Rebuilding Children's Oral Health Care

By Erik Skinner | August 2021


Over the two decades leading up to the COVID-19 pandemic, the United States saw increases in the rates of child dental coverage and child dental care utilization. These increases were largely driven by a rise in public insurance coverage, specifically expansions of dental services in Medicaid and the Children’s Health Insurance Program (CHIP). However, experts estimate that rates of children’s public and private dental coverage declined as a result of the pandemic, partially due to unemployment and the loss of employer-sponsored dental insurance for children.

Data show a pandemic-related drop in annual dental visits for kids, with children enrolled in Medicaid more likely to encounter challenges receiving preventive dental care. The pandemic caused many dental clinics to temporarily close, and parents were cautious to schedule routine care due to the risk of transmission in dental settings. This disproportionately affected children with the highest unmet dental needs, exacerbating existing racial and socioeconomic disparities, as well as disparities in underserved rural and urban communities.

These challenges predate COVID-19, and state action before and after the start of the pandemic address the same underlying issues: workforce shortages, access to preventive services, low rates of enrollment in and use of public oral health programs, and social determinants of health.

State policymakers may explore various state and federal policy options to improve children’s oral health coverage and utilization to pre-pandemic levels.

Federal Action

Medicaid and CHIP are major providers of children’s oral health coverage. While each state decides how to meet federal requirements for children’s dental coverage, other federal programs can support states to provide quality dental coverage for children. For example, the Centers for Medicare and Medicaid Services (CMS) collaborates with states on oral health action plans. At least 25 states have submitted state oral health action plans to CMS. States can use templates developed by CMS and the Medicaid-CHIP State Dental Association to address national oral health goals in conjunction with the federal agency. Alabama, for example, set targets and progress goals for increasing access, improving professional education and integration, and promoting health literacy. California set goals to improve oral health by addressing the social determinants of health, developing communication strategies to inform and educate the public about oral health, and aligning dental delivery systems, payment systems and community programs to increase utilization of dental services.

State Action

Each state has a variety of policy levers available to address children’s oral health such as workforce, dental homes, school-based oral health programs and dental screening programs, teledentistry and Medicaid coverage. The examples below were enacted in the 2020 or 2021 legislative sessions. 

States may address specific oral health settings and providers to improve children’s access to services. Nebraska enacted LB 312 in August 2020, removing certain restrictions around the services dental hygienists can provide to children in public health settings and health care facilities. The bill also requires the Department of Health and Human Services to submit an annual report on the delivery of dental hygiene services in Nebraska to the legislature.

Dental homes center care around the individual by establishing the patient-provider relationship, a system for referrals and preventive care. Providers and policymakers increasingly utilize dental homes to ensure timely access to care for children. Minnesota HB 33, enacted in 2021, requires the Dental Services Advisory Committee to develop a dental home demonstration project and recommendations to relevant legislative committees by February 2022. The demonstration project requires input from nonprofit dental clinics serving children, populations with public coverage, communities of color and other stakeholders.

Schools can also be an important source of preventive oral health services and education. Many school-based oral health programs experienced significant drops in utilization, reallocation of staff time, and reduced time to plan and implement these programs due to the pandemic. Illinois SB 346, enacted in 2021, requires the Department of Healthcare and Family Services to administer and regulate a school-based dental program that allows for the out-of-office delivery of preventive dental services in a school setting to children under 19 years of age.

Fifteen states require dental screening for students of various ages, with Michigan becoming the latest state in 2020. Oregon enacted HB 2969 in 2021, requiring the board of education to develop age-appropriate oral health care instruction in all public school districts. The pandemic has complicated some of these efforts. A recent survey of 44 state oral health program directors noted that 70% of respondents had not produced communication materials on changes to the school-based oral health programs, but many intended to do so to communicate infection control measures and highlight the safety of their programs.  

Teledentistry can be a tool to reach underserved children in rural areas, through school-based health centers or other community settings. Providers use teledentistry to maintain routine care and identify children with more urgent oral health issues. At least nine states expanded teledentistry since the beginning of the pandemic. For example, Colorado enacted SB 139 in 2021 to require reimbursement of teledentistry services for dental plans or health benefit plans issued in the state. Utah passed legislation in 2020 to authorize the use of teledentistry services by dental professionals in the state.

Providing funding and programming for children’s oral health coverage does not guarantee access, but states can analyze their coverage programs to identify opportunities that support equity, decrease disparities and ensure coverage translates to access. Washington’s Access to Baby and Child Dentistry (ABCD) program supports oral health access and utilization for Medicaid-eligible newborns and children. The Washington Legislature enacted HB 2905 in 2020 to enhance access to the ABCD program, citing higher rates of tooth decay for children of color and lower utilization for 2-year-olds. The legislation provides funds for increased outreach and provider engagement with the stated goal to reduce racial and ethnic disparities in oral health outcomes.