Medicaid
Extent of Dental Disease in Children Has Not Decreased, and Millions Are Estimated to Have Untreated Tooth Decay Gao ID: GAO-08-1121 September 23, 2008In recent years, concerns have been raised about the adequacy of dental care for low-income children. Attention to this subject became more acute due to the widely publicized case of Deamonte Driver, a 12-year-old boy who died as a result of an untreated infected tooth that led to a fatal brain infection. Deamonte had health coverage through Medicaid, a joint federal and state program that provides health care coverage, including dental care, for millions of low-income children. Deamonte had extensive dental disease and his family was unable to find a dentist to treat him. GAO was asked to examine the extent to which children in Medicaid experience dental disease, the extent to which they receive dental care, and how these conditions have changed over time. To examine these indicators of oral health, GAO analyzed data for children ages 2 through 18, by insurance status, from two nationally representative surveys conducted by the Department of Health and Human Services (HHS): the National Health and Nutrition Examination Survey (NHANES) and the Medical Expenditure Panel Survey (MEPS). GAO also interviewed officials from the Centers for Disease Control and Prevention, and dental associations and researchers. In commenting on a draft of the report, HHS acknowledged the challenge of providing dental services to children in Medicaid, and cited a number of studies and actions taken to address the issue.
Dental disease remains a significant problem for children aged 2 through 18 in Medicaid. Nationally representative data from the 1999 through 2004 NHANES surveys--which collected information about oral health through direct examinations--indicate that about one in three children in Medicaid had untreated tooth decay, and one in nine had untreated decay in three or more teeth. Projected to 2005 enrollment levels, GAO estimates that 6.5 million children aged 2 through 18 in Medicaid had untreated tooth decay. Children in Medicaid remain at higher risk of dental disease compared to children with private health insurance; children in Medicaid were almost twice as likely to have untreated tooth decay. Receipt of dental care also remains a concern for children aged 2 through 18 in Medicaid. Nationally representative data from the 2004 through 2005 MEPS survey--which asks participants about the receipt of dental care for household members--indicate that only one in three children in Medicaid ages 2 through 18 had received dental care in the year prior to the survey. Similarly, about one in eight children reportedly never sees a dentist. More than half of children with private health insurance, by contrast, had received dental care in the prior year. Children in Medicaid also fared poorly when compared to national benchmarks, as the percentage of children in Medicaid who received any dental care--37 percent--was far below the Healthy People 2010 target of having 66 percent of low-income children under age 19 receive a preventive dental service. Survey data on Medicaid children's receipt of dental care showed some improvement; for example, use of sealants went up significantly between the 1988 through 1994 and 1999 through 2004 time periods. Rates of dental disease, however, did not decrease, although the data suggest the trends vary somewhat among different age groups. Younger children in Medicaid--those aged 2 through 5--had statistically significant higher rates of dental disease in the more recent time period as compared to earlier surveys. By contrast, data for Medicaid adolescents aged 16 through 18 show declining rates of tooth decay, although the change was not statistically significant.
GAO-08-1121, Medicaid: Extent of Dental Disease in Children Has Not Decreased, and Millions Are Estimated to Have Untreated Tooth Decay
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Decreased, and Millions Are Estimated to Have Untreated Tooth Decay'
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
September 2008:
Medicaid:
Extent of Dental Disease in Children Has Not Decreased, and Millions
Are Estimated to Have Untreated Tooth Decay:
GAO-08-1121:
GAO Highlights:
Highlights of GAO-08-1121, a report to congressional requesters.
Why GAO Did This Study:
In recent years, concerns have been raised about the adequacy of dental
care for low-income children. Attention to this subject became more
acute due to the widely publicized case of Deamonte Driver, a 12-year-
old boy who died as a result of an untreated infected tooth that led to
a fatal brain infection. Deamonte had health coverage through Medicaid,
a joint federal and state program that provides health care coverage,
including dental care, for millions of low-income children. Deamonte
had extensive dental disease and his family was unable to find a
dentist to treat him.
GAO was asked to examine the extent to which children in Medicaid
experience dental disease, the extent to which they receive dental
care, and how these conditions have changed over time. To examine these
indicators of oral health, GAO analyzed data for children ages 2
through 18, by insurance status, from two nationally representative
surveys conducted by the Department of Health and Human Services (HHS):
the National Health and Nutrition Examination Survey (NHANES) and the
Medical Expenditure Panel Survey (MEPS). GAO also interviewed officials
from the Centers for Disease Control and Prevention, and dental
associations and researchers.
In commenting on a draft of the report, HHS acknowledged the challenge
of providing dental services to children in Medicaid, and cited a
number of studies and actions taken to address the issue.
What GAO Found:
Dental disease remains a significant problem for children aged 2
through 18 in Medicaid. Nationally representative data from the 1999
through 2004 NHANES surveys”which collected information about oral
health through direct examinations”indicate that about one in three
children in Medicaid had untreated tooth decay, and one in nine had
untreated decay in three or more teeth (see figure). Projected to 2005
enrollment levels, GAO estimates that 6.5 million children aged 2
through 18 in Medicaid had untreated tooth decay. Children in Medicaid
remain at higher risk of dental disease compared to children with
private health insurance; children in Medicaid were almost twice as
likely to have untreated tooth decay.
Receipt of dental care also remains a concern for children aged 2
through 18 in Medicaid. Nationally representative data from the 2004
through 2005 MEPS survey”which asks participants about the receipt of
dental care for household members”indicate that only one in three
children in Medicaid ages 2 through 18 had received dental care in the
year prior to the survey. Similarly, about one in eight children
reportedly never sees a dentist. More than half of children with
private health insurance, by contrast, had received dental care in the
prior year. Children in Medicaid also fared poorly when compared to
national benchmarks, as the percentage of children in Medicaid who
received any dental care”37 percent”was far below the Healthy People
2010 target of having 66 percent of low-income children under age 19
receive a preventive dental service.
Survey data on Medicaid children‘s receipt of dental care showed some
improvement; for example, use of sealants went up significantly between
the 1988 through 1994 and 1999 through 2004 time periods. Rates of
dental disease, however, did not decrease, although the data suggest
the trends vary somewhat among different age groups. Younger children
in Medicaid”those aged 2 through 5”had statistically significant higher
rates of dental disease in the more recent time period as compared to
earlier surveys. By contrast, data for Medicaid adolescents aged 16
through 18 show declining rates of tooth decay, although the change was
not statistically significant.
Proportion of Children in Medicaid Aged 2 through 18 with Tooth Decay,
Untreated Tooth Decay, and Untreated Tooth Decay in Three or More
Teeth, 1999-2004:
[refer to PDF for image]
* About three in five children (62%) had experienced tooth decay.
* About one in three children (33%) had tooth decay that had not been
treated.
* Close to one in nine children (11%) had untreated tooth decay in
three or more teeth, which can be a sign of a more severe oral health
problem or higher levels of unmet need.
Source: GAO analysis of 1999 through 2004 NHANES survey data.
[End of figure]
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-1121]. For more
information, contact James Cosgrove at (202) 512-7114 or
cosgrovej@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Dental Disease and Inadequate Receipt of Dental Care Remain Significant
Problems for Children in Medicaid:
Concluding Observations:
Agency Comments:
Appendix I: NHANES Analysis:
Appendix II: MEPS Background and Analysis:
Appendix III: Comments from the Department of Health and Human
Services:
Appendix IV: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Percentage of Children Aged 2 through 18 Who Have Experienced
Tooth Decay, by Health Insurance Status, 1988-1994 and 1999-2004:
Table 2: Percentage of Children Aged 2 through 18 with Untreated Tooth
Decay, by Health Insurance Status, 1988-1994 and 1999-2004:
Table 3: Percentage of Children Aged 2 through 18 with Untreated Tooth
Decay in Three or More Teeth, by Health Insurance Status, 1988-1994 and
1999-2004:
Table 4: Percentage of Children Aged 6 through 18 with Dental Sealants,
by Health Insurance Status, 1988-1994 and 1999-2004:
Table 5: Percentage of Children Aged 2 through 18 with an Urgent Need
for Dental Care, by Health Insurance Status, 1999-2004:
Table 6: Percentage of Children Aged 2 through 18 Who Had Received
Dental Care in the Previous Year, by Health Insurance Status, 1996-1997
and 2004-2005:
Table 7: Percentage of Children Aged 2 through 18 Who Never See a
Dentist, by Health Insurance Status, 1996-1997 and 2004-2005:
Table 8: Percentage of Children Aged 2 through 18 Who Were Unable to
Access Necessary Dental Care, by Health Insurance Status, 2004-2005:
Table 9: Reasons for Children's Inability to Access Necessary Dental
Care, by Health Insurance Status, 2004-2005:
Figures:
Figure 1: Tooth Decay and Its Possible Adverse Outcomes if Untreated:
Figure 2: Proportion of Children in Medicaid Aged 2 through 18 with
Tooth Decay, Untreated Tooth Decay, and Untreated Tooth Decay in Three
or More Teeth, 1999-2004:
Figure 3: Percentage of Children Aged 2 through 18 with Untreated Tooth
Decay, by Age and Insurance Status, 1999-2004:
Figure 4: Proportion of Children in Medicaid Nationwide Not Receiving
Dental Care or Unable to Access Dental Care, 2004-2005:
Figure 5: Percentage of Children in Medicaid Nationwide Who Received
Dental Care in the Previous Year, by Age and Insurance Status, 2004-
2005:
Figure 6: Surveyed Measures of Tooth Decay Rates, by Insurance Status,
1988-1994 and 1999-2004:
Figure 7: Surveyed Measures of Children Who Visited a Dentist in the
Previous Year, by Insurance Status, 1996-1997 and 2004-2005:
Abbreviations:
AAPD: American Academy of Pediatric Dentistry:
AHRQ: Agency for Healthcare Research and Quality:
CDC: Centers for Disease Control and Prevention:
CMS: Centers for Medicare & Medicaid Services:
EPSDT: Early and Periodic Screening, Diagnostic, and Treatment:
HHS: Department of Health and Human Services:
MEPS: Medical Expenditure Panel Survey:
NHANES: National Health and Nutrition Examination Survey:
SCHIP: State Children's Health Insurance Program:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
September 23, 2008:
The Honorable Dennis J. Kucinich:
Chairman:
Subcommittee on Domestic Policy:
Committee on Oversight and Government Reform:
House of Representatives:
The Honorable Elijah E. Cummings:
House of Representatives:
In recent years, concerns have been raised about the adequacy of dental
care for low-income children. Attention to this subject became more
acute due to the widely publicized case of Deamonte Driver, a 12-year-
old boy who died as a result of an untreated infected tooth that led to
a fatal brain infection. Deamonte had health coverage through Medicaid,
a joint federal and state program that provides health care coverage,
including dental care, for millions of low-income children. Even though
Deamonte was entitled to dental care from his Medicaid managed care
organization, Deamonte's family had experienced significant
difficulties in obtaining needed dental care, including finding a
dentist in their Maryland neighborhood who would accept Medicaid
patients.[Footnote 1]
May 2007 and February 2008 congressional hearings investigated the
effectiveness of federal oversight of state Medicaid dental programs by
the Department of Health and Human Services' (HHS) Centers for Medicare
& Medicaid Services (CMS), the agency that oversees state Medicaid
programs at the federal level. Concerns raised at the hearings about
low-income children's oral health, including the extent that children
in Medicaid experience dental disease and receive dental care, are not
new. Our reports dating back to 2000 highlighted the problem of chronic
dental disease and the factors that contribute to low use of dental
care by low-income populations, including children in Medicaid.
[Footnote 2]
You asked us to examine two aspects of children's oral health: the
extent to which children in Medicaid experience dental disease and the
extent to which they receive dental care. You also asked us to assess
how these conditions have changed over time. This report presents
information from national health surveys on key indicators of the oral
health status of children in Medicaid, specifically, the rate of dental
disease and their receipt of dental care, and changes in these
indicators over time.[Footnote 3] To determine the extent to which
children in Medicaid experience dental disease, we analyzed data from a
survey conducted by HHS--the National Health and Nutrition Examination
Survey (NHANES). NHANES--administered by the Centers for Disease
Control and Prevention's (CDC) National Center for Health Statistics--
obtains nationally representative information on the health and
nutritional status of the U.S. population through direct physical
examinations, including dental examinations, and interviews. The dental
examinations include a dentist's assessment of tooth decay and the
presence of dental sealants, and the interviews include questions on
various health and demographic characteristics, including information
on insurance status. We grouped NHANES survey data from 1999 through
2004 (the most recent data based on direct oral examinations by
dentists available)[Footnote 4] in order to include a sufficient number
of examinations to provide a reliable basis for assessing the extent of
dental disease in the Medicaid population of children aged 2 through
18.[Footnote 5] To assess how the rate of dental disease experienced by
children in Medicaid has changed over time, we compared NHANES data
from 1999 through 2004 with NHANES data from 1988 through 1994. We
analyzed results from three different groups based on their health
insurance status: children with Medicaid, children with private health
insurance, and uninsured children. The group of children with private
insurance included both children with dental coverage and children
without dental coverage,[Footnote 6] while the group of uninsured was
children who had neither health insurance nor dental insurance.
To assess children's receipt of dental care, we analyzed data from
another HHS survey, the Medical Expenditure Panel Survey (MEPS). MEPS-
-administered by HHS's Agency for Healthcare Research and Quality
(AHRQ)--obtains nationally representative information on Americans'
health insurance coverage and use of health care, including information
on receipt of dental care, such as how often participants see a dentist
and whether they have experienced problems accessing needed dental
care. Our MEPS analysis was based on surveys conducted in 2004 and 2005
(the most recent data available); to assess how receipt of dental care
has changed over time, we compared the data from 2004 and 2005 with the
earliest available MEPS data, from 1996 and 1997. We analyzed the MEPS
data using the same three insurance groups we used for the NHANES data.
To estimate the number of children in each Medicaid category with a
given condition, we applied certain proportions from NHANES or MEPS
data to an estimate of the 2005 average monthly Medicaid enrollment of
children aged 2 through 18 (20.1 million children). Similar to NHANES,
the Medicaid category included children enrolled in the State
Children's Health Insurance Program (SCHIP) for the later time period
(2004 through 2005 for MEPS).[Footnote 7] To assess the reliability of
NHANES and MEPS data, we spoke with knowledgeable agency officials,
reviewed related documentation, and compared our results to published
data. We determined these data to be reliable for the purposes of this
report. Appendixes I and II contain more information on our NHANES and
MEPS analyses. Finally, we obtained information on oral health and the
Medicaid population from CDC and from dental associations and experts
including the Children's Health Dental Project and the Medicaid/SCHIP
Dental Association. This work was conducted in accordance with
generally accepted government auditing standards from December 2007
through September 2008.
Results in Brief:
Dental disease and inadequate receipt of dental care remain significant
problems for children in Medicaid. Nationally representative survey
data from 1999 through 2004 indicate that about one in three children
aged 2 through 18 in Medicaid had untreated tooth decay, and one in
nine had untreated decay in three or more teeth. Projecting the survey
results to the 2005 average monthly Medicaid enrollment of 20.1 million
children, we estimate that 6.5 million children aged 2 through 18 in
Medicaid had untreated tooth decay. Children in Medicaid remain at
higher risk of dental disease compared to children who have private
health insurance; children in Medicaid were almost twice as likely to
have untreated tooth decay.
Survey data from 2004 and 2005 showed that only about one in three
children in Medicaid had received dental care in the prior year; about
one in eight children reportedly never sees the dentist. More than half
of children with private health insurance, by contrast, had received
dental care in the prior year. Children in Medicaid also fared poorly
when compared to national benchmarks, as the percentage of children in
Medicaid who received any dental care--37 percent--was far below HHS's
Healthy People 2010 target of having 66 percent of low-income children
under age 19 receive a preventive dental service in the prior year.
Survey data on Medicaid children's receipt of dental care showed some
improvement for children in more recent surveys. For example,
comparison of NHANES survey data from 1988 through 1994 to more recent
data from 1999 through 2004 showed that the percentage of children aged
6 through 18 in Medicaid with at least one dental sealant increased
nearly threefold, from 10 percent in 1988 through 1994 to 28 percent in
1999 through 2004. However, over the same time periods, dental disease
in the overall Medicaid population aged 2 through 18 did not decrease,
although the data suggest the trends vary somewhat among different age
groups. Younger children--those aged 2 through 5--had statistically
significant higher rates of dental disease in the more recent time
period examined as compared to earlier surveys. By contrast, data for
adolescents--children in Medicaid aged 16 through 18--show declining
rates of tooth decay, although the change was not statistically
significant.
We provided a draft of this report for comment to HHS. HHS provided
written comments, including comments from CMS, CDC, and AHRQ, and
technical comments which we incorporated as appropriate. CMS
acknowledged the challenge of providing dental services to children in
Medicaid, as well as all children nationwide, and cited a number of
activities undertaken by CMS in coordination with states. CDC commented
that trends in dental caries (tooth decay) vary by age group and for
primary versus permanent teeth. We revised our report to further
clarify the trends by age group, and note that due to sample sizes, we
were unable to comment further on trends in the Medicaid child
population by both age and by dentition (primary versus permanent
teeth). We also added information on CDC's findings in the general
population. AHRQ commented that its own work on dental use, expenses,
dental coverage and changes had not been cited and sought additional
clarification on the methodology we used to analyze the data. We
revised our report to cite AHRQ's findings on dental services for
children and to further describe our methodology.
Background:
In 2000, a report of the Surgeon General noted that tooth decay is the
most common chronic childhood disease.[Footnote 8] Left untreated, the
pain and infections caused by tooth decay may lead to problems in
eating, speaking, and learning. Tooth decay is almost completely
preventable, and the pain, dysfunction, or on extremely rare occasion,
death, resulting from dental disease can be avoided (see fig. 1).
Preventive dental care can make a significant difference in health
outcomes and has been shown to be cost-effective. For example, a 2004
study found that average dental-related costs for low-income preschool
children who had their first preventive dental visit by age 1 were less
than one-half ($262 compared to $546) of average costs for children who
received their first preventive visit at age 4 through 5.[Footnote 9]
Figure 1: Tooth Decay and Its Possible Adverse Outcomes if Untreated:
[See PDF for image]
This figure contains two illustrations, as well as the following
descriptive text:
What is tooth decay?
The American Academy of Pediatric Dentistry describes dental caries
(commonly known as cavities or tooth decay) as a process where bacteria
in the mouth formacids which demineralize tooth enamel. Tooth decay can
be prevented by good oral health practices, such as brushing with
flouride toothpaste regularly, but if not treated, could result in
pain, infection, and tooth loss.
How can tooth decay lead to death?
Untreated tooth decay can penetrate the tooth surface, allowing
bacteria to infect the interior of the tooth, causing an abscess. From
there, if the infection is not dealt with by antibiotics or other
treatment, it can travel to surrounding tissue or other organs,
including the brain, and on extremely rare occasions, cause death.
Source: GAO and the American Academy of Pediatric Dentistry.
[End of figure]
The American Academy of Pediatric Dentistry (AAPD) recommends that each
child see a dentist when his or her first tooth erupts and no later
than the child's first birthday, with subsequent visits occurring at 6-
month intervals or more frequently if recommended by a dentist. The
early initial visit can establish a "dental home" for the child,
defined by AAPD as the ongoing relationship with a dental provider who
can ensure comprehensive and continuously accessible care.
Comprehensive dental visits can include both clinical assessments, such
as for tooth decay and sealants,[Footnote 10] and appropriate
discussion and counseling for oral hygiene, injury prevention, and
speech and language development, among other topics. Because resistance
to tooth decay is determined in part by genetics, eating patterns, and
oral hygiene, early prevention is important. Delaying the onset of
tooth decay may also reduce long-term risk for more serious decay by
delaying the exposure to caries risk factors to a time when the child
can better control his or her health behaviors.
Recognizing the importance of good oral health, HHS in 1990 and again
in 2000 established oral health goals as part of its Healthy People
2000 and 2010 initiatives. These include objectives related to oral
health in children, for example, reducing the proportion of children
with untreated tooth decay. One objective of Healthy People 2010
relates to the Medicaid population: to increase the proportion of low-
income children and adolescents under the age of 19 who receive any
preventive dental service in the past year, from 25 percent in 1996 to
66 percent in 2010.[Footnote 11]
Medicaid, a joint federal and state program which provides health care
coverage for low-income individuals and families; pregnant women; and
aged, blind, and disabled people, provided health coverage for an
estimated 20.1 million children aged 2 through 18 in federal fiscal
year 2005.[Footnote 12] The states operate their Medicaid programs
within broad federal requirements and may contract with managed care
organizations to provide Medicaid benefits or use other forms of
managed care, when approved by CMS. CMS estimates that as of June 30,
2006, about 65 percent of Medicaid beneficiaries received benefits
through some form of managed care.[Footnote 13] State Medicaid programs
must cover some services for certain populations under federal law. For
instance, under Medicaid's EPSDT benefit, states must provide dental
screening, diagnostic, preventive, and related treatment services for
all eligible Medicaid beneficiaries under age 21.[Footnote 14]
Dental Disease and Inadequate Receipt of Dental Care Remain Significant
Problems for Children in Medicaid:
Children in Medicaid aged 2 through 18 often experience dental disease
and often do not receive needed dental care, and although receipt of
dental care has improved somewhat in recent years, the extent of dental
disease for most age groups has not. Information from NHANES surveys
from 1999 through 2004 showed that about one in three children ages 2
through 18 in Medicaid had untreated tooth decay, and one in nine had
untreated decay in three or more teeth. Compared to children with
private health insurance, children in Medicaid were substantially more
likely to have untreated tooth decay and to be in urgent need of dental
care. MEPS surveys conducted in 2004 and 2005 found that almost two in
three children in Medicaid aged 2 through 18 had not received dental
care in the previous year and that one in eight never sees a dentist.
Children in Medicaid were less likely to have received dental care than
privately insured children, although they were more likely to have
received care than children without health insurance. Children in
Medicaid also fared poorly when compared to national benchmarks, as the
percentage of children in Medicaid ages 2 through 18 who received any
dental care--37 percent--was far below the Healthy People 2010 target
of having 66 percent of low-income children under age 19 receive a
preventive dental service.[Footnote 15] MEPS data on Medicaid children
who had received dental care--from 1996 through 1997 compared to 2004
through 2005--showed some improvement for children ages 2 through 18 in
Medicaid. By contrast, comparisons of recent NHANES data to data from
the late 1980s and 1990s suggest that the extent that children ages 2
through 18 in Medicaid experience dental disease has not decreased for
most age groups.
National Survey Data from 1999 through 2004 Show That One in Three
Children in Medicaid Had Untreated Tooth Decay:
Dental disease is a common problem for children aged 2 through 18
enrolled in Medicaid, according to national survey data (see fig. 2).
NHANES oral examinations conducted from 1999 through 2004 show that
about three in five children (62 percent) in Medicaid had experienced
tooth decay,[Footnote 16] and about one in three (33 percent) were
found to have untreated tooth decay.[Footnote 17] Close to one in nine-
-about 11 percent--had untreated decay in three or more teeth, which is
a sign of unmet need for dental care and, according to some oral health
experts, can suggest a severe oral health problem. Projecting these
proportions to 2005 enrollment levels, we estimate that 6.5 million
children in Medicaid had untreated tooth decay, with 2.2 million
children having untreated tooth decay involving three or more teeth.
[Footnote 18]
Figure 2: Proportion of Children in Medicaid Aged 2 through 18 with
Tooth Decay, Untreated Tooth Decay, and Untreated Tooth Decay in Three
or More Teeth, 1999-2004:
[See PDF for image]
* About three in five children (62%) had experienced tooth decay.
* About one in three children (33%) had tooth decay that had not been
treated.
* Close to one in nine children (11%) had untreated tooth decay in
three or more teeth, which can be a sign of a more severe oral health
problem or higher levels of unmet need.
Source: GAO analysis of 1999 through 2004 NHANES survey data.
Note: The NHANES survey data for Medicaid also include data for
children in SCHIP, which we estimate to be about 15 percent of the
total.
[End of figure]
Compared with children with private health insurance, children in
Medicaid were at much higher risk of tooth decay and experienced
problems at rates more similar to those without any insurance. As shown
in figure 3, the proportion of children in Medicaid with untreated
tooth decay (33 percent) was nearly double the rate for children who
had private insurance (17 percent) and was similar to the rate for
uninsured children (35 percent). These children were also more than
twice as likely to have untreated tooth decay in three or more teeth
than their privately insured counterparts (11 percent for Medicaid
children compared to 5 percent for children with private health
insurance). These disparities were consistent across all age groups we
examined.
Figure 3: Percentage of Children Aged 2 through 18 with Untreated Tooth
Decay, by Age and Insurance Status, 1999-2004:
[See PDF for image]
This figure is a multiple vertical bar graph depicting the following
data:
Ages: 2-5;
Privately insured: 15%;
Medicaid: 29%;
Uninsured: 32%.
Ages: 6-11;
Privately insured: 21%;
Medicaid: 39%;
Uninsured: 38%.
Ages: 12-15;
Privately insured: 13%;
Medicaid: 29%;
Uninsured: 31%.
Ages: 16-18;
Privately insured: 16%;
Medicaid: 27%;
Uninsured: 35%.
Ages: All ages;
Privately insured: 17%;
Medicaid: 33%;
Uninsured: 35%.
Source: GAO analysis of 1999 through 2004 NHANES survey data.
Note: The NHANES survey data for Medicaid also include data for
children in SCHIP, which we estimate to be about 15 percent of the
total.
[End of figure]
According to NHANES data, more than 5 percent of children in Medicaid
aged 2 through 18 had urgent dental conditions, that is, conditions in
need of care within 2 weeks for the relief of symptoms and
stabilization of the condition. Such conditions include tooth
fractures, oral lesions, chronic pain, and other conditions that are
unlikely to resolve without professional intervention. On the basis of
these data, we estimate that in 2005, 1.1 million children aged 2
through 18 in Medicaid had conditions that warranted seeing a dentist
within 2 weeks.[Footnote 19] Compared to children who had private
insurance, children in Medicaid were more than four times as likely to
be in urgent need of dental care.
The NHANES data suggest that the rates of untreated tooth decay for
some Medicaid beneficiaries could be about three times more than
national health benchmarks. For example, the NHANES data showed that 29
percent of children in Medicaid aged 2 through 5 had untreated decay,
which compares unfavorably with the Healthy People 2010 target for
untreated tooth decay of 9 percent of children aged 2 through 4.
[Footnote 20]
National Survey Data from 2004 through 2005 Showed That Nearly Two in
Three Children in Medicaid Did Not Receive Dental Care in the Previous
Year:
Most children in Medicaid do not visit the dentist regularly, according
to 2004 and 2005 nationally representative MEPS data (see fig. 4).
According to these data, nearly two in three children in Medicaid aged
2 through 18 had not received any dental care in the previous
year.[Footnote 21] Projecting these proportions to 2005 enrollment
levels, we estimate that 12.6 million children in Medicaid have not
seen a dentist in the previous year.[Footnote 22] In reporting on
trends in dental visits of the general population, AHRQ reported in
2007 that about 31 percent of poor children (family income less than or
equal to the federal poverty level) and 34 percent of low-income
children (family income above 100 percent through 200 percent of the
federal poverty level) had a dental visit during the year.[Footnote 23]
Survey data also showed that about one in eight children (13 percent)
in Medicaid reportedly never see a dentist.[Footnote 24]
Figure 4: Proportion of Children in Medicaid Nationwide Not Receiving
Dental Care or Unable to Access Dental Care, 2004-2005:
[See PDF for image]
This figure contains three pie-charts and the following accompanying
information:
* In 2004 through 2005, nearly two in three children (63%) had not
received any dental care in the previous year.
* About one in eight children (13%) reportedly never sees a dentist.
* About one in 25 children (4%) were unable to access dental care in
the previous year.
Source: GAO analysis of 2004 through 2005 MEPS survey data.
Note: The MEPS survey data for Medicaid also include data for children
in SCHIP, which we estimate to be about 16 percent of the total.
[End of figure]
MEPS survey data also show that many children in Medicaid were unable
to access needed dental care. Survey participants reported that about 4
percent of children aged 2 through 18 in Medicaid were unable to get
needed dental care in the previous year. Projecting this percentage to
estimated 2005 enrollment levels, we estimate that 724,000 children
aged 2 through 18 in Medicaid could not obtain needed care.[Footnote
25] Regardless of insurance status, most participants who said a child
could not get needed dental care said they were unable to afford such
care.[Footnote 26] However, 15 percent of children in Medicaid who had
difficulty accessing needed dental care reportedly were unable to get
care because the provider refused to accept their insurance plan,
compared to only 2 percent of privately insured children.
Children enrolled in Medicaid were less likely to have received dental
care than privately insured children, but they were more likely to have
received dental care than children without health insurance. (See fig.
5.) Survey data from 2004 through 2005 showed that about 37 percent of
children in Medicaid aged 2 through 18 had visited the dentist in the
previous year, compared with about 55 percent of children with private
health insurance, and 26 percent of children without insurance. The
percentage of children in Medicaid who received any dental care--37
percent--was far below the Healthy People 2010 target of having 66
percent of low-income children under age 19 receive a preventive dental
service.
Figure 5: Percentage of Children in Medicaid Nationwide Who Received
Dental Care in the Previous Year, by Age and Insurance Status, 2004-
2005:
[See PDF for image]
This figure is a multiple vertical bar graph depicting the following
data:
Healthy People 2010 target for low-income children under age 19: 66%.
Ages: 2-5;
Privately insured: 42%;
Medicaid: 32%;
Uninsured: 24%.
Ages: 6-11;
Privately insured: 64%;
Medicaid: 45%;
Uninsured: 35%.
Ages: 12-15;
Privately insured: 58%;
Medicaid: 38%;
Uninsured: 26%.
Ages: 16-18;
Privately insured: 50%;
Medicaid: 30%;
Uninsured: 18%.
Ages: All ages;
Privately insured: 55%;
Medicaid: 37%;
Uninsured: 26%.
Source: GAO analysis of 2004 through 2005 MEPS survey data.
Note: The MEPS survey data for Medicaid also include data for children
in SCHIP, which we estimate to be about 16 percent of the total.
[End of figure]
The NHANES data from 1999 through 2004 also provide some information
related to the receipt of dental care. The presence of dental sealants,
a form of preventive care, is considered to be an indicator that a
person has received dental care. About 28 percent of children in
Medicaid had at least one dental sealant, according to 1999 through
2004 NHANES data. In contrast, about 40 percent of children with
private insurance had a sealant. However, children in Medicaid were
more likely to have sealants than children without health insurance
(about 20 percent).
Comparison of Past and Recent Survey Data Suggests That the Rate of
Dental Disease in Children in Medicaid Is Not Decreasing, although the
Receipt of Dental Care Has Improved Somewhat in More Recent Years:
While comparisons of past and more recent survey data suggest that a
larger proportion of children in Medicaid had received dental care in
recent surveys, the extent that children in Medicaid experience dental
disease has not decreased. A comparison of NHANES results from 1988
through 1994 with results from 1999 through 2004 showed that the rates
of untreated tooth decay were largely unchanged for children in
Medicaid aged 2 through 18: 31 percent of children had untreated tooth
decay in 1988 through 1994, compared with 33 percent in 1999 through
2004 (see fig. 6). The proportion of children in Medicaid who
experienced tooth decay increased from 56 percent in the earlier period
to 62 percent in more recent years. This increase appears to be driven
by younger children, as the 2 through 5 age group had substantially
higher rates of dental disease in the more recent time period, 1999
through 2004.[Footnote 27] This preschool age group experienced a 32
percent rate of tooth decay in the 1988 through 1994 time period,
compared to almost 40 percent experiencing tooth decay in 1999 through
2004 (a statistically significant change). Data for adolescents, by
contrast, suggest declining rates of tooth decay. Almost 82 percent of
adolescents aged 16 through 18 in Medicaid had experienced tooth decay
in the earlier time period, compared to 75 percent in the latter time
period (although this change was not statistically significant). These
trends were similar for rates of untreated tooth decay, with the data
suggesting rates going up for young children, and declining or
remaining the same for older groups that are more likely to have
permanent teeth. According to CDC, these trends are similar for the
general population of children, for which tooth decay in permanent
teeth has generally declined and untreated tooth decay has remained
unchanged. CDC also found that tooth decay in preschool aged children
in the general population had increased in primary teeth.
Figure 6: Surveyed Measures of Tooth Decay Rates, by Insurance Status,
1988-1994 and 1999-2004:
[See PDF for image]
This figure contains two multiple vertical bar graphs depicting the
following data:
Have experienced tooth decay:
Uninsured:
1988-1994 data: 59%;
1999-2004 data: 59%.
Medicaid:
1988-1994 data: 56%;
1999-2004 data: 62%.
Privately insured:
1988-1994 data: 51%;
1999-2004 data: 45%.
Have untreated tooth decay:
Uninsured:
1988-1994 data: 39%;
1999-2004 data: 35%.
Medicaid:
1988-1994 data: 31%;
1999-2004 data: 33%.
Privately insured:
1988-1994 data: 18%;
1999-2004 data: 17%.
Source: GAO analysis of 1988 through 1994 and 1999 through 2004 NHANES
survey data.
Notes: For the privately insured and for those with Medicaid, changes
between the two time periods in the percentage of children aged 2
through 18 who experienced tooth decay were statistically significant
at the 95 percent level. For this measure, changes in the percentage of
children aged 2 through 18 who were uninsured were not statistically
significant. For untreated tooth decay, none of the changes between the
two time periods were found to be statistically significant at the 95
percent level. The 1999 through 2004 NHANES survey data for Medicaid
also include data for children in SCHIP, which we estimate to be about
15 percent of the total.
[End of figure]
At the same time, indicators of receipt of dental care, including the
proportion of children who had received dental care in the past year
and use of sealants, have shown some improvement. Two indicators of
receipt of dental care showed improvement from earlier surveys:
* The percentage of children in Medicaid aged 2 through 18 who received
dental care in the previous year increased from 31 percent in 1996
through 1997 to 37 percent in 2004 through 2005, according to MEPS data
(see fig. 7). This change was statistically significant. Similarly,
AHRQ reported that the percent of children with a dental visit
increased between 1996 and 2004 for both poor children (28 percent to
31 percent) and low-income children (28 percent to 34 percent).
* The percentage of children aged 6 through 18 in Medicaid with at
least one dental sealant increased nearly threefold, from 10 percent in
1988 through 1994 to 28 percent in 1999 through 2004, according to
NHANES data, and these changes were statistically significant. The
increase in receipt of sealants may be due in part to the increased use
of dental sealants in recent years, as the percentage of uninsured and
insured children with dental sealants doubled over the same time
period.[Footnote 28] Adolescents aged 16 through 18 in Medicaid had the
greatest increase in receipt of sealants relative to other age groups.
The percentage of adolescents with dental sealants was about 6 percent
in the earlier time period, and 33 percent more recently.
The percentage of children in Medicaid who reportedly never see a
dentist remained about the same between the two time periods, with
about 14 percent in 1996 through 1997 who never saw a dentist, and 13
percent in 2004 through 2005, according to MEPS data.
Figure 7: Surveyed Measures of Children Who Visited a Dentist in the
Previous Year, by Insurance Status, 1996-1997 and 2004-2005:
[See PDF for image]
This figure is a multiple vertical bar graph depicting the following
data:
Uninsured:
1996-1997 data: 20%;
2004-2005 data: 26%.
Medicaid:
1996-1997 data: 31%;
2004-2005 data: 37%.
Privately insured:
1996-1997 data: 48%;
2004-2005 data: 55%.
Source: GAO analysis of 1996 through 1997 and 2004 through 2005 MEPS
survey data.
Notes: For each group, changes between the two time periods in the
percentage of children aged 2 through 18 who had received dental care
in the previous year were statistically significant at the 95 percent
level. The 2004 through 2005 MEPS survey data for Medicaid also include
data for children in SCHIP, which we estimate to be about 16 percent of
the total.
[End of figure]
More information on our analysis of NHANES and MEPS for changes in
dental disease and receipt of dental care for children in Medicaid over
time, including confidence intervals and whether changes over time were
statistically significant, can be found in appendixes I and II.
Concluding Observations:
The information provided by nationally representative surveys regarding
the oral health of our nation's low-income children in Medicaid raises
serious concerns. Measures of access to dental care for this
population, such as children's dental visits, have improved somewhat in
recent surveys, but remain far below national health goals. Of even
greater concern are data that show that dental disease is prevalent
among children in Medicaid, and is not decreasing. Millions of children
in Medicaid are estimated to have dental disease in need of treatment;
in many cases this need is urgent. Given this unacceptable condition,
it is important that those involved in providing dental care to
children in Medicaid--the federal government, states, providers, and
others--address the need to improve the oral health condition of these
children and to achieve national oral health goals.
Agency Comments:
We provided a draft of this report for comment to HHS. HHS provided
written comments which we summarize below. The text of HHS's letter,
including comments from CMS, CDC, and AHRQ, is reprinted in appendix
III. HHS also provided technical comments, which we incorporated as
appropriate. In commenting on the draft, CMS acknowledged the challenge
of providing dental services to children in Medicaid, as well as all
children nationwide, and cited a number of activities undertaken by CMS
in coordination with states, such as completing 17 focused dental
reviews and forming an Oral Health Technical Advisory Group. CDC
commented that trends in dental caries vary by age group and for
primary versus permanent teeth. CDC also noted that beginning in 2005,
trained health technologists conducted basic assessments of caries
experience. We revised our report to further clarify the differing
trends by age groups and to acknowledge the assessments performed by
health technologists. We did not analyze the data by both age and
dentition (primary versus permanent teeth) due to small sample sizes;
we note that the trends for the youngest and oldest age groups in the
Medicaid child population that we identified are consistent with those
that CDC found in the general population by age and dentition.
AHRQ commented that agency staff had completed a Chartbook that
summarizes dental use, expenses, dental coverage, and changes from 1996
and 2004 for the general population that was not cited and referenced
in our report, and indicated it was unclear why the same analytical
approach was not followed for the determination of public coverage
status. In technical comments, AHRQ noted that their reported findings
are generally comparable to GAO's findings. We revised our report to
cite AHRQ's findings on dental services for children and to further
describe our methodology. Regarding our determination of public
coverage status, we did not use AHRQ's analytical approach that
describes "public coverage" because the focus of this report was on
children covered by Medicaid. AHRQ's approach did not distinguish
Medicaid from other types of public coverage.
We are sending copies of this report to other interested congressional
committees and to the Secretary of HHS. We will also make copies
available to others upon request. In addition, the report will be
available at no charge on the GAO Web site at [hyperlink,
http://www.gao.gov].
If you or your staffs have any questions regarding this report, please
contact me at (202) 512-7114 or cosgrovej@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. Key contributors are listed in
appendix IV.
Signed by:
James C. Cosgrove:
Director, Health Care:
[End of section]
Appendix I: NHANES Analysis:
The National Health and Nutrition Examination Survey (NHANES),
conducted multiple times since the early 1960s by the Department of
Health and Human Services' (HHS) National Center for Health Statistics
of the Centers for Disease Control and Prevention (CDC), is designed to
provide nationally representative estimates of the health and nutrition
status of the noninstitutionalized civilian population of the United
States. NHANES provides information on civilians of all ages. Prior to
1999, three periodic surveys were conducted. Since 1999, NHANES has
been conducted annually. For this study, we examined data from 1999
through 2004 and data from 1988 through 1994. We did not analyze any
NHANES data after 2004 because, beginning in 2005, NHANES surveys do
not include examinations by dentists for tooth decay, dental sealants,
and most other oral health conditions.[Footnote 29]
Our analysis of NHANES data focused on the oral examination of children
ages 2 through 18. As part of an overall physical examination, dental
examiners inspect children's mouths and collect data on the number and
condition of teeth and the condition of gums. To analyze these data, we
considered three categories of children, based on their health
insurance status as reported by their parents or guardians on the
interview section of the survey: children with Medicaid, children with
private health insurance, and children without health insurance.
[Footnote 30] These categories include more than 90 percent of children
who were given dental examinations as part of NHANES. We do not present
results for children with other forms of government health insurance,
such as TRICARE or Medicare, and we do not present results for children
whose parents or guardians provided no information on their health
insurance status (about 1.5 percent of children fell into this
category). For the 1999 through 2004 time period, the Medicaid category
includes some children enrolled in the State Children's Health
Insurance Program (SCHIP); we estimate that about 85 percent of the
children for that time period were enrolled in Medicaid with the
remainder enrolled in SCHIP.[Footnote 31] To assess the reliability of
NHANES data, we interviewed knowledgeable officials, reviewed relevant
documentation, and compared the results of our analyses to published
data. We determined that the NHANES data were sufficiently reliable for
the purposes of our engagement.
Using the NHANES data, we analyzed the percentage of children with
untreated tooth decay, the percentage of children who had experienced
tooth decay, the percentage of children with tooth decay in three or
more teeth, and the percentage of children with dental sealants (see
tables 1 through 5). We also analyzed the dental examiner's
recommendation for care as the basis for determining whether a child
had an urgent need for dental care. For each of these measures, we
estimated the percentage, with 95 percent confidence intervals (that
is, there is a 95 percent probability that the actual number falls
within the lower and upper limits of our estimates), of children in
each of the three insurance categories using raw data and appropriate
sampling weights. We also used standard errors to calculate if changes
from the 1988 through 1994 time period to the 1999 through 2004 time
period were statistically significant at the 95 percent level. To
estimate the number of children in the Medicaid category with a given
condition, we multiplied the calculated percentage by an estimate of
the 2005 average monthly enrollment of children ages 2 through18 in
Medicaid (20.1 million children). We estimated the 2005 average monthly
enrollment of children ages 2 through 18 in Medicaid using CMS
statistics, by age group, for children ages 1 through 18 (we reduced
this number to account for children age 1 using Census data).
Table 1: Percentage of Children Aged 2 through 18 Who Have Experienced
Tooth Decay, by Health Insurance Status, 1988-1994 and 1999-2004:
All children (2-18): Private insurance;
1988-1994: Percentage: 50.7[A];
1988-1994: Lower limit: 48.2;
1988-1994: Upper limit: 53.1;
1999-2004: Percentage: 45.0[A];
1999-2004: Lower limit: 42.6;
1999-2004: Upper limit: 47.4.
All children (2-18): Medicaid;
1988-1994: Percentage: 55.5[A];
1988-1994: Lower limit: 50.3;
1988-1994: Upper limit: 60.7;
1999-2004: Percentage: 61.6[A];
1999-2004: Lower limit: 58.7;
1999-2004: Upper limit: 64.4.
All children (2-18): Uninsured;
1988-1994: Percentage: 59.1;
1988-1994: Lower limit: 53.1;
1988-1994: Upper limit: 65.0;
1999-2004: Percentage: 58.5;
1999-2004: Lower limit: 54.0;
1999-2004: Upper limit: 62.9.
Children 2-5: Private insurance;
1988-1994: Percentage: 19.9;
1988-1994: Lower limit: 17.2;
1988-1994: Upper limit: 22.7;
1999-2004: Percentage: 21.1;
1999-2004: Lower limit: 17.5;
1999-2004: Upper limit: 24.8.
Children 2-5: Medicaid;
1988-1994: Percentage: 32.3[A];
1988-1994: Lower limit: 27.6;
1988-1994: Upper limit: 37.0;
1999-2004: Percentage: 39.5[A];
1999-2004: Lower limit: 34.9;
1999-2004: Upper limit: 44.0.
Children 2-5: Uninsured;
1988-1994: Percentage: 37.1;
1988-1994: Lower limit: 29.0;
1988-1994: Upper limit: 45.1;
1999-2004: Percentage: 38.2;
1999-2004: Lower limit: 29.0;
1999-2004: Upper limit: 47.4.
Children 6-11: Private insurance;
1988-1994: Percentage: 52.1;
1988-1994: Lower limit: 47.8;
1988-1994: Upper limit: 56.5;
1999-2004: Percentage: 47.7;
1999-2004: Lower limit: 42.9;
1999-2004: Upper limit: 52.5.
Children 6-11: Medicaid;
1988-1994: Percentage: 65.0;
1988-1994: Lower limit: 55.8;
1988-1994: Upper limit: 74.1;
1999-2004: Percentage: 71.1;
1999-2004: Lower limit: 67.0;
1999-2004: Upper limit: 75.2.
Children 6-11: Uninsured;
1988-1994: Percentage: 61.7;
1988-1994: Lower limit: 52.3;
1988-1994: Upper limit: 71.2;
1999-2004: Percentage: 60.5;
1999-2004: Lower limit: 52.2;
1999-2004: Upper limit: 68.8.
Children 12-15: Private insurance;
1988-1994: Percentage: 58.7[A];
1988-1994: Lower limit: 53.6;
1988-1994: Upper limit: 63.9;
1999-2004: Percentage: 47.7[A];
1999-2004: Lower limit: 44.4;
1999-2004: Upper limit: 50.9.
Children 12-15: Medicaid;
1988-1994: Percentage: 63.8;
1988-1994: Lower limit: 54.7;
1988-1994: Upper limit: 72.9;
1999-2004: Percentage: 67.7;
1999-2004: Lower limit: 62.9;
1999-2004: Upper limit: 72.6.
Children 12-15: Uninsured;
1988-1994: Percentage: 54.5;
1988-1994: Lower limit: 45.4;
1988-1994: Upper limit: 63.5;
1999-2004: Percentage: 58.9;
1999-2004: Lower limit: 51.6;
1999-2004: Upper limit: 66.2.
Children 16-18: Private insurance;
1988-1994: Percentage: 78.4[A];
1988-1994: Lower limit: 73.2;
1988-1994: Upper limit: 83.6;
1999-2004: Percentage: 62.5[A];
1999-2004: Lower limit: 58.6;
1999-2004: Upper limit: 66.4.
Children 16-18: Medicaid;
1988-1994: Percentage: 81.9;
1988-1994: Lower limit: 73.3;
1988-1994: Upper limit: 90.4;
1999-2004: Percentage: 74.8;
1999-2004: Lower limit: 67.6;
1999-2004: Upper limit: 82.1.
Children 16-18: Uninsured;
1988-1994: Percentage: 76.9;
1988-1994: Lower limit: 68.8;
1988-1994: Upper limit: 85.1;
1999-2004: Percentage: 70.3;
1999-2004: Lower limit: 64.8;
1999-2004: Upper limit: 75.9.
Source: GAO analysis of 1988 through 1994 and 1999 through 2004
National Health and Nutrition Examination Survey (NHANES) data.
Notes: Data in the Medicaid category from the 1988 through 1994 period
only included children who were enrolled in Medicaid, while data from
the 1999 through 2004 period included children who were enrolled in
Medicaid and children who were enrolled in SCHIP. We estimated that
about 85 percent of the children in the Medicaid category from 1999
through 2004 were enrolled in Medicaid, while the remaining 15 percent
were enrolled in SCHIP (either in separate child health programs or
Medicaid expansion programs). We considered an individual as having
experienced tooth decay if any of their teeth had untreated decay, if
any of their teeth had been treated for decay, or if any of their teeth
were missing due to decay.
[A] Change from the 1988 through 1994 period to the 1999 through 2004
period was statistically significant at the 95 percent level.
[End of table]
Table 2: Percentage of Children Aged 2 through 18 with Untreated Tooth
Decay, by Health Insurance Status, 1988-1994 and 1999-2004:
All children (2-18): Private insurance;
1988-1994: Percentage: 17.9;
1988-1994: Lower limit: 15.9;
1988-1994: Upper limit: 19.9;
1999-2004: Percentage: 16.8;
1999-2004: Lower limit: 14.9;
1999-2004: Upper limit: 18.6.
All children (2-18): Medicaid;
1988-1994: Percentage: 30.7;
1988-1994: Lower limit: 26.0;
1988-1994: Upper limit: 35.3;
1999-2004: Percentage: 32.5;
1999-2004: Lower limit: 29.5;
1999-2004: Upper limit: 35.4.
All children (2-18): Uninsured;
1988-1994: Percentage: 38.7;
1988-1994: Lower limit: 33.5;
1988-1994: Upper limit: 43.8;
1999-2004: Percentage: 34.6;
1999-2004: Lower limit: 30.4;
1999-2004: Upper limit: 38.8.
Children 2-5: Private insurance;
1988-1994: Percentage: 14.9;
1988-1994: Lower limit: 12.4;
1988-1994: Upper limit: 17.3;
1999-2004: Percentage: 15.1;
1999-2004: Lower limit: 11.9;
1999-2004: Upper limit: 18.4.
Children 2-5: Medicaid;
1988-1994: Percentage: 26.1;
1988-1994: Lower limit: 21.5;
1988-1994: Upper limit: 30.8;
1999-2004: Percentage: 28.9;
1999-2004: Lower limit: 24.4;
1999-2004: Upper limit: 33.4.
Children 2-5: Uninsured;
1988-1994: Percentage: 32.9;
1988-1994: Lower limit: 25.0;
1988-1994: Upper limit: 40.7;
1999-2004: Percentage: 32.1;
1999-2004: Lower limit: 23.2;
1999-2004: Upper limit: 40.9.
Children 6-11: Private insurance;
1988-1994: Percentage: 22.6;
1988-1994: Lower limit: 19.3;
1988-1994: Upper limit: 25.9;
1999-2004: Percentage: 20.6;
1999-2004: Lower limit: 17.6;
1999-2004: Upper limit: 23.7.
Children 6-11: Medicaid;
1988-1994: Percentage: 36.9;
1988-1994: Lower limit: 29.4;
1988-1994: Upper limit: 44.4;
1999-2004: Percentage: 38.7;
1999-2004: Lower limit: 33.8;
1999-2004: Upper limit: 43.6.
Children 6-11: Uninsured;
1988-1994: Percentage: 42.6;
1988-1994: Lower limit: 32.6;
1988-1994: Upper limit: 52.6;
1999-2004: Percentage: 37.6;
1999-2004: Lower limit: 30.5;
1999-2004: Upper limit: 44.8.
Children 12-15: Private insurance;
1988-1994: Percentage: 12.4;
1988-1994: Lower limit: 9.5;
1988-1994: Upper limit: 15.3;
1999-2004: Percentage: 12.8;
1999-2004: Lower limit: 10.4;
1999-2004: Upper limit: 15.2.
Children 12-15: Medicaid;
1988-1994: Percentage: 28.1;
1988-1994: Lower limit: 18.0;
1988-1994: Upper limit: 38.1;
1999-2004: Percentage: 29.1;
1999-2004: Lower limit: 22.1;
1999-2004: Upper limit: 36.1.
Children 12-15: Uninsured;
1988-1994: Percentage: 33.3;
1988-1994: Lower limit: 25.4;
1988-1994: Upper limit: 41.2;
1999-2004: Percentage: 30.8;
1999-2004: Lower limit: 24.8;
1999-2004: Upper limit: 36.7.
Children 16-18: Private insurance;
1988-1994: Percentage: 19.6;
1988-1994: Lower limit: 14.6;
1988-1994: Upper limit: 24.5;
1999-2004: Percentage: 16.2;
1999-2004: Lower limit: 12.9;
1999-2004: Upper limit: 19.5.
Children 16-18: Medicaid;
1988-1994: Percentage: 31.0;
1988-1994: Lower limit: 19.2;
1988-1994: Upper limit: 42.9;
1999-2004: Percentage: 27.0;
1999-2004: Lower limit: 19.5;
1999-2004: Upper limit: 34.6.
Children 16-18: Uninsured;
1988-1994: Percentage: 43.1;
1988-1994: Lower limit: 35.1;
1988-1994: Upper limit: 51.2;
1999-2004: Percentage: 35.0;
1999-2004: Lower limit: 29.0;
1999-2004: Upper limit: 41.0.
Source: GAO analysis of 1988 through 1994 and 1999 through 2004
National Health and Nutrition Examination Survey (NHANES) data.
Notes: Data in the Medicaid category from the 1988 through 1994 period
only included children who were enrolled in Medicaid, while data from
the 1999 through 2004 period included children who were enrolled in
Medicaid and children who were enrolled in SCHIP. We estimated that
about 85 percent of the children in the Medicaid category from 1999
through 2004 were enrolled in Medicaid, while the remaining 15 percent
were enrolled in SCHIP (either in separate child health programs or
Medicaid expansion programs).
None of the changes from the 1988 through 1994 period to the 1999
through 2004 period were found to be statistically significant at the
95 percent level.
[End of table]
Table 3: Percentage of Children Aged 2 through 18 with Untreated Tooth
Decay in Three or More Teeth, by Health Insurance Status, 1988-1994 and
1999-2004:
All children (2-18): Private insurance;
1988-1994: Percentage: 5.3;
1988-1994: Lower limit: 4.3;
1988-1994: Upper limit: 6.2;
1999-2004: Percentage: 5.0;
1999-2004: Lower limit: 4.0;
1999-2004: Upper limit: 6.0.
All children (2-18): Medicaid;
1988-1994: Percentage: 12.5;
1988-1994: Lower limit: 9.0;
1988-1994: Upper limit: 16.0;
1999-2004: Percentage: 11.1;
1999-2004: Lower limit: 9.3;
1999-2004: Upper limit: 13.0.
All children (2-18): Uninsured;
1988-1994: Percentage: 15.0;
1988-1994: Lower limit: 12.2;
1988-1994: Upper limit: 17.9;
1999-2004: Percentage: 14.5;
1999-2004: Lower limit: 11.2;
1999-2004: Upper limit: 17.7.
Children 2-5: Private insurance;
1988-1994: Percentage: 6.8;
1988-1994: Lower limit: 4.8;
1988-1994: Upper limit: 8.8;
1999-2004: Percentage: 5.7;
1999-2004: Lower limit: 3.3;
1999-2004: Upper limit: 8.1.
Children 2-5: Medicaid;
1988-1994: Percentage: 13.1;
1988-1994: Lower limit: 9.8;
1988-1994: Upper limit: 16.4;
1999-2004: Percentage: 14.7;
1999-2004: Lower limit: 11.2;
1999-2004: Upper limit: 18.2.
Children 2-5: Uninsured;
1988-1994: Percentage: 16.9;
1988-1994: Lower limit: 10.7;
1988-1994: Upper limit: 23.1;
1999-2004: Percentage: 18.7;
1999-2004: Lower limit: 10.8;
1999-2004: Upper limit: 26.6.
Children 6-11: Private insurance;
1988-1994: Percentage: 5.9;
1988-1994: Lower limit: 4.3;
1988-1994: Upper limit: 7.4;
1999-2004: Percentage: 6.5;
1999-2004: Lower limit: 5.0;
1999-2004: Upper limit: 8.0.
Children 6-11: Medicaid;
1988-1994: Percentage: 14.9;
1988-1994: Lower limit: 9.4;
1988-1994: Upper limit: 20.4;
1999-2004: Percentage: 10.6;
1999-2004: Lower limit: 7.8;
1999-2004: Upper limit: 13.5.
Children 6-11: Uninsured;
1988-1994: Percentage: 21.5;
1988-1994: Lower limit: 13.9;
1988-1994: Upper limit: 29.2;
1999-2004: Percentage: 16.9;
1999-2004: Lower limit: 11.9;
1999-2004: Upper limit: 22.0.
Children 12-15: Private insurance;
1988-1994: Percentage: 3.0;
1988-1994: Lower limit: 1.6;
1988-1994: Upper limit: 4.4;
1999-2004: Percentage: 3.0;
1999-2004: Lower limit: 1.9;
1999-2004: Upper limit: 4.0.
Children 12-15: Medicaid;
1988-1994: Percentage: 8.2;
1988-1994: Lower limit: 1.0;
1988-1994: Upper limit: 15.5;
1999-2004: Percentage: 8.2;
1999-2004: Lower limit: 3.7;
1999-2004: Upper limit: 12.8.
Children 12-15: Uninsured;
1988-1994: Percentage: 8.4;
1988-1994: Lower limit: 4.9;
1988-1994: Upper limit: 11.9;
1999-2004: Percentage: 7.7;
1999-2004: Lower limit: 4.5;
1999-2004: Upper limit: 10.9.
Children 16-18: Private insurance;
1988-1994: Percentage: 5.0;
1988-1994: Lower limit: 2.4;
1988-1994: Upper limit: 7.6;
1999-2004: Percentage: 4.1;
1999-2004: Lower limit: 2.3;
1999-2004: Upper limit: 6.0.
Children 16-18: Medicaid;
1988-1994: Percentage: 11.4;
1988-1994: Lower limit: 1.5;
1988-1994: Upper limit: 21.4;
1999-2004: Percentage: 8.9;
1999-2004: Lower limit: 4.5;
1999-2004: Upper limit: 13.4.
Children 16-18: Uninsured;
1988-1994: Percentage: 11.2;
1988-1994: Lower limit: 6.6;
1988-1994: Upper limit: 15.8;
1999-2004: Percentage: 13.8;
1999-2004: Lower limit: 10.0;
1999-2004: Upper limit: 17.6.
Source: GAO analysis of 1988 through 1994 and 1999 through 2004
National Health and Nutrition Examination Survey (NHANES) data.
Notes: Data in the Medicaid category from the 1988 through1994 period
only included children who were enrolled in Medicaid, while data from
the 1999 through 2004 period included children who were enrolled in
Medicaid and children who were enrolled in SCHIP. We estimated that
about 85 percent of the children in the Medicaid category from 1999
through 2004 were enrolled in Medicaid, while the remaining 15 percent
were enrolled in SCHIP (either in separate child health programs or
Medicaid expansion programs).
None of the changes from the 1988 through 1994 period to the 1999
through 2004 period were found to be statistically significant at the
95 percent level.
[End of table]
Table 4: Percentage of Children Aged 6 through 18 with Dental Sealants,
by Health Insurance Status, 1988-1994 and 1999-2004:
All children (6-18): Private insurance;
1988-1994: Percentage: 23.7[A];
1988-1994: Lower limit: 19.8;
1988-1994: Upper limit: 27.6;
1999-2004: Percentage: 39.9[A];
1999-2004: Lower limit: 37.0;
1999-2004: Upper limit: 42.7.
All children (6-18): Medicaid;
1988-1994: Percentage: 9.5[A];
1988-1994: Lower limit: 5.1;
1988-1994: Upper limit: 13.9;
1999-2004: Percentage: 27.7[A];
1999-2004: Lower limit: 23.0;
1999-2004: Upper limit: 32.4.
All children (6-18): Uninsured;
1988-1994: Percentage: 11.3[A];
1988-1994: Lower limit: 6.1;
1988-1994: Upper limit: 16.5;
1999-2004: Percentage: 19.9[A];
1999-2004: Lower limit: 15.4;
1999-2004: Upper limit: 24.3.
Children 6-11: Private insurance;
1988-1994: Percentage: 24.0[A];
1988-1994: Lower limit: 19.6;
1988-1994: Upper limit: 28.5;
1999-2004: Percentage: 35.8[A];
1999-2004: Lower limit: 31.8;
1999-2004: Upper limit: 39.8.
Children 6-11: Medicaid;
1988-1994: Percentage: 11.6[A];
1988-1994: Lower limit: 5.8;
1988-1994: Upper limit: 17.5;
1999-2004: Percentage: 22.6[A];
1999-2004: Lower limit: 15.5;
1999-2004: Upper limit: 29.6.
Children 6-11: Uninsured;
1988-1994: Percentage: 16.2;
1988-1994: Lower limit: 7.9;
1988-1994: Upper limit: 24.5;
1999-2004: Percentage: 16.1;
1999-2004: Lower limit: 9.8;
1999-2004: Upper limit: 22.3.
Children 12-15: Private insurance;
1988-1994: Percentage: 26.8[A];
1988-1994: Lower limit: 20.9;
1988-1994: Upper limit: 32.7;
1999-2004: Percentage: 46.2[A];
1999-2004: Lower limit: 41.7;
1999-2004: Upper limit: 50.7.
Children 12-15: Medicaid;
1988-1994: Percentage: 8.7[A];
1988-1994: Lower limit: 0.5;
1988-1994: Upper limit: 16.9;
1999-2004: Percentage: 34.2[A];
1999-2004: Lower limit: 26.1;
1999-2004: Upper limit: 42.4.
Children 12-15: Uninsured;
1988-1994: Percentage: 11.8[A];
1988-1994: Lower limit: 3.1;
1988-1994: Upper limit: 20.5;
1999-2004: Percentage: 28.0[A];
1999-2004: Lower limit: 20.8;
1999-2004: Upper limit: 35.3.
Children 16-18: Private insurance;
1988-1994: Percentage: 18.6[A];
1988-1994: Lower limit: 14.7;
1988-1994: Upper limit: 22.6;
1999-2004: Percentage: 39.6[A];
1999-2004: Lower limit: 35.9;
1999-2004: Upper limit: 43.3.
Children 16-18: Medicaid;
1988-1994: Percentage: 5.6[A];
1988-1994: Lower limit: 1.3;
1988-1994: Upper limit: 9.9;
1999-2004: Percentage: 33.0[A];
1999-2004: Lower limit: 25.9;
1999-2004: Upper limit: 40.1.
Children 16-18: Uninsured;
1988-1994: Percentage: 3.2[A];
1988-1994: Lower limit: 0.0;
1988-1994: Upper limit: 6.8;
1999-2004: Percentage: 18.4[A];
1999-2004: Lower limit: 11.8;
1999-2004: Upper limit: 25.0.
Source: GAO analysis of 1988 through1994 and 1999 through 2004 National
Health and Nutrition Examination Survey (NHANES) data.
Notes: Data in the Medicaid category from the 1988 through1994 period
only included children who were enrolled in Medicaid, while data from
the 1999 through 2004 period included children who were enrolled in
Medicaid and children who were enrolled in SCHIP. We estimated that
about 85 percent of the children in the Medicaid category from 1999
through 2004 were enrolled in Medicaid, while the remaining 15 percent
were enrolled in SCHIP (either separate child health programs or
Medicaid expansion programs).
[A] Change from the 1988 through 1994 period to the 1999 through 2004
period was statistically significant at the 95 percent level.
[End of table]
Table 5: Percentage of Children Aged 2 through 18 with an Urgent Need
for Dental Care, by Health Insurance Status, 1999-2004:
All children (2-18): Private insurance;
Percentage: 1.3;
Lower limit: 0.7;
Upper limit: 2.0.
All children (2-18): Medicaid;
Percentage: 5.4;
Lower limit: 3.4;
Upper limit: 7.4.
All children (2-18): Uninsured;
Percentage: 6.7;
Lower limit: 4.5;
Upper limit: 9.0.
Children 2-5: Private insurance;
Percentage: 1.4;
Lower limit: 0.0;
Upper limit: 2.9.
Children 2-5: Medicaid;
Percentage: 5.9;
Lower limit: 3.3;
Upper limit: 8.5.
Children 2-5: Uninsured;
Percentage: 6.9;
Lower limit: 1.8;
Upper limit: 11.9.
Children 6-11: Private insurance;
Percentage: 1.6;
Lower limit: 0.8;
Upper limit: 2.4.
Children 6-11: Medicaid;
Percentage: 3.9;
Lower limit: 1.9;
Upper limit: 5.9.
Children 6-11: Uninsured;
Percentage: 9.7;
Lower limit: 5.4;
Upper limit: 13.9.
Children 12-15: Private insurance;
Percentage: 1.0;
Lower limit: 0.4;
Upper limit: 1.7.
Children 12-15: Medicaid;
Percentage: 7.2;
Lower limit: 2.6;
Upper limit: 11.8.
Children 12-15: Uninsured;
Percentage: 4.2;
Lower limit: 1.9;
Upper limit: 6.5.
Children 16-18: Private insurance;
Percentage: 1.2;
Lower limit: 0.5;
Upper limit: 1.9.
Children 16-18: Medicaid;
Percentage: 5.7;
Lower limit: 0.9;
Upper limit: 10.5.
Children 16-18: Uninsured;
Percentage: 3.7;
Lower limit: 1.7;
Upper limit: 5.7.
Source: GAO analysis of 1999 through 2004 National Health and Nutrition
Examination Survey (NHANES) data.
Notes: Data from the Medicaid category included children who were
enrolled in SCHIP. We estimated that about 85 percent of the children
in the Medicaid category were enrolled in Medicaid, while the remaining
15 percent were enrolled in SCHIP (either separate child health
programs or Medicaid expansion programs).
Children were categorized as having an urgent need for care if the
examiner recommended that the child see a dentist immediately or within
the next 2 weeks; that is, if the examiner found that the child was in
need of care within 2 weeks for the relief of symptoms and
stabilization of their condition. Such conditions include tooth
fractures, oral lesions, chronic pain, and other conditions that are
unlikely to resolve without professional intervention.
[End of table]
Our analysis of the NHANES data was conducted in accordance with
generally accepted government auditing standards from December 2007
through September 2008.
[End of section]
Appendix II: MEPS Background and Analysis:
The Medical Expenditure Panel Survey (MEPS), administered by HHS's
Agency for Healthcare Research and Quality (AHRQ), collects data on the
use of specific health services--frequency, cost, and payment. We
analyzed results from the household component of the survey, which
surveys families and individuals and their medical providers.[Footnote
32] Our analysis was based on data from surveys conducted in 1996
through 1997 and 2004 through 2005. We used the 1996 through 1997 data
because they were the earliest available and we used the 2004 through
2005 data because they were the most current available.
The household component of MEPS collects data from a sample of families
and individuals in selected communities across the United States, drawn
from a nationally representative subsample of households that
participated in the prior year's National Health Interview Survey (a
survey conducted by the National Center for Health Statistics at the
Centers for Disease Control and Prevention). The household interviews
feature several rounds of interviewing covering 2 full calendar years.
MEPS is continuously fielded; each year a new sample of households
throughout the country is introduced into the study. MEPS collects
information for each person in the household based on information
provided by one adult member of the household. This information
includes demographic characteristics, health conditions, health status,
use of medical services, provider charges, access to care, satisfaction
with care, health insurance coverage, income, and employment. We
analyzed responses to questions on the use of dental care as well as
responses to questions on the difficulty accessing needed dental care.
As with the National Health and Nutrition Examination Survey (NHANES)
data, we analyzed results from children aged 2 through 18 and divided
children into three categories on the basis of their health insurance
status. Similar to NHANES, the Medicaid category included children
enrolled in the State Children's Health Insurance Program (SCHIP) for
the later time period (2004 through 2005 for MEPS). The privately
insured category included children with private health insurance, some
of whom had dental coverage and others who did not, while the uninsured
category comprised children who had neither health insurance nor dental
insurance.
To determine the reliability of the MEPS data, we spoke with
knowledgeable agency officials and reviewed related documentation and
compared our results to published data. We determined that the MEPS
data were sufficiently reliable for the purposes of our engagement.
We analyzed data according to four different questions asked by the
MEPS survey (see tables 6 through 9). The questions asked (1) whether
the child had seen or talked to any dental provider in a given time
period; (2) how often the child got a dental checkup; (3) whether the
child had trouble accessing needed dental care; and (4) if the
respondent answered yes to the third question, then what the reasons
were for having trouble accessing needed dental care. Using sampling
weights, we estimated the percentage of children in each category as
well as a lower and upper limit of this percentage, calculated at the
95 percent confidence interval. We also used standard errors to
calculate if changes from the 1996 through 1997 time period to the 2004
through 2005 time period were statistically significant at the 95
percent level.
To estimate the number of children ages 2 through 18 in Medicaid not
receiving dental care in the previous year, we calculated the
percentage that had not received dental care in the previous year (62.6
percent) and applied this percentage to an estimate of the 2005 average
monthly enrollment of children ages 2 through18 in Medicaid (20.1
million children). We estimated the 2005 average monthly enrollment of
children ages 2 through 18 in Medicaid using CMS statistics, by age
group, for children ages 1 through 18 (we reduced this number using
Census data to account for children age 1).
Table 6: Percentage of Children Aged 2 through 18 Who Had Received
Dental Care in the Previous Year, by Health Insurance Status, 1996-1997
and 2004-2005:
All children (2-18): Private insurance;
1996-1997: Percentage: 48.2[A];
1996-1997: Lower limit: 46.2;
1996-1997: Upper limit: 50.1;
2004-2005: Percentage: 55.0[A];
2004-2005: Lower limit: 52.8;
2004-2005: Upper limit: 57.1.
All children (2-18): Medicaid;
1996-1997: Percentage: 30.6[A];
1996-1997: Lower limit: 28.2;
1996-1997: Upper limit: 33.0;
2004-2005: Percentage: 37.4[A];
2004-2005: Lower limit: 35.1;
2004-2005: Upper limit: 39.8.
All children (2-18): Uninsured;
1996-1997: Percentage: 19.9[A];
1996-1997: Lower limit: 17.1;
1996-1997: Upper limit: 22.6;
2004-2005: Percentage: 26.4[A];
2004-2005: Lower limit: 23.1;
2004-2005: Upper limit: 29.8.
Children 2-5: Private insurance;
1996-1997: Percentage: 30.9[A];
1996-1997: Lower limit: 28.2;
1996-1997: Upper limit: 33.6;
2004-2005: Percentage: 42.0[A];
2004-2005: Lower limit: 38.5;
2004-2005: Upper limit: 45.5.
Children 2-5: Medicaid;
1996-1997: Percentage: 20.7[A];
1996-1997: Lower limit: 17.3;
1996-1997: Upper limit: 24.0;
2004-2005: Percentage: 31.5[A];
2004-2005: Lower limit: 28.4;
2004-2005: Upper limit: 34.7.
Children 2-5: Uninsured;
1996-1997: Percentage: 13.8[A];
1996-1997: Lower limit: 8.1;
1996-1997: Upper limit: 19.5;
2004-2005: Percentage: 23.6[A];
2004-2005: Lower limit: 17.8;
2004-2005: Upper limit: 29.4.
Children 6-11: Private insurance;
1996-1997: Percentage: 58.1[A];
1996-1997: Lower limit: 55.4;
1996-1997: Upper limit: 60.9;
2004-2005: Percentage: 63.6[A];
2004-2005: Lower limit: 60.9;
2004-2005: Upper limit: 66.3.
Children 6-11: Medicaid;
1996-1997: Percentage: 38.1[A];
1996-1997: Lower limit: 34.3;
1996-1997: Upper limit: 41.9;
2004-2005: Percentage: 45.1[A];
2004-2005: Lower limit: 42.0;
2004-2005: Upper limit: 48.1.
Children 6-11: Uninsured;
1996-1997: Percentage: 25.9[A];
1996-1997: Lower limit: 20.8;
1996-1997: Upper limit: 30.9;
2004-2005: Percentage: 35.1[A];
2004-2005: Lower limit: 30.0;
2004-2005: Upper limit: 40.2.
Children 12-15: Private insurance;
1996-1997: Percentage: 51.6[A];
1996-1997: Lower limit: 48.4;
1996-1997: Upper limit: 54.9;
2004-2005: Percentage: 57.6[A];
2004-2005: Lower limit: 54.4;
2004-2005: Upper limit: 60.8.
Children 12-15: Medicaid;
1996-1997: Percentage: 33.7;
1996-1997: Lower limit: 28.5;
1996-1997: Upper limit: 38.9;
2004-2005: Percentage: 37.5;
2004-2005: Lower limit: 33.7;
2004-2005: Upper limit: 41.3.
Children 12-15: Uninsured;
1996-1997: Percentage: 18.2[A];
1996-1997: Lower limit: 13.7;
1996-1997: Upper limit: 22.7;
2004-2005: Percentage: 26.3[A];
2004-2005: Lower limit: 20.0;
2004-2005: Upper limit: 32.7.
Children 16-18: Private insurance;
1996-1997: Percentage: 46.7;
1996-1997: Lower limit: 43.4;
1996-1997: Upper limit: 50.0;
2004-2005: Percentage: 50.4;
2004-2005: Lower limit: 46.5;
2004-2005: Upper limit: 54.2.
Children 16-18: Medicaid;
1996-1997: Percentage: 25.5;
1996-1997: Lower limit: 20.3;
1996-1997: Upper limit: 30.7;
2004-2005: Percentage: 29.8;
2004-2005: Lower limit: 24.8;
2004-2005: Upper limit: 34.8.
Children 16-18: Uninsured;
1996-1997: Percentage: 18.0;
1996-1997: Lower limit: 12.8;
1996-1997: Upper limit: 23.2;
2004-2005: Percentage: 17.9;
2004-2005: Lower limit: 12.8;
2004-2005: Upper limit: 23.0.
Source: GAO analysis of 1996 through 1997 and 2004 through 2005 Medical
Expenditure Panel Survey (MEPS) data.
Notes: Data in the Medicaid category from the 1996 through 1997 period
only included children who were enrolled in Medicaid, while data from
the 2004 through 2005 period included children who were enrolled in
Medicaid and children who were enrolled in SCHIP. We estimated that
about 84 percent of the children in the Medicaid category from the 2004
through 2005 period were enrolled in Medicaid, while the remainder were
enrolled in SCHIP (either in separate child health programs or Medicaid
expansion programs).
Data presented in this table were based on the survey responses of an
adult member of the child's household.
[A] Change from the 1996 through 1997 period to the 2004 through 2005
period was statistically significant at the 95 percent level.
[End of table]
Table 7: Percentage of Children Aged 2 through 18 Who Never See a
Dentist, by Health Insurance Status, 1996-1997 and 2004-2005:
All children (2-18): Private insurance;
1996-1997: Percentage: 7.8;
1996-1997: Lower limit: 6.9;
1996-1997: Upper limit: 8.6;
2004-2005: Percentage: 7.0;
2004-2005: Lower limit: 6.3;
2004-2005: Upper limit: 7.7.
All children (2-18): Medicaid;
1996-1997: Percentage: 14.3;
1996-1997: Lower limit: 12.4;
1996-1997: Upper limit: 16.3;
2004-2005: Percentage: 12.5;
2004-2005: Lower limit: 11.2;
2004-2005: Upper limit: 13.8.
All children (2-18): Uninsured;
1996-1997: Percentage: 18.0;
1996-1997: Lower limit: 15.4;
1996-1997: Upper limit: 20.7;
2004-2005: Percentage: 19.4;
2004-2005: Lower limit: 16.8;
2004-2005: Upper limit: 22.0.
Children 2-5: Private insurance;
1996-1997: Percentage: 26.6;
1996-1997: Lower limit: 23.8;
1996-1997: Upper limit: 29.3;
2004-2005: Percentage: 25.4;
2004-2005: Lower limit: 22.7;
2004-2005: Upper limit: 28.1.
Children 2-5: Medicaid;
1996-1997: Percentage: 31.7;
1996-1997: Lower limit: 28.4;
1996-1997: Upper limit: 35.1;
2004-2005: Percentage: 30.0;
2004-2005: Lower limit: 26.8;
2004-2005: Upper limit: 33.2.
Children 2-5: Uninsured;
1996-1997: Percentage: 42.2;
1996-1997: Lower limit: 35.6;
1996-1997: Upper limit: 48.8;
2004-2005: Percentage: 43.9;
2004-2005: Lower limit: 36.9;
2004-2005: Upper limit: 50.8.
Children 6-11: Private insurance;
1996-1997: Percentage: 2.4;
1996-1997: Lower limit: 1.7;
1996-1997: Upper limit: 3.1;
2004-2005: Percentage: 1.8;
2004-2005: Lower limit: 1.2;
2004-2005: Upper limit: 2.5.
Children 6-11: Medicaid;
1996-1997: Percentage: 6.7;
1996-1997: Lower limit: 4.3;
1996-1997: Upper limit: 9.0;
2004-2005: Percentage: 4.5;
2004-2005: Lower limit: 3.3;
2004-2005: Upper limit: 5.7.
Children 6-11: Uninsured;
1996-1997: Percentage: 11.9;
1996-1997: Lower limit: 8.6;
1996-1997: Upper limit: 15.3;
2004-2005: Percentage: 11.9;
2004-2005: Lower limit: 9.0;
2004-2005: Upper limit: 14.8.
Children 12-15: Private insurance;
1996-1997: Percentage: 1.3;
1996-1997: Lower limit: 0.7;
1996-1997: Upper limit: 1.9;
2004-2005: Percentage: 1.6;
2004-2005: Lower limit: 1.1;
2004-2005: Upper limit: 2.2.
Children 12-15: Medicaid;
1996-1997: Percentage: 7.1;
1996-1997: Lower limit: 4.3;
1996-1997: Upper limit: 9.9;
2004-2005: Percentage: 4.8;
2004-2005: Lower limit: 3.3;
2004-2005: Upper limit: 6.2.
Children 12-15: Uninsured;
1996-1997: Percentage: 10.7;
1996-1997: Lower limit: 7.2;
1996-1997: Upper limit: 14.1;
2004-2005: Percentage: 13.2;
2004-2005: Lower limit: 9.6;
2004-2005: Upper limit: 16.7.
Children 16-18: Private insurance;
1996-1997: Percentage: 2.6;
1996-1997: Lower limit: 1.5;
1996-1997: Upper limit: 3.7;
2004-2005: Percentage: 2.7;
2004-2005: Lower limit: 1.9;
2004-2005: Upper limit: 3.6.
Children 16-18: Medicaid;
1996-1997: Percentage: 6.8;
1996-1997: Lower limit: 3.4;
1996-1997: Upper limit: 10.2;
2004-2005: Percentage: 9.5;
2004-2005: Lower limit: 6.9;
2004-2005: Upper limit: 12.0.
Children 16-18: Uninsured;
1996-1997: Percentage: 14.0;
1996-1997: Lower limit: 9.5;
1996-1997: Upper limit: 18.5;
2004-2005: Percentage: 17.5;
2004-2005: Lower limit: 13.8;
2004-2005: Upper limit: 21.1.
Source: GAO analysis of 1996 through 1997 and 2004 through 2005 Medical
Expenditure Panel Survey (MEPS) data.
Notes: Data in the Medicaid category from the 1996 through 1997 period
only included children who were enrolled in Medicaid, while data from
the 2004 through 2005 period included children who were enrolled in
Medicaid and children who were enrolled in SCHIP. We estimated that
about 84 percent of the children in the Medicaid category from the 2004
through 2005 period were enrolled in Medicaid, while the remainder were
enrolled in SCHIP (either in separate child health programs or Medicaid
expansion programs).
Data presented in this table were based on the survey responses of an
adult member of the child's household.
None of the changes from the 1996 through 1997 period to the 2004
through 2005 period were found to be statistically significant at the
95 percent level.
[End of table]
Table 8: Percentage of Children Aged 2 through 18 Who Were Unable to
Access Necessary Dental Care, by Health Insurance Status, 2004-2005:
Private insurance;
Percentage: 1.6;
Lower limit: 1.1;
Upper limit: 2.0.
Medicaid;
Percentage: 3.6;
Lower limit: 2.7;
Upper limit: 4.4.
Uninsured;
Percentage: 6.8;
Lower limit: 5.3;
Upper limit: 8.4.
Source: GAO analysis of 2004 through 2005 Medical Expenditure Panel
Survey (MEPS) data.
Notes: Data from the Medicaid category included both children who were
enrolled in Medicaid and children who were enrolled in SCHIP. We
estimate that 84 percent of the children in the Medicaid category were
enrolled in Medicaid, while the remainder were enrolled in SCHIP
(either in separate child health programs or Medicaid expansion
programs).
Data presented in this table were based on the survey responses of an
adult member of the child's household.
[End of table]
Table 9: Reasons for Children's Inability to Access Necessary Dental
Care, by Health Insurance Status, 2004-2005:
Reason given: Could not afford care;
Private insurance: Percentage: 64.2;
Private insurance: Lower limit: 53.3;
Private insurance: Upper limit: 75.0;
Medicaid: Percentage: 50.4;
Medicaid: Lower limit: 39.1;
Medicaid: Upper limit: 61.8;
Uninsured: Percentage: 96.8;
Uninsured: Lower limit: 95.6;
Uninsured: Upper limit: 97.9.
Reason given: Insurance company would not approve/cover/pay;
Private insurance: Percentage: 10.9;
Private insurance: Lower limit: 2.9;
Private insurance: Upper limit: 18.8;
Medicaid: Percentage: 11.6;
Medicaid: Lower limit: 4.7;
Medicaid: Upper limit: 18.6;
Uninsured: Percentage: 0.6;
Uninsured: Lower limit: 0.5;
Uninsured: Upper limit: 0.7.
Reason given: Doctor refused insurance plan;
Private insurance: Percentage: 2.4;
Private insurance: Lower limit: 0.0;
Private insurance: Upper limit: 6.0;
Medicaid: Percentage: 14.8;
Medicaid: Lower limit: 4.3;
Medicaid: Upper limit: 25.2;
Uninsured: Percentage: 0.0;
Uninsured: Lower limit: 0.0;
Uninsured: Upper limit: 0.0.
Reason given: Problems getting to the doctor's office;
Private insurance: Percentage: 4.2;
Private insurance: Lower limit: 3.3;
Private insurance: Upper limit: 5.1;
Medicaid: Percentage: 3.3;
Medicaid: Lower limit: 1.7;
Medicaid: Upper limit: 4.9;
Uninsured: Percentage: 0.0;
Uninsured: Lower limit: 0.0;
Uninsured: Upper limit: 0.0.
Reason given: Could not get time off work;
Private insurance: Percentage: 0.0;
Private insurance: Lower limit: 0.0;
Private insurance: Upper limit: 0.0;
Medicaid: Percentage: 1.1;
Medicaid: Lower limit: 0.9;
Medicaid: Upper limit: 1.2;
Uninsured: Percentage: 0.0;
Uninsured: Lower limit: 0.0;
Uninsured: Upper limit: 0.0.
Reason given: Didn't know where to get care;
Private insurance: Percentage: 2.0;
Private insurance: Lower limit: 0.0;
Private insurance: Upper limit: 6.0;
Medicaid: Percentage: 4.3;
Medicaid: Lower limit: 2.3;
Medicaid: Upper limit: 6.4;
Uninsured: Percentage: 0.5;
Uninsured: Lower limit: 0.5;
Uninsured: Upper limit: 0.6.
Reason given: Was refused services;
Private insurance: Percentage: 0.0;
Private insurance: Lower limit: 0.0;
Private insurance: Upper limit: 0.0;
Medicaid: Percentage: 1.7;
Medicaid: Lower limit: 0.9;
Medicaid: Upper limit: 2.4;
Uninsured: Percentage: 0.2;
Uninsured: Lower limit: 0.0;
Uninsured: Upper limit: 0.7.
Reason given: Could not get child care;
Private insurance: Percentage: 0.0;
Private insurance: Lower limit: 0.0;
Private insurance: Upper limit: 0.0;
Medicaid: Percentage: 0.6;
Medicaid: Lower limit: 0.0;
Medicaid: Upper limit: 1.7;
Uninsured: Percentage: 0.0;
Uninsured: Lower limit: 0.0;
Uninsured: Upper limit: 0.0.
Reason given: Did not have time;
Private insurance: Percentage: 4.3;
Private insurance: Lower limit: 1.1;
Private insurance: Upper limit: 7.5;
Medicaid: Percentage: 2.8;
Medicaid: Lower limit: 0.0;
Medicaid: Upper limit: 6.0;
Uninsured: Percentage: 1.0;
Uninsured: Lower limit: 0.8;
Uninsured: Upper limit: 1.3.
Reason given: Other;
Private insurance: Percentage: 12.0;
Private insurance: Lower limit: 9.5;
Private insurance: Upper limit: 14.7;
Medicaid: Percentage: 9.5;
Medicaid: Lower limit: 4.9;
Medicaid: Upper limit: 14.1;
Uninsured: Percentage: 0.9;
Uninsured: Lower limit: 0.0;
Uninsured: Upper limit: 1.9.
Source: GAO analysis of 2004 through 2005 Medical Expenditure Panel
Survey (MEPS) data.
Notes: Data from the Medicaid category included both children who were
enrolled in Medicaid and children who were enrolled in SCHIP. We
estimate that 84 percent of the children in the Medicaid category were
enrolled in Medicaid, while the remainder were enrolled in SCHIP
(either in separate child health programs or Medicaid expansion
programs).
Data presented in this table were based on the survey responses of an
adult member of the child's household.
[End of table]
Our analysis of the MEPS data was conducted in accordance with
generally accepted government auditing standards from December 2007
through September 2008.
[End of section]
Appendix III: Comments from the Department of Health and Human
Services:
Note: Page numbers in the draft report may differ from those in this
report.
Department Of Health & Human Services:
Office Of The Secretary:
Assistant Secretary for Legislation:
Washington, DC 20201:
September 16, 2008:
James Cosgrove:
Director, Health Care:
Government Accountability Office:
441 G Street NW:
Washington, DC 20548:
Dear Mr. Cosgrove:
Enclosed are the Department's comments on the U.S. Government
Accountability Office's (GAO) draft report entitled: "Medicaid: Extent
of Dental Disease in Children Has Not Decreased, and Millions Are
Estimated to Have Untreated Tooth Decay" (GAO-08-1121).
The Department appreciates the opportunity to review and comment on
this report before its publication.
Sincerely,
Signed by:
Jennifer R. Luong, for:
Vincent J. Ventimiglia, Jr.
Assistant Secretary for Legislation:
Attachment:
Comments Of The U.S. Department Of Health And Human Services (HMS) On
The U.S. Government Accountability Office's (GAO) Draft Report
Entitled, "Medicaid: Extent Of Dental Disease In Children Has Not
Decreased, And Millions Are Estimated To Have Untreated Tooth Decay"
(GAO 08-1121):
The Department of Health and Human Services (HHS), including the
Centers for Medicare & Medicaid Services (CMS), the Centers for Disease
Control and Prevention (CDC) and the Agency for Healthcare Research and
Quality (AHRQ), appreciates the opportunity to comment on the
Government Accountability Office (GAO) Draft Report entitled, "Extent
of Dental Disease in Children has Not Decreased and Millions are
Estimated to Have Untreated Tooth Decay" (GAO-08-1121). The objective
of this report was to examine the oral health status of children in
Medicaid, including the extent to which children in Medicaid experience
dental disease, the extent they receive dental care, and how these
conditions have changed over time. We understand a second report will
he issued at a later date addressing State and CMS oversight activities
of children receiving Medicaid dental services.
GAO Recommendations:
There were no recommendations included in this draft report.
Additional Comments:
Comments of the Centers for Medicare & Medicaid Services:
CMS acknowledges that the provision of dental services is a challenge
for children covered by Medicaid as well as children in the country as
a whole. It is important to note that States administer the Medicaid
Program with general oversight from CMS. By design, each State's
program is unique and targeted to the population served. Additionally,
the barriers to receiving dental care are multi-factorial. Thus, there
is no one single activity that can be implemented to stimulate
improvement. CMS seeks to support States in their efforts to improve
services through interventions focused in the areas of improved access
to required dental services, reimbursement aligned with desired
outcomes, and attention to the quality and transparency of services
provided. The following are a few of the activities that CMS has led in
coordination with the States:
* To assist in obtaining data for purposes of improvement, CMS
completed 17 State dental reviews between February and May. The
findings from these reviews will be summarized in a national report
that will be used to inform future policy and focus improvement
activities in the strategic areas listed above.
* In addition to the 17 State focused reviews, CMS collected
information on the availability of Dental Periodicity Schedules from
all 50 States. Our initial review indicated that all but three States
had some type of periodicity schedule, although they were not all in
compliance with the CMS regulations and were not always easily
accessible by providers and beneficiaries. As a result, CMS Regional
Offices issued further guidance to States on expectations related to
periodicity schedules.
* In collaboration with the National Association of State Medicaid
Directors (NASMD), CMS recently developed an Oral Health Technical
Advisory Group (TAG) and has held four meetings to date to address
issues related access to care, quality improvement and collecting and
reporting data. We have received technical advice from the American
Dental Association (ADA) regarding evidence-based performance
indicators that can be used to measure improvements in access and
quality consistently throughout the country. We continue to seek
information from other dental professional groups and have met with the
American Academy of Pediatric Dentistry and the Medicaid and SCHIP
Dental Association and presented at the National Oral Health Conference
that was held April 28-30, 2008.
* Our spring 2008 Quality Teleconference Call held on April 3, 2008
focused on promising practices in children's dental care. The
Conference included presentations on innovative approaches to financing
dental care, including information from the State of North Carolina on
its "Into the Mouth of Babes" program, the State of Tennessee's
approach to increasing provider participation and access, the State of
Michigan's Healthy Kids Dental program and the State of California's
proposed dental performance measures for their SCHIP population. The
conference call was well received and there were over 400 participants.
Subsequently we posted several dental "promising practice" on our
website to disseminate information regarding their programs.
Additionally, we recently funded a contract to explore child heath
promising practices in Medicaid and SCHIP that we expect to complete by
the end of the year.
* Last year we also established a Medicaid Quality Improvement Goal to
improve States' abilities to assess quality of care and move toward the
development of a national framework for quality. We have developed a
comprehensive state-specific Quality Assessment Report that provides an
analysis of nearly every quality activity occurring in a state Medicaid
or SCHIP program. Dental services are included among the various
performance areas. We have also funded a contract that will focus on
helping many Medicaid Managed Care Organizations collect quality
performance information in a consistent manner that will allow for
Benchmarking with plans across the country.
* We arc also working aggressively to ensure the submission of accurate
dental services data on the CMS-416 so that we can continue to analyze
and monitor progress in the provision of dental services.
* We recognize that real change in the system occurs at the local level
by State administrators, local providers and their patients. Reform
activities are being led by new and innovative approaches from States
such as Maryland, Vermont, Pennsylvania, Tennessee, Alabama,
Connecticut and many other States.
Comments of the Centers for Disease Control and Prevention:
In the general population of children, caries in permanent teeth has
generally declined and untreated decay has remained unchanged. In
preschool school children, caries has increased in primary teeth, but
among elementary-school aged children caries in primary teeth has
remained unchanged. Moreover, aggregating permanent and primary teeth
across large age ranges can provide misleading information regarding
caries trends. It would be better to describe caries trends more on a
age-dentition based relationship such as describing caries in only
primary teeth for very young children, caries in mixed (primary and
permanent) for early elementary-aged children, and caries in permanent
teeth for older children and adolescents.
CDC notes that NHANES data show two clear different trends: a decrease
in the prevalence and severity of caries in the permanent dentition
(children from age 12 and older have full permanent dentition), and a
no change in the prevalence and severity of caries in the primary
dentition (children aged 2-5 have a full set of primary teeth and some
may have already a first permanent molar). While children in the 6-11
age groups have a combination of primary and permanent teeth - mixed
dentition, combining the age groups of 2-18 to indicate that there is
no "decrease" is inaccurate since the aggregate data mask the reduction
in permanent teeth. Thus, the report should focus on both dentitions
separately.
The following are specific comments to the report:
* Page 2, footnote 4: It is true that after 2004, NHANES has not
conducted a comprehensive oral health examination that can provide data
for an extensive caries analysis or an analysis similar to what GAO has
done. However, CDC has recognized the need to conduct periodic
comprehensive dental caries examinations and has begun planning to
alternate between a comprehensive caries examination similar to what
was conducted during NHANES III and NHANES 1999-2004, and a more
limited caries screening as has been conducted during NHANES 2005-2008.
NCHS suggests revising the footnote, as follows, to make this clear:
After 2004, direct oral examinations by dentists were eliminated in
NHANES; these were replaced in 2005-2008 by a basic assessment of
caries experience and untreated decay conducted by trained health
technologists.
* Page 8, Footnote 15: (now page 9, footnote 17) While it is accurate
to say that the prevalence of untreated dental caries may be an
underestimate of the true prevalence of untreated decay because dental
radiographs (x-rays) were not taken as part of the caries assessment on
NHANES and, therefore, our ability to assess the areas in between teeth
with precision is limited, our NHANES examiners are trained to detect
untreated cavities visually and with a dental explorer. Nevertheless,
the methods used on NHANES III and NHANES 1999-2004 are identical,
therefore, any assessment in the overall trend is not biased.
* Page 8, Footnote 15: (now page 9, footnote 17) We don't believe that
this is a correct assessment. The criteria used n NHANES are the same
used in previous national surveys, so we can assess trends.
The underestimation occurs in all surveys because we do not have other
diagnostic tools available at the clinical setting. But in epidemiology
and surveillance we always deal with that issue. Furthermore, if the
methods underestimate disease, they do across all subpopulation groups.
Is "visibly significant" what they are really told or is it "obvious
signs of dental decay." The caries diagnostic criteria are spelled out
in the NHANES exam manual but are hard to categorize in a simple
phrase.
* Page 13, Footnote 25: (now page 15, footnote 27) CDC has found the
rates of untreated decay among low-income children to have declined
since the early 1970s for permanent teeth only. This is not true when
looking at primary teeth only or when primary and permanent teeth are
combined.
* Page 14 bullet 2: (now page 17, footnote 28) We think it would be
useful to specify why sealant use in low-income children has increased
in recent years. There are two reports (MMWR and NCHS Series 11) that
elaborate on this statistic. Although we have no hard data on the
contribution of school-based sealant programs to the increase of
sealant prevalence in low-income children we do know that many state
health departments have long-term programs that have delivered sealants
to a sizable number of low-income children over the past decade. We
reference an MMWR report from Ohio Impact of targeted, school-based
dental sealant programs in reducing racial and economic disparities in
sealant prevalence among schoolchildren-Ohio, 1998-1999; MMWR
2001;50(34):736-738 that provides some level of detail.
Comments of the Agency for Healthcare Research and Quality:
AHRQ notes that the report indicates that GAO staff spoke with agency
officials regarding the use of MEPS data for their analyses; however,
AHRQ is not aware of specific requests from GAO staff for substantive
assistance on the analyses directed to 1) assessing the relationship of
public coverage and use of dental services in children; 2) discussions
regarding the analytic approach taken with the MEPS data to ascribe
public coverage in children; 3) the age restriction that was considered
(2-18); and 4) the details of how the two consecutive year MEPS data
sets were utilized to inform these analyses (e.g. were the 2 years
pooled or was this the longitudinal 2 year data?). Specifically, we
note the additional concerns:
* AHRQ staff completed a Chartbook that summarizes Dental Use,
Expenses, Dental Coverage, and Changes, 1996 and 2004, with particular
attention to changes experienced by individuals under the age of 21.
The reference to this report follows: AHRQ Pub. No. 08-0002, Dental
Use, Expenses, Dental Coverage and Changes, 1996 and 2004, Chartbook 17
found at: [hyperlink,
http://www.meps.ahrq.gov/mepsweb/data_files/publications/cbl71cb17.ndf].
This Chartbook presents data from the 1996 and 2004 Medical Expenditure
Panel Survey (MEPS) on dental use and dental coverage for the U.S
civilian non-institutionalized (community) population. Data are
presented for the overall community population, children age birth to
age 20, adults age 21 to age 64, and older adults age 65 and older.
However, the MEPS study was not cited and referenced, and it is unclear
why the same analytical approach was not followed for the determination
of public coverage status and estimates as noted in the MEPS Chartbook.
* AHRQ has standard approaches for the determination of national dental
utilization estimates for each calendar year and it is unclear what has
been done analytically to convey how the estimates cover the periods
1996-1997 and 2004-2005. Consequently, the report should be specific in
the analytical and estimation approaches that were adopted for this
report and how they either coincide or depart from standard methods
used in MEPS.
We thank the GAO staff for their work in this important area of oral
health status of children in Medicaid, including the extent to which
children in Medicaid experience dental disease, the extent they receive
dental care, and how these conditions have changed over time.
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
[End of section]
GAO Contact:
James C. Cosgrove, (202) 512-7114 or cosgrovej@gao.gov:
Staff Acknowledgments:
In addition to the individual named above, Katherine M. Iritani,
Assistant Director; Susannah Bloch; Alex Dworkowitz; Erin Henderson;
Martha Kelly; Ba Lin; Elizabeth T. Morrison; Terry Saiki; Hemi
Tewarson; and Suzanne Worth made key contributions to this report.
[End of section]
Related GAO Products:
Medicaid: Concerns Remain about Sufficiency of Data for Oversight of
Children's Dental Services. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-07-826T]. Washington, D.C.: May 2, 2007.
Medicaid Managed Care: Access and Quality Requirements Specific to Low-
Income and Other Special Needs Enrollees. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-05-44R]. Washington, D.C.:
December 8, 2004.
Medicaid and SCHIP: States Use Varying Approaches to Monitor Children's
Access to Care. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-03-
222]. Washington, D.C.: January 14, 2003.
Medicaid: Stronger Efforts Needed to Ensure Children's Access to Health
Screening Services. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-
01-749]. Washington, D.C.: July 13, 2001.
Oral Health: Factors Contributing to Low Use of Dental Services by Low-
Income Populations. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO/HEHS-00-149]. Washington, D.C.: September 11, 2000.
Oral Health: Dental Disease Is a Chronic Problem Among Low-Income
Populations. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-00-
72]. Washington, D.C.: April 12, 2000.
Medicaid Managed Care: Challenge of Holding Plans Accountable Requires
Greater State Effort. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO/HEHS-97-86]. Washington, D.C.: May 16, 1997.
[End of section]
Footnotes:
[1] Low-income children eligible under a state Medicaid plan generally
are entitled to screening, diagnostic, preventive, and treatment
services--including dental services--under Medicaid's Early and
Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit.
[2] A list of related GAO products can be found at the end of this
report.
[3] Our ongoing work is examining state and federal efforts to ensure
that children in Medicaid receive needed dental services.
[4] After 2004, direct oral examinations by dentists were eliminated as
part of NHANES. According to CDC, these examinations by dentists were
replaced in 2005 through 2008 NHANES by a basic assessment of tooth
decay experience and untreated decay conducted by trained health
technologists.
[5] Our figures for Medicaid include children enrolled in the State
Children's Health Insurance Program (SCHIP), because NHANES contains a
single category that combines Medicaid and SCHIP beneficiaries. SCHIP
provides health care coverage to children in low-income families who
are not eligible for traditional Medicaid programs. States may
implement SCHIP programs by expanding their existing Medicaid programs,
establishing separate child health programs, or a combination of both.
States with Medicaid expansion programs must provide to SCHIP
beneficiaries all benefits that are available to the traditional
Medicaid population. SCHIP enrollment in fiscal year 2006 was 6.6
million children. Nationwide, about 29 percent of children enrolled in
SCHIP were in states that have chosen to expand their existing Medicaid
programs. Of the total Medicaid and SCHIP population, about 15 percent
were enrolled in SCHIP during the 2000 through 2004 time period.
Although state Medicaid programs may cover children under age 21, SCHIP
covers children under age 19. Therefore, to ensure our analyses of age
and insurance status were comparable we limited our analyses to
children ages 2 through 18.
[6] We analyzed the data for privately insured children with and
without dental coverage separately, and found that the indicators of
oral health and dental utilization for both groups were similar.
Consequently, in this report we present the data for children with
private insurance as one group.
[7] We estimate that, of the total number of children in the MEPS 2004
through 2005 Medicaid and SCHIP category, about 16 percent were in
SCHIP.
[8] U.S. Department of Health and Human Services, National Institute of
Dental and Craniofacial Research, National Institutes of Health, Oral
Health in America: A Report of the Surgeon General (Rockville, Md.,
2000).
[9] Matthew F. Savage, Jessica Y. Lee, Jonathan B. Kotch, and William
F. Vann Jr., "Early Preventive Dental Visits: Effects on Subsequent
Utilization and Costs," Pediatrics, 114 (2004). The study examined the
effects of preventive care on subsequent utilization and costs of
dental services among preschool-aged children in North Carolina
continuously enrolled in Medicaid between 1992 and 1997.
[10] According to the American Academy of Pediatric Dentistry (AAPD),
dental sealants, a plastic material put on the chewing surfaces of back
teeth, have been shown to prevent decay on tooth surfaces where food
and bacteria can build up. AAPD recommends sealants for 6-year and 12-
year molars as soon as possible after eruption.
[11] The Healthy People 2010 goal was increased from 57 percent when it
was first established in 2000 to 66 percent during a mid-course review
in the mid-2000s. The goal defines preventive dental care to include
examination, x-ray, fluoride treatment, cleaning, or sealant
application. See U.S. Department of Health and Human Services, Public
Health Service, Progress Review: Oral Health (February 7, 2008).
[12] Estimate based on CMS statistics for children ages 1 through 18 in
Medicaid, less the estimated number of children aged 1 in that group
(the latter of which was estimated using Census data).
[13] CMS's statistics include the Medicaid population enrolled in
capitated plans (typically defined as plans that contract with states
to receive a prepaid per enrollee payment for coverage of Medicaid
services) and primary care case management models.
[14] These Medicaid dental services must be provided at intervals which
meet reasonable standards of dental practice or as medically necessary
and must include relief of pain and infections, restoration of teeth,
and maintenance of dental health.
[15] The MEPS measures receipt of any dental care, whereas the 2010
Healthy People target is for receipt of a preventive dental service.
This comparison may underestimate the actual gap.
[16] We considered a child as having experienced tooth decay if he or
she had a tooth with untreated decay, had a tooth that had been treated
for decay (meaning had a filling), or had lost a tooth due to decay.
[17] The extent of dental disease may be even more severe than these
statistics suggest. Oral health experts told us that the extent of
untreated tooth decay identified in NHANES is likely an underestimate
because NHANES examiners consider a tooth as decayed only if the decay
is "visibly significant."
[18] These estimates are based on 95 percent confidence intervals--that
is, there is a 95 percent probability that the actual number falls
within this range. For children with untreated tooth decay, the lower
and upper limits are 5.9 million and 7.1 million, respectively. For
children with untreated tooth decay in three or more teeth, the lower
and upper limits are 1.9 million and 2.6 million, respectively.
[19] This estimate is based on a 95 percent confidence interval--that
is, there is a 95 percent probability that the actual number falls
within a specific range. For children with an urgent need to see a
dentist, the lower and upper limits of the range are 700,000 and 1.5
million, respectively.
[20] The age groups we used for our analysis of NHANES differ slightly
from the age groups measured for purposes of Healthy People 2010.
According to HHS, prevalence of untreated tooth decay among 2 through 4
year olds in the general population increased from 16 percent during
the 1988 through 1994 time period, to 19 percent for the 1999 through
2004 time period (this increase was not statistically significant). For
this objective, the trends may be moving in the opposite direction of
the target. HHS has also reported that among young children aged 2 to 4
years, the prevalence of tooth decay in primary teeth increased from 18
percent for the 1988 through 1994 time period to 24 percent for the
1999 through 2004 time period. By comparison with older children, tooth
decay in preschool children in the general population increased
significantly. According to HHS, this trend could portend a future
increase in tooth decay in older children, as influenced by changes in
diet or food consumption patterns. The target for this goal is 11
percent.
[21] MEPS asks an adult if the children in the household had received
any dental care in the previous year. If they respond affirmatively,
then surveyors ask about the type of provider they visited: a dentist,
a hygienist, oral surgeon, orthodontist, endodontist, periodontist, or
dental technician.
[22] This estimate is based on a 95 percent confidence interval--that
is, there is a 95 percent probability that the actual number falls
within a specific range. For children without a dental visit in the
previous year, the lower and upper limits of this range are 12.1
million and 13.0 million, respectively.
[23] U.S. Department of Health and Human Services, Agency for
Healthcare Research and Quality, "Dental Use, Expenses, Private Dental
Coverage, and Changes, 1996 and 2004," MEPS Chartbook, no. 17 (2007),
[hyperlink,
http://www.meps.ahrq.gov/mepsweb/data_files/publications/cb17/cb17.pdf]
(downloaded Sept. 16, 2008).
[24] As part of the MEPS survey, participants are asked: "On average,
how often does [person] receive a dental check-up?" One of the
responses to this question is that the individual in question "never
goes to a dentist." The percentage of children who "never go to the
dentist" varied by age group. The youngest group, ages 2 through 5, was
the group most likely to never see a dentist, with 30 percent of
children falling in that category. However, even some of the older
children never see a dentist. We found that about 10 percent of
children aged 16 through 18 in Medicaid were in this category.
[25] This estimate is based on a 95 percent confidence interval--that
is, there is a 95 percent probability that the actual number falls
within this range. For children who could not obtain needed dental
care, the lower and upper limits of this range are 543,000 and 884,000,
respectively.
[26] MEPS asked participants for the reason they were unable to get
needed care. Possible responses included (1) could not afford care, (2)
insurance company would not approve/cover/pay, (3) doctor refused
insurance plan, (4) problems getting to doctor's office, (5) could not
get time off work, (6) didn't know where to get care, (7) was refused
services, (8) could not get child care, (9) did not have time, and (10)
other. Table 9 in app. II lists the reasons for MEPS participants'
inability to access necessary dental care by insurance status. MEPS is
a nationally representative survey that also includes privately insured
and uninsured individuals; it does not illuminate why beneficiaries
with health coverage such as Medicaid (which has no cost sharing for
certain beneficiaries) would report that they could not afford care, or
the reasons for providers refusing to accept insurance plans.
[27] We found that the rates of untreated tooth decay for children with
Medicaid did not decrease from the period 1988 through 1994 to the
period 1999 through 2004. Similarly, CDC found that the rates of
untreated primary tooth decay in children aged 2 through 11 had not
decreased between 1988 through 1994 and 1999 through 2004. However, CDC
has found that rates of untreated tooth decay in permanent teeth for
low-income children have declined since the early 1970s.
[28] According to HHS officials, many state health departments have
long-term programs that have delivered sealants to a sizable number of
low-income children over the past decade. See for example, CDC, "Impact
of Targeted, School-Based Dental Sealant Programs in Reducing Racial
and Economic Disparities in Sealant Prevalence Among School Children,
Ohio, 1998-1999," Morbidity and Mortality Weekly Report, 50 no. 34
(2001),736-8.
[29] For 2005 through 2008, NHANES collected basic information on tooth
decay experience and untreated decay using a screening assessment
conducted by trained health technologists. According to CDC officials,
CDC has begun planning to alternate between a comprehensive tooth decay
examination and a more limited screening for future NHANES.
[30] The privately insured category comprises children with private
health insurance, some of whom had dental coverage and others who did
not, while the uninsured category comprises children who had neither
health insurance nor dental insurance.
[31] States may implement SCHIP programs by expanding their existing
Medicaid programs, establishing separate child health programs, or a
combination of both. States with Medicaid expansion programs must
provide to SCHIP beneficiaries all benefits that are available to the
traditional Medicaid population. SCHIP enrollment in fiscal year 2006
was 6.6 million children. Nationwide, about 29 percent of children
enrolled in SCHIP were in states that have chosen to expand their
existing Medicaid programs. Of the total Medicaid and SCHIP population,
about 15 percent were enrolled in SCHIP during the 2000 through 2004
time period.
[32] To facilitate analysis of subpopulations, it was necessary to pool
together more than 1 year of MEPS data to yield sample sizes large
enough to generate reliable estimates. To facilitate use of these data
and the calculation of designed-based standard errors, we used the AHRQ
public use file HC-036. This file provides a standardized set of
variance estimation units over all years of MEPS. Using this file,
estimates can be made with datasets created by combining multiple years
of annual MEPS data.
[End of section]
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