Accounting for uncertainty in policy decision making: Improving access to pediatric dental care

Dental care access for children in the United States

OBJECTIVES

To evaluate access to dental care for children in the United States.

METHODS

The study population included children in 48 states and the District of Columbia. Using multiple data sources, dental care access was estimated at the community level by matching dental care supply and demand using mathematical modeling accounting for access constraints. Outcome measures included percent-met demand, travel distance, and percentage of underserved and unserved communities. Multiple scenarios to improve Medicaid/CHIP participation of dentists were evaluated.

RESULTS

Medicaid-insured and CHIP-insured children exhibited lower access compared to those privately insured. The percent-met demand was lower than 50% for Medicaid-insured children and CHIP-insured children for 42 and 34 states, respectively. Percent-met demand was higher than 50% for private-insured children except for Texas and West Virginia. Increasing Medicaid/CHIP participation of dentists resulted in improving access for public-insured children. At 100% Medicaid/CHIP participation, all states exhibited different degrees of percent-met demand increase for publicly insured children, from 7% to 46%. The percent-met demand across all children ranged in 23.8%-82.9% under 70% participation rate versus 22%-83% under 100% participation rate. No single participation rate improved access for all children uniformly across all states.

CONCLUSIONS

This study found that dental care access was lower for children with public insurance than those with private access across all states, although states responded differently to changes in Medicaid/CHIP participation. Increasing access for children with public insurance would reduce disparities, but overall children's access to dental care would be better improved by expanding the oral health workforce.

The impact of dentists' availability in delivering dental care in Florida Elementary Schools

OBJECTIVE

This study evaluates the dentists' availability to deliver preventive dental care to children in schools and the impact of school-based programs on access.

METHODS

The study population included Florida elementary-school children, differentiated by dental insurance (Medicaid, CHIP, private, or none). We considered the implementation of school-based programs using optimization modeling to (re)allocate the dentists' caseload to schools to meet demand for preventive care under resource constraints. We considered multiple settings for school-based program implementation: (i) school prioritization; and (ii) dentists' participation in public insurance. Statistical inference was used to identify communities to improve access and reduce disparities.

RESULTS

School-based programs reduced unmet demand (3%-12%), being more efficient if prioritizing schools in communities targeted to improve access. The access improvement varied by insurance status and geography. Uninsured urban children benefited most from school-based programs, with 15%-75% unmet need reduction. The percentage of urban communities targeted to improve access decreased by 12% against no-school program. Such percentage remained large for suburban (15%-100%) and rural (50%-100%) communities. Disparity in access for public-insured vs. private-insured children persisted under school-based programs (32%-84% identified communities).

CONCLUSION

School-based programs improve dental care access; the improvement was however different by insurance status, with uninsured children benefiting the most. Accounting to the dentists' availability in prioritizing schools resulted in effective resource allocation to school-based programs. Access disparities between public and private-insured children did not improve; school-based programs shifted resources from public-insured to uninsured. School-based programs are effective in addressing access barriers to those children experiencing them most.

Evaluating access to pediatric oral health care in the southeastern states

BACKGROUND

In this article, the authors addressed shortcomings in existing research on pediatric oral health care access using rigorous data and methods for identifying statistically significant disparities in oral health care access for children.

METHODS

The study population included children, differentiated by insurance status (Medicaid, Children's Health Insurance Program, private, none). The authors measured provider-level supply as the number of oral health care visits, stratified by provider type and urbanicity-rurality. The authors defined demand as the number of dental visits for children and derived demand and supply mainly from 2019 and 2020 data. Using statistical modeling, the authors evaluated where disparities in travel distance across communities or by insurance status were statistically significant.

RESULTS

Although Dental Health Professional Shortage Areas are primarily rural, this study found that the proportions of rural, suburban, and urban communities identified for access interventions ranged from 24% through 66% and from 8% through 86%, respectively. For some states (Florida, Louisiana, Texas), rural and suburban communities showed a need for interventions for all children, whereas in the remaining states, the lack of Medicaid and Children's Health Insurance Program access mainly contributed to these disparities. Variations in access disparities with respect to insurance status across states or by urbanicity-rurality were extensive, with the rate of communities identified for reducing disparities ranging from 1% through 100%.

CONCLUSIONS

All states showed a need for access interventions and for reducing disparities due to geographic location or insurance status. The sources of disparities were different across states, suggesting need for different policies and interventions across the 10 states.

PRACTICAL IMPLICATIONS

The study findings support the need for policies toward reducing disparities in oral health care access.

Accounting for uncertainty in policy decision making: Improving access to pediatric dental care

OBJECTIVE

To introduce a statistical inference framework for policy decision making on access to pediatric dental care.

DATA SOURCES

Secondary data were collected for the state of Colorado for year 2019.

STUDY DESIGN

The access model was an optimization model, matching the demand (patients) and supply (providers) of dental care. Sampling distributions of model inputs were specified using hierarchical Bayesian models, with hyperparameters informed by prior information derived from multiple data sources. Simultaneous inference was applied to identify areas for access improvement. The model was applied to make inference on the pediatric dental care in Colorado, accounting for financial access, differentiated into public (Medicaid and CHIP), private (commercial and out-of-pocket), and without financial access.

DATA COLLECTION/EXTRACTION METHODS

Multiple data sources informed the access measurement approach including: 2017 American Community Survey, 2019 Colorado Dental Board, and 2019 National Provider Plan and Enumeration System, 2019 InsureKidsNow.gov among others.

PRINCIPAL FINDINGS

The median access measure (travel distance) was greater than the Colorado access standards in 16.9% and 65.1% of census tracts for children with private financial access and publicly insured, respectively. Accounting for uncertainty (confidence level 99%), these percentages decreased to 14.6% and 25.6%, respectively, with mostly suburban and rural tracts failing to meet the standards. The median disparity for Medicaid and CHIP versus private financial access was greater than 5 miles in 84.5% and 81.6% of census tracts, respectively. Accounting for uncertainty (confidence level 99%), these percentages declined to 19.5% and 10.5%, respectively, with significant disparities around the metropolitan areas.

CONCLUSIONS

While many communities failed to meet access standards, when accounting for uncertainty, most urban ones did not fail. Disparities in spatial access between publicly and privately insured were most acute in urban communities. Medicaid insured experienced higher disparities than CHIP insured; those differences were not identified when not accounting for uncertainty.