[Senate Hearing 107-539]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 107-539
 
       THE CRISIS IN CHILDREN'S DENTAL HEALTH: A SILENT EPIDEMIC
=======================================================================



                                HEARING

                               BEFORE THE

                     SUBCOMMITTEE ON PUBLIC HEALTH

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS
                          UNITED STATES SENATE

                      ONE HUNDRED SEVENTH CONGRESS

                             SECOND SESSION

                                   ON

EXAMINING THE CRISIS IN CHILDREN'S DENTAL HEALTH, FOCUSING ON CREATING 
  AN EFFECTIVE ORAL HEALTH INFRASTRUCTURE, INCREASE ACCESS TO DENTAL 
   CARE, AND RELATED PROVISIONS OF S. 1626, TO PROVIDE DISADVANTAGED 
                CHILDREN WITH ACCESS TO DENTAL SERVICES

                               __________

                             JUNE 25, 2002

                               __________

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                                Pensions







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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

               EDWARD M. KENNEDY, Massachusetts, Chairman

CHRISTOPHER J. DODD, Connecticut     JUDD GREGG, New Hampshire
TOM HARKIN, Iowa                     BILL FRIST, Tennessee
BARBARA A. MIKULSKI, Maryland        MICHAEL B. ENZI, Wyoming
JAMES M. JEFFORDS (I), Vermont       TIM HUTCHINSON, Arkansas
JEFF BINGAMAN, New Mexico            JOHN W. WARNER, Virginia
PAUL D. WELLSTONE, Minnesota         CHRISTOPHER S. BOND, Missouri
PATTY MURRAY, Washington             PAT ROBERTS, Kansas
JACK REED, Rhode Island              SUSAN M. COLLINS, Maine
JOHN EDWARDS, North Carolina         JEFF SESSIONS, Alabama
HILLARY RODHAM CLINTON, New York     MIKE DeWINE, Ohio

           J. Michael Myers, Staff Director and Chief Counsel
             Townsend Lange McNitt, Minority Staff Director

                                 ______

                     Subcommittee on Public Health

                      EDWARD M. KENNEDY, Chairman

TOM HARKIN, Iowa                     BILL FRIST, Tennessee
BARBARA A. MIKULSKI, Maryland        JUDD GREGG, New Hampshire
JAMES M. JEFFORDS, Vermont           MICHAEL B. ENZI, Wyoming
JEFF BINGAMAN, New Mexico            TIM HUTCHINSON, Arkansas
PAUL D. WELLSTONE, Minnesota         PAT ROBERTS, Kansas
JACK REED, Rhode Island              SUSAN M. COLLINS, Maine
JOHN EDWARDS, North Carolina         JEFF SESSIONS, Alabama
HILLARY RODHAM CLINTON, New York     CHRISTOPHER S. BOND, Missouri

                      David Nexon, Staff Director
                 Dean A. Rosen, Minority Staff Director

                                  (ii)














                            C O N T E N T S

                               __________

                               STATEMENTS

                         Tuesday, June 25, 2002

                                                                   Page
Bingaman, Hon. Jeff, a U.S. Senator from the State of New Mexico.     1
Sessions, Hon. Jeff, a U.S. Senator from the State of Alabama....     3
Hutchinson, Hon. Tim, a U.S. Senator from the State of Arkansas..     4
Satcher, David, M.D., Senior Visiting Fellow, Kaiser Family 
  Foundation, and Director-Designee, National Center for Primary 
  Care, Morehouse School of Medicine, Atlanta, GA................     5
Edelstein, Burton L., Director, Children's Health Project, and 
  Director, Division of Community Health, Columbia University 
  School of Dental and Oral Surgery, New York, NY; Lynn Douglas 
  Mouden, Director, Office of Oral Health, Arkansas Department of 
  Health, Little Rock, AR; Gregory Chadwick, Charlotte, NC, 
  President, American Dental Association; Ed Martinez, Chief 
  Executive Officer, San Ysidro Health Center, San Ysidro, CA, on 
  behalf of the National Association of Community Health Centers, 
  Inc.; and Timothy Shriver, President and Chief Executive 
  Officer, Special Olympics, Inc., Washington, DC................    15

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    David Satcher, M.D...........................................    33
    Burton L. Edelstein..........................................    38
    Lynn Douglas Mouden..........................................    41
    American Dental Association..................................    47
    Ed Martinez..................................................    51
    Timothy Shriver..............................................    54
    Stanley B. Peck..............................................    67
    Sarah M. Greene..............................................    73

                                 (iii)
















       THE CRISIS IN CHILDREN'S DENTAL HEALTH: A SILENT EPIDEMIC

                              ----------                              


                         TUESDAY, JUNE 25, 2002

                               U.S. Senate,
                     Subcommittee on Public Health,
of the Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 2:50 p.m., in 
room SD-430, Dirksen Senate Office Building, Senator Bingaman, 
presiding.
    Present: Senators Bingaman, Sessions, and Hutchinson.

                 Opening Statement of Senator Bingaman

    Senator Bingaman [presiding]. The hearing will come to 
order.
    Thank you all very much, and I apologize for starting a 
little late. We had a vote on the floor which delayed us a 
little bit.
    This is a very important hearing on ways to improve access 
to and delivery of dental health services to our Nation's 
children. The oral health problems facing children were 
highlighted in a landmark report that was issued by the Surgeon 
General and the Department of Health and Human Services 
entitled, ``Oral Health in America: A Report of the Surgeon 
General,'' in which Dr. Satcher, who is our first witness here 
today, observed that our Nation is facing what amounts to a 
``silent epidemic'' of dental and oral diseases.
    In fact, dental caries, which refers to both decayed teeth 
and filled cavities, is the most common childhood disease. 
According to the Surgeon General, among 5- to 17-year-olds, 
dental caries is more than five times as common as a reported 
history of asthma and seven times as common as hay fever. In 
short, dental care is, as the Surgeon General adds, the most 
prevalent unmet health need among America's children.
    The severity of the problem is even greater among children 
in poverty. Poor children age 2 to 9 have twice the levels of 
untreated decayed teeth as nonpoor children. The problem is 
exacerbated in certain ethnic groups. For example, the Surgeon 
General found that poor Mexican American children have rates of 
untreated decayed teeth that exceed 70 percent, a rate of true 
epidemic proportions. In the case of American Indian and 
Alaskan Native children age 2 to 4, they have five times the 
rate of dental decay of other children.
    For these children, their personal suffering is real. Many 
of the oral diseases and disorders can cause severe pain, 
undermine self-esteem, undermine self-image, discourage normal 
social interactions, cause other health problems, and 
compromise nutritional status, and lead to chronic stress and 
depression as well as, of course, cause substantial financial 
cost to the families involved.
    Lack of treatment is estimated to result in a loss of 1.6 
million school days annually according to the National Center 
for Health Statistics.
    Incredibly, almost all of this could be prevented. As the 
Surgeon General's report notes, preventive programs in oral 
health that have been designed and evaluated for children using 
a variety of fluoride and dental sealant strategies have the 
potential of virtually eliminating dental caries in all 
children. Unfortunately, children do not get the dental 
services they need. For example, there are 23 million children 
who have no dental insurance. Even when children do have dental 
coverage, access to care is often sorely lacking. Medicaid is 
the largest insurer of dental coverage for children, yet 
despite the design of the Medicaid program to ensure access to 
comprehensive services for children, including dental care, the 
inspector general of the Department of Health and Human 
Services reported in 1996 that only 18 percent of children 
eligible for Medicaid received even a single preventive dental 
service. The factors are complex, but the primary one is due to 
limited dentist participation in Medicaid.
    The good news is that many States including my home State 
are taking actions to improve the participation of dentists in 
the Medicaid program by raising the low payment rates and 
reducing the administrative requirements. Dr. Burt Edelstein of 
the Children's Dental Health Project has some important data 
with respect to these issues, and I look forward to hearing 
that today.
    In addition, the Federal Government administers other 
health care programs providing dental services for providers 
for low-income children and their families, including services 
administered by community health centers and Indian Health 
Service. Unfortunately, both of these programs are underfunded. 
The GAO report found difficulty in meeting the dental needs of 
their target populations.
    We are fortunate that Ed Martinez is here today to discuss 
the many challenges that community health centers such as the 
one he has in San Ysidro, CA face in delivering dental services 
to low-income children.
    In addition to Dr. Satcher, Dr. Edelstein, and Mr. 
Martinez, I am pleased that we will also be hearing from Dr. 
Timothy Shriver, who is president and CEO of the Special 
Olympics, about the oral health issues confronting children 
with special health care needs; Dr. Gregory Chadwick, who is 
president of the American Dental Association; and Dr. Lynn 
Mouden, who is the State Dental Director from Arkansas.
    We are glad to have all of them here to address the 
problems that we will hear about today.
    We have put together some bipartisan legislation with 
Senator Cochran that has been cosponsored by Senators Dodd and 
Harkin and Collins and Hutchinson on our committee. S. 1626, 
the Children's Dental Health Improvement Act, would improve 
access and delivery of dental health services to our Nation's 
children through the Medicaid program, through the State 
Children's Health Insurance Program, through the Indian Health 
Service, and through the Nation's safety net of community 
health centers.
    These problems are well-documented, and they call out for 
congressional action as soon as possible.
    In addition to the testimony of the witnesses which we will 
receive today, I want to insert in the record testimony from 
the American Dental Education Association, the American Dental 
Hygienists' Association, and the National Head Start 
Association.
    Senator Bingaman. Before I actually introduce our first 
witness, Dr. Satcher, let me call on Senator Sessions for any 
comments he has, and then on Senator Hutchinson.

                 Opening Statement of Senator Sessions

    Senator Sessions. Thank you, Mr. Chairman.
    I am very pleased that we are holding a hearing on this 
important issue. I thank you for chairing it, and I thank 
Senators Gregg and Frist for allowing me to serve as ranking 
member today. This is an issue that I have some real interest 
in and concern about.
    I would like to extend a special welcome to Dr. Satcher, a 
native Alabamian. Thank you for your service to your country. 
We are glad that you are here today, Dr. Satcher.
    As the witnesses today will testify, oral diseases are 
predictable and preventable. Thus, it really is inexcusable 
that so many children lack dental care and must suffer from 
oral diseases. We must do better.
    I applaud Senator Collins for her efforts to improve access 
to dental health care with her bill, the Dental Health 
Improvement Act, which she introduced last year and which was 
included in the health care safety net legislation this 
committee passed and which is now awaiting final action by the 
House.
    Alabama, like so many other States, is suffering from a 
dental health crisis. According to the Department of Public 
Health, we have 312,000 Alabama schoolchildren in need of some 
dental treatment, and as many as 10 percent of those have 
urgent needs. African American and rural children have the most 
dental diseases. Fifteen percent of rural African American 
children have five or more teeth with a cavity.
    Alabama has 38 dentists per 100,000 population; that is 
compared to 54 per 100,000 throughout the United States. Most 
of Alabama has been designated as a dental professional 
shortage area.
    Eighty-two percent of the water supply in the State is 
fluoridated, and Alabama is only one of 22 States that meet the 
national Healthy People 2000 objectives for fluoridation, which 
is good news. Five hundred out of approximately 1,700 
practicing Alabama dentists are now treating Medicaid patients. 
That is up from only 135 a few years ago, thanks to improved 
reimbursement levels and an outreach to the dental community in 
Alabama by the Medicaid department.
    In December of 2000, my home town newspaper, the Mobile 
Register, Mr. Chairman, ran a series called ``The Dental 
Divide'' that dealt with the problem of poverty and lack of 
dental care. In this series, the reporter of Sam Hodges 
revealed the terrible condition of dental health in Alabama as 
well as the challenges of providing dental care in a rural 
State.
    Although since the article was published, many improvements 
have been made, there is still much to be done, and indeed, one 
reason why we have gone from 135 Medicaid-accepting dentists to 
500 is a direct result of that article; it was a tremendous 
series of articles that really would touch the heart of anybody 
who read them. There were photographs of young children with 
terrible dental problems, terrible problems, that had to have 
affected their ability to learn, their ability to be good 
students, as well as their self-esteem.
    So Mr. Chairman, I think this is an important hearing. I 
intend to be a supporter of the legislation you just mentioned. 
It is something that I think we should focus on. We are almost 
there. As has been shown in Alabama, with some good, aggressive 
outreach, with a little better funding increases for dentists, 
we can get a real surge in the number of dentists willing to 
take Medicaid patients, and that would go a long way toward 
dealing with many of the more severe problems.
    Thank you.
    Senator Bingaman. Thank you very much.
    Senator Hutchinson, did you have a statement that you would 
like to make?

                Opening Statement of Senator Hutchinson

    Senator Hutchinson. Yes, Mr. Chairman.
    Let me first thank you for holding the hearing today and 
for sponsoring S. 1626. I am pleased to cosponsor this 
legislation with you. Dental health is an important subject, 
and I want to welcome Dr. Satcher. It is good to see him again, 
and when I have the opportunity, I look forward to introducing 
Dr. Mouden, who is director of the Office of Oral Health in the 
Arkansas Department of Health. I am pleased to have him on the 
second panel.
    As you have pointed out, Mr. Chairman, tooth decay is 
considered the most chronic disease of childhood, and even 
though advances have been made through the years in 
preventative dental procedures and techniques, untreated tooth 
decay and its consequences remain a significant and growing 
problem.
    Children of low socioeconomic status make 37 percent fewer 
visits to the dentist's office than do those of higher 
socioeconomic groups. And actually, 25 percent of children 
under the age of 19 in the United States endure 80 percent of 
all tooth decay. Children in families with incomes below 200 
percent of the Federal poverty level, although most of them are 
eligible for Medicaid and SCHIP, have significantly more unmet 
dental treatment needs than those from families with higher 
incomes. This is because of lack of access to adequate dental 
services, be it a lack of transportation, as we oftentimes see 
in rural areas, or a lack of dental professionals in a given 
area.
    In Arkansas, approximately 139,000 children are eligible 
for dental care through either Medicaid or the SCHIP program, 
but only 77,000, or about 55 percent of these children, were 
seen by a dentist in 2001.
    We are fortunate in Arkansas to have over 37 percent of our 
about 1,000 dentists who are willing to treat these children, 
while the national average is only about 32 percent.
    This is a big problem, and it is one that I am pleased to 
see the committee addressing. We need to develop creative 
solutions that will engage the provider community and reduce 
the barriers for these low-income families.
    Senator Bingaman. Our first witness is Dr. David Satcher, 
who is of course well-known to the committee for his 
outstanding service as the Nation's Surgeon General. He is now 
a Visiting Fellow at the Kaiser Family Foundation until he 
assumes the new post which I believe he is about to assume as 
director of the new National Center for Primary Care at 
Morehouse School of Medicine in Atlanta, GA this fall.
    Dr. Satcher, thank you very much for being here.

   STATEMENT OF DAVID SATCHER, M.D., SENIOR VISITING FELLOW, 
   KAISER FAMILY FOUNDATION, AND DIRECTOR-DESIGNEE, NATIONAL 
CENTER FOR PRIMARY CARE, MOREHOUSE SCHOOL OF MEDICINE, ATLANTA, 
                               GA

    Dr. Satcher. Thank you, Mr. Chairman and members of the 
subcommittee.
    I am delighted to be able to join you and especially to 
support your efforts in the area of improving children's dental 
health.
    Of all of the reports that I released as Surgeon General, 
this report has certainly stimulated more discussion and action 
at the local, State and Federal level than perhaps any other. 
The support that it has received from within Government and 
outside Government has certainly been outstanding, yet as you 
well know, there is room for so much more to be done.
    This report was released in May of 2000, and it was 
entitled, ``Oral Health in America: A Report of the Surgeon 
General.'' I also want to point out that a month later, we had 
a Surgeon General's workshop on children and oral health in 
June, and part of my remarks are based on that workshop.
    A lot of other things have happened throughout the country 
in terms of activities surrounding the report, and I am very 
grateful for that, because it is one thing to release a report; 
it is another thing to really have people work to make the 
recommendations real.
    I am especially pleased that this hearing today focuses on 
children's oral health, because one of my priorities as Surgeon 
General was to ensure that every child had an optimal 
opportunity for a healthy start in life, and my commitment to 
that issue continues today.
    We also released a report on the special health needs of 
children with mental retardation, working very closely with Dr. 
Tim Shriver whom you will hear from later today. That was the 
last report that I released, and in that report, we pointed out 
the very severe dental and oral health needs of children with 
developmental disabilities, especially mental retardation.
    Over one-third of the U.S. population has no access to 
community water fluoridation, despite all the evidence that CDC 
and others have accumulated over the years about the potential 
of water fluoridation to prevent dental decay.
    Over 108 million children and adults lack dental insurance, 
which is over two and a half times the number who lack medical 
insurance.
    Expenditures for dental services alone make up 4.7 percent 
of the Nation's health expenditures as of 1998. That is about 
$54 billion out of a budget of $1.3 trillion. As you can see, 
there are many reasons why we need to pay more attention 
individually and collectively to our oral health, but there are 
also opportunities for action for health professionals, for 
individuals, and for communities to work together to improve 
health.
    First, I would like to focus on some of the findings of the 
report. Let me say that there was some good news in this 
report. The good news was that we have had dramatic improvement 
in oral health over the last 50 years. Great progress has been 
made in understanding the common oral diseases such as tooth 
decay and gum disease, and today, most middle-aged and younger 
American expect to retain their natural teeth throughout their 
lifetime. That is significant progress.
    But there was also very bad news in that report, and it was 
that we are experiencing a virtual ``silent epidemic'' of 
dental and oral diseases across the country. Many of us still 
experience needless pain and suffering, complications that 
devastate overall health and well-being, as well as high 
financial and social costs that diminish the quality of life at 
work, at school, and at home.
    Oral and forensic cancers, for example, are diagnosed in 
about 30,000 Americans each year. In fact, 8,000 people die 
annually from these cancers, and that makes them the sixth-
leading cancer cause of death in the country.
    Nearly one in four Americans between the ages of 65 an 74 
has very severe periodontal disease. Oral clefts are one of the 
most common birth defects in the United States, with a 
prevalence of about one per 1,000.
    We tried to make some major points in the report, and the 
first one is that the mouth has a way of reflecting the general 
health and well-being of the entire today. By examining the 
mouth, we can detect problems in the circulatory system, 
nutritional problems, and infectious diseases. So in that 
sense, the mouth is sort of a mirror of the rest of the body.
    Oral disease and disorders, however, in and of themselves 
affect health and well-being throughout life in so many ways--
the ability to eat, to chew one's food, therefore influencing 
the type of foods selected; the ability to speak, the ability 
to smile and to relate to other people. Many things that 
determine growth and development for children are impacted if 
there is poor oral health.
    Oral diseases and conditions are often associated with 
other health problems. For example, in people with periodontal 
disease, there is an increased risk of cardiovascular disease, 
diabetes, and adverse reproductive outcomes. And even though, 
as we pointed out in the report, we do not understand how 
periodontal disease relates specifically to these problems of 
heart disease, diabetes, and difficult reproductive outcomes, 
it is an association that needs more research.
    But safe and effective measures exist to prevent the most 
common dental diseases, and those are dental caries and 
periodontal disease. If those methods were used--and some of 
them are at home, in terms of regular brushing and flossing, 
good nutrition; some of them are seeing a dentist and getting 
dental sealants and other things that can happen in that 
setting to prevent dental caries.
    Lifestyle behaviors that affect general health--things like 
tobacco use and excessive alcohol use, poor dietary choices--
also affect oral and craniofacial health.
    There are profound and consequential oral health 
disparities within the U.S. population, as you have implied, 
but among the poor, among minorities, among persons with 
developmental disabilities, there are major oral health 
problems such that 20 to 25 percent of children experience over 
80 percent of all of the oral health problems.
    More information is needed, so I do want to make the point 
that scientific research is key to further reduction in the 
burden of diseases and disorders that affect the face, the 
mouth, and the teeth.
    Now, specifically as it relates to children's oral health, 
dental caries are the single most common class of chronic 
disease among children, as you have heard, and that is 
something that is very important since children experience 51 
million hours of lost school days because of tooth decay and 
toothache.
    As one of the most common birth defects, cleft lip and 
palate is estimated to affect one in 1,000 births--one in 600 
live births for whites, one in 1,850 live births for African 
Americans.
    In addition, dental caries is the most frequently unmet 
health need of children in this country.
    There are striking disparities in dental disease by income, 
so poverty is a major factor here, and that is why access is 
such a challenge. Unintentional injuries, many of which include 
head, mouth, and neck injuries, are common in children, but by 
the same token, intentional injuries commonly affect the 
craniofacial tissue.
    Professional care is necessary for maintaining oral health, 
yet 25 percent of poor children have not seen a dentist before 
entering kindergarten. We pointed out in our report that 
medical insurance is a strong predictor of access to dental 
care. Uninsured children are 2.5 times less likely than insured 
children to receive dental care. Children from families without 
dental insurance are 3 times more likely to have dental needs 
than children with either public or private insurance.
    For each child without medical insurance, there are at 
least 2.6 children without dental insurance.
    Medicaid has not been able to fill the gap in providing 
dental care to poor children. In our report, we said that in 
the year before our report, only one in five children on 
Medicaid saw a dentist. So Medicaid for many reasons is not 
able to fill that gap, and as you point out, in many cases 
because many dentists do not see children on Medicaid. And when 
you talk with dentists about this, as I have throughout the 
country, many of them will point out that it really in some 
cases is not worth their while to accept Medicaid for seeing 
children, that the cost of the time that it would take to fill 
out the forms is not adequately reimbursed in terms of Medicaid 
reimbursement.
    I am very pleased that there are changes taking place. 
Several States have now increased their Medicaid reimbursement. 
It is not enough. We need to continue to push for improving the 
Medicaid reimbursement, because it really impacts upon 
children's access to dental health services.
    Children with disabilities including mental retardation 
have more dental health problems, and you will hear more about 
this later from Dr. Shriver. I had an opportunity to attend the 
Special Olympics in Alaska last year, and they have some very 
interesting screening programs which you will hear about. But 
it had a tremendous impact on my perspective of the health care 
needs of the mentally retarded.
    Let me close by sharing these recommendations for action. 
Everyone has a role in improving and promoting oral health. 
Through a collaborative process, we can develop a framework for 
action. We can change perceptions. We really need to educate 
the public, policymakers, and health providers regarding oral 
health and disease so that oral health becomes an accepted 
component of general health.
    We need to accelerate the building of the science and 
evidence base and apply science effectively to improve oral 
health.
    We need to build an effective oral health infrastructure 
that meets the oral health needs of all Americans and integrate 
oral health effectively into overall health.
    We need to remove the known barriers between people and 
oral health services, especially children.
    We need to use public-private partnerships to improve the 
oral health of those who still suffer disproportionately from 
oral disease, and I must say there are some very impressive 
programs. The Kellogg Community Voices Program is one that I am 
familiar with, as well as the Healthy Smiles Program, the 
Bright Smile Program. Colgate Palmolive and Procter and Gamble 
both support programs for getting dental care to children who 
are poor and underserved. Rosie O'Donnell has set up a 
foundation to improve access to dental health care. So there 
are some very interesting public-private partnerships.
    Mr. Chairman, in the past half-century, we have come to 
recognize that the mouth is in fact a mirror of the whole body. 
It is a sentinel of disease, and it is critical to overall 
health and well-being. The challenge facing us today--to help 
all Americans achieve oral health--demands the best efforts of 
the public and private agencies as well as individuals.
    I am pleased to have this opportunity to present this 
overview. I have submitted a full written report for the 
record, and I will be happy to respond to any questions.
    [The prepared statement of Dr. Satcher may be found in 
additional material.]
    Senator Bingaman. Thank you very much, Dr. Satcher.
    Let me give you a very uneducated view of this situation 
just to get your reaction, Dr. Satcher. In my home State of New 
Mexico, several of our schools make available to parents who 
want their children to participate in it a dental sealant 
program. I believe is in the early grades, second or third 
grade, when they do that.
    My impression is that that is been very successful in that 
it does reduce the incidence of dental caries, and it is very 
cost-effective. It does not cost much money. Everyone seems 
very pleased with it.
    Based on that, I wonder why we cannot have as a goal trying 
to implement that kind of program in all the public schools in 
the country and, just as we have programs to immunize school-
age children at certain ages, have this as part of what is 
expected by all parents and all children and all those involved 
with our public school system throughout the country.
    As I said, that is an uneducated notion that I have had, 
but have you looked at anything like that, or did you have a 
chance to as part of the study that you did?
    Dr. Satcher. We have been involved in several studies, and 
let me just say that we tried to make very clear in the report 
that we are talking about problems that are preventable, and 
clearly, dental sealants play a major role in preventing tooth 
decay in children.
    I am of the impression that it would be a very good 
investment in the long run and that we would prevent a lot of 
unnecessary oral health problems if we invested in things like 
access to dental sealants at a very early age. So we strongly 
recommend that.
    I think it is an interesting issue, because here is 
something where there are things that must be done at home by 
parents and their children, where regular brushing and 
flossing, good nutrition are very important. But it is also 
critical that children have access to those kinds of dental 
health services very early, and if they had that, it would 
prevent a lot of problems later on.
    I do believe very strongly that poor oral health negatively 
impacts upon children's growth and development in many ways--
their ability to relate to their peers; their comfort in 
speaking in public. Of course, in our study, we found older 
people on Indian reservations who were shamed to speak in 
public because of their dental health problems, so you can 
image what children go through when they have very bad teeth.
    So with toothaches, the pain and discomfort can interfere 
with learning, but also, at a very important stage of social 
development, children suffer needlessly, and I think we ought 
to invest in preventing that.
    Senator Bingaman. One of the things that you alluded to in 
your testimony was the problem of inadequate fluoridation of 
our water systems. Do you have a plan or a proposal for us to 
consider on that? I know we have some things in this 
legislation that Senator Cochran and I and Senator Hutchinson 
and various others have introduced to try to move in that 
direction. But is there a clear role that you see for the 
Federal Government in trying to meet this need so that we have 
fluoridation of our water more generally available?
    Dr. Satcher. I think several local communities have 
struggled with this issue, and just in the last few years, 
several local communities have made the decision to go to 
fluoridation of water.
    Unfortunately, there are a lot of misconceptions out there 
about fluoride. A lot of people paint pictures of danger. CDC 
has done years of research on the impact of fluoride and listed 
it as one of the ten leading public health developments of the 
20th century. No. 1, I think we really need to do a better job 
of educating the general public, because these decisions are 
made in local communities by vote. I think the Federal 
Government can help with that, but I also think we can provide 
incentive for communities to work toward water fluoridation.
    Obviously, it is an issue of the role of the local 
government versus State versus Federal, but this is such a 
critical issue for the health of children that I think the 
Federal Government should provide all the support that it can 
to move local communities in that direction, including 
financial incentives for them to do so.
    Senator Bingaman. I will not put you on the spot right now, 
but I would just urge that if you could look at this 
legislation that we have introduced and give us any comments 
you have about things we could add or improve in order to carry 
out some of the recommendations in your report and in your 
testimony today, I think that would be very helpful to us.
    Dr. Satcher. I would be happy to.
    Senator Bingaman. And again, thank you very much for being 
here.
    Dr. Satcher. I would like to comment, because I did mention 
our concern about the growing shortage of dentists, and as you 
know, many dental schools in the country closed in the eighties 
and the nineties. I think we are at 26 now. So there is a 
growing concern about the shortage of dentists all over the 
country because the rate of enrollment now will not meet the 
needs. So that is also an issue that is going to need 
attention, and I know that the American Dental Education 
Association and many others have been struggling with this. We 
need to provide much more support for getting students into 
fields of oral health.
    Senator Sessions. On that subject, Dr. Satcher, why is 
that? People get turned down at dental schools regularly. I 
hear about people trying to get in who might not be accepted 
unless they have the most exceedingly high test scores and that 
sort of thing.
    What can we do to make sure we have the capacity for the 
dentists that we need?
    Dr. Satcher. I think dental education is expensive, and I 
think we need to invest in it. In some ways, when you compare 
it with medical education, for example, the cost of the tools 
and equipment to educate a dentist, and sometimes even access 
to patients, can be very difficult. So I think we need to 
really look critically at what we need to do as a nation to 
really foster access to dental education.
    The dental schools are struggling themselves, because they 
have to provide funding for faculty and others, and it is not 
as easy to support that with clinical care and other things as 
some other health professions. So I think we need to look at 
the unique needs of dental education in this country and how we 
can target specific programs to enhance dental education and 
better support of dental schools so they can expand their 
enrollment.
    It is no accident, of course, that all those dental schools 
closed, because dental education is expensive, and it became 
very difficult for some. Universities that have more than one 
health professions school, of course, tend to compare them in 
terms of what they bring in in terms of resources and what they 
require to support faculty and others. But I think we really 
need to make a commitment to dental education and provide the 
support that it is going to take. It would be a good investment 
in the long run.
    Senator Sessions. With regard to rural health care, 
generally, there is a higher level of poverty, compounded by 
the problem of dentists preferring to be in more urbanized 
areas.
    What do you think are the impediments, and what can we do 
to improve dental care out there in the rural areas?
    Dr. Satcher. I think rural health in general is a major 
challenge in terms of getting people who have gone through 
health professions schools to live and work in rural 
communities. But part of the problem is in fact the poverty of 
rural areas--that is one of the problems, because there is also 
lack of transportation and so on--but poverty in and of itself 
means that a disproportionate number of people who live in 
rural communities rely on Medicaid or their completely 
uninsured.
    So a dentist who is in another kind of community may be 
able to choose that he will see so many Medicaid patients, but 
he will also see a lot of patients who are private pay. But if 
you are in a community where the overwhelming majority of 
patients are poor, it becomes very difficult. We have to 
realize that it takes more support for people to practice in 
rural areas and in underserved inner city communities as well, 
for people to really be able to make a living. If you are 
relying on Medicaid, and Medicaid reimbursement is as low as we 
have all agreed that it is, you can imagine how difficult it is 
to make a go of it in a rural community when the majority of 
the patients are poor. If you talk to dentists throughout the 
country, that is what you hear.
    Senator Sessions. And that is one reason why they are 
choosing to practice in the more urban environments.
    Dr. Satcher. Exactly; that is one of the major reasons. It 
is very hard to make a living practicing dentistry in a rural 
community where you are depending upon reimbursement or no pay 
for the care that you provide.
    If Medicaid reimbursement is a problem for dentists even in 
established communities where a small percentage of their 
patients are Medicaid, you can imagine what it is like when you 
must rely upon that as your major source of pay.
    Senator Sessions. Is the Medicaid reimbursement set by the 
States totally, or do you know the numbers on that?
    Dr. Satcher. As you know, Medicaid is a partnership between 
the Federal and State governments, but the States set the 
reimbursement. But I don't want to imply that it is just a 
State problem. Medicaid is a partnership between Federal and 
State governments, and it may well be that the Federal 
Government will need to provide some form of assistance to help 
get Medicaid reimbursement up.
    States have to make that decision, and several States have 
made the decision, as you pointed out, to increase their 
Medicaid reimbursement. But when they do that, of course, they 
do it in the context of funding that is a partnership between 
the Federal and the State governments.
    Senator Sessions. Mr. Chairman, I don't know exactly how it 
happened, but as you read the articles in the Mobile newspaper 
and talk to dentists, you get a little bit of an impression 
that dentists felt like they were so underappreciated and so 
underfunded that gradually, many of them just gave up Medicaid 
practice, and we ended up with a real crisis.
    Dr. Satcher. Exactly.
    Senator Sessions. There has been an increase in Medicaid 
funding. The State Dental Association has worked hard to 
encourage dentists to get back into giving Medicaid patients, 
and we have had about a threefold increase in the last several 
years in the number of dentists who have been willing to do 
that. But I think this may be a bigger problem around the 
country than we like to think about.
    Dr. Satcher. I think it is a very big problem. Some of the 
same dentists who do not accept Medicaid patients and 
reimbursement, for example, provide free care. They join in 
programs to provide free care to poor children in certain 
communities. So it is an interesting paradox.
    Senator Sessions. Thank you.
    Senator Bingaman. Thank you.
    Senator Hutchinson?
    Senator Hutchinson. Thank you, Mr. Chairman.
    I think you have covered the subject very well, but just 
help me to understand one thing. In your testimony, you 
mentioned that for every one person who does not have health 
insurance in our country, there are 2.5 persons who do not have 
dental coverage. So if there are 40 million Americans without 
health insurance, that equates to 100 million without dental 
coverage.
    Why is it that health insurance plans do not typically 
cover dental health?
    Dr. Satcher. I am not sure that I can fully answer that 
question, but that is a major problem.
    In the workplace, for example, we found that only 60 
percent of baby boomers had dental care as a part of their 
insurance plans. So there are a lot of people who work every 
day who get their insurance from their employers, but do not 
get dental coverage.
    Again, when we look at health comprehensively, we have to 
really think about oral health as a part of overall health and 
well-being. So you cannot segment it out and say we will take 
care of this part of the body, but we will not take care of 
that part. It makes no sense, and that is what we tried to 
point out in our report, that oral health is such a critical 
component of overall health and well-being that we have got to 
move to a point in this country where we incorporate it into 
overall health. That includes insurance programs.
    Now, States set rules, I guess, for insurance coverage, and 
I know that there are guidelines set at the Federal level, but 
people really need to be educated as to the importance of oral 
health and the importance of it being part of the coverage.
    Senator Hutchinson. So in fact this lack of emphasis on 
dental care is very shortsighted.
    Dr. Satcher. That is why I started off my recommendations 
with the first recommendation to really educate and change the 
perception of the general public and policymakers, because a 
lot of people do not realize how important oral health is. Some 
people say that it is just cosmetic. It is much more than that, 
even though I would not downplay the importance of the cosmetic 
part in terms of people feeling comfortable about themselves 
and relating to others. But beyond that, there are other major 
problems that stem from poor oral health.
    Senator Hutchinson. From what Senator Sessions was saying, 
I would say that our most vulnerable population, our children, 
who are low-income, are faced with several barriers. We have a 
shortage of dentists. We also have a maldistribution of oral 
health care providers, and we have low participation of dental 
providers in the Medicaid program. And those three barriers are 
all interrelated as to what the reimbursement rate is, what 
kind of participation rate we get, and where dentists are going 
to locate to provide care.
    Would you comment on that?
    Dr. Satcher. I think you are right. I think they are all 
interrelated. We are doing two things. Obviously, we have 
created a potentially major problem in terms of the shortage of 
dentists in this country, and that is looming over our heads as 
we speak. But also, I think we have programmed oral health 
services in such a way that we end up shunning people in 
certain areas and leaving large proportions of the population 
out in terms of access to oral health services. So I think they 
are all interrelated in terms of where dentists are--first, how 
many dentists there are and will be, where dentists practice, 
whether or not they see children who are on Medicaid. They are 
all interrelated in the extent to which we value oral health 
and the extent to which we reflect that in our reimbursement 
programs.
    Senator Hutchinson. Thank you, Dr. Satcher.
    Senator Bingaman. Thank you very much.
    Let me just make one other comment and get any reaction 
that you may have. When I started hearing a lot about dental 
health problems was by visiting emergency rooms in my home 
State. In Albuquerque, for example, people would say, you know, 
you could take a lot of pressure off our emergency rooms if you 
could figure out some way to provide adequate dental care, 
particularly to kids. A lot of them are here because nobody is 
paying any attention to their dental health needs.
    I do not know if that is true nationwide, but it is 
certainly something that I have encountered.
    Dr. Satcher. I do not think there is any question about the 
fact that emergency rooms treat a lot of problems that are not 
emergencies in the classical sense and would not be problems at 
all if people had access to primary dental health services in 
their communities.
    In general, as you probably know, emergency rooms estimate 
that over half of the patients they see do not have emergencies 
in the classical sense.
    Now, when somebody has a toothache because they have not 
gotten dental care, you have created an emergency. So we create 
a lot of emergencies by not providing primary care, if you 
will. So I know the American Academy of Pediatrics and the 
American Academy of Dentistry and the American Dental 
Association and others are working very hard to increase 
awareness and develop models for solving these problems.
    The Boys and Girls Clubs, for example--if you want to look 
at some of the programs around the country to try to improve 
access that represent private efforts, there are several Boys 
and Girls Club programs that are being supported. Some dental 
schools, for example, will send dentists in vans to Boys and 
Girls Clubs to provide dental health services, and some of the 
foundations are supporting that, like Procter and Gamble, Rosie 
O'Donnell, and others.
    Senator Bingaman. Again, thank you very much, Dr. Satcher, 
for your testimony and your leadership on this issue. I do 
think the report that you issued as our Surgeon General has 
shined a light on the problem, and we are anxious to follow 
through with some actual legislation in this area. So thank you 
again for your help.
    Dr. Satcher. Thank you.
    Senator Sessions. I would like to add my thanks, Dr. 
Satcher, for the report and for your service.
    Dr. Satcher. Thank you.
    Senator Bingaman. We have a distinguished second panel 
consisting of five witness, and I will ask them to come forward 
now. I will introduce four of them, and Senator Hutchinson 
wishes to introduce one of the five.
    Dr. Burt Edelstein is the founding director of the 
Children's Dental Health Project. He is director of the 
Division of Community Health at Columbia University School of 
Dental and Oral Surgery. I have known Dr. Edelstein for several 
years. He is one of our Nation's leading authorities on 
children's dental health, and we appreciate him being here.
    Dr. Timothy Shriver is president and chief executive 
officer of the Special Olympics. He is a leading authority on 
children with special health care needs.
    Dr. Gregory Chadwick is current president of the American 
Dental Association, operates a private dental practice in 
Charlotte, NC. I want to particularly thank him and the 
American Dental Association for their longstanding support and 
advocacy in improving our Nation's oral health.
    Mr. Ed Martinez is chief executive officer of San Ysidro 
Health Center in California and a leader in addressing the 
needs of low-income Hispanic children along the U.S.-Mexico 
border.
    Senator Hutchinson, did you want to go ahead with the 
introduction of Dr. Mouden?
    Senator Hutchinson. Yes, I would be honored to. Thank you, 
Mr. Chairman.
    It is a real pleasure to introduce Dr. Lynn Mouden. Dr. 
Mouden is director of the Office of Oral Health in the Arkansas 
Department of Health. He came to us from Missouri, where he had 
been in private dental practice and was later the associate 
chief of Missouri's Bureau of Dental Health.
    Dr. Mouden is currently president of the National 
Association of State and Territorial Dental Directors. He 
serves on the External Review Panel at the Institute of 
Medicine, and he is a consultant to the American Dental 
Association's Council on Access, Prevention, and 
Interprofessional Relations.
    Dr. Mouden is also very involved in my home State, where he 
is the State coordinator of the Arkansas Special Olympics, 
chairman-elect of the Arkansas section of the American College 
of Dentists, and is on the faculty of both the School of Public 
Health and the School of Dental Hygiene at the University of 
Arkansas for Medical Sciences. He has published numerous dental 
articles and lectured extensively on dental subjects, and I am 
very pleased that he is going to be testifying today.
    I have made my apologies to him for having to excuse myself 
early, but I am very interested in this subject and look 
forward to reviewing the record.
    Thank you, Mr. Chairman.
    Senator Bingaman. Thank you very much, and thanks for being 
here and participating actively in the hearing.
    Why don't we just start on my right with Dr. Edelstein and 
then go right across the table? Let me also say that we will 
include the entire testimony of each of you in the full record. 
I think the best way to proceed if you could is to make the 
main points or summarize the main points that you think we need 
to be focused on, and do that in 5 or 6 minutes each, and then 
we'll have time for a few questions.
    Dr. Edelstein, thank you for being here.

STATEMENTS OF BURTON L. EDELSTEIN, DIRECTOR, CHILDREN'S HEALTH 
 PROJECT, AND DIRECTOR, DIVISION OF COMMUNITY HEALTH, COLUMBIA 
  UNIVERSITY SCHOOL OF DENTAL AND ORAL SURGERY, NEW YORK, NY; 
LYNN DOUGLAS MOUDEN, DIRECTOR, OFFICE OF ORAL HEALTH, ARKANSAS 
   DEPARTMENT OF HEALTH, LITTLE ROCK, AR; GREGORY CHADWICK, 
   CHARLOTTE, NC, PRESIDENT, AMERICAN DENTAL ASSOCIATION; ED 
 MARTINEZ, CHIEF EXECUTIVE OFFICER, SAN YSIDRO HEALTH CENTER, 
   SAN YSIDRO, CA, ON BEHALF OF THE NATIONAL ASSOCIATION OF 
 COMMUNITY HEALTH CENTERS, INC; AND TIMOTHY SHRIVER, PRESIDENT 
     AND CHIEF EXECUTIVE OFFICER, SPECIAL OLYMPICS, INC., 
                         WASHINGTON, DC

    Mr. Edelstein. Thank you, Senator Bingaman.
    I very much appreciate the opportunity to speak before this 
group and to recognize the sophistication of the opening 
remarks and the questions that were asked of Dr. Satcher. My 
effort will be to put some of the facts and figures that you 
have heard today into context and to try to point out the 
opportunities that this subcommittee has to advance children's 
oral health.
    I speak as the founding director of the Children's Dental 
Health Project. The Children's Dental Health Project is a not-
for-profit policy shop that works exclusively to improve 
children's access to dental services and their oral health. I 
also speak as a member of two organizations--the American 
Dental Education Association and the American Academy of 
Pediatric Dentistry, the 4,800 pediatric dentists in the 
country who serve children with direct dental services.
    My message is really quite simple, although the issue is 
indeed complex. The message is simply this. Far too many 
children suffer far too much disease that is consequential to 
their lives but overwhelmingly preventable. That is the irony 
of the entire problem.
    It is wonderful that there is a hearing. It is terrible 
that it has to be called ``The Crisis in Children's Dental 
Health: A Silent Epidemic,'' because indeed, it is a problem 
that should not exist.
    The good news is that with the tremendous improvements we 
have had for the majority of the population, the residual 
problem is solvable, and there are specific actions that can be 
taken that can make a real difference.
    How do we know that it is consequential, and how do we know 
it is important? I think that one of the most salient 
statistics, one that has not yet been featured today, is that 
when the National Health Interview Survey asks parents if their 
children have any unmet health care needs, three-quarters or 73 
percent of all those who report that their children have an 
unmet health care need report that that need is for dental 
care.
    So there is indeed a strong resonance with your 
constituencies, and there is a strong resonance in communities.
    The press has become ever more engaged in this issue, 
reflecting the fact that the population at-large is recognizing 
that there is a problem. Whether we are talking about this 
week's NPR story or last year's front page, above-the-fold New 
York Times article, this is an issue that is getting ever more 
attention.
    Foundations have become increasingly involved. State 
government has become increasingly involved. There are bits and 
pieces of voluntary efforts, some of which are sustainable, the 
majority of which are not, some of which are replicable, others 
that are idiosyncratic to their areas. But there are efforts 
underway that can lay the groundwork for Federal programs and 
Federal policies.
    Let me consider for a moment the statistics that you have 
heard today but in a different context. Wrap them into a story 
that indeed explains what it is that we are talking about here.
    In a very real sense, for those children who are still 
underserved, those children who still suffer significant 
disease, all the things that are problematic for child health 
care in this country are highlighted by oral health. Let me 
give you some examples.
    You have already heard about coverage. For every child who 
lacks medical coverage, there are 2.6 children who lack dental 
coverage. Let us talk about disease burden. It was already 
mentioned that dental caries is five times more common than 
asthma. Senator Bingaman mentioned that in his opening remarks. 
To bring that down to a more personal level, one out of every 
five children between the ages of 2 and 4 has a visible cavity 
upon inspection. One out of every two children in second grade 
has experienced tooth decay.
    If we are talking about access, we have a profound 
disparity where those children who have the greatest need have 
the least access, and those who have the least need have the 
greatest access.
    If we are talking about disparities again, we have the 
Hispanic population, the fastest-growing population in the 
United States of subset of children, and these are the children 
who have markedly higher caries rates--kids who are putting 
greater pressure on the delivery system in order to be served, 
many of whom are also low-income and many of whom depend upon 
Medicaid, a program which has overwhelmingly failed in the 
majority of States. I think we should State clearly that Smile 
Alabama is a notable exception, one of the six States that has 
made real progress in improving dental services.
    And if we are talking about disability, I think it is 
important to mention that 5 percent, one in every 20 children, 
have disease severe enough that it impedes their normal 
function.
    But having clearly described the problem and having heard 
about the problem, it is time to move along to solutions. And 
when we confront the solutions, the solutions themselves 
confront structural barriers. Some of them, you have already 
discussed today--work force. In work force, we have already 
heard about declining numbers of dentists and a maldistribution 
of dentists. But we also have a real profound problem with the 
diversity of dentists. The dentists of America do not reflect 
the composition of the American population. We also have an 
issue about the dentists' preparedness and comfort with 
treating those children with special health care needs, those 
children who are very young, those children who have the most 
advanced disease.
    We have a safety net issue. Any child with a broken arm can 
find his or her way into any emergency room and obtain care for 
that broken arm; but any child with a toothache, as you heard 
Dr. Satcher say, can get to the emergency room but will walk 
out only with pain medication and perhaps a prescription for 
antibiotics--no definitive care.
    We have a problem in education. Our dental schools are 
small in number--there are only 55--and we have a real crisis 
coming in the number of dental school faculty, with over 300 
unfilled funded slots in dental education today.
    Perhaps most important, NIH has done some tremendous 
research on the cause and progression of tooth decay. Some of 
that has simply not made it over to programs that identify 
children by risk and bring all the benefits of science to truly 
preventing disease in the first place.
    What are those congressional opportunities? The first is 
oversight. There are tremendous programs out there already that 
simply require closer congressional oversight to ensure that 
when they are talking about children's health, they mean 
children's total health and not just their medical care.
    The second is authorizing legislation like S. 1626--a bill 
that fills in some of the gaps that are missing because dental 
health had not in prior years been considered as important as 
your group now considers it.
    The third is appropriations to appropriately empower and 
sustain programs that can make a real difference.
    And of course, perhaps the most important is simple, 
straightforward leadership on your part, leadership that 
champions this problem and makes clear to the public that you 
hear them and that you understand what a problem it is for 
parents.
    So on behalf of America's children, on behalf of America's 
parents, we thank you. We thank you for S. 1626. We thank you 
for the other efforts represented, and most of all for the 
tremendous bipartisanship that this issue has received. And we 
look forward to supporting your efforts to move this from a 
bill to a markup to legislation that becomes law to programs 
that really make a difference for children.
    You see pictures here of the kinds of conditions that 
children are in. This committee, with its concern for 
education, works hard to make sure that there are school lunch 
programs, that children are well taken care of and prepared to 
learn. We have already heard that if they are in poor dental 
health, they are not prepared to learn. Not only do we provide 
them with lunch programs, but now, let us make sure that they 
are able to eat them.
    Thanks very much.
    Senator Bingaman. Thank you very much, Dr. Edelstein.
    [The prepared statement of Mr. Edelstein may be found in 
additional material.]
    Senator Bingaman. Dr. Mouden, thank you very much for being 
here. Please go right ahead.
    Mr. Mouden. Thank you, Mr. Chairman.
    As both Arkansas' State dental director and as president of 
the Association of State and Territorial Dental Directors, I 
thank you for the opportunity to talk about the importance of 
improving oral health for all of America.
    I would like to start by answering a question you asked 
earlier about why we seem to have let oral health slide down 
the ladder of importance. I think it is a matter of national 
priorities. Quite frankly, we live in a country where even 
insurance companies are allowed to end their insurance coverage 
the neck. For reasons unknown, we do not cover, dental, mental, 
and vision in the same way that we cover other health problems.
    I would like to give a little perspective on Arkansas and 
then reflect on the country as a whole. Arkansas is often 
described as the unhealthiest State in the Nation based on a 
wide variety of health indicators. It also mirrors the Nation 
in that oral disease remains pervasive among families with low 
income, those with limited education, the frail elderly, 
persons with disabilities, those who are underserved, and 
ethnic minorities.
    Arkansas' recent Statewide oral health assessment showed 
that on average, Arkansas third grade children suffer from 
three cavities each, and Statewide, more than three-fourths of 
our children have had tooth decay.
    Obviously, the slogan of the 1960's of ``Look, Ma, no 
cavities,'' is not being realized in Arkansas. Worse yet, 
Arkansas is not unique.
    More than 40 percent of Arkansas' children attend school 
with untreated cavities, and one in 12 has emergency dental 
needs. Such severe dental problems adversely affect how these 
children eat--or cannot eat--how they sleep--or cannot sleep--
how they succeed in school--or cannot succeed. These children 
also enter adult life with a mouth that no one would hire to 
smile at a customer.
    Consider for a moment if these same dental statistics 
applied to the 100 Members of the U.S. Senate. I wonder how 
well the Senate's business would proceed if 40 Senators had 
untreated tooth decay and 8 of them tried to work with a 
toothache. I will leave it to the members of the committee to 
decide which eight they would like to have a toothache. 
[Laughter.]
    Senator Bingaman. That may be why we have such trouble 
getting along with some of our colleagues here. [Laughter.]
    Senator Sessions. Some give me a headache. [Laughter.]
    Mr. Mouden. Our problems are even worse in the Mississippi 
River Delta and in the inner city of Little Rock, with 50 
percent more of the children needing emergency care. These 
areas are predominantly poor and with a higher percentage of 
ethnic minorities.
    A recent screening brought one such child to our attention. 
The boy, when asked if he had a toothbrush, responded: ``Yes, 
but it does not have any hairs on it anymore.'' The toothbrush 
was so worn that it no longer had even one bristle, but by the 
same token, he was proud to have a toothbrush.
    Insufficient funding of Medicaid continues to plague 
Arkansans. Arkansas Medicaid only pays approximately 50 percent 
of a participating dentist's usual fees. In a profession where 
overhead is typically 70 percent of income, it is amazing that 
dentists are put into a unique position of having to subsidize 
their services by providing dental care at less than cost.
    And increased funding for Medicaid is not the whole answer, 
because dentistry's commitment to the underserved is well-
documented. In Arkansas alone, dentists donate more than $8 
million each year in free dental care. However, it is often the 
bureaucratic barriers that can make participation in Medicaid 
an administrative nightmare for dentists.
    S. 1626 provides several methods to ensure optimum oral 
health for all. The requirement that States provide adequate 
reimbursement to dentists will bolster our system. The 
requirement that State plans guarantee access for children 
equal to that available in the general population will ensure 
dental care for those children at highest risk.
    S. 1626 also provides an important initiative to support 
oral health promotion and disease prevention. Dentistry and 
State oral health programs have a long history of primary 
prevention activities. Community water fluoridation has long 
been heralded as the most effective, most economical and safest 
method for preventing tooth decay. However, without continued 
and increased funding to support fluoridation, communities 
working to balance difficult budgets often discontinue this 
important public health program.
    In addition, other proven prevention programs such as 
dental sealant initiatives also rely on Federal support for 
success.
    Although fluoridation and dental sealants are proven 
prevention methods, Arkansas has only 59 percent of its 
citizens enjoying the benefits of fluoridation, and only one-
fourth of our children have dental sealants. In the poorer 
areas of Arkansas, less than 2 percent of our children have 
sealants.
    Arkansas recently received a grant from the CDC Division of 
Oral Health--and I do ask that the written comments be 
corrected, that it is the ``Division'' of Oral Health. Through 
that grant, our State has made tremendous inroads in 
establishing rural health partnerships throughout Arkansas. The 
grant has helped us ensure effective preventive activities. We 
are now able to reach out to other professions, educating them 
on the effect of oral health upon a patient's general health. 
We also have new programs to enhance oral health services for 
our most vulnerable populations, especially those individuals 
with developmental disabilities.
    However, only five States received this funding in 2001. S. 
1626 would greatly enhance support for State and local 
programs, allowing us to increase access for the underserved 
populations of Arkansas and the Nation.
    In addition, I encourage you to support increased funding 
to the CDC to build upon the successful cooperative agreement 
initiative.
    In 2000, our association published a study on 
infrastructure and capacity in State oral health programs. The 
study identified the administrative and financial barriers to 
improving the Nation's oral health. Leadership from State 
dental directors is imperative to make dental public health 
programs succeed. However, even among the members of this 
committee, some of these States do not have dental directors so 
are already lacking in dental public health resources.
    Many Americans enjoy the highest quality of dentistry in 
the world. If a child lives in Maumelle, AR and has plenty of 
money, access to dental care is no problem. However, if that 
child lives in poverty in the Arkansas Delta, access to dental 
care is almost impossible. Eliminating disparities in oral 
health must be our goal.
    In closing, I want to thank you, Mr. Chairman, for 
recognizing the oral health crisis in this country and for the 
efforts to make a difference.
    I applaud Arkansas' Senators Hutchinson and Lincoln and the 
others who have supported this effort.
    I thank you for giving us the chance to champion the chance 
for all American children to enjoy oral health--to eat, to be 
free from pain, and to smile. I ask that you continue to work 
with us, those of us at the local, State, and national levels, 
to make optimum oral health for everyone in America a reality.
    Thank you.
    Senator Bingaman. Thank you very much.
    [The prepared statement of Mr. Mouden may be found in 
additional material.]
    Senator Bingaman. Dr. Chadwick, please go right ahead.
    Mr. Chadwick. Thank you, Mr. Chairman.
    I am Greg Chadwick, president of the American Dental 
Association, which represents over 70 percent of the dentists 
in this country. I speak today on behalf of the community of 
dental professionals.
    We are sincerely grateful for this opportunity to present 
to you at this first ever hearing on oral health and children's 
health.
    Dentists are proud that most Americans enjoy excellent oral 
health, but we also believe it is a national disgrace that in 
America today, thousands of children cannot sleep or eat 
properly, cannot pay attention in school, and do not smile 
because of untreated dental disease which is so easily 
preventable.
    Dentists are fighting to bring these children into the 
system, but we cannot do it alone. Until we as a nation find 
the political will to make oral health a priority, our children 
will continue to suffer.
    While we are making progress, our biggest challenge remains 
convincing legislators that oral health is just as important as 
medical care, and not simply a throwaway benefit or the easiest 
program to be cut from a tight budget.
    We are committed to changing this. Next February, the ADA 
will join dental societies all across the country in a one-day 
campaign to deliver free services to children who would not 
otherwise receive dental care.
    Although the ``Give Kids a Smile'' project will help 
thousands of children, our larger purpose will be to deliver 
the message that we cannot solve this problem alone and that 
for every child that we care for that day, there are hundreds 
of thousands more that will continue to suffer until the Nation 
gets serious about oral health.
    Charity alone will never fix the problem, because charity 
is not a health care system. The real irony is that preventive 
programs could effectively eliminate dental disease, and they 
do not cost a lot of money. Community water fluoridation and 
sealants can prevent pain and save billions, yet 100 million 
people in this country do not have access to fluoridated water.
    Take a look at the posters that we have brought today. One 
of them shows a 4-year-old boy who was hospitalized for 5 days 
with a preventable facial infection, costing the taxpayers over 
$20,000. Routine dental care would have prevented the pain, the 
emotional trauma, and the expense.
    The problems are clear, and the solutions are not 
difficult. The missing element is committed leadership at the 
national and State levels.
    The dental Medicaid program is broken. Some State Medicaid 
programs reimburse dentists at 30 cents or less for every 
dollar of care provided. The cost to provide the care is over 
twice that much, exclusive of any compensation to the provider.
    Many States set fee structures that are inadequate and then 
leave them in place for as long as 15 or 20 years. Here in our 
Nation's capital, Medicaid rates have not increased, even to 
cover the cost of inflation, since 1985.
    Federal law under Medicaid requires the States to cover and 
provide dental services to children, but States are struggling 
to make ends meet, and the Federal Government is not enforcing 
the law. All in all, government is not living up to the 
statutory obligation. The cost of this untreated childhood 
disease has far-reaching consequences. People who do not have 
teeth do not have good jobs.
    Some States are testing innovative programs to improve 
Medicaid and SCHIP programs. Michigan, for example, has 
designed a program that functions very much like a private 
program, with rates and features that mirror the marketplace. 
Consequently, the number of children treated has increased from 
18 to 45 percent.
    There are other good States examples like, for example, the 
Smile Alabama program, which has been mentioned a couple of 
times today.
    Another barrier to access is lack of dentists, particularly 
pediatric dentists, in underserved areas. Congress can help 
States establish programs to attract dentists to underserved 
areas, especially rural areas, through tax credits and student 
loan forgiveness.
    This committee can also support HRSA dental training 
programs that have been targeted for severe cutbacks and 
sometimes even elimination.
    We must also strengthen our dental schools, which are 
front-line and in some areas a main delivery system for care. 
Many dental schools face faculty shortages and lack of 
diversity among faculty and student bodies. Additional support 
is vitally needed to train a future dental work force so that 
access problems are not exacerbated.
    I want to take a moment to thank you, Mr. Chairman and also 
Senator Collins, for your leadership in introducing bills to 
help more States pursue innovative solutions to improve 
children's access to care. You and your cosponsors are taking 
action, and I urge all Senators to join you in passing these 
important bills.
    I wish I could tell you that if Congress did a few simple 
things, the problem would be solved, but I cannot. And our 
profession does not expect Congress to solve the Nation's oral 
health crisis with a stroke of a pen. But we do expect you to 
join us in making this a national priority. Let us start with 
our children, our common future, and build outward from there.
    Thank you, and we look forward to work with you, Mr. 
Chairman.
    Senator Bingaman. Thank you very much for your testimony, 
Dr. Chadwick.
    [The prepared statement of Mr. Chadwick may be found in 
additional material.]
    Senator Bingaman. Mr. Martinez, please go right ahead.
    Mr. Martinez. Mr. Chairman, thank you very much.
    My name is Ed Martinez, and I am the CEO of San Ysidro 
Health Center in San Ysidro, CA, which is a small community in 
the southern part of the City of San Diego adjacent to the 
U.S.-Mexico border.
    It is my privilege this afternoon to testify in support of 
S. 1626 as a representative of the National Association of 
Community Health Centers and the millions of patients that we 
take care of every year.
    Currently, there are nearly 800 federally-supported health 
centers operating nearly 3,400 community sites across the 
country. Together with more than 200 other health centers known 
as FQHC look-alikes, we treat approximately 12 million people 
annually. Out of this population, 5 million are children.
    Our dental network consists of 402 dental clinics. We 
employ approximately 1,000 dentists. In the year 2000, we had 
1.3 million dental patients. We have generated approximately 3 
million dental visits.
    Collectively, we have produced a model of health care that 
has demonstrated that this Nation can meet compelling health 
needs while containing health care costs. The health center 
legacy probably shows the value and vast potential of a 
community-based health system that is lifting the barriers to 
health care, safeguarding health, revitalizing communities, 
keeping people healthy at cost savings to the Nation.
    A few words about my health center. It was started in 1969 
by a local women's organization that was interested and 
concerned about the lack of dentists and doctors in their 
community in San Ysidro. The women went to the San Diego 
Medical Society and the University of California School of 
Medicine and were collectively successful in opening a free 
clinic in 1969.
    Today, through the help of State and Federal resources and 
private foundations, we operate a network of nine neighborhood 
health centers, and we have approximately 40,000 registered 
patients. Last year, we generated 180,000 visits in medical, 
behavioral, and dental health services.
    Our patient population is 80 percent from the Latino 
background of low-income households. Our services emphasize 
early screening and intervention which are key to oral health 
initiatives.
    What has been our experience in terms of oral health? Since 
1973, when our first dental clinic opened, we have been the 
primary dental safety net for the South Bay Region of San Diego 
County. Each month, we treat approximately 1,700 patients, 
adults and children. Out of this population, about 500 children 
are under the age of 10. Most of these children present at our 
dental clinic with advanced stages of dental disease. Most if 
not all come from families without medical and dental 
insurance.
    At the urging of our dentists when I first arrived at the 
health center 4 years ago, we decided to perform an oral health 
needs assessment in our community. We did this in the year 
2000. Our dentists spent 4 months in the community, going to 
preschools, Head Start programs, local school districts. We 
examined 2,000 children all under the age of 5. The statistics 
were alarming. Sixty-nine percent of the children surveyed had 
untreated dental disease. Forty percent had one to six caries. 
Twenty percent, or almost 200 children, had 12 or more caries.
    We know from other studies that 5 percent of this 
population, or approximately 100 children, would eventually 
require restorative care in the operating room under 
anesthesia. In our State, this kind of procedure will cost 
Medicaid close to $5,000 to $7,000, something that we all pay 
for.
    This information was very clear and explained why the 
dentists were so frustrated working at 100 percent capacity to 
keep up, or at least try to keep up, with the tidal wave of 
underserved children with dental disease. I think it is fair to 
say that collectively across this country, we are all caught in 
a frustrating cycle of running to keep up with this increasing 
demand for treatment, while recognizing the fact that over 
time, the only effective way to reduce the burden of children's 
dental disease is to implement community-based disease 
prevention and health promotion initiatives.
    With limited program capacity and increasing dental disease 
among children, additional resources are desperately needed to 
effectively respond at the community level. I am here today to 
say that the health centers in America stand ready to work on 
improving children's care and oral health and on improving the 
implementation of S. 1626.
    There are three primary reasons why I feel that we are up 
to it. No. 1, health centers are strategically positioned, 
uniquely positioned, to make S. 1626 successful. We are located 
in high-need underserved communities, and the communities trust 
us.
    We have a nationwide care delivery system of 3,400 delivery 
sites in underserved communities. We are governed by community 
boards, and we have a legacy of organizational commitment to 
serving those who have no insurance or are underserved and in 
need of care.
    Second, health centers are in a high State of readiness. 
Although our safety net is thin, and in some areas, it has 
holes in it, our commitment is strong. We have a 
multidisciplinary work force that is committed to working in 
our community centers. They could work anywhere because of 
their background and experience, but they choose to serve the 
community.
    We have the essential administrative infrastructure in 
place to manage service expansion initiatives in a cost-
effective and timely manner.
    I believe we have effective accountability systems in place 
that can manage and oversee the financial management and 
quality assurance of our services.
    We have developed a history of effective community-based 
disease prevention programs and pediatric and prenatal 
programs--again, early screening and early intervention.
    Finally, health centers can deliver much of what S. 1626 
proposes. We work with the children in the communities that are 
at risk now. We can find the children who are at risk.
    We have treatment programs in place. We can connect the 
children to treatment services. We have essential enabling and 
support services such as translation, transportation, help with 
referrals. Once the children are in service, we can support 
their families in the maintenance and continuity of the care, 
which over time is really the secret to what we are talking 
about.
    Finally, we have the passion and the commitment at the 
community level to develop innovative strategies and procedures 
for preventing disease, engaging parents, and long-term 
sustainable efforts to stop the cycle of disease.
    For all of these reasons, I believe that health centers 
stand ready to support you in this very important initiative.
    Thank you very much.
    Senator Bingaman. Thank you very much for your testimony, 
Mr. Martinez.
    [The prepared statement of Mr. Martinez may be found in 
additional material.]
    Senator Bingaman. Dr. Shriver, please proceed.
    Mr. Shriver. Mr. Chairman, Senator Sessions, distinguished 
guests, Special Olympics volunteers--among whom I gather I have 
a colleague on the panel--distinguished panelists, Special 
Olympics athletes and family members who are here, I am 
enormously grateful, like the other members of the panel, to be 
here.
    I come representing a movement of a million athletes 
participating in the Special Olympics around the world, over 
500,000 who participate in this country alone every year. It is 
a movement that is 35 years old and built on a simple concept. 
It is built on the concept that everyone deserves a chance and 
everyone when given a chance can make a difference.
    Special Olympics just completed its first publication 
designed for and by athletes. I want to recognize Renee Deitz, 
a former athlete who is here, who helped in the design of this 
little booklet which you have in front of you. It brings sound 
health care advice to our athletes when they come to our events 
and enter our health screenings. It has a mirror on the cover 
which cost a few cents extra, but the athletes told us it was 
an important reminder. I encourage the possibility that we 
might think of the mirror in a different way than a toothache, 
as a mirror on our own responsiveness to this population as we 
proceed with this legislation and its important agenda.
    I think that if we were to look in the mirror today and ask 
the question, are we responding to the health care needs of 
people with mental retardation, we would have to answer no.
    I come today after several years of embarking on this work 
in the Healthy Athletes Program to say that the athletes of 
Special Olympics who are Americans, who deserve respect, who 
are heroes in some cases in their own communities, are 
reporting being shunned, discriminated against, overlooked and 
forgotten in the delivery of health care to them and to their 
families in this country. They are not, Senators, being given a 
chance in the way in which our movement would hope to embody.
    We first learned this 7 year ago when, at the Special 
Olympics World Summer Games in Connecticut in 1995, we had 
40,000 volunteers and for the first time set up health 
screening centers providing health screening in oral health and 
eye health and vision health. At the end of the week, I heard 
the results of the several thousand athletes who had passed 
through those screenings. On the oral health care front alone, 
68 percent of the athletes had gingivitis; one in three 
athletes, untreated decay; 20 percent, one in five, reported 
pain in the oral cavity. Fifteen percent had to be referred to 
emergency rooms from the Special Olympics venues because of 
such severe pain or disease.
    In the days that followed, we embarked on an attempt to 
understand this. We talked to several doctors, and I remember 
one explanation in particular. A doctor took me aside and said, 
``Tim, in most cases, doctors do not want to treat these 
patients. They either do not know how, or there are not 
adequate reimbursements, but often even when they do, it is not 
real care. It is a `quick and dirty'--get them in, get them 
out.''
    Other doctors have reinforced this unfortunate situation. 
Just last month, one of our leading dentists, Dr. Steve 
Perlman, who has blue-chip credentials, talked about changes in 
the dental profession over the last 20 years. He said, and I 
quote: ``Almost everyone has given up treating Medicaid 
patients, and it seems all have given up treating people with 
special needs. Many of us were told by our fellow 
professionals, Oh, you take care of people with special needs 
because you are not good enough to treat normal people; you can 
get away with anything.''
    When he makes referrals, he says he refers patients to 
other specialists, and he has met with: ``If you let one in, 
you let them all in.''
    Over the last few years, we have tried to respond to this 
crisis. We have created this health program called Healthy 
Athletes which includes year-around community-based health 
screening, care, and referral efforts designed to reach people 
with mental retardation and closely-related developmental 
disabilities and their families. It is enormously successful, 
and it is growing. We are continuing to seek Federal support 
for its expansion. We believe that it is a model for a 
nontraditional public health delivery system using a sports 
program to deliver at least some basic information, care, and 
referral services at events like Special Olympics. But we just 
cannot continue to listen to parents, who tell us over and over 
again: ``I cannot find a dentist to treat my son'' or daughter. 
I know you can imagine from your own work with your 
constituents how painful it is to hear that message--and 
sometimes it is transportation, but frequently, it is training 
or openness or willingness to care.
    This bill holds great potential, and I support the 
statements of all the prior speakers including and especially 
former Surgeon General Satcher, who has been an advocate for 
the health care needs of people with mental disabilities.
    However, Senator, you mentioned earlier the opportunity to 
have input and make suggestions. I would respectfully ask that 
you consider the possibility of specific mention of the oral 
health care needs of people with mental retardation and closely 
related developmental disabilities.
    Our experience shows very simply that when they are not 
mentioned specifically in legislation, they are overlooked. I 
know there are thousands of special interest groups, but this 
is a population that is routinely and regularly overlooked in 
the delivery of these kinds of services, so specific mention of 
policies to affect reimbursements for the care of people with 
mental disabilities--specific mention of requirements for 
provider training in the care of people with mental 
disabilities--would be enormously valuable additions to this 
bill and would give us a sense that when it is enacted, as I'm 
sure it will be, our population will not once again be 
forgotten.
    My time is up, but let me close with a short story that 
came to me last week from a mother of one of our athletes whose 
son graduated from high school in Vermont last week. She 
describes her son preparing to give a short, 2-minute speech. 
Her name is Kim Daniels, her son is Troy Daniels.
    Troy's speech was only 2 minutes long, but I want to quote 
from it here today. In part, he said in his speech--this is a 
young man with Down syndrome who often uses a communicative 
device because he is hard to understanding--but speaking on his 
own, he said: ``Not long ago, people with disabilities could 
not go to school with other kids, could not have real friends. 
Not long ago, they called people like me `a retard.' That 
breaks my heart. When I came to school, there was a law that 
says all kids go to school in the place where they live. The 
law says that I can come to school, but no law can make me have 
friends. I want all people to know and to see that the students 
I call my friends are the real teachers in life. They are 
showing you how it should be. They are the teachers for all of 
you to follow their lead. Yes, I am a person with a disability, 
and the law says I am included--but it is my friends who say, 
`T.D., come sit by me.' ''
    At the end of Troy's speech, there was a standing ovation, 
as you might guess. But today, I come with the simple message, 
really echoing his words, that I am asking on behalf of our 
athletes and their fellow citizens with mental disabilities, 
over 7 million in this country, that the U.S. Senate and the 
United States Congress, leading policymakers, the people on 
this panel and others, listen to Troy's invitation and say to 
him: ``Come sit by me. Come sit in my waiting room. Come and 
sit in a dental chair and receive the care that you need and 
the care that I will give you.''
    This is a population that has its own special challenges; 
it needs special attention in order to receive the just care 
that it deserves.
    Thank you.
    [The prepared statement of Mr. Shriver may be found in 
additional material.]
    Senator Bingaman. Thank you, and I thank all the witnesses. 
I think this has been very valuable testimony.
    Let me ask a few questions, and I am sure Senator Sessions 
will have a few questions as well.
    On the issue of work force shortages that we have all 
talked about and several of you discussed, what can we be doing 
proactively other than what we have in this legislation, if 
there are thoughts that any of you have, to deal with this 
growing problem?
    In my State, we have never had a dental school. We have 
always depended on people in our State who wanted to become 
dentists going to some nearby State and getting their training 
and hopefully coming back. More often than not, they decided 
not to come back for financial reasons or whatever. I think we 
are 49 out of 50 States in the number of dentists that we have 
per capita in my State of New Mexico. So if the Nation overall 
has a shortage of dentists, we have a real shortage of dentists 
in my State.
    What can we be doing to solve this problem? It seems to me 
like something does not fit here. The compensation levels are 
very high for dentists in my State--at least, that is what I am 
informed. It is a very good profession to pursue from a 
financial point of view. There are problems getting dentists to 
settle in rural parts of our State, but that does not explain 
to me why there is an overall shortage.
    If any of you has some additional insight into this, I 
would be anxious to hear it.
    Dr. Chadwick, you are in charge of the dentists in the 
country. Why don't you explain it first?
    Mr. Chadwick. I wish I were in charge of the dentists. If 
you will make me in charge of the dentists in this country, we 
can get some things solved.
    Senator Bingaman. OK. Go ahead and tell us the answer.
    Mr. Chadwick. You started your comments by saying ``other 
than what is in our bill''; I would say first of all, let us 
make sure that the things that are in the legislation--well, 
first of all that we get the bill passed, and then we begin to 
implement it. So I think you are off to a great start, and I 
think you have some of the more salient features.
    I would point out two that jump out at me in your 
legislation. One is the loan repayment provisions, and the 
other is the $1,000 per month stipend for those who see a 
significant number of Medicaid patients. According to the 
students, that is significant, so we certainly would not want 
to underestimate those.
    In general, I think we need to make sure we are providing 
adequate financial incentives for advanced general dentistry 
programs, for residency programs in pediatrics, to treat some 
of the children in the rural and underserved areas.
    You said the problem was overall. I suspect that in the 
more urban areas, you probably have an adequate number of 
dentists. It is when you go into those underserved areas, and 
therein lies the challenge of beginning to get people to go to 
or back to an underserved area. I think Dr. Satcher put it very 
well. In poorer areas, there is often not enough to attract 
physicians and dentists to those areas. So I think we have to 
give them some special incentives.
    I was speaking to a dentist in rural Kansas not long ago, 
and he said, ``I do not have anybody to take over my practice, 
and I have lived here and practiced here all my life.'' And in 
the conversation, it turned out that he had a daughter who was 
in dental school, and he said that she was coming back to take 
his place, but she is marrying a physician, and they have 
decided to stay in Kansas City. So therein lies our challenge, 
which is providing adequate incentives to get people back to 
those rural areas.
    Let us not discount the diversity issue, either. We need to 
attract more diverse students to our dental schools. We need to 
attract more diverse people into our profession. Certainly, our 
patients are a lot more diverse than our profession itself.
    Last weekend at the ADA, for example, we had a conference 
on diversity, and we met with a number of these groups, and one 
of the main things that we were talking about in that afternoon 
was how can we work together to recruit minority dentists, 
racial and ethnic minorities, into dentistry. And I do not 
think the place to look is necessarily in the high school 
senior class or the folks who are in college. Maybe we need to 
go back even further; maybe we need to be talking about this in 
junior high and in early high school with guidance counselors 
to begin to get people to realize that there is a possibility 
for a profession in dentistry.
    Senator Bingaman. Let me ask Dr. Edelstein or any of the 
other panelists, does it make sense to do what Dr. Shriver is 
recommending here and build into the training of dentists and 
dental hygienists and others some particular training related 
to individuals with mental disabilities? Is that something that 
is in the training now, and should it be in the training?
    Mr. Edelstein. Without doubt, it is essential, and it 
relates very closely to your former question about the number 
of dentists available, because the number of dentists available 
really matters at the level of the number of dentists available 
to those who most need services. So it is a complex issue that 
relates to productivity, accessibility, dentist preparation and 
comfort with the various patients who most need services--and 
not just numbers.
    So that, for example, let us look at Michigan as an example 
of a State that has made a major reform. Overnight, by changing 
the administration of their Medicaid program, the Medicaid 
child became identical to the commercially insured child, and 
service rates begin to approach the commercial insured rates 
for children. There were no increased numbers of dentists in 
the demonstration counties. There was simply a change in the 
program so that the children on Medicaid looked identical to 
the children in the premium insurance program.
    Senator Bingaman. And that was because they raised the 
reimbursement rate under Medicaid?
    Mr. Edelstein. Not only did they raise the reimbursement 
rate, but the State signed onto a commercial network using the 
standard methods that dentists use for filing claims, for 
having prior authorizations--all the paperwork that is involved 
in running a dental office became identical for Medicaid as for 
the commercial program. So it just fit with and made sense to 
the private dental community.
    The safety net is equally hampered by low Medicaid 
reimbursement, and it has tremendous capacity where private 
providers are not as available. But the overwhelming numbers of 
dentists today re still located in the private sector, so 
programs like Michigan's that bring in the private sector to 
people who would otherwise have no access become critically 
important.
    Senator Bingaman. Let me ask one more question, and then I 
will defer to Senator Sessions.
    Mr. Martinez, you indicated that there are 3,400 community 
health center delivery sites in the country.
    Mr. Martinez. Yes.
    Senator Bingaman. And there are 402 dental clinics.
    Mr. Martinez. Yes.
    Senator Bingaman. If I am understanding those numbers, the 
obvious conclusion is that there is a tremendous number of 
delivery sites that do not provide any kind of oral health 
care.
    Mr. Martinez. That is correct. One of the issues that we 
are dealing with is the capital required to by the equipment, 
which is very expensive; it is about $40,000 per operatory, to 
do the construction, recruit the staff. There is a scarcity of 
resources right now that we are all dealing with, and 
consequently, of the 800 federally-funded health centers, about 
402 have dental clinics.
    There is an expansion initiative that the Bureau of Primary 
Health Care has right now, and they are providing additional 
dollars to allow centers to add dental to their program.
    If I could, I would like to talk a little bit about the 
pipeline of professionals, dentists. I think we can do more in 
the area of finding students early, in elementary school, and 
introducing them to the profession of dentistry.
    We are affiliated with a local hospital at the University 
of California, and we have a family medicine residency training 
program. Next year, one of the first graduates will be a 
gentleman, a doctor, from San Ysidro. His mother brought him to 
the clinic for his shots when he was an infant. He graduated 
from Harvard Medical School and had the choice of different 
residencies to complete, and he selected our center. So we 
``grew our own,'' and I think this is what we have to do, 
partnering with dental schools. There are some high schools 
that have health career programs, and bringing the students in 
and showing them what the dental profession is all about, I 
think will do a lot.
    Senator Bingaman. Thank you.
    Senator Sessions?
    Senator Sessions. Thank you, Mr. Chairman.
    This has been extremely interesting, and I guess the 
question gets down to how can we actually make things work 
better, and Mr. Chairman, I believe that the legislation that 
you are proposing takes us a good step.
    Dr. Chadwick, you are familiar with dental practice in 
America, the practical aspects of it. What can we do to 
identify at an earlier age, and are we doing enough through 
schools and other institutions to identify children wit 
problems, to use sealants, as Senator Bingaman suggested? Could 
we, through management and with, all things considered, a 
relatively small amount of money make some big progress in 
identifying and protecting children earlier?
    Mr. Chadwick. I think certainly we could, and I think 
prevention has to be our gold standard. You have got to 
appreciate that dental disease starts, it progresses, and it 
keeps on going. It is not like a common cold; you do not get 
rid of it. You have got to either restore it or, if it is in a 
primary tooth, that tooth comes out. It is completely 
progressive.
    So prevention works if you can start at the beginning of 
the pipeline. It would be an interesting experiment if we could 
actually get a commitment from everybody in this country that 
oral health was important, and we agreed on that today. The 
first baby born right now would not have a tooth for 6 months, 
so we would have 6 months to get this thing under way and then, 
have every baby seen when their teeth first erupt by a dentist 
to diagnose any problems and then have the team begin to apply 
sealants and fluorides and so on. We could really curtail that 
common disease of childhood which is dental caries.
    But yes, prevention works. It is a good investment, 
especially when you talk about sealants and why don't you just 
go ahead and put sealants on teeth----
    Senator Sessions. Why don't we?
    Mr. Chadwick. One reason--let us do it, but let us do it in 
the right order. It is kind of like painting a house. If you 
have peeling paint, and you have problems in the wood, you do 
not just put a new coat of paint on it. It is the same thing 
with sealants. If we are going to do something like this, let 
us have those children see a dentist; let us diagnose the 
problems and see if there are any minor problems there to begin 
with, and let us go ahead and treat those and then put the 
sealants on--and then, let us see them periodically every 
couple of years or every year to see if those sealants are 
holding up and if one of them needs to be replaced.
    And while we are talking about prevention, let us not 
forget fluoride. That does not require going to a dentist or 
anything. All you have to do is drink water that has been 
fluoridated. And as I said in my statement, we have 100 million 
people in this country right now who do not drink fluoridated 
water--and fluoride is about 60 percent effective in preventing 
decay.
    Senator Sessions. Dr. Edelstein, in terms of investment--
you have stated these numbers--it seems like this is a winnable 
war. It is an effort where, for a relatively small investment, 
we could get tremendous returns which would save larger costs 
and may even come close to paying for itself. Certainly, if it 
does not pay for itself financially, it does health-wise for 
the people that we treat.
    Do you have any comments on that?
    Mr. Edelstein. Without forgetting about the children who 
already have disease that needs to be repaired--and that is an 
expensive bill--without forgetting about those children, the 
promise of comprehensive care that has an essential preventive 
component is tremendous. You have real potential cost savings.
    Senator Sessions. But the ones who need care now will only 
get worse and become even more expensive with every week that 
goes by unless they are treated; isn't that true?
    Mr. Edelstein. Absolutely. As an expression of that, CMS 
was asked to estimate the cost of general anesthesia procedures 
just to have children treated under general anesthesia, because 
they are very young and their disease is severe. The estimate 
was that $100 to $300 million a year of Medicaid expenditure in 
the country go to general anesthetic services that make it 
possible to provide restorative care.
    So there are some significant expenses. On the other hand, 
the cost of dental services in Medicaid across the country 
averages about 0.5 percent of total State Medicaid 
expenditures. If a significant increase were implemented, we 
would still be talking about a very marginal cost in a large 
program.
    So the potential to spend little and have tremendous 
results as you suggest is absolutely the case.
    Senator Sessions. Mr. Martinez and Dr. Edelstein, I 
recently visited with Claude Allen, Secretary Thompson's top 
assistant, five community health centers in rural areas in 
Alabama. I remember distinctly that one of them had a fully-
equipped dentist's office with no dentist; others were having 
trouble getting dentists part-time. This is a real problem.
    After that visit, I am inclined to believe that we need to 
enlist the private health care system more and work more 
effectively with the community health centers, but do you have 
any comments on how we can deal with this problem?
    Mr. Martinez. This is a problem. In our community, we have 
rural areas in East San Diego County and parts of the north 
county. All the clinics in San Diego came together as a 
consortium and approached a local foundation for some support 
to put together a dental safety net that would cover the 
country geographically. Our thought was that we would first 
build the primary care treatment with basic funding, and then 
go on to request other funding for a specialty pool where we 
could contract with specialists, dentists working as 
specialists who could go to different centers on a limited 
basis, maybe 1 day a week, and provide services needed in that 
community. We are looking at mobile services as well.
    I think the key is that the health centers and the local 
dental society community, working together, can best solve this 
problem, because really, it is a community problem.
    Senator Sessions. Dr. Edelstein and Dr. Chadwick, if you 
would like to comment on that, too, I would appreciate it.
    Mr. Edelstein. I would like to echo Ed's remarks and 
suggest that HRSA does allow the contracting of private 
dentists to community health centers, and that is a potential 
avenue for expanding the availability of services for the 
populations that seek care in community health centers and 
engage them in a situation where comprehensive dental care is 
available.
    Senator Sessions. Dr. Chadwick?
    Mr. Chadwick. I would really just echo that, but I did want 
to bring up one point. When we were talking about the community 
centers, we talked about how prohibitive it could be to have a 
dental clinic in some of them because it was $40,000 per 
operatory. That is why the dentist's overhead is so high, 
because the dentists have already put that capital investment 
out there.
    So I am really encouraged to hear about the possibility of 
working with the community health centers, maybe on a 
contractual basis, to let some of those children be funded, and 
let them be seen in the dental offices. We have about 180,000 
dentists out there, and most of them have dental offices that 
these children could be seen in, either contractually seen in a 
health center, or seen in the private dental office.
    Senator Sessions. Thank you, Mr. Chairman, for this good 
hearing. I would just say that I would like to know why we are 
having so many people turned down for medical and dental 
schools when everybody is saying we need more doctors and 
dentists. I think that is a problem that we need to work on 
also.
    Senator Bingaman. Again, thank you all very much for your 
testimony. I think it has been very useful. We will urge our 
colleagues to support our efforts to pass this legislation, and 
we will do our very best to get it passed with some of the 
suggestions that you have made; we will try to incorporate 
those in the legislation.
    Thank you. That completes the hearing.
    [Additional material follows.]

                          Additional Material

               Prepared Statement of David Satcher, M.D.
    Mr. Chairman, Members of the Subcommittee, good afternoon. My name 
is David Satcher--I am currently a Senior Visiting Fellow at the Henry 
J. Kaiser Family Foundation and Director-Designee of the National 
Center for Primary Care at Morehouse School of Medicine. I also served 
as the 16th Surgeon General of the United States from February 1998 to 
February 2002.
    I appreciate this opportunity to appear before you today to discuss 
the critical issue of children's oral health. As you may know, I 
reported on the state of oral health in this country in May 2000 in 
``Oral Health in America: A Report of the Surgeon General,'' which 
emphasized that good oral health and good general health are 
inseparable. The report noted the remarkable strides that have been 
made in improving the oral health of the American people and also 
illustrated the profound disparities that affect those without the 
knowledge or resources to achieve good oral care. It also called for a 
national partnership to provide opportunities for individuals, 
communities, and the health professions to work together to maintain 
and improve the nation's oral health.
    I am especially pleased that this hearing today focuses on 
children's oral health because one of my priorities as Surgeon General 
was to ensure that every child has an optimal opportunity for a healthy 
start in life--and my commitment to this issue continues today. We held 
a Surgeon General's Workshop on Children and Oral Health in June 2000 
to bring attention to the impact of oral health on children's overall 
health and well-being and to promote action steps to eliminate 
disparities in children's oral health.
    Through our extensive study of this issue, we have found that oral 
diseases are progressive and cumulative and become more complex over 
time. They can affect our ability to eat, the foods we choose, how we 
look, and the way we communicate. These diseases can affect economic 
productivity and compromise our ability to work at home, at school or 
on the job. Health disparities exist across population groups at all 
ages. Over one third of the US population (100 million people) has no 
access to community water fluoridation. Over 108 million children and 
adults lack dental insurance, which is over 2.5 times the number who 
lack medical insurance. Expenditures for dental services alone made up 
4.7 percent of the nation's health expenditures in 1998--$53.8 billion 
out of $1.1 trillion. As you can see, there are many reasons we need to 
pay more attention individually and collectively to our oral health. 
But there are also opportunities for action--for all health 
professions, individuals, and communities to work together to improve 
health. But first I'd like to discuss the actual findings of our 
report.
     major findings of the surgeon general's report on oral health
    For years Surgeon General's reports have helped frame the science 
on vital health issues in a way that has helped educate, motivate and 
mobilize the public to deal more effectively with those issues.
    When we speak of oral health, we are talking about more than 
healthy teeth. We are talking about all of the mouth, including the 
gums, the hard and soft palates, the tongue, the lips, the chewing 
muscles, the jaws; in short, all of the oral tissues and structures 
that allow us to speak and smile, smell, taste, touch, chew and 
swallow, and convey a world of feelings through facial expressions.
    With that in mind, oral health means being free of oral-facial pain 
conditions, oral and pharyngeal cancers, soft tissue lesions, birth 
defects such as cleft lip and palates, and a host of other conditions.
    We also found that oral health is integral to overall health. 
Simply put, that means you cannot be healthy without oral health. New 
research is pointing to associations between chronic oral infections 
and heart and lung diseases, stroke, low birth-weight, and premature 
births. Associations between periodontal disease and diabetes have long 
been noted. Oral health must be a critical component in the provision 
of health care, and in the design of community programs.
    Looking at the oral health of our country, there is good news and 
bad news. The good news is that there have been dramatic improvements 
in oral health over the last 50 years. Great progress has been made in 
understanding the common oral diseases, such as tooth decay and gum 
diseases. This has resulted in marked improvements in our oral health. 
Today, most middle-age and younger Americans expect to retain their 
natural teeth over their lifetimes.
    Even so, the bad news is that we still see a ``silent epidemic'' of 
dental and oral diseases across the country. Many of us still 
experience needless pain and suffering, complications that devastate 
overall health and well-being, as well as high financial and social 
costs that diminish the quality of life at work, at school, and at 
home.
    Some examples: Tooth decay is currently the single most common 
chronic childhood disease-five times more common than asthma and seven 
times more common than hay fever; Oral and pharyngeal cancers are 
diagnosed in about 30,000 Americans each year, and 8,000 people die 
annually from these diseases. They are the 6th leading cancer cause of 
death; Nearly one in four Americans between the ages of 65 and 74 has 
severe periodontal disease; And, oral clefts are one of the most common 
birth defects in the United States, with a prevalence rate of about 1 
per 1,000 births.
    Another concern we found is that not all Americans are achieving 
the same degree of oral health. Although safe and effective means exist 
of maintaining oral health for a majority of Americans, this report 
illustrates profound disparities that affect those without the 
knowledge or resources to achieve good oral care. Those who suffer the 
worst oral health include poor Americans, especially children and the 
elderly. Members of racial and ethnic groups also experience a 
disproportionate level of oral health problems. And people with 
disabilities and complex health conditions are at greater risk for oral 
diseases that, in turn, further complicate their health.
    Major barriers to oral health include socioeconomic factors, such 
as lack of dental insurance or the inability to pay out of pocket, and 
access problems including a lack of transportation or the ability to 
take time off work to seek care. While about 44 million Americans lack 
medical insurance, about 108 million lack dental insurance. Only 60 
percent of baby boomers receive dental insurance through their 
employers, while most older workers lose their dental insurance at 
retirement. Meanwhile, uninsured children are 2.5 times less likely to 
receive dental care than insured children, and children from families 
without dental insurance are three times as likely to have dental needs 
compared to their insured peers.
    We also found that, safe and effective measures for preventing oral 
disease exist, including water fluoridation, dental sealants, proper 
diet, and regular professional care, as well as tobacco cessation. 
However, they are underused. For example, 100 million Americans do not 
have fluoridated water. And the smoking rate in America remains at 
about 23 percent, even though every practically every Surgeon General's 
report on tobacco since 1964 has established the connection between 
tobacco use and oral diseases.
    There were 8 major findings of the report:
    1) Oral diseases and disorders in and of themselves affect health 
and well-being though-out life. The burden of oral problems is 
extensive and may be particularly severe in vulnerable populations. It 
includes common dental diseases and other oral infections (such as cold 
sores and candidiasis) that can occur at any stage of life, as well as 
birth defects in infancy, and the chronic facial pain conditions and 
oral cancers seen in later years. Many of these conditions may 
undermine self-image and self-esteem, discourage normal social 
interaction, and lead to chronic stress and depression as well as incur 
great financial cost. They may also interfere with vital functions such 
as breathing, eating, swallowing and speaking and with activities of 
daily living such as work, school, and family interactions.
    2) Safe and effective measures exist to prevent the most common 
dental diseases--dental caries and periodontal diseases. Community 
water fluoridation is safe and effective in preventing dental caries in 
both children and adults. Water fluoridation benefits all residents 
served by community water supplies regardless of their social or 
economic status. Professional and individual measures, including the 
use of fluoride mouthrinses, gels, dentifrices, and dietary supplements 
and the application of dental sealants, are additional means of 
preventing dental caries. Gingivitis can be prevented by good personal 
oral hygiene practices, including brushing and flossing.
    3) Lifestyle behaviors that affect general health such as tobacco 
use, excessive alcohol use, and poor dietary choices affect oral and 
craniofacial health as well. These individual behaviors are associated 
with increased risk for craniofacial birth defects, oral and pharyngeal 
cancers, periodontal disease, dental caries, and candidiasis, among 
other oral health problems. Opportunities exist to expand the oral 
disease prevention and health promotion knowledge and practices of the 
public through community programs and in health care settings. All 
health care providers can play a role in promoting healthy lifestyles 
by incorporating tobacco cessation programs, nutritional counseling, 
and other health-promotion efforts into their practices.
    4) There are profound and consequential oral health disparities 
within the US population. Disparities for various oral conditions may 
relate to income, age, sex, race or ethnicity, or medical status. 
Although common dental diseases are preventable, not all members of 
society are informed about or able to avail themselves of appropriate 
oral health-promoting measures. Similarly, not all health providers may 
be aware of the services needed to improve oral health. In addition, 
oral health care is not fully integrated into many care programs. 
Social, economic, and cultural factors and changing population 
demographics affect how health services are delivered and used, and how 
people care for themselves. Reducing disparities requires wide-ranging 
approaches that target populations at highest risk for specific oral 
diseases and involves improving access to existing care. One approach 
includes making dental insurance more available to Americans. Public 
coverage for dental care is minimal for adults, and programs for 
children have not reached the many eligible beneficiaries.
    5) More information is needed to improve America's oral health and 
eliminate health disparities. We do not have adequate data on health, 
disease, and health practices and care use for the US population as a 
whole and its diverse segments, including racial and ethnic minorities, 
rural populations, individuals with disabilities, the homeless, 
immigrants, migrant workers, the very young, and the frail elderly. Nor 
are there sufficient data that explore health issues in relation to sex 
or sexual orientation. Data on state and local populations, essential 
for program planning and evaluation, are rare or unavailable and 
reflect the limited capacity of the US health infrastructure for oral 
health. Health services research, which could provide much needed 
information on the cost, cost-effectiveness, and outcomes of treatment, 
is also sorely lacking. Finally, measurement of disease and health 
outcomes is needed. Although progress has been made in measuring oral-
health-related quality of life, more needs to be done, and measures of 
oral health per se do not exist.
    6) The mouth reflects general health and well-being. The mouth is a 
readily accessible and visible part of the body and provides health 
care providers and individuals with a window on their general health 
status. As the gateway of the body, the mouth senses and responds to 
the external world and at the same time reflects what is happening deep 
inside the body. The mouth may show signs of nutritional deficiencies 
and serve as an early warning system for diseases such as HIV infection 
and other immune system problems. The mouth can also show signs of 
general infection and stress. As the number of substances that can be 
reliably measured in saliva increases, it may well become the 
diagnostic fluid of choice, enabling the diagnosis of specific disease 
as well as the measurement of the concentration of a variety of drugs, 
hormones, and other molecules of interest. Cells and fluids in the 
mouth may also be used for genetic analysis to help uncover risks for 
disease and predict outcomes of medical treatments.
    7) Oral diseases and conditions are associated with other health 
problems. Oral infections can be the source of systemic infections in 
people with weakened immune systems, and oral signs and symptoms often 
are part of a general health condition. Associations between chronic 
oral infections and other health problems, including diabetes, heart 
disease, and adverse pregnancy outcomes, have also been reported. 
Ongoing research may uncover mechanisms that strengthen the current 
findings and explain these relationships.
    8) Scientific research is key to further reduction in the burden of 
diseases and disorders that affect the face, mouth, and teeth. The 
science base for dental diseases is broad and provides a strong 
foundation for further improvements in prevention; for other 
craniofacial and oral health conditions the base has not yet reached 
the same level of maturity. Scientific research has led to a variety of 
approaches to improve oral health through prevention, early diagnosis, 
and treatment. We are well positioned to take these prevention measures 
further by investigating how to develop more targeted and effective 
interventions and devising ways to enhance their appropriate adoption 
by the public and the health professions. The application of powerful 
new tools and techniques is important. Their employment in research in 
genetics and genomics, neuroscience, and cancer has allowed rapid 
progress in these fields. An intensified effort to understand the 
relationships between oral infections and their management and other 
illnesses and conditions is warranted, along with the development of 
oral-based diagnostics. These developments hold great promise for the 
health of the American people.
    There are three major points I'd like to make today: 1) Disparities 
in oral health are profound, but with individual, professional, and 
community action we can work toward eliminating them, 2) There are 
limitations to how far providing access can go toward improving oral 
health, so we must adopt a balanced approach, and 3) Many opportunities 
for prevention exist and it is crucial that we take advantage of them.
                       disparities in oral health
    Eliminating disparities is not a zero-sum game--one person's gain 
does not mean another's loss. I believe that to the extent we care for 
the needs of the most vulnerable among us, we do the most to promote 
the health of the nation. That's true of oral health, where we have 
seen some of the greatest health disparities.
    Disparities in oral health are clearly evident from review of 
Healthy People 2010's goals and objectives. As the nation's health 
agenda for the decade, Healthy People 2010 contains 467 objectives that 
fall under 2 main goals. The first goal is to increase the years and 
quality of healthy life and is particularly relevant because it is 
clear quality of life can be enhanced significantly by improving oral 
health. In doing so, we must look across the lifespan, beginning to 
address oral health in early childhood and continuing all the way 
through the latter years.
    The second goal of Healthy People 2010--eliminating racial and 
ethnic disparities in health--is well-illustrated by the problems in 
oral health. Not all Americans are experiencing the same degree of oral 
health. For example, African Americans are more likely than Whites to 
experience and die from cancer of the mouth and pharynx. Although most 
American children enjoy excellent oral health, a significant subset 
suffers a high level of oral disease. The most advanced disease is 
found primarily among children living in poverty, some racial and 
ethnic populations, disabled children, and children with HIV infection. 
And while dental caries have declined dramatically among school-aged 
children, they remain a significant problem, particularly among certain 
racial and ethnic groups and poor children.
    The last report I released as Surgeon General, ``Closing the Gap: A 
National Blueprint to Improve the Health of Persons with Mental 
Retardation,'' is a good illustration of oral health disparities. As 
many of you are aware, there's a real dearth of data on the health 
status of people with mental retardation, but of the data that is 
available, the Special Olympics may have some of the best. As part of 
their Special Olympics Healthy Athletes Program, they have conducted 
annual oral, vision, and hearing screenings and provided health 
assessments, health education, disease prevention and corrective health 
care to the athletes. One of the things they learned from those 
screenings is that people with mental retardation have worse health 
overall, including in the area of oral disease. Their findings are 
outlined in a joint report with Yale University. That report found that 
while dental services for many children are covered under Medicaid, 
only 1 in 5 eligible children receives any dental services each year. 
These data has been recently updated by the Centers for Medicare and 
Medicaid Services (CMS), whose statistics indicate that one million 
more Medicaid-eligible children now receive annual dental care than was 
the case when the report was published. Added to that is the fact that 
most states have limited dental care benefits for adults, so that 
individuals with mental retardation are no longer eligible for dental 
care coverage under Medicaid, once they reach the age of maturity.
                  access: necessary but not sufficient
    Access is a major issue when it comes to oral health. We have found 
people tend to pose two major reasons for not visiting the dentist: (1) 
denial that a problem exists, and (2) cost.
    While 43 million Americans are without health insurance, 108 
million are without dental insurance. Only 60 percent of baby boomers 
receive dental insurance through their employers, while most older 
workers lose their dental insurance at retirement. Meanwhile uninsured 
children from families without dental insurance are three times more 
likely than their peers to have dental needs.
    But we know that addressing insurance alone, while certainly 
critical, is not enough. There are many barriers to oral health, and 
even when comprehensive dental coverage is available through states, 
use of dental care is low. A report by the Department=s Inspector 
General revealed serious shortcomings in Medicaid dental programs in 
the United States and demonstrated that the level of reimbursement from 
Medicaid is a major concern.
    We must also address issues surrounding socioeconomic status, such 
as education, income, and housing. Some poor children have limited 
access oral health care, as well as some nursing home residents. Low 
educational level has often been found to have the strongest and most 
consistent association with tooth loss, among all predisposing and 
enabling variables. We also must eliminate discrimination in quality by 
professionals.
                      opportunities for prevention
    In addition to raising awareness about oral health, changing 
perceptions about its significance, and removing barriers to oral 
health services, we must also encourage Americans to improve their 
health behaviors and practice a simple but often overlooked device: 
prevention.
    One of my priorities as Surgeon General, and one that continues 
today, is moving the nation toward a balanced community health system. 
That means balancing health promotion, disease prevention, early 
detection and universal access to care.
    As one of the components necessary to achieving a balanced 
community health system, we must encourage Americans to adopt good 
preventive general health practices and preventive oral health 
practices. We must increase the use of effective prevention measures 
such as water fluoridation, dental sealants, proper diet, tobacco 
cessation and regular professional care.
    The report notes that general health risk factors, such as tobacco 
use and poor dietary practices, also affect oral and craniofacial 
health. The evidence for an association between tobacco use and oral 
diseases has been clearly delineated in every Surgeon General's report 
on tobacco since 1964. Tobacco use is a risk factor for oral disease, 
specifically periodontal disease and cancer of the orapharynx. The risk 
of oral cancer increases when tobacco use is combined or alcohol use. 
Poor nutrition is another risk factor for oral diseases. When coupled 
with dietary factors, physical inactivity is the second leading cause 
of preventable death, resulting in over 300,000 deaths each year. Also, 
when poor nutrition is coupled with physical inactivity, the risk of 
overweight and obesity is increased. So we must find ways to support 
better dietary choices. Moreover, recent research findings have pointed 
to possible associations between chronic oral infections and diabetes, 
heart and lung disease, stroke, and low-birth-weight premature births. 
The report assesses these emerging associations and explored possible 
mechanisms that may underlie these oral-systemic disease connections.
    One of the biggest challenges we have as a nation is convincing 
people to adopt healthy lifestyles. The best science-based information 
on healthy habits is readily available but the will and commitment to 
good health do not always follow.
                         children's oral health
    Unfortunately, children as a group illustrate the nation's oral 
health problems well. Dental and oral disorders are common in children 
and have a significant impact on children and families. Dental caries 
(tooth decay) is the single most common chronic childhood disease--5 
times more common than asthma and 7 times more common than hay fever. 
As one of the most common birth defects, cleft/lip palate is estimated 
to affect 1 out of 600 live births for whites and 1 out of 1,850 live 
births for African Americans. In addition, dental care is the most 
frequent unmet health need of children.
    Some highlights of oral health data on children from the report:
    There are striking disparities in dental disease by income. Poor 
children suffer twice as much dental caries as their more affluent 
peers, and their disease is more likely to be untreated. These poor-
nonpoor differences continue into adolescence. One out of four children 
in America is born into poverty, and children living below the poverty 
line (annual income of $17,000 for a family of four) have more severe 
and untreated decay.
    Other birth defects such as hereditary ectodermal dysplasias, where 
all or most teeth are missing or misshapen, cause lifetime problems 
that can be devastating to children and adults.
    Unintentional injuries, many of which include head, mouth, and neck 
injuries, are common in children.
    Intentional injuries commonly affect the craniofacial tissues.
    Tobacco-related oral lesions are prevalent in adolescents who 
currently use smokeless (spit) tobacco.
    Professional care is necessary for maintaining oral health, yet 25 
percent of poor children have not seen a dentist before entering 
kindergarten.
    Medical insurance is a strong predictor of access to dental care. 
Uninsured children are 2.5 times less likely than insured children to 
receive dental care. Children from families without dental insurance 
are 3 times more likely to have dental needs than children with either 
public or private insurance. For each child without medical insurance, 
there are at least 2.6 children without dental insurance.
    Medicaid has not been able to fill the gap in providing dental care 
to poor children. Fewer than one in five Medicaid-covered children 
received a single dental visit in a recent year-long study period. 
While recent CMS data indicate progress in this area with one million 
more Medicaid-eligible children now receiving annual dental care than 
was the case in 1996, there is still a long way to go to ensuring 
greater access. Although new programs such as the State Children's 
Health Insurance Program (SCHIP) may increase the number of insured 
children, many will still be left without effective dental coverage.
    The social impact of oral diseases in children is substantial. More 
than 51 million school hours are lost each year to dental-related 
illness. Poor children suffer nearly 12 times more restricted-activity 
days than children from higher-income families. Pain and suffering due 
to untreated diseases can lead to problems in eating, speaking, and 
attending to learning.
    Over 50 percent of 5- to 9-year-old children have at least one 
cavity or filling, and that proportion increases to 78 percent among 
17-year-olds. Nevertheless, these figures represent improvements in the 
oral health of children compared to a generation ago.
                         a framework for action
    Everyone has a role in improving and promoting oral health. Through 
a collaborative process, we developed a framework for action put forth 
in the report with the following principal components:
    Change perceptions (of the public, policymakers and health 
providers) regarding oral health and disease so that oral health 
becomes an accepted component of general health.
    Accelerate the building of the science and evidence base and apply 
science effectively to improve oral health.
    Build an effective oral health infrastructure that meets the oral 
health needs of all Americans and integrates oral health effectively 
into overall health.
    Remove known barriers between people and oral health services.
    Use public-private partnerships to improve the oral health of those 
who still suffer disproportionately from oral diseases.
    With specific regard to the oral health infrastructure, as with the 
rest of public health, we need to focus on building an effective 
infrastructure. A key component of this is creating and enhancing state 
oral health programs--dental public health workers at the state level 
play a critical role in improving the oral health of children and 
families. We all also look forward to the appointment of a Chief Dental 
Officer for CMS.
    Mr. Chairman, in the past half-century, we have come to recognize 
that the mouth is a mirror of the body, it is a sentinel of disease, 
and it is critical to overall health and well-being. The challenge 
facing us today-to help all Americans achieve oral health-demands the 
best efforts of public and private agencies as well as individuals.
    I am pleased to have had this opportunity to present an overview of 
the state of America's oral health for you to consider as you proceed 
with the work of this subcommittee. I am happy to answer any questions 
you may have.
               Prepared Statement of Burton L. Edelstein
    As Founding Director of the Children's Dental Health Project in 
Washington and a professor of dentistry and public health at Columbia 
University, I appreciate the Health Education Labor and Pension 
Committee's commitment to exploring the issues that underlie 
significant problems in access to dental care for our nation's 
children. I am pleased to submit this testimony also on behalf of the 
American Academy of Pediatric Dentistry and the American Dental 
Education Association.
    My message is simple: far too many children suffer far too much 
dental disease that is consequential to their lives and overwhelmingly 
preventable. Access to essential dental services for our nation's 
children is too often promised but not delivered by federal and state 
programs. And, ironically, much of the disease that goes untreated--
disease that results in pain and infection and dysfunction--could have 
been prevented if we had simply started early enough and used 
established science well enough. Finally, my message is that the U.S. 
Senate Subcommittee on Health holds tremendous opportunity to bring 
focus and action to this problem in ways that can solve it with only a 
small investment of your time and authority and only a small investment 
in dollars.
    The Children's Dental Health Project is dedicated to assisting 
policymakers, health professionals, advocates, and parents improve 
children's oral health and increase their access to dental care. It was 
developed in 1998 through the cooperation of the American Academy of 
Pediatric Dentistry; the American Dental Education Association, and the 
American Academy of Pediatrics, all of which support this mission. 
Additionally, the DC-based child health coalition, representing over 40 
groups that are familiar to federal policymakers has shown longstanding 
commitment to the inclusion of dental services, along with mental 
health services, in the very definition of child health care.
    We are fully aware that many regard children's oral health as a 
trivial concern compared with other US healthcare, education, and 
social issues that this Committee deals with. Those unfamiliar with the 
problem may scoff at the title of today's hearing, not understanding 
that there is a crisis in oral health and that dental disease remains 
epidemic amid some of our child populations. But we are also fully 
aware that no one who hears out a constituent about their inability to 
provide essential care for their children, no one who examines the 
alarming statistics substantiating the problem, no one who understands 
that many of our children suffer from high disease levels and 
inadequate dental care, will long consider this issue trivial.
    The Children's Dental Health Project greatly appreciates the many 
requests and opportunities that Members of Congress have extended to us 
to provide technical assistance in their work on oral health. In the 
current session of Congress, the Children's Dental Health Project has 
worked with staff on the Children's Dental Health Improvement Act 
introduced by Senator Bingaman and Senator Cochran and already 
receiving significant co-sponsorship; with Senator Collins and Senator 
Feingold on the Dental Health Improvement Act which has been 
incorporated into the safety-net reauthorization legislation by this 
Committee; and with Senator Edwards on the Perinatal Dental Health 
Improvement Act which the Committee Chairman recently included in his 
mark-up of the women's health bill, amongst others.
    These actions build well on past years' GAO reports, the Surgeon 
General's report on Oral Health in America, and the efforts of so many 
child and health proponents, state and national foundations, 
associations of state officials, and professional groups who highlight 
this problem and have begun to tackle it effectively. Proposed 
legislation reflects an ever-increasing demand by your constituents 
that they obtain meaningful access to essential dental care for their 
children and an ever-growing press coverage of this issue by both print 
and broadcast media.
    While I now serve children through policy advocacy and education, 
for 24 years I learned about children's oral health more immediately by 
caring for children at the dental chair. Since my first encounter with 
a child patient in 1970, I have been aware of the stark disconnect 
between perception and reality around children's oral health. The too-
widespread belief that childhood dental disease has been vanquished 
stands in contrast to the thousands upon thousands of toothaches and 
acute abscesses experienced daily by America's children--many as young 
as two years of age. From clinical observation, I grew to recognize 
that while dental disease was declining in general, we are raising a 
new generation of low-income and minority children for whom this 
disease is both familiar and often devastating--interrupting their 
ability to eat, to sleep, to play, and to attend to learning. As 
managing partner of a growing pediatric dental practice, I came to 
share my colleagues' understanding that federal and state health and 
finance programs hold much promise but too often provide little in the 
way of performance. In particular, I did not see Medicaid deliver on 
its legal promise of comprehensive dental care for children through 
EPSDT. Rather, what I saw in my home town is what is true in nearly 
every home town across the nation--fewer dentists, more disease and 
less dental care for children with treatment needs. I also observed 
firsthand a cascade of missed opportunities for governmental programs 
to meaningfully attend to oral health.
    Federal data substantiates the reality of significant pediatric 
dental disease among America's children. Whatever health concern may 
exist about children--their disease burden, insurance coverage, racial 
and income disparities, unmet need for healthcare, special 
considerations for children with special healthcare needs, or the 
prevention of functional impairments--children's dental care 
unfortunately too often stands in as the ``poster-child'' of problems. 
Examples derived from federal data include the following:
    Disease burden: As reported by former Surgeon General Satcher, 
tooth decay is five times more prevalent than asthma. In fact, one-in-
five two to four year olds (18%) has at least one visible cavity and 
one-in-two second graders (52%) has experienced tooth decay according 
to the third National Health and Nutrition Examination Survey. While 
disease is more prevalent among low-income and minority groups of 
children, many pediatric dentists are today reporting anectodally an 
upsurge of disease among children from middle class and affluent 
families.
    Insurance coverage. For every child without health insurance there 
are more than two (2.6) without dental coverage according to the 
National Health Interview Survey.
    Disparities: Poor preschoolers in America are twice as likely to 
have tooth decay, have twice as many cavities when they do experience 
decay, have twice the pain experience, yet have only half the dental 
visits as their affluent peers. Very high prevalence of tooth decay 
among fast-growing Hispanic populations portends an upturn in future 
disease burden.
    Unmet need: Three times as many parents report that their child has 
an unmet need for dental care as for medical care according analyses of 
the National Health Interview Survey data. In fact, three-quarters 
(73%) of parents reporting unmet need for health care claim that the 
unmet need is for dental care.
    Special needs: Fully one-in-four parents of a child with special 
healthcare needs claim that their child is in need of dental care.
    Treatment: Medicaid-enrolled children are nearly four times more 
likely to obtain a medical visit in a year than a dental visit 
according to CMS data.
    Costs: Dental care for children in the US accounts for 20-30% of 
child health expenditures while dental care for Medicaid children 
accounts for only an average of 2.3% of Medicaid child health 
expenditures.
    Impairments. We have simply failed too many of our children 
throughout their years of growth--leaving too many of them as toddlers 
with an inability to eat and sleep, as school children with swollen 
faces, as teens with embarrassing appearances, and as young adults with 
oral dysfunctions, This lack of attention to children extends into 
dysfunctions for adult populations including our military personnel. 
During Desert Storm the most common reason for soldiers presenting to 
sick call was reportedly for dental pain. New recruits are often found 
to be in need of extensive dental treatment in order to become combat-
ready.
    Many are working hard to address these problems at the state and 
local levels. But some solutions require greater involvement and 
partnership with federal government. Multiple state policymaking 
organizations including the National Governors Association, National 
Conference of State Legislatures and associations of health officers 
are attentive to this issue and stand ready to build on federal 
programs and policies. Foundations, notably the WK Kellogg Foundation's 
Community Voices Programs. the Robert Wood Johnson Foundation, and 
number of state-level foundations provide strategic grantmaking that 
demonstrates both what can and cannot work. These foundations and their 
partners have pointed the way for formulating effective public policies 
and programs that can improve both oral health and access to dental 
care. Government has much to learn from their trials and their risk-
taking.
    Those who work daily to address remaining concentrations of poor 
oral health among US children have come to recognize the power of 
public-private partnerships and have come to understand that neither 
parents nor dentists are to blame for the current failures in oral 
health and dental care. But public-private-partnerships require the 
active interest and involvement of federal public health programs. We 
encourage the Committee to reinvigorate such partnerships and to 
stimulate public attention to this bellweather health problem.
    In almost every one of the states, there have been public-private 
efforts to address inadequate dental access. But these efforts among 
your constituents have too-often hit against one or another structural 
walls--walls that federal interventions can break down. On the public 
insurance side, most Medicaid dental programs are dysfunctional with 
fewer than ten states now meeting federal provider-payment requirements 
under the ``equal access provision.'' On the public health side, far 
too many programs that could include oral health have failed to do so 
and existing programs are unevenly evident across the country. Regular 
and ongoing Congressional oversight of federal agencies is essential if 
we are to deliver services already promised or potentially provided 
through federal programs.
    The walls that stand between children and dental care are many. 
Many of them are complex Yet there are ample opportunities for this 
Committee to address these barriers.
    Workforce issues include a declining number of dentists relative to 
population, an inadequate supply of pediatric dentists, a 
maldistribution of providers so that we now have a real and palpable 
loss of providers in many rural and inner city areas, and a profound 
dearth of minority dentists and hygienists.
    Education and training issues include a paucity of dental school 
faculty; especially minority faculty, and difficulties ensuring that 
our new dental graduates are fully prepared to treat young children 
competently and confidently. Students are graduating with impressive 
debt that limits their willingness and ability to take lower-paying 
positions in public health or teaching than in private practice. In 
addition to dentists, we need to train all who work with young children 
to promote oral health. Pediatricians, day care workers, teachers. WIC 
nutritionists, Head Start personnel, and home health visitors can all 
incorporate oral health into their health-promotion work with young 
children.
    The dental safety net is small, understaffed. and sparsely 
distributed. For example, if any child in the US has a broken arm, that 
child can obtain definitive care at almost any emergency room. If that 
same child has a face swollen from dental infection, he or she can 
typically obtain only a pain pill and prescription for an antibiotic.
    States without effective dental public health infrastructure are 
hampered in any effort to address access. At this time nearly one-
quarter of the states represented on the Public Health Subcommittee--
like many states--have no full time state dental director. Without a 
director, fluoridation and prevention programs, surveillance, and 
direct service programs suffer.
    Science that can be put to work to improve health but doesn't reach 
people at risk is sterile science. The most common pediatric dental 
disease, tooth decay, is now well understood as an infectious and 
transmissible disease that can be prevented or suppressed. We 
appreciate the National Institute for Dental and Craniofacial 
Research's Centers to Reduce Oral Health Disparities program, the 
Centers for Disease Control and Prevention's Oral Health Division's 
work, and many other Department of Health and Human Services efforts. 
We now look to the HELP Committee to further promote dental programs 
and to further empowering the Agency for Healthcare Research and 
Quality, the Health Resources and Services Administration, Head Start, 
and many other agencies within its jurisdiction to attend to children's 
oral health in a more focused and robust way through specific 
programmatic authorizations and requirements.
    We have provided staff with specific information on each of the 
states represented by Members of the Subcommittee on Public Health. 
Data provided include CMS reports on the percentage of children 
obtaining a dental visit in a year and their associated costs; dentist-
to-population trends that occurred during the last decade, and 
information on the status of state dental directors. Because of the 
Committee's responsibility for education, we have also provided a fact 
sheet entitled, ``Oral Health and Learning'' issued by the National 
Center for Education in Maternal and Child Health. This fact sheet 
substantiates that learning impairments can arise from untreated dental 
disease.
    I close with a specific request of the Committee. We at the 
Children's Dental Health Project join with the American Academy of 
Pediatric Dentistry and others concerned with improving children's oral 
health to ask that the HELP Committee commits to improving our 
children's oral health and access to dental care by featuring oral 
health when considering general pediatric health policies and programs, 
by stepping up oversight of existing programs and agencies, by 
monitoring the effectiveness and performance of public programs, by 
enacting legislation when needed to fill voids where children's dental 
care has been missed in the past, and by opening avenues to hear 
constituents tell their elected officials about their need to ensure 
dental care for their children.
                   Prepared Statement of Lynn Mouden
    Mr. CHAIRMAN, my name is Lynn Mouden. I am an Arkansas dentist and 
Director of the Office of Oral Health in the Arkansas Department of 
Health. I have 27 years experience in both private practice and public 
health. As Arkansas State Dental Director, I am charged by Arkansas 
state law to plan, direct and coordinate all dental public health 
programs in the state.
    I also serve as President of the Association of State and 
Territorial Dental Directors, whose mission is to increase awareness of 
oral health issues; to assist in the development of initiatives for the 
prevention and control of oral diseases; and to provide leadership on 
sound national oral health policy. On behalf of the Association and 
especially the citizens of Arkansas, I thank you for this opportunity 
to discuss the importance of improving oral health for all Americans.
    Arkansas is often described as the unhealthiest state in the 
nation, based on a wide variety of health indicators. Arkansas also 
mirrors the nation in that oral disease remains pervasive among 
families with low income, those with limited education, the frail 
elderly, persons with disabilities, those who are underinsured, and 
ethnic minorities.
    Our recent statewide oral health assessment shows that on average 
Arkansas third-grade children suffer from three cavities each. 
Statewide, more than three fourths of these children have had tooth 
decay. Obviously, the slogan from the 1960's of ``Look, Ma, no 
cavities'' is not being realized across Arkansas.
    More than 40% of Arkansas children attend school with untreated 
cavities, and 8% have emergency dental needs. Such severe dental need 
adversely affects how these children eat--or can't eat; how they 
sleep--or can't sleep; and how they succeed in school--or can't 
succeed. These children also enter adult life with a mouth no one would 
hire to smile at a customer. Consider for a moment if these same dental 
statistics applied to the 100 members of the US Senate. We would wonder 
how well the Senate's business would proceed if 40 Senators had 
untreated tooth decay and 8 of them tried to work with toothaches.
    Problems are even worse in the underserved areas of Arkansas, 
specifically the Mississippi River Delta region and inner city Little 
Rock, with 50% more of the children needing emergency dental care. 
These areas are predominantly poorer and with a higher percentage of 
ethnic minorities. The data point out once again that a minority of our 
children suffers with a majority of dental problems. A recent screening 
brought one particular child to our attention. The boy, when asked if 
he had a toothbrush responded, ``Yes, but it doesn't have any hairs on 
it anymore.'' The toothbrush was so worn it no longer had even one 
bristle--but he was proud to have a toothbrush.
    Insufficient funding of Medicaid continues to plague Arkansans. 
Arkansas Medicaid only pays approximately 50% of a participating 
dentist's usual fees. In a profession where overhead typically is 70% 
of income, it is amazing that dentists are put into the unique position 
of having to subsidize their services by providing dental care at less 
than cost.
    And, increased funding for Medicaid is not the whole answer, 
because dentistry's commitment to the underserved is well documented. 
In Arkansas alone, dentists donate more than eight million dollars each 
year in free dental care. It is often the bureaucratic barriers can 
make participation in Medicaid an administrative nightmare for 
dentists, most of whom are in solo private practice.
    SB1626 provides several methods to ensure optimum oral health for 
all. The requirement that states provide adequate reimbursement to 
dentists will bolster our system. The requirement that state plans 
guarantee access for children equal to that available in the general 
population will ensure dental care for those children at highest risk.
    SB1626 also provides an important initiative to support oral health 
promotion and disease prevention. Dentistry and state oral health 
programs have a long history of primary prevention activities. 
Community water fluoridation has long been heralded as the most 
effective, most economical and safest method for preventing tooth 
decay. However, without continued and increased funding to support 
fluoridation, communities working to balance difficult budgets often 
discontinue this important public health program. In addition, other 
proven prevention programs such as dental sealant initiatives, also 
rely on Federal support for success. Although fluoridation and dental 
sealants are proven prevention methods, Arkansas has only 59% of its 
citizens enjoying the benefits of water fluoridation and only one-
fourth of our children have dental sealants. In our poorer areas of 
Arkansas, less than 2% of children have sealants.
    Arkansas recently received a grant from the CDC Office of Oral 
Health to start programs. Through that grant, our state has made 
tremendous inroads in establishing oral health partnerships throughout 
Arkansas. The grant has helped us ensure effective prevention 
activities. We are now able to reach out to other health care 
professionals, educating them on the effect of oral health upon 
patients' general health. We also have new programs to enhance oral 
health services for our most vulnerable populations, especially those 
individuals with developmental disabilities.
    However, only five states received this funding starting in 2001. 
SB1626 would greatly enhance support for state and local programs, 
allowing us to increase access for the underserved populations of 
Arkansas and the nation. In addition, I encourage you to support 
increased funding to the CDC to build upon the successful cooperative 
agreement initiative and to ensure that collaboration between state and 
Federal entities continues to address our most serious oral health 
problems.
    In 2000, our Association published the study on Infrastructure and 
Capacity in State Oral Health Programs. The study identified the 
administrative and financial barriers to improving the nation's oral 
health. Leadership from state dental directors is imperative to make 
dental public health programs succeed. However, Senators, just among 
the members of this committee, some of your own states don't have 
dental directors, so you are already lacking in dental public health 
resources for your states.
    Many Americans enjoy the highest quality of dentistry in the world. 
If a child lives in Maumelle, Arkansas and has plenty of money, access 
to dental care is no problem. However, if that child lives in poverty 
in the Arkansas Delta region, access to dental care is almost 
impossible. Eliminating disparities in oral health must be our goal.
    In closing, I want to thank Senator Bingaman for recognizing the 
oral health crisis in this country and for his efforts to make a 
difference in our nation's oral health. I applaud Senator Hutchinson 
and the others that have supported this effort. I thank Senator 
Hutchinson and the Committee for inviting us here today to champion the 
chance for all of America's children to enjoy oral health--to eat, to 
be free from pain and to smile. I ask that you continue to work with 
us--those of us at the local, state and national level--to make optimum 
oral health for everyone in America a reality. Thank you.
                                 ______
                                 
Building Infrastructure & Capacity in State and Territorial Oral Health 
                                Programs
a summary of the april 2000 report prepared by the association of state 
                    and territorial dental directors
    In 1999-2000, the Association of State and Territorial Dental 
Directors assessed the resources needed to achieve the oral health 
objectives of Healthy People 2010 (the nation's health promotion and 
disease prevention agenda). The study focused on the infrastructure and 
capacity of state and territorial oral health programs, the health 
agencies' oral health units. Infrastructure consists of the systems, 
people, relationships and resources that would enable state and 
territorial oral health programs to perform public health functions. 
Capacity describes the expertise and competence needed to implement 
strategies. Infrastructure and capacity provide the foundation to 
eliminate the ``silent epidemic'' of oral diseases and improve the oral 
health of all Americans.
    For the study, state dental directors and lead dental consultants 
from health agencies in 43 states identified and reached a consensus on 
ten essential elements in building infrastructure and capacity for 
state and territorial oral health programs. These top elements are:
    1. Provide leadership with a full-time state dental director and 
adequate staffing.
    2. Establish and maintain a state-based oral health surveillance 
system.
    3. Develop and maintain a state plan for oral health improvement.
    4. Develop and promote policies for better oral health and to 
improve health systems.
    5. Provide oral health communications and education to policymakers 
and the public.
    6. Build linkages with partners interested in reducing the burden 
of oral diseases.
    7. Integrate and implement population-based interventions for 
prevention of oral diseases.
    8. Build community capacity to implement community-level 
interventions.
    9. Develop health systems interventions to facilitate quality 
dental care services.
    10. Leverage resources to adequately fund public health functions.
    Not every state health agency has an oral health program. Not all 
state oral health programs have sufficient resources to address oral 
health needs. For example, at the time of the study, although 31 states 
and five territories have full time dental directors, 20 states 
(including the District of Columbia) have only part time or vacant 
dental director positions. About half of the states, with populations 
totaling 92 million people, have a budget of $500,00 or less for each 
of their oral health programs. Furthermore, 43 states reported gaps in 
their dental public health infrastructure and capacity related to the 
ten essential elements listed above, including the need to develop 
comprehensive state-based oral health surveillance system. Currently no 
state has a comprehensive surveillance system and only 19% states have 
surveillance components. Only 38% of the states had an oral health 
improvement plan, and only 48% had an oral health advisory committee 
with partners representing a broad-based constituency.
    The ASTDD Report recommends that states have sufficient funding to 
sustain effective oral health capacity and infrastructure. 
Recommendations are dependent on state population and other factors. In 
general, states with less than 3 million population require $500,000 to 
$700,000; states with 3 to 5 million residents require $1 to $1.6 
million; states with more than 11 million residents need $3 to $5 
million in funding to support effective oral health programs.
    The Surgeon General's Report on Oral Health states that ``the 
public health infrastructure for oral health is insufficient to address 
the needs of disadvantaged groups, and the integration of oral and 
general programs is lacking'' (U.S. Department of Health and Human 
Services, 2000). Leadership within a strong oral health unit with 
sufficient infrastructure and capacity is critical when agencies and 
organizations are determining priorities, setting agendas, developing 
plans, making funding decision, and establishing policies that impacts 
the oral health of Americans.
                                 ______
                                 
                   The Arkansas Oral Health Coalition
    The Arkansas Oral Health Coalition began in 2001 as Arkansas' team 
at the National Governor's Association (NGA) Policy Academy on 
Improving Oral Health Access for Children. The academy team consisted 
of seven individuals representing Governor Mike Huckabee's Office, the 
Arkansas General Assembly, the Office of Oral Health, the Division of 
Medical Services, the Arkansas State Dental Association, the Arkansas 
State Dental Hygienists' Association, and BHM International, Inc. The 
team worked with a faculty of national experts to develop Arkansas oral 
health goals in access, education, prevention and policy. To continue 
the academy efforts, the team invited other interested parties and 
expanded over the subsequent 10 months to what is now the Arkansas Oral 
Health Coalition. The Coalition has adopted the slogan ``SMILES: AR, 
U.S.''
    The Coalition enjoys participation from a diverse set of 
organizations and agencies from across the state. Members of the 
Arkansas Oral Health Coalition are:
    Arkansas Academy of General Dentistry
    Arkansas Advocates for Children and Families (AACF)
    Arkansas Center for Health Improvement
    Arkansas Dental Assistants' Association (ASDAA)
    Arkansas Department of Education, Office of Comprehensive Health 
Education
    Arkansas Department of Health, Office of Oral Health (OOH)
    Arkansas Department of Health, Office of Rural Health and Primary 
Care
    Arkansas Department of Human Services, Division of Medical Services
    Arkansas Department of Higher Education
    Arkansas Head Start Association (AHSA)
    Arkansas Nurses Association (ANA)
    Arkansas School Nurses Association (ASNA)
    Arkansas State Dental Association (ASDA)
    Arkansas State Dental Hygienists' Association (ASDHA)
    BHM International, Inc.
    Community Dental Clinic
    Community Health Centers of Arkansas, Inc. (CHCA)
    Delta Dental Plan of Arkansas (DDPA)
    Healthy Connections, Inc.
    Partners for Inclusive Communities (PIC)
    Pulaski Technical College Dental Assisting Program
    UALR Share America
    UAMS College of Public Health
    UAMS Department of Dental Hygiene
    Vision 2010 Quality of Life Dental Committee
    Activities of the Coalition have included the UALR Share America 
Future Smiles dental sealant project, the Health Connections dental 
sealant project, the Delta Oral Health Initiative, the Dental Services 
Project, and various assessment and program activities within the 
Office of Oral Health.
    The Future Smiles project screened more than 2000 Head Start and 
Early Head Start children and elementary school students in the fall of 
2001. Based on those screenings, students in 2nd and 6th grade were 
identified for dental sealants. During February and March of 2002, 
volunteer dentists and dental hygiene students from UAMS placed a total 
of 401 sealants for 109 students. The program was received so well that 
it is already planned in an expanded format in the upcoming school 
year.
    Based on the success of the Future Smiles project, Healthy 
Connections in Mena, Arkansas replicated the project in elementary and 
middle schools in Mena. Using volunteer dentists and dental hygiene 
students from UAFS, 89 students received a total of 281 dental 
sealants.
    The Delta Oral Health Initiative concentrates its efforts on 
increasing access to oral health services in the Mississippi River 
Delta region of Arkansas. While the Initiative members worked 
diligently beginning in mid-2001, no funding has yet been identified to 
move programs forward.
    The Dental Services Project concentrates on oral health issues for 
the developmentally disabled population in Arkansas. Because of the 
Olmstead decision, dental services are required to be provided to 
developmentally disabled individuals that chose to live in the 
community instead of an institutional setting. No data has ever been 
collected on the dental needs of this population in Arkansas. 
Therefore, in November of 2001, volunteer dentists and dental 
hygienists screened 121 ambulatory adults with developmental 
disabilities, all living in community settings. Based on the screening, 
analysis showed that the patients screened required more than 
$117,000.00 in immediate dental needs.
    Along with current assessment and program activities within the 
Office of Oral Health, Coalition members are also currently pursuing 
additional grant opportunities for programs in increased oral health 
access and training for dental professionals in treating HIV+ patients.
   2002 arkansas oral health needs assessment surveys: findings and 
                              conclusions
Purpose
    The Office of Oral Health, created in the Arkansas Department of 
Health in 1999, faces new challenges in assessment, policy development 
and assurance as it relates to dental public health in our state. 
Because little data has ever been collected on oral health needs within 
Arkansas, the first challenge was to collect baseline data on oral 
health. With an appropriate database, decisions can be made to guide 
dental public health policy. A survey with limited scope was conducted 
in 2000 and again in 2001. To increase the available data, during the 
spring of 2002, the Office of Oral Health conducted an expanded 
statewide oral health needs assessment under the CDC Cooperative 
Agreement on State Oral Disease Prevention Programs.
    In addition, data is necessary for reporting to agencies of the 
federal government. The Health Resources and Services Administration's 
(HRSA) Maternal and Child Health Bureau provides leadership, 
partnership opportunities and resources to advance the health of the 
Nation's mothers, infants, children, adolescents and families through 
Title V of the Maternal and Child Health (MCH) Block Grant. The block 
grants provided to states create federal/state partnerships to develop 
community service systems to meet critical challenges in maternal and 
child health. These challenges include reducing infant mortality, 
providing comprehensive care for children and adolescents with special 
health care needs, reducing adolescent pregnancy and providing 
comprehensive prenatal care. As required by the block grant, Arkansas 
reports annually on eighteen national performance measures and eight 
state-selected performance measures related to maternal and child 
health.
    One of the national performance measures is the percent of third-
grade children who have received protective sealants on at least one 
permanent molar tooth. Dental caries (tooth decay) affects two-thirds 
of children by the time they are 15 years of age. Developmental 
irregularities, called pits and fissures, are the sites for 80-90% of 
childhood caries. Dental sealants selectively protect these vulnerable 
sites, which are found mostly in permanent molar teeth. Targeting 
dental sealants to those children at greatest risk for caries has been 
shown to increase their cost effectiveness. Although dental sealants in 
conjunction with community water fluoridation have the potential to 
prevent almost all childhood tooth decay, sealants have been 
underutilized.
Methods
    Sealant utilization and assessment of oral health requires primary 
data collection or screening of a representative sample of school 
children. During 1999, the Arkansas Oral Health Advisory Committee 
developed a plan to collect data on sealant utilization. This plan was 
expanded for the 2000 and 2001 surveys to include data on decayed, 
missing and filled primary and permanent teeth; caries rates; and 
untreated caries along with sealant data. This data set was utilized 
for the expanded 2002 survey.
    Elementary schools were randomly selected for the study. Letters of 
invitation to participate in the study were sent to twenty school 
principals across Arkansas. Of those, nineteen principals invited to 
participate agreed to assist with the survey.
    An information sheet on dental sealants, explaining the survey, was 
sent to each student's home along with a permission slip for survey 
participation. Only students whose parents or guardians signed and 
returned permission forms were screened.
    Only licensed dentists, and licensed dental hygienists under the 
supervision of a dentist, are allowed to perform dental examinations in 
Arkansas. Although the 2000 and 2001 study was conducted by the 
Director, Office of Oral Health, the 2002 survey utilized the services 
of seven contract dentists, paid a daily rate plus expenses. The 
Program Manager assisted with the surveys and provided screenings in 
most of the schools, alongside a contract dentist.
    Examinations were conducted in the classroom utilizing a portable 
dental light, and sterile, single-use mirrors and explorers. Each 
school was asked to provide an adult to enter data as it was collected. 
Some schools provided adult volunteers while in other schools the 
teacher did the data entry. The newly created recording form allowed 
for easy data entry by non-dental personnel.
    Following the examinations, each student was provided with a 
referral form to take home. The form stated that school-based 
screenings do not take the place of regular dental examinations in a 
dental office, but are to collect data on a large population. The form 
allowed the examiner to indicate to the parents that oral health 
conditions were adequate, conditions existed that needed attention when 
convenient, or that conditions existed that needed immediate attention. 
Referrals in the most serious category indicated that the child had 
apparent pulpal involvement, the child already experienced pain or, in 
the examiner's clinical judgment, the conditions would soon cause 
abscess or pain. Referrals in the second or third categories were not 
made if, in the examiner's opinion, a carious primary tooth would be 
exfoliated before more adverse conditions presented.
    An estimate of socio-economic level was made using the percentage 
of children participating or eligible for the free or reduced-cost 
lunch program. Free/reduced lunch data for each school was provided by 
the Arkansas Department of Education.
Findings
    Survey Subjects:
    A total of 698 children were examined.
    Of the 698 children participating, 485 were White, non-Hispanic, 
190 were African-American, 17 were Hispanic, 3 were of Asian or Pacific 
Islander heritage and 3 were listed as other.
    Referrals:
    167 children (23.9%) were referred for dental care with an 
additional 56 (8%) referred for immediate attention.
    Sealant and Caries Rates:
    24.4% of children examined had at least one dental sealant. 
Individual schools had a sealant rate of from 4.3% to 45.5%.
    The 698 children examined had 2404 teeth that had been affected by 
decay, meaning that the tooth was decayed, had already been filled, or 
had been lost prematurely due to decay. This results in a DMF (decayed, 
missing or filled) rate of 3.44, meaning that on the average, each 
third-grade student in the survey has approximately three to four teeth 
that are decayed, or have been decayed.
    Of the children examined, 698 children or 72.2% had teeth affected 
by caries.
    Of the children examined, 294 children or 42.1 % had untreated 
dental caries.
    Socio-economic Indicators:
    55% of the children participate or are eligible for the free or 
reduced cost lunch program in their schools. The rate of eligibility in 
the individual schools ranged from a low of 10% to a high of 98%.
Discussion
    According to the National Institutes of Health, the placement of 
sealants is a highly effective means of preventing pit and fissure 
caries. Sealants are safe and placed easily and painlessly. Sealants 
are currently underused in both private and public dental care delivery 
systems. Sealant usage in Arkansas is similar to the national rate 
(24.4% compared to 23.0% from NHANES III) while the Healthy People 2010 
objective 9.9a calls for increasing the proportion of 8year-old 
children who have received dental sealants on their first permanent 
molars to 50%.
    The overall rate of 42.1% of all third-graders with untreated 
caries points out that access to quality dental care continues to be a 
problem for many children. This data shows that Arkansas lags seriously 
behind the Healthy People 2010 goal of 16% of 6-8 year olds with 
untreated caries on primary and permanent teeth.
    The reasons for the underutilization of sealants are complex, but 
are affected in great part by the personal preferences of local 
dentists and their auxiliaries. Intensive efforts should be undertaken 
to increase sealant use through professional and lay education. 
Expanding the use of sealants would substantially reduce the occurrence 
of dental caries in this population.
    The 1960's era of ``Look mom, no cavities'' has not yet arrived in 
Arkansas. Seven out of ten children are still affected by dental 
caries. Because Arkansas currently has only 59.9% of the population 
served by community water systems enjoying the benefits of water 
fluoridation (cp. Healthy People 2010 Objective of 75%) and no state-
wide fluoride mouth rinse initiative, efforts to expand sealant usage 
along with these other proven preventive measures must be expanded to 
protect the oral health of our children.
                                summary:
    The Year 2002 Arkansas Oral Health Needs Assessment Survey shows 
that only 24.4% of children surveyed had one or more dental sealants on 
permanent molars compared to the national Healthy People 2010 goal of 
50%. The majority (72.2%) of all children surveyed had been affected by 
dental disease with an average of almost three decayed teeth per child 
(DMF = 3.44). Access to dental care is unattainable for many children, 
evidenced by the high number of children with untreated dental decay 
(42.1%). Efforts and resources must be targeted to increase the use of 
dental sealants, increase the percentage of Arkansans that enjoy the 
benefits of community water fluoridation, and assure that specific 
preventive and restorative dental services be provided to those 
children at greatest risk of oral disease.
         Prepared Statement of the American Dental Association
    The American Dental Association (ADA), applauds the committee for 
holding this hearing to address children's access to oral health care, 
and appreciates the opportunity to testify today.
    As Surgeon General Satcher noted in his 2000 landmark report ``Oral 
Health in America,'' while most Americans have access to the best oral 
health care in the world, the burden of oral disease continues to 
spread unevenly throughout the population directly affecting low-income 
children. In fact, what most public leaders do not understand is that 
dental decay is the most prevalent chronic disease of childhood, five 
times more common in children than asthma. According to the Surgeon 
General 's report, overall utilization of dental services by 
underserved children is less than one in five. This is true despite the 
fact that federal law requires states to cover dental services for 
Medicaid-eligible children through the Early, Preventive, Screening, 
Diagnostic, and Treatment program (EPSDT). There is no shortage of 
shocking statistics or distressing anecdotes to describe the access 
problems faced by thousands of underserved children. It is critical for 
policymakers at the federal and state level to acknowledge that oral 
health is integral to general health and well-being you are not healthy 
without good oral health.
                      federal support and response
    The dental community believes that Congress should assist and 
encourage states to develop their own individualized initiatives toward 
enhancing access to oral health care within their populations. 
Legislation has been introduced in this Congress that would help to do 
just that. Senators Susan Collins and Russ Feingold introduced The 
Dental Health Improvement Act (S. 998), which subsequently was 
incorporated into the Senate-passed Health Care Safety Net Amendments 
of 2001 (S. 1533). This legislation recognizes that for those 
individuals living in rural and inner city locations, obtaining dental 
care can be all too difficult. It provides for incentive-based programs 
to attract dentists to underserved areas and to help improve the oral 
health infrastructure and service delivery in these locations. Senator 
Jeff Bingaman introduced The Children's Dental Health Improvement Act 
(S. 1626), which would reward states that seek to enhance acce ss to 
oral health care for children served by Medicaid, the State Children's 
Health Insurance Program (SCHIP), and our nation's safety net programs. 
This legislation has been endorsed by a bipartisan group of Senators 
and several private organizations. The groups representing organized 
dentistry strongly support both bills and are thankful to those 
Senators who have offered their endorsement.
                       dental community response
    On behalf of the dental profession, the ADA wants to make clear 
that dentists find it unacceptable that in 21st century America there 
are children who cannot sleep or eat properly and cannot pay attention 
in school because they're suffering from untreated dental disease a 
disease that can be easily prevented. Dentists across the country, both 
as individuals and through their professional societies, are fighting 
for these children. But we can't do this alone.
    As a nation, we must recognize how critical oral health is to 
overall health especially to the healthy development of a child and 
find the political will to do a better job of caring for the next 
generation of children. The dental community is committed to working 
with Congress, the federal agencies and the states to address and 
remedy this fixable problem.
    The oral health community has come a long way these last few years 
in working to address issues affecting access to oral health care. 
Dental providers have joined with Governors, state legislators, 
Medicaid officials and many others to tackle barriers impeding 
children's access to care. As a result, some states have worked to make 
oral health a priority, but as a result of serious state budget 
cutbacks, several others have lost ground.
    In the absence of effective public health financing programs, many 
state dental societies have sponsored voluntary programs to deliver 
free or discount oral health care to underserved children. Building on 
these efforts, next February, state dental societies and the ADA will 
sponsor a national program, hosting events around the country to reach 
out to underserved communities, providing a day of free oral health 
care services through a program called ``Give Kids A Smile.'' This 
program will help to educate the public, state and local policymakers 
about the importance of oral health care while providing needed and 
overdue care to thousands of underserved children. Dentists are working 
to do what is necessary to reach out to these children; however, 
charity alone is not a permanent system. Congress and the states must 
work with dentists to establish an improved health care system for the 
delivery of oral health care to our most needy and vulnerable citizens.
    How can Congress work with states to help address the access 
problem? Let us examine some particular areas where there are 
recognized problems.
                    oral health prevention programs
    First, states must continue to work with the Centers for Disease 
Control and Prevention (CDC) and Health Resources and Services 
Administration (HRSA) to invest in successful cost-effective public 
health prevention programs, such as community water fluoridation and 
sealant programs. There are still an unacceptably high number of 
individuals and communities who do not have access to these necessary 
services. Prevention programs like fluoride and sealants are truly a 
cost-effective investment in the oral health of our nation's children 
and must continue to be expanded to ensure equal access for all 
populations.
    States should also be encouraged to work with the dental community 
to continue promoting health prevention to adolescents through tobacco 
cessation and oral cancer detection. Last fall the ADA joined with the 
dental industry on a National Oral Cancer Awareness campaign. 
Billboards and subway signs went up across the country as a national 
alert. Many people question the value of campaigns like these. But, we 
have seen first hand how truly effective they can be. Earlier this 
year, the ADA received an email from a mother with heartfelt gratitude 
for the campaign. Her son made an appointment as a result of seeing the 
campaign information, and the appointment resulted in the removal of a 
malignant lesion. The ``oral cancer information campaign has no 
boundaries,'' said the relieved mom, ``information regarding oral 
cancer does save lives.''
    Prevention is one of the core precepts of oral health care. Most 
oral diseases are predictable and preventable with routine home care, 
regular check-ups, good nutrition and the assistance of public health 
prevention programs like community water fluoridation. Many patients 
who have not had the benefit of preventive care often end up in an 
emergency room, seeking attention for severe dental problems. The 
resulting cost of emergency room treatment for patients and taxpayers 
far exceeds the cost of preventive dental care. In addition, emergency 
room care is limited to pain management. The patient must still see a 
dentist for necessary restorative service. This year, Secretary Tommy 
Thompson began a prevention campaign to alert states and communities 
about the importance of focusing on preventable diseases as a way to 
reduce health care expenditures and enhance quality of life for our 
citizens. We ask that Congress help impress upon the Secretary the 
importance of incorporating oral health prevention into the 
Administration's health improvement initiatives, recognizing that good 
oral health must be a priority for all states and communities.
                        dental medicaid program
    Dentists seek to work with members of Congress, the Centers for 
Medicare and Medicaid Services (CMS) and states to improve the Medicaid 
program in terms of financing and administration in order to increase 
dental participation. Over the last several years, dentists have joined 
with policymakers and stakeholders at national and state-based meetings 
to address why many dentists limit their participation in Medicaid, do 
not participate, or are leaving the program. Several problems affecting 
provider participation have been identified these problems include 
Medicaid reimbursement rates at less than what it costs dentists to 
provide care, excessive paperwork and other billing and administrative 
complexities, and lack of case management and other social barriers 
that result in a high rate of broken appointments.
    There are several ways to address these recognized problems. One of 
the most critical strategies is for states to raise Medicaid rates to 
more closely mirror the marketplace, rather than allow dentists to be 
reimbursed for care at significantly less than what it costs them to 
provide it. In some states, inadequate fee increases set a standard in 
the state sometimes for as many as 15 or 20 years. Our nation's capital 
Washington, DC is an example of this situation, where Medicaid 
reimbursement rates for dental care have not been adjusted since the 
1980's not even for cost-of-living adjustments. How can dentists 
effectively provide care to patients if the system will not afford that 
care?
    Recent state budget cutbacks have escalated the problem of 
inadequate reimbursement rates. Dentists who have signed up to 
participate in the program are often punished as their legislature 
targets provider reimbursement rates as a means to reduce state 
Medicaid expenditures. In 2000, for example, the Iowa legislature 
increased reimbursement rates from 60 to 70 percent of a dentist's 
usual charges only to cut these rates to half that amount in 2002. It 
is impossible to achieve increased and consistent dental participation 
in such an inconsistent system. No matter how much dentists want to 
provide care to Medicaid beneficiaries, when typical office costs are 
about 65 to 70 percent of a dentist's earnings, it is impossible to 
provide care and keep the dental office doors open. Dentists should not 
have to accept 30 cents, or less, on every dollar spent to provide 
care.
    The good news is that there are success stories. There are model 
states that have succeeded in increasing and stabilizing rates that at 
least 75 percent of dentists find acceptable such as Michigan, South 
Carolina and Delaware. The state of Michigan decided to creatively work 
to improve not only the financing structure of their Medicaid program, 
but also the delivery of the program. With the support of the dental 
community, the state contracted with Delta Dental to administer its 
Medicaid program within 37 counties, naming it the ``Healthy Kids 
Dental'' program. The result a Medicaid program that functions like a 
private program, with each Medicaid-eligible individual bearing a Delta 
Dental coverage card. The program offers reimbursement rates at market 
levels, has eliminated administrative complexities and functions like a 
private insurance benefit. Since this partnership, the number of 
Michigan Medicaid kids seen by a dentist has increased from 18 percent 
to 45 percent. Undoubtedly, this public-private model is a success 
story, and there are others. Through additional public-private 
partnerships, models like this can be achieved elsewhere.
    Some officials express disagreement about the success increased 
reimbursement rates may have, but they do so by failing to look at the 
complexity of the issue. In September 2000, the U.S. General Accounting 
Office issued a report on the Medicaid dental program, titled ``Factors 
Contributing to Low Use of Dental Services by Low-Income Populations.'' 
The report issued many legitimate findings regarding dental 
participation in Medicaid; however, its conclusions lacked significant 
insight. For example, the report stated that ``raising Medicaid payment 
rates for dental services a step 40 states have taken recently appears 
to result in a marginal increase in use but not consistently.'' In that 
statement, the GAO oversimplifies a very complex issue and makes a 
conclusion without a proper assessment. The report does not explain 
that several states have raised rates to a level that continues to fall 
below dental overhead costs. The report fails to acknowledge the 
numerous factors affecting provider participation in Medicaid and fails 
to quantify their impact on utilization. To simply issue a conclusion 
that increased payment rates have an inconsistent impact on dentist 
participation is inappropriate and can have a devastating effect on 
state efforts to achieve needed improvements in reimbursement, 
particularly now when states are faced with increased budget cutbacks.
    Where state fiscal situations impede increases in provider 
reimbursement, state dental societies are working to encourage 
improvements in the administration of the Medicaid program. Some 
examples are improved case management, transportation services to 
assist patients with scheduled appointments and public education on the 
importance of oral health. Many dentists have faced years of 
frustration with the Medicaid program, resulting in a great deal of 
mistrust. Too often the ADA and other dental organizations have heard 
their members outline the administrative hassles they face within these 
programs. Medicaid bureaucracy through lengthy provider applications, 
prior authorization requirements, and complex claims forms deter 
provider participation. Congress should ensure that the appropriate 
federal agencies work with states to help address this bureaucracy and 
improve the system.
    There is certainly room for more public education on the importance 
of seeing a dentist at an early age mostly to educate parents or 
guardians. With some federal support through HRSA and the 
Administration for Children and Families (ACF), states have shown how 
this can be effectively done through Maternal and Child Health 
Departments, Women, Infants and Children (WIC) and Head Start programs 
but more support is necessary.
                         training and workforce
    Ensuring the development of a responsive, competent, diverse and 
``elastic'' workforce is a key priority of the ADA, particularly as it 
relates to underserved locations many which are further limited by 
geographic location. We need programs and policies that ensure that an 
adequate network of providers is available in each state, including 
rural communities. We recognize that nationwide, a serious 
maldistribution of dentists exists within the states and that some 
states face a shortage of generalist dental providers and several face 
a shortage of pediatric dentists. Currently, there are only 3,800 
pediatric dentists in the country; some states have fewer than 10. We 
must do more to fund additional training programs to meet the 
increasing need for pediatric oral health care services as 25 percent 
of the pediatric population experiences 80 percent of the dental 
disease, and this is concentrated in low-income, minority populations.
    HRSA administers several programs to help bring providers to 
underserved communities in need of dental care through pediatric and 
general residency training programs and the National Health Service 
Corps program. These programs have been threatened by existing budget 
proposals, and dentistry is gravely concerned about their longevity and 
what affect such cuts will have on patient access to care. The 
population of underserved children served by both Medicaid and SCHIP 
experience disproportionately high levels of oral disease, increasing 
the need for pediatric dentists, as well as dentists with general 
residency dental training. Pediatric dentists treat a disproportionate 
percentage of those populations as well as medically compromised and 
disabled children. It is critical that the federal government support 
states in addressing this growing and persistent problem.
    Together, we can do more to encourage the states to create 
incentives that will attract dentists and other dental team members to 
underserved areas. Senators Susan Collins and Russ Feingold provide for 
such incentives in their legislation, allowing for student loan 
repayment and forgiveness programs and tax credits for those who 
practice in underserved locations. With the level of debt many dental 
students face today when they graduate, those measures could be just 
what it takes to get a commitment from them to begin their years of 
practice in areas where they are needed most.
    Dental schools and their satellite clinics are on the front lines 
of combating oral disease. For innumerable children, including many of 
the 23 million who have no dental insurance, these dental facilities 
are the sole source of oral health care. These facilities play an 
integral role in addressing access issues and working to eliminate 
disparities among Medicaid, SCHIP and uninsured populations where more 
than 65 percent are members of families with annual incomes of less 
than $15,000. Yet, many schools are facing a shortage of dental 
faculty. During the 2001-2002 academic year, approximately 350 budgeted 
dental faculty positions were vacant. State and federal incentive 
programs are critical to curb this shortage and ensure that enough 
qualified faculty members are available to train future dental 
practitioners.
    Congress can also do more to support additional funding for dental 
training programs, including programs to fund courses on caring for 
individuals with special health care needs. The ADA, Special Olympics 
and other concerned organizations participated in a Surgeon General's 
Conference last December to address the health concerns of people 
living with mental retardation. Access to oral health care was 
repeatedly mentioned as a key concern for this community. Dentistry 
pledges its support to partner and work toward developing solutions to 
this unacceptable problem.
                federal/state oral health infrastructure
    Dentistry is working at the federal level to ensure a strong oral 
health infrastructure within the agencies of the Department of Health 
and Human Services. Programs and positions must exist to address oral 
health issues concerning insurance coverage, prevention, research and 
outreach activities. Because dentistry is such a small percentage of 
nationwide health care expenditures, oral health sometimes ranks low on 
the list of critical issues agencies like CMS must address, and the 
focus of health care is generally on medical care. However, as Surgeon 
General Satcher and other Surgeon Generals before him have noted, oral 
health is integral to overall health and cannot be ignored.
    Most recently, the dental community successfully worked with CMS to 
establish a full time dental officer position to represent the oral 
health-related programs and policies of the agency. The posting for 
this position was released just last month. The dental community would 
like to recognize the agency for this support and looks forward to 
working with the new dental officer on several key issues, most 
importantly access to oral health care for children served by Medicaid 
and the SCHIP Program.
    Likewise, we seek to work with HRSA to ensure similar oral health 
representation exists within the agency's national and regional 
offices. States depend on the information relayed through technical 
assistance and the funding support received from these agencies in 
order to operate effective oral health programs. An inadequate federal 
infrastructure is detrimental to the existence of strong oral health 
programs in the states, significantly affecting access to care.
    At the same time, building an oral health infrastructure within 
each state is critical if we are to ensure that oral health is treated 
as a health care priority. We need recognized dental directors within 
each state who have access to Governors' offices, Medicaid officials, 
and public and private practitioners to propose access ideas and 
solutions. One way to build this infrastructure is through improved 
funding for HRSA's Maternal and Child Health Bureau, which provides 
support to state oral health programs through its Block and 
Discretionary Grant programs.
    States also need support and guidance to improve data collection 
and surveillance within their communities to best identify where the 
most serious oral health access problems exist. Congress should 
encourage continued collaboration between the CDC and states to develop 
databases that monitor and help analyze the public's oral health needs.
                               conclusion
    Dentists are justifiably proud of the overall state of the nation's 
oral health, which, for most Americans, is excellent. But we cannot 
forget the fact that millions of people in this country particularly 
children aren't getting even basic preventive and restorative dental 
care. These children are out there suffering. There are dentists out 
there who want to end that suffering. Working with Congress and the 
states, together we must find the will to break down the barriers that 
separate them.
                   Prepared Statement of Ed Martinez
    Mr. Chairman and members of the Committee, my name is Ed Martinez 
and I'm the CEO of San Ysidro Health Center in San Ysidro, California, 
a neighborhood of the City of San Diego that is located adjacent to the 
U.S.--Mexico border crossing. It is my privilege to testify today in 
support of Senate Bill 1626 as a representative of the National 
Association of Community Health Centers, Inc. and the millions of 
patients that America's health centers serve every year.
                  overview of america's health centers
    Currently there are nearly 800 federally supported health centers 
operating nearly 3,400 community sites across the country. Together 
with more than 200 other health centers known as FQHC ``look-alikes,'' 
these centers have produced a model of health care that has 
demonstrated this nation can meet compelling health needs while 
containing health care costs. The health center legacy proudly shows 
the value and vast potential of a community-based health system that is 
lifting the barriers to health care-safeguarding health--revitalizing 
communities--keeping people health at cost savings for the nation.
    Key to the success of health centers over the years has been the 
four core program elements that today still define each community-
based, non-profit health center--these include:
    1. Services are located in high-need communities;
    2. Programs deliver comprehensive health and related services 
(e.g., ``enabling'' services such as translation, case management, 
transportation, etc.);
    3. Services are open to all residents, regardless of ability to 
pay, with sliding fee scale charges based on income; and
    4. Health centers are governed by community boards to assure 
responsiveness to local needs and aspirations.
    Today, health centers are the family doctor and health care home 
for almost 12 million Americans, including substantial percentages of 
key groups of uninsured and underserved, including:
    1 of 9 Uninsured Persons (4.9 million)
    1 of 8 Medicaid Recipients (4.1 million)
    1 of 6 Low-Income Children (4.9 million)
    1 of 5 Low-Income Births (400,000 annually)
    1 of 10 Rural Americans (5.4 million)
    8 million of People of Color; 600,000 Migrant Farmworkers; 600,000 
Homeless Persons
    San Ysidro Health Center (SYHC), the program I have the privilege 
to represent, was established in 1969 out of the efforts of a community 
women's' organization that had a vision for addressing the unmet 
medical and oral health needs of thousands of underserved residents in 
the San Ysidro community. Through developmental resources provided by 
the federal government and other public agencies, our health center has 
grown over the years in response to community needs. We now provide 
medical, dental, behavioral, as well as enabling services through a 
network of nine neighborhood service centers. Each year SYHC provides 
services to approximately 40,000 registered patients. Last year, SYHC 
generated 180,000 patient visits in the areas of medical, dental, and 
behavioral services. Approximately 75% of the families utilizing our 
services have household incomes equal to or below the Federal Poverty 
Level.
    San Ysidro Health Center, like many other health centers, relies 
not on one--or even a few--but on a variety of funding sources to 
support ongoing programs--the following represents the typical mix of 
funding sources:
    35% Medicaid and other public payors
    26% Federal grants
    19% State/Local/Other
    7% Patient Income
    6% Medicare
    Our health center programs maintain a very delicate balance between 
the adequacy of revenues from these many sources and the capacity to 
serve the patient populations that need our services and support. Like 
all core safety net providers, health centers also face many 
challenges, any of which could upset that delicate balance, and a 
combination could have severe and profound consequences.
    The biggest challenge all health centers face today is the 
continued rise in the overall number of persons without health 
insurance. This significant trend has been further compounded by 
cutbacks from local and state funding agencies--and private charitable 
organizations--all of whom have been squeezed by unexpected budgetary 
shortfalls. As a result, health centers and other core safety net 
providers have experienced high concentrations of uninsured patients 
unmatched by any other provider types. This might help to explain why, 
with barely one percent of the nation's practicing physicians, health 
centers now provide one-fifth of all ambulatory care for uninsured 
people in the country.
         dental caries (tooth decay) is a public health problem
    Tooth decay is the most common chronic disease of childhood, 
affecting 5-8 times as many children as does asthma. Early childhood 
caries (ECC) is an aggressive form of the disease that can begin as 
soon as the teeth emerge into the mouth at about 6 months of age. Among 
2-4 year-olds nationally, 17% had experienced dental caries in their 
primary (baby) teeth. Depending on the criteria used, Mexican-American 
children in the national study were 3.5-4.6 times more likely to have 
early childhood caries than white non-Hispanic and black non-Hispanic 
children. Among preschool children in California, in a 1993-94 
statewide survey by the Dental Health Foundation, 40% of Head Start 
programs have higher decay rates than children in other preschool 
settings. Children from poor families with incomes below 200% of the 
federal poverty level (FPL) are 5 times as likely to have unmet dental 
care needs as children from families above 200% FPL. While some risk 
factors for ECC have been identified (e.g., prolonged bottle feeding 
with sweetened beverages, use of sweetened pacifier, untreated dental 
decay in mothers), their effects on specific ethnic groups or on very 
young preschool children have not been adequately investigated.
  what has been san ysidro health center's experience with children's 
                         oral health problems?
    Since 1973, SYHC's oral health program has functioned as the 
principal dental safety net provider in the South Bay Region of San 
Diego County. Our health center currently operates two dental clinics 
with a total of 19 operatories--our dental workforce consists of seven 
full time dentists--one pediatric dentist and six general dentists. 
Each month our dentists provide comprehensive oral health services to 
approximately 1,700 adults and children. Of this population, 
approximately 500 are children under the age of 10 years; many of these 
children present with advanced stages of dental disease requiring 
extensive restorative services. These are children of families who do 
not have dental insurance, or who are underinsured, who generally come 
to us requiring urgent or emergency care.
    Over the past several years, our dentists have reported 
difficulties in responding to an increasing rate of untreated oral 
diseases, primarily among children living in poverty and of racial and 
ethnic minorities. To clearly define the magnitude of the dental 
disease problem our health center was experiencing, our health center 
implemented a scientifically designed oral health needs assessment of 
2,000 preschool children. This scientific study documented the fact 
that 69 percent of the surveyed preschool-age population (under 5 
years) had untreated dental disease. This incidence of dental disease 
significantly exceeds both state and national disease rates.
    As front-line providers of dental care services, it is quite 
evident that our health center is dealing with an epidemic of dental 
disease that is currently sweeping through our community, and--unless 
checked--threatens to overwhelm our community's limited treatment 
resources. Although our dental staff works at 100% capacity in 
providing urgent/emergency restorative dental care to underserved 
children, we are only able to scratch the surface, relative to 
arresting the epidemic of tooth decay that is now sweeping our 
community. By necessity, our dental program concentrates on short-term, 
``drill and fill'' services that serve to relieve the pain and 
suffering associated with acute and chronic dental disease. Health 
centers across the country report similar experiences in responding to 
the tidal wave of children suffering from rampant dental disease. 
Collectively, we are all caught in a frustrating cycle of running to 
keep up with the spiraling (upward) demand for urgent treatment 
services, while recognizing the fact that over time, the only effective 
strategy to reduce the burden of children's dental disease is to 
implement community-based, disease prevention/health promotion 
initiatives. With limited program capacity and increasing dental 
disease among children, additional resources are needed to effectively 
treat and prevent oral disease.
 using the strengths of community health centers to improve children's 
                              oral health
    Since the beginning of the community health center movement in the 
early 1960's, community health centers have clearly demonstrated their 
effectiveness in delivering affordable, high quality, and culturally 
competent services to low-income, traditionally underserved 
populations. To provide the full scope of program services required for 
federal funding (pediatrics, ob/gyn, medicine, social services, and 
case management), CHCs have pioneered a number of innovative strategies 
for delivering services to high risk, traditionally underserved 
populations. Conceptually, these well-established service delivery 
strategies are ideally suited to effectively address ECC in high-risk 
communities. Four strategies we have used to improve the health of our 
community can be readily applied to young children with early childhood 
caries:
    1. Targeting high-risk populations with early intervention 
initiatives. Federally funded CHCs operate within designated 
``Medically Underserved Areas,'' as well as ``Health Professional 
Shortage Areas.'' By definition, these geographic areas are populated 
by high-risk populations experiencing significant access-to-care 
barriers. Therefore, CHCs have the capacity to deliver early screening 
and health promotion programs to high-risk populations that include 
low-income women, children and adolescents.
    2. To address ECC effectively for high-risk children, it is 
understood that primary prevention measures must begin between the ages 
of 1-2 years. SYHC as well as hundreds of other CHCs operate, and 
collaborate with, WIC and Headstart programs to reach high-risk 
children in a timely way. Over the past 3-6 months, SYHC's WIC program 
has provided services to an average of 4,000 preschoolers per month. 
Through our ongoing WIC program, SYHC has established personal 
relationships with mothers and families that will facilitate the 
implementation of early dental intervention initiatives.
    3. In the work of early childhood development, it is a well-
established fact that a multidisciplinary approach is essential to 
optimize a child's overall health and welfare. SYHC and many other CHCs 
are moving towards an integrated approach to delivering pediatric, 
prenatal, mental health, and WIC services to high-risk mothers, 
children, and families. Discussions are in progress to collaborate with 
agencies offering family-support services such as early child 
development counseling, parenting skills, and home visitation services. 
This comprehensive services approach represents an expansion of SYHC's 
traditional model of care and builds on the goal of developing a more 
holistic approach to improving the quality of life for our community.
    4. Historically, case management techniques have been well 
established in CHC programs. High-risk populations (e.g., diabetics, 
homeless, emotionally disturbed, HIV/AIDS) require focused attention, 
individualized treatment plans, and care coordination. Given the 
psychosocial and cultural characteristics of our community, this case 
management expertise is an essential piece to developing effective 
intervention programs for children at high risk for dental disease.
     s. 1626, ``children's dental health improvement act of 2001''
    As a front-line provider of dental safety-net services, S. 1626 
represents a bold, comprehensive vision for improving the oral health 
status of America's children. The Children's Dental Health Improvement 
Act of 2001 provides much needed public resources that will help create 
a stable economic platform that has the potential to stimulate and fund 
community-based innovations in the areas of service delivery, health 
promotion and disease prevention. New public resources will make it 
possible for health centers to design, organize and implement 
children's oral health initiatives that have the potential to 
significantly reduce the incidence of dental disease, while responding 
to our community's urgent need for treatment services.
    As we consider passage of this bill, I believe it is appropriate to 
highlight the strategic role America's health centers could play in 
implementing a nationwide oral health improvement initiative:
    1. Health centers are well position/poised to implement S. 1626 
because health centers: represent a nationwide care delivery system 
made up of approximately 1000 centers and 3,400 delivery sites; have a 
tradition of organizational commitment to serving poor and underserved 
communities, as well as advocating for improvements in the public 
health services; provide a continuum of prevention and primary care 
services to millions of low-income, underserved children--we approach 
the oral health problems of children as a ``pediatric health'' issue 
vs. strictly a ``dental'' problem; have demonstrated effectiveness in 
building broad-based community partnerships to advance important public 
health initiatives, and throughout the country, health centers are now 
working to increase the public's awareness regarding children's oral 
health issues.
    2. Health centers are in a high state of readiness to act in 
support of S. 1626 because health centers: have the essential 
administrative infrastructure to manage service expansion initiatives 
in a cost-effective and timely manner; have effective accountability 
systems in place for monitoring a broad range of clinical and 
operational performance standards; have successfully developed public-
private partnerships that are now formulating community-based 
strategies for improving access to care and reducing disparities in 
oral health status; are experienced in leveraging public resources with 
other funding programs in order to optimize service delivery.
    3. Health centers can help deliver much of what S. 1626 proposes 
because health centers: currently provide services to millions of 
children at-risk for dental disease--we can find the high-risk 
children; currently provide dental treatment services to millions of 
high-risk children--we can connect the children to treatment services; 
currently provide essential support services for high-risk children and 
their families--we can support ongoing professional management of a 
child's oral health maintenance; will take the lead in developing 
community-based strategies for developing effective oral health 
promotion and disease prevention programs.
    Looking forward, America's community health centers stand ready to 
implement the bold dental health vision presented by S. 1626. Through 
the program resources provided by S. 1626 and the collective efforts of 
all child health advocates, we envision the day in the not too distant 
future where all children, regardless of financial background, have 
access to comprehensive, quality oral health services.
    Thank you for the opportunity to express my comments on the 
important issue of children's oral health. I would be happy to answer 
your questions at this time.
                 Prepared Statement of Timothy Shriver
    Mr. Chairman and esteemed Committee members, I am thankful for the 
invitation and eager to present testimony to you today concerning the 
oral health needs of persons with mental retardation. I commend you for 
conducting this hearing that focuses on a critical health issue for 
children and that certainly impacts a population that Special Olympics 
strives to serve every hour, every day, around the world. I had the 
good fortune in March of 2001, to present testimony before a Field 
Hearing of the Subcommittee of the Committee on Appropriations of the 
United States Senate. At that time, I stated to the best of my 
knowledge, that was the first time that a Federal legislative hearing 
had ever been dedicated to the health needs of persons with mental 
retardation. I can similarly state that in the 34 years of its 
existence, this is the first time that Special Olympics has ever been 
called to a hearing in Washington, D.C. to speak to the health concerns 
of persons with mental retardation.
    I am sure that you are aware that Special Olympics is dedicated to 
providing year round training and competition for children and adults 
with mental retardation in Olympic type sports. We have effectively 
used sport as a vehicle to provide life opportunities to persons with 
mental retardation and to educate the public and policy makers about 
what people with mental retardation can accomplish when unnecessary, 
unfair, and sometimes illegal barriers, that are too often placed in 
their way, are reduced or eliminated. We currently serve one million 
athletes in 150 countries through more than 200 franchised Special 
Olympics programs at state and national levels that put on nearly 
20,000 sports competitions each year. We are aggressively working to 
increase our service delivery to 2 million athletes worldwide by 2005. 
With continued persistence and support from a broad array of advocates 
and partners, including private citizens, corporations, academic 
entities, non-profit organizations, and governments around the world, 
we expect to reach that goal.
    There is, however, a challenge that greatly affects our athletes, 
their families, and Special Olympics' ability to provide a quality 
sports experience; that is, the health needs of our athletes. A little 
over a decade ago, we became aware that many of our athletes had health 
problems that caused them pain, limited their ability to perform in 
Special Olympics and compete in life, and that actually put them at 
risk. I personally experienced this in 1995 during our World Summer 
Games in Connecticut. When I looked at the data from our health 
screenings, I was appalled at what I saw: 50% of the athletes screened 
had ocular pathology; 25% had muscle disorders of the eyes; nearly 30% 
had general untreated visual problems; 23% had failed a test for visual 
acuity; 68% had gingival infection; and, one-third had obvious 
untreated dental decay. Most frightening, almost 15% of the Special 
Olympics athletes who chanced into our clinic suffered from acute pain 
or disease, necessitating immediate referral for care.
    When I asked one of our senior clinical volunteers how such 
situations could exist, he did not seem surprised. Basically, he said, 
providers have low expectations for what such patients need or could 
possibly be expected to accomplish. Those that do get into the care 
system, get a ``quick and dirty'', meaning just good enough to get by.
    From that point, I knew that even though Special Olympics is a 
sports organization, we could not go forward assuming that the unmet 
health needs of our athletes would be taken care of or that flawed 
policies and discriminatory behaviors on the part of the health care 
system would resolve on their own. We have been forced to take steps to 
identify the scope and nature of the problems using objective 
scientific approaches, to communicate our findings broadly to the 
public and policy makers, and to take the lead in demonstrating models 
that can facilitate improved health and access to needed health 
services for our athletes and others with mental retardation. Make no 
mistake, we did not take on this challenge because we did not have 
enough to do promoting our sports initiatives. We simply had no choice.
    I place before you two Special Olympics reports that document the 
health needs, including dental care needs, of persons with mental 
retardation. While there is not the abundance of data available that we 
would like, there clearly is enough to indicate that there is a big 
problem. The Health Status and Needs of Persons with Mental Retardation 
is a comprehensive literature review prepared by Dr. Sarah Horwitz and 
colleagues at Yale University. Promoting the Health of Persons with 
Mental Retardation: A Critical Journey Barely Begun is a policy 
oriented document created by Special Olympics that cites our own 
findings of the health needs of Special Olympics athletes and describes 
our efforts to address those needs through our Healthy Athletes 
initiative and research. Additionally, there is the Special Olympics 
Report of the field hearing conducted before a Subcommittee of the 
Committee on Appropriations of the United States Senate.
    Let me also acknowledge and commend Dr. David Satcher, former U.S. 
Surgeon General and Assistant Secretary for Health, for the leadership 
he demonstrated in convening the first Surgeon General's Conference on 
the health needs of persons with mental retardation in December 2001 
and for producing the report Closing the Gap: A National Blueprint to 
Improve the Health of Persons with Mental Retardation. Special Olympics 
is working hard to address the key issues raised in this report and we 
anxiously await to see how governmental agencies and private 
professional, education and advocacy organizations will seriously take 
up the baton of responsibility to pursue actions to address the 
findings in the report. Special Olympics is in the process of entering 
into a grant relationship through the U.S. Centers for Disease Control 
and Prevention to implement the Healthy Athletes Initiative as called 
for in the FY 2002 Federal Appropriations Act.
    In focusing in on the oral health issues specifically, consider the 
following facts from our 2001 Healthy Athletes screening data, 
collected through 31 U.S. screening sites and involving over 9,000 
athletes: 30% of the athletes we screen have active tooth decay 
(infection) that is apparent without the use of x-rays or highly 
sensitive examination methods; 30% are missing one or more permanent 
teeth, likely the result of extractions due to tooth decay or 
periodontal infection. Could this be another example of ``quick and 
dirty''?; 38% need care of a more pressing nature than ``routine''; 14% 
report to be in pain from a tooth or other oral cause at the time of 
the screening; 44% show obvious signs of gingival infection; 4% have no 
natural teeth left in their mouth.
    Data for non-U.S. athletes are even more alarming and we must 
assume that our athletes who participate in state level Games are 
likely to be the ones with better skills and more involved caregivers 
who are able to either provide or direct good oral health habits. The 
conclusion is that the unmet oral health needs among Special Olympics 
athletes and the larger population with mental retardation are high and 
care is difficult to obtain for this population.
    While I have shared some hard data with you about the oral health 
needs of persons with mental retardation, let me also share some hard 
personal stories. Because, underneath the sterile dispassion of data 
tables are human lives--people who day-to-day, hour-by-hour have to 
deal with compounding challenges just to get through the basic 
functions of life. I want to share this with you through the lens of 
the person with mental retardation and through the lens of the 
concerned health care professional who is overwhelmed with what it's 
like to face the challenges of oral diseases without adequate support. 
This information comes from two people ``on the ground''. Dr. Steven 
Perlman is the founder and Global Clinical Advisor for Special Olympics 
Special Smiles. His private practice in the Boston area is dedicated 
almost exclusively to treating Medicaid patients, including many, many 
persons with mental retardation and other disabilities. JoAnn Simons is 
the Executive Director of EMARC, a former Special Olympics Board 
member, and parent of a child with mental retardation.
    Accessibility to dental care is a major issue for individuals with 
mental retardation because of both the funding issues and the 
unwillingness of many dentists to provide care to this patient group. 
In Massachusetts, Medicaid eligible children, and both children and 
adults with special needs, face a most difficult task in obtaining 
dental care. Only around 10% of the dentists in the state accept 
MassHealth (Medicaid) and about a fifth of pediatric specialists. I am 
not sure that any periodontists, endodontists or prosthodontists in the 
state accept patients with Medicaid. Medicaid serves as the principal 
payment mechanism for health care for persons with mental retardation 
in every state throughout the country.
    As of March 15, 2002, the fees for the children's Medicaid program 
in Massachusetts were raised by 38%, but indications are that it did 
not induce many new providers to accept patients. Numerous other states 
have noted similar findings over the past several years.
    For adults (over age 21 years) with disabilities, it is even more 
difficult to obtain care. The criteria are very strict; the dentist 
must have a note from a physician and a prior approval in order to 
provide any treatment. In addition, Massachusetts did not raise the 
adult fees when they raised fees for children's dental care services 
and, therefore, the provider must accept fees that are approximately 
20-30% of usual and customary (UCR) for their most difficult and time 
consuming patients. There are only six or so dental practices in the 
state that are willing to treat adults with disabilities. Practitioners 
who are willing to step up and treat this population often find that 
they are overwhelmed by desperate parents and caregivers seeking a 
willing dental provider and scores of dentists seeking a willing dental 
provider to refer the case to.
    Families and providers of mental retardation services in 
Massachusetts report that they must often travel great distances to 
either find a willing community dentist or they must receive care in a 
state funded, Medicaid eligible facility. Often, willing providers even 
tell parents of patients with mental retardation, ``I will treat your 
child, but don't let anyone know or I'll be overwhelmed''.
    Families and caregivers recognize the importance of maintaining 
good oral health; however, the reality is that many individuals with 
mental retardation go without daily oral hygiene care simply because it 
is too difficult to get the necessary compliance. This makes the access 
to reliable dental care even more essential.
    Medicaid administrators, when confronted with these issues, point 
to institutional care provided through the Tufts program as the 
appropriate care provider for people with disabilities. Isn't it 
amazing, after decades of enlightened efforts to move people out of 
repressive institutional settings and into the larger community, that 
we would look to drive them back to institutions even for routine care.
    The system does not have any incentives for dentists to treat this 
population; in fact, incentives exist for dentists not to treat. Most 
are able to fill their practices with private paying patients who do 
not require special attention.
    Recently, Special Olympics published an important booklet for our 
athletes that was actually designed by our athletes. The title is 
provocative: Are You A Healthy Athlete? The cover shows two athletes, 
one of whom is holding up a hand mirror. Clearly, we are challenging 
the athletes to take a look in the mirror and to take their health 
seriously. This booklet contains simple sound advice for how our 
athletes can take actions to improve and protect their health and 
presents real athletes as role models for these behaviors. I am 
extremely proud that two of our athletes will be presenting a poster 
session on this work at a national health meeting in November.
    I must say, though, that it is unfair and unrealistic to expect 
that our athletes and others with mental retardation will have enough 
personal resources and influence to deal with all of their health care 
needs. The mirror that the athlete is holding should really be for 
those who are in a position to make a difference--health policy 
experts, public officials, administrators of health systems, and 
leaders in the health field, as well as rank and file health care 
providers at the community level. To date, our athletes and others with 
mental retardation have gotten short shrift. This must change.
    Special Olympics, for its part, has implemented the Healthy 
Athletes program. We conduct health screenings, provide health 
education, deliver some definitive care (e.g., prescription 
eyeglasses), and make referrals for follow-up care. Currently, Healthy 
Athletes includes, Special Smiles, Opening Eyes, Healthy Hearing, and 
Athlete Health Promotion. We are developing new screening protocols on 
a continuing basis where we think that our athletes can benefit.
    Many individuals and organizations have assisted us in this effort, 
including the Lions Clubs International, Grottoes Humanitarian 
Foundation, Patterson Dental Supply, Colgate Oral Pharmaceuticals, Oral 
Health America, American Dental Association Health Foundation, Sultan 
Chemists, Biologic, Essilor, Luxotica, Liberty Optical, and many more. 
Additionally, many health professional and allied health professional 
schools and associations have provided faculty, students and leadership 
to make the Healthy Athletes program accessible to athletes. And, 
thousands of health professionals have volunteered their time and 
talents to bring needed services to our athletes.
    As I said earlier, we at Special Olympics are not a health care 
system, nor do we intend to be. We are committed, however, to compel 
others to take up these responsibilities even as we demonstrate 
effective ways to serve our athletes. We were fortunate, in 2002, to 
receive our first Federal assistance in support of Healthy Athletes. We 
are hopeful that leaders in Congress, including yourselves, will view 
our efforts as exceptional and important and worthy of your continued 
support in 2003 and beyond.
    Senator Bingaman, your proposed legislation has the potential to 
redress many of the shortcomings in the current health care system so 
that millions of additional children will receive the dental care that 
they need in order to be healthy. I do wish to point out to you some 
additional considerations for your bill that would help assure that 
those with intellectual disabilities do not fall through the cracks as 
your bill becomes law. We have lived with the challenges of getting 
needed health care, including dentaI care, for our athletes for 
decades. While enhanced reimbursement levels and salary supplements for 
dental providers are important, they are not, in themselves, enough to 
assure that persons with mental retardation will receive the care that 
they need. Our experience is that few dentists and hygienists have 
received any significant training or experience in dealing with this 
population during professional school, in post-graduate work, or 
through continuing professional education. Actual teaching hours in 
dealing with these types of patients has declined in dental schools 
over the last decade. You would be hard pressed, in reviewing listings 
of current continuing dental professional education opportunities, to 
find offerings that deal with treating this population. We find that 
when we orient, train and provide hands-on experience for our Special 
Smiles volunteers, wondrous things happen. Dental providers gain 
confidence, new skills, improved attitudes and a commitment to serve 
our population. I recommend that you give consideration to adding 
provisions to your bill to address these concerns.
    I recommend that your bill, in Title II, specifically challenge all 
of those institutions, providers and government agencies that would 
receive funding toward its implementation to address specifically the 
oral health care needs of those with disabilities, including mental 
retardation, and to explicitly establish baselines of need using 
objective criteria and scientific methods. Further, they should be 
required to explicitly plan approaches to address the special needs of 
individuals with mental retardation, wherever they live, and to 
establish quantitative and qualitative goals for improving their oral 
health status and access to care, and to monitor progress toward their 
improvement.
    It is also important to recognize that utilization of traditional 
dental health professional shortage area criteria could still leave 
persons with disabilities and other Medicaid eligibles without 
accessible care. There are many geographic areas with an abundance of 
trained health professionals, but with inadequate access to care for 
persons such as those with mental retardation. A shortage should be 
viewed from the perspective of the patient needing and seeking care, 
rather than the perspective of just provider count. If trained, 
licensed health professionals choose not to treat persons with mental 
retardation, regardless of the number of providers, then surely there 
is a shortage. I recommend that any dentist willing to serve a 
significant number of Medicaid eligible individuals, whether as an 
employee or as an independent practitioner, be included as eligible for 
supplemental remuneration. Each of our athletes and others with mental 
retardation need a ``dental home'' where qualified, willing dental 
providers will commit to handling their oral health needs from 
prevention through rehabilitation on a continuing basis.
    Consistent with this, I recommend that persons with mental 
retardation be regarded as a specific catchment group for which efforts 
should be targeted. Further, given the role that reimbursement plays in 
people not getting the dental care that they need, serious 
consideration needs to be given to market rational reimbursement 
policies that would reflect the additional care and time that patients 
with mental retardation may require. This would include reimbursement 
rates for oral health services comparable in market index to 
reimbursement rates for medical services under Medicare and 
additionally adjusted for case intensity.
    I recommend that additional organizations, beyond those listed in 
Title II, be eligible to receive grants for purposes of improving oral 
health care access for underserved populations, including those with 
mental retardation. And, finally, I find it ludicrous that across the 
country, youth with a chronological age of 21 years, even while having 
a mental age well below this, age out of reasonable dental care under 
the Medicaid program as it now stands. While it is reasonable that, at 
some point, young people on Medicaid should become self sufficient 
adults, how could such logic be applied straight across to persons with 
mental retardation. In many cases, adults with mental retardation 
become more needy of support as their caregivers age, become infirm, 
dependent themselves, or pass away. To abandon their oral health care 
needs at age 21 is cruel and unscientific. I believe that age 
restrictions on Medicaid dental care services for those with mental 
retardation, who are otherwise eligible, should be waived the 23-year-
old person with mental retardation and unmet dental care needs or who 
is in pain is no less vulnerable or deserving of care than the 17-year-
old.
    Loretta Claiborne, a highly accomplished Special Olympics athlete 
from Pennsylvania, offered the following riveting testimony before the 
U.S. Senate hearing last year in Anchorage: ``We do more in this 
country to give health care to people in prison than we do for people 
like me who have done nothing wrong''. Senator Bingaman, I believe that 
the legislation you have proposed could go a long way toward redressing 
this scandal. I am hopeful that we can see it passed and that the 
issues I have raised for your consideration can be reflected.
    I would be happy to try and answer any questions that you may have.
              Prepared Statement of Special Olympics, Inc.
                                summary
    As the largest organization in the world promoting acceptance 
through sport, Special Olympics has a 32 year track record of 
demonstrated success in providing year-round sports training and 
competition opportunities for children and adults with mental 
retardation. Founded in 1968 by Eunice Kennedy Shriver, Special 
Olympics, Inc. (SOI) is incorporated in the District of Columbia as a 
not-for-profit corporation focused on international sports.
    Special Olympics flourishes in 150 nations and in each of the 50 
states, the District of Columbia, Puerto Rico, Guam, the Virgin 
Islands, and American Samoa. One million people with mental retardation 
annually participate in Special Olympics training and competition 
programs globally. One million volunteers and 250,000 coaches around 
the world support these efforts, training athletes in 22 Olympic-type 
sports and organizing more than 20,000 local, regional, national and 
international sporting events annually. Through regular sports training 
programs, Special Olympics athletes enhance their athletic skills, 
improve their overall physical fitness, and develop increased self-
confidence and self-esteem. In fact, published research indicates that 
for people with mental retardation, regular participation in Special 
Olympics sports training and competition activities yields all of these 
benefits and often leads to sustained improvement in overall physical 
fitness and emotional well-being (1).
                prevalence/causes of mental retardation
    The World Health Organization estimates that there are 
approximately 170 million people with mental retardation worldwide (2). 
In other words, nearly 3% of the world's population has some form of 
mental retardation. Accordingly, mental retardation is 50 times more 
prevalent than deafness; 28 times more prevalent than neural tube 
disorders like spina bifida; and 25 times more prevalent than 
blindness.
    A person is diagnosed as having mental retardation based on three 
generally accepted criteria: intellectual functioning level (IQ) is 
below 70-75; significant limitations exist in two or more adaptive 
skills areas (e.g., communication, self-care, functional academics, 
home living); and the condition manifests before age 18. Mental 
retardation can be caused by any condition that impairs development of 
the brain before birth, during birth, or in childhood years. Genetic 
abnormalities, malnutrition, premature birth, environmental health 
hazards, fetal alcohol syndrome, prenatal HIV infection, and physical 
abnormalities of the brain are just some of the known causes of mental 
retardation.
    This report is the result of an analysis that was undertaken to 
identify and highlight the health status and needs of persons with 
mental retardation and to suggest approaches that could be implemented, 
given current knowledge and technology, to improve both the length and 
quality of their lives over the coming decade. Length and quality of 
life are central concerns of numerous high-level policy initiatives in 
many countries, including the United States. The recent launch of the 
Healthy People 2010 (3) initiative marks the third decade of a national 
commitment to improving the health and wellbeing of Americans. Major 
goals of the initiative include increasing the quantity and quality of 
life and reducing health disparities among various groups. However, if 
one focuses on the health status, needs and opportunities for persons 
with disabilities, the public policy record is much more Spartan. The 
previous Healthy People 2000 initiative (4), launched by the U.S. 
Department of Health and Human Services in 1990, included little direct 
focus on the health status and needs of persons with disabilities.
    To its credit, the Healthy People 2010 report (3) dedicates a 
chapter and a number of objectives and ``developmental objectives'' to 
persons with disabilities. Yet, the chapter does not address 
specifically the health status, needs and access issues confronting 
millions of Americans with mental retardation or other specific 
disability groups. Further, there are notations of ``no available 
data'', ``inadequate data'', or ``unanalyzed data'' concerning persons 
with disabilities throughout the document. Similarly, several recent 
highly visible federal reports addressing oral health challenges and 
lack of access to oral health services for several special needs 
populations barely mentioned the population with disabilities, 
including individuals with mental retardation (5-7).
    This is the central reason why Special Olympics is taking a 
leadership role with respect to the health status and needs of persons 
with mental retardation. While Special Olympics is not a health 
organization per se, it recognizes that individuals can not effectively 
or safely participate in sports training and competition at any level 
if they are constantly challenged by health liabilities and 
disparities.
    Special Olympics is exerting leadership in the area of health for 
persons with mental retardation because, to date, adequate leadership 
has not emerged from the health care and public policy communities. 
Moreover, while there has been some welcome progress in terms of 
increased life expectancy and quality of life for persons with mental 
retardation over the past several decades, major health gaps remain and 
health improvement opportunities remain widely underaddressed. Healthy 
People 2010 (3) makes a clear statement that is rationale enough for 
this report:
    ``. . . the principle--that regardless of age gender, race, 
ethnicity, income, education, geographic location, disability (emphasis 
added), and sexual orientation--every person in every community across 
the Nation deserves equal access to comprehensive, culturally 
competent, community-based health care systems that are committed to 
serving the needs of individuals and promoting community health'' .
    The major findings, conclusions and recommendations of this report 
are drawn from several sources, including: an independent, 
comprehensive review of the literature undertaken by scholars at Yale 
University (8); learned opinions from health and disability experts 
from various countries; administrative data derived from Special 
Olympics programs; and direct experiences of Special Olympics athletes, 
their families, program staff, and volunteers. Consistent with policies 
of Special Olympics, the findings, conclusions and recommendations in 
this report have been shared with a number of Special Olympics 
athletes.
                             major findings
    Individuals with mental retardation suffer from a wide range of 
chronic and acute diseases and conditions. In many instances, they 
experience more frequent and severe symptoms than the general 
population. This is not solely a result of the primary disability of 
mental retardation, but reflects more fully the totality of risk 
factors and risk reduction opportunities made available to or denied to 
them. Importantly, their life and health experiences can not be 
adequately explained or rationalized solely by the fact that they have 
mental retardation, since they are impacted by secondary conditions and 
persisting environmental factors (social, economic, physical, etc.) 
that fail to ameliorate or actually exacerbate their risks.
    Evaluating isolated categorical health deficits or conditions in 
persons with mental retardation through simple disease/condition 
comparisons with the general population is not, in itself, adequate for 
assessing health status or the need for health improvement. Even where 
there is evidence that the prevalence of a specific disease or 
condition may be similar between the general population and those with 
mental retardation, the adverse impacts can be greater on those with 
mental retardation. Health must be seen in overall functional terms, 
especially for populations with disabilities and including the aspect 
of meaningful social participation.
    Numerous measures indicate that persons with mental retardation 
experience lower life expectancy and lower quality of life than the 
population in general. The magnitude of these gaps can not be explained 
solely by the existence of the mental retardation condition.
    Notwithstanding the increasing focus on personal and population 
health promotion and disease prevention, both in the United States and 
elsewhere, persons with mental retardation have received little 
consideration in terms of health improvements that they may be able to 
realize. Consistent with this finding, the information concerning the 
health status and needs of persons with mental retardation is entirely 
inadequate. Further, there is a dearth of information as to specific 
disease prevention and health promotion interventions that could 
improve the quality and length of life for persons with mental 
retardation.
    Even in situations where persons with mental retardation experience 
similar levels of disease to persons without mental retardation, access 
to timely and appropriate health care often is not adequate and 
generally poorer than for the overall population. This leads to 
unnecessary suffering, functional compromise, and costs to individuals, 
families and society.
    Although persons with mental retardation need health and health 
financing programs that are responsive to their particular needs, too 
often they are forced into general programs that actually can 
compromise their health. The most recent example of this is the 
movement toward managed care in Medicaid.
    Families have served as principal advocates for the health care of 
their children with mental retardation. While many families are 
fortunate to have private health insurance and/or personal resources to 
help cover health care expenses, too many families and individuals face 
substantial health care costs on their own. While a large percentage of 
the population with mental retardation is covered under state Medicaid 
programs, many of these programs are plagued by a variety of problems, 
including poor reimbursement rates to providers, excessive paperwork 
and delays, limitations and exclusions in benefits, and a generally 
poor reputation among providers.
    As an example, while dental services for many children are covered 
under Medicaid, only one-in-five eligible children receive any dental 
services each year (9). In most states, there are limited dental care 
benefits for adults, so that children with mental retardation are no 
longer eligible for dental care coverage under Medicaid, once they 
reach the age of maturity. Also, it should be noted that dental care is 
essentially unavailable under Medicare.
    The majority of health professionals who are otherwise qualified to 
treat persons with mental retardation fail to do so. This is largely 
the result of a lack of appropriate, specific training, inadequate 
reimbursement policies, fear, and prejudice.
    Existing federal, state and voluntary programs to meet the health 
needs of persons with mental retardation are inadequate. Enhanced and 
new efforts with supplemented and targeted resources will be required. 
Coordinated and integrated rather than piecemeal efforts must be a 
priority.
    Significant additional targeted research is needed to more fully 
characterize and understand the health status and needs of persons with 
mental retardation and to test models for improving health. Still, 
existing data are adequate to conclude that persons with mental 
retardation are woefully under addressed in terms of national 
(virtually every nation's) health priorities. The Special Olympics 
Strategic Research Plan (10) can serve as a blueprint for many research 
efforts. However, strong research partners, including funders, will be 
necessary.
                            recommendations
    All public and private programs, initiatives and reports that 
address the health needs of the public should explicitly examine the 
unique needs of persons with mental retardation. Because of the complex 
constellation of physical, mental, and social variables that combine to 
challenge the health and wellbeing of this population, general 
conclusions based on individual demographic or risk factors are 
inadequate for designing effective policies and programs to help 
persons with mental retardation. ``One size fits all'' solutions to the 
financing and delivery of services will assure that persons with mental 
retardation will continue to be underserved and/or receive 
inappropriate services.
    An expert working group should be convened by the Secretary, U.S. 
Department of Health and Human Services to address equity gaps and 
opportunities that exist to better characterize the health needs of 
persons with mental retardation. If necessary, to stimulate action, 
public hearings should be convened by Congress to garner necessary 
focus and priority.
    The goals of the Healthy People initiative only can be achieved 
when the health status and needs of specific populations are well 
documented, effective community and clinical education programs exist, 
prevention and treatment programs are designed, and adequate resources 
are made available.
    Specific health objectives for persons with mental retardation 
should be established, consistent with the overall goals of Healthy 
People 2010 (3)--namely, to increase quality life years and to reduce 
the gaps in health status. Leadership should come from the U.S. 
Department of Health and Human Services through the Administration on 
Developmental Disabilities, Centers for Disease Control and Prevention 
(CDC) and the National Institutes of Health (NIH), in conjunction with 
the Department of Education.
    The CDC should conduct a comprehensive review of the degree to whch 
data collection and analysis regarding the health and wellbeing of 
persons with mental retardation have positively or negatively impacted 
the lives of persons with mental retardation and what opportunities 
exist to redress past shortcomings.
    Substantially enhanced documentation of the health status and needs 
of persons with mental retardation is needed. Currently, too many 
surveillance processes fail to collect adequate information on this 
population and fail to perform relevant data analyses in a timely 
fashion, which then could inform policy development and program design.
    A diverse expert working group should be convened to examine the 
health and wellbeing for persons with mental retardation from the 
perspective of what could be achieved to enhance health opportunities, 
if existing disparities and conflicts in policies and organizational 
priorities could be resolved. This will directly impact the health of 
persons with mental retardation and the costs to society.
    Too often, efforts to describe the scope of health and social 
challenges for persons with mental retardation have focused on the 
magnitude of disability and the cost of long-term and respite care. 
Policy makers and health organizations need to frame appropriately the 
opportunities that exist to facilitate skill development and 
independence for persons with mental retardation. They need to 
identify, in qualitative and in quantitative terms, the benefits to 
society for investing in the potential of persons with mental 
retardation.
    Special Olympics should convene a blue ribbon corporate health 
advisory group for persons with mental retardation to develop a 
strategic and integrated corporate strategy for maximizing the impact 
of corporate contributions (intellectual, technical assistance, in-
kind, cash) for the betterment of persons with mental retardation.
    Given the inadequate resources and attention to the health needs 
and possibilities for persons with mental retardation, it is time for 
leading health organizations, including pharmaceutical companies, 
health equipment and supply companies, health insurers, and government 
and philanthropic organizations to commit resources to promoting health 
and preventing disease in this population, so that by 2010, clear 
health gains and realistic health promotion opportunities are created 
for persons with mental retardation.
    Likewise, leading philanthropic organizations need to undertake a 
critical self-examination of the degree to which they have addressed 
the health needs of persons with mental retardation. Organizations with 
weak records of support in this area should make concrete commitments 
to funding programs and projects to improve the health of persons with 
mental retardation.
    A focused effort to create health literacy enhancement 
opportunities for persons with mental retardation needs to be 
undertaken. Closing the gap in health literacy has been identified in 
the Healthy People initiative (3) as a principal strategy for reducing 
health disparities. Persons with mental retardation also need to have 
health information presented to them in ways that may empower and 
motivate them toward seeking higher levels of health. While this will 
not be possible universally, there are tens of millions of persons with 
mental retardation globally who can not simply be categorized as unable 
of taking an active role in their own healthcare. Further, caretakers 
will be more motivated to act in the best health interests of persons 
with mental retardation if they are aware of what appropriate standards 
are.
    The Inspector General, of the U.S. Department of Health and Human 
Services, as well as the Association of State Attorneys General, should 
evaluate whether the provisions of publicly funded and private health 
programs are providing equal or equitable protection to persons with 
disabilities, including those with mental retardation.
    A broad public health assessment of mental retardation needs to be 
undertaken by leading public health and professional organizations that 
can lead to formulations of effective organizational policies and 
programs. The new National Center on Birth Defects and Developmental 
Disabilities at CDC should have an explicit program focus and adequate 
resources to fund research, surveillance, and assessments on the 
prevention of secondary disabilities among persons with mental 
retardation.
    The public health community needs to reassess and reprioritize 
mental retardation as an important public health challenge that goes 
beyond simply primary prevention of diseases and conditions that result 
in mental retardation.
    The NIH and other federal agencies with a health research mission 
should allocate increased levels of research funds to issues critical 
to understanding all dimensions of mental retardation and where 
research opportunities exist to pursue the prevention and rectification 
of the primary and secondary effects of mental retardation. Special 
Olympics should formally transmit its strategic research agenda to 
these agencies as a basis for consensus development around the 
strategic role of federal agencies in such research.
                        additional perspectives
    The findings and recommendations in this report have as their 
principal basis the comprehensive literature review conducted by 
Horwitz et. al. at Yale University (8), data and perspectives from 
Special Olympics program offerings and services delivery, and responses 
from key informants from a number of countries who are knowledgeable of 
and work in areas related to mental retardation.
    Dr. Stephen Corbin and Dr. Donald Lollar asked professional 
colleagues in several countries to respond to a survey instrument 
(available from Special Olympics upon request) containing items 
addressing the existence of data, policies, laws, and programs for 
individuals with mental retardation, and their health status and needs. 
The key informant responses were solicited after completion of the 
other portions of the report so that they might serve a validation 
function. Responses came from individuals in Kenya, India, Australia, 
and the Czech Republic. As it turned out, these responses validated the 
findings and recommendations that had been articulated.
    To date, health data collection and analysis for the population 
with mental retardation has not been a priority in these countries. 
Representative country data were not available to characterize in any 
comprehensive way the health status and needs of persons with mental 
retardation. Data that are available are not collected on an ongoing or 
periodic, scheduled basis. The tendency is for official data collection 
sources to seek data on disability in general or to rely on general 
population data which are of limited utility for understanding the 
health needs of persons with mental retardation.
    Some institutional data are available (Czech Republic), but the 
depth of information varies significantly. It was noted that in 
Australia, de-institutionalization of persons with mental retardation 
has interrupted not only the availability of health services to these 
persons, but also negatively impacted the collection of information 
about the health needs and health service access for much of this 
population.
    All respondents indicated that access to necessary health care 
services for individuals with mental retardation is a problem. Even in 
countries where medical care is made available by law to all citizens, 
persons with mental retardation have difficulty receiving needed care 
from qualified providers. Children with mental retardation tend to fare 
better than do adults with mental retardation. Those living in cities 
generally receive inadequate care and those in villages are even worse 
off. NGOs provide some assistance (Kenya), but this is not sufficient. 
It was pointed out that in Australia, many conditions could be 
ameliorated and or prevented by early intervention, but periodic 
screening is not a well-established part of the system. Disease 
prevention and health promotion services for persons with mental 
retardation do not appear in any systematic way through government or 
private sources and are not a public priority.
    Further, bias against persons with mental retardation is reported 
to exist still, even among health care providers, and most persons with 
mental retardation are not in a strong position to communicate their 
health needs and desires. Several respondents indicated that 
individuals with mental retardation may be eligible for a level of 
services similar to those provided to individuals with other 
disabilities, but, in actuality, they usually end up with poorer access 
to care. For example, in India individuals with visual impairments and 
individuals who are orthopedically challenged have better access to 
health services than do individuals with mental retardation. Lack of 
adequate resources to pay for needed care is a consistent problem and, 
in the case of institutions (Czech Republic), adequate resources to 
provide appropriate staffing levels is a challenge.
    The greatest barriers to the improvement in health status for 
persons with mental retardation include attitudes by the public, 
governments, service providers, and, in some instances, even family 
members. The health needs of persons with mental retardation do not 
register high enough on the priority scale to attract the resources and 
attention that they merit. Even where policies and laws exist that 
should provide a basis for needed services for persons with mental 
retardation, there is little attention to surveillance and enforcement.
    Informants made a number of suggestions as to the most important 
actions that could be taken over the next decade in order to increase 
life expectancy and quality of life for persons with mental 
retardation. These include: Earlier, more adequate and frequent health 
screening; A more responsive general health system; Additional training 
and strong encouragement for health professionals to meet the needs of 
people with mental retardation; The development of a network of 
specialized tertiary referral health clinics to support the general 
health services and to provide a base for research and training; 
Adequate national data bases; Implementation of existing laws; 
Implementation of a mass awareness program through print and electronic 
media, including the internet, to better sensitize the public as to the 
nature and needs of persons with mental retardation; A firm stabilized 
health insurance system with adequate financing; Standardized, periodic 
screening targeting prevention and needed care; Better communication 
about the lives and personalities of persons with mental retardation, 
coupled with training in communications and ethics for care providers; 
Governments recognizing mental retardation as a special entity and 
enacting policies favorable to this group; and, Popularization of the 
idea of Special Olympics through which governments, the general public, 
professionals, and organizations can assist in health promotion and 
disease prevention efforts on behalf of persons with mental 
retardation.
 special olympics healthy athletes--an initial approach to addressing 
          the health needs of persons with mental retardation
    Special Olympics has provided year round sports training and 
competition opportunities for persons with mental retardation for more 
than three decades. Over a million athletes of all ages participate in 
a variety of summer and winter Olympic-type sports. Special Olympics 
was started by Eunice Kennedy Shriver in 1968 because persons with 
mental retardation consistently were excluded from societal 
opportunities, including sports and recreation. She recognized that 
persons with mental retardation could accomplish significant things 
through sport, while, at the same time, finding meaning in their lives. 
Since that time, the public record of service and opportunity provided 
to persons with mental retardation through Special Olympics has been 
well documented, through extensive print and electronic media and a 
continuing stream of highly visible public events.
    In recent years, Special Olympics has expanded its interest in the 
health of its athletes by supporting research activities, organizing 
medical symposia, and collaborating with international organizations on 
prevention issues.
    Beginning in 1989, the health needs of persons with mental 
retardation were highlighted as a result of vision screenings initiated 
through the Sports Vision Section of the American Optometric 
Association. These initial screenings demonstrated that Special 
Olympics athletes had significant and highly prevalent vision 
impairments and that they were woefully lacking in quality vision care 
opportunities.
    In the early 1990s, an additional program, Special Olympics Special 
Smiles, was created to address the unmet oral health needs of Special 
Olympics athletes. Like Special Olympics Opening Eyes, Special Olympics 
Special Smiles demonstrated that Special Olympics athletes had a 
significant unmet need for oral health care. Boston University's 
Goldman School of Graduate Dentistry provided the founding 
institutional home for Special Smiles and enabled the program to grow 
quickly.
               what is special olympics healthy athletes?
    Special Olympics Healthy Athletes is a diverse program of health 
assessment, professional training, service provision, and referral for 
Special Olympics athletes. Special Olympics Healthy Athletes screening 
venues are conducted in conjunction with sports competitions at local, 
state, national, regional, and global levels. These programs are 
elective for Special Olympics Programs and Games Organizing Committees. 
Despite the non-mandatory aspect, Special Olympics Healthy Athletes 
Programs have been expanding rapidly, based on the recognition that 
they bring a new and valuable range of services and resources to 
Special Olympics athletes. Special Olympics Healthy Athletes is not 
intended to be a comprehensive health care system, but rather is a 
short-term, limited, yet practical means for bringing a range of health 
services closer and more convenient to Special Olympics athletes and in 
a welcoming, respectful, and non-discriminatory setting.
    Special Olympics Healthy Athletes programming includes: Direct 
health services delivery to Special Olympics athletes; Health education 
services for athletes; Athlete referral for needed follow-up care; 
Documentation of the health status and needs of athletes; Recruitment 
and training of health personnel in treating people with mental 
retardation; Advocacy for improved public policies in support of the 
health needs of people with mental retardation; and, Advancing 
knowledge about the delivery of health care to persons with mental 
retardation.
                       range of services provided
    Special Olympics Healthy Athletes program components offer the 
following range of personal health services, varying by discipline and 
specific screening protocols: Screening assessment, Clinical 
examination, Health education/counseling, Preventive services, 
Corrective services, Personal preventive supplies, Referral for follow-
up care, Interaction between athletes and specially trained and 
motivated health care providers.
    Qualified experts from the health disciplines within Special 
Olympics Healthy Athletes determine the appropriate contents and 
standards for their screening and service offerings, based on the state 
of science and clinical practice, with adaptations for the special 
population that is being served. Special Olympics program leaders along 
with the Special Olympics Global Medical Advisory Committee and legal 
staff monitor and approve overall program scope and practices.
    In 2001, more than 100 Special Olympics Healthy Athletes screening 
clinics will be conducted. This includes screening events at local, 
state, national, and international levels. Also, beginning in 1999, 
several additional health disciplines were pilot tested for the first 
time as Special Olympics Healthy Athletes components. They include: 
hearing; physical therapy; dermatology; and orthopedics. Screening 
clinics in these disciplines have been conducted at a number of Games 
in the U.S. and abroad, and further growth in these and other medical 
disciplines is anticipated.
           special olympics healthy athletes program findings
    In addition to the health services that Special Olympics athletes 
receive through the Special Olympics Healthy Athletes Program, valuable 
insights have been gained as to the health status and needs for this 
population group. As reflected in the Yale University literature review 
(8), Healthy People 2010 (3), and feedback by key informants from 
different countries, there is a general lack of information as to the 
health status and needs of persons with mental retardation. Further, 
available data generally are from small institutionally based studies 
or administrative records of public agencies.
    Specific advantages of the data derived from Special Olympics 
programs is that the population served is substantial and includes 
athletes of all ages from around the world. Literally tens of thousands 
of Special Olympics athletes have been screened through the Healthy 
Athletes Program to date. Further, the data have been collected using 
standardized protocols developed by experts in the field (e.g., U.S. 
Centers for Disease Control and Prevention).
    Limitations in the data that must be recognized include the large 
number of examiners involved, the limited sensitivity of the survey 
instrument in some cases to detect quantitative differences in levels 
of disease (e.g. oral health screening instrument), and the convenience 
aspects of the population being reported on--i.e., athletes 
participating in Special Olympics events are not fully reflective of 
the larger community of institutionalized and non-institutionalized 
persons with mental retardation worldwide. As pointed out in the Yale 
University literature review, there appear to be certain health 
advantages or disadvantages to individuals based on their residential 
status. A number of disease conditions may be more prevalent among 
individuals with milder retardation living in freer environments where 
they must make conscious choices to avoid health risks (e.g. tobacco 
use) or to practice healthy habits on their own (e.g. oral hygiene, 
physical exercise, etc.). Nevertheless, there is little doubt that that 
Special Olympics Healthy Athletes data make a valuable contribution 
toward understanding the health status and needs of persons with mental 
retardation and planning programs and policies to address unmet needs.
               vision health of special olympics athletes
    Nearly 10,000 athletes have received vision assessments through the 
Special Olympics Opening Eyes Program since its inception. It is 
anticipated that in 2001, due to a program expansion facilitated by a 
major, multi-year grant from the Lions Clubs International Foundation, 
an additional 6,000-7,000 athletes will directly receive such 
screenings. Findings have been fairly consistent over several years of 
assessments. Special Olympics athletes had not received adequate vision 
care in terms of timeliness and many require corrective services. Over 
60% had not received a vision assessment in the past three years. 
Between one-fifth and one-third of athletes required glasses for the 
first time or replacement glasses. In many instances, athletes were 
wearing prescriptions that were found to be grossly inaccurate. The 
prevalence of astigmatism (44.2%) and strabismus (17.8%) were high. A 
high percentage of athletes examined would be classified as legally 
blind according to World Health Organization criteria.
    Many anecdotal reports identified athletes who, after receiving 
eyewear through the Special Olympics Opening Eyes Program, could, for 
the first time, see the finish line, their friends and families 
cheering for them. In a number of instances, coaches and family members 
reported that the new eyewear literally changed the personality of 
individual athletes and immediately enhanced their quality of life, 
while reducing certain risks (e.g. injury from falls or collisions). 
Many athletes additionally have received prescription swim goggles or 
prescription or plano safety sports glasses intended to prevent sports 
injuries.
                oral health of special olympics athletes
    Oral health assessments have been provided to approximately 20,000 
athletes through the Special Olympics Special Smiles Program over the 
past seven years. Most screening clinics have been conducted in the 
United States, although it is anticipated that major program growth, 
starting in 2001, will take place outside the United States. Special 
Olympics Special Smiles utilizes an assessment instrument developed by 
CDC especially for Special Olympics. The instrument was designed to be 
reliable when used by a variety of trained examiners under varying 
conditions. This comes at the expense of providing great quantitative 
detail. Thus, as an example, an athlete would be assessed for obvious 
dental decay in at least one tooth. If such were the case, the 
assessment form would be marked ``yes''. However, if several teeth for 
an athlete had obvious decay, the ``yes'' category likewise would be 
marked. Thus, there would be no apparent distinction when examining 
data as to the extent of dental disease in an individual athlete. This 
protocol differs from more sophisticated epidemiological studies 
conducted periodically by federal and state governments that precisely 
quantify the presence of dental disease down to relatively small caries 
lesions on individual tooth surfaces. The limitations of government 
studies, however, is that they fail to include an adequate number of 
individuals with mental retardation to provide meaningful results or 
they fail to identify individuals by disability category.
    Notwithstanding the limitations in data derived from the Special 
Olympics Special Smiles screenings, a good overall picture emerges of 
the oral health status and needs of Special Olympics athletes. The 1999 
Special Olympics World Summer Games in Raleigh, North Carolina are 
representative. For the over 2,200 athletes of all ages examined, 
nearly 20% reported pain in the oral cavity, the vast majority 
attributed to tooth pain. Much untreated dental decay exists in Special 
Olympics athletes. Nearly one-in-three had active dental decay 
(untreated) in molar teeth and more than one-in-ten had active decay in 
pre-molar or anterior (front) teeth. Less than one-in-ten screened 
athletes had preventive dental sealants present on any molar teeth.
    There is a clear need for more professional care to be made 
available to this population. More than 40% of screened athletes were 
in need of professional care beyond the level of routine, maintenance 
care, and more than one-third of these needed urgent care. There were 
substantial differences between U.S. and non-U.S. athletes in terms of 
needed professional care. Nearly half of non-U.S. athletes were in need 
of care beyond routine maintenance care compared to 28.4% of U.S. 
athletes. Urgent care was required nearly three times as often (19.9%) 
for non-U.S. athletes as for U.S. athletes (7.1%).
    During 2000, 35 Special Olympics Special Smiles screening clinics 
were conducted, serving nearly 10,000 athletes. While the results from 
site to site demonstrated some variations in individual measurement 
categories, overall the data were consistent with the athlete data 
gathered at the 1999 Special Olympics World Summer Games.
              hearing health of special olympics athletes
    The Special Olympics Healthy Hearing Program is much newer than the 
Special Olympics Opening Eyes or Special Smiles Programs. The first 
hearing screening was conducted as part of the Special Olympics World 
Summer Games in 1999. A second large-scale event was conducted at the 
2000 Special Olympics European Games in Groningen, Netherlands.
    During the European Games, 529 athletes were screened at the 
Special Olympics Healthy Hearing venue. The athletes were from 61 
countries. Screenings including otoscopic examination of external ear 
canals, otoacoustic emissions (OAE) hearing tests, pure tone 
audiometry, and tympanometry to screen middle ear function. Twenty-six 
percent (26%) of the athletes failed the hearing screening as compared 
to a general population rate expected to be under 5%. Of this group, 
52% did not pass tympanometric screening, suggesting the presence of a 
conductive (probably medically correctable) hearing loss. Conversely, 
48% passed the tympanometric screen, which implies that they failed the 
hearing screening due to a sensorineural (permanent) hearing loss.
    Of the nearly three-quarters of the screened athletes who passed 
the screening protocol, one-in-five had ear canals blocked or partially 
blocked with cerumen (ear wax), reflecting a lack of ear hygiene and 
professional care. The results from the Groningen screening were 
similar to those compiled at the 1999 Special Olympics World Summer 
Games.
       overweight as a risk factor for special olympics athletes
    According to Healthy People 2010 (3), the prevalence of overweight 
individuals is on the rise with 11% of school age children and 23% of 
adults being classified as obese. The prevalence of obesity in the 
population with mental retardation has been reported as more common 
than in the general population. Obesity has been implicated as a major 
preventable health risk factor for the general population. These risks 
include a higher prevalence for these individuals of cardiovascular 
disease, cerebrovascular disease, diabetes mellitus, and certain types 
of cancer.
    For the first time during a World Special Olympics Games, in 
Raleigh, North Carolina in 1999, nutritional assessment and education 
were included in the Healthy Athletes Program. This was stimulated by 
the increasing focus on the nutritional status of both under and over 
nutrition in the general population. For Special Olympics athletes who 
train and enter athletic competition, under or over weight, 
representing poor nutritional status, may affect general wellbeing and 
performance. Ten hundred and sixty six (1066) Special Olympic athletes 
were assessed by anthropometric measurements. These included height and 
weight used to calculate Body Mass Index (weight (Kg) / ht (m2)) for 
each athlete. There were 421 athletes from the United States and 645 
from other areas of the world.
    The Body Mass Index (BMI) measurements were standardized for age 
using the NHANES III BMI values. BMI values for children and adults 
have been standardized in the U.S., but there are presently no 
available established reference ranges for BMI for children and adults 
with mental retardation. Each athlete who volunteered was evaluated 
anthropometrically by obtaining height and weight. BMI percentile 
ranges across ages were then compared. BMI below the 5th percentile 
represented malnutrition and between the 5th and 15th percentile a risk 
of under nutrition. BMI greater than 85th percentile represented 
obesity and greater than 95th super obesity with significant health 
risk factors.
    For U.S. athletes, 3.3% were below the 5th percentile compared to 
5.2% of athletes from other countries. The 5th to 15th percentile 
included 5% of U.S. athletes and 7.1% of athletes from other countries. 
There were 11.2% of U.S. athletes between the 15th and 50th percentile 
and 30.9% from other countries. For the 50th to 85th percentiles, there 
were 27.6% of athletes from the U.S. and 36.6% of other athletes. Fifty 
three percent (53%) of U.S. athletes and 20% of athletes from other 
countries were greater than the 85th percentile BMI, with 33% of 
American athletes and 7% of athletes from other countries greater than 
95th percentile.
    These findings reflect that the majority of U.S. athletes at the 
World Summer Special Olympics in 1999 were above the 85th percentile 
and, thus, were obese and 33% would be considered in a group with 
significant health risk because of super obesity. Whether these data 
represent all individuals with mental retardation, it is apparent the 
BMI values obtained from a majority of individuals who represent the 
Special Olympics athletes from the U.S. are at significant risk. More 
data for specific age, sex, living condition and diagnoses for 
nutritional status in the population with mental retardation need to be 
obtained. Also, the percentage of patients with Down syndrome relative 
to the general population with mental retardation is known to be more 
obese and may need to be studied separately. This large sample of 
Special Olympic athletes, although not representing the general mental 
retardation population, particularly for those from the U.S., indicated 
that these individuals may be at significantly increased health risk.
    Thus, it is apparent that greatly increased efforts to work with 
athletes, coaches, families, teachers, health care providers, and 
program administrators in the area of diet, nutrition, weight control, 
and fitness are needed.
 training health professionals to treat persons with mental retardation
    It stands to reason that for individuals with mental retardation to 
have their health needs met, there must be trained, willing health care 
providers available. As reflected in the Yale University literature 
review, a number of reports indicate that health care providers overall 
feel ill prepared and minimally motivated to treat persons with mental 
retardation, even for conditions found routinely in the general patient 
population. Health professional students receive little didactic 
exposure to the health needs of persons with mental retardation during 
their training and even fewer have meaningful clinical experiences with 
such patients.
    Accordingly, Special Olympics has made it a priority to train 
health professional volunteers and to provide them with hands-on 
experience in serving persons with mental retardation. Typically, 
health professional volunteers for the Special Olympics Healthy 
Athletes Program receive didactic training as to the nature of mental 
retardation, special health and social challenges faced by persons with 
mental retardation, special aspects of their own discipline relating to 
mental retardation, and effective techniques for rendering quality 
clinical services to this population. Volunteers additionally receive 
actual experience, lasting from several hours to several days, 
depending on the nature of the event, to provide service to and 
interact with Special Olympics athletes. They are accorded continuing 
professional education credit for this experience.
    Consistently, health professional volunteers report their Special 
Olympics Healthy Athletes experience in extremely positive terms. Many 
individuals characterize the experience as the most meaningful 
professional encounter of their careers. Students typically become 
highly motivated to seek additional experience with special 
populations. Research conducted by Special Olympics clinical 
consultants on health professional volunteers indicates that volunteer 
optometrists have a reasonably high expectation for the capabilities of 
persons with mental retardation prior to their Special Olympics Healthy 
Athletes experience, and, that after their experience, they report even 
more positively in terms of what persons with mental retardation can 
accomplish in life and contribute to society. Oral health providers 
(dentists, dental students, dental hygienists) evaluated using the same 
instrument showed similar, albeit less consistent, results.
    While the health services provided to Special Olympics athletes in 
conjunction with Special Olympics Games are valuable in their own 
right, they are minimal in the context of the overall health needs of 
persons with mental retardation on a year round basis. The ultimate 
goal of the Special Olympics Healthy Athletes program is to create a 
legacy of care for persons with mental retardation. The practicality of 
such a goal will only be apparent after additional research is 
conducted to determine whether, in addition to improved health 
professional attitudes, active commitments to outreach and the care of 
persons with mental retardation can be realized in providers' home 
clinics, hospitals and practices. Another important question is whether 
health professionals who have had such experiences subsequently reach 
out and encourage colleagues to become providers of care to persons 
with mental retardation. Only when this happens to a significant degree 
can the goals espoused in Healthy People 2010 (3) be achieved for all 
people.
                 Prepared Statement of Stanley B. Peck
                              introduction
    The American Dental Hygienists' Association (ADHA) appreciates this 
opportunity to submit testimony regarding ``The Crisis in Children's 
Dental Health: A Silent Epidemic.'' ADHA applauds the Senate Committee 
on Health, Education, Labor and Pensions for holding this important 
Public Health Subcommittee hearing on children's oral health. ADHA is 
hopeful that henceforth, whenever Senators think of general health, 
they will also think of oral health. As today's lead-off witness, 
former Surgeon General David Satcher, will confirm, oral health is a 
fundamental part of overall health and well-being.
    ADHA is the largest national organization representing the 
professional interests of the more than 120,000 dental hygienists 
across the country. Dental hygienists are preventive oral health 
professionals who are licensed in each of the fifty states.
    As prevention specialists, dental hygienists understand that 
recognizing the connection between oral health and total health can 
prevent disease, treat problems while they are still manageable and 
conserve critical health care dollars. Dental hygienists are committed 
to improving the nation's oral health, an integral part of total 
health. Indeed, all Americans can enjoy good oral health because the 
principal oral maladies (caries, gingivitis and periodontitis) are 
fully preventable with the provision of regular preventive oral health 
services such as those provided by dental hygienists. Regrettably, the 
experience, education and expertise of dental hygienists are now 
dramatically underutilized. ADHA wants to be part of the solution to 
the current problems of oral health disparities and inadequate access 
to oral health services and ADHA believes that increased utilization of 
dental hygienists is an important part of that solution.
 adha supports senate legislative efforts to address the nation's oral 
                             health crisis
    ADHA is pleased that legislation has been introduced by members of 
the Senate Health Committee to address the national epidemic of oral 
disease among our nation's children. In particular, the strong 
leadership of Senator Jeff Bingaman on oral health issues is greatly 
appreciated by ADHA and by the New Mexico Dental Hygienists 
Association. Senator Bingaman's devotion to improving the oral health 
of children is inspiring and ADHA is proud to support S. 1626, the 
Children's Dental Health Improvement Act, introduced in November 2001 
by Senator Bingaman.
    ADHA also supports companion legislation in the House of 
Representatives, H.R, 3659, introduced by Representatives John Murtha 
and Fred Upton in January 2002. More than 40 organizations have 
endorsed S. 1626 and H.R. 3659, including non-dental groups such as the 
American Public Health Association, the Association of Maternal and 
Child Health Programs and the March of Dimes. This legislation is 
designed to improve the access and delivery of oral health services to 
the nation's children through Medicaid, the State Children's Health 
Insurance Program (SCHIP), the Indian Health Service and the nation's 
safety net of community health centers.
    ADHA also supports S. 2202, the Perinatal Dental Health Improvement 
Act of 2002. Introduced in April 2002 by Senator John Edwards and 
Senator Bingaman, this legislation recognizes the link between severe 
periodontal disease in pregnant women and pre-term low birth weight 
babies.
    ADHA additionally supports S. 998, the Dental Health Improvement 
Act, introduced in June 2001 by Senators Susan Collins and Russ 
Feingold. This legislation would expand the availability of oral health 
services by strengthening the dental workforce in designated 
underserved areas. The Senate passed S. 998 in March 2002 as part of 
the Health Care Safety Net Amendments. ADHA is hopeful that this 
important legislation will be enacted into law before Congress recesses 
for the August district work period.
    ADHA applauds this Committee for its increasing interest in oral 
health issues and pledges to work with members of this Committee and 
all lawmakers to enact the above-mentioned oral health efforts into 
law.
    u.s. surgeon general's may 2000 report on oral health in america
    Former U.S. Surgeon General David Satcher issued Oral Health in 
America: A Report of the Surgeon General in May 2000. This landmark 
report confirms what dental hygienists have long known: that oral 
health is an integral part of total health and that good oral health 
can be achieved. Key findings enumerated in the Report include:
    1. Oral diseases and disorders in and of themselves affect health 
and well-being throughout life.
    2. Safe and effective measures exist to prevent the most common 
dental diseases--dental caries (tooth decay) and periodontal (gum) 
diseases.
    3. Lifestyle behaviors that affect general health such as tobacco 
use, excessive alcohol use, and poor dietary choices affect oral and 
craniofacial health as well.
    4. There are profound and consequential oral health disparities 
within the U.S. population.
    5. More information is needed to improve America's oral health and 
eliminate health disparities.
    6. The mouth reflects general health and well-being.
    7. Oral diseases and conditions are associated with other health 
problems.
    8. Scientific research is key to further reduction in the burden of 
diseases and disorders that affect the face, mouth and teeth.
             addressing the silent epidemic of oral disease
    The Surgeon General's Report on Oral Health challenges all of us--
in both the public and private sectors--to address the compelling 
evidence that not all Americans have achieved the same level of oral 
health and well-being. The Report describes a ``silent epidemic'' of 
oral disease, which disproportionately affects our most vulnerable 
citizens--poor children, the elderly, and many members of racial and 
ethnic minority groups.
    This nation must address the inequality in oral health status that 
is pervasive across America. All Americans, regardless of economic 
status or geographic location, should enjoy the benefits of good oral 
health. Indeed, ADHA maintains that ``oral health care--a fundamental 
part of total health care--is the right of all people.'' Please see 
Attachment A, the ADHA Access to Care Position Paper, in which this 
belief is enunciated.
    ADHA is committed to working in partnerships at all levels with 
policymakers, parents, advocates, additional health care providers--
both dental and non-dental--and others in order to improve general 
health and well-being through the promotion of optimal oral health. 
Fundamental to this goal is work to promote awareness of the fact that 
oral health is an integral part of total health and work to increase 
access to oral health care services.
    ADHA further believes that we must focus first on our nation's most 
precious resource--our children. That is why it is vital that we 
buttress the innovations states are pioneering with respect to Medicaid 
and SCRIP, such as the recent trend toward recognition of dental 
hygienists as Medicaid providers.
               improving the nation's ``oral health iq''
    This U.S. Senate hearing today is a critically important step 
forward in the effort to change perceptions regarding oral health and 
disease so that oral health becomes an accepted component of general 
health. Indeed, the perceptions of the public, policymakers and health 
providers must be changed in order to ensure acceptance of oral health 
as an integral component of general health. AHDA urges members of the 
Senate Health Committee to work to educate their colleagues in Congress 
with respect to the importance of oral health to total health and 
general well-being. This hearing is an important signal to the public 
that oral health is important. ADHA hopes that further signals will be 
forthcoming.
    The national oral health consciousness will not change overnight, 
but working together we can heighten the nation's ``oral health IQ.'' 
ADHA is already working hard to change perceptions so that oral health 
is rightly recognized as a vital component of overall health and 
general well being. For example, ADHA has launched a public relations 
campaign to highlight the link between oral health and overall health. 
Our slogan is ``Want Some Lifesaving Advice? Ask Your Dental 
Hygienist.''
    This ADHA campaign builds on the Surgeon General's report, which 
notes that signs and symptoms of many potentially life-threatening 
diseases appear first in the mouth, precisely when they are most 
treatable. Dental hygienists routinely look for such signs and 
symptoms. For example, most dental hygienists conduct a screening for 
oral cancer at every visit and can advise patients of suspicious 
conditions. Other diseases with oral manifestations are diabetes, HIV 
and osteoporosis. Bulimia nervosa and anorexia nervosa also exhibit 
oral manifestations, such as localized enamel erosion. Scientific 
evidence is now building which demonstrates that periodontal (gum) 
disease also may be a risk factor for pre-mature, low birthweight 
babies. Pregnant women who have periodontal disease may be seven times 
more likely to have a baby that is born too early and too small. Caring 
for low birthweight babies and their mothers is extremely expensive. If 
the public, policymakers and health providers are educated about these 
links, their appreciation for the importance of oral health will be 
heightened.
 additional entry points into the oral health care delivery system are 
                                 needed
    The current oral health care system is not meeting the oral health 
care needs of all Americans. Additional access points must be added, 
particularly for those who are economically disadvantaged. Indeed, 
despite the proven benefits of preventive oral health measures, less 
than one in five Medicaid-eligible children (4.2 million out of 21.2 
million) actually received preventive oral health services in 1993, 
according to a 1996 U.S. Department of Health and Human Services report 
entitled Children's Dental Services Under Medicaid. And only one in 
four Native American children received any dental care in a recent one-
year period according to the Indian Health Service. Moreover, only 41% 
of adults (25 years and older) with less than a high school education 
had an annual dental visit while only 74% of adults with at least some 
college had an annual dental visit (NHIS 1997).
    Clearly, the current structure of the oral health care system needs 
to change. ADHA believes that additional access points to oral health 
care must be utilized. The vast majority of dental hygienists currently 
work in a dentist's private practice. Others work, for example, in 
public health settings, educational institutions, as well as in 
research, and in business. Interestingly, in 1948 only approximately 
50% of dental hygienists worked in private dental offices. Others 
worked in schools, hospitals, public health facilities and other 
settings. Clearly, dental hygienists have lost significant outreach 
avenues over the years. Reversing this trend would no doubt help 
address the serious access to care problems confronted by too many 
Americans. ADHA urges policymakers to facilitate additional access 
points to the oral health care delivery system.
                     lack of oral health insurance
    The failure to integrate oral health effectively into overall 
health is seen in the distinction between oral health insurance and 
medical insurance. While 43 million Americans lack medical insurance, a 
whopping 108 million--or 45% of all Americans--lack oral health 
insurance coverage. Studies show that those without dental insurance 
are less likely to see an oral health care provider than those with 
insurance. Moreover, the uninsured tend to visit an oral health care 
provider only when they have a problem and are less likely to have a 
regular provider, to use preventive care or to have all their dental 
needs met. ADHA urges that the Senate Health Committee work to 
strengthen and enhance Medicaid and SCHIP dental benefits and ADHA 
looks forward to a future in which all Americans have dental health 
insurance coverage.
    Even those who have dental insurance coverage, particularly 
Medicaid-eligible children, are not assured of access to care. ADHA is 
committed to increasing the percentage of Medicaid and SCHIP-eligible 
children who receive oral health services. One way to promote this goal 
is to facilitate state recognition of dental hygienists as Medicaid 
providers of oral health services. Indeed, states are increasingly 
recognizing dental hygienists as Medicaid providers and providing 
direct reimbursement for their services.
 supporting the work of entities within the u.s. department of health 
                           and human services
    The federal oral health infrastructure must be strengthened. Oral 
health must be fully integrated into overall health. ADHA urges this 
Committee to actively promote oral health programs within the 
Department of Health and Human Services (HHS). ADHA is very pleased 
that the position of Chief Dental Officer at the Centers for Medicare 
and Medicaid Services (CMS) has apparently been made permanent. Given 
the increasing recognition of the importance of oral health and the key 
role of CMS's Chief Dental Officer, it is imperative that this position 
be institutionalized. In addition, ADHA urges that this Committee 
encourage each state to name a Dental Director.
    ADHA further encourages this Committee to buttress the important 
oral health work of the Oral Health Division of the Centers for Disease 
Control and Prevention, the Maternal and Child Health Bureau and the 
Oral Health Initiative of the Health Resources and Services 
Administration (HRSA).
    An increased federal focus on oral health will yield positive 
results for the nation. To illustrate, the work of the National 
Institute on Dental and Craniofacial Research (NIDCR) in dental 
research has not only resulted in better oral health for the nation, it 
has also helped curb increases in oral health care costs. Americans 
save nearly $4 billion annually in dental bills because of advances in 
dental research and an increased emphasis on preventive oral health 
care, such as the widespread use of fluoride. To enable NIDCR to 
continue and to build upon its important research mission, ADHA urges 
that NIDCR be maintained as an independent institute at the National 
Institutes of Health.
                            workforce issues
    As the General Accounting Office (GAO) confirmed in two separate 
reports to Congress, ``dental disease is a chronic problem among many 
low-income and vulnerable populations'' and ``poor children have five 
times more untreated dental caries (cavities) than children in higher-
income families. The GAO further found that the major factor 
contributing to the low use of dental services among low-income persons 
who have coverage for dental services is ``finding dentists to treat 
them.''
    Increased utilization of dental hygienists in non-traditional 
settings such as schools, medical clinics, after school programs and 
nursing homes etc. would promote increased use of dental services among 
low income persons. These dental hygienists can serve as a pipeline 
that can refer patients to dentists. Increased utilization of dental 
hygiene services is critical to addressing the nation's crisis in 
access to oral health care for vulnerable populations.
    Dental hygienists are prevention specialists who are licensed in 
each of the fifty states and the District of Columbia. In order to be 
eligible for a license, prospective practitioners must graduate from 
one of the 260 dental hygiene education programs accredited by the 
American Dental Association Commission on Dental Accreditation. The 
accreditation standards for dental hygiene education programs require 
graduates to be competent in conducting thorough periodontal and dental 
examinations, developing a dental hygiene diagnosis and treatment plan, 
and making appropriate referrals for additional treatment needs. 
Further, candidates for dental hygiene licensure must pass a national 
written examination and a regional or state clinical examination. In 
addition, 48 states require continuing education for licensure renewal.
    Since 1990, the number of dentists per 100,000 U.S. population has 
continued to decline. This decline is predicted to continue so that by 
the year 2020 the number of dentists per 100,000 U.S. population will 
fall to 52.7. By contrast, since 1990, the number of dental hygiene 
programs has increased by 27% and, from 1985-1995, the number of dental 
hygiene graduates increased by 20%, while the number of dentist 
graduates declined by 23%.
    Some states have begun to examine dental workforce issues. The 
WWAMI Center for Health Workforce Studies at the University of 
Washington assessed the patterns and consequences of the distribution 
of the dental workforce in Washington state. This November 2000 study 
revealed that Washington state ``does not have a dental workforce 
sufficient to meet Healthy People 2010 goals.'' The study found that 
``gaps in the state dental workforce will be difficult to fill with 
dentists because the nationwide per capita supply of dentists is 
decreasing; specialization is increasing, and programs to encourage 
dentists to practice in underserved areas are limited.'' The study 
recommended that ``policymakers should consider expanding the role of 
hygienists . . . to deliver some oral health services in shortage 
areas.''
    In Washington state, policymakers have enacted a school sealant 
program for underserved populations where dental hygienists provide the 
services without any requirement for authorization from a dentist.
    ADHA urges that the Committee work to facilitate increased 
utilization of the experience, education and expertise of dental 
hygienists.
increased access to preventive oral health services is key to improving 
                        the nation's oral health
    Unlike most medical conditions, the three most common oral 
diseases--dental caries (tooth decay), gingivitis (gum disease) and 
periodontitis (advanced gum and bone disease)--are proven to be 
preventable with the provision of regular oral health care. Despite 
this prevention capability, tooth decay--which is an infectious 
transmissible disease--still affects more than half of all children by 
second grade. Clearly, more must be done to increase children's access 
to oral health care services.
    While the profession of dental hygiene was founded in 1923 as a 
school-based profession, today the provision of dental hygiene services 
is largely tied to the private dental office. Increased utilization of 
dental hygienists in schools, nursing homes, and other sites--with 
appropriate referral mechanisms in place to dentists--will improve 
access to needed preventive oral health services. This increased access 
to preventive oral health services will likely result in decreased oral 
health care costs per capita and, more important, improvements in oral 
and total health.
    ADHA feels strongly that restrictive dental hygiene supervision 
laws constitute one of the most significant barriers to oral health 
care services. Indeed, ADHA is committed to lessening such barriers, 
which restrict the outreach abilities of dental hygienists and tie oral 
health care delivery to the fee-for-service private dental office, 
where only a fraction of the population is served. To illustrate, here 
are a few examples of limitations on practice settings outside of the 
private dental office. In West Virginia, dental hygienists are limited 
to industrial clinics and schools; in Illinois, dental hygienists are 
limited to mental health institutions and nursing homes and in 
Arkansas, dental hygienists are limited to prisons.
    Some states are pioneering less restrictive supervision and 
practice setting requirements. These innovations facilitate increased 
access to oral health services. Maine and New Hampshire, for example, 
have what is called public health supervision, which is less 
restrictive than general supervision. Oregon and California have 
expanded dental hygiene practice through the use of limited access 
permits and special license designations like the Registered Dental 
Hygienist in Alternative Practice (RDHAP).
    Other states have unsupervised practice, which means that a dental 
hygienist can initiate treatment based on his or her assessment of 
patient needs without the specific authorization of a dentist, treat 
the patient without the presence of a dentist, and maintain a provider-
patient relationship without the participation of the patient's dentist 
of record
    By the early 1990s, California and Washington recognized dental 
hygienists as Medicaid providers of oral health services and provided 
direct reimbursement for their services. Over the last several years, 
an additional five states followed: Oregon in 1999; Colorado, 
Connecticut, and Missouri in 2001; and Maine in 2002. Other states 
should adopt this approach, which appropriately recognizes the 
experience, education and expertise of dental hygienists and fosters 
increased access to much needed Medicaid oral health services.
    States should heed the recommendations of organizations such as the 
Illinois Center for Health Workforce Studies which called for ``new 
solutions'' to the problem of limited access to oral health care 
services for Medicaid and SCHIP children. In February 2001, the Center 
called for ``modifying the [Illinois] state practice act to allow 
dental hygienists to provide preventive care in public health settings 
without a dentist on-site.''
    ADHA encourages policymakers to recognize and encourage these 
innovations, which improve access to oral health care services and work 
to reduce the tremendous disparities in oral health in America. Rest 
assured that ADHA will continue to work to expand the practice settings 
of dental hygienists so that additional people may access needed oral 
health services. Dental hygienists should be viewed as essential entry 
points into the oral health care system. Physicians and dental 
hygienists should partner to ensure patients receive oral health care 
services. ADHA also will work to ensure that this dental hygiene 
outreach is linked appropriately with the restorative services of 
dentists.
  public-private partnerships are critical to addressing the nation's 
                   silent epidemic of dental disease
    An innovative public-private partnership in South Carolina called 
Health Promotion Specialists (HPS) provides a shining example of the 
effectiveness of public-private partnerships. This partnership has 
performed dental screenings for over 33,000 children during the past 
year and has delivered preventive dental hygiene care to over 12,000 
children. Further, many thousands of children have been linked to 
dentists for the provision of restorative care.
    This school-based oral health program is a collaborative effort 
between school health officials, community support services, dentists, 
dental hygienists and the state health agency. In fact, in February 
2002 both the South Carolina Dental Association and the South Carolina 
Dental Hygiene Association joined with the South Carolina Department of 
Education and the South Carolina Department of Health and Environmental 
Control to endorse this type of public/private partnership. Upon return 
of a signed parental consent form, HPS provides oral hygiene 
instructions and preventive services that include cleanings, the 
application of fluoride and the application of dental sealants on 
permanent back teeth.
    HPS provides these services at regular intervals as part of a 
continuing care program. HPS works to refer children who need 
restorative services to local dentists, clinics and available mobile 
dental vans. Public-private partnerships such as the school-based oral 
health program administered by HPS are vital to the oral health of 
America.
    To illustrate the effectiveness of such partnerships and the 
dramatic impact these partnerships can make in the life of a child, 
ADHA wishes to share one of the many success stories realized through 
this program. A child in Marlboro County had been in dental pain for 
more than three months before HPS arrived. The school nurse and the 
school principal had been unable to get dental care for him. HPS 
arranged for a mobile dental van to go to Marlboro County to see this 
first grader. On the day the dental hygienist was to leave the school, 
the student saw her in the school hallway, hugged her, and gave her a 
big smile, and said ``I don't hurt anymore.'' Because of this public-
private partnership, that first grader is now able to focus on first 
grade instead of pain in the oral cavity. That's what makes it all 
worthwhile and ADHA hopes that lawmakers, educators, public health 
officials, dentists, dental hygienists, advocates, families and all 
those who care about the nation's oral health to come together in order 
to improve the health of the American people.
    Another example of a public-private partnership that successfully 
increased access to care occurred recently in Oregon. This partnership 
is particularly heartening in that it involved both the Oregon Dental 
Association and the Oregon Dental Hygienists' Association. At the 
suggestion of the Oregon state legislature, these two associations came 
together to develop a proposal to increase access to care by relieving 
certain dental hygiene supervision requirements.
    A Task Force created by the two associations proposed the creation 
of a Limited Access Permit for experienced dental hygienists. This 
proposal was subsequently passed, without a single dissenting vote, by 
the Oregon legislature in 1997. Currently, approximately 20 dental 
hygienists hold a Limited Access Permit, which enables a dental 
hygienist to provide preventive oral health services in certain 
settings without a prior dental visit. Permit holders must have 
completed at least 5,000 hours of supervised dental hygiene clinical 
practice in the five years previous to receiving their permit; they 
also must complete forty classroom hours in specified courses. Twelve 
hours of continuing education are required to maintain the permit; this 
is in addition to the twenty-four hours required to maintain the dental 
hygiene license. Further, a Limited Access Permit Dental Hygienist must 
refer a patient annually to a dentist who is available to treat the 
patient. There are approximately 100 dental hygienists currently in the 
process of qualifying for the Limited Access Permit. The oral health of 
Oregonians will be better served when these candidates obtain their 
permits.
    To illustrate, one dental hygienist holding a Limited Access Permit 
works weekly in an extended care facility with an on-site dental 
clinic. Depending on their dental hygiene treatment needs, she sees six 
to ten patients a day. Her services are appropriately linked to the 
services of a dentist, who visits the extended care facility at least 
once monthly to provide needed services. Over a given year, this 
hygienist provides care to approximately 400 patients in their place of 
residence. The resident and/or guardian's private insurance or Medicaid 
pays for the cost of their care. Importantly, the large majority of 
these patients are unable to leave the facility to access dental care.
    Initially, provision of dental hygiene services under the Limited 
Access Permit was largely restricted to extended care facilities, 
including adult foster care and assisted living. In 2001, however, the 
Oregon legislature broadened the range of facilities in which Limited 
Access Permit holders could provide services to include public and 
private schools (grades kindergarten through twelve), pre-schools, 
correctional facilities and job training sites. This confirms the 
increasing trend among states to explore ways to increase access to 
care through maximum utilization of the experience, education, and 
expertise of the dental hygienist.
                               conclusion
    In closing, the American Dental Hygienists' Association appreciates 
this opportunity to provide written testimony on ``The Crisis in 
Children's Dental Health: A Silent Epidemic.'' ADHA looks forward to a 
future in which the education, experience and expertise of dental 
hygienists are appropriately recognized and utilized; this will 
increase access to oral health services and work to ameliorate oral 
health disparities. ADHA is committed to working with lawmakers, 
educators, researchers, policymakers, the public and dental and non-
dental groups to improve the nation's oral health which, as Oral Health 
in America: A Report of the Surgeon General so rightly recognizes, is a 
vital part of overall health and well-being.
    Thank you for this opportunity to submit the views of the American 
Dental Hygienists' Association. Please do not hesitate to contact me or 
our Washington Counsel, Karen Sealander of McDermott, Will & Emery 
(202/756-8024), with questions or for further information.
                 Prepared Statement of Sarah M. Greene
    On behalf of the National Head Start Association, I am pleased to 
testify in support of increasing access to dental care for all children 
in America. I know that without the leadership of this committee this 
important issue may not have been brought to the forefront.
    The National Head Start Association is a private nonprofit 
membership organization representing more than 900,000 children and 
their families, 168,000 staff, in nearly 2,400 Head Start programs 
across the country, including over 550 Early Head Start programs and 
the more than 40,000 children and families they currently serve.
    Children's health is an essential component to assuring children's 
overall wellness and performance. If children are to develop strong 
literacy and language skills, good health is essential. Burton 
Edelstein, of the Children's Dental Health Project, stated that ``it is 
simply impossible for a child to focus and accomplish well in school 
when they are distracted by a relentless toothache.'' At Head Start we 
believe that the comprehensive services we provide, such as the dental 
services, are critical for successful child development.
    Head Start children in particular tend to have significant dental 
health issues. Several studies have found that more than 60 percent of 
Head Start children have cavities and that the average number of teeth 
affected is five. Self reported data from the 1998 Head Start Program 
Information Reports (PIR) found that 76 percent of enrolled children 
needed dental care. Finally, low-income children in Minneapolis who 
qualified for Medicaid were 1.4 times more likely to be in need of 
emergency services than children of higher incomes.
    Unfortunately, medical services for low-income families are often 
unaffordable, and crucial medical and dental procedures are often a low 
priority for low-income families. Without essential preventive 
measures, severe conditions can develop in a child that will affect 
their health even as they become adults. Therefore, subsidized programs 
are necessary to ensure low-income children and families receive 
medical services.
    Sadly, most state Medicaid dental plans have been little more than 
a hollow entitlement for Head Start children. The children are provided 
dental coverage, but they are unable to benefit from it in a meaningful 
way. Low reimbursement rates only aggravate the situation. Medical 
professionals, especially dental providers, can be hesitant to provide 
services when payment barely covers their cost for the services they 
provide. In a July 2000 study by the American Public Human Services 
Association, researchers concluded from a survey of 44 state Medicaid 
agencies that low--reimbursement rates to dental providers was the 
leading barrier to dental care for low-income children. Presently, 
adequate medical resources are inaccessible when a Head Start program 
or other community-based program attempts to provide the services 
through federal, state, tribal, and/or local medical and dental 
treatment programs due to reimbursement rates lower than the market 
value of the services.
    Low reimbursement rates have forced many Head Start programs to use 
their regular grant funds to supplement medical expenses for their 
program's children. Covering those medical expenses in turn frequently 
becomes an unanticipated expense forcing the program to reduce funding 
for other services it provides. (Head Start and Early Head Start funds 
may be used for professional medical and dental services when no other 
source of funding is available.) Once a program experiences this 
situation, they do anticipate and budget for the expenses into their 
subsequent annual grant application. Adequate reimbursement rates that 
reflect true market value would cure budget shortfalls and ensure all 
children in Head Start programs adequately receive necessary medical 
and dental screenings.
    In many states, shoddy Medicaid programs with low reimbursement 
rates have required Head Start children to wait unreasonably long to 
get appointments, travel long distances to receive services, and in 
some cases to go without treatment until it was too late. The 
Children's Dental Health Project estimates that only 25 to 35 percent 
of dentists nationwide participate in Medicaid even in a limited way. 
One reason is that there are very few dentists who accept Medicaid. In 
Missouri, only 38 percent of the state's 115 counties had a dentist 
willing to accept M+/Medicaid. With so few dentists willing to accept 
Medicaid, a child in a Missouri Head Start program has to wait an 
average of 6\1/2\ weeks just to get an appointment. While in a recent 
study of 54 centers in North and South Carolina, only 7 percent of 
3,375 dentists reported that they accept Head Start children as 
patients. The average wait for an initial visit was 3.7 weeks.
    In Tennessee the situation is not any better. Glenda Jewell, 
Assistant Director for Child Health Services, at the Southwest HRA Head 
Start in Henderson. Tennessee asserts that ``getting dental care for 
our children is a real problem.'' She reports that often Head Start 
families must travel close to 100 miles and sometimes up to two hours 
just to find a dentist willing to accept TennCARE. the state's Medicaid 
program. Ms. Jewell says that dentists are simply unwilling to accept 
reimbursements so low that they won't even cover the cost of a 
procedure. Area dentists have told her that the confusing red tape, 
inconsistent plans, and the inefficiency of state offices makes 
accepting TennCARE an unattractive choice for most.
    Due to such an inadequate system of dental coverage, Head Start 
children are truly suffering. Because of the long drive, Head Start 
children frequently miss school for the day and must stay over night at 
the place of treatment. Many children also go so long without necessary 
dental treatment that minor oral health problems develop into much more 
serious conditions. Jewell claims that many Head Start children end up 
being hospitalized because of problems that go untreated. A little boy 
in her program had to have his front teeth removed last year because 
his dental problems went untreated for so long. Furthermore, because 
TennCARE would not pick the cost of a necessary bridge for the child, 
the Head Start program was forced to divert its own funds so that the 
child would not be tormented with speech problems.
    Since the enactment of SCHIP, every state has expanded health care 
coverage to children in low-income families. Fifteen states developed 
separate programs, 19 expanded Medicaid, and 17 used a combination of 
these two approaches. Before SCHIP, income eligibility for children 
averaged 121 percent of the federal poverty level across all states and 
ages. After SCHIP, the average increased to 206 percent of the federal 
poverty level. Still, steps can be taken to facilitate the provision of 
medical insurance to the uninsured millions falling within the 
eligibility guidelines. This includes allowing additional facilities 
such as child-care referral centers to determine presumptive 
eligibility (Head Start agencies currently are able to do so) and 
strongly encouraging all states to streamline and simplify their SCHIP 
and Medicaid application processes.
    Despite the incredible inadequacy of dental health coverage, there 
are many dentists that have gone beyond the call of duty. We consider 
them to be real Head Start heroes. In particular, I would like to 
highlight the work of Justin Moody. Dr. Moody, DDS recently received 
the Alliance for Youth award at our national conference in Phoenix, 
Arizona held in late April. For four years Dr. Moody has driven 2\1/2\ 
hours to make sure that children enrolled at the Northwest Community 
Action Head Start in Chadon, Nebraska receive professional dental 
screenings. The mass screening takes up the entire day and is always 
done within the mandated 45-day deadline. Dr. Moody's volunteerism is 
equivalent to a yearly donation of almost $2,000. It is the work of 
heroes like Dr. Moody and many other dentists across the country that 
make it possible for many Head Start children to receive the important 
dental care they desperately need. However, it is clear that more must 
be done so that all Head Start children do not need to depend on the 
heroic acts of a few dentists, but can rather rely on having regular 
access to quality dental care.
    To remedy the problems that plague children as a result of 
inadequate dental care, the National Head Start Association recommends 
that:
    1) The federal government take over a larger share of Medicaid 
funding.
    2) Incentive grants be provided to states to increase their 
Medicaid reimbursement rates.
    3) An extensive study be commissioned by the Head Start Bureau to 
examine the problem of inadequate dental coverage and its findings 
brought before this committee in a timely manner.
    4) The Head Start Bureau be required to work more closely with 
states to form partnerships and collaborations to improve dental 
services.
    Thank you for allowing NHSA to present issues of importance to the 
Head Start community before the committee.

    [Whereupon, at 4:32 p.m., the subcommittee was adjourned.]

                                    

      
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