Oral Health Care Needs of Young Adults Transitioning from Foster Care

Oral Health Care Needs of Young Adults Transitioning from Foster Care Abstract Children who have aged out of the foster care system face considerable barriers in accessing oral health care. Although this population of foster care alumni may have Medicaid insurance while they are in care to cover dental care, 39 percent of youths who have aged out of foster care do not have dental insurance. This mixed methods study examines factors that contribute to the oral health care disparities of children who have transitioned from foster care. Multivariate analysis revealed that foster care alumni without dental insurance are 93.5 percent less likely to have their dental needs met than those with dental insurance. Themes from the qualitative data indicated a lack of oral health care, quality-of-life issues, and lack of support to access ongoing dental care. Most state Medicaid programs do not provide comprehensive dental care for adults past the age of 20, contributing to oral health disparities among this population. The addition of oral health care coverage under the Patient Protection and Affordable Health Care Act of 2010 for foster care alumni would greatly enhance their quality of life. The article concludes with a discussion of the implications for the role of social workers in promoting oral health care for foster care youths. foster care, Medicaid policy, oral health, Patient Protection and Affordable Care Act of 2010, transition Whereas social work has historically played an important role in medical health care, dentistry has for the most part not included a social work model of care as part of its operation. As children in foster care are largely dependent on social workers to ensure their health and well-being, there is a need for social workers to understand the current landscape surrounding the oral health of child welfare–involved youths and how to ensure that foster care youths are accessing preventive and treatment-based oral health care services (Petrosky, Colaruotolo, Billings, & Meyerowitz, 2009). Empirical evidence indicates that adolescents in foster care experience challenges in accessing quality and timely oral health services (Committee on Early Childhood, Adoption, and Dependent Care, 2002; Government Accountability Office [GAO], 2008; Melbye, Huebner, Chi, Hinderberger, & Milgrom, 2013). Current oral health policies and practices necessitate that children in foster care and those transitioning from foster care primarily rely on Medicaid to meet their oral health care needs (GAO, 2008; Courtney et al., 2011). Children with Medicaid dental benefits have significant problems accessing dental care. One-third of children with Medicaid have untreated tooth decay and are almost twice as likely to have untreated dental caries compared with children who have private insurance (GAO, 2008). Additional barriers include difficulty accessing care due to affordability and dentists who are willing to accept Medicaid or individual state policy (GAO, 2008). As this population transitions out of the foster care system, the aforementioned barriers increase. Individual states are responsible for developing policies and procedures concerning the implementation of oral health care under Medicaid (American Dental Association, 2013; Patient Protection and Affordable Care Act of 2010 [ACA] [P.L. 111-148]). Dental services for those 21 years of age or older are not a mandatory service of Medicaid (U.S. Department of Health and Human Services [HHS], Centers for Medicare and Medicaid Services [CMS], 2016). Therefore, states that do provide dental care are not obligated to establish any minimum requirements for dental coverage (HHS, CMS, 2016). Currently, 30 states provide Medicaid eligibility to foster care alumni up to age 21 (Pergamit, McDaniel, Chen, Howell, & Hawkins, 2012). These states have much latitude in deciding what oral health periodicity schedule is used, what constitutes a minimal level of services, and what services are medically necessary (HHS, CMS, 2016). For example, in Michigan, the focus of this study, dental exams with prophylaxis and treatment as needed, including fluoride, are a Michigan Medicaid–covered service recommended every six months (Michigan Department of Health and Human Services [MDHHS], 2016b), which is consistent with the recommendations of the American Academy of Pediatric Dentistry (American Academy of Pediatric Dentistry, Clinical Affairs Committee, Council on Clinical Affairs, 2013). However, the state of Michigan foster care policy manual recommends that “a dental re-examination shall be obtained at least every 12 months, unless a greater frequency is indicated” after the age of three years (MDHHS, 2016a), creating a barrier that contributes to oral health disparities among foster care children and alumni. Our study addresses a gap in what we know about dental care access and the oral health status of foster care alumni. The purpose of this mixed methods study is to identify factors that positively or negatively influence appropriate and timely dental care among this population. Our study seeks to answer the following three questions: (1) What is the relationship between age, permanency arrangement, and dental insurance status and having dental needs met among for foster care alumni? (2) What are the barriers and facilitators experienced when seeking oral health care among foster care alumni? (3) How does the lack of dental care access and poor oral health affect the quality of daily life among foster care alumni? Institutional review board approval was obtained for this study. Survey data and verbatim transcripts of interviews and focus groups are available upon request from the authors. Method Study Design A mixed methods research design with a concurrent triangulation approach was used to compare the quantitative and qualitative data to verify results (Creswell, 2009). Survey, focus group, and interview data were collected at the same time between 2006 and 2008. Survey data were collected from participants to understand their current dental health and level of access to oral health care services. For the purposes of this article, survey data are limited to the subset of questions that queried participants on their oral health and access to dental care. The survey instrument was informed, in part, by the Youth Risk Behavior Survey, which includes questions regarding participants’ experiences with different health domains, including oral health (HHS, Centers for Disease Control and Prevention, 2005). Quantitative study measures included the predictor variables, age, permanency arrangement, and dental insurance status; and the outcome variable, the met or unmet oral health needs. Age was measured as a dichotomous variable (participants who were 20 years old or younger, and those 21 years of age or older), because these age groups were relevant to the Medicaid eligibility policy in place at the time of the study. Permanency arrangement options included being reunified with family, being adopted, receiving guardianship, and being without a permanency arrangement. Dental insurance status was measured as those with and without dental insurance at the time of the study. Control variables included gender, race, and number of placements. Qualitative data from this study were collected in focus groups or individual interviews to explore the impact of poor oral health on quality of life. Interview and focus group questions focused on the lived experiences of foster care alumni in obtaining health care services, including dental care, while in foster care and after leaving care. The semistructured interview protocol used to conduct the focus groups and individual interviews consisted of five questions that inquired about participants’ experiences with the foster care system, the impact of dental health problems on their daily activities, barriers faced in securing dental health care treatments, and recommendations to people making decisions about policies that affect foster care youths. The results of the analysis of the survey data are compared with the themes from the focus groups and interviews to uncover points of congruency and dissimilarity. Participants and Data Collection Participants were foster care alumni residing in the state of Michigan. Participants were recruited through convenience and snowball sampling methods, using public and private child welfare agency contacts and foster care alumni networks. To be included in the sample, participants had to have transitioned from child welfare care and be legally emancipated or age 18 or older. Eight were excluded from the current study because of outlier status due to older age. The final sample was 66 former foster care youths who participated in the study over an 18-month period from 2006 to 2008. All participants completed informed consent documents. All respondents were asked to participate in a focus group. Fifty-two percent (n = 34) agreed to participate in this group process. Another 24 percent (n = 16) of participants agreed to individual interviews. The remaining 24 percent (n = 16) of respondents completed the survey only. Analysis We used SPSS (version 20) software to conduct descriptive, inferential, and multivariate analyses. Inferential statistics were used to assess whether any associations existed between unmet and met dental needs and the covariates, which included gender, race, and number of placements. The control variables that were statistically associated with the unmet and met dental needs were included in the multivariate analysis. Using logistic regression, we conducted multivariate analyses to estimate the effect of the permanency arrangement, age, and dental insurance status on the unmet dental needs. Qualitative data derived from the focus groups and individual interviews were audio-recorded and transcribed verbatim. Transcripts from the focus groups and individual interviews were analyzed using QSR International’s (2012) NVivo (version 9) software and the phenomenological analytical process as set forth by Moustakas (1994). The primary focus of phenomenological analysis is to capture the essence of the meaning of the experience as described by the participants through a process of observing and describing the phenomena being studied (Giorgi, 2009). Results Descriptive Analysis The majority of participants (68.2 percent) were female (n = 45). Half the sample identified as white, 41 percent (n = 27) were African American. The mean age was 24 years. A little over half the group reported having unmet dental needs (52 percent). Approximately 42 percent of the sample reported they did not have dental insurance at the time of their participation in the study. Forty-four percent had public health insurance, 29 percent had private insurance, and 26 percent did not have health insurance. See Table 1 for additional demographic information. Table 1: Additional Participant Demographics and Descriptives (N = 66) Characteristic  n  %  Age       20 years or younger  28  42.4   21 years or older  38  57.6  Permanency arrangement       Yesa  19  28.8   Nob  47  71.2  Number of placements       1–2  18  27.3   3–5  20  30.3   6 or more  28  42.4  Characteristic  n  %  Age       20 years or younger  28  42.4   21 years or older  38  57.6  Permanency arrangement       Yesa  19  28.8   Nob  47  71.2  Number of placements       1–2  18  27.3   3–5  20  30.3   6 or more  28  42.4  aReunified with family, adopted, or received guardianship. bNo permanency arrangement, that is, independent living. Bivariate Analysis The predictor variables of gender, race, age, number of foster care placements, permanency arrangement, and dental insurance status were examined for between-group differences. Gender, permanency arrangement, and dental insurance status were significantly associated with having unmet dental needs. Specifically, age approached significance (p = .08) whereas race (p > .05) and number of placements (p > .05) were not significantly associated with having unmet dental needs. The full results of the bivariate analysis are found in Table 2. Table 2: Between-Group Differences in Having Unmet Dental Needs (N = 66) Characteristic  Unmet Dental Needs (n = 33)  Met Dental Needs (n = 31)  r  n  %  n  %  χ2  p  Gender          4.32  .04  .26   Female  27  81.8  18  58.1         Male  6  18.2  13  41.9        Race          0.60  .74     White  16  48.5  16  51.6         African American  13  39.4  13  41.9         Othera  4  12.1  2  6.5        Age          3.00  .08     20 years or younger  11  33.3  17  54.8         21 years or older  22  66.7  14  45.2        Number of placements          0.73  .69     1–2  8  24.2  10  32.2         3–5  9  27.3  9  29.1         6 or more  16  48.5  12  38.7        Permanency arrangement          6.90  .01  .33   Yes  5  15.2  14  45.2         No  28  84.8  17  54.8        Dental insurance (n = 31)          20.57  .001  .58   Yes  10  32.3  26  89.7         No  21  67.7  3  10.3        Characteristic  Unmet Dental Needs (n = 33)  Met Dental Needs (n = 31)  r  n  %  n  %  χ2  p  Gender          4.32  .04  .26   Female  27  81.8  18  58.1         Male  6  18.2  13  41.9        Race          0.60  .74     White  16  48.5  16  51.6         African American  13  39.4  13  41.9         Othera  4  12.1  2  6.5        Age          3.00  .08     20 years or younger  11  33.3  17  54.8         21 years or older  22  66.7  14  45.2        Number of placements          0.73  .69     1–2  8  24.2  10  32.2         3–5  9  27.3  9  29.1         6 or more  16  48.5  12  38.7        Permanency arrangement          6.90  .01  .33   Yes  5  15.2  14  45.2         No  28  84.8  17  54.8        Dental insurance (n = 31)          20.57  .001  .58   Yes  10  32.3  26  89.7         No  21  67.7  3  10.3        aAmerican Indian, Asian, or Hispanic. Multivariate Analysis A logistic regression was performed to determine which of the independent variables—gender, permanency arrangement at the time of leaving care, dental insurance status, and age—were associated with having dental needs met. Based on the results of the bivariate analyses, race and the number of placements were not significant and were excluded from the multivariate analysis. All other variables were loaded in the model, including gender, permanency arrangement, and dental insurance. Age was also included in the model because it approached significance in the bivariate analysis. The final model indicated that gender, age, and permanency arrangement were not associated with having dental needs met. Dental insurance status was significantly associated with having dental needs met. While controlling for gender (p = .240), age (p = .669), and permanency arrangement (p = .112), foster care alumni who do not have dental insurance are 93.5 percent less likely to have their dental needs met than foster care alumni who have dental insurance. The Nagelkerke pseudo R2 measurement indicated that the model accounted for 48.1 percent of the variance explained by the independent variables. Multivariate regression results are found in Table 3. Table 3: Multivariate Results of Having Unmet Dental Needs Characteristic  Estimated OR  95% CI  Lower  Upper  Permanency arrangement  3.24  0.76  13.77  Gender  2.41  0.55  10.50  Dental insurance  0.065***  0.015  0.289  Age  1.33  0.02  0.29  Characteristic  Estimated OR  95% CI  Lower  Upper  Permanency arrangement  3.24  0.76  13.77  Gender  2.41  0.55  10.50  Dental insurance  0.065***  0.015  0.289  Age  1.33  0.02  0.29  Notes: OR = odds ratio; CI = confidence interval. ***p < .001. Qualitative Themes Six themes (presented in Table 4) emerged from the focus groups and individual interviews. Thirty-four percent of the participants identified two major areas of concern: current dental needs not being met and lack of insurance and income to pay for dental care. In addition, 26 percent of alumni discussed their difficulties obtaining information on how to maintain their Medicaid once they exited foster care. Two themes relating to quality-of-life issues emerged: the impact of poor oral health on daily living and the stress of trying to manage chronic dental pain. The sixth theme concerned the unevenness of their experience receiving appropriate and timely dental care while in foster care. Each theme is discussed with quotations to illustrate the experiences of foster care alumni in accessing dental care and their oral health status. Table 4: Major Themes and Examples (N = 50)   Theme  n  %  1  Ongoing need for treatment of serious dental problems  17  34  2  Difficulties accessing dental care with Medicaid, without insurance, or inadequate income to pay  17  34  3  Lack of information on continuing Medicaid eligibility when exiting foster care  13  26  4  Stress and resilience due to the lack of dental care  10  20  5  Quality-of-life implications of poor oral health  7  14  6  Inconsistent dental care received in foster care  5  10    Theme  n  %  1  Ongoing need for treatment of serious dental problems  17  34  2  Difficulties accessing dental care with Medicaid, without insurance, or inadequate income to pay  17  34  3  Lack of information on continuing Medicaid eligibility when exiting foster care  13  26  4  Stress and resilience due to the lack of dental care  10  20  5  Quality-of-life implications of poor oral health  7  14  6  Inconsistent dental care received in foster care  5  10  Ongoing Need for Treatment of Serious Dental Problems Slightly more than one-third of participants (34 percent) indicated that they had wisdom teeth or broken and abscessed teeth that needed to be pulled or had jaw alignment problems. One alumna said that she needed to have multiple teeth pulled that had broken off or rotted: “These ones over here are getting holes in them, and they’ve all been filled while I was in foster care. Just kept being filled and kept being filled. And now, I have pains. I take ibuprofen.” Another participant echoed having to deal with the pain of dental problems on her own: I had a toothache that was driving me crazy. Like, pulling my hair out, sit up at three o’clock in the morning, tears streaming down my face, toothache. . . . They told me it was gonna be $400 to have them clip the nerve, pull the tooth, and realign everything how it needs to be. [She was unable to pay.] And I said, fine, OK, I have a bottle of Vicodin, I will make it work. Other alumni noted, “Well, I need, you know, insurance so bad. I haven’t been to a dentist for years.” And: “Wisdom teeth, night guard. I clench my teeth at night, and it causes soreness in my jaw and teeth. I need my wisdom teeth out.” Difficulties Accessing Dental Care with Medicaid, without Insurance, or Not Having Adequate Income to Pay Young adults from this study reported difficulties obtaining dental care without dental insurance. One participant thought that she was being referred to a community clinic that would take her regardless of her insurance status; but this was not the case when she arrived: Because I don’t have a job, and I don’t have enough for a down payment, so they said no, we cannot see you. And then they referred me to . . . this one right in Michigan, and if you don’t have any kind of insurance, they can’t see you at all. Several young adults reported not having any insurance and paying out of pocket. One participant reported, “I don’t have dental insurance and I have a tooth that’s really bad, and I have paid money out of my own pocket because I can’t get insurance for dental, because I’m past [the age of] 21.” Paying for medical expenses adds to the financial burden that these young people are dealing with after exiting foster care. Alumni report having medical insurance that does not include dental insurance. Therefore, having Medicaid does not ensure that the person had access to dental care: “Even though you have Medicaid, a lot people don’t want to take it, ’cause you’re 21 and over or it’s crappy insurance.” And: I know I have a copay now; I don’t know if that’s because I turned 21 or if it’s because of the [geographic] area or what it is. But I know I’m limited because nobody will take Medicaid for dental at all. Lack of Information on Continuing Medicaid Eligibility When Exiting Foster Care Foster care alumni report losing Medicaid at the time of exiting foster care and then not having sufficient information to reapply through the state system. Foster care alumni often lack information and understanding of their eligibility for continued Medicaid past their exit from foster care and how to maintain those benefits. Alumni report that their child welfare worker would begin the process but not follow through, or alumni were not given information as they aged out about how to reapply for Medicaid if they lost their coverage. One participant reported, “I have four wisdom teeth that need to be taken out . . . . I’m not even sure if I have health, or any insurance right now, because I’m 18, I’ve aged out of Medicaid.” Others reported, “I never got the information to reapply for it [Medicaid] so I didn’t, so I didn’t go to the dentist for like two years.” And: “I would’ve liked somebody to have told me that I need to apply for Medicaid, when I’m out there on my own. Like a caseworker or somebody to let me know.” Stress Due to Lack of Dental Care Foster care alumni experience frustration and anger because they cannot access appropriate dental care for dental problems, some of which cause a great deal of pain. Participants talked about their tooth pain, saying, “So, when my benefits kick in, that’s the first thing I’m doing, is going to get my tooth fixed.” And: “You have a toothache and you don’t have insurance, it’s one of those things where makes you wanna run in, face first, into a wall and knock yourself out, because it hurts so bad.” Another participant noted, I know my insurance won’t cover it [jaw] because it’s cosmetic and blah, blah, blah, but that’s bullshit! I mean if it’s affecting my speech, and the way I’m eating, and I’m talking, . . . I think I should be able to get it done. Quality-of-Life Implications of Poor Oral Health Foster care alumni are cognizant of the consequences of poor oral health on social and economic relationships and on their long-term health. As one alumnus stated, Nobody wants to walk around looking like a pumpkin, you know? It’s just embarrassing. People aren’t going to be confident in applying for jobs or going to school if they’re ashamed of what they look like. . . . The kinds of things that Medicaid pays for is not always the best. Others reported, They said childbirth was like a toothache. I won’t survive because my toothache almost killed me. . . . It’s one of those pains where if you don’t have anything to deal with it, you won’t go to work, you won’t get out of bed. You’ll lie there, rolling from side to side tryin’ to figure out how to get it to go away. Foster care alumni know that poor dental health can cause other health problems. A young pregnant woman who did not have dental insurance was concerned about not having regular dental care and said, “My sister-in-law just sent me an e-mail on proper dental care and improper dental care being linked to . . . premature labor and . . . problems with unborn babies. And that’s pretty scary, so I definitely started flossing.” Inconsistent Dental Care Received in Foster Care The last theme concerned the lack of dental services while in child welfare care on oral health after transitioning from care. Whereas some alumni reported receiving regular dental care, others reported unreliable experiences: “They never took me to the dentist. . . . So I went 11 years or so without seeing a dentist. It took me a while to get my dental health back under control because of that neglect.” And: “Yeah, my dental needs were never met while I was in the system. Which really sucks because I still can’t afford it.” Discussion This study examined the impact of gender, race, age, number of placements, permanency arrangement, and access to dental insurance on having oral health needs met. The quantitative results indicated that dental insurance status was a negative predictor to having unmet dental needs. When controlling for the covariates in the logistic regression model, those participants without insurance were much less likely to report having their dental needs met, compared with those who had insurance. This is an important finding because there are approximately 415,000 children in the foster care system in this country (HHS, Administration for Children and Families, 2015), and it is clear that this vulnerable population is experiencing oral health disparities. For foster care alumni, transitioning into adulthood often means a loss of dental care coverage. Having dental insurance can lead to access to preventive oral health care, which can ensure that dental needs are met. Furthermore, research indicates that ensuring that dental needs are met will contribute to the overall health of this population (Otomo-Corgel, Pucher, Rethman, & Reynolds, 2012). Our qualitative findings indicate that numerous barriers exist for foster care alumni in accessing oral health care. Specifically, foster alumni reported that they experienced a lack of support to understand their Medicaid eligibility once they transitioned from care. The lack of understanding about maintaining Medicaid eligibility and lack of education to apply for Medicaid once they have transitioned contribute to oral health disparities and provide opportunities for educational interventions to decrease oral health disparities among this population. Educational interventions may be effective with this population based on their awareness that they want access to appropriate oral health care. Implications for Policy and Practice There are several implications based on the findings of this investigation, including the enhancement of the ACA to include oral health care, maintaining Medicaid eligibility, and providing incentives to dentists. Under the ACA, foster youths are eligible for dental services between the ages of 21 and 26 years only if their state opts to provide these services to adult Medicaid beneficiaries, and only if they were in care on their 18th birthday. Therefore, when states close foster care cases before age 18, there are serious consequences for dental care and foster care alumni. Increasing covered services of foster care alumni up to age 26 to include a full range of oral health care services such as those provided under the Early and Periodic Screening, Diagnosis, and Treatment benefits would do much to support the quality of oral health care and decrease the disparities in this population. In addition, the adoption of automatic reenrollment policies in all states would ensure continuous Medicaid health insurance coverage for foster care alumni to maintain their Medicaid eligibility. Foster care youths may be challenged by the reenrollment process, including navigation through complex bureaucratic procedures to reestablish Medicaid benefits to which they are entitled. In addition, alumni who leave the state in which they had received foster care services are not automatically eligible for Medicaid under the foster care eligibility category in other states (HHS, CMS, 2013). Requiring mandatory dental coverage and automatic enrollment for foster care alumni could increase access to dental insurance. However, unless there are corresponding incentives for dentists to provide oral health care services to children and adults who are insured through Medicaid, having public insurance will do little to change access to oral health care. Some suggestions include providing information to dentists about tax incentives (Internal Revenue Service, 2012) that might encourage dentists to take a more active role in provision of oral health care to foster care youths. There are several limitations to this study: the small sample size and the use of convenience sampling in one state. We recognize the limits of generalizability because foster care alumni in other states may have different experiences with dental services given the individual state-run Medicaid programs. Nevertheless, this study sheds light on a topic that is sparsely addressed in the current literature and targets a vulnerable population that may not otherwise be included in research investigations. Conclusion This study highlights the fact that having dental insurance has a unique and significant impact on oral health, even when race, gender, age, and permanency arrangement are controlled for foster care alumni. Having appropriate dental care is crucial to overall health, quality of life, and employability. Poor dental health care can lead to systemic health issues in the form of heart and lung disease, strokes, and problems with pregnancy and diabetes (National Institutes of Health, National Institute of Dental and Craniofacial Research, 2014). The findings from this study indicate that access to insurance is the most important factor, but that these associations warrant further studies that are longitudinal with larger sample sizes. Considering the high percentage of social workers who are employed as community health workers, and the profession’s commitment to social justice, including the eradication of health disparities of vulnerable populations, such as children placed in out-of-home care settings, we are uniquely positioned to provide leadership in the development of policy and practices that promote increased access and service utilization of oral health care treatments (Perez & Martinez, 2008). As oral health care is directly related to overall health (Otomo-Corgel et al., 2012), it should be given the same priority for prevention and intervention as other forms of physical health care. The ACA calls for the provision of health care benefits for youths who age out of the United States’ foster care system through age 26 (Emam, 2014). This provision should be expanded to include support for dental coverage to ensure that foster care alumni are in the best health as they forge their paths into adulthood. References American Academy of Pediatric Dentistry, Clinical Affairs Committee, Council on Clinical Affairs. ( 2013). Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. Retrieved from http://www.aapd.org/media/policies_guidelines/g_periodicity.pdf American Dental Association. ( 2013). Affordable Care Act: Dental benefits examined. 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Retrieved from https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Dental-Care.html © 2017 National Association of Social Workers http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Health & Social Work Oxford University Press

Oral Health Care Needs of Young Adults Transitioning from Foster Care

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Oxford University Press
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© 2017 National Association of Social Workers
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0360-7283
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1545-6854
D.O.I.
10.1093/hsw/hlx044
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Abstract

Abstract Children who have aged out of the foster care system face considerable barriers in accessing oral health care. Although this population of foster care alumni may have Medicaid insurance while they are in care to cover dental care, 39 percent of youths who have aged out of foster care do not have dental insurance. This mixed methods study examines factors that contribute to the oral health care disparities of children who have transitioned from foster care. Multivariate analysis revealed that foster care alumni without dental insurance are 93.5 percent less likely to have their dental needs met than those with dental insurance. Themes from the qualitative data indicated a lack of oral health care, quality-of-life issues, and lack of support to access ongoing dental care. Most state Medicaid programs do not provide comprehensive dental care for adults past the age of 20, contributing to oral health disparities among this population. The addition of oral health care coverage under the Patient Protection and Affordable Health Care Act of 2010 for foster care alumni would greatly enhance their quality of life. The article concludes with a discussion of the implications for the role of social workers in promoting oral health care for foster care youths. foster care, Medicaid policy, oral health, Patient Protection and Affordable Care Act of 2010, transition Whereas social work has historically played an important role in medical health care, dentistry has for the most part not included a social work model of care as part of its operation. As children in foster care are largely dependent on social workers to ensure their health and well-being, there is a need for social workers to understand the current landscape surrounding the oral health of child welfare–involved youths and how to ensure that foster care youths are accessing preventive and treatment-based oral health care services (Petrosky, Colaruotolo, Billings, & Meyerowitz, 2009). Empirical evidence indicates that adolescents in foster care experience challenges in accessing quality and timely oral health services (Committee on Early Childhood, Adoption, and Dependent Care, 2002; Government Accountability Office [GAO], 2008; Melbye, Huebner, Chi, Hinderberger, & Milgrom, 2013). Current oral health policies and practices necessitate that children in foster care and those transitioning from foster care primarily rely on Medicaid to meet their oral health care needs (GAO, 2008; Courtney et al., 2011). Children with Medicaid dental benefits have significant problems accessing dental care. One-third of children with Medicaid have untreated tooth decay and are almost twice as likely to have untreated dental caries compared with children who have private insurance (GAO, 2008). Additional barriers include difficulty accessing care due to affordability and dentists who are willing to accept Medicaid or individual state policy (GAO, 2008). As this population transitions out of the foster care system, the aforementioned barriers increase. Individual states are responsible for developing policies and procedures concerning the implementation of oral health care under Medicaid (American Dental Association, 2013; Patient Protection and Affordable Care Act of 2010 [ACA] [P.L. 111-148]). Dental services for those 21 years of age or older are not a mandatory service of Medicaid (U.S. Department of Health and Human Services [HHS], Centers for Medicare and Medicaid Services [CMS], 2016). Therefore, states that do provide dental care are not obligated to establish any minimum requirements for dental coverage (HHS, CMS, 2016). Currently, 30 states provide Medicaid eligibility to foster care alumni up to age 21 (Pergamit, McDaniel, Chen, Howell, & Hawkins, 2012). These states have much latitude in deciding what oral health periodicity schedule is used, what constitutes a minimal level of services, and what services are medically necessary (HHS, CMS, 2016). For example, in Michigan, the focus of this study, dental exams with prophylaxis and treatment as needed, including fluoride, are a Michigan Medicaid–covered service recommended every six months (Michigan Department of Health and Human Services [MDHHS], 2016b), which is consistent with the recommendations of the American Academy of Pediatric Dentistry (American Academy of Pediatric Dentistry, Clinical Affairs Committee, Council on Clinical Affairs, 2013). However, the state of Michigan foster care policy manual recommends that “a dental re-examination shall be obtained at least every 12 months, unless a greater frequency is indicated” after the age of three years (MDHHS, 2016a), creating a barrier that contributes to oral health disparities among foster care children and alumni. Our study addresses a gap in what we know about dental care access and the oral health status of foster care alumni. The purpose of this mixed methods study is to identify factors that positively or negatively influence appropriate and timely dental care among this population. Our study seeks to answer the following three questions: (1) What is the relationship between age, permanency arrangement, and dental insurance status and having dental needs met among for foster care alumni? (2) What are the barriers and facilitators experienced when seeking oral health care among foster care alumni? (3) How does the lack of dental care access and poor oral health affect the quality of daily life among foster care alumni? Institutional review board approval was obtained for this study. Survey data and verbatim transcripts of interviews and focus groups are available upon request from the authors. Method Study Design A mixed methods research design with a concurrent triangulation approach was used to compare the quantitative and qualitative data to verify results (Creswell, 2009). Survey, focus group, and interview data were collected at the same time between 2006 and 2008. Survey data were collected from participants to understand their current dental health and level of access to oral health care services. For the purposes of this article, survey data are limited to the subset of questions that queried participants on their oral health and access to dental care. The survey instrument was informed, in part, by the Youth Risk Behavior Survey, which includes questions regarding participants’ experiences with different health domains, including oral health (HHS, Centers for Disease Control and Prevention, 2005). Quantitative study measures included the predictor variables, age, permanency arrangement, and dental insurance status; and the outcome variable, the met or unmet oral health needs. Age was measured as a dichotomous variable (participants who were 20 years old or younger, and those 21 years of age or older), because these age groups were relevant to the Medicaid eligibility policy in place at the time of the study. Permanency arrangement options included being reunified with family, being adopted, receiving guardianship, and being without a permanency arrangement. Dental insurance status was measured as those with and without dental insurance at the time of the study. Control variables included gender, race, and number of placements. Qualitative data from this study were collected in focus groups or individual interviews to explore the impact of poor oral health on quality of life. Interview and focus group questions focused on the lived experiences of foster care alumni in obtaining health care services, including dental care, while in foster care and after leaving care. The semistructured interview protocol used to conduct the focus groups and individual interviews consisted of five questions that inquired about participants’ experiences with the foster care system, the impact of dental health problems on their daily activities, barriers faced in securing dental health care treatments, and recommendations to people making decisions about policies that affect foster care youths. The results of the analysis of the survey data are compared with the themes from the focus groups and interviews to uncover points of congruency and dissimilarity. Participants and Data Collection Participants were foster care alumni residing in the state of Michigan. Participants were recruited through convenience and snowball sampling methods, using public and private child welfare agency contacts and foster care alumni networks. To be included in the sample, participants had to have transitioned from child welfare care and be legally emancipated or age 18 or older. Eight were excluded from the current study because of outlier status due to older age. The final sample was 66 former foster care youths who participated in the study over an 18-month period from 2006 to 2008. All participants completed informed consent documents. All respondents were asked to participate in a focus group. Fifty-two percent (n = 34) agreed to participate in this group process. Another 24 percent (n = 16) of participants agreed to individual interviews. The remaining 24 percent (n = 16) of respondents completed the survey only. Analysis We used SPSS (version 20) software to conduct descriptive, inferential, and multivariate analyses. Inferential statistics were used to assess whether any associations existed between unmet and met dental needs and the covariates, which included gender, race, and number of placements. The control variables that were statistically associated with the unmet and met dental needs were included in the multivariate analysis. Using logistic regression, we conducted multivariate analyses to estimate the effect of the permanency arrangement, age, and dental insurance status on the unmet dental needs. Qualitative data derived from the focus groups and individual interviews were audio-recorded and transcribed verbatim. Transcripts from the focus groups and individual interviews were analyzed using QSR International’s (2012) NVivo (version 9) software and the phenomenological analytical process as set forth by Moustakas (1994). The primary focus of phenomenological analysis is to capture the essence of the meaning of the experience as described by the participants through a process of observing and describing the phenomena being studied (Giorgi, 2009). Results Descriptive Analysis The majority of participants (68.2 percent) were female (n = 45). Half the sample identified as white, 41 percent (n = 27) were African American. The mean age was 24 years. A little over half the group reported having unmet dental needs (52 percent). Approximately 42 percent of the sample reported they did not have dental insurance at the time of their participation in the study. Forty-four percent had public health insurance, 29 percent had private insurance, and 26 percent did not have health insurance. See Table 1 for additional demographic information. Table 1: Additional Participant Demographics and Descriptives (N = 66) Characteristic  n  %  Age       20 years or younger  28  42.4   21 years or older  38  57.6  Permanency arrangement       Yesa  19  28.8   Nob  47  71.2  Number of placements       1–2  18  27.3   3–5  20  30.3   6 or more  28  42.4  Characteristic  n  %  Age       20 years or younger  28  42.4   21 years or older  38  57.6  Permanency arrangement       Yesa  19  28.8   Nob  47  71.2  Number of placements       1–2  18  27.3   3–5  20  30.3   6 or more  28  42.4  aReunified with family, adopted, or received guardianship. bNo permanency arrangement, that is, independent living. Bivariate Analysis The predictor variables of gender, race, age, number of foster care placements, permanency arrangement, and dental insurance status were examined for between-group differences. Gender, permanency arrangement, and dental insurance status were significantly associated with having unmet dental needs. Specifically, age approached significance (p = .08) whereas race (p > .05) and number of placements (p > .05) were not significantly associated with having unmet dental needs. The full results of the bivariate analysis are found in Table 2. Table 2: Between-Group Differences in Having Unmet Dental Needs (N = 66) Characteristic  Unmet Dental Needs (n = 33)  Met Dental Needs (n = 31)  r  n  %  n  %  χ2  p  Gender          4.32  .04  .26   Female  27  81.8  18  58.1         Male  6  18.2  13  41.9        Race          0.60  .74     White  16  48.5  16  51.6         African American  13  39.4  13  41.9         Othera  4  12.1  2  6.5        Age          3.00  .08     20 years or younger  11  33.3  17  54.8         21 years or older  22  66.7  14  45.2        Number of placements          0.73  .69     1–2  8  24.2  10  32.2         3–5  9  27.3  9  29.1         6 or more  16  48.5  12  38.7        Permanency arrangement          6.90  .01  .33   Yes  5  15.2  14  45.2         No  28  84.8  17  54.8        Dental insurance (n = 31)          20.57  .001  .58   Yes  10  32.3  26  89.7         No  21  67.7  3  10.3        Characteristic  Unmet Dental Needs (n = 33)  Met Dental Needs (n = 31)  r  n  %  n  %  χ2  p  Gender          4.32  .04  .26   Female  27  81.8  18  58.1         Male  6  18.2  13  41.9        Race          0.60  .74     White  16  48.5  16  51.6         African American  13  39.4  13  41.9         Othera  4  12.1  2  6.5        Age          3.00  .08     20 years or younger  11  33.3  17  54.8         21 years or older  22  66.7  14  45.2        Number of placements          0.73  .69     1–2  8  24.2  10  32.2         3–5  9  27.3  9  29.1         6 or more  16  48.5  12  38.7        Permanency arrangement          6.90  .01  .33   Yes  5  15.2  14  45.2         No  28  84.8  17  54.8        Dental insurance (n = 31)          20.57  .001  .58   Yes  10  32.3  26  89.7         No  21  67.7  3  10.3        aAmerican Indian, Asian, or Hispanic. Multivariate Analysis A logistic regression was performed to determine which of the independent variables—gender, permanency arrangement at the time of leaving care, dental insurance status, and age—were associated with having dental needs met. Based on the results of the bivariate analyses, race and the number of placements were not significant and were excluded from the multivariate analysis. All other variables were loaded in the model, including gender, permanency arrangement, and dental insurance. Age was also included in the model because it approached significance in the bivariate analysis. The final model indicated that gender, age, and permanency arrangement were not associated with having dental needs met. Dental insurance status was significantly associated with having dental needs met. While controlling for gender (p = .240), age (p = .669), and permanency arrangement (p = .112), foster care alumni who do not have dental insurance are 93.5 percent less likely to have their dental needs met than foster care alumni who have dental insurance. The Nagelkerke pseudo R2 measurement indicated that the model accounted for 48.1 percent of the variance explained by the independent variables. Multivariate regression results are found in Table 3. Table 3: Multivariate Results of Having Unmet Dental Needs Characteristic  Estimated OR  95% CI  Lower  Upper  Permanency arrangement  3.24  0.76  13.77  Gender  2.41  0.55  10.50  Dental insurance  0.065***  0.015  0.289  Age  1.33  0.02  0.29  Characteristic  Estimated OR  95% CI  Lower  Upper  Permanency arrangement  3.24  0.76  13.77  Gender  2.41  0.55  10.50  Dental insurance  0.065***  0.015  0.289  Age  1.33  0.02  0.29  Notes: OR = odds ratio; CI = confidence interval. ***p < .001. Qualitative Themes Six themes (presented in Table 4) emerged from the focus groups and individual interviews. Thirty-four percent of the participants identified two major areas of concern: current dental needs not being met and lack of insurance and income to pay for dental care. In addition, 26 percent of alumni discussed their difficulties obtaining information on how to maintain their Medicaid once they exited foster care. Two themes relating to quality-of-life issues emerged: the impact of poor oral health on daily living and the stress of trying to manage chronic dental pain. The sixth theme concerned the unevenness of their experience receiving appropriate and timely dental care while in foster care. Each theme is discussed with quotations to illustrate the experiences of foster care alumni in accessing dental care and their oral health status. Table 4: Major Themes and Examples (N = 50)   Theme  n  %  1  Ongoing need for treatment of serious dental problems  17  34  2  Difficulties accessing dental care with Medicaid, without insurance, or inadequate income to pay  17  34  3  Lack of information on continuing Medicaid eligibility when exiting foster care  13  26  4  Stress and resilience due to the lack of dental care  10  20  5  Quality-of-life implications of poor oral health  7  14  6  Inconsistent dental care received in foster care  5  10    Theme  n  %  1  Ongoing need for treatment of serious dental problems  17  34  2  Difficulties accessing dental care with Medicaid, without insurance, or inadequate income to pay  17  34  3  Lack of information on continuing Medicaid eligibility when exiting foster care  13  26  4  Stress and resilience due to the lack of dental care  10  20  5  Quality-of-life implications of poor oral health  7  14  6  Inconsistent dental care received in foster care  5  10  Ongoing Need for Treatment of Serious Dental Problems Slightly more than one-third of participants (34 percent) indicated that they had wisdom teeth or broken and abscessed teeth that needed to be pulled or had jaw alignment problems. One alumna said that she needed to have multiple teeth pulled that had broken off or rotted: “These ones over here are getting holes in them, and they’ve all been filled while I was in foster care. Just kept being filled and kept being filled. And now, I have pains. I take ibuprofen.” Another participant echoed having to deal with the pain of dental problems on her own: I had a toothache that was driving me crazy. Like, pulling my hair out, sit up at three o’clock in the morning, tears streaming down my face, toothache. . . . They told me it was gonna be $400 to have them clip the nerve, pull the tooth, and realign everything how it needs to be. [She was unable to pay.] And I said, fine, OK, I have a bottle of Vicodin, I will make it work. Other alumni noted, “Well, I need, you know, insurance so bad. I haven’t been to a dentist for years.” And: “Wisdom teeth, night guard. I clench my teeth at night, and it causes soreness in my jaw and teeth. I need my wisdom teeth out.” Difficulties Accessing Dental Care with Medicaid, without Insurance, or Not Having Adequate Income to Pay Young adults from this study reported difficulties obtaining dental care without dental insurance. One participant thought that she was being referred to a community clinic that would take her regardless of her insurance status; but this was not the case when she arrived: Because I don’t have a job, and I don’t have enough for a down payment, so they said no, we cannot see you. And then they referred me to . . . this one right in Michigan, and if you don’t have any kind of insurance, they can’t see you at all. Several young adults reported not having any insurance and paying out of pocket. One participant reported, “I don’t have dental insurance and I have a tooth that’s really bad, and I have paid money out of my own pocket because I can’t get insurance for dental, because I’m past [the age of] 21.” Paying for medical expenses adds to the financial burden that these young people are dealing with after exiting foster care. Alumni report having medical insurance that does not include dental insurance. Therefore, having Medicaid does not ensure that the person had access to dental care: “Even though you have Medicaid, a lot people don’t want to take it, ’cause you’re 21 and over or it’s crappy insurance.” And: I know I have a copay now; I don’t know if that’s because I turned 21 or if it’s because of the [geographic] area or what it is. But I know I’m limited because nobody will take Medicaid for dental at all. Lack of Information on Continuing Medicaid Eligibility When Exiting Foster Care Foster care alumni report losing Medicaid at the time of exiting foster care and then not having sufficient information to reapply through the state system. Foster care alumni often lack information and understanding of their eligibility for continued Medicaid past their exit from foster care and how to maintain those benefits. Alumni report that their child welfare worker would begin the process but not follow through, or alumni were not given information as they aged out about how to reapply for Medicaid if they lost their coverage. One participant reported, “I have four wisdom teeth that need to be taken out . . . . I’m not even sure if I have health, or any insurance right now, because I’m 18, I’ve aged out of Medicaid.” Others reported, “I never got the information to reapply for it [Medicaid] so I didn’t, so I didn’t go to the dentist for like two years.” And: “I would’ve liked somebody to have told me that I need to apply for Medicaid, when I’m out there on my own. Like a caseworker or somebody to let me know.” Stress Due to Lack of Dental Care Foster care alumni experience frustration and anger because they cannot access appropriate dental care for dental problems, some of which cause a great deal of pain. Participants talked about their tooth pain, saying, “So, when my benefits kick in, that’s the first thing I’m doing, is going to get my tooth fixed.” And: “You have a toothache and you don’t have insurance, it’s one of those things where makes you wanna run in, face first, into a wall and knock yourself out, because it hurts so bad.” Another participant noted, I know my insurance won’t cover it [jaw] because it’s cosmetic and blah, blah, blah, but that’s bullshit! I mean if it’s affecting my speech, and the way I’m eating, and I’m talking, . . . I think I should be able to get it done. Quality-of-Life Implications of Poor Oral Health Foster care alumni are cognizant of the consequences of poor oral health on social and economic relationships and on their long-term health. As one alumnus stated, Nobody wants to walk around looking like a pumpkin, you know? It’s just embarrassing. People aren’t going to be confident in applying for jobs or going to school if they’re ashamed of what they look like. . . . The kinds of things that Medicaid pays for is not always the best. Others reported, They said childbirth was like a toothache. I won’t survive because my toothache almost killed me. . . . It’s one of those pains where if you don’t have anything to deal with it, you won’t go to work, you won’t get out of bed. You’ll lie there, rolling from side to side tryin’ to figure out how to get it to go away. Foster care alumni know that poor dental health can cause other health problems. A young pregnant woman who did not have dental insurance was concerned about not having regular dental care and said, “My sister-in-law just sent me an e-mail on proper dental care and improper dental care being linked to . . . premature labor and . . . problems with unborn babies. And that’s pretty scary, so I definitely started flossing.” Inconsistent Dental Care Received in Foster Care The last theme concerned the lack of dental services while in child welfare care on oral health after transitioning from care. Whereas some alumni reported receiving regular dental care, others reported unreliable experiences: “They never took me to the dentist. . . . So I went 11 years or so without seeing a dentist. It took me a while to get my dental health back under control because of that neglect.” And: “Yeah, my dental needs were never met while I was in the system. Which really sucks because I still can’t afford it.” Discussion This study examined the impact of gender, race, age, number of placements, permanency arrangement, and access to dental insurance on having oral health needs met. The quantitative results indicated that dental insurance status was a negative predictor to having unmet dental needs. When controlling for the covariates in the logistic regression model, those participants without insurance were much less likely to report having their dental needs met, compared with those who had insurance. This is an important finding because there are approximately 415,000 children in the foster care system in this country (HHS, Administration for Children and Families, 2015), and it is clear that this vulnerable population is experiencing oral health disparities. For foster care alumni, transitioning into adulthood often means a loss of dental care coverage. Having dental insurance can lead to access to preventive oral health care, which can ensure that dental needs are met. Furthermore, research indicates that ensuring that dental needs are met will contribute to the overall health of this population (Otomo-Corgel, Pucher, Rethman, & Reynolds, 2012). Our qualitative findings indicate that numerous barriers exist for foster care alumni in accessing oral health care. Specifically, foster alumni reported that they experienced a lack of support to understand their Medicaid eligibility once they transitioned from care. The lack of understanding about maintaining Medicaid eligibility and lack of education to apply for Medicaid once they have transitioned contribute to oral health disparities and provide opportunities for educational interventions to decrease oral health disparities among this population. Educational interventions may be effective with this population based on their awareness that they want access to appropriate oral health care. Implications for Policy and Practice There are several implications based on the findings of this investigation, including the enhancement of the ACA to include oral health care, maintaining Medicaid eligibility, and providing incentives to dentists. Under the ACA, foster youths are eligible for dental services between the ages of 21 and 26 years only if their state opts to provide these services to adult Medicaid beneficiaries, and only if they were in care on their 18th birthday. Therefore, when states close foster care cases before age 18, there are serious consequences for dental care and foster care alumni. Increasing covered services of foster care alumni up to age 26 to include a full range of oral health care services such as those provided under the Early and Periodic Screening, Diagnosis, and Treatment benefits would do much to support the quality of oral health care and decrease the disparities in this population. In addition, the adoption of automatic reenrollment policies in all states would ensure continuous Medicaid health insurance coverage for foster care alumni to maintain their Medicaid eligibility. Foster care youths may be challenged by the reenrollment process, including navigation through complex bureaucratic procedures to reestablish Medicaid benefits to which they are entitled. In addition, alumni who leave the state in which they had received foster care services are not automatically eligible for Medicaid under the foster care eligibility category in other states (HHS, CMS, 2013). Requiring mandatory dental coverage and automatic enrollment for foster care alumni could increase access to dental insurance. However, unless there are corresponding incentives for dentists to provide oral health care services to children and adults who are insured through Medicaid, having public insurance will do little to change access to oral health care. Some suggestions include providing information to dentists about tax incentives (Internal Revenue Service, 2012) that might encourage dentists to take a more active role in provision of oral health care to foster care youths. There are several limitations to this study: the small sample size and the use of convenience sampling in one state. We recognize the limits of generalizability because foster care alumni in other states may have different experiences with dental services given the individual state-run Medicaid programs. Nevertheless, this study sheds light on a topic that is sparsely addressed in the current literature and targets a vulnerable population that may not otherwise be included in research investigations. Conclusion This study highlights the fact that having dental insurance has a unique and significant impact on oral health, even when race, gender, age, and permanency arrangement are controlled for foster care alumni. Having appropriate dental care is crucial to overall health, quality of life, and employability. Poor dental health care can lead to systemic health issues in the form of heart and lung disease, strokes, and problems with pregnancy and diabetes (National Institutes of Health, National Institute of Dental and Craniofacial Research, 2014). The findings from this study indicate that access to insurance is the most important factor, but that these associations warrant further studies that are longitudinal with larger sample sizes. Considering the high percentage of social workers who are employed as community health workers, and the profession’s commitment to social justice, including the eradication of health disparities of vulnerable populations, such as children placed in out-of-home care settings, we are uniquely positioned to provide leadership in the development of policy and practices that promote increased access and service utilization of oral health care treatments (Perez & Martinez, 2008). As oral health care is directly related to overall health (Otomo-Corgel et al., 2012), it should be given the same priority for prevention and intervention as other forms of physical health care. The ACA calls for the provision of health care benefits for youths who age out of the United States’ foster care system through age 26 (Emam, 2014). This provision should be expanded to include support for dental coverage to ensure that foster care alumni are in the best health as they forge their paths into adulthood. References American Academy of Pediatric Dentistry, Clinical Affairs Committee, Council on Clinical Affairs. ( 2013). Guideline on periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. Retrieved from http://www.aapd.org/media/policies_guidelines/g_periodicity.pdf American Dental Association. ( 2013). Affordable Care Act: Dental benefits examined. 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Health & Social WorkOxford University Press

Published: Feb 1, 2018

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