Modeling Dental Service Use among the Elderly with Endogenous Selection into Dental Coverage

Regular dental care is imperative in maintaining good oral health, for preventing dental disease, for diagnosing oral related problems, and for identifying symptoms of other systemic conditions (IOM 2011). Unfortunately, many in the United States do not receive timely, adequate, or appropriate dental care. As a result, a large percentage of adults experience chronic tooth decay and other oral health problems. These conditions frequently cause chronic pain and nutritional difficulties which can adversely impact physical and mental health.

Having adequate dental insurance coverage is a key determinant of the decision to seek care and the ability to find a dentist willing to provide treatment. However, nearly two-thirds of Americans ages 65 and older lack dental coverage altogether. Medicare covers dental procedures only under exceptional circumstances. Dental coverage is an optional benefit under Medicaid, but even when states choose to cover it, few dental providers participate because of low payment rates. Among older Medicare beneficiaries with supplemental private coverage, only a third report dental coverage and this coverage is often limited. We seek to better understand the relationship between dental coverage, coverage generosity, and key sociodemographic characteristics in determining use of preventive and restorative dental services among older Americans.

Our approach builds on our previous work estimating the demand for dental treatment among privately insured non-elderly adults (Meyerhoefer, Zuvekas & Manski 2014). Dental services are classified into one of four categories— preventive, basic (for example, fillings and extractions), major (for example, crowns and root canals), and orthodontia—based on common cost-sharing tiers found in a survey conducted by the National Association of Dental Plans. We jointly estimate the probability of preventive dental care and both basic and major restorative dental services (omitting orthodontia services) using a correlated random effects panel data model (Chamberlain 1980) that controls for endogenous out-of-pocket prices, endogenous dental and health insurance coverage, and other control variables.

The panel data model is estimated with data from the 2007-2015 Medical Expenditure Panel Survey (N=13,549, T=2 years). In preliminary estimates, we find modest effects of coverage on use of preventive and restorative dental services and that use is insensitive to out-of-pocket price conditional on coverage. Educational attainment is strongly and positively correlated with use of all types of dental care. Older Americans in poor health or with activity limitations are less likely to use preventive dental services suggesting additional barriers to access besides insurance coverage.