In October 2015, Grim Jobs Report Is Likely

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1 Projecting the Demand for Dental Care in 2040 Richard J. Manski, DDS, MBA, PhD; Chad D. Meyerhoefer, PhD Abstract: The purpose of this study was to provide a forward-thinking assessment of the underlying factors likely to impact trends in dental care demand and the need for dental providers in 2020, 2025, and beyond. Dental workforce trends and their likely impact on the need for dentists are a function of predicted dental care demand, which will in turn be determined by the size and characteristics of our population size, economic outlook, the state of public and private dental care insurance, trends in dental care delivery, professionally determined dental care need, and population health beliefs. Projecting rates of dental care utilization far into the future is difficult because projections must be made using historical data, and established trends may not persist if there is structural change in the future. Nonetheless, when structural change occurs, it does not typically affect all aspects of the economy, so there is value in describing the likely future impact of current trends. This article was written as part of the project Advancing Dental Education in the 21 st Century. Dr. Manski is Professor and Chair, Dental Public Health, University of Maryland School of Dentistry; and Dr. Meyerhoefer is Professor, Department of Economics, Lehigh University. Direct correspondence to Dr. Richard J. Manski, Department of Dental Public Health, University of Maryland School of Dentistry, 650 West Baltimore Street, Room 2209, Baltimore, MA 21201; ; rmanski@umaryland.edu. Keywords: dental care utilization, dental workforce, forecast, projections Submitted for publication 1/5/17; accepted 2/16/17 doi: /JDE In October 2015, Grim Jobs Report Is Likely to Delay a Move by the Fed on Rates was the headline in a New York Times article. 1 As recently as July 2015, however, the Federal Reserve had said, The U.S. economy and job market continue to strengthen leaving the door open for a possible interest rate hike when central bank policymakers next meet in September. 2 September passed, and a modest interest rate increase of 25 basis points from the near zero level did not materialize until a subsequent meeting in December. Yet, the economy continues to remain in flux. Decision making in an environment of uncertainty is difficult; decision making over an extended period of time is even more difficult, and making predictions beginning with an unstable period of significant economic volatility is perilous at best. However, decisions must be made, and policy planning must go on. Whereas uncertainty cannot be eliminated, the extent to which it will impact policy can be better understood with a careful cataloging and examination of the factors likely to contribute to the state of affairs during the period in question. Dental workforce trends through 2040 and their likely impact on the need for dentists will be a function of predicted dental care demand, which will in turn be determined by the size and characteristics of our population size, economic outlook, the state of public and private dental care insurance, trends in dental care delivery, professionally determined dental care need, and population health beliefs. The purpose of this article is to provide a forwardthinking assessment of the underlying factors likely to impact trends in dental care demand and the need for dental providers in This article was written as part of the project Advancing Dental Education in the 21 st Century. Population Trends The U.S. population has steadily and consistently expanded. Increasing from 181 million in 1960 to 319 million in 2015, the U.S. population is projected to grow to 347 million in 2025 and 380 million in Whereas the overall growth is steady, age-related population shifts have been observed and are expected to continue. For instance, during the period 1960 to 2015 the growth pattern of the overall population was dominated by adults age While some growth was seen for adults over age 65, population growth for children under 18 was relatively flat. On the other hand, projections to the year 2040 suggest that we are likely to observe shifting patterns among age groups. Beginning in 2015, growth for persons under 18 is expected to be flat, and for adults age growth is projected to es133

2 be substantially lower than during the period prior to Growth for adults 65 and over is projected to occur at an increased rate compared with the period prior to In the period 1960 to 2015, the population of blacks and whites experienced steady and consistent growth that is projected to continue but at a slower pace in the period 2015 to Hispanic population growth has been at a faster rate since 1980 (first year that data were available) than blacks and whites and is projected to continue at a higher rate through In 2010, 81% of the population resided in an urban area, up slightly from 79% in 2000, a trend that has steadily continued for the last 60 years and is likely to continue for the foreseeable future. For the period prior to and including 2007, patterns of population growth and decline held steady for decades, reflecting long-term suburbanization. 4 On the other hand, more recent data suggest a possible interruption in suburbanization, possibly ending major demographic shifts that have transformed small towns and rural areas throughout the country for years. A transformation of the U.S. population has also occurred as a result of changing patterns of immigration. Since 1960, the rate of immigration to the U.S. has steadily increased. 5 While patterns of immigration from Europe have remained somewhat steady since 1960, the rate of persons obtaining lawful permanent resident status from Asia, Mexico, and Central America have increased. Additional population shifts have also been observed. For instance, during the period 1940 to 2015, married couple households decreased from 76% in 1940 to 48% in 2015, and the average number of children per family decreased from 2.19 in 1955 to 1.86 in ,7 Economic Trends: National Income Estimates and Projections A December 2015 headline proclaimed the middle class to be no longer in the majority of the U.S. population. 8 According to a report by the Pew Research Center, the middle class is losing ground, the share of income held by the middle class has plummeted, and the gap in income between middleincome and upper-income households has widened considerably since The middle class has not fared well of late. Consistent with these headlines, the percentage of households with income between $35,000 and $74,999 has steadily decreased over the last 50-plus years, suggesting a trend that is likely to continue. 10 Other trends are notable as well. Since 1967, the percentage of households with income below $35,000 has slightly decreased, and the percentage of households with income between $75,000 and $99,999 has remained somewhat flat. On the other hand, the percentage of households with income $100,000 and over has increased, with a rapid rise during a 20-year period between 1980 and 2000 resulting in an ever-increasing gap between rich and poor. Current conditions make any forecast unusually difficult. The recession that began in 2007, while technically ending in 2009, still lingers in effect especially as measured by household income, GDP, labor force participation, and shifting patterns of jobs from full-time to part-time. In addition, contradictory economic indicators persist. For instance, while the employment rate has improved, suggesting that the economy has recovered, other labor indicators such as the labor force participation rate suggest that it has not. Prior to the recession in 2007, the unemployment rate was 4.6%. 11 As of November 2015, the unemployment rate was 5.0%, having dropped from a high of 10.0% in October ,12 On the other hand, the labor force participation rate during that period dropped from 66.4% in January 2007 to 62.5% in November 2015, a low not seen since October Another uncertainty regarding the state of the economy was reported by Mutikani in December 2015 that three out of four of the nearly 1 million hires this year are part-time and many of the jobs are low-paid. 14 The median weekly earnings of part-time wage and salary workers in 2014 were $240 compared with $791 for full-time wage and salary workers. 15,16 These factors combined hinder the prospects for a quick, full, and robust recovery, which has been evident as measured by the U.S. gross domestic product (GDP). The percent change from the preceding period in real GDP in the third quarter of 2015 was 2.1%. 16 Since the recession ended in 2009, GDP growth peaked at 4.6% with a low of -1.5% averaging about 2.2% for each of the last 25 three-month periods. 17 The short-run impact of the Great Recession on dental demand is difficult to assess because it affected composition of the labor force in addition to consumer disposable income. Also, it is likely that full emergence from the recession will occur differentially across economic sectors, geographic areas, and time. On the other hand, the long-run impact of es134 Journal of Dental Education Volume 81, Number 8 Supplement

3 the 2007 recession is likely to have limited impact on the demand for dental care in the year However, while the likelihood of impact on 2040 is low, it will take several years to determine if the 2007 recession resulted in structural change that will have a long-lasting impact on dental care demand patterns. Dental Care Measures and Trends Multiple data sources are available to assess dental care measures and trends. The Medical Expenditure Panel Survey (MEPS), the National Health Interview Survey (NHIS), and the National Health and Nutrition Examination Survey (NHANES) provide detailed national estimates on dental care use. Whereas analyses have historically produced national estimates that varied, sociodemographic trends remain generally consistent across these major national surveys. 18 On the other hand, MEPS is unique in providing national estimates for expenditures and service-specific care. MEPS estimates are also comparable with data obtained from earlier versions of expenditure surveys. Specifically, the 1977 National Medical Care Expenditure Survey (NMCES), the 1987 National Medical Expenditure Survey (NMES), and the MEPS provide comparable detailed national estimates of health expenditures, utilization, sources of payment, and insurance coverage for the civilian population of the United States. Each expenditure survey oversamples population groups of particular policy interest, including persons with limitations in activities of daily living, blacks, Hispanics, and the poor. All survey components are designed to provide statistically unbiased estimates representative of the civilian, non-institutionalized population. MEPS differs from the NMCES and NMES in that data on household respondents in each panel are collected for two consecutive years and the survey is fielded continuously Additional expenditure data are available from the Center for Medicare & Medicaid Services (CMS). Whereas MEPS estimates are limited to the community non-institutionalized population, the National Health Expenditure Accounts (NHEA) represent aggregate health care spending in the U.S. and provide estimates of annual expenditures for health care by type of service, sources of funding, and type of sponsor dating back to ,23 A recent Health Policy Perspective published in the Journal of the American Dental Association asked, Where have all the dental care visits gone? 24 According to the author, the total number of dental visits decreased by 7% from 2006 to 2012, was especially pronounced among adults, and began before the recent economic downturn. That article was interesting, thought-provoking, and in many ways correct. During 2004, total visits peaked at almost 316 million visits across the U.S., declined to a low of 278 million visits in 2011, but then increased again to 308 million visits in Adjusting for an increasing population, Figure 1 shows the continued and ongoing decrease since 1977, but as with total visits, also shows an increase in Looking back almost 40 years suggests that periods of fluctuation are somewhat normal, but with the exception of 2013 (last year for which data are available) a continued and ongoing decrease was observed, although people were just as likely to have a dental visit then as they were 40 years ago. Interestingly, whereas total visits and visits per person have experienced a persistent multi-year decline, use rates have remained relatively stable within a relatively narrow range (Figure 2). 26 Whereas the amount of care obtained does seem to have diminished during this extended period, use rates have remained remarkably stable. Expenditures During 2012, there were approximately $85 billion total expenditures for dental care visits in the U.S. population. 21 Perhaps relatively small compared with the $1.3 trillion in total health expenditures, it is sizeable when compared with the $409 billion inpatient hospital, $113 billion outpatient hospital, $56 billion emergency department, and $221 billion outpatient expenditures. As a subspecialty of medicine, dental expenditures would be considerable. Looking beyond, we also considered the NHEA, which provides aggregate estimates for the entire U.S. population of a full range of dentalrelated spending, including dental care, government administration, net cost of insurance, public health services, and investment in research, structures, and equipment. 23 From 1960 to 2012, total national health spending steadily increased each and every year. 22 Controlling for population growth, per person national health spending also steadily increased each and every year. The rate of growth has also been steady with the exception of the last few years when the rate of growth slowed somewhat. During this same period between 1960 and 2012, overall total national dental spending (Figure 3) increased, es135

4 Figure 1. Dental visits per person, United States, Note: Dental visits per person=total dental visits/total U.S. community population. Sources: Agency for Healthcare Research and Quality national medical care expenditure survey; 1987 national medical expenditure survey; and 1996 medical expenditure panel survey. Rockville, MD: Agency for Healthcare Research and Quality, various years. Figure 2. Percent of the population with a dental visit, United States, Sources: Agency for Healthcare Research and Quality national medical care expenditure survey; 1987 national medical expenditure survey; and 1996 medical expenditure panel survey. Rockville, MD: Agency for Healthcare Research and Quality, various years. with the exception of some retrenchment in and a slowing during and Controlling for population growth, per person national dental spending also increased with the exception of a decline during the periods and and a slowing during the periods , , , and es136 Journal of Dental Education Volume 81, Number 8 Supplement

5 Figure 3. Aggregate dental spending, United States, Note: Real total dental expenditures are in 2012 USD. Sources: Center for Medicare & Medicaid Services. National health expenditure accounts, Baltimore, MD: Center for Medicare & Medicaid Services, various years. Socioeconomic and Demographic Trends While aggregate utilization rates have been generally stable over an extended period, some differences within socioeconomic and demographic groups are notable Looking back to 1977 and then considering changes in 1987 and 1996, we find that one study provided a detailed comparative analysis over a 20-year period. 25 According to this study, elderly respondents and young children were more likely to report a dental visit in 1996 than in 1987 or in In addition, dental care use rates increased among persons under six years and 65 years and older. Dental use rates for children between six and 18 were the highest of any age group in each of the three years. Poorer persons and persons with less education were less likely to report a dental visit than those with more income or more education during each of the periods. In addition, the gap between lower and higher income persons widened over the 20-year period but remained stable across education levels. Generally, race/ethnicity use rates were unchanged in each of the survey years analyzed, except for a narrowing of the use rate gap between whites and nonwhites by Female or employed individuals were more likely to report a dental visit than their counterparts in 1977, 1987, and Interestingly, while variation occurred in the likelihood of obtaining a dental visit among some subgroups, the trend of decreased visits per person with a visit was consistent across all groups for 1977 to A later study continued with 1996 data in assessing changes of dental use and dental coverage for the U.S. civilian noninstitutionalized (community) population through According to this study, while adults age were less likely to report a visit in 2004 than in 1996, children age 21 or less were more likely to report having a dental visit in 2004 than in No change was observed among adults and adults 65 and over. Middle-income family members were more likely to have a dental visit in 2004 than in Whereas black non-hispanics were less likely than white non-hispanics to have reported a dental visit in years 1996 and 2004, the gap between the two groups did narrow. While less persistent than in earlier time periods, the trend of decreased visits per persons with es137

6 a visit was observed among several subgroups. 25,27 The average number of dental visits per person for those with a dental visit decreased for adults age 45-64, adults with low or middle income, college graduates, and persons with private dental coverage from 1996 to A subsequent report with a focus on the period 2000 to 2013 contains two key findings. 26 First, in 2013 dental care utilization did not decline among working-age adults a first since Second, consistent with a continuing trend, dental care utilization increased among children in 2013 to its highest level. Specifically, while adults were 3.4% less likely to report a visit in 2013 than in 2000, children 2-18 and adults 65 and older were more likely (by 5.9% and 3.9%, respectively) to report having a dental visit in 2013 than in Whereas children from families with limited income (FPL 200%) experienced an increase in use rates between 2000 and 2013, the poorest older adults (FPL <100%) experienced a decrease in use rates between those years. Dental Care Coverage and Insurance Dating back to earliest days of the 20th century, employment has been the foundation of the private health insurance system in the United States Employer-sponsored health insurance is offered to employees and their dependents as part of a compensation package and to attract and retain workers. 31 For the employee and the employer, group purchase of health insurance has important advantages, not the least of which is that it is subsidized with favorable tax policy and is less costly than policies purchased in the individual marketplace During the late 1960s, insurance companies began offering coverage for dental expenditures to large groups already underwritten for medical expense coverage Public dental care coverage began much later when the Social Security Act of 1965 was signed into law on July 30, Medicare is health insurance provided for people age 65 or older, people under age 65 with certain disabilities, and people of any age with End-Stage Renal Disease and Amyotrophic Lateral Sclerosis. Generally, Medicare does not cover routine dental care. However, Medicare will pay for certain dental services that are needed as a result of a hospital stay-related medical condition. 38 In addition, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 provided for additional plan design flexibility creating incentives for contracted private insurance carriers to offer Medicare Advantage managed care plans with additional benefits that include dental care coverage. 39 Public coverage was also offered through Medicaid, which provides health care coverage to eligible low-income individuals and (sometimes) their families. 40 Unlike Medicare, Medicaid is jointly funded by the state and federal governments and is managed by the states. Dental services are a required service for most Medicaid-eligible individuals under the age of 21, as a required component of the Early and Periodic Screening, Diagnostic, and Treatment benefit. 41 In addition, dental services are an optional service for the adult population age 21 and older. 40 While many states provide at least emergency dental services for adults, less than half of the states provide comprehensive dental care There are no minimum requirements for adult dental coverage. 40 In 1997, the Children s Health Insurance Program (CHIP) extended benefits including dental benefits to uninsured children and pregnant women in families with incomes too high to qualify for most state Medicaid programs but often too low to afford private coverage. 41 In March 2010, the Affordable Care Act (ACA) was signed into law. The ACA provides comprehensive health insurance designed to improve access, affordability, and quality in health care for all Americans. 45 The ACA complements Medicare and Medicaid and provides opportunities for all uninsured to obtain coverage. The ACA requires insurance plans to include pediatric oral health services for children up to 21 years of age as an essential health benefit for private insurance plans and expands Medicaid eligibility. The ACA also makes available to small groups and individuals pediatric dental coverage through state health insurance exchanges At present, however, only 31 states, including the District of Columbia, have elected to expand their Medicaid programs under the ACA. 48 In states that do expand their programs, dental coverage eligibility would be expanded to low-income adults if the state currently provides adult coverage under its traditional Medicaid program. Otherwise, the ACA does not provide dental care coverage benefits to adults, adults with disabilities, or seniors According to the National Association of Dental Plans, approximately 205 million Americans, or 64% of the population, had some type of dental es138 Journal of Dental Education Volume 81, Number 8 Supplement

7 benefit in The number of Americans covered by private dental insurance has increased steadily from 4.5 million in 1967 to approximately 100 million in 1985 and then 158 million in ,28 Today, approximately 155 million people have some form of private dental care coverage Private plans are typically obtained through employment. While approximately 56% of all establishments offered health insurance, only 35% of all establishments and 63% of establishments that offered health insurance offered dental insurance. 35,49 Of the $85 billion spent on dental care in 2012 (Figure 4), $35 billion was paid by private dental insurance, $4.7 billion was paid by Medicaid, $789 million was paid by Medicare, and $41 billion was paid directly out-of-pocket by patients. The impact of dental care coverage on dental visitation and access (Figure 5) is profound. 27 Persons with public dental coverage are more likely to report a dental visit (31.9%) than persons with no coverage (26.9%) but fall far behind persons with private coverage (56.9%). Looking Forward Our findings are consistent with a recent study of expenditures showing that per person dental expenditures are expected to grow, especially among older adults, in the next 30 years albeit at a lower rate. 50 Whereas our findings were similar, our approach was somewhat different in that we focused on dental visits rather than expenditures. Expenditures are a function of population size, number of visits, price per visit, and procedure mix per visit. For instance, if in the year 2040, the mix of dental procedures shifts towards more expensive restorative care, overall expenditures could be higher among fewer total patients with fewer visits. 51 On the other hand, if the mix of dental procedures shifts towards less expensive preventive care, overall expenditures could be lower among a higher number of patients seeking more dental visits. It will be the number of patients and number of expected patient visits that determine the needed supply of Figure 4. Total dental care expenditures by source of coverage, 2012 Source: Agency for Healthcare Research and Quality medical expenditure panel survey. Rockville, MD: Agency for Healthcare Research and Quality, es139

8 Figure 5. Dental care visits by coverage status, 2004 Source: Manski RJ, Brown E. Dental use, expenses, private dental coverage, and changes, 1996 and Agency for Healthcare Research and Quality At: publications/cb17/cb17.pdf. providers. Since the purpose of this assessment is to provide a better understanding of the underlying factors likely to impact trends in dental care demand and the need for dental providers in 2040, we focus on and project the total number of visits expected in Discussion Projecting rates of dental care utilization far into the future is difficult because projections must be made using historical data, and established trends may not persist if there is structural change in the future. Nonetheless, when structural change occurs, it does not typically affect all aspects of the economy, so there is value in describing the likely impact of current trends. Based on our analysis, there are several demographic and economic trends that are consistent with future increases in dental care utilization. The most significant of these is the projected 19% growth in the U.S. population between 2015 and If both use rates and rates of dental visits per person were to remain unchanged in the future, this increase in population would translate directly into a proportional increase in dental care utilization. However, the fact that population growth will be strongest among the over-65 population suggests that utilization could increase more than proportionally, based on population growth alone. Another potential driver of increased utilization is changes in access to dental insurance resulting from the ACA. Both the Medicaid expansion and mandated pediatric dental coverage in private insurance plans will reinforce rising rates of dental care utilization among children. The ACA also counters, to a certain extent, some of the demographic trends that have limited access to private dental coverage among low- to middle-income children in the past: the increase in both part-time employment and single parent households. This is because pediatric dental care coverage can be purchased in the state exchanges. The ACA increases access to dental insurance to a lesser extent among adults, through the Medicaid expansion in states that offer adult dental coverage and the sale of stand-alone dental insurance on some state exchanges. Despite the fact that these policies will affect only some adults, prior research has found that dental insurance is one of the strongest es140 Journal of Dental Education Volume 81, Number 8 Supplement

9 determinants of preventive and restorative dental care demand by adults. 48,49 Other long-term trends either have an ambiguous effect on future dental care utilization or are expected to decrease utilization. Although incomes are expected to rise modestly with the economy s emergence from recession, income is a weaker determinant of dental care utilization than factors such as dental insurance and educational attainment, and it differentially affects preventive and restorative dental services. 49 There is evidence that improvements in dental care technologies may serve to decrease dental care utilization over the long run by decreasing the need for subsequent dental visits following initial treatment. This is evident from the fact that dental visits per person have experienced a persistent decline across all population subgroups, while use rates have remained constant. One way to project dental care utilization in the future in the presence of multiple trends moving utilization in different directions is through a time series prediction from aggregate historical utilization data. Figure 6, Figure 7, and Figure 8 show time series forecasts made using a linear predictor for total dental visits, dental visits per person, and the population of individuals with at least one dental visit. We use data from different versions of the MEPS (and its predecessor surveys) that is measured in ten-year intervals. For the 2017 data point, we use three estimates: the 2012 MEPS estimate, 2013 MEPS estimate, and average of the 2012 and 2013 MEPS estimates. There was a sharp increase in dental care utilization between the 2012 and 2013 estimates, and some of this increase may be due to changes in the survey protocol to correct for underestimation in previous years. However, the remainder of the 2013 increase is likely due to a shift in utilization. As result, our preferred projections are based on the average. Under our preferred model, total dental visits rise steadily from 294 million in 2017 to 319 million in 2040 (Figure 6). This 8.5% increase is less than the projected 19% population growth over roughly the same period. This is because we project that dental visits per person will continue to drop from 0.92 in 2017 to 0.84 in 2040 (Figure 7). The percentage of Figure 6. Total dental visits, 1977 to 2040 Sources: Agency for Healthcare Research and Quality national medical care expenditure survey; 1987 national medical expenditure survey; and 1996 medical expenditure panel survey. Rockville, MD: Agency for Healthcare Research and Quality, various years. es141

10 Figure 7. Dental visits per person, 1975 to 2040 Note: Dental visits per person=total dental visits/total U.S. community population. Sources: Agency for Healthcare Research and Quality national medical care expenditure survey; 1987 national medical expenditure survey; and 1996 medical expenditure panel survey. Rockville, MD: Agency for Healthcare Research and Quality, various years. Figure 8. Percent of U.S. population with dental visits, 1977 to 2040 Sources: Agency for Healthcare Research and Quality national medical care expenditure survey; 1987 national medical expenditure survey; and 1996 medical expenditure panel survey. Rockville, MD: Agency for Healthcare Research and Quality, various years. es142 Journal of Dental Education Volume 81, Number 8 Supplement

11 the population with a dental visit will increase from 41.9% in 2015 to 44.2% in 2040 (Figure 8). This implies that the number of people with a dental visit will increase by 25% over the same time period. One limitation of this approach is that it does not allow us to separately account for trends in the different determinants of dental care utilization and to conduct sensitivity analyses of different assumptions over those trends. In addition, it does not allow us to incorporate expected future trends that are not reflected in historical data. For example, the impact of the ACA cannot be fully captured using this method because much of its impact is not reflected in the 2013 data. A more refined analysis using a structural model of utilization would allow us to incorporate the likely impact of the ACA on the 2040 projection, which we leave to future studies. Finally, translating increases in demand into detailed workforce projections would require that utilization forecasts are made for specific procedure groups in order to account for possible substitution across different types of providers. Conclusion In this article, we provide an assessment of the underlying factors likely to impact trends in dental care demand and the need for dental providers in 2020, 2025, and beyond. Dental workforce trends and their likely impact on the need for dentists are a function of predicted dental care demand, which will in turn be determined by the size and characteristics of our population, our economic outlook, the state of public and private dental care insurance, trends in dental care delivery, professionally determined dental care need, and population health beliefs. Our findings suggest that total dental visits will rise steadily from 294 million in 2017 to 319 million in 2040, that dental visits per person will drop from 0.92 in 2017 to 0.84 in 2040, and that the percentage of the population with a dental visit will increase from 41.9% in 2015 to 44.2% in Editor s Disclosure This article is published in an online-only supplement to the Journal of Dental Education as part of a special project that was conducted independently of the American Dental Education Association (ADEA). Manuscripts for this supplement were reviewed by the project s directors and the coordinators of the project s sections and were assessed for general content and formatting by the editorial staff. Any opinions expressed are those of the authors and do not necessarily represent the Journal of Dental Education or ADEA. REFERENCES 1. Cohen P. Grim jobs report is likely to delay a move by the Fed on rates. New York Times. At: com/2015/10/03/business/economy/jobs-report-hiringunemployment-wages-fed-rates.html. Accessed 5 Dec Schneider H, Flaherty M. Fed says economy improving; September rate hike in view. At: 3. U.S. Census Bureau. National population projections. At: 4. U.S. Department of Agriculture. Shifting geography of population change. At: rural-economy-population/population-migration/shiftinggeography-of-population-change.aspx. Accessed 5 Dec U.S. Department of Homeland Security. Yearbook of immigration statistics, At: files/publications/ois_yb_2013_0.pdf. Accessed 5 Dec U.S. Census Bureau. Trends in the prevalence of household types: 1940 to present. At: families/data/households.html. 7. U.S. Census Bureau. Average number of children per family: current population survey, annual social and economic supplements, 1955 to At: families/data/families.html. 8. Lee D. Middle-class families, pillar of the American dream, are no longer in the majority, study finds. Los Angeles Times. At: Accessed 5 Dec Pew Research Center. The American middle class is losing ground: no longer the majority and falling behind financially At: files/2015/12/ _middle-class_final-report. pdf. 10. DeNavas-Walt C, Proctor BD. Current population reports, P60-252: income and poverty in the United States, U.S. Census Bureau. At: Census/library/publications/2015/demo/p pdf. 11. Bureau of Labor Statistics. Employment status of the civilian non-institutional population, 1942 to date: household data annual averages. At: Bureau of Labor Statistics. Unemployment rate, 2005 to 2015: labor force statistics from the current population survey. At: data.bls.gov/timeseries/lns Accessed 5 Dec Bureau of Labor Statistics. Labor force participation rate, 1948 to 2015: labor force statistics from the current population survey. At: data.bls.gov/timeseries/lns es143

12 14. Mutikani L. 75 percent of jobs created this year were parttime due to weak economy, Obamacare concerns. Huffington Post. At: part-time-job-creation_n_ html. Accessed 5 Dec Bureau of Labor Statistics. Median weekly earnings of full-time wage and salary workers by selected characteristics: household data annual averages. At: cps/cpsaat37.pdf. 16. Bureau of Labor Statistics. Median weekly earnings of part-time wage and salary workers by selected characteristics: household data annual averages. At: cps/cpsaat38.pdf. 17. Bureau of Economic Analysis. Percent change from preceding period in real gross domestic product: seasonally adjusted at annual rate. At: m?reqid=9&step=1#reqid=9&step=3&isuri=1&903= Macek MD, Manski RJ, Vargas CM, Moeller J. Comparing oral health care utilization estimates in the U.S. across three nationally representative surveys. Health Serv Res 2002;37(2): U.S. National Health Care Expenditures Study. Annotated bibliography. NCHSR publication Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, National Center for Health Services Research and Health Care Technology Assessment, Harper T, Berlin M, DiGaetano R, et al. National medical expenditure survey: household survey final methodology report. Deliverable no Rockville, MD: Westat, Inc., Cohen J. Design and methods of the medical expenditure panel survey household component. MEPS methodology report no. 1, AHCPR pub. no Rockville, MD: Agency for Health Care Policy and Research, Center for Medicare & Medicaid Services. National health expenditure accounts. At: NationalHealthExpendData/NationalHealthAccountsHistorical.html. 23. Bernard D, Cowan C, Selden T, et al. Reconciling medical expenditure estimates from the MEPS and NHEA, Medicare Medicaid Res Rev 2012;2(4):E Vujicic M. Where have all the dental care visits gone? J Am Dent Assoc 2015;146(6): Manski RJ, Moeller JF, Maas W. Dental services: an analysis of utilization over twenty years. J Am Dent Assoc 2001;132(5): Nasseh K, Vujicic M. Dental care utilization rate continues to increase among children, holds steady among workingage adults and the elderly. Research Brief, Health Policy Resources Center, American Dental Association At: Research/HPI/Files/HPIBrief_1015_1.ashx. Accessed 5 Dec Manski RJ, Brown E. Dental use, expenses, private dental coverage, and changes, 1996 and Rockville, MD: Agency for Healthcare Research and Quality, Health Insurance Association of America. HIAA source book, Washington, DC: Health Insurance Association of America, Lichtenstein M. Health insurance from invention to innovation: a history of the Blue Cross and Blue Shield Companies. At: html?referrer. 30. Employee Benefit Research Institute. History of health insurance benefits. At: index.cfm?fa=0302fact. 31. Employee Benefit Research Institute. Offering benefits still gives employers a competitive advantage. At: www. ebri.org/pdf/pr nov.13.wbs.pdf. Accessed 5 Dec Enthoven AC, Fuchs VR. Employment-based health insurance: past, present, and future. Health Affairs 2006;25(6): Delta Dental Plans Association. Our history of dental benefits expertise. At: Company/mission.jsp. 34. Delta Dental of Washington. Our history. At: Accessed 5 Dec National Association of Dental Plans. NADP history. At: Accessed 5 Dec National Association of Dental Plans. Who has dental benefits? At: Dental_BB_1.aspx. 37. Center for Medicare & Medicaid Services. CMS s program history, Medicare and Medicaid. At: gov/about-cms/agency-information/history/index. html?redirect=/history/. 38. Center for Medicare & Medicaid Services. Medicare dental coverage overview. At: DentalCoverage. 39. Center for Medicare & Medicaid Services. Medicare advantage plans cover all Medicare services. At: www. medicare.gov/what-medicare-covers/medicare-healthplans/what-medicare-advantage-plans-cover.html. Accessed 5 Dec Center for Medicare & Medicaid Services. Dental care for Medicaid and CHIP enrollees At: gov/medicaid-chip-program-information/by-topics/ Benefits/Dental-Care.html. 41. Center for Medicare & Medicaid Services. Early and periodic screening, diagnostic, and treatment. At: www. medicaid.gov/medicaid-chip-program-information/bytopics/benefits/early-and-periodic-screening-diagnosticand-treatment.html. 42. Center for Medicare & Medicaid Services. Medicaid/ CHIP oral health services. At: medicaid-chip-program-information/by-topics/benefits/ downloads/2010-dental-factsheet.pdf. Accessed 5 Dec Government Accountability Office. Oral health, factors contributing to low use of dental services by low-income populations. GAO/HEHS Washington, DC: Government Accountability Office, Government Accountability Office. Dental disease is a chronic problem among low-income populations. GAO/ HEHS Washington, DC: Government Accountability Office, es144 Journal of Dental Education Volume 81, Number 8 Supplement

13 45. Center for Medicare & Medicaid Services. About the Affordable Care Act: dental coverage. At: gov/coverage/dental-coverage/. 46. American Dental Association. Affordable Care Act dental benefits examined. At: National Association of Dental Plans and Delta Dental Plans Association. Offering dental benefits in health exchanges: a roadmap for federal and state policymakers. At: Kaiser Family Foundation. Status of state action on the Medicaid expansion decision. At: kff.org/health-reform/ state-indicator/state-activity-around-expanding-medicaidunder-the-affordable-care-act/. Accessed 19 Dec Manski RJ, Cooper PF. Characteristics of employers providing dental coverage in the U.S. J Am Dent Assoc 2010;141(6): Nasseh K, Vujicic M. Dental expenditure expected to grow at a much lower rate in the coming years. American Dental Association. At: ashx. 51. Meyerhoefer CD, Zuvekas SH, Manski RJ. The demand for preventive and restorative dental services. Health Econ 2014;23(1): es145