Association between Medicaid expansion, dental coverage policies for adults, and children's receipt of preventive dental services

Racial Disparities in Access to Preventive Dental Services in Pediatric Population: A Secondary Data Analysis

BACKGROUND AND OBJECTIVES

Though preventive measures are available to alleviate the burden of dental caries, there remain racial disparities in the utilization of preventative dental care. Our objectives were to determine whether racial disparities persisted in receiving preventive oral procedures between (1) Black children and white children; and (2) Hispanic children and white children.

METHODS

We used pooled Medical Expenditure Panel Survey data in the United States from 2018 to 2021. The key outcome variable involved the use of preventive dental services (ie, examination, x-rays, cleaning, dental sealant fitting, and fluoride treatment), while the main predictor variable involved race (ie, whether they were white, Black, or Hispanic children).

RESULTS

Controlling for covariates, there was no statistical significance in the odds of Hispanic and white children in receiving x-rays, sealants, and fluoride treatment ( P < .001). Black children had significantly lower odds of receiving oral examination, x-rays, and fluoride treatment than their white counterparts ( P < .01).

CONCLUSIONS

This study highlights the massive strides made in the utilization of preventive dental services by Hispanic children in the United States along with the persisting disparities largely present for Black children; however, further studies are needed focusing on structural, sociocultural, and factors contributing to these disparities.

Dental Care Use Among Children and Adolescents in Medicaid: Associations With State-Level Medicaid Policy Factors and Provider Availability

OBJECTIVES

The aim of this study was to assess the relative strength of association of four state-level factors-Medicaid reimbursement, Medicaid adult dental benefit (MADB) generosity, dentist Medicaid participation, and dentist supply-on individual-level dental care use among children and adolescents in Medicaid.

METHODS

This national cross-sectional study used 2018-2019 National Survey of Children's Health data to estimate dental care utilization among children aged 1-17 enrolled in Medicaid. Subgroup analyses were conducted by child age group. A hierarchical regression approach was used; a series of logistic regression models assessed relative effect sizes among the four state-level variables.

RESULTS

Among children aged 1-17, and the age 1-3 subgroup, dentist Medicaid participation was positively associated with dental care use. Among children aged 4-11, children in states with Emergency/No dental coverage for adults had greater odds of having a dental visit compared to children in states with Extensive dental coverage. Among adolescents aged 12-17, no state-level factors were associated with dental utilization.

CONCLUSIONS

There was considerable variation by age group in the associations of state-level factors on dental care use among children and adolescents in Medicaid. Dentist participation in Medicaid was associated with dental care use among very young children. State-level policy levers have the potential to improve access to dental care for children enrolled in Medicaid, and are critical to achieve improvement toward oral health equity for children.

A Scoping Review to Identify Community- and Societal-Level Strategies Evaluated from 2013 to 2023 for Their Potential Impact on Child Well-Being in the United States

There is increased recognition for solutions that address the social determinants of health (SDOHs)-the context in which families are raising children. Unfortunately, implementing solutions that address inequities in the SDOHs has proven to be difficult. Many child and family serving systems and communities do not know where to start or do not have the capacity to identify and implement upstream SDOH strategies. As such, we conducted a scoping review to assess the status of evidence connecting strategies that address the SDOHs and child well-being. A total of 29,079 records were identified using natural language processing with 341 records meeting inclusion criteria (e.g., outcomes focused on child well-being, interventions happening at a population level, and evaluations of prevention strategies in the United States). Records were coded, and the findings are presented by the SDOH domain, such as strategies that addressed economic stability (n = 94), education access and quality (n = 17), food security (n = 106), healthcare access and quality (n = 96), neighborhood and built environment (n = 7), and social and community context (n = 12). This review provides an overview of the associations between population-level SDOH strategies and the impact-good and bad-on child well-being and may be a useful resource for communities and practitioners when considering equitable solutions that promote thriving childhoods.

Spillover Effects of Prenatal Care Coordination on Older Siblings Beyond the Mother-Infant Dyad

BACKGROUND

Pregnancy care coordination increases preventive care receipt for mothers and infants. Whether such services affect other family members' health care is unknown.

OBJECTIVE

To estimate the spillover effect of maternal exposure to Wisconsin Medicaid's Prenatal Care Coordination (PNCC) program during pregnancy with a younger sibling on the preventive care receipt for an older child.

RESEARCH DESIGN

Gain-score regressions-a sibling fixed effects strategy-estimated spillover effects while controlling for unobserved family-level confounders.

SUBJECTS

Data came from a longitudinal cohort of linked Wisconsin birth records and Medicaid claims. We sampled 21,332 sibling pairs (one older; one younger) who were born during 2008-2015, who were <4 years apart in age, and whose births were Medicaid-covered. In all, 4773 (22.4%) mothers received PNCC during pregnancy with the younger sibling.

MEASURES

The exposure was maternal PNCC receipt during pregnancy with the younger sibling (none; any). The outcome was the older sibling's number of preventive care visits or preventive care services in the younger sibling's first year of life.

RESULTS

Overall, maternal exposure to PNCC during pregnancy with the younger sibling did not affect older siblings' preventive care. However, among siblings who were 3 to <4 years apart in age, there was a positive spillover on the older sibling's receipt of care by 0.26 visits (95% CI: 0.11, 0.40 visits) and by 0.34 services (95% CI: 0.12, 0.55 services).

CONCLUSION

PNCC may only have spillover effects on siblings' preventive care in selected subpopulations but not in the broader population of Wisconsin families.

Health Care Access and Use Among Children & Adolescents Exposed to Parental Incarceration-United States, 2019

OBJECTIVE

The United States has the highest incarceration rate in the world, with spillover impacts on 5 million children with an incarcerated parent. Children exposed to parental incarceration (PI) have suboptimal health care access, use, and outcomes in adulthood compared to their peers. However, little is known about their access and utilization during childhood. We evaluated relationships between PI and health care use and access throughout childhood and adolescence.

METHODS

We analyzed the nationally representative 2019 National Health Interview Survey Child Sample to examine cross-sectional associations between exposure to incarceration of a residential caregiver, access to care, and health care use among children aged 2-17. Respondents were asked about measures of preventive care access, unmet needs due to cost, and acute care use over the last year. We estimated changes associated with PI exposure using multiple logistic regression models adjusted for age, sex, race, ethnicity, parental education, family structure, rurality, income, insurance status, and disability.

RESULTS

Of 7405 sample individuals, 467 (weighted 6.2% [95% CI 5.5-6.9]) were exposed to PI. In adjusted analyses to produce national estimates, exposure to PI was associated with an additional 2.2 million children lacking a usual source of care, 2 million with forgone dental care needs, 1.2 million with delayed mental health care needs, and 865,000 with forgone mental health care needs.

CONCLUSIONS

Exposure to PI was associated with worse access to a usual source of care and unmet dental and mental health care needs. Our findings highlight the need for early intervention by demonstrating that these barriers emerge during childhood and adolescence.

The impact of dental care programs on healthcare system and societal outcomes: a scoping review

BACKGROUND

Dental diseases have detrimental effects on healthcare systems and societies at large. Providing access to dental care can arguably improve health outcomes, reduce healthcare utilization costs, and improve several societal outcomes.

OBJECTIVES

Our objective was to review the literature to assess the impacts of dental care programs on healthcare and societal outcomes. Specifically, to identify the nature of such programs, including the type of services delivered, who was targeted, where services were delivered, and how access to dental care was enabled. Also, what kind of societal and healthcare outcomes have been attempted to be addressed through these programs were identified.

METHODS

We conducted a scoping review by searching four databases, MEDLINE, EMBASE, CINAHL, and Sociological Abstracts. Relevant articles published in English language from January 2000 to February 2022 were screened by four reviewers to determine eligibility for inclusion.

RESULTS

The search resulted in 29,468 original articles, of which 25 were included in the data synthesis. We found minimal evidence that answers our proposed research question. The majority of identified programs have demonstrated effectiveness in reducing medical and dental healthcare utilization (especially for non-preventive services) and avert more invasive treatments, and to a lesser degree, resulting in cost-savings. Moreover, some promising but limited evidence about program impacts on societal outcomes such as reducing homelessness and improving employability was reported.

CONCLUSION

Despite the well-known societal and economic consequences of dental problem, there is a paucity of studies that address the impacts of dental care programs from the societal and healthcare system perspectives.

MESH TERMS

Delivery of Health Care, Dental Care, Outcome assessment, Patient acceptance of Health Care.

Effects of the Children's Health Insurance Reauthorization Act on immigrant children's healthcare access

OBJECTIVE

To estimate the effects of Children's Health Insurance Reauthorization Act (CHIPRA), a policy that provided states the option to extend Medicaid/CHIP eligibility to immigrant children who have not been legal residents for five years or more, on insurance coverage, access, utilization, and health outcomes among immigrant children.

DATA SOURCES

Restricted use 2000-2016 National Health Interview Survey (NHIS).

STUDY DESIGN

We used a difference-in-differences design that compared changes in CHIPRA expansion states to changes in non-expansion states.

DATA COLLECTION

Our sample included immigrant children who were born outside the US, aged 0-18 with family income below 300% of the Federal Poverty Level (FPL). Subgroup analyses were conducted across states that did and did not have a similar state-funded option prior to CHIPRA (state-funded vs. not state-funded), by the length of time in the US (5 years vs. 5-14 years), and global region of birth (Latin American vs. Asian countries).

PRINCIPLE FINDINGS

We found that CHIPRA was associated with a significant 6.35 percentage point decrease in uninsured rates (95% CI: -11.25, -1.45) and an 8.1 percentage point increase in public insurance enrollment for immigrant children (95% CI: 1.26, 14.98). However, the effects of CHIPRA became small and statistically not significant 3 years after adoption. Effects on public insurance coverage were significant in states without state-funded programs prior to CHIPRA (15.50 percentage points; 95% CI:8.05, 22.95) and for children born in Asian countries (12.80 percentage points; 95% CI: 1.04, 24.56). We found no significant changes in health care access and utilization, and health outcomes, overall and across subgroups due to CHIPRA.

CONCLUSIONS

CHIPRA's eligibility expansion was associated with increases in public insurance coverage for low-income children, especially in states where CHIPRA represented a new source of coverage versus a substitute for state-funded coverage. However, we found evidence of crowd-out in certain subgroups and no effect of CHIPRA on access to care and health. Our results suggest that public coverage may be an important tool for promoting the well-being of immigrant children but other investments are still needed.

Effects of Adult Medicaid Dental Benefits Elimination on Child Dental Care Use

OBJECTIVE

The objective of this study was to examine the effect of adult dental benefit cuts on child dental use in Washington state Medicaid and determine if cuts affect child demographic subgroups differentially.

RESEARCH DESIGN

The study used an interrupted time-series methodology to measure differences in child dental use after adult dental benefit elimination and reinstatement. Monthly data came from Washington state Medicaid enrollee and dental claim files from January 2008 to December 2015.

SUBJECTS

Medicaid-enrolled children with at least one Medicaid-enrolled adult in the same household were the intervention group, and Medicaid-enrolled children without a Medicaid-enrolled adult in the same household were the control group.

MEASURES

The outcome was the monthly proportion of Medicaid-enrolled children with a dental examination per 10,000 Medicaid-enrolled children.

RESULTS

After adult dental benefits elimination, dental examinations among children with Medicaid-enrolled adults in the same household gradually decreased, corresponding to 65 fewer dental examinations per 10,000 children per year (5.4 fewer dental examinations per 10,000 children per month; 95% confidence interval: -7.7, -3.1; P =0.006). Adult dental benefits had no effect on dental examination for children without a Medicaid-enrolled adult in the same household. Dental examinations for children with a Medicaid-enrolled adult in the same household continued to gradually decrease after adult benefits reinstatement. Children younger than age 6 were the most adversely impacted by changes to adult Medicaid dental benefits.

CONCLUSION

Policymakers should consider the spillover effects and ethical considerations of eliminating adult Medicaid dental benefits on children's access to dental care.

The Association Between Medicaid Adult Dental Coverage And Children's Oral Health

Although all state Medicaid programs cover children's dental care, Medicaid-eligible children are more likely to experience tooth decay than children in higher-income families. Using data from the 1999-2016 National Health and Nutrition Examination Survey and the 2003, 2007, and 2011-12 waves of the National Survey of Children's Health, we examined the association between Medicaid adult dental coverage (an optional benefit) and children's oral health. Adult dental coverage was associated with a statistically significant 5-percentage-point reduction in the prevalence of untreated caries among children after Medicaid-enrolled adults had access to coverage for at least one year. These policies were also associated with a reduction in parent-reported fair or poor child oral health with a two-year lag between the onset of the policy and the effect. Effects were concentrated among children younger than age twelve. We estimated declines in poor oral health among all racial and ethnic subgroups, although there was some evidence that non-Hispanic Black children experienced larger and more persistent effects than non-Hispanic White children. Future assessments of the costs and benefits of offering adult dental coverage may consider potential effects on the children of adult Medicaid enrollees.

The Impact of the Affordable Care Act on Dental Care: An Integrative Literature Review

The goal of the Patient Protection and Affordable Care Act (ACA) is to increase access to health insurance and decrease health care cost while improving health care quality. With more articles examining the relationship between one of the ACA provisions and dental health outcomes, we systematically reviewed the effect of the ACA on dental care coverage and access to dental services. We searched literature using the National Library of Medicine's Medline (PubMed) and Thomson Reuters' Web of Science between January 2010 and November 2020. We identified 33 articles related to dental coverage, and access/utilization of dental care services. This systematic review of studies showed that the ACA resulted in gains in dental coverage for adults and children, whereas results were mixed with dental care access. Overall, we found that the policy led to a decrease in cost barriers, an increase in private dental coverage for young adults, and increased dental care use among low-income childless adults. The implementation of the ACA was not directly associated with dental insurance coverage among people in the U.S. However, results suggest positive spillover effects of the ACA on dental care coverage and utilization by people in the national level dataset.

Association between Medicaid expansion, dental coverage policies for adults, and children's receipt of preventive dental services

OBJECTIVE

To examine whether low-income children's use of preventive dental services is linked to variation in state Medicaid policies that affect parents' access to dental care in Medicaid.

DATA SOURCES

Medical Expenditure Panel Survey (2011-2016), Area Health Resources File, and Medicaid adult dental coverage policies.

STUDY DESIGN

We conducted a quasi-experimental analysis using linked parent-child dyads in low-income families (≤125 percent of the Federal Poverty Level). We assessed whether expansions of Medicaid to low-income adults under the Affordable Care Act were associated with increases in the use of preventive dental services among low-income children when state Medicaid programs did vs did not cover these services for adults.

PRINCIPAL FINDINGS

Over the study period, 37.8 percent of low-income children received at least one annual preventive dental visit. We found no change in children's receipt of preventive dental care associated with Medicaid expansions in states that covered (1.26 percentage points; 95% CI: -3.74 to 6.27) vs did not cover preventive dental services for adults (3.03 percentage points; 95% CI: -2.76 to 8.81). (differential change: -1.76 percentage points; 95% CI: -8.09, 4.56). However, our estimates are imprecise, with wide confidential intervals that are unable to rule out sizable effects in either direction.

CONCLUSION

We did not find an association between Medicaid expansions with concurrent coverage of preventive dental services for adults and children's use of these services. Factors other than parental access to dental benefits through Medicaid may be more salient determinants of preventive dental care use among low-income children.