摘要：To examine how proposed Medicaid reform plans are experienced by racial/ethnic minority older adults and what the implications are for their ability to access dental care through Medicaid, from 2013 to 2015 we conducted focus groups in northern Manhattan, New York, New York, among African American, Dominican, and Puerto Rican adults aged 50 years and older. Participants reported problems with affording copayments for care, complicated health and social issues, the need for vision and dental care close to home, and confusion about and stigmatization with Medicaid coverage. Federal, state, and local public health agencies can help by clarifying and simplifying Medicaid plans and sustaining benefits that older adults need to live healthy and dignified lives. Because of increased life expectancy and improvements in oral health over the past 60 years in the United States, older adults are retaining greater numbers of their natural dentition. 1 Nonetheless, oral health disparities exist in the aging population regarding untreated dental caries (cavities) and edentulism (complete tooth loss) related to income, gender, race/ethnicity, and education. 2 We devised a conceptual model titled, “ecological model of social determinants of oral health for older adults” for thinking about mechanisms whereby social determinants at various scales influence oral health and related health outcomes, toward promoting healthy aging. 3 In this framework, oral health in older adults is owing to the lifelong accumulation of advantageous and disadvantageous experiences at multiple scales, from the microscale of the mouth to the societal scale that involves inequalities in the distribution of material wealth and educational attainment and ideologies such as ageism and racism. Note that this model is compatible with the life course perspective, because both view oral disease as cumulative. 4,5 It has also been argued that disparities in public policy regarding oral health for older adults nationally and on a state-by-state basis may compound social inequities. 2 Nearly 70% of older US persons currently have no form of dental insurance. 6 At the federal level, the Medicare program, which covers elderly adults and nonelderly adults with disabilities, provides no dental benefits for preventive or routine care. 7 At the state level, 42% of states provide no dental benefit or only emergency coverage through adult Medicaid. 8 At present, market-based solutions that are part of Medicaid expansion plans may be appealing from a cost perspective but may have untoward consequences for vulnerable populations, including racial/ethnic minority older adults. For instance, the main elements of the Kentucky Health plan—with the stated intention of preparing people with expansion Medicaid coverage to become active consumers of health care—are (1) monthly premiums that increase over time; (2) a volunteer or work requirement; (3) the elimination of benefits, including vision and dental and nonemergency medical transportation; and (4) an incentivized “My Rewards” account in which credits would be accumulated for approved behaviors deemed appropriate, such as community service or work, and debited for behaviors deemed inappropriate, such as nonurgent emergency department use. 9 Of course, these elements are also part of other Medicaid reform plans submitted by the governors of states such as Arizona, Arkansas, Tennessee, and Indiana and are not new or innovative in and of themselves. 9 A recent critique of the Medicaid reform plan proposed by the governor of Kentucky, Matt Bevin, underscored the need for evidence to guide policy. 9 In an ecological model derived from a systematic review of the complex factors that influence disparities in access to and quality of services, the endpoints of interest included clinical outcomes, avoidable hospital admissions, equity of services, and costs, along with patient experiences of care. 10 A simplified schematic of this framework that focuses on level 4 (policy and community), its associated intervention targets (neighborhood and community resources), and the health care processes (principally, interactions between patients and support networks and their health care providers) leading to outcomes (notably patient experiences of care) is provided in Figure 1 . Open in a separate window FIGURE 1— Policy and Community Level Factors That Result in Patient Experiences of Care Source . We derived this graphic from the conceptual model called “factors that influence disparities in access to care and quality of health care services, by level,” from Purnell et al. 2 We addressed the patient perspective on proposed Medicaid reforms, particularly that of racial/ethnic minority older adults, who are the focus of ongoing social science research to promote oral health equity (Northridge ME, Shedlin MG, Schrimshaw EW et al., unpublished data). 11 The question that guided our qualitative analysis was this: How might the elements of proposed Medicaid reform plans be experienced by racial/ethnic minority older adults and what are the implications for their ability to access dental care through Medicaid?
