In recent analyses, researchers have demonstrated

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1 ARTICLE 2 The effect of growing income disparities on U.S. adults dental care utilization Kamyar Nasseh, PhD; Marko Vujicic, PhD In recent analyses, researchers have demonstrated that dental care utilization among adults has declined in the past decade. 1,2 Given the importance of oral health to wages, labor productivity 3 and general health, 4,5 this decline should be of concern to the health care and business community. Lack of access to dental care causes many people to seek care in hospital emergency departments, 6 further increasing health care costs. These associated costs are assumed by the hospitals because many patients do not have dental coverage. Poor adults, whom we define as people with incomes at or below the federal poverty threshold, face significant financial barriers to accessing dental care in the United States. 7 A recent documentary titled Dollars and Dentists highlighted the oral health crisis facing poor adults and children in the United States. 8 Research findings at the national level have shown a gap in dental care utilization defined as whether a person visited a dentist in the previous 12 months between poor and nonpoor people, and this gap increased between 1977 and To our knowledge, the only research at the state level showed that the gap in dental care utilization between those with health insurance and those without any insurance has widened since However, the data for that study do not allow identification of dental insurance status. One key driver of these observed differences in dental care utilization, according to insurance or income status, is Medicaid. Medicaid programs in most states offer limited dental benefits because states are not mandated to provide dental benefits to adults. 11 In many states, low-income adults who qualify for Medicaid likely have limited dental benefits, and these benefits vary widely across states. For children enrolled in Medicaid, states must provide access to comprehensive dental benefits through the Early Periodic Screening, Diagnostic, and Treatment program. 12 The results of an American Dental Association analysis of adult dental benefits in state Medicaid programs in 2012 showed that 11 states (Alaska, Connecticut, Iowa, New Mexico, New York, North Carolina, North Dakota, ABSTRACT Objective. The authors conducted a study to measure the gap in dental care utilization between poor and nonpoor adults at the state level and to show how the gap has changed over time. Methods. The authors collected data from the 2002, 2004, 2006, 2008 and 2010 Behavioral Risk Factor Surveillance System prevalence and trends database maintained by the Centers for Disease Control and Prevention to measure differences in dental care utilization between poor and nonpoor adults. Poor adults are defined as those at or below the federal poverty threshold. The authors estimated a series of linear probability models to measure the dental care utilization gap between poor and nonpoor adults, while controlling for potentially confounding covariates. Results. In 12 states (Arkansas, California, Florida, Georgia, Illinois, Indiana, Nebraska, Ohio, Oklahoma, South Carolina, Texas and Washington), the gap in dental care utilization between poor and nonpoor adults grew from 2002 through The remaining states had a stable utilization gap from 2002 through The study results show that four states (Alaska, Massachusetts, Minnesota, New York) and the District of Columbia had a smaller gap in dental care utilization in 2010 than that in other states. Conclusions. At the state level, poor adults face greater access barriers to dental care than do nonpoor adults. As states limit dental coverage through Medicaid, poor adults are at greater risk of experiencing poor oral health outcomes. Practical Implications. In states that are experiencing increasing inequality in dental care utilization between poor and nonpoor adults, policymakers may wish to explore alternative approaches that could address this situation. Key Words. Dental care utilization; income inequality; access to dental care; oral health; Medicaid. JADA 2014;145(5): doi: /jada Dr. Nasseh is a health economist, Health Policy Resources Center, American Dental Association, 211 E. Chicago Ave., Chicago, Ill , nassehk@ada.org. Address correspondence to Dr. Nasseh. Dr. Vujicic is managing vice president, Health Policy Resources Center, American Dental Association, Chicago. JADA 145(5) May

2 Ohio, Oregon, Rhode Island and Wisconsin) provided extensive dental benefits; the District of Columbia and 14 states (Arkansas, Indiana, Kentucky, Louisiana, Massachusetts, Michigan, Minnesota, Nebraska, New Jersey, Pennsylvania, South Dakota, Vermont, Virginia and Wyoming) provided limited dental benefits; 17 states (Arizona, Colorado, Florida, Georgia, Hawaii, Idaho, Illinois, Kansas, Maine, Mississippi, Missouri, Montana, New Hampshire, South Carolina, Texas, Washington and West Virginia) provided emergency benefits only; and eight states (Alabama, California, Delaware, Maryland, Nevada, Oklahoma, Tennessee and Utah) provided no dental benefits to adults through Medicaid. 13 Between 2002 and 2012, 24 states (Alabama, Arizona, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Kansas, Kentucky, Louisiana, Maine, Mississippi, Nebraska, Nevada, New Hampshire, New Mexico, New York, North Dakota, Oklahoma, South Carolina, Vermont, West Virginia and Wisconsin) made no changes in dental benefits provided to adults enrolled in Medicaid; TABLE 1 Gap in dental care utilization between poor and nonpoor adults, according to the BRFSS.* STATE ESTIMATED DIFFERENCE IN DENTAL CARE UTILIZATION BETWEEN POOR AND NONPOOR ADULTS IN 2002, IN PERCENTAGE POINTS (95% CI ) ESTIMATED DIFFERENCE IN DENTAL CARE UTILIZATION BETWEEN POOR AND NONPOOR ADULTS IN 2010, IN PERCENTAGE POINTS (95% CI) Alabama 11.7 ( ) 16.0 ( ) Arkansas 10.2 ( ) 19.7 ( ) Arizona 11.0 ( ) 15.7 ( ) Alaska 15.3 ( ) 6.9 ( ) California 8.3 ( ) 14.6 ( ) Colorado 17.9 ( ) 14.7 ( ) Connecticut 10.1 ( ) 11.4 ( ) Delaware 13.3 ( ) 11.7 ( ) District of Columbia 3.0 ( ) 7.4 ( ) # Florida 11.0 ( ) 16.9 ( ) Georgia 8.9 ( ) 18.0 ( ) Hawaii 7.9 ( ) 9.2 ( ) Idaho 9.0 ( ) 14.3 ( ) Illinois 7.7 ( ) # 19.6 ( ) Indiana 9.8 ( ) 16.7 ( ) Iowa 11.8 ( ) 16.2 ( ) Kansas 16.2 ( ) 16.2 ( ) Kentucky 13.2 ( ) 13.2 ( ) Louisiana 11.2 ( ) 15.4 ( ) Maine 15.3 ( ) 18.6 ( ) Maryland 15.5 ( ) 13.8 ( ) Massachusetts 8.5 ( ) 4.5 ( ) Michigan 17.9 ( ) 19.8 ( ) Minnesota 11.8 ( ) 7.2 ( ) # Mississippi 10.6 ( ) 13.2 ( ) Missouri 15.0 ( ) 20.0 ( ) Montana 12.3 ( ) 14.9 ( ) Nebraska 2.9 ( ) 16.3 ( ) Nevada 9.1 ( ) # 14.3 ( ) New Hampshire 12.1 ( ) 18.4 ( ) * BRFSS: Behavioral Risk Factor Surveillance System. Source: Centers for Disease Control and Prevention. 16 Each survey year (2002, 2004, 2006, 2008, 2010) took into account dental care utilization that occurred during that year and the previous year. Adults were 18 years or older. Regression-adjusted differences included year indicator variables and control variables for age, sex, marital status, ethnicity or race, employment status, education, self-reported health status, body mass index and number of children. CI: Confidence interval. All estimates are weighted, and standard errors account for the complex survey design of the BRFSS. Significant at P.01. Significant at P.05. # Significant at P.10. the District of Columbia and 11 states (Alaska, Arkansas, Colorado, Iowa, North Carolina, Ohio, Oregon, Rhode Island, Texas, Virginia and Wyoming) increased coverage; and 15 states (California, Illinois, Indiana, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, New Jersey, Pennsylvania, South Dakota, Tennessee, Utah and Washington) decreased coverage. 14 In this study, we measured the gap in dental care utilization between poor adults (defined as adults at or below the federal poverty threshold) 15 and nonpoor adults (defined as adults above the federal poverty threshold). ABBREVIATION KEY. ACA: Affordable Care Act. BMI: Body mass index. BRFSS: Behavioral Risk Factor Surveillance System. MEPS: Medical Expenditure Panel Survey. NHIS: National Health Interview Survey. 436 JADA 145(5) May 2014

3 TABLE 1 (CONTINUED) STATE ESTIMATED DIFFERENCE IN DENTAL CARE UTILIZATION BETWEEN POOR AND NONPOOR ADULTS IN 2002, IN PERCENTAGE POINTS (95% CI ) We also measured trends over time with respect to this gap within each state. To our knowledge, this is the first state-by-state multivariate analysis of dental care utilization among adults that focuses on differences between adults who are poor and those who are nonpoor. METHODS Data source. To measure the gap in dental care utilization between poor and nonpoor adults, we collected data from the 2002, 2004, 2006, 2008 and 2010 Behavioral Risk Factor Surveillance System (BRFSS) prevalence and trends database, sponsored by the Centers for Disease Control and Prevention. 16 The BRFSS, which collects uniform state-specific data about chronic disease, behavioral risk factors and health care utilization, is a nationally representative telephone survey of the U.S. adult population 18 years or older. Personnel from state health departments interview only one adult per household. Approximately 400,000 adults are interviewed each year. On an annual basis, all states (and the District of Columbia) conduct monthly interviews of adults in households whose telephone numbers are selected randomly. The annual BRFSS includes a core component, which is a standard set of questions asked in all states relating to ethnicity or race, marital status, number of adults in the household, income, age, sex, number of children, chronic disease, obesity, self-reported health status and insurance status. The BRFSS does not identify people who have private dental insurance or public insurance through Medicaid. 17 Interviewers collect oral health information pertaining to dental visits, dental cleaning and tooth extractions in even-numbered years. The BRFSS combines information from responses to the dental cleaning and dental visit queries to indicate whether an adult had a dental visit in the preceding 12 months. Each survey year, investigators take into account dental care utilization that occurred during the current year and the previous year. For example, an adult interviewed on March 10, 2002, could report a dental visit that occurred during the period from March 10, 2001, through March 9, Study sample and variable definitions. We analyzed the gap in dental care utilization between adults in poverty and those above the poverty threshold for all adults 18 years or older surveyed in 2002, 2004, 2006, 2008 and The BRFSS does not classify adults directly into poverty levels. Therefore, we constructed a binary poverty indicator by using information from responses to the household income question and the questions regarding the number of children and adults in the survey household. Each year, the U.S. Census Bureau determines federal poverty thresholds on the basis of family income and family size. 15 For example, if an adult surveyed in 2010 reported that the income for his or her household was between $15,000 and $20,000 and a total of three people lived in that household, we classified that adult as being in poverty because the federal poverty threshold in 2010 for a three-person household was $17, We classified all three-person households surveyed in 2010 with reported annual income below $10,000, $10,000 to less than $15,000 or $15,000 to less than $20,000 as being at or below the federal poverty threshold. To account for inflation over time, we matched the poverty thresholds each year from the U.S. Census to the corresponding ESTIMATED DIFFERENCE IN DENTAL CARE UTILIZATION BETWEEN POOR AND NONPOOR ADULTS IN 2010, IN PERCENTAGE POINTS (95% CI) New Jersey 12.6 ( ) 12.9 ( ) New Mexico 9.4 ( ) 9.4 ( ) New York 7.1 ( ) 6.4 ( ) North Carolina 12.6 ( ) 13.2 ( ) North Dakota 8.1 ( ) 14.8 ( ) Ohio 8.0 ( ) 15.2 ( ) Oklahoma 8.8 ( ) 18.4 ( ) Oregon 9.5 ( ) 13.5 ( ) Pennsylvania 11.0 ( ) 14.2 ( ) Rhode Island 11.3 ( ) 14.3 ( ) South Carolina 8.4 ( ) 19.2 ( ) South Dakota 5.5 ( ) # 11.5 ( ) Tennessee 15.0 ( ) 13.4 ( ) Texas 8.5 ( ) 15.6 ( ) Utah 11.6 ( ) 15.7 ( ) Vermont 14.3 ( ) 15.1 ( ) Virginia 16.8 ( ) 10.6 ( ) Washington 6.9 ( ) 13.9 ( ) West Virginia 13.1 ( ) 18.7 ( ) Wisconsin 8.7 ( ) 12.2 ( ) Wyoming 18.7 ( ) 18.3 ( ) JADA 145(5) May

4 survey year in the BRFSS to generate our poverty status variable. Our dependent variable is a binary indicator defined as whether an adult visited a dental clinic, dentist or dental hygienist or had a dental cleaning within the preceding 12 months. The independent variables used in this analysis include a categorical variable denoting year of survey, binary indicator variables for overweight and obesity based on body mass index (BMI), age, age squared, sex, a categorical variable for education (high school dropout, high school graduate, some college education or college graduate), a categorical variable for number of children (none, one, two, three, four, or five or more), a categorical variable for ethnicity or race (Hispanic, African American, white, multiracial or other race), a binary indicator variable for self-reported good health, a categorical variable for employment status (employed, unemployed, self-employed, unable to work, homemaker or student), a categorical variable for marital status (single, married, divorced, separated, widowed or cohabiting) and a binary indicator variable for poverty status. Methodology. To measure the impact of poverty on adult dental care utilization for each state and the District of Columbia, we estimated a series of linear probability models that regress an indicator of dental care utilization in the previous 12 months on the categorical variable for year of survey and poverty status while controlling for age, sex, self-reported health status, marital status, employment status, number of children, ethnicity or race, education and BMI. We used TABLE 2 Change in dental care utilization gap among adults from 2002 through 2010, according to the BRFSS.* STATE ESTIMATED CHANGE, IN PERCENTAGE POINTS (95% CI ) Alabama 4.3 ( ) Arkansas 9.5 ( ) Arizona 4.7 ( ) Alaska 8.4 ( ) California 6.4 ( ) Colorado 3.2 ( ) Connecticut 1.3 ( ) Delaware 1.6 ( ) District of Columbia 4.4 ( ) Florida 5.9 ( ) Georgia 9.1 ( ) Hawaii 1.3 ( ) Idaho 5.3 ( ) Illinois 11.9 ( ) Indiana 6.9 ( ) Iowa 4.3 ( ) Kansas 0.02 ( ) Kentucky 0.1 ( ) Louisiana 4.2 ( ) Maine 3.3 ( ) Maryland 1.7 ( ) Massachusetts 4.0 ( ) Michigan 1.9 ( ) Minnesota 4.6 ( ) Mississippi 2.5 ( ) Missouri 5.0 ( ) Montana 2.6 ( ) Nebraska 13.4 ( ) # Nevada 5.2 ( ) New Hampshire 6.3 ( ) * BRFSS: Behavioral Risk Factor Surveillance System. Source: Centers for Disease Control and Prevention. 16 Each survey year (2002, 2004, 2006, 2008, 2010) took into account dental care utilization that occurred during that year and the previous year. Adults were 18 years or older. Regressionadjusted differences included year indicator variables and control variables for age, sex, marital status, ethnicity or race, employment status, education, self-reported health status, body mass index and number of children. CI: Confidence interval. All estimates are weighted, and standard errors account for the complex survey design of the BRFSS. Significant at P.05. Significant at P.10. # Significant at P.01. linear probability models for ease of estimation and interpretation. Demographic factors, health status and the general economic environment influence dental care utilization. Manning and Phelps 19 controlled for health status, level of education and socioeconomic environment when determining the factors that influence dental care utilization. In an analysis of dental care utilization among children, Wang and colleagues 20 controlled for age, sex, race, self-reported general health status, family income, number of family members and parents education. Choi 21 controlled for age, sex, education, race, marital status and obesity when evaluating the impact of Medicaid expansion on dental care utilization. We controlled for employment status to net out the effect of any large labor market changes on dental care utilization during our period of 438 JADA 145(5) May 2014

5 TABLE 2 (CONTINUED) STATE study. Investigators in the earlier studies established the factors that influence the demand for dental care, which we modeled in this analysis. In addition, these variables are correlated with income, which can confound the relationship between income and dental care utilization. By controlling for age, sex, self-reported health status, marital status, employment status, number of children, ethnicity or race, education and BMI, we held these effects constant to examine the influence of poverty status on the demand for dental care. The estimated coefficient on the binary poverty status variable is a measure of the gap in dental care utilization between poor adults and nonpoor adults. In our model, we multiplied our constructed poverty variable with the categorical variable for year of survey to measure the changing dental care utilization gap between poor and nonpoor adults over time. We estimated the change in the utilization gap from 2002 through 2010 while controlling for the variables described earlier. According to data from the 2010 BRFSS, about 13 percent of respondents did not reveal their income or did not know their actual income. 22 To mitigate bias from nonresponse, we used imputation to fill in missing values for the independent variables in our model. 23 Our estimates, standard errors and computed t statistics accounted for the complex sampling design of the BRFSS, as well as for imputation. We conducted all analyses by ESTIMATED CHANGE, IN PERCENTAGE POINTS (95% CI ) New Jersey 0.3 ( ) New Mexico ( ) New York 0.7 ( ) North Carolina 0.6 ( ) North Dakota 6.6 ( ) Ohio 7.2 ( ) Oklahoma 9.6 ( ) # Oregon 4.0 ( ) Pennsylvania 3.2 ( ) Rhode Island 3.0 ( ) South Carolina 10.8 ( ) # South Dakota 6.0 ( ) Tennessee 1.6 ( ) Texas 7.2 ( ) Utah 4.1 ( ) Vermont 0.8 ( ) Virginia 6.2 ( ) Washington 7.0 ( ) West Virginia 5.6 ( ) Wisconsin 3.5 ( ) Wyoming 0.4 ( ) using statistical software (Stata, Release 11, StataCorp, College Station, Texas). Study limitations. There are a number of limitations to our study. First, the BRFSS respondents were asked to report their household income by category, not to provide their exact income level. In addition, the BRFSS provides data regarding household size and household income, not family income and family size. The U.S. government determines poverty status on the basis of family income and size, not on the basis of household income and size. We cannot identify multiple-family households in the BRFSS data. Because of the income categories in the BRFSS, we may be overestimating the percentage of respondents in poverty in a given year, which potentially could bias our policy estimates and result in an underestimation of the impact of poverty on dental care utilization. The BRFSS also is subject to significant recall bias. 24 Survey respondents may be subject to social desirability bias, as they may underreport unhealthy behaviors or overreport healthy behaviors, such as the frequency of dental visits. 25,26 As in the National Health Interview Survey (NHIS), the BRFSS asks respondents whether they had seen a dentist in the previous 12 months. Macek and colleagues 26 reported that the NHIS overestimated dental care utilization in comparison with the Medical Expenditure Panel Survey (MEPS). The shorter recall period in the MEPS may make respondents in that survey less vulnerable to social desirability bias. Because any social desirability bias inherent in the BRFSS remains constant over time, we would not expect any significant bias in our estimates of the differences in dental care utilization between poor and nonpoor adults. As of the 2010 BRFSS, survey responses from cellular telephone only households were not included in the regular sample; however, the BRFSS has conducted pilot studies to enable cellular telephone only households to be included in future surveys. 17 Younger adults who may prefer cellular telephones to landline telephones may be underrepresented in the BRFSS. Omitting this group from the BRFSS may mitigate and bias our measured impact of poverty status on dental care utilization. The percentage of households that did not have a landline telephone increased to 26.6 percent in 2010, which may make the 2010 BRFSS results not entirely representative of the U.S. population. 27 JADA 145(5) May

6 CHANGE IN PERCENTAGE POINT GAP IN DENTAL CARE UTILIZATION BETWEEN POOR AND NONPOOR ADULTS, Alaska Massachusetts New York Minnesota District of Columbia Hawaii Virginia Connecticut Wisconsin Nebraska Ohio Washington Indiana Texas Florida California Kentucky Maryland Idaho Colorado Louisiana Alabama Illinois South Carolina Oklahoma Arkansas Georgia West Virginia Michigan Missouri PERCENTAGE POINT GAP IN DENTAL CARE UTILIZATION BETWEEN POOR AND NONPOOR ADULTS, 2010 Figure. Percentage point gap in dental care utilization between poor and nonpoor adults in 2010 versus the change in percentage point gap between poor and nonpoor adults from 2002 through RESULTS Table 1 16 shows the gap in dental care utilization between poor and nonpoor adults in each state and the District of Columbia in 2002 and 2010; we controlled for age, sex, marital status, ethnicity or race, employment status, education, self-reported health status, BMI and number of children. In all states in 2002 and 2010, poor adults had a lower dental care utilization rate than that of nonpoor adults. For example, in California in 2002, the estimated dental care utilization gap between poor and nonpoor adults was 8.3 percentage points. In 2010 in California, the dental care utilization gap between poor and nonpoor adults increased to 14.6 percentage points. Table 2 16 shows the change in the gap between poor adults and nonpoor adults from 2002 through 2010 in all states and the District of Columbia; we controlled for age, sex, marital status, race, employment status, education, self-reported health status, BMI and number of children. A positive estimate indicates a widening gap in dental care utilization between poor adults and nonpoor adults, whereas a negative estimate indicates the opposite. In California, the gap in dental care utilization widened by 6.4 percentage points between 2002 and 2010, a statistically significant change. As the tables show, the gap in dental care utilization between adults who were poor and those who were nonpoor grew or remained constant in all states and the District of Columbia from 2002 to The figure plots the change in the dental care utilization gap from 2002 through 2010 against the gap in dental care utilization in We placed states on the horizontal axis if our estimate of the change in the gap between poor and nonpoor adults was not statistically significant. We placed states on the vertical axis if our estimate of the gap in dental care utilization between poor and nonpoor adults in 2010 was not statistically significant. Twelve states (Arkansas, California, Florida, Georgia, Illinois, Indiana, Nebraska, Ohio, Oklahoma, South Carolina, Texas and Washington) (shown in the upper right quadrant of the figure) experienced a large gap in dental care utilization in 2010, and the gap in these states had been growing since Four states (Alaska, Massachusetts, Minnesota, New York) and the District of Columbia experienced a smaller gap in dental care utilization in 2010 compared with the gap in other states. In the remaining states, the gap in dental care utilization between poor and nonpoor adults was steady over time. Between 2002 and 2010, the gap in dental care utilization between poor and nonpoor adults did not close in any state. DISCUSSION The results of this study revealed a growing gap in dental care utilization between poor and nonpoor adults in 12 states since In 2002 and 2010, most states had a statistically significant dental care utilization gap between poor and nonpoor adults. These findings suggest that 440 JADA 145(5) May 2014

7 if policymakers are interested in narrowing income inequality in adult dental care utilization, many states have more work to do. In fact, not a single state experienced a narrowing of the gap in dental care use between poor and nonpoor adults between 2002 and On average, from 2002 through 2012, a slow erosion in dental Medicaid benefits for adults occurred, as 24 states reported no change in benefits, 11 states and the District of Columbia increased benefits and 15 states decreased benefits 14 ; these results may suggest why there was not a statistically significant change in the size of the gap in many states. More research is needed to evaluate changes in dental care utilization among the poor and nonpoor, particularly at the state level. The overall decline in dental care utilization among adults, as reported by Wall and colleagues 2 and Vujicic and Nasseh 28 at the national level and by us at the state level, appears to be driven by a decline in dental care utilization among poor adults. Our study results corroborate those of Kenney and colleagues, 1 who found that dental care utilization by adults at the national level declined the most among the uninsured and those with public insurance from 2000 to Since the Great Recession, which began in December 2007 and extended through 2009, 29 states have imposed austerity measures that have eroded further the social safety net for poor adults. Unfortunately, dental coverage for Medicaid-eligible adults often is a target for state governments that impose austerity measures. 30 Research findings show it is likely that state-level reductions in adult dental benefits or in dental-provider reimbursement fees within Medicaid programs are contributing to the widening gap in dental care utilization between poor and nonpoor adults, but this possibility requires further investigation. 31 A 2012 report published by the Henry J. Kaiser Family Foundation indicated that lack of access to dental care among adults enrolled in Medicaid poses a serious challenge for public health in the United States. 32 The number of adults without dental insurance coverage is three times as large as the number of adults without health insurance coverage, which indicates that many private health insurance plans do not include dental insurance coverage. 32 The Affordable Care Act (ACA) does not require dental benefits for adults. 33 Given the widening gap in dental care utilization between poor and nonpoor adults in the 12 states listed earlier, the oral health of poor adults in these states could deteriorate in the next decade. However, these states still have an opportunity to increase access to dental care among poor adults. States have the option to expand adult dental benefits in their Medicaid programs 21 or offer dental benefits in the state-based health insurance exchanges. 34 The results of a recent study by Nasseh and Vujicic 35 show that dental care utilization among poor adults in Massachusetts increased significantly after the state restored dental benefits in Medicaid and expanded benefits for poor adults through the state-based exchange in The 2006 Massachusetts health care law is seen as the template for the ACA. 36 States also have the opportunity to increase access to dental care for poor adults through increases in dental provider incentives or by streamlining administrative processes for dentists participating in Medicaid. 37,38 Although accountable care organizations focus mostly on Medicare populations, these entities potentially could integrate dental care and medical care, particularly for the poor. In states that offer comprehensive adult Medicaid benefits, there may be a stronger incentive to integrate dental care into accountable care organizations and increase care coordination. 39 CONCLUSIONS Over the last decade, there has been a growing gap in dental care utilization in some states and a large and persistent gap in dental care utilization between poor and nonpoor adults in many states. Dental care remains an optional benefit within state Medicaid programs under the ACA. However, states still will have many options to expand access to dental services for poor adults, either through coverage expansion in Medicaid or through their state health insurance exchange marketplace policies. Disclosure. Drs. Nasseh and Vujicic did not report any disclosures. The views expressed by the authors do not necessarily reflect those of the American Dental Association. 1. Kenney GM, McMorrow S, Zuckerman S, Goin DE. 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