Dental Service Use and Dental Insurance Coverage -- United States, Behavioral Risk Factor Surveillance System, 1995

In the United States, 94% of adults have evidence of past or current tooth decay, and only one third of adults aged 35-44 years have all of their permanent teeth (1). Dental insurance is associated with increased use of dental services and improved oral health status (2,3). This report summarizes state-specific and aggregated state data on both private and public sources of dental insurance coverage and the use of dental services among adults in 25 states * who participated in the oral health module of the 1995 Behavioral Risk Factor Surveillance System (BRFSS). The findings indicate that nearly half (44.3%) of adults in this survey reported having no dental insurance coverage.

The BRFSS is a continuous, state-based, random-digit-dialed telephone survey of the U.S. noninstitutionalized population aged greater than or equal to 18 years. In 1995, a total of 56,339 adults participated in the core BRFSS in the 25 states that included the oral health module. State response rates ranged from 52.3% to 84.5% (median: 68.4%). Participants were asked whether they had had a dental visit within the previous 12 months (a past-year visit), one of the national health objectives for the year 2000 for oral health (objective 13.4) (4); reasons for not having had a past-year visit; and whether they had any kind of insurance coverage that pays for some or all of their dental care, including dental insurance, prepaid plans such as health-maintenance organizations (HMOs), or government plans such as Medicaid. Persons who reported having no dental-care coverage at the time of the interview were considered to be uninsured. Weighted prevalence estimates and 95% confidence intervals (CIs) were calculated by sex, age, education level, annual household income, and dentate status (i.e., the presence or absence of natural teeth: edentate=no teeth, dentate=one or more teeth) by SUDAAN.

Of respondents to the core BRFSS questionnaire, 93.3% participated in the oral health module. Of these, 69.0% (95% CI=plus or minus 0.8 percentage points) reported having had a past-year dental visit (range: 61.4% {Arkansas} to 74.5% {Wisconsin}) (Table_1). Women were more likely than men to report having had a past-year visit (70.7% {95% CI=plus or minus 1.0 percentage points} and 67.1% {95% CI=plus or minus 1.2 percentage points}, respectively) (Table_2). The highest prevalences of such visits were among dentate adults aged greater than or equal to 65 years (75.0%) and all persons aged 35-44 and 45-54 years; the lowest prevalences were among edentate adults aged greater than or equal to 65 years (18.5%). The percentage of adults reporting a past-year visit varied directly with education levels and family incomes. The prevalence of a past-year visit was higher among insured adults than among uninsured adults (78.3% compared with 57.6%) and higher among dentate adults than among edentate adults (72.5% compared with 24.3%).

A total of 44.3% (95% CI=plus or minus 0.8 percentage points) of participants reported being uninsured at the time of interview (range: 31.8% {Alaska} to 60.4% {Maine}) (Table_1). This proportion was similar for both men (43.5% {95% CI=plus or minus 1.2 percentage points}) and women (45.2% {95% CI=plus or minus 1.0 percentage points}) (Table_2). The percentage of uninsured persons was lowest among persons aged 35-44 years and 45-54 years and highest among persons aged greater than or equal to 65 years and varied inversely with education level and family income. In addition, the likelihood of being uninsured was higher among edentate adults than dentate adults (67.1% compared with 42.4%) and higher among adults whose last dental visit was greater than or equal to 5 years ago than those with a past-year visit (69.4% compared with 36.5%).

The two most common reasons cited by respondents who did not have a past-year visit were that they did not perceive they had a dental problem (44.6%) and cost (26.6%). Among edentate adults, however, 89.5% did not perceive a problem, and 2.5% cited cost as a reason for not having had a past-year visit. Similar percentages of insured respondents (42.9%) and uninsured respondents (45.6%) did not perceive the need to visit a dentist. However, 36.0% of uninsured adults cited cost as the reason for not having had a past-year visit compared with 11.9% of insured adults.

Reported by: J Cook, MPA, Alabama; P Owen, Alaska; B Bender, Arizona; J Senner, PhD, Arkansas; B Davis, PhD, California; E Pledger, MPA, Georgia; C Johnson, MPH, Idaho; B Steiner, MS, Illinois; N Costello, MPA, Indiana; A Wineski, Iowa; D Maines, Maine; D Brooks, MPH, Massachusetts; P Smith, Montana; T Melnik, DrPH, New York; J Kaske, MPH, North Dakota; R Indian, MS, Ohio; J Grant-Worley, MS, Oregon; J Hesser, PhD, Rhode Island; K Condon, Texas; R Giles, Utah; R McIntyre, PhD, Vermont; L Redman, Virginia; K Wynkoop-Simmons, PhD, Washington; E Cautley, MS, Wisconsin; M Futa, MA, Wyoming. Behavioral Surveillance Br, Div of Adult and Community Health; Surveillance, Investigations, and Research Br, Div of Oral Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The BRFSS oral health module generates state-specific estimates that for the first time document variation in past-year dental visits and dental insurance coverage for adults in participating states. Overall, state-specific prevalences of persons reporting a past-year visit varied inversely with prevalences of persons without dental insurance. This association is consistent with results of the National Health Interview Survey (2) and other previously published studies (5,6). However, in some states (e.g., Massachusetts, Ohio, and Vermont), use was high despite lower percentages of dental insurance coverage. Such differences may reflect differences in age distribution, income, or education level of adults in these states. Twelve states exceeded the national health objective of greater than or equal to 70% of adults aged greater than or equal to 35 years using the oral-health-care system during each year (4).

Among specific population groups (e.g., younger and older age groups, lower income or education level groups, or edentate persons), lower percentages of adults reported dental insurance coverage and dental services use. Because dental insurance typically is provided as an employee benefit, groups less likely to have dental insurance include young adults and elderly retired persons. Overall, uninsured adults were three times more likely than insured adults to cite cost as the main reason for not having had a past-year visit. Infrequent use of dental services has been associated with poor oral health among adults with lower income and education levels; such persons have more decayed teeth requiring treatment, more severe periodontal disease, and are more likely to be edentate than adults with more education and higher incomes (7). Regardless of insurance status, however, almost half the adults who did not have a past-year visit in 1995 did not perceive the need for one. This finding was particularly evident among edentate adults and is of concern because adults without teeth are older, and the incidence of oral cancers that could be detected during an oral examination is higher among older adults (8-10).

Interpretations of these survey results are subject to at least two limitations. First, because the BRFSS does not include households without a telephone, these findings may underestimate the prevalence of being uninsured in some population groups (e.g., lower income or education level). Second, adults who are eligible for Medicaid or who have Medicare who reported having dental insurance may not be aware that coverage for many dental services may be limited or nonexistent.

The BRFSS can provide routinely available, timely, state-specific data on reported use of dental services and dental insurance coverage that may be used for monitoring trends over time and the effects of changes in the dental health-care delivery system. Changes may include the provision of coverage of some dental services offered to Medicare beneficiaries by HMOs; increasing proportions of the population, including those eligible for Medicaid, covered by managed-care versus fee-for-service dental insurance plans; and increases in the price of dental services relative to the Consumer Price Index. The BRFSS also can serve as the basis for planning and evaluating oral health promotion and disease prevention programs. Such programs are designed to enhance knowledge and behaviors that can maintain and improve oral health (e.g., routine oral examinations and primary and secondary prevention services).

References

1. National Center for Health Statistics. Healthy people 2000 review, 1995-96. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1996.

2. Bloom B, Gift HC, Jack SS. Dental services and oral health: United States, 1989. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1992:8-11; DHHS publication no. (PHS)93-1511. (Vital and health statistics; series 10, no. 183).

3. Damiano PC, Shugars DA, Johnson JD. Expanding health insurance coverage and the implications for dentistry. J Public Health Dent 1992;52:52-8.

4. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1990; DHHS publication no. (PHS)91-50212.

5. Manning WG, Bailit HL, Benjamin B, Newhouse JP. The demand for dental care: evidence from a randomized trial in health insurance. J Am Dent Assoc 1985;110:895-902.

6. Grembowski D, Conrad D, Milgrom P. Utilization of dental services in the United States and an insured population. Am J Public Health 1985;75:87-9.

7. Chen M-S. Oral health of disadvantaged populations. In: Cohen LK, Gift HC, eds. Disease prevention and oral health promotion: socio-dental sciences in action. Munksgaard, Copenhagen: Federation Dentaire International, 1995:153-212.

8. CDC/National Institutes of Health. Cancers of the oral cavity and pharynx: a statistics review monograph, 1973-1987. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, 1991.

9. Silverman S Jr. Oral cancer. Atlanta, Georgia: American Cancer Society, 1985.

10. US Preventive Services Task Force. Guide to clinical preventive services: report of the US Preventive Services Task Force. 2nd ed. Baltimore, Maryland: Williams & Wilkins, 1996:175-80.

* Alabama, Alaska, Arizona, Arkansas, California, Georgia, Idaho, Illinois, Indiana, Iowa, Maine, Massachusetts, Montana, New York, North Dakota, Ohio, Oregon, Rhode Island, Texas, Utah, Vermont, Virginia, Washington, Wisconsin, and Wyoming.

TABLE 1. Weighted percentage of persons reporting a dental visit during the previous 12 months and
persons reporting having no dental insurance, by state -- United States, Behavioral Risk Factor
Surveillance System, 1995 *
====================================================================================================
                           Dental visit                      No dental
                        during previous 12                   insurance
                              months
                      ------------------------         --------------------------
State                   %            (95% CI+)           %             (95% CI)
----------------------------------------------------------------------------------------------------
Alabama                64.1          (+/-2.7%)          49.8          (+/-2.8%)
Alaska                 73.3          (+/-3.2%)          31.8          (+/-3.2%)
Arizona                66.5          (+/-3.2%)          43.9          (+/-3.2%)
Arkansas               61.4          (+/-2.6%)          55.4          (+/-2.6%)
California             66.5          (+/-2.4%)          43.7          (+/-2.3%)
Georgia                71.8          (+/-2.2%)          36.4          (+/-2.3%)
Idaho                  65.9          (+/-2.0%)          46.6          (+/-2.1%)
Illinois               73.5          (+/-2.6%)          39.4          (+/-3.1%)
Indiana                65.2          (+/-2.2%)          43.7          (+/-2.2%)
Iowa                   68.1          (+/-1.8%)          46.0          (+/-1.9%)
Maine                  66.0          (+/-3.0%)          60.4          (+/-3.1%)
Massachusetts          74.2          (+/-2.3%)          46.0          (+/-2.6%)
Montana                65.6          (+/-3.0%)          57.3          (+/-3.1%)
New York               71.1          (+/-3.3%)          44.5          (+/-3.4%)
North Dakota           68.9          (+/-2.4%)          58.8          (+/-2.7%)
Ohio                   73.9          (+/-2.7%)          47.3          (+/-3.2%)
Oregon                 70.8          (+/-1.9%)          41.1          (+/-2.0%)
Rhode Island           69.2          (+/-2.5%)          43.2          (+/-2.6%)
Texas                  65.1          (+/-2.7%)          47.0          (+/-2.7%)
Utah                   73.3          (+/-2.2%)          39.5          (+/-2.5%)
Vermont                73.0          (+/-2.0%)          48.3          (+/-2.3%)
Virginia               73.5          (+/-2.4%)          40.8          (+/-2.6%)
Washington             68.8          (+/-1.8%)          40.6          (+/-1.9%)
Wisconsin              74.5          (+/-2.3%)          42.0          (+/-2.6%)
Wyoming                66.4          (+/-2.2%)          46.3          (+/-2.3%)
Total                  69.0          (+/-0.8%)          44.3          (+/-0.8%)
----------------------------------------------------------------------------------------------------
* n=56,339. Excludes persons who said they did not know or who refused to respond.
+ Confidence interval.
====================================================================================================

TABLE 2. Weighted percentage of persons reporting a dental visit during the previous 12 months and persons
reporting having no dental insurance, by selected characteristics -- United States, Behavioral Risk Factor
Surveillance System, 1995 *
=============================================================================================================
                                    Dental visit                       No dental
                                 during previous 12                    insurance
                                       months
                             ----------------------------       ---------------------------
Characteristic                    %            (95% CI+)           %             (95% CI)
-------------------------------------------------------------------------------------------------------------
Sex
 Men                            67.1           (+/-1.2%)         43.5           (+/-1.2%)
 Women                          70.7           (+/-1.0%)         45.2           (+/-1.0%)
Age group (yrs)
 18-24                          67.4           (+/-2.5%)         44.3           (+/-2.7%)
 25-34                          67.1           (+/-1.6%)         39.8           (+/-1.8%)
 35-44                          72.5           (+/-1.8%)         34.2           (+/-1.8%)
 45-54                          75.0           (+/-1.8%)         35.9           (+/-2.2%)
 55-64                          69.8           (+/-2.0%)         49.7           (+/-2.2%)
  >=65                          61.6           (+/-1.6%)         69.3           (+/-1.8%)
Education level (yrs)
  <12                           50.0           (+/-2.2%)         63.4           (+/-2.2%)
   12                           66.4           (+/-1.4%)         47.9           (+/-1.4%)
 >=13                           75.6           (+/-0.9%)         36.9           (+/-1.0%)
Annual household income
 <$15,000                       51.2           (+/-2.5%)         67.2           (+/-2.5%)
 $15,000-$24,999                59.2           (+/-1.8%)         61.0           (+/-1.8%)
 $25,000-$34,999                67.6           (+/-1.8%)         43.4           (+/-1.8%)
 >=$35,000                      79.4           (+/-1.0%)         28.2           (+/-1.2%)
Insurance status
 Insured                        78.3           (+/-1.0%)          --
 Uninsured                      57.6           (+/-1.2%)          --
Dentate status&
 Edentate                       24.3           (+/-2.3%)         67.1           (+/-2.5%)
 Dentate                        72.5           (+/-0.4%)         42.4           (+/-0.4%)
Time since last visit
 <=1 year                        --                              36.5           (+/-1.0%)
 >=5 years                       --                              69.4           (+/-2.5%)
Total                           69.0           (+/-0.8%)         44.3           (+/-0.8%)
-------------------------------------------------------------------------------------------------------------
* n=56,339. Excludes persons who said they did not know or who refused to respond.
+ Confidence interval.
& Edentate=no teeth, dentate=one or more teeth.
=============================================================================================================

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