Objectives: To inform policy with better information about the oral health-care
needs of aMedicaid population that engages in employment, that is, people ages 16
to 64 with Social Security-determined disabilities enrolled in a Medicaid Buy-In
program.
Methods: Statistically test for significant differences among responses to aMedicaid
Buy-In program satisfaction survey that included oral health questions from the
Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance
System and the Oral Health Impact Profile (OHIP) to results for the state’s general
population and the US general population.
Results: All measures of dental care access and oral health were significantly worse
for the study population as comparedwith a state general population or aUS general
population. Differences were particularly pronounced for the OHIP measure for
difficulty doing one’s job due to dental problems, which was almost five times higher
for the study population.
Conclusions: More comprehensive dental benefits for the study population could
result in increased oral and overall health, and eventual cost savings to Medicaid as
more people work, have improved health, and pay premiums for coverage

Chapman, Shawna L. C.

Hall, Jean P.

Kurth, Noelle K.

KU ScholarWorks

B R I E F C O M M U N I C AT I O N jphd_359 79..82Poor oral health as an obstacle to employment for Medicaidbeneficiaries with disabilitiesJean P. Hall, PhD; Shawna L. Carroll Chapman, PhD; Noelle K. Kurth, MSDivision of Adult Studies, University of Kansas, Lawrence, KS, USAAbstractObjectives: To inform policy with better information about the oral health-careneeds of a Medicaid population that engages in employment, that is, people ages 16to 64 with Social Security-determined disabilities enrolled in a Medicaid Buy-Inprogram.Methods: Statistically test for significant differences among responses to a MedicaidBuy-In program satisfaction survey that included oral health questions from theCenters for Disease Control and Prevention’s Behavioral Risk Factor SurveillanceSystem and the Oral Health Impact Profile (OHIP) to results for the state’s generalpopulation and the US general population.Results: All measures of dental care access and oral health were significantly worsefor the study population as compared with a state general population or a US generalpopulation. Differences were particularly pronounced for the OHIP measure fordifficulty doing one’s job due to dental problems, which was almost five times higherfor the study population.Conclusions: More comprehensive dental benefits for the study population couldresult in increased oral and overall health, and eventual cost savings to Medicaid asmore people work, have improved health, and pay premiums for coverage.IntroductionPeople with disabilities are a dental disparity population atgreater risk for poor oral health than other members of thegeneral population (1). Because poor oral health, in turn, isassociated with systemic infection and multiple chronichealth conditions it can jeopardize overall health outcomes,particularly among people with existing chronic conditionsor disabilities (2). Long-term effects of poor oral healthcan, therefore, threaten work efforts of people with disabili-ties and diminish the promise of work incentive programs toincrease their independence. Yet in 22 states Medicaid benefi-ciaries with disabilities have no or only emergency dentalcoverage and only 16 states provide full dental coverage (3).Kansas’ Working Healthy program, one of 44 state Medic-aid Buy-In programs nationally, is a work incentive programthat allows people ages 16 to 64 with Social Security-determined disabilities to work and maintain Medicaid cov-erage, even when their income and assets are higher thannormally allowed by Medicaid. Participants pay a sliding-scale premium for coverage if their income is above thefederal poverty level, thus offsetting some of their medicalcosts (4,5). Their dental coverage is limited, like in many otherstates, to emergency dental services and extractions.As the Working Healthy program evaluators since itsinception in 2002, we annually conduct a satisfaction surveyof participants. Throughout the years we observed thatsurvey respondents consistently indicated dental or oralhealth needs in open-ended questions about ways to improvetheir Medicaid coverage. For example, one respondent madethe following plea:Dental services are needed very badly. I need work done[and am] not a good candidate for dentures. Any infectioncan go directly to my heart – potentially fatal or a longexpensive stay in ICU. The dental work would be cheaperthan ICU!Another respondent simply noted, “I need dental work,[because] medication rots out my teeth.” The frequency andmagnitude of such comments suggested further study of oralhealth was warranted.Keywordsdental Medicaid programs; disability insurance;access to health care.CorrespondenceDr. Jean P. Hall, Institute for Health andDisability Policy Studies, University of Kansas,1122 West Campus Road, J.R. Pearson Hall,Room 517, Lawrence, KS 66045. Tel.:785-864-7083; Fax: 785-864-7799; e-mail:jhall@ku.edu. Jean P. Hall, Shawna L.Chapman, and Noelle K. Kurth are with theDivision of Adult Studies, University of Kansas.Received: 12/12/2011; accepted: 7/9/2012.doi: 10.1111/j.1752-7325.2012.00359.xJournal of Public Health Dentistry 73 (2013) 79–82Journal of Public Health Dentistry . ISSN 0022-400679© 2012 American Association of Public Health DentistryMethodsTo better quantify and understand oral health-care needs ofthis population, we included in the 2010 Working Healthysatisfaction survey a set of oral health questions from theCenters for Disease Control and Prevention Behavioral RiskFactor Surveillance System (BRFSS) and the Oral HealthImpact Profile (OHIP) (6,7). Using two-tailed z-tests to iden-tify significant differences in proportions, we compared theWorking Healthy enrollees’ responses to BRFSS items withBRFSS results for Kansas’ general population and the OHIPitem responses to the US population (6,8).We also conductedanalysis of variance (ANOVA) to test for differences in dentalmeasures within the study population.The three BRFSS items included in the Working Healthysurvey were:1. How long has it been since you last visited a dentist or adental clinic for any reason?2. How many of your permanent teeth have been removedbecause of tooth decay or gum disease?3. How long has it been since you had your teeth cleaned by adentist or dental hygienist?The three OHIP items in the Working Healthy survey were:1. Do you have painful aching in your mouth?2. Do you find it uncomfortable to eat any foods because ofproblems with your teeth, mouth or dentures?3. Do you have difficulty doing your usual job(s) because ofproblems with your teeth, mouth or dentures?The Working Healthy sample consisted of 433 surveyrespondents with an average age of 48.9 years [standarddeviation (SD) = 10.1; range 21-64]; 56.1 percent werefemale. The average age of the 2010 Kansas BRFSS sample(ages 18 to 64 selected for comparability) was 41.0(SD = 13.0), and 49.3 percent of this sample were female (6).Similarly, the OHIP national sample average age was 43 (8).Other demographic characteristics of the Working Healthysample and Kansas BRFSS sample are presented in Table 1.The authors’ institutional Human Subjects Committee,which is a federally recognized institutional review board,approved this study under the guidance set forth in the reportof the National Commission for the Protection of HumanSubjects of Biomedical and Behavioral Research. Further,Health Insurance Portability and Accountability Act privacystandards were also observed in all aspects of the study.Table 1 Demographics for Working Healthy 2010 Survey Respondents and Kansas BRFSS Weighted SampleCharacteristic Working healthy survey respondents (n = 433) (%) Kansas BRFSS weighted sample* (n = 5,560) (%)RaceWhite 83.8 90.1Black 5.1 3.2Multiracial 3.9 1.9Native American/Hawaiian/Pacific Islander 2.1 1.0Asian 0.2 0.6Other – 2.8Undisclosed/missing 4.8 0.4EthnicityHispanic/Latino(a) 2.5 6.8Non-Hispanic/Latino(a) 92.6 93.0Undisclosed/missing 4.8 0.2Primary disability typeMental illness† 35.6 –Physical and Traumatic Brain Injury 23.6 –Chronic illness‡ 20.6 –Intellectual/Cognitive§ 14.5 –Sensory 3.0 –Undisclosed/missing 2.8 –Level of educationLess than high school 9.0 6.1High school diploma or equivalent 39.5 25.0Any postsecondary education 48.7 68.8Undisclosed/missing 2.8 –* BRFSS percentages reported have been weighted according to Centers for Disease Control and Prevention guidelines and formulas for probability ofhousehold selection and nonresponse; and represent respondents between 18 and 64 years of age.† Mental Illness category includes such conditions as schizophrenia, bipolar disorder, and depression.‡ Chronic Illness category includes such conditions as end-stage renal disease, lupus, epilepsy, HIV/AIDS, and cystic fibrosis.§ Intellectual/Cognitive category includes such conditions as intellectual disability, learning disability and attention deficit hyperactivity disorder.BRFSS, Behavioral Risk Factor Surveillance System.Oral health as an obstacle to employment for Medicaid beneficiaries with disabilities J.P. Hall et al.80 © 2012 American Association of Public Health DentistryResultsStatistically significant differences existed between thegeneral Kansas population and Working Healthy surveyrespondents on all measures of dental care access and oralhealth (Table 2). Working Healthy participants were muchmore likely to be missing teeth due to decay or gum disease,and were much less likely to have had their teeth profession-ally cleaned or to have visited a dentist or dental clinic in thelast year compared with Kansans as a whole.Working Healthy participants also had significantlygreater (i.e., worse) scores than the US general populationon all three of the OHIP measures included in the survey(P < 0.0001). Participants reported experiencing high ratesof oral pain, with 38 percent having occasional or frequentpain. More than half (51.1 percent) also reported at leastoccasionally having problems eating due to dental prob-lems. Finally, one in six reported at least occasionally havingdifficulty doing their usual job(s) because of problems withtheir teeth, mouth, or dentures. Importantly, this rate ofjob-related difficulty is almost five times higher than thatreported for the general population. As one of the surveyrespondents noted, “If you really think about it, if you havea severe toothache and you can’t get it taken care of, you’renot going to go to work, right?”Within the Working Healthy sample, people with chronicillnesses (e.g., cystic fibrosis, diabetes, HIV/AIDS, lupus) astheir primary disability had significantly worse oral healthmeasures than all other disability groups for missing teeth,F(1, 416) = 10.427, P = 0.001; time since last seeing a dentist,F(1, 416) = 10.099, P = 0.002; and having a professionalcleaning F(1, 408) = 15.846, P < 0.001. Conversely, peoplewith intellectual disabilities had significantly better scores(P < 0.005) on five of the dental questions asked (all excepttime since last visiting a dentist). A possible explanation forthis disability-related discrepancy is that, through November2009, the home and community-based services waiverprogram for people with intellectual disabilities included fulldental coverage; some of the Working Healthy participantswith intellectual disabilities may therefore have had betteraccess to care in the year prior to the survey. Older individuals(age 50 and older) also had significantly worse scores on allthe dental questions (P < 0.05), except difficulty doing theirjob. Finally, participants making less than $10 per hour scoredsignificantly worse on the measure of when they had lasthad their teeth cleaned, F(1, 366) = 4.909, P = 0.027. OtherTable 2 Working Healthy 2010 Survey Responses Compared with Kansas BRFSS Weighted Sample or US PopulationItems Working healthy enrollees (%) Comparison population (%) P valueBRFSS items compared with Kansas BRFSS†No teeth missing due to decay or gum disease‡ 35.7 66.3 0.0001*1-5 teeth missing due to decay or gum disease 31.8 24.5 0.0008*6 teeth missing due to decay or gum disease 18.9 6.4 <0.0001*All teeth missing due to decay or gum disease 13.6 2.9 <0.0001*Teeth professionally cleaned in past 12 months¶ 39.3 72.1 <0.0001*1 year since teeth professionally cleaned 13.1 8.9 0.0042*2 years since teeth professionally cleaned 14.3 7.4 <0.0001*5 years ago since teeth professional cleaned 26.2 11.0 <0.0001*Teeth never professionally cleaned 7.1 0.7 <0.0001*Visited dentist or dental clinic in past 12 months§ 48.7 72.3 <0.0001*1 year since visited dentist or dental clinic 15.2 9.7 0.0003*2 years since visited dentist or dental clinic 15.2 7.8 <0.0001*5 years since visited dentist or dental clinic 19.6 9.8 <0.0001*Never visited a dentist or dental clinic 1.4 0.5 <0.0001*OHIP items compared with US population for percentage that had problem at level of occasional or abovePainful aching• 38.6 19.5 <0.0001*Uncomfortable to eat• 51.4 16.8 <0.0001*Difficulty doing usual job(s)• 16.0 3.4 <0.0001** P < 0.01.† BRFSS percentages reported have been weighted according to Centers for Disease Control and Prevention guidelines and formulas for probability ofhousehold selection and nonresponse.‡ Kansans n = 5,504; Working Healthy n = 428.¶ Kansans n = 5,250; Working Healthy n = 420.§ Kansans n = 5,521; Working Healthy n = 429.• US n = 4,907; Working Healthy n = 427.• US n = 4,907; Working Healthy n = 430.BRFSS, Behavioral Risk Factor Surveillance System; OHIP, Oral Health Impact Profile.J.P. Hall et al. Oral health as an obstacle to employment for Medicaid beneficiaries with disabilities81© 2012 American Association of Public Health Dentistrydemographic characteristics, such as race, ethnicity, location,and number of hours worked were not associated with sig-nificant differences on any of the dental measures among theWorking Healthy participants.DiscussionMore than half of Working Healthy participants had notvisited a dentist in the prior 12 months and 60 percent hadnot had their teeth cleaned in that time period. Comparedwith the general population, the Working Healthy group hadsignificantly greater rates of oral pain, difficulty eating, anddifficulty working due to dental problems. This group’s lackof regular dental care has serious health implications, par-ticularly for those experiencing chronic health conditionsexacerbated by poor oral health. For a Medicaid populationthat engages in employment to help offset Medicaid costs,poor dental health also may limit work efforts both in theshort term in the form of acute or chronic oral pain, and inthe long term in the form of decreased health over time. Cutsto adult dental services in Medicaid programs have beenshown to result in minimal cost savings to Medicaid and inlikely cost shifting to other state or federally funded programs(9,10). For Medicaid beneficiaries participating in workincentive programs, lack of coverage for dental services mayresult in increased Medicaid costs if oral health issuesdecrease or prevent employment efforts. Conversely, coverageof more comprehensive dental benefits could result inincreased oral and overall health, increased work efforts, andeventual cost savings to Medicaid as more people paid premi-ums for coverage and, potentially, decreased utilization ofother health services (9).AcknowledgmentsThe research was funded by the Kansas Health Policy Author-ity (#KHPA2007-055) through a grant from the US Depart-ment of Health & Human Services, Centers for Medicare &Medicaid Services. We thank Mary Ellen Wright, the WorkingHealthy Program Director, for her support of research tobetter understand the needs of program enrollees.References1. Oral Health in America. A report of the surgeon general.Rockville, MD: US Department of Health and HumanServices, National Institute of Dental and CraniofacialResearch, National Institutes of Health; 2000. NIHpublication 00-4713.2. Li X, Kolltveit KM, Tronstad L, Olsen I. Systemic diseasecaused by oral infection. Clin Microbiol Rev. 2000;13(4):547-58.3. McGinn-Shapiro M. Medicaid coverage of adult dentalservices. Washington, DC: State Health Policy Monitor,National Academy for State Health Policy; 2008. Availablefrom: http://www.nashp.org/publication/medicaid-coverage-adult-dental-services. Accessed September 25, 2009.4. Medicaid Infrastructure Grants, Research Assistance toStates. 2011. Getting Started. Available from:http://mig-rats.org5. Gruman C, Croake S, Schimmel J, Liu S. A GovernmentPerformance and Results Act (GPRA) report: the status of theMedicaid infrastructure grants program as of 12/3/07.Washington, DC: Mathematica Policy Research; 2008.6. Centers for Disease Control and Prevention (CDC).Behavioral risk factor surveillance system survey data. Atlanta,GA: US Dept of Health and Human Services, Centers forDisease Control and Prevention; 2010. Available from:http://www.cdc.gov/BRFSS/technical_infodata/surveydata/2010.htm Accessed February 24, 2012.7. Slade GD. Derivation and validation of a short-form oralhealth impact profile. Community Dent Oral Epidemiol.1997;25(4):284-90.8. Sanders AE, Slade GD, Lim S, Reisine ST. Impact of oraldisease on quality of life in the US and Australianpopulations. Community Dent Oral Epidemiol. 2009;37:171-81.9. Wallace NF, Carlson MJ, Mosen DM, Snyder JJ, Wright BJ.The individual and program impacts of eliminating Medicaiddental benefits in the Oregon health plan. Am J Public Health.2011;101(11):2144-50.10. Pryor C, Monopoli M. Eliminating adult dental coverage inMedicaid: an analysis of the Massachusetts experience. KaiserCommission on Medicaid and the Uninsured Report #7378.Washington, DC: The Kaiser Family Foundation; 2005.Oral health as an obstacle to employment for Medicaid beneficiaries with disabilities J.P. Hall et al.82 © 2012 American Association of Public Health Dentistry

Poor oral health as an obstacle to employment for Medicaid beneficiaries with disabilities

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Poor oral health as an obstacle to employment for Medicaid beneficiaries with disabilities

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