Health insurance is associated with dental care use among university students in Washington State

Oral health influences systemic health outcomes and wellbeing across the life course [1, 2]. University students are a subgroup of young adults who are particularly vulnerable to poor oral health because the transition to university is associated with lifestyle changes and increased risk factors [3]. University students are at high risk for stress [4], alcohol and drug use [5, 6], poor diet quality [7], inadequate sleep [8], and weight gain [9, 10], all of which potentially contribute to poor oral health [11‐16]. Given the multiple risk factors for poor oral health for university students, finding ways to connect the most vulnerable students to oral health care could be one way to minimize the burden of oral diseases. Students who lack health insurance and who hold historically marginalized identities may be among the students most susceptible to poor oral health outcomes.

Preventive dental care, which includes dental cleanings, may be particularly relevant in protecting the oral health of university students, but no studies have examined the association in the university student subpopulation. Studies across adolescent and young adult populations have found that routine preventive dental care is associated with better self-reported oral health and fewer missing teeth and dental caries [17]. Despite the known benefits of preventive dental care, as of 2019, one-in-four U.S. university students reported they had not used preventive dental care in the past year [18]. Health insurance could be a contributing factor to preventive dental use. At least one study reported that adults without health insurance are significantly less likely to have a dental visit compared to those with health insurance, independent of dental insurance coverage [19]. Type of health insurance among university students may also be associated with non-use of preventive dental care.

Student identity may be another important determinant of dental care use. Students who hold historically marginalized identities on the basis of gender, race or ethnicity, sexual orientation, disability status, citizenship, or socioeconomic class may experience barriers accessing health care services [20] like preventive dental care and may experience downstream consequences in the form of oral diseases. Identifying which student subgroups experience the most severe inequities in access to oral health care could inform targeted multi-level interventions aimed at oral health promotion on college campuses.

The overarching goal of this study was to examine the association between health insurance and preventive dental care use among university students, a population overlooked in oral health research. We examined the association between health insurance and preventive dental care separately for undergraduate and graduate students given differences in health insurance availability. As a secondary aim, we also explored the associations between student identity (race, ethnicity, gender, sexual orientation, disability status) and preventive dental care use. We analyzed existing survey data to examine these associations. Findings are expected to guide future intervention efforts aimed at addressing oral health inequities among university students.

In this study, we examined the association between health insurance and preventive dental care use among university students. We found that the odds of not having a dental cleaning in the past 6 months were greater among university students who did not have health insurance and publicly-insured university students compared to university students with private health insurance based in WA. There were also lower odds of receiving a dental cleaning among university students who hold historically marginalized identities. Lastly, results from a stratified analysis showed that graduate/professional students with university insurance did not have lowered odds of a dental cleaning. These findings can be used in the development of interventions on college campuses aimed at addressing oral health inequities.

University students without health insurance had almost four times higher odds of not receiving a dental cleaning compared to university students with private insurance based in WA. In addition, publicly-insured university students had about three times the odds of not receiving a dental cleaning compared to privately-insured university students. Given that health insurance is related to health care access and preventive care use [21], it is not surprising it was associated with preventive dental care use in this study. Consistent with our finding, a previous study reported that adults without health insurance, regardless of dental insurance, were significantly less likely to have a dental visit than insured counterparts [19]. Previous work has also highlighted similar inequities in preventive dental care use when comparing publicly-insured children to children with private insurance [22]. Publicly-insured adults are also more likely to report unmet dental needs compared to privately-insured adults [23]. While public insurance programs like Medicaid provide insurance for low-income adults and adults with disabilities, adult dental benefits are not mandatory, which perpetuates cost-related barriers to dental care for populations with limited financial flexibility [23‐25]. However, dental benefits are covered for adults in WA Medicaid and coverage includes dental cleanings. There may be other explanations for the disparity in dental cleanings in our study. For instance, publicly-insured university students may face other barriers including lack of knowledge about benefits, inability to find a dental office that accepts public insurance, and actual or perceived insurance-based discrimination [26].

International students, students of color, and LGBTQ+ students all had higher odds of not receiving a dental cleaning compared to their counterparts. Similar inequities in preventive dental care use among international students and students of color were found in the National College Health Assessment [27]. Potential reasons behind this inequity could be that international students hold different beliefs and cultural practices around preventive dental care use or seek dental care in their home countries. Regardless, efforts should be made to connect international students with local dental care services. Studies across other age groups in the U.S. have documented race-based inequities in preventive dental care use regardless of insurance status [28, 29], which further supports the premise that inequities in preventive dental care use among university students may be rooted in factors like systemic racism and discrimination. Fewer studies have considered preventive dental care use among LGBTQ + communities, but historical discrimination and non-inclusive health care settings [30] may explain lower levels of preventive dental care use among the LGBTQ+ university students in this study. These findings suggest that in addition to uninsured students, students with historically marginalized identities may benefit most from referrals to discrimination-free and inclusive dental care. Additional studies that use measures of discrimination may be able to evaluate the extent to which disparities in preventive dental care use are explained by exposure to discrimination.

Graduate and professional students covered by university insurance in the study did not have lowered odds of receiving a dental cleaning compared to graduate and professional students with private insurance based in WA. This relationship did not hold for undergraduate students. One explanation could be the different availability of university insurance; university insurance is not available to undergraduate students who are not international students. Expanding availability of university insurance to undergraduate students may be one way to improve use of dental cleanings. However, more work is needed to understand the costs and benefits of expanding availability of university insurance, especially since university insurance is only available to graduate students who meet certain requirements for eligibility, such as holding a university job.

Multi-level interventions could help to address inequities in oral health care access on university campuses. Potential campus-based interventions include student outreach efforts that educate uninsured students on how to sign up for health insurance and interpret covered benefits. This is particularly important for publicly-insured students who had low odds of receiving a dental cleaning in this study, despite coverage for dental care services through WA Medicaid. In addition, college campuses with dental schools can partner with the university to offer lower-cost dental care options for students. Policy efforts should address inequities that stem from historical marginalization and connect international students with dental care resources. Campus health centers can also offer resources to improve oral health behaviors by offering oral hygiene products (including toothbrushes and fluoridated toothpaste) and opportunities to participate in interventions that reinforce optimal health behaviors. Such interventions could be implemented within on-campus residential housing settings, mobile phone apps, or social media sites but formative feasibility and sustainability research involving university students is needed to help refine promising intervention approaches. It is also possible that oral health among university students could be improved by developing programs to improve oral health literacy on college campuses [31] based on international work that has documented a link between oral health literacy and improved clinical oral health among college students [32].

In this study, we found that health insurance was significantly associated with preventive dental care use among university students. University students with no health insurance and publicly-insured students had the lowest odds of preventive dental care use. Addressing oral health inequities on college campuses will require targeted efforts to connect the most vulnerable students to care. In addition to direct referrals to dental care, multilevel interventions at the campus level and broader policy changes that support dental care access may be needed.