摘要：Although ability to pay is associated with dental care utilization, provision of public or private dental insurance has not eliminated dental care disparities between African American and White adults. We examined insurance-related barriers to dental care in interviews with a street-intercept sample of 118 African American adults in Harlem, New York City, with recent oral health symptoms. Although most participants reported having dental insurance (21% private, 50% Medicaid), reported barriers included (1) lack of coverage, (2) insufficient coverage, (3) inability to find a dentist who accepts their insurance, (4) having to wait for coverage to take effect, and (5) perceived poor quality of care for the uninsured or underinsured. These findings provide insights into why disparities persist and suggest strategies to removing these barriers to dental care. Research has documented large racial/ethnic disparities in oral health among adults in the United States. 1 – 3 Specifically, African American adults are more likely to report tooth pain, tooth decay, loose teeth, and to have lost more teeth than are White adults. 1 , 4 – 6 Further, African Americans are less likely than are White adults to have visited a dentist in the past year. 2 , 7 – 9 In fact, even African Americans who experience dental symptoms are less likely to obtain dental care than are symptomatic Whites. 4 , 6 These disparities appear not to be attributable to differences in perceived need, as African Americans are more likely to perceive themselves in need of dental care than are Whites. 10 Given these disparities, it is not surprising that a household survey among African Americans in Harlem, New York City, found problems with their teeth and gums was the most commonly reported health complaint, 11 suggesting a large unmet need for dental care in this population. One factor that may in part account for these disparities in oral health and dental care may be the financial barriers that limit access to dental care among minorities more often than among Whites. Indeed, major theories addressing health disparities consistently highlight the importance of differences in availability of financial resources to access health care. 12 – 15 Those with the ability to pay for dental care, either out of pocket or through dental insurance, are significantly more likely to obtain care than are those without such resources. 3 , 8 , 11 , 16 – 19 Although the financial inability to pay for dental care is not unique to African Americans, which is consistent with observed racial/ethnic disparities in dental visits, African Americans are both less likely to report being financially able to pay for dental care out of pocket 1 , 7 and less likely to have dental insurance 2 , 16 , 18 , 20 than are Whites. However, several studies have documented that insurance status and the financial ability to pay do not account for the disparities in dental care and oral health that exist between African American and White adults. 2 , 3 , 5 , 8 , 18 , 19 , 21 Nevertheless, little research has examined the reasons why dental insurance fails to result in equal access to dental care. Dental insurance may not significantly reduce disparities in access to care if additional barriers to utilization of that insurance exist for African Americans. One such barrier may be that African Americans are disproportionately covered by public (i.e., Medicaid) rather than private insurance. 3 , 19 , 20 The limited dental services provided by adult Medicaid is associated with a lower likelihood of obtaining dental care 11 , 19 and potentially poorer quality care (i.e., a higher prevalence of tooth extractions rather than more expensive root canals) 3 , 22 , 23 among African American adults. Qualitative studies of caregivers' experiences in attempting to obtain dental care for their children 24 , 25 have identified additional barriers to obtaining care, including difficulty finding a dentist who accepts public dental insurance and perceptions that their children experience greater discrimination and poorer quality care because of their public dental insurance. 24 , 25 To better understand the range and complexity of insurance-related barriers to obtaining dental care and the reasons why dental insurance does not always facilitate access to care among African American adults, we conducted qualitative interviews with 118 African Americans living in Central Harlem who had experienced a recent oral health symptom. This work extends existing work on barriers to accessing dental care by examining the insurance-related barriers to obtaining care experienced by both insured and uninsured African Americans, as well as the perceived quality of care received. Such information is important to efforts to remove or reduce barriers to quality dental care and in so doing decrease or eliminate racial/ethnic disparities in oral health.
