Published online June 22, 2007
PEDIATRICS Vol. 119 No. 3 March 2007, pp. e544-e553 (doi:10.1542/peds.2006-1958)
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ARTICLE

Preventive Dental Care for Children in the United States: A National Perspective

Charlotte W. Lewis, MD, MPHa,b,c,d, Brian D. Johnston, MD, MPHa,b,e, Kristi A. Linsenmeyar, DDSd, Alexis Williams, BSc and Wendy Mouradian, MDa,b,d

a Division of General Pediatrics, Department of Pediatrics
c Child Health Institute
d Department of Pediatric Dentistry, University of Washington, Seattle, Washington
b Children's Hospital and Regional Medical Center, Seattle, Washington
e Department of Pediatrics, Harborview Medical Center, Seattle, Washington


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVE. Preventive dental care is a cornerstone of optimal oral health. However, in 1996, only 38% of US children received preventive dental care. We used the National Survey of Children's Health to (1) describe the proportion of US children with ≥1 preventive dental visit within the previous year, (2) identify factors that were associated with preventive dental care use, and (3) test the hypothesis that preventive dental care use by near-poor children is associated with State Child Health Insurance Program policies for covering dental care.

METHODS. The National Survey of Children's Health includes data from 102353 children, weighted to represent 72.7 million children, nationally. Our outcome of interest was ≥1 preventive dental visit in the past year. We conducted multivariate regression analysis to identify factors that were associated significantly with this outcome using Stata survey capabilities.

RESULTS. In 2003, 72% of US children had a reported preventive dental care visit in the previous year. On multivariable analysis, we found that being young, black or multiracial relative to white, lower income, and lacking a personal doctor were variables with a significantly lower likelihood of a preventive dental visit. Children in states with State Child Health Insurance Program dental coverage and broadest income eligibility had a 24% higher likelihood of a preventive dental visit when compared with children in states with limited or no State Child Health Insurance Program coverage for dental services, on adjusted analysis.

CONCLUSIONS. Although the proportion of US children with a preventive dental visit now is higher than previously reported, children who are at highest risk for dental problems still are those who are least likely to receive preventive dental care. When states cover preventive dental care at income eligibility levels ≥200% of the federal poverty level, there is a greater likelihood that near-poor children will receive preventive dental care.

Key Words: dental care • prevention • oral health

Abbreviations: MEPS—Medical Expenditure Panel Survey • NSCH—National Survey of Children's Health • SCHIP—State Child Health Insurance Program • EPSDT—Early Periodic Screening, Diagnosis, and Treatment • FPL—federal poverty level • MSA—metropolitan statistical area • OR—odds ratio

Preventive dental care is considered the cornerstone of optimal oral health promotion. Previous research from the 1996 Medical Expenditure Panel Survey (MEPS) indicated that 38% of US children had a preventive dental visit in the previous year, with even lower rates among younger, low-income, and minority children.1 With recent release of the National Survey of Children's Health (NSCH),2 we have an important opportunity to describe and reassess preventive dental care use using a nationally representative pediatric data set.

In the past 10 years, a number of events with potential to increase access to preventive dental visits for children have occurred. Key among these was creation of Title XXI, the State Children's Health Insurance Program (SCHIP), as part of the Balanced Budget Act of 1997. Under SCHIP, states could choose whether to receive federal matching funds to expand their Medicaid programs, purchase coverage through state-designed programs, or develop a combination of the 2 approaches.

With SCHIP enactment came the opportunity to expand health and dental care access for near-poor children who previously had exceeded income eligibility for Medicaid. However, SCHIP differs from Medicaid in a number of ways, including its coverage for dental care. Preventive and other dental care is a mandated benefitfor Medicaid-eligible poor children through Early Periodic Screening, Diagnosis, and Treatment (EPSDT) legislation. In contrast, under SCHIP, states have the option of including dental care as part of covered services. At the onset of SCHIP's implementation, 2 states, Colorado and Delaware, elected not to include dental care among SCHIP covered services. Florida provided SCHIP dental coverage only on a county-by-county basis. In 2003, Texas discontinued dental coverage under SCHIP (but recently restored it). The remaining states all cover preventive dental care and varying types of other dental treatment.3,4

Under SCHIP, states also have more flexibility in establishing family income levels for eligibility.5 The maximum family income to qualify for SCHIP varies across states from 140% of the federal poverty level (FPL) to 350% of the FPL,6 whereas income eligibility for EPSDT-Medicaid is standard across all states; coverage is mandated for all eligible children who are younger than 6 years and have family incomes at or under 133% of the FPL and for children who are ≥6 and at or under 100% of the FPL, although certain states have extended Medicaid eligibility to higher incomes.7

A number of reports have documented increases in the proportion of insured children and expanded access to health care since SCHIP's implementation.8–12 Less is known about the effect of SCHIP on dental care use; the few published studies have focused on single states, where modestly positive effects were reported.11,13,14 In addition, a Mathematica Policy Research report on 27 states found that the implementation of SCHIP seems to have improved low-income children's access to and use of dental services as of 2003 but there is variation across the states studied.15 We could identify no study to date that used national data in evaluating the impact of SCHIP and associated Medicaid expansions on preventive dental visits.

With this in mind, the objectives of this research were (1) to describe the proportion of US children in 2003–2004 with at least 1 preventive dental visit within the previous year, (2) to identify factors that were associated independently with preventive dental care use in the previous year, and 3) to test the hypothesis that preventive dental care use by near-poor children is associated with state SCHIP policies regarding eligibility for dental care.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Data Source
We relied on data from the NSCH, which was sponsored and directed by the Maternal and Child Health Bureau of the US Health Resources and Services Administration along with the Centers for Disease Control and Prevention, and the National Center for Health Statistics.16 The survey was conducted between January 2003 and July 2004 and was intended to collect information on the physical, emotional and behavioral health and health care experience of a large sample of representative US children.2 The State and Local Area Integrated Telephone Survey (SLAITS) mechanism was used to complete 102353 telephone surveys of households with children who were 0 to 17 years of age, with ~2000 respondents from each of the 50 US states and the District of Columbia.17 After identifying a household with children, the interviewers asked for the birth dates of all children who were younger than 18 years. One child in this age range then was randomly selected to be the subject of the interview. The respondent was the parent or guardian in the household who was most knowledgeable about the health and health care of the children who were younger than 18 years. In general, this was the child's mother (79%) or father (17%). Grandparents or other relatives or guardians composed the remainder (4%). Surveys were conducted in English and Spanish (6% of interviews).16

The data file is publicly available and contains population weights, stratum identifiers (ie, state name), and primary sampling unit codes that account for the complex sample design and permit population-based estimates with accurate SEs. Poststratification adjustments before release of the data ensure that population subgroups were represented properly in the weighted estimates that were generated from the data set.17

Variable Selection and Sources
Our primary outcome of interest was report of a preventive dental visit during the previous 12 months, which was derived from this NSCH survey question, "During the past 12 months, did your child see a dentist for any routine preventive dental care, including checkups, screenings, and sealants?" This question was not asked of children who were younger than 12 months or who did not yet have any natural teeth.17 Before undertaking our data analysis, we identified potential variables that we hypothesized to be associated with preventive dental care use, on the basis of a comprehensive literature review. These variables included patient and family variables that were available in the NSCH. With regard to insurance, participants were asked whether they had health care insurance and whether this coverage was Medicaid or SCHIP (yes or no), without differentiating which of the 2 the child had. In addition, participants were asked whether the child had insurance to help pay for routine dental care but did not otherwise inquire about the specific kind of dental insurance.

We drew on other data sources to inform pertinent state variables, including (1) per capita distribution of general dentists,18 (2) proportion of dentists who participated in Medicaid and SCHIP,19 (3) percentage of Medicaid/SCHIP-eligible children who were enrolled,20 (4) maximum income by percentage of the FPL to qualify for Medicaid/SCHIP, and (5) type of Medicaid/SCHIP program (separate SCHIP, Medicaid expansion only, or combination).6

To enhance our analyses, we created additional variables from those that were available in NSCH. We classified states by maximum income for SCHIP/Medicaid eligibility and dental coverage under SCHIP6 into the following categories:

  1. States that did not offer statewide SCHIP dental services from program onset or that had discontinued dental coverage (Delaware, Colorado, Florida, and Texas): "no/limited SCHIP dental eligibility states." These states all had separate SCHIP programs and annual Medicaid eligibility cutoffs equivalent to the minimum mandated (≤133% of the FPL for children 1–5 years and ≤100% of the FPL for ≥6 years).
  2. States with SCHIP/Medicaid eligibility <200% of the FPL and that included dental coverage under SCHIP: "SCHIP dental/intermediate income eligibility states."
  3. States with SCHIP/Medicaid eligibility ≥200% of the FPL and that included dental services under SCHIP: "SCHIP dental/broadest income eligibility states."
Within the last 2 state categories, we further stratified states into those with separate SCHIP or combination programs and those with only Medicaid expansion to reflect differences in how families may realize and perceive access to preventive dental care within the 2 systems. Stratification did not reveal any statistically significant differences in likelihood of preventive dental care, and we present only the nonstratified results here.

We developed a new race/ethnicity variable that combined the separate race and Hispanic ethnicity variables in the NSCH. Hispanic ethnicity combined with any race was classified as Hispanic, and the other races (white, black, multiracial, and other) were left unchanged. Using methods described by Mayer et al,21 we assigned a metropolitan statistical area (MSA) status to states where it had been suppressed to protect confidentiality in the original data. MSA was recoded from missing to non-MSA for states with small MSA samples (ie, most individuals lived in non-MSA or more rural locations [Alaska, Idaho, Maine, Montana, North Dakota, South Dakota, Vermont, and Wyoming]). Similarly, MSA status was recoded from missing to MSA for states with small non-MSA samples (Connecticut, Delaware, Hawaii, Massachusetts, Maryland, New Hampshire, Nevada, and Rhode Island). We also imputed poverty level for use in the multivariable regression models in the ~9000 cases for which this information was missing from the NSCH, using best subsets regression.22

Study Design and Data Analysis
Data were analyzed with Stata 8.0 (Stata Corp, College Station, TX). To account for the complex survey design, we used Stata survey commands and the population weights provided in the data files when generating population-level estimates and SE. We conducted descriptive analysis including bivariable tests of the association between explanatory covariates and our primary outcome: a preventive dental visit in the previous 12 months. In addition, we developed 2 multivariable logistic regression models. The first model included all of the hypothesized covariates of interest (Table 1) and was used to determine the independent associations between a preventive dental visit in the previous 12 months and the potential explanatory covariates.


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  		TABLE 1 Covariates That Were Hypothesized to Be Associated With a Preventive Dental Visit in the Previous Year

 
The second model included an interaction term between the SCHIP eligibility dental coverage category and the child's household income relative to the FPL. We relied on this model to test our hypothesis that near-poor children who reside in states with SCHIP dental coverage and broader income eligibility would have a higher likelihood of a preventive dental care visit. We estimated a linear combination of coefficients to determine the odds ratio (OR) for preventive dental care for the 3 categories of SCHIP dental and income eligibility (no/limited SCHIP dental eligibility states, SCHIP dental/intermediate income eligibility states, and SCHIP dental/broadest income eligibility states) for 3 groups of children as defined by EPSDT/Medicaid income eligibility criteria:
  1. "Poor children" who would be Medicaid eligible only and not SCHIP eligible in any state. That is, their household income is ≤133% of the FPL if they are younger than 6 and ≤100% of the FPL for 6 and older. We defined this group to reflect differences in mandated Medicaid income eligibility by age, although technically it included some near-poor children who were 5 years and younger.
  2. "Near-poor children," that is, 1- to 5-year-old children at 133% to 199% of the FPL and children who are older than 5 years at 100% to 199% of the FPL. "Near-poor" children were of primary interest because they were the intended target of SCHIP/Medicaid expansions. This group also is where we would expect to see variation in preventive dental care use across states depending on the state's SCHIP dental coverage and SCHIP/Medicaid income eligibility level.
  3. "Higher income children" who had family incomes ≥400% of the FPL across all ages and would be neither SCHIP eligible nor Medicaid eligible in any state.

Assuming that we had accounted adequately for confounding variables, we posited that near-poor children who lived in the broadest SCHIP dental/broadest income eligibility states would have the greatest likelihood of preventive dental care in the previous 12 months and children who resided in states that had no/limited SCHIP dental eligibility would have the lowest. In contrast, we would not expect a trend across state SCHIP dental/income eligibility categories in likelihood of preventive dental use among poor Medicaid-eligible (ie, non-SCHIP eligible) children regardless of state of residence because these children theoretically have consistent dental benefits across all states under EPSDT. Neither would we expect a trend across state dental and income eligibility categories for preventive dental visits among the higher income children, who presumably had other sources of coverage for dental care.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
The 102353 children on whom data were collected were weighted to represent 72.7 million children, nationally. Of these, 94% had responses to the preventive dental care question. Overall, 72% of US children were reported to have had a preventive dental visit in the previous 12 months. There was variability across states and the District of Columbia in the proportion of children with a preventive dental visit in the previous year. (Fig 1) Among children who were at or below 200% of the FPL, 62.5% had a reported preventive dental visit in the previous year. There were 6.35 million (8.6%) children who lacked health insurance and 16.3 million (22.8%) children who lacked dental insurance; the ratio of dental care uninsured to health care uninsured children was 2.6.


Figure 1
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  		FIGURE 1 Preventive dental visits across all ages, by state (more specific state-level results are available from the authors).

 
In examining the association of various potential explanatory variables on preventive dental care use, children who were 5 years and younger, were of nonwhite race/ethnicity, were of lower income, lacked dental insurance, lacked a personal doctor, lived in non-MSA areas or states, or were not born in the United States or whose parents were non–English speaking or unemployed or did not graduate from high school were significantly less likely, on bivariable analysis, to have had a preventive dental visit in the previous 12 months. (Table 2). Children who were 5 years and younger were the group with the lowest proportion receiving preventive dental care. There was variation on the state level (Fig 2), with Hawaii having the highest number of young children receiving preventive dental care (62%) and Nevada having the lowest (38%).


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  		TABLE 2 Weighted Proportion of Children With a Preventive Dental Visit and Weighted Results of Bivariable and Multivariable Tests of Association for Outcome of a Preventive Dental Visit in the Previous Year (Weighted N = 72.7 Million)

 

Figure 2
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  		FIGURE 2 Preventive dental visits in children who were 5 years and younger, by state (more specific state-level results are available from the authors).

 
On multivariable analysis, being young, black or multiracial relative to white, having lower income, lacking dental insurance, lacking a personal doctor, living in a non-MSA area, being foreign born, and having parents with less than a high school education or who were unemployed all were independently associated with a statistically significant lower odds of a preventive dental visit in the previous year (Table 2). Being Hispanic and having a non-English primary language no longer were associated with a statistically significant lower likelihood of a preventive dental visit on the adjusted analysis.

Near-poor children in states with the SCHIP dental/broadest income eligibility had a 24% higher likelihood of a preventive dental visit relative to children in states with limited/no SCHIP dental services, on adjusted analysis. A statistically significant trend in ORs for preventive dental care among near-poor children was seen across SCHIP dental/income eligibility state categories (Fig 3). This trend was not seen among children who were outside of the near-poor group; that is, poor children who met Medicaid eligibility criteria (with theoretically consistent dental benefits across all states under EPSDT) and higher income children who would likely have other sources of payment for dental care regardless of SCHIP coverage within their state of residence. We did not find any significant difference in our results when we stratified states further by type of SCHIP program, whether Medicaid expansion, SCHIP, or combination.


Figure 3
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  		FIGURE 3 Adjusted OR of preventive dental care in the previous year for poor, near-poor, and higher income children by state SCHIP dental eligibility category. Adjusted for age, race, dental insurance, having a personal doctor, MSA status, parental education, English primary home language, and parental employment and state per capita dentist distribution, the percentage of state dentists participating in Medicaid/SCHIP, and the percentage of Medicaid/SCHIP-eligible children who were enrolled.

 

   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
We found that 72% of US children in 2003–2004 had at least 1 preventive dental visit in the previous year, as reported by their parent or other primary caregiver. Only a few previous studies separated out preventive dental visits from dental visits in general. Using 1996 MEPS data, Watson et al1 found that 38% of children overall and 20% of children who were at or under 200% of the FPL had a preventive dental visit in the previous year. More recently, in a study of low-income children, Kenney et al3 found that 71% of children who were at or under 200% of the FPL had at least 1 reported preventive dental visit. In this current research, in which we relied on data from all 50 states and Washington, DC, as well as an order of magnitude larger sample size than these 2 previous studies, we found that 62.5% of low-income children had a reported preventive dental visit in the previous year. Certain groups continue to be underrepresented in their receipt of preventive dental care after adjustment for confounders. These include children who are young, who are black or multiracial, lack dental insurance, lack a personal doctor, are under 400% of the FPL (with a progressively negative impact as the household income drops), live in nonmetropolitan areas or states, or are foreign born.

Hispanic and white children were statistically similar in their likelihood of preventive dental care after controlling for other variables such as income, insurance, primary language, and being foreign born. Black children, however, have lower odds of preventive dental care that persists even after adjustment for income and insurance status. Among the many underlying factors of lower preventive dental care use in this population, cultural perceptions about preventive dental care and the lack of accessible professional dental care in predominantly black neighborhoods deserve additional attention.

We found an independent positive effect of having a personal doctor on the receipt of preventive dental care in the previous year. This is the first time to our knowledge that such an association has been recognized for the US pediatric population as a whole. We previously noted a similar relationship between having a personal doctor and not having an unmet dental care need among children with special health care needs.23 Families who identify a regular doctor for their child may have values and attributes that also lead them to seek preventive dental care; however, this relationship persisted despite controlling for a number of other confounders that also were associated with preventive habits and health care–seeking behaviors. It also is possible that physicians play an important role in referring patients to dental care or reinforcing the importance of preventive dental care to their patients and families. By whatever mechanism, there exists a link between having a personal doctor and receiving preventive dental care that deserves additional attention and study.

Younger children continue to be substantially underrepresented among those who received preventive dental care in the previous year. Children who were 1 to 5 years had an adjusted OR of a preventive dental visit of only 0.18 relative to children who were older than 5 years. There are a number of potential reasons for this. Despite recommendation by professional dental organizations, such as the American Academy of Pediatric Dentistry and the American Dental Association,24 for the first dental visit by 1 year of age, only 15% of pediatricians agreed with this concept in a 1999 national survey and therefore may not be recommending earlier dental visits for their patients.25 It was not until 2003 that the American Academy of Pediatrics specifically recommended an oral health evaluation by 1 year of age; before that, the recommended age was 3 years.26 Parents may not be aware of recommendations or may not perceive a need for dental care in their young children. In addition, general dentists, who make up the bulk of the dental workforce, may not feel comfortable caring for young children. Nevertheless, caries often have their onset in early childhood, particularly among those who are at high risk; National Health and Nutrition Examination Survey data that were collected between 1999 and 2002 indicated that 28% of US children who were between 2 and 5 years of age had caries, and substantially higher levels were observed among black, Mexican American, poor, and near-poor children.27 Therefore, it remains important to promote early initiation of preventive dental care for young children. Certain states perform substantially better than others in the proportion of children who are younger than 6 years and have had a preventive dental visit. This may reflect state and local efforts during the last 5 years to encourage preventive dental care use and increase access to professional dental care for very young children. These efforts largely grew out of the Surgeon General's report and conference on children's oral health in 2000.

We found that in states that cover preventive dental care at income eligibility levels at or >200% of the FPL through either SCHIP or Medicaid expansion, there is a greater likelihood of near-poor children's receiving preventive dental care in that state. Under SCHIP, states have flexibility to establish income eligibility and whether dental care is a covered benefit. Thus, our findings bear consideration as we evaluate current SCHIP performance and contemplate potential revisions in anticipation of SCHIP legislative renewal in 2007. Certainly, improvement is needed; even in the best states, near-poor children lag substantially behind their higher income counterparts in preventive dental care use.

There are a few possible reasons for why we did not see a greater improvement in preventive dental use among children who were in the near-poor group and had the SCHIP dental coverage/broadest income eligibility. We controlled for a number of factors that would be expected to influence dental care access and use, such as the proportion of dentists within the state participating in Medicaid and SCHIP, as well as factors that reflect SCHIP outreach and accessibility using child SCHIP/Medicaid participation rates as a proxy. However, our adjustment may have been incomplete. In addition, 2003–2004 were challenging years for SCHIP. Many states faced budget crises that had an adverse impact on SCHIP and that led states to freeze or cap enrollment, implement copays or premiums, or reduce outreach efforts.28 Services under Medicaid largely were spared on the state level during these financially difficult times because of federal mandates that were in place. During this period, families may have heard of and been concerned about copayments, although these are prohibited for preventive care services under Title XXI legislation.29 Likewise, SCHIP-enrolled families may not have received adequate information about SCHIP dental coverage. This possibility was borne out in focus groups of SCHIP-enrolled parents, where some parents did not know that preventive dental care was a SCHIP covered service in their state.15

Increasing dental insurance availability should be a priority. Although lack of dental insurance is 1 of a number of factors that contribute to disparities in preventive dental care use in the United States, it nevertheless is an important one, and it may be more amenable to intervention than are some of the other broader socioeconomic and racial/ethnic determinants. Increasing the proportion of children with dental insurance could be accomplished through SCHIP reform (ie, all states offer preventive dental services under SCHIP and expand income eligibility to include all near-poor children) and wider availability of employment-related dental benefits. To avoid crowd-out, states could offer a SCHIP dental-only benefits package that would be available to working families who received medical insurance but not dental insurance through their employer. This also would help to address the disparity in the ratio of dental-uninsured to health-uninsured children, which at 2.6 has remained constant since it last was reported using 1995 data.30

Dental coverage is relatively inexpensive when compared with health insurance. In the late 1990s, actuarial estimates of the cost to provide comprehensive preventive, diagnostic, restorative, and select orthodontic care for all SCHIP-covered children ranged between $17 and $20 per child per month.31 More recently, a 2006 report for the Virginia State Proposed Model Insurance Product estimated that premium cost for private dental insurance for small business employees at 100% to 300% of the FPL would be $26/month for the employee and $75 for the employee and family.32

Certain limitations bear mention. In this survey, preventive dental visits were determined by parental report. Parents may have overestimated the frequency of their children's dental visits to provide more desirable responses. In addition, the phrasing of the NSCH preventive dental care question encompassed a broad spectrum of possibilities for preventive dental care; our results should not be taken to mean that children who had a preventive dental visit necessarily had a usual source of dental care or a "dental home." Given the relatively limited number of variables that were available to us, there may be unmeasured variables that also had an impact on the likelihood of preventive dental care. For example, we had to rely on indirect measures of access to dental care (eg, proportion of dentists participating in Medicaid or SCHIP), and these may not reflect adequately some families' experiences in seeking preventive dental care. We did not have data on in which public insurance program (Medicaid or SCHIP) in the child was enrolled. However, because we were interested in the overall effect of the state's SCHIP dental coverage and SCHIP/Medicaid income eligibility on near-poor children as a group, it was less concerning to be lacking more specific child insurance information. Finally, because of the cross-sectional nature of this survey, establishing causality, for example, between having a personal doctor and receiving preventive dental care, was not possible.

Although this research was centered on preventive dental visits, the goals of such visits are to promote oral health and prevent disease. Unfortunately, caries concentrate in lower income children. Although this study identified higher rates of a preventive dental care visit than were measured using MEPS data in 1996, children who are at highest risk for dental problems, that is, lower income and minority children, still are those who are least likely to receive preventive dental care. Moreover, during early childhood, when establishing preventive habits and imparting preventive knowledge should be paramount, children are substantially less likely to have had a preventive dental visit; children who were younger than 6 years were only one fifth as likely to have received a preventive dental visit compared with older children.

With 62.5% of children at or below 200% of the FPL reported to have had a preventive dental visit, we now exceed the Healthy People 2010 goal of 57% of low-income children receiving preventive dental care in the previous year.33 Apart from asking whether this goal ever was good enough for poor and near-poor children, we still have a long way to go before we can say that all US children are receiving the preventive dental care that they need.


   FOOTNOTES
 
Accepted Oct 10, 2006.

Address correspondence to Charlotte W. Lewis, MD, MPH, UW Box 359420, Seattle, WA 98195. E-mail: cwlewis{at}u.washington.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics



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C. HOFFMAN and J. PARADISE
Health Insurance and Access to Health Care in the United States
Ann. N.Y. Acad. Sci., June 1, 2008; 1136(1): 149 - 160.
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