Health Reform In Massachusetts Increased Adult Dental Care Use, Particularly Among The Poor

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1 By Kamyar Nasseh and Marko Vujicic Health Reform In Massachusetts Increased Adult Dental Care Use, Particularly Among The Poor doi: /hlthaff HEALTH AFFAIRS 32, NO. 9 (2013): Project HOPE The People-to-People Health Foundation, Inc. ABSTRACT States frequently expand or limit dental benefits for adults covered by Medicaid. As part of statewide health reform in 2006, Massachusetts expanded dental benefits to all adults ages whose annual income was at or below 100 percent of the federal poverty level. We examined the impact of this reform and found that it led to an increase in dental care use among the Massachusetts adult population, driven by gains among poor adults. Compared to the prereform period, dental care use increased by 2.9 percentage points among all nonelderly adults in Massachusetts, relative to all nonelderly adults in eight control states. For poor Massachusetts adults, the effect was larger an elevenpercentage-point increase in dental care use above the increase among the state s nonpoor residents. The Massachusetts experience provides evidence that providing dental benefits to poor adults through Medicaid can improve dental care access and use. Our results imply that the lack of expanded dental coverage for low-income adults under the Affordable Care Act is a missed opportunity to improve access to oral care. Kamyar Nasseh (nassehk@ ada.org) is a health economist atthehealthpolicy Resources Center, American Dental Association, in Chicago, Illinois. Marko Vujicic is the managing vice president of the Health Policy Resources Center, American Dental Association. Routine dental care is an important component of oral and general health. 1 As of 2010 gum disease affected nearly half of US adults. 2 Although the relationship is not well understood, gum disease is linked to chronic diseases such as cardiovascular disease and diabetes. 3,4 Improved oral health has also been shown to have a positive effect on employment and wages. 5 Poor adults, with poor defined here as having self-reported household incomes at or below 100 percent of the federal poverty level, 6 tend to face significant barriers to dental care. 7 Dental care use decreased at the national level among poor adults from 2000 to 2010, in part as a result of Medicaid policies toward dental benefits for adults. 8 States are obligated to provide dental benefits for poor children through Medicaid or the Children s Health Insurance Program, but providing dental benefits for Medicaid-eligible adults is optional. 9 In the past decade several states have scaled back dental benefits for such adults. 10 For example, Missouri eliminated all adult dental Medicaid benefits in 2005, and California went from full dental Medicaid coverage to no coverage in July Washington State went from full adult dental Medicaid benefits in 2002 to limited coverage in 2003, reinstated full dental coverage in 2007, and ultimately eliminated all adult dental benefits in Several studies have analyzed the impact of expanding or eliminating dental benefits for adults covered by Medicaid. A national analysis showed that the expansion of Medicaid to include adult dental benefits resulted in a sevento-ten-percentage-point increase in the likelihood of a dental visit among adults with less than $10,000 in annual household income. 11 After California eliminated adult Medicaid dental benefits in July 2009, the percentage of adult September :9 Health Affairs 1639

2 Medicaid beneficiaries receiving dental services dropped from 35 percent to 12 percent in a single year. 12 The elimination of adult Medicaid dental benefits in Oregon in 2003 resulted in an increase in dental-related emergency department use and in the incidence of unmet oral health needs among adult beneficiaries. 13 Massachusetts has gone through several major health policy reforms in recent years. Up until 2002 Massachusetts provided dental benefits to poor adults through its Medicaid program, MassHealth, but budgetary restraints forced the scaling back of benefits. The percentage of adult MassHealth enrollees who received dental care dropped from 24 percent in 2001 to 11 percent in 2004, and a drop was observed in the number of dentists participating in Mass- Health. 14 In April 2006 Massachusetts health care reform expanded MassHealth for children whose household incomes were up to 300 percent of the federal poverty level. It also established subsidized insurance through Commonwealth Care, a program of private health insurance for all adults with incomes up to 300 percent of poverty, and implemented an individual mandate. 15 Parents with income up to 133 percent of poverty, long-term unemployed adults with income less than 100 percent of poverty, pregnant women with income less than 200 percent of poverty, and disabled adults regardless of income level remained eligible for MassHealth. 16 The reform also restored comprehensive adult dental benefits through MassHealth and expanded dental benefits for adults with incomes at or below 100 percent of poverty through Plan Type 1 of Commonwealth Care. 17,18 Individuals are eligible to participate in Plan Type 1 if their income is at or below 100 percent of poverty. There are no monthly premiums associated with Plan Type 1, but there are modest copayments associated with prescription drugs. 17 Prior research using data from Massachusetts has shown that after health reform, use of preventive health care services, including dental visits, increased. In one study the percentage of adults ages who reported that they did not get needed dental care for any reason in the past twelve months dropped to 9.3 percent in 2007 from 12.7 percent in In another study the percentage of adults ages with a dental visit increased by five percentage points from 2006 to Among adults ages with incomes below 300 percent of poverty, the percentage with a dental visit in the past twelve months increased by 10.9 percentage points from 2006 to Using National Health Interview Survey data from the period , Sharon Long and Karen Stockley assessed the impact of Massachusetts s health reform by comparing dental care use among the state s nonelderly population and a subpopulation of nonelderly adults with family income below 300 percent of poverty to that of a control population of higher-income adults in the same region (New Jersey, New York, and Pennsylvania), higher-income adults in large states (Alabama, Arizona, California, Colorado, Florida, Georgia, Illinois, Indiana, Louisiana, Maryland, Michigan, Minnesota, Missouri, New Jersey, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Washington, and Wisconsin), and childless adults with family income below 300 percent of poverty in another set of large states (Alabama, Illinois, Missouri, North Carolina, South Carolina, Texas, and Wisconsin). They found that the share of Massachusetts adults reporting that they could not get needed dental care because of cost declined and that their dental care use increased postreform when compared with the control population in other states. However, the authors note that because of the limited sample size, they could detect with confidence only relative large changes in access to care and utilization. 22 In this article we build on previous analyses of how health reform in Massachusetts affected the dental care use of adults ages We used data through 2010 and analyzed dental care use of the Massachusetts study population relative to the dental care use of a control population of adults ages in eight states: Connecticut, Maine, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. The analysis included comparisons before and after the 2006 health reform was implemented in Massachusetts.We relied on a large data set that is representative at the state level, has a much larger sample size than that used in previous research, 22 and spans a wider period. Study Data And Methods Data Source For our analysis we used data from the Behavioral Risk Factor Surveillance System (BRFSS), which is well suited for state-level analysis. The BRFSS is a nationally representative survey of adults age eighteen and older whose information is collected by the Centers for Disease Control and Prevention at the state level. Nationwide, about 350,000 adults one per household are surveyed each calendar year. The BRFSS collects core information pertaining to race, marital status, number of adults in the household, income, age, sex, number of children, chronic disease, body mass index, selfreported health status, and health insurance 1640 Health Affairs September :9

3 The Massachusetts experience is particularly important in the current context of national health reform. coverage. 23 In even years the BRFSS collects data related to dental visits, 24 dental cleaning, 25 and tooth extractions. 26 Responses from the dental cleaning and dental visit questions were combined to determine whether an adult had a dental visit in the past twelve months. 27 Study Sample And Variable Definitions Each survey year in which oral health questions are asked, the BRFSS takes into account dental care use in the past twelve months. A person interviewed on February 5, 2010, could report a dental visit during the period February 5, 2009 February 4, In 2002 Massachusetts limited dental benefits for adults enrolled in MassHealth, 14 so we excluded BRFSS data from survey year 2002 from the analysis, to eliminate any policy shock that could confound the analysis. The prereform period includes BRFSS data for (survey year 2004). Responses from survey year 2006 were not considered in the analysis because this was the year in which Massachusetts health reform was passed and implemented. The postreform period includes data for (survey year 2008) and (survey year 2010). In total, the analysis contains 32,157 individuals from Massachusetts and 125,577 individuals from the control states. The dependent variable used in this analysis is a binary variable indicating whether or not an adult visited a dental clinic, dentist, or dental hygienist or had a dental cleaning during the past twelve months. Given our interest in poor adults, one of the key explanatory variables in our analysis was a generated poverty status indicator. The BRFSS does not classify adults into poverty levels but instead classifies them into income categories based on self-reported data. 28 We defined poor adults as those with household incomes at or below 100 percent of the federal poverty level in that year. All other adults were considered nonpoor. To determine whether an adult lived at or below the federal poverty level, we used information on household income, the number of adults and children living in the household, and US census federal poverty thresholds for each survey year. 29 The census thresholds account for inflation. Adults with household incomes in categories containing the poverty threshold were considered poor. For example, an adult in a three-person household surveyed in 2010 that reported income between $15,000 and $20,000 was classified as poor because the federal poverty threshold in 2010 for a three-person household was $17,374. All adults living in three-person households in 2010 with reported income in the three lowest income brackets (less than $10,000, $10,000 to less than $15,000, and $15,000 to less than $20,000) were classified as poor. Based on previous research 11,30 34 and the variables available in the BRFSS, we included as explanatory variables a body mass index categorical variable (normal weight, overweight, or obese), a dummy variable classifying the respondent as a current or previous smoker, age, sex, a categorical variable for education (less than high school, high school graduate, some college education, or college graduate), a dummy variable indicating prior diagnosis of diabetes, a categorical variable for ethnicity and race (Hispanic, black, white, other race, or multiracial), a dummy variable for self-reported good or better health, a categorical variable for employment status (employed, unemployed, unable to work, homemaker, retired, or student) and a marital status categorical variable (single, married, divorced, separated, widowed, or living with a partner). Methodology We conducted a difference-indifferences analysis to measure the impact of health reform on adults in Massachusetts. Specifically, we compared dental care utilization rates in Massachusetts before and after reform to dental care utilization rates in eight comparison states over the same period. These states (listed above) were chosen for two reasons. First, previous research on the impact of the Massachusetts reform using a similar methodology to ours used these comparison states. 35 Second, Medicaid policy related to adult dental benefits was stable in these states during the period when the Massachusetts reform was designed and implemented. 10 Nevertheless, we also tested the sensitivity of our results by varying the composition of the comparison states (see the online Appendix). 36 While controlling for a wide range of covariates, researchers have used a similar differencein-differences framework to assess the impact of a policy change For example, recent studies have used a difference-in-differences framework September :9 Health Affairs 1641

4 Exhibit 1 with control states to assess the impact of Massachusetts health reform as well as dental policy reforms in other states. 13,22,35,40 Because the health care law specifically expanded dental coverage to poor adults, we also estimated a variation of the difference-in-difference-indifferences model commonly used in previous research 39,41,42 to estimate differential effects of health reform on poor and nonpoor adults. 43 The difference-in-difference-in-differences analysis excluded students, who were not eligible for dental coverage under Plan Type 1 through Commonwealth Care. 44 In the 2010 BRFSS, about 13 percent of respondents did not reveal or know their actual income. To impute missing values in our data, we used multiple imputation by chained equations. 36,45 Our estimates, standard errors, and computed t-statistics accounted for the complex sampling design of the BRFSS. We used a linear probability model 36,46 and conducted all analysis using the statistical software STATA, version 11. Limitations There were a number of limitations to our study. Instead of providing actual family income for each survey respondent, the BRFSS data classify income into a number of categories. This may introduce measurement error in this variable. The BRFSS provides data on household size and income, not family size and income. Census poverty thresholds are determined based on the latter, not the former. Hence, we are introducing increased error into our measure of poverty. We cannot identify multiple-family households in the BRFSS. Proportion Of Adults With A Dental Visit In The Past Twelve Months, Massachusetts And Comparison States, Before And After Massachusetts Health Reform, Selected Years Percent with dental visit Comparison states SOURCE Behavioral Risk Factor Surveillance System, survey years 2004, 2008, and NOTES Amongadultsages Survey year 2004 (prereform) captures dental utilization that occurred in 2003 and Survey year 2008 (postreform) captures dental utilization that occurred in 2007 and Survey year 2010 (also postreform) captures dental utilization that occurred in 2009 and Estimates are weighted. Also, because of the fixed income categories in the BRFSS, we may be overestimating the percentage of respondents who were poor in a given year, which could bias our policy estimates and underestimate the impact of the reform on dental care use. As a sensitivity test, we present an analysis in the Appendix 36 that used education levels as a proxy for household income. We also varied the definition of poverty by using different income and household size combinations as a further sensitivity test. As a result of all of these factors, our measure of adults below the federal poverty threshold is subject to some error. The BRFSS is also subject to significant recall bias since survey respondents self-report their health behavior and use of services over the course of a year to state agencies that administer the BRFSS. 47 Survey respondents are also subject to social desirability bias, in that they may misrepresent unhealthy behavior. 48 Because of this bias, the rate of dental care use in the BRFSS may be overestimated. In fact, it has been shown that the National Health Interview Survey, which like the BRFSS asks survey respondents whether they have seen a dentist in the past twelve months, has been shown to overestimate dental care use in comparison to the Medical Expenditure Panel Survey. 49 Because any recall or social desirability bias is constant over time, we would not expect our policy estimates to misrepresent the impact of health reform on dental care use in Massachusetts. Study Results Exhibit 1 presents simple differences in dental care use in Massachusetts and the comparison states before and after the reform. Dental care use in Massachusetts increased three percentage points between and (postreform). Dental care use remained constant in the comparison states during the years we examined. Exhibit 2 presents simple differences in dental care use among poor and nonpoor adults ages in Massachusetts and the comparison states. The changes portrayed in Exhibit 2 suggest that health care reform in Massachusetts increased dental care use, primarily among poor adults. In the comparison states, dental care use among poor adults declined two percentage points, while it held steady among the nonpoor. These results indicate very little change in dental care use among the nonpoor in both Massachusetts and the comparison states during the reform period. Our main difference-in-differences result is shown in Appendix Table 2, Model Relative to the comparison states, dental care use 1642 Health Affairs September :9

5 in Massachusetts did not increase significantly in , but it did increase by about 2.9 percentage points in Appendix Table 3 36 shows the results from our difference-in-difference-in-differences estimates. Health reform in Massachusetts appeared to have had a much greater impact among the poor relative to the nonpoor. As shown in Appendix Table 3, Model 1, among the poor, health reform was associated with a 7.2-percentage-point increase in dental care use in and an 11-percentage-point increase in dental care use in over and above any impact on the nonpoor. Exhibit 2 Proportion Of Poor And Nonpoor Adults With A Dental Visit In The Past Twelve Months, Massachusetts And Comparison States, Before And After Massachusetts Health Reform, Selected Years Percent with dental visit Mass., poor Comparison states, poor Mass., nonpoor Comparison states, nonpoor Discussion Findings from this study suggest that Massachusetts made substantial progress in increasing dental care use among the adult population, driven by gains among poor adults. The percentage of poor adults in Massachusetts went from about 10.4 percent in 2004 to around 11.3 percent in Although our results corroborate previous findings, we build on previous research by comparing dental care utilization patterns in Massachusetts to those in a group of comparison states. More important, our results contribute to the growing evidence 11,19 22 that expanding benefits in Medicaid and the health insurance exchanges to include dental coverage for adults has the potential to influence dental care use, particularly among the poor. Despite the demonstrated positive impact of providing dental benefits to adults within Medicaid programs, fiscal pressures are causing many states to continue to consider limiting those benefits. 51 In recent years Arizona, California, Hawaii, Utah, and Washington have eliminated or restricted adult Medicaid dental benefits. 10 Even Massachusetts significantly reduced adult dental benefits through MassHealth in and just recently announced that some benefits will be restored in It is interesting to note that when Massachusetts eliminated adult dental Medicaid benefits in the early 2000s, the state saved less than 1 percent of total state spending on MassHealth. 14 State governments should carefully consider the negative impact on access to dental care from eliminating dental benefits for poor adults, balancing it against the relatively small budgetary savings from doing so. SOURCE Behavioral Risk Factor Surveillance System, survey years 2004, 2008, and NOTES Amongadultsages Survey year 2004 (prereform) captures dental utilization that occurred in 2003 and Survey year 2008 (postreform) captures dental utilization that occurred in 2007 and Survey year 2010 (postreform) captures dental utilization that occurred in 2009 and Estimates are weighted. Conclusion The Massachusetts experience is particularly important in the current context of national health reform. It provides insight into what might happen to dental care use among poor adults in the entire nation going forward if the Affordable Care Act included dental benefits for adults in the essential health benefit package or if states were to expand adult dental benefits within Medicaid. Excluding adult dental care from essential health benefits might be viewed as a missed opportunity for the nation to reverse the trend in falling dental care use and increased financial barriers to care among the poor. 7 Nevertheless, state governments directly or through their management of health insurance exchanges are free to choose the level of dental benefits provided to adults in plans offered in the exchanges and through Medicaid. States that choose to expand Medicaid through the Affordable Care Act will receive an enhanced match rate for the Medicaid expansion population that is 100 percent for the initial three years and phased down annually until it reaches 90 percent in 2020 and beyond. 54 Adult dental benefits, even though they are not mandated, are eligible for the enhanced match for the expansion population. 55 States now have the opportunity to expand coverage, including for dental care, to poor populations. September :9 Health Affairs 1643

6 The views expressed by the authors do not necessarily reflect those of the American Dental Association. NOTES 1 Department of Health and Human Services. Oral health in America: a report of the surgeon general [Internet]. Rockville (MD): Public Health Service; 2000 [cited 2013 Mar 14]. Available from: www2.nidcr.nih.gov/sgr/sgrohweb/ home.htm 2 Eke PI, Dye BA, Wei L, Thornton- Evans GO, Genco RJ. Prevalence of periodontitis in adults in the United States: 2009 and J Dent Res. 2012;91(10): Lockhart PB, Bolger AF, Papapanou PN, Osinbowale O, Trevisan M, Levinson ME, et al. Periodontal disease and atherosclerotic vascular disease: does the evidence support an independent association? A scientific statement from the American Heart Association. Circulation. 2012;125: Simpson TC, Needleman I, Wild SH, Moles DR, Mills EJ. Treatment of periodontal disease for glycemic control in people with diabetes. Cochrane Database Syst Rev. 2010; (5):CD Glied S, Neidell M. The economic value of teeth. J Hum Resour. 2010;45(2): According to the Census Bureau. The Department of Health and Human Services also releases annual federal poverty guidelines based on family income and number of household members. The figures released by the Census Bureau and Department of Health and Human Services are nearly identical year over year. 7 American Dental Association. Breaking down barriers to oral health for all Americans: the role of finance [Internet]. Chicago (IL): ADA; 2012 Apr [cited 2012 Oct 10]. Available from: sections/advocacy/pdfs/7170_ Breaking_Down_Barriers_Role_ of_finance-final pdf 8 Wall TP, Vujicic M, Nasseh K. Recent trends in the utilization of dental care in the United States. J Dent Educ. 2012;76(8): Medicaid.gov. Dental care [Internet]. Baltimore (MD): Centers for Medicare and Medicaid Services; [cited 2013 Jul 29]. Available from: Medicaid-CHIP-Program- Information/By-Topics/Benefits/ Dental-Care.html 10 Myers J. How have Medicaid dental benefits changed in your state? The Rundown [blog on the Internet]. Washington (DC): Public Broadcasting Service; 2011 Nov 17 [cited 2013 Jul 29]. Available from: rundown/2011/11/how-havemedicaid-dental-benefits-changedin-your-state-1.html 11 Choi MK. The impact of Medicaid insurance on dental service use. J Health Econ. 2011;30(5): Maiuro L. Eliminating adult dental benefits in Medi-Cal: an analysis of impact [Internet]. Oakland (CA): California HealthCare Foundation; 2011 Dec [cited 2013 Jul 29]. (Issue Brief). Available from: LIBRARY%20Files/PDF/E/PDF %20EliminatingAdultDental MediCalcx.pdf 13 Wallace NT, Carlson MJ, Mosen DM, Snyder JJ, Wright BJ. The individual and program impacts of eliminating Medicaid dental benefits in the Oregon Health Plan. Am J Public Health. 2011;101(11): Pryor C, Monopoli M. Eliminating adult dental coverage in Medicaid: an analysis of the Massachusetts experience [Internet]. Washington (DC): Kaiser Commission on Medicaid and the Uninsured; 2005 Aug 31 [cited 2013 Jul 29]. Available from: upload/7378.pdf 15 Blue Cross Blue Shield of Massachusetts Foundation. Health reform in Massachusetts: expanding access to health insurance coverage assessing the results [Internet]. Boston (MA): The Foundation; 2012 May [cited 2013 Mar 1]. Available from: %2520Care%2520Reform/ Overview/HealthReformAssessing theresults.pdf 16 Seifert RW, Anthony S. The basics of MassHealth [Internet]. Boston (MA): Massachusetts Medicaid Policy Institute; [updated 2011 Feb; cited 2013 Jul 29]. (Fact Sheet). Available from: CWM_CHLE/Included_Content/ Right_Column_Content/Mass Health%20Basics% FINAL.pdf 17 Bianchi AJ. An employers guide to the 2006 Massachusetts health care reform act [Internet]. Boston (MA): Mintz Levin; 2008 Jan [cited 2013 Jul 29]. Available from: EBEC-Alert-MHCRA-Guide-02-07/ MHCRA-Emp-Guide.pdf 18 Health Connector Commonwealth Care. Commonwealth Care health benefits and copayments (copays) [Internet]. Boston (MA): Health Connector Commonwealth Care; [cited 2013 Jul 29]. Available from: Us/ Connector Programs/Benefits and Plan Information/HealthBenefits AndCopays.pdf 19 Long SK, Masi PB. Access and affordability: an update on health reform in Massachusetts, fall Health Aff (Millwood). 2009;28(4): w DOI: /hlthaff.28.4.w Long SK, Stockley K, Dahlen H. Massachusetts health reforms: uninsurance remains low, self-reported health status improves as state prepares to tackle costs. Health Aff (Millwood). 2012;31(2): Long SK, Stockey K, Dahlen H. Health reform in Massachusetts as of fall 2010: getting ready for the Affordable Care Act and addressing affordability [Internet]. Boston (MA): Blue Cross Blue Shield of Massachusetts Foundation; 2012 Jan [cited 2013 Mar 14]. Available from: PDF/ Health-Reform-in- Massachusetts-as-of-Fall-2010.pdf 22 Long SK, Stockley K. The impacts of state health reform initiatives on adults in New York and Massachusetts. Health Serv Res. 2011; 46(1 Pt 2): Centers for Disease Control and Prevention, Office of Surveillance, Epidemiology, and Laboratory Services. Overview: BRFSS 2010 [Internet]. Atlanta (GA): CDC; 2010 [cited 2013 July 29]. Available from: technical_infodata/surveydata/ 2010/overview_10.rtf 24 The BRFSS asks, How long has it been since you last visited a dentist or a dental clinic for any reason? Include visits to dental specialists, such as orthodontists. Possible answers are within the past year (anytime less than 12 months ago); within the past 2 years (1 year but less than 2 years ago); within the past 5 years (2 years but less than 5 years ago); 5 or more years ago; and never. 25 The BRFSS asks, How long has it 1644 Health Affairs September :9

7 been since you had your teeth cleaned by a dentist or dental hygienist? Possible answers are within the past year (anytime less than 12 months ago); within the past 2 years (1 year but less than 2 years ago); within the past 5 years (2 years but less than 5 years ago); 5 or more years ago; and never. 26 The BRFSS asks, How many of your permanent teeth have been removed because of tooth decay or gum disease? Include teeth lost to infection, but do not include teeth lost for other reasons, such as injury or orthodontics. (If wisdom teeth are removed because of tooth decay or gum disease, they should be included in the count for lost teeth). Possible answers are 1 to 5; 6 or more, but not all; and none. 27 If a patient has visited a dentist or dental clinic for any reason in the past year or had his or her teeth cleaned by a dentist or dental hygienist in the past year, then that patient is defined as having seen a dentist within the past year. 28 Households are asked if they earn less than $10,000, $10,000 to less than $15,000, $15,000 to less than $20,000, $20,000 to less than $25,000, $25,000 to less than $35,000, $35,000 to less than $50,000, $50,000 to less than $75,000, or $75,000 or more. Income is self-reported in the BRFSS. 29 Census Bureau. Poverty poverty thresholds [Internet]. Washington (DC): Department of Commerce; [cited 2012 Jun 27]. Available from: poverty/data/threshld/index.html 30 Manning WG, Phelps CE. The demand for dental care. Bell J Econ. 1979;10: Wang H, Norton ED, Rozier RG. Effects of the State Children s Health Insurance Program on access to dental care and use of dental services. Health Serv Res. 2007;42(4): Tomar SL, Lester AL. Dental care and other health care visits among U.S. adults with diabetes. Diabetes Care. 2000;23(10): Chen H, Moeller J, Manski RJ. The influence of co-morbidity and other health measures on dental and medical care use among Medicare beneficiaries J Public Health Dent. 2011;71(3): Bloom B, Adams PF, Cohen RA, Simile CM. Smoking and oral health in dentate adults aged NCHS Data Brief. 2012;(85): Miller S. The impact of the Massachusetts health care reform on health care use among children. Am Econ Rev: Papers and Proceedings. 2012;102(3): To access the Appendix, click on the Appendix link in the box to the right of the article online. 37 Meyer BD, Viscusi WK, Durbin DL. Workers compensation and injury duration: evidence from a natural experiment. Am Econ Rev. 1995; 85: Blundell R, Costas Dias M. Evaluation methods for non-experimental data. Fisc Stud. 2000;21(4): Girma S, Paton D. The impact of emergency birth control on teen pregnancy and STIs. J Health Econ. 2011;30(2): Kolstad JT, Kowalski AE. The impact of health care reform on hospital and preventive care: evidence from Massachusetts [Internet]. Cambridge (MA): National Bureau of Economic Research; 2010 May [cited 2012 July 31]. Available from: Gruber J. The incidence of mandated maternity benefits. Am Econ Rev. 1994;84: Wooldridge JM. Econometric analysis of cross section and panel data. 2nd ed. Cambridge (MA): MIT Press; See the Appendix (Note 36) for details regarding the difference-indifferences and difference-indifference-in-differences estimation techniques and the full model specification. 44 Health Connector Commonwealth Care. Commonwealth Care program guide [Internet]. Boston (MA): Health Connector Commonwealth Care; 2012 Oct 1 [cited 2013 Mar 14]. Available from: binary/com.epicentric.content management.servlet.content DeliveryServlet/About%2520Us/ CommonwealthCare/Common wealth%2520care%2520program %2520Guide.pdf 45 Royston P, White IR. Multiple imputation by chained equations: implementation in Stata. J Stat Softw. 2011;45(4): For ease of interpretability, previous research has used the linear probability model in a pre-post differencein-differences framework; see Notes 11 and 22. We also provide alternative difference-in-difference estimates using probit models; see the Appendix (Note 36). 47 Centers for Disease Control and Prevention. Prevalence of physical activity, including lifestyle activities among adults United States, MMWR Weekly [serial on the Internet]. Atlanta (GA): CDC; 2003 Aug 15 [cited 2013 Jul 29]. Available from: preview/mmwrhtml/ mm5232a2.htm 48 Arleck PD, Settle RB. The survey research handbook: guidelines and strategies for conducting a survey. 2nd ed. New York (NY): McGraw- Hill; Macek MD, Manski RJ, Vargas CM, Moeller JF. Comparing oral health care utilization estimates in the United States across three nationally representative surveys. Health Serv Res. 2002;37(2): The online Appendix (see Note 36) contains the result from a series of sensitivity analyses. We also compared policy estimates from linear probability and probit models. Estimates did not differ significantly across model specifications. 51 National Association of State Budget Officers. The fiscal survey of states [Internet]. Washington (DC): NASBO; Spring 2012 [cited 2013 Jul 29]. Available from: files/pdf/fss1206.pdf 52 Massachusetts League of Community Health Centers. Impact of cuts to Medicaid and Commonwealth care adult dental coverage on Massachusetts community health centers: report [Internet]. Boston (MA): The League; 2011 [cited 2013 Feb 28]. Available from: DentalCutImpactReport2011.pdf 53 Otto M. Economics push Mass. to restore Medicaid dental benefits [Internet]. Tucson (AZ): DrBicuspid.com; 2013 Mar 12 [cited 2013 Mar 13]. Available from: sec=sup&sub=pmt&pag=dis&item ID= Kaiser Family Foundation. Financing new Medicaid coverage under health reform: the role of the federal government and states [Internet]. Menlo Park (CA): KFF; 2010 May [cited 2013 Jul 31]. (Focus on Health Reform). Available from: files/kff_financing_new_ MEDICAID.pdf 55 Vujicic M, Goodell S, Nasseh K. Dental benefits to expand for children, likely decrease for adults in coming years [Internet]. Chicago (IL): American Dental Association; 2013 Apr [cited 2013 Jul 12]. (Health Policy Resources Center Research Brief). Available from: Resources/pdfs/HPRCBrief_0413_1.pdf September :9 Health Affairs 1645