Although there have been numerous epidemiological studies documenting that insurance status alone does not explain the persistent disparities in dental care between African American and White adults,2,3,5,8,18
few have investigated why insurance fails to eliminate these disparities. To address this issue, we examined the insurance-related barriers to accessing dental care reported by African American adults in Central Harlem. We identified several insurance-related barriers that limit African Americans’ access to dental care and potentially explain the failure of insurance to increase access to dental care. Further, the qualitative methods used provide unique insight into African Americans’ experiences contending with these barriers as they attempt to obtain treatment of their current oral health symptoms.
Consistent with a large body of quantitative research,3,8,11,16–18
uninsured participants perceived the lack of dental insurance as a major barrier to their obtaining care. However, although most of the sample was either privately or publicly insured (75%) many of those who were insured reported that their insurance, both private and adult Medicaid, was often insufficient to pay for the care they needed. They described how insurance would pay for a cleaning but often would not cover more expensive treatments, including a root canal or tooth replacement. As such, many insured participants described how their insurance was inadequate when they experienced their recent symptoms and were in need of treatment rather than preventative care. Other participants described being unable to obtain care because of the need to wait for their dental insurance to take effect. For those who obtained a new job or who had just applied for Medicaid, this often meant a significant delay until they received treatment of their symptoms. Finally, many insured participants described how their insurance did not facilitate obtaining care because they could not find a dentist who accepted Medicaid patients or patients with their type of private insurance. The lack of participating providers clearly impeded these participants from obtaining treatment of their symptoms. Together, the insurance-related barriers described by our participants emphasize that insurance alone is not enough because low-quality private insurance and publicly funded insurance programs (e.g., Medicaid) often do little to eliminate the barriers to obtaining needed dental treatment.
Even when participants were able to receive dental care by using adult Medicaid, many believed that they obtained poorer care (e.g., longer waits, fewer restorative treatments, more tooth extractions) than did those with private insurance. Similar experiences were reported by uninsured participants when they visited public dental clinics. Often, this expectation that they would receive substandard care served as a barrier to seeking dental care. Their reports of their negative experience with some Medicaid dental providers (both finding one and the care received) are consistent with the findings of previous qualitative research among low-income caregivers attempting to obtain care for their children on Medicaid.24,25
Our current study is unique because the qualitative methods allow African Americans to relate their experiences in their own words and thus provide important insights into their perceptions of the dental care system and the insurance-related barriers that limit their access to care. Clearly expressed in the quotes presented is the frustration many experienced when personally confronting these barriers. This frustration was present not only for the uninsured but also for the publicly and privately insured who described their inability to find a dentist or who felt that they were kept from obtaining what they saw as the best quality of care. The participants’ quotes describing these barriers also clearly reflect the resignation that many African Americans felt regarding the futility of engaging with the oral health care system. Many described how Medicaid patients, and the residents of Central Harlem more generally, have such difficulty obtaining care that they delayed seeking treatment, had forgone treatment altogether because they believed it was not worth the hassle and would lead to a disappointing outcome, or it was simply not possible for them to obtain dental care.
The finding that participants on Medicaid reported a number of barriers is particularly important because this program is often promoted as a means to meaningfully reduce barriers to care and health disparities. That Medicaid was viewed as not facilitating care for adults in Central Harlem is particularly significant because the New York State Medicaid program provides more comprehensive dental benefits to adult Medicaid patients than most other states in the United States.28,29
This finding suggests that dental patients in other states may be even more dissatisfied with the available dental services than those described in New York. Likewise, New York State reimburses dentists for services to Medicaid patients at a much higher rate than do other states.28,29
Although this would lead to the expectation that more dentists in New York would be willing to accept Medicaid patients than in other states, studies have shown that reimbursement rates remain a barrier to dentists’ participation in Medicaid.30,31
The finding that participants had difficulty finding dentists who participate in Medicaid in New York suggests that this barrier may be even greater in states where Medicaid dental benefits are underfunded (or nonexistent).
The study findings identify barriers that must be addressed to improve the oral health of African Americans by increasing their access to oral health treatment. Clearly, efforts to increase the number of dentists participating in Medicaid and increase the types of services covered by Medicaid would improve the participants’ ability to obtain care. Increasing the reimbursement rate for dental services for adult Medicaid patients is also necessary because even in New York State (where reimbursement is better than elsewhere), many dentists are unable to financially afford to treat adult Medicaid patients.31
Likewise, providing tax incentives, student loan repayments, or other economic incentive programs for dentists who provide services to adult Medicaid patients in underserved urban areas may also address this barrier. Efforts to recruit and train more African American dental students, and providing financial support for them, may also encourage some of these minority dentists to serve underserved minority communities.32
Furthermore, programs in which midlevel dental practitioners (e.g., dental therapists) provide oral health care to children from rural underserved areas (of Alaska, Minnesota, New Zealand, and Canada)33,34
might be expanded to treat both children and adults in underserved urban areas to further reduce barriers to accessing care. Indeed, an expansion and evaluation of midlevel dental providers has been included in the 2010 US health care reform law.35
However, changes in current practices may not dispel existing and long-standing negative impressions of Medicaid dental care (and the resulting unwillingness to obtain care) unless outreach efforts are made. Such outreach is needed to educate the community about changes that have been made to the program, dispel old perceptions of Medicaid, and create a more positive impression about its dental benefits and services. Community outreach regarding where to obtain dental care from Medicaid-participating dentists would serve to reduce barriers to care as well. Such outreach could be implemented either through community-wide public health media campaigns or through the provision of dental case management to increase oral health literacy and assist patients in navigating the oral health care system, such as by identifying a participating dentist.36
Additional outreach efforts to educate the community about the importance of keeping their dental appointments or providing advance notice if they are unable to do so may also encourage dentists to serve Medicaid patients. This problem of missed appointments is an oft-cited reason for nonparticipation in the dental Medicaid program,36
and there is evidence that community outreach is effective in recruiting dentists, increasing patient participation, and increasing knowledge about the importance of keeping their dental appointments.36
It is clear that finding new methods of providing affordable options for quality dental care for the uninsured is essential, but the findings also suggest that additional sources of affordable dental care would also benefit Medicaid and underinsured participants. Although publicly funded providers (either dentists or midlevel dental therapists) would be 1 potential source of affordable dental care regardless of insurance status, all such clinics in the Harlem area were closed shortly after this study was completed because of city budget constraints, leaving only hospital-based emergency care. As the United States implements health care reform legislation,35
many new and innovative models of health care provision and payment will be developed and evaluated through the Center for Medicare and Medicaid Innovation at both the state and local levels.37
These models are designed to expand access, contain costs, and increase the quality of care provided. To the extent that access to dental care is included in health care reform, the expansion of affordable, quality dental care would be a great benefit to underserved communities such as Harlem. Clearly, these data provide not only evidence of the need to include dental care in health care reform but also a warning about potential pitfalls that new efforts need to avoid.
The current study is one of the first to qualitatively examine insurance-related barriers to obtaining dental care, but it does have potential limitations that must be noted. First, the sample is a small convenience sample, and therefore, the results may not be generalizable to all African Americans living in Central Harlem. Nevertheless, the use of street-intercept recruitment does eliminate some of the self-referral bias that exists in many community-based studies and therefore is likely representative of this population. Further, the sample size, although small for statistical analyses, is rather large for a qualitative study, helping to ensure that the themes identified here are common within the Central Harlem community.
The restriction of the sample to only African American adults living in Central Harlem also potentially limits the generalizability of these findings to other African American samples. However, the focus on Central Harlem does provide critical data that will be useful in addressing the documented unmet oral health care needs within this community.11
Although these findings may not generalize to uninsured and underinsured Whites, past research makes clear that financial barriers to dental care are not unique to African Americans. Therefore, future research should examine whether similar barriers exist in White samples, or whether White and African American samples report similar insurance-related barriers. Finally, because of the semistructured qualitative nature of the interviews in which participants self-nominated barriers, rather than being asked whether they had experienced a predetermined set of barriers, we cannot determine exactly how many participants experienced each barrier. Nevertheless, this method does ensure that the barriers described here are the most salient ones experienced by our participants.
Despite these limitations, the current study provides critical information on the insurance-related barriers that African Americans in Central Harlem experience when attempting to obtain care for their oral health symptoms. As such, the current research provides critical insights into the barriers that must be addressed to reduce the oral health disparities found between African American and White adults.