Answer the following questions after reading the attached article:
Oral Health
By Brandy J. Lipton, Tracy L. Finlayson, Sandra L. Decker, Richard J. Manski, and Mingan Yang
doi: 10.1377/hlthaff.2021.01135
The Association Between Medicaid
Adult Dental Coverage And
Children’s Oral Health
HEALTH AFFAIRS 40,
NO. 11 (2021): 1731–1739
©2021 Project HOPE—
The People-to-People Health
Foundation, Inc.
Brandy J. Lipton (blipton@
sdsu.edu) is an assistant
professor in the School of
Public Health, San Diego
State University, in San Diego,
California.
ABSTRACT 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 nonHispanic 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.
D
espite considerable progress,
tooth decay remains the most
common childhood chronic disease.1 Medicaid-eligible children
are more likely to experience
tooth decay compared with children in higherincome families but are less likely to visit the
dentist annually (29 percent versus 55 percent).2
All state Medicaid programs cover a comprehensive set of preventive and restorative dental services for children under the Early and Periodic
Screening, Diagnostic, and Treatment benefit.
Although financial barriers are frequently reported as the reason for not receiving needed
dental care among both adults and children,3
noncost barriers may also play an important role
in explaining income-based disparities in children’s dental care use.
Tracy L. Finlayson is a
professor in the School of
Public Health, San Diego
State University.
Sandra L. Decker is a health
economist in the Division of
Research and Modeling,
Center for Financing, Access,
and Cost Trends, Agency for
Healthcare Research and
Quality, in Rockville, Maryland.
Richard J. Manski is a
professor in and chair of the
Department of Dental Public
Health at the University of
Maryland School of Dentistry,
in Baltimore, Maryland.
Mingan Yang is an associate
professor in the School of
Public Health, San Diego
State University.
Children are more likely to have regular dental
visits when their parents have dental coverage or
a recent dental visit.4–6 Parental dental coverage
may facilitate children’s dental care use in several ways. For example, providers may relay information about recommended dental care or dental benefits available to publicly insured children
when a parent has a dental visit. As many general
dentists treat both adults and children,7 families
may cluster their appointments when both parents and children have dental coverage, reducing
transportation barriers and requiring less time
off work. Parent dental coverage may also reduce
out-of-pocket health care spending,8 which
could increase available resources for children’s
health care needs.
In contrast to the requirements for children,
states are not required to provide any level of
N ov e m b e r 202 1
Downloaded from HealthAffairs.org on January 10, 2022.
Copyright Project HOPE—The People-to-People Health Foundation, Inc.
For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.
40: 1 1
H e a lt h A f fai r s
1731
Oral Health
Medicaid adult dental benefits. Most states provide emergency services (for example, tooth extractions for relief of pain and infection), but
coverage of preventive and restorative services
varies for adults across states, with many states
expanding and contracting benefits in recent
years.9 Studies that used state-level policy
changes to examine the effects of providing adult
dental coverage suggest increased dental visits
among adults5,8,9 and children.5 Most estimates
of the impact of Medicaid adult dental coverage
on adult dental visits are in the range of 9–14 percentage points.5,8,9 One recent study indicates
that among parents who visit the dentist in response to a state’s decision to offer adult dental
benefits, 20–37 percent also take their children
to the dentist as a result of gaining coverage.5
This study examined the association between
Medicaid adult dental coverage and exam-based
and parent-reported measures of oral health
among children in low-income families, using
state-by-year changes to these policies between
1999 and 2016. Although past research has found
that Medicaid adult dental coverage increases
children’s use of dental care, it is unknown
whether these policies improve children’s oral
health. More generally, there is little research at
the national level that examines the link between
health care policies and objective, exam-based
oral health measures among children. Our analysis adds to this limited evidence base.
Study Data And Methods
Data Sources And Outcomes This study used
data from the 1999–2016 National Health and
Nutrition Examination Survey (NHANES), conducted by the Centers for Disease Control and
Prevention, and the 2003, 2007, and 2011–12
waves of the National Survey of Children’s
Health (NSCH), directed by the Health Resources and Services Administration, Department of
Health and Human Services. NHANES is a nationally representative repeated cross-sectional
survey that combines interviews with standardized physical examinations in mobile examination centers. The NHANES oral health assessment is the only national source of exam-based
data on dental conditions. Responses to interview questions about a child’s characteristics are
provided by an adult household member for children under age 16, and self-reported by children
ages 16 and older.
NHANES identifies teeth with carious lesions
(that is, coronal caries), using either a surfacebased exam or basic screening exam, depending
on the survey year. The surface-based exam
counts all tooth surfaces with a carious lesion,
whereas the basic screening exam examines each
173 2
Health A ffairs
N ov e m b e r 202 1
tooth until at least one tooth with a carious lesion
is found, at which point the exam ends. In 1999–
2004 and 2011–16 NHANES used protocols
based on the surface-based exam, and in 2005–
10 NHANES used protocols based on the basic
screening exam. In addition, the examiner type
differed between these two periods (licensed
dentists in 1999–2004 and 2011–16 and trained
health technologists in 2005–10). Finally, the
minimum age of children included in the assessment varied from one to five years, depending on
the survey year. These changes are summarized
in online appendix exhibit S1.10 Reliability analyses suggest high interexaminer agreement for
each of these different protocols.11,12
We constructed binary measures of any caries,
any untreated caries, and any tooth restorations,
using the oral health assessment data. Considering the presence of at least one cavity or tooth
restoration allowed us to use data from all survey
years, including those that used the basic screening exam. The any caries category included both
untreated tooth decay and tooth restorations.
The untreated caries and tooth restorations categories were mutually exclusive (that is, if a person had untreated caries and tooth restorations,
they would be classified as having untreated
caries). For comparison with existing work, we
also examined children’s dental visits, which
were available in survey years 1999–2004 and
2011–16.
The NSCH is a nationally representative survey
that includes detailed information on children’s
health care access and health status. Responses
to questions about a child’s characteristics and
outcomes are provided by the adult household
member with the most knowledge of the child’s
health and health care, hereafter referred to as
“parent reported.” The survey was conducted by
telephone in 2003, 2007, and 2011–12 and by
mail and web beginning in 2016. Because of
sampling and methodological changes, the earlier and later years of the NSCH are not comparable. We used data from the three earlier waves
that spanned nine years and covered a substantial number of state-level changes in Medicaid
adult dental coverage policies.
We constructed two binary variables based on
parent-reported children’s oral health status (excellent, very good, good, fair, or poor). The first
indicator was equal to 1 for responses of fair or
poor and 0 otherwise, and the second was equal
to 1 for responses of excellent or very good and
0 otherwise.
Approach And Statistical Analysis This
study used a difference-in-differences design
that took advantage of within-state changes in
adult dental coverage over time. The Kaiser
Family Foundation was the primary source for
40: 1 1
Downloaded from HealthAffairs.org on January 10, 2022.
Copyright Project HOPE—The People-to-People Health Foundation, Inc.
For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.
dental coverage policies, as described in previous research.5,9 Following prior studies,5,8,9 we
defined a binary indicator equal to 1 in states
that provided coverage of at least one preventive
or restorative service beyond emergency care
for adults and 0 otherwise. Nearly all states that
were classified as providing dental coverage
covered regular cleanings and dental exams.
According to our definition, nineteen states
added, dropped, or both added and dropped
adult dental coverage during 1999–2016
(Alaska, Arkansas, California, Colorado, Florida,
Hawaii, Idaho, Illinois, Kansas, Massachusetts,
Michigan, Missouri, Oklahoma, South Carolina,
South Dakota, Utah,Washington,Wyoming, and
Washington, D.C.) (exhibit 1).
Because we anticipated that gaining adult dental coverage would first affect a parent’s use of
dental care before changing children’s dental
care use and oral health outcomes, we considered a policy indicator equal to 1 in the first and
subsequent years after the addition of adult dental coverage (that is, “concurrent coverage”), as
well as lagged effects of dental coverage policies.
Existing evidence provides support for considering lagged effects of coverage because adult den-
tal coverage has been found to have larger effects
on children’s dental visits after the policy has
been in place for more than a year.5 We present
results for both the one- and two-year lagged
effects of adult dental coverage (that is, policy
indicators equal to 1 after adult dental coverage
was provided for at least one and at least two full
years, respectively, and 0 otherwise). Appendix
exhibit S2 provides more detail on the state-level
policy changes included in each analysis.10
We estimated multivariable regression models
that controlled for the adult dental coverage indicator, child and family characteristics, timevarying state-level variables, and state and year
fixed effects. Child- and household-level controls
included male sex, child age in years, race and
ethnicity (Hispanic, non-Hispanic Black, and
non-Hispanic other race versus non-Hispanic
White), citizenship (NHANES only), household
size, an indicator for highest adult educational
attainment being a high school diploma or equivalent or less education, an indicator for family
income under the federal poverty level, and an
indicator for being in the cell phone sample
(NSCH only). State indicators accounted for
fixed characteristics that could be correlated
Exhibit 1
Medicaid adult dental coverage policies, 1999–2016
SOURCE Authors’ analysis of Medicaid adult dental coverage policies from the Kaiser Family Foundation, state Medicaid websites, and
internet research.
N ov e m b e r 202 1
Downloaded from HealthAffairs.org on January 10, 2022.
Copyright Project HOPE—The People-to-People Health Foundation, Inc.
For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.
40: 1 1
Health Affairs
1733
Oral Health
with both dental coverage policies and outcomes, and year indicators accounted for secular
trends in the outcomes over time. Time-varying
state-level variables included the Medicaid income eligibility limit for working parents, the
state Earned Income Tax Credit as a percentage
of the federal benefit, the maximum Temporary
Assistance for Needy Families benefit for a family
of four, the unemployment rate, and number of
dentists per capita. Inclusion of these controls
accounted for changes in other policies, economic conditions, and dentist supply during our
study period. We estimated linear probability
models to enable interpretation of our estimates
as percentage-point effects. All models were
weighted, and errors were clustered at the state
level.
The analytic samples included children ages
1–17 in low-income families with complete outcome and demographic information. Income information was collected differently in the two
surveys, so we used slightly different thresholds
to define the sample in each data set. The
NHANES sample included 17,588 children ages
1–17 with family incomes up to 250 percent of
poverty who participated in the oral health assessment. The NSCH analysis sample included
78,721 children with family incomes up to
200 percent of poverty. Nearly all states had
adult income eligibility limits below 250 percent
of poverty during our entire study period. Appendix exhibit S3 summarizes sample characteristics for both data sets.10
We conducted subgroup analyses by child age
(ages 1–11 versus 12–17) and race and ethnicity.
Child age groups were selected based on existing
evidence that adult dental coverage policies have
larger effects on dental visits among children
younger than age twelve.5 To estimate subgroup
effects, we stratified our sample based on each
characteristic and estimated models identical to
those used in our analysis of all children on each
subsample.
We conducted additional analyses to assess the
robustness and validity of our results. First, we
estimated the association between adult dental
coverage and outcomes among children in
higher-income families that were less likely to
have a parent who meets Medicaid income-eligibility criteria. Second, our analytical strategy
required that outcome trends in states that
changed their dental coverage policies would
have mirrored those in other states absent any
policy changes (“parallel trends”). It was not
possible to assess this assumption in the NSCH
data, given that there were only three survey
waves, conducted several years apart. Further,
because of the sensitivity of the restricted
NHANES data, we were not permitted to conduct
173 4
Health A ffairs
November 2021
These results
contribute to the
limited evidence base
on the impacts of oral
health policy at the
family level.
a typical event history analysis that assessed
single-year state differences. Therefore, we used
a modified analysis that assessed the difference
in linear outcome trends over a number of years
in a selected set of states that changed their policies later in the study period, as described in
more depth in the description of appendix exhibit S6.10 Third, we examined the sensitivity of our
NHANES analysis to excluding survey years that
used the basic screening exam protocol (2005–
2010), as well as to restricting the sample to
children ages five and older to ensure consistency in the sample child age range across years.
Finally, we tested the sensitivity of our results
to using alternative income thresholds to define
the study samples and estimated logit models
instead of linear probability models for all
NHANES and NSCH outcomes.
Limitations Our analysis had important
strengths and weaknesses. Although both the
NHANES and NSCH data sets are nationally representative, NHANES does not include respondents from each state in every year, and the sample is smaller relative to that of the NSCH, which
is state representative. The NSCH, although having a larger sample size, was available for 2003,
2007, and 2011–12 only. However, NHANES is
the only nationally representative, exam-based
source of data on oral health conditions for the
US population, allowing us to address a gap in
the literature on the potential for health policy to
improve objective oral health measures. The parental report of children’s oral health information available in the NSCH data complemented
our analysis of exam-based caries measures in
the NHANES data.
In addition, our analysis focused on children
in lower-income families who were more likely to
be affected by Medicaid dental coverage policies
rather than children with a parent on Medicaid,
as parent insurance status was not available in
either of our data sources. However, an advantage of considering all children in lower-income
40:1 1
Downloaded from HealthAffairs.org on January 10, 2022.
Copyright Project HOPE—The People-to-People Health Foundation, Inc.
For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.
families is that estimates are not biased by any
potential effects of adult dental coverage availability on a parent’s enrollment decisions. Further, the protocol, examiner type, and minimum
age of children included in the NHANES oral
health assessment varied across survey years.
However, the 1999–2004 and 2011–16 survey
years used similar protocols and licensed dentists to conduct the exam, and results were
similar when we restricted the analysis to these
years.
Finally, similar to other observational studies,
we could not exclude the possibility that changes
to other state policy or population variables contributed to our findings. However, our analysis
did not suggest significant divergence in outcome trends in states that did and did not change
their policies before these changes occurred. Relatedly, emerging research suggests that difference-in-differences results may be biased when
there is substantial variation in the timing when
states change their policies.13 Although we were
limited in our ability to assess this possibility in
the present analysis, a previous study of adult
dental coverage policies suggested that this was
an unlikely source of bias for estimates of effects
on children’s dental visits.5
Study Results
Main Regression Results The main differencein-differences estimates for the NHANES and
NSCH outcomes are in exhibit 2. Although concurrent adult dental coverage policies were
not significantly associated with children’s outcomes, children’s oral health appeared to improve in the years after a state’s decision to provide adult dental coverage. We estimated that
providing adult dental coverage was associated
with declines of about 3.43 and 2.98 percentage
points in the prevalence of any caries when con-
sidering the one- and two-year lagged effects of
the policies, respectively. These estimates represent reductions of about 7 percent and 6 percent,
respectively, relative to the average rate of any
caries among the sample (52 percent). These
declines were driven by a significant decrease
of about 5 percentage points in any untreated
caries that was similar when considering the
one- and two-year lagged effects of adult dental
coverage. This estimate represents a more than
22 percent reduction relative to the average rate
of any untreated caries (22 percent). The lagged
associations between adult dental coverage and
the likelihood that a child had any tooth restorations were positive, at about 2 percentage points
each, but not statistically significant.
Similar to the NHANES exam-based measures,
changes in fair or poor oral health status in the
NSCH data appeared to occur with a lag after
changes to adult dental coverage. However, we
only observed a significant effect two or more
years after a change to adult dental coverage
policies. We estimated that providing adult dental coverage was associated with a significant
1.18-percentage-point decline in the likelihood
that the condition of a child’s teeth was reported
as fair or poor (8 percent reduction relative to the
average rate) and a nonsignificant increase of
0.65 percentage points in reports of excellent
or very good condition when considering the
two-year lagged effect of adult dental coverage
(exhibit 2).
Consistent with previous research,5 we estimated a positive association between adult dental coverage and children’s past-six-month dental visits (appendix exhibit S4).10 The estimate
for the concurrent policy indicator (3.91 percentage points) was in line with existing estimates,
although not statistically significant at conventional levels. We estimated significant increases
of about 7.41 and 6.57 percentage points when
Exhibit 2
Regression estimates of the association between Medicaid adult dental coverage and oral health among children in lowincome families, 1999–2016
Outcomes and policy variables
NHANES 1999–2016
Any caries (rate: 52%)
Any untreated caries (rate: 22%)
Any restored teeth (rate: 30%)
NSCH 2003, 2007, 2011–12
Excellent or very good condition of teeth (rate: 57%)
Fair or poor condition of teeth (rate: 14%)
Concurrent coverage
One-year lag
Two-year lag
0.0001
−0.0041
0.0042
−0.0343**
−0.0538***
0.0195
−0.0298*
−0.0477**
0.0178
−0.0162
0.0242
−0.0149
0.0189
0.0065
−0.0118**
SOURCE National Health and Nutrition Examination Survey (NHANES), 1999–2016, and National Survey of Children’s Health (NSCH),
2003, 2007, and 2011–12. NOTES Estimates are the coefficients on the Medicaid adult dental coverage indicator (concurrent, one-year
lag, and two-year lag, as labeled). See Study Data and Methods for a list of control variables in our regressions and sample selection
criteria for our NHANES and NSCH samples. All regressions were weighted, and errors were clustered at the state level. *p < 0:10
**p < 0:05 ***p < 0:01
N ov e m b e r 202 1
Downloaded from HealthAffairs.org on January 10, 2022.
Copyright Project HOPE—The People-to-People Health Foundation, Inc.
For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.
40: 1 1
Health Affairs
1735
Oral Health
Exhibit 3
Regression estimates of the association between Medicaid adult dental coverage and
untreated caries among children in low-income families, by child age, 1999–2016
SOURCE National Health and Nutrition Examination Survey (NHANES), 1999–2016. NOTES Estimates
are the coefficients on the Medicaid adult dental coverage indicator as described in the exhibit 2
notes. All regressions were weighted, and errors were clustered at the state level. ***p < 0:01
Exhibit 4
Regression estimates of the association between Medicaid adult dental coverage and
untreated caries among children in low-income families, by child race and ethnicity,
1999–2016
SOURCE National Health and Nutrition Examination Survey (NHANES), 1999–2016. NOTES Estimates
are the coefficients on the Medicaid adult dental coverage indicator as described in the exhibit 2
notes. All regressions were weighted, and errors were clustered at the state level. **p < 0:05
***p < 0:01
173 6
He a lt h Affair s
N ov e m b er 2 0 2 1
considering the one- and two-year lagged effects,
respectively (appendix exhibit S4).10
Exhibits 3 and 4 present the association between adult dental coverage and untreated caries
by age and race and ethnicity, respectively. Similar to the results for the full sample, concurrent
coverage was not associated with significant declines in untreated caries among any of the subsamples we considered. Lagged effects were negative and significant among children younger
than age 12, whereas the corresponding estimates for children ages 12–17 were much smaller
in magnitude and were not statistically significant (exhibit 3).
We estimated significant declines in untreated
caries among all racial and ethnic groups, although the magnitude and patterns of these
effects differed (exhibit 4). Estimates for nonHispanic Black children were largest in magnitude and statistically significant when considering both the one- and two-year lagged effects of
adult dental coverage policies. Estimates for Hispanic children were statistically significant when
considering the two-year lag, but not the oneyear lag, of the effects of adult dental coverage,
whereas non-Hispanic White children exhibited
the opposite pattern. Differences between the
estimates for each racial and ethnic group were
generally not statistically significant with the
exception of the difference between non-Hispanic Black and non-Hispanic White children when
considering the two-year lagged policy effect.
However, it is important to note that the nonHispanic White subgroup was the smallest sample we analyzed and included only 3,651 children
who completed the NHANES oral health assessment.
Sensitivity And Placebo Analyses Appendix exhibit S5 presents placebo estimates of the
concurrent and lagged associations between
adult dental coverage policies and the NHANES
and NSCH outcomes among children in higherincome families.10 The estimates were generally
small in magnitude relative to analogous estimates for children in lower-income families
(shown in exhibit 2) and also were generally
not statistically significant at conventional levels. Our NHANES analysis of differences in outcome trends before adult dental coverage policy
changes did not suggest significant differences
for any of the outcomes (appendix exhibit S6).10
Results for the NHANES outcomes were generally similar when we excluded the 2005–10 survey years and restricted the sample to children
ages five and older (appendix exhibit S7).10 Estimates were qualitatively similar but larger in
many instances when considering alternative income thresholds of 100 percent and 150 percent
of poverty (appendix exhibit S8).10 Estimates
40:11
Downloaded from HealthAffairs.org on January 10, 2022.
Copyright Project HOPE—The People-to-People Health Foundation, Inc.
For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.
These findings
suggest that adult
dental coverage may
take time to influence
children’s dental care
use and oral health.
from logit models were also qualitatively similar
to our main estimates (appendix exhibit S9).10
Discussion
This study found an association between providing Medicaid adult dental coverage and improvements in children’s oral health after parents had
access to coverage for at least one year. These
results contribute to the limited evidence base on
the impacts of oral health policy at the family
level—a gap in the oral health services literature
recently identified by AcademyHealth’s Oral
Health Interest Group.14 Our findings were consistent with a recent study of children’s dental
visits that examined a similar period using comparable methods and National Health Interview
Survey (NHIS) data.5 The magnitude of the association between concurrent adult dental coverage and children’s dental visits in the present
study was in line with analogous estimates from
the NHIS, although not statistically significant,
which may be because of smaller sample sizes
in NHANES. Also consistent with previous research, we found larger effects on children’s outcomes after adult dental coverage policies had
been in effect for at least one full year. These
findings suggest that adult dental coverage may
take time to influence children’s dental care use
and oral health. Our estimates for lagged effects
of dental coverage policies on children’s dental
visits were somewhat larger than those implied
by NHIS, however.
In contrast, research examining the Affordable
Care Act’s (ACA’s) Medicaid expansions and
children’s dental visits did not find an effect,
although the authors note that their estimates
were imprecise.15 Studies of the association between the ACA’s Medicaid expansions and adult
dental care use generally suggest more modest
increases than research examining pre-ACA
changes to adult dental coverage policies.16–18
One study suggested a significant increase in
dental visits among childless adults but a decline
among parents as a result of the ACA’s expansions.18
We estimated a significant reduction in untreated caries (a 5-percentage-point decline) but
a smaller and nonsignificant change in tooth
restorations (a 2-percentage-point increase)
when considering lagged effects from adult dental coverage policies. The fact that our estimate
for any untreated caries was larger than for any
tooth restorations was expected. A child who
visits the dentist and receives a filling would
initially be categorized as having untreated caries and then as having tooth restorations after
the visit. Conversely, a child who stops visiting
the dentist may develop untreated caries whether or not they initially had tooth restorations.
Although preventing the development of caries
is optimal, there are many factors that may influence a child’s caries experience including access to dental care, diet, and health behavior.19
Because we were unable to distinguish new from
existing restorations, the presence of any tooth
restorations could reflect a child’s oral health
status several years before the NHANES interview. Having untreated caries, however, represents a current unmet health care need that is
often easily addressed in a single visit to the
dentist.
Our results for the exam-based oral health
measures suggested that effects persisted, as estimates for the one- and two-year lagged effects
of the policy changes were similar in magnitude.
In contrast, the association between adult dental
coverage and parent-reported oral health was
only statistically significant two or more years
after a policy change. Although research suggests a significant correlation between parentreported and exam-based caries measures,20 parent-reported outcomes may be subject to social
desirability bias and other inaccuracies.21 Gaps
in parental awareness and reporting may explain
differences in the exam-based and parentreported results. However, the exam-based and
parent-reported measures were derived from
separate data sets covering different study years,
which could also explain these differences.
The lag between changes in adult dental coverage policies and effects on children’s oral
health may also depend on whether a state adds
or drops coverage. For example, adding adult
dental coverage may result in fairly expeditious
treatment of existing untreated caries, whereas
untreated caries may take time to develop in a
child who has lost dental care but had it previously. By this logic, oral health improvements
might be expected to occur faster when a state
adds adult dental coverage than oral health
declines when a state drops dental coverage.
November 2021
Downloaded from HealthAffairs.org on January 10, 2022.
Copyright Project HOPE—The People-to-People Health Foundation, Inc.
For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.
40:11
H ea lt h A f fai r s
1737
Oral Health
Adding and dropping dental coverage may also
have different behavioral effects. For example,
parents who visit the dentist regularly may receive advice about their children’s oral health
care from their provider, and this knowledge
is unlikely to be lost immediately when a state
drops dental coverage. On the contrary, some
Medicaid-enrolled adults may be unaware of
their dental benefit status and may therefore be
slower to respond to gaining dental coverage.22
Our analysis was not able to separately identify
the effects of adding and dropping coverage,
given our data limitations; future research with
larger state-specific samples is warranted.
The prevalence of untreated caries among children has declined over time, and disparities in
poor oral health by income and race and ethnicity have narrowed in recent years.23 However,
rates of untreated caries remain higher for Hispanic and non-Hispanic Black children than for
non-Hispanic White children, as well as for
children with family incomes below the federal
poverty level compared with children in higherincome families.23 Our subgroup analysis suggested that adult dental coverage was associated
with 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 relative to non-Hispanic White children. Further,
as expected, the effects of adult dental coverage
were concentrated among children in lowincome families, with no evidence of effects
among children in higher-income families.
These findings suggest that adult dental coverage may have greater effects on the children with
the highest unmet oral health care needs.
A conference abstract of this study was
accepted for oral presentation at the
Association for Public Policy Analysis
and Management Fall Research
Conference in Austin, Texas, March 27–
29, 2022. The research reported in this
Conclusion
This analysis builds on previous research that
found a positive association between Medicaid
adult dental coverage and children’s dental visits
by providing evidence that these gains may
translate to a reduction in caries among children
in low-income families. Medicaid reimbursement rates and the availability of dental providers that accept Medicaid patients are important determinants of dental care access among
Medicaid-enrolled adults9,17 and children.24,25 Although not addressed in the present study, these
and other state and local factors may amplify or
depress the beneficial effects of Medicaid adult
dental coverage we document.
According to a recent American Dental Association report, the total cost of offering extensive
dental benefits in the twenty-eight states that do
not currently provide them would be $836 million per year, or about $4.64 per adult Medicaid
enrollee per month.26 Although offering adult
dental coverage is unlikely to be a cost-effective
means to increase dental visits and improve oral
health among children if that were the only objective, the combined benefits for adults and children may make adult dental coverage an attractive investment for states.5,8,9 Future assessments
of the costs and benefits of offering Medicaid
adult dental coverage may also consider potential effects on the children of adult enrollees.
These effects may be long lasting, as research
suggests that policies that increase oral health
care access at early ages are also associated with
better adult oral health.27,28 ▪
article was supported by the National
Institute of Dental and Craniofacial
Research of the National Institutes of
Health, Grant No. R03DE029799. The
content is solely the responsibility of
the authors and does not necessarily
represent the official views of the
National Institutes of Health or the
Agency for Healthcare Research and
Quality.
[cited 2021 Sep 14]. Available from:
https://www.ada.org/~/media/
ADA/Science%20and%20
Research/HPI/Files/HPIBrief_
0419_1.pdf?la=en
4 Finlayson TL, Asgari P, Dougherty E,
Tadese BK, Stamm N, Nunez-Alvarez
A. Child, caregiver, and family factors associated with child dental
utilization among Mexican migrant
families in California. Community
Dent Health. 2018;35(2):89–94.
5 Lipton BJ. Adult Medicaid benefit
generosity and receipt of recommended health services among lowincome children: the spillover effects
of Medicaid adult dental coverage
expansions. J Health Econ. 2021;
75:102404.
6 Edelstein BL, Rubin MS, Clouston
SAP, Reusch C. Children’s dental
service use reflects their parents’
dental service experience and insurance. J Am Dent Assoc. 2020;
151(12):935–43.
7 Seale NS, Casamassimo PS. Access to
dental care for children in the United
States: a survey of general practitioners. J Am Dent Assoc. 2003;
134(12):1630–40.
8 Abdus S, Decker SL. Association
between Medicaid adult nonemer-
NOTES
1 Crall JJ, Vujicic M. Children’s oral
health: progress, policy development, and priorities for continued
improvement. Health Aff
(Millwood). 2020;39(10):1762–9.
2 Berdahl T, Hudson J, Simpson L,
McCormick MC. Annual report on
children’s health care: dental and
orthodontic utilization and expenditures for children, 2010–2012.
Acad Pediatr. 2016;16(4):314–26.
3 Gupta N, Vujicic M. Main barriers to
getting needed dental care all relate
to affordability [Internet]. Chicago
(IL): American Dental Association,
Health Policy Institute; 2019 Nov
173 8
Health A ffairs
N ov e m b e r 202 1
40: 1 1
Downloaded from HealthAffairs.org on January 10, 2022.
Copyright Project HOPE—The People-to-People Health Foundation, Inc.
For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.
gency dental benefits and dental
services use and expenditures. J Am
Dent Assoc. 2019;150(1):24–33.
9 Decker SL, Lipton BJ. Do Medicaid
benefit expansions have teeth? The
effect of Medicaid adult dental coverage on the use of dental services
and oral health. J Health Econ.
2015;44:212–25.
10 To access the appendix, click on the
Details tab of the article online.
11 Dye BA, Li X, Lewis BG, Iafolla T,
Beltran-Aguilar ED, Eke PI. Overview and quality assurance for the
oral health component of the National Health and Nutrition Examination Survey (NHANES), 2009–
2010. J Public Health Dent. 2014;
74(3):248–56.
12 Dye BA, Afful J, Thornton-Evans G,
Iafolla T. Overview and quality assurance for the oral health component of the National Health and
Nutrition Examination Survey
(NHANES), 2011–2014. BMC Oral
Health. 2019;19(1):95.
13 Goodman-Bacon A. Difference-indifferences with variation in treatment timing. J Econom. 2021 Jun 12.
[Epub ahead of print].
14 Burgette JM, Vujicic M, Booth M,
Meltzer D, Best TJ, Neill J, et al.
Advancing oral health policy
through persuasive messaging and
effective research measures. J Public
Health Dent. 2021;81(1):77–83.
15 Khouja T, Burgette JM, Donohue
JM, Roberts ET. Association between Medicaid expansion, dental
coverage policies for adults, and
children’s receipt of preventive
dental services. Health Serv Res.
2020;55(5):642–50.
16 Nasseh K, Vujicic M. The impact of
the Affordable Care Act’s Medicaid
expansion on dental care use
through 2016. J Public Health Dent.
2017;77(4):290–4.
17 Wehby GL, Lyu W, Shane DM. The
impact of the ACA Medicaid expansions on dental visits by dental coverage generosity and dentist supply.
Med Care. 2019;57(10):781–7.
18 Singhal A, Damiano P, Sabik L.
Medicaid adult dental benefits increase use of dental care, but impact
of expansion on dental services use
was mixed. Health Aff (Millwood).
2017;36(4):723–32.
19 Centers for Disease Control and
Prevention. Children’s oral health
[Internet]. Atlanta (GA): CDC; [last
updated 2021 Apr 21; cited 2021 Sep
14]. Available from: https://www.cdc
.gov/oralhealth/basics/childrensoral-health/index.html
20 Sohn W, Taichman LS, Ismail AI,
Reisine S. Caregiver’s perception of
child’s oral health status among lowincome African Americans. Pediatr
Dent. 2008;30(6):480–7.
21 Sanzone LA, Lee JY, Divaris K,
DeWalt DA, Baker AD, Vann WF Jr. A
cross sectional study examining social desirability bias in caregiver reporting of children’s oral health behaviors. BMC Oral Health. 2013;
13(1):24.
22 Yarbrough C, Nasseh K, Vujicic M.
Key differences in dental care seeking behavior between Medicaid and
non-Medicaid adults and children
[Internet]. Chicago (IL): American
Dental Association, Health Policy
Institute; 2014 Sep [cited 2021 Sep
14]. Available from: http://www.ada
.org/~/media/ADA/Science%20and
%20Research/HPI/Files/HPIBrief_
0814_4.ashx
23 Centers for Disease Control and
Prevention. Oral health surveillance,
2019 [Internet]. Atlanta (GA): CDC;
2019 [last updated 2020 Dec 15;
cited 2021 Sep 17]. Available from:
https://www.cdc.gov/oralhealth/
publications/OHSR-2019-index
.html
24 Decker SL. Medicaid payment levels
to dentists and access to dental care
among children and adolescents.
JAMA. 2011;306(2):187–93.
25 Nasseh K, Vujicic M. The impact of
Medicaid reform on children’s dental care utilization in Connecticut,
Maryland, and Texas. Health Serv
Res. 2015;50(4):1236–49.
26 Vujicic M, Fosse C, Reusch C,
Burroughs M. Making the case for
dental coverage for adults in all state
Medicaid programs [Internet].
Chicago (IL): American Dental Association, Health Policy Institute;
2021 Jul [cited 2021 Sep 14]. Available from: https://www.ada.org/~/
media/ADA/Science%20and%20
Research/HPI/Files/WhitePaper_
0721.pdf
27 Lipton BJ, Wherry LR, Miller S,
Kenney GM, Decker S. Previous
Medicaid expansion may have had
lasting positive effects on oral health
of non-Hispanic black children.
Health Aff (Millwood). 2016;35(12):
2249–58.
28 Glied S, Neidell M. The economic
value of teeth. J Hum Resour. 2010;
45(2):468–96.
N ov e m b e r 2 0 2 1
Downloaded from HealthAffairs.org on January 10, 2022.
Copyright Project HOPE—The People-to-People Health Foundation, Inc.
For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.
40:11
Health Affa irs
1739
Order an Essay Now & Get These Features For Free:
Turnitin Report
Formatting
Title Page
Citation
Outline
