By Marko Vujicic, Thomas Buchmueller, and Rachel Klein

and infections, restoration of teeth, [and] maintenance of dental health, and all services must be provided if determined medically necessary. 6 In contrast, dental care for adults is not covered by Medicare and is an optional benefit in Medicaid, with no minimum standards. According to the most recent data available, over eight million adults are enrolled in Medicaid in the twenty-two states whose Medicaid programs do not provide adult dental benefits beyond emergency services. 7 The ACA s essential health benefits package perpetuates the long-standing division between dental and other health care services by excluding dental coverage for adults. It requires dental coverage for children, although implementing these provisions has posed challenges. For example, because dental benefits are offered primarily as stand-alone products, not as part of a medical plan, the purchase of dental benefits cannot be enforced, and dental benefits are excluded from premium tax credit calculations. 8 Even though the ACA does not have specific provisions that address adult dental care, it is likely that the law has modestly increased dental coverage through two channels. First, one providoi: 10.1377/hlthaff.2016.0800 HEALTH AFFAIRS 35, NO. 12 (2016): 2176 2182 2016 Project HOPE The People-to-People Health Foundation, Inc. By Marko Vujicic, Thomas Buchmueller, and Rachel Klein Dental Care Presents The Highest Level Of Financial Barriers, Compared To Other Types Of Health Care Services Marko Vujicic (vujicicm@ada.org) is the chief economist at and vice president of the Health Policy Institute, American Dental Association, in Chicago, Illinois. Thomas Buchmueller is the Waldo O. Hildebrand Professor of Risk Management and InsuranceintheRossSchool of Business, University of Michigan, in Ann Arbor. Rachel Klein was director of organizational strategy for Families USA, in Washington, D.C., at the time of this writing. ABSTRACT The Affordable Care Act is improving access to and the affordability of a wide range of health care services. While dental care for children is part of the law s essential health benefits and state Medicaid programs must cover it, coverage of dental care for adults is not guaranteed. As a result, even with the recent health insurance expansion, many Americans face financial barriers to receiving dental care that lead to unmet oral health needs. Using data from the 2014 National Health Interview Survey, we analyzed financial barriers to a wide range of health care services. We found that irrespective of age, income level, and type of insurance, more people reported financial barriers to receiving dental care, compared to any other type of health care. We discuss policy options to address financial barriers to dental care, particularly for adults. The Affordable Care Act (ACA) is having a significant impact on the US health care system. Early evidence shows that the number of Americans without health insurance has declined and access to health care services has improved. 1 3 However, the percentage of Americans without dental insurance has always been higher than the percentage without health insurance, and there are large differences in dental coverage rates between children and adults. In 2013, 12 percent of children and 33 percent of nonelderly adults had no dental insurance, compared to 6 percent of children and 20 percent of nonelderly adults who lacked health insurance. 4,5 The higher rate of dental coverage for children, compared to nonelderly adults and seniors, is partly explained by the fact that dental services are a mandatory benefit within Medicaid for children. For child Medicaid beneficiaries, dental services are part of a comprehensive set of benefits provided through the Early and Periodic Screening, Diagnosis, and Treatment Program. Under the program, dental services for children must minimally include: relief of pain 2176 Health Affairs December 2016 35:12

sion allows young adults to remain on their parents private insurance plans until age twentysix. 9 While dental benefits were not subject to the provision, which was implemented in September 2010, there is evidence of a spillover effect, and access to dental care has improved among adults younger than twenty-six. 10 Second, twenty-five states chose to both expand eligibility for Medicaid and provide at least limited adult benefits in their Medicaid program. 11 Nationally, just over eight million nonelderly adults were expected to gain dental benefits via this Medicaid expansion channel. 12 To date, however, there has been no evaluation of the impact of the Medicaid expansion on access to dental care. The differential policy treatment of dental care for adults and children, both before and after implementation of the ACA, has important implications for oral health. Emerging evidence demonstrates that children and adults are experiencing very different trends when it comes to access to and use of dental care, and financial barriers to receiving that care. 13 15 Over the past decade, an increasing number of children, particularly low-income children, have been visiting the dentist. In nearly every state, the gap in rates of use of dental care between low-income and high-income children is narrowing. 13 In contrast, use of dental care among nonelderly adults is declining, and many states are actually seeing a widening gap between low-income and highincome nonelderly adults. 14 Americans ages sixty-five and older particularly those with low incomes also face significant challenges to accessing dental care. 15 Low-income nonelderly adults are experiencing the most severe challenges when it comes to accessing dental care. It is important to understand the implications of the different policy approaches to dental and medical coverage in the US health care system. In this study we examined the most current data on financial barriers to dental care in the United States.We analyzed differences in these financial barriers across age groups and types of insurance, and we compared financial barriers to dental care with barriers to a broad range of other health care services. Study Data And Methods Data Sources Our main source of data was the 2014 National Health Interview Survey (NHIS). 16 The NHIS is conducted annually and is nationally representative of the civilian noninstitutionalized US population. The advantages of using the NHIS instead of other data sources 17 to explore financial barriers to dental care include the survey s large sample size, high response rate, detailed information on dental insurance, and inclusion of children and both nonelderly and elderly adults in the sample. The Family Core component collects information on every member of a sample household, including information on the members demographic and health characteristics and their insurance. In 2014, 112,053 individuals were interviewed for the survey. Up to one adult and one child (ages 0 17) were randomly selected from each household to be included in the Sample Adult Core and Sample Child Core components. These people (or, in the case of a young child, his or her parent) were asked to respond to a more detailed questionnaire that included, among other things, questions related to cost barriers for a range of health care services. The combined size of the child and adult samples was 50,077 people. We also examined data from the Oral Health and Well-Being Survey, conducted by the American Dental Association s Health Policy Institute. The Health Policy Institute partnered with the Harris Poll to conduct an online survey of 14,962 adults ages eighteen and older. The survey was conducted in the period June 23 August 7, 2015. It included questions regarding oral health status, attitudes related to the importance of oral health, use of dental care, dental care coverage, and barriers to receiving dental care. In this article we focus on the answers to questions regarding barriers to dental care. A full description of the survey methodology is available elsewhere. 18 Study Sample, Variables, And Methodology The NHIS includes questions related to cost barriers for five categories of health care services: dental care, medical care, mental health care, prescription drugs, and eyeglasses. The dependent variable in our analysis was a binary variable based on the response to the following survey question: During the past twelve months, was there ever a time when you needed [health care service] and didn t get it because you could not afford it? We analyzed responses to the question about financial barriers to dental care and other health care services by age group and type of insurance. We focused on children (ages 2 18), nonelderly adults (ages 19 64), and seniors (ages 65 and older). We divided nonelderly adults into four categories based on their medical and dental insurance: those with private health and private dental insurance, those with private health insurance but no private dental benefits, those covered by Medicaid, and those with no health insurance or dental benefits. For each of the three age groups, we report cost barriers to dental care by household income categories as a percentage of the federal poverty level (less than 100 percent, 100 199 percent, 200 399 percent, December 2016 35:12 Health Affairs 2177

and 400 percent or more). Limitations Our study had several limitations. First, dental benefits for adults are an optional benefit within Medicaid, and there is variation in the level of dental benefits across states. 12 We did not have access to state-level identifiers within the NHIS data. Thus, we were not able to determine if adults with Medicaid coverage had dental benefits under Medicaid. Second, data on our main outcome variable financial barriers to dental and other health care were self-reported. As a result, respondents may have differed in how they interpreted their need for services. This is especially important in the case of dental care, where some services are discretionary. Ideally, the variable related to financial barriers would be conditional on having a need for a particular health care service, but this is not the case. A low prevalence of financial barriers for a particular type of care could be accounted for partly by a lack of need for that type of care. For example, some seniors may perceive a lack of need for dental care because they no longer have their natural teeth. 19 If this is true, our results will underestimate financial barriers to dental care for seniors. However, we know of no other data set that avoids this limitation, and the NHIS data on financial barriers have been widely used in previous health services research, including dental care research. 20 22 Finally, it is important to emphasize that our analysis is entirely descriptive.we document factors that are correlated with financial barriers to care, but we make no claims regarding causality. Study Results Across age groups, we found that the percentage of respondents reporting financial barriers to receiving dental care was higher than the percentage for any other type of care (Exhibit 1). Compared to children and seniors, nonelderly adults were more likely to face financial barriers to all types of care. For example, 12.8 percent of nonelderly adults reported not receiving needed dental care because of cost, compared to 7.2 percent of seniors and 4.3 percent of children. Within each insurance category, more nonelderly adults reported financial barriers to dental care, compared to barriers to other types of health care (Exhibit 2). Even among nonelderly adults with both private medical and private dental insurance, 5.3 percent reported forgoing needed dental care, compared to 3.4 percent who did not receive needed medical care. As noted above in the Limitations section, the results for the Medicaid subsample were difficult to interpret because this group included both individuals with and those without dental coverage. When we looked only at dental care, we found income gradients for all age groups in financial barriers to care (Exhibit 3). For example, nearly one-quarter of nonelderly adults with incomes below 100 percent of poverty reported that in the previous twelve months, they had not obtained needed dental care because of cost. In contrast, fewer than 5 percent of nonelderly adults in the highest income category reported financial barriers to dental care. In each income group, the group with the smallest percentages of not receiving needed dental care because of cost was children. For seniors, the rates were between those for children and nonelderly adults, and the income gradient was less clear: A slightly higher percentage of seniors whose incomes were 100 199 percent of poverty reported financial barriers, compared to those with incomes below that threshold. According to the Oral Health and Well-Being Survey, cost was 2.7 times more likely to be reported as the reason for not going to the dentist than the next most common reason (Exhibit 4). Among adults who had not visited the dentist within the past twelve months, 59 percent cited cost as the reason. The second most common reason cited was fear of the dentist, and the third most common was an inconvenient appointment time or office location. Cost was the main reason irrespective of age, income level, or dental insurance status (data not shown). It is important to note that cost was the top barrier to dental care even for adults with private dental insurance. Discussion Our analysis supports two broad conclusions regarding financial barriers to receiving dental care. First, consistent with other research using alternative data sources and methods, 20,23 we found that cost was the most common reason cited by nonelderly adults for avoiding dental care. Second, also consistent with previous research, 17,24 we found that more people reported financial barriers to dental care than to any other health care, regardless of age, income level, or type of insurance. As we noted in the Limitations section, our use of self-reported data means that the exact nature of the dental care that people reported not receiving because of cost is unclear. For example, to some respondents needed care could mean only urgent, acute oral health conditions such as infections and decay that cause severe pain and difficulty chewing and speaking, while other respondents might consider needed care to include elective procedures such as teeth whit- 2178 Health Affairs December 2016 35:12

ening and orthodontic services that are not medically necessary. Even if some of the care that is forgone because of cost is elective, results from a number of other studies suggest that adults are suffering serious consequences from not receiving dental care because of cost. Hospital emergency department visits for dental conditions have doubled over the past decade, with young adults and lowincome adults having the highest visit rates. 25 Nonelderly adults have the highest incidence of untreated cavities of any age group. 26 Nearly one in three young adults reported having oral health issues so severe that they affected the respondent s ability to interview for a job. 18 Avoiding needed dental care could also adversely affect health outcomes beyond the mouth and contribute to increased health care costs among older Americans with chronic conditions such as diabetes. 27 Why are financial barriers to dental care so severe in comparison to barriers to other health care, particularly for adults? As noted above, before health insurance expansion under the ACA, adults were roughly twice as likely to have lacked dental insurance than medical insurance, 4,5 and the design of the ACA reinforced this coverage gap. Moreover, the current design of both public and private dental insurance has important shortcomings when it comes to protecting consumers from financial burden. In states that provide dental benefits to adults in their Medicaid program, there are often annual dollar limits Exhibit 1 Percentages of National Health Interview Survey respondents who did not get selected health care services they needed in the past 12 months because of cost, by age group, 2014 SOURCE Authors analysis of data for 2014 from the National Health Interview Survey. NOTES The sample consisted of 50,077 respondents. For all age groups, the difference between dental care and medical care not obtained was significant (p < 0:05). ranging from $500 to $2,500 a year or procedure restrictions. 5,11 Many states limit the number of fillings or crowns that their Medicaid program will pay for, the types of crowns that can be used on certain teeth, and how often root canals are covered. For example, Connecticut and Illinois limit coverage for Medicaid adults to one Exhibit 2 Percentages of National Health Interview Survey respondents ages 19 64 who did not get selected health care services they needed in the past 12 months because of cost, by type of insurance, 2014 SOURCE Authors analysis of data for 2014 from the National Health Interview Survey. NOTES The sample consisted of 50,077 respondents. For all types of insurance, the difference between dental care and medical care was significant (p < 0:10 for no insurance; p < 0:05 for all other types of insurance). December 2016 35:12 Health Affairs 2179

Exhibit 3 Percentages of National Health Interview Survey respondents who did not obtain needed dental care during the past 12 months because of cost, by household income, 2014 SOURCE Authors analysis of data for 2014 from the National Health Interview Survey. NOTES The sample consisted of 50,077 respondents. For all income levels, the difference between dental care and medical care not obtained was significant (p < 0:05). FPL is federal poverty level. filling per year. North Dakota, Rhode Island, and Washington limit coverage for root canals to front teeth only. 28 It is important to note that children s dental coverage within public programs is much more comprehensive than the coverage for adults, with little to no cost sharing. This could partly explain why financial barriers to dental care are much more prevalent for adults than for children. Typical private dental insurance plans also have many provisions that limit consumers financial protection. There are significant coinsurance rates (for example, 20 50 percent Exhibit 4 Top reasons given by 14,962 adults for not having visited the dentist in the past 12 months, 2015 SOURCE Authors analysis of data for 2015 from the Oral Health and Well-Being Survey of the American Dental Association s Health Policy Institute. for fillings and crowns) and annual maximum benefit limits. Average inflation-adjusted annual maximum benefit levels have decreased significantly over time. 29,30 In fact, a recent analysis showed that for the vast majority of nonelderly adults with private dental insurance, total expenditures on premiums, coinsurance, and copayments significantly exceed the market value of the dental services they used. 31 This could cause many beneficiaries to question the value of private dental insurance from a financial perspective. As a result of these limitations in coverage, out-of-pocket spending accounts for a much higher share of total dental spending than it does for total health spending. In 2014, 40 percent of total US spending on dental care was out of pocket, compared to 11 percent of total health spending. 32 Policy Implications To reduce financial barriers to dental care in the United States, particularly for adults, there are several policy options to consider. These options can be divided into two broad categories: expanding dental insurance coverage, and redesigning the coverage so that it provides enhanced financial protection. Coverage expansion would most likely require a shift in federal and state policy with respect to dental care for adults. This could entail defining dental care for adults as an essential health benefit within the ACA, making dental care a required benefit in Medicaid, and adding dental coverage to Medicare. A recent analysis estimated that implementing a comprehensive dental benefit for Medicaid adults in the twenty-two states that lack one would require an additional $1.4 $1.6 billion per year, with the state portion amounting to about 1 percent of total Medicaid spending. 7 Expanding Medicaid adult dental benefits has been shown to increase access to dental care, 33 and evidence suggests that the dental care system has the capacity to absorb such an expansion. 34 36 There is also emerging evidence that there may be fiscal offsets in the form of reductions in medical care costs associated with increased use of dental care among patients with chronic conditions. 27 These savings are especially important when considering the cost of adding a dental benefit in Medicaid and especially in Medicare. Including dental insurance within the individual mandate under the ACA would require a significant change in current law. In addition, implementing the dental insurance mandate for children has been challenging because dental insurance is most often sold separately from 2180 Health Affairs December 2016 35:12

medical insurance. Only 28 percent of medical plans offered on the Marketplace website Healthcare.gov include dental benefits for children, and just 1 percent include dental benefits for adults. 37 Beyond coverage expansion, the nature of dental insurance both public and private needs to be reexamined. Ideally, dental benefit plans should be designed so that they pay for the beneficiary s oral health and well-being instead of for checklists of procedures, often with tooth-bytooth restrictions and arbitrary dollar limits. Although new tools have recently been developed to provide a practical way of measuring oral health and well-being, 18 these concepts are still not well defined, and the move toward outcomesbased models of care delivery and financing is only just beginning in the dental arena. For policy makers seeking alternatives to the status quo for dental insurance for adults, the dental benefit design for children in Medicaid provides a good blueprint on which to draw. Conclusion Our analysis showed that cost was the most significant factor keeping Americans from accessing needed dental care. We also found that irrespective of age, income level, and type of insurance, more people reported financial barriers to receiving dental care than they did for any other health care. There is compelling evidence that financial barriers to dental care result in serious consequences to oral health and overall health and well-being, especially among lowincome adults. These patterns are in part a result of the approach taken toward coverage for dental care by federal and state health policy in the United States. Dental care for adults is not considered an essential health benefit. This is in contrast to dental care for children, which is compulsory in Medicaid and the Children s Health Insurance Program and is part of the individual mandate under the ACA. Policy makers ought to consider reforms at the federal and state level to ease financial barriers to dental care and better integrate dental and health coverage. TheauthorsthankThomasWallfor research assistance and Brittany Harrison for editorial assistance in completing this article. Both Wall and Harrison are with the American Dental Association s Health Policy Institute. NOTES 1 Uberoi N, Finegold K, Gee E. Health insurance coverage and the Affordable Care Act, 2010 2016 [Internet]. Washington (DC): Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation; 2016 Mar 3 [cited 2016 Oct 17]. (ASPE Issue Brief). Available from: https://aspe.hhs.gov/sites/default/files/pdf/ 187551/ACA2010-2016.pdf 2 Sommers BD, Gunja MZ, Finegold K, Musco T. Changes in self-reported insurance coverage, access to care, and health under the Affordable Care Act. JAMA. 2015;314(4):366 74. 3 Wherry LR, Miller S. Early coverage, access, utilization, and health effects associated with the Affordable Care Act Medicaid expansions: a quasiexperimental study. Ann Intern Med. 2016;164(12):795 803. 4 Nasseh K, Vujicic M. Dental benefits coverage rates increased for children and young adults in 2013 [Internet]. Chicago (IL): American Dental Association; 2015 Oct [cited 2016 Oct 17]. (Health Policy Institute Research Brief). Available from: http:// Files/HPIBrief_1015_3.pdf?la=en 5 Kaiser Commission on Medicaid and the Uninsured. Key facts about the uninsured population [Internet]. Washington (DC): The Commission; 2015 Oct [cited 2016 Oct 17]. (Fact Sheet). Available from: http://files.kff.org/attachment/fact-sheet-keyfacts-about-the-uninsuredpopulation 6 Medicaid.gov. Dental care: dental benefits for children in Medicaid [Internet]. Baltimore (MD): Centers for Medicare and Medicaid Services; [cited 2016 Oct 17]. Available from: https://www.medicaid.gov/ Medicaid-CHIP-Program- Information/By-Topics/Benefits/ Dental-Care.html 7 Yarbrough C, Vujicic M, Nasseh K. Estimating the cost of introducing a Medicaid adult dental benefit in 22 states [Internet]. Chicago (IL): American Dental Association; 2016 Mar [cited 2016 Oct 17]. (Health 0316_1.ashx 8 Reusch C. FAQ: pediatric oral health services in the Affordable Care Act [Internet]. Washington (DC): Children s Dental Health Project; 2014 Mar 5 [cited 2016 Oct 17]. Available from: https://www.cdhp.org/ resources/165-faq-pediatric-oralhealth-services-in-the-affordablecare-act 9 Sommers BD, Buchmueller T, Decker SL, Carey C, Kronick R. The Affordable Care Act has led to significant gains in health insurance and access to care for young adults. Health Aff (Millwood). 2013;32(1): 165 74. 10 Vujicic M, Yarbrough C, Nasseh K. The effect of the Affordable Care Act s expanded coverage policy on access to dental care. Med Care. 2014;52(8):715 19. 11 Hinton E, Paradise J. Access to dental care in Medicaid: spotlight on nonelderly adults [Internet]. Menlo Park (CA): Henry J. Kaiser Family Foundation; 2016 Mar 17 [cited 2016 Oct 17]. (Issue Brief). Available from: http://kff.org/medicaid/issue-brief/ access-to-dental-care-in-medicaidspotlight-on-nonelderly-adults/ 12 Yarbrough C, Vujicic M, Nasseh K. More than 8 million adults could gain dental benefits through Medicaid expansion [Internet]. Chicago (IL): American Dental Association; 2014 Feb [cited 2016 Oct 17]. (Health 0214_1.pdf?la=en 13 Vujicic M, Nasseh K. Gap in dental care utilization between Medicaid and privately insured children narrows, remains large for adults [Internet]. Chicago (IL): American Dental Association; 2015 Dec [cited December 2016 35:12 Health Affairs 2181

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Washington (DC): MACPAC; 2015 Jun [cited 2016 Oct 17]. Chapter 2: Medicaid coverage of dental benefits for adults. Available from: https:// www.macpac.gov/wp-content/ uploads/2015/06/medicaid- Coverage-of-Dental-Benefits-for- Adults.pdf 29 Greany TJ, Lambrecht KR. Improving oral health care delivery in America [Internet]. 2013 [cited 2016 Oct 17]. Chapter 2: How did we get here? The history of third (and fourth) party payment in dental care. Louisville (CO): Symbyos; 2013. Available from: http://dentalstudy.- toothiq.com/history-of-dentalbenefits/default.aspx 30 Health Resources Administration, Division of Dentistry. Survey of dental benefit plans, 1973. Washington (DC): Government Publishing Office; 1979?. 31 Yarbrough C, Vujicic M, Aravamudhan K, Blatz A. An analysis of dental spending among adults with private dental benefits [Internet]. Chicago (IL): American Dental Association; 2016 May [cited 2016 Oct 17]. (Health Policy Institute Research Brief). 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Forthcoming. 37 American Dental Association. Millennials struggle to navigate the dental options on HealthCare.gov [Internet]. Chicago (IL): ADA; [cited 2016 Oct 17]. Available from: http:// Files/HPIgraphic_0516_1.pdf?la=en 2182 Health Affairs December 2016 35:12