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2015 Washtenaw County Dental Assessment: 

A Focus on Low Income Populations and Safety Net Providers 

Written by Ruth Kraut, Erin Shigekawa, Kersten Lausch and Kirsten Bondalapati

 

Executive Summary

In 2011, the oral health group within Washtenaw Health Initiative conducted an assessment of dental services and need within Washtenaw County. Since that time, much has changed in the dental landscape in Washtenaw County. The current assessment was conducted by the WHI’s Community Coordination and Dental Services Workgroup. As was true in 2011, this assessment focuses on low income populations and safety net providers.

The assessment begins with a history and context of dental care in Washtenaw County, including current programs and services for children and adults, providers and insurance agencies providing dental care and coverage, and the industry context of the medical-dental divide. Demographic information, insurance payer mix, provider need and Michigan budget figures are included. Activity of the safety-net dental providers gives an idea of capacity within the county. Specific populations encounter access barriers to dental care. Included in the current assessment is an in-depth look at barriers and clinical issues in receiving dental care among children years 0 – 5 years old, the aging population, Limited English Proficiency and recent immigrants, low income populations, persons with special health care needs and pregnant women. Access and cost issues are highlighted for each population.  Other issues affecting access to dental care include benefit reimbursement rates for dentists and their participation in low income and safety-net programs, such as Medicaid, and the use of the emergency room for dental care.

Key findings include:

  • Access to dental care for low-income populations, overall, has improved, particularly because of the expansion of Healthy Kids Dental for children, the Healthy Michigan Plan Medicaid expansion for adults, and the new Washtenaw County Dental Clinic.
  • Significant access issues continue to exist for specific populations, particularly for adult populations between 138 – 200 percent of the federal poverty level (FPL), low-income senior citizens, and individuals who don’t speak English well.
  • There is an increasing understanding that oral health affects physical health, and physical health affects oral health, yet the links between the medical and dental organizations in the county are weak.

Over the coming year, initiatives to tackle access to care issues for specific populations and problems should be developed.

Introduction

The Washtenaw Health Initiative (WHI) Oral Health workgroup first completed a dental assessment in the spring of 2011. Since 2011, three major changes have altered the dental environment in Washtenaw County and beyond: the Healthy Kids Dental Program, the Healthy Michigan Plan and the newly opened Washtenaw County Dental Clinic. This report has been updated and provides an overview of the dental state in Washtenaw County, including:

  • History and Context (programs, clinics, providers and industry context)
  • Current State (demographics, insurance recipients, state budget and provider need)
  • Safety Net Activity
  • Patient Populations (access barriers and clinical issues)
    • Children (0 – 5)
    • Aging
    • Limited English Proficiency and recent immigrants
    • Low income
    • Special health care needs
    • Pregnant women
    • People with diabetes
  • Benefit and Reimbursement Information
  • Use of Emergency Department for Dental Services
  • Provider Participation (Medicaid, charity care and alternative payment options)
  • Proposals for Future Activity

Based on current assessment and discussion among the work group members, the group elected to focus on three populations for future activity:

  • Low Income Populations (specifically between 138 – 200 percent above the FPL)
  • Aging Populations
  • Limited English Proficiency and Recent Immigrant Populations

In a separate document, project and proposals for moving forward will address the needs of the above focus populations.

History and Context

Healthy Kids Dental

Healthy Kids Dental is a partnership between the Michigan Department of Health and Human Services and Delta Dental, which operates in 80 of 83 Michigan counties.[1],[2] There are high participation rates in this program; in the 80 counties where the program operates, approximately 80 percent of dentists who treat children accept Healthy Kids Dental. Healthy Kids Dental reimbursement rates are comparable to private insurance rates. Medicaid enrollees under age 21 are covered for treatment by any dentist in the Healthy Kids Dental program.

Healthy Michigan Plan

Michigan launched the Healthy Michigan Plan on April 1, 2014. The Healthy Michigan Plan covers residents between 19 and 64 years of age who have a household income below 138 percent of the Federal Poverty Level (FPL) and do not qualify for Medicare or other Medicaid programs.[3] Unlike the state’s traditional Medicaid program, in which dental benefits are separate, the Healthy Michigan Plan includes dental coverage through the individual’s assigned managed care plan. Health plans can opt to self-administer their dental benefit, or contract out dental services.  In Washtenaw County, four plans are available: Blue Cross Complete of Michigan, HAP Midwest Health Plan Inc., Meridian Health Plan of Michigan and Molina Healthcare of Michigan.

Statewide, there are 12 participating plans providing coverage for Healthy Michigan Plan enrollees; these plans either use Delta Dental, Healthy Michigan Dental (an affiliate of DENCAP) or self-administered dental benefits.

Figure 1. Healthy Michigan Plan Dental Benefit Administrators.

Health Plan Dental Benefit Administrator Reimbursement Rates
*Meridian Health Plan of Michigan Delta Dental Delta’s PPO
*HAP Midwest Health Plan, Inc. Delta Dental Delta’s PPO
Upper Peninsula Health Plan Delta Dental Delta’s PPO
*Molina Health Care (includes HealthPlus Partners) Delta Dental Delta’s PPO
Physicians Health Plan Delta Dental Delta’s PPO
Priority Health Choice, Inc. Delta Dental Delta’s PPO
McLaren Health Plan Delta Dental Delta’s PPO
Total Health Care Healthy Michigan Dental Healthy Michigan Dental
*Blue Cross Complete of Michigan Healthy Michigan Dental Healthy Michigan Dental
Harbor Health Plan, Inc. Healthy Michigan Dental Healthy Michigan Dental
UnitedHealthcare Community Plan Self-Administered Traditional Medicaid
Aetna Better Health (previously CoventryCares of Michigan) Self-Administered See Posted Fee Schedule

* Plans available in Washtenaw County.

The Washtenaw County Dental Clinic

The Washtenaw County Dental Clinic opened in February 2015. The clinic serves residents with Medicaid dental coverage, or residents who are uninsured and low-income. The clinic has eleven chairs and will see an estimated 6,000 patients annually with about 15,000 visits. St. Joseph Mercy Health System is providing the clinic space, located in downtown Ypsilanti (Haab Building, 111 N. Huron Street). Washtenaw County owns the Washtenaw County Dental Clinic and Washtenaw County Public Health contracts with Michigan Community Dental Clinics to operate the facility. The Washtenaw Health Plan and Washtenaw County Public Health have contributed startup costs for the clinic. Additionally, the public health department is eligible for additional federal funds to supplement Medicaid reimbursement rates.[4]

Washtenaw Children’s Dental Clinic

Amidst major changes in the dental landscape, the Washtenaw Children’s Dental Clinic closed at the end of 2013 following the implementation of Healthy Kids Dental. The Washtenaw Children’s Dental Clinic provided care to uninsured children only (through age 18), and saw an estimated 254 patients in 2010.[5]

WHI Acute Dental Care Program

The Acute Dental Care Program created a new referral process for patients who presented to local emergency departments with dental infections, whether uninsured or with Medicaid. The St. Joseph Mercy Health System and the University of Michigan Health System emergency departments referred these patients to the Community Dental Center. In 2014, the program treated about 107 patients, with approximately half referred for additional services.[6] A program evaluation is expected in 2015. The Acute Dental Care Program is funded by the Washtenaw Health Plan.

WHI Reduced Fee Dental Initiative

The Reduced Fee Dental Initiative allows patients to directly pay dentists a reduced fee based on their income. The Washtenaw Health Plan administered the program. Over its course, the program enrolled a total of 103 patients.[7] However, approximately half of these patients never went to the dentist after enrollment due to cost.

Medical-Dental Divide

Medical and dental services and insurance plans have historically been segregated from one another. Reasons include the separate development of dental and medical professions, prevailing medical models that viewed teeth as separate from the rest of the body, and different cost models for care.[8]

Dental and medical insurance have developed divergent payment structures. In medical insurance, consumers pay out-of-pocket until they hit a deductible amount (e.g. $2,000) after which services are covered by their insurance. In dental insurance, the opposite is true. Consumers are covered by their insurance until they reach a maximum amount (e.g. $1,000), and then all services must be paid out-of-pocket. This may be due to differing goals, where medical insurance aims to reduce the impact of unexpected, high-cost expenditures, while dental insurance aims to improve dental health.[9]

Dental plans are offered stand-alone and there is no individual mandate to have dental insurance. Under the ACA, dental is an essential health benefit for children only, meaning insurance companies must provide an option for child dental coverage; however, individuals are not required to purchase coverage for their children. For adults, dental is not required and is only included in some markets and plans.[10]

Other problems that magnify the dental and medical divide include few dentists who serve Medicaid patients due to low or no reimbursement, silos between dental and medical schools, and information gaps between dental and primary care.[11] The divide makes it difficult for certain populations to access dental care, resulting in poor health outcomes and increased medical costs.

Current State

County Demographics

Overall, estimates indicate that in 2013, Washtenaw County was home to a population of 347,563. The county’s median household income is $59,126, with 13 percent of residents living in poverty (46,533), and an unemployment rate of 5.7 percent. In 2015 health outcomes, the county ranks 9th of 83 counties in the state.[12] As of April 2015, there are 36,762 Medicaid recipients in Washtenaw County, with an estimated 15,355 enrolled in the Healthy Michigan Plan, for a total of 52,117 individuals. [13]

Figure 2. Medicaid Recipients and Healthy Michigan Plan Enrollees in Washtenaw County and the State of Michigan.

Medicaid Recipients Healthy Michigan Plan Total
Washtenaw County 36,762 15,355 52,117
State of Michigan 1,761,761 603,450 2,365,211

Source: Michigan Green Book, April 2015.

In Washtenaw County, Healthy Michigan Plan enrollees receive dental care from one of four dental plans: Blue Cross Complete of Michigan, HAP Midwest Health Plan Inc., Meridian Health Plan of Michigan and Molina Healthcare of Michigan (Figure 3).

Figure 3. Medicaid Health Plan Enrollees and Dental Plan in Washtenaw County, February 2015.[14]

Plan Enrollees
Blue Cross Complete of Michigan 18,732
HAP Midwest Health Plan Inc. 8,158
Meridian Health Plan of Michigan 4,859
Molina Healthcare of Michigan 1,560
County Total 33,309

Source: Michigan Department of Health and Human Services, February 2015.

In 2010, 24 percent of adults in Washtenaw County reported not having dental insurance.[15] In 2008, approximately 71 percent of Michigan residents reported having dental insurance.[16] Nationally, roughly 60 percent had dental coverage in 2012.[17] About half of all dental expenditures are paid out-of-pocket by the patient, nationally, and about 45 percent are paid by the consumer in Michigan.[18]

The supply of dentists in the county is greater than in the rest of the state and nationally. In Washtenaw County, the ratio of residents to dentists is 663:1, compared to 1,485:1 in the state.[19]

Figure 4. Ratio of Residents to Dentists in Washtenaw County, Top US Performers[20] and in Michigan.

Washtenaw County Top US Performers Michigan
Ratio of residents to dentists 663:1 1,377:1 1,485:1

Source: County Health Rankings.

As of February 2015, there were 387 practicing dentists in Washtenaw County, according to the Michigan Dental Association, including 302 general dentists, 10 with a focus on pediatric dentistry, 11 on endodontics, 13 in oral surgery, 19 in orthodontics and 20 in periodontics.

Figure 5. Oral Health Providers in Washtenaw County, February 2015.

[Image coming soon]

 

Source: Michigan Dental Association, Michigan Department of Licensing and Regulatory Affairs.

Budget Recommendations and Policy Proposals

In late May of 2015, Governor Snyder and legislative leaders determined spending targets for the 2016 fiscal year budget. The Michigan Department of Health and Human Services conference committee has developed recommendations (Figure 6) to align the House and Senate budget proposals, which have differences in plans for the Healthy Kids Dental and Medicaid Adult Dental Program.

Figure 6. Approved Budget for Healthy Kids Dental and Medicaid Adult Dental Program, FY 2016.

Budget Recommendations and Proposals Healthy Kids Dental Recommendations Medicaid Adult Dental Recommendations
Conference Committee (6/3/2015)[21] $37.0 million ($12.7 million GF/GP) to expand Healthy Kids Dental to children 0 – 12 in Kent, Oakland and Wayne Counties. (In all other Michigan counties up to age 21.) No changes will be made to reimbursement rates.

Source: Michigan Legislature.

The Michigan Oral Health Coalition has published two calls to action regarding Healthy Kids Dental and the Medicaid Adult Dental Program. For the Healthy Kids Dental Program, the coalition recommends expanding the program to Kent, Oakland and Wayne counties to persons up until the age of 21 (the executive budget recommendation agree with expanding to the counties but only for children 0 – 12 years old). The coalition recommends transitioning Michigan’s fee-for-service Medicaid adult dental program to a statewide managed care contract, and has emphasized improved payment rates and quality measures. In their call to action, the group compared Medicaid reimbursement rates for an adult comprehensive oral exam in Michigan and other states, with Michigan’s rate falling below many other states’ rates (Figure 7).

Figure 7. Adult Comprehensive Oral Exam Medicaid Reimbursement Rates Across States, 2014. 

[Image coming soon]

     Source: Michigan Oral Health Coalition.

Safety Net Activity

The safety net provider landscape includes Hope Clinic, Community Dental Center, the UM Dental School and the newly opened Washtenaw County Dental Clinic. Other new providers in the safety net include dental practices such as Destiny Dental and Dental Dreams, as well as some smaller private practices, which accept Medicaid patients. In late 2014, Packard Health converted to a Federally-Qualified Health Center Look-Alike (FQHC-LA). Packard Health would like to offer dental services or contract with a dental provider in the future. However, there are no set plans in place at this point.[22]

 Figure 8. 2014 Visits to UM Dental School and Community Dental Center.

Activity 1/1/14 – 12/31/14 – Washtenaw County Residents Only
UM Dental School CDC Hope Clinic TOTALS
# Patients 9,157 1,460 1,311 11,928
ADULT 5,374 1,337 1,102 7,813
CHILD 1,590 123 209 1,922
# Visits 29,009 3,260 4,529 36,789
ADULT 24,306 3,036 3,978 31,320
CHILD 4,703 224 551 5,478
Payer Mix UM Dental School CDC Hope Clinic
Medicaid 14% 23% Free clinic
Other Ins* 49% 67% Free clinic
Self-Pay 36% 10% Free clinic
100% 100% Free clinic

Source: UM Dental School; Hope Clinic.

*Notes: “Other Ins” includes any Medicaid insurance that is processed through Delta Dental, including Healthy Kids Dental.

Patient Populations

Certain patient populations may face unique access barriers to dental care; patients may also face barriers because of clinical indications (e.g., pregnancy, chronic conditions).

Patient Populations and Access Barriers

Some patient populations that face unique barriers to dental care access include:

  • Children (age 0 – 5);
  • The aging population;
  • People with Limited English Proficiency (LEP) and recent immigrants;
  • People with low incomes (particularly between 138 – 200 percent of the FPL);
  • People with special health care needs.

The Oral Health Task Force’s 2012 Dental Survey asked dentists in Washtenaw County about their interest in serving special populations who frequently have trouble accessing services, specifically the elderly, people with developmental disabilities and recent immigrants. As displayed in Figure 9, 47 percent reported an interest in serving one or more these special populations.

Figure 9. Washtenaw County Dentist Interest in Serving Special Populations.

Special Population Percent Interested in Serving Population
Elderly living on own 31% (15)
Elderly in nursing homes 14% (7)
People with developmental disabilities 20% (10)
Recent immigrants 16% (8)
Not interested 53% (26)

Source: 2012 Oral Health Task Force Survey.

Children (Age 0 – 5)

Dental caries are the most common chronic disease among children, leading to more than 51 million lost school hours each year in the United States.[23] Children with caries in their primary teeth are almost three times more likely to develop caries in their permanent teeth.[24] As of 2013, in Washtenaw County, 5.3 percent of the population is comprised of children less than 5 years of age (an estimated 17,721 children). This percentage has declined slightly from 6.6 percent children under 5 in 2005.[25]

To prevent dental caries, the American Academy of Pediatric Dentistry (AAPD) recommends children begin routine dental care starting at age 1, or when the first tooth emerges. However, less than 25 percent of children in Michigan begin routine dental care at the recommended age.[26]

A study conducted by the University of Michigan’s Child Health Evaluation and Research Unit, on behalf of the Early Childhood Investment Corporation, identified possible reasons for this discrepancy between clinical recommendations and practice, including:

  1. Parental awareness: Of Michigan parents surveyed, only 37 percent believed a child’s first dental visit should occur at 1 year of age.[27]
  2. Provider awareness and comfort: Three-quarters of general dentists surveyed in Michigan knew the AAPD recommendation, but only about one-third recommend their own patients begin routine dental care at age 1. The age at which the dentists recommend starting routine dental care was strongly linked to how comfortable they were with providing care to young children.[28] In a separate survey, dentists in Washtenaw County reported that they began seeing children at 27 months on average.[29]

Fluoride varnish prevents dental caries and the Michigan Department of Health and Human Services has promoted this treatment among children 0 – 5. In 2007, the Michigan Department of Health and Human Services used a $250,000 grant from Delta Dental to develop Varnish! Michigan. The program provides free fluoride varnish treatments to children enrolled in Early Head Start (0 – 3 years) and Head Start (3 – 5 years) across the state.[30] From October 2007 through October 2008, the program saw 7,391 children from 13 Early Head Start and Head Start programs. During this period, 7 percent of children seen by the program were in need of urgent dental care and 9.5 percent had one or more carious lesion. The program also found that Hispanic or Latino children were more likely to have caries compared to white children and children 3 – 5 were more likely to have caries compared to children under 3.[31]

Low Income Populations

Low income populations face disproportionate barriers to dental care. Low income adults are more likely to be uninsured than low income children due to the lower income cutoff for adults (139 percent of the FPL) compared to children (217 percent of the FPL), and the relatively high cost of private insurance for low income adults. Adults over 138 percent of the FPL and those with Medicaid may have medical but not dental insurance. In terms of providers, Healthy Kids Dental has allowed close to 80 percent of dentists who see children in Washtenaw County to see children with Medicaid. Hope Clinic also sees children at any time without insurance. With more coverage and higher reimbursements for child dental care, there is a greater need for adult dental care among low income populations.

Prior to the ACA’s implementation, it was estimated that, nationally, 26 percent of adults aged 19 – 64 had untreated caries.[32] However, adults with incomes below 100 percent of the FPL were over three times as likely to have untreated caries as adults with incomes above 400 percent of the FPL. Low income adults were less likely to have had a dental visit within the last year than higher-income adults. In 2010, 42 percent of adults with incomes below 200 percent of the FPL had a dental visit in the previous year versus 70 percent of adults with incomes above 200 percent.[33] State figures mirrored these national trends with poorer access and oral health indicators among lower income adults.[34]

Following the enactment of the Healthy Michigan Plan, adults between 138 and 200 percent of the FPL are one possible focus population for dental care barriers. Adults in this population are low income, but do not qualify for Medicaid. Furthermore, because dental insurance plans on the Marketplace are not subsidized, many people in this income group will not be able to purchase dental coverage due to the cost. Because of their income bracket, they are unlikely to be able to afford to see a dentist by paying for services out-of-pocket.

The WHI’s Reduced Fee Dental Initiative enrolled over 100 individuals into a program where individuals could access dental care with private dentists at a reduced fee. However, over half of the individuals who were enrolled never went to the dentist because they could not afford the cost.

Limited steps have been taken to address this population. For several years, the Washtenaw Health Plan has funded emergency dental care to uninsured county residents through the Barrier Busters (county-coordinated) program. Currently, Washtenaw County is funding a Washtenaw County Dental Fund that will help subsidize uninsured persons under 200% of the poverty level who want to use the Washtenaw County Dental Clinic.

Aging Populations

Individuals 65 years of age and older face several barriers to oral health care, including affordability, lack of dental insurance, and transportation issues. Dental insurance access for older adults is more limited than coverage for children, and unlike dental coverage for children, the ACA largely did not address expanding dental coverage for adults. Medicare generally does not offer any dental coverage, and Medicaid in Michigan for older adults uses a fee-for-service, low reimbursement model.[35]

According to a 2009 survey, over half (57 percent) of vulnerable senior patients (patients over age 65 with any of the following: limited mobility, limited resources, or complex health status) in Michigan were not covered by insurance that paid or partially paid for dental services.[36]

The Washtenaw County Health Improvement Plan survey asked respondents, “Do you have any kind of insurance coverage that pays for some or all of your routine dental care?” Responses indicate that across all age groups in the county, estimated dental insurance coverage was 73 percent in 2010.[37] In 2010, dental insurance coverage among adults aged 65 – 74 was 87 percent and 62 percent for adults 75 and older.[38]

Figure 10. Respondent Answers to the Question “Do you have any kind of insurance coverage that pays for some or all of your routine dental care?” Age 65+, 2010

Age Yes No
 65 – 74 87% (118) 13% (18)
 75+ 62% (57) 38% (35)

Source: Washtenaw Health Improvement Plan Survey, 2010.

Another important consideration for dental care among the aging population is the transition from living with full independence (including ability to maintain dental hygiene) to requiring some assistance with hygiene or living in a care setting, such as a long term care facility. This may cause a disruption in the individual’s dental care routine and is an important factor for clinicians to take into consideration.

In 2010, the Michigan Department of Health and Human Services conducted an oral health screening and survey of residents aged 65 and older living in Alternative Long Term Care Facilities (ALTCF). The Michigan Department of Health and Human Services found that seniors in an ALTCF face, in addition to the barriers of affordability and lack of dental insurance, a shortage of dentists willing to provide them with services in the facility. Of the 186 seniors surveyed:

  • 22 percent reported not visiting a dentist in at least three or more years;
  • 52 percent reported that they did not have dental insurance, while 13 percent were unaware of their dental insurance status; and
  • 30 percent (45 seniors) had untreated tooth decay, of which 82 percent (37 seniors) had restorative dental care needs and 18 percent (8 seniors) had major or urgent dental needs. [39]

The need for dental services by seniors is likely to increase in the coming years. Due to community water fluoridation and increased oral health access, baby boomers have experienced less tooth decay and have more of their natural dentition than older generations. This means baby boomers will have a continued need for access to affordable dental care as they age.[40]

Dentures

A common dental issue among aging adults is the need for dentures. Dental problems among older adults, such as difficulty eating with dentures, dental pain, gum disease, or missing teeth can have other health effects. Notably, these dental issues among older adults can alter their eating habits and nutrition. For example, people who do not have natural teeth tend to eat less fresh fruit and vegetables compared to those who still have their teeth.[41]

Denture usage and related conditions are associated with disparities between groups of older adults. For example, low income adults have gum disease at more than twice the rate of their higher income counterparts. Individuals who live in poverty in the United States are 61 percent more likely to have lost all teeth compared to higher income adults. Racial and ethnic disparities also exist for denture usage and associated conditions. For example, older African American adults are 1.88 times more likely to have periodontitis than whites.[42] In Michigan, dentures are a covered benefit under Medicaid, but most older adults do not have Medicaid. Figure 11 shows details of Medicaid benefits for dentures in Michigan.[43]

Figure 11. Medicaid Benefits for Dentures in Michigan.

State Benefit Covered Copayment Required? Prior Approval Required Limit on Services Days Reimbursement Methodology
Michigan Yes $3/denture Yes 1 full upper and/or lower denture or 1 partial/5 years Fee for service, Public Health Dental Clinics paid average commercial rate

Source: 2012 State Health Facts, Kaiser Family Foundation.


Limited English Proficiency and Recent Immigrant Patients

Compared to the rest of the state (9.1 percent), Washtenaw County has a larger portion of residents who speak a language other than English at home (14.2 percent, from 2009 – 2013).[44] Patients with Limited English Proficiency (LEP) do not speak English as their primary language and have limited ability to read, write, speak or understand English.[45] Persons with LEP may face barriers to care, as dental practices may not have interpreter services. In the 2012 Oral Health Task Force Survey, just 16 percent of dentists (8 individuals) indicated an interest in treating recent immigrants.[46]

In 2014, Casa Latina (the county’s only Latino community center), the Washtenaw County Public Health Department and the University of Michigan School of Public Health partnered to field a survey of 500 Latino community members. The survey revealed that over 50 percent of Latino respondents in Washtenaw County had lost one or more teeth to tooth decay in the previous year, compared to 24 percent among the general public. The survey also found that 50 percent of respondents found difficulty interacting with others due to language barriers.[47]

Any healthcare provider who receives federal dollars is required to provide language services to patients with LEP, including undocumented immigrants, so they can access federal programs.[48] Issues providing LEP services, such as bilingual staff and interpreter services, include lack of awareness among physicians that they need to provide LEP services and cost of and availability of obtaining LEP services.[49] In addition, persons with LEP are unlikely to request services due to lack of knowledge regarding their right to services, fear of losing health insurance or healthcare, fear of losing citizenship potential and discomfort in asking for services.[50]

The Community Dental Center, UM Dental Clinic and Washtenaw County Dental Clinic all offer chairside telephonic access to LEP services. However, all of these clinics plus Hope Clinic have identified the need for better interpretation services.

There are varied barriers to dental care for recent immigrants, many of which are dependent on immigration status. Undocumented immigrants are unable to purchase health coverage on the marketplace and are ineligible for tax credits. They are also ineligible for Medicaid and the Children’s Health Insurance Program.[51] Undocumented immigrants are able to receive emergency services through the Emergency Services Only (ESO) Medicaid Program, but dental services beyond the emergency are not included. [52] Undocumented immigrants are able to purchase health insurance through employers.

Recent, lawful immigrants who are not yet citizens also face many barriers to dental care. Individuals who are not citizens are more likely to be uninsured compared to US born citizens (47 percent compared to 16 percent).[53] They are also more likely to be low-income compared to citizens (median 2011 income of $27,400 for non-citizens and $48,380 for citizens). Most recent immigrants face a five-year waiting period for Medicaid and CHIP eligibility.[54]

Notably, uninsured rates among children are associated with their parents’ citizenship status, with the lowest uninsured rates among US-born parents:[55]

  • 29 percent uninsured rate among non-citizen children with non-citizen parents
  • 16 percent uninsured rate among citizen children with non-citizen parents
  • 13 percent uninsured rate among citizen children and naturalized parents
  • 7 percent uninsured among US-born parents

Among recent immigrants, there are many barriers to dental care. This group may perceive that health care is unaffordable and costly and may be unfamiliar with dental primary prevention strategies. Some may be concerned that using public benefits will jeopardize immigration status. There also exist various language barriers in accessing quality dental services.[56]

People with Special Health Care Needs

People with special health care needs[57] appear to have poorer oral health compared to a general population.[58] Access to dental services among this population varies by age, with better access among children with special health care needs for preventive dental care compared to adults.[59] Oral health disparities among people with special health care needs stem from numerous sources. In some cases, they may have reduced ability to complete daily oral health care tasks (e.g., brushing, flossing) due to physical or cognitive disabilities, and may rely on others to complete these tasks. Some people in this population may take medications which reduce saliva, contributing to a greater risk of periodontal disease and dental caries. Other barriers include transportation issues, wheel chair accessibility, prohibitive costs and dental practices that are not trained to work with people with special health care needs.[60],[61] Furthermore, many dentists do not accept patients with special health care needs. Only 20 percent of respondents (10 dentists) to the 2012 Oral Health Task Force Survey expressed interest in serving patients with developmental disabilities.[62]

In the 2012 MiBRFS, adults with disabilities (42 percent) were more likely to have gone without a dental visit in the past year compared to non-disabled adults (29 percent).[63] In the 2010 MiBRFS, adults with disabilities were more likely to have six or more missing teeth (28 percent), compared to adults without disabilities (9 percent). Also in 2010, adults with disabilities were more likely to have gone without dental care access in the previous year due to cost (22 percent) compared to adults without disabilities (10 percent). Lastly, the 2008 MiBRFS found that adults without a disability were more likely to have dental insurance than adults with a disability.[64]

Some resources exist in the state for people with special needs. There are twelve dental practices in Washtenaw County that appear to treat dental patients with special needs.[65] The Developmentally Disabled Dental Program is a state program which provides some funding assistance for dental services for people with severe developmental disabilities. Funding is provided on a referral basis through case managers.[66] In the future, the University of Michigan Dental School has plans to open a dental clinic for people with special needs.[67]

Patient Populations and Clinical Issues

Certain patient populations may face access barriers due to other existing clinical circumstances. Their clinical conditions in turn may create access issues. These patient populations include:

  • Pregnant women
  • People with chronic conditions (e.g., diabetes, heart disease)

Pregnant Women

In 2011, the State of Michigan launched the Infant Mortality Reduction Plan to improve infant mortality and strengthen the system of perinatal care available to women and infants. As part of the plan, the state is focusing on improving the oral health of pregnant women as recent studies have reported associations between oral diseases, particularly periodontal disease, and increased risks for poor birth and pregnancy outcomes.[68] Receiving dental care during pregnancy is safe for both women and the developing baby, and is recommended by the American College of Obstetricians and Gynecologists.[69]

In Michigan, almost half (43 percent) of women who reported having a dental problem during pregnancy do not receive treatment.[70] Dental care barriers for pregnant women include a lack of awareness among patients and providers that dental care during pregnancy is important and a lower percentage of dentists who accept Medicaid (which covers half of all pregnancies).[71],[72] Another barrier is reluctance among dentists to treat pregnant patients. This reluctance has been attributed to dental school curricula of the past that taught dentists not to treat women during pregnancy and fear of litigation. In 2009, 77 percent of surveyed obstetrician gynecologists reported having a patient be declined dental services because of pregnancy.[73]

People with Diabetes

People with diabetes have an increased risk for periodontal disease, and other dental problems such as dry mouth and difficulty healing post-dental surgery. Because of these issues, it is recommended that diabetics have dental cleanings and exams more frequently than the general public, about three to four times annually. However, people with diabetes are less likely to visit a dentist. In Michigan, the number of adults with diabetes who have lost six or more teeth has declined significantly (52 percent in 1996 to 30 percent in 2010).[74] Meanwhile, the portion of adults with diabetes who see a dentist has increased from 57 percent in 1996 to about 67 percent in 2008.[75]

Benefit and Reimbursement Information

Benefit and reimbursement differs among various plans, impacting dental participation across various plans, and thus, patient access to dental services. For a comparison of dental reimbursement across various plans that serve Medicaid consumers, see Appendix A. Generally, Delta Dental plans for the Healthy Michigan Plan, Healthy Kids Dental and MIChild have the highest overall reimbursement rates and traditional fee-for-service Medicaid has the lowest rate.

Use of Emergency Department for Dental Services

According to a study by Anderson Economic Group, treatment for preventable dental conditions in hospitals in the State of Michigan cost at least $15 million in 2011.[76] The study estimated that there were about 7,000 visits to the emergency room for preventable dental conditions, and over 1,000 hospitalizations for these kinds of conditions. The study estimated that payments from both patients and insurers for these services totaled more than $15 million.

Data from St. Joseph Mercy Health System displays encounters in the emergency room for dental services from FY 2011 – FY 2013. The data indicates that Medicaid enrollees and the uninsured are more likely to access the Emergency Department for dental services and comprise 35.51 percent, 32.65 percent and 34.49 percent of ED encounters for dental services in FY 2011, 2012 and 2013, respectively.  Conversely, Medicare and Washtenaw Health Plan members are less likely than other insurance types, including private insurance, to access the St. Joseph Mercy Health System Emergency Department for dental services (Figure 12). It is important to note that these are pre-Healthy Michigan Plan figures.

Figure 12. Dental Encounters in the St. Joseph Mercy Health System Emergency Room by Insurance Type, FY 2011 – FY 2013.

    St. Joseph Mercy Health System University of Michigan
Fiscal Year Insurance Type  Encounters % of Total Encounters % of Total
FY11 Medicaid 294 35% 222 37%
  Medicare 83 10% 58 10%
  Private 147 18% 251 42%
  Uninsured 225 27% 9 2%
  Washtenaw Health Plan 79 10% 55 9%
FY11 Total   828 100% 595 100%
FY12 Medicaid 286 33% NA NA
  Medicare 100 11% NA NA
  Private 154 18% NA NA
  Uninsured 246 28% NA NA
  Washtenaw Health Plan 90 10% NA NA
FY12 Total   876 100% 526 100%
FY13 Medicaid 297 34% NA NA
  Medicare 108 13% NA NA
  Private 152 18% NA NA
  Uninsured 240 28% NA NA
  Washtenaw Health Plan 64 7% NA NA
FY13 Total   861 100% 608 100%
Grand Total   2,565 1,729 100%

Source: St. Joseph Mercy Health System.
Note: Data on encounters by payer is not available for UMHS FY12 and FY13

Providers

In the 2012 Oral Health Task Force Survey, just 15 percent (8 dentists) reported accepting Medicaid patients.[77] In the changing dental landscape, there are some dental provider issues that remain unclear. Currently, information on providers who are accepting Medicaid patients is unreliable, as practices listed as accepting Medicaid patients may not actually accept them. The changes with Healthy Kids Dental and the Healthy Michigan Plan signify that there are new providers who are now participating in Medicaid programs. Anecdotally, some providers who previously had little interaction with Medicaid or uninsured patients are struggling to manage a more diverse patient population.[78]

Charity Care and Alternative Payment

It is difficult to quantify the amount of charity care that dentists provide in the state, and the proportion of dentists who offer alternative payment options for patients who cannot afford treatment. A 2013 Michigan Dental Association report estimates that Michigan dental practices provide, on average, $62,000 annually in care to disadvantaged adults and children (with $45,000 in care provided by dentists and $17,000 provided by dental staff). However, this information is not centrally reported. In Michigan Dental Association’s survey of 990 dentists across the state, 88 percent of surveyed dentists reported donating care to underinsured and uninsured children and adults. The majority of the donated care (55 percent) was for restorative services (e.g., fillings, crowns), with 16 percent for oral surgery and 7 percent for preventive care.[79]

From 2007 to 2012, respondents to the Oral Health Task Force Survey reported a decline in provision of free care from 58 percent in 2007 to 40 percent in 2012. Similarly, there was a decline in reported use of a sliding fee scale, from 46 percent in 2007 to 29 percent in 2012 (Figure 13). While payment plans do not qualify as charity care, in Washtenaw County in 2012, 90 percent of dentists reported providing alternative payment options for existing patients, up slightly from 88 percent in 2007.[80]

Figure 13. Percent of Dentists Providing Charitable Care or Sliding Fees to Patients, 2007 and 2012.

Type of Service 2007 (N=57) 2012 (N=52)
Free Care 58% 40%
Sliding Fee Scale 46% 29%

Source: Oral Health Task Force Surveys, 2007 and 2012.

When dentists cannot provide care, they often refer individuals to other sources of charitable care. According to the 2012 Oral Health Task Force Survey, the UM Dental School was the most common referral location, followed by Hope Dental Clinic and the Community Dental Center.[81]

Figure 14. Referral Location for Charitable Care Among Surveyed Dentists, 2012.

Referral location for charitable care Percent Participating
UM Dental School 88%
Hope Dental Clinic 56%
Community Dental Center 48%

Source: Oral Health Task Force Surveys, 2012.

In 2007 and 2012, a majority of respondents indicated they provide a payment plan or Care Credit financing. In 2007, 12 percent of dentists reported it was the only alternative option they offered. In 2012, 33 percent reported only selected the “other category”, nearly all of which indicated the alternative they provided was a payment plan or Care Credit financing.

Hope Clinic reports that the need for charity dental care has not decreased even in the light of the Healthy Michigan Plan and Medicaid expansion. Many people who now have medical insurance still do not have any dental insurance.

Volunteerism

Figure 15 shows the Washtenaw County rates of dentists volunteering outside of their practice in 2012.

Figure 15. Percent of Dentists Volunteering Outside of Practice.

Volunteer Organizations 2012 (N=52)
Hope Dental Clinic 17%
Community Dental Center 4%
Reduced Fee Dental 10%
Michigan Donated Dental Services 33%

Source: Oral Health Task Force Survey, 2007 and 2012.

Conclusion

There have been significant changes in the dental care landscape in Washtenaw County since the previous dental assessment conducted in 2011. Some of these changes include the expansion of Medicaid with the Healthy Michigan Plan and the implementation of Healthy Kids Dental. With various programs catering to the dental needs of children, there exists a greater need for dental care among adults. There are specific populations in which steps still need to be taken to address their needs. These populations include children (age 0 – 5), low income (138 – 200 percent of the FPL), aging, Limited English Proficiency and recent immigrants, special health care needs, pregnant women and people with diabetes. The Washtenaw Health Initiative Community Coordination and Dental Services Workgroup looks forward to identifying proposals and next steps that could have a meaningful impact on the needs of low-income residents in Washtenaw County.

 


[1]
Delta Dental, “Healthy Kids Dental Counties,” http://www.deltadentalmi.com/MediaLibraries/Global/documents/HKD-Coverage-Map.pdf (accessed 7/8/15).

[2] Healthy Kids Dental will expand into the three remaining counties (Kent, Oakland and Wayne County) to children 0 – 12 only beginning Fall 2015.

[3] Michigan Department of Health and Human Services, “Healthy Michigan Plan Frequently Asked Questions,” http://www.michigan.gov/mdch/0,4612,7-132-2943_66797-325160–,00.html (accessed 7/8/15).

[4] Washtenaw County, “Washtenaw County Dental Clinic Opening 2015!” http://www.ewashtenaw.org/government/departments/public_health/news/2014-news-items/washtenaw-county-dental-clinic-opening-2015 (accessed 7/8/15).

[5] Washtenaw Health Initiative Community Outreach and Dental Service 2011 Dental Assessment.

[6] WHI 2014 Annual Report, Feb. 2015. https://docs.google.com/file/d/0Bx4lt2rIHSK0ZjFyS3RTbENuZnc/edit (accessed 7/8/15).

[7] Ibid.

[8] American Dental Association, “History of Dentistry Timeline,” http://www.ada.org/en/about-the-ada/ada-history-and-presidents-of-the-ada/ada-history-of-dentistry-timeline (accessed 7/8/15).

[9] D. Bendall and P. Asubonteng, “The effect of dental insurance on the demand for dental services in the USA: a review,” Journal of Management in Medicine, 1996, 9(6):55 – 68.

[10] “Dental Coverage in the Marketplace,” HealthCare.gov: https://www.healthcare.gov/coverage/dental-coverage/ (accessed 6/2/15).

[11] R. Banham, “Bridging the dentist-doctor divide,” The Wall Street Journal. http://online.wsj.com/ad/article/aetna-bridging-the-dentist-doctor-divide (accessed 7/8/15).

[12] 2015 County Health Rankings. http://www.countyhealthrankings.org/app/michigan/2015/overview (accessed 7/8/15).

[13] Michigan Department of Human Services, Green Book Report of Key Program Statistics, April 2015, Table 1. http://www.michigan.gov/documents/mdhhs/2015_03_GreenBook_490864_7.pdf (accessed 7/8/15).

[14] Michigan Department of Community Health, Medicaid Health Enrollees, Feb. 2015:6. https://www.michigan.gov/documents/mdch/JE02022015_481584_7.pdf (accessed 7/8/15).

[15] Washtenaw County, “Community Health Assessment: Access to Care,” http://www.ewashtenaw.org/government/departments/public_health/health-promotion/hip/cha-chip-landing-page/cha-access (accessed 7/8/15).

[16] MDCH, Burden of Oral Disease in Michigan 2013, March 2013:41: http://www.michigan.gov/documents/mdch/FINAL_BOD_2012_430147_7.pdf (accessed 7/8/15).

[17] National Association of Dental Plans, 2012 NADP/DDPA Joint Dental Benefits Report: Enrollment, 2013. http://www.nadp.org/docs/default-source/lms/Dental_Insured_and_Uninsured.pdf?sfvrsn=0 (accessed 7/8/15).

[18] F. Rohde, Dental Expenditures in the 10 largest States, 2006, (Rockville, MD: Agency for Healthcare Research and Quality, Sep. 2009): http://meps.ahrq.gov/mepsweb/data_files/publications/st263/stat263.pdf (accessed 7/8/15).

[19] 2015 County Health Rankings.

[20] County Health Rankings defines Top US Performers as 90th percentile, i.e., only 10% are better.

[21] FY 2015-16 General Omnibus Budget. Summary: Conference Report, SB 133 (S-1) CR-1, June 2015.

[22] Personal communication with Mark Jacoby, Chief Operating Officer at Packard Health.

[23] Oral Health in America: A Report of the Surgeon General, (Rockville, MD: National Institute of Dental and Craniofacial Research, 2000):  http://silk.nih.gov/public/hck1ocv.@www.surgeon.fullrpt.pdf (accessed 7/8/15).

[24] “Guideline Summary: HealthPartners Dental Group and Clinics caries guideline,” guideline.gov: http://www.guideline.gov/content.aspx?id=47755 (accessed 7/8/15).

[25] U.S. Census Bureau, QuickFacts, 2014: http://quickfacts.census.gov/qfd/states/26/26161.html (accessed 5/22/15).

[26] Great Start for Kids, “The Case for Infant Dental Care: Oral Health Care for Young Children 0-5 Years,” (Lansing, MI: Early Childhood Investment Corporation, Nov. 2012): http://greatstartforkids.org/sites/default/files/Oral%20Health%20Synthesis%20to%20Support%20Recommendations%20Final-1.pdf (accessed 7/8/15).

[27] Ibid.

[28] Ibid.

[29] 2012 Oral Health Task Force Survey.

[30] T. Bucholz, “Delta Dental Gives $250,000 to MDCH to Launch Fluoride Varnish Program for Low Income Children,” MDHHS: http://www.michigan.gov/mdch/0,1607,7-132–168296–,00.html (accessed 5/26/15).

[31] N. Akarte, S. Korzeniewski, S. Vandenbush et al. “Assessment of the Prevalence and Predictors of Dental Caries and Loss to Follow-up: Michigan Department of Community Health Fluoride Varnish Application Program.” (Lansing, MI: MDCH): https://www.michigan.gov/documents/mdch/Flouride_Varnish_279308_7.ppt (accessed 5/26/15).

[32] Kaiser Family Foundation analysis of NHANES, 1999-2004.

[33] Kaiser Family Foundation, Oral Health and Low-Income Nonelderly Adults: A Review of Coverage and Access, June 2012: https://kaiserhealthnews.files.wordpress.com/2013/11/7798-02.pdf (accessed 7/8/15).

[34] Michigan Dental Association, A United Voice for Oral Health: Final Report and Recommendations from the Michigan Access to Oral Health Care Work Group, (Lansing, MI: Public Sector Consultant, 2013): http://www.smilemichigan.com/Portals/pro/ProDocuments/DonatedCare/united_voice_for_oral_health.pdf (accessed 7/8/15)

[35] Oral Health American, State of Decay: Are Older Americans Coming of Age Without Oral Healthcare? http://s.bsd.net/teeth/default/page/-/StateOfDecayVol2.pdf (accessed 7/8/15).

[36] Coalition for Oral Health for the Aging, 2009 Oral Health Care of Vulnerable Elderly Patients, 2009: http://www.micoha.org/uploads/6/6/7/0/6670832/survey.pdf (accessed 7/8/15).

[37] Washtenaw County HIP Survey, 2010: https://secure.ewashtenaw.org/HIP/HIP.do;jsessionid=78D446060C7A90964AC0DAAE59BBF092 (accessed 7/8/15).

[38] Ibid.

[39] MDCH, Michigan Senior Smiles Basic Screening Survey Report, 2010: http://www.michigan.gov/documents/mdch/Senior_Smiles_Report_Final_050311_355657_7.pdf (accessed 7/8/15).

[40] MDCH, Oral Health of Michigan Seniors: Michigan Oral Health Surveillance Brief, Feb. 2015: http://www.michigan.gov/documents/mdch/2.2015_Seniors_483687_7.pdf (accessed 7/8/15).

[41] C. Vargas, E. Kramarow, J. Yellowitz, The Oral Health of Older Americans, (Hyattsville, MD: National Center for Health Statistics, March 2001): http://www.cdc.gov/nchs/data/ahcd/agingtrends/03oral.pdf

[42] State of Decay, Oral Health America.

[43] Kaiser Family Health State Health Facts, Medicaid Benefits: Dentures, 2012: http://kff.org/medicaid/state-indicator/dentures/ (accessed 7/8/15).

[44] U.S. Census Bureau, QuickFacts , 2014.

[45] “LEP Frequently Asked Questions,” lep.gov, http://www.lep.gov/faqs/faqs.html (accessed 7/8/15).

[46] 2012 Oral Health Task Force Survey.

[47] Encuesta Buenos Vecinos: Building Capacity to Promote and Sustain Washtenaw County Latino Health, June 2014: http://www.ewashtenaw.org/government/departments/public_health/health-promotion/hip/2014-chc-meetings/ebv-presentation (accessed 7/8/15).

[48] US Department of Justice Civil Rights Division, Title VI Legal Manual, justice.gov, Jan. 2001: http://www.justice.gov/crt/about/cor/coord/vimanual.php#IV. “In the United States” (accessed 7/8/15).

[49] J. Coren, F. Filipetto, L. Weiss, “Eliminating Barriers for Patients With Limited English Proficiency,” Journal of the American Osteopathic Association, Dec. 2009, 109:634-640.

[50] IMIA, Health Care For a Population With Limited English Proficiency: Findings from a Sample of Connecticut Organizations, http://www.imiaweb.org/uploads/pages/442_3..pdf (accessed 7/8/15).

[51] Fifteen states (including Michigan) provide care to expecting mothers regardless of immigration status. Through the MOMS program, women can access care if they are otherwise eligible for Medicaid or CHIP. MOMS does not offer dental care.

[52] MDCH, Emergency Services Only Medicaid, Nov. 2005: https://www.michigan.gov/documents/MSA_05-61_142996_7.pdf

[53] Kaiser Family Foundation, Key Facts on Health Coverage for Low-Income Immigrants Today and Under the Affordable Care Act, March 2013: https://kaiserfamilyfoundation.files.wordpress.com/2013/03/8279-02.pdf (accessed 7/8/15).

[54] Twenty states have eliminated the waiting period for pregnant women and 25 have eliminated it for children. Michigan has not eliminated either waiting period; however, the “unborn child option” does apply to lawful immigrants in Michigan

[55] Kaiser Family Foundation, Key Facts… March 2013

[56] M. Marcus, C. Maida, N. Guzman-Becerra et al, Policy Implications of Access to Dental Care for Immigrant Communities, (California Policy Research Center, Feb. 2001): http://www.academia.edu/2315324/Policy_Implications_of_Access_to_Dental_Care_for_Immigrant_Communities

[57] The Institute of Medicine Report, “Improving Access to Oral Health Care for Vulnerable and Underserved Populations” defines children and adults with special health care needs as “those who have, or are at increased risk for, a chronic physical, developmental, behavioral or emotional condition and who also require health and related services of a type or amount beyond that required by children or adults generally.”

[58] Institute of Medicine Report, “Improving Access to Oral Health Care for Vulnerable and Underserved Populations.”

[59] Ibid

[60] Ibid.

[61] MDCH Oral Health Policy Paper: http://www.michigan.gov/documents/mdch/oral_health_policy_paper_with_link_to_HIWG_2.18.09_274106_7.pdf

[62] 2012 Oral Health Task Force Survey

[63] C. Fussman, Health Risk Behaviors in the State of Michigan: 2012 Behavioral Risk Factor Survey. 26th Annual Report, (Lansing, MI: MDCH, Sep. 2013).

[64] Burden of Oral Disease in Michigan 2013, MDCH, March 2013.

[65] MDCH Dental Directory: Treating Patients with Special Care Needs: http://www.michigan.gov/documents/mdch/Special_Needs_Directory_335122_7.pdf (accessed 7/8/15).

[66]C. Farrell and S. Deming, “Improving Oral health in Michigan,” MDOH Oral Health: http://www.mcrh.msu.edu/documents/conferences/17th_Annual_Michigan_Rural_Health_Conference/Presentations/Improving_Oral_Health.pdf (accessed 7/8/15).

[67] Personal communication with Bonita Neighbors, DDS.

[68] MDCH, A Summary of the 2013 Michigan Perinatal oral Health Conference, Aug. 2013: http://www.michigan.gov/documents/mdch/PerinatalOralHealthConfReport_FINAL_446125_7.pdf (accessed 7/8/15).

[69] American College of Obstetricians and Gynecologists, Committee Opinion No. 569: http://www.acog.org/-/media/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/co569.pdf?dmc=1&ts=20150708T1447168885 (accessed 7/8/15).

[70] D. Byrappagari. “Michigan Landscape Perinatal Oral Health,” UDM Dental. http://www.michigan.gov/documents/mdch/Divesh_Byrappagari_Handout_Perinatal_Conference_430863_7.pdf (accessed 7/8/15).

[71]  H. Amini and P. Casamassino. “Prenatal dental care: A review.” General dentistry. May 2010.

[72] George Washington University School of Public Health and Health Services, “Medicaid Pays for Nearly Half of All Births in the United States,” Sep. 2013: http://publichealth.gwu.edu/content/medicaid-pays-nearly-half-all-births-united-states (accessed 7/8/15).

[73] H. Silk, A. Douglass, J. Douglass, L. Silk. “Oral Health During Pregnancy.” American Family Physician. 2008 77:8.

[74] Burden of Oral Disease in Michigan 2013, MDCH, March 2013.

[75] Ibid.

[76] Delta Dental Plan of Michigan, The Cost of Dental-Related Emergency Room Visits in Michigan, (East Lansing: Anderson Economic Group, April 2014): http://www.midental.org/hub_sites/michigan-dental/www/assets/uploads/files/AEG-Delta-Dental_Report.pdf (accessed 7/8/15).

[77] 2012 Oral Health Task Force Survey.

[78] Personal communication with Bonita Neighbors, DDS.

[79] Washtenaw District Dental Society, WDDS Newsletter, Aug. 2013, 28(1): http://www.washtenawdentalsociety.org/august-2013.html (accessed 7/8/15).

[80] 2012 Oral Health Task Force Survey, 2007 Oral Health Task Force Survey

[81] Ibid.