Research Brief
Fewer Americans Forgoing Dental Care
Due to Cost
Authors: Thomas Wall, M.A., M.B.A.; Kamyar Nasseh, Ph.D.; Marko
Vujicic, Ph.D.
The Health Policy Institute (HPI)
is a thought leader and trusted
source for policy knowledge on
critical issues affecting the U.S.
dental care system. HPI strives
Key Messages

to generate, synthesize, and
disseminate innovative research

for policy makers, oral health
advocates, and dental care
providers.

The percentage of the population reporting cost as a barrier to receiving needed dental
care fell in 2013. This decline is now in its third year, reversing the increase that occurred
from 2000 to 2010.
The largest decrease in cost barriers to dental care was among adults ages 21-34. The
percentage reporting cost barriers declined from 17.1 percent in 2012 to 14.8 percent in
2013.
Despite improvements in affordability over the last few years, cost still remains the most
critical barrier to obtaining needed dental care.
Who We Are
HPI’s interdisciplinary team of
health economists, statisticians,
and analysts has extensive
expertise in health systems
Introduction
The ADA Health Policy Institute is leading a comprehensive research program on access to
dental care, including closely monitoring the percentage of the U.S. population reporting cost
policy research. HPI staff
as a barrier to dental care.1 Studies have shown that affordability is the most common
routinely collaborates with
reason many segments of the U.S. population avoid or delay receiving dental care they
researchers in academia and
need.2,3,4 Research has also shown that cost barriers are higher for dental care compared to
policy think tanks.
other healthcare services.5
In this research brief, we use newly released data to update our previous analysis of cost
Contact Us
Contact the Health Policy
barriers to dental care through 2013. We analyze cost barriers to dental care by age and by
household income.
Institute for more information on
products and services at
[email protected] or
call 312.440.2928.
© 2013 American Dental Association All Rights Reserved.
October 2014
Research Brief
Data & Methods
Results
We used data from the National Health Interview
Figure 1 shows the percentage of the population
Survey (NHIS).6 This survey, conducted annually, is
reporting cost as a barrier to obtaining needed dental
nationally representative of the civilian non-
care, medical care, prescription drugs, mental health
institutionalized U.S. population. The family core
services and eyeglasses. The trends over time were
component collects information on every member of a
similar for all five services – a fairly steady increase
sample household, including information on
from 2000 to 2010, followed by a decrease from 2010
demographics, health characteristics and insurance
to 2013. Changes from 2000 to 2010 and from 2010 to
coverage. The interviewed sample in 2013 consisted of
2013 were statistically significant. Changes between
104,520 individuals. One adult and one child (ages 0-
2012 and 2013 for all health care services were not
17) per household were randomly selected for the
statistically significant.
sample adult and sample child components.
Figure 2 shows that from 2000 to 2010, the percentage
We compared cost barriers for five categories of health
of population who experienced cost barriers to dental
care services: (1) dental care, including check-ups (2)
care increased among all age groups, with the notable
medical services, (3) mental health services, (4)
exception of children. From 2010 to 2013 cost barriers
prescription drugs and (5) eyeglasses. The dependent
to dental care declined among both children and
variable in the analysis was a binary variable based on
working-age adults. The percentage of adults ages 21-
the response to the following question: “During the past
34 reporting cost as a barrier to dental care fell from
12 months was there ever a time when you needed
17.1 percent in 2012 to 14.8 percent in 2013, the
[health care service] and didn’t get it because you
largest decrease of any age group. All of these
could not afford it?”
changes were statistically significant. In 2013, young
adults ages 21-34 were just as likely as adults 35-64 to
We examined trends in cost as a barrier to dental care
report cost barriers to dental care. Young adults are
for children ages 2-20, three non-elderly adult age
no longer the age group with the highest level of cost
groups (21-34, 35-49 and 50-64) and elderly adults
barriers to dental care.
ages 65 and older. We also reported results for nonelderly adults by four levels of household income as
Figure 3 shows trends for adults 21-64 broken down by
defined in the NHIS: (1) less than 100% of the Federal
household income level. From 2000 to 2010, the
Poverty Level (FPL), (2) 100-199% of the FPL, 200-
percentage who could not obtain needed dental care
399% of the FPL and (4) 400% of the FPL and higher.
due to cost increased among all income groups. From
2010 to 2013, it declined among all income groups.
We tested for statistical significance across time using
Both of these changes over time were statistically
a chi-squared test. Our point estimates and statistical
significant. However, changes from 2012 to 2013 were
inferences take into account the complex survey
not statistically significant.
design of the NHIS.
2
Research Brief
Figure 1: Percentage of the Population Who Needed But Did Not Obtain Select Health Care Services
during the Previous 12 Months Due to Cost, 2000-2013
16%
2000
14%
2001
2002
12%
2003
2004
10%
2005
8%
2006
2007
6%
2008
2009
4%
2010
2%
2011
2012
0%
Prescription Drugs
Dental Care
Mental Health
Services
Eyeglasses
Medical
2013
Source: National Health Interview Survey, National Center of Health Statistics. Notes: Changes from 2000 to 2010 for all services
were statistically significant at the 1% level. Changes from 2010 to 2013 for all services were statistically significant at the 1% level.
Changes from 2012 to 2013 were not statistically significant.
Figure 2: Percentage of the Population Indicating Cost as a Barrier to Receiving
Needed Dental Care by Age Group, 2000-2013
25%
20.3%
20%
14.8%
14.8%
15%
11.5%
10%
14.1%
10.0%
7.1%
5%
6.4%
5.8%
6.7%
3.9%
3.4%
0%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
2 to 20
21 to 34
35 to 49
50 to 64
65 +
Source: National Health Interview Survey, National Center for Health Statistics. Notes: Changes from 2000 to 2010 for age
groups 21-34, 35-49, 50-64 and 65 + were statistically significant at the 1% level. Changes from 2010 to 2013 for age groups 2-20,
21-34 and 35-49were statistically significant at the 1% level. Change from 2010 to 2013 for age group 50-64 was statistically
significant at the 5% level. For adults ages 21-34, the change from 2012 to 2013 was statistically significant at the 1% level. For
other age groups, changes from 2012 to 2013 were not statistically significant.
3
Research Brief
Figure 3: Percentage of the Adults Ages 21-64 Indicating Cost as a Barrier to Receiving
Needed Dental Care by Household Income, 2000-2013
35%
30.1%
30%
24.5%
25%
20%
15%
17.4%
19.1%
13.5%
10.7%
10%
5.4%
5%
4.0%
0%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
FPL<100%
FPL 100-199%
FPL 200-399%
FPL 400%+
Source: National Health Interview Survey, National Center for Health Statistics. Notes: Changes from 2000 to 2010 were
statistically significant at the 1%level for all income groups. Changes from 2010 to 2013 were statically significant at the 1% level for
all income groups except for < 100% FPL which was statistically significant at the 10% level. Changes from 2012 to 2013 were not
statistically significant.
Discussion
The percentage of the U.S. population reporting cost
Effort (MOE) provisions enacted under the Affordable
barriers to dental care continues to decrease, with
Care Act (ACA), which end for adults in 2014 and for
young adults experiencing the most significant decline.
children in 2019, helped to preserve ongoing coverage
While a full analysis of the underlying causes driving
in Medicaid and CHIP.8 The policy change could have
this improvement in the affordability of dental care is
reduced the percentage of low-income adults and
beyond the scope of this research brief, we offer some
children with cost barriers to dental care.
possible explanations.
The ACA’s expanded dependent coverage provision is
One important factor contributing to the overall decline
likely to have played a role in improving affordability of
in cost barriers to dental care could be changes in the
dental care for young adults. Since September 2010,
actual cost of dental care. A recent analysis shows that
the ACA has allowed young adults to remain on their
dental care prices have grown at much lower rates in
parents’ private health insurance until age 26.9
recent years and have increased less than the price of
Although this policy does not apply directly to private
other health care services.
7
dental benefits, a recent study reported that relative to
the pre-reform period, private dental benefits coverage
Policy changes at the national level that occurred
between 2010 and 2013 may have contributed to the
decline in access barriers due to cost. Maintenance of
among adults 19-25 increased in 2011 and 2012 as a
result of the reform.10 This dental benefits “spillover”
effect also led to an increase in dental care utilization
4
Research Brief
and a decrease in cost barriers to dental care among
This expansion of dental benefits coverage could
young adults.
further improve the affordability of dental care,
although there is considerable uncertainty at this stage
While the improvements in affordability of dental care
in the type of dental benefit plans being purchased in
observed in the past few years are encouraging, cost
the health insurance marketplaces as well as the
still remains the most important reason for avoiding or
readiness of Medicaid programs in many states to
delaying needed dental care.
11,12
Looking forward, up
absorb an influx of new beneficiaries.17 Problems such
to 8.7 million children are expected to gain dental
as administrative burdens and low reimbursement
benefits by 2018 as a result of the ACA.13 Up to 8.3
rates may limit the number of dental providers that
million adults are eligible to gain Medicaid dental
accept Medicaid.18 Recent studies show that reforming
benefits due to the Medicaid expansion.14 In addition,
Medicaid, including increasing reimbursement rates
through April 19, 2014 about 1.1 million adults and
closer to market levels, is associated with an increase
88,000 children obtained private dental coverage
in dental care utilization.19,20The Health Policy Institute
through stand-alone dental plans in the new health
will continue to monitor barriers to needed dental care
insurance marketplaces, with an unknown number
in the coming years.
gaining dental coverage through private medical
insurance.15 Adults ages 26-34 were by far the most
likely age group to purchase dental benefits in the
marketplaces.16
This Research Brief was published by the American Dental Association’s Health Policy Institute.
211 E. Chicago Avenue
Chicago, Illinois 60611
312.440.2928
[email protected]
For more information on products and services, please visit our website, www.ada.org/hpi.
5
Research Brief
References
1
Wall T, Nasseh K Vujicic M. Financial Barriers to Dental Care Declining after a Decade of Steady Increases. Health
Policy Institute Research Brief. American Dental Association. September 2013. Available
from:http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_1013_1.ashx. Accessed
August 5, 2014.
2 Bloom B, Simile CM, Adams PF, Cohen RA. Oral health status and access to oral health care for U.S. adults aged
18-64; National Health Interview Survey, 2008. National Center for Health Statistics. Vital Health Stat 10(253). 2012.
3
Brown T, Finlayson T, Fulton B, Jahedi S. The demand for dental care and financial barriers in accessing care among
adults in California. CDA Journal. 2009;37(8).
4 Wall T, Nasseh K, Vujicic M. Most important barriers to dental care are financial, not supply related. Health Policy
Institute Research Brief. American Dental Association. October 2014. Available from:
http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_1014_2.ashx. Accessed October 8,
2014.
5
Wall T, Nasseh K Vujicic M. Financial Barriers to Dental Care Declining after a Decade of Steady Increases. Health
Policy Institute Research Brief. American Dental Association. September 2013. Available
from:http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_1013_1.ashx. Accessed
August 5, 2014.
6
National Center for Health Statistics. National Health Interview Survey, 2013. Public-use data file and documentation.
Available at: http://www.cdc.gov/nchs/nhis/quest_data_related_1997_forward.htm#2013_NHIS. Accessed August 5,
2014, 2014.
7
Wall T, Nasseh K Vujicic M. Financial Barriers to Dental Care Declining after a Decade of Steady Increases. Health
Policy Institute Research Brief. American Dental Association. September 2013. Available from:
http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_1013_1.ashx. Accessed August 5,
2014.
8
The Kaiser Commission on Medicaid and the Uninsured. Medicaid Enrollment: June 2012 Data Snapshot. August
2013. Available at: http://kff.org/medicaid/issue-brief/medicaid-enrollment-june-2012-data-snapshot/. Accessed August
5, 2014.
9 Leonard Davis Institute of Health Economics. The Effects of the ACA’s Under-26 Mandate: What Do We Know? June
2014. Available at: http://ldi.upenn.edu/voices/2014/06/18/the-effects-of-the-aca-s-under-26-mandate-what-do-weknow. Accessed August 5, 2014.
10
Vujicic M, Yarbrough C, Nasseh K. The Effect of the Affordable Care Act's Expanded Coverage Policy on Access to
Dental Care. Med Care. 2014;52(8):715-719.
11 Wall T, Nasseh K, Vujicic M. Most important barriers to dental care are financial, not supply related. Health Policy
Institute Research Brief. American Dental Association. October 2014. Available from:
http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_1014_2.ashx. Accessed October 8,
2014.
12 Bloom B, Simile CM, Adams PF, Cohen RA. Oral health status and access to oral health care for U.S. adults aged
18-64; National Health Interview Survey, 2008. National Center for Health Statistics. Vital Health Stat 10(253). 2012.
13
Nasseh K, Vujicic M, O’Dell A. Affordable Care Act expands dental benefits for children but does not address critical
access to dental care issues. Health Policy Institute Research Brief. American Dental Association. April 2013. Available
from: http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_0413_3.ashx.
Accessed August 5, 2014.
14 Yarbrough C, Vujicic M, Nasseh K. More than 8 Million Adults Could Gain Dental Benefits through Medicaid
Expansion. Health Policy Institute Research Brief. American Dental Association. February 2014. Available from:
http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_0214_1.ashx. Accessed August 5,
2014.
15 Yarbrough C., Vujicic M., Nasseh K. Update: Take-Up of Pediatric Dental Benefits in Health Insurance Marketplaces
Still Limited. Health Policy Institute Research Brief. American Dental Association. May 2014. Available from:
6
Research Brief
http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPI%20Research%20Brief%20%20Update%20Takeup%20of%20Pediatric%20Dental%20Benefits.ashx. Accessed August 5, 2014.
16
Vujicic M, Yarbrough C. Young adults most likely age group to purchase dental benefits in health insurance
marketplaces. Health Policy Institute Research Brief. American Dental Association. August 2014. Available from:
http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_0814_3.ashx. Accessed August 14,
2014.
17 Yarbrough C, Vujicic M, Nasseh K. Health Insurance Marketplaces Offer a Variety of Dental Benefit Options, but
Information Availability is an Issue. Health Policy Institute Research Brief. American Dental Association. March 2014.
Available from: http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_0314_1.ashx.
Accessed October 6, 2014.
18
Government Accountability Office. 2000. “Oral Health. Factors Contributing the Low Use of Dental Services by LowIncome Populations.” GAO/HEHS-00-149. Available from: http://www.gao.gov/assets/240/230602.pdf. Accessed
October 8, 2014.
19 Decker SL. Medicaid payment levels to dentists and access to dental care among children and adolescents. JAMA.
2011;306(2):187-93.
20Nasseh
K, Vujicic M. The impact of Medicaid reform on children’s dental care utilization in Connecticut, Maryland and
Texas. Health Serv Res. Forthcoming 2015.
Suggested Citation
Wall T, Nasseh K, Vujicic M. Fewer Americans forgoing dental care due to cost. Health Policy Institute Research Brief.
American Dental Association. October 2014. Available from:
http://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_1014_6.ashx.
7