New data show that Americans are still not getting the dental care they need

Costs as a deterrent to care… Growing racial disparities across the system… Lack of access to dental coverage.

These are just some of the continuing challenges that are driving deep inequities in our oral health-care system, according to a new national study. Earlier this year, CareQuest Institute for Oral Health conducted its second annual State of Oral Health Equity in America survey―a nationally representative survey of 5,682 adults to study knowledge, attitudes, experiences, and behaviors related to oral health―and uncovered valuable and worrying insights about the state of the industry.

The survey is the largest and most comprehensive of its kind, and its depth and breadth offer researchers the ability to uncover trends in oral health equity gaps for specific populations based on race/ethnicity, sexual orientation, income, insurance status, disability status, and social determinants of health.

According to the results of the survey, two years after dental care was disrupted for millions of Americans, many are still not getting the dental care they need, and disparities in oral health care persist. One of the most shocking revelations is that 77 million adults in the United States do not have dental insurance.¹ Data in the survey give additional insight into the many barriers that historically underserved populations—including people of color, low-income or uninsured people, and veterans—face when accessing oral health care.

Four key takeaways from the 2022 survey

Black, Hispanic, Asian, and American Indian/Alaska Native (AI/AN) populations face disparities in oral health

This survey confirms what is already widely recognized—our health-care system does not work for everyone, and deep-rooted racial inequities exist across our nation. New insights from the survey show that race and ethnicity are closely linked with the health of an individual’s mouth and their livelihood.

Black, Hispanic, Asian, and AI/AN populations often reported worse oral health status than their white counterparts. Nearly six in 10 (59%) of Black adults have lost one or more permanent teeth due to decay or gum disease compared to 45% of all adults. Further, higher proportions of Black (34%) and Hispanic (25%) adults rate their oral health as fair or poor compared to white adults (23%).¹

These populations also reported various barriers to care. According to the survey, higher proportions of Asian (49%), Hispanic (49%), and Black (48%) populations reported experiencing discrimination in oral health care compared to their white counterparts (33%). Thirty-two percent (32%) of Black adults and 30% of Hispanic adults reported at least moderate difficulty getting care for oral pain, compared to 21% of white adults.¹

Oral health disparities exist due to lack of dental coverage

Results from the survey show that oral health inequities also exist due to lack of insurance. For instance, 16% of adults without dental insurance report they haven’t seen a dentist in more than five years compared to just 5% of adults with dental insurance. Forty percent of adults without dental insurance reported cost is the reason they haven’t visited the dentist in the past two years, compared to 14% of adults with dental insurance.¹

Further, the lack of dental insurance impacts oral health status: One in four (25.1%) people without dental insurance reported that their overall health has gotten worse over the past year compared to those with dental insurance (19.9%), and higher proportions of those without dental insurance rated their oral health as poor (11.5%) compared to those with dental insurance (5.5%).¹

Oral health inequities persist for veterans

On the heels of a white paper by A merican Institute of Dental Public Health and CareQuest Institute, the survey data indicates that veterans face significant inequities in oral health care. Nearly half (49%) of veterans reported that a disability in their household made it difficult to access needed care compared to nonveterans (19.9%). Fourteen percent of veterans reported losing six or more teeth due to decay or gum disease, compared to 8% of nonveterans.¹

Disparities in oral health status exist by income

The survey reveals that low-income individuals often face significant barriers to oral health care and report worse oral health status. More adults identified cost as a reason they are likely to avoid dental care in 2022 (43%) than in 2021 (38%).² More than twice the proportion of Americans in the lowest income category (13%) compared to those in the highest category (5%) rate their oral health as poor.¹

This survey data provides valuable insights into our oral health system, but the data we collect is only as good as what we do with it. Too often, we don’t have the oral health data we need to drive systemic change. That’s why a survey of this size and scope is critical to the development of actionable steps to help transform the oral health system into one that is more accessible, equitable, and integrated. The insights gathered can—and should—be used to inform advocacy, policy, technology advancement, and clinical integration to increase access to oral health care, especially for historically marginalized populations.

Solutions to address oral health disparities

There are solutions that can meet these challenges and help break down these barriers to care. They include:

Expand Medicaid and Medicare coverage: The survey reaffirms that inequity in access to necessary preventive care and treatment of oral disease persists for millions of people, including many people of color. A key issue contributing to racial inequities in oral health is insurance coverage. In states that have not expanded Medicaid coverage, Black and Hispanic adults make up more than half of those in the “coverage gap”³—individuals who fall into this gap have incomes that are too low for subsidized health insurance under the Affordable Care Act but too high to be eligible for Medicaid. Prior research has found that expansion of Medicaid benefits contributes to reduced racial health disparities.⁴ That’s why any meaningful effort to reduce oral health disparities must include the expansion of Medicaid benefits and the inclusion of an adult dental benefit.

Under the Medicaid program, low-income children in all states are insured for a comprehensive set of dental services, but adult coverage varies significantly by state.⁵ In a slight majority of states, Medicaid programs offer no adult dental benefits, restrict adult coverage to emergency-only care, or offer limited coverage. States without an extensive dental benefit make it harder for adults to maintain healthy mouths.

Medicare also does not cover routine dental services. Nearly 24 million Medicare beneficiaries lack critical oral health coverage,⁶ meaning many older adults do not receive regular dental services.

All Americans should receive regular dental care to prevent oral health problems from developing. When cost, lack of transportation, or other barriers lead people to postpone care, oral infections are likely to worsen and become more difficult and costly to treat.

Community engagement: Sustainable solutions to integrating oral health, expanding access, and improving outcomes must be community informed and community driven. Engaging communities must be an intentional part of effective policy change to integrate oral health into overall health. That means empowering historically marginalized communities that are most directly impacted by oral health inequities, including communities of color, rural communities, older adults, LGBTQ+, people with disabilities, and tribal communities. Those closest to the problem have historically been, and continue to be, denied the opportunity to influence and drive the development of solutions. In order to drive transformative change, the voices of those with lived experience must be meaningfully included and amplified.

Expanding and diversifying the dental workforce: Critically important to addressing disparities in oral health care is diversifying the dental workforce to look more like the population of the US, which will help strengthen the acceptance of good oral health among hard-to-reach populations and promote health equity. By creating accessible pathways for people from areas with little access to oral health care to pursue dental careers, communities will have better access to dental care in environments that may feel more culturally responsive to their needs.

Expanding the dental workforce through the expanded use of dental hygienists and dental therapists is another way to reduce barriers to dental care. Further, integrating oral health into other health-care settings, such as primary care, holds the promise of further expanding the oral health workforce and increasing access to care. Expanding the reach of the oral health workforce is a way in which the broader oral health-care system can be redesigned to provide more equitable person-centered, value-based, and prevention-oriented care.

As we continue to analyze this survey data, these new insights into the many barriers facing historically underserved populations will help inform ongoing work to address inequities in our oral health-care system, implement systemic change, and break the cycle of oral health disparities. Because to build a healthier nation, we need to make sure all people have the keys they need to access good oral health. That is what a just oral health system looks like.

Editor's note: This article appeared in the November 2022 print edition of Dental Economics magazine. Dentists in North America are eligible for a complimentary print subscription. Sign up here.

References

Tranby EP, Thakkar-Samtani M, Sonnek AC, Johnson IB. How’s America’s oral health? Barriers to care, common problems, and ongoing inequity. CareQuest Institute for Oral Health. June 2022. Accessed September 7, 2022. https://www.carequest.org/education/webinars/hows-americas-oral-health-barriers-care-common-problems-and-ongoing-inequity?check_logged_in=1
2. Heaton LJ, Sonnek AC, Schroeder K, Tranby EP. Americans are still not getting the dental care they need. CareQuest Institute for Oral Health. April 2022. doi:10.35565/CQI.2022.2020
3. Lukens G, Sharer B. Closing Medicaid coverage gap would help diverse group and narrow racial disparities. Center on Budget and Policy Priorities. June 2021. Accessed September 7, 2022. https://www.cbpp.org/research/health/closing-medicaid-coverage-gap-would-help-diverse-group-and-narrow-racial
4.Guth M, Artiga S, Pham O. Effects of the ACA Medicaid expansion on racial disparities in health and health care. Kaiser Family Foundation. September 2020. Accessed September 7, 2022. https://www.kff.org/medicaid/issue-brief/effects-of-the-aca-medicaid-expansion-on-racial-disparities-in-health-and-health-care/
5. Healthy mouths: Why they matter for adults and state budgets. CareQuest Institute for Oral Health. February 2020. doi:10.35565/CQI.2020.1001
6. Freed M, Ochieng N, Sroczynski N, Damico A, Amin K. Medicare and dental coverage: a closer look. Kaiser Family Foundation. July 2021. Accessed September 7, 2022. https://www.kff.org/medicare/issue-brief/medicare-and-dental-coverage-a-closer-look/