[House Hearing, 110 Congress]
[From the U.S. Government Printing Office]




                               before the


                                 of the

                         COMMITTEE ON OVERSIGHT
                         AND GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION


                              MAY 2, 2007


                            Serial No. 110-8


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                 HENRY A. WAXMAN, California, Chairman
TOM LANTOS, California               TOM DAVIS, Virginia
EDOLPHUS TOWNS, New York             DAN BURTON, Indiana
PAUL E. KANJORSKI, Pennsylvania      CHRISTOPHER SHAYS, Connecticut
CAROLYN B. MALONEY, New York         JOHN M. McHUGH, New York
ELIJAH E. CUMMINGS, Maryland         JOHN L. MICA, Florida
DENNIS J. KUCINICH, Ohio             MARK E. SOUDER, Indiana
DANNY K. DAVIS, Illinois             TODD RUSSELL PLATTS, Pennsylvania
JOHN F. TIERNEY, Massachusetts       CHRIS CANNON, Utah
WM. LACY CLAY, Missouri              JOHN J. DUNCAN, Jr., Tennessee
DIANE E. WATSON, California          MICHAEL R. TURNER, Ohio
STEPHEN F. LYNCH, Massachusetts      DARRELL E. ISSA, California
BRIAN HIGGINS, New York              KENNY MARCHANT, Texas
JOHN A. YARMUTH, Kentucky            LYNN A. WESTMORELAND, Georgia
BRUCE L. BRALEY, Iowa                PATRICK T. McHENRY, North Carolina
    Columbia                         BRIAN P. BILBRAY, California
BETTY McCOLLUM, Minnesota            BILL SALI, Idaho
JIM COOPER, Tennessee                ------ ------
PAUL W. HODES, New Hampshire

                     Phil Schiliro, Chief of Staff
                      Phil Barnett, Staff Director
                       Earley Green, Chief Clerk
                  David Marin, Minority Staff Director

                    Subcommittee on Domestic Policy

                   DENNIS J. KUCINICH, Ohio, Chairman
TOM LANTOS, California               DARRELL E. ISSA, California
ELIJAH E. CUMMINGS, Maryland         DAN BURTON, Indiana
DIANE E. WATSON, California          CHRISTOPHER SHAYS, Connecticut
CHRISTOPHER S. MURPHY, Connecticut   JOHN L. MICA, Florida
DANNY K. DAVIS, Illinois             MARK E. SOUDER, Indiana
JOHN F. TIERNEY, Massachusetts       CHRIS CANNON, Utah
BRIAN HIGGINS, New York              BRIAN P. BILBRAY, California
                    Jaron R. Bourke, Staff Director

                            C O N T E N T S

Hearing held on May 2, 2007......................................     1
Statement of:
    Cosgrove, James, Ph.D., Director, Health Care, Government 
      Accountability Office; and Dennis Smith, Director, Center 
      for Medicaid and State Operations, Health and Human 
      Services...................................................    54
        Cosgrove, James..........................................    54
        Smith, Dennis............................................    77
    Finklestein, Allen, chief dental officer, United Health Care; 
      Susan Tucker, MBA, executive director, Office of Health 
      Services, Maryland Department of Health and Mental Hygiene; 
      and Jane Perkins, legal director, National Health Law 
      Program....................................................   109
        Finklestein, Allen.......................................   109
        Perkins, Jane............................................   129
        Tucker, Susan............................................   121
    Norris, Laurie, staff attorney, Public Justice Center; 
      Frederick Clark, D.D.S, dentist, Prince George's County, 
      National Dental Association, member; and Norman Tinanoff, 
      D.D.S, Chair, Department of Pediatric Dentistry Dental 
      School, University of Maryland.............................    13
        Clark, Frederick.........................................    24
        Norris, Laurie...........................................    13
        Tinanoff, Norman.........................................    31
Letters, statements, etc., submitted for the record by:
    Clark, Frederick, D.D.S, dentist, Prince George's County, 
      National Dental Association, member, prepared statement of.    26
    Cosgrove, James, Ph.D., Director, Health Care, Government 
      Accountability Office, prepared statement of...............    57
    Davis, Hon. Danny K., a Representative in Congress from the 
      State of Illinois, prepared statement of...................    44
    Finklestein, Allen, chief dental officer, United Health Care, 
      prepared statement of......................................   111
    Kucinich, Hon. Dennis J., a Representative in Congress from 
      the State of Ohio, prepared statement of...................     5
    Norris, Laurie, staff attorney, Public Justice Center, 
      prepared statement of......................................    15
    Perkins, Jane, legal director, National Health Law Program, 
      prepared statement of......................................   131
    Smith, Dennis, Director, Center for Medicaid and State 
      Operations, Health and Human Services, prepared statement 
      of.........................................................    79
    Tinanoff, Norman, D.D.S, Chair, Department of Pediatric 
      Dentistry Dental School, University of Maryland, prepared 
      statement of...............................................    33
    Towns, Hon. Edolphus, a Representative in Congress from the 
      State of Maryland, prepared statement of...................   160
    Tucker, Susan, MBA, executive director, Office of Health 
      Services, Maryland Department of Health and Mental Hygiene, 
      prepared statement of......................................   124



                         WEDNESDAY, MAY 2, 2007

                  House of Representatives,
                   Subcommittee on Domestic Policy,
              Committee on Oversight and Government Reform,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 1:05 p.m. in 
room 2154, Rayburn House Office Building, Hon. Dennis J. 
Kucinich (chairman of the subcommittee) presiding.
    Present: Representatives Kucinich, Waxman, Cummings, 
Watson, Davis of Illinois, Issa, and Shays.
    Also present: Representatives Towns, Sarbanes, and Wynn.
    Staff present: Jaron R. Bourke, staff director; Noura 
Erakat, counsel; Jean Gosa, clerk; Auke Mahar-Piersma, 
legislative director; Natalie Laber, press secretary, Office of 
Congressman Dennis J. Kucinich; Karen Lightfoot, communications 
director/senior policy advisor; Leneal Scott, information 
systems manager; Jacy Dardine, intern; Tim Westmoreland, health 
consultant; Andy Schneider, chief health counsel; Art 
Kellermann, health science fellow; Susie Schulte, minority 
senior professional staff member; and Alex Cooper, minority 
professional staff member.
    Mr. Kucinich. The subcommittee will come to order.
    We are expecting a series of votes, but I think what we 
will try to do is at least get the opening statements in, and 
so I want to welcome our witnesses and welcome everyone in the 
audience to this hearing of the Domestic Policy Subcommittee of 
the Oversight and Government Reform Committee, to today's 
hearing, ``Evaluating Pediatric Dental Care under Medicaid.''
    I want to thank our ranking member, Mr. Issa, for being 
here, and thank Mr. Cummings, who was instrumental in creating 
the circumstances which caused this committee to come forward 
and have a hearing.
    Mr. Cummings, thank you once again for your help.
    Good afternoon. This subcommittee has come to order, and 
today we are taking a closer look at the circumstances that led 
to the death of Deamonte Driver, a 12 year old Medicaid 
eligible boy who died of a brain infection caused by untreated 
tooth decay.
    This hearing will focus on the adequacy of oversight of 
pediatric dental care and Medicaid.
    In its 2000 report, Oral Health in America, U.S. Surgeon 
General David Satcher demonstrated that oral health is 
essential to general health. The mouth and its surrounding 
tissues provide protection against microbial infections and 
environmental germs, and they are associated with detecting 
nutritional deficiencies and systemic diseases.
    We have a series of slides here, and I will just proceed 
and will ask staff to just try to synchronize the slides with 
the text.
    All oral diseases are progressive, cumulative, and 
consequential. Tooth decay often occurs in early childhood and 
is the most common childhood disease. It is five times as 
common as asthma and seven times as common as hay fever. This 
has the most detrimental impact on low-income communities. As 
the slide indicates, 80 percent of cavities occur in only 25 
percent of children, predominantly low-income children. Low-
income children suffer twice as much from tooth decay than do 
the more affluent children.
    Medicaid is the largest source of health insurance for low-
income children, providing care for one out of every four 
children. Despite the coverage provided by Medicaid, it has 
been unable to fill the gap of providing dental care to poor 
    In 1999, 26.12 percent of eligible children received any 
dental services, and by 2000 that number had risen to only 
about 34 percent, not many percentage points more than dental 
service utilization by uninsured children.
    On Monday, the Center for Disease Control issued a new 
national study that found that tooth decay in baby teeth had 
increased among U.S. toddlers and pre-schoolers age 2 to 5. The 
CDC study also found that 74 percent of young children with 
cavities were in need of dental repair.
    In late February we witnessed the most tragic consequences 
of untreated oral disease. On February 25th, 12 year old 
Deamonte Driver died of a brain infection caused by untreated 
tooth decay. By the time Deamonte received any care for his 
tooth, the abscess had spread to his brain, and after 6 weeks 
and two operations Deamonte died. Filling a cavity, performing 
a root canal, or extracting the tooth might have saved 
Deamonte's life, and yet the challenges in finding a dentist 
and ensuring care precluded that opportunity.
    Deamonte's death demonstrates both the importance of oral 
health to children's welfare, as well as the sometimes fatal 
and often costly consequences of its inadequate success.
    We will take a closer look at Medicaid in Deamonte's home 
State, Maryland. Using the Health Plan Employer Data and 
Information Set measures, they estimate that 45.8 percent of 
Medicaid eligible children age 4 to 20 and enrolled for 320 
days received dental care in 2005. Using the CMS form 416 
measure, which is slightly different, the Maryland utilization 
rate for 2005 is 30.7 percent.
    Oversight by Government agencies is critical to ensuring 
that Medicaid serves the population as intended. But what is 
the quality of the data used in this oversight function? 
Consider this: one of the factors State regulators look at is 
the number of health care providers in the provider network. 
The managed care organizations providing the dental health 
services report this number to the Maryland Department of 
Health and Mental Hygiene. Now, according to Maryland, between 
2005 and 2006 the number of dentists serving the Medicaid 
population in Prince George's County increased from 162 to 360 
providers. In Deamonte Driver's case, there were 24 dentists in 
all of Prince George's County, according to the directory 
published on the Web site of United Health Care.
    In preparing for this hearing, I directed my staff to do a 
spot check of dentists listed in United Health Care's provider 
network. Of the 24 dentists that they called, 23 of the numbers 
were either disconnected, incorrect, or belonged to a dentist 
who does not take Medicaid patients. The 24th dentist did 
accept Medicaid patients, but only for oral surgery and not for 
general dentistry. Effectively, none of the 24 numbers listed 
would have been of any use to Deamonte Driver.
    The regulators who use MCO-provided data would have 
believed that the number of dentists that could have served 
Deamonte was 24, because that is what United Health Care would 
have told them, but the real number is zero.
    The case of Deamonte Driver raises a question we are 
considering in today's hearing: do the figures used by 
Government and for government oversight accurately reflect the 
accessibility and utilization of dental care?
    We will also consider the role played by the Centers for 
Medicaid and State Operations [CMS]. The Federal Government 
provides half or more of Medicaid funding to every State. It is 
the function and responsibility of CMS to ensure that money is 
being spent effectively to provide dental care to Medicaid 
eligible children.
    CMS uses the form 416 to ensure that children receive 
dental care as mandated by the Social Security Act. Although 
the form 416 is the only oversight mechanism used by CMS to 
ensure compliance with the act, not all States submit their 
form 416s annually. One of the witnesses today will testify 
even when the form 416s are submitted, the data may not be 
reliable or informative.
    Form 416s do not tell us why utilization rates are low, how 
many children received adequate and appropriate care, how many 
of the children that received the screening received 
preventative or restorative care for that screening, how many 
dentists are providing the care for children, and they don't 
tell us whether or not a handful of benevolent dentists are 
providing the care that should be spread across a broad network 
of providers. All the form 416s tell us is how many children 
are enrolled in Medicaid, how many of them receive a screening, 
how many receive preventative care, and how many receive 
restorative care.
    Our hearing will afford us the opportunity to ask how can 
we confirm that dental care and Medicaid is adequate if the 
only information available to us is either incomplete, 
unreliable, or both.
    We know even less about Medicaid managed care 
organizations. Managed care organizations don't complete the 
form 416s. They only report to the States. All of the data the 
MCOs report is created by the MCOs, themselves. This is 
concerning, since 47 States and the District of Columbia enroll 
some or all of their Medicaid populations in managed care.
    In 2004, managed care provided benefits for approximately 
60 percent of Medicaid beneficiaries nationwide. How do numbers 
reported by Medicaid managed care organizations and overseen by 
Federal agencies reflect the reality of access to and 
availability of dental care? What do these statistics really 
mean? What do they tell us about children's dental care? Do we 
know enough to prevent another tragedy like Deamonte's?
    Medicaid's inability to provide adequate dental care to 
children has been known since at least 2000, when the U.S. 
Surgeon General published his report. At the time of the 
report's publication, Deamonte was only 5 years old.
    A year later, on January 18, 2001, when Deamonte was 6 
years old, the former Director of the Center for Medicaid and 
State Operations issued a Dear State Medicaid Director letter. 
These letters are often used by CMS to provide information, 
guidance, and direction regarding Medicaid policy. In that 
letter, the Director requested information on State efforts to 
ensure children's access to dental services under Medicaid.
    The January 18, 2001, letter indicated that HCFA, presently 
known as CMS, would undertake intensive oversight of States 
whose dental utilization rates, as indicated on the HCFA 416 
annual reports, were below 30 percent, including the site 
visits by the regional office staff. States between 30 and 50 
percent would be subject to somewhat less stringent review.
    This letter was written 6 years before Deamonte's tragic 
death, at a time when something could have been done to save 
him. Significantly, Maryland was among the 15 worst performers. 
In 2005, the date of the most recent documentation, Maryland 
had just climbed out of the lowest category.
    That raises the question: would Deamonte's fate have been 
any different if CMS had subjected Maryland to a stringent 
review in 2001, as indicated by the January 18th letter? Was a 
critical opportunity lost to save a boy's life?
    This is not a case of an unfortunate boy fallen through the 
cracks, since the majority of Medicaid eligible children do not 
receive dental care. Rather, it is a tragic consequence of a 
system that creates a captive population for managed care 
organizations and allows managed care organizations to report 
on themselves to Government regulators. This is a system that 
puts profit above people.
    A little boy died for lack of a dentist. A dental screening 
would have only cost the managed care organization in which he 
was enrolled about $15. Taxpayers paid the managed care company 
about $4,800 over the course of the last 5 years of Deamonte's 
young life to provide him with a dentist and routine screenings 
that he obviously never received. The managed care company's 
parent retained about $12.5 billion in net profits during the 
same period.
    [The prepared statement of Hon. Dennis J. Kucinich 





    Mr. Kucinich. Mr. Issa, you are recognized for a statement.
    Mr. Issa. Thank you, Mr. Chairman.
    I would ask unanimous consent that all members of the 
committee be allowed to include their statements and extraneous 
material into the record.
    Mr. Kucinich. So ordered.
    Mr. Issa. Thank you, Mr. Chairman.
    Now I will be brief, because there is a vote on, but I 
think it is important to, first of all, thank you for holding 
this hearing today. It is very clear that we do have a crisis 
within an existing system. Little Deamonte's death is not 
anecdotal. It may be one of the few deaths, but it is just the 
tip of the iceberg of people who have losses in the quality of 
life and probably in many cases in the length of their life.
    The absence to have good dental care and preventive 
maintenance early on in life reduces both quality and 
longevity. It leads to early loss of teeth. Obviously, the 
abscesses, the other diseases can often be devastating, 
sometimes fatal. The loss of the bone due to tooth loss can 
lead to a number of other problems later in life.
    It is clear that, although we were well meaning in the 
establishment of a Medicare system that relies on private 
health care, that over the years, as public health institutions 
and public health doctors have been replaced by for-profit 
private systems, that we have not held them accountable to the 
highest level.
    The death of young Deamonte Driver is one of those 
tragedies that had no bad actors. We cannot look at malice or 
any wrongdoing of any of the individuals involved. What we can 
look to is a system that did not hold all of those involved to 
a standard that would have prevented this.
    I, for one, recognize through my own life experience and 
those of my employees over the years, that, unlike health care, 
in general, which you may or may not need, you need preventive 
dental care from the time your first tooth comes in until the 
time you breathe your last breath, and if you do not have it, 
both the quality and length of life will be diminished.
    So, unlike other areas of health care that you may or may 
not go for a period of time and feel that I don't know what is 
happening but I am probably OK, every absence of a tooth 
cleaning, every absence of a timely inspection leads to the 
kinds of problems that we saw here with young Deamonte Driver.
    Maryland, with only 16 percent of its 5,500 dentists 
participating, certainly is a poster child for this problem, 
but, Mr. Chairman, I commend you for bringing this to national 
attention. This is a national tragedy. It is one that can only 
be solved by fundamental oversight and reforms in the system.
    I commend you for bringing this beginning of the process 
here today. I look forward not only to this hearing but to real 
reform and real legislation to make sure that preventive 
dentistry becomes part of overall health for all of us in 
America, but particularly for those who cannot afford it on 
their own.
    With that, I yield back.
    Mr. Kucinich. I want to thank the gentleman for his spirit 
of cooperation. I appreciate the spirit of your statement.
    Without objection, the Chair and ranking minority member 
will have time to include extraneous materials in the record. 
Without objection, Members and witnesses may have 5 legislative 
days to submit a written statement or extraneous materials. And 
without objection we will be joined on the dais by Members not 
on our committee for the purpose of participating in this 
hearing, making opening statements, and asking questions of our 
    I think at this point what we will do is take a brief 
recess of about 20 minutes. We will take a recess of 20 
minutes. We are going to vote. We will be right back.
    Thank you very much.
    Mr. Kucinich. The committee will come to order.
    This is a meeting of the Domestic Policy Subcommittee of 
the Oversight and Government Reform Committee. The topic for 
today's hearing is Evaluating Pediatric Dental Care under 
    I am Dennis Kucinich, chairman of the committee.
    At this time I will ask if any other Member seeks 
recognition to make an opening statement.
    Mr. Cummings. Mr. Chairman.
    Mr. Kucinich. Mr. Cummings of Maryland.
    Mr. Cummings. Thank you very much, Chairman Kucinich. I 
take this moment to express my sincere gratitude to you for 
taking an interest in this important issue and agreeing to host 
this hearing today before the Domestic Policy Subcommittee.
    Your staff had the tremendous task of organizing this 
hearing, and I thank them for their efforts.
    I requested this hearing to investigate critical breakdowns 
in the Federal Medicaid program which have left so many 
children unable to access the dental care services that they 
are entitled to by law. I emphasize that--entitled to by law.
    Many of you in this room will be familiar with the name of 
Deamonte Driver. It is for him and other children who find 
themselves similarly situated that I requested this hearing.
    For those of you who are not familiar, allow me to explain. 
Deamonte Driver was a 12 year old boy from my home State of 
Maryland who died on February 25th when a tooth infection 
spread to his brain. A routine dental checkup might have saved 
his young life, but Deamonte's family was poor and they did not 
have access to a dentist.
    When I read Deamonte's story in the Washington Post, I was 
shaken and shocked. I asked myself, how could this happen in 
the United States of America, a country that sends folks to the 
moon. How could this happen? How in the 21st century, with all 
the resources available to us, did we thoroughly fail this 
little boy?
    I often say that as adults we have a responsibility to 
provide for and protect our children. Here, ladies and 
gentlemen, we simply failed to meet those responsibilities for 
this young man.
    I think we all should be ashamed by that fact. I know I am. 
But shame will not correct the situations that allowed this 
young man to die an early death. That is why I have made it a 
commitment to attack the issue of insufficient access to dental 
care from every single angle.
    In the weeks leading up to this hearing, my staff and I 
have met with patient advocates, dentists, dental 
organizations, health care providers, and Government officials 
to fully comprehend the scope of this problem. I have joined my 
colleagues in reintroducing the Children's Dental Health 
Improvement Act of 2007, H.R. 1781, and in working to ensure 
that dental coverage is included in the forthcoming State's 
Children's Health Insurance Program [SCHIP], reauthorization.
    I have also worked with my colleagues on the House Armed 
Services Committee, Personnel Subcommittee, to request a 
Government Accountability Office study to examine the quality 
of dental care provided to our troops and the effects of that 
care on readiness.
    Poor dental health is a leading cause of delayed 
deployment, and for many of these troops dental problems, that 
is right, began when they were children.
    Through our work I have become acutely aware of the 
barriers facing Medicaid patients who seek dental care. More 
and more, dentists are not accepting Medicaid insurance because 
it pays only $0.20 to $0.35 on the dollar. Further, Medicaid 
patients are more likely to cancel appointments, and the 
paperwork burden is large.
    Finally, I know also that there is a shortage of dentists 
capable of doing this work. Many dentists are uncomfortable 
treating the sort of complicated cases presented by Deamonte 
and others who have not had regular access to care.
    The University of Maryland Dental School, the only dental 
school in the State of Maryland, graduates just three pediatric 
dentists per year. But our purpose today is not to address the 
issue of access to dental care. That is a role better played by 
the authorizing committees. Today we will investigate the 
systematic failures of the Centers for Medicaid and Medicare 
Services and its State partners to comply with the section 
1905(R)(3) of the Social Security Act, which ensures that every 
Medicaid eligible child will have access to medically necessary 
dental care under the early periodic screening, diagnostic, and 
treatment, or SDSDT, provision.
    We know that this service was not extended to Deamonte 
Driver. Evidence suggests that he is certainly not alone. I 
think it is worthwhile to take another look at the chart the 
chairman just put up. As this chart indicates, of the 24 dental 
offices listed as Medicaid providers in the State of Maryland 
that the committee staff called, 23 were disconnected, 
incorrect, or belonged to a dentist who does not take Medicaid 
patients. The 24th was an oral surgeon, not a dentist.
    At my request the majority staff of the committee has 
prepared an analysis of the alterations of the guide created by 
a leading pediatric dentistry organization to Children's Dental 
Care and Medicaid.
    I ask unanimous consent, Mr. Chairman, that this analysis 
be included in the record of today's proceedings.
    We must do everything in our power to identify what went 
wrong and to fix the broken system not yesterday but now. I 
simply cannot and we cannot allow another child to suffer 
Deamonte's fate.
    I look forward to the testimonies of today's witnesses and 
again, Mr. Chairman, I thank you so very much for acting on 
this so expeditiously and so thoroughly.
    With that, I yield back.
    Mr. Kucinich. I thank the gentleman. Without objection, the 
information that you requested be included in the record will 
be included. So ordered.
    The Chair welcomes and wishes to recognize for purposes of 
an introduction Mr. Sarbanes.
    Mr. Sarbanes. Thank you, Mr. Chairman. Thank you for 
holding the hearing.
    Thank you to you, Congressman Cummings, for requesting a 
hearing, and thank you for your continued incredible leadership 
on behalf of the State of Maryland.
    I wanted to join you very briefly this morning to join you 
in welcoming one of the witnesses today, Laurie Norris. I had 
the opportunity to work with Ms. Norris for 7 years when I was 
on the board at the Public Justice Center in Baltimore. I know 
of her good work. I know of her incredible skills as an 
advocate and a lawyer, particularly on behalf of under-served 
families and communities and children. I know that her 
testimony today will be compelling, and I expect wrenching at 
times, but it is incredibly important.
    I thank you again for the opportunity to join in welcoming 
her today.
    Thank you.
    Mr. Kucinich. I thank the gentleman.
    The subcommittee will now receive testimony from the 
witnesses before us today.
    I want to start by introducing our first panel.
    Ms. Laurie Norris, I want to thank you very much for your 
presence here.
    Dr. Frederick Clark has practiced dentistry in Prince 
George's County for the past 17 years. Dr. Clark has served on 
the State of Maryland Oral Health Advisory Committee. He has 
also served as a member of the HeadStart Advisory Committee.
    Dr. Norman Tinanoff is a practicing pediatric dentist in 
Baltimore and is a professor and chairman of the Department of 
Health Promotion and Policy at the University of Maryland 
Dental School. Dr. Tinanoff has authored over 50 articles 
concerning preventing dental care carries and oral health 
access in under-served child populations. Before joining the 
University of Maryland, Dr. Tinanoff was the director of the 
Pediatric Dentistry Graduate Program at the University of 
Connecticut's Health Center for 16 years. Dr. Tinanoff has also 
served at the Army Institute of Dental Research at the Walter 
Reed Army Medical Center.
    Welcome, Doctor.
    It is the policy of the Committee on Oversight and 
Government Reform to swear in all witnesses before they 
testify, and I would ask the witnesses to please rise and raise 
your right hands.
    [Witnesses sworn.]
    Mr. Kucinich. Let the record reflect that the witnesses 
answered in the affirmative.
    I ask that each witness now give a brief summary of their 
testimony, and to keep the summary under 5 minutes in duration. 
I want you to bear in mind that your complete statement will be 
included in the hearing record.
    Ms. Norris, you will be our first witness. At this point we 
welcome your testimony. Thank you.



    Ms. Norris. Thank you, Chairman Kucinich and members of the 
committee. I have the pleasure to be here today, but the sad 
duty of telling you the story of Deamonte Driver and his 
    I assisted Deamonte's mother in trying to get dental care 
for her children. Let me just briefly summarize what happened 
when I tried to do that.
    Deamonte was the third of five children in his family, all 
boys. They were born and raised in rural Prince George's 
County, MD. They were at high risk for dental disease because 
they were a low-income family, and Deamonte especially because 
he was a later-born child. He was the third child in the 
    All children in the family had a medical home. They all had 
a pediatrician that they could go to for regular childhood 
illnesses and immunizations, but none of the children in the 
Driver family had a dental home. They did not have a primary 
care dentist to look after their preventive dental care needs, 
their regular checkups, or dental education.
    As we have heard, Deamonte was 12 years old. During the 
course of this story, Deamonte had a younger brother, DeShawn, 
who was 10 in the summer of 2006, and I really want to start 
with him.
    All the boys were enrolled in United Health Care Medicaid 
managed care. In the summer of 2006, DeShawn started to 
experience dental pain and swelling, and his mother worked to 
find a dentist to treat him. And she was successful. She did 
find a contracted dentist through United and took DeShawn to 
the dentist, but the dentist refused to treat DeShawn because 
he wiggled too much in the chair. She sent him away and she 
didn't help the mother find another dentist to treat DeShawn. 
The mother tried, but was unsuccessful in finding another 
dentist, and so she called me in September 2006.
    I agreed to take the case and to help her out, and I called 
United Health Care directly to try to find a contracted 
dentist, and they referred me to Dental Benefit Providers, 
which is their dental subcontracted administrator. The DBP 
folks sent me a list of contracted dentists in DeShawn's 
geographic area, but they warned me to check first to see if 
the dentist still accepted United Health Care, because they 
said a lot of the dentists had recently dropped the contract.
    I had my administrative assistant start at the top of the 
list. She called the first 26 names on the list and none of 
them agreed to take DeShawn as a patient because they said they 
didn't accept that insurance.
    So at that point I called the State Agency Department of 
Health and Mental Hygiene. They have a help line. I called 
there and eventually, through their case management unit and 
the Prince George's County local Health Department, and 
assistance from United Health Care, we did find a dentist for 
DeShawn in October. It took one mother, one lawyer, one help 
line supervisor, and three case management professionals to 
make a dental appointment for one Medicaid child.
    But finding the dentist was just the beginning. DeShawn saw 
this dentist on October 5, 2006 and learned that he needed to 
have six teeth pulled. DHMH assisted with finding an oral 
surgeon, but the first available appointment was November 16th, 
6 weeks later. DeShawn went to that appointment. It was a 
consultation. No treatment was given.
    A December appointment was set. The dentist canceled that 
appointment. A January appointment was set. The dentist 
canceled that appointment, too, because he said by then he had 
dropped the plan.
    So DeShawn still has six rotten teeth in his mouth, no 
dental treatment. It is now 6 months later.
    DHMH located a third oral surgeon and a first appointment 
was set for February 7, 2007, and DeShawn did have his first 
tooth pulled. That dentist recommended that DeShawn have one 
tooth pulled each month for the next 5 months.
    So let's go back to Deamonte for a minute now. Deamonte had 
not complained of any dental problems. Nobody in his family 
knew that he had dental issues. He did begin experiencing 
severe headaches and he was diagnosed with a sinus infection in 
early January 2007. On January 12th, he was rushed to the 
hospital, had emergency brain surgery, and 6 weeks later, as we 
have heard, he passed away.
    Now, DeShawn eventually did get all six of his teeth 
pulled, but that was only because he transferred his care to 
the University of Maryland Dental Clinic, Dr. Tinanoff's 
clinic, and was expeditiously taken care of, and so we still 
have DeShawn with us today.
    I hope it is obvious that if we substitute the name 
Deamonte for DeShawn in DeShawn's story, the result is the 
same. Deamonte would still have had his brain infection. It 
took 7 months for Ms. Driver to get treatment for DeShawn, even 
though she was actively seeking it and doing everything she 
could think of to access that care.
    As we have heard, Deamonte and DeShawn are not exceptions.
    I will just close by saying that at the Federal level it 
seems to me that there has been a toleration for gross under-
performance by the States in providing oral health to our 
children, and that just needs to stop.
    Thank you, Chairman.
    [The prepared statement of Ms. Norris follows:]

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    Mr. Kucinich. Dr. Clark, thank you. You may proceed.


    Dr. Clark. Thank you very much, Chairman Kucinich, members 
of the committee. Thank you for inviting me to testify today.
    Mr. Kucinich. Dr. Clark, before you begin, I want to note 
that we have been joined by the distinguished Congresswoman 
from California, Congresswoman Watson.
    Dr. Clark. My name is Dr. Frederick Clark. I have been a 
practitioner in Temple Hills, MD, Prince George's County, for 
some 17 years. I am a dental health care advocate.
    I am here today because a child in my county and in my city 
in Temple Hills, MD, lost his life because he couldn't receive 
dental care in a timely manner. I am here to provide my 
personal perspective on problems related to access to care for 
children in the Medicaid program, and those who are uninsured 
and barriers that may exist in Prince George's County.
    I feel that one of the primary barriers to access is lack 
of adequate participation by private dental offices in the 
Medicaid program. Prince George's County has approximately 
43,000 to 50,000 child Medicaid participants. Some 200 dental 
offices are listed as providers, according to the Prince 
George's County Health Department, but when those offices were 
contacted to check on their participation, only 25 percent of 
those offices would see a child Medicaid patient.
    With this disproportionate ratio of patients to providers, 
it is virtually impossible for a parent to find a dentist to 
treat a child's dental concerns. Why does this disparity exist? 
There are many reasons, but some cited were, of course, low 
reimbursement rates for dental services, inability to receive 
timely payments for services rendered, inadequate network of 
specialists in which to refer difficult cases, poor 
communication between dental providers and the managed care 
organizations, interference with the doctor/patient 
relationship, difficulty in the credentialing process, and high 
broken appointment rates amongst Medicaid patients.
    For years dentists have had difficulty participating in 
Medicaid programs, even before the plans were taken over by 
managed care organizations. Some of the same complaints existed 
for years, resulting in refusal by many offices to participate 
in Medicaid. HMOs and MCOs have created a new landscape in 
which the medical field has had to adapt, but the changes have 
not been favorable to doctors.
    The way managed care plans are structured inherently create 
an antagonistic relationship within the medical and dental 
communities due to fee setting, low co-payment by patients, 
non-negotiation with the providers of care to provide payments, 
and low capitation rates.
    The combination of managed care plans and Medicaid makes an 
unpalatable mix that most doctors refuse to have any part of.
    At the treatment level, there is a silent scream which we 
in the treatment community hear on a daily basis. At Ground 
Zero there is a constant inundation of phone calls of patients 
attempting to acquire appointments. Parents report of calls to 
numerous offices and inability to receive appointments. There 
are reports of children in pain, children with abscesses. When 
children can be seen, there may be three, four, five children 
in a single family, all of whom have a number of cavities and 
dental disease.
    Sometimes they can be treated if a child is manageable, but 
if they are not the search begins for a pediatric dentist, 
which is almost impossible to find. A search through our local 
Yellow Pages revealed that there were only four listings for 
pediatric dentists in a county which has 800,000 residents and 
50,000 child Medicaid recipients.
    I have served this Medicaid population, in spite of 
problems of low compensation, and in some instances refusal to 
be paid. I grew up in south central Los Angeles as a poor 
child, and I feel a commitment to treat these children who know 
that if I were not there, there would be no one to serve them, 
there may be no one to serve them.
    The patients who pay for services allow me to treat some of 
the patients who have little or nothing. Pro bono care is a 
part of the norm in our community. This also occurs in 
treatment of adults who are indigent.
    Dental Medicaid dollars ultimately are allocated to ensure 
that poor children are able to receive desperately needed 
health services. The managed care role in this process is to 
create the network of providers and set up a compensation 
structure that ensures that the process works.
    My primary concern is that Medicaid dollars should go the 
Medicaid treatment and as little as possible to administrative 
costs. This program was not set up for someone to profit off 
the backs of children. I do not begrudge a for-profit business 
making Native American profit, but this program was designed to 
help children and should be run as a nonprofit organization 
with open books, so that the bottom line of the business is not 
the primary concern.
    I am not in a position to say if the managed care 
organizations have anything to hide, but obviously the fees are 
still too low to encourage private dental office participation 
in Medicaid.
    Thank you very much.
    [The prepared statement of Dr. Clark follows:]

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    Mr. Kucinich. We thank the gentleman.
    Dr. Tinanoff.


    Dr. Tinanoff. Chairman Kucinich and members of the 
Subcommittee on Domestic Policy, thank you for inviting me here 
today to discuss the issues of oral health care for poor 
children, especially the situation in Maryland.
    I would like to give you my perspective on how, in one of 
the richest States in the country, Medicaid can fail our most 
vulnerable children, as evidenced by the most recent tragic 
death of a child due to a dental infection.
    In 1997, access to oral health care for Maryland's poor 
children was the worst in the country; however, there has been 
incremental progress made, primarily through the enactment of 
Maryland State legislation championed by key legislators and 
promoted by oral health advocates. Nevertheless, much more 
progress is needed, as many Maryland children still suffer from 
pain and infection from oral conditions and parents continue to 
struggle to find dental providers to get the needed reparative 
services for their children.
    I am going to give you an analysis of some of the oral 
health care issues in Maryland and compare these to the several 
Maryland Department of Health and Mental Hygiene's--that is 
    The DHMH October 2006, report lists 918 unduplicated 
Medicaid providers. A more realistic calculation of the actual 
providers may be generated from direct calling of those 
dentists who are on the provider list who ask the question, 
will you take a new Medicaid patient? Using this method, the 
following information was obtained from 748 of the listed 918 
providers. This table shows that there is perhaps only one-
fifth the actual number of listed Medicaid providers who will 
see a new patient.
    DHMH's 2006 report also lists a number of children 
receiving dental services counting only those children ages 4 
to 20 who have been enrolled for at least 320 days. However, 
the April 2005, report of the National Oral Health Policy 
Center mandates that States use form 416, which requires 
counting total eligible children. This table compares, for 
2005, the number of children enrolled in Medicaid and the 
percent receiving any dental service, as reported by Maryland's 
DHMH and as reported by CMS's form 416.
    Additionally, the last columns show the ratio of dental 
providers to enrollees for 2006, as reported by DHMH. This 
should be dentists, not children. With this, it shows that with 
DHMH they report one dentist for 439 children. Yet, if one uses 
the total eligible number of children that is in form 416 per 
the number of providers, those willing to accept a new patient, 
the ratio would be about one dentist for every 2,500 children, 
exceeding the ratio of 1 to 2,000 as required by Maryland law.
    In 2001 DHMH conducted town meetings to assess issues 
regarding the Medicaid system. Although these meetings 
concerned total health care in the system, reports from those 
who attended these meetings indicated that most of the 
discussions focused on lack of access to oral health care. 
However, of the four quality reports of managed care published 
by DHMH in 2005 and 2006, only one of 118 pages of these 
reports addresses oral health care.
    It is difficult to appreciate why these reports essentially 
do not include oral health care issues, since access to oral 
health care has been a continued concern in Maryland for so 
many years.
    Although the reimbursement rates for 12 selected 
restorative procedures were increased in 2003, most of the 
rates for procedures still are far below what the dentist will 
accept. The American Dental Association survey of March 2004, 
ranks Maryland as 39th out of 50 States regarding reimbursement 
rates for diagnostic and preventive procedures. Incredibly, 
this report lists Maryland as the worst State in the country 
for reimbursement rates for restorative procedures.
    An illustration of this problem is the current 
reimbursement rate for dental sealings. Maryland Medicaid pays 
$9 per sealing, whereas the 50th percentile for dentist fees in 
Maryland for sealing is $40. It is unreasonable to expect a 
high number of dentists to participate in Medicaid when their 
rates do not cover their overhead costs and do not equal an 
acceptable discount rate for dentist participation.
    Furthermore, paperwork, red tape issues, and no-show rates 
are frequently cited by dentists as reasons for not 
participating in Medicaid.
    Oral health care for children in Maryland Medicaid 
continues to be inadequate. Part of this inadequacy may be the 
result of reporting efforts that may mask the severity of 
access issues. Inaccurate reporting frustrates parents and 
health care workers seeking care for their children and 
adversely affects decisions of policymakers.
    In summary, oral health care in Maryland Medicaid needs 
improvement and closer scrutiny as children with untreated 
dental problems continue to suffer from pain and infection and 
    Thank you for your attention and for your interest in oral 
health care for poor children.
    [The prepared statement of Dr. Tinanoff follows:]

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    Mr. Kucinich. Thank you, Dr. Tinanoff, Dr. Clark, Ms. 
Norris. We are now going to proceed with questions from Members 
of Congress.
    I would like to begin with Ms. Norris. In your practice 
have you heard from other patients of Medicaid eligible 
children who have trouble finding dental care for their 
    Ms. Norris. Yes, Mr. Chairman, I have heard from quite a 
few families that have had trouble finding dental care. They 
complain that the provider lists are inaccurate. They complain 
that they have to call many, many dentists before they find one 
who is either contracted or will accept a new patient. They 
complain of having to wait many months for an appointment. 
Sometimes they have to drive very long distances to see a 
dentist, sometimes more than an hour, sometimes across the Bay 
Bridge. We have strange geography in Maryland and we have part 
of our State that isn't really connected to the rest of the 
State. I even had one family tell me that they had an 
appointment and they drove an hour-and-a-half to get to the 
appointment and they were turned away at the door with no 
    So I have heard many, many stories from many parents, and 
this is really an endemic problem.
    Mr. Kucinich. The information I presented at the beginning 
of this hearing, where I pointed out that the staff of this 
committee called 24 dentists, 23 numbers disconnected or 
incorrect, belonged to a dentist who did not take Medicaid 
patients, 24th didn't accept Medicaid patients or did accept 
but only for oral surgery, not general dentistry, and that 
effectively none of the 24 numbers listed would have been any 
use to Deamonte. Do you find this consistent with your own 
    Ms. Norris. Yes, very much so. The dental provider lists 
are absolutely unreliable.
    Mr. Kucinich. Now, given your understanding, Ms. Norris, of 
why Medicaid eligible children have not been able to access 
adequate and appropriate dental care and Medicaid, what changes 
would you recommend?
    Ms. Norris. Well, the first thing is, as I mentioned 
before, the tolerance of the gross under-performance of the 
State agencies. I think that if CMS were to exercise its 
statutory right to sanction States financially for failing to 
perform in this area, that would light a fire under the States 
and encourage them to reform.
    Mr. Kucinich. So we are talking in terms of increased 
oversight by CMS of dental access in State Medicaid programs?
    Ms. Norris. Absolutely. Yes, Mr. Chairman, that is 
absolutely critical to fixing this problem.
    Mr. Kucinich. Thank you very much.
    Dr. Clark, you mentioned that in order to see Medicaid 
patients a dentist must be willing to subsidize the patient's 
treatment. Why is that the case, and why do you think 
reimbursement rates for dentists are so low?
    Dr. Clark. Well, I think that if you are going to be 
treating a population of people as large as we have in Prince 
George's County, that you are invariably going to run across 
children who don't have access to care, and you are not going 
to be compensated at the rate that you would with patients who 
have insurance or pay out of pocket. So basically what goes on 
is, as was mentioned, they are paying between 20 and 25 cents 
on the dollar. So any time you take any number of patients 
under Medicaid that you are treating, you are going to be 
subsidizing their care, based on the fact that there are other 
patients who pay for their services.
    Mr. Kucinich. So why do you think the reimbursement rates 
are so low? I mean, your experience is probably similar to 
others, except that you make sure these kids receive help.
    Dr. Clark. Well, traditionally the Medicaid reimbursement 
rates have been low, even before managed care got involved with 
the process, so there has never been an effort on the parts of 
those who fund dentistry for Medicaid or for under-served 
populations to actually pay the cost of what the service truly 
is. I think part of that comes from the fact that there is not 
a participation by the dental community to help aid in setting 
fees that is being listened to by those who have control over 
    Mr. Kucinich. Thank you.
    Dr. Tinanoff, you explained that you obtained your data 
from making individual calls to dentists in Maryland. Have you 
ever requested the same data from the State Medicaid agency to 
avoid the trouble of making all those calls? And what type of 
response did you get for your request for data?
    Dr. Tinanoff. I specifically didn't ask them to do that 
type of analysis, but for some time I have been trying to work 
with them to try to solve some of these issues by collecting 
data. Not until just very recently, maybe in the last week, was 
I given new data that will help us analyze and understand the 
situation much better in Maryland.
    I think that Maryland Medicaid would benefit greatly by 
working with people outside their agency to analyze their data 
and help them to analyze the problem. Part of the problem that 
we see here is that the data that is being presented to 
policymakers and legislators is presented in a way that doesn't 
excite legislators to put any more money into the budget. 
Currently, the dental component of the Maryland Medicaid budget 
is only 1 percent.
    Mr. Kucinich. Thank you, Doctor. I just was informed by 
staff that you did receive data this week from Maryland; is 
that right?
    Dr. Tinanoff. Yes.
    Mr. Kucinich. OK. The Chair will recognize Mr. Cummings. 
Again, Mr. Cummings, this subcommittee owes you a debt of 
gratitude for not just calling this to our attention but for 
urging this hearing today. I was more than happy to comply. 
Please proceed.
    Mr. Cummings. Thank you very much.
    I want to just pick up where the chairman left off. The 
data that you received, what did that data say?
    Dr. Tinanoff. Excuse me?
    Mr. Cummings. He just asked you about some data that you 
just received this week. What did the data say?
    Dr. Tinanoff. I haven't had a chance to analyze it because 
it is an enormous amount of data. It breaks down all the 
procedures by all the different types of dental procedures 
versus age, so it is pages and pages of data. It will take me 
some time to understand it.
    Mr. Cummings. Would you provide us with your conclusions at 
that point where you are able to come to some, please?
    Dr. Tinanoff. I would be happy to.
    Mr. Cummings. I want to just thank you very much, chairman.
    I want to go to you, Ms. Norris, and, as you know, Federal 
law mandates that every Medicaid eligible child will have 
access to medically necessary dental care under the early 
periodic screening diagnostic and treatment or EPSDT provision. 
What is your assessment of that provision and how it is carried 
    Ms. Norris. Well, the provision----
    Mr. Cummings. So that means that every child should be able 
to get treatment.
    Ms. Norris. Well, each State sets its own dental 
periodicity schedule, and what that means is each State is 
required to say how frequently a child is supposed to get 
dental care and at what age they are supposed to begin.
    Maryland does have a periodicity schedule that starts at 
age 1 and provides for 6-month visits every year up until age 
    Mr. Cummings. So you are saying that a child in Maryland 
should be getting some type of dental screening starting at age 
    Ms. Norris. Yes.
    Mr. Cummings. All right.
    Ms. Norris. It looks good on paper. The problem is that 
periodicity schedule exists in the pediatrician's section of 
the manual, and the pediatricians don't do this work. There is 
no requirement for dentists to actually do this work and there 
is no oversight of whether dentists have actually done this 
work, so nobody is doing it, and nobody is noticing that nobody 
is doing it.
    Mr. Cummings. That is deep. So, in other words, you have a 
provision and everybody is either assuming that they are not 
doing it or that they are doing it and nobody is doing it?
    Ms. Norris. Nobody is doing it. Part of the reason why 
nobody is doing it is nobody is looking to see if anybody is 
doing it, and another reason is because we don't have the 
dentists. We don't have sufficient dentists willing to see 
these children.
    Mr. Cummings. So, going back to this EPSDT provision, the 
breakdown then is not with the law and the way it is written, 
but is, rather, with the implementation; is that correct?
    Ms. Norris. Enforcement and implementation. Absolutely 
    Mr. Cummings. And what is the best situation for oversight? 
I mean, I am sure you have thought about this many times, and 
if we could give you the magic wand and say how would you deal 
with oversight of this, and I am assuming that oversight you 
think would go a long way as long as there were sanctions 
connected with the oversight, what would your wish be?
    Ms. Norris. Well, I think we need to actually look at 
whether care is provided to individual children according to 
the EPSD schedule. We need to collect data about that, which we 
are not doing right now. We are just collecting data about 
whether a child saw a dentist this year. So it is not nearly 
detailed enough.
    We are also not looking at the oral health status that 
children are achieving through getting all this dental care 
that they are not getting.
    I think that CMS needs to change its data collection and 
they need to require dentists to participate in the EPSDT 
reporting, not just pediatricians.
    Mr. Cummings. Do you think the Centers for Medicaid and 
Medicare Services are doing what they are supposed to do under 
the law? And you might want to answer this too, Dr. Tinanoff. 
You can go first.
    Dr. Tinanoff. Part of the thing that is being reported to 
CMS is total number of visits, total number of preventive 
visits and restorative visits. Not all the States are actually 
doing those reports on a yearly basis. I think it is somewhere 
around 35 of the States are reporting out of the 50 States. One 
thing that is being emphasized, both at the State level and at 
the Federal level, is whether a child has seen a dentist in the 
past year. I don't know if that is the best indicator, because 
in Maryland, for instance, DHMH reports 45 percent of the 
children see a dentist, but the actual number of children that 
are getting care, restorative care, is probably close to 13 
percent, according to CMS's form 416.
    Mr. Cummings. I am going to come back to you. I see my time 
is running out. I do want to ask this question, though. Dr. 
Clark and Dr. Tinanoff, I understand that less than one-half of 
1 percent of all Medicaid spending goes to provide dental 
coverage. Is that your understanding? And if that is true, do 
you think that is sufficient.
    Dr. Tinanoff. It is less than 1 percent.
    Mr. Cummings. It is less than 1 percent. Let's go with 1 
percent. That is fine.
    Ms. Norris. OK. Nationwide, dental Medicaid is about 5 
percent. In the public sector, with regard to health care, 25 
percent of health care for children is spent in dentistry. So 
you can see that Medicaid is insufficient, and in Maryland 
dental care is very insufficient with regard to funding.
    Mr. Cummings. And these are probably the folks that need it 
the most.
    Dr. Tinanoff. That need it the most.
    Mr. Kucinich. Mr. Cummings brings up an important point, 
and I would just respectfully suggest to the members of this 
subcommittee that a followup to this meeting would be a 
discussion, a meeting with Medicare or Medicaid to talk about 
the role of dental care in overall health and how they may have 
to start dramatically appreciating the amount of money that is 
spent for dental care, because, as medical science understands, 
there is a closer relationship to dental health than to general 
health and maybe what previously thought when these guidelines 
were first adopted.
    The Chair recognizes the gentlelady from California, 
Congresswoman Watson. Thank you.
    We have been joined by the gentleman from Maryland, Mr. 
Wynn. Thank you.
    Ms. Watson. Mr. Chairperson, I want to thank you for 
holding this hearing. The timing is so right to look at the 
    What is troubling to me is that we are setting up systems 
that are so dysfunctional, and you can see it when we have a 
tragedy like the one we have been talking about this afternoon. 
We build a bureaucracy that attempts to thwart the consumer and 
the patient from getting services. And why is that? Because 
they feel in these programs, the Medicaid program and others, 
that they do not get reimbursed enough.
    I could go on all afternoon, Mr. Chairman, with another 
issue that has to do with dentistry, but I am going to stick on 
this one.
    We are finding that the ratio of patients to providers is 
unacceptable. We are finding that students at the medical 
school are not going into dentistry because they don't want to 
get into a profession where they cannot get reimbursed 
    And then I was just thinking, I think all of our 
universities that have medical schools ought to have emergency 
dental care, and then we would never have to have the kind of 
tragic situation that happened with Deamonte.
    So I guess my question goes to the panel. And there are two 
other panels, Mr. Chairman?
    Mr. Kucinich. Yes, the gentlelady is correct.
    Ms. Watson. Because I want to get into the use of mercury. 
You knew that was coming, dental amalgams. I have to get into 
that, because that goes along with the lower socio-economic 
groups and the inexpensive cost of that one.
    But panelists, how would you like to see us improve on the 
provisions of services through CMA so we will never have these 
tragedies reported to us again? And is that Dr. Tinanoff? Yes, 
we will start with you.
    Dr. Tinanoff. There are many things that need to be 
improved, and it is a complicated question. There are 
Congressmen and Senators that are working on legislation as we 
speak. But for sure dentistry in Medicaid in Maryland and 
across the country is under-funded. That is the first and most 
important step. There are many other steps that need to be 
done, but that has to be addressed first.
    Ms. Watson. Sometimes you know the answers when you throw 
these questions out.
    Dr. Clark.
    Dr. Clark. Yes. I think that there is a breakdown in 
communication between the legislature of various States and 
funding for Medicaid programs. My understanding is that the 
State of Maryland's dental budget is about $63 million. Of that 
$63 million, we don't know how much actually gets to the 
treatment end, and that is what needs to be established.
    How much is required for administrative costs versus how 
much is required for treatment? I think that if $63 million is 
not enough, then that needs to be expressed to our legislators 
to let them know, and I think the managed care organizations 
have a role to say if it is not enough money, to encourage them 
and say well, our budget needs to be better than 1 percent of 
the overall Medicaid budget.
    Ms. Watson. All right. Ms. Norris, do you know if there is 
a cap? Let's just use Maryland, since we are starting there. Is 
there a cap on the cost of the overhead to provide services?
    Ms. Norris. Yes. In Maryland I believe it is 15 percent for 
overhead and 2 percent for profit.
    Ms. Watson. Would adjusting that cap downward help this, or 
would we put all the dentists out of business?
    Ms. Norris. Well, the dentists are not in the business of 
providing care to Medicaid children yet, but I don't think by 
adjusting the 15 percent administrative cost we would put the 
health plans out of business. We certainly would not. I think 
that is one place to start.
    I also think in Maryland there are two layers. There is the 
health plan and then there is the subcontracted dental plan, so 
there are two sets of administrative costs in Maryland. I don't 
know if that is true in other States. I would make two other 
recommendations, in addition to more money. I think more money 
will help us get dental homes for all these children. All these 
children need to have assigned primary care dentists so that 
they don't have to go through this red tape of finding a 
contracted dentist.
    The other thing I would recommend--and this I think might 
be able to come from the Centers for Disease Control--we need 
to have a nationwide high-profile public education campaign 
concerning the importance of getting children into early dental 
care so that the preventive end can be taken care of. I think 
even parents don't understand the importance of dental care to 
their children. I think that needs to be addressed at a 
national level.
    Ms. Watson. Thank you so much.
    Thank you, Mr. Chairman.
    Mr. Kucinich. I think that is a very valuable suggestion 
and one that this subcommittee is going to certainly be 
instrumental in promoting in followup to this hearing.
    Ms. Norris. Thank you.
    Mr. Kucinich. The gentleman from Chicago, Mr. Davis, has 
long been active in a range of issues relating to the children 
of the inner city. Congressman Davis, you are recognized.
    Mr. Davis of Illinois. Thank you very much, Mr. Chairman. 
Let me apologize to the panelists because I didn't hear all of 
their testimony because I was engaged in some HeadStart 
activity. That still deals with children.
    Let me thank you, Mr. Chairman, for calling the hearing, 
and also let me just ask if I might have unanimous consent to 
put into the record an opening statement that I had prepared, 
as well as a document, Access to Dental Care for Low Income 
Children in Illinois.
    Mr. Kucinich. Without objection, so ordered.
    [The prepared statement of Hon. Danny K. Davis follows:]

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    Mr. Davis of Illinois. Thank you very much.
    It has been my contention for a long time that dental 
health was actually the step-child of health care delivery. I 
think that is a fundamental premise, and I think that is where 
we really have to begin and start from when we look at it.
    I have always been fascinated because I couldn't quite 
understand it whether or not people were saying that dental 
health was not as important as physical health or mental 
health, although we don't do too well with mental health, 
    Would either of you venture an opinion as to why dentistry, 
dental health, has had such a low place in health care 
    Dr. Tinanoff. Maybe I could start, Congressman. Thank you 
for your interest in oral health care and your interest in 
HeadStart. I just want to give you a survey that we did at the 
University in 2001 regarding Maryland HeadStart children. We 
found that 45.6 percent of the 3-year olds in HeadStart had 
cavities, and many of these kids were in pain.
    It escapes me why dentistry for these children is a step-
child. Many of the kids that we see are in pain. We have a 
significant number that have infections. When Medicaid budgets 
are cut, dentistry seems like it is the first one that goes.
    Mr. Davis of Illinois. Of course, I have never felt that 
Medicaid adequately funded anything, quite frankly, in terms of 
maybe some services for some professionals, but certainly not 
hospital care. I mean, it certainly does not do that.
    Dr. Clark, would you care to comment?
    Dr. Clark. Yes. My perspective on why dentistry does not 
have a high priority is that we haven't adequately gotten the 
message across to the general public that dentistry is very 
important. My perception is that the biggest concern that 
people have is that they don't need to see a dentist because 
there is a continual lack of perceived need. In other words, if 
you don't have pain, you don't have bleeding, if you don't have 
presence of infection which is noticeable, there is generally, 
amongst most people, not a need to seek the treatment of a 
    I think that if we were to engage in public health 
initiatives that involved public service announcements, 
commercials, and education about dentistry, if we were to 
listen to what is coming from organized dentistry about how we 
need to approach educating people, in general, about 
dentistry--I don't mean just in Maryland, I mean in the United 
States and in the whole world--the attitude would change. But 
as it is right now, a lot of information concerning dentistry 
is never disseminated to the public unless you go to a dentist, 
because the information that we primarily get comes from the 
toothpaste manufacturers and manufacturers of mouthwashes. They 
will tell you to brush and floss and see your dentist and you 
are going to be fine.
    But I always say to people, I say if you brush and floss 
and you see the dentist, people still manage to get toothaches, 
they still manage to loose teeth, they still manage to get 
dentures and have root canals. So obviously there is a disease 
process going on which is silent, which most people are not 
aware of it and we are not educating them. I think that is 
where we need to go to start to begin to educate people that 
not treating these disease conditions can cause much worse 
problems, it can cause what happened with Deamonte Driver, it 
can cause problems related to heart disease and stroke, it can 
cause all kinds of deleterious health effects, but we are not 
communicating that to the general public.
    Mr. Davis of Illinois. So education is the key.
    Ms. Norris, could I ask you, I mean, I have always been 
intrigued also by the EPSDT that most of the emphasis seems to 
have been on the EPSD and virtually none on the T. I am saying 
many people seem to act as though the T is not there. I am 
saying States seem to act as though the T is not there. People 
who do the screening and detection seem to act as though the T 
is not there. And oftentimes the recipients don't really know 
that they can push the T. How do we overcome that?
    Ms. Norris. The T is the expensive part.
    Mr. Davis of Illinois. Yes.
    Ms. Norris. That is the treatment. Very often the people 
who do the screening and the diagnosis are not the same people 
who have to do the treatment, so that involves a referral. We 
also do a better job, I think, of tracking whether the 
screenings are being done. We don't collect as much data as 
religiously concerning the T. We don't watch that. I think that 
could help a lot if we cared about whether the T happened and 
we put enough money into this system to guarantee that the 
treatment could take place.
    Mr. Davis of Illinois. Well, thank you very much. Mr. 
Chairman, I assure you if this committee can just do something 
about this one issue over the next 2 years, it will have been 
worth its weight in gold. Thank you very much for calling this 
hearing. I thank the witnesses.
    Mr. Kucinich. And I want to thank Congressman Davis for 
saying that, because I think we have the composition of this 
committee and experience on this committee to be able to make a 
major impact on this issue, and certainly this testimony today 
provides us with incentive.
    When you look at the picture of that beautiful boy there, 
when you look at his face and you can see that maybe there was 
a doctor there, maybe there was a lawyer there, maybe there was 
a legislative leader, future Member of Congress, a life that 
was cut short, you really realize how serious our 
responsibilities are to make sure that the Deamontes of the 
world who are out there who you, Dr. Clark, have been dedicated 
to treating, and you, Dr. Tinanoff, have been dedicated, and 
you, Ms. Norris, make sure they have access. I mean, we really 
go deeply into this, so this is a good subcommittee to do that.
    The Chair wants to recognize the gentleman from Maryland, 
Mr. Wynn, for purposes of a statement and questions as a 
    Mr. Wynn. Well, thank you very much, Mr. Chairman. First, 
let me commend you for holding this hearing and thank you for 
your kindness and generosity in allowing me to participate.
    I also want to thank the witnesses for coming in. I 
apologize that prior commitments prevented me from hearing your 
testimony, although I have been briefed and I appreciate the 
contributions that you are making here today.
    This young man is my constituent. This was a tragedy that 
devastated our community because it seems so needless, and 
people all across the country were appalled to learn that a 
young man died from a problem that basically started with tooth 
decay, a problem that was preventable with access to adequate 
dental care, and a problem that shed light on a tremendous gap 
in the U.S. health care system.
    Tooth decay is the most common disease among children, one 
of the most common diseases amongst children. I was amazed to 
find it is five times as common as asthma.
    But what I was dismayed to find is that there are Medicaid 
hassles or administrative problems that seem to be a barrier to 
care. As a matter of fact, I heard from some dentists that they 
would rather give free care than have to work through the 
Medicaid system, which I think is a very telling statement.
    I am working on a bill with the National Dental 
Association, the American Dental Association, the American 
Dental Education Association, the American Academy of Pediatric 
Dentistry to work to develop a bill that will remove some of 
these barriers. But I wanted to ask a couple of questions about 
some of the testimony and some of the views of the panelists 
    I believe, Ms. Norris, you said there was a cap on overhead 
of 15 percent. Do you consider that to be a fair cap or 
realistic or realistically calculated or realistically 
    Ms. Norris. I think it is fairly typical. I don't think it 
is out of range of what most managed care organizations feel 
they need. I would certainly like to see less money go to 
administrative care. As I mentioned before, with the double 
layer of the health plan and the dental plan, I don't know how 
much of the money is sucked up in additional administrative 
costs because of that double layer.
    Mr. Wynn. Would a lower cap reduce the number of physicians 
    Ms. Norris. If the health plans had to spend more money on 
dental care and less money on administration, it would 
certainly help, because more money would be going to care for 
the Deamonte's of the world. Yes.
    Mr. Wynn. Now, what about the 2 percent profit cap that you 
referred to? What is the impact of that? Should we increase it? 
How would that work?
    What we are trying to get at is actually more access. What 
changes would help us with access?
    Ms. Norris. Well, we need more money in the system, and 2 
percent of $63 million is $1.2 million that is going directly 
to corporate profit and not going to dental care, so if there 
is any way we could reduce that amount, that would be terrific.
    I also think we need to set our sights a little higher than 
just getting children into care once a year. I think we need to 
set our sights on achieving oral health for this population, 
and that would require a different set of performance measures, 
but I think we need to go there.
    Mr. Wynn. Dr. Clark, you are a practitioner in the county 
that I represent. What is your view in terms of the Medicaid 
program and why so few--I believe the figure quoted was 46--why 
are so few dentists willing to participate in the Medicaid 
    Dr. Clark. When you look at the overall expense of 
providing care, if you don't at least meet the number 
percentage-wise to cover overhead, then you are operating at a 
deficit. At $0.25 on a dollar when you need $0.65 or $0.70 on a 
dollar is just not going to get it. You have to hire staff to 
treat people. You are doing a fee for service Medicaid plan, 
which means that for every dollar that you receive you are 
going to have to give treatment, which means you have to hire 
some staff person to pay them. So by the time you hire 
somebody, whatever money you receive, you are already operating 
in the red. So it is just not feasible to incorporate this into 
a private practice business.
    Mr. Wynn. What about the administrative hassles?
    Dr. Clark. It is not just with managed care organizations, 
it is with any type of third party payer. When you submit a 
claim for treatment, there is no guarantee of payment. When you 
submit the claim, there are occasions when the claim is sent 
back to you. You may call and check on claims, and therein lies 
a big problem because you are dealing with an automated system, 
you are dealing with time consumed just to followup on getting 
paid, so a lot of people don't want to deal with the red tape 
of trying to followup on something for which there is very low 
compensation anyway, so it has inherent barriers just in 
administering the plan.
    Mr. Wynn. I would like to ask the entire panel, I guess, 
one last question. Would you favor more school-based programs 
or school-linked programs as a way to provide greater access to 
    Dr. Tinanoff. Maybe I will start with that. There are so 
many kids in the system that are not getting care that school-
based and school-linked may not be sufficient. You may not have 
sufficient providers. You really have to engage the private 
dental community and the public health sector, as well. One of 
the ways to do that is to increase the fees to a point where 
dentists will accept these fees, and if that is the case then 
you have a sufficient number of providers in the system. To get 
that, you probably have to have a discount rate of 20 to 30 
percent of normal fees rather than where it is right now, where 
in this case Maryland is one of the lowest in the country, and 
that is the reason why there are so few providers that will 
accept the Medicaid rates.
    Mr. Wynn. Actually, Deamonte's mother was relatively 
conscientious in some respects with regard to getting dental 
care. Would a school-based program help the children of less-
conscientious parents?
    Dr. Tinanoff. With a school-based program the kids will be 
there for sure, but there may be a great difficulty still to 
find dental providers, to find dentists that would work in the 
school systems, so it still may not relieve the problem.
    Ms. Norris. If I may take a moment just to say that there 
are some preventive measures such as fluoride varnishes and 
sealants that may be able to be done in a school setting, maybe 
not cavity pulling and filling teeth, but there may be a 
specific role for dental care in the schools, but it would not 
cover the entire territory.
    Mr. Wynn. What about screening in the schools? I know my 
time must be out. What about screening in a school-based 
program so that the school is at least able to identify 
potential problems and see what resources are available. Could 
that help the situation?
    Dr. Clark. A school-based program might be good in 
identifying the problem, but after you identify the problem you 
get right back to the same situation of, how do you followup 
with treatment, and that is where the problem really lies.
    Mr. Wynn. Thank you.
    Thank you, Mr. Chairman.
    Mr. Kucinich. I thank the gentleman. Again, we are 
definitely going to do some followup in this subcommittee, and 
one of the things, as a result of your questioning, Mr. Wynn 
is, there has to be a connection also with diet, and school is 
not a bad place to start that discussion, as well.
    So let's now move to our distinguished colleague, Mr. Shays 
from Connecticut. Thank you, Mr. Shays.
    Mr. Shays. Thank you, Mr. Chairman. Mr. Chairman, sorry I 
missed the beginning of this hearing.
    Mr. Kucinich. We are glad to have you here. Thank you.
    Mr. Shays. We served together as a team on the subcommittee 
on National Security, and I just think this is a great 
subcommittee for you, as well.
    This is a very important issue. I don't have a question to 
ask, but I just want to say to start that in my State we rank 
at the very bottom, Connecticut, in reimbursement, so I have 
doctors that work on $0.20 on the dollar of what they would 
charge, and we have hardly anyone in the State that wants to 
help individuals receive Medicaid assistance.
    It is beyond disgraceful. My State, frankly, it can't be a 
Republican or Democratic issue because it is a very strong 
legislative body that is Democratic and a Republican Governor.
    I want to be on record as saying that I think there needs 
to be some type of percent. Is it 75 percent of whatever the 
market price is, 85, whatever, but it shouldn't be 20 percent.
    I just would like to ask you, Dr. Clark, there was 
mentioned earlier in your testimony, in testimony, that 
appointments are broken. Is that because we are saying that 
clients are reluctant to use this service and they will make an 
appointment casually and not keep it? What is the problem?
    Dr. Clark. I think when you are dealing with people in 
socio-economic areas that may not have transportation by car, 
rely on public transportation or someone else to bring them to 
the dentist, and you also find this population that if you call 
to confirm appointments sometimes phone numbers have changed or 
they are using a cell phone as primary form of communication, 
it is just difficult to sometimes ascertain whether or not they 
are going to keep an appointment, even when you schedule it.
    Mr. Shays. Isn't it the other issue, though, that if you 
let your teeth deteriorate so badly that you almost feel that 
the medicine kills the patient, I mean, talking about five 
teeth being pulled. I wouldn't want to make that appointment no 
matter what.
    Dr. Clark. There is a big problem with phobias and fear.
    Mr. Shays. Well, that is a darn scary thing.
    Dr. Clark. Yes, that is true, and that is the way the 
general public thinks about it. I mean, ideally we would like 
to think that we could treat every patient in a setting where 
we could sedate them. This is just not realistic.
    Mr. Shays. Right. But the point is, though, that patients 
don't really know.
    Dr. Clark. Right.
    Mr. Shays. I have seen people that their teeth don't look 
in good condition and you want to say why don't you just go to 
a dentist, but if you have never really gone to a dentist your 
worst fears are what you think.
    Dr. Clark. Right.
    Mr. Shays. And, frankly, there are things that I wouldn't 
want to do. I wouldn't want to get an MRI in a little tube. I 
don't know I'd say I would rather die first, but you are not 
getting me in that thing.
    Dr. Clark. I find patients don't want to get their teeth 
    Mr. Shays. Yes.
    Dr. Clark. They just find dentistry obnoxious. So it is the 
nature of the beast. I mean, we have to deal with people who 
are fearful. We have to deal with children who are more fearful 
than adults are. So it is something we have to deal with.
    Mr. Shays. Let me ask you, Ms. Norris, you handled and were 
an activist for the young man's family who passed away helping 
with another child.
    Ms. Norris. Yes.
    Dr. Clark. I wasn't associated with that.
    Mr. Shays. Ms. Norris.
    Dr. Clark. Sorry.
    Ms. Norris. Yes.
    Mr. Shays. Would you make an assessment that, when we are 
talking about health care, that you would rank up as one of the 
neglected areas dental care as one of the higher?
    Ms. Norris. Most certainly. Most certainly. This system is 
close to impenetrable for low income parents. It is complex and 
there isn't, even when they puncture the red tape, there aren't 
any dentists at the other end. It is definitely a step-child of 
medical care and something needs to be done about it.
    Mr. Shays. What I was told by the dentists, as well, is 
that just, for instance, cleaning teeth, they may end up paying 
$60 to their assistant, and in Connecticut they get $20.
    Ms. Norris. Right.
    Mr. Shays. So they literally are out of pocket. It is not 
their time being used.
    Ms. Norris. Right.
    Mr. Shays. It is literally out of pocket.
    Ms. Norris. They are not only donating their own time that 
they do see the patient, but they are out of pocket. 
Absolutely. And we only have about 200 dentists in the entire 
State of Maryland who are willing to participate in that, and 
we have 500,000 children to treat, so it is just not working.
    Mr. Shays. What is the overall statistic of dentists and 
participation? I am told it is only about 10 percent 
    Ms. Norris. In Medicaid?
    Mr. Shays. Yes.
    Ms. Norris. Well, the State's numbers say 16 percent, but, 
as Dr. Tinanoff's survey shows, it is much less than that.
    Mr. Shays. I'm sorry. That was covered before.
    Ms. Norris. Yes.
    Mr. Shays. Thank you all very much.
    Mr. Chairman, I am really grateful you have had this 
hearing. A lot of work needs to be done. I know you will seek a 
solution on both sides of the aisle on this.
    Mr. Kucinich. Certainly we can rely on the gentleman from 
Connecticut, Mr. Shays, to participate in any of our efforts to 
seek a solution.
    Before we discharge this panel and go on to the next, I 
want to take my prerogative as Chair to recognize a young 
advocate of health care for children who just happens to be 
right behind me. This is Ari Bourke, and Ari is here today on 
Capitol Hill advocating on a very important child health care 
issue. We wanted to welcome you and thank you for sitting in on 
this hearing, which is about children's health and, in 
particular, making sure that children have access to dental 
    Mr. Shays. If you would like, you can sit on this side of 
the aisle. We need as many recruits as possible.
    Mr. Kucinich. It is funny how they never fail to keep 
recruiting. We are so happy that you are here, Ari, and just 
wanted to let you know.
    Did you want to say anything about health care for 
    Mr. Bourke. No.
    Mr. Kucinich. OK. Well, we will be your voice today. Thank 
you so much. Please join me in thanking Ari for being with us 
    Mr. Kucinich. Once again, thanks to the first panel. Our 
staff will be in contact with you regarding followup on some of 
these issues as we continue to do the work of this subcommittee 
in assuring that children are going to have more access to 
dental health and that we look at the systemic issues that are 
brought forward by this panel and the work of the subcommittee.
    On behalf of the subcommittee, we thank each of you for 
your attendance here, and we will now move to the second panel.
    While the second panel is getting ready to come forward, 
this second panel will include the Director of Health Care for 
the Government Accountability Office and also the Director for 
the Director for Medicaid and State Operations in Health and 
Human Services.
    I would ask staff if they could provide the appropriate 
name cards, and then we will begin.
    I would seek unanimous consent to enter into the record 
documents that relate to managed care organization Health 
Choice, provider agreement, American Dental Education 
Association, an article on Protecting Children with Acute Care 
Dental Needs, and a memorandum to the House Committee on 
Oversight and Government Reform from Specialists in Social 
Education, Domestic Social Policy Division, CRS.
    Without objection, so ordered.
    Mr. Wynn. Mr. Chairman, could I also ask that my statement 
be included in the record?
    Mr. Kucinich. So ordered, without objection. The statement 
of Mr. Wynn is included. Thank you, sir.
    Thank you very much. I would like to introduce panel two.
    Dr. James Cosgrove is an Acting Director at the U.S. 
Government Accountability Office focused on health policy 
issues. During his tenure at GAO, Mr. Cosgrove has directed 
several studies on Medicaid financing and policy topics, 
including States' restructuring of their Medicaid programs 
using 1115 waivers, use of competitive bidding to set Medicaid 
managed care premiums, and the implication of block grant 
financing for Medicaid.
    In related health policy work at GAO, Mr. Cosgrove has led 
numerous studies on Medicare financing and policy topics that 
cover, among other things, managed care, physician services, 
and specialty hospitals.
    Prior to joining GAO in 1989, Mr. Cosgrove was an assistant 
professor of economics at Marquette University.
    Welcome, Dr. Cosgrove.
    Next after Dr. Cosgrove we will hear from Dennis Smith. Mr. 
Smith is the Director of the Center for Medicaid and State 
Operations. In this capacity, he oversees Medicaid, the State 
Children's Health Insurance Program survey and certification, 
and the Clinical Laboratories Improvement Act. The Center also 
serves as the focal point for all CMS interactions with States 
and local governments.
    Mr. Smith has been the director of CMSO since 2001, and 
prior to his appointment Mr. Smith served on the Bush-Cheney 
Transition Team as Chief Liaison to the U.S. Department of 
Health and Human Services and previously served as the director 
of the Department of Medical Assistance Services for the 
Commonwealth of Virginia.
    We are, indeed, fortunate to have these two outstanding 
witnesses on our second panel.
    To the witnesses, it is the policy of our Committee on 
Oversight and Government Reform to swear in all witnesses 
before they testify. I would ask that you would rise and raise 
your right hands.
    [Witnesses sworn.]
    Mr. Kucinich. Let the record reflect that the witnesses 
answered in the affirmative.
    As with the first panel, I ask each witness to give an oral 
summary of his testimony and to keep his summary under 5 
minutes in duration, to bear in mind that your complete written 
statement will be included in the hearing record.
    Dr. Cosgrove, thank you for being here. We will begin with 



    Mr. Cosgrove. Mr. Chairman, members of the subcommittee, I 
am pleased to be here as you discuss Medicaid's dental care for 
children. By virtue of their Medicaid eligibility, more than 30 
million children from low-income families are entitled to 
receive both preventive dental care and treatment for dental 
disease. However, untreated tooth decay is much more common 
among children from low-income families than it is among 
children from higher-income families. And, as you have heard 
today, lack of timely dental treatment may have serious and 
sometimes tragic consequences.
    Medicaid dental services are required under the early and 
periodic screening and diagnostic and treatment, or EPSDT, 
program. As the agency responsible for overseeing 
administration of States' Medicaid programs, CMS has an 
important role in ensuring that States comply with Federal 
requirements, including reporting requirements. My remarks 
today will describe the data that CMS requires States to submit 
on provision of dental services and discuss the extent to which 
these data are sufficient to inform CMS's oversight of States' 
    My comments are based in part on relevant reports we 
published between 2000 and 2003. To the extent that we could in 
the time we had available before this hearing, we updated key 
findings by reviewing selected reports from CMS and 
researchers, and also interviewing officials from CMS, five 
State Medicaid programs, and several national health 
    In brief, CMS annually collects State data for purposes of 
overseeing the delivery of dental and other required EPSDT 
services. States submit these data on a form known as the CMS 
416, which captures State-level summary data such as number of 
Medicaid eligible children within a State to receive any dental 
service, a preventive dental service or dental treatment.
    States are required to report information on all EPSDT 
dental services provided to children, regardless of whether 
those services are provided under fee-for-service arrangement 
or managed care arrangement.
    We reported in 2001 and found again in 2007 that not all 
States submit the required CMS 416s on time or at all. We 
further reported that many CMS 416s were not accepted because 
they were incomplete or unreliable.
    Currently, seven States have not submitted their 416s for 
fiscal year 2005, which were due to CMS more than a year ago, 
and two States have submitted reports considered to be 
deficient by CMS. We estimate that these nine States account 
for 20 percent of all children enrolled in Medicaid nationwide. 
This finding is, however, an improvement over what we reported 
in 2001. In that year we reported that CMS form 416s for fiscal 
year 1999 were missing or deficient for 30 States.
    The problem goes beyond missing data, however, in 2001 we 
also reported that CMS 416 data were unreliable. According to 
the State and National Health Association officials we recently 
interviewed, the data have improved over time; however, many of 
these officials stated that data reliability problems remain. 
For example, they cite inconsistencies in how States report 
data and urge caution in using the data to compare one State to 
another. One official illustrated this point by saying that 
some States inappropriately include oral health assessments 
conducted by school nurses and other health professionals as 
dental exams.
    In addition to data completeness and reliability issues, 
the type of data collected on the 416s limit their usefulness 
for program oversight.
    Let me mention three key limitations. First, rates of 
dental services delivered to children in managed care cannot be 
identified distinct from fee for service. Second, the extent to 
which children have received the recommended number of visits 
cannot be determined. And, finally, the data do not reveal the 
specific factors such as the availability of beneficiaries to 
find dentists to treat them, which may be responsible for the 
low use of dental services in a State.
    In conclusion, I want to underscore the importance of good 
data for program oversight. Accountability starts with 
performance measures that are comprehensive, accurate, and 
transparent. Currently, the CMS 416s, while improved from prior 
years, fall far short of those standards. More work needs to be 
done so we can quickly identify problems, recognize and promote 
best practices, engage the progress of individual States in our 
Nation in meeting the oral health care needs of children from 
low-income families.
    Mr. Chairman, this concludes my prepared statement. I would 
be happy to respond to any questions you have, or members of 
the subcommittee.
    [The prepared statement of Mr. Cosgrove follows:]

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    Mr. Kucinich. I thank the gentleman.
    We will now hear from Mr. Smith.

                   STATEMENT OF DENNIS SMITH

    Mr. Smith. Good afternoon, Mr. Chairman and members of the 
committee. It is a pleasure to be with you this afternoon.
    I hope that I am helpful to you in helping you to sort out 
the Medicaid system, itself, how it works, that it is a 
partnership with our States. The Federal Government funds 
approximately 57 percent of the Medicaid program. The States 
fund 43 percent of the Medicaid program on a national basis. 
That varies by State, which is calculated every year by what is 
called the FMAP, the Federal Matching Assistance Percentage. 
That changes every year.
    While there is a Federal framework for Medicaid program, 
itself, States have flexibility within that framework. Above 
the Federal mandated eligibility groups, for example, the 
States can go higher up in the eligibility groups. There are 
certain mandatory services spelled out in the Federal Medicaid 
program. There are certain optional services that are provided 
for under Federal law.
    States control the reimbursement rates. It is the States 
who set how much they will pay their providers. In terms of 
dental, in particular, and services for children, all children 
are eligible for, as has been mentioned earlier today, EPSDT, 
and therefore for all dental preventative benefits and 
treatment that they may need. In fact, Medicaid in many 
respects is a richer benefit package than what you would find 
in your typical private insurance benefit package, as it does 
cover all those preventative care, as well as treatment.
    In terms of Medicaid being a system, again the Federal law 
provides for certain rights and appeals that the beneficiary 
has. Those appeals are generally heard at the State level, that 
they are appealed at that State level.
    The managed care organizations that again have been 
referenced earlier this afternoon, it is the States that 
contract with those health plans. There are certain enforcement 
provisions that are available to the States for health plans 
that do not live up to their contractual obligations and to the 
requirements of the Medicaid program, so there is an 
enforcement on the State side, as well.
    On the Federal side, we did hear a little bit earlier today 
about sanction and enforcement. Sanction and enforcement at the 
Federal level against the States fundamentally means taking 
money away from the States. That is the sanction that the 
Federal Government has. And I think that is a responsibility 
that we do not take lightly. It is a responsibility that is 
important to bear in mind that, in fact, is what we are talking 
about. When the Federal Government is enforcing compliance, 
that is a financial penalty against the States.
    In terms of dental, we have heard this morning--I think Dr. 
Clark gave my testimony for me in terms of pinpointing the real 
pressure points on the Medicaid system: low reimbursement 
rates, patient education and awareness, and compliance as being 
the issues, but he also fundamentally also said in his 
testimony the real issue is about funding. Funding is 
determined by the State, not by the State Medicaid Director but 
by those men and women who get elected to make those decisions 
in the State capitals. They are the ones who set the 
reimbursement rates. They are the ones who make those difficult 
decisions of balancing priorities. Where do we put our dollars? 
Do we put them into expanding eligibility? Do we put them into 
provider rates? Do we put them into more services?
    The competing interests and the competing values that are 
worked out at the State level really are fundamental to 
everything else that you see. It all really reflects those 
decisions that get made.
    The EPSDT form 416, I think everyone acknowledges we have 
struggled with the accuracy of what 416 tells you. 
Fundamentally, it does tell you the percentages of children who 
had any dental treatment whatsoever. It tells you whether they 
had preventative treatment, as well, and it tells you the 
percentage of the children who are in managed care 
    We all acknowledge, I think on everybody's part, I think, 
the difficulty of moving from EPSDT reporting on 416, which 
really in effect reflected a fee for service environment, to 
where now we have moved to the managed care environment. How do 
we sort that back out?
    But I would suggest that form 416 is not the only thing 
that has informed us that there are issues in terms of access 
for Medicaid recipients. In 1998, the State of Maryland knew it 
had a problem with access. It had a Statewide effort to 
identify those issues. In 2000, the GAO told Congress that 
there is a problem with access in the Medicaid program. States 
do go out. They do their own. There are a number of reports and 
studies you can get, like researchers from the gentlemen on the 
previous panel that are going out there and telling you, 
telling all of us that there is an access problem for Medicaid 
recipients for dental care. They are also telling us why.
    Mr. Chairman, I look forward to your questions.
    [The prepared statement of Mr. Smith follows:]

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    Mr. Kucinich. Thank you very much, Mr. Smith.
    Mr. Cummings. Would the chairman yield?
    Mr. Kucinich. Yes, Mr. Cummings.
    Mr. Cummings. Mr. Chairman, I just would like to ask Mr. 
Smith a few questions.
    You mention in your prepared statement that your agency 
partnered with experts to produce a guide to dental care, and 
that this publication and community partnerships has helped get 
children the preventive and dental care that they need; did you 
not? Did you say that in your written statement?
    Mr. Smith. In our testimony.
    Mr. Cummings. Yes, you did. I would like to ask you some 
questions about that guide.
    It is my understanding that the original draft of that 
guide was submitted to your agency in 2001, but that you did 
not publish it until 2004; is that correct?
    Mr. Smith. I believe that is correct.
    Mr. Cummings. That is correct. It took you 3 years to 
publish a 52-page document. But, more important than the delay, 
the original draft of the guide and the published guide are 
very different. Did you know that? Are you aware of that?
    Mr. Smith. Oftentimes reports and studies go through a 
number of layers of review. Yes.
    Mr. Cummings. Well, someone made a lot of changes in this 
instance. Let me just point some of them out to you.
    For instance, the original draft contained the statement 
``National surveys and Federal and State studies continue to 
demonstrate substantial disparities in both oral health and 
access to services. Only a small percentage of children 
enrolled in Medicaid receive safe and effective preventive 
measures.'' These are the statements that were in the original 
    These statements make it clear that most children in 
Medicaid are not getting good dental care. Someone took out 
these statements. Do you know why they did?
    Mr. Smith. Not offhand, sir. It is a statement I would 
agree with. We know that we have access problems in the 
Medicaid program.
    Mr. Cummings. But yet still someone from your agency took 
out the very statements that you now say were true. Do you 
understand that?
    Mr. Smith. I----
    Mr. Cummings. Do you know why?
    Mr. Smith. Not offhand, sir, no.
    Mr. Cummings. And so you do believe that most children in 
Medicaid are not getting good dental care; is that right?
    Mr. Smith. I think we all acknowledge that there are access 
problems for children in the Medicaid program.
    Mr. Cummings. It gets worse. The original draft contained 
these statements: ``The Medicaid program is ultimately 
responsible for ensuring that the child receives a complete 
diagnostic evaluation, and for developing quality assurance 
procedures to assure comprehensive care.'' And it goes on. This 
is the original statement: ``State Medicaid programs are 
ultimately responsible for assuring that direct referrals are 
made, that necessary followup and treatment services are made, 
and that children identified as needing such services get to 
dentists' offices.''
    These statements make it clear that the Federal and State 
governments are ultimately responsible for assuring that 
children get dental care. But guess what--somebody took them 
out. Why? Why is that, Mr. Smith?
    Mr. Smith. Again, sir, I don't know.
    Mr. Cummings. You don't know.
    Mr. Smith. I'm saying I do not remember as----
    Mr. Cummings. But do you agree with the original 
    Mr. Smith. I think this statement, again, is what I have 
stated here this morning. We have a responsibility to make sure 
that children on Medicaid have access to those services, and 
access to those services in Medicaid has been a longstanding 
    Mr. Cummings. Do you believe that the State government is 
not responsible for assuring that children in Medicaid get 
dental care?
    Mr. Smith. I believe that the children on Medicaid have a 
right to dental care and it is a responsibility that 
individuals who are entitled to that care receive it.
    Mr. Cummings. By the way, a little bit earlier you talked 
about sanctions. Has anybody been sanctioned? Any State been 
    Mr. Smith. I have not sanctioned States for not increasing 
reimbursement rates. I would have to go back to see in the 40 
year history whether that has been----
    Mr. Cummings. Sir, you----
    Mr. Smith [continuing]. A tool that the Federal 
    Mr. Cummings. But you don't know of any sanctions; is that 
right? Anybody being sanctioned?
    Mr. Smith. I have been Medicaid Director since July 2001. I 
can assure you I have not sanctioned a State for the access 
issues in dental care. In dental care what we have been seeing 
is that States have improved their performance, and a greater 
percentage of children are receiving dental care than they did 
previously. So we do see improvement in access. Access is still 
a problem.
    Mr. Cummings. Thank you very much.
    I yield back.
    Mr. Kucinich. I thank the gentleman.
    We are going to go to Mr. Shays.
    Mr. Shays. Thank you.
    Mr. Smith, I remember when I was chairing the contract that 
oversees the Department of Health a number of years ago the 
then Secretary of HHS actually testified before my 
subcommittee, and for 2 years the Clinton administration did 
not move forward on a Commission that was supposed to help 
ensure the safety of the blood supply. I just remember we lost 
25,000 hemophiliacs to AIDS because of that.
    Well, it was important to me, and the reason why she 
testified was just trying to understand what she could do 
better. So I knew her heart was in the right place. I didn't 
want to rail on her for 2 years of inaction by the Department 
because I knew that she was working on so many issues.
    So she came and testified and said what she is going to do, 
and it was very impressive, and we licked the problem, but it 
existed for a while.
    I am less interested in where there is a failing right now 
in the past. I am more interested to know--and I need to know 
where you come down on this--how can I feel comfortable when a 
doctor is only getting 20 or 30 percent of what they should 
get, and that we have a fraction, anywhere from 10 to 16 
percent, of the doctors participating, so there aren't many 
choices of where they can go. Why should I feel comfortable 
with that?
    Mr. Smith. Mr. Shays, I think that, again, I would say the 
decisions about what providers get paid how much money really 
is a decision that gets made in the State capitals.
    Mr. Shays. OK. That is not what I asked. That is not what I 
asked at all.
    Mr. Smith. OK.
    Mr. Shays. But why should I feel comfortable the State only 
gives anywhere from 10 to 16 percent of what a doctor--first of 
all, we only have one doctor basically participating, maybe 
two. He is overworked. He has a waiting list of 6 months. He 
loses money. He basically spends 2 days a week giving away 
money is what he does because he believes in it, and he has one 
practice in the more affluent part of my town, in my District, 
and then he has another practice in Bridgeport. He would not be 
able to pass that practice on in Bridgeport to anyone. No one 
would take it. He can't even get a young doctor coming out of 
dental school because they have large dental costs.
    So I am going to ask it again, whether or not you think you 
should change it. Why should I feel comfortable with that 
    Mr. Smith. I think the changes that you see in health care 
as health care continues to evolve and Medicaid does, as well--
    Mr. Shays. You know what the answer should be? It is a 
simple one. If I was advising you before you were testifying 
before this committee, it is not your fault, you could have 
just come and said we shouldn't be comfortable and we need a 
plan to deal with that. I mean, I would think you would be 
advocating States fund this system better and make sure doctors 
get--I mean, heck, they could at least get $0.50 on the dollar. 
I mean, if it costs someone to pay their employee $60 for a $20 
reimbursement, they are actually taking money out of their 
pocket and giving it away. That is the system we have here.
    The answer is I shouldn't feel comfortable. The difference 
between you and the former Secretary of HHS is she would have 
come here and said we shouldn't be comfortable and we are going 
to lick it.
    Why I am not feeling very sympathetic toward you right at 
the moment is that you don't think there is a problem.
    Mr. Smith. I disagree that I didn't say there is not a 
problem. I think I said very clearly there is a problem with 
access to dental services.
    Mr. Shays. So?
    Mr. Smith. And the solutions, again, have been spelled out 
a number of times by GAO, by----
    Mr. Shays. But what I recommend----
    Mr. Smith [continuing]. Many, many places about what the 
problem with access is.
    Mr. Shays. The problem is that we are not paying our 
doctors enough. To start with, we don't have enough doctors in 
the system. That is the problem. And the reason is they are 
basically being asked to do it for less than their cost.
    Mr. Smith. Mr. Shays, if I may, in dental, in particular, 
Medicaid rules allow the States to pay rates.
    Mr. Shays. I am not arguing what they allow, but you can be 
an advocate. I mean, you could be an advocate for a system that 
is causing bad health care and hurting our kids and hurting our 
elderly, as well.
    Mr. Smith. And, if I may, I think we described some of the 
things that we are doing in our testimony about trying to 
improve quality of care in the Medicaid system, in terms of the 
different States. There is a lot of talk about pay for 
performance. Medicaid actually has been doing pay for 
performance in a number of States and we are trying to help 
find the better models that work in the----
    Mr. Shays. The better model would be just to pay someone to 
cover their costs. You are a government employee, aren't you?
    Mr. Smith. Yes, sir.
    Mr. Shays. You work, you get paid, as a government 
    Mr. Smith. My salary is about $165,000, sir.
    Mr. Shays. OK. Why don't we suggest that you work for 
$25,000. Just come, and we will be fair, you get, say, 10 
percent, we will give you 20 percent, so you could make 
$32,000. Could you afford to go to work?
    Mr. Smith. Mr. Shays, again, I am agreeing with your point 
    Mr. Shays. You couldn't afford to go to work at $32,000 and 
yet we have doctors who are being asked to do the same thing.
    Thank you, Mr. Chairman.
    Mr. Kucinich. I thank the gentleman, and his point is well 
    The Chair at this point is going to recognize the gentleman 
from California who is the chairman of the full committee, Mr. 
    Mr. Waxman, thank you.
    Mr. Waxman. Thank you very much, Mr. Chairman.
    Mr. Smith, I find it interesting that nowhere in your 
written statement did you refer to Deamonte Driver or his death 
from untreated tooth decay. He was enrolled for many years in 
the program you administer. He was entitled to dental services 
to relieve pain and infections and restore teeth, and he didn't 
get the services he needed, and died.
    Has your agency conducted a review of this to determine 
what went wrong, why, what changes are needed to be made to 
prevent this from happening to anybody else who is also in 
Medicaid? If so, what were your findings?
    Mr. Smith. Mr. Waxman, the tragic death of a young child, 
we are certainly sorry for the loss and the family. I think 
    Mr. Waxman. I asked you if you did an analysis of what 
happened to him. Did you?
    Mr. Smith. I did not.
    Mr. Waxman. OK. And did anybody in your agency conduct a 
critical incident review?
    Mr. Smith. I believe the regional office had discussions 
with the States in terms of trying to understand what the 
situation was. In terms of the individual, of course, those 
would be subject to any privacy rules.
    Mr. Waxman. You left it to the State then?
    Mr. Smith. Again, I think----
    Mr. Waxman. Let me go into this issue of the Federal 
Medicaid requirements. Federal Medicaid law requires that all 
children be given both routine dental services and any 
necessary treatments on a periodic basis. In 2004 the State of 
Maryland formally reported to your office that only 28 percent 
of the Medicaid children got any dental services at all. What 
action did you take when you received that information?
    Mr. Smith. That information, as I had said earlier, is 
information I think that has been known in the Medicaid program 
for quite some time.
    Mr. Waxman. But you are running the Medicaid program at the 
Federal level. What action did you take?
    Mr. Smith. In terms of that particular--again, it is 
information that is already known within the Medicaid program 
at the State and the Federal level. There is an access problem.
    Mr. Waxman. And you really did nothing. You received the 
information. For all 50 States, your own CMS data for 2004 show 
that the average number of Medicaid children who got any dental 
services at all was 32 percent. When you heard that is what is 
happening in the country, even though the program promises 
these services, what action did you at the Federal level 
running this program take?
    Mr. Smith. The enforcement tools, as I mentioned earlier, 
are to sanction the State financially, and where reimbursement 
rates are already low----
    Mr. Waxman. Has CMS ever taken any action to enforce the 
Federal requirement that children get dental services?
    Mr. Smith. As I mentioned earlier, I have not. I don't know 
if my predecessors did.
    Mr. Waxman. OK. While there is no minimum Federal payment 
rate for State Medicaid program reimbursing for health 
services, there is a statutory requirement that rates be 
``Sufficient to enlist enough providers so that care and 
services are available at least to the same extent they are to 
the general population.''
    GAO studies of Medicaid programs have repeatedly shown that 
reimbursement rates for dental services are very low. Other 
reports show that the overhead costs of a dental practice are 
about 60 to 70 percent of its billings. That means that 
reimbursement below that level is actually a net loss to the 
dentist. You don't expect the dentist to take on a Medicaid 
patient if they are going to lose money, do you?
    Mr. Smith. Mr. Waxman, as I have said, we believe that a 
variety of sources have been telling us and State legislatures 
and the Congress that access is a problem in the Medicaid 
program because of low reimbursement.
    Mr. Waxman. But if a State is reimbursing dentists at a 
rate that is 50 percent of the average in the State, I assume 
you would agree that the State is violating the statutory 
requirement about sufficient rates?
    Mr. Smith. And, again, then it becomes an enforcement 
mechanism. Should I be taking money away----
    Mr. Waxman. You agree it is a violation, then? then the 
question is what you do about it? Is that what you are saying?
    Mr. Smith. That is where enforcement comes. What action do 
I take against a State.
    Mr. Waxman. OK. Well, has CMS ever taken any action to 
enforce that provision of the law regarding sufficient rates 
for dental services?
    Mr. Smith. I have not during the time that I have been 
there, Mr. Waxman.
    Mr. Waxman. Has CMS ever taken any action to enforce that 
provision of the law regarding sufficient rates for any 
Medicaid service?
    Mr. Smith. Again, I can speak only while I have been there. 
I do not know what my predecessors did on how they addressed 
issues, whether they took sanctions against the State, 
financial penalties against the State for those reasons. I do 
know that the percentage of children on Medicaid receiving 
dental services is higher while we have been here than 
previously. I do know that.
    Mr. Waxman. What we have is a Federal program where we 
spend an enormous amount of money. In fact, the Federal 
Government is going to pay $33 billion to help States purchase 
Medicaid services for nearly 30 million lower-income children 
enrolled in Medicaid, and there are a lot that should be 
enrolled but are not. Given this kind of level of investment by 
the Federal Government, don't we have a strong interest in 
assuring performance by the States and providers to receive the 
funds and to do the work and to get the children to get the 
care that they need?
    Mr. Smith. Which, again, the strategy that we have tried to 
pursue is through quality initiatives, through best practices, 
through things like pay for performance. In terms of managed 
care, I was a Medicaid director in Virginia, and we went to 
managed care. I don't know by what factor, but we tremendously 
expanded access not only to primary care physicians and 
dentists, but also specialists, as well.
    Mr. Waxman. Wait a minute. Before you tell me all the good 
things you are doing, the national average for Medicaid dental 
visits by children in 2005 was 33 percent.
    Mr. Smith. Which is a----
    Mr. Waxman. Two out of every three children enrolled in 
Medicaid received no dental services of any kind, preventive or 
restorative, during that year. So, as we have heard, Deamonte 
was among those children with no dental visits. Is 33 percent 
acceptable to you? If not, what specific steps is your agency 
going to take to improve this performance?
    Mr. Smith. Again, Mr. Waxman, I would say it illustrates 
that there is an access problem in the Medicaid program. I 
would also say that those percentages, while they are still not 
the levels that any one of us like to see, they are higher than 
previously. States are showing improvement.
    Mr. Waxman. Have you ever asked a State to increase their 
reimbursement levels? Have you ever told them they are breaking 
the law by not providing a sufficient reimbursement level to 
provide the care for those people who are eligible?
    Mr. Smith. Again, Mr. Waxman, enforcement is about taking 
financial penalties against the States, and----
    Mr. Waxman. This is not even taking a penalty. This is 
simply telling them they are not living up to the law. Have you 
ever done that?
    Mr. Smith. Again, Mr. Waxman, I think everyone--Maryland 
did their own review and said we have an access problem. This 
is information that they know.
    Mr. Waxman. They know it, but you are in charge of the 
program. You are in charge of over $30 billion of Federal 
funds. We want to be sure that when we are spending $30 billion 
of money that we are getting the job done, and the law says the 
job is done when every child has access to care, and we can't 
get that if we don't reimburse at a sufficient rate for people 
to provide the care.
    You notice that the State of Maryland and probably most 
other States are not doing the job. Did you ever say to them 
you ought to do more?
    Mr. Smith. I think we have done a number of things to help 
States improve the quality of care for Medicaid children.
    Mr. Waxman. Such as?
    Mr. Smith. Well, one thing we did in direct outreach to 
individuals--again, Dr. Clark talked about patient awareness in 
education. We have mailed out----
    Mr. Waxman. If the patients are aware they are entitled to 
the benefit and they can't find anybody to give them the 
benefit, then what is the patient supposed to do?
    Mr. Smith. Again, there are a number of steps if the 
patient does not have access. There are----
    Mr. Waxman. What steps?
    Mr. Smith. We spend----
    Mr. Waxman. Tell me the steps.
    Mr. Smith. We spend----
    Mr. Waxman. What would the young man's family have been 
able to do? What steps?
    Mr. Smith. Again, there are----
    Mr. Waxman. Obviously, the guy running the Federal program 
doesn't seem to do anything about it. The people at the State 
level don't feel they have the ability to do anything about it. 
The law requires it. Should they call their Congressman and say 
pass a law to require that we get these services? Congressman 
would say yes, that is right, but we already have a law. What 
protection is the law if it is not giving them the benefits?
    Mr. Smith. The law says----
    Mr. Waxman. You are in charge of running this program.
    Mr. Smith. Under the Medicaid law, Federal dollars follow 
State dollars. It is the State that must commit that dollar 
    Mr. Waxman. And if they don't shouldn't you tell the State 
they have a obligation to do something more than what they are 
    Mr. Smith. Again, Mr. Waxman, I think that as a system 
there are rights for the individual, there are systems of 
people to help give access. We spend $3 billion on what is 
called targeted case management, which is supposed to be simply 
connecting individuals to the services that they need. I think 
there is a wide variety of people who come into contact with 
individuals who need care, and, again, I think----
    Mr. Waxman. Well, what you are saying is that somebody 
ought to provide the care for them for free?
    Mr. Smith. No, sir.
    Mr. Waxman. You are saying it ought to be charitable?
    Mr. Smith. No, sir.
    Mr. Waxman. Done charitably. But on the other hand we have 
a law that says they are entitled to these benefits, that the 
States are obligated to pay at reimbursement levels sufficient 
for people to take these cases, dentists in particular when we 
are talking about dental services, and if the State is not 
living up to the law the Federal Government should tell them 
you have to live up to the law, even if you don't take 
enforcement actions. But if you are not even telling them to 
live up to the law, they are not hearing from the people 
running the program.
    We have gone around in circles and I think you should--are 
you proud of the job that Medicaid is doing when two out of 
three kids aren't getting dental services?
    Mr. Smith. I think Medicaid does a tremendous amount of 
good for the 30 million children who are enrolled in the 
Medicaid program.
    Mr. Waxman. And for the one out of three that do get the 
dental care we are proud of it, but what about the two out of 
three that don't? Are we proud of that?
    Mr. Smith. I think, again----
    Mr. Waxman. Are you satisfied with that?
    Mr. Smith. I think, again, Mr. Waxman, many different 
sources have identified what the issue is for access. As I 
said, Federal dollars follow State dollars, and the decisions 
that get made by the elected men and women who serve in State 
capitals are making decisions that are what is a priority, what 
gets funded----
    Mr. Waxman. The chairman has been generous and we have gone 
around in circles. You are passing the buck. You were appointed 
by elected people in the Government of the United States to 
enforce the law with the States, but to tell the States they 
have to live up to the law, and what you have decided is since 
they aren't living up to the law you are not going to do 
anything about it because they already know about it.
    I don't find that a very satisfactory answer, and therefore 
I have to hold the people responsible that appointed you to say 
to them they are elected officials and they are not getting the 
job done at the Federal level, and I have to hold you 
responsible, as well, because you are the one in charge of the 
program, and the least you could do is sometimes write a State 
a letter saying you are not doing a job if the reimbursement 
rates are so low. You ought to come to the administration and 
say Congress has to do something more because this program is 
not working for two out of three kids when it comes to dental 
services, and I'm sure for many others in other services, as 
    I haven't seen any proposals from the administration other 
than to cut back on Medicaid, other than to give States more 
flexibility to cut back even more. I just think that the buck 
is not going to be passed on, as far as I am concerned. It is 
on your lap and I don't think you have done a very good job 
with it.
    Mr. Smith. Mr. Waxman, if I may, again, Medicaid as a 
system, a construct within the Federal system that has been 
built with the Medicaid program, but if you have built a car 
and you have designed it and you have engineered it, you still 
have to put gas in the tank to make it run.
    Mr. Waxman. Yes, and you need people running----
    Mr. Smith. The gas in the tank is what----
    Mr. Waxman [continuing]. The program who will make sure 
that the law is upheld. You are running the program. Federal 
law requires they get these services. Federal law requires that 
the States must put in reimbursement levels sufficient for 
people to provide the services. You can't say well, it is a 
whole system that is just not working. That is not an answer.
    Mr. Smith. But may I add----
    Mr. Waxman. I don't know that the Chair--there are others 
who are waiting to ask questions. Maybe you can pass the buck 
during their time, but you have said about all you can say.
    Mr. Kucinich. Mr. Chairman, Mr. Waxman has as much time as 
you require.
    Mr. Waxman. Do you have anything more to say?
    Mr. Smith. Again, I think that there are improvements that 
we have found in the Medicaid program through a variety of 
different strategies that we have been pursuing with the States 
as our partners. While you correctly cite the participation or 
the rates of which the percentage of Medicaid children are 
receiving dental benefits, they are higher than they were under 
my predecessor. Again, a number of sources, including the GAO, 
a number of sources have been telling that access is a problem, 
and I agree that access is a problem.
    The key to improving access principally, from the provider 
perspective, is to increase reimbursement rates.
    Mr. Waxman. Right, and Federal law requires that.
    Mr. Smith. And that is a State decision.
    Mr. Waxman. And that is what?
    Mr. Smith. And that is a State decision.
    Mr. Waxman. But Federal law says for the States to be a 
participant in the Medicaid program they have to provide enough 
    Mr. Smith. That is correct, and to sanction them----
    Mr. Waxman. Therefore, don't you have any responsibility in 
all of this?
    Mr. Smith. The sanction that I can apply against a State 
for failure for a State plan is to withdraw all of its Federal 
    Mr. Waxman. Yes.
    Mr. Smith. That doesn't seem to be the right solution.
    Mr. Waxman. So do you have a suggestion for changing the 
    Mr. Smith. Not today, Mr. Waxman.
    Mr. Waxman. OK. And do you have, other than the law is 
tough, any other reason to tell us why you are not enforcing 
the law? Do you feel you have an obligation to enforce the law? 
Couldn't you have written a letter to Maryland?
    Mr. Smith. Again, I believe, with the different reviews 
that have been done, and my staff has corrected me where I 
wasn't able to come up with the figure on how many reviews have 
been done, we have done 11 reviews from States based on their 
EPSDT reports. So we do go back into the States. We do reviews 
at all different types of or different parts of the program, 
and I think, again, while access is clearly an issue, it is an 
issue that the program, itself, at the State, the Federal 
level, and Congress, as well, has been aware of it for some 
    Mr. Waxman. Mr. Chairman, let me just conclude my comments 
by saying Federal law requires these services be made available 
to the children for dental services for the children that are 
eligible for the program. We now find for the most part two out 
of three kids are not getting any of the services that they are 
entitled to. Federal law requires that the States must pay a 
reimbursement level, and that is not happening. Federal law 
should require that the Department or the Center for Medicare 
and Medicaid make sure that when there is a case like this they 
do an investigation and tell the State they are not doing what 
they should be doing in that case.
    I don't see any of those things having been done by CMS, 
and I must say, Mr. Smith, you are just giving me a lot of 
bureaucracy, a bureaucratic answer. It is a system. It is not 
working. It is just too bad. The States are not doing their 
job. I don't see any sense of responsibility, and I don't think 
that is the way the Federal Government ought to be operating.
    Mr. Smith. If that is your conclusion, sir, then I haven't 
done a very good job in trying to express the different ways 
that we have been trying to improve the quality of care in the 
Medicaid program. My statement reflects----
    Mr. Waxman. I don't say that you are doing everything 
wrong, but I am saying you are not doing a good enough job. 
That is at the minimum when two out of three kids don't get 
pediatric dental care and they are eligible for it.
    Thank you, Mr. Chairman.
    Mr. Kucinich. The Chair thanks Mr. Waxman for his 
participation. I note the gentleman, Mr. Smith, talked about 
Congress' responsibilities, and this subcommittee will endeavor 
to discharge those responsibilities.
    Mr. Smith, in January 2001, there was a Dear State Medicaid 
Director letter about dental benefits under Medicaid. States 
received a letter from CMS noting that a number of States are 
not meeting participation goals for pediatric dental services, 
and then the letter goes on to say these States must take 
further action to improve access to these services.
    Staff may have a copy of that. If you want to put up that 
slide, that would be appreciated.
    The letter also----
    Mr. Smith. This is the January 18th letter? Is that what 
you are referring to, Mr. Chairman?
    Mr. Kucinich. Mr. Smith, I haven't finished my statement.
    Mr. Smith. I just wanted to make sure I understood----
    Mr. Kucinich. Let me finish my statement.
    Mr. Smith. OK.
    Mr. Kucinich. That was January 2001. That letter also said 
that the Federal Government was going to increase our oversight 
activities to assess State compliance with statutory 
requirements. It laid out a plan to have Federal reviews and 
visits to States with special attention to States in which 
fewer than 30 percent of the Medicaid children have received 
dental services. Forty-nine States responded to that letter, as 
shown in slide No. 2, 49 States responded. Among those who 
responded, 15 States reported that less than 30 percent of the 
Medicaid children had received dental services. Maryland was 
one of those States.
    Mr. Smith, did you carry out the plan to have Federal 
reviews and visits to States?
    Mr. Smith. Mr. Chairman, those reviews were done. Every 
State except one submitted a corrective action plan based on 
that information.
    Mr. Kucinich. Did Maryland have a Federal review then and 
visit for oversight?
    Mr. Smith. I understand that Maryland did their own plan.
    Mr. Kucinich. So the answer is no? Did Maryland have a 
Federal review and a visit for oversight?
    Mr. Smith. Maryland did not have a review.
    Mr. Kucinich. Did every State do its own plan?
    Mr. Smith. Every State but one submitted a corrective 
action plan. Yes, sir.
    Mr. Kucinich. Did you take any actions to require Maryland 
to comply with the requirements?
    Mr. Smith. Again, I think the Maryland plan, itself, as I 
said earlier, Maryland since 1998 had identified the problems 
of access to dental in their own program. They set up Statewide 
advisory committees. They had, I think, a pretty comprehensive 
plan on how they intended to increase access.
    Mr. Kucinich. Did you take any actions to require Maryland 
to comply with the requirements?
    Mr. Smith. Again, Mr. Chairman, I think the information was 
the State was taking corrective action, had its own plan for 
what steps it would take.
    Mr. Kucinich. Did you take any actions to require any State 
to comply with the requirements? There is a difference between 
States saying we are going to straighten this out and the 
Federal Government reviewing it and saying look, you haven't 
straightened it out, here is what we want you to do. Did you 
take any action on that?
    Mr. Smith. Again, we have taken a number of actions. We 
meet regularly with the Medicaid directors on a State basis. 
There are 10 regional offices across the country. There are a 
number of different ways we have contacts with States at the 
national level, at the policy level. We meet twice a year with 
the Medicaid directors. We have technical assistance groups. 
Again, those are more on the policy side of things that apply 
to all States.
    Mr. Kucinich. So how many States now meet their legal 
requirement to have adequate dental services?
    Mr. Smith. Again, Mr. Chairman, I think the increase in 
access to dental services is lower than, again, what we--it 
clearly continues to show us there is an access problem in 
    Mr. Kucinich. Wait. Wait. There is an access problem. We 
can all agree with that. But what about the oversight and 
enforcement from your office? I mean, there are legal 
requirements here.
    Mr. Smith. And, again, they----
    Mr. Kucinich. If they don't meet those requirements, aren't 
you supposed to take action under statute?
    Mr. Smith. It is a rather big step, which is saying they 
are not in compliance with----
    Mr. Kucinich. How many aren't compliant?
    Mr. Smith [continuing]. The State plan, which is to take 
all of their Medicaid dollars away from them.
    Mr. Kucinich. But how many are compliant?
    Mr. Smith. In terms of access----
    Mr. Kucinich. No. How many are compliant in terms of the 
law with respect to the legal requirement to have adequate 
dental services? How many are compliant? Isn't the answer zero?
    Mr. Smith. Mr. Chairman, I think you are looking at----
    Mr. Kucinich. I am looking at your responsibility, sir. How 
many are compliant? How many States are compliant?
    Mr. Smith. The use of dental services varies for a wide 
variety of reasons, including the individuals seeking the 
dental services in the first place.
    Mr. Kucinich. How many are compliant?
    Mr. Smith. I have not found any State to be out of 
compliance, Mr. Chairman.
    Mr. Kucinich. Are you telling this committee that you are 
prepared to produce for this committee documentation that 50 
States are meeting the legal requirement to have adequate 
dental services? Are you telling us that under oath?
    Mr. Smith. I think you are----
    Mr. Kucinich. I don't want to have any misunderstanding 
about this. I am just going to give you another chance to 
answer the question. Are you telling us that?
    Mr. Smith. I think to some extent we are looking at this 
two separate ways. In terms of the individual, their right to 
access dental benefits, they are entitled to those benefits. 
The extent to which that individual has rights of appeals, the 
extent to which health plans are operating within the Medicaid 
law and within those requirements, I believe I can tell you 
that those things, in fact, are present.
    Using a measure of how many children sought and received 
dental care is a different measure. Those measures clearly say 
we have an access problem. The reason we have an access 
problem, I think as I said before, Dr. Clark pinpointed those 
reasons very well.
    So in terms of compliance with the parameters of the 
Medicaid program, and again States have responsibilities that 
they certify to us that certain things are being met, that 
those rights and responsibilities are present for use by the 
beneficiaries, the constructs I can say I do believe those are 
present in all of the States.
    Using a measure, though, to say how many children are 
reported to have received services is a different measure, and 
I cannot say, by using that measure, that the Medicaid program 
is in full compliance.
    Mr. Kucinich. So, to answer my question, when I asked how 
many are compliant, is the answer zero?
    Mr. Smith. By using the measure that you are using, yes, 
Mr. Chairman.
    Mr. Kucinich. Well, that is what I wanted to find out, and 
I am going to ask staff to develop a series of questions to be 
quite specific State-by-State to followup on determining 
compliance and specifically reviewing with respect to 
utilization goals.
    I want to pick up on a question that Mr. Waxman had about 
changes, about reimbursement for dental services to children 
under Medicaid and the Guide to Children's Dental Care and 
Medicaid. The original draft contained seven full pages about 
reimbursing dentists adequately under Medicaid for taking care 
of children. The draft contained statements such as ``a 
substantial gap in funding levels exists in most States between 
current Medicaid dental program allocations and market-based 
requirements,'' and average Medicaid reimbursements ``may not 
cover the cost of providing services and are not likely to be 
viewed as positive incentives for dentists' participation.''
    Now, someone took these statements, and, as Mr. Cummings 
pointed out, many more pages about the inadequacy of Medicaid 
payment rates out. Why?
    Mr. Smith. Again, Mr. Chairman, as I was trying to draw on 
my memory to address Mr. Cummings, we are not disagreeing. I am 
not disagreeing today. I think that the access about dental 
rates is a core issue as to why we have an access problem.
    Mr. Kucinich. You agree with that, but there was a document 
produced. Those statements were taken out, which actually, if I 
am right, Mr. Cummings, these undermine the concern that people 
would have about whether or not dentists are being adequately 
    Mr. Smith. Again, I----
    Mr. Kucinich. Excuse me. I am having a colloquy--and 
therefore would cause a lack of participation. Wouldn't you 
agree, Mr. Cummings?
    Mr. Cummings. I would agree 100 percent. I was just sitting 
here thinking, Mr. Chairman, this is a very sad state of 
affairs when the very people who are supposedly making sure 
that a system works and works well then take out the very words 
that are the essence of--it is like the Bible for making sure 
it works well. I mean, something is wrong with this picture.
    I yield back.
    Mr. Kucinich. I would just say that I think this committee 
needs to probe a little bit more deeply into why was this taken 
out. Do you have any idea? Did you know this was taken out?
    Mr. Smith. I remember yes, I did review it.
    Mr. Kucinich. Were you the person who excised it?
    Mr. Smith. Again, I am trying to draw on my memory of the 
dental guide, itself, in terms of the purpose and the use of 
it, and I do recall having discussions and making changes, 
myself, that the guide was being--the purpose of the guide was 
for a particular reason, that reimbursement rates didn't--they 
were not a part of the purpose of the guide, itself, is my 
    Mr. Chairman, yes, I did review the guide. Yes, I did make 
edits to the guide. And I do remember that and I will be happy 
to go back, but my recollection is the guide was for one thing 
and the financing pieces seemed to me that they weren't 
appropriate to what the guide, itself, is being used for.
    Mr. Cummings. Would the gentleman yield, please?
    Mr. Kucinich. Yes, I will yield.
    Mr. Cummings. Mr. Chairman, you just talked about or asked 
Mr. Smith some questions about things that have been taken out, 
and, Mr. Smith, you said just now that some of the things were 
taken out because I guess you felt that, although you agreed 
with them, you thought that they were inappropriate for this 
guide; is that correct?
    Mr. Smith. For the purpose of what the guide was to be for.
    Mr. Cummings. And what was the purpose of the guide? I 
guess that is the better question.
    Mr. Smith. Again, I am----
    Mr. Cummings. Wasn't it to lay out the States' 
responsibilities for meeting Federal regulations? Wasn't that 
the reason?
    Mr. Smith. That is not my recollection of what the guide 
was for.
    Mr. Cummings. Well, what is your recollection?
    Mr. Smith. And I----
    Mr. Cummings. Don't tell me you don't remember, please. And 
let me tell you why I am saying that. I have never said that to 
a witness ever in a courtroom or since I have been here in the 
Congress 11 years, but you just sat there and you just told us 
that you made changes, you participated in the changes because 
you felt like certain things were not appropriate for this. And 
now please don't tell me you now forgot. Did you?
    Mr. Smith. Mr. Cummings, the guide, itself, for the purpose 
of the guide, if I recall--and I might--the purpose of the 
guide was not about explaining financing and reimbursement 
about Medicaid. It was about, if my recollection is, it was 
about quality and measures and of that nature.
    Mr. Cummings. I understand that, but let me ask you this 
question: the original draft had these words: ``Improvements in 
Medicaid will cost more--'' listen to this--``because more 
children will be served and have more of their treatment needs 
met, but that as children receive care--'' listen to what they 
are saying--``unmet need should decline and ongoing costs 
should be less.'' That was in the original.
    But it went on. It said, ``Dental program improvements can 
be expected to yield significant savings in treatment costs on 
an individual level and reduce the overall need for investments 
in safety net clinic capacity.''
    Those words were also taken out. Do you remember that? Did 
you participate in that, too?
    Mr. Smith. I don't remember the specific words, Mr. 
Cummings. I did participate in editing the guide, and the guide 
was about clinical information. Financing, I am trying to 
recall my rationale that discussing the reimbursement side 
wasn't regarding clinical standards.
    Mr. Cummings. Yes, but this piece--and I will yield back, 
Mr. Chairman, in a second--but this piece here sort of goes to 
it is talking about cost and reimbursement, but it is also 
talking about being helpful to children, to children that we, 
as adults, are supposed to help and provide for, the children 
that you are supposed to be helping through your agency.
    What I am saying to you is that it seems like this goes to 
the essence of making sure that they are treated, because what 
it is basically saying is that we do these things and there is 
less--you can pay me now or you can pay me later scenario. But 
the one big factor is at least the children are healthy, as 
opposed to--because when we pay later we have situations like 
this young man, Mr. Driver.
    Mr. Smith. Mr. Cummings, I agree with you. Health care is 
driven in many respects by under-utilization of services that 
are preventative, that will make that investment today will 
save you money down the road as well as improving the quality 
of care.
    Mr. Cummings. Ms. Norris, I think it was, said something in 
her testimony. This is my last question. She said that we need 
to have a campaign, your organization needs to have a campaign 
about folks making sure that kids get dental care early.
    Mr. Smith. Yes.
    Mr. Cummings. Do you do any of that kind of thing now?
    Mr. Smith. Mr. Cummings, we have mailed out, we have 
provided more than 50 million copies. This is direct to 
Medicaid families.
    Mr. Cummings. OK.
    Mr. Smith. This is the first year of life. There is one for 
every month. This is for the parents for what they need to do 
for their child. At month six we talk about the need for----
    Mr. Kucinich. Excuse me. I am going to ask if staff could 
obtain what the gentleman is saying and we could just take a 
look at it.
    Mr. Smith. Sure.
    Mr. Cummings. I yield back, Mr. Chairman.
    Mr. Kucinich. No, continue, Mr. Cummings.
    Mr. Cummings. I mean, Ms. Norris is a person who, as you 
heard her say, I mean, that is what she does. She helps folks 
get care. And she sat at that table, and when we asked what 
should your organization be doing she said apparently she 
believes that you should be doing more of getting the word out 
and encouraging people.
    Mr. Smith. To my knowledge, Mr. Cummings, this is the first 
time the Federal Government has ever produced something like 
this for beneficiaries to help them to understand the health 
care for their children. As I said, we have distributed more 
than 50 million copies of this. This is the series, the first 
year of life, so there is one for every month. In month six it 
starts talking about the importance of oral health care.
    Again, we are in passionate agreement about the need for 
greater patient awareness of the importance of oral health.
    Mr. Cummings. I yield back.
    Mr. Kucinich. The Congresswoman from California has been 
very patient. I wish to yield to her such time as she may 
consume, a minimum of 10 minutes. You may proceed, 
    I want to say that at the conclusion of your questioning I 
have a followup question relative to testimony based on a 
document just handed to me, so if you could just go ahead.
    Ms. Watson. All right, because I am taking my discussion in 
a little different direction, you might want to go ahead now, 
since it is relevant to this discourse. I want to talk about 
another aspect.
    Mr. Kucinich. OK. That is fine, and I appreciate the 
indulgence of the gentlelady.
    In response to my question, Mr. Smith, relative to how many 
States were, in fact, in compliance, you bifurcated your 
answer. You gave, on the one hand, if you are talking about 
financing of dental services, and on the other hand if you are 
talking about the organization of dental services.
    Now, isn't it true that CMS issued a contract to the 
American Academy of Pediatric Dentistry for the purpose of 
reviewing the original guide?
    Mr. Smith. Yes, sir. I believe that is correct.
    Mr. Kucinich. And didn't they issue a contract for 
developing a revision for use by stakeholders concerned about 
children's oral health and Medicaid?
    Mr. Smith. I don't remember the timing and when, but I 
believe that was concluded in 2004.
    Mr. Kucinich. And isn't it true that the contractor was 
requested to incorporate information on not only the 
organization but on the financing of dental services, dental 
work force and capacity and accountability?
    Mr. Smith. I don't know what the original contract called 
for, Mr. Chairman. I am sorry I don't.
    Mr. Kucinich. I want to submit into the record a preface 
page from a Guide to Children's Dental Health and Medicaid and 
to help you to recall that the operative language here is that 
the contractor was requested to incorporate information on the 
organization and financing of dental services, dental work 
force and capacity and accountability, along with other 
administrative issues which might be of assistance to State 
Medicaid agencies and stakeholders in their efforts to improve 
access to oral health services for children. I want to state, I 
mean, there is an obvious significance to this.
    If, in fact, CMS issued a contract to the American Academy 
of Pediatric Dentistry to incorporate information on the 
financing of dental services in the report and if, in fact, we 
see issues relating to finance and the ability for 
reimbursement, for example, for dentists taken out of the final 
report, we have reached one of these teachable moments, Mr. 
    I want you to square for this committee how in the world 
you requested a contractor to provide information on the 
financing of dental services and then you simultaneously took 
out of the contractor's report information that was absolutely 
critical for States to be able to make an assessment about the 
delivery of pediatric dental care to the children of the United 
    Mr. Smith. Mr. Chairman, I didn't write the original 
contract. I didn't review the contract.
    Mr. Kucinich. I am going to withdraw the question. I have 
to say, in going along with Mr. Cummings, this is really an 
extraordinary hearing because the response that we are getting 
is so obtuse that it is non-responsive, and, rather than waste 
the time of this committee with non-responsiveness, I am going 
to go to Ms. Watson.
    Thank you.
    Ms. Watson. Mr. Chairman, I am sorry that Mr. Waxman left 
because I wanted to commend you and Mr. Waxman for the 
oversight. I have been here going on my 6th year, and we never 
had these kinds of hearings. We were not fulfilling our 
responsibility to oversee the agencies that we fund.
    The reason I can be patient is because I was listening to 
the responses, and it comes to me that in this country we set 
priorities, and we talk about homeland security. It is not 
about the land, it is about the people on the land. And when we 
sit up here at a Federal agency and allow a young man to die 
because he didn't get the kind of dental care, it is our 
responsibility. So I am pleased that we are trying to get down 
to where the flaw is in this system. We just have not set a 
priority on the health of Americans.
    There is another issue that I wanted to bring up. I have 
been championing this issue for decades. When I was the Chair 
in California of the Health and Human Services Committee, we 
learned that mercury is a neurotoxin. What does that mean? That 
means that it poisons the body, and particularly the brain.
    I don't know if you out there listening--and maybe Dr. 
Clark in the back knows this--the amalgam fillings that most 
people, and people who you serve, Dr. Clark, that silver 
filling is 50 percent mercury, and mercury is the most toxic 
substance in the environment. Guess what? We put it into your 
mouths. Regardless of how tightly encased the mercury is, it 
still can escape. We had a spill last year in Virginia and we 
had to close three high schools down because kids were playing 
with mercury. It balls up and it bounces down and it is fun, 
but it is poisoning.
    With mercury in your amalgam, it goes up in your T-zone. 
Hello? It is always emitting. It goes up into your T-zone. It 
is like lead. It starts to destroy the meninges. That is the 
thin skin over the brain. And we allow it.
    And so for 15 years in California my legislation instructed 
the Dental Board to come up with a pamphlet that could be given 
out to the patients. It took 15 years to get it done, and we 
didn't get it done until I came here, put some pressure, held 
some hearings in Los Angeles. We held hearings and I joined in 
a nonpartisan way with my colleague, Dan Burton, and we finally 
got them to do that.
    So I am a sponsor, and you need to know this is coming down 
the line, Mr. Smith. I am a sponsor of legislation that would 
ban the use of mercury dental amalgams immediately in children 
and pregnant women and phase it out for the rest of the 
population over a period of 2 years.
    The number of mercury-free dentists--and they are becoming 
aware--is slowly rising in this Nation. In fact, Clinical 
Research Associates of Utah State in a recent survey said 
roughly one-third of dentists licensed in the United States now 
have mercury-free practices.
    In 2005 and 2006 in a survey conducted by the Consumers of 
Dental Choice, it found that all of the 31 States that 
responded do allow their Medicaid patients a choice of either 
dental amalgam or non-mercury fillings. But none of the States, 
zero, had a program to publicize to patients that they have a 
    I should also note that dentists with mercury-free 
practices have refused to participate in their State's Medicare 
programs because they may still believe that State Medicare 
rules would only allow them to use dental amalgams.
    Mercury is a neurotoxin and we still allow it to be used, 
so my bill would require the banning of mercury amalgams in 
children under 18 and in pregnant women and in lactating 
mothers because of the toxicity of mercury amalgam.
    So my question to you: are you doing anything to educate 
the dentists across the 50 States to the dangers of using 
mercury amalgams, Mr. Smith?
    Mr. Smith. Congresswoman, you are bringing up a subject 
that is entirely new to me.
    Ms. Watson. OK. Fair enough. But you see that is my thing. 
I am passionate about it. We fought for it in the State of 
California. Our Medicaid program is MediCal, and during my 
tenure there, 17 years as the Chair, I was there 20 years, but 
17 years as the Chair, we added 32 to 34 benefits that were not 
required under Medicaid. I am sure since I have been gone these 
6 years or so they have added others, because our people 
demanded it.
    I think the people in the State of Maryland and across this 
country ought to demand more from their Federal Government in 
terms of these programs we have created.
    That is my statement. I wanted to get that out to you. It 
is a heads-up. Watch for my bill. I intend to have it signed 
into law, because I have the other side working with me on this 
in the best interest of health in America.
    Thank you, Mr. Chairman. I am going to go to the floor. We 
have a vote.
    Mr. Kucinich. I thank the gentlelady.
    Before I dismiss the second panel, I would just like to 
thank Mr. Cosgrove for his attendance and appreciate your being 
here. We appreciate Mr. Smith, as well.
    I would like to just let Mr. Smith know that this committee 
will be giving you a detailed request to produce all documents 
relating to the editing of that particular guide and any type 
of communication that was in-house or that you received in e-
mails or such. We would ask the committee staff to communicate 
with Mr. Smith's office to make sure that you could get this to 
this committee expeditiously.
    We want to thank you for your participation here today. The 
second panel is dismissed.
    We will proceed with the third panel for their opening 
statements, and then we are going to recess for votes. Thank 
you very much.
    This is the third panel of the Domestic Policy Subcommittee 
hearing on evaluating pediatric dental care under Medicaid.
    This panel includes: Dr. Allen Finklestein, who is a former 
U.S. Army Captain who is assigned to the Post-Preventive Dental 
Office at Fort Bragg, NC. Dr. Finklestein has been a practicing 
dentist for more than 35 years, with a specialization in 
periodontal prosthesis. His professional memberships include 
the Rhode Island Dental Association and the New Jersey Dental 
Association, the Essex County Dental Association, and Alpha 
Omega Dental Association. Currently, Dr. Finklestein serves as 
chief dental officer of AmeriChoice. This business segment 
within United Health Group is exclusively focused on serving 
beneficiaries of Medicaid and the State Children's Health 
Insurance Programs [S-CHIP]. AmeriChoice serves over 1.4 
million Medicaid members, including children in 13 States.
    We will be hearing from Ms. Susan Tucker, who recently 
rejoined the staff of the Department of Health and Mental 
Hygiene. She is executive director of the Office of Health 
Services for the Maryland Medicaid Program. The Office of 
Health Services is responsible for developing and implementing 
policy relating to Medicaid covered services. Ms. Tucker has 19 
years of experience with State Medicaid programs. She has 
special expertise in maternal and child care programs within 
    Finally, we will hear from Ms. Jane Perkins, who is the 
legal director at the National Health Law Program, a public 
interest law firm working on behalf of low-income people, 
children, people of color, and individuals with disabilities. 
Ms. Perkins focuses on public insurance and civil rights 
issues. She engages advocacy on these topics, manages the 
National Health Law Program's litigation docket, and has 
written numerous articles on Medicaid and children's health 
    I would ask the witnesses to please rise. It is the policy 
of this committee to swear in all witnesses before they 
    [Witnesses sworn.]
    Mr. Kucinich. Let the record reflect that all of the 
witnesses answered in the affirmative.
    In order to provide the witnesses with the full opportunity 
for uninterrupted testimony, we are going to take a recess 
right now. Unfortunately, I have been informed that Congress 
has at least 1 hour and 15 minutes of votes, so if there is any 
difficulty in any of the panelists staying you should let our 
staff know, but I would ask you to stay. I am going to make 
sure that Members of Congress know that you are still present 
so we can give them the opportunity to participate.
    I am grateful for your being here. I thank you for your 
    This committee will stand in recess for 1 hour and 15 
minutes, which means that we will be back here at approximately 
20 to 7. Thank you.
    Mr. Kucinich. The committee will come to order.
    This is the Domestic Policy Subcommittee. Our hearing today 
is on evaluating pediatric dental care under Medicaid.
    We are now beginning our third panel. I have been informed 
that due to the extenuating circumstances of the congressional 
schedule with so many roll call votes that we have now 
encroached into someone's travel time. What I want to do for 
the witnesses, Ms. Perkins, if you have a flight to catch I 
would be happy to have you read your testimony. Did you have a 
flight to catch? Is that correct?
    Ms. Perkins. I now do tomorrow morning.
    Mr. Kucinich. OK. Tomorrow morning? Tonight?
    Ms. Perkins. Not any more. I am good.
    Mr. Kucinich. Oh, it is tomorrow? OK. Great. We are not 
going to be here until tomorrow morning. I promise. I will 
promise you that. This is a long hearing, but we are not going 
to go that long.
    Well, then, let us begin, if we may, with Dr. Finklestein. 
Thank you, Doctor. Please proceed.



    Dr. Finklestein. Good evening, Mr. Chairman. Thank you for 
the opportunity to testify here today.
    I am Dr. Allen Finklestein. I am the chief dental officer 
for AmeriChoice, which is part of United Health Group. We serve 
the Medicaid population. I have also been a practicing dentist 
for 37 years. As a health care professional, I take care and 
pride in treating people. That is why I am deeply moved by the 
death of Deamonte Driver.
    I want to add my personal condolences to the family. I hope 
with all my heart that we can keep this from ever happening 
    I have worked with governments for many years. As a young 
Army Captain, I helped design a preventive program to avoid 
dental emergencies in Vietnam. More recently I was on the 
forensic team that helped identify victims of September 11th. 
But, first and foremost, I am a dentist, and a dentist always 
has been trained to fix problems.
    Now we need to take a broader approach, a move to a 
preventive model. We have heard today about access to dental 
care, but access is not the only problem. We have to get past 
all barriers and deliver dental care.
    Clearly, one barrier is poverty, itself. For family S with 
Medicaid, dental care is a lower priority than food, shelter, 
and safety. You have heard today that some dentists don't want 
to take new Medicaid patients. The reimbursements may be one of 
the reasons. But even more of a factor that I find when I build 
networks is missed or broken appointments. Lots of dentists are 
willing to treat my children, but if the child doesn't show up 
the dentist has lost a slot and missed an opportunity to treat 
another patient.
    I want to help every child, but I can't help them unless 
they sit in my chair or my colleague's chair.
    The AmeriChoice approach is to help Medicaid patients get 
their appointments. Our multi-lingual call center is staffed 
around the clock, and the phone number is clearly written on 
every member's card. It is an 800 number. The call center can 
help make appointments, even arrange for transportation to the 
office and back home. We also reach out by mail and by phone, 
but that doesn't help if the member doesn't have a phone or a 
fixed home.
    So AmeriChoice is developing innovative ways to connect 
with our members. We are collaborating with everyone who 
touches the lives of these children, including government 
agencies, schools, community organizations, parents, and health 
care providers. This collaboration is not some hypothetical 
concept. It leads to real benefits in the lives of real people.
    Rhode Island is a great example. We worked with the State 
to create a program called Right Smiles, which now serves all 
of the Medicaid population 6 and under, all 32,000 of them. By 
stressing preventive care, we hope to start them on a path of a 
lifetime of oral health. Now the State wants to expand this 
program to reach older children.
    In Maryland and other States, we partner with local 
dentists to run screenings in schools. Each child gets a 
toothbrush, dental education, and, above all, a dental baseline 
    Elementary schools are incredibly important. I may look 
young, but nearly 60 years ago I had to have a dental checkup 
before I could enter kindergarten or return to any grade 
subsequent to that. We are working with schools in Patterson, 
NJ, which now require an annual dental checkup before a child 
can return to school. We partner with retailers adjacent in 
Maryland and elsewhere. We give parents a $10 gift certificate 
for taking a child to the dentist.
    A family with Medicaid is much more likely to see their 
physician than to go to a dentist, so we are working with Brown 
University and Hasborough Hospital in Providence to teach early 
signs of dental disease to physicians.
    What we are doing in Rhode Island can be replicated in any 
State. We are eager to help. These partnerships are good for 
patients, they are good for the community, and they are good 
for AmeriChoice. If I can treat a young child in my dental 
chair, that child is so unlikely to have a dental emergency 
    Surgeon General Satcher called it the silent epidemic. As 
you can see from today's testimony, it is not so silent. We 
have to partnership. We have to collaborate together. This 
disease is totally preventable and only when we can do 
preventive measures.
    Thank you for your time. I appreciate all that the 
committee has done.
    [The prepared statement of Dr. Finklestein follows:]

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    Mr. Kucinich. I thank the gentleman.
    Ms. Tucker.

                   STATEMENT OF SUSAN TUCKER

    Ms. Tucker. Chairman Kucinich, my name is Susan Tucker. In 
March 2007, I rejoined the Maryland Department of Health and 
Mental Hygiene as executive director of the Office of Health 
Services within the Medicaid program. I am accompanied today by 
the new Secretary of the Department, John Colmer, who is behind 
    The death of Deamonte Driver is a tragedy. We have been 
asked to address the oversight mechanisms the Department uses 
to ensure access to oral health services for Maryland 
Medicaid's eligible children and to address any measures that 
we have taken to avoid another tragic loss like that of 
Deamonte Driver.
    Maryland, like all States, has a problem with access to 
dental services for low-income children. We have been working 
on increasing access to dental care for years, and, while we 
have made progress, we recognize that much more needs to be 
    All stakeholders need to help with this issue in Maryland: 
dental providers, public health programs, parents and 
caregivers, Medicaid agencies, pediatricians, managed care 
organizations, and Federal policymakers. This is a national 
    Only about half of all children in the United States have a 
regular annual dental checkup. White, non-Hispanic children are 
almost twice as likely to have usual routine dental checkups as 
Hispanic or Black children. Children in households where 
neither parent attended college are much less likely to have an 
annual dental checkup. Children with Medicaid fall into many of 
these risk categories. They are more likely to be minority. 
They are more likely to be poor and to have parents with lower 
educational levels. This is not an excuse.
    This situation is intolerable from a human and public 
health perspective, but it is a fact. That means that public 
health agencies providing services for Medicaid populations 
start from a difficult position.
    One of the first priorities of the O'Malley administration 
in Maryland has been to address dental access issues. We are 
hiring a State Dental Director and forming a Dental Action 
Committee, which will include a full array of stakeholders. The 
stakeholders will be examining the system and social issues 
which may have contributed to Deamonte's untimely death, and to 
make recommendations regarding appropriate reimbursement rates 
for dentists, education to encourage families to improve oral 
hygiene in the home and to seek preventive dental services in 
order to assure that children don't get to the point where they 
are seeking dental care in the emergency rooms, strategies to 
allow other dental health professionals to provide more 
preventive services in under-served areas, strategies to 
increase the training of pediatric dentists--only three 
pediatric dentists graduate a year from the University of 
Maryland--and strategies to improve access at federally 
qualified health centers and school-based health centers.
    The Secretary of the Department has requested 
recommendations by September 2007 and is committed to 
thoroughly reviewing these recommendations and implementing 
changes to improve access to dental services.
    In regard to oversight, the Maryland Medicaid program 
implemented a mandatory managed care program called 
HealthChoice in 1997. Our main goal at the time was to improve 
medical and dental care for children. Prior to implementing the 
program, only about 20 percent of continuously enrolled 
children received a dental service. Today, 46 percent receive a 
    When we monitor the MCOs we review the dental data on a 
regular basis to see how many children receive services. We 
have made improvements. Are we satisfied that we have completed 
the job? Absolutely not. Are we convinced that we need new 
efforts and strategies to address the problem? Yes.
    We also require MCOs to develop and implement an annual 
outreach plan. This plan describes outreach activities and 
includes written materials that MCOs send to encourage families 
to seek regular care. We review these plans and we do look at 
the materials that the MCOs do send out to families.
    We have addressed rates in this session. DHMH does have low 
payment rates, but we did increase dental fees substantially in 
2001, partly in response to Federal studies, and in 2004 we 
increased rates again for the restorative procedures. Despite 
these increases, we recognize that our payment rates are below 
what dentists receive from private-paying patients. Although 
fees are not the only answer to increasing dental 
participation, we know we need to do better.
    DHMH also requires MCOs to contract with dentists. In 
Maryland, as elsewhere, dentists will not contract to take a 
limitless number of Medicaid patients. If MCOs required 
contracting dentists to take all Medicaid patients presenting 
for treatment, most would decline to participate in the program 
    We acknowledge that the current approach makes it difficult 
for patients to find dentists and nearly impossible for the 
State to monitor ever-changing dental networks. This is 
unacceptable to us, and we are working with the MCOs to reach 
out to contracted providers. However, we must also jointly find 
a way to engage the dental community in Maryland. Dentists in 
the program need to accept more patients, and dentists not 
participating need to step up to the plate.
    We have met with the Maryland Chapter of the American 
Dental Association and the Maryland Dental Society, and they 
have committed to assisting us in this effort.
    We also require MCOs to have an infrastructure to assist 
enrollees with locating and accessing services. They need to be 
more proactive in assisting patients in receiving dental 
    The Department also has a complaint resolution line, and 
each member has this information on their card and in their 
member handbooks. We do receive a lot of calls on this line, 
but, interestingly enough, we don't receive a lot of dental 
calls, so families don't call us very often with assistance in 
this area. We receive about 20 a month. That is not a lot, 
considering there are 400,000 children on the Maryland Medicaid 
    Finally, Maryland provides modest financial incentives and 
disincentives to encourage managed care organizations to 
improve access to services. One of the areas that we look at in 
terms of our pay for performance is dental utilization.
    In conclusion, we take our oversight of MCO performance 
seriously and are committed to implementing additional 
strategies to increase access to dental services. We ask the 
committee's assistance in recommending additional Federal 
dollars for education of pediatric dentists, dental clinics and 
schools, and federally qualified health centers, and in funding 
a national dental education campaign to highlight the 
importance of dental hygiene in the home and regular early 
preventive dental care.
    Thank you.
    [The prepared statement of Ms. Tucker follows:]

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    Mr. Kucinich. Thank you very much, Ms. Tucker.
    Ms. Perkins, you may proceed. Thank you.

                   STATEMENT OF JANE PERKINS

    Ms. Perkins. Thank you. Thank you for having me here this 
    I wanted to, in my few moments, just go through again some 
issues that are present in the States and talk about a few more 
issues with respect to this Centers for Medicare and Medicaid 
    To flip the statistics that have been used today, in 2004 
70 percent of kids who were eligible didn't get any dental 
care, 80 percent of kids who were eligible didn't get any 
preventive care, and over 85 percent of kids who are eligible 
didn't get corrective treatment.
    It is true that the Driver's stories are not unique to 
Maryland. In the District of Columbia, children enroll in one 
of four managed care organizations. The Medicaid Act requires 
States or MCOs, managed care organizations, to assure CMS and 
the States that they maintain a sufficient number, mix, and 
distribution of providers; however, the participation list in 
the District had been repeatedly inaccurate, listing dentists 
as participating when they no longer do, when they have closed 
offices. Some have moved overseas.
    According to the D.C. Action for Children, 5 percent of 
licensed dentists in the District participate in Medicaid, and 
by saying participate there, that means taking even one claim. 
That doesn't talk about active participation.
    The court monitor, in an ongoing case in the District, 
found ``substantial evidence that the majority of children 
eligible are not receiving adequate dental care.''
    According to the District's 416 report, which we just 
received for 2006, 22 percent received a preventive dental 
service, and that was less than had received preventive dental 
care in 2005.
    Mr. Kucinich. Excuse me? What was that percentage?
    Ms. Perkins. It was 22 percent in 2006 versus 25 percent in 
2005. Only one of the four participating managed care 
organizations increased their percentages. The others, Health 
Right, Charter, and AmeriGroup, showed decreases.
    In Miami-Dade County, a pilot project that was proposed by 
Governor Jeb Bush and approved by CMS in record time requires 
children to enroll in a capitated managed care plan. A report 
from the State's contractor found that the number of children 
who received dental care through the program dropped 40 percent 
in the first year. The number of participating dentists 
declined from 669 to 251. An analysis by Columbia University 
found that the State lost value under the program by paying the 
same amount for less care and less quality.
    To give an example, a dental group which was paid $4.25 a 
month for each of 790 children provided services to 45 of them. 
That is 5.7 percent during the first 6 months of 2005. Thus, 
the group was paid $20,145 for treating 45 children.
    A handful of Medicaid programs in States such as Alabama, 
Indiana, South Carolina, Vermont, and Virginia have targeted 
children's oral health services. These efforts share some 
common features: first, increases in payment levels tied to 
usual and customary fees; second, streamlined administration; 
third, appointment of a high-level position to focus on problem 
solving; fourth, effective outreach to beneficiaries; and, 
fifth, case management to address appointment no-shows.
    South Carolina's effort to tie patient navigators with 
beneficiaries has resulted in 85 percent of beneficiaries 
keeping their appointments. I would point out that case 
management is a covered Medicaid service. Athens County, OH, 
and Oakland, CA, are a couple of other examples of areas that 
have used case management to make sure kids get to their 
    To use an example from Virginia, until recently, as Mr. 
Smith pointed out, Virginia has delivered services using a 
capitated managed care mode; however, the State recently 
transitioned out of that model and back to fee for service. 
This move, coupled with additional changes, a 30 percent 
increase in rates and a number of recruitment and retention 
strategies for dentists resulted in 76 additional dentists 
enrolling in the program between July and November 2006, and 
there was a 43 percent increase in preventive services and a 75 
percent increase in restorative services delivered to Medicaid 
eligible children between 2005 and 2006.
    Many of the points that I wanted to make or was going to 
make about CMS have been covered here already. I will just add 
three points.
    First, the Medicaid Act requires that the Secretary of 
Health and Human Services shall annually develop and set 
participation goals for EPSDT for each State. Given the 
increased use of managed care and the stated rule of managed 
care to provide children a medical and dental home, it could be 
expected that the Secretary would increase these participation 
goals over time. However, the last time the Secretary developed 
and set participation goals was 1990.
    Second, CMS appears committed to privatizing monitoring by 
allowing States and MCOs to use performance measures that are 
tied to those or offered by private accreditation standards. 
However, the private standards lack the degree of specificity 
needed to assure that States are complying with the Medicaid 
Act. For example, 2007 HEDIS includes only one dental measure, 
annual dental visit. By contrast, 416 requires States to report 
on the number of eligible children receiving services, the 
number receiving preventive services, and the number receiving 
corrective treatment.
    Moreover, the HEDIS is not measuring what Congress has 
required in the statute for the States to do, and that is to 
ensure dental visits according to schedules arrived at by the 
State after consultation with dental providers. Our review 
found that, as of May 2005, all but three States called for 
children to receive a dental exam every 6 months, not annually.
    Third, CMS has not enforced the Medicaid Act, so it is 
important that beneficiaries' rights to enforce the provisions 
of the act be reaffirmed by Congress.
    Thank you for having me here today.
    [The prepared statement of Mr. Perkins follows:]

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    Mr. Kucinich. I want to thank all the witnesses for their 
    At this point we will go to questions.
    I want to thank Congressman Cummings for rejoining us.
    I would like to begin the questions with Dr. Finklestein.
    Doctor, in 2006 how many children eligible for Medicaid in 
Maryland enrolled in your plan?
    Dr. Finklestein. Out of total membership of 110,000, 
approximately 80 percent of those are children.
    Mr. Kucinich. That was 110,000 that were what, please?
    Dr. Finklestein. It is 110,000 total membership, of which 
80 percent are children.
    Mr. Kucinich. OK. The Department paid, according to the 
information we had, the Department paid United Health Care 
$339.3 million in 2006. How much in total revenue did you 
receive from the State of Maryland Medicaid program for 
enrolling these children during 2006?
    Dr. Finklestein. Sir, I don't have those numbers. I would 
be happy to share them with the committee to make sure they are 
    Mr. Kucinich. Thank you, sir.
    And in 2006 do you know how many of the Maryland Medicaid 
children enrolled in your plan received at least one preventive 
dental service?
    Dr. Finklestein. Yes, sir. Over 45 percent.
    Mr. Kucinich. So 45 percent. OK.
    Dr. Finklestein. And if I can followup?
    Mr. Kucinich. Of course.
    Dr. Finklestein. Again, I am a dentist. That is 55 percent 
of my children that didn't receive. That is unacceptable, 
totally unacceptable. Until we get 100 percent, then we are 
talking about the numbers that I can do the proper health care 
for my children.
    Mr. Kucinich. Thank you, Doctor. And how many received at 
least one dental treatment service during the year?
    Dr. Finklestein. At least one?
    Mr. Kucinich. You said 45 percent received at least one 
preventive dental service, but how many have received at least 
one dental treatment service during the year?
    Dr. Finklestein. I could make that available to the 
    Mr. Kucinich. Could you do that, please?
    Dr. Finklestein. Sure.
    Mr. Kucinich. Now, Doctor, did Deamonte Driver see a 
dentist in the year before he was hospitalized?
    Dr. Finklestein. Sir, in all my years of treating patients, 
there has always been a certain trust. Discussing this 
individual case would be a total violation of that.
    Mr. Kucinich. Have you been advised by counsel not to 
discuss it?
    Dr. Finklestein. This is the person sitting in front of 
    Mr. Kucinich. This committee, you should be informed, 
Doctor, has oversight jurisdiction specifically and actually a 
specific exemption from HIPAA with respect to gathering 
information and data, so we are going to ask you, if you cannot 
do it now, to provide for the committee the following 
    Staff has just given me something, and I would like to read 
this to you. This is section 45, and it is 35th chapter, No. 
164.512(d)(1) states that ``A covered entity may disclose 
protected health information to a health oversight agency for 
oversight activities authorized by law, including--'' 
subparagraph 2--``Government benefit programs for which health 
information is relevant to beneficiary eligibility.''
    The Committee on Oversight and Government Reform is the 
principal oversight committee in the House of Representatives 
with broad investigative jurisdiction as set forth in House 
Rule 10, so information--and I just want to make sure that you, 
as a witness, have that information. So what I am going to say, 
if you are not prepared to answer that question at this 
moment--and I will respect that you aren't available to answer 
that question at this moment--we are going to ask you to submit 
to this committee the following information: Whether or not 
Deamonte Driver saw a dentist in the year before he was 
hospitalized; whether he saw a dentist in the year before that 
or the year before that, the previous year. We could actually 
go back 5 years, at least.
    And I would ask you to provide the following information, 
as well: if United Health Care received a capitation fee for 
Deamonte Driver in the year before he was hospitalized and in 
the 5-years preceding that.
    Would you be able to answer that now? If you can answer 
some of these questions now, that would be helpful, but if you 
want time to do it and you want to prepare a response----
    Dr. Finklestein. I would appreciate that.
    Mr. Kucinich. You would like to have time to do it?
    Dr. Finklestein. Yes, sir.
    Mr. Kucinich. I respect that, Doctor.
    I would like to ask you, Doctor, what statistic does United 
Health Care generate about its own performance that would 
capture Deamonte's last 5 years of life? For example, do you 
report a statistic to the State about the number of enrollees 
who do not receive dental services in the preceding year?
    Dr. Finklestein. Sir, if I can talk globally?
    Mr. Kucinich. Of course.
    Dr. Finklestein. If that is OK with you, we have a tracking 
system throughout the country. It is called universal tracking. 
This is a report card on all of our children that are EPSDT. 
The T is the key. I totally agree with that.
    In that report card, it is sent on to the primary care 
physician. Primary care physicians get a report on the child 
for not only baseline examination, physical examination--this 
is the pediatrician--they get lead screening, well child, 
immunization, and dental. Those are sent to the physicians so 
that they know exactly which children fall in or fall out.
    In addition to that, as a company we do total outreach to 
our members that have not seen their dentist. That includes 
phone calls, it includes mailings, it includes educational 
material on a quarterly basis that is sent, and there is a 24-
hour call center that is available to all of our members. Not 
only that, they are trained to educate members. They also help 
to navigate them through the system. Again, transportation to 
and from, and even scheduling them so that they can be rewarded 
with a gift certificate when they do go to the dentist.
    Mr. Kucinich. OK. What I would like you to do, Doctor, I am 
going to ask you this information and I would urge you to 
consult with your attorneys so that you could make sure that 
you feel comfortable reporting this, and I can assure you that 
if any information is necessarily privileged for some legal 
reason, such as a pending lawsuit or anything like that, our 
staff attorneys will be glad to acquaint you with the way in 
which this committee handles such information.
    So we are going to want you to provide us with a report 
whether or not you keep statistics about the number of 
enrollees who do not receive dental services, if you report 
those statistics to the State, what the report. We would like 
you to have that available for at least the last 5 years, 
assuming, of course, that it is possible to generate such 
statistics. I mean, if you have them, the committee would like 
to take a look at them.
    I assume that you do keep statistics?
    Dr. Finklestein. Yes, we do, sir.
    Mr. Kucinich. So it is possible----
    Dr. Finklestein. Absolutely.
    Mr. Kucinich [continuing]. To determine utilization?
    Dr. Finklestein. Absolutely.
    Mr. Kucinich. OK. So we want to be able to determine, of 
course, whether or not you are informing the State about the 
existence of individuals who are chronically not receiving 
dental care. I think you would have to agree that would be 
relevant for the State to know.
    I would now like to ask you, Doctor, United Health Care 
uses HEDIS measures to estimate how many children are eligible 
for Medicaid, correct?
    Dr. Finklestein. HEDIS? Yes.
    Mr. Kucinich. Yes. Now, according to HEDIS, eligible 
children are 4 to 20 years old and enrolled in Medicaid for 320 
consecutive days. In 2006, according to information that this 
committee has been given, Deamonte was not enrolled for 63 
days. Is that correct according to your information?
    Dr. Finklestein. I would have to confirm that.
    Mr. Kucinich. OK. If anyone is not enrolled for that length 
of time, would that person be ineligible according to HEDIS 
    Dr. Finklestein. Would they be for reporting purposes?
    Mr. Kucinich. Yes. I will go over it again.
    Dr. Finklestein. No, I understand the question.
    Mr. Kucinich. If they weren't enrolled for, let's say, 60-
some days, would that person then be ineligible according to 
HEDIS standards?
    Dr. Finklestein. No. They wouldn't be a required reporting 
    Mr. Kucinich. Excuse me?
    Dr. Finklestein. They would fall out of reporting only. 
Again, we are treating children, if they are enrolled with our 
plan for 1 month or for an entire year. HEDIS says our 
denominator consists of only children that are continuously 
enrolled for 320 days. That is only a reporting statistic. This 
does not interfere with their dental coverage. Whoever the 
patient is would have dental coverage for as long as they are 
enrolled in our plan.
    Mr. Kucinich. We are trying to establish whether or not 
Deamonte, based on the circumstances, would have been part of 
the eligible children that you list. Would he have been 
considered eligible?
    Dr. Finklestein. Any child in our health plan is eligible 
for care. What we are doing----
    Mr. Kucinich. You are eligible for care, but are they 
reported as such?
    Dr. Finklestein. They are not required to be reported under 
the definition of HEDIS.
    Mr. Kucinich. So someone could be eligible but they could 
fall out of reporting?
    Dr. Finklestein. That is correct, sir.
    Mr. Kucinich. Now, what kind of a bearing does that have on 
United Health Care's responsibility for making sure that a 
patient gets access to health care, which includes dental?
    Dr. Finklestein. None, whatsoever.
    Mr. Kucinich. In other words, whether someone is reported 
or not, it has no bearing on the service, but it does have a 
bearing on whether or not the State can determine utilization, 
    Dr. Finklestein. If I may expound, HEDIS is a pure measure 
of one time dental treatment, I can tell this committee. Do I 
find quality in that? There is no quality component to it. It 
is strictly----
    Mr. Kucinich. No quality component?
    Dr. Finklestein. There is no quality component at all.
    Mr. Kucinich. To what?
    Dr. Finklestein. To the HEDIS measure. OK? I am talking 
    Mr. Kucinich. It is strictly eligibility?
    Dr. Finklestein. It is strictly a way to show utilization. 
It was so pointed out by Mr. Davis when he spoke about 
treatment. When I go into the OR with a child who has been 
devastated, totally devastated by milk bottle decay----
    Mr. Kucinich. By what?
    Dr. Finklestein. Milk bottle decay, which means that the 
child has been going to sleep at night, and the only way to 
bring this child back to oral health is in the operating room. 
That is the same HEDIS count as if the child came to my office 
and I did a quick screening. It is a one-time hit. If that is 
quality, not in my dental life.
    Mr. Kucinich. Now, I think we mentioned this earlier. The 
State of Maryland paid United Health $339.3 million in 2006. 
Those are the figures that we had. In Deamonte's case, in 
particular, you were paid about $80.96 a month. Does Deamonte 
appear in your annual records?
    Dr. Finklestein. Again, sir, I will talk globally about my 
members. Any member will appear in our records. OK? It has 
nothing to do with HEDIS. From the day they are in, if they are 
brought into a dental office--you have one of our top doctors 
was here before testifying. He has one of the highest 
utilizations at the University of Maryland with quality 
outcomes. That was available. Care was available. The only way 
I can treat a child--I said that in my statement--is by having 
them in my dental chair. The same thing with Dr. Tinanoff and 
Dr. Clark.
    Mr. Kucinich. I accept what you are saying, except that if 
you could tell me how do the numbers account for failure to 
provide care in Deamonte's or in anybody's case?
    Dr. Finklestein. In anybody's case?
    Mr. Kucinich. Yes.
    Dr. Finklestein. It is absolutely. I don't know if we can 
say the word failure, but it is.
    Mr. Kucinich. What is a failure?
    Dr. Finklestein. A failure is not having 100 percent of our 
children in this country seeing the dentist. A failure is not 
having the ability to mandate that my children go to the 
dentist. A failure is having school systems that won't let me 
in to do screening because they take away from chair time, 
education time.
    Mr. Kucinich. Doctor, would the failure also be if the 
numbers weren't kept to account?
    Dr. Finklestein. No. No, sir. I pride myself and this 
company prides itself on individual care, on outcomes. That is 
what it is about. Numbers are wonderful----
    Mr. Kucinich. But the numbers have to be reported so there 
can be some kind of assessment of utilization; am I correct?
    Dr. Finklestein. That is so true.
    Mr. Kucinich. OK. And so would the numbers that are 
reported to be able to assess utilization in any way reflect 
the failure? You just said, 55 percent aren't cared for. Is 
that one way of looking at it?
    Dr. Finklestein. That is exactly right. Not only that. The 
way I assess it, we have a system called Metrix, and Metrix 
looks at what each individual child is getting when they do 
access care, not that it is a one-time exam. What we do is 
measure on their recall, when they come back 6 months, do I 
have baseline health. That is what it is all about. Getting the 
child in, getting them healthy, maintaining health, not 5 years 
prior, but every day of their life, that is my commitment to 
    Mr. Kucinich. Doctor, what in your records or figures of 
United Health Care reflects the death of Deamonte?
    Dr. Finklestein. Again, sir, I have never violated this in 
my life. If you want, I will present you with anything----
    Mr. Kucinich. I don't want to ask you to do anything the 
you are really uncomfortable with, but I do want to say that 
this committee needs the following information.
    Dr. Finklestein. OK, sir.
    Mr. Kucinich. We want to know specifically where did 
Deamonte appear in your annual records. We want to know the 
manner in which your statistical evaluation and your numbers 
account for any failure to provide him with care. We want to 
know what in your records or figures reflects the death of 
Deamonte. And, again, this is consistent with the right to 
information which this committee has, and specifically under 
rule 8(a)(1) of the Rules of the Committee on Oversight and 
Government Reform.
    Doctor, again, thank you. We verbally requested documents 
reflecting United Health Care's costs, their earnings, and 
revenues from the Department of Health and Mental Hygiene. That 
Department refused. We made the verbal request a second time. 
We submitted a document request to the Department of Health and 
Mental Hygiene that included a request for United Health Care's 
costs, earnings, and revenues. We were told by the Department 
that United Health Care refused to release that information 
because it was described as proprietary.
    Again, I know that you are a doctor, you are not an 
attorney, I understand, but I want you to know that we insisted 
that our subcommittee had the right to that information under 
rule 8(a)(1) of the Rules of the Committee on Oversight and 
Government Reform. The Department responded that United Health 
Care did not grant express consent to release that information 
and therefore refused our request a second time.
    We are entering a written request as well as refusals to 
produce the requested documents in writing into the record. 
Without objection, Mr. Cummings, this goes in.
    Now, Doctor, half of United Health Care's funding is 
Federal, and we have an obligation and responsibility to make 
sure that funding is spent appropriately. This is exactly why 
this subcommittee has broad jurisdiction and investigative 
jurisdiction as set forth in House Rule 10. Now, would you be 
at liberty at this moment to tell us what United Health Care's 
costs, earnings, and revenues were in Maryland?
    Dr. Finklestein. No, I do not have that information.
    Mr. Kucinich. OK. So our subcommittee is formally making 
that request right now for you to provide the cost, earnings, 
and revenues in Maryland.
    Now, my understanding is that the National Children's 
Medical Center incurred expenses in excess of $200,000 in 
providing emergency care and treatment to Deamonte in the last 
few weeks of his life. He was uninsured at the time of 
admission into the hospital. He leaves no estate. His family is 
unable to afford the charges. I am assuming that the Maryland 
Medicaid program will not be paying the charges and that the 
United Health managed care plan with which Maryland Medicaid 
contracted to manage Deamonte's care also will not pay. Do you 
have any advice for the National Children's Medical Center as 
to where they might turn to recoup even some of the costs they 
incurred in attempting to save his life?
    Dr. Finklestein. At this time, again, I can't comment on 
the individual nature. I don't even have this material in front 
of me, sir.
    Mr. Kucinich. OK. Doctor, one measures of how much value a 
public program like Medicaid gets from purchasing care through 
a managed care organization like United Health, as you 
understand, is the medical care ratio. This is the amount that 
the MCO pays out for medical cost divided by the amount of 
premium revenues that the MCO takes in. Are you familiar with 
the medical care ratio, Doctor?
    Dr. Finklestein. I know exactly what you are talking about. 
I just happen to call it benefit.
    Mr. Kucinich. You call it benefit?
    Dr. Finklestein. I call it benefit, not medical. There is 
more to it than just----
    Mr. Kucinich. So the higher the ratio or the benefit, the 
better the value for Medicaid. And for example, if an MCO's 
medical cost ratio on a Medicaid managed care contract is 60 
percent, then only $3 out of every $5 the State and Federal 
Government pay the MCO goes to purchase hospital, physician, 
dental, and other health care services. The remaining $2 goes 
to administration, marketing, and, in the case of a for-profit 
company like United Health, profits.
    So if the medical cost ratio is 90 percent, then $9 out of 
every $10 the State and Federal Government pay the MCO goes to 
purchase health care services and only $1 goes for 
administration, marketing, and profits.
    Now, according to form 10K that United Health filed with 
the Securities and Exchange Commission on March 6, 2007, their 
company's overall medical care ratio in 2006 was 81.2 percent. 
In other words, a little under $1 out of every $5 you get paid 
in premium goes to marketing and administration and profits.
    Now, would you be able to tell us what the medical care 
ratio was on your risk contract with the Maryland Medicaid 
program in 2006? Would you be able to tell us that?
    Dr. Finklestein. No, I don't have that.
    Mr. Kucinich. If you could please----
    Dr. Finklestein. May I just put in you still have a claims 
run. It would be an approximation.
    Mr. Kucinich. If you could provide us with the information, 
understanding that there is a claims run, we would like to get 
    I think that is the only questions I have right now before 
we go to Mr. Cummings.
    I just want to say, Doctor, I admire the spirit in which 
you presented your concern for the children who you are 
dedicated to serving. You speak of them as your children, and I 
think it is heartening to see the concern that you expressed 
for the children. I think you understand that our committee has 
the same motivation in asking for the information which we feel 
we need to be able to effectively evaluate this case and to, 
from a public health policy standpoint, to be able to use the 
information we gather not simply as an analysis of United 
Health Care, but to look at it from the more global experience 
of the industry, itself.
    So I think it would be good if we were able to proceed on 
this in a cooperative way, because I think that it can be a 
very favorable experience for everyone who is involved in 
committing themselves in the care of children.
    Dr. Finklestein. Thank you. I appreciate those kind words. 
The frustration that is inside of me, I can't even tell you. 
This is not the first case. I hope and pray it is the last 
case. Any skilled dentist could have brought health to any one 
of these children, whether it was Mississippi this month, New 
York 3 years ago, and this unfortunate situation. Sir, we have 
the ability to heal these children. We could keep them healthy. 
We must get them in to see the dentist. We need your help. I 
need it so desperately I am begging for it right now.
    Mr. Kucinich. I believe you. I think we are having a dialog 
here that I think is going to be very productive. I certainly 
appreciate your testimony.
    Mr. Cummings, thank you.
    Mr. Cummings. Mr. Chairman.
    Ms. Perkins, CMS Director Dennis Smith seemed to indicate 
that his hands were tied with regard to the agency's response 
to the States that are not complying with EPSDT for dental 
care. Is that your view?
    Ms. Perkins. The impression that I got from Mr. Smith's 
testimony was that it was being portrayed as an all or nothing 
alternative, either we have to withdraw all Federal funding or 
we don't have much power. I don't agree with that. The CMS has 
and States know that CMS has the power of the purse string. The 
Federal Government is funding from $0.50 to $0.73 out of every 
dollar that is spent in States on Medicaid. When CMS is serious 
about something and wants something done, States listen.
    I think that the January 18, 2001, letter that was sent 
from CMS to States is just one example of that. The 49 States 
sent back plans of action. I have been at the National Health 
Law Program 22 years, and there are numerous examples of that 
    Now, it is also true that the Secretary at Health and Human 
Services is, in the Medicaid Act, and has always in the 
Medicaid Act been charged with the responsibility of taking 
enforcement action when the Secretary finds that the State's 
plan is no longer in compliance with the Medicaid Act. There 
are State plans that are no longer in compliance with the 
Medicaid Act. The notice to the State can tell the State that 
the action and the funding involved is directed at the service 
that is out of compliance. That doesn't mean that the funding 
is stopped the next day. There is a process for the State to go 
through to have a hearing and for an impartial decision to be 
made ultimately about what to do about that funding.
    We see in the Federal Register numerous, numerous occasions 
of notices where the Federal Government is saying we are not 
going to approve this. We don't think it complies with the act. 
Many, many of those cases settle, again, going back to my first 
point, because the Federal Government has such a powerful purse 
string with the Federal funding.
    Mr. Cummings. Ms. Perkins, it is interesting that we have 
seen over and over again--and I think it was Ms. Watson a 
little bit earlier who talked about it--the systems that are 
supposed to work that don't work. We see it. I see it as the 
chairman of the Coast Guard Subcommittee on another committee. 
I have seen it in this committee, Oversight and Government 
Reform. We have systems, but because of individuals who either 
are incompetent, lack empathy, negligent, or just don't care, 
the systems break down. I see it over and over and over again.
    If you look at the problems that we have had in this 
country--Katrina was a good example--we are seeing it in a 
program called Deepwater where we spent $24 billion for some 
boats that don't float, in this country.
    I am just trying to figure out what are the kind of things 
you would like to see in place so that, no matter what, when 
you have the kind of problem I just talked about, lack of 
empathy, negligence, people who just don't care, you are going 
to have that, but how do you minimize that in a situation like 
this? Are you following my question?
    Ms. Perkins. I do. I think that the solution is already on 
paper, and it is what Congress has already passed in the 
Medicaid Act. Congress has made it incredibly clear what it 
wants States to do in providing early and periodic screening 
services to children. It has made it clear to the Secretary 
what kind of reporting it wants to have happen. And it has made 
it clear what kind of oversight it wants to have States engage 
in where they are contracting with capitated managed care plans 
that are getting paid ahead of time to provide the care that 
kids are going to need.
    So I think that the blueprint is on paper. It isn't a 
matter of having the will to enforce the law and to take the 
law that Congress has passed more seriously, than the desire, 
for example, to have private accreditation companies and their 
HEDIS measures be what is going to be equated with quality and 
a well-running program.
    Mr. Cummings. I am going to move on to you, Dr. 
Finklestein. We kept hearing this term a dental home. What is 
the significance of that?
    Dr. Finklestein. The significance of a dental home is a 
place that anyone--in this case, youngsters--can receive dental 
care 24 hours a day. Not to say the dentist is there 24 hours a 
day, but our contracted doctors are required to provide 
emergency, urgent care, and routine care.
    What we have to do is seize the opportunity of the dental 
home. It is almost like how do we get the water where we want 
it. We have to go into schools. We have to start screening 
programs in schools and then assign these children to dental 
homes that are permanent. This is the model that will work. 
Every child should know they have a dental home. A lot of them 
don't. We often treat a youngster 1, 2, or 3. This is a child 
that is in pain. That is a child that cries himself or herself 
to sleep, a child with low self-esteem, a child that misses 
school. This is a cycle that can be ended.
    If we can't get our members to come to us, we are going to 
have to change the model. We are going to have to get into the 
school systems, work with school systems, and then assign a 
dental home to them. That is the only way.
    Mr. Cummings. So is the dental home the primary?
    Dr. Finklestein. It would be my practice. If you came to 
me, I am your dental home.
    Mr. Cummings. OK. Now, United deals with medical and 
dental; is that right?
    Dr. Finklestein. Yes, sir.
    Mr. Cummings. Now, do we assign folks medical homes?
    Dr. Finklestein. Yes, we do. We do assign a primary care 
    Mr. Cummings. And do you assign them dental homes?
    Dr. Finklestein. We do not. We have open access.
    Mr. Cummings. Let's say Johnny Watts would be receiving 
medical treatment through you.
    Dr. Finklestein. Yes, sir.
    Mr. Cummings. And receiving dental treatment through you.
    Dr. Finklestein. That is correct.
    Mr. Cummings. Why would he have a medical home and not a 
dental home?
    Mr. Cummings. Our model throughout the country, we have 
found that it is easier to have access, not restrictive access. 
If that dentist is not there, they can call our 800 number, we 
can get them another dentist.
    Another way, when you sign panels, most of this panel and 
dental home assignment came off of something that was touched 
up eloquently about capitation. Doctors receive remuneration to 
have X amount of patients, let's say 100 patients who are 
assigned to them, to treat them. There is no incentive to treat 
when you pre-pay.
    Our model is to do a fee for service and give you access, 
just as you have with your--you have a plan, you have doctors, 
you have 700 dentists in the State of Maryland. You can choose 
any one of them. And if you are in need of transportation, we 
will get you there.
    Mr. Cummings. So having a dental home is your philosophy, 
and I guess the philosophy of your company, that it is better 
to not have a dental home than to have one; is that right?
    Dr. Finklestein. No. We give you the dental home, but you 
select the doctor of your choice. You find that home. He is 
your dentist, or she is your dentist.
    Mr. Cummings. But if you can't find a dental home----
    Dr. Finklestein. That is our job. That is why if you call 
right now there is someone answering the phone, how can we 
assist you, in any language that you can make up, any language 
in the world. We will respond and we will help them, as I said, 
navigate through the system.
    Mr. Cummings. You had said a little earlier in answer to 
one of the chairman's questions, you said something about 45 
percent that you said that used the system had, I think, one 
dental screening in 2006, at least one, is that right? Was that 
45 percent?
    Dr. Finklestein. Yes, 45 percent of unique dental visits. 
    Mr. Cummings. And you put your head down and said it should 
have been--you wished that you could have gotten the other 55 
percent, or something to that effect; is that right?
    Dr. Finklestein. That is my profession. My profession is to 
treat. That means 55 percent of my youngsters never got to see 
a dentist. That is unacceptable in this country. It is 
    Mr. Cummings. And you believe they should have, the other 
55 percent?
    Dr. Finklestein. With all my heart.
    Mr. Cummings. Period?
    Dr. Finklestein. Period.
    Mr. Cummings. So, in other words, everybody enrolled with 
United, you want to see have at least what a year?
    Dr. Finklestein. Get them to baseline health, whatever it 
takes. You see, it is an investment. It is a good investment. 
The children that come in that I can get healthy and keep them 
healthy, then your medical loss ratio kicks in on the smart 
end, not on the negative end. Not treating catastrophic 
illness; treating preventable disease. There is nothing so 
    This disease, you heard, five times asthma, etc., Doctor 
Satcher called it the silent epidemic. It is unbelievable that 
we can't control. Sometimes with my colleagues I will sit and 
talk. We have basically two diseases to deal with, besides 
congenital defects, birth defects, that we found in the mouth: 
periodontal disease, more in adults, and decay. We can't get it 
under control and we have to make it mandatory that every child 
sees a dentist. Then we will have results. Then we will have 
healthy children that won't miss school, that will have self 
esteem, that will sleep at night, and that is it.
    We also have our obstetricians. That is where we start. We 
have our obstetricians talking to our future moms. You can't 
give a bottle to this child to go to sleep. It is difficult. 
They have so many problems. They do not know where they are 
living, etc. The child is sleeping. It is so simple to give a 
bottle with lactic acid. That is what it breaks down. And then 
I have no teeth to restore. I have abscesses. I have potential 
disasters on my hand, all because someone--and here is the 
biggest problem. I am so happy you asked this question. The 
physicians have to buy into this. I'm tired of being the repair 
man. Sixty-three years of age, almost 38 years in this 
profession, why can't I do preventive dentistry. Why am I not 
rewarded for doing what is right instead of fixing what went 
    This is the basic premise. This is the problem in dentistry 
    Mr. Cummings. You said that we don't pre-pay dentists 
because there would be no incentive for them to see patients; 
is that what you said?
    Dr. Finklestein. That is correct. That is correct. That is 
a capitated program.
    Mr. Cummings. Couldn't the same be said for the pre-paying 
of United Health?
    Dr. Finklestein. No, sir.
    Mr. Cummings. What is the difference?
    Dr. Finklestein. The difference is when I get a child 
healthy in dentistry I save money.
    Mr. Cummings. Yes.
    Dr. Finklestein. That is a preventive model. When I have a 
disaster, it is financially a disincentive and it affects the 
family, transportation. You just look at the cost. There was 
one mentioned. The cost of that for a simple extraction, for a 
simple extraction that a sophomore dental student could do? 
Early diagnosis, early treatment, that is EPSDT. But I need 
these kids. I need them terribly. I won't let you down if I get 
the kids. If I don't get them, I cannot treat them, sir.
    Mr. Cummings. So if they never get there, then it doesn't 
cost you anything?
    Dr. Finklestein. If they never get there it costs me much. 
It hits on my medical end. It hits on the emergency room end. 
Oh, it costs me. It costs me way more than doing preventive 
    Mr. Cummings. I see Ms. Perkins shaking her head. You in 
agreement with him?
    Ms. Perkins. That is one of the measures that we use as an 
indicator of a broken system, how many children are getting 
their dental services in the emergency room.
    Mr. Cummings. Yes. And did you look at Maryland in that 
    Ms. Perkins. We were looking actually at North Carolina.
    Mr. Cummings. I found it interesting what you said. I just 
want to go back to Ms. Perkins for a moment, what you said 
about the South Carolina system. You seem to be very impressed 
with that; is that right?
    Ms. Perkins. Well, by making changes to its program, it is 
behind only the State of Vermont in terms of screening the most 
number of kids. Their rates are at the 75th percentile of 
dentist rates in the region. They have really focused on 
partnering with dentists to get them to train general dentists 
to provide services to pediatric cases to kids, special needs 
kids, so you can get services in rural areas where there are 
general provider shortages. They partnered with the AME 
churches where they have done over 110 screenings. And the 
screening levels have increased dramatically. That is what the 
end game is here. It is not how much a doctor or dentist is 
getting paid, but how many kids are seeing a dentist for 
preventive care and getting the corrective treatment.
    Mr. Cummings. If I yield to the chairman, then he is going 
to yield back to me, but let me just ask this real quick 
question. Who drove that plan? Who made that happen? Was it the 
Governor? Did it come through the State legislature? Do you 
    Ms. Perkins. I don't know.
    Mr. Cummings. Well, we can find out.
    Ms. Perkins. Yes.
    Mr. Cummings. I yield to the chairman.
    Mr. Kucinich. Thank you, Mr. Cummings.
    In the course of your discussion with the doctor, something 
occurred to me to ask because, again, I see this great 
compassion expressed for the children, which is mandatory. Now, 
Doctor, I have heard you say a couple of times that you can't 
help your kids unless they are sitting in your dental chair. I 
have heard you say that a few times, and I understand the 
spirit that motivates that statement.
    Here is what I am wondering. Earlier today our staff 
provided me with information that said that they did a spot 
check of dentists that were listed in United Health Care's 
provider network. They called 24 dentists. The score is up on 
the screen there. Twenty-three of the numbers were either 
disconnected, incorrect, or belonged to a dentist who did not 
take Medicaid patients. The 24th did accept Medicaid patients, 
but only for oral surgery and not general dentistry. So 
effectively, according to the spot check by the congressional 
subcommittee staff, none of the numbers listed would have been 
of any use to Deamonte.
    Help me with this. What is going on?
    Dr. Finklestein. The locale? Was that Prince George's 
    Mr. Kucinich. Yes, sir.
    Dr. Finklestein. OK. I can only give you my statistics. I 
am not finding any----
    Mr. Kucinich. I want you to explain that, though. I mean, 
help me.
    Dr. Finklestein. I will. I will explain it the way I can 
see it.
    First of all, I would have to look at the access 
availability studies, because we do those also. We also have 
something called a silent shopper. We make appointments. This 
is done. We report this to the State. We constantly do access 
and availability.
    But the number that sticks in my mind--now, I am not 
finding fault with the survey, because I really haven't studied 
it--is that in Prince George's County last year, 2006, United 
Health Care paid unique claims to 78 dentists that are in our 
network, 78 dentists, and we can share this information with 
you, received payment from us as par, meaning participating, 
    Mr. Kucinich. Is it possible that any of the information 
that is in that list on the provider network could be 
    Dr. Finklestein. It is interesting. My windshield was 
broken on the way down and I called to make an appointment to 
have my windshield fixed. I called the Yellow Pages. It was a 
wrong phone number, and it was the recent directory. I went to 
this place in New York prior. Is it possible? Perhaps.
    Mr. Kucinich. Hopefully you would have a better batting 
average with repairing your windshield than our staff did with 
trying to find a provider.
    Dr. Finklestein. I would hope so.
    Mr. Kucinich. Now, this was on your Web site, I might add, 
which hopefully has high reliability. I think it is important 
for us to look at that, because, while I believe you when you 
say you want to get those kids sitting in a dental chair, I 
think it is really important to try to square that with the 
apparent lack of availability. It came from, admittedly, a 
single study, but, nevertheless, I would guess that if we did a 
second study, it would probably be pretty close, if we called 
the same numbers, probably pretty close response to what we had 
the first time. So I wanted to call that to your attention----
    Dr. Finklestein. Yes, sir.
    Mr. Kucinich [continuing]. Because I think that what I 
would like to do to staff is to have staff review this with the 
doctor so that you should know what we found.
    Dr. Finklestein. Absolutely.
    Mr. Kucinich. And I would be happy to share it with you so 
that maybe we could have a greater understanding as to how that 
could occur.
    Now, part of your job, Doctor, is to create a dental 
provider network.
    Dr. Finklestein. Yes, sir.
    Mr. Kucinich. We talked about the dental house. What have 
you done to broaden the dental provider network?
    Dr. Finklestein. The basis, first of all, we are getting 
more pediatricians involved in early screening, early 
recognition of disease, and then we also have a reimbursement 
for a wonderful program for fluoride varnish. A lot of decay 
that is in a youngster's mouth can, believe it or not, be 
arrested and reversed. It is a whole new concept. It is not as 
new as we think, but it took the American Dental Association to 
2007 to finally give me a code that I can reimburse on. That 
just happened January 1, 2007. But we are including 
pediatricians in this now.
    Mr. Kucinich. Yes.
    Dr. Finklestein. So we are broadening the denominator of 
providers. We also have to get to the medical schools. They 
have to learn what the disease entity in the mouth is. It is so 
simple to look at the throat and beyond. They do not look that 
carefully at teeth. I am not finding fault with my colleagues, 
but I am finding fault with them. It is just the same thing 
with my colleagues on the dental end. There are systemic 
linkages between periodontal disease and systemic disease. We 
have to take this further.
    If I can prevent one prenatal birth, one low birth weight, 
perhaps, I want healthy new moms giving birth.
    But let me get back, because I will start talking dentistry 
and we will be here until midnight. The piece that we do when I 
recruit--and I do a lot of recruiting hands-on. I like my 
providers to have my telephone number. I like them to have my 
pager number. I want to be involved in patient care. That is 
really my life. The statistics you asked for, that will come. 
That is not my life. My life is the kids.
    What we are doing now is you have to see not every dental 
provider is the same. You have to have unique ways of 
contracting. Reimbursement, and then measure their outcomes. 
Doctor, you don't know how they love when I say no more pre-
authorizations, no more you are getting this rate. We are going 
to make it so you are a total partnership. We only do a retro 
review to make sure our children are having the right outcomes. 
This is the uniqueness of it.
    Yes, you have to have a fee differential and, as was stated 
our Medicaid rates in Maryland have gone up. They have gone up 
throughout the country. We are recruiting. We have a more 
robust network than we ever had before.
    Mr. Kucinich. So when you say outcomes, you mean on the 
care to the patient?
    Dr. Finklestein. See, that is a better measure than HEDIS.
    Mr. Kucinich. But do you also measure their outcomes with 
respect to whether someone's care for a patient exceeds a 
certain threshold that goes beyond the capitation?
    Dr. Finklestein. We don't do capitation.
    Mr. Kucinich. Beyond the fee for service.
    Dr. Finklestein. Yes, obviously.
    Mr. Kucinich. Right.
    Dr. Finklestein. Obviously.
    Mr. Kucinich. And that has never had a bearing on whether 
someone is in the provider network?
    Dr. Finklestein. It is medical and dental. You have to----
    Mr. Kucinich. But I mean has that ever had a bearing as to 
whether or not someone is invited to be in or out of your 
    Dr. Finklestein. No, no. The barrier's could be if they are 
fraudulent, obviously, if they are fraudulent, but that is 
certainly a barrier. But the best way is to discuss and try to 
find out. What I see on a claim and radiographs, I am not the 
treating dentist, so I sit, we talk. Let's find out what is 
going on.
    Mr. Kucinich. Mr. Cummings.
    Mr. Cummings. Did you hear Ms. Norris' testimony?
    Dr. Finklestein. Yes, sir.
    Mr. Cummings. Did you hear her talk about the hoops that 
she had to go through to get a dentist in this case? I am not 
asking you to talk about this; I am just asking did you hear 
her testimony.
    Dr. Finklestein. I heard it, sir.
    Mr. Cummings. How did that make you feel?
    Dr. Finklestein. I would just say could you take the 
member's card, could you dial the 800 number and see if I 
failed you. Let us navigate it. Let us get the appointment. Let 
us be the health insurer. That is all I am asking for. If you 
want a test, check the 800 number, and that is how you check 
access to care.
    Mr. Cummings. I don't have her testimony in front of me, 
    Dr. Finklestein. I heard it.
    Mr. Cummings [continuing]. It seems like she did that. She 
did all those things. She is back there shaking her head, by 
the way.
    Dr. Finklestein. I don't know, sir.
    Mr. Cummings. Let me tell you where I am. The chairman has 
heard more of your testimony than I have. I was at another 
meeting, and so I didn't hear all of your testimony. He has 
concluded that you are a very caring person, and I believe 
that. What I find difficult to synchronize is numbers like that 
and the caring person that he has just described.
    Dr. Finklestein. Yes, sir.
    Mr. Cummings. I understand that there are a lot of people 
that work for your company. I understand that. Because this is 
the bottom line: if I make a commitment to do something and, 
for whatever reasons, don't have the capability of delivering 
it, that is a problem. And when you see numbers like that, I 
can be the most loving, caring person in the world, but if I 
can't deliver, that is a problem.
    So I guess what I am trying to say to you is, the chairman 
asked you about what you do to try to improve numbers like 
that. I would imagine that after this case you all did some 
things, but are things better in Maryland? Is that a fair 
    Dr. Finklestein. Yes.
    Mr. Cummings. Are they better?
    Dr. Finklestein. Yes, they are better in Maryland, but, on 
the other hand, we have some models in other States that are 
time that we make some changes in the Maryland model. You 
weren't here, sir, when I spoke about our Rhode Island model. 
It is a change. What we did is we took EPSDT, which is kind of 
restrictive, and mixed it into a commercial model, and we came 
out with a blend that dentists can live with. It is time. It is 
working there. It only started September 1, 2006. We didn't get 
full enrollment of 32,000 youngsters until November 1st. And 
now the State is so pleased that they are trying to increase 
more membership to United on this model.
    Whatever I do has to be re-evaluated not only by you but by 
myself. My outcomes have to constantly be evaluated. When I 
have a patient come back to me, as I had this past Saturday, of 
40 years, and I saw a restoration, a filling that I did 40 
years ago, that is pride. I have to put the pride back into 
this program, sir. If there is anything that I can do--and you 
used the word commitment. That is what I am pledging to you 
today is my commitment to make this program better throughout 
the country--that is, Medicaid--working with you and anybody 
else in collaboration, because it is unacceptable to have a 
result as we had that you read in the newspaper. That is 
    Mr. Cummings. In fairness to Ms. Norris--and I just want us 
to be clear--I just want to read a little bit of her written 
    Dr. Finklestein. Yes.
    Mr. Cummings. She's talking about DeShawn, now, that 
DeShawn was enrolled in Maryland's Medicaid HealthChoice 
program, and his managed care plan was United Health Care. ``I 
called United Health Care's customer service number.''
    Dr. Finklestein. OK.
    Mr. Cummings. The number I guess you talked about, 1-800. 
``From there, I was transferred to the plan's dental benefits 
administrator, a separate company called the Dental Benefits 
Providers, or DBP. A very helpful customer service 
representative explained that DeShawn would first have to see a 
general dentist to get a referral to an oral surgeon in order 
to get the treatment he needed. She also explained that the 
Medicaid part of United Health Care Company was called 
AmeriChoice, and that this was the company the dentist would be 
contracted with, not United Health Care.''
    Dr. Finklestein. You just hit it right on the head. It is 
    Mr. Cummings. Yes.
    Dr. Finklestein. I have to look into it. I have to look at 
root cause analysis on that.
    Mr. Cummings. Yes.
    Dr. Finklestein. There is confusion and there shouldn't be 
    Mr. Cummings. And I am telling you that when people--Dr. 
Finklestein, I have lived in the inner city and refused to move 
from the inner city for 56 years. I live where a lot of the 
people that we are talking about live, by choice. A lot of 
these folks, just trying to get from day to day is a struggle.
    Dr. Finklestein. Admittedly.
    Mr. Cummings. It is a struggle. So then when they have to 
go through these kind of hurdles, I am amazed that they got as 
far as they got. I am just being very frank with you. We can 
say what we want about them, but the fact is that is reality. 
So all I am saying is I think it is very clear that we have to 
find--first of all, nobody should have to go through what Ms. 
Norris did. Now, she is a professional, and if she is 
frustrated, a professional now, imagine somebody who is doing 
it on their own.
    So then the question becomes, if I have this product--and 
this is assuming I have a product to get them to--and if they 
have to go through 50 million changes to get there, they may 
never get there. And, as she said, once they get there, then 
there is no there. That is a problem. That is why it is very 
difficult for me to sit here and feel--I have to tell you, I am 
just being frank with you. It is hard for me, when I try to 
synchronize the way the chairman has talked about you so 
nicely, and then to see what ends up.
    I have just got a few more questions, Mr. Chairman. I can 
see you are getting anxious over there, but I am almost 
    I want to go to you, Ms. Tucker. I want to thank you for 
appearing before our committee here today, and I know it has 
not been easy. I realize that. I do appreciate your willingness 
to speak candidly, and I do appreciate all the things that 
Governor O'Malley is doing trying to straighten this situation 
out. I understand there has been legislation that has been 
passed, and the question becomes funding for the legislation. I 
am just wondering where that stands. I have been told by some 
of the people who have looked at Maryland that we have 
legislation but there is no money to do it with. Can you 
comment on that? Will you comment on that, please?
    Ms. Tucker. There was legislation this year to fund 
increased public health dental outreach efforts, and there 
wasn't funding attached to the legislation, and we are looking 
at alternative ways to do some of those activities, even 
without the funding that was attached.
    For example, there is a Maryland Health Resource Commission 
that gives out grants. It has funding to give out grants to try 
to improve health care access to different kinds of services. 
We are going to be working with that Commission to see if they 
will do a special solicitation for dental services and to try 
to fund some of what was not funded in the legislation. It was 
originally $2 million, to try to fund it through other 
mechanisms like that.
    Mr. Cummings. Well, we are going to hold you to it. I mean, 
that is just very important. I realize we are dealing with the 
legislature, and I used to be in the legislature, so I know how 
that goes, but we have a situation here where we don't want to 
see another one of these situations come forward. In the 
meantime, I think, as I said to some other folks, I do believe 
sadly these incidents like this happen, and it is very, very 
unfortunate, but it also is supposed to shine a bright light on 
places we need to go and things we need to address.
    Ms. Tucker. I agree with you.
    Mr. Cummings. Speaking of bright lights, I know that you 
have a list of strategies, which sounds very good, but one of 
the things that I did not see was oversight of managed care 
organizations. Is that a part of your----
    Ms. Tucker. That was actually the second part of my 
presentation. We do a lot of activity.
    Mr. Cummings. Did you make that presentation?
    Ms. Tucker. I did.
    Mr. Cummings. OK.
    Ms. Tucker. But we do monitor the utilization of encounter 
data. We actually require managed care organizations in our 
State to submit every medical encounter that occurs for all 
recipients, so we do look at that to look at how many 
individuals receive care, all different kinds of care, not just 
dental care.
    We require annual outreach plans. We review them carefully. 
They have to have a dental section. They have to have materials 
that they send to recipients. We review those for literacy and 
for how they are going to do that. The United dental outreach 
plan also includes incentives, $10 incentives for families who 
take their children in for a checkup, for example. There are 
all these different strategies. So there is this outreach plan 
that we review.
    Mr. Cummings. Let me ask you this: how much control does 
the Health Department, the State Health Department, have over 
the validity of the MCO's listed practitioners?
    Ms. Tucker. We monitor the MCO encounter data very 
carefully. This is not data the MCOs make out; this is data 
that providers submit. We run it through a rigorous review, 
just like we review all our claims data that comes in to our 
system, to look to make sure that the provider is on the file, 
that the procedure makes sense, that there is not duplicate 
procedures going through the system, etc., so that we can then 
do the measures to look and see what is happening with our 
    The thing that is not the best about it is that it is not 
like an electronic medical record. It is not real time. So it 
is hard to use it for tracking and for looking to see if 
children need services immediately, because what we are doing 
is the provider is billing United or AmeriGroup or any of our 
MCOs, and then they are forwarding the provider's claims data 
to the State.
    Mr. Cummings. Let me tell you something, Ms. Tucker. There 
is no one that I know of in the United States that is better at 
tracking than Governor O'Malley.
    Ms. Tucker. I understand that.
    Mr. Cummings. I am just saying I don't know of anybody.
    Ms. Tucker. Right.
    Mr. Cummings. All I am saying is maybe you ought to talk to 
the Governor, because there may be some things that he can 
bring to this process that might help us.
    Ms. Tucker. It is the whole----
    Mr. Cummings. I know it is very complicated. I understand 
    Ms. Tucker. Yes. Electronic medical records is a whole----
    Mr. Cummings. I understand. I understand. He is the master 
of that.
    Ms. Tucker. Right.
    Mr. Cummings. Let me ask you this, and this is just one 
last thing. First of all, let me go back to the chairman. I 
really do appreciate his can-do attitude. When Democrats took 
over the Congress, one of the things that we were very 
concerned about is accountability, but we are also very 
concerned about results. What the chairman has said, as I heard 
him, is we are trying to figure out results that come out of 
all of this. We just don't want to be meeting here until 9:30 
or 9. So I don't know how all this works, but you have Dr. 
Finklestein saying that he wants to do everything in his power 
to help the situation--am I right?
    Dr. Finklestein. Yes, sir.
    Mr. Cummings. And you have experts like Ms. Perkins, who 
has given wonderful testimony. I mean, is there things that you 
all can do working together to come up with some solutions? Let 
me tell you something. Let me tell you what is so frustrating 
about being here in the Congress. I'm sure the chairman will 
agree with me. Sometimes, as much as we like to make laws, it 
takes time.
    In the meantime, when people can resolve matters, that is 
nice, but it takes time. I am hoping that there are some things 
that you all can do. That is not to say that Congress will not 
act and do some things, but there are some things that perhaps 
you all can do working together with others in your situation, 
Dr. Finklestein, to help remedy some of these problems.
    I take it that you have taken some steps since this case 
came up and you are doing some things. I was just wondering, do 
any of those things involve companies like United and the 
    Ms. Tucker. The action group that we are pulling together 
has a full array of stakeholders, including MCOs, including 
dentists, including parents, public health professionals, so it 
is going to have a full array of stakeholders, including 
individuals like Ms. Norris, advocates. So we are pulling 
together this action committee.
    Mr. Cummings. And would you ask them to take a look at the 
South Carolina model?
    Ms. Tucker. We can definitely look at any models. What we 
want to do is get the group together to look at all the 
different issues, and we want them to come up with an action 
plan quickly so that they can get recommendations to the 
Secretary by September, which is still time for possible budget 
initiatives for next year. That is why the timing is kind of a 
rapid turn-around. Definitely we can look at South Carolina.
    Mr. Cummings. Like I said, I think that as a citizen of the 
State of Maryland I can tell you I want a person like Ms. 
Perkins to come before a committee and say, you know what? 
Everybody ought to be like Maryland. Maryland is a leader in 
health care and everybody ought to be like Maryland. I think 
that is so important. As I say many times, if we can send 
people to the moon, we ought to be able to do these earthly 
things and pull folks together to make things work.
    So I want to thank you all for your testimony. I know the 
chairman is going to say a few other words, but I want to thank 
you all. I don't ask, because asking is simply too cheap; I beg 
you to address these issues. We just can't have this. We can't. 
This is America. It doesn't work that way and we shouldn't have 
    Thank you all.
    Mr. Kucinich. Thank you, Mr. Cummings. I want to thank you 
for all the work that you have done today and in cooperating to 
put this hearing together.
    We can send someone to the moon, but the question of this 
hearing is can we send a child into a dental chair. According 
to the Congressional Research Service, of the 502,000 Maryland 
children eligible for Medicaid in 2005, 75 percent, or 375,000, 
did not receive even one preventive dental service during the 
    What is the State's plan for accelerating its rate of 
    Ms. Tucker. As I outlined in my testimony, what we are 
doing is we are pulling together this Dental Action Committee 
to look at all sorts of strategies. Medicaid agencies can't do 
this by ourselves. We need the dental community to be involved, 
the provider community. We need parents to be involved. We need 
Federal policymakers like you all to help us with funding for 
some of the safety net connects to make sure that federally 
qualified health centers have dental suites, to consider 
screening in schools. We need your help.
    Mr. Kucinich. So would you agree that there is a connection 
between low dental payment rates for providers and the lack of 
access to the dental chair?
    Ms. Tucker. I definitely think there is a problem, but it 
is not the whole problem. For example, Ms. Perkins just talked 
about the District of Columbia. They have the highest rate in 
the area, and yet their dental utilizations seem to be very, 
very poor.
    We have tried to work on improving dental rates, but our 
rates are still low in Maryland.
    About 2 or 3 years ago the State of Maryland decided to 
finally bring physician rates up to the Medicare rates. Our 
physician rates had lagged for years and years and years, and 
some of them were 10 percent of Medicare rates they were so 
low. The legislature decided to tackle that and provide over a 
5-year funding to try to bring us up to 80 percent of Medicare.
    Mr. Kucinich. Now let's----
    Ms. Tucker. We need to do the same kind of thing with 
dental. We need----
    Mr. Kucinich. OK. So here is the question: has the 
Department required managed care organizations to beef up their 
provider networks with dentists who will actually accept as 
patients the low-income children for whom the managed care 
organization has responsibility for managing care?
    Ms. Tucker. I think that I have heard a lot of very 
distressing testimony about the dental networks. We do know 
that there are 918 unduplicated dentists in the networks that 
the MCOs use. We do know that those dentists do bill. What that 
means is that they have accepted Medicaid patients, that they 
are seeing Medicaid patients, but what it doesn't mean is that 
they are open to new patients necessarily, which is bad.
    Mr. Kucinich. We had Dr. Tinanoff looking at 19 of 
Maryland's 23 counties, and he found that, of 743 listed 
dentists, only 170 are willing to accept new Medicaid patients.
    Ms. Tucker. New patients. I agree. And we have to look at a 
different way to give information to patients. Rather than 
giving them lists of providers who have contracts with MCOs, we 
are going to have to look at, instead, not giving them lists of 
providers that have contracts, but actually actively linking 
them with a dentist that does accept new patients.
    Mr. Kucinich. The next question is how can the Department 
expect parents to find dentists for their children if the 
information that is provided isn't reliable?
    Ms. Tucker. I totally agree. One of the things that we are 
doing is we are meeting tomorrow with the MCOs to talk about 
all of the dental issues that have come up in the hearing 
today, and that we have been talking about actually over the 
years and during the last 2 months. This is going to be one of 
the top items on the agenda.
    Mr. Kucinich. So has the Department required these managed 
care organizations to demonstrate improved outcomes in the 
dental health of low-income children for whom they have the 
responsibility for managing care, such as a reduction of 
untreated cavities?
    Ms. Tucker. That is a really hard measure to get at. What 
you would have to do is you would have to do actual oral exams 
of Medicaid patients to then measure that. What we try to do is 
look for measures where we can get data. But this is something 
that we are going to need to talk to, again, with our Action 
Committee to see if there are some other measures that we might 
be able to use in addition to the HEDIS measure.
    The reason that we do use the HEDIS measure is because it 
is the only way we can compare our performance with other 
States. It is the only measure that the managed care system 
uses across the board, and so that is the measure we have used, 
but it doesn't mean it is the ideal measure or it is an 
outcomes oriented measure, so it is something that we should 
talk about in our action committee.
    Mr. Kucinich. So do you regularly check the number of 
providers still? Do you run a constant canvass on the number of 
providers? How often do you update your number of providers?
    Ms. Tucker. I actually am not sure how often we do that. I 
do know that we look to see if the providers are billing, and 
we do look to see if they have contracts with the MCOs. But I 
am not sure that we do regular checks in terms of whether or 
not they are open. I know that they open and close frequently. 
It is very frustrating in trying to monitor that situation.
    Mr. Kucinich. Well, do you think it would be helpful if you 
found a way to be in contact or have some vehicle for 
contacting providers so you would be able to really know how 
many providers you have, and therefore you could guess how many 
people are going to be able to have access to some of these?
    Ms. Tucker. We can try to set up a program. It is only 
going to be as good as the day you do the calls, because they 
open and close at will, based on their current case load.
    Mr. Kucinich. In your testimony you talked about you made 
20 calls?
    Ms. Tucker. I did not. It must have been someone else's 
    Mr. Kucinich. OK. I would like to ask Ms. Perkins a 
question about D.C. You talked about the accuracy of lists?
    Ms. Perkins. Yes.
    Mr. Kucinich. How accurate are those lists?
    Ms. Perkins. We have looked at them on a couple of 
different occasions in March 2005. Let me just say that it was 
very difficult getting these lists in the first place from the 
District, who was having great difficulty getting them from the 
managed care organizations, but of the 135 unduplicated dental 
providers named, only 45 individual dentists and one clinic 
confirmed that they accepted Medicaid eligible children, that 
is even to take one child. It doesn't say anything about the 
extent of participation.
    And of those 45 dentists, 29 were general dentists, 6 were 
oral surgeons, 3 were pediatric dentists, and there was one 
orthodontist. When you check that one orthodontist, there were 
four plans. There were two MCOs in the District who had no 
orthodontist on their plan.
    Mr. Kucinich. And you did testify that only 16 percent of 
children received any dental treatment services at all with 
respect to in States that were reporting to the CMS.
    Ms. Perkins. In 2004. We could not use 2005 data because, 
although it appears that the GAO was able to get access to 
additional data that is not publicly available, there are 15 
States missing in the public data.
    Mr. Kucinich. What was the percentage of dentists you say 
that participate in Medicaid? Did you say 5 percent overall?
    Ms. Perkins. In the District of Columbia, 5 percent of 
licensed dentists. Again, that is just meaning that they take 
one person. It doesn't say how active that participation is, 
whether they have age cutoffs for the number of kids they are 
going to serve, or whether they limit the number of patients 
they are going to serve.
    Mr. Kucinich. And I want to ask a question to Ms. Tucker. 
Thank you. In your contract with United Health Care there is a 
managed care reimbursement clause that states that ``The 
Department has the authority to recover any over-payments made 
to MCOs.'' The contract does not define over-payments. Do you 
consider the capitation payments made for children who do not 
receive services that they need, such as Deamonte, do you 
consider that an overpayment?
    Ms. Tucker. No, sir.
    Mr. Kucinich. And how many years would have to pass during 
which children did not get the services they needed for it to 
be considered that an overpayment has been made?
    Ms. Tucker. There is no time limit. That isn't the 
methodology for developing it, a capitation rate. A capitation 
rate is based on the general population in the program, and it 
is more of an average rate for individuals in different groups.
    Mr. Kucinich. I understand, but what do you do with 
children who chronically receive no services? I mean, does the 
State hold these managed care organizations accountable by 
recovering payments made for children who chronically receive 
no services?
    Ms. Tucker. We don't. It is not a fee for service program, 
so we don't do a cost settlement based on each individual 
child, just like we don't pay them more if they spend more on 
other individuals. That is not the way capitation works. That 
is not the way insurance works. We are not just paying them for 
providing those services; we are providing them for taking 
risks for catastrophic services, as well. It is all built into 
the capitation rate.
    Mr. Kucinich. OK.
    Ms. Tucker. So, again, it is not a fee for service program, 
and it is not a program with--no insurance is a program where, 
when you are paying for insurance, other than a fee for 
service, no insurance program is one where you pay for the 
individual patient's cost, or capitation program.
    Mr. Kucinich. OK. I think we are at the point where we are 
going to be soon concluding this hearing, and I want to thank 
all of those who came here to testify and participate in what 
has been a very long day on a very critical subject.
    I think that, Mr. Cummings, you would agree that, with the 
individuals on this committee who have participated from this 
afternoon, that there is a high degree of interest in looking 
at some policy issues here where Congress can effectively 
participate to make sure that the case of Deamonte is never 
going to be repeated.
    Before I conclude, would you like to say something?
    Mr. Cummings. I would just like to thank our witnesses. I 
know it has been a very long day. If there are things that you 
all want to submit--Ms. Tucker, you, in particular, I noticed 
some things in your testimony--but if there are things that you 
want to submit as to what we can do to help move this process 
along, we would ask that you submit it as soon as possible. 
There may have been some things that you heard today that 
caused you to say well maybe this is something the Congress 
needs to look at. We just want to be effective and efficient 
and make a positive difference.
    Thank you all very much.
    Mr. Kucinich. Thank you, Mr. Cummings.
    I am going to just have a final word here.
    In the United States of America we spend approximately $2.2 
trillion a year on health care. That is about 16 percent of our 
gross domestic product. About 31 cents on $1, according to a 
Harvard University study, goes for the activities of the for-
profit health care sector for corporate profits, stock options, 
executive salaries, advertising, marketing, the cost of 
paperwork, 15 to 30 percent in the private sector as compared 
to Medicare's 2 to 3 percent.
    If the United States had a health care program where it was 
not for profit and we took the approximately $660 billion a 
year that is spent in for-profit medicine and put it into a 
not-for-profit system, we would have enough not only to meet 
all medical needs but to provide every child, and every 
American, for that matter, with fully paid dental care, fully 
covered, vision care, mental health, long-term care, 
prescription drugs that, in fact, Americans are already paying 
for this. They are not getting it. We are talking about a 
system that would have no premiums, co-pays, deductibles. This 
is the essence of the Conyers-Kucinich bill, H.R. 676.
    I mention that because when I think of the doctor's 
commitment to children, I share that same commitment. I think 
of how we may some day in this country create a system where 
everyone is covered, and then people aren't chasing around 
trying to find someone because every dentist would be required 
to provide care and they would receive a fair reimbursement.
    So it may be that down the road there is only going to be 
one solution to this, but in the meantime we have a lot of work 
to do. The witnesses here have all helped us provide some very 
detailed definition to the work that is cut out for us.
    I think it is worthy of our efforts to devote our continued 
work to the memory of Deamonte, because this little boy whose 
life demonstrated a total breakdown of a system, maybe what we 
can do is provide some deeper meaning that can help children 
everywhere get the care they need.
    Thank you.
    I am Dennis Kucinich. This is the Subcommittee on Domestic 
Policy. I am here with Congressman Cummings from Maryland. We 
have held a day-long and into-the-evening hearing on evaluating 
pediatric dental care under Medicaid.
    I want to thank all the witnesses.
    This committee is adjourned.
    [Whereupon, at 9:15 p.m., the subcommittee was adjourned.]
    [The prepared statement of Hon. Edolphus Towns and 
additional information submitted for the hearing record