Reinstating MassHealth Dental Coverage is Just the Start of a Successful Intervention-
A Critique Emphasizing the Need For Social Change in Order to Improve Oral Health Outcomes-Kate Porta
Government-provided health services faced a budget reduction of $5.8 million in fiscal year 1996 (1). Part of the way the
Legislation was passed in January 2006 to reinstate these benefits in hopes to decrease health disparities and to improve the overall oral health of
In 2000, the Surgeon General identified oral health as integral to general health (4). According to the CDC’s Behavioral Risk Surveillance System (BRFSS), rates of “visits to a dentist or dental clinic within the past year” have been steady for the past eight years (the earliest data available was from 1999) (5). This indicates that people are not visiting an oral health professional more often even though there has been an increase in scientific literature about the importance of oral health. With the reinstatement of dental benefits under MassHealth, the government expects to see a rise in this trend. However, despite this expansion of benefits, rates of dental decay, periodontal disease, tooth loss, and oral cancer may not improve because there are many social and behavioral aspects that keep people from visiting the dentist. Recent statistics show only 30% of people enrolled in Medicaid receives dental care (6). The population that MassHealth serves faces multiple barriers in achieving and sustaining oral health.
Access to health care is an important factor in determining health. Health disparities are exacerbated by social economic status (SES), which is a strong indicator of lifestyle and geographic location. These two factors largely determine the availability and ability a person has to access the care they need and deserve. Even if the cost of the care itself is covered by insurance, issues of transportation, time commitments, and the monetary obligations associated with each offset the value of having dental insurance.
A needs assessment survey was conducted at the Buffalo School of Dental Medicine in 2002. Finances, medical bills, transportation, housing, mental health, legal concerns, and family issues were reported as barriers to care. Only thirty-two percent of the patients had a top priority of “health” (7). The U.S. Surgeon General’s report identified impoverished individuals as being the most vulnerable to the difficulty of accessing dental care and as having the poorest oral health in the nation (8). These statements are supported by the recent death (February, 2007) of a young boy from a poor family due to tooth decay complications (9).
MassHealth eligibility is defined by income. Recipients are categorized as “poor” and do not have enough money to cover necessary life expenses. Direct transportation is expensive, especially in the city. A substantial taxi fee is required to traverse a short distance and the luxury of owning a car is offset by the high prices of parking garages, car insurance, and parking tickets. The Department of Health and Human Services attempted to address this issue, but was unsuccessful in its efforts. Information to assist with transportation and out of pocket costs associated with dental visits is available on the Mass.Gov website. However, much of the population that MassHealth serves does not have regular access to the internet; they are poor and many live in shelters. Additionally, the information is hard to find.
Disparities are prominently reflected in the geographical distribution of dentists (4), especially dentists that accept MassHealth payments. Nearly seventy five percent of dentists do not treat Medicaid-insured patients (4). There are about fifty five providers within the city of
These issues of access are realistic barriers to receiving care. MassHealth recipients do not posses the same income or have access to the same means as the majority of the population. It is unreasonable to expect positive oral health outcomes when additional resources are not provided along with dental coverage.
Self-efficacy plays a necessary role in explaining the disproportionate oral health status among MassHealth recipients compared to the general population. Self-efficacy is defined as “a person’s belief in his or her ability to take action” (11). Without the ability to carry out a behavior, one will not be able to perform that specific behavior. In order to execute an action, the actor needs to believe the task is accomplishable, and have a sense of self-efficacy.
Independent of insurance coverage, a person will not seek dental care if they believe the barriers are insurmountable. The issue of access presents an intrinsic difficulty, but when someone is cognoscente of the barriers they will have to face after they make a dental appointment, the only option for many people may be to not make the appointment at all. If an individual is disadvantaged, he or she cannot afford to get to the dentist, cannot take time off from work, and cannot bring children with them to a three hour appointment. If these are the issues people are facing, attempting to go to the dentist is futile. It will not happen, so it is not worth trying. Someone with this reasoning lacks self-efficacy.
Communication between the dentist and the patient is extremely important. An individual who can speak freely to and understand their oral health professional will be more likely to go to the dentist and to follow the dentist’s recommendations (12). Without the ability to communicate, a patient will not feel comfortable going to the dentist. Additionally, much of the oral health workforce is not prepared to offer culturally competent care to a variety of ethnicities, races, and lifestyles (4). Without the comfort of cultural competency and control of communication, an individual’s self-efficacy will decrease.
Although many behavior models are not sufficiently designed to predict behavior outcomes, they do provide a basic “map” of behavior characteristics. The Social Cognitive Theory is a behavior model that predicts behavior change according to the interactions that occur between individuals and their environment (11). All actions are results of the combination of individual interpretations and external factors. Therefore, when adverse environmental and social surroundings predispose an individual to lack self-efficacy, behavior change is inhibited.
Possessing self-efficacy is an important part of initializing and following through with behaviors. An individual cannot be expected to have control over their behavior when they are aware of the barriers that lack of time, transportation, cost, and communication create. Issuing dental coverage alone does not empower the recipients to go to the dentist.
Patient Knowledge and Perceptions
According to the health belief model, intention leads to behavior change. There needs to be some aspect of perceived susceptibility and perceived severity of the consequences in order for this transition to occur (11). People, even if they have coverage, will not go see a dentist if they do not know they need to or are not aware of the detriment that often arises from not seeing an oral health professional regularly.
Often, the general public does not appreciate the importance of oral health and perceives it as independent from and secondary to general health (4). Yet, oral health is an indicator and predictor of total health and quality of life (8). 75% of 3000 adults interviewed during a survey reported an enhancing of or reduction of quality of life due to oral health status (13). Additionally, oral health is associated with certain health conditions. Pregnant women who have gum disease are seven times as likely to deliver their babies earlier than women who have healthy gums (14). The prevalence of gingivitis and periodontal disease in diabetics is double that of people not suffering from diabetes (15). HIV-positive men, women, and children are more prone to dental caries as well as opportunistic infections in the mouth compared to people who are HIV-negative (16). Most people are unaware of these connections between oral health and overall health and do not understand the severity of the consequences that can occur when teeth are not brushed or flossed and an oral health professional is not visited regularly.
A recent survey of low-income women administered in a day shelter in downtown
The new MassHealth bill does not include a widespread effective public awareness campaign to educate about the connection between oral health and total health. Fact sheets (2) that contain sparse information about oral health are posted on the Member Services webpage, which is electronically linked to the MassHealth web page. This coupled with the fact that not everyone has access to the internet and that the fact sheets are difficult to locate make it unlikely that they will be effective.
The state’s effort to battle dental disease by providing dental insurance coverage through MassHealth fails to include an important educational component that addresses the combination of social demographic characteristics, beliefs, perceptions of oral health, and the presence of disease as contributing factors to receiving care. According to the behavior model, without perceived susceptibility or severity of consequences, behavior will most likely not change even if other enablers exist. The lack of need perception inhibits an individual’s ability to utilize existing health care services (18).
Many factors interact with one another to make a person able and willing to go to the dentist besides dental insurance coverage. To ensure that people receive the care they need, the variety of social issues revolving around the barriers that limit access to oral health care need to be addressed.
The solution to equal and adequate health care transcends the issue of insurance coverage. Disparities have to be eliminated to ensure equal health outcomes across the population. Providers, politicians, and recipients of dental care need to work together to increase social awareness about oral health and to raise the issue that total health reform cannot be delivered in the form of a single bill. Reinstating dental coverage to people who are poor only begins to solve this problem.
1. Meyer, Jack, and Silow-Carroll, Sharon, Policy Options to Ensure Access to Health Care for People Leaving Welfare for Work, Economic and Social Research Institute, Washington D.C., September 1996.
2. MassHealth Dental Portal, Department of Health and Human Services,
3. Official Website of the Commonwealth of Massachusetts, Department of Health and Human Services, Commonwealth of Massachusetts, http://www.mass.gov.
4. Haden, N. et al, Improving Oral Health Status of All Americans: Roles and Responsibilities of Academic Dental Institutions, Journal of Dental Education, May 2003, 563-583.
5. Behavioral Risk Factor Surveillance System, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, Georgia, http://www.cdc.gov/brfss.
6. Centers for Medicaid and Medicare Services, Department of Health and Human Services,
7. Zittle-Palamara, Kimberly, et el, Improving Patient Retention and Access to Oral Health Care: The CARES Program, Journal of Dental Education, 69:912-918.
8. Department of Health and Human Services, Oral Health in
9. Otto, Mary, For Want of a Dentist,
10. Raffi Miller, DMD,
11. Edberg, Mark, Essentials of Health Behavior,
12. Fadiman, Anne, The Spirit Catches You and You Fall Down,
13. McGrath, C. et el., Measuring the Impact of Oral Health on Life Quality in Two National Surveys, Community Dentistry and Oral Epidemiology, 2002, 30: 254-259.
15. Ryan, Maria, Carnu, Oana, and Kamer, Angela, The Influence of Diabetes on the Periodontal Tissues, Journal of American Dentistry, October 2003, 134: 34S-40S.
16. Abel, S.N. et el. Principles of Oral Health Management for the HIV/AIDS
17. Office of Oral Health, Results of a Dental Needs and Awareness Survey at the Women’s Lunch Place, Boston Public Health Commission, 2007.
18. Astrom, Anne and Kida, Irene, Perceived Dental Treatment Need Among Older Tanzanian Adults- A Cross Sectional Study,