摘要：Objectives. We determined how elimination of dental benefits among adult Medicaid beneficiaries in Oregon affected their access to dental care, Medicaid expenditures, and use of medical settings for dental services. Methods. We used a natural experimental design using Medicaid claims data (n = 22 833) before and after Medicaid dental benefits were eliminated in Oregon in 2003 and survey data for continuously enrolled Oregon Health Plan enrollees (n = 718) covering 3 years after benefit cuts. Results. Claims analysis showed that, compared with enrollees who retained dental benefits, those who lost benefits had large increases in dental-related emergency department use (101.7%; P < .001) and expenditures (98.8%; P < .001) and in all ambulatory medical care use (77.0%; P < .01) and expenditures (114.5%; P < .01). Survey results indicated that enrollees who lost dental benefits had nearly 3 times the odds (odds ratio = 2.863; P = .001) of unmet dental need, and only one third the odds (odds ratio = 0.340; P = .001) of getting annual dental checkups relative to those retaining benefits. Conclusions. Combined evidence from both analyses suggested that the elimination of dental benefits resulted in significant unmet dental health care needs, which led to increased use of medical settings for dental problems. Dental coverage is considered optional under Medicaid, and 22 states have either no coverage (6 states) or emergency-only coverage (16 states) that does not cover preventive services. 1 Moreover, recent budget shortfalls have caused many states to consider eliminating Medicaid dental benefits for adults. In response to budget shortfalls, California recently eliminated dental benefits for its Medicaid program. 2 The optional status of dental coverage under Medicaid and the varied uptake and uncertain maintenance of these benefits by the states suggest that they are not perceived to be as effective or valuable as other coverage. However, having dental insurance is associated with receipt of regular preventive dental care 3 – 6 and subsequently with improved overall oral health. 6 Although improved oral health is arguably an important outcome in itself, recent research has also demonstrated important relationships between oral health and other physical health. Specifically, periodontal disease has been found to be associated with cardiovascular and cerebrovascular disease, 7 – 10 diabetes mellitus, 11 and adverse pregnancy outcomes. 12 – 16 Moreover, among patients with diabetes mellitus who have periodontal disease, treatment of periodontal disease can actually improve glycemic control. 17 Despite the clear links between dental coverage and oral health, and the additional linkage between oral and physical health, oral diseases have been called the “neglected epidemic.”18(pS82) As such, the importance of improving access to oral health care has been emphasized as an objective in Healthy People 2010 . 3 Access to dental care is particularly important for vulnerable populations, for whom Medicaid is often the primary opportunity for dental coverage, as they often have the greatest need of dental care 3 , 4 , 19 – 21 and the poorest access to oral health care services. 22 – 24 Two prior studies have examined the elimination of dental benefits in state Medicaid programs. A Massachusetts study found that after the elimination of Medicaid dental benefits, adult enrollees were less than half as likely to receive dental services, with 24% receiving services before the cuts and only 11% receiving services afterwards. 25 Moreover, findings from focus groups conducted with enrollees of Mass-Health (Massachusetts's Medicaid program) suggested that nearly all respondents interviewed were living with “ongoing, serious pain from untreated dental problems” as well as diminished self-esteem. 25 (p3) Another study, conducted in Maryland, found that the elimination of reimbursements to dentists for dental-related emergencies resulted in a 12% increase in dental-related emergency department visits. 26 That study also found an 8% decrease in dental-related primary care visits during the same time period. 27 In early 2003, changes made to Oregon's Medicaid Program resulted in the elimination of specific benefits, including dental coverage, and the imposition of copayments on the remaining covered care for one segment of the adult Medicaid population. These changes created an ideal natural experiment for examining the impacts of eliminating dental benefits on low-income adults. Specifically, dental benefits were eliminated, along with other discrete coverage (e.g., mental health outpatient care), and copayments were imposed for Oregon Health Plan Standard (OHP Standard) enrollees. OHP Standard enrollees, known as Oregon's expansion population, include adults and couples eligible for OHP solely on the basis of incomes below 100% of the federal poverty level as established by the US Department of Health and Human Services. Oregon Health Plan Plus (OHP Plus) enrollees, which include individuals eligible for OHP on the basis of federal statutory criteria such as enrollment in the Temporary Aid to Needy Families (TANF) program or presence of a disabling condition, had no changes to their Medicaid benefits and retained their dental coverage. We compared those who lost dental benefits (OHP Standard enrollees) with those who retained benefits (OHP Plus enrollees) to examine the impact of eliminating dental coverage from an individual consumer and Medicaid program perspective. We assessed the impact of dental benefit cuts from an individual consumer perspective using self-report of unmet dental needs and receipt of annual dental exams. We assessed the impact of the benefit cuts on the Medicaid program through expenditures and use of outpatient medical settings and emergency departments for dental problems within the Medicaid program.
