A Mouthful of Pain and Postponed Dental Work

Why Disparities in Dental Care Persist for African Americans Even When They Have Insurance Coverage

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'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 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%).

“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.

The study found that insured participants reported insurance-related difficulties, such as insufficient to coverage for needed treatments, inability to find a dentist who accepts their insurance, and having to wait for coverage to take effect. 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.”

The study was supported by a grant from the National Institute of Dental and Craniofacial Research.