Abstract
To examine how proposed Medicaid reform plans are experienced by racial/ethnic minority older adults and what the implications are for their ability to access dental care through Medicaid, from 2013 to 2015 we conducted focus groups in northern Manhattan, New York, New York, among African American, Dominican, and Puerto Rican adults aged 50 years and older.
Participants reported problems with affording copayments for care, complicated health and social issues, the need for vision and dental care close to home, and confusion about and stigmatization with Medicaid coverage.
Federal, state, and local public health agencies can help by clarifying and simplifying Medicaid plans and sustaining benefits that older adults need to live healthy and dignified lives.
Because of increased life expectancy and improvements in oral health over the past 60 years in the United States, older adults are retaining greater numbers of their natural dentition.1 Nonetheless, oral health disparities exist in the aging population regarding untreated dental caries (cavities) and edentulism (complete tooth loss) related to income, gender, race/ethnicity, and education.2
We devised a conceptual model titled, “ecological model of social determinants of oral health for older adults” for thinking about mechanisms whereby social determinants at various scales influence oral health and related health outcomes, toward promoting healthy aging.3 In this framework, oral health in older adults is owing to the lifelong accumulation of advantageous and disadvantageous experiences at multiple scales, from the microscale of the mouth to the societal scale that involves inequalities in the distribution of material wealth and educational attainment and ideologies such as ageism and racism. Note that this model is compatible with the life course perspective, because both view oral disease as cumulative.4,5
It has also been argued that disparities in public policy regarding oral health for older adults nationally and on a state-by-state basis may compound social inequities.2 Nearly 70% of older US persons currently have no form of dental insurance.6 At the federal level, the Medicare program, which covers elderly adults and nonelderly adults with disabilities, provides no dental benefits for preventive or routine care.7 At the state level, 42% of states provide no dental benefit or only emergency coverage through adult Medicaid.8
At present, market-based solutions that are part of Medicaid expansion plans may be appealing from a cost perspective but may have untoward consequences for vulnerable populations, including racial/ethnic minority older adults. For instance, the main elements of the Kentucky Health plan—with the stated intention of preparing people with expansion Medicaid coverage to become active consumers of health care—are (1) monthly premiums that increase over time; (2) a volunteer or work requirement; (3) the elimination of benefits, including vision and dental and nonemergency medical transportation; and (4) an incentivized “My Rewards” account in which credits would be accumulated for approved behaviors deemed appropriate, such as community service or work, and debited for behaviors deemed inappropriate, such as nonurgent emergency department use.9 Of course, these elements are also part of other Medicaid reform plans submitted by the governors of states such as Arizona, Arkansas, Tennessee, and Indiana and are not new or innovative in and of themselves.9
A recent critique of the Medicaid reform plan proposed by the governor of Kentucky, Matt Bevin, underscored the need for evidence to guide policy.9 In an ecological model derived from a systematic review of the complex factors that influence disparities in access to and quality of services, the endpoints of interest included clinical outcomes, avoidable hospital admissions, equity of services, and costs, along with patient experiences of care.10 A simplified schematic of this framework that focuses on level 4 (policy and community), its associated intervention targets (neighborhood and community resources), and the health care processes (principally, interactions between patients and support networks and their health care providers) leading to outcomes (notably patient experiences of care) is provided in Figure 1.
FIGURE 1—
Policy and Community Level Factors That Result in Patient Experiences of Care
Source. We derived this graphic from the conceptual model called “factors that influence disparities in access to care and quality of health care services, by level,” from Purnell et al.2
We addressed the patient perspective on proposed Medicaid reforms, particularly that of racial/ethnic minority older adults, who are the focus of ongoing social science research to promote oral health equity (Northridge ME, Shedlin MG, Schrimshaw EW et al., unpublished data).11
The question that guided our qualitative analysis was this: How might the elements of proposed Medicaid reform plans be experienced by racial/ethnic minority older adults and what are the implications for their ability to access dental care through Medicaid?
METHODS
As part of an ongoing study funded by the US National Institutes of Health to understand factors that serve as barriers to oral health and health care among racial/ethnic minority older adults, we conducted 24 focus groups with 194 African American, Dominican, and Puerto Rican participants aged 50 years and older living in northern Manhattan, New York, New York. We approached and screened older adults for possible participation in the study at senior centers located throughout northern Manhattan. Details of the recruitment and screening procedures are available elsewhere (Northridge ME, Shedlin MG, Schrimshaw EW et al., unpublished data).
Following standard focus group techniques,12 we conducted separate groups on the basis of important characteristics that may influence either the issues discussed or the ability of the members to build rapport, notably, gender, race/ethnicity, and history of dental care. Groups consisted of an average of 8 participants (SD = 2.4) and lasted an average of 1.3 hours (SD = 13 minutes). We audio-recorded and transcribed for analysis all group discussions.
Trained moderators conducted focus groups using a series of semistructured questions about the factors that serve as facilitators or barriers to obtaining dental care. Among the topics explored in each group were factors affecting the affordability of care and whether there was an understanding of what services Medicaid covers.
We transcribed group discussions conducted in Spanish in Spanish and then translated the transcription into English. To ensure accurate transcription and translation, the assistant moderator (I. E.), who was present for all focus group discussions, compared the resulting transcripts with the original audio-recordings. We analyzed the transcripts using thematic content analysis.13
The research team members began the analysis by familiarizing themselves with the data, which involved independently reading and rereading the focus group transcripts to immerse themselves in the data and become intimately familiar with its content. The subsequent phase involved generating succinct labels (codes) to identify important features of the data that might be relevant to the research question. Next, the team met to discuss the topics identified and to construct a list of 20 topic codes. Although many (15) of these topics were directly explored with questions in the interview guide, we collapsed some of the original guide topics and identified unanticipated codes and included them in our analysis. We achieved consensus among all research team members.
One of the codes identified was “financial and insurance.” This code included Medicaid, Medicare, insurance, cost issues, policies regarding what dental procedures are and are not covered, and changes owing to retirement. To identify the text in which participants discussed Medicaid reform proposals, we read all transcripts to identify sections of text in which groups discussed Medicaid, and we took detailed notes on the specific comments participants made about their views of the Medicaid program. Participants reported difficulties in using Medicaid and confusion over what dental services were covered. We have reported the most commonly reported views. We selected quotations that best represented the perceptions that the majority of participants described regarding the implications of 4 proposed Medicaid reforms on the lives of Medicaid recipients and their ability to access care through the program: (1) monthly premiums, (2) a volunteer or work requirement, (3) eliminating covered services, and (4) behavioral incentives.
RESULTS
The sociodemographic characteristics of the focus group participants by race/ethnicity and for the total sample are presented in Table 1. Approximately half (53.6%) of the participants were women, and nearly half (48.5%) spoke primarily Spanish at home. We have presented representative focus group quotations that relate to each of these 4 proposed reforms.
TABLE 1—
Sociodemographic Characteristics of Older Adult Focus Groups Participants by Race/Ethnicity and Total Sample: New York, NY, 2013–2015
| Characteristic | African American | Dominican | Puerto Rican | Total |
| Participants, no. | 72 | 69 | 53 | 194 |
| Focus groups, no. | 8 | 8 | 8 | 24 |
| Age, y | ||||
| Mean ±SD | 68.3 ±10.2 | 71.6 ±9.6 | 68.5 ±10.0 | 69.5 ±10.0 |
| Range | 50–92 | 50–90 | 50–91 | 50–92 |
| Age group, y, % (no.) | ||||
| 50–54 | 11.1 (8) | 4.3 (3) | 13.2 (7) | 9.3 (18) |
| 55–59 | 6.9 (5) | 1.4 (1) | 7.5 (4) | 5.2 (10) |
| 60–64 | 15.3 (11) | 20.3 (14) | 17.0 (9) | 17.5 (34) |
| 65–69 | 20.8 (15) | 15.9 (11) | 11.3 (6) | 16.5 (32) |
| 70–74 | 23.6 (17) | 15.9 (11) | 20.8 (11) | 20.1 (39) |
| 75–79 | 8.3 (6) | 21.7 (15) | 18.9 (10) | 16.0 (31) |
| 80–84 | 5.6 (4) | 11.6 (8) | 7.5 (4) | 8.2 (16) |
| 85–89 | 4.2 (3) | 5.8 (4) | 0.0 (0) | 3.6 (7) |
| ≥ 90 | 4.2 (3) | 2.9 (2) | 3.8 (2) | 3.6 (7) |
| Gender, % (no.) | ||||
| Male | 44.4 (32) | 49.3 (34) | 45.3 (24) | 46.4 (90) |
| Female | 55.6 (40) | 50.7 (35) | 54.7 (29) | 53.6 (104) |
| Time of last dental visit, % (no.) | ||||
| Within past year | 54.2 (39) | 59.4 (41) | 47.2 (25) | 54.1 (105) |
| 1–3 y ago | 26.4 (19) | 29.0 (20) | 26.4 (14) | 27.3 (53) |
| > 3 y ago | 19.4 (14) | 11.6 (8) | 26.4 (14) | 18.6 (36) |
| Primary language, % (no.) | ||||
| English | 100.0 (72) | 0.0 (0) | 18.9 (10) | 42.3 (82) |
| Spanish | 0.0 (0) | 98.6 (68) | 49.1 (26) | 48.5 (94) |
| Both | 0.0 (0) | 1.4 (1) | 32.1 (17) | 9.3 (18) |
| Neighborhood of residence, % (no.) | ||||
| Inwood | 4.2 (3) | 13.0 (9) | 1.9 (1) | 6.7 (13) |
| Washington Heights | 13.9 (10) | 58.0 (40) | 5.7 (3) | 27.3 (53) |
| East Harlem | 15.3 (11) | 5.8 (4) | 79.2 (42) | 29.4 (57) |
| Central Harlem | 30.6 (22) | 4.3 (3) | 5.7 (3) | 14.4 (28) |
| West Harlem | 20.8 (15) | 8.7 (6) | 3.8 (2) | 11.9 (23) |
| Other | 15.2 (11) | 10.1 (7) | 3.8 (2) | 10.3 (20) |
Note. The racial/ethnic groups did not differ significantly on any of the listed sociodemographic characteristics, with the exceptions of primary language and neighborhood of residence, in accordance with the sampling strategy.
Reform 1: Monthly Premiums
First, regarding the suitability of monthly payments that increase over time, many of the older adult participants reported problems with affording care at current copayment levels.
Group 1 (African American women with dental care).
Moderator (M): Great, so in terms of the affordability, what [have] been other people’s experiences?
Participant 1 (P1): Like she said the expense. Seniors or whatever, the way they have the insurance now, you got the copayments. A lot of them don’t accept Medicaid. And, seniors [have] basically Medicare now. Then certain work that you’re getting done, your insurance.
P2: It’s not covered.
P1: . . . may not cover it or a lot of it’s still coming out of your pocket. Very expensive.
Group 13 (African American men without dental care).
P1: Copayments. That’s one of the [reasons] why I don’t go to the doctor too much. I’m telling you: I haven’t been to the doctor in a while. I’m 80 years old.
P2: That’s the reason why.
P3: I haven’t been to the doctor in almost 2 years now.
P4: Damn.
Group 1 (African American women with dental care).
There was uncertainty regarding what is covered under Medicaid.
M: So, in terms of yourselves and other seniors in the senior center, is there a good understanding, do you think, of what Medicaid pays . . . .
P1: No.
M: . . . for what Medicare pays for, what other—and what services are paid for, what that’ll do?
P2: No.
P3: No.
P4: . . . Most people are not aware of their rights in terms of copayments, the different [types of coverage].
Group 17 (African American men with dental care).
M: Does Medicare cover anything for dental?
P1: No. No.
P2: No. No. But see: when you retire. . . . OK, so before you retire, you know like. You are indirectly to the union. But they’ll put you . . . in Healthfirst14 [provides no-cost and low-cost health insurance plans]. . . . And then that—they take that out of your Medicaid. So you pay for it out of that. So now you’re covered on that end. Like see, now, I got Healthfirst. Right? So now Healthfirst is paying for my glasses. And they’ll pay for my teeth. My teeth and all that. You know? But they get their money from my social security.
Group 5 (Dominican men with dental care; translated from Spanish).
In addition to stated confusion over what plans cover what services, participants also expressed the desire for government to lend a helping hand.
P1: One point that is outside of what we are discussing is, for example, if the government here, for example, helps people; we get help with food coupons. It helps us with programs designed to help us. If it weren’t for that, we would live in worse conditions than the ones that we are in. We couldn’t live like that. It’s hard. The situation is not easy.
P2: Look, [names moderator].
P3: It’s not easy.
P4: Those are the insurance plans I have.
P2: I changed plans—from Medicaid to Medicare, no?
P5: Tell her about that.
P2: And I was doing better because there was a dentist at the medical center who went to fix my little mouth there. To all of us, where I lived. But, what happens? When I changed insurance, trying to find someone who would deign [to] fix my mouth, I changed from Obama[care], from Medicaid to Medicare, to get my mouth fixed and they have refused to fix it for me. And I am going to quit from that insurance and see if someone accepts me so I can get my mouth fixed. My mouth has deteriorated completely.
Reform 2: Volunteer or Work Requirement
Second, regarding a volunteer or work requirement, many of the participants reported complicated health and social issues that would interfere with fulfilling this obligation.
Group 24 (Puerto Rican men with dental care translated from Spanish).
P1: . . . First my plan dropped. They changed me to a crazy plan just because they don’t take Medicaid. . . . They sent me to a dentist far away. I’m in disability, I can’t walk too much . . . find me a place close to my house and refer me. “Look this is close to your house. Check.” So, you choose your best option. But the plan force[s] you to take what they have available only. I do not agree with only choosing what the plan has available.
Group 8 (African American men without dental care).
P1: . . . But I’m not concerned about myself now. I’m [gonna] talk to you about my wife. I’m worried about her.
P2: There you go!
P1: While she had to go through so much changes. And she, she’s a diabetic and she’s had cancer and her teeth, they [were] decaying and they told her—now she had enough to have Medicaid. Why she had Medicaid? ’Cause she had to pay some money and she had to go to the counseling program so—I don’t know if you’ve ever heard of it, Sloan Kettering. That’s one of the bigger counselors, doctors and hospitals. . . .
P3: Like in New York, by NYU.
P1: Yeah, and so she goes there. Sometime[s] we go every day. Last month we went every day, in a row. . . . She was doing alright for about 20 years. Went in remission and it came back now if, she go again. It’s started. It’s in her ribs now. It came back. It’s in her inner rib or something like that. And plus, she’s a diabetic. So we have to go through all that travel—I’m not worried about myself. I’m just trying to say that she had this Medicaid—it used to be every 4 years. Now, they changed it to 8 years. So what she [has] to do for 8 years? And she’s losing a lot of weight because—her teeth, she had teeth need to be extracted, and she [needs] teeth to be put in. Went to Columbia. They extracted teeth, but that’s all they do.
P4: Well, people don’t realize that your mouth take. . . .
P1: You understand? That’s a big part of your life.
P5: Part of your health.
P6: Oh yeah!
Reform 3: Eliminating Covered Services
Third, the loss of benefits, including dental coverage for adults, would undermine the ability of older adults to access preventive care.
Group 13 (African American men without dental care).
P1: ’Cause for me, since my father passed—been 8 months, 9 months. It seems like, ’cause I was taking care of him. He was 87. It seems like since he passed, all of the sudden I notice all of these things that need to be done before my body goes. I don’t know if they were there before and I was so focused on him that I wasn’t paying attention or it’s just, you know, the natural progression of age but I mean as far as dentists and doctors, I need to get my Medicaid back, just go like up there and, you know, get checked in the office.
Group 9 (African American women with dental care).
There is empathetic agreement among racial/ethnic minority older adult participants that providers ought to accept the coverage that community members are entitled to so that they can access needed health services.
P1: You got to be able to take Medicaid . . . you gotta be able to take all of that. Don’t come and say, “We don’t do this.” Well, f*** you. You need to be out. You don’t need to come to a neighborhood if you are not going to be able to service the people who are here.
P2: That’s right.
[Note that several women are echoing and following this speaker as she explains.]
P3: Why refuse us when you are here in our community?
P1: Just make sure that they come in knowing that you are not going to make a million dollars here for your practice.
P2: Right.
P1: ’Cause we don’t have it like that.
P4: All these dentists, they should take so many people.
Reform 4: Behavioral Incentives
Fourth, an incentivized My Reward account that rewards older adults (e.g., for work or community service) and penalizes older adults (e.g., for nonurgent emergency department use) would no doubt prove even more confusing and stigmatizing for older adults than Medicaid coverage already is at present.
Group 20 (Puerto Rican men with dental care; in English).
P1: . . . My problem was Medicaid to pay for my dentures. I fought Medicaid. It took me 8 years to get my dentures because every time. First it started with 4 years, so I had to wait 4 years because they did some bad dentures. Now I gotta live with 4 years of dentures sitting in a cup looking at me. So I wait 4 years. I go to a dentist. They changed they law!
Group 20 (Puerto Rican men with dental care; in English).
P1: I got a letter from a doctor because it was 8 years and no dentures. I lost a lot of weight.
P2: Yeah!
P3: I had a, a doctor wrote me a letter that I was lacking vitamins in my body. I can’t chew meat because I tried once and I almost choked. So I had to be careful with what I was eating. Now I’m eating. And they made a letter for me and I gave it to Medicaid. I made a copy—kept me a copy and I sent it to Medicaid. I waited and waited. Because of not having dentures, it cost me a deficiency. A vitamin deficiency. That’s the only way I got an approval to go ahead and get the dentures then. Other than that. . . .
P3: That still don’t make no sense.
Group 23 (African American men with dental care).
P1: Now listen, listen to you and listen to me. You paying and they are happy. I’m welfare recipient, and you are paying. They are going to treat you better than they treat me, and we both live in the same building and you live next door to me. ’Cause you are paying cash, they are going to give you a more special service, than I’m going to pay with Medicaid they are going to treat me different. Maybe I have the same problem. They might say well we can save your teeth to you ’cause you are paying cash, and to me oh we are going to take your teeth out cause you are using Medicaid. See that is the problem.
The Patient Perspective
Our qualitative findings add a valued perspective that complements the quantitative evidence reported in the literature to date. For instance, Neely et al. found that dental-related emergency department visits increased 2% the first and 14% the second year after Medicaid cuts in Massachusetts.15 Further, percentage increases were highest among older adults, minorities, and persons receiving charity care, Medicaid, and Medicare.15 Hence, it appears likely that certain elements of the Kentucky First and of similar Medicaid expansion plans would be in direct opposition; for example, eliminating adult dental benefits would increase emergency department use and associated costs, thus further exacerbating the health and welfare of already disadvantaged and disabled older adults.
Instead Medicaid needs to be responsive to the experiences of older adults who seek care through the program. In the words of study participants, provision of respectful and comprehensive health care ought to be the guiding principle.
Group 8 (African American men without dental care).
P1: You have to be cordial. You have to show that you are really concerned about their health. So, listen. We adapt very well to people who show us respect.
P2: Right.
P1: Seniors like respect because we’ve paid our dues. We really have. We’ve suffered some real indignities and now that we’ve gotten older, they got worse.
[Group laughs.]
P1: I mean they really have! We shouldn’t have to have discussions about senior health. This should have been a foregone conclusion years ago. All that’s been happening is that stuff has been taken away from us. It’s made it more difficult for us to live like decent human beings.
Group 15 (Dominican men with dental care translated from Spanish).
Racial/ethnic older adults need information on oral health and health care delivered in the formats that are accessible to them and their peers.
P1: I think that in this community, we need a lot more information. Many times we are orphaned of information. Those of us who have information are those of us who go to the centers, are paying attention to what is happening. But there are a lot of people who don’t even know what is happening in their community. We need a lot of communication at the level of the [senior] centers, public offices, the libraries. We need information via radio.
P2: At the drug store!
P1: On television. The Hispanic community needs television. In other words, more information. Because it’s through more information that you do consciousness building. More conscientious people [access] more easily those services [than] those who don’t know that those things exist.
Group 5 (Dominican men with dental care translated from Spanish).
Focus group participants underscored the need for affordable services.
P1: I say, if a clinic is there or there, I’d choose any of them but they have to treat me for free and it belongs to the government.
P2: Yup.
P1: But that doesn’t exist.
P3: Or at least a clinic that charges low fees so one can pay.
P1: A minimum fee.
P3: Something that’s not free, but that is reasonable.
P1: According to your income.
P2: It’s not possible another way. It’s too expensive.
Group 3 (African American women without dental care).
Mobile services, such as those currently available through select dental schools, were also endorsed.
M: What kinds of things would you do to try to get seniors to go who aren’t already going?
P1: They have the children’s dental truck. They have it for children. Vans. So why don’t they have one for grown-ups?
P2: That’s a good idea.
P3: People would just go, take a morning and do all the screening and then once a month they’ll do it or something every other week. Because it’s easy. They don’t have to travel anyplace. . . . They offered screening, or everything, even if they’re just a screening, okay. And then I refer you back to your own dentist or back to a regular dentist.
Group 24 (Puerto Rican men with dental care translated from Spanish).
Dental home visits were another idea.
P1: I would get nurses or dentists, you know, go check the teeth out and in your apartment, you know.
M: Home visits?
P1: Visits to your apartment to check all the elderly people. So they don’t have to come. Give me all the number of all the elderly people and all the kids. You go to the families; you check all the families. People are scared. If there was one person or a women who says let’s check your teeth, they open their mouth to check them and do not take anything out. . . . In Puerto Rico they have buses that go for the elderly people to fix their teeth and everything.
DISCUSSION
A critical step toward reducing racial/ethnic inequities in oral health and health care for older adults is to fund Medicaid well enough to deliver the standard of care for everyone, not just the privately insured.5 Clearly just the provision of public dental insurance is not sufficient to eliminate disparities in the receipt of oral health care.16
Previously suggested public health priorities for reducing disparities in oral health and health care for older adults include better integrating oral health into medical care, implementing community programs to promote healthy behaviors and improve access to preventive services, developing a comprehensive strategy to address the oral health needs of the homebound and long-term care residents, and assessing the feasibility of ensuring a safety net that covers preventive and basic restorative services to eliminate pain and infection.17
To these we would add incorporating the views of older adults into public health programs and policies. Scientific approaches exist, including collaborative, interdisciplinary systems science inquiry, that provide opportunities to meaningfully integrate the experiences of both patients and providers in efforts to promote oral health equity.18 Finally, instead of cutting Medicare, Medicaid, and other critical health care programs serving our nation’s most vulnerable populations, policymakers ought to improve public health and modernize our largest insurance programs by expanding coverage and benefits, including comprehensive dental care.8
ACKNOWLEDGMENTS
This study was supported by the National Institute for Dental and Craniofacial Research and the Office of Behavioral and Social Sciences Research, National Institutes of Health for the project titled Integrating Social and Systems Science Approaches to Promote Oral Health Equity (grant R01-DE023072).
HUMAN PARTICIPANT PROTECTION
This research was approved by the Columbia University, New York University, and University at Buffalo institutional review boards, and all Health Insurance Portability and Accountability Act safeguards were followed.
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