Emergency Dental Care in the ACA Era: Rural–Urban Disparities and Their Association With State Medicaid Policy

ABSTRACT

Objectives

Rural US populations face greater barriers to dental care than urban residents. This study examines emergency department (ED) visits for nontraumatic dental conditions (NTDCs) among adults, comparing rural and urban areas. It also explores how Medicaid expansion and varying state Medicaid dental policies influence the likelihood of NTDC‐related ED visits.

Methods

We conducted a cross‐sectional analysis using 2019 ED data from eight states. Descriptive statistics characterized NTDC‐related ED visits by patient, visit, and county‐level variables across four Medicaid policy groups. Chi‐squared tests and T‐tests assessed rural–urban differences in visit characteristics and payer mix. Logistic regression models estimated the likelihood of NTDC ED visits by rurality and payer type, adjusting for sociodemographic factors and stratified by Medicaid expansion and adult dental benefit status.

Results

Rural NTDC ED visits were shorter (2.5 h) and less costly ($1602) than urban visits (over 3 h, $2532). Analysis of rurality and payer mix revealed three key patterns: (i) rural residents consistently had higher visit rates than urban residents in three of the four groups; (ii) uninsured patients—both rural and urban—had the highest probability of NTDC ED visits in three of the four groups; and (iii) among Medicaid‐covered visits, rural enrollees in non‐expansion states without adult dental benefits had the highest likelihood of NTDC ED visits.

Conclusions

This study highlights continued ED reliance for NTDCs 5 years post‐ACA, driven by Medicaid policy and access gaps. Expanding rural oral healthcare remains vital for improving access, especially for the uninsured.

1. Introduction

Access to oral healthcare remains a persistent challenge in the United States, with rural populations facing particularly multifaceted barriers. These include a chronic shortage of dental providers, geographic isolation, limited transportation options, and higher rates of poverty and public insurance reliance [1, 2]. As of 2023, approximately two‐thirds of all designated dental health professional shortage areas were located in rural regions, severely limiting access to timely and preventive dental services [3]. According to a 2024 report by the CareQuest Institute, nearly 40% of rural adults had not visited a dentist in the past year, which was substantially higher than the 30% and 35% reported among suburban and urban adults, respectively [4]. These access disparities contribute to significantly worse oral health outcomes in rural communities, including elevated rates of untreated dental caries, permanent tooth loss, and edentulism [4]. One key indicator of inadequate access to routine dental care is the use of emergency departments (EDs) for nontraumatic dental conditions (NTDCs) [5]. Most ED visits for NTDCs are not life‐threatening and are typically triaged as non‐urgent or semi‐urgent, offering only temporary relief rather than definitive treatment. ED‐based management of dental conditions is not only costly and inefficient but also places unnecessary strain on already overburdened emergency care systems [6, 7].

The Affordable Care Act (ACA) Medicaid expansion aimed to improve healthcare access by extending coverage to low‐income adults, which included the potential for expanded dental benefits. While the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit mandates dental coverage for children, adult dental benefits remain optional and vary widely by state. In states that adopted Medicaid expansion and offered adult dental benefits, improvements in oral health outcomes were observed, including increased dental visits and reduced prevalence of untreated dental caries [8, 9]. Based on each state's decision to expand Medicaid and the scope of adult dental benefits offered, US states are typically categorized into four groups: (1) no dental coverage, (2) emergency‐only coverage (e.g., treatment for acute pain or uncontrolled bleeding), (3) limited coverage (including diagnostic, preventive, and minor restorative procedures), and (4) extensive coverage (which includes major restorative services) [10, 11]. As of 2019, four states—Alabama, Arizona, Delaware, and Tennessee—did not provide any adult dental benefits. The remaining 46 states and the District of Columbia offered some level of coverage: 15 states provided emergency‐only benefits, 17 offered limited coverage, and 15 provided extensive benefits [10, 11].

Researchers conducting a systematic literature review showed that rural adults are significantly more likely to use EDs for NTDCs compared to their urban counterparts [12]. Despite these disparities, little is known about how Medicaid policy influences dental ED utilization in rural settings. Our study addresses this gap by analyzing ED discharge data from eight states representing four distinct Medicaid policy groups described above. By profiling the socio‐demographic and utilization characteristics of rural dental ED visits, our research aims to inform targeted policy and programmatic interventions to reduce oral health disparities and promote equity in access to care for rural populations. Our study aims to answer the following questions: (1) How do characteristics of NTDC ED visits vary according to rural–urban residence? (2) What is the association between rural versus urban residence and the likelihood of an NTDC ED visit across states with different Medicaid expansion status and adult dental benefit coverage? (3) Does this observed association differ by payer source?

2. Methods

2.1. Data Source

Data for this study came from the 2019 State Emergency Department Databases (SEDD) for 8 states in the United States: Arizona, Florida, Kentucky, North Carolina, Nebraska, New York, Vermont, and Wisconsin. The SEDD is part of the family of databases developed for the Healthcare Cost and Utilization Project (HCUP) and sponsored by the Agency for Healthcare Research and Quality (AHRQ). It contains discharge information on treat‐and‐release emergency visits at hospital‐based EDs, regardless of payer. It also captures clinical and resource use information such as diagnoses, procedures, and total charges, patient demographic characteristics, expected payment source, contextual information such as county of residence, rural–urban classification of county, and median household income for each patient's residential zip code.

2.2. Sample Selection

This study focused on individuals aged 20 and above who had a documented county of residence and a specified primary payer on their discharge records. Discharge records without a documented county of residence were excluded from the analysis. We selected states based on the presence of rural populations, data availability during the study timeframe, and financial considerations. Despite these criteria, our sample included states from each of the four US Census regions.

We obtained data on each state's Medicaid expansion status as of 2019 from a variety of sources, including the KFF [4], official state Medicaid websites, and academic literature [7, 9]. We identified states that had both approved and enacted the expansion as of 2019 and categorized them as Medicaid expansion states. We obtained information regarding adult dental benefits under Medicaid for non‐disabled, non‐pregnant adults from the Medicaid and CHIP Payment and Access Commission (MACPAC) [13] and the Center for Health Care Strategies (CHCS) [14]. We classified states offering no dental services or only emergency dental care as not providing dental coverage. In contrast, we considered states offering either limited or comprehensive dental benefits to have dental coverage [13]. We obtained data on Dental Health Professional Shortage Area (DHPSA) designations and the number of dental providers per 100,000 population in patients' counties of residence from the 2019 Area Health Resources File [15].

2.3. Variables

The dependent variable in this analysis was binary, coded as “1” for ED visits attributed to NTDCs and “0” for all other visits. We identified NTDC‐related ED visits using the first five diagnosis fields on the discharge record, based on the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD‐10‐CM) codes. This identification strategy is supported by the Association of State and Territorial Dental Directors (ASTDD) [5] and has been validated in prior research [16]. The complete list of ICD‐10‐CM codes used to define NTDCs, as recommended by ASTDD, is available [5].

The primary independent variables included (1) state‐level Medicaid expansion status and the scope of adult dental benefits during the study period and (2) the rural–urban classification of the patient's county of residence. Using the patient's state of residence noted on the discharge record, we classified the visits into four state groups: expansion states with adult dental benefits (Kentucky, New York, and Vermont), an expansion state without adult dental benefits (Arizona), non‐expansion states with adult dental benefits (Nebraska, North Carolina, and Wisconsin), and a non‐expansion state without adult dental benefits (Florida). We determined rurality using the 2013 National Center for Health Statistics (NCHS) urban–rural classification scheme, which categorizes counties into six levels: Large Central Metropolitan (central counties of metro areas with populations exceeding 1 million), Large Fringe Metropolitan (adjacent to large central metros), Medium Metropolitan (250,000–999,999 residents), Small Metropolitan (50,000–249,999 residents), Micropolitan (10,000–49,999 residents), and Noncore (neither metropolitan nor micropolitan). We classified the latter two categories as rural.

Additional covariates included a range of patient‐, visit‐, and county‐level characteristics. Patient‐level variables comprised age, gender, race/ethnicity, primary payer source, and median household income at the ZIP code level. We categorized age into four groups: 20–29, 30–44, 45–64, and 65 years and older. We classified race and ethnicity as White, Black, Hispanic, Asian or Pacific Islander, Native American, and Other. We obtained median household income categories from the SEDD. Insurance status was categorized as Medicare, Medicaid, commercial insurance, self‐pay (uninsured), and other, which included uncompensated care.

Visit‐level characteristics included the visit day (weekday vs. weekend), visit time (standard work hours: 8:00 a.m.–5:00 p.m. vs. after‐hours), the duration of the ED visit in hours and minutes, and the total charges in 2019 US dollars. To minimize the influence of outliers, we excluded the top and bottom 5% of total charges from the analysis. County‐level characteristics included the dental health professional shortage area (DHPSA) designation of the patient's county of residence, classified as full, partial, or none, and the number of dental providers per 100,000 population.

2.4. Statistical Analysis

We first generated descriptive statistics to examine the distribution of all ED visits, comparing NTDC and non‐NTDC visits using chi‐squared and t‐tests. Next, we assessed rural–urban differences in NTDC‐related ED visits across patient‐, visit‐, and county‐level characteristics, again using chi‐squared and t‐tests to evaluate statistical significance. Finally, we analyzed rural–urban differences in payer mix for NTDC ED visits across four Medicaid policy categories, defined by expansion status and coverage of adult dental benefits, to determine whether insurance coverage patterns varied by geographic location and Medicaid policy.

To examine the association between rural versus urban residence and the likelihood of an NTDC‐related ED visit across states with varying Medicaid expansion and adult dental benefit coverage, we constructed a multivariable logistic regression model. The outcome was the probability of an NTDC ED visit. The model included an interaction term between rural/urban residence and a categorical variable representing the four Medicaid policy groups. Covariates were age, gender, median ZIP code income, and payment source. We used predictive margins to estimate adjusted probabilities and tested rural–urban differences using contrasts of predictive margins.

To assess whether rural–urban differences varied by payer source, we ran four separate logistic regression models (one for each Medicaid policy group), each including an interaction between rural/urban residence and payer source. Covariates remained consistent across models. Predictive margins and contrasts were again used to evaluate differences in NTDC ED visit probabilities by geography and payer type.

Observations with missing data were excluded via listwise deletion. All analyses were conducted using Stata version 17. Statistical significance was set at p < 0.05. The SEDD data are publicly available and de‐identified; therefore, this study was deemed exempt from human subjects research by the lead author's Institutional Review Board.

3. Results

We identified a total of 371,100 NTDC ED visits and 20,901,760 non‐NTDC ED visits (Table 1). We found significant differences across patient‐, visit‐, and county‐level characteristics (p < 0.001 for all comparisons). Adults aged 30 to 44 years accounted for the largest share of NTDC visits (40.7%), followed by those aged 20 to 29 (31.2%), while older adults (65 to 84) made up only 5.5% compared to 22.61% of non‐NTDC visits. Males represented 46.4% of NTDC visits versus 42.29% of non‐NTDC visits. Non‐Hispanic Black individuals had a higher proportion of NTDC visits (30.9%) than non‐NTDC (22.74%), while Hispanic and Asian/Pacific Islander patients had higher proportions of non‐NTDC visits (15.2% and 1.35%, respectively). Compared to non‐NTDC visits, NTDC visits were more common among Medicaid (35.7% vs. 24%) and self‐pay/no charge patients (32.4% vs. 15.9%) but less common among those with Medicare (10.5% vs. 25.9%) or private insurance (19.8% vs. 30.3%).

TABLE 1.

Characteristics of all emergency department (ED) visits, State Emergency Department Database, Year 2019.

Characteristics	Total ED visits (%)	Total non‐NTDC ED visits (%)	Total NTDC ED visits (%)	p
All NTDC ED visits	21,272,860	20,901,760	371,100	< 0.001
Patient‐level characteristics
Age
20–29	23.4	20.58	31.2	< 0.001
30–44	30.4	26.7	40.7
45–64	28.11	30.11	22.5
65–84	18.1	22.61	5.5
Gender
Male	43.3	42.29	46.4	< 0.001
Female	56.7	57.71	52.6
Race/ethnicity
NH White	54.92	55.93	52.6	< 0.001
NH Black	25.01	22.74	30.9
Hispanics	14.25	15.2	11.5
Asian/Pacific Islanders	1.22	1.35	0.9
Native Americans	0.83	0.85	0.8
Other	3.77	3.92	3.3
Payer
Medicare	21.83	25.9	10.5	< 0.001
Medicaid	27.1	24.0	35.7
Private	27.5	30.3	19.8
Self‐pay/No charge	20.3	15.9	32.4
Other	3.3	3.9	1.6
Median household income of residents in the patient's ZIP Code
Quartile 1 ($1–47,999)	40.4	38.6	45.5	< 0.001
Quartile 2 ($48,000–$60,999)	30.2	29.8	30.8
Quartile 3 ($61,000–$81,999)	19.1	20.1	16.7
Quartile 4 ($82,000+)	10.3	11.6	7.0
Visit‐level characteristics
Admission day
Weekday	72.1	73.1	69.5	< 0.001
Weekend	27.8	26.9	30.5
Admission hour
During work hours (8.00 a.m. to 5.00 p.m.)	46.2	45.2	48.6	< 0.001
After work hours (5.01 p.m. to 7.59 a.m.)	53.5	54.8	51.4
Duration of visit (in hours and minutes)	5 h, 30 min	6 h, 29 min	3 h, 3 min	< 0.001
Total charges (in 2019 USD)	$5160.15	$6152.41	$2367.90	< 0.001
County‐level covariates
Dental Health Professional Shortage Area designation
Full	8.02	8.0	8.3	< 0.001
Partial	0.99	1.0	1.1
None	91	91.0	90.7
Dental providers per 100,000 population in rural and urban counties	55.9	56.6	54.0	< 0.001

Note: States included in study: Arizona, Florida, Kentucky, North Carolina, Nebraska, New York, Vermont, and Wisconsin.

Patients from the lowest income quartile (< $48,000) accounted for 45.5% of NTDC visits versus 38.6% of non‐NTDC visits; only 7.0% came from the highest income quartile (≥ $82,000). Compared to non‐NTDC visits, NTDC visits were more likely to occur on weekends (30.5% vs. 26.9%) and less likely after work hours (51.4% vs 54.8%). The average duration of NTDC visits was shorter (3 h 3 min) than non‐NTDC (6 h 29 min), with lower charges ($2367.90 vs. $6152.41). Most NTDC visits occurred in counties not designated as DHPSAs (90.7%), similar to non‐NTDC visits (91%). However, patients with NTDC visits had fewer dental providers per 100,000 population (54) compared to non‐NTDC patients (56.6). Patient‐ and visit‐level characteristics associated with NTDC ED visits are presented in Table 2. Across both urban and rural settings, approximately four in ten visits were made by adults aged 30 to 44, followed by those aged 20 to 29. Gender distribution was similar in both settings, with females accounting for just over half of the visits (rural, 53.8%; urban, 53.6%). Racial and ethnic composition varied notably by location: rural NTDC ED visits were predominantly from NH White individuals (73.6%), whereas urban visits were more racially diverse, with lower proportions of NH White patients (48.4%). Compared to rural areas, urban areas had significantly higher proportions of visits from NH Black (33.4% vs. 18.5%), Hispanic (13.1% vs. 3.5%), and individuals from other racial groups (3.6% vs. 1.8%). Medicaid covered a slightly higher proportion of visits in rural areas (37.1% vs. 35.4%), while a greater share of urban visits was made by uninsured individuals (33% vs. 29.5%). With regards to socioeconomic status, in rural areas, the majority of visits originated from residents of the poorest neighborhoods (quartile 1, 64.7%), whereas urban visits were more evenly distributed across the lower three income quartiles (quartiles 1–3).

TABLE 2.

Characteristics of emergency department (ED) visits for nontraumatic dental conditions (NTDC) in rural and urban areas, State Emergency Department Database, Year 2019.

Characteristics	Total NTDC ED visits (%)	Rural NTDC ED visits (%)	Urban NTDC ED visits (%)	p
All NTDC ED visits	371,100	62,298 (16.8%)	308,802 (83.2%)
Patient‐level characteristics
Age
20–29	31.2	32.2	31.1	< 0.001
30–44	40.7	41.2	40.7
45–64	22.5	21.6	22.7
65–84	5.5	5.0	5.6
Gender
Male	46.4	47.4	46.2	< 0.001
Female	52.6	53.8	53.6
Race/ethnicity
NH White	52.6	73.6	48.4	< 0.001
NH Black	30.9	18.5	33.4
Hispanics	11.5	3.5	13.1
Asian/Pacific Islanders	0.9	0.2	1.0
Native Americans	0.8	2.4	0.5
Other	3.3	1.8	3.6
Payer
Medicare	10.5	11.1	10.4	< 0.001
Medicaid	35.7	37.1	35.4
Private	19.8	20.9	19.6
Self‐pay/No charge	32.4	29.5	33.0
Other	1.6	1.5	1.7
Median household income of residents in the patient's ZIP Code
Quartile 1 ($1–47,999)	45.5	64.7	41.6	< 0.001
Quartile 2 ($48,000–$60,999)	30.8	28.2	31.4
Quartile 3 ($61,000–$81,999)	16.7	7.0	18.7
Quartile 4 ($82,000+)	7.0	0.2	8.3
Visit‐level characteristics
Admission day
Weekday	69.5	68.3	69.8	< 0.001
Weekend	30.5	31.7	30.2
Admission hour
During work hours (8.00 a.m. to 5.00 p.m.)	48.6	46.6	48.9	< 0.001
After work hours (5.01 p.m. to 7.59 a.m.)	51.4	53.4	51.1
Duration of visit (in hours and minutes)	3 h, 3 min	2 h, 39 min	3 h, 13 min	< 0.001
Total charges (in 2019 USD)	$2367.90	$1602.20	$2532.9	< 0.001
County‐level covariates
Dental Health Professional Shortage Area designation
Full	8.3	16.8	6.5	< 0.001
Partial	1.1	5.1	0.3
None	90.7	78.1	93.2
Dental providers per 100,000 population in rural and urban counties	—	35.5	57.7

Note: States included in study: Arizona, Florida, Kentucky, North Carolina, Nebraska, New York, Vermont and Wisconsin.

Across urban and rural settings, approximately 70% of visits occurred on weekdays (rural, 70.3%; urban, 70.1%), with the remaining 30% taking place on weekends. A slightly higher proportion of visits in rural areas occurred during regular working hours (53.0%) compared to urban areas (51.1%). Rural visits were generally shorter in duration and incurred lower charges, averaging 2.5 h and $1602 per visit, whereas urban visits averaged over 3 h and $2532 in charges. Additionally, a greater proportion of visits in rural areas originated from counties designated as Dental Health Professional Shortage Areas (16.0%), in contrast to urban areas, where most visits (93%) came from non‐shortage areas. Data from the Area Health Resources File further revealed differences in provider availability, with 35.5 dental providers per 100,000 population in rural counties where the visits originated from, compared to 57.7 in urban counties.

The distribution of NTDC ED visits by state Medicaid expansion status and payer source, stratified by rural and urban residence, is presented in Table 3. In Medicaid expansion states, most visits were made by Medicaid enrollees, followed by individuals with private insurance and those who were self‐pay. In contrast, non‐expansion states saw a higher proportion of visits from uninsured individuals. Within expansion states, Medicaid‐covered visits were more prevalent among rural residents compared to their urban counterparts. This pattern was particularly pronounced in Arizona, where 61% of rural NTDC ED visits were covered by Medicaid, despite the absence of adult dental benefits under the program. In urban areas of expansion states, privately insured and uninsured adults sought ED care for NTDCs at similar rates.

TABLE 3.

Distribution of emergency department (ED) visits for nontraumatic dental conditions (NTDCs) by Medicaid expansion status, payer source, and rural–urban residence.

	Medicaid expansion + dental benefits (KY, NY, VT)		Medicaid expansion + no dental benefits (AZ)		No Medicaid expansion + dental benefits (NE, NC, WI)		No Medicaid expansion + no dental benefits (FL)
	Rural, %	Urban, %	Rural, %	Urban, %	Rural, %	Urban, %	Rural, %	Urban, %
Total NTDC ED visits (n)	24,732	87,316	1479	24,729	27,773	74,072	8314	122,685
Payer
Medicare	12.4	11.5	12.3	12.2	10.2	8.4	9.6	10.4
Medicaid	53.6	49.0	61.1	56.6	23.2	24.6	34.2	28.4
Private	19.4	20.7	13.5	14.6	23.8	22.3	15.8	17.7
Self‐pay/No charge	13.3	17.6	9.0	14.7	41.4	43.5	39.2	41.6
Other	1.4	1.3	4.2	1.9	1.4	1.3	1.2	2.0

Note: p value for all comparisons was < 0.001. States included in study: AZ—Arizona, FL—Florida, KY—Kentucky, NC—North Carolina, NE—Nebraska, NY—New York, VT—Vermont, and WI—Wisconsin.

The predicted probabilities from the multivariable logistic regression analysis examining the association between rural versus urban residence and the likelihood of an NTDC ED visit across states with differing Medicaid expansion policies and dental coverage are presented in Figure 1. The probabilities of NTDC ED visits were slightly higher in non‐expansion states compared to expansion states. In three of the four groups, rural residents had a higher likelihood of NTDC ED visits. The highest predicted probability was observed among rural residents in non‐expansion states without adult dental benefits (predicted probability = 0.32). Statistical significance for rural–urban contrasts in predicted probabilities was < 0.05 and detailed in Supplementary Appendix 1.

FIGURE 1.

Predicted probabilities of emergency department (ED) visits for nontraumatic dental conditions (NTDCs) by rural–urban residence and state Medicaid policy. Covariates included: age, gender, median income for patient's residential zip code, and payment source.

Figure 2 presents the distribution of NTDC ED visits, stratified by Medicaid expansion status, the availability of adult dental benefits, and payer source across rural and urban settings. Three key patterns emerged: (i) NTDC ED visits are predominantly driven by the uninsured, irrespective of a state's Medicaid expansion status or dental benefit provisions, even so, the probability of visits among the uninsured is higher in rural areas, (ii) rural Medicaid enrollees exhibit higher rates of NTDC ED visits than their urban counterparts, particularly in states that have expanded Medicaid and offer adult dental benefits (predicted probability, Medicaid covered [Group 1], rural = 0.32; urban = 0.29, p for rural–urban contrasts < 0.001), and in non‐expansion states with no benefits (predicted probability, Medicaid covered [Group 4], rural = 0.39; urban = 0.34, p for rural–urban contrasts < 0.001), and (iii) among Medicaid enrollees, the highest probability of NTDC ED visits is observed among rural enrollees in non‐expansion states lacking adult dental benefits (predicted probability, Medicaid covered [Group 4], rural = 0.39). The p‐values for all contrasts are shown in Supplementary Appendix 2.

FIGURE 2.

Predicted probabilities of emergency department (ED) visits for nontraumatic dental conditions (NTDCs) by rural–urban residence, state Medicaid policy, and payer mix. Covariates included: age, gender, median income for patient's residential zip code, and payment source.

4. Discussion

This study provides a cross‐sectional examination of NTDC ED visits across rural and urban settings in 2019, highlighting how patient‐, visit‐, and county‐level characteristics, as well as state Medicaid policies, shape patterns of emergency dental care utilization. While prior research has explored rural–urban differences in overall ED use [17], this study is among the first to focus specifically on dental‐related ED visits for conditions that can be managed through routine dental care, particularly in the context of rural health. The findings reveal both shared patterns and notable differences in NTDC ED visit characteristics across rural and urban settings. Rural residents were more likely to be covered by Medicaid, reside in the lowest income quartile, live in areas designated as Dental Health Professional Shortage Areas (DHPSAs), and experience lower dental provider availability. Rural NTDC ED visits were predominantly from NH White individuals, whereas urban visits reflected greater racial and ethnic diversity. While this likely mirrors broader demographic distributions [18], it also suggests that racial and ethnic minority populations in urban areas may encounter distinct barriers to accessing preventive dental care, contributing to higher ED utilization.

Further, despite rural populations tending to be older overall [18], the age distribution of NTDC ED visits was similar across both settings. This indicates that adults aged 19 to 44 face the most significant challenges in accessing routine dental care, as is consistent with the literature [12], regardless of geographic location. Although Medicaid was the predominant payer in both rural and urban settings, rural areas had a slightly higher proportion of Medicaid‐covered visits, while urban areas saw a greater share of visits from uninsured individuals. This finding aligns with existing literature indicating that rural residents are more likely to qualify for Medicaid due to a combination of factors, including lower household incomes, limited access to employer‐sponsored insurance, higher private insurance premiums, and increased rates of disability [19, 20]. While rural dental providers are generally more likely to accept Medicaid [21], access to care may still be compromised by other structural barriers. These include lower provider density, higher poverty rates, and greater geographic isolation. Together, these factors may limit the practical availability of dental services for rural Medicaid enrollees, despite nominal coverage. Finally, rural visits were shorter and less costly, potentially reflecting differences in ED resource availability, lower patient volumes, or treatment intensity [17].

The analysis of state Medicaid groups as it related to Medicaid expansion and dental care shows the difference in NTDC ED visit patterns based on the policy environment. First, we found that rural residents consistently had a higher likelihood of NTDC ED visits in three policy environments. This suggests that geographic barriers, such as provider shortages and transportation challenges, persist even when policy environments are more supportive of coverage. These findings are also consistent with research showing higher rates of ED use among rural residents nationally [17]. Second, across all groups, the probability of an NTDC ED visit was highest among the rural uninsured, suggesting a higher proportion of unmet dental needs among this group. Oral health care already presents the greatest financial barriers among all types of medical care, and these challenges are particularly acute for the uninsured [22]. Addressing these disparities requires continued efforts to eliminate financial barriers to necessary dental care for all adults, with a particular focus on expanding access for rural uninsured populations. Third, when focusing on Medicaid‐covered visits, the highest predicted probability of NTDC ED visits was observed among rural Medicaid enrollees in Florida (Group 4), a non‐expansion state without adult dental benefits. This subgroup faces a dual burden: limited insurance coverage and restricted access to care, resulting in more preventable dental emergencies and greater uncompensated care burdens on hospitals.

Arizona (Group 2) is a Medicaid expansion state that does not offer adult dental benefits. Yet, the probability of Medicaid‐covered NTDC ED visits in Arizona was only slightly lower than in expansion states that do provide dental benefits (Group 1). Without offering dental benefits, the state continued to bear the financial burden of NTDC ED visits among its Medicaid enrollees. This suggests that expanding Medicaid coverage without including dental benefits does little to reduce dental‐related ED utilization among Medicaid enrollees.

Ongoing efforts to expand oral healthcare access in rural areas such as scope of practice regulation changes, mobile clinics, school‐based programs, and academic training continue to be critical in expanding access to affordable routine dental care. For example, analysis of emergency data shows that states with less stringent scope of practice regulations for dental hygienists have slightly fewer preventable dental ED visits in rural areas compared to urban areas [13]. Further, programs from the Health Resources and Services Administration continue to be critical in supporting federally qualified health centers, community‐based dental academic training, and specific groups such as people living with HIV/AIDS. Other programs that have shown some success include situating dentists in hospital and ED settings and care coordination programs that divert patients to primary dental care settings [14].

The findings from this study are especially timely given the proposed Medicaid cuts in year 2025, which could significantly worsen access to preventive dental care. The House‐passed budget bill includes up to $1 trillion in cuts to Medicaid and ACA marketplaces, imposes work requirements, and increases cost‐sharing for low‐income adults [23, 24]. These changes are expected to cause millions to lose coverage, potentially shifting more dental care needs to ED. As states face mounting fiscal pressure, optional benefits like adult dental services may be among the first to be cut, likely increasing reliance on EDs for dental care. These developments underscore the need to advocate for the preservation of preventive care and equitable access to essential health services.

5. Limitations

This study has several limitations. First, the analysis is based on data from eight states. While including data from all 50 states and the District of Columbia would have provided a more comprehensive national picture, the associated costs made this infeasible. Nevertheless, the selected states represent all four US Census regions, which offers a geographically diverse sample. Second, the State Emergency Department Databases (SEDD) capture data at the visit level and, in most states, do not include unique patient identifiers. Consequently, repeat visits by the same individuals during the study period could not be accounted for. Third, the cross‐sectional design of the study limits the ability to assess trends over time. Although post‐ACA data from 2019 were used, which reflect the landscape NTDC visits 4 years after ACA implementation, longitudinal patterns remain unexplored. Fourth, due to data constraints, we lacked detailed patient histories, including prior access to preventive dental care. Fifth, due to sample size limitations and the potential for reduced interpretability, we did not stratify the analysis by states offering limited versus comprehensive adult dental benefits to assess differences in NTDC‐related ED use. Sixth, discharge records without a documented county of residence were excluded from the analysis, and observations with missing values in other key variables were omitted from the multivariable models. As a result, we were unable to assess the potential association between these visits with incomplete records and NTDC ED visits. Finally, the SEDD only includes visits to community‐based emergency departments, excluding other care settings such as urgent care centers and physician offices, where patients may also seek treatment for acute dental issues.

6. Conclusion

This study provides insights into the patterns of ED utilization for NTDCs across a geographically diverse sample of US states. We highlight the persistent reliance on EDs for dental care, particularly in the context of varying state‐level policy environments and access to preventive services. Our findings also highlight the ongoing challenges in addressing dental care needs through emergency settings, despite the broader implementation of the ACA. Future research should aim to incorporate longitudinal data, patient‐level identifiers, and broader care settings to develop a more holistic understanding of dental care utilization patterns.

Funding

This work was supported by the 2024 American Association for Dental, Oral, and Craniofacial Research and Delta Dental Institute Oral Health Equity Research Award.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Data S1: Supporting Information.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.