SCHIP Takes a Bite Out of the Dental Access Gap for Low-Income Children

Shanna Shulman
November 16, 2004

T
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SCHIP Takes a Bite Out of the Dental Access Gap for Low-Income Children
disproportionately likely to be among those who have untreated dental disease (Edelstein
2002; and Vargas et al. 1998).
The American Academy of Pediatric Dentistry (AAPD) recommends that all children
age 2 and older receive at least two preventive dental visits each year (American Academy of
Pediatric Dentistry 2003). National data suggest that U.S. children, especially low-income
children, were far from reaching this goal in the years prior to the introduction of SCHIP.
According to 1996 data from the Medical Expenditure Panel Survey (MEPS), only 31
percent of low-income children ages 2 to 18 had a dental visit in the previous year. This is
substantially lower than the percentage of children ages 2 to 18, at all income levels, who had
a dental visit in the past year (47 percent), thus demonstrating a significant disparity in dental
care access by income (Agency for Healthcare Research and Quality 2003).2 Given that even
the general child population falls short of meeting the AAPD goal, a more appropriate
benchmark against which to track the progress of the SCHIP program may be the Healthy
People 2010 goal that at least 57 percent of low-income children receive a preventive dental
visit each year (U.S. Department of Health and Human Services 2000b).3
INSURANCE IS KEY ELEMENT IN ACCESS TO CARE
Inadequate access to dental insurance accounts for much of the disparity in access to
care (U.S. Department of Health and Human Services 2000a).4 In 1996, before the
introduction of the SCHIP program, 26 percent of low-income children? compared to 52
percent of children from all income brackets?had private dental coverage (Manski et al.
2001). Although some low-income children had access to dental care through the Medicaid
program, Medicaid coverage does not appear to confer the same advantage as private dental
coverage. During 1996, low-income children with Medicaid coverage were one-third less
likely to receive a dental visit than low-income children with private coverage (Manski et al.
2001),5 a difference most likely due to institutional barriers to dental care within the
Medicaid program (U.S. Government Accounting Office 2000).6 Still, the benefit of having
2Other data sources report substantially higher rates of dental visits. For example, according to data from
the 2001 National Health Interview Study, approximately 73 percent of all U.S. children and 62 percent of poor
and near-poor children reported having a dental visit in the previous year (National Center for Health Statistics
2001). However, MEPS data has been shown to be a more accurate measurement of overall dental utilization,
as well as being the metric used to set the Healthy People national goals (Macek et al. 2002).
3The Healthy People 2010 goals were developed to provide attainable public health goals for the U.S.
population. The annual dental preventive care goal for low-income children was established to be slightly
higher than the current rate of annual preventive care among children of any single income group (U.S.
Department of Health and Human Services 2000b).
4Lack of provider availability and low caregiver prioritization of dental care are also generally found to be
associated with poor access to dental care (Kenney et al. 2000).
5This particular finding concerns children living in families under 133 percent of FPL.
6These data predate implementation of the SCHIP program. More recent studies of children?s dental
utilization rates by insurance status (such as Kenney et al. 2003) aggregate Medicaid and SCHIP utilization into
a single rate. Consequently, little is known about how dental access and utilization may differ in the Medicaid
and SCHIP programs.
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SCHIP Takes a Bite Out of the Dental Access Gap for Low-Income Children
any dental insurance is clear. Only 19 percent of uninsured children in families below 133
percent of FPL received dental care during 1996, compared to 28 percent of those with
Medicaid coverage, and 43 percent of those with private dental coverage (Manski et al.
2001).
SCHIP?S POTENTIAL TO CLOSE THE LOW-INCOME GAP
Enacted in 1997 to provide health insurance coverage to low-income uninsured
children, SCHIP offers states a unique opportunity to address the lack of dental coverage
within this population. Under SCHIP, states are required to offer general medical benefits
comparable to benchmark plans in their state. Dental care is one of several optional services
that states can add to their core medical packages. As of 2003, every state but Delaware had
chosen to offer some type of dental coverage. Most SCHIP programs cover both preventive
and diagnostic care in accordance with AAPD recommendations as well as some level of
restorative care. By statute, SCHIP programs may not collect a copayment for preventive
services and few states require cost-sharing for restorative care. In those states that do
collect a copayment, the amount ranges from $2 to $5. Only one state plan requires
coinsurance (Rosenbach et al. 2003; and Wooldridge et al. 2003).7 Many states cited the
importance of dental care to child health and development as their primary rationale for
adoption of the benefit.
METHODOLOGY
To better understand how state SCHIP programs may be increasing access to and
utilization of dental care among low-income children, we reviewed annual state SCHIP
reports submitted to the Centers for Medicare & Medicaid Services (CMS). Title XXI does
not require states to report a standard set of performance measures for their SCHIP
programs. Instead, states may document whatever measures they believe best represent
progress toward access and utilization goals.8 Twenty-seven states reported at least one type
of dental access or utilization measure in their 2000, 2001, 2002, or 2003 annual reports.9
From these annual state reports, and reviews of published literature and internet sources, we
compiled two types of evidence: (1) studies documenting change in dental care access and
utilization upon SCHIP enrollment in eight states, and (2) point-in-time dental visit rates
within 21 state SCHIP programs, which we compare to the Healthy People 2010 goal for
low-income children. We supplemented these materials with focus group and site visit
7One of Utah?s dental plans requires coinsurance equal to 20 percent of the allowed charge for restorative
services. Utah?s other plan requires a copay of $3 for all services (Utah Department of Health 2003).
8CMS began requesting that states voluntarily report core performance measures in their federal fiscal
year 2003 annual reports. Dental care is not one of those proposed as a core measure.
9While the most commonly reported dental measure in the state annual reports was the percentage of
SCHIP-enrolled children who received dental care in a 6- or 12-month period (reported by 21 of the 27 states
including dental measures), a few states also reported on other measures, such as claims per 1000 members,
dental visit counts, and frequency of untreated tooth decay.
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SCHIP Takes a Bite Out of the Dental Access Gap for Low-Income Children
evidence obtained through Mathematica Policy Research?s (MPR?s) national evaluation of
SCHIP.
CHANGES IN ACCESS AND UTILIZATION IN CONJUNCTION WITH SCHIP
ENROLLMENT
As shown in Table 1, we identified evaluations in eight states that document change in
dental care access and utilization under SCHIP. Each of these studies compared dental
access and use in the SCHIP program to a period before enrollment in the program using
one of the following three types of research designs:
! The Iowa, Kansas, North Carolina, and Pennsylvania evaluations used a
pre/post design in which a single cohort of SCHIP enrollees was surveyed at
two points in time. The first survey, occurring soon after SCHIP enrollment,
asked about the cohort?s dental utilization and access during the year preceding
SCHIP enrollment. These results were then compared to those of a second
survey, occurring a year later, which asked about the cohort?s experiences while
enrolled in SCHIP. The Pennsylvania evaluation (Lave et al. 2002) used 1995
data concerning access and utilization in a pre-SCHIP public insurance program,
which was for low-income children in western Pennsylvania.
! The Florida, New Hampshire, and Texas evaluations used a non-equivalent
comparison design in which concurrent surveys were conducted with two
cohorts: ?continuous? enrollees (those enrolled in the SCHIP program for six or
more months) and ?new? enrollees (those enrolled for fewer than three months).
The experiences of the continuous enrollees over the prior year (or, in one case,
six months) while enrolled in SCHIP were then compared to the experiences of
new enrollees over the year prior to their SCHIP coverage. These evaluations
were all conducted by the same lead investigator.
! The Alabama evaluation used a retrospective design in which a cohort of
enrollees was surveyed within one year of SCHIP enrollment about their
experiences accessing dental care while enrolled in SCHIP, compared to their
experiences accessing care during the year before they were enrolled.
Results from these eight states suggest that both access to and utilization of dental care
improved in conjunction with SCHIP enrollment. After enrolling in SCHIP, more families
reported that their children received a dental visit in the past year, had a usual source of
dental care, experienced a reduction of unmet dental needs and delayed access to care, and
increased the total number of dental visits. While all but one of the documented
improvements exceeded 10 percent, the magnitude of these changes varied depending on
the study and measure. For example, the percentage of children with any dental visit in the
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SCHIP Takes a Bite Out of the Dental Access Gap for Low-Income Children
Table 1. Change in Access and Utilization of Dental Services under SCHIP: State Findings
State Study Authors Study Designa
Any
Dental
Visit
Usual
Source of
Dental
Care
Reduction
of Unmet
Dental
Need
Reduction
of Delay of
Dental
Care
Number
of Dental
Provider
Contacts
Alabama Mulvihill et al.
(2000)
Retrospective +b
Florida Shenkman et al.
(2000, 2003)
Nonequivalent
comparison
+b,c +b,d
Iowa Damiano
(2003)
Pre/post + + + +
Kansas Fox et al.
(2003)
Pre/post + +
New
Hampshire
Shenkman
(2002)
Nonequivalent
comparison
+b
North
Carolina
Mofidi et al.
(2002)
Pre/post + + +
Pennsylvania Lave et al.
(2002)
Pre/post + + +e +e +
Texas Shenkman
(2003)
Nonequivalent
comparison
+b
Notes: Improvements in access and utilization upon SCHIP enrollment are represented by the ?+? symbol. If the study employed
significance testing, a ?+? symbol denotes a significant difference was found at the 0.05 level or lower. Those studies not
employing significance testing are noted otherwise. Shading denotes measures that were not included in these particular
studies. All measures reflect dental access and utilization within the past year, unless otherwise noted.
aFour state evaluations (Iowa, Kansas, North Carolina, Pennsylvania) measured changes in dental access and utilization upon SCHIP
enrollment using a pre/post design, surveying enrollees within 3 months of their initial enrollment and again after at least 11 months of
enrollment. Three other state evaluations (Florida, New Hampshire, Texas) measured access and utilization using a non-equivalent
comparison design by simultaneously surveying new and continuous enrollees to compare their dental access and utilization over the
previous year. One other state evaluation (Alabama) used a retrospective design by surveying a single cohort of established enrollees
about their access and utilization experiences under SCHIP, compared to their experiences before they were enrolled in the program.
bThese results were not subject to significance testing.
cThis measure, presented in the 2000 report only, reflects dental access and utilization in the past six months.
d2003 report only.
eThese measures were asked as a single question (?whether the child experienced unmet needs or delayed care?).
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SCHIP Takes a Bite Out of the Dental Access Gap for Low-Income Children
past year increased between 44 and 50 percent across four states, while unmet need was
reduced 28 to 86 percent across the eight states.10 Because the methods used to document
these changes were not uniformly rigorous, they should be interpreted with caution.
However, in the aggregate, these results are in accordance with data comparing a Medicaid
population to an uninsured population collected prior to SCHIP?s implementation, as cited
earlier (Manski et al. 2001). They are also in agreement with more recent national data
indicating that children covered by Medicaid or SCHIP are 1.5 times more likely to have had
a dental visit in the past year, compared to uninsured children (Kenney et al. 2003). In sum,
the results from Table 1 support the promising role of SCHIP in improving dental access
and utilization among low-income children.
ANNUAL AND SEMI-ANNUAL DENTAL VISIT RATES IN SCHIP PROGRAMS
Another way of looking at dental access within the SCHIP program is to consider
point-in-time estimates of dental utilization across states. Table 2 presents the most recent
data for each of the 21 states reporting some form of this measure. As shown, there is wide
variation in rates of semi-annual and annual dental visits reported by the 21 states?from a
low of 17 percent of children receiving a visit in the past year in Wisconsin, to a high of 76
percent of children receiving a visit in the past year in Alabama and among older children in
Florida. This wide range reflects the various approaches states took to measuring dental
utilization, the differences among state programs, and the substantial flexibility that states
have in reporting utilization measures in their annual SCHIP reports. The measurements
presented in Table 2 vary by type of program, reporting year, data source, data
characteristics, and sampled population. Some of these differences, such as age (Florida) and
type of visit (Wisconsin), have a clear influence on the reported rate. When possible, we
have noted these differences in the table and table notes.
The Healthy People 2010 goal provides a national benchmark against which to compare
12-month dental utilization rates in the SCHIP program. Of the 17 states that reported 12-
month dental visit rates, 7 appear to have surpassed the goal of 57 percent of low-income
children reporting at least one dental visit each year (Figure 1).11,12 It is important to note
that some differences across states may be due to methodological variation. Seven of the
10The 44 percent increase in any dental visits refers to an increase from 48 percent to 69 percent in Iowa
(Damiano 2003). The 50 percent increase in any dental visits refers to an increase from 40 percent to 60
percent in Pennsylvania (Lave et al. 2002). The 28 percent reduction in unmet need refers to a decrease from
25 to 18 percent among older children in Florida (Shenkman et al. 2003). The 86 percent reduction in unmet
need refers to a decrease from 53 percent to 7 percent in Alabama (Mulvihill et al. 2000).
11The Healthy People 2010 goal refers to preventive care visits only, whereas the rates presented in Figure
1 reflect any type of dental visit. However, we assume that the overwhelming majority of reported visits
contained some degree of preventive care assessment or guidance, in accordance with general dental practice.
12Of the five states reporting six-month data, one (North Dakota) reported a rate surpassing the 12-
month goal of Healthy People 2010.
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SCHIP Takes a Bite Out of the Dental Access Gap for Low-Income Children
Table 2. Dental Visit Rates in State SCHIP Programs: Percent of Children Receiving a Dental Visit in the Past Six
Months or the Past Year
State
Program
Typea
Reporting
Year
Data
Source Data Source Notes (where reported)
Percent
Receiving Dental
Care in Past Six
Months
Percent Receiving
Dental Care in
Past Year
Alabama COMBO 2001-2002 Survey Response rate: 55%
Population: S-SCHIP only
76%b
Alaska M-SCHIP 2001 Survey n = 1,072
Response rate: 64%
Population: Medicaid and SCHIP combined
52%
Arkansas M-SCHIP
1999-2000 Claims Ages 4-21
Population: Medicaid and SCHIP combined
46%
Arizona S-SCHIP 2000-2001 Claims Ages 3-18 36%
Colorado S-SCHIP 2002-2003 Claims Ages 0-18 34%
Florida COMBO 2001-2002 Survey Ages 5-19
n = 382
Response rate: 67%
Population: S-SCHIP only
62% (ages 5-10)
76% (ages 11-19)
Georgia S-SCHIP 2000 Survey;
Claims
Ages 2-18
Response rate: 70%c
44%c 64%d
Iowa COMBO 2000-2001 Survey n = 2,005
Response rate: 39%
Population: S-SCHIP only
74%
Kentucky COMBO 2001-2002 Survey n = 1,958
Response rate: 34%
Population: Medicaid and SCHIP combined
53%
Maine COMBO 1999 Survey n = 298
Response rate: 60%
Population: all publicly insured childrene
62%
Maryland M-SCHIP 2000 Claims Ages 3-20
Population: Medicaid and SCHIP combined
29%
Michigan COMBO
2001 Claims Ages 4-19
Population: S-SCHIP only
43%
Montana S-SCHIP 2002 Survey n=392
Response rate: 41%
50%
New York COMBO
2002 Claims Ages 4-21
Population: S-SCHIP only
41%
North
Carolina
S-SCHIP 1999-2000 Survey Ages 6-18
n = 439
Response rate: 74%
65%
North Dakota COMBO 2001 Survey n = 629
Response rate: 50%
64%
Ohio M-SCHIP 2001 Claims Ages 4-21
Population: Medicaid and SCHIP combined
41%
South Dakota COMBO 2001-2002 Survey n = 302
Response rate: 34%
63%
Tennessee M-SCHIP 1999-2000 Claims Population: Medicaid and SCHIP combined 33%b
West Virginia S-SCHIP 2000-2001 Survey n = 4,473
Response rate: 35%
55%
Wisconsin M-SCHIP 2000 Claims Ages 3-21
Population: managed care only
17%b
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SCHIP Takes a Bite Out of the Dental Access Gap for Low-Income Children
Source: State Title XXI Annual Reports from 2000 through 2003.
Notes: M-SCHIP denotes that the state operates a Medicaid expansion program; S-SCHIP denotes that the state
operates a separate child health program; COMBO denotes that the state operates both an M-SCHIP and
an S-SCHIP program. Some states reported dental visit rates for a subpopulation of their SCHIP
program (for example, only S-SCHIP enrollees in a COMBO program) or for a broader population (for
example, Medicaid and SCHIP enrollees combined in an M-SCHIP program), as described under
?population? in the Data Source Notes column.
aReflects type of program during reporting year specified. Two states, Alabama and Maryland, have since changed the
structure of their programs. Alabama switched from a COMBO program to an S-SCHIP program as of October
2002. Maryland switched from an M-SCHIP program to a COMBO program as of July 2001.
bPreventive care visits or examinations only.
cSurvey data.
dClaims data.
eIncludes children enrolled in SCHIP, Medicaid, Tricare, Medicare, and Indian Health Service.
Figure 1. State Rates of Dental Visits Among SCHIP Enrollees Over Past 12
Months, in Comparison to Healthy People 2010 National Goal
0
10
20
30
40
50
60
70
80
AL FL FL IA ME NC SD WV AZ AR CO GA MD MI NY OH TN WI
State and Program Typed
State Rates
S
aHealthy People 2010 goal that 57 percent of low-income children will receive annual preventive dental care by 2010. This goal is
part of the U.S. Department of Health and Human Services' Healthy People 2010 initiative to establish national public health goals
(U.S. Department of Health and Human Services 2000b).
bAges 5-10.
cAges 11-19.
dReflects type of program during reporting year specified in Table 2. M = Medicaid expansion program; S = separate child health
program; C = combination program. For those states reporting rates for different populations within these programs: C/S= data
reported for S-SCHIP only; C/P = data reported for all publicly insured children; M/M = data reported for Medicaid and SCHIP
population combined. See Table 2 notes for detail.
Claims data
Survey data
c b
HP2010
Goala
Source: State Title XXI Annual Reports from 2000 through 2003.
C/S C/S C/S C/P C S S M/M M/M M/M M/M M S S C/S C/S C/S
SCHIP Takes a Bite Out of the Dental Access Gap for Low-Income Children
9
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SCHIP Takes a Bite Out of the Dental Access Gap for Low-Income Children
states relied on survey data to calculate annual rates, while 10 used claims data. All but one
of the states that reported rates exceeding the Healthy People goal relied on survey data that
may be more prone to over-reporting bias when compared to claims data.13
There was also substantial variation in utilization rates by program type. None of the
states with Medicaid expansion SCHIP (M-SCHIP) programs appear to have reached the
Healthy People 2010 goal. In contrast, two of the five separate child health (S-SCHIP)
programs and five of the seven combination SCHIP programs surpassed the goal.14 As
shown in Figure 1, all of these M-SCHIP programs relied on claims data, whereas the five
combination programs surpassing the goal reported survey data, as did one of the two SSCHIP
programs.15 Therefore, it is not possible to discern if these distinctions reflect the
reporting differences of these programs or a program type effect.
FAMILIES? EXPERIENCES ACCESSING SCHIP DENTAL SERVICES
Tables 1 and 2 suggest that the implementation of SCHIP has improved low-income
children?s access to and utilization of dental services, but that utilization rates vary
substantially across states. Focus groups conducted with parents of SCHIP enrollees in
seven states further illustrate families? diverse experiences accessing dental care through
SCHIP.16
Overall, SCHIP enrollees were grateful for the program?s provision of dental coverage,
with several parents reporting that the dental benefit was instrumental in their decision to
apply to SCHIP. Once enrolled, families receiving dental services reported satisfaction with
SCHIP?s preventive care benefits. A South Carolina parent described dental care for her
child under SCHIP as a ?wonderful experience,? and a Kentucky parent reported that the
benefits gave her ?peace of mind.? A Pennsylvania mother described a similar sentiment:
?The idea of not getting care because you can't afford it ? it's heart-breaking for a
parent.?I've grown up with [poor dental care] ? my children shouldn't have to. And they
13Several studies suggest that surveys tend to report higher rates of utilization, in comparison to claims
data, due to recall error (see, for example, Fowles et al. 1997, 1999; May and Tontell 1998; and Thompson et al.
2001).
14Some states reported dental visit rates for a subpopulation of their SCHIP program (for example, only
S-SCHIP enrollees in a COMBO program) or for a broader population (for example, Medicaid and SCHIP
enrollees combined in an M-SCHIP program ). Of the seven combination programs shown in Figure 1, five
reported rates for the S-SCHIP component only and one reported a rate based on a sample of all publicly
insured children in the state. Of the five Medicaid expansion programs shown in Figure 1, four reported rates
for a combined Medicaid and SCHIP population. See Table 2 notes for detail.
15This is likely due to the claims-based reporting requirements of the Medicaid program.
16These focus groups were conducted in the following seven states from April 2003 to January 2004 as
part of MPR?s national evaluation of SCHIP: Georgia (S-SCHIP), Kansas (S-SCHIP), Kentucky
(Combination), Maryland (Combination), Ohio (M-SCHIP), Pennsylvania (S-SCHIP), South Carolina (MSCHIP),
and Utah (S-SCHIP).
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SCHIP Takes a Bite Out of the Dental Access Gap for Low-Income Children
have, because I've been neglectful taking them because I couldn't afford it. Now I can and I
am just very glad for that.?
A Georgia parent expressed how easy it was to access dental care under SCHIP:
?I?got a list of dentists and just called one up [to make an appointment].? Another South
Carolina parent reported that SCHIP ?covered every bit of the dental cleaning. [The
provider] gave me a printout for what [my child] had to have done in the future, which was
about $1,400 worth of stuff. And she said, your insurance will cover all of it.? An Ohio
parent whose child used SCHIP dental services reported that ?everything has worked out
fine so I?m really pleased and impressed.?
Although anecdotal, other comments from focus group participants help to shed light
on areas for program improvement. The challenges families faced in accessing coverage
were focused on a lack of awareness about the dental benefit, the scope of the benefit
package in some states, and difficulties identifying and accessing available providers.
Awareness of dental benefits. Parents in some states were not aware that SCHIP
coverage included dental benefits. Multiple participants reported hearing about the dental
benefit through word of mouth or did not know about the coverage until attending the
focus groups. Several South Carolina parents described dental coverage under SCHIP as a
?secret.? One Ohio parent commented about ?the lack of information given out at the
initial application? [my caseworker] gave you the impression that medical was all your kids
[got]?but medical to me meant medical?not dental?? Another Ohio parent reported
that she ?didn?t realize all the stuff you could get. Vision, the dental. I didn?t realize?I
thought it was just doctor visits, that?s it.?
Scope of dental benefits. Parents in two states cited limitations in covered services as
problematic.17 For example, some Kentucky participants questioned why the state?s benefit
package limited SCHIP enrollees to one preventive visit per year, in contrast to the AAPD
recommendation of preventive dental care every six months. ?If they recommend every six
months, then why can?t they pay for it every six months?? asked a Kentucky parent.
Utah parents expressed frustration over a temporary policy limiting restorative services
such as fillings. ?I found out that my five-year-old needed a filling and they were more than
willing to pull the tooth, but not fill it,? reported one Utah parent. Parents described how
these restrictions served as a deterrent from seeking any dental services at all. ?Why even
bother having cleanings and checkups if you can?t get the cavities taken care of?? questioned
another Utah participant. Finally, some Utah participants felt that the state should have
emphasized the limited scope of dental coverage under SCHIP when families enrolled in the
17Parents in all seven focus group states consistently commented on the limited orthodontic coverage
under SCHIP. A Kansas parent described the challenge of accessing orthodontic care under SCHIP: ?[Even if
you] have teeth coming out of the top of your head, they?re not going to help you out with that.? A parent in
Ohio reported that she was told by several orthodontists ?don?t waste your time ? you will not get coverage
for? this care. Because this paper focuses on access to preventive and restorative dental care under SCHIP, we
do not explore the orthodontia issue further.
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SCHIP Takes a Bite Out of the Dental Access Gap for Low-Income Children
program. A Utah parent explained that, ?we should be, as we all are, grateful that the
program is here. But at the same time, [the state should] not even call it?. dental insurance.
Just say dental cleanings. It?s not clear.? Since the focus groups were conducted in May
2003, many of the restorative services in Utah have been reinstated.
Availability of providers. Another prominent theme heard across the focus groups
was the challenge of finding dental providers who accepted SCHIP. In the words of a
Maryland parent, ?they provide the service?they don?t provide the doctor.? A
Pennsylvania parent listed her struggles in seeking dental care for her child as ?number one,
I had a hard time finding a dentist and number two, I had a very hard time getting an
appointment for [my child] because they're so full.? While privately-insured children at
higher income levels often face similar difficulties in obtaining access to dental providers,18
many SCHIP parents felt that their search for dentists was especially challenging because of
SCHIP?s limited provider networks and low payment rates. Multiple parents reported calling
?every dentist in the phone book? before finding an available SCHIP provider. As a
Maryland parent explained, ?You can?t find a dentist just for a regular cleaning. So it piles
up to have dental problems, and then it escalates to where you need a specialist and there?s
nothing [available] at all. I?ve had really bad problems with it.? Other families described
how lists of participating dentists distributed by the state were often outdated and little
guidance was offered in selecting providers. A Kentucky parent described how ?you don?t
like to have to choose someone because they?re the only one who will take you.?
Upon finding a provider, some parents reported restricted provider scheduling for
SCHIP enrollees. For example, when a Kentucky parent tried to schedule an after-school
appointment, she was told by her dentist?s receptionist that they ?have our medical card
patients come between the hours of ten and two.? An Ohio parent described how she was
required by her children?s dentist to change to an inconvenient office location after she
signed up for SCHIP.
Finally, some Kansas parents faced the challenge of shifting provider networks that
affected their children?s continuity of care. Kansas families whose incomes fluctuated each
month frequently alternated eligibility between SCHIP and Medicaid. Because the networks
of providers in these programs are not equivalent, children often had to switch providers
when their eligibility status changed. Parents felt that ?there should be some way that
[children] can stay seeing the same doctor once they?ve enrolled in [the SCHIP] program.?
STATE INITIATIVES TO IMPROVE DENTAL ACCESS UNDER SCHIP
Site visit interviews conducted with state officials, dental providers, and professional
associations in eight states, as well as a review of the American Dental Association?s recent
compendium of state innovations for low-income children, indicate that SCHIP programs
are attempting to address many of the coverage and access challenges described by focus
18The Oral Health America National Grading Project assigned a ranking of C- in the category of Access
to Care for all Americans (Oral Health America 2003).
13
SCHIP Takes a Bite Out of the Dental Access Gap for Low-Income Children
group participants.19 States are working to overcome these issues through widespread
efforts to increase payment rates and streamline claims and administrative procedures. Many
states are also increasing access by implementing enhanced case management, developing
novel provider recruitment practices, and widening the provider pool by making more dental
providers eligible to participate in SCHIP. States have frequently chosen to combine
initiatives across their SCHIP and Medicaid programs, as many of the programs use the
same fee schedule and provider networks (U.S. Government Accounting Office 2000).
Innovations in both programs hold promise for improving dental access and utilization
among SCHIP participants. 20
Increasing payment rates. In response to dental provider complaints about low
payment, a substantial number of states have increased their dental payment rates in recent
years.
! In 2000, the state of South Carolina collaborated with its state dental association
to increase payment rates with the goal of enlisting more SCHIP and Medicaid
providers. This effort led to a significant jump in provider participation, with
most newly enlisted dentists agreeing to accept 50 or more Medicaid and SCHIP
enrollees.
! A Kentucky rate increase during 2000-2001 prompted many providers who were
already participating to increase their panel sizes to include more SCHIP
enrollees, although this did not appear to significantly increase the total provider
count.
Streamlining administrative procedures. Responding to dental provider complaints
about the administrative burden of SCHIP and Medicaid, a majority of states have reduced
the level of paperwork and documentation required of participating dentists.
! Several states, such as Kentucky, have shortened SCHIP and Medicaid provider
registration forms. Other states, such as Ohio, have uploaded their registration
forms onto the Internet to ease completion.
19The site visit interviews were conducted in the following eight states from September 2002 to March
2003, as part of MPR?s national evaluation of SCHIP: Georgia, Kansas, Kentucky, Maryland, Ohio,
Pennsylvania, South Carolina, and Utah. Reported innovations are a synthesis of site visit interviews and the
American Dental Association?s ?State Innovations to Improve Access to Oral HealthCare for Low-Income
Children: A Compendium? (2003). Examples of earlier state innovations are described in the National
Conference of State Legislatures? ?Increasing Dentists' Participation in Medicaid and SCHIP? (2001).
20Although not included in our site visit interviews, California has recently implemented a comprehensive
initiative to improve access to and utilization of dental services among SCHIP enrollees. The initiative involves
one-on-one health education and case management follow-up with families to ensure that parents keep their
children?s dental appointments and follow care guidelines. The initiative also plans to use mobile dental vans
that circulate among preschools in low-income areas to provide children with a ?dental home? (Centers for
Medicare & Medicaid Services 2003).
14
SCHIP Takes a Bite Out of the Dental Access Gap for Low-Income Children
! Many states have streamlined claims processing by accepting the standardized
ADA claim form and implementing electronic billing procedures for both
Medicaid and SCHIP.
! Some states, such as South Carolina, have also improved patient eligibility
confirmation procedures by adopting plastic eligibility swipe-cards and automatic
phone systems to confirm eligibility.
Reducing missed appointments and non-compliance. Some states are responding
to provider complaints about missed appointments and non-compliance among SCHIP and
Medicaid enrollees by expanding their case management services for enrolled populations to
coordinate dental appointments and offer transportation services.
! One of the case study counties in Ohio dedicates a caseworker to coordinate
dental appointments for SCHIP and Medicaid enrollees based on dental
providers? schedules and availability. This county consequently reduced its noshow
rate to less than 10 percent each month.
! Maryland funded a rural demonstration project to evaluate the barriers that lowincome
populations face in accessing dental care. The effort combined provider
outreach with patient case management and education. Under this initiative, the
no-show rate dropped to less than 5 percent among the targeted patient
population.
Increasing provider awareness of SCHIP. States are encouraging dental providers to
expand their practices incrementally to SCHIP and Medicaid enrollees through statewide
outreach campaigns.
! The State of Georgia and the Georgia Dental Association initiated the ?Take
Five? program in October 2001, encouraging dentists to accept at least five new
Medicaid or SCHIP patients each year. Coincident with this campaign, the state
increased its payment rates (in 2000 and again in 2002), which proved crucial to
expanding provider capacity to serve the new SCHIP enrollees.
! Alabama?s ALL-Kids SCHIP program, which delivers dental services through
Blue Cross/Blue Shield (BC/BS), expanded provider networks by requiring
dentists who accept new privately insured patients under BC/BS to also accept
ALL-Kids enrollees.
! Many states are collaborating with dental associations to promote opportunities
for dentists to voluntarily provide care to low-income children. These initiatives
are aimed at helping dentists recognize unmet need within their communities and
expanding their publicly-insured patient panels. For example, dentists in many
states participate in national "Give Kids a Smile" day, providing volunteer dental
15
SCHIP Takes a Bite Out of the Dental Access Gap for Low-Income Children
services for low-income populations and public awareness efforts about dental
care under SCHIP and Medicaid.
Expanding the eligible provider pool. Several states are looking beyond dentists
now practicing to increase provider participation in SCHIP and Medicaid through
recruitment of recent dental graduates and hygienists.
! Multiple states have established loan repayment incentives for dental providers
who demonstrate a commitment to treating SCHIP and Medicaid enrollees. For
example, recent dental graduates working in North Dakota?s underserved areas
and Connecticut?s dental providers serving in community health centers have the
opportunity to waive a portion of their dental school fees.
! The Kansas legislature recently passed a bill that expands hygienists' eligibility to
deliver preventive care to children enrolled in the SCHIP and Medicaid
programs.
CONCLUSION
Our review of published and unpublished literature, including data from annual state
SCHIP reports, suggests that access to dental care for low-income children is improving
under SCHIP. While wide variation remains in the progress of state SCHIP programs
toward national goals for pediatric dental care, the decision of states to offer the optional
dental benefit through SCHIP is an important first step in reducing the gap in dental access
between low-income children and those of higher income levels. Overall, children enrolled
in SCHIP appear to have greater access to dental care and utilization as compared to before
they entered the program, consistently evidencing improvements in utilization and
reductions in unmet need and delayed care.
The relative success of state SCHIP programs in increasing access to dental care
prompts further questions about what features of the programs are associated with
improved access. For example, does type of plan (S-SCHIP, M-SCHIP, combination),
delivery system (managed care or fee-for-service), or target population (such as age of child
or income) affect access to dental care? In addition, to what extent does data source (for
example, claims or survey) account for the variation in rates? Finally, comparisons of dental
access between the SCHIP and Medicaid programs may suggest whether performance varies
across these two programs.
Despite budgetary constraints, states have continued to demonstrate their commitment
to providing dental services to low-income children through SCHIP. While our focus group
results suggest that some barriers still remain to families accessing dental services through
SCHIP, interviews with both providers and dental associations reflect that states are aware
of and working towards promising innovations to address these challenges. Through these
efforts, SCHIP programs appear to be working toward reducing the dental access gap
experienced by previously uninsured, low-income children.
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