Ensuring Smiles

Since 2015, Colorado has seen an overall improvement in key oral health measures. 

According to the Colorado Health Access Survey (CHAS), three in four Coloradans had dental insurance in 2019, up from 70.6% in 2015. And more Coloradans visited a dental provider (dentist or dental hygienist)  — 73.6% in 2019, compared with 68.3% in 2015. That’s good news: Poor oral health can exacerbate conditions such as heart disease, pneumonia, and Alzheimer’s disease and can contribute to social withdrawal and poor mental health. Left untreated in children, poor oral health and related gum and tooth pain can contribute to decreased appetite and increased inattention and distractibility, which can negatively impact school performance. Access to dental care and preventive treatments can help prevent chronic disease.

But despite the overall improvement in utilization, not all Coloradans got the dental care they needed. People who live in rural areas and Black and Hispanic/Latinx Coloradans were less likely to get dental care. And Coloradans who did not have dental insurance or were enrolled in Health First Colorado, the state’s Medicaid program, used significantly less dental services than those with private insurance. 

The 2019 CHAS also reveals a troubling trend for the youngest Coloradans: Young children enrolled in Medicaid were less likely to see a dental professional in 2019 than in 2017.

Increasing the number of people who have dental insurance and closing dental service utilization gaps are important steps toward improving the health of all Coloradans. As Colorado state leaders work to address these gaps, it will also be critical that policymakers take steps to preserve improvements made against the backdrop of new barriers resulting from the COVID-19 pandemic and subsequent budget cuts.

Healthy Mouth, Healthy Body

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Lack of access to or use of dental services impacts both physical and mental health. 

Poor oral health is a contributing factor, and a consequence, of many chronic diseases. Periodontal disease, marked by gum infection and tooth decay, has been linked to high blood pressure. Additionally, people with diabetes are more susceptible to negative oral health symptoms such as infections, dry mouth, and problems tasting food.

Some Coloradans are at higher risk of experiencing poor oral health. Coloradans with low incomes were more likely to report fair or poor oral health than those with higher incomes in 2019. Close to 30% of Coloradans with incomes below 139% of the Federal Poverty Level (FPL) reported poor or fair oral health, compared with only 11.0% of those with incomes above 400% FPL ($104,800 for a family of four). 

Non-Hispanic/Latinx Black and Hispanic/Latinx Coloradans were also more likely to report poor oral health status (28.5% and 22.8%, respectively) than non-Hispanic/Latinx white Coloradans (16.9%). 

This may be tied to access to dental care: Both Black and Hispanic/Latinx Coloradans were less likely to have visited a dental provider in the past year than white Coloradans, as were lower-income Coloradans (See Figure 2). Hispanic/Latinx Coloradans were also more likely than other racial and ethnic groups to be uninsured, likely due to socioeconomic factors and fear around immigration policy and practice. This may lead to poorer oral health due to avoidance of – or lack of access to – care. 

CHAS data also indicate that people experiencing fair or poor overall health are more likely to experience poor oral health. Of Coloradans who report excellent or good overall health, only 11.4% report fair or poor oral health. Conversely, 58.8% of Coloradans who report fair or poor overall health also report fair or poor oral health (see Figure 3).

And in 2019, over a third (38.1%) of Coloradans with poor oral health also reported poor mental health. All of this is a reminder of the critical role access to dental care and services play to support not only oral health, but physical and mental health.

Barriers to Access

Cost and access to oral health providers were significant barriers when it came to receiving dental care. Many Coloradans struggled to afford dental services. In 2019, one in five (20.6%) Coloradans did not see a dental professional in the past 12 months because of cost. But the prevalence of this challenge varies widely across the state, from 31.7% in Eagle County to 13.5% in El Paso County (See Figure 4).

Cost was not the only barrier to seeking care. People in rural and frontier areas of the state face provider shortages, which can make it difficult to receive dental care. The majority of dental offices who accept Medicaid are located along the Front Range. And in many parts of the state, there is no dentist within a 15-minute drive.  Five rural counties do not have a licensed dentist. This contributes to a disparity in access: In rural areas, just 67.0% of residents saw a dental professional in the past year, compared with 75.0% of Coloradans in urban areas.

Dental Utilization: Coverage Matters

Coloradans with dental coverage were more than twice as likely to have used dental services in the past year than Coloradans without dental insurance. In 2019, only one in three (36.1%) uninsured Coloradans (no medical and dental insurance) saw a dental professional, compared with 59.2% of those with medical but no dental insurance and 81.4% of Coloradans with both medical and dental insurance.

There was an overall increase in dental visits in 2019 compared with 2017, when only 29.4% of uninsured Coloradans and 76.2% of Coloradans with dental insurance saw a dental professional (See Figure 6). This positive trend could be a result of Colorado’s economic growth during this time, which may have made it easier for people to pay for care. 

Organizations such as Delta Dental of Colorado Foundation, The Colorado Health Foundation, and Caring for Colorado Foundation also made strong philanthropic commitments to support access to dental care for those without insurance during this period. 

Coloradans With Medicaid Less Likely to Visit Dental Professional

Even though Health First Colorado covers dental services for all enrollees, there was a substantial difference in utilization between those who had private and public insurance. Most Medicaid enrollees are people or families with incomes below 139% of FPL. A family of four that is eligible to enroll in Medicaid has an annual income of $36,156 or less. 

Historically, Medicaid has only covered dental benefits for children under age 21. In 2013, a limited dental benefit was created for adults 21 and older to cover some dental services such as annual dental exams and cleanings, dentures, and extractions. Adult members could receive up to $1,500 annually toward the cost of needed dental services. (In 2020, Colorado’s legislature reduced this benefit to $1,000 annually due to budget cuts during the COVID-19 pandemic.)

Yet Coloradans enrolled in Medicaid used dental services at lower rates than those with private coverage. In 2019, four out of five Coloradans (81.4%) with private coverage utilized dental services. In that same time, the overall use of dental services among Coloradans enrolled in Medicaid remained relatively unchanged at around 60%. 

Many enrollees may be unaware of their dental benefits. The CHAS asks respondents to indicate if they have coverage that pays for some or all of their routine dental care. Medicaid enrollees who did not indicate that they had dental coverage used services significantly less (35.6%) than those enrollees who also say they have dental insurance (67.7%). 

Coloradans enrolled in Medicaid struggle with cost as a barrier to dental care. One in four (27.8%) of Medicaid enrollees did not see a dental professional in the past 12 months because of cost, a higher rate than the state average. This group also reported that it was challenging to access dental providers who accept Medicaid. 

According to the 2019 CHAS, 16.0% of Medicaid enrollees did not see a dental professional for reasons other than cost. These may include language or transportation barriers, which make accessing services more difficult. 

Ensuring Coloradans enrolled in Medicaid understand their benefits fully and can access services could be a significant step toward to improving oral health among this population.

Losing Ground Among Youngest Medicaid Enrollees

The most common chronic disease in young children is dental caries, or tooth decay. Good oral health habits in early childhood can prevent dental caries. And interventions such as supplemental fluoride and sealants have been shown to significantly reduce the risk of tooth decay.

Overall, a higher percentage of young children received dental care in 2019. Approximately two in three (62.3%) children under age 7 visited a dental provider in 2019, up from 56.7% in 2017.  

Yet the CHAS showed a different trend among young children under age 7 enrolled in Medicaid. This group’s rate of receiving care dropped to 68.2% in 2019 from 78.9% in 2015. But over the same period, dental service use among Medicaid enrollees ages 7-19 and adults ages 20-65 ticked upward (see Figure 7). 

 

Decreases in utilization among young children enrolled in Medicaid could be driven by providers limiting the number of Medicaid enrollees they treat. In other cases, parents may struggle to afford dental care or may be unaware of the importance of receiving dental services for very young children.

Efforts to reduce costs and increase the number of patients accepted by Medicaid providers and number of practices that participate in Medicaid could make a profound difference in improving the oral health of many Coloradans. Interventions to educate parents about the value of oral health care in early childhood may also be beneficial. 

Dental Services in the Wake of COVID-19

While 2019 marked a high point for dental service utilization in Colorado, data in 2020 and beyond may tell a different story due to COVID-19 and its effects. As a respiratory infection, COVID-19 presents unique obstacles for oral health providers to administer services while implementing appropriate infection control measures. 

At the start of the pandemic, all non-emergency dental visits were suspended. By the summer of 2020, dental offices resumed non-emergency dental visits, such as cleanings, but with added safety precautions and increased sanitation efforts. But other precautions, like telephone screenings prior to appointments and limits on the number of visitors in the office, can reduce the number of patients that can be seen daily. In instances where a patient has signs of symptoms consistent with COVID-19, the elective visit is being delayed.

Policy changes and budget cuts in response to the COVID-19 pandemic could also impact the accessibility and affordability of dental care for many Coloradans in 2020 and beyond. 

For instance, as of February 2020, nearly a quarter of the state’s population, 1.2 million Coloradans, received dental insurance through Colorado’s Medicaid program. State budget cuts due to COVID-19 lowered the annual adult dental benefit from $1,500 to $1,000 effective April 2021. According to the 2017 CHAS, the average out-of-pocket expense for dental services for Medicaid enrollees was $753.64, suggesting that the lower benefit limit may be a barrier to care for some enrollees. While this cut may have an impact on access to care, especially as many enrollees cited cost as a reason for forgoing needed care, it is a less extreme measure than an initial proposal to eliminate the benefit entirely. 

Additionally, many school-aged children receive dental services through school-based health centers, which provide preventive oral health screenings and sealants to students. Delayed school, online learning, and possible future closures threaten access to these centers, which could result in worsening dental health conditions. 

Conclusion

Data from the 2019 CHAS highlight the fact that not all Coloradans have the same access to dental services. Children under the age of 7 enrolled in Medicaid lost critical ground between 2015 and 2019. And racial disparities in utilization and differences in access due to geographic location exist. 

COVID-19 poses an added challenge to ensuring Coloradans receive the dental care they need. Policies that balance providing oral health services with minimizing the risk of transmitting COVID-19 are critical to preventing a backslide in dental service utilization in the years to come.

Access to affordable preventive dental care can decrease the onset of negative oral health conditions and reduce oral health disparities in communities of need. Prevention and intervention in childhood is important for establishing healthy habits and for early detection of disease. 

Expanding educational opportunities to increase awareness of the importance of oral health in early childhood among parents and of available Medicaid benefits and other low-cost services could improve access to and use of dental care among thousands of Coloradans – and by closing these gaps in utilization, the health of all Coloradans can benefit. 

About the CHAS

The Colorado Health Access Survey (CHAS) is the premier source of information about health insurance coverage, access to health care, and use of health care services in Colorado. The biennial survey of more than 10,000 households has been conducted since 2009. The 2019 CHAS was conducted between February 26 and July 14, 2019. Survey data were weighted to reflect the demographics and distribution of the state’s population. The survey was conducted in English and Spanish.

The 2019 CHAS was administered mostly online — a change from the telephone surveys of previous years. A small random sample of respondents was surveyed by phone to confirm data from the online survey could be compared with prior phone-based surveys.

In 2019, new questions were added, including questions on social factors such as housing and food security.

The CHAS is Colorado’s only consistent data source about oral health care and coverage. It provides unique insights on the connections between oral health and other important health and social factors. It can inform the extent to which Colorado’s public and private oral health policies and programs are achieving their intended outcomes and how these vary by geography and specific populations.