FUTURE OFDENTISTRY
communities may have a more difficult challenge in
securing needed dental care. There is no reason to
expect that within the next 5 to 10 years large
numbers of dentists will establish practices in rural
or economically depressed areas. Government
programs to encourage dentists to locate in under-
served areas are valuable in specific locations when
they succeed, but so far, the number of dentists
placed on a long-term basis is relatively small.
This is unlikely to improve in the next decade and
may even become worse.
Physical and mental disability, whether associat-
ed with advanced age, illness, congenital condition,
or injury, is a significant barrier to access. In addi-
tion to low-income and other health problems that
are associated with disabilities, the fact is that most
dental practices are organized with fully ambulato-
ry patients as the primary, if not exclusive, focus.
Disability and special needs will continue to be a
significant barrier to access.Financing of and Access to Dental ServicesThe dental profession's vision for access to dental
care is that all Americans will be able to receive the
dental care that they both need and want. That is, all
Americans, regardless of their financial, geographic,
physical or other special circumstances, will have the
ability to receive the highest quality dental care.
For most Americans the current dental services
delivery system works very well. More than three
out of four people from non-poor families report at
least one dental visit in the previous year. For these
people access is excellent and will continue to be in
the future. Even among the disadvantaged, access
to care and oral health has improved significantly in
the last 30 years. Nevertheless, many financially
disadvantaged people and people who live in geo-
graphically isolated areas continue to have inade-
quate access to care. The following strategies focus
on achieving dentistry's vision for access.
IMPROVING FINANCIAL ACCESS
Low-income individuals and families are a diverse
group. While many low-income people are unem-
ployed, others are employed but make relatively lit-
tle money. In 1996, 38 million people were low-
income, defined as income below the poverty line,
and long-term unemployed, representing 14%
of the United States population. Low-income
employed people are often referred to as "the work-
ing poor." The income of the working poor is gen-
erally defined to be 100 to 200% of the federal
poverty level. In 1996, 53 million people, 20% of
the population, were "working poor."
For the long-term unemployed, expansion of pub-
lic financing that compensates dental care providers
at or above market rates is indicated. It is essential
that professional fees for services provided to the
disadvantaged not be allowed to fall below prevail-
ing market rates. Therefore, in the long term, fees
should be indexed accordingly.
These changes should be phased in over a 5-to-
10-year period to allow the dental care system to
accommodate to the resultant increased demand. In
addition, priority should be given to covering chil-
dren first. Private carriers, who would be responsi-
ble for managing programs for the disadvantaged,
should use the same procedures and systems as
employer-based dental prepayment plans. There is
strong indication that this will increase utilization
by the poor and participation by the dentist.
Some segments of the population may need addi-
tional support to obtain dental care. Examples of
the kinds of support include education, transporta-
tion, and convenient access to care for institutional-
ized or semi-institutionalized populations.
The working poor are generally employed in eco-
nomic sectors in which private dental prepayment is
not prevalent. The issue with this group is lack of
affordable private prepayment. Therefore, a two-
pronged strategy to encourage financing of private
prepayment might be necessary.
Under this strategy, the government would pro-
vide individuals with a stipend to subsidize the pur-
chase of either a traditional prepayment plan or a
dental savings account. The federal or state govern-
ments would facilitate the necessary approaches to
risk-spreading by creating risk pools. The adminis-
tration of the program would be contracted to the pri-
vate sector. This will empower the disadvantaged to
make choices regarding dental care in a manner simi-
lar to the rest of the population. By bypassing the
employer and going directly to the individual, the dif-