FUTURE OFDENTISTRYIn the 1989 NHIS (Bloom et al, 1992), by far the
most common reason given for not having a dental
visit in the prior year was "no dental problem,"
regardless of age, sex, race and ethnicity, place of
residence, income, prepayment, or activity limita-
tions. Overall, "no dental problem was cited by
46.8% of individuals as the reason that they did not
have a visit in the prior year. This was the most com-
mon reason cited by virtually every subgroup, except
for the oldest adults, where "no teeth" was the major
factor. After "no problem" and "no teeth," the next
most common reason given was "cost," which over-
all was cited by 13.7% of people as the reason for no
dental visit in the prior year. Cost as a reason reached
its highest levels in people with low incomes, no pre-
payment, and activity limitations.
While "no dental problem" "no teeth," and "cost"
account for the vast majority of the reasons for not vis-
iting a dentist, the category of "access problem" was
rarely cited. This category includes the statements
"don't know [a] dentist," "dentist too far," and "can't
get there." Overall only 1.7% of non-users cited access
as the primary reason for not having a dental visit.
Some subpopulations face unique barriers be-
cause they have special problems (e.g., persons with
disabilities and complex medical conditions). Their
conditions make it additionally difficult to access
services. Although the economically disadvantaged
may face similar barriers to care as the general pop-
ulation, these barriers force much starker tradeoffs
and are much harder for disadvantaged persons to
overcome without help.
Barriers for the Disadvantaged
COST BARRIERS
For economically disadvantaged people, the cost of care
is a significant barrier. They do not have the financial re-
sources to meet the needs of everyday living and still
afford dental care as easily as the rest of the United States
population. Long-term solutions to improving their access
to care are the same that will improve their economic sta-
tus––such as better education, better job skills, safer neigh-
borhoods, and more stable personal lives. But for imme-
diate impact, increased direct financial aid is needed. This
aid, which has been inadequate, has been usually provid-
ed through philanthropic endeavors or public-funded pro-
grams. More is needed in the way of public support for
dental care for disadvantaged adults. To date, Medicaid
and Head Start have provided limited care for disadvan-
taged children (Barnett and Brown, 2000).
MEDICAID PROGRAM LIMITATIONSThe Barnett and Brown study concluded that in-
adequate reimbursements and Medicaid administra-
tive burdens limit the effectiveness of the Medicaid
program (Barnett and Brown, 2000). Observers
identify the cause of inadequate reimbursement as
lack of political will.
Medicaid serves only a small fraction of the chil-
dren that it is supposed to provide with dental care.
Unfortunately, there is considerable uncertainty
regarding the percentage of children eligible for
Medicaid who actually receive dental care and more
accurate data are needed.
At present, most analyses rely on data concerning
services paid for by Medicaid. These data do not
account for other services children receive outside of
Medicaid - such as free care donated by the dentist. The
amount of dental care that dentists provide free of
charge could be of approximately the same magnitude
as Medicaid services. Thus, the extent to which the
Medicaid population is underserved is unclear, though
it is obvious that Medicaid itself does not provide the
level of services that it is intended to provide. Head
Start, however, has increased the rate of dental care
usage for its children substantially above the rate for
higher income pre-school children. Barnett and Brown
also identify a number of other barriers as important,
though clearly of secondary importance compared to
inadequate reimbursement.LIMITED PROVIDER MEDICAID PARTICIPATIONSurvey data indicate that the lack of dentists who are
willing to accept new Medicaid patients is a significant
problem. Dentists do not participate in Medicaid, pri-
marily, because of low program reimbursement rates.
In addition, the administrative burden and the high
"no-show" rate of Medicaid clients discourage den-
tists' participation. For the vast majority of dentists,
the opportunity cost of serving a Medicaid client is far
higher than the Medicaid reimbursement rate (Barnett
and Brown, 2000).MICHIGAN'S HEALTHY KIDS DENTAL PROGRAM -
A PROMISING EXAMPLE OF MEDICAID REFORMThe data suggest that for low-income persons, the
major barriers to care appear to be perception of
need and cost. There is promising early evidence
that removal of the cost barrier can be a majorFinancing of and Access to Dental Services