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ISSN 2691-7475Health Policy BriefJuly 2020Despite Insurance, the Poorest AdultsHave the Worst Access to Dental CareNadereh Pourat and Maria DitterSUMMARY: Oral health is critical for overallhealth and well-being, yet it is not consideredan essential health benefit for adults underthe Patient Protection and Affordable CareAct. Long-standing income disparities inoral health have been documented and arelinked to lower rates of dental insurance andsubsequent limited access to oral health care.We examined pooled data from the 2017 and2018 California Health Interview Surveys toassess whether there were income and dentalinsurance disparities among California adults,and, if so, whether such disparities included‘‘Dental servicesare not anessential healthbenefit under theACA and arenot covered bypublic programssuch as Medicare.’’Oral health is an integral componentof overall health.1 Evidenceindicates that oral health depends on timelycare that includes oral health education,preventive services, and early detection andtreatment of dental problems.1 However,evidence also indicates that low-incomeadults have poorer oral health, whichis potentially linked to lack of dentalinsurance.2Like health insurance, dental insurancepromotes access to care by reducing financialbarriers to access.3 However, dental insuranceis different from health insurance in severalrespects. For one thing, private dentalinsurance is offered less frequently than healthinsurance by employers. Without premiumsharing from employers, dental insurancepremiums are less affordable to lower-incomepopulations. In addition, dental services arenot considered an essential health benefitaccess to timely dental care. We found that lowincome California adults were less likely to havehad timely dental visits, more likely to have hadvisits for dental problems, and less likely to havehad private dental insurance than their higherincome counterparts. We also found that dentalinsurance alleviated some, but not all, incomedisparities in access. These findings highlightthe importance of considering dental healthas an essential health benefit and of ensuringparity in dental benefits, among other potentialpolicy solutions for reducing disparities indental coverage and access.under the Patient Protection and AffordableCare Act and are not covered by publicprograms such as Medicare. Adult dentalbenefits are optional for Medicaid (Medi-Calin California), and California is one of 35states that include this benefit.4 Most dentalinsurance policies have an annual cap onbenefit amounts, as well as restrictions oncoverage of some services.5,6 Medi-Cal haslower provider reimbursement levels anda lower rate of provider participation thanprivate dental insurance.7 Private insurancemay also have high levels of cost sharing onspecific services, which may contribute toreduced dental visits.8Access to dental care is measured by visits todental providers to receive preventive care anddental treatment. Healthy People 2020 set thetarget for this access indicator as at least onedental visit per year for 49% of the populationby 2020.9 The frequency of visits varies by

UCLA CENTER FOR HEALTH POLICY RESEARCH2Exhibit 1Timeliness of Dental Visits by Federal Poverty Level (FPL), Adults Ages 18 and Older,California, 2017–201817%24%18%13%6%14%23%13%More than 5 years agoor neverMore than 1 year andup to 5 years ago6 to 12 months ago17%Up to 6 months ago67%41%0%–138% FPL(6.97 million)47%139%–249% FPL(5.11 million)At or Above 250% FPL(17.49 million)Sources: 2017 and 2018 California Health Interview Surveys‘‘Our aimwas to assesswhether incomedisparities inaccess to dentalcare exist, andwhat potentialrole dentalinsurancemight have inaddressing thesedisparities.’’dentist recommendations, which are basedon the oral health of individuals. Most dentalinsurance policies and Medi-Cal cover up totwo preventive visits per year.This policy brief examines timeliness of andreasons for dental visits among Californiaadults by income and insurance coverage.We pooled data from the 2017 and 2018California Health Interview Surveys (CHIS)to obtain the most recent available data onoral health access for California adults. Ouraim was to assess whether income disparitiesin access to dental care exist among Californiaadults, and, if such disparities exist, whatpotential role dental insurance might have inaddressing these disparities.We used the federal poverty level (FPL)to measure income, identifying Californiaadults with incomes at or below 138% FPL( 17,237 for a single person and 35,535 fora household of four) as those whose incomeswere lowest and were consistent with MediCal eligibility criteria.Low-Income Californians Have LessTimely Dental Visits Than Higher-IncomeIndividualsThere is no single requirement for frequencyof dental visits, as the need for care is highlydependent on individual risk factors. However,the American Dental Association recommendsa minimum of one annual visit, and mostsurvey data examine this frequency.10 CHISrespondents reported on how long it hadbeen since they had had a dental visit, whichallowed us to examine both variations inannual visits and the time intervals betweenvisits. We found that these indicators variedby income (Exhibit 1). Among low-incomeadults (0%–138% FPL), we found that 41%had had a dental visit less than six months ago,and 18% had had a visit 6–12 months ago.Combined, 59% of low-income adults (datanot shown) had visited a dentist in the lastyear. In contrast, 67% of those with incomesabove 250% FPL ( 31,225 for a single personand 64,375 for a household of four) had hada visit less than six months ago, and 13% had

UCLA CENTER FOR HEALTH POLICY RESEARCHhad a visit 6–12 months ago. Combined, 80%of adults with the highest incomes had had adental visit last year.Low-Income Californians Visit DentistsMore Frequently Than Higher-IncomeAdults for Dental ProblemsCHIS respondents were asked whether theirlast dental visit was for preventive care, aspecific problem, or both. We examinedwhether low-income adults (0%–138% FPL)had visited dentists for specific problems(including those who had visited for bothpreventive and specific problems) at adifferent rate than that of higher-incomeadults. We found that 41% of low-incomeadults had visited a dentist for specificproblems, compared to 23% of adults withincomes at or above 250% FPL (Exhibit 2).Medi-Cal Is the Dominant Form of DentalCoverage Among Low-Income AdultsWe identified adults with private dentalinsurance, Medi-Cal, and no dental insuranceand examined types of coverage reportedby income. Sixteen percent of low-incomeadults (0%–138% FPL) had private dentalinsurance, and 64% had Medi-Cal (Exhibit 3).In contrast, 69% of those with incomesLast Dental Visit for Specific Problem byFederal Poverty Level (FPL), Adults Ages 18and Older, California, 2017–201830%35%23%0%–138% FPL(6.59 million)139%–249% FPL(4.95 million)At or Above250% FPL(17.28 million)Sources: 2017 and 2018 California Health Interview Surveysat or above 250% FPL had private dentalinsurance, and 8% had Medi-Cal (a smallshare of higher-income populations receivedMedi-Cal under specific circumstances,including high medical expenses). Data alsoshowed that a smaller proportion of lowincome adults (20%) had no dental insurancecompared to those with incomes at or above250% FPL (24%).24%8%64%36%69%Private16%139%–249% FPL(5.11 million)Sources: 2017 and 2018 California Health Interview SurveysNote: Private dental insurance may include a small proportionwith military or other publicly funded coverage.UninsuredMedi-Cal34%0%–138% FPL(6.97 million)Exhibit 241%Type of Dental Insurance by Federal Poverty Level (FPL), Adults Ages 18 and Older,California, 2017–201820%3At or Above 250% FPL(17.49 million)Exhibit 3

UCLA CENTER FOR HEALTH POLICY RESEARCH4Exhibit 4Timeliness of Dental Visits by Dental Insurance and Federal Poverty Level (FPL), Adults Ages18 and Older, California, 43%41%36%28%PrivateMedi-Cal Uninsured0%–138% FPL(4.14 million)PrivateMedi-Cal Uninsured139%–249% FPL(3.23 million)6 to 12 months ago57%PrivateMedi-Cal UninsuredAt or Above 250% FPL(14.05 million)Up to 6 months agoSources: 2017 and 2018 California Health Interview SurveysNote: Private dental insurance may include a small proportionwith military or other publicly funded coverage.‘‘Having a higherincome wassignificantlyassociated withmore visits . forboth privatelyinsured anduninsuredadults.’’Dental Insurance Improves Timelinessof Dental Visits, but Income DisparitiesRemainWhen we examined the joint relationship oftype of insurance coverage with timelinessof visits by income, we found that having ahigher income was significantly associatedwith more visits within the past six monthsfor both privately insured and uninsured adults(Exhibit 4). Among privately insured adults,56% of low-income adults (0%–138% FPL)had had a visit within the past six months,compared to 73% of those with incomes at orabove 250% FPL. Among uninsured adults,28% of low-income adults had had a dentalvisit within the past six months, compared to57% of those with incomes at or above 250%FPL. Among adults with Medi-Cal coverage,however, the timeliness of dental visits didnot significantly increase by income.

UCLA CENTER FOR HEALTH POLICY RESEARCH5Last Dental Visit for Specific Problem by Federal Poverty Level (FPL) and Dental Insurance,Adults Ages 18 and Older, California, 2017–2018Exhibit 543%43%39%38%32%31%28%27%20%PrivateMedi-Cal Uninsured0%–138% FPL(6.59 million)PrivateMedi-Cal Uninsured139%–249% FPL(4.95 million)PrivateMedi-Cal UninsuredAt or Above 250% FPL(17.28 million)Sources: 2017 and 2018 California Health Interview SurveysNote: Private dental insurance may include a small proportionwith military or other publicly funded coverage.Dental Visits for Specific Problems AreLeast Common Among Privately InsuredAdults, but Income Disparities PersistWe analyzed the data to determine whetherrates of dental visits for a specific problemvaried by type of dental insurance and income(Exhibit 5). Overall rates for visits due to aspecific problem declined significantly forhigh-income individuals, irrespective of typeof insurance. However, results also indicatedthat privately insured adults in all incomegroups visited dentists for a specific problemsignificantly less often than adults who hadMedi-Cal or who were uninsured. These ratesalso varied by income. Among low-incomeadults (0%–138% FPL), 31% of those whowere privately insured reported having visiteda dentist for a specific problem, compared to43% of the Medi-Cal and uninsured groups.Among those with incomes at or above 250%FPL, these rates were lower for those withprivate insurance (20%) or Medi-Cal (32%)and those who were uninsured (28%).Implications and Policy RecommendationsWe found that a higher percentage ofCalifornia adults had had a dental visit inthe last year than the Healthy People 2020target of 49%. However, we found incomedisparities in timeliness of visits, withlow-income adults more likely than highincome adults to have had a visit for a dentalproblem. Furthermore, we found that amongthose who were uninsured, low-incomeadults (0%–138% FPL) had the lowest ratesof dental visits compared to their higher-‘‘Low-incomeadults are morelikely to havehad a visitfor a dentalproblem.’’