outcome indicators due to differences in response rates and survey skip patterns. “No out-of-pocket costs” includes those who indicated out-of-pocket costs but then said they had no problem paying, or later indicated they paid $0 in out-ofpocket costs. Values are statistically different from CHIP enrollees at the *P ¼ .05 or **P ¼ .01 level. †CHIP enrollees are those continuously enrolled in CHIP for at least 12 months at time of sampling. ‡Uninsured children had 5 or more months without any coverage in the past 12 mo. §Privately insured children had 12 mo of private coverage in the past 12 mo. Source: 2012 Congressionally Mandated Survey of CHIP and Medicaid Enrollees and Disenrollees. Survey states included Alabama, California, Florida, Louisiana, Michigan, New York, Ohio, Texas, Utah, and Virginia.
CHIP enrollees were reported to have had an unmet dental care need. Dental care was the most frequently cited unmet health need reported in the CHIP survey, a result consistent with prior studies.16,17 Although there were similar patterns across subgroups for most outcomes, there were several significant differences in the dental experiences among subgroups of CHIP enrollees (data not shown). Younger children (ages 1 to 5 years old) were less likely to have had a dental checkup or cleaning than older children (69% for younger children vs 89% for children ages 6 to 12, and 84% for children ages 13 to 18 years old). Children with a special health care need were more likely to have unmet dental needs compared to children with no special health care need (16% vs 10%). Hispanic children in families speaking mainly Spanish were less likely than those speaking mainly English or non-Hispanic white children to have teeth reported to be in excellent/good condition (35% for Hispanic children in families speaking mainly Spanish vs 59% and
67% for the other 2 groups, respectively). Finally, children whose resident parent did not complete high school were considerably less likely to have teeth reported to be in excellent/good condition than children with bettereducated parents (36% vs 57%). CHIP ENROLLEES COMPARED TO UNINSURED CHILDREN According to parental reports, children enrolled in CHIP had better access to dental benefits and care than the preCHIP experiences of the children who had been uninsured before enrolling (Table). Comparisons are based on regression-adjusted demographic and socioeconomic differences that control for observed differences between the 2 groups. Online Appendix Table 2 provides unadjusted estimates of uninsured children. The parents of uninsured children were 67 percentage points less likely to report that the child had dental coverage compared to the parents of CHIP enrollees. In addition, the parents of uninsured children appeared to have lower
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awareness of the need for dental care among children, as these parents were 8 percentage points more likely to report that their child does not need a dentist (data not shown). CHIP enrollees were 38 percentage points more likely than uninsured children to have a usual source of dental care. The parents of CHIP enrollees were 18 percentage points more likely to report that scheduling appointments with the child’s usual source of dental care was usually easy compared the parents of uninsured children. Receipt of preventive services was more common among CHIP enrollees compared to uninsured children, with CHIP enrollees 38 percentage points more likely to have had a dental checkup/cleaning in the past year. No significant difference between CHIP and uninsured was detected in the proportions recommended for additional follow-up treatment or in the proportions of those with recommended follow-up treatment who had a subsequent visit. CHIP enrollees over age 6 were 13 percentage points more likely to have had dental sealants placed on their molars compared to their uninsured counterparts. CHIP enrollees were also 12 percentage points less likely than uninsured children to be reported as having unmet dental needs and 8 percentage points more likely to have teeth reported to be in excellent/very good condition. CHIP ENROLLEES COMPARED TO PRIVATELY INSURED CHILDREN According to parental reports, children in CHIP tended to have better access to dental benefits and care than children with private insurance (Table). Online Appendix Table 2 provides unadjusted estimates of privately insured children. The parents of CHIP enrollees were 15 percentage points more likely to report having dental benefits compared to parents of privately insured children. However, the parents of CHIP enrollees were 5 percentage points more likely to have trouble finding a dentist to see their child. Even so, CHIP enrollees generally had better access to dental care than privately insured children—they were 7 percentage points more likely to have a usual source of dental care and 8 percentage points more likely to have access to their usual source of dental care in the evenings or on weekends. CHIP enrollees were also 5 percentage points more likely than privately insured children to have had a dental visit or checkup in the past year. Yet the percentage of children reported to have teeth in excellent or very good condition was 7 percentage points higher for privately insured children than for CHIP enrollees. There was no difference in reported unmet need for dental care between the 2 groups.
DISCUSSION Analysis of the 10-state CHIP sample indicated that covered children had considerable access to oral and dental care in 2012. Most had a usual source of dental care, most had a dental checkup or cleaning in the past year, and most of children over age 6 had sealants placed on their molars. In addition, most parents of CHIP enrollees were aware
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that CHIP covers dental benefits, and most did not report having trouble finding a dentist who would see their child. Even so, about 1 in 8 CHIP enrollees had unmet dental needs, and many did not get follow-up dental treatment that had been recommended by a dentist. Another indication of unmet oral health needs among CHIP enrollees was that nearly half were reported to have teeth in less than excellent/very good condition. Further research is needed to understand the factors that impede access to follow-up dental treatment for these children, which may well affect the condition of their teeth. Among children with a special health care need, the relatively high share with unmet dental needs suggested that these children face additional barriers to care relative to other children in CHIP. This is a particularly serious problem because children with a special health care need are at increased risk for oral diseases throughout their lifetime, and there may be a lack of trained providers willing to accept them as patients.18,19 The findings from the comparison analysis showed that children covered by CHIP are much more likely than uninsured children who later enroll in CHIP to have a usual source of dental care, are much more likely to have had a dental checkup in the past year, and are much less likely to have an unmet need for dental care. These findings provide strong evidence that enrolling eligible uninsured children in CHIP will to lead to improvements in their access to preventive dental care, as well as reductions in their unmet dental care needs. Our findings comparing CHIP enrollees with privately insured children who later enroll in CHIP indicated that children covered by CHIP had better dental benefits and access to care; were more likely to have a usual source of dental care; were more likely to have a dental checkup/ cleaning; and were less likely to have an unmet need for dental care. However, parents of children in CHIP were more likely to report having trouble finding a dentist to see their child than were parents of privately insured children. Moreover, although children covered by CHIP appeared to have somewhat greater access to dental care along a number of different measures, compared to children with private coverage, nearly half were reported to have problems with the condition of their teeth. The share of children reported to have problems with the condition of their teeth was nearly as high among the comparison group of privately insured children. This suggests that Medicaid and CHIP could be doing more to address gaps in dental benefits for privately insured children who are eligible for CHIP, as authorized under CHIPRA. It provides further impetus for conducting research to understand the factors that impede access to follow-up dental treatment for such children. These findings are consistent with expectations based on differences between CHIP and private coverage. On the one hand, CHIP’s broader dental benefit packages and lower cost sharing relative to private dental coverage should reduce both financial and nonfinancial barriers to care, and may enhance access. On the other hand, to the
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extent that CHIP reimbursement rates to providers are lower than those of commercial plans,20,21 dentists may be less likely to accept these publicly insured children as new patients compared to privately insured children, which could lead to CHIP enrollees having more problems finding dentists who will accept them compared to children with private dental coverage. This study has 2 key limitations. First, our estimates relied on parental reports of dental care and oral health; they did not verify the receipt of dental care or the assessment of oral health. Previous research has demonstrated the validity of self-reported dental care.22 However, our estimates could be subject to reporting error. Second, despite performing sensitivity analyses, estimates comparing CHIP experiences to uninsured or privately insured experiences may not be indicative of intrinsic differences that are due to possible unobserved differences between CHIP enrollees and the comparison groups. Despite the potential limitations, the findings presented here provide information about children’s access to and use of dental care in CHIP and comparisons to privately insured children. Both CHIPRA and the Affordable Care Act (ACA) include opportunities to expand dental coverage to children who lack access to these benefits. Inclusion of pediatric oral health benefits in the ACA’s Essential Health Benefits requires states to offer some pediatric dental benefits in all nongrandfathered plans in the individual and small group markets inside and outside the state and federally facilitated marketplaces; or stand-alone pediatric dental policies in the state and federally facilitated marketplaces. The comprehensiveness of these benefits is largely left to state discretion, however. The ACA also requires that some pediatric preventive dental benefits, when covered by a nongrandfathered private and employer-sponsored plan, be provided at no out-of-pocket cost. Concerns remain, however, that high premiums, limited benefits, and high cost-sharing requirements associated with the stand-alone pediatric dental plans may combine to put dental coverage out of the reach of many of the targeted low-income families. In addition, federal subsidies for marketplace coverage do not apply to stand-alone pediatric dental plans in at least some states. Even apart from affordability concerns for families, the evidence reported here indicates that addressing the oral health problems of children enrolled in CHIP will likely require more aggressive and effective implementation of outreach and education policies. Potential improvements in pediatric dental health may come from providing more anticipatory guidance to parents with young children on oral health issues so that problems can be avoided.23 This includes promoting good oral health through changes in children’s diets and oral hygiene practices, particularly among the youngest children. In addition, policies that increase access to dental services for those enrolled in CHIP through community health centers, school-based health centers, and private providers will likely support further improvements in oral health. Ultimately, oral health problems are preventable in children, and these findings indicate that CHIP programs are providing critical access to
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dental care but have more work to do in improving oral health.
ACKNOWLEDGMENTS This research was supported by the US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, under contract HHSP23320095642WC/HHSP23337021T. The views expressed in this report are those of the authors and do not necessarily represent those of the US Department of Health and Human Services, the Office of the Assistant Secretary for Planning and Evaluation, the Urban Institute, or Mathematica Policy Research.
SUPPLEMENTARY DATA Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.acap.2015.02.009.
REFERENCES 1. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, Md: Health and Human Services; National Institutes of Health; National Institute of Dental and Craniofacial Research; 2000. 2. Edelstein BL. Putting teeth in CHIP: 1997–2009 retrospective of congressional action on children’s oral health. Acad Pediatr. 2009; 9:467–475. 3. Kenney GM, Ko G, Ormond BA. Gaps in Prevention and Treatment: Dental Care for Low-Income Children. Washington, DC: Urban Institute; 2000. Policy Brief B-15. 4. Kenney GM, McFeeters JR, Yee JY. Preventive dental care and unmet dental needs among low-income children. Am J Public Health. 2005; 95:1360–1366. 5. Yu SM, Bellamy HA, Kogan MD, et al. Factors that influence receipt of recommended preventive pediatric health and dental care. Pediatrics. 2002;110:e73. 6. Romaire MA, Bell JF, Huebner CE. Variations in children’s dental service use based on four national health surveys. Pediatrics. 2012; 130:e1182–e1189. 7. US Department of Health and Human Services. The Department of Health and Human Services 2013 Annual Report on the Quality of Care for Children in Medicaid and CHIP. Washington, DC: US Department of Health and Human Services. Available at: http:// www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/ Quality-of-Care/Downloads/2013-Ann-Sec-Rept.pdf; 2013. Accessed March 17, 2015. 8. Borck R, Vine M, Crall J, et al. Improving oral health care delivery in Medicaid and CHIP: a toolkit for states. Available at: http://www. medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/ Downloads/Oral-Health-Quality-Improvement-Toolkit-for-States. pdf; 2014. Accessed March 17, 2015. 9. Harrington M, Trenholm C, Smith K, et al. CHIPRA 10-State Evaluation: Evaluation Design Report. Princeton, NJ: Mathematica Policy Research. Washington, DC: Urban Institute; 2011. 10. Henry J. Kaiser Family Foundatation. Number of children ever enrolled in the Children’s Health Insurance Program. Available at: http://kff.org/other/state-indicator/annual-chip-enrollment. Accessed March 17, 2015. 11. Smith K, Ingels J, Barrett K, et al. Methods for the 2012 Survey of Medicaid and CHIP Enrollees and Disenrollees. Report submitted to the US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Washington, DC: Mathematica Policy Research; 2014. 12. Clemans-Cope L, Kenney GM, Waidmann T, et al. How well CHIP and Medicaid are addressing health care access and affordability for children. In: Harrington M, Kenney GM, Smith K, et al., eds. CHIPRA Mandated Evaluation of the Children’s Health Insurance Program: Findings from the 2012 Survey of CHIP and Medicaid Enrollees and Disenrollees. Report submitted to the US Department of Health
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