Racial Disparity Trends in Children’s Dental Visits: US National Health Interview Survey, 1964–2010

Discussion

This is the first study to take nearly a half-century perspective on changes in children’s use and disparities in dental care, beginning before the implementation of Medicaid and other Great Society programs. For the study period spanning 1964–2010, we demonstrate significant improvements in children’s receipt of dental care overall, as well as a dramatic narrowing in African American/white disparities. For the more recent time period of 1989–2010, our results indicate that utilization improvements were greater among publicly insured children, as well as poor and near-poor children. The implementation and expansion of the federal programs over time have had a cumulative and growing impact. The gradual but progressive program expansions and the high enrollment rates of African American children may have contributed to progressive reductions in dental access disparities over time. The programs disproportionately benefited African American children largely because more were eligible for these programs. African American children, although being only approximately half as likely as their white counterparts to have private health insurance in 2007, were almost 3 times as likely to have public coverage, primarily Medicaid or CHIP.¹⁶ The achievement of near African American/white equality in dental visits by 2010 was confirmed by using multivariable analyses adjusting for other factors associated with race, such as parental educational attainment.

Importantly, however, not all data sources reveal similar results. A MEPS Web site data query indicated in 2007 that non-Hispanic African American children aged 2 to 17 years were more likely than their white peers to lack dental visits in the past year (58% vs 41%).²⁸ However, the MEPS-based dental visit rates differ considerably from other national and state surveys, not just the NHIS. A 2007 National Survey of Children’s Health Web site data query indicates no significant differences in non-Hispanic African American and white children ages 1 to 17 years without a preventive dental visit in the past year (21.7% vs 19.1%, respectively).²⁹ Data from the 2007 California Health Interview Survey also reveal no statistically significant differences in the proportion of non-Hispanic African American and white children without a dental visit in the past year (17.1% vs 12.1%, respectively).³⁰ It is unclear why MEPS dental visit rates differ so greatly from other surveys, though it may stem partly from differences in survey methodologies. One study comparing dental utilization estimates across 3 nationally representative surveys noted MEPS estimates were consistently lower than the NHIS or NHANES.³¹ The authors attributed these differences to design issues and differential approaches to dental visit assessments. Edelstein,¹⁷ in discussing the discrepancies, suggests the MEPS may understate visit rates, whereas the NHIS might overstate visit rates. The NHIS has the advantage of providing nationally representative dental care use estimates from 1957 (electronic data are available beginning with 1964) permitting analysis of health care utilization trends over time, including before Medicaid.

Even with marked decreases in African American/white disparities in children’s dental visits demonstrated in this study, other data reveal persistent and substantial disparities in children’s oral health status.³² Examination data from the 2001–2004 NHANES reveal that African American children aged 2 to 5 years were 67% more likely to have untreated dental caries than their white counterparts, whereas African American children and adolescents ages 6 to 19 years were 45% more likely to have untreated caries.³³ Over the past 20 years, African American children have experienced substantial reductions in untreated dental caries rates. However, untreated caries continues to be far more prevalent among African American children, with the racial gap actually increasing somewhat for the younger age group.³³

The persistent gap in oral health status by race, despite improvements in dental utilization patterns, may be attributable to various factors. Dental care is 1 of many contributors to children’s oral health, so for their oral health status to improve, these additional factors must also be addressed. Numerous factors at multiple levels (individual, family, and community) also influence oral health.^13,34–37 For example, communities differ in socioeconomic disadvantage, culture, cohesion, or access to resources (eg, fluoridated water, dentists, and healthy foods) they afford their residents. Such contextual differences may help explain differences in oral health and dental utilization between races. Tellez et al³⁸ demonstrated that the number of neighborhood grocery stores was associated with caries levels among African American caregivers in Detroit. Further, the quality (technical and interpersonal), frequency, and type of dental care (especially extent of preventive services) African American and white children receive may differ.^39,40 Minority children have more symptom-related dental visits than their peers¹⁷ and have longer intervals between visits.⁴¹ In some states, African American Medicaid-enrolled children receiving dental care were less likely than their white peers to receive comprehensive dental services, including restorative and surgical treatment.⁴² These same children were also more likely to be treated by dental providers who mostly provide diagnostic and preventive dental services.⁴² Although preventive dental care can be effective in reducing dental disease,^43,44 some children still require restorative or surgical dental treatment. Access to preventive dental care is associated with receiving comprehensive dental treatment,⁴⁵ but a significant percentage of Medicaid-enrolled children who receive preventive dental care still have unmet restorative dental treatment needs.^46,47

These findings suggest that additional measures are needed to ensure children receive appropriate and comprehensive dental care commensurate with their needs. Research suggests health disparities can be impacted through providing prevention oriented medical care that addresses social determinants of health within the context of clinical care delivery.^48,49 Such efforts could be especially helpful in reducing racial disparities given that a disproportionate percentage of African American children are enrolled in Medicaid.

Under Medicaid’s EPSDT program, states must provide dental screening, diagnostic, preventive, and treatment services for all enrolled children, even if those services are not normally covered under the state’s Medicaid program. However, these federal regulations are inconsistently enforced. Indeed, advocates in several states have resorted to class action litigation to enforce EPSDT regulations, but these efforts are piecemeal, often dragging on for years in the courts without definitive resolution.*

Despite these shortcomings, the EPSDT program has had some modest impact. The Centers for Medicare and Medicaid Services reports that between 2000 and 2009, children’s access to dental care in Medicaid/CHIP improved, although improvements varied across states.⁵⁰ The significant increase in numbers of children enrolled in Medicaid/CHIP and associated enhancements in dental provider capacity could have facilitated improved access to dental care overall. The Centers for Medicare and Medicaid Services recently developed oral health goals to improve preventive dental service usage for children in Medicaid/CHIP programs. In addition to these efforts, a stronger federal hand requiring that states adhere to EPSDT regulations could have pronounced benefits in improving health care delivery and ultimately, health care outcomes. The federal and state governments could also work together to establish guidelines and policies to ensure children identified with untreated oral health problems during dental screenings are linked to dental providers able to offer timely comprehensive treatment.

This study has several limitations. The NHIS relies on parental self-reported dental visits and does not verify actual receipt of dental care. Although studies demonstrated the validity of self-reported dental visits,^51,52 our findings could be subject to reporting inaccuracy. We could not differentiate dental visit types because the NHIS does not distinguish among emergency, restorative, and preventive dental visits. Although the wording of the NHIS dental visit questions changed slightly over time, we have no reason to expect that these changes would affect responses for white and African American children differentially. Although the NHIS design minimizes nonresponse bias, differential measurement error by race remains a possibility. Changes in how race was measured (observer-coded versus self-reported) and categorized in the NHIS over time could also have affected our results. Another important limitation is the change in the conceptualization of race in US health research over the years.^53,54 Race is now more widely considered a social construct based on phenotype rather than a biological construct.^55–57

Results from our multivariable models could also be biased. Kaufman et al⁵⁸ caution about multivariable analyses that make racial/ethnic comparisons because potential confounders are associated with both the outcome variables and the group indicators. Further, multivariable models that adjust for individual- and family-level socioeconomic status (SES) measures do not fully account for various unmeasured characteristics differing between racial groups.⁴⁹ Because of factors such as measurement error, SES categorization, variable aggregation, and nonequivalent SES measures across race, residual confounding is a concern.⁵⁸ Finally, we do not demonstrate a causal relationship between public health insurance expansions and reductions in racial disparities over the study period. Other contemporaneous events that we were unable to measure could have played contributory roles. Therefore, our findings should be interpreted with caution. Nonetheless, the results provide a template for continued disparity monitoring, as well as a baseline for assessing the impact of future changes in public programs and private health insurance. Findings can also inform the development of policies designed to improve access to care and eliminate disparities among other racial/ethnic groups, including Hispanic children.