Examining America's Dental Safety Net

MARCH 2018

ADEA Office of Policy, Research and Diversity | Omar A. Contreras, M.P.H.; Denice Stewart, D.D.S., M.H.S.A.; Richard W. Valachovic, D.M.D., M.P.H.

At least 74 million Americans had no form of dental coverage in 2016.1 Adults continue to face financial barriers to dental care. For children, the financial barriers are fewer. As a result of the Patient Protection and Affordable Care Act (ACA) and its impact on the Children’s Health Insurance Program (CHIP), dental insurance among low-income children has been expanding steadily.2 Many vulnerable and underserved populations, including low-income individuals, the elderly, racial and ethnic minorities and medically compromised persons, face substantial barriers to accessing dental care. Examples of oral health disparities include:

• Children: Untreated dental caries (cavities) was more than twice as high for Hispanic children (8.8%) compared with non-Hispanic white children.3
• Adolescents: Approximately, 21% of nonHispanic black adolescents ages 13–15 have untreated caries compared with non-Hispanic white adolescents (13.4%). 3
• Adults: Adults with incomes less than 100% of the federal poverty level (FPL) are three times more likely to have untreated caries.4
• Seniors: Of seniors age 65 and older with incomes below 100% FPL, 37% do not have any teeth compared with 16% of those with incomes at or above 200% FPL.2,3
  
  

The dental safety net refers to the structures supporting populations facing considerable barriers to accessing dental care. This typically involves individuals without private insurance and/or those who are unable to pay for services out of pocket. The dental safety net is comprised of practitioners, payment programs and facilities that provide clinical, nonclinical and support services. It includes Medicaid, CHIP, federally qualified health centers (FQHCs), school-based health centers and academic dental institutions, among other entities. If not for dental safety net providers, millions more Americans would be without access to dental care.

Academic dental institutions are dental safety net providers in the United States for various populations. Additionally, many academic dental institutions serve as one of the larger Medicaid and CHIP providers within their respective states.

• Service: Academic dental institutions provide services to people who lack access to dental care, whether due to economics, lack of dental insurance or residence in a health professional shortage area (HPSA) (visit datawarehouse.hrsa.gov/ExportedMaps/HPSAs/HGDWMapGallery_BHPR_HPSAs_DC.pdf for a map, or datawarehouse.hrsa.gov for more reports).
• Community Involvement: In communities across the country, academic dental institutions are at the center of the delivery of dental care to the economically disadvantaged, the elderly, the uninsured, under-insured and those residing in rural or urban oral health deserts.

Dental and allied dental students provide direct services to patients under the close supervision of faculty and residents, nationwide (Figure 1).

• In 2016–2017, predoctoral dental students provided care during more than 3,100,000 dental visits.5
• Of the 3,124,500 dental visits, 2,656,542 were provided in dental school clinics and 467,958 in extramural dental school facilities.5
• Academic dental institutions are a resource to specialty dental services that are not generally accessible to Medicaid and low-income uninsured patients.6
• Partnerships between dental institutions and FQHCs are pivotal in building the pipeline of new dentists practicing in underserved areas through externships and dental residency rotations.7
  
  

The needs of the dental safety net are multifaceted: to provide adequate resources to support the dental safety net providers, develop policies that will facilitate access and delivery of dental care, and educate the next generation of dental providers to meet the growing demand. Access to dental care is equally important to the young, the old, the medically compromised and citizens who reside in dental HPSAs.

1. National Association of Dental Plans. Who has dental benefits today? At: http://www.nadp.org/ Dental_Benefits_Basics/Dental_BB_1.aspx. Accessed: April 6, 2018.
2. Yarbrough C, Nasseh K, Vujicic M. Key insights on dental insurance decisions following the rollout of the Affordable Care Act. Health Policy Institute, American Dental Association, 2014.
3. Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental caries and sealant prevalence in children and adolescents in the United States, 2011-2012. US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, 2015.
4. Medicaid and CHIP Payment and Access Commission. Medicaid Coverage of Dental Benefits for Adults. At: https://www.macpac.gov/wp-content/uploads/2015/06/ June-2015-Report-to-Congress-on-Medicaid-and-CHIP. pdf. Accessed: February 20, 2018.
5. American Dental Association, Health Policy Institute, 2016-2017 Survey of Dental Education. At: https:// www.ada.org/en/science-research/health-policyinstitute/data-center/dental-education. Accessed: February 20, 2018.
6. American Dental Education Association. Webinar Series: The Dental Safety Net. At: http://www.adea.org/ dentalsafetynet. Accessed: October 27, 2014.
7. Langelier M, Surdu S, Rodat C. Oral Health Workforce Research Center. Survey of Federally Qualified Health Centers to Understand Participation with Dental Residency Programs and Student Externship Rotations. At: http://www.chwsny.org/wp-content/uploads/2017/01/ FQHC_Dental_Residents_Externs_Policy_Brief_2016. pdf. Accessed: February 20, 2018.