Access to Oral Health Care: The Role of Federally Qualified Health Centers in Addressing Disparities and Expanding Access

摘要

Objectives. We examined utilization, unmet need, and satisfaction with oral health services among Federally Qualified Health Center patients. We examined correlates of unmet need to guide efforts to increase access to oral health services among underserved populations. Methods. Using the 2009 Health Center Patient Survey, we performed multivariate logistic regressions to examine factors associated with access to dental care at health centers, unmet need, and patient experience. Results. We found no racial or ethnic disparities in access to timely oral health care among health center patients; however, uninsured patients and those whose insurance does not provide dental coverage experienced restricted access and greater unmet need. Slightly more than half of health center patients had a dental visit in the past year, but 1 in 7 reported that their most recent visit was at least 5 years ago. Among health center patients who accessed dental care at their health center, satisfaction was high. Conclusions. These results underscore the critical role that health centers play in national efforts to improve oral health status and eliminate disparities in access to timely and appropriate dental services. The “silent epidemic” of poor oral health in America was highlighted by the US Surgeon General’s 2000 report, Oral Health in America, which also called attention to the disparities that persist in oral health status, access to care, and unmet need for dental care. 1 A Government Accountability Office report from the same year echoed the need to address oral health disparities, noting that oral health problems are the most prevalent chronic disease suffered by children despite being largely preventable. 2 As with medical care, numerous studies also have found that both disease burden and access to oral health care are associated with income, 3 race and ethnicity, 4 language, 5 and insurance status and type. 6 These factors are associated with barriers to access in underserved communities such as affordability, lack of provider availability, inadequate transportation, and low health literacy around the need for oral health care. Whereas nationally almost 60% of individuals with high incomes had a dental visit in the past year, less than 30% of low-income patients (those with incomes below 200% of the federal poverty level) had a dental visit in the past year. 7 In the 2011 brief Advancing Oral Health in America, the Institute of Medicine (IOM) offered recommendations for improving access to oral health prevention and treatment services through a variety of mechanisms, including expanding the focus on oral health in primary care settings. Components of the strategy included training primary care providers to screen patients for emergent oral health issues, to assess patient risk for oral health problems, and to refer patients to dental professionals when appropriate. The IOM also called for improving oral health literacy through education efforts aimed at individuals, communities, and health care professionals. For example, community-wide public education campaigns were recommended to enhance awareness and knowledge about the causes and implications of oral disease and the importance of preventive oral health services. Building the health literacy of patients and promoting healthy behaviors may increase patient activation around these issues, especially when coupled with guidance on how to access oral health services in the community. 8 A subsequent IOM report, Improving Access to Oral Health Care for Vulnerable and Underserved Populations, suggested ways to narrow or eliminate disparities and improve the oral health status of vulnerable populations, guided by the principles that (1) oral health is essential to overall health and, thus, is an important part of comprehensive health care, and (2) any broad strategy to increase access to care should include components aimed at oral health promotion and disease prevention. 9 Building on the existing literature, recommendations for improving access to oral health services for underserved individuals included expanding oral health care capacity by encouraging the integration of oral health services into overall health care. 10 Improving dental education and training for nondental primary care providers may facilitate such integration. 11 Financial and administrative barriers such as the lack of coverage for dental care need to be addressed, while supporting policies that encourage all professionals to practice to the full extent of their training and licensure. 12 Federally Qualified Health Centers (health centers) play a key role in these strategies as they are uniquely positioned to increase access to oral health services in the communities experiencing the most acute access problems. Health centers provided comprehensive primary care to 19.5 million patients in 2010, while also serving as an affordable and convenient access point to oral health services for underserved co