1. Improving Accessibility and Utilization of Dental Services for Vulnerable Populations Child Health Policy Research Symposium University of Southern California March 2, 2009 Dana Hughes, DrPH Institute for Health Policy Studies & Dept. of Family and Community Medicine

2. 2 Topics to be Covered Models of Improved Access and Utilization –Outreach and enrollment –Insurance –Providers Policy Implications –Opportunities and Challenges SECTION HEADING

3. High Level of Need Among Children in California Two-thirds of Kindergarteners and third graders have filled cavities and 28% have untreated cavities One-fourth of children ages 0-11 have never visited a dentist Half of all children ages 0-5 have never visited a dentist Children ages 0-11 with: No insurance: 40% never visited a dentist Denti-Cal: 27% never visited a dentist HF and other public: 16% never visited a dentist 3

4. Pregnant Women, California, 2002-2007 Dental problemNo dental careNo dental care- women w/dental problem 52%66%62% 4 Dental problems and lack of receipt of dental care during pregnancy among women delivering in CA, MIHA 2002-2007 (n=21,732) Marchi, K, Weintraub, et.al. UCSF Center on Social Disparities in Health, Dept. of Family and Community Medicine. Unpublished data.

5. Children’s Health Initiatives Two major components: New insurance product called “Healthy Kids” Aggressive and coordinated outreach and enrollment assistance 5

6. Enrollment Analysis Quasi-Experiment That Compares Enrollment Before and After CHI Between: – Santa Clara County (“treatment sample”) – External comparison area (“comparison sample”) 6

7. Outcome Measure New Entries to Medi-Cal and Healthy Families from 2001-2002: “All children enrolling in Medi-Cal or Healthy Families who have not had coverage through one of these programs in the prior 11 months” 7

8. CHI Has Had a Significant Impact Source: Enrollment Files for the Medi-Cal and Healthy Families Programs. *Difference is significantly different at the.01 level. New Entries 48,629 62,084*

9. Total Impact: Medi-Cal, Healthy Families and Healthy Kids 77,000 48,629 New Entries 15,000 Without CHIWith CHI

10. Impact on Access and Utilization Survey to Compare the Experiences of Recent and Established Enrollees Recent Enrollees –Children who recently became eligible for Healthy Kids –Measure experiences during six months before enrolling Established Enrollees –Children who recently renewed eligibility at one year –Measure experiences during the prior six months on Healthy Kids 10

11. Percentage Impact of Healthy Kids on Having a Usual Source for Dental Care **Difference is statistically significant at p-value < 0.01. Los Angeles study includes children ages 4 and 5; San Mateo includes ages 3 to 18; Santa Clara includes ages 4 to 18. **

12. Percentage Impact of Healthy Kids on Having a Preventive Dental Visit In the Past Six Months ** **Difference is statistically significant at p-value < 0.01. San Mateo study includes children ages 3 to 18; Santa Clara includes ages 4 to 18.

13. Percentage Impact of Healthy Kids on Having a Dental Treatment In the Past Six Months ** NOTE: Dental treatment includes a cavity filling or tooth extraction **Difference is statistically significant at p-value < 0.01. San Mateo study includes children ages 3 to 18; Santa Clara includes ages 4 to 18.

14. Percentage Impact of Healthy Kids on Unmet Need for Dental Care In the Past Six Months ** **Difference is statistically significant at p-value < 0.01. Los Angeles study includes children ages 4 and 5; San Mateo includes ages 3 to 18; Santa Clara includes ages 4 to 18.

15. Average Annual Costs per Enrollee for Dental and Other Services, San Mateo Healthy Kids Enrollees, 2006 Type of Service Costs Dental Care Costs $234.93 Other Care Costs $483.60 Total Costs $718.53 N 1,380 Source: Health Plan of San Mateo

16. Healthy Kids Dental Users by Type of Provider, San Mateo, 2005 Percent of Provider All Users San Mateo Med. Center 39.1 and County Clinics Private Dentists 43.3 Private Dental Groups 20.9 Sonrisas Dental Clinic 5.8 Tooth Mobile 0.5 N 1778 Source: Health Plan of San Mateo

17. 17 Challenges and Opportunities Insurance Coverage  Declining employment-based/dependent coverage  Healthy Kids programs funding  Eligible but unenrolled Provider Availability  Reimbursement rates  Ramifications of loss of Adult Dental Benefit under Medi-Cal  Mounting pressures on safety net “Cultural”/Clinical Attitudes  Lack of importance place on oral health  Lack of attention on care during early years and pregnancy SECTION HEADING

18. SCHIP reauthorization  Dental wrap-around option  Mandatory performance reporting  New parent education  Mandatory information for beneficiaries  Studies and commissions  Expanded outreach/enrollment activities Slow, but increasing attention to oral health, in general and needs of young children and pregnant women, specifically. 18 Challenges and Opportunities