County-level contextual factors related to dental care use for Medicaid-enrolled children with chronic health conditions: A multi-level analysis

Objective: To identify the county-level contextual factors related to dental use for Medicaid-enrolled children with chronic health conditions (CHCs).

Methods: We identified children ages 3-14 with CHCs, using the 3M Clinical Risk Grouping methods, enrolled in Iowa Medicaid for 11-12 months in 2005/2006 (N=25,993). The outcome measure was dental use in 2006. Child-level covariates were obtained from Medicaid files and included: sex, age, race/ethnicity, intellectual/developmental disability, CHC severity, whether the child had a Medicaid-enrolled sibling/caregiver, and use of preventive medical care. County-level covariates were obtained from the Area Resource Files and included: dental Health Professional Shortage Area (HPSA), number of teen births, infant mortality, income, percent poverty, percent child poverty, number of child Medicaid enrollees, percent food stamp recipients, percent uninsured, unemployment, physician density, emergency room visits, Medicaid inpatient hospital days, and county population. We ran 2-level linear regression models with robust standard errors to identify the relationship between each county-level factor and dental use, adjusted for child-level factors.

Results: Higher levels of the following county-level factors were significantly associated with higher probability of child-level dental use (income, percent uninsured, county population) or with lower probability of dental use (dental HPSA, percent poverty, percent child poverty, percent food stamp recipients, unemployment).

Conclusions: County-level contextual factors that indicate concentrated socioeconomic disadvantage were significantly related to dental use. Future interventions and policies should target county-level factors as well as other known determinants of dental use to improve disparities in access to dental care for Medicaid-enrolled children with CHCs.