Research Findings #20: Dental Services: Use, Expenses, and Sources of Payment, 1996-2000

by Erwin Brown, Jr., B.S., and Richard Manski, D.D.S., M.B.A., Ph.D

Abstract

This report from the Agency for Healthcare Research and Quality (AHRQ) characterizes how the civilian noninstitutionalized population used and paid for dental care from 1996 through 2000, using data from the Medical Expenditure Panel Survey (MEPS). The percent of people with any use of dental services each year as well as the average number of visits per year are presented. Estimates include annual expenses and sources of payment (including out-of-pocket amounts). These estimates are presented for the total population as well as for specific population groups categorized in terms of insurance coverage, income, employment, and Census region. The report emphasizes change over time.

The estimates in this report are based on the most recent data available at the time the report was written. However, selected elements of MEPS data may be revised on the basis of additional analyses, which could result in slightly different estimates from those shown here. Please check the MEPS Web site for the most current file releases.

Introduction

This report presents estimates from the Medical Expenditure Panel Survey (MEPS) on the use of dental services as well as expenses and payments for those services from 1996 through 2000. MEPS is an ongoing annual survey of the civilian noninstitutionalized population of the United States. MEPS collects information on how Americans use and pay for health care, their health insurance coverage, and their access to and quality of health care. This report, presenting data on use of and expenses for dental care, is similar to earlier reports prepared with data from the 1987 National Medical Expenditure Survey (Moeller and Levy, 1996; Hahn and Lefkowitz, 1992). While estimates are presented for each year from 1996 through 2000, the focus of this report is on the 2000 estimates and changes in dental use and expenses between 1996 and 2000.

Only differences in estimates that are statistically significant at the p ≤ .05 level are discussed in the text. The technical appendix provides substantial detail on the sample design and definitions of measures used in this report.

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Use of Dental Care

In 2000, less than half (41.6 percent) of the civilian noninstitutionalized population of the United States obtained dental care from a dentist, dental technician, dental hygienist, dental surgeon, orthodontist, endodontist, or periodontist (Table 1).  From 1996 to 2000, the percent of people with a dental visit in each year remained comparatively stable (Table 1).

In 2000, the mean number of dental visits for people who received any dental care was 2.5 (Table 2).  This translates into about 290 million dental care visits, or an average of about 1.0 visit per person in the civilian noninstitutionalized population of 278.4 million people in 2000.  From 1996 through 2000, the mean number of dental visits per person remained stable (Table 2).

Demographic Characteristics

In 2000, children under age 6 were the age group least likely to receive dental care (21.1 percent), while those ages 6-18 were the most likely to use dental care (Table 1).   Although overall the percent of the population using any dental care remained stable during the 5-year period, the proportion among adults ages 19-44 declined from 41.1 percent in 1996 to 38.3 percent in 2000 (Table 1).

During 2000, among people with any dental care during the year, the average number of visits was higher for children ages 6-18 (2.9 visits), adults 45-64 (2.6 visits), and those 65 years and over (2.8 visits) than for younger adults ages 19-44 (2.1 visits) or children under 6 (1.6 visits).   Between 1996 and 2000, the average number of dental visits per person remained relatively stable.

In each year, females were more likely than males to use dental services.  For example, in 2000, 44.9 percent of females had at least one dental visit, compared with 38.2 percent of males (Table 1).  In three of the five years (2000, 1998, and 1997), females had a higher mean number of total visits per person with a visit than males—2.6 and 2.4, respectively (Table 2).

A higher proportion of whites (46.7 percent) than blacks (26.8 percent) or Hispanics (25.7 percent) had at least one dental visit in 2000 (Table 1).  The difference between blacks and Hispanics in the proportion of the population receiving dental care during 2000 is not significant.  Among people who received dental care during 2000, whites had more visits per user (2.6) than either Hispanics (2.1) or blacks (2.1).  This relationship was observed in each year from 1996 through 2000 (Table 2).

Insurance Coverage

In this report, insurance coverage refers to general health insurance coverage and does not necessarily reflect the presence of dental benefits. In 2000, people with private insurance were more likely to have at least one dental visit during the year (Table 1). Among people under age 65, 47.8 percent of those with any private insurance during 2000 had at least one dental visit, compared to 28.9 percent of those with public insurance and only 19.2 percent of those who were uninsured for the full year. A similar pattern was observed for people age 65 and over: 48.7 percent of the elderly with private insurance as well as Medicare had at least one dental visit, while 34.0 percent of those with Medicare only and 17.1 percent of those with public insurance in addition to Medicare received any dental care in 2000 (Table 1).

The relationship between any use of dental care and insurance coverage generally remained stable over the period 1996-2000. However, among people under 65 with private insurance, the percent receiving any dental care declined from 50.0 percent in 1996 to 47.8 percent in 2000 (Table 1).

Income and Employment

In 2000, people with high or middle family incomes were more likely to have a dental visit (53.5 and 40.4 percent, respectively) than people with family incomes categorized as low income, near poor, or poor (29.9, 26.7, and 25.7 percent, respectively; Table 1). The relationship between family income and the probability of use exhibited a consistent pattern each year. However, the likelihood of having a dental visit decreased from 1996 to 2000 for families with middle or high incomes: from 44.9 percent in 1996 to 40.4 percent in 2000 for people in middle-income families and from 56.6 percent to 53.5 percent for people in high-income families (Table 1). People with family incomes categorized as poor had fewer mean visits than those with higher family incomes—low income, middle income, and high income (Table 2). The mean number of visits per user for people in families below the poverty line in 2000 was 2.0 visits. From 1996 through 2000, the mean number of dental visits per person for each income category remained stable (Table 2).

People 16 and over who were employed during 2000 were more likely than their counterparts who were not employed to have at least one dental visit (43.4 percent and 37.8 percent, respectively; Table 1). In contrast, in every year except 1999, the average number of dental visits for people who had a visit was slightly higher for people who were not employed than for those who were employed (Table 2). The rate at which employed people received any dental care declined from 45.8 percent in 1996 to 43.4 percent in 2000 (Table 1).

Region

The percent of people using any dental services remained constant in each Census region between 1996 and 2000. In 2000, residents of the West and South were less likely to have at least one dental care visit than people living in the Northeast and Midwest. During 2000, people living in the Northeast had a higher average number of visits per user (2.7) than people in all other regions.

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Expenses and Sources of Payment

Annual expenses and sources of payment are shown in Tables 3-7.  In 2000, 115.8 million people in the civilian noninstitutionalized population of the United States spent nearly 56 billion dollars on dental care (not shown).  The average dental expense in 2000 for people with a visit was $480 (Table 7).  This represents a 28-percent increase in spending over the annual average expense in 1996 ($374; Table 3).  About half of expenses for dental care were paid out of pocket each year.  These out-of-pocket payments by self or family also accounted for the highest share of payments each year, followed by private health insurance payments, other sources, and Medicaid (Tables 3-7).

Demographic Characteristics

Among people using dental care during 2000, children ages 6-18 had the highest total annual dental expense ($607), while children under 6 had the lowest annual expense ($184).  Medicaid contributed about one-quarter of the payments for dental care for children under 6–more than for any other age group.  Out-of-pocket contributions were highest among the elderly, who paid more than three-quarters of their incurred expenses out of pocket.  As a percent of total expense for dental care, private health insurance payments were lowest for the elderly (14.9 percent) and highest for adults ages 19-44 (49.0 percent). Between 1996 and 2000, mean total expenses for people with a dental visit increased significantly except for the elderly.

In 2000, there were no significant differences in mean dental expenses between males and females.  For persons with a visit, mean expenses rose for both sexes between 1996 and 2000 (Tables 3 and 7).  Average expenses for males with a dental visit rose from $362 in 1996 to $449 in 2000.  During the same period, expenses for females rose from $384 to $505.   Consistently over the 5-year period, about half of expenses were paid out of pocket for both sexes.  Private health insurance was the next largest payer, accounting for 40.2 percent of expenses for males and 43.3 percent of expenses for females in 2000.  A similar ranking of payment sources was seen for all five years (Tables 3-7).

During 2000, mean total dental expenses were lower for blacks ($343) and Hispanics ($337) than whites ($506).  In each of the five years, expenses incurred by whites were higher than those incurred by blacks.  Whites had significantly higher expenses than Hispanics in four of the five years from 1996 to 2000. In every year studied in this report, whites had a lower percent of their expenses paid for by Medicaid than either Hispanics or blacks. 

Insurance Status

Among people under 65 who received dental services, those having any private insurance coverage and those who were uninsured for all of 2000 had higher mean dental expenses than people with public insurance. Interestingly, while they were less likely to receive dental services, the uninsured did not significantly differ in mean dental expenses from the privately insured population during 2000. Among people under 65, the uninsured paid nearly 80 percent of their dental health expenses out of pocket, with 20 percent coming from other sources.  Medicaid covered 66.4 percent of the expenses of people with public insurance, while private health insurance picked up about half the expenses incurred by people with private coverage during 2000 (Table 7).

Over the period 1996-2000, mean expenses increased for individuals under 65 who were either privately or publicly insured (Tables 3 and 7).  The distribution of sources of payment exhibited a consistent pattern over the time period.

Income and Employment

During 2000, people in families with middle or high incomes had higher mean total dental expenses than people in poor families (Table 7).  Between 1996 and 2000, annual expenses for people in low, middle, and high-income families increased.  Mean expenses also increased for people in poor and near-poor families during that time period, but the difference was not statistically significant.

Between 1996 and 2000, people in low and middle-income families experienced a decrease in the proportion of their dental expenses paid for by private health insurance.  People in low-income families saw the percent of their expenses paid for by private insurance drop from 37.1 percent in 1996 to 24.4 percent in 2000.  For these people, the percent paid out of pocket was unchanged. For people in middle-income families, the percent of dental expenses paid for by private insurance dropped from 44.9 percent to 40.0 percent.

Among people 16 and over, average annual dental expenses increased from 1996 to 2000 for both people who were employed with those who were not (Tables 3 and 7).  During 2000, employed people paid for less than half  (47.0 percent) of their dental expenses out of pocket, while people who were not employed paid for 63.7 percent of their dental expenses out of pocket (Table 7).  In each of the five years, people who were not employed paid a higher share of their annual dental expenses out of pocket than those who were employed (Tables 3-7).

Region

Between 1996 and 2000, average annual dental expenses rose in each of the four Census regions.  There was a decline in the portion of dental expenses paid for by private health insurance in the Midwest: from more than half (51.4 percent) in 1996 to 45.7 percent in 2000.

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Out-of-Pocket Expenses

Out-of-pocket dental expenses for 1996-2000 are shown in Tables 8-12. Between 1996 and 2000, the average out-of-pocket expense for people with a dental visit increased from $192 to $237. At the same time, the percent of the population incurring no expense increased slightly, from 30.2 percent to 31.6 percent. The percent of the population incurring $200 or more in out-of-pocket expenses also increased over the period, from 20.4 percent in 1996 to 23.0 percent in 2000 (Tables 8 and 12)

Demographic Characteristics

In 2000, children under 6 incurred the lowest annual out-of-pocket expenses for dental care ($47) and were the most likely to incur no expense at all (52.2 percent). People 65 and over had the highest annual out-of-pocket expenses, an average of $400. Only 10.5 percent of the elderly paid no out-of-pocket expenses for dental care, and 39.1 percent paid $200 or more out of pocket (Table 12).

Also in 2000, while males and females had similar mean out-of-pocket expenses and a similar distribution of out-of-pocket expenses, there were differences by race and ethnicity. Because of their higher use of dental care and lower rates of reimbursement from public programs (Tables 8-12 ), whites had higher mean out-of-pocket expenses ($252) than either blacks ($138) or Hispanics ($174). Whites were also less likely to incur no out-of-pocket expense and more likely to have out-of-pocket expenses of $200 or more. These patterns were unchanged over the 1996-2000 period.

Insurance Status

During 2000, people under 65 with public insurance coverage only had lower out-of-pocket expenses ($75) than either the uninsured ($322) or those with private coverage ($220). Nearly four-fifths (79.5 percent) of those with public coverage incurred no out-of-pocket expense, although 7.3 percent incurred $200 or more in out-of-pocket expenses.

Among people age 65 and over who had dental care during 2000, those with Medicare only had the highest level of out-of-pocket expenses ($550), while those with Medicare and other public coverage had the lowest ($164). Among the elderly with only Medicare coverage who had dental care, there was an increase in the average out-of-pocket expenses for dental services: from $384 in 1996 to $550 in 2000 (Tables 8 and 12).

Income and Employment

During 2000, people in families with incomes categorized as poor had the lowest level of out-of-pocket dental expenses and were the most likely to incur no expense out of pocket. Among people who used dental services in 2000, there were no significant differences in the average out-of-pocket expense for people in low, middle, and high-income families.

People ages 16 and over who were employed had lower mean out-of-pocket expenses in 2000 and were more likely to incur no out-of-pocket expense at all than people who were not employed. Mean out-of-pocket expenses for dental services rose significantly from 1996 to 2000 for both employed and unemployed people (Tables 8 and 12).

Region

Average out-of-pocket expenses for people with at least one dental visit in 2000 were highest in the Northeast and lowest in the Midwest. Looking at the proportion of people with no out-of-pocket expenses, it was largest in the South (25.8 percent) and highest in the West (38.8 percent). Residents of the South, Midwest, and West who had a dental visit experienced a substantial increase in their mean out-of-pocket expense from 1996 to 2000 (Tables 8 and 12). A decline in the percent of residents who paid only $1-$99 out of pocket for dental services was observed for the Midwest, South, and West from 1996 to 2000 (Tables 8 and 12).

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Summary and Conclusions

About 42 percent of the civilian noninstitutionalized population had at least one dental care visit in 2000. This represents an average of 2.5 visits per person with a visit, or about 1.0 visit per person overall. The percent of the population with at least one dental visit remained stable between 1996 and 2000.

Consistently, between 1996 and 2000, children ages 6-18 who had at least one visit annually maintained high rates of use for dental services. In that time period, among the elderly, people with private supplemental coverage were more likely to use dental services than those with Medicaid and Medicare or those with Medicare alone. Females were more likely than males to use dental services. In each of the years included in this report, whites had higher rates of dental care use than either blacks or Hispanics.

Employed people were more likely to use dental care than people who were unemployed. Employed people also had a greater share of their expenses paid for by private health insurance. Income, too, was related to use of dental care. People in middle and high-income families were the most likely to use dental care.

The mean expense per person with a dental care visit in 2000 was $480, and almost half (49.3 percent) of dental expenses were paid for out of pocket. Private health insurance covered 42 percent, with Medicaid and other sources picking up the remainder.

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References

Cohen J. Design and methods of the Medical Expenditure Panel Survey Household Component. Rockville (MD): Agency for Health Care Policy and Research; 1997. MEPS Methodology Report No. 1. AHCPR Pub. No. 97-0026.

Cohen S. Sample design of the 1996 Medical Expenditure Panel Survey Household Component. Rockville (MD): Agency for Health Care Policy and Research; 1997. MEPS Methodology Report No. 2. AHCPR Pub. No. 97-0027.

Hahn B, Lefkowitz D. Annual expenses and sources of payment for health care services. Rockville (MD): Agency for Health Care Policy and Research; 1992. National Medical Expenditure Survey Research Findings 14. AHCPR Pub. No. 93-0007.

Moeller J, Levy H. Dental services: a comparison of use, expenditures, and sources of payment, 1977 and 1987. Rockville (MD): Agency for Health Care Policy and Research; 1996. AHCPR Pub. No. 96-0005.

Monheit A, Wilson R, Arnett R. (Editors). Informing American health care policy. San Francisco: Jossey-Bass, Inc.; 1999.

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Tables

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Technical Appendix

The data used in this report were obtained from interviews conducted as part of the Household Component of the Medical Expenditure Panel Survey (MEPS) for 1996, 1997, 1998, 1999, and 2000. MEPS is an ongoing annual survey of the civilian noninstitutionalized population. MEPS collects detailed information on health care use and expenditures (including sources of payment), health insurance, health status, access, and quality. It also collects detailed demographic and economic information on the persons and households surveyed. More information about MEPS can be found at http://www.meps.ahrq.gov. For a detailed description of the survey and its methodology, also see J. Cohen (1997) and S. Cohen (1997).

Survey Design

Each year, the MEPS sample is drawn from households that completed the prior year’s National Health Interview Survey (NHIS). Households selected for participation in the 1996 MEPS completed interviews in the 1995 NHIS, the 1997 MEPS sample was drawn from the 1996 NHIS, and so on. Because NHIS is used as a sampling frame, the MEPS design is not only nationally representative of the civilian noninstitutionalized population but also includes an oversampling of Hispanics and blacks.

MEPS collects data in an overlapping panel design. Each household completes five interviews (“rounds” of data collection) over a period of 2 1/2 years, providing data for two full calendar years of estimates. Data from Rounds 1, 2, and 3 provide information for the first year of estimation, and data from Rounds 3, 4, and 5 provide data for the second year of estimates. For example, estimates for 2000 are derived from combining Rounds 3, 4, and 5 of the 1999 panel and Rounds 1, 2, and 3 of the 2000 panel. An exception is 1996, when the MEPS longitudinal data collection was initiated. For that year, a single panel’s data were used for estimation. In MEPS, a single respondent provides most of the information to an interviewer using computer-assisted personal interviewing (CAPI). In addition to the CAPI interview, beginning in 2000, limited data have been collected using a self-administered questionnaire (SAQ).

Definitions

Dental services/visit. This refers to care by or visits to any type of dental care provider, including general dentists, dental hygienists, dental technicians, dental surgeons, orthodontists, endodontists, and periodontists.

Dental expenditures (expenses). In this report, expenditures are the amount actually paid for dental services. More specifically, in MEPS, expenditures are defined as the sum of payments for care received, including out-of-pocket payments and payments made by private insurance, Medicaid, Medicare, and other sources.

This definition of expenditures differs somewhat from the definition used in predecessor surveys, the 1987 National Medical Expenditure Survey (NMES) and the 1977 National Medical Care Expenditure Survey, in which charges rather than payments were used to measure medical expenditures. Users who wish to compare the expenditure data presented in this report with data from the 1987 and/or 1977 surveys should consult Monheit, Wilson, and Arnett (1999). AHRQ has developed factors to apply to the 1987 NMES expenditure data to facilitate longitudinal analysis. These can be accessed via the CFACT Data Center. See http://www.meps.ahrq.gov/data_stats/onsite_datacenter.jsp for more information. Details on the editing and imputation methodology used to develop the dental expenditure variables presented in this report can be found in the documentation for the dental event files. See http://www.meps.ahrq.gov/data_stats/download_data/pufs/h51b/h51bdoc.shtml for the 2000 dental event file link.

It should also be noted that it is common for several dental visits to be included in a single fee. These “flat fees” are particularly common for orthodontia and some types of dental reconstruction and surgery. These flat fee groups may cross calendar years. For flat fees, expenses for the entire episode are placed on the initial event.

Sources of payment. In this report, categories of payments that sum to total expenditures are reported. Out-of-pocket payments are payments made by the user or the user’s family. Private health insurance includes employment-related as well as directly purchased insurance, including any dental benefit plans. In this report, the “other” category includes Federal programs such as programs of the Department of Veterans Affairs, TRICARE (Armed-Forces-related coverage), the Indian Health Service, and military facilities; State and local programs other than Medicaid; and other sources such as Workers’ Compensation, automobile insurance, and other kinds of insurance not specified.

Age. In this report age is the sampled person’s age as of December 31st of the reported year.

Race/ethnicity. Classification by race and ethnicity was based on information provided by the household respondent for each household member. The respondent was asked if each person’s race was best described as black, white, Asian or Pacific Islander, American Indian, or Alaska Native. The respondent was also asked if each person’s main national origin or ancestry was Puerto Rican, Cuban, Mexican, Mexicano, Mexican American, or Chicano; other Latin American; or other Spanish. Persons claiming a main national origin or ancestry in one of these Hispanic groups, regardless of racial background, were classified as Hispanic. Since the Hispanic grouping an include persons of any race, the race categories of black and white/other exclude Hispanics.

Insurance status. Respondents were asked about health insurance coverage for themselves and all household members at each round of interviewing. The insurance variables reflect having general medical insurance, which may or may not include coverage of dental care.
Persons under 65 were classified according to whether they had private health insurance, had public coverage only, or were uninsured all year.

• Any private insurance. This group includes those who, at any time in the survey year, had individual or group plan coverage for medical or related expenses, including prepaid health plans such as health maintenance organizations but excluding extra cash coverage plans, medical benefits linked only to specific diseases (dread disease plans), and casualty benefit plans (such as automobile insurance).

• Public insurance only. This group includes persons who were never covered by private insurance during the year but who were covered at any time by Medicare, TRICARE (which covers retired members of the uniformed services and the spouses and children of active-duty military), Medicaid, and other State and local medical assistance programs.

• Uninsured all year. This refers to all persons under age 65 with neither public nor private insurance coverage throughout the calendar year.

In this report, persons over age 65 were classified by whether they were covered by Medicare only, by Medicare and other public coverage, or by Medicare and private insurance programs.

Employment status. For each year of the report, persons 16 years old and over were asked whether they were currently employed. Persons with a job at any time during the year were considered employed in this report.

Income. Each year, persons were classified according to their family’s income in terms of poverty status. In this report, poverty status is the ratio of the family’s income to the Federal poverty thresholds, which control for the size of the family and the age of the head of the family. In this report, the following classification of poverty status was used.

• Poor—Persons in families with income less than 100 percent of the poverty line, including those who reported negative income.

• Near poor—Persons in families with income from 100 percent to less than 125 percent of the poverty line.

• Low income—Persons in families with income from 125 percent to less than 200 percent of the poverty line.

• Middle income—Persons in families with income from 200 percent to less than 400 percent of the poverty line.

• High income—Persons in families with income over 400 percent of the poverty line.

In MEPS, personal income from each household member was summed to create family income. Potential income sources asked about in the survey interview include annual earnings from wages, salaries, bonuses, tips, and commissions; business and farm gains and losses; unemployment and Workers’ Compensation payments; interest and dividends; alimony, child support, and other private cash transfers; private pensions; individual retirement account (IRA) withdrawals; Social Security and Department of Veterans Affairs payments; Supplemental Security Income and cash welfare payments from public assistance, TANF (Temporary Assistance for Needy Families; formerly known as Aid to Families with Dependent Children, or AFDC); gains or losses from estates, trusts, partnerships, S corporations, rent, and royalties; and a small amount of “other” income.

Region of residence. Each MEPS sampled person was classified as living in one the the following four regions as defined by the U.S. Census Bureau.

• Northeast—Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New York, New Jersey, and Pennsylvania.

• Midwest—Ohio, Indiana, Illinois, Michigan, Wisconsin, Minnesota, Iowa, Missouri, South Dakota, North Dakota, Nebraska,and Kansas.

• South—Delaware, Maryland, District of Columbia, Virginia, West Virginia, North Carolina, South Carolina, Georgia, Florida, Kentucky, Tennessee, Alabama, Mississippi, Arkansas, Louisiana, Oklahoma, and Texas.

• West—Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, Nevada, Washington, Oregon, California, Alaska, and Hawaii.
 

Sample Design and Accuracy of Estimates

The statistics presented in this report are affected by both sampling error and sources of nonsampling error, which include nonresponse bias, respondent reporting errors, interviewer effects, and data processing misspecifications. The MEPS person-level estimation weights include nonresponse adjustments and poststratification adjustments to population estimates derived from the Current

Population Survey based on cross-classifications by region, metropolitan statistical area, age, race/ethnicity, and sex. The overall MEPS response rate reflects response to both the MEPS and NHIS interview. The sample size and annual response rates are:

Rounding

Estimates presented in the tables were rounded to the nearest 0.1 percent. Population estimates were rounded to the nearest thousand. Because of this (as well as conventions for displaying missing data, as indicated in each table), some of the subpopulation estimates presented in the tables will not sum exactly to the overall population total. Standard errors, presented in Tables A-L, were rounded to the nearest 0.01.