FUTURE OFDENTISTRY
largest percent were unhappy with the plan's fees
(71.7%). The next most frequently mentioned rea-
son for dissatisfaction was limitations placed on
dentists by the plan (34.7%).
More than half of dentists who participated in cap-
itation dental plans (54.0%) expressed some level of
dissatisfaction with their largest capitation plan.
Dissatisfied capitation plan dentists were most likely
(54.0%) to list reimbursement levels as the most com-
mon reason. One-fourth of the re-sponding dentists
were dissatisfied with limitations placed on the den-
tists by the plan. Other most frequently cited source
of dentist dissatisfaction included co-payment issues,
paperwork, and patient compliance problems.
DEFINED CONTRIBUTION DENTAL
PREPAYMENT PLANS
In addition to employer-based prepayment prod-
ucts, defined contribution plans are emerging.
Under a defined contribution plan, the employer
provides an agreed amount to a discretionary health
services fund for each employee. The employee can
use the fund to purchase the insurance coverage of
his/her choice.
Defined contribution plans are a potentially im-
portant alternative to defined benefit plans. The
enrollee has discretion to expend these funds as
needed but there is no group risk sharing. While
this approach currently represents a small portion of
the prepayment market, several varieties of these
plans have begun to develop. Two of these plan
types will be discussed here (direct reimbursement
and Medical Savings Accounts).
SELF-FUNDED PAYMENT ARRANGEMENTS
Direct Reimbursement
Direct reimbursement is a self-funded program in
which the individual is reimbursed based on a per-
centage of dollars spent for dental care provided,
and which allows beneficiaries to seek treatment
from the dentist of their choice (ADA, 1999).
Hybrid plans are developing with this concept.
Growth varies according to region.
Medical Savings Accounts
Medical Savings Accounts (MSA) are available on
a limited basis. MSAs are tax-exempt accounts,
similar to Individual Retirement Accounts (IRA)
(Goodman and Musgrave, 1994). Contributions
are not taxed, and the account balance grows tax-
free over time. The funds accumulated in MSAs can
be used to pay for routine eligible medical expenses.
Money not spent in the account can be rolled over
to the next year or transferred to an IRA. MSAs are
usually considered supplemental to other basic cov-
erage. At a minimum, an individual would want
also to have a catastrophic health insurance policy
as a safety net to protect against very high costs.PUBLICLY FUNDED PAYMENT ARRANGEMENTS:
THE DENTAL SAFETY NETMedicaid
The poor and near-poor often cannot pay for den-
tal care from their own resources. To date, public
programs such as Medicaid have not provided ade-
quate financial access to care. Thirty-two state
Medicaid programs do not cover adult dental care,
except for emergency services. Most Medicaid pro-
grams do provide coverage for indigent children and
parents, mainly single mothers, enrolled in the Aid
to Families with Dependent Children (AFDC) pro-
gram (Bailit, 1999).
In addition, states are required by Federal law to
provide basic dental care to all Medicaid eligible
children under the Early and Periodic, Screening,
Diagnosis and Treatment (EPSDT) program. About
20 million children are covered by EPSDT.
Nevertheless, only 20-30% of Medicaid eligible
children see a dentist annually and an unknown, but
much smaller, percentage receives comprehensive
preventive and curative care.State Children's Health Insurance Program (SCHIP)
The 1997 Federal legislation establishing State
Children's Health Insurance Program (SCHIP)
promises to extend dental benefits to about
10,000,000 children not currently covered
by Medicaid. The bill provides no direct legis-
lative mandate for dental services, but Federal
matching funds are available for states that
cover dental benefits. To date, most states have
enacted SCHIP through Medicaid expansions.
Nine states have established dental programs
separate from Medicaid, and three (Colorado,
Delaware, Montana) have excluded dental
services altogether in their initial filings.
Pennsylvania offers dental care in only part of the
state. Since most states have enrolled SCHIP-
eligible children through an extension of theirFinancing of and Access to Dental Services