[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
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
U.S. GOVERNMENT PRINTING OFFICE
80-497 WASHINGTON : 2003
___________________________________________________________________________
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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
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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.]