Brown is among the 83 people who said they didn’t have a primary care doctor in response to a health-care usage survey by the Conn. Health I-Team and Southern Connecticut State University. The team surveyed 500 people and interviewed dozens statewide between January and March.

About 83 percent of respondents said they had a primary care doctor, but the rate was lower for African American (78 percent) and Hispanic respondents (75 percent). Meanwhile, white respondents were more likely than the average—at 88 percent—to have a primary care doctor. These numbers have decreased since 2015, when C-HIT conducted a similar survey. In 2015, 93 percent of whites, 84 percent of African Americans, and 86 percent of Hispanics had a primary care doctor.

What residents had to say about their health care, hosted by SCSU student Michael Riccio.

The survey results highlight health care disparities between wealthier residents and those in lower income brackets, and between white respondents and minorities—findings that mirror those of the 2015 study.

In general, white residents and those making more than $50,000 a year were more likely to have health insurance and use it. Those over 50 years old in both groups were more likely to have undergone a colonoscopy. The wealthier respondents more often lived close to their primary care doctor.

But in some cases, those making below $50,000, and people of color, were more likely to have had some preventive care screenings, such as chest X-rays for smokers, screenings for depression, and interventions from doctors regarding their weight.

About 110 people said even though they had insurance, there were barriers preventing them from accessing health care. Of those, 54 cited co-pays, 39 said time or travel expenses, and 17 said there was a language barrier to accessing health care.

For Natasha Gerasimopoulos, 36, of Milford, the problem is finding a doctor covered by insurance. Gerasimopoulos, who is insured through Husky Health along with her son, doesn’t have co-pays for her office visits, but she said it’s hard to find specialists who take Husky.

“The doctors’ offices will say ‘Oh, we don’t take that insurance,’ or ‘We stopped taking it a long time ago’,” Gerasimopoulos said. Or, she said, if she can find a doctor who takes her insurance, the office is far from her home.

Most people, at 92.6 percent, reported having health insurance for 2018. But Hispanics and blacks were less likely to have health insurance, at 80.2 percent and 89.2 percent, than whites, at 97.7 percent.

More people reported being uninsured than in the 2015 survey, when 3.6 percent said they had no medical insurance. Connecticut’s uninsured rate for 2016, the most recent numbers available from the National Center for Health Statistics, was 5.8 percent.

Recent changes to the Affordable Care Act, first enacted in 2010, have negatively impacted health care access, according to Pat Baker, president of the Connecticut Health Foundation.

An example, she said, is a change in the number of state residents who qualify for Medicaid.

“Originally Medicaid in Connecticut covered individuals up to 185 percent of poverty,” Baker said. “What we saw happening since 2015 is that has been reduced to 155 percent of poverty, with the rationale that all those [excluded], about 18,000 people, could go get coverage through the exchange, Access Health CT.”

Instead, Baker said, only 20 percent of those dropped by Medicaid were able to purchase insurance through the exchange. The Connecticut Health Foundation and Access Health CT believe cost was a major factor, as survey respondent Beverly Malerba of Ansonia said. “I can’t afford it, really,” she said. “I wish [health care] was universal, like they have in Canada.”

“What remains consistent is the disparate rate between the connection to care between the majority population and people of color, particularly African Americans,” Baker said.

Of those with insurance surveyed by C-HIT:

• 57 percent said they receive insurance through an employer plan;

• 17 percent of respondents are insured through Medicaid;

• 12 percent through Medicare;

• about 8 percent purchased insurance through the Access Health CT exchange;

• 3 percent said they had private insurance, but didn’t indicate how they received it; and

• 1 percent are insured through both Medicaid and Medicare;

One of the barriers to care is travel time to a doctor, especially for those earning less than $30,000 annually.

Half of the respondents made more than $50,000 a year, and 56 percent were women. The respondents skewed younger, with 65 percent responding they were in their 40s or younger, and 29 percent in their 20s. About 53 percent of respondents were white, 20.7 percent were African American and 19.5 percent were Hispanic.

Women’s preventive care results were mixed. Overall, 87.7 percent of women over 40 had received a recommended mammogram in the last year, and 77.4 percent of women over 20 had received a recommended Pap test.

Women making more than $50,000 were more likely to have received Pap tests. But the results for women over 40 who had received mammograms in the last year were split on income levels. Those making $100,000 or more were most likely to have had a mammogram in the last two years (93 percent), but those making less than $30,000 were close behind (89 percent).

Black women were the most likely to have received a mammogram (93 percent) and Pap tests (91 percent). White respondents stated they had received recommended mammograms at 89 percent, and Pap tests at 76 percent. For Hispanic women, the results were 75 percent and 71 percent, respectively.

In dozens of interviews, Connecticut residents spoke of the challenges with their health care.

Like Steven S. Siebold, 44, of Trumbull, who said he pays a high premium for his healthcare—about $1,400 a month.

“It’s terribly expensive for what I get,” Siebold said.

Maria Zhumi, of New Haven, said while she has health care through the exchange, she hasn’t been able to get her 9-year-old daughter on the plan because she doesn’t have a Social Security number. Zhumi said she has been paying for her daughter’s health care out of pocket.

Confusion over her citizenship status is preventing Mayelin Jimenez of New Haven from obtaining health care, she said. When she lived in New York, she paid for private insurance, she said, but canceled that policy when she moved to New Haven in November. When she tried to obtain HUSKY insurance, she was told she had to have been living in the U.S. for five years to meet Connecticut’s eligibility requirements. Jimenez said she must wait until July before she qualifies for HUSKY benefits.

“What if I have an accident?” she asked. “I have no insurance.”

Laurinda Bernardo, 65, of New Britain, said rising deductibles have caused stress for her family. Her 2-year-old granddaughter has mitochondria depletion syndrome and requires constant care. Bernardo’s daughter had good insurance, but it still came with a $5,000 deductible. The next year, the deductible increased to $6,000.

“So that year she ended up paying $16,000 just to have the bills paid,” Bernardo said. “Who has that kind of money just sitting around?”

Barbara Collado, a mother of three from New Haven, has had HUSKY A insurance for around 10 years, ever since she moved to Connecticut from Puerto Rico.

In an interview conducted in both Spanish and English, Collado said her HUSKY coverage helped as she and her children have undergone evaluations for health issues. Collado said HUSKY paid for everything. The experience, she said, changed how she viewed her health, and she began seeking health care regularly at her primary clinic, the Cornell Scott-Hill Health Center.

Collado said, however, that it takes her two buses to get to the Hill Center. When the bus is late, she’s late for her appointments. But it’s worth it to Collado.

“I have a good relationship with them,” she said.

Kaitlyn Regan is a senior at Southern Connecticut State University.

This project was reported by the students in the Multimedia Journalism course at Southern Connecticut State University, taught by Assistant Professor Jodie Mozdzer Gil. The students are: Ryan Conchado, Kevin Crompton, Jailene Cuevas, Melanie Espinal, Jonathan Gonzalez, Ethan Goodrich, Andrew Hans, Megan Hill, Quinn O’Neill, August Pelliccio, Michael Riccio, Alyssa Rice and Regan.

Lisa Massicotte, Jeniece Roman and Matt Wynn, C-HIT data specialist, contributed reporting.

Vern Williams Photo.

Southern Connecticut State University students who worked on this project, under the supervision of Assistant Professor Jodie M. Gil

“While these data do not tell us why differences exist, they show where we have problems and can help spur efforts to understand what can be done to reduce or eliminate these differences, ” said Dr. Cara James, director of the Centers for Medicare & Medicaid Services (CMS) Office of Minority Health, which released the report.

The report looks at 27 clinical care measures and eight patient experiences to gauge differences in treatment among whites, blacks, Hispanics, and Asians or Pacific Islanders.

iStock Photo.

Blacks and Hispanics were less likely to receive preventive care services, a CMS report found.

It has some bright spots: Blacks and Hispanics reported slightly better communication with doctors than whites did. Hispanics had higher rates than non-Hispanic whites of colorectal screenings, blood sugar testing for diabetes, and treatment for osteoporosis (among women) after a fracture.

Elderly black patients with dementia were less likely to be put on antipsychotics, benzodiazepines or other potentially harmful medications than whites.

But the bulk of the report shows disparities in clinical care by race and ethnicity. Whites reported an easier time getting the prescription drugs they needed than either blacks or Hispanics. Blacks and Hispanics with diabetes were less likely to have their blood sugar under control than whites were—63.9 percent of black patients and 69.3 percent of Hispanics, compared to 71.2 percent of whites.

In the area of mental health, white patients diagnosed with a new episode of major depression were more likely (70.4 percent) to remain on antidepressant medications for at least 84 days than were Hispanics (57.6 percent), blacks (56.9 percent) or Asians or Pacific Islanders (64.3 percent). Thirty-five percent of whites hospitalized for a mental health disorder had an outpatient visit or partial hospitalization within seven days of discharge, compared to just 25 percent of blacks and 34.9 percent of Hispanics.

Overall, whites reported getting appointments and care more quickly than did blacks, Hispanics or Asians or Pacific Islanders.

In several clinical categories, including screening for colorectal cancer and adequate control of hypertension, Asians and Pacific Islanders received care that was similar to or better than the care received by whites, the data show.

At the Hispanic Health Council, Sandra Sapere, associate director of the risk reduction unit, said she was not surprised by the ongoing disparities, especially involving access to care.

“With Latinos, usually in my experience, they don’t go to preventive care. They’re more likely to go to the ER,” she said. “Some of it is about education, and some is about access to care.”

Pat Baker, president and CEO of the Connecticut Health Foundation, also said the federal report’s findings were not surprising.

“Connecticut sees these disparities as well, but our access to such strong data is limited,” she said.

She said Medicare has put a strong emphasis on accountability and quality measurement, “which is critical in improving outcomes which may contribute to (a narrowing of disparities).” But she noted, “The difficulty is that this is 2014 data, so it is very hard for providers to improve performance unless they get real-time data.”

The data are based on two sources of information: The Healthcare Effectiveness Data and Information Set (HEDIS), which collects information from medical records and administrative data on how well the needs of Medicare beneficiaries are met for a variety of medical issues; and the Medicare Consumer Assessment of Healthcare Providers and Systems Survey, which is conducted annually by CMS.

The state Department of Public Health reports that 83,000 adults in Connecticut have prediabetes, which occurs when a person’s blood sugar level is higher than normal but not high enough to be classified as Type 2 diabetes. Nearly 9 percent of adults in the state—about 257,000 people—have been diagnosed with Type 2 diabetes.

Prediabetes has few early warning signs, but a blood test by a primary care doctor can detect at-risk patients. Once detected, changes in diet and exercise, sometimes with medication, can stave off the disease, doctors say.

iStock Photo.

African-Americans are 1.7 times more likely to be diagnosed with diabetes than are whites.

“Prediabetes is completely silent,” said Dr. Bismruta Misra, an endocrinologist at the Diabetes & Endocrine Center at Stamford Hospital. While those with prediabetes might feel a bit sluggish or unusually thirsty, she said, the disease is typically discovered through routine blood tests and not on the basis of symptoms.

The problem is that people who don’t get regular checkups likely don’t get screened, Misra said.

A 2002 study of prediabetic patients by the National Institutes of Health’s Diabetes Prevention Program found that lifestyle intervention—including a change in diet and regular exercise—reduced the incidence of diabetes by 58 percent.

“Prediabetes is a huge problem,” said Maria Daigneault, an advanced practice registered nurse at Hartford Hospital’s Diabetes LifeCare center. “People are walking around with it and have no idea what the risk factors are.”

Dr. Latha Dulipsingh, population management champion at the Center for Diabetes and Metabolic Care at St. Francis Hospital and Medical Center, said that screening for the disease should be done at the primary care level. “But if your doctor is not aware of your risk factors and doesn’t screen,” prediabetes can go undetected and become Type 2 diabetes.

Making people aware of those risk factors—such as a family history, poor diet, and a sedentary lifestyle—might encourage more high-risk people to seek screenings, doctors say.

Lack of sleep is also a major risk factor. Misra cites statistics showing that people who routinely sleep less than eight hours a day have a 22 percent higher risk of developing prediabetes or diabetes than those who get adequate sleep; those who sleep less than six hours have a 48 percent greater risk.

Daigneault said she can often look at a patient and see if he or she is at risk.

“People with central obesity, who carry their weight at the center of their body, are at elevated risk. A bigger waistband is a contributing factor to Type 2 diabetes,” Daigneault said. Other signs include acanthosis nigricans, which Daigneault describes as “a darkening of the skin around skin folds, at the neck or the wrists.”

Misra said, “I would much rather have a patient who is prediabetic than diabetic. We have an opportunity to make a big impact by intervening when people are prediabetic. Once you’re diabetic, you’re diabetic.”

The American Diabetes Association recommends that people with risk factors be screened for diabetes and prediabetes, as should people over age 45.

The Centers for Disease Control and Prevention, which uses data from the National Health Nutrition Examination Surveys to calculate prediabetes population estimates, reports that men are more likely to be prediabetic than women. Prediabetes and diabetes are more common among African Americans and Hispanics compared to whites, the CDC reports. Overall, risk increases with age. On its website, the CDC has a one-minute diabetes quiz to check for risk.

Patricia Baker, president of the Connecticut Health Foundation, said, “People of color are at higher risk, and we don’t know why.”

Baker says that Connecticut’s African-Americans at 13.6 percent and Hispanics at 10.7 percent have significantly higher rates of diabetes than whites at 8.1 percent.

And, she said, data from 1995 through 2013 show an “increased prevalence of diabetes disparity between blacks and whites.” Diabetes-related mortality rates were more than twice as high for blacks than for whites: 92.6 per million black people versus 47.5 per million white people.

But Baker said relatively small lifestyle changes, such as losing seven to 10 percent of your body weight, can significantly reduce the risk of prediabetes and diabetes.

“You can intervene and make a difference,” she said. But, for most people, Baker said, “Something is not happening early enough to stop this disease.”

C-HIT is hosting a free community forum on diabetes from 5 to 7:30 p.m. Thursday at Chrysalis Center, 255 Homestead Ave., Hartford. Live Spanish translation will be provided. The event will include an appearance by Chef Jay Lewis who will offer some healthy food choices. Please register here.

Two waivers in particular—Affordable Care Act (ACA) Section 1332 and Medicaid Section 1115—would let the state disregard certain federal requirements, possibly lowering health care costs for some individuals, according to a policy brief commissioned by the Universal Health Care Foundation of Connecticut and the Connecticut Health Foundation.

“What we need to do in Connecticut is really think about … how could we creatively, imaginatively, innovatively use waivers to expand coverage to quality care and really help improve health,” said Frances Padilla, president of Meriden-based Universal Health Care Foundation of Connecticut. “We haven’t had that conversation yet in Connecticut.”

The ACA waiver isn’t available until 2017 but the Medicaid waiver is already being used by dozens of other states to lower costs, she said.

“It allows a state to get past some of the requirements of Medicaid and do some things that are innovative,” she said of the Medicaid waiver.

Exploring the Medicaid waiver is particularly timely, Padilla said, because many enrollees are being bumped from Medicaid due to budget cuts, and many aren’t enrolling in insurance plans via state’s Access Health CT marketplace as was the hope.

A growing number of Connecticut residents have gained health insurance since the passing of the Affordable Care Act, but many aren’t using it because of expensive deductibles and co-pays, she said.

Access Health CT announced in late January that it enrolled nearly 109,000 people in private health insurance plans.

“We’ve come a long way with the ACA but there is not perfection with it,” agreed Patricia Baker, president and CEO of the Hartford-based Connecticut Health Foundation. “Affordability is such a huge issue for everyone. The conversation [about waivers], we believe, is absolutely important.”

Forty-three states and Washington, D.C., use at least one Medicaid Section 1115 waiver, according to the brief, which was authored by analysts at the University of Massachusetts’ Center for Health Law and Economics.

The waiver, according to the brief, lets states disregard many aspects of their Medicaid plan if the federal Centers for Medicare and Medicaid Services determine it makes sense and is cost effective.

The waiver can let states raise income eligibility limits and add benefits that aren’t usually covered by Medicaid, among other things. Once states apply for the waiver, it usually takes months or years to negotiate terms and gain approval, according to the brief.

On Aug. 31, some Connecticut residents lost their ability to qualify for HUSKY A, state Medicaid that covers low-income children and teens, under a state law that changed income eligibility standards. The change lowered the income eligibility level for parents and caregivers—from 201 percent to 155 percent of the federal poverty level—meaning those earning more than 155 percent of the poverty level no longer can receive HUSKY A.

If Connecticut were to pursue it, the state would need to file an application with the U.S. Department of Health and Human Services. Legislative approval is not required.

The forthcoming ACA 1332 waiver will let states opt out of major components of the Affordable Care Act, including the mandate that a state-run marketplace (Access Health CT) exist. To get the waiver, states will have to prove that alternative programs would provide equally comprehensive coverage to a comparable number of people without increasing the federal deficit, according to the brief.

The brief outlines potential pitfalls to using the waivers. Among them: state finances could be at risk if projected federal revenue to support programs falls short; political changes could jeopardize waiver programs that require federal approval; and using waivers could hurt Access Health’s clout and financing base by taking people out of the marketplace.

“There’s always the good, the bad and the ugly,” Padilla said, so any waiver needs to be researched before deciding whether to proceed.

Connecticut currently participates in 11 Medicaid waiver programs, according to David Dearborn, spokesman for the Department of Social Services (DSS) that administers the state’s Medicaid program. DSS has overall responsibility for the waivers, he said, but five of them are under DSS directly, five are under the state Department of Developmental Services and one is under the Department of Mental Health and Addiction Services. Connecticut’s existing waivers pertain to early childhood autism, acquired brain injuries, personal attendants and a state home care program for elders, among other things, Dearborn said.

Using the waivers has made the state a “national leader” when it comes to “creative and effective ways of adapting Medicaid rules” to provide home- and community-based services to people who otherwise would need nursing home care or institutionalization, he said.

“There’s already a lot of positive action going in Connecticut,” he said, with the state taking innovative steps to expand Medicaid’s reach.

Similarly, even more state residents could potentially access services under ACA Section 1332 and Medicaid Section 1115 waivers, Baker said.

“There’s nothing intrinsically good or bad about waivers, but they are an opportunity that this state should explore,” she said.

She didn’t ask about preventive care screenings, such as a mammogram or Pap test, in part because she worried they might involve an insurance co-pay or deductible. Her household income is below $30,000 a year.

“I got a physical, they did some blood work, and that was it,” she said.

Kerrishian McCants, 31, of Hartford, a mother of four, has a family history of diabetes and high blood pressure, but has not discussed those possible risks with her doctor. She hasn’t asked about preventive care or screenings, she says, because she doesn’t want to pay extra on her limited income.

The two women are not unusual, according to a health-care utilization survey of 444 state residents conducted by the Conn. Health I-Team.

While 88.4 percent of residents surveyed said they have a primary care doctor, only slightly more than half said they had received preventive screenings in the last two years. Of those who said they had not received preventive care, 59 percent said they believed such services would cost them money out-of-pocket, in co-pays or deductibles.

That perception persists in Connecticut despite an expansion of free preventive care since the passage of the Affordable Care Act. Adults are now entitled to 15 preventive services, including depression and diabetes screening, diet counseling, and tobacco-cessation programs, while women are entitled to 22 other preventive services, including mammograms, domestic violence screening and counseling, and osteoporosis checks (for those over 60) — with no cost sharing.

The survey, distributed in New Haven, Hartford and surrounding towns, found that 44.4 percent of respondents said they had not received preventive care screenings, such as mammograms and diabetes screening. Whites were more likely than African-Americans and Hispanics to report receiving such care – 62 percent, compared to 46 percent of Hispanic respondents and 58 percent of African-Americans. Preventive care also was more likely for those with higher household incomes – over $50,000 – than for those below $50,000.

Forty-eight percent of respondents who had not received preventive care said that concerns about cost were a reason.

Pat Baker, president of the Connecticut Health Foundation, said the finding that respondents were worried about cost in accessing preventive care was concerning — but also an opportunity for improvement.

“If they are limiting their own access because of fear of cost, I think we have to look at, what are the systems in place and the obligations of the system and others to make sure that as people sign up for coverage or renew coverage, we put a headlight on the message: ‘Preventive care is covered,’” Baker said.

State Healthcare Advocate Victoria Veltri said she was not surprised that many people believe preventive care will cost them money, given the high deductibles and cost sharing under some plans.

“We need to do a much better job of telling people that these services are free,” she said. With newly insured residents, “we did a lot of marketing about pre-existing conditions. I think the prevention message got lost. What it calls for is more messaging – personalized messaging – from providers, employers, people in the community . . . Enrollment is not the end game; we need to move the discussion from coverage to actually getting care.”

The survey found that while 88 percent of all respondents reported that they had a primary care doctor, whites were more likely to report having a provider (93 percent) than Hispanics (86 percent) and African-Americans (84 percent). People with household incomes exceeding $50,000 were more likely than those with lower incomes to report having a primary care physician. Eighty-two percent of respondents with incomes between $30,000 and $50,000 reported having a primary care provider, compared with 96 percent of people earning $50,000 to $100,00.

Some of the findings mirror those in a recent survey by Access Health CT, the state’s health insurance exchange. That survey found that 36 percent of exchange customers had not used their insurance coverage in 2015, up from 26 percent in 2014, and that 28 percent lacked a primary care physician. Customers who were white, older and had a bachelor’s degree or higher education were most likely to have used insurance and have a primary care provider.

The C-HIT survey found racial/ethnic and income disparities in respondents’ receipt of preventive care. The majority – 70.7 percent – of those who reported seeing a primary care doctor in the last three years said they had not been screened for depression or other mental health problems. Whites were far more likely to report such screenings (46.3 percent) than Hispanics (24 percent) or African-Americans (26 percent).

Similarly, while 69.9 percent of all respondents said they had received flu shots in the last two years, the rate among whites was higher (75.8 percent) than among Hispanics (69.7 percent) or blacks (61.1 percent.)

Despite the focus on obesity, only 31.6 percent of all respondents reported knowing what their BMI (body mass index) was. Of those who reported that their BMI was high, only 52.6 percent said their clinician had talked to them about it and recommended interventions. Those discussions were more likely for whites than for Hispanics and African-Americans, and for higher-income residents than low-income patients, according to the survey.

In terms of individual procedures, rates for some preventive services rose as household income rose. Overall, 72.6 percent of respondents over 50 said they had received colonoscopies, but the rate for people with incomes under $30,000 was lower than for people with higher incomes – 64.4 percent, compared with 78.7 percent for those with incomes between $50,000 and $100,000. Pap testing followed the same pattern.

One exception was mammograms. Women in households earning $30,000 to $50,000 were more likely to have had a mammogram in the last two years than those in higher-income groups, and African-Americans and Hispanics reported higher rates than whites.

CT residents discuss their health care usage.

Baker said she was not surprised by the racial and income disparities, saying the uneven use of preventive care stems largely from “the quality of the interaction” between providers and patients.

“Consistently, almost across the board, we know that people of color are not offered the same level of screening and care – and yet, they, in fact, shoulder a huge burden of health outcomes,” she said. Similarly, income and education levels impact the quality of care.

How much of the reason for that disparity is related to the provider offering services, and how much to the patient requesting services, is unclear. In the case of a patient with a high BMI or obesity, for example, “that can be a challenging conversation” for a provider to have with some patients, Baker said.

“Good preventive screenings shouldn’t be dependent on patients asking questions,” she said. Both patients and providers need to be encouraged to stress preventive care; “it needs to be a partnership,” she said.

Chronic conditions that can be detected early, such as heart disease, cancer and diabetes, are responsible for seven in 10 deaths among Americans each year, and account for nearly 75 percent of the nation’s health spending, according to the Centers for Disease Control and Prevention.

Other survey findings include:

• 68.5 percent of respondents said they would contact their primary care provider if they had a virus or flu, with 28 percent saying they would go to a hospital emergency room or clinic.

• 85 percent of respondents said they had spoken to their primary care provider about their family medical histories, with women more likely than men to have had those conversations, and whites more likely than blacks or Hispanics.

• 36 percent of respondents reported a history of smoking within the last 15 years, but just 38 percent of those people reported having a chest X-ray in the last five years.

• 78 percent of respondents reported having an annual physical exam in the last year, with Hispanics and African-Americans reporting higher rates than whites.

• About one-third of respondents reported traveling between 20 minutes and one hour to see their primary care provider.

• 3.6 percent of respondents said they had no medical insurance, similar to state estimates.

C-HIT data analyst Matt Wynn contributed to this story.

This Wednesday, Oct. 7, C-HIT, in collaboration with ConnectiCare, is hosting a free forum, “Get Health Wise: The Benefits of Preventive Care,” from 5:30 to 7:30 p.m. at the Artists Collective, 1200 Albany Ave., Hartford. The keynote speaker is Dr. Jewel Mullen, commissioner of the state Department of Public Health. Register here.

At the end of last year, there were 2,002 dentists who accepted Medicaid or HUSKY plans. That’s nearly three times the 703 dentists who accepted Medicaid or HUSKY on Dec. 31, 2008, according to the state Department of Social Services (DSS).

“That’s a pretty expansive network,” Donna Balaski, director of dental services at DSS, said of the 2014 figure. “We have better access than commercial plans in our state.”

While more dentists are accepting Medicaid and HUSKY plans, health advocates say there is room for improvement in utilization and access to oral health care, especially for low-income adults.

“It’s a very different story around adults,” said Patricia Baker, president and CEO of the Connecticut Health Foundation, a Hartford-based nonprofit that has studied dental access trends in Connecticut for the past 15 years. Even with the gains made, “the choices for adults are still incredibly narrow.”

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Dentists have developed several programs to reach low-income clients.

In 2014, 192,263 adults on Medicaid or HUSKY utilized dental services, up from 49,839 in 2008, according to Balaski. Over the same time span, HUSKY-enrolled children receiving oral care rose from 67,522 to 237,010. Statewide there were 775,938 enrollees in Medicaid and HUSKY, of which 435,448 were younger than 21, according to DSS data for the end of 2014.

Though dentists have made great progress and still strive to serve more low-income patients, it is “a little trickier” for them to reach adults than children, said Dr. John Mooney, a dentist who practices in Putnam and is co-chairman of the Connecticut State Dental Association’s Council on Legislation.

Many dentists who see HUSKY-enrolled children also will provide services to caregivers who accompany the children to appointments, he said. But the non-caregiver Medicaid population and working poor are difficult to reach, he added.

“We still have holes” in coverage, Mooney acknowledged.

Reaching Out

Dentists have developed a number of programs to reach low-income clients.

They volunteer their services at Connecticut Mission of Mercy free dental clinics held statewide, including one recently in Danbury that provided free services to about 2,000.

In New Haven, the Fair Haven Community Health Center sends its mobile dental clinic into neighborhoods and offers exams, cleaning, fillings, fluoride treatments and other services to children and families.

Children can see dentists and dental hygienists in school-based health centers.

In Bridgeport, for example, children can receive semiannual cleanings as well as fillings and sealants, according to Linda Smith, the school-based health center program director for Bridgeport at Optimus Health Care Inc., which operates clinics in elementary and high schools.

“A lot of children do not have private dentists,” she said, and the center “is a safety net that keeps children from falling through the cracks and not having dental services provided.”

Statewide, 11 cities and towns have school-based centers providing dental services, according to the Connecticut Association of School Based Health Centers. They are in Bridgeport, Danbury, East Hartford, Groton, Hartford, Middletown, New Britain, New London, Norwich, Stamford and Waterbury.

Children enrolled in HUSKY also benefitted from a lawsuit filed in 2000 and settled eight years later that provides more oral care access for low-income children. The lawsuit claimed that children enrolled in HUSKY couldn’t find dentists to serve them, a violation of federal Medicaid laws. The settlement increased the reimbursement rate paid to dentists for treating HUSKY enrollees, Balaski said.

But health advocates worry the state’s current fiscal situation will threaten some of the progress that has been made.

Under Gov. Dannel P. Malloy’s proposed budget, parents with income between 138 and 201 percent of the federal poverty level – or $28,000 to $40,000 for a family of three – would lose HUSKY eligibility. Also, pregnant women with income between 138 and 263 percent of the federal poverty level – about $28,000 to $52,000 for a family of three – would no longer be eligible.

That would result in thousands of people losing coverage, according to Connecticut Voices for Children. They would be expected to buy private insurance coverage through the state’s health insurance exchange, according to the advocacy group.

The group estimates as many as 10,000 parents enrolled in HUSKY would go without coverage due to expensive premiums and co-payments they can’t afford.

Health Benefits

The gains in oral health visits have had major impacts – potentially life-saving ones, according to Dr. Joseph Feuerstein, director of integrative medicine wellness at Stamford Hospital and assistant clinical professor at Columbia University in New York.

“Good oral health is a reflection of good health,” he said. Regular dental visits are extremely important because dentists can detect problems in the mouth that may be red flags signaling more serious ailments, Feuerstein said.

Research has shown that inflammation in the mouth could be a sign of inflammation of the blood vessels, a potential underlying cause of heart disease, he said. In some cases, bacteria from the mouth can enter the bloodstream and infect heart valves, leading to heart failure or death, he said.

There also may be a link between tooth or bone jaw loss and osteoporosis, he said, and emerging research shows a potential link between early tooth loss and Alzheimer’s disease. Additionally, gum inflammation in pregnant women has been linked to premature birth and low birth weight, he said.

Each of these warning signs could be detected with regular dental visits, which would save patients, dentists, the state and private insurers money in the long run, Feuerstein said.

That rate was “very high,” said Frances Padilla, president of the Universal Health Care Foundation of Connecticut. She said she was also struck that 28 percent of adults aged 18 to 44 reported in the new Connecticut Health Care Survey that they have one of those serious illnesses.

“With so many people reporting chronic illnesses and their complications, we have to have better access to care,’’ she said.

Six health foundations released the results of a telephone survey of 5,447 adults conducted between June 2012 and February 2013. As in previous reports, the survey found persistent disparities in health care between racial and ethnic groups, but foundation officials said this is the first time residents have provided details about their own health.

“You don’t hear from the users enough,” said Lisa Honigfeld, vice president for health initiatives for the Child Health and Development Institute of Connecticut. “We need their input.”

While many state residents have access to high-quality health care, blacks and Latinos were more likely than whites to rate their health as fair or poor, have higher rates of obesity and say that cost has kept them from filling prescriptions.

They were also less likely to have health insurance although that could change now that 208,000 residents have signed up for insurance under the Affordable Care Act, said Patricia Baker, president and CEO of the Connecticut Health Foundation.

“The issue we face is of health equity and disparity in Connecticut,’’ Baker said. “We have disparities in the prevalence of obesity, diabetes and other conditions.”

Some of the survey’s findings include:

• Twenty-three percent of adults reported that they were obese, compared to a national average of 29 percent, and 34 percent of the adults reported that their children were overweight or obese.

• Thirteen percent of children were reported to have asthma, compared to a national average of 9.3. That figure was surprisingly high and needs more analysis, Honigfeld said.

• About a quarter of black and Latino adults reported that their health is fair or poor compared to 10 percent of whites.

• Among adults, 11 percent said they did not get the care they needed in the past year, and 28 percent reported postponing needed medical care.  More than half of them said they worried about the cost.

Children’s Health Care

Foundation officials said there were bright spots in the survey, including that children have particularly high rates of being insured and receiving quality dental care.

State agencies and non-profit groups have focused heavily since 2005 on encouraging parents to bring their children to a dentist by age one instead of previously waiting until age three, Honigfeld said. Pediatricians have also been trained to promote better dental care, such as encouraging parents to water down the juice their children drink, she said.

“Lo and behold, kids are getting better preventive dental care,’’ she said.

The survey revealed that many aspects of children’s health care are working, including that 98 percent of children were reported as being healthy and that 98 percent are covered by health insurance.

Only 6 percent of parents reported postponing medical care for their children in the past year, compared to 28 percent of adults who reported that they delayed their care.

CHDI reported that some problems remain, including that communication between pediatricians and specialists is often lacking.

Despite the high reported rate of obesity among children, many parents did not report receiving counseling by doctors about nutrition, exercise and minimizing “screen time” – the time children spend watching TV or using a computer.

“I’m amazed and perplexed that that there is so little counseling in these areas that relate to obesity,’’ Honigfeld said. “Or at least that’s the perception of parents. Pediatricians may be talking themselves blue in the face.”

Consistent Care

Health care advocates said that having a regular place to go for care improves trust between doctors and patients and leads to better health outcomes.

In the survey, 86 percent of adults reported having a usual place they go for care. Of that group, 18 percent said it was a clinic or health care center. In the survey, 46 percent of Latinos and 34 percent of blacks reported visiting a clinic, compared to 13 percent of whites.

Younger people were also more likely to use federally funded health clinics or school-based clinics, Padilla said. She and Baker said the clinics provide important, consistent care for many residents, but their funding is often in jeopardy.

“These clinics are providing a vital safety net, but they are going to be receiving less state support this year in the budget that was just passed,’’ Baker said.

The survey was sponsored by The Aetna Foundation, Connecticut Health Foundation, the Patrick and Catherine Weldon Donaghue Medical Research Foundation, the Foundation for Community Health, Universal Health Care Foundation of Connecticut, and the Children’s Fund of Connecticut.

A discussion about its findings will be held at WNPR’s Health Equity Forum on May 21. The conversation will be recorded for WNPR’s “Where We Live” show, hosted by John Dankosky.  The segment is expected to air on May 27 and on June 24.

To read the report go here: