Information on Coverage, Payments, and Fee Variation
GAO-13-754: Published: Sep 6, 2013. Publicly Released: Sep 12, 2013.
What GAO Found
Overall, trends in dental coverage show little change from 1996 to 2010--around 62 percent of individuals had coverage. The percentage of the population with private dental coverage decreased from 53 to 50 percent. Dental coverage through Medicaid or the State Children's Health Insurance Program (CHIP), which was established in 1997, rose from 9 to 13 percent. The increase was due primarily to an increase in the number of children covered by these federal-state health programs with mandated pediatric dental coverage. Individuals with no dental coverage decreased from 28 to 25 percent, and coverage for 10 to 12 percent of the population was unknown. Use of dental services--the percentage of individuals who had at least one dental visit--also remained relatively unchanged at around 40 percent from 1996 to 2010. Medicaid and CHIP beneficiaries, children in particular, showed increases in the use of dental services (from 28 to 37 percent), but still visited the dentist less often than privately insured children (58 percent in 2010).
GAO's analysis showed that average annual dental payments--the total amount paid out of pocket by individuals and by other payers--increased 26 percent, inflation-adjusted, from $520 in 1996 to $653 in 2010. Average annual out-of-pocket payments increased 21 percent, from $242 to $294, for individuals with private insurance and 32 percent, from $392 to $518, for individuals with no dental coverage.
Dental fees charged by local dentists and health centers varied widely. For 8 of 24 common procedures GAO examined, reported upper-end fees (the 95th percentile of the range in local dentist fees) were at least double the midpoint fees (the 50th percentile of the range in local dentist fees) in several communities. For example, in Miami, Florida, the upper-end fee of $150 for a periodic oral examination was more than twice the midpoint dental fee of $62. Dental fees also varied between local dentists billing private insurers and health centers serving residents of the same community. In general, most health centers in GAO's review offered a 100 percent discount--resulting in no fee--to the lowest-income patients for many, but not all, dental services.
Why GAO Did This Study
High rates of dental disease remain prevalent across the nation, especially in vulnerable and underserved populations. According to national surveys, 42 percent of adults with tooth or mouth problems did not see a dentist in 2008 because they did not have dental insurance or could not afford the out-of-pocket payments, and in 2011, 4 million children did not obtain needed dental care because their families could not afford it.
In 2011, the Institute of Medicine reported that there is strong evidence that dental coverage is positively tied to access to and use of oral health care. For families without dental coverage, federally funded health centers may offer an affordable dental care option. Health centers are required to offer sliding fee schedules with discounts of up to 100 percent for many low-income patients.
GAO was asked to examine dental services in the United States. This report describes (1) trends in coverage for, and use of, dental services; (2) trends in payments by individuals and other payers for dental services; and (3) the extent to which dental fees vary between and within selected communities across the nation. To do this work, GAO examined HHS national health survey data and national dental expenditure estimates, dental insurance claims data, and health center dental fees in 18 selected communities (based on census region, population, and dental claims volume). GAO also interviewed HHS officials and academic experts.
HHS provided technical comments on a draft of this report, which were incorporated as appropriate.
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