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Dental insurance, generally not covered in Medicare, is an important factor in the decision to seek dental care. We examine the convergence of an aging population, retirement and a decreased availability of dental care coverage using data from the Health and Retirement Study. We show that being in the labor force is a strong predictor of having dental coverage. For older retired adults not in the labor force, the only source for dental coverage is either a post retirement health benefit or spousal coverage.
Having dental insurance has been shown to be an important factor in the decision to seek dental care.1 Failure to receive treatment early may make necessary the provision of less definitive, less than adequate and more costly care. A growing number of U.S. adults are retaining an increasing number of their teeth throughout their life span.2 As a result, a relative increase in coronal and root caries, periodontal diseases, inadequate or absent prostheses and preventive needs may result from a greater number of retained teeth among the elderly.3
Despite the importance of dental insurance, Medicare, which provides health insurance coverage to virtually all Americans age 65 and older, generally does not cover dental care. With the exception of dental care made more complicated by a concomitant medical problem, Medicare insurance does not pay for dental care.4 Despite past interest in expanding Medicare to include dental coverage, this is unlikely in the near future due to macroeconomic conditions, unless it is part of a broader health reform package. Indeed, while 54 percent of the non-elderly population had private dental insurance in 2004, only 24 percent of those age 65 and older had private dental coverage.5 Public coverage via Medicaid and other sources covers a small fraction, but 70 percent of adults age 65 and older lacked dental coverage altogether in 2004, compared to 35 percent of younger adults. Among older adults, older cohorts were less likely to have dental coverage than younger cohorts with the youngest cohort rates approaching that of the general population.6
While the transition to Medicare is partially responsible for declining rates of dental insurance coverage among the elderly, the loss of employer-based insurance coverage at the time of retirement also contributes to higher dental uninsurance. By Medicare eligibility at age 65, more than half are no longer working full-time.7 Most workers do not have access to post-retirement health benefits, and dental coverage may not be included in the fringe benefit packages even among those who do have retiree health insurance. Indeed, in the 20 years since 1988, firm offers of retiree health benefits have fallen by 50%, meaning that an increasing fraction of retirees face a lack of dental coverage in retirement.8 Individuals without public or employer-based coverage are left to purchase coverage in the non-group market, or to self-insure, paying out of pocket for care when it is obtained. For a retired population relying on limited resources for retirement, these options can be potentially costly and financially risky.
The purpose of this article is to further examine the convergence of an aging population and a decreased availability of dental care coverage using data from the Health and Retirement Study (HRS). In particular, we consider more closely the impact of retirement on the likelihood of having dental coverage.
The Health and Retirement Study (HRS), administered by the Institute for Social Research (ISR) at the University of Michigan and sponsored by the National Institute on Aging, is a longitudinal household survey useful for the study of aging, retirement, and health among older populations in the United States.9,10 Every two years, individuals over age 50 and their spouses are surveyed by the HRS; approximately 20,000 interviews are completed in each survey wave. Each respondent is asked a large battery of questions including information about demographics; income and assets; physical and mental health; cognition, family structure and social supports; health care utilization and costs; health insurance coverage; labor force status and job history; and retirement planning and expectations.
This analysis focuses on dental insurance coverage reported in the HRS for the two-year period prior to the most recent survey in 2006. Dental coverage in the 2006 HRS was identified in one of two ways: either (1) the respondent reported seeing a dentist for dental care during the two-year period preceding the survey and having expenses at least partially covered by insurance, or (2) the respondent did not see a dentist but reported that they would expect any costs to be covered by insurance if he or she did need to see a dentist. Using this information, we calculate national estimates of the number and characteristics of those persons age 51 years and above covered by dental insurance by labor force and retirement status, and source of coverage.
Because dental insurance is oftentimes tied to one's employer, understanding how coverage relates to retirement under various definitions is important. We base the retirement status on survey questions regarding retirement status and employment class, and on the derived labor force status from the RAND HRS. For this reason, we split retirement status into two categories--fully or partially retired. Survey respondents are designated as fully retired if at the time of the survey interview they were not working for pay and either (1) said that they were completely retired, or (2) reported their sole employment status as retired, or (3) were assigned a labor force status of retired. Partial retirement is used for individuals who are not fully retired but either (1) reported their employment status as retired along with another employment status (such as working, disabled, or unemployed) or (2) said they were partly retired, or (3) were assigned a partly retired labor force status.
Individuals not classified as fully or partly retired are designated as either in or out of the labor force. Those classified as in the labor force report (1) report working for pay or (2) have a labor force status of working full or part time or unemployed. Those identified as not in the labor force have a labor force status of disabled or not in the labor force. This latter category also includes individuals who have never been in the labor force.
For those individuals reporting dental coverage in the 2006 HRS survey period, we identified the self-reported coverage source from the HRS health insurance data. We then divided coverage source into three categories: (1) own coverage, (2) spousal coverage, and (3) coverage source undetermined.
Along with calculating the bivariate relationship between dental coverage and retirement status, we also estimate a multivariate model controlling for other potentially confounding variables. Given the dichotomous dependent variable for dental coverage, we use logistic regression to measure the association of retirement status on dental coverage while controlling for potential demographic and other confounders in the dental coverage equation.
In order to assure sufficient numbers to produce reliable national estimates, variable categories were combined when necessary. Observations with missing data for specific categorical variables were too few in number to show separately in the tables, so they are not shown and were omitted from the regression analysis. The HRS core sample design is a multistage area probability sample of households, so all estimates and statistics reported were computed taking into account this design with the use of the software packages SUDAAN and STATA.11,12
There were 16,955 total participants in the 2006 HRS representing 76,543,869 members of the community-based population age 51 and above. Of these, more than half of the participants were female (57%, N=9,742). Fourteen percent (N=2,360) of the participants were non-Hispanic Black and 9 percent (N=1,529) were Hispanic. Twenty-eight percent (N=4,712) of the participants were age 75 or older, 36 percent (N=6,171) were between the ages of 65 and 74, and 36 percent (N=6,072) were between the ages of 51 and 64.
Tables Tables1,1, ,22 and and33 show dental coverage status by retirement status, labor force status, and source of coverage as defined above. Table 1 shows the number and characteristics of persons age 51 years and above in 2006 with dental coverage by retirement status for each of several selected population characteristics. Overall, forty-eight percent of all older adults had dental coverage during 2006, but the coverage rate drops steeply for persons 65 years and older, consistent with our previous findings. Moreover, older adults not retired are more likely (p <.05) to have dental coverage than retired older adults, though coverage rates only differed significantly by retirement status for the elderly between 51 and 64 years of age. We also noted differences (p < .05) in coverage rates for race/ethnicity, income, age, marital status, family size, health status, education categories and presence of teeth. Non-Hispanic Whites and Hispanics were less likely (p< .05) to have dental coverage than were non-Hispanic Blacks. High income older adults were more likely (p < .05) to have dental coverage than middle income, low income and poor older adults. While poor older adults were more likely (p < .05) to have dental coverage than low income older adults, they were no more likely (p > .05) to have dental coverage than middle income adults. In addition, college graduates were more likely (P < .05) to have coverage than were high school graduates. Both college graduates and high-school graduates were more likely (p < .05) to have coverage than were older adults with less formal education (less than high school education). Married older adults, older adults with a larger family, and those in excellent health were more likely to have dental coverage than widowed or divorced older adults, older adults from a smaller family, or those in poorer health. For adults age 51 to 64, males and females, non-Hispanic Blacks, non-Hispanic Whites, high and middle income older adults, high school graduates and college graduates, all marital status family size and health status categories, older adults not retired were more likely (p < .05) to have dental coverage than retired older adults. On the other hand, retirement status appears to have no effect on the likelihood of having dental coverage among older adults age 65 and above, Hispanics and other race/ethnic groups, persons without high school degrees, and poor older adults.
Table 2a shows the number and characteristics of non-retired persons age 51 years and above in 2006 with dental coverage by labor force status for each of several selected population characteristics. Labor force status appears to have no effect on the likelihood of having dental coverage among older adults age 75 and above, poor older adults, persons in the “other” race/ethnicity group, and adults who have never married. For each other demographic and socioeconomic category, non-retired older adults in the labor force were more likely (p<.05) to have dental coverage than non-retired older adults not in the labor force.
Table 2b shows the number and characteristics of retired persons age 51 years and above in 2006 with dental coverage by extent of retirement status for each of several selected population characteristics. The extent to which a person is retired (partially versus fully) appears to have a variable effect on the likelihood of having dental coverage among older adults. Overall, partially retired older adults were more likely (p < .05) to have dental coverage than fully retired older adults. Partially retired male and female older adults, non-Hispanic White older adults, high income older adults, high school and college graduate older adults, married older adults, older adults in excellent, very good, or good health, older adults in households of size two, and older adults who have not lost all of their permanent teeth are more likely to have dental coverage than similar fully retired older adults.
Table 3 shows the number and characteristics of persons age 51 years and above in 2006 with dental coverage, by source of coverage (as defined above) and selected characteristics. For each demographic and socioeconomic category, the source for coverage was overwhelmingly (p<.05) obtained from one's own dental coverage. While spousal dental coverage appears to decline (p <.05) with age, age has no effect on the likelihood of obtaining dental coverage from one's own plan. Males are more likely (p <.05) than females to receive their coverage from their own plan; females are more much more likely to receive their dental coverage from their spouse. Poorer adults were less likely (p < .05) to obtain their dental coverage from a spousal plan and more likely (p < .05) to receive their dental coverage from their own plan than higher income older adults.
Retired persons were slightly less likely to have their own dental coverage than non-retired older adults, but this difference was not offset by higher spousal coverage for the retired group compared to the non-retired group.13
Table 4 shows the adjusted odds ratio of the probability of having dental care coverage during the year 2006. Overall, estimates from our multivariate model confirm the stability of the bivariate relationship between retirement status and dental coverage controlling for other potentially confounding variables, though it indicates some differences. For instance, when controlling for confounding variables we find that females, widowed older adults and older adults in poor health are no less likely to have dental coverage than males, married older adults or older adults in excellent health. We also find that older adults living in a household of three or more and older adults who were never married are no more likely to have dental coverage than married older adults or older adults living alone.
Analyses show that being in the labor force is a strong predictor of having dental coverage for older adults between the ages of 51 and 64. Older adults who are retired are less likely to have dental coverage than non-retired older adults in the same age group and partially retired older adults were more likely to have dental coverage than fully retired older adults. Unlike medical care coverage, dental coverage is generally not included in Medicare and minimally provided by Medicaid. For older retired adults no longer in the labor force the only source for dental coverage is either a post retirement health benefit or spousal coverage.
More than one third of fully retired older adults have dental coverage and about sixty-eight percent of retired older adults with dental coverage receive their coverage from their own source. Only twenty-three percent of retired older adults with dental coverage receive their coverage from a spouse.
Non-Hispanic Blacks were more likely to have dental coverage than were non-Hispanic Whites. Although a similar difference had been found in 2004 for the elderly 65 years and over, the unexpected size of the difference observed in the HRS data appears to be driven by the relatively high percentage of non-Hispanic Blacks, classified as covered who had no dental use but expected coverage if they had use (40.0 percent, not shown) compared to the much smaller percentage for White non-Hispanics (18.9 percent, not shown). The racial differences in coverage rates observed in the HRS data may well depend on how realistic these expectations of coverage might be, including differences in perceptions about Medicare coverage of dental services, across racial groups. We note that non-Hispanic Blacks, classified as covered without dental use had a higher percentage of likely dental coverage from public sources than comparable non-Hispanic White (32.7 vs. 23.1 percent, not shown) and a lower percentage of likely private coverage (52.8 vs. 67.6 percent, not shown) than comparable non-Hispanic Whites.
Poor older adults were more likely to have dental coverage than low income older adults suggesting that the minimally available Medicaid dental coverage may be reaching some poor older adults.
Some bivariate relationships did not hold up in our multivariate model. For instance, while married older adults, older adults with a larger family or older adults in excellent health appeared to be more likely to have dental coverage in our bivariate model, these differences disappeared in the multivariate model.
While spousal dental coverage appears to decline with age, age has no effect on the likelihood of obtaining dental coverage from one's own plan. Spousal coverage could decline with age because the likelihood that one's spouse is retired and therefore less likely to be covered by an employer plan increases with age, and also because the likelihood of widowhood increases with age. The decline in spousal coverage due to widowhood would be more likely for women as they have longer life expectancies, but we did not stratify our results by gender. In addition, poorer adults were less likely to obtain their dental coverage from a spousal plan and more likely to receive their dental coverage from their own plan than higher income older adults. If lower-paying jobs provide dental insurance for the worker but not the spouse or dependents, this result would be expected, though we cannot confirm it with the data.
The HRS data are useful, comprehensive, and provide estimates that are nationally representative. Nonetheless, they do have limitations, and analyses of data from different survey sources have historically resulted in national estimates of dental coverage that vary. The self-reporting of data, as is done in the HRS, is less accurate than collection by observation. Further, data available in the HRS do not disaggregate results by benefit plan generosity, or show the extent to which public coverage or individual dental health insurance purchased directly from an insurance company is included. Despite these limitations, the richness of the dataset and importance of dental coverage in an aging population warrants additional study.
Future work should explore coverage type and coverage dynamics of older Americans as they transition from full-time employment to retirement. Health insurance coverage in the 55-64 year old cohort has been shown to be quite volatile, though overall rates of uninsurance are lower than in younger cohorts.14,15 Dental care has been shown to be sensitive to insurance coverage and the price of care, and therefore understanding insurance transition dynamics may help predict the likelihood of pent-up demand and delayed dental care among near-elderly populations.16,17
Understanding the dynamics of retirement and dental insurance transitions and the associated effect on utilization is particularly important in the current economic climate. It is possible and indeed likely that the economic downturn will affect both the retirement decisions of individuals and the offering of dental benefits to either current or retired workers by firms. In this environment, it is imperative that we better understand the relationship between retirement and dental coverage, including the availability of individual dental health insurance products, in order to identify the best ways of improving oral health and access to care among older Americans.
This investigation was supported by the National Institute on Aging of the National Institutes of Health. (R01 AG026090-01A2, Dental Coverage Transitions, Utilization and Retirement)
The HRS (Health and Retirement Study) is sponsored by the National Institute of Aging (grant number NIA U01AG009740) and is conducted by the University of Michigan.