Racial disparities in oral healthcare in the United States: Considerations in the COVID-19 era
The year 2020 presented previously unimaginable challenges to the U.S. healthcare system, but many of these challenges had origins that predated the COVID-19 global pandemic. One such challenge is the effect of racial disparities on healthcare. The existence of racial disparities in healthcare is well documented—the U.S. Department of Health and Human Services (HHS) Healthy People 20201 plan clearly illustrated the spectrum of racial disparities existing in the delivery of healthcare at the beginning of this century. This article focuses on specific oral healthcare measures and findings from the Healthy People 2020 plan and explores key areas of the oral healthcare delivery system that are potentially impacted by the COVID-19 pandemic and further highlighted by the presence of racial disparities in the United States. Throughout the discussion, we use terminology for race and ethnicity consistent with the studies and research referenced.
Efforts across decades
On December 2, 2010, HHS announced “new 10-year goals and objectives for health promotion and disease prevention”2 in its Healthy People 2020 plan. The plan included objectives centralized around improving the overall health of all Americans by separating common health conditions into segments that can be managed and improved incrementally over 10 years under the program. The objectives were further segmented by race or ethnicity and age group, giving exact metrics by which improvement is measured. A common metric, the reduction of dental caries (more commonly known as cavities or generally as tooth decay), was studied for several age groups. Dental caries and untreated tooth decay are preventable, treatable conditions often found in children. If left untreated, they may result in permanent tooth extraction in adult years.
HHS published baseline data upon which it based its 2020 target oral health goals. Data from the period 1999 to 2004 showed that 41.4% of Mexican-American and 35.7% of Black (non-Hispanic/Latino) children ages 6 to 9 years old had untreated dental decay in their primary or permanent teeth compared to 25.1% of white (non-Hispanic/Latino) children of the same age.3 Further, 85.9% of Black (non-Hispanic/Latino) adults and 76.7% of Mexican-American adults ages 45 to 64 experienced permanent tooth loss due to dental caries or periodontal disease.4 The midcourse status of Healthy People 2020’s oral health Initiatives showed that, while a total of 19 out of 33 objectives were measurable and fell into either “met or exceeded 2020 targets” or “were improving,” several of the objectives continued to yield statistically significant disparities by race and ethnicity.5
The COVID-19 pandemic is an additional, multifaceted challenge that further compounds the disparate access to dental. The remainder of this article addresses several of these facets.
Job loss and reduction in disposable income due to COVID-19
People with dental insurance are more likely to visit the dentist than those without.6 Similarly, utilization of dental services correlates with the broader economy and specifically household disposable income.7
In response to economic pressures of COVID-19, businesses turned to workforce reductions throughout 2020. Four in 10 individuals surveyed responded that a member of their households lost a job as a result of COVID-19. The loss of employer-sponsored health insurance coverage as a result of becoming unemployed has also affected households at alarmingly disparate rates. Hispanic/Latino and Black households experienced loss of employer-sponsored coverage by a household member at 61% and 44% of households, respectively, while 29% of white households had a member experiencing this loss of coverage.8
Furthermore, Hispanic/Latino and Black households experienced wage loss at 15% and 5% higher rates, respectively, compared to white households, and 15% and 17% of Hispanic/Latino and Black households have had problems making rent or mortgage payments. More recent surveys show that half of those who lost jobs due to COVID-19 remain unemployed, indicating that wage loss continues to impact households into 2021. With wage loss for Hispanic/Latino and Black households exceeding white households, the reduction in disposable income has put further disproportional pressure on access to oral health services for these populations.
Restricted access to school-based dental programs
The foundation of school-based dental programs is to provide necessary preventive oral healthcare services. By providing these services in the school environment, programs may reach higher volumes of children and adolescents in at-risk age groups. The most common service delivered in school-based oral health programs is dental sealants, which are shown to be highly effective in preventing dental caries.9,10 Despite the fact that dental caries are known to be largely preventable with proper routine dental care, according to the Centers for Disease Control and Prevention (CDC), dental caries remains the most common chronic disease of children ages 6 to 11 years and adolescents ages 12 to 19 years.11 Left untreated, dental caries can lead to significant oral health issues in adulthood, and in some cases can require the permanent removal of teeth. Non-Hispanic/Latino Black, Hispanic/Latino, and Asian children and adolescents in these at-risk age groups are more likely to have untreated dental caries than their white counterparts.12
In the 2020-21 school year, many states sought to prevent community spread of COVID-19 by closing schools, shifting learning to virtual settings. Implications of removing children and young adults from the traditional learning setting may remain unclear for months and years to come. With the closing of schools, other necessary programs—including school-based dental programs—were discontinued. Hybrid learning, where students spend a portion of the school week at home and a portion in school, presents new challenges for school-age children and their parents looking to obtain school-based services. Communication channels and scheduling mechanisms will require careful planning to ensure families are aware of reinstatement of programs, and COVID-19-related safety requirements for successfully participating in these programs. Parents, children, and school administrators will need to work collaboratively to work through any barriers that hinder accessibility for those in greatest need of this type of program.
Medicaid coverage of dental care
Children from certain racial and ethnic groups experience a disproportionate reliance upon Medicaid and the Children’s Health Insurance Program (CHIP) for their health and dental insurance coverages. With more than 50% of children classified as Black, Latino, or Other/Multiracial and covered by Medicaid or CHIP, those programs become a relevant component of our discussion.13
Prior to the COVID-19 pandemic and even more so after, access to Medicaid dental care providers has been more limited than access to private dental insurance providers. As of 2016, only 39% of U.S. dentists participated in Medicaid or CHIP, with a state-by-state range of 15.4% to 85.5%.14 Lower reimbursement is a predominant factor driving the low participation, with average Medicaid fee-for-service (FFS) rates only 61.8% and 46.1% for child and adult services, respectively, as compared to the reimbursement to dentists under private dental insurance.15 With state and federal government budgets feeling the impact of COVID-19, increases to Medicaid dental fee schedules may be unlikely even though the average cost of dental services has been forced to increase due to requirements for personal protective equipment (PPE) and the spreading of fixed cost expenses across fewer patients in response to social distancing requirements.
According to a Health Policy Institute (HPI) poll, 7% of dental practices previously enrolled as Medicaid providers cited insufficient reimbursement and other COVID-19 considerations as reasons they planned to disenroll by the end of June 2020.16 Another 19% indicated they were not sure about their future participation in Medicaid.17 HPI’s polls for the months of August 2020 through November 2020 indicate that 16% to 20% of the respondent clinics or health centers that provide public health-specific dental services are open and have returned to business as usual.18 The corresponding percentage across all dental practice respondents grew to almost 50% at the end of August 2020 but has since decreased to 38% in HPI’s poll of November 2, 2020.19 During the same multi-month polling period, public health dental providers reported that 7% to 8% were either closed but seeing emergency-only patients or closed and not seeing any patients compared to only approximately 1.5% of all dental respondents.20,21 All of these statistics suggest that access to Medicaid dental providers has suffered more than access to dental providers across the commercial marketplace due to the COVID-19 pandemic, adding to the racial disparity in dental care.
Fear of returning to care delivery settings
As of May 2020, during an early peak of the pandemic in the United States, dental checkups and procedures were more likely to be deferred than other healthcare-related appointments, and 52% of individuals said they or someone in their family skipped or delayed getting medical or dental care because of COVID-19.22
As businesses and provider offices began reopening after initial COVID-19 lockdowns, the CDC warned that interaction in a dental care delivery setting involving prolonged close contact with the patient’s eyes, nose, or mouth (i.e., a dental cleaning) may pose higher risk of transmission compared to other interactions (e.g., a blood pressure check).23 In contrast to this early guidance, the last several months have since shown that COVID-19 cases remain very low among dental professionals,24 and procedures to ensure patient and provider safety have been widely adopted and effective. Concerns about catching the virus, or spreading it to others, were higher among certain racial and ethnic groups compared to their white counterparts,25 further influencing these populations to forgo necessary care so long as the threat of infection remains.
These fears further compound existing challenges that people of color face when seeking healthcare services. In 2015, the New York Times published "The Case for Black Doctors," wherein the author discusses the impact that Black physicians in the healthcare workforce have on the health of the Black population. The Times reported that Black Americans as a population tend to be less trusting of physicians and their medical advice—often unknowingly to their detriment. The American Dental Association (ADA) along with groups that advocate for the dental profession report that the number of Black and Hispanic/Latino dentists is disproportionate to the U.S. population, at 4.3% and 5.3%, respectively.26 This may limit provider choice for patients who prefer care delivery from a provider of the same race. Combining this with the barriers to access created by the COVID-19 pandemic, it is likely that racial disparities in access to oral health have further deteriorated over the last year. Efforts to address these disparities including access to regular dental care routines will require an approach to both addressing the lingering fears about the pandemic and rebuilding trust among groups with historically disparate healthcare experiences.
According to the Kaiser Family Foundation, people of color—including members of the Black and American Indian and Alaskan Native (AIAN) populations—are experiencing a disproportionate burden of COVID-19 cases and deaths and they are at an increased risk of hospitalization for the disease.27 Non-Hispanic/Latino Black people also disproportionately occupy the top nine essential occupations, making them especially vulnerable to exposure to the disease28 as essential jobs continued despite widespread lockdowns and business closures in other industries. The development and distribution of COVID-19 vaccines has promised to bring normalcy to care delivery, but vaccination efforts thus far fall short of creating adequate access for the Black population. With only 5.7% of Black Americans having received at least one dose of a COVID-19 vaccine, healthcare systems continue to face challenges of rebuilding trust through an approach that specifically targets and combats anti-Black racism in healthcare.29
Closing thoughts: As we look forward
As we move through the spring months of 2021 after a year of life in a global health emergency, we continue to reflect on the variety of ways that COVID-19 has further exposed racial inequities in our healthcare systems. While it is important to consider each of the above challenges, we must further acknowledge how these challenges interact with and compound one another. Individuals and families faced with any of the above challenges are likely exposed to a combination of these challenges, making each issue more difficult to address on its own. Ultimately, a framework to address racial disparity and inequities in dental care and oral health must identify and address the complex matrix of underlying factors that continue to perpetuate disparity in dental care while creating broader opportunities for access.
The recent development and continuing distribution of an effective vaccine provides an optimistic path forward for containing and potentially eradicating COVID-19. However, it is imperative that policymakers and pandemic response resources are dedicated to ensuring that the above challenges, whether related directly to dental care specifically or instead to the larger whole-person healthcare, are addressed in the process. Addressing racial disparity in dental care is much like addressing racial disparity across all types of healthcare, requiring a multipronged approach in order to break down complex systems and rebuild those that provide equitable care to all members of the population—regardless of race.
1HHS. Healthy People 2030. Retrieved April 18, 2021, from https://www.healthypeople.gov/2020/. Note that Healthy People 2030 is an update to the Healthy People 2020 initiative.
2HHS (December 2, 2010). HHS announces the nation’s new health promotion and disease prevention agenda. HHS News. Retrieved April 18, 2021, from https://www.healthypeople.gov/sites/default/files/DefaultPressRelease_1.pdf.
3HHS. Data Chart: Disparities Details by Race and Ethnicity for 1999-2004. Retrieved April 18, 2021, from https://www.healthypeople.gov/2020/data/disparities/detail/Chart/5017/3/2004.
4HHS. Data Chart: Adults With Permanent Tooth Loss Due to Dental Caries or Periodontal Disease (percent, 45-64 years), By Total. Retrieved April 18, 2021, from https://www.healthypeople.gov/2020/data/Chart/5024?category=1&by=Total&fips=-1.
5CDC. Chapter 32: Oral Health. Healthy People 2020 Midcourse Review. Retrieved April 18, 2021, from https://www.cdc.gov/nchs/data/hpdata2020/HP2020MCR-C32-OH.pdf.
6Blackwell, D.L., Villarroel, M.A., & Norris, T. (May 2019). Regional Variation in Private Dental Coverage and Care Among Dentate Adults Aged 18–64 in the United States, 2014–2017. CDC. Retrieved April 18, 2021, from https://www.cdc.gov/nchs/products/databriefs/db336.htm.
7CDC. Considerations for School Sealant Programs During the Coronavirus Disease 2019 (COVID-19) Pandemic. Retrieved April 18, 2021, from https://www.cdc.gov/oralhealth/dental_sealant_program/school-sealant-programs-considerations-during-COVID-19.html.
8Hugo Lopez, M., Rainie, L., & Budiman, A. (May 5, 2020). Financial and health impacts of COVID-19 vary widely by race and ethnicity. Pew Research Center. Retrieved April 18, 2021, from https://www.pewresearch.org/fact-tank/2020/05/05/financial-and-health-impacts-of-covid-19-vary-widely-by-race-and-ethnicity/.
9CDC. Dental Sealants. Retrieved April 18, 2021, from https://www.cdc.gov/oralhealth/dental_sealant_program/index.htm.
10NYU (March 1, 2021). School-based Dental Program Reduces Cavities by More than 50 Percent. Retrieved April 18, 2021, from https://www.nyu.edu/about/news-publications/news/2021/march/school-based-dental-program.html.
11CDC. Hygiene-related Diseases: Dental Caries (Tooth Decay). Retrieved April 18, 2021, from https://www.cdc.gov/healthywater/hygiene/disease/dental_caries.html.
12Ruff, R.R. & Niederman, R. (April 2018). School-Based Caries Prevention, Tooth Decay, and the Community Environment. JDR Clinical & Translational Research. Retrieved April 18, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5858650/pdf/10.1177_2380084417750612.pdf.
13Brooks, T. & Gardner, A. (July 2020). Snapshot of Children With Medicaid by Race and Ethnicity, 2018. Georgetown University Health Policy Institute. Retrieved My 3, 2021, from https://ccf.georgetown.edu/wp-content/uploads/2020/07/Snapshot-Medicaid-kids-race-ethnicity-v4.pdf.
14ADA (March 14, 2018). 39 percent of U.S. dentists participate in Medicaid or CHIP for child dental services. ADA News. Retrieved May 3, 2021, from https://www.ada.org/en/publications/ada-news/2018-archive/march/more-than-a-third-of-all-us-dentists-participate-in-medicaid-or-chip-for-child-dental-services.
15Gupta, N. et al. (April 2017). Medicaid Fee-for-Service Reimbursement Rates for Child and Adult Dental Care Services for All States, 2016. HPI Research Brief. Retrieved April 18, 2021, from https://www.ada.org/~/media/ADA/Science and Research/HPI/Files/HPIBrief_0417_1.pdf.
16Brooks, T. & Gardner, A. op cit.
17HPI (June 11, 2020). The Dental Care Rebound: How Far Have We Gotten? How Far Will We Go? Retrieved April 18, 2021, from https://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPI_Covid_Webinar_June_2020.pdf?la=en.
18HPI. COVID-19: Economic Impact on Public Health Dental Programs: Week of November 2. Retrieved April 18, 2021, from https://surveys.ada.org/reports/RC/public/YWRhc3VydmV5cy01ZmEzMWM5Y2I1ZGI0YTAwMTE0YTJmNDEtVVJfM3BaeGhzWm12TnNMdjB4.
20ADA (March 14, 2018), op cit.
22Hugo Lopez, M., Rainie, L., & Budiman, A., op cit.
23CDC (March 4, 2021). Clinical Questions About COVID-19: Questions and Answers. Retrieved April 18, 2021, from https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html.
24Pugle, M. (October 15, 2020). Dentists Are Reporting a Low Rate of COVID-19: Here’s Why. Healthline. Retrieved April 18, 2021, from https://www.healthline.com/health-news/why-dentists-are-reporting-a-low-rate-of-covid-19.
25Hugo Lopez, M., Rainie, L., & Budiman, A., op cit.
26HPI. Racial and Ethnic Diversity Among Dentists in the U.S. Retrieved May 3, 2021, from https://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIgraphic_1117_6.pdf?la=en.
27Artiga, S., Corallo, B., & Pham, O. (August 17, 2020). Racial Disparities in COVID-19: Key Findings From Available Data and Analysis. Kaiser Family Foundation. Retrieved April 18, 2021, from https://www.kff.org/disparities-policy/issue-brief/racial-disparities-covid-19-key-findings-available-data-analysis/.
28Rogers, T.N. et al. (2020). Racial Disparities in COVID‐19 Mortality Among Essential Workers in the United States. World Medical and Health Policy. Retrieved April 18, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7436547/pdf/WMH3-9999-na.pdf.
29Boyd, R. (March 5, 2021). Opinion: Black people need better COVID-19 vaccine access, not better vaccine attitudes. New York Times. Retrieved April 18, 2021, from https://www.nytimes.com/2021/03/05/opinion/us-covid-black-people.html.