African Americans receive poorer dental care than white Americans, even when they have some dental insurance coverage. To better understand why this is so, researchers at Columbia University's Mailman School of Public Health and the College of Dental Medicine, surveyed African American adults with recent oral health symptoms, including toothaches and gum disease. Their findings provide insights into why disparities persist even among those with dental insurance and suggest strategies to removing barriers to dental care.
The findings are published online ahead of print in the American Journal of Public Health.
The study is a qualitative survey of 118 men and women intercepted on the street in Central Harlem. Although the majority (75%) of adults in the study reported at least some type of dental insurance coverage, this was largely limited to Medicaid (50%) rather than private coverage (21%) or other types of dental insurance (4%).
The findings indicated that insured participants reported insurance-related difficulties, such as insufficient coverage for needed treatments, inability to find a dentist who accepts their insurance, and having to wait for coverage to take effect.
"For the 25% of respondents who reported having no dental insurance coverage, the costs of dental care and the lack of insurance coverage were consistently noted as critical barriers to obtaining quality dental treatment of their dental symptoms," said Eric Schrimshaw, PhD, assistant professor of Sociomedical Sciences at the Mailman School, and first author. "Even among those who had some dental insurance – such as Medicaid -- it was often not enough to eliminate the obstacles to obtaining needed dental treatment," noted Dr. Schrimshaw.
For instance, one 58-year-old man with a toothache described his difficulty paying for out-of-pocket costs despite having dental coverage. Consequently, he sought only emergency dental care during the 5 years before his interview:
"The dental plan is only going to pay for so much. And then there are a lot of out-of-pocket expenses… If you don't have that dental care, you just go to the dentist on emergency when that teeth need to be come out or whatever. That's the only time you go."
The authors also report that even when participants were able to see a dentist with the limited insurance they had or while uninsured, many believed that because of their lack of private insurance they received a poorer quality of care than did others. For instance, one 46-year-old woman on Medicaid with pain and irritation of her gums who had not been to a dentist in nearly five years said this:
"I feel as though that they didn't give me the best service that they could, and that's only because I didn't have the money or medical coverage to pay for it. It's all about money. And they showed it . . . you can see how they treat you differently."
The finding that participants on Medicaid reported a number of impediments is particularly important, according to the researchers, as this program is often promoted as a means to meaningfully reduce barriers to care and health disparities. "Although Medicaid allowed some participants to obtain basic care such as dental cleanings, the barriers identified suggest that enhancements to the program would significantly improve many patients' ability to obtain treatment," Dr. Schrimshaw added. He suggested that efforts to increase the number of dentists participating in Medicaid and increase the types of services (for example, root canals rather than just tooth extractions) covered by Medicaid would improve individuals' ability to obtain needed treatment.
The Columbia researchers also point out that although publicly funded dental clinics would be one potential source of affordable dental care regardless of insurance status, all such city-funded dental clinics in the Harlem area were closed shortly after this study was completed because of city budget constraints, leaving only hospital-based emergency care.
"Many of the new and innovative models of healthcare provision and payment provided for in the Patient Protection and Affordable Care Act are designed to expand access, contain costs, and increase the quality of care provided. What is needed is for access to dental care be included in this healthcare reform; the expansion of affordable, quality dental care would be a great benefit to underserved communities like Harlem," said Dr. Schrimshaw.
"The lack of affordable dental care and insurance coverage lead many of our participants to postpone or do without dental treatment, often for years. But these untreated symptoms inevitably get more severe, resulting in people requiring treatment in the emergency department at a much greater public expense than if they had been provided dental treatment when the symptoms first occurred. Further, given the research evidence on the relationship between untreated oral symptoms and systemic health problems such as cardiovascular disease and stroke, providing better oral health treatment may not only reduce suffering but also may prevent expensive physical health problems in the future."
Co-authors of the study include Karolynn Siegel, PhD, Natalie H. Wolfson, BA, Dennis A. Mitchell, DDS, MPH, and Carol Kunzel, PhD.
The study was supported by a grant from the National Institute of Dental and Craniofacial Research.
About Columbia University's Mailman School of Public Health
Founded in 1922 as one of the first three public health academies in the nation, Columbia University's Mailman School of Public Health pursues an agenda of research, education, and service to address the critical and complex public health issues affecting New Yorkers, the nation and the world. The Mailman School is the third largest recipient of NIH grants among schools of public health. Its over 300 multi-disciplinary faculty members work in more than 100 countries around the world, addressing such issues as preventing infectious and chronic diseases, environmental health, maternal and child health, health policy, climate change & health, and public health preparedness. It is a leader in public health education with over 1,000 graduate students from more than 40 nations pursuing a variety of master's and doctoral degree programs. The Mailman School is also home to numerous world-renowned research centers including the International Center for AIDS Care and Treatment Programs (ICAP), the National Center for Disaster Preparedness, and the Center for Infection and Immunity. For more information, please visit www.mailman.columbia.edu
Columbia University College of Dental Medicine (CDM) was established in 1916 as the School of Dental and Oral Surgery, when the School became incorporated into Columbia University. The College's mission has evolved into a tripartite commitment to education, patient care, and research. The mission of the College of Dental Medicine is to train general dentists, dental specialists, and dental assistants in a setting that emphasizes comprehensive dental care delivery and stimulates professional growth; inspire, support, and promote faculty, pre- and postdoctoral student, and hospital resident participation in research to advance the professional knowledge base; and provide comprehensive dental care for the underserved community of northern Manhattan. For more information, please visit: http://dental.columbia.edu
Journal
American Journal of Public Health