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


 
INSURING BRIGHT FUTURES: IMPROVING ACCESS TO DENTAL CARE AND PROVIDING 
                               A HEALTHY
                           START FOR CHILDREN

=======================================================================

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                             MARCH 27, 2007

                               __________

                           Serial No. 110-25


      Printed for the use of the Committee on Energy and Commerce

                        energycommerce.house.gov


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                    COMMITTEE ON ENERGY AND COMMERCE

    JOHN D. DINGELL, Michigan,       JOE BARTON, Texas
             Chairman                    Ranking Member
HENRY A. WAXMAN, California          RALPH M. HALL, Texas
EDWARD J. MARKEY, Massachusetts      J. DENNIS HASTERT, Illinois
RICK BOUCHER, Virginia               FRED UPTON, Michigan
EDOLPHUS TOWNS, New York             CLIFF STEARNS, Florida
FRANK PALLONE, Jr., New Jersey       NATHAN DEAL, Georgia
BART GORDON, Tennessee               ED WHITFIELD, Kentucky
BOBBY L. RUSH, Illinois              BARBARA CUBIN, Wyoming
ANNA G. ESHOO, California            JOHN SHIMKUS, Illinois
BART STUPAK, Michigan                HEATHER WILSON, New Mexico
ELIOT L. ENGEL, New York             JOHN B. SHADEGG, Arizona
ALBERT RUSSELL WYNN, Maryland        CHARLES W. ``CHIP'' PICKERING, 
GENE GREEN, Texas                        Mississippi
DIANA DeGETTE, Colorado              VITO FOSSELLA, New York
    Vice Chairman                    STEVE BUYER, Indiana
LOIS CAPPS, California               GEORGE RADANOVICH, California
MIKE DOYLE, Pennsylvania             JOSEPH R. PITTS, Pennsylvania
JANE HARMAN, California              MARY BONO, California
TOM ALLEN, Maine                     GREG WALDEN, Oregon
JAN SCHAKOWSKY, Illinois             LEE TERRY, Nebraska
HILDA L. SOLIS, California           MIKE FERGUSON, New Jersey
CHARLES A. GONZALEZ, Texas           MIKE ROGERS, Michigan
JAY INSLEE, Washington               SUE WILKINS MYRICK, North Carolina
TAMMY BALDWIN, Wisconsin             JOHN SULLIVAN, Oklahoma
MIKE ROSS, Arkansas                  TIM MURPHY, Pennsylvania
DARLENE HOOLEY, Oregon               MICHAEL C. BURGESS, Texas
ANTHONY D. WEINER, New York          MARSHA BLACKBURN, Tennessee        
JIM MATHESON, Utah                   
G.K. BUTTERFIELD, North Carolina     
CHARLIE MELANCON, Louisiana          
JOHN BARROW, Georgia                 
BARON P. HILL, Indiana               
                                     
_________________________________________________________________

                           Professional Staff

   Dennis B. Fitzgibbons, Staff 
             Director
Gregg A. Rothschild, Chief Counsel
   Sharon E. Davis, Chief Clerk
   Bud Albright, Minority Staff 
             Director

                                  (ii)
                         Subcommittee on Health

                FRANK PALLONE, Jr., New Jersey, Chairman
HENRY A. WAXMAN, California          NATHAN DEAL, Georgia,
EDOLPHUS TOWNS, New York                 Ranking Member
BART GORDON, Tennessee               RALPH M. HALL, Texas
ANNA G. ESHOO, California            BARBARA CUBIN, Wyoming
GENE GREEN, Texas                    HEATHER WILSON, New Mexico
    Vice Chairman                    JOHN B. SHADEGG, Arizona
DIANA DeGETTE, Colorado              STEVE BUYER, Indiana
LOIS CAPPS, California               JOSEPH R. PITTS, Pennsylvania
TOM ALLEN, Maine                     MIKE FERGUSON, New Jersey
TAMMY BALDWIN, Wisconsin             MIKE ROGERS, Michigan
ELIOT L. ENGEL, New York             SUE WILKINS MYRICK, North Carolina
JAN SCHAKOWSKY, Illinois             JOHN SULLIVAN, Oklahoma
HILDA L. SOLIS, California           TIM MURPHY, Pennsylvania
MIKE ROSS, Arkansas                  MICHAEL C. BURGESS, Texas
DARLENE HOOLEY, Oregon               MARSHA BLACKBURN, Tennessee
ANTHONY D. WEINER, New York          JOE BARTON, Texas (ex officio)
JIM MATHESON, Utah
JOHN D. DINGELL, Michigan (ex 
    officio)
  
                             C O N T E N T S

                              ----------                              
                                                                   Page
Allen, Hon. Tom, a Representative in Congress from the State of 
  Maine, opening statement.......................................    12
Blackburn, Hon. Marsha, a Representative in Congress from the 
  State of Tennessee, opening statement..........................     6
Burgess, Hon. Michael C., a Representative in Congress from the 
  State of Texas, opening statement..............................     8
Capps, Hon. Lois, a Representative in Congress from the State of 
  California, opening statement..................................     9
Deal, Hon. Nathan, a Representative in Congress from the State of 
  Georgia, opening statement.....................................     3
DeGette, Hon. Diana, a Representative in Congress from the State 
  of Colorado, opening statement.................................     6
    Prepared statement...........................................     7
Dingell, Hon. John D., a Representative in Congress from the 
  State of Michigan, prepared statement..........................    18
Engel, Hon. Eliot, a Representative in Congress from the State of 
  New York, opening statement....................................    17
Eshoo, Hon. Anna G., a Representative in Congress from the State 
  of California, prepared statement..............................    19
Green, Hon. Gene, a Representative in Congress from the State of 
  Texas, opening statement.......................................     4
Hooley, Hon. Darlene, a Representative in Congress from the State 
  of Oregon, opening statement...................................    14
Matheson, Hon. Jim, a Representative in Congress from the State 
  of Utah, opening statement.....................................    15
Murphy, Hon. Tim, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................    11
Pallone, Hon. Frank Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     1
Solis, Hon. Hilda, a Representative in Congress from the State of 
  California, opening statement..................................    13
Towns, Hon. Edolphus, a Representative in Congress from the State 
  of New York, opening statement.................................    16
Wilson, Hon. Heather, a Representative in Congress from the State 
  of New Mexico, opening statement...............................    13

                               Witnesses

Chapman, Jack, M.D., president, Health Access Initiative, 
  Gainesville, GA................................................    81
    Prepared statement...........................................    83
Corbin, Stephen B., D.D.S., senior vice president, constituent 
  services and support, Special Olympics International, 
  Washington, DC.................................................    56
    Prepared statement...........................................    58
Edelstein, Burton L., D.D.S., founding director, Children's 
  Dental Health Project, Washington, DC..........................    19
    Prepared statement...........................................    21
Farrell, Christine, Medicaid policy specialist, Michigan 
  Department of Community Health, Lansing, MI....................    45
    Prepared statement...........................................    47
Koyanagi, Chris, policy director, Bazelon Center for Mental 
  Health Law, Washington, DC.....................................    84
    Prepared statement...........................................    86
Krol, David M., M.D., associate professor, pediatrics, University 
  of Toledo College of Medicine, Toledo, OH, on behalf of the 
  American Academy of Pediatrics.................................    76
    Prepared statement...........................................    78
Mosca, Nicholas G., D.D.S., clinical professor, pediatric and 
  public health dentistry, University of Mississippi School of 
  Dentistry, Jackson, MS, on behalf of American Dental Education 
  Association....................................................    49
    Prepared statement...........................................    51
Roth, Kathleen, D.D.S., president, American Dental Association, 
  Washington, DC.................................................    24
    Prepared statement...........................................    26
Scheppach, Raymond C., executive director, National Governors 
  Association, Washington, DC....................................    40
    Prepared statement...........................................    41

                           Submitted Material

Hoyer, Hon. Steny, a Representative in Congress from the State of 
  Maryland, statement............................................    98
Fletcher, Hon. Ernie, Governor, Commonwealth of Kentucky, letter 
  of March 15, 2007 to the Committee on Energy and Commerce......   100
``For Want of a Dentist,'' article from the Washington Post of 
  February 28, 2007, by Mary Otto................................   101
McClellan, Mark B., M.D., Administrator, Centers for Medicare and 
  Medicaid Services, statement, submitted by Mr. Deal............   107
Leavitt, Michael O., Secretary, Department of Health and Human 
  Services, letter of August 25, 2006 to Mr. Barton, submitted by 
  Mr. Deal.......................................................   107


                   INSURING BRIGHT FUTURES: IMPROVING
                   ACCESS TO DENTAL CARE AND PROVIDING
                      A HEALTHY START FOR CHILDREN

                              ----------                              


                        TUESDAY, MARCH 27, 2007

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:10 a.m., in 
room 2123 of the Rayburn House Office Building, Hon. Frank 
Pallone, Jr. (chairman) presiding.
    Members present: Representatives Towns, Green, DeGette, 
Capps, Allen, Baldwin, Engel, Solis, Hooley, Matheson, Deal, 
Murphy, Burgess, Blackburn and Wilson.
    Staff present: Elizabeth Ertel, Yvette Fontenot, Brin 
Frazier, Amy Hall, Christie Houlihan, Bridgett Taylor, Lauren 
Bloomberg, and Robert Clark.

 OPENING STATEMENT OF HON. FRANK PALLONE JR., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. I want to call the subcommittee to order.
    Today we are having a hearing on ``Insuring Bright Futures: 
Improving Access to Dental Care and Providing a Healthy Start 
for Children.'' I now would recognize myself for an opening 
statement.
    I would like to thank our witnesses for appearing before 
the subcommittee today and I am certain that we will learn much 
from your expertise. Today's hearing was brought about after a 
12-year-old Maryland boy lost his life because he was unable to 
access the dental care he needed to treat an abscessed tooth. 
What started out as a simple toothache quickly developed into a 
far worse problem that cut the boy's life far too short. When 
news of this tragedy spread throughout the country, many people 
were shocked. It was unimaginable to think that something as 
minor as a toothache could have such dire consequences.
    Indeed, for most of us, we take for granted the convenience 
of going to see a dentist, but the truth of the matter is, for 
millions of Americans, proper dental care is often out of reach 
and sadly, most of those people are children. Indeed, the truly 
frightening thing about Diamonte Driver's death is the number 
of American children who are at risk of a similar fate. The 
problem of poor oral health is nationwide and impacts millions 
of children. There has already been another boy in Mississippi 
who died because of delayed dental care.
    Now, the question is: just how big is this problem? 
Statistics show that chronic infectious disease that causes 
cavities remains second only to the common cold in terms of 
prevalence in children. Unlike a cold, however, tooth decay 
does not go away; it only gets worse. Pain from untreated 
dental disease can make it difficult for children to eat, 
sleep, pay attention in school, and it can affect their self-
esteem. Poor children are more than twice as likely to have 
cavities than children who come from wealthier households. 
Medicaid is able to provide comprehensive dental care to many 
low-income children through its early periodic screening, 
diagnosis and treatment benefits. Similarly, many States 
provide dental benefits as part of their children's health 
insurance programs, and I have no doubt that if it were not for 
these two programs, the problems that our children face in 
securing primary dental care would be exponentially worse.
    But clearly, we need to do more. There are many children 
who are eligible for Medicaid or SCHIP who are not enrolled. 
That means that there are millions of children who should be 
receiving dental care but are not, and we need to invest more 
funds to improve enrollment in these important programs and 
provide the financial resources to ensure that they can access 
the benefits once they are enrolled. But there are many 
children who are not eligible for public health insurance 
programs who are unable to also receive proper dental care.
    When I am home in New Jersey and I am visiting a community 
health center or a hospital clinic, I see firsthand how 
difficult it is for low-income families to obtain primary 
dental care. The community health centers that I talk to 
describe the difficulty they have in securing dentists to 
provide care to their patients, and I look forward to hearing 
from our witnesses about their recommendations on how Congress 
might be able to encourage dentists to provide care in many of 
these underserved communities. But the problem of access to 
dental care goes even further. For millions of Americans who 
have health insurance, dental benefits are often not included. 
Indeed, millions of families who obtain their health insurance 
from their employers do not have policies that cover dental 
care, leaving them with few places to seek care.
    I truly believe that we are seeing a crisis when it comes 
to dental care for kids but poor oral health is just the tip of 
the iceberg. It certainly is not the only health care problem 
affecting our Nation's children. Obesity, for example. Obesity 
rates among adolescents have doubled in the past two decades 
and now affects 16 percent of children ages 16 to 19. When 
compared with other developed countries, it is very clear that 
our fragmented health system is failing our children, and as a 
consequence, our children are suffering. The United States 
maintains higher rates of infant and child mortality, higher 
prevalence of asthma, and injuries and rapidly increasing rates 
of mental health problems with a limited ability to respond. 
Congress can and should do more to address these problems. 
Unfortunately, over the years, the interest of our children has 
often taken a back seat to more politically powerful interests. 
Unfortunately, I think that it has been too easy for previous 
Congresses to overlook the needs of our children simply because 
they lack the political voice that other groups might have, and 
that clearly needs to change. Our Nation's children can no 
longer wait for Congress to act on this pressing health issue. 
The longer we wait, the more children we put at risk.
    A Nobel laureate and poet, Gabrielle Mistral, said, and I 
quote, ``Many things we need can wait. The child cannot. Now is 
the time. His bones are being formed, his blood is being made, 
his mind is being developed. To him, we cannot say tomorrow. 
His name is today.'' And I don't know if it is proper but I 
will say that because this is so important, I have my own wife 
and children here today listening to the hearing, at least in 
the beginning, and I mention that only because I can relate to 
the problems that these kids face and it is one of the reasons 
that I am particularly interested in it because I have children 
of my own.
     So with that, I will yield back my time and recognize the 
ranking member, Mr. Deal, for an opening statement.

  OPENING STATEMENT OF HON. NATHAN DEAL, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF GEORGIA

    Mr. Deal. Thank you, Mr. Chairman, and welcome to our 
panelists and to our guests, and I am pleased to see Mr. 
Pallone's family here too and I see at least one set of braces 
over there so he is contributing to the industry, I might add.
    I understand we have some special guests in our audience 
today, Mr. Chairman, some members of the American Dental 
Association. If it would be appropriate, I would like to see 
them if they would raise their hands, please. Don't be bashful. 
Oh, there they are. Oh, they are everywhere. I thought they 
were a bigger crowd than that. Well, let me thank you for being 
here. Certainly this is an important component of addressing 
the future needs of dental services in our country. My State, I 
am told, that we have about 240 dentists every year who are 
retiring and we are only graduating about 60, as I understand 
it, from our dental schools. So it is important for you to 
continue in your educational pursuits, and we thank you for 
coming today.
    Our hearing today is an essential element of focusing on 
essential elements of children's care and that is their dental 
care, and I would thank our witnesses and I look forward to 
their testimony. Our witnesses, I am sure, today will tell us 
that there are a number of barriers to proper oral health care 
despite the fact that all States must provide dental services 
as a part of their Medicaid programs and every State with an 
SCHIP program includes dental benefits. It seems that the 
impediments to adequate coverage in the public programs exist 
not necessarily because the benefit does not exist. For 
instance, many dentists choose not to participate in the public 
programs. In 2000, only about a quarter, 26.3 percent, of 
dentists participated in the Medicaid program. Also in my 
conversations with dentists, many cite the overwhelming 
administrative burden of providing services through the public 
programs. I believe it is shortsighted to point only to 
reimbursement levels when dentists will choose to provide their 
services on a pro bono basis rather than participate in the 
public programs. Moreover, many people do not recognize the 
importance of oral health and simply fail to take advantage of 
the benefits that are available to them. This is true for both 
individuals covered by private and public insurance. Dental 
services are certainly an important component of health care 
coverage but encouraging individuals to take advantage of 
provided benefits seems equally important. At some point, 
people must take responsibility for their oral health on a 
regular basis.
    I am afraid that many in our committee have an interest in 
creating mandates with SCHIP like the dental benefit in 
Medicaid which would make it more difficult for States to 
provide health coverage appropriate to the needs and conditions 
of the individual States. The Governors' frequent frustration 
with the rigid structure of the Medicaid program helped inform 
the steps we took in the Deficit Reduction Act to provide 
benefit flexibility to the States in Medicaid. This flexibility 
allows Governors to design effective programs which meet the 
specific needs of their State. Dr. Scheppach will tell us how 
the flexibility of the SCHIP program contributes significantly 
to its success. I fear that if we remove the flexibility of 
SCHIP, we will seriously hamper the States' ability to design 
innovative health care reform proposals to cover their 
uninsured.
    In these discussions about SCHIP and Medicaid, it is also 
too easy to lose sight of the role played by free clinics, 
health centers and collaborations like the Health Access 
Initiative in my hometown, and we will have a speaker on the 
next panel to talk about it. These organizations provide an 
effective way to bring health care to the uninsured. For 
instance, in the case of dental care, dentists who may want to 
avoid the administrative burden of the Federal programs but 
still want to help meet the needs of their local community 
could volunteer their time at a clinic. I hope the committee 
will spend time examining ways to make these initiatives and 
institutions more effective, perhaps through liability reform 
or even providing a tax deduction to physicians who provide 
their services for free in a clinic setting.
    I look forward to the testimony of the witnesses today and 
to their insights into this very distinct and unique problem, 
and I am sure that we will be informed by your testimony. Thank 
you for being here.
    Thank you, Mr. Chairman.
    Mr. Pallone. Thank you, Mr. Deal.
    I now recognize our vice chair, Mr. Green from Texas.

   OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF TEXAS

    Mr. Green. Thank you, Mr. Chairman, for holding this 
hearing on access to dental care for our Nation's children.
    I am glad that one of our early hearings on access issues 
will highlight dental care because it is such an important 
component of children's health care. Tooth decay remains the 
most prevalent chronic health care condition faced by our 
children today, which is why dental issues should be part of 
our discussion involving increased access to health care. A 
lack of access to dental care is no different from other health 
care since the effect of inaction is the same. Without 
preventive dental care, dental problems are often left 
untreated until they reach emergency proportions and the 
patient arrives in the hospital emergency room with a condition 
that could have been treated earlier and at much lower cost. In 
fact, Medicaid statistics show that the cost of managed dental 
problems through preventive dental care is 10 times less costly 
than inpatient dental treatment in hospital ERs. Despite the 
obvious benefit of preventive dental care, we have serious 
uninsured problems with dental benefits that restrict access to 
care. In fact, for every child who goes without health 
insurance, there are three children who lack dental insurance. 
This discrepancy leaves children without insurance being five 
times as likely to have unmet dental needs than their 
classmates who have insurance.
    Unfortunately, Congress contributed to this disparate 
treatment of dental and health insurance when it created the 
State Children's Health Insurance Program in 1997. While States 
that use SCHIP dollars to expand their Medicaid programs had to 
include the full range of dental benefits provided to the 
traditional Medicaid population, Congress made the dental 
benefit optional for States like Texas, who have separate SCHIP 
programs. The result, when funding got tight and State 
legislators got a little uncomfortable about balanced budgets, 
the SCHIP dental benefit found itself on the chopping block and 
I am sorry to say that is exactly what the Texas Legislature 
did in 2003 when it was the first State in the country to 
eliminate the SCHIP program's dental benefit. I understand the 
State of Georgia is considering a similar tactic and I assure 
my friends in Georgia that the elimination of this critical 
benefit is a misguided health policy. In fact, we may have an 
amendment we might call the Charlie Norwood amendment since Dr. 
Norwood served on our committee a very long time and passed 
away recently and was a dentist in Georgia.
    In Texas, public outrage over SCHIP dental policy and other 
cuts led the State legislature to restore the benefit in 2005. 
Unfortunately, the Texas children got only half a loaf with the 
Texas SCHIP program imposing $175 annual cap on preventive and 
diagnostic services and a $400 cap per enrolled child on 
therapeutic services like tooth extractions and root canals. 
Despite being passed in 2005, the benefit only became available 
to Texas children in the beginning of April 2006, meaning that 
too many of the 300,0000 Texas children that remain on SCHIP 
rolls went far too long without dental checkups and preventive 
services.
    The recent news of the 12-year-old child in Maryland who 
died tragically and needlessly from complications of untreated 
dental infection sheds an unmistakable light on our children's 
needs for increased access to dental care. Sadly, the problem 
is not limited to Maryland. In fact, 46 counties out of our 254 
in my State of Texas do not have a practicing dentist. Without 
access to dental care, the children living in these counties 
and similar communities throughout the country have little more 
than hope to ensure that their dental health does not 
deteriorate into irreversible health problems.
    I want to thank the chairman for drawing attention to this 
as we focus on improving access to health care and specifically 
the SCHIP reauthorization. I hope that we will take the 
opportunity to address the dental needs of our children and do 
everything possible to increase their access to critical dental 
care, and again, I thank our witnesses on our two panels today, 
and I yield back my time.
    Mr. Pallone. Thank you, Mr. Green.
    I recognize the gentlewoman from Tennessee, Mrs. Blackburn.

OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF TENNESSEE

    Mrs. Blackburn. I thank the chairman for holding this 
hearing today and I want to extend my welcome to your family. 
Also, I appreciate the panel that is before us. I am delighted 
that we have a diverse panel of witnesses who have assembled 
for us today.
    I think we all agree that lack of access and lack of 
knowledge of how to use that access when it comes to dental 
health services for children is a serious problem. It is also a 
frustrating problem and it is one that could be remedied and 
should be remedied with some commonsense, practical solutions. 
We all know the Centers for Disease Control numbers that nearly 
25 percent of our children under age 5 are affected by dental 
decay and half of our children age 12 to 15 are affected. We 
know that low-income children are the hardest hit and that 
about half of those 6 to 19 have untreated decay, absolutely 
phenomenal numbers when you think about this being 2007. We 
also know that these untreated cavities can cause pain, 
dysfunction, absence from school, underweight, poor appearance, 
all items that greatly affect a child's ability to be 
successful in their current life and in their future life, and 
these facts are disturbing to all of us.
    At a time when we are shifting from responsive medicine to 
preventative medicine, there is no excuse for allowing the 
problem to continue. We all had grandmothers who would quote to 
us, ``an ounce of prevention is worth a pound of cure.'' We 
should apply this to the problem of children's dental health. 
Not only is proper oral care common sense, it is also extremely 
cost-effective and provides significant savings of health care 
dollars during an individual's entire lifetime.
    I am looking forward to hearing the testimony today and 
working with all of you on how we can best address the 
situation, how we consider SCHIP, how we allow States 
flexibility, and how we continue and allow health care 
innovation. I am looking forward to a thoughtful consideration 
of the options before us.
    I yield back.
    Mr. Pallone. Thank you.
    I recognize the gentlewoman from Colorado, Ms. DeGette.

 OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF COLORADO

    Ms. DeGette. Thank you, Mr. Chairman. I would ask unanimous 
consent to put my full statement in the record and simply point 
out that as we consider the need for dental coverage for 
children, we also need to think about the need for more dental 
providers to give those children care.
    The title VII primary medicine and dentistry cluster plays 
a critical role in our Nation's health care safety net. 
Programs supported by title VII produce an essential pipeline 
for a number of essential medical providers, general and 
pediatric dentists who go on to work in community health 
centers, rural health clinics, inner city urban clinics, 
hospitals and dental school clinics, exactly the providers that 
serve the populations we are talking about today. These are the 
places where the SCHIP kids are enrolled and other indigent 
kids who don't have any other recourse to dental care. Funding 
for all of title VII has been drastically cut in the last few 
years, which severely constricts our pipeline for dentists. I 
hope the witnesses today will talk with us about the challenges 
faced in States to meet the demand for dentists, because if we 
don't have dentists, it is going to be hard to see how we can 
give all of our kids dental care.
    One other issue I want to mention, as we look at the 
reauthorization of SCHIP, we need to examine, as Mr. Pallone 
says, the holistic needs of the child, not just the dentistry, 
not just the medical needs, but we also need to look at mental 
health for the kids and I think that is widely underestimated. 
I also serve on the Oversight and Investigation Subcommittee 
which had a hearing last week about the medical infrastructure 
of New Orleans and trying to rebuild after Hurricane Katrina. 
Over and over again, we heard from providers in community 
health centers about the unbelievable need for mental health 
services. This is particularly true for children who have lost 
everything, who are depressed and who in many cases have 
suffered post-traumatic stress disorder yet while we know the 
need for mental health care services is severe in the 
hurricane-affected regions, the need is no less acute for other 
children around the country. Many face mental and behavioral 
health problems as well as developmental disabilities that 
require extensive care and that is care that they are currently 
unable to afford. I know the primary purpose of this hearing is 
dentistry but on the second panel we have witnesses who can 
help us talk about these other challenges for children and how 
we can use SCHIP more effectively to address their needs.
    Mr. Chairman, reauthorization of SCHIP is of paramount 
importance both to myself and to this committee in the next few 
months. As we do so though, we need to make sure that we 
carefully consider all of the health needs of those children 
and how we can best meet them.
    I yield back the balance of my time.
    [The prepared statement of Ms. DeGette follows:]

Prepared Statement of Hon. Diana DeGette, a Representative in Congress 
                       from the State of Colorado

    Mr. Chairman, thank you for calling this hearing today. As 
we prepare to reauthorize the State Children's Health Insurance 
Program (SCHIP) it is critical that we ensure that the benefits 
provided through this program effectively meet the health care 
needs of the children enrolled.
    As we have all heard, two young boys--one in Maryland, one 
in Mississippi--recently lost their lives when an infection 
from an abscess tooth spread into their blood. In both cases, 
each boy lacked health insurance with dental coverage. Instead 
of a minor procedure in a dentist's office, the boys were 
rushed to the emergency room, underwent extensive surgery, and 
eventually died. In the case of the boy in Maryland, $250,000 
worth of care was spent to keep him alive. Covering this boy in 
SCHIP with proper dental coverage would have prevented this 
from occurring.
    As we consider the need for dental coverage for children, I 
hope that we can also discuss the need for more dental 
providers to give care. The Title VII Primary Medicine and 
Dentistry cluster plays a critical role in our Nation's health 
care safety net. Programs supported by title VII produce an 
essential pipeline for a number of essential medical providers, 
general and pediatric dentists who go on to work in community 
health centers, rural health clinics, inner city urban clinics, 
hospitals and dental school clinics. These are the very places 
that provide much of the dental care to those children enrolled 
in SCHIP. Funding for all of title VII has been drastically cut 
in recent years, severely constricting our pipeline for 
dentists. I hope that our witnesses will be able to share with 
us today the challenges faced in states to meet the demand for 
dentists.
    Mr. Chairman, in addition to the Health Subcommittee, I 
also serve on the Oversight and Investigations Subcommittee. We 
recently held a hearing about rebuilding the medical 
infrastructure of New Orleans after Hurricane Katrina. Over and 
over again, we heard from providers in community health centers 
about the need for mental health care services. This is 
particularly true for children, who have lost everything, who 
are depressed, and in many cases have post-traumatic stress 
disorder. Yet, while we know the need for mental health care 
services is severe in the hurricane affected regions, the need 
is no less acute for some children throughout the country. Many 
face mental and behavioral health problems, as well as 
developmental disabilities, that require extensive care--care 
that they are currently unable to afford. I look forward to 
hearing from the witnesses on our second panel today about the 
need to help children with these challenges and ideas about how 
we can use SCHIP more effectively to address their needs.
    Mr. Chairman, reauthorization of SCHIP is certainly of 
paramount importance during the next several months. However, 
as we do so we need to make sure that we carefully consider all 
of the health care needs of those who are and will be covered.
    I yield back the balance of my time.
                              ----------                              

    Mr. Pallone. Thank you, and if I could just mention, as you 
know, the supplemental has I guess about $730 million for SCHIP 
for the rest of this fiscal year and the budget that came out 
of committee has a $50 billion reserve fund for the next 5 
years, and when we come back after the break, we will start the 
process of reauthorizing SCHIP. So I just want all of you to 
know that we are on top of that, and through all your help, 
through all the members of the committee.
    Dr. Burgess.

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE 
              IN CONGRESS FROM THE STATE OF TEXAS

    Mr. Burgess. Thank you, Mr. Chairman.
    I want to thank my friend from Texas, Mr. Green, for 
invoking the spirit of Charlie Norwood, certainly the dental 
conscience of our committee. Charlie was a tireless advocate 
for improved health care in the United States. He was a 
tireless advocate for making the system work for everyone for 
whom it was supposed to work, and Charlie of course was famous 
for being a straight talker, and in fact today I hope that we 
can all engage in a little straight talk about this problem 
because the Maryland case of about a month ago is why we are 
here today. That tragic story has called attention to the fact 
that the system failed a family multiple times, and the 
question before us today is, what do we do about it.
    Congress is reauthorizing the SCHIP program and we need to 
decide in which direction to take the program. Now, certainly 
we could mandate dental coverage under SCHIP but the fact is 
that several States already do offer at least some level of 
dental coverage. Seventy-three percent of federally qualified 
health centers offer children's dental coverage. So the 
question is, is that somewhat redundant? Certainly we could 
allocate more funding to SCHIP but there are some of us who 
believe that a return on investment for additional funding is 
sometimes not what we would envision. We could have the 
Government take over the entire system but the Government 
programs we already have in place face some serious issues.
    I would like to refer to a Washington Post article today 
that quotes a dentist, Aldred Williams. He is the lead dentist 
at Small Smiles, a district clinic that services Medicaid-
qualified children and young adults. His quote is, ``There are 
so many barriers to treating these kids covered by Medicaid 
including lower reimbursement rates and the bureaucracy. 
Private practices often end up paying out of pocket to cover 
the full cost of care.'' That is why the penetration of private 
providers in this program are only at about 17 percent. Doctors 
don't want to see Medicaid patients because they don't get paid 
fairly and we can't seem to figure out how to pay for all the 
services we would like to see, so forgive me if I am skeptical 
that we will improve anything by expanding programs already 
plagued by irreconcilable systemic problems.
    Instead, I believe we should actually address the 
underlying problems, so I am very interested in the ADA's 
report on improving access to dental care. I would like to talk 
about improving Medicaid reimbursement, streamlining the 
bureaucracy and improving health literacy so that doctors and 
their patients can navigate the health care system without 
needing an advanced degree in medical administration or public 
health policy administration and so that doctors have an 
incentive to treat indigent patients beyond just the goodness 
of their hearts. I would like to hear more about the public-
private partnership in Michigan and I would like to hear their 
thoughts on what has made it successful. I would like to hear 
their ideas for education and prevention so we can encourage 
Medicaid patients to actually get the care the program covers.
    As a physician, I have always tried to make decisions based 
on what I would want for myself and for my family, and were I 
homeless and were my family homeless, I would want Medicaid and 
SCHIP to work and work effectively and work properly but I also 
wouldn't want to be on it for the rest of my life. I would want 
the safety net to function as a safety net instead of staying 
on a minimalist Government program that always falls just short 
of what was really intended. I would want the knowledge and 
education that allowed me to navigate the system and make my 
own appropriate decisions for myself and my children and I 
would want the power to determine my own fate and the power to 
change the situation.
    Mr. Chairman, you have been very kind in letting me go over 
but that is what I would be interested in hearing our panel 
address today, and I will yield back the balance of my time.
    Mr. Pallone. Thank you, Doctor.
    I next recognize for an opening statement the gentlewoman 
from California, Mrs. Capps.

   OPENING STATEMENT OF HON. LOIS CAPPS, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Mrs. Capps. Thank you, Chairman Pallone, and welcome to 
your children and good testimony to the topic at hand today.
    I am very pleased that we are here to discuss the 
importance of providing children with an early healthy start to 
their lives. For me it is an issue I have dedicated my whole 
life to as a public health nurse, a school nurse, for 20 years 
and now as a public servant, and I waited a long time ever 
since being in Congress for this hearing today. We are going to 
have the opportunity to focus on two areas of health care too 
often overlooked but so critically important to ensuring the 
health of children.
    Again, I will just mention the name Diamonte Driver, a 
tragic reminder of our duty to protect and preserve children's 
health. Unfortunately, there are many Diamontes in classrooms 
today with abscesses in their teeth across this country. I 
think it is nothing short of a miracle that more of them don't 
end up with involving their brain, a stark reminder of the 
consequences of failing to provide access to preventive health 
care so cost effective, so important in its results including 
dental and mental health care. I have been advocating, as I 
said, for improved children's dental health for years. Children 
are already vulnerable as a group but children from low-income 
households are particularly vulnerable. Every school in the 
country today when a child comes with a swollen jaw and can't 
eat, can't study, somebody in the school is going to scramble 
around trying to find some pro bono care, trying to find a 
provider, and that is health care in our country today. These 
low-income children are twice as likely to suffer from dental 
caries than children from higher income families because they 
are more likely to lack access to dental health care.
    In my district, there is a wonderful nonprofit organization 
that provides a well-run mobile dental clinic to many of the 
migrant families in my area. Ironically, it is a nonprofit 
organization designed to provide medical services to Third 
World countries. They find lots of people to assist right in my 
backyard.
    A few years ago I was honored, it has been mentioned 
already, to introduce the Children's Dental Health Preservation 
Act with our late colleague, Charlie Norwood, a bill seeking to 
identify children at risk for developing cavities as well as to 
train health care professionals, already been referred to, to 
educate patients on the importance of preventive health care, 
dental care, and I think it would be a fitting memorial to our 
colleague to name this legislation that I hope will result for 
him. And with SCHIP reauthorization covering the uninsured at 
the forefront of this committee, I am hopeful we can finally 
make progress.
    Of course, children's mental health is equally as 
important. Again, I have seen so many children lagging behind 
their peers because they are not afforded proper treatment or 
identification of behavior problems which are really mental 
health issues. Not only are school nurses not equipped to 
provide comprehensive mental health services, there is a dire 
shortage of school nurses to identify and refer out and a dire 
shortage of places for young children to get the kind of 
treatment that early in life is so effective in changing and 
responding to this situation.
    I hope our witnesses today will help provide us the tools 
to formulate the kind of policies that will put in place the 
best models of dental and mental health care for our children, 
and I yield back.
    Mr. Pallone. Thank you, Mrs. Capps.
    I recognize Mr. Murphy of Pennsylvania.

   OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN 
         CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

    Mr. Murphy. Thank you, Mr. Chairman, and thank you for your 
leadership on making sure this issue is addressed by this 
committee and Congress.
    We all know in the comments made so far we have talked 
about how preventive dental care reduces disease and risk 
before symptoms appear, and I know even in my role as a 
psychologist, many times kids that I would be seeing, young 
children we would note as part of their medical concerns that 
many of them had dental problems that needed to be addressed 
and so too it was that I worked with families, helping them to 
search through the bureaucracy to find ways of getting that 
care. Luckily, there are clinics around for children but many 
times families are not aware of this and they put off the care 
and we can see just how bad this can get on something we take 
for granted that can really lead to infections and to terrible 
tragedies.
    Of course, part of the problem is that many families don't 
have a medical home and there doesn't seem to be enough 
available dentists as part of that. I would like to point out 
that one solution that I have offered is legislation that would 
help us expand children's access to community health centers 
and free clinics, community health centers in particular which 
are nonprofit community-supported health care providers who 
offer primary and preventive health care services to low-
income, underinsured and uninsured families. There are a number 
of these in the country. Unfortunately, we need many more, but 
one of the problems is that there is just a vast shortage of 
many medical providers at these clinics, 10 to 15 to 20 percent 
shortages of everyone from family physicians, OB/GYNs, 
pediatricians, et cetera.
    Now, one of the things that I know in working with dentists 
too is that many of them would love to have an opportunity even 
to volunteer some time. One fellow said to me, if I am going to 
offer pro bono work, I would like to do it at some other office 
or clinic where I can do that and give a day or two a month to 
do that. Unfortunately, the way our bureaucracy is set up, that 
if someone works at a community health center, they are covered 
under the Federal Torts Claim Act. If they want to volunteer 
their time, they are not, and so what they find themselves 
dealing with is high medical malpractice insurance when all 
they wanted to do was give some of their time and help children 
in their community. So I introduced H.R. 1626, which is the 
Family Health Care Accessibility Act, which extends the Federal 
Tort Claims Act coverage to volunteer doctors and dentists who 
want to volunteer at community health centers. I am hoping at 
some point this committee and subcommittee can take up those 
issues.
    But what is being pointed out, and I look forward to 
hearing some of the testimony today from the dental 
association, is just what is this wall of bureaucracy. I hear 
legends of pages and pages and pages that dentists have to fill 
out if they even want to work with children, and it comes to 
the point that the time demands of dealing with the bureaucracy 
is so much so that they see this as a problem and that is why 
reading the article in Maryland, there are only a few hundred 
dentists out of the thousands which are available who actually 
work with Medicare.
    I look forward to hearing this information today, and 
again, thank you, Mr. Chairman, for your leadership on this.
    Mr. Pallone. Thank you.
    I recognize Mr. Allen of Maine.

   OPENING STATEMENT OF HON. TOM ALLEN, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF MAINE

    Mr. Allen. Thank you, Mr. Chairman. Thank you for calling 
this hearing today to examine the critical issue of improving 
access to dental care and mental health services for America's 
children.
    Dental decay is the most common chronic childhood disease 
but it is also the most preventable. We know that dental 
problems can have a profound impact on children's ability to 
learn and advance in school. It can also hinder their ability 
to speak and eat. Left untreated, it can lead to chronic 
disease and even death.
    I am pleased to support Chairman Dingell's Children's 
Health First Act which would expand and significantly increase 
funding for the SCHIP program. The lack of adequate access to 
dental care is particularly acute among children from low-
income families. Therefore, the bill would require States to 
offer dental coverage under SCHIP in virtually all cases. It 
would also require the benefit to mirror the Medicaid early 
periodic screening, diagnosis and treatment benefit if a State 
designs its own SCHIP plan rather than simply expanding 
Medicaid to cover SCHIP children. States would be able to offer 
SCHIP dental coverage as a wraparound benefit to children who 
meet the income requirements but who have private medical 
coverage.
    Medicaid patients often don't receive timely dental care 
because there are not enough dentists participating in the 
Medicaid program. In rural States like Maine, there is a severe 
shortage of oral health professionals, particularly pediatric 
dentists. Maine has approximately 600 dentists but only 278 
participate in the Medicaid program. Of these dentists, only 
nine are pediatric dentists. We need to strengthen the title 
VII health professions training programs including the 
pediatric dentistry program. That program provides seed money 
for startup or expansion of pediatric dentistry residency 
programs that focus on underserved populations. Investing in 
children's oral health makes economic sense. For every dollar 
spent on preventive care, between $8 and $50 can be saved in 
emergency treatment.
    I want to commend the dentists, dental hygienists and other 
oral health professionals who volunteer their services and give 
free care to needy individuals, both children and adults. The 
ADA's Give Kids a Smile Day and innovative State-based public-
private partnerships like No Cavities Maine, which reaches 
children and senior citizens through the YMCA, go a long way to 
improve access to dental services for low-income individuals. 
But as one dentist in Maine told me recently, it is not just 
about 1 day of service or one weekend of volunteering but a 
daily commitment to provide care for the needy. I want to thank 
you all for your service.
    I look forward to hearing from our distinguished panel on 
ways we can improve children's access to health care services, 
and with that, Mr. Chairman, I yield back.
    Mr. Pallone. Thank you.
    I recognize Mrs. Wilson of New Mexico.

 OPENING STATEMENT OF HON. HEATHER WILSON, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF NEW MEXICO

    Mrs. Wilson. Thank you, Mr. Chairman. I appreciate your 
holding this hearing today.
    In New Mexico, we have a very serious problem with access 
to dental care for our population as a whole but particular 
this is a significant problem with children, and particularly 
those who are low-income and uninsured in rural areas in Indian 
country, and it is something we have to address. It is 
something that I saw as a State official responsible for foster 
children. Sixty-four percent of third graders in New Mexico 
have tooth decay and 34 percent have untreated tooth decay. So 
in a classroom of 30 kids, 10 of them are having problems with 
their teeth. New Mexico ranks 49th among the States in dentists 
per capita and we have a similar shortage of dental hygienists. 
Part of our problem is that 21 percent of our population is 
eligible for Medicaid. Part of it is that we are a very rural 
State and it has been difficult to attract dentists to New 
Mexico. We also in the entire State of New Mexico, the fifth 
largest by land area State in the country, we do not have a 
school of dentistry, so New Mexicans who want to become 
dentists go out of State and oftentimes we never see them come 
back.
    This problem is something I think we need to address 
systemically, and unfortunately, our State government is not 
particularly interested in addressing this problem. In the 
Department of Health, they don't even have a dentist who is 
focused on oral health.
    I appreciate your having this hearing today so that we can 
look at innovative ways and look at the problem in its entirety 
of scope. It doesn't matter if you have insurance or it is 
included under Medicaid if you can't find a dentist or if the 
dentist you can find won't take Medicaid because the 
bureaucracy and the paperwork is such a terrible nightmare. We 
need to address these problems so that kids get access to care 
no matter where they live.
    Thank you, Mr. Chairman.
    Mr. Pallone. Thank you.
    I recognize next Ms. Solis of California.

 OPENING STATEMENT OF HON. HILDA L. SOLIS, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Ms. Solis. Thank you, Mr. Chairman, and I want to also 
applaud you for having this very important hearing this 
morning.
    Oral health is closely linked to overall physical health 
and I believe oral health has to be a big priority for us both 
at the local level, the State level and the Federal level and 
that is why I am glad we are having the hearing today.
    The California Oral Health Needs Assessment revealed that 
three out of every 10 Californian third graders had untreated 
tooth decay. These numbers are particularly troublesome for 
children in minority and underrepresented communities. Latinos 
along with African-Americans and Native Americans have the 
poorest dental health of any racial group in the United States, 
and in California, the State that I represent, Latino 
kindergarteners were 2.4 times more likely to have untreated 
tooth decay than white children. Their oral health dramatically 
affects their ability to lead active lives. For example, Latino 
children are more likely to miss school due to oral health 
problems, and we are all aware of the problems associated with 
the lack of medical insurance yet the situation for dental 
coverage is equally important. For every child who lacks health 
insurance, approximately three children lack dental health 
care. In California, 25 percent of our children lack dental 
insurance, which decreases the likelihood that they will 
receive regular checkups and treatment. Low reimbursement rates 
add to the problem for programs like Denti-Cal, the California 
dental Medicaid program, and the lack of providers willing to 
take on Medicaid patients also poses a major obstacle to 
accessing dental care, and more and more families are unable to 
afford health insurance. Many of our children do not receive 
the proper health and dental care they deserve, and I hope that 
through SCHIP and Medicaid we will address the critical need 
for dental services and improve dental coverage overall. We 
must work closely with our schools and with our public health 
clinics to expand care so that our families are all served.
    In my district in California, the 32d, I worked very hard 
to partner with L.A. Unified in one of our middle schools to 
provide a dental clinic there to help provide wraparound 
services, mental health services and daily checkups, not just 
for the students attending the school but the outlying 
community that could also benefit from that help. I am also 
proud to say that one of our local clinics that was just 
reopened in the city of Azusa in L.A. County is now beginning 
to look at offering dental services for residents in Azusa who 
are primarily Latino, about 70 to 80 percent, and have incomes 
below $30,000.
    So I am pleased that we are having this discussion and 
debate and I also want to mention that the Congressional 
Hispanic Caucus, as task force chair during the past few years 
we were able to work closely with Univision, one of the major 
Spanish language networks, to create public awareness programs 
in Spanish to provide briefings and better understanding about 
dental care and we did it in conjunction with the dental 
association. So I want to thank them for that. I look forward 
to your testimony today and look forward to seeing the 
expansion of dental care services for our children.
    Thank you. I yield back the balance.
    Mr. Pallone. Thank you.
    I now recognize Ms. Hooley of Oregon.

 OPENING STATEMENT OF HON. DARLENE HOOLEY, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF OREGON

    Ms. Hooley. Thank you, Mr. Chairman.
    Like my colleagues, I was shocked and deeply saddened to 
hear about the death of 12-year-old Diamonte Driver. The death 
of a child is always a terrible event. However, Diamonte's 
passing is particularly distressing because we know that his 
death could easily have been prevented with low-cost dental 
care. Most Americans including myself were shocked that a child 
could die in the United States for want of such a basic dental 
service.
    While we should shine a light on the heart wrenching 
tragedy of Diamonte's death, it is also important to remember 
that poor oral health has other consequences that are less 
severe but still detrimental to a child's well-being. As a 
former schoolteacher, I can attest to the fact that a child's 
toothache can have a very disruptive effect on the learning 
process. Not only is the child in pain, unable to learn, but a 
child in pain is often a disruptive force that hampers the 
ability of other children to focus and participate in class. 
That challenge to effective learning is unfortunately only part 
of the overall harm. In addition, more than 850,000 school days 
each year are missed by students because of dental-related 
illness. A child who is not in class obviously cannot learn. At 
a time when there is a strong emphasis on student achievement, 
I hope we can take an expansive view of what impacts learning. 
I think oral health is one of those factors that should get a 
lot more attention.
    The mental health problems of children often similarly do 
not receive the focus that they warrant. Again from my years as 
a teacher, I know that there is nothing more frustrating than 
seeing a child struggle who could flourish if he or she 
received appropriate mental health services. I look forward to 
discussing access issues resulting from the lack of mental 
health providers or too few participating providers.
    Mr. Chairman, again I thank you for holding this hearing on 
these very important but often unappreciated issues. Thank you.
    I yield back.
    Mr. Pallone. Thank you.
    The gentleman from Utah, Mr. Matheson.

  OPENING STATEMENT OF HON. JIM MATHESON, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF UTAH

    Mr. Matheson. Thank you, Mr. Chairman. Thank you for 
holding this hearing today. It is an issue that is very 
important to our national health care debate. Although I am 
saddened by the events that have brought us together, I feel we 
have an opportunity to honor the memories of these two boys by 
examining how our Nation's uninsured children are accessing 
dental care.
    In my State, children without dental insurance receive most 
of their services in safety-net clinics such as community 
health centers, donated dental services and primary children's 
medical centers. We have a program called the Utah Oral Health 
Program and it has completed an oral health survey of 6- to 8-
year-old children in the fall of 2005. Of those surveyed, 25 
percent indicated they had no dental insurance, 20 percent 
indicated they had not seen a dentist in the past year, and 10 
percent indicated they needed dental care in the past year but 
could not get it. Of those surveyed, 21 percent had obvious 
dental decay. These are troubling statistics and ones that we 
are working hard to address.
    In an effort to educate Utahans on the importance and far-
reaching impact of preventive dental care for children, we have 
been proactively promoting preventive oral health care 
throughout the State in a number of ways. For example, the 
statewide campaign by the Utah Dental Association emphasized 
the importance of the early diagnosis of oral cancer. The Baby 
Your Baby campaign includes information on the relationship 
between periodontal disease and low birth weight pre-term 
births. In addition to the oral health program, the Utah Dental 
Association and the Utah Dental Hygienists Association have 
completed several activities throughout the State to promote 
the first dental visit for children by age 1 or within 6 months 
of the first tooth erupting. Outreach to Utahans has included 
visits to local dental societies, presentations to local health 
departments, presentations to conferences, newsletter articles 
and brochures. That is a quick list of the outreach we try to 
do in our State.
    I mentioned to this committee before that my wife is a 
pediatric infectious disease doctor at the Primary Children's 
Medical Center in Salt Lake. I have heard very much around the 
dinner table stories about the importance of preventive care in 
terms of oral health. Access to care is such a critical issue 
for our country. I look forward to hearing the suggestions of 
the committee and the witnesses on identifying responsible ways 
to improve access to dental care for our kids.
    Mr. Chairman, I will yield back.
    Mr. Pallone. Thank you.
    Next is the gentleman from New York, Mr. Towns.

 OPENING STATEMENT OF HON. EDOLPHUS TOWNS, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF NEW YORK

    Mr. Towns. Thank you very much, Mr. Chairman, for holding 
this hearing. I think this is a very important hearing.
    Eighty percent of all tooth decay is found in 25 percent of 
children. Despite the magnitude of need, dental coverage 
remains an optional benefit in SCHIP. All States have 
recognized that poor oral health affects children's general 
health and have opted to make dental coverage an option. 
However, dental coverage is often the first benefit cut when 
States seek budgetary savings. I believe that Congress must 
stabilize access to dental care for children by establishing a 
Federal guarantee for dental coverage in SCHIP.
    In addition, the National Dental Association and the 
National Dental Hygienists Association, which represents 
African-American dentists and dental hygienists, believe we 
must substantially increase the number of minorities entering 
the field of dentistry and other allied oral health fields if 
we are to turn around the tragedy related to underserved 
communities and oral health.
    It is also time we stopped punishing parents with moderate 
incomes whose children receive medical, but not dental, 
benefits through employer-sponsored health plans. Many of these 
parents and their children cannot afford dental coverage. We 
need to develop a dental wraparound benefit in SCHIP that 
allows these parents to purchase dental insurance if they meet 
other eligibility standards. It is time we commit ourselves to 
quality dental care for all because it is less expensive to 
prevent advanced oral problems than to deal with them in an 
emergency room. I think Dr. Ellerman is right when she said 
that we must now begin to think of our children. They are 25 
percent of the population but 100 percent of our future. I am 
sure that our witnesses this morning will be able to shed some 
light on the issue of dental care under SCHIP and that we will 
be able to do a much better job on behalf of our children.
    On that note, Mr. Chairman, I yield back.
    Mr. Pallone. Thank you.
    And our other gentleman from New York, Mr. Engel.
    Mr. Engel. Thank you, Mr. Chairman. When you said the 
gentleman from New York for Mr. Towns, I started to push my 
button.
    Mr. Towns. It would have been OK.

 OPENING STATEMENT OF HON. ELIOT L. ENGEL, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF NEW YORK

    Mr. Engel. But I agree with everything Mr. Towns said, and 
I want to thank you for holding this hearing. It shouldn't take 
a tragedy to call attention to the need for comprehensive 
accessible health care but that certainly is what the senseless 
death of Diamonte Driver has done this month, a 12-year-old who 
died of a brain infection initially caused by an infected tooth 
and had been covered by Medicaid, which would have covered his 
health problems. A series of events led to the loss of his 
coverage though, which certainly highlights the need for 
presumptive eligibility. A simple dental procedure that could 
have cost $80 to cover went untreated and manifested in a 
serious brain injury requiring nearly a quarter of a million 
dollars in care which ultimately could not save this child.
    Considering that dental care is the most prevalent unmet 
health need among American children, and that is a quote 
according to the U.S. Surgeon General, it simply makes sense to 
shore up our public programs that provide dental care to low-
income children. While the Medicaid program provides 
comprehensive coverage for children's dental care through the 
Early Periodic Screening Detection and Treatment benefit, 
access to care is hampered by low Medicaid reimbursement rates. 
States that can compensate dental care providers with rates 
closer to market-based fees have been able to enroll more 
providers in the Medicaid program and in turn successfully 
treat more children. The SCHIP program by contrast does not 
even require that children be entitled to dental care. While 
all States have elected to provide some coverage, the benefits 
and access to treatment varies widely from State to State. As 
we move to authorize the SCHIP program, I believe we should 
modernize it to establish a Federal guarantee for dental 
coverage. We should also strongly consider developing a dental 
wraparound benefit in SCHIP to support families with low to 
moderate incomes covered in the private market who do not 
receive dental coverage for their children.
    Mr. Chairman, while all the witnesses on the two panels are 
impressive, I would like to extend a warm welcome to Dr. 
Edelstein of the Children's Dental Health Project and Columbia 
University in New York City, where I am from. The Columbia 
University teaching clinic offers outstanding primary and 
specialty oral health care at reduced cost to patients. At the 
onsite dental clinic, general oral health and specialty 
practitioners handle more than 80,000 patient visits each year. 
It is a great service to the community and I commend Columbia 
for this work.
    Mr. Chairman, there is no question that well-child care 
should include comprehensive dental care. I am pleased that you 
have convened this hearing to discuss these important issues 
and look forward to the witnesses' testimony today, and I yield 
back the balance of my time.
    Mr. Pallone. Thank you.
    That concludes the opening statements by members of the 
subcommittee, and I would ask unanimous consent any other 
statements be included in the record at this time.
    [The prepared statements follow:]

    Prepared Statement of Hon. John D. Dingell, a Representative in 
                  Congress from the State of Michigan

     Today's hearing will focus on providing a healthy start 
for children. It is common sense that keeping children healthy 
and treating illness early is a wise investment. Children who 
are healthy do better in school. They are at lower risk for 
developmental problems. And their future healthcare costs are 
likely to be less.
     Medicaid and the State Children's Health Insurance Program 
(S-CHIP) provide the health insurance and a healthy start for 
nearly a quarter of U.S. children. These two programs are 
primarily responsible for preventing these children from 
joining the increasing number of those who are uninsured. Our 
Nation has made good progress in getting children immunized 
against disease, but progress has been slower on dental care 
and mental health care. Clearly more needs to be done.
     Medicaid's coverage of dental and mental health benefits 
is exemplary. And many States meet Medicaid's standard of 
coverage under SCHIP, as well. But many do not. And that means 
many children still have unmet needs in these two areas.
     Dental disease is the most common childhood disease--more 
prevalent than asthma and diabetes. It is also the most easily 
prevented. Proper care, however, must start in infancy, 
including oral checkups, preventive care, sealants, fluoride, 
and at home oral care.
     If left untreated, however, dental disease can be deadly. 
Sadly, the Nation learned this recently from the much-
publicized case of a 12-year-old child from Maryland named 
Deamonte Driver. In Mississippi, there was recently an equally 
tragic and equally preventable death that would have been 
prevented if action had been taken sooner. Six-year-old 
Alexander Callendar died due to untreated dental disease.
     The need for action exists on several levels. The Congress 
has a role to play in ensuring States have sufficient resources 
in Medicaid and SCHIP to address the unmet dental need among 
children. The Federal Government needs take steps to prevent 
future tragedies from occurring. We need to play a role in 
training and education of dentists. And we have a role to play 
in ensuring access in all communities.
     I will soon introduce a bipartisan bill that will move us 
forward toward addressing many of these issues. I hope that my 
colleagues on the committee will join me in cosponsoring this 
legislation. It should be a national priority.
     Likewise, children's mental health care is also a 
significant challenge for families, especially the uninsured or 
under-insured. Private insurance coverage is limited or 
inadequate for those with the greatest need. Under Medicaid and 
SCHIP we need to do more to make community-based mental health 
care an option. There are more than 12,000 children across the 
country who are on waiting lists because existing programs lack 
space. In addition, the Centers for Medicare and Medicaid 
Services (CMS) has recently initiated efforts that would 
restrict or even eliminate States' ability to manage the care 
of children with the most severe mental illnesses. We need to 
be assisting children and States in this area, not further 
restricting access for children to receive needed care. CMS's 
actions are unacceptable and this is something we will explore 
in the near future.
     I thank Chairman Pallone for this hearing. It is timely. 
It is necessary. I look forward to working with my colleagues 
on these important health priorities.
                              ----------                              


 Prepared Statement of Hon. Anna G. Eshoo, a Representative in Congress 
                      from the State of California

    Thank you, Mr. Chairman, for holding this hearing on the 
role of early health care interventions to ensure that children 
have a chance for a healthy start in life. Two health care 
benefits most often overlooked are dental and mental health 
care.
    Tooth decay is the most common childhood disease, affecting 
five times more children than asthma, and seven times more 
children than hay fever. In February and March of 2007, 
untreated dental problems caused the deaths of two children in 
Mississippi and Maryland. Had these children had access to 
preventive dental care, they would be alive today.
    Mental health care is also an important benefit for 
children. The Urban Institute estimates that at least one-tenth 
of children suffer from a serious mental health problem that 
causes impairment. Poor children have more mental health 
problems than other children, yet they have fewer options for 
mental health screening and care.
    Programs like Medicaid and the State Children's Health 
Insurance Program (SCHIP) play an important role in providing 
preventive health services to low-income children. Medicaid is 
widely considered the largest provider of funds for mental 
health services for children and it also provides comprehensive 
coverage for children's dental care needs. However, due to 
differences in how States operate their SCHIP programs, access 
to mental health and dental care benefits vary geographically.
    Childhood is the most important time in a person's life for 
preventive screening and treatment of mental and physical 
ailments. We must assure that children and their families have 
access to resources and services that promote positive early 
health and development.
    I urge my colleagues on this subcommittee and in Congress 
to ensure that children have access to important, preventive 
health care which includes comprehensive dental and mental 
health benefits. We can do this by including these benefits in 
our reauthorization of the State Children's Health Insurance 
Program later this year.
    Thank you, Mr. Chairman, and I look forward to hearing the 
testimony of our expert witnesses.
                              ----------                              

    Mr. Pallone. I will now turn to our witnesses, and our 
first panel is already there. I want to welcome you again. Let 
me introduce each of you, starting from my left to right. First 
we have Dr. Burton Edelstein, who is founding director of the 
Children's Dental Health Project. Second, we have Dr. Kathleen 
Roth, who is president of the American Dental Association. And 
then we have Mr. Raymond Scheppach, who is the executive 
director of the National Governors Association, and then we 
have Christine Farrell, who is the Medicaid policy specialist 
with the Michigan Department of Community Health, Medical 
Services Administration. And next is Dr. Nicholas Mosca, who is 
clinical professor of pediatric and public health dentistry at 
the University of Mississippi School of Dentistry, and last is 
Dr. Stephen Corbin, who is senior vice president of Constituent 
services and support for the Special Olympics International.
    Thank you again for being here. We are going to have 5-
minute opening statements from each of you. Those statements 
will be made part of the hearing record and each witness may in 
the discretion of the committee submit additional briefs and 
pertinent statements in writing for inclusion in the record. 
And I will start, again from my left, and recognize Dr. 
Edelstein for an opening statement.

  STATEMENT OF BURTON L. EDELSTEIN, D.D.S., M.P.H., FOUNDING 
           DIRECTOR, CHILDREN'S DENTAL HEALTH PROJECT

    Dr. Edelstein. Thank you, Mr. Pallone.
    My name is Burton Edelstein. I am a pediatric dentist who 
has been involved with dental coverage for poor and low-income 
children as a student, clinician, educator, researcher and 
policy analyst for 37 years, nearly as long as the Medicaid 
EPSDT benefit that so many of you mentioned. I speak to you 
today as founding director of Children's Dental Health Project, 
a DC-based nonprofit policy organization committed to improving 
children's oral health in America. My testimony has also been 
endorsed by my professional association, the American Academy 
of Pediatric Dentistry.
    The committee has shown a strong command of the issue and 
has so well described the problem. I seek today to pull much of 
what you said together and make some recommendations for 
solutions. I thank the committee for addressing children's oral 
health, an issue highlighted tragically by the death of 
Diamonte Driver that has been noted. I dedicated my testimony 
today to him but also to the hundreds of thousands of other 
children who suffer significantly and unnecessarily from 
completely preventable dental problems.
    My testimony is grounded in three straightforward facts. 
First, that tooth decay is virtually preventable, almost 
completely preventable, yet ironically, as you note, it remains 
the single-most common chronic disease of childhood in the 
United States and is present in one-quarter of all 2- to 5-
year-olds. Second, dental care is essential to overall health, 
yet for reasons that make neither biologic sense nor policy 
sense, dental care has been legislated as an optional service 
as though the mouth were not integral to the body. Third, 
preventive care is cost-effective yet far few children obtain 
the kinds of routine care that would prevent pain, infection, 
sleepless nights, missed meals and poor school performance that 
you have noted.
    Medicaid itself, as envisioned by Congress, is tremendously 
valuable. It is appropriately designed and it is fully 
accountable. In the handful of States that have taken their 
dental Medicaid programs seriously and reformed them well, 
Medicaid has been shown to work for dentists, for children, for 
families, and the number of dentists participating has 
increased dramatically, twofold, threefold, fourfold. These 
States have been creative and they have taken advantage of 
flexibility that already exists in the program. But in too many 
States, there has not been attention to the opportunities in 
Medicaid and the programs have been allowed to fail, fail 
children and fail the providers who care for them. Congress can 
play a stronger role in assuring that Medicaid works for all 
children across the country by helping States, by enhancing 
your oversight, by providing grants to support State program 
improvements, by offering technical assistance, by promoting 
best practices and by holding States accountable for the 
performance that is already required by Medicaid law.
    SCHIP is a different story. It is now 10 years old and due 
up for reauthorization, which provides a terrific opportunity 
for Congress to do many of those things that you spoke of. With 
the three recommendations that I make now, I am speaking for 12 
national dental membership organizations including all of those 
present at this table as well as organizations of pediatric and 
general dentists, Hispanic and black dentists, dental 
hygienists, dental researchers, State dental officers and 
dental students. Together we ask you to do three things with 
SCHIP.
    Firstly, put the mouth back into well-child care. Recognize 
with us that the mouth is integral to the body and that dental 
care cannot be considered an optional service, and because 
States are already significantly involved in providing dental 
care, this can occur at very little cost. Second, allow States 
to offer that wraparound dental coverage that some of you have 
mentioned. This will incentivize poor and working-class 
families to retain their private medical coverage and not drop 
it so that they obtain their medical and dental coverage 
together through SCHIP. And third, require States to report on 
their dental program performance in SCHIP. After 10 years, we 
know almost nothing about the performance of SCHIP for dental 
coverage while we know a great deal in Medicaid. Similar 
reporting in SCHIP would help you and help children gain the 
benefit that they already have available to them.
    With these few Medicaid and SCHIP fixes, the benefit of 
cost-effective prevention can bring savings to Government and 
better health to children. This is unusual, to be able to have 
both better health and cost savings at the same time. For 
example, Diamonte could have received preventive care for 12 
years. He could have had a sealant. He could have had a 
filling. He could have had a root canal. He could have had a 
number of dental treatments, no one of which would have cost 
more than one one-thousandth of what his hospital stay cost.
    The problem of childhood tooth decay is also global. The 
U.S. has recently joined with other nations representing half 
of the world's population to eliminate childhood dental caries. 
Unlike most of the partner nations, the U.S. has no Federal 
entity that coordinates and integrates the various programs 
across its agencies. We in the U.S. would benefit greatly if 
Congress were to charge the Department of Health and Human 
Services to develop an interagency taskforce on children's oral 
health with strong leadership and strong Congressional support. 
In this way, the U.S. could set the international standard for 
children's oral health.
    On behalf of America's children, I urge you and the 
committee to continue attending to pediatric oral health, to 
continue beyond this hearing, to maximize opportunities for 
cost-effective prevention, to ensure that dental care is never 
again considered an optional service as though it didn't 
matter, and to integrate oral health into each and every 
Federal program that addresses children's health and well-
being. Diamonte is sadly only one example of what happens when 
we fail as a nation to sustain attention to children's oral 
health. The problem with childhood oral health is fixable and 
fixable at low cost. Let us work together to enhance Medicaid 
and SCHIP, to do more to educate the public, to improve 
training of dental professionals and to care for young children 
for the benefit of prevention for all.
    Thank you so much.
    [The prepared statement of Dr. Edelstein follows:]

                Testimony of Burton L. Edelstein, D.D.S.

    Good morning. My name is Burton Edelstein. I am a pediatric 
dentist who first cared for a child with Medicaid coverage 37 
years ago--just 3 years after Congress mandated dental services 
for children in Medicaid. Since that time I have been actively 
engaged in Medicaid and SCHIP as a private practice clinician 
in Connecticut, as a dental educator now at Columbia 
University, and as founder of the Children's Dental Health 
Project--a DC-based independent policy organization committed 
to improving children's oral health in America.
    I have learned about publicly financed dental coverage from 
my patients and their families, from students and colleagues, 
and from working with Congress and the Department of Health and 
Human Services. I have also observed much from the public's 
response to the tragic and completely avoidable death of 
Deamonte Driver, the Maryland 12 year old who died just up 
North Capitol Street from here at National Children's Medical 
Center from complications of a dental infection. Sadly, 
Deamonte represents the worst case scenario of multiple systems 
failures. I dedicate my testimony to him and to the hundreds of 
thousands of other children who suffer significantly and 
unnecessarily from preventable dental problems.
    My testimony today reflects the totality of this 
experience. It is based on three facts:

     first, that tooth decay is overwhelmingly 
preventable;
     second, that dental care is essential to 
children's overall health and wellbeing; and
     third, that dental care is cost effective.

    All three qualities have strong implications for the 
committee's oversight of Medicaid and the State Child Health 
Insurance Program.
    Regarding Medicaid: Medicaid dental coverage for children 
as envisioned by Congress is tremendously valuable, 
appropriately designed, and fully accountable. The handful of 
States that have implemented Medicaid dental coverage well have 
demonstrated that this program works for children, their 
families, and their caregivers. But in the majority of States, 
Medicaid dental coverage is little more than an unfulfilled 
promise--adequate coverage but inadequate services. Congress 
has many options to further strengthen dental Medicaid 
performance across the Nation through improved oversight; 
incentives and sanctions, Federal grants to States for program 
improvements, and beneficiary empowerment by granting legal 
standing to beneficiaries when the program fails them.
    Regarding SCHIP: In the aftermath of Deamonte's death which 
so clearly demonstrated that the teeth and mouth are an 
integral part of the body, dental coverage can no longer be 
considered an ``optional service'' in SCHIP. Just as the mouth 
is integral to the body, so too must dental care be legislated 
as an integral component of well baby and well child care. With 
SCHIP reauthorization now underway, Congress can take steps to 
stabilize and improve dental coverage in SCHIP by requiring 
that it provides both dental preventive and dental treatment 
services. Congress can enact ``wrap around'' dental coverage in 
SCHIP for those children from working-poor families who have 
medical but no dental coverage and it can require dental 
performance information from States so that they are 
accountable to both the Federal Government and to the children.
    The fact that dental care is prevention oriented, essential 
to children's health, and cost effective also makes it a very 
favorable healthcare service from a public insurance 
perspective. A small upfront investment in comprehensive dental 
care for all children would pay considerable dividends in both 
health outcome and dollars saved. But effective preventive 
dental care requires that children receive care early and 
periodically in a dental home--an identified source of ongoing 
care that provides complete oversight and care coordination for 
each child. For example, if Deamonte Driver had had a dental 
home starting with the recommended age-one dental visit, his 
disease may well have been prevented through health education 
and counseling, fluoride treatments, and placement of dental 
sealants. Had this level of treatment been insufficient and he 
still developed cavities, they would have been found early and 
treated at low cost. Rather than a quarter million dollar bill 
to Maryland Medicaid for neurosurgery, he could have been 
treated with a sealant, a filling, or, if necessary, an 
extraction--any one of which would cost the State less than 
$150.
    Dental disease matters: Ordinary tooth decay needs no 
longer be the single most common chronic disease of childhood 
in America. As a nation, we can reach our elusive Healthy 
People 2010 goals for children's oral health and can reverse 
the recent upswing in tooth decay reported by CDC for our 
youngest children. CDC reported in August 2005 that more than a 
quarter (28 percent) of 2-5 year olds already have cavities in 
their baby teeth and half (49 percent) of children ages 6-11 
have cavities in their adult teeth. Toothaches that distract 
from eating, sleeping, and attending to schoolwork are 
completely preventable and--when they do occur--are completely 
treatable at low cost. Dental abscesses that lead to swollen 
faces like that shown in the photograph before you, and even to 
head and neck infections that can proceed to cause significant 
morbidity and occasional mortality are similarly avoidable--and 
when they occur--treatable at low cost. Yet many children 
insured through Medicaid seek relief of toothaches in the 
emergency rooms of our community hospitals because of 
difficulty accessing dental care in private and safety-net 
offices. One Texas study reported that the cost to Medicaid is 
three times greater for emergency room care--care that doesn't 
solve the underlying dental problem--than the total cost of 
preventive care would have been to assure oral health in the 
first place \1\
---------------------------------------------------------------------------
    1 Pettinato ES, Webb MD, Seale NS. A comparison of Medicaid 
reimbursement for non definitive pediatric dental treatment in the 
emergency room versus periodic preventive care. Pediatric Dentistry, 
2000
---------------------------------------------------------------------------
    Dental coverage matters. Federal data confirm that children 
with dental coverage, whether in Medicaid, SCHIP, or employer-
based insurance, obtain more dental care than similarly 
situated children without coverage. Yet Medicaid and SCHIP have 
not realized their full potential in most States as far fewer 
children in these programs are able to access care than 
children in commercial coverage. According to the most recently 
available CMS data on Medicaid program performance, only 30 
percent of children enrolled in Medicaid at any time during the 
year had at least one dental visit and only 25 percent had at 
least one preventive dental visit--less than half the rate of 
services obtained by commercially insured children. State-by-
State performance varies greatly--ranging as low as 13 percent 
in one State to as high as 47 percent in another. We know far 
less about SCHIP effectiveness because Congress has not to date 
required systematic dental performance reporting in SCHIP.
    Effective Medicaid and SCHIP dental coverage matters. 
According to a HRSA report, young children in poor and working 
poor families (<200 percent FPL) eligible for Medicaid and 
SCHIP are five times more likely to have cavities than children 
in higher income families (>300 percent FPL). They have three 
times more teeth decayed and are twice as likely to seek a 
dental visit for pain relief--but are only half as likely to 
obtain a dental visit in a year. These disparities can be well 
addressed by effective SCHIP and Medicaid administration in the 
States and by working collaboratively with families, dentists, 
and government to ensure that the program meets diverse needs 
and constraints.
    Prevention matters: CDC promotes prevention programs 
including community water fluoridation that continues to 
effectively dampen decay experience in America and sealant 
programs that protect permanent teeth that are most susceptible 
to decay--like the tooth that ultimately led to Deamonte's 
demise. The Maternal and Child Health Bureau's focus on the 
oral health of young children in Head Start and on children 
with special health care needs promotes early and timely 
prevention. NIH-sponsored research over the past 40 years has 
well established that tooth decay is an infectious disease that 
is typically transmitted from mothers to children during a 
child's first years of life. This and other scientific 
knowledge about the nature of the disease provide a number of 
options for ``providing a healthy start'' for all children 
through universal acceptance of the age-one dental visit, 
parent and provider education, and regular dental care in a 
dental home. Lacking only in these Federal programs is 
sufficient support, coordination, and dissemination of best 
practices to realize tremendous financial and health returns 
for our children.
    Global perspective: Childhood tooth decay is a global 
problem. Pediatric oral health activists in the US from inside 
and outside of Federal Government have recently engaged in a 
global campaign to reduce childhood tooth decay through both 
prevention and treatment approaches. With sufficient ongoing 
Congressional attention to dental care for our children--
particularly for those who are eligible for Medicaid and 
SCHIP--the US can set the standard of good oral health for 
children and can become the international leader among the 11 
participating nations that represent half of the world's child 
population.
    On behalf of America's children, I urge you and your 
committee to continue attending to pediatric oral health, to 
maximize opportunities for cost-effective cavity prevention, to 
ensure that dental care is never again considered optional in 
SCHIP, and to integrate oral health into each and every Federal 
program that addresses the health and welfare of our Nation's 
children. You have before you many policy options and 
opportunities for ``improving access to dental care and 
providing a healthy start for children.'' My colleagues and I 
look forward to your questions today and to providing ongoing 
assistance in your efforts to ensure ``bright futures'' for all 
children.
    Thank you.
                              ----------                              

    Mr. Pallone. Thank you, Doctor.
    I am going to ask Dr. Roth to speak next. I know that it is 
hard to keep to the 5 minutes, but if you can, I would 
appreciate it because we do have a lot of people. Thank you.

STATEMENT OF KATHLEEN ROTH, D.D.S., PRESIDENT, AMERICAN DENTAL 
                          ASSOCIATION

    Dr. Roth. Yes. Good morning, Mr. Chairman and members of 
the subcommittee. I am Kathleen Roth from Wisconsin, a 
practicing dentist and currently the president of the American 
Dental Association. I have participated in Medicaid and SCHIP. 
I have firsthand knowledge of providing care to those 
underserved children so severely in need of dental care and I 
understand the havoc that no care can really cause in a child's 
mouth.
    Like all of us, I was very shocked at the death of 12-year-
old Diamonte Driver, who lived just a short distance from here. 
I believe that we have an obligation to honor this child and 
his family by saying no more: no more children unable to eat 
and sleep properly, no more needless deaths, no more unable to 
pay attention in school and no more unable to smile because of 
severe dental disease that could so easily be prevented and 
treated. If we do not resolve to reform the system now, we are 
ignoring the warning that this tragedy is sending us and the 
Nation's children will continue to suffer the consequences. It 
is not just the poor that are affected. As you will hear from 
Dr. Corbin in his descriptions, mentally disabled children and 
adults also face severe barriers to receiving oral health care.
    I have provided care to the underserved in my community for 
many years. Every dentist I know provides some free or 
discounted care to people who need it and otherwise would not 
be able to get it. We do this both individually and 
collaboratively. One study published in the mid-1990's 
estimated that dentists deliver $1.6 billion in free or 
discount care in a single year, but the sad fact is that all of 
our volunteerism and charitable efforts are not enough and they 
never will be enough because charity is not a healthcare 
system.
    Wisconsin is an all-too-typical example of how the so-
called safety net is anything but. The Badger Care 
reimbursement schedule is so meager that in most cases it does 
not even cover dentist overhead. The paperwork is onerous and 
confusing. The entire process is actually so frustrating that 
it discourages dentists from participating in the program at 
all.
    It is critical that we build a preventive infrastructure 
that ultimately will be the only way that we will end what the 
former surgeon general, David Satcher, famously titled the 
silent epidemic. To that end, every child should see a dentist 
within 6 months of the appearance of that first tooth and 
certainly no later than the first birthday. We need more 
community-based initiatives such as water fluoridation and the 
broader availability of dental sealants and topical fluorides.
    We must embrace innovations in the dental workforce. The 
ADA has modeled a new type of an allied dental provider, the 
community dental health coordinator, which will greatly enhance 
the productivity of a dental team by extending our reach into 
underserved communities. The CDHC model is unique in that it 
combines the provision of preventive services along with 
triage, case management and referral to qualified dentists when 
care is needed.
    Ninety percent of the Nation's dentists are in private 
practice. We need to make it possible for more of them, many 
more of them, to participate in Medicaid. Several States have 
refined their Medicaid programs to do that. You will hear about 
Michigan's program in a moment. Tennessee has reformed 
TennCare, and Smile Alabama is an excellent example. In some 
cases programs have succeeded in enrolling Medicaid 
beneficiaries into existing and very well-designed private 
sector dental plans. Congress can do a great deal to encourage 
and make it possible for more States and communities to take 
similar measures through grants and other means. Chairman 
Dingell has been a leader in this area and working with 
Congressman Mike Simpson, who is also a dentist, as well as 
many of you members on this committee who are sponsoring the 
Children's Dental Health Improvement Act.
    Mr. Chairman, the most vulnerable amongst us, especially 
the children, deserve much better, better than the fate that 
befell Diamonte Driver, and better than the untold numbers of 
children, someone within a few blocks of where we are today, 
who are suffering from untreated dental disease. Dentists can 
do more but only if the State and Federal Governments will give 
us the support that we need to do that. We call upon our many 
friends here in Congress to work with us to ensure that every 
American child can face his or her future with a smile.
    Thank you.
    [The prepared statement of Dr. Roth follows:]

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    Mr. Pallone. Thank you, Dr. Roth.
    And next we have Mr. Raymond Scheppach.

STATEMENT OF RAYMOND C. SCHEPPACH, EXECUTIVE DIRECTOR, NATIONAL 
                     GOVERNORS ASSOCIATION

    Mr. Scheppach. Thank you, Mr. Chairman. I appreciate the 
opportunity to appear before you on behalf of the Nation's 
Governors.
    I would essentially like to focus on three major issues. 
First, what States are currently doing to extend dental health 
benefits to children; second, how any particular benefit in 
SCHIP or Medicaid relate to new State reform initiatives; and 
three, I think it is important to be aware of State Medicaid 
spending and how it is related to other priorities like 
education.
    Since the enactment of the State Children's Health Care 
Program in 1997, there has been a substantial expansion of 
dental services. While this is an optional benefit, all States 
have provided some dental benefits. Currently the enhanced 
match and increased flexibility to tailor benefits has 
contributed to the overall success of this program.
    SCHIP and Medicaid dental benefits are important, but 
having benefits does not necessarily mean that individuals 
receive services. This is particularly true, given the shortage 
of dentists in many areas, and more importantly, the more acute 
shortage of pediatric dentists, especially those trained to 
provide services to children with special health care needs. 
Therefore, States have taken a more holistic approach to this 
problem. First, they have been doing a fair amount in terms of 
promoting education and prevention, in terms of PSAs, public 
awareness, working with communities on fluoridation. They have 
also tended to increase coverage and access at times working 
with States like Michigan and with network providers. They have 
also focused to some extent on enhancing the dental workforce, 
trying to provide special incentives for underserved areas, 
also providing tax credits, loan forgiveness for the education 
of dentists and improving finance through increasing 
reimbursements. Investments in children's health are extremely 
important but Governors are also well aware of the need to look 
holistically at making investments in children's futures. This 
is especially true in the area of early childhood development.
    I would like to turn now and summarize very quickly, Mr. 
Chairman, some of the things that are happening at the State 
level in terms of health care reform. In 2003, the State of 
Maine enacted a comprehensive proposal with the goal of 
universal coverage by 2009. This was quickly followed by 
Vermont and Massachusetts, who enacted plans in 2006 with the 
ambitious goals to cover all of the insured. There are now 
about four States who have committed to universal coverage 
while another 10 are developing proposals for universal access. 
Several others are focused on universal care for children and 
many others are pursuing more incremental reforms. There is a 
number of common elements in all of these reforms. They 
obviously include coverage expansions. They include connectors, 
essentially trying to bring together providers with low-income 
individuals to provide the best appropriate benefits and 
allowing choice and portability. They have worked on the so-
called tax incentives, making sure everybody is aware of 
section 125. States are experimenting with both employer 
mandates in terms of where is the cutoff in terms of small 
business. They are experimenting with individual mandates also 
with quality improvements and measurements. They are also 
negotiating with providers to increase a number of affordable 
benefit packages.
    Mr. Chairman, I think we are at the point now where it is 
very possible over the next 2 to 3 years that we may witness as 
many as eight or ten States who have actually enacted and begun 
to implement universal care or universal access, and I think as 
you move forward on the reauthorization of SCHIP and other 
programs, you have got to question how that fits in with 
essentially what is happening at the State level.
    I would just a raise a couple of potential cautions as you 
move forward with respect to any mandates on SCHIP or Medicaid. 
First, it would require States to spend more money per person 
on these programs which redirects funds from eligible 
expansions. I think if we continue to have 47 million 
uninsured, it is a real public policy question of whether we 
create a more robust benefit package for some or whether we try 
to get a basic benefit package for a wider population.
    Second of all, it could limit State efforts to create 
affordable consolidated insurance markets. Most States' 
coverage efforts include negotiations with providers to develop 
basic benefit packages that would be subsidized for States and 
offered through a connector. Essentially what the connector 
does is, it consolidates the individual and the small group 
markets into a pool. It then matches providers by offering 
benefits with the demand for health care for State employees, 
SCHIP, Medicaid as well as small business. This approach 
reduces risk, lowers costs, stabilizes the small market, 
essentially mandates that changes to benefits packages could 
become an obstacle to the efficiencies of these pools. Rather 
than allow Federal programs to be integrated into the overall 
health care system, SCHIP and Medicaid may well continue to be 
separate, more expensive programs.
    I would just like to end with a few comments on Medicaid 
and State budgets. Unfortunately, Medicaid has grown about 11 
percent per year over the last 25 years. It is now almost 23 
percent of State budgets. It is more than all elementary and 
secondary education. In some States, it is 34, 35 percent. With 
State revenues growing only 5 to 6 percent, Medicaid has been 
funded by cutting virtually all other components of State 
spending.
    Mr. Pallone. I know you said you are wrapping up but you 
have already gone over a minute, so----
    Mr. Scheppach. Let me just say that we have two challenges, 
it seems, universal health care and overall competitiveness. 
States are trying to make the balance between education 
commitments and health care.
    Thank you, Mr. Chairman.
    [The prepared statement of Mr. Scheppach follows:]

                   Statement of Raymond C. Scheppach

    Mr. Chairman: I appreciate the opportunity to appear before 
you today to discuss the issue of dental health as it relates 
to Medicaid and S-CHIP. It is important to continue to evaluate 
the structure of benefits for both of these programs and how 
they relate to health care reform in general.
    This morning I would like to focus on three major issues as 
follows.
     First, what States are currently doing to extend dental 
health benefits to children and how this benefit relates to 
other early childhood services. Second, since there is 
essentially an explosion of health care reform activity in the 
States, is important to evaluate how any particular benefit 
mandate relates to these new reform initiatives. Third, it is 
important to be aware of State Medicaid spending and how it is 
related to other State priorities such as education.

                   Dental Health and Early Childhood

    Since the enactment of the State Children's Health 
Insurance Program (S-CHIP) in 1997, there has been a 
substantial expansion of dental services. While this was an 
optional benefit, all States have provided some dental 
benefits. Clearly, the enhanced Federal match and increased 
flexibility to tailor benefits have contributed to the success 
of S-CHIP benefit program. Without both of these incentives the 
strength of the program would be jeopardized.
    Access to dental services and outcomes are better in S-CHIP 
than in Medicaid. Any further improvements in children's dental 
health must come from building on the strengths and successes 
of S-CHIP, and that includes both funding and flexibility. 
Benefit mandates, or any other attempt to make S-CHIP more like 
Medicaid will only serve to thwart this progress and could 
ultimately erode the improvements made so far. NGA will 
continue to oppose Federal mandates.
    States are using S-CHIP to meet children's primary health 
care needs, including dental health services. Research has 
shown the S-CHIP enrollees are more likely to have a medical 
home and more likely to receive preventive dental care. More 
than half of S-CHIP children have had a dental check-up in the 
past 6 months and over 80 percent have a usual source of dental 
care.
    States have been working over a number of years to try to 
improve access to dental care for children. There are a variety 
of approaches that States have been using, including those that 
you have heard about today from Michigan. The good news is that 
dental access is improving for children. Beyond dental, States 
are also working to meet children's primary health care needs 
as well as expand affordable health coverage. S-CHIP has seen a 
success in this area too with over 90 percent of children in 
the program reporting that they have a usual source of medical 
care. The overwhelming success of S-CHIP in improving health 
care coverage and outcomes is why there is unanimous support 
among governors for a timely reauthorization of the program.
    While S-CHIP and Medicaid dental benefits are important, 
simply having a benefit does not necessarily mean that children 
receive services. This is particularly true given the shortage 
of dentists in many areas and more importantly the more acute 
shortage of pediatric dentists, especially those trained to 
provide services to children with special health care needs. 
Therefore, States have taken a more holistic approach to dental 
care by:

      Promoting Education and Prevention. Much of the 
disease experienced by children could be prevented with better 
personal care and water fluoridation. Several States have 
launched public awareness campaigns to educate parents and 
children about proper dental care and to build public support 
for children's oral health policy initiatives.
      Increasing Coverage and Access. Though many low- 
income children have dental coverage through Medicaid, most 
receive no preventive dentist visits. Many States are trying to 
strengthen the safety net by encouraging providers to 
participate in Medicaid and by including dental benefits in S-
CHIP.
      Enhancing the Dental Workforce. Many States are 
trying to attract dentists to chronically underserved areas, 
yet the number of dentists graduating from dental school is 
decreasing nationally. To succeed, States are using loan 
forgiveness, tax credits, and other incentives and are trying 
to enhance dentist training to adequately address pediatric 
needs.
      Improving Financing and Reimbursement. Many 
providers refuse to participate in Medicaid because of the low 
rate at which they are reimbursed. Some States have increased 
provider reimbursements in Medicaid to attract new dentists as 
well as to bring back dentists who have stopped participating.

    Investments in children's health are extremely important, 
but Governors are also well aware of the need to look more 
holistically at making investments in children's futures. This 
is especially true in the area of early childhood development.
    Motivated by compelling child development research, 
impressive cost-benefit evidence, and the persistent 
achievement gap plaguing our Nation's education system, 
governors are pursuing pre-kindergarten expansion, full-day 
kindergarten, child care quality improvement and expansion, 
infant-toddler initiatives, and other strategies to invest in 
children's learning and development from birth into the early 
elementary years. For example:

      New York Governor Elliot Spitzer is calling for 
full funding of the State's $645 million Universal Pre-K 
program and for full-day kindergarten planning grants for high-
need districts.
      Nevada Governor Jim Gibbons has committed $50 
million to support full day kindergarten pilot programs in at-
risk schools
      Arizona's recent ballot initiative will direct 
$188 million in new funds for early childhood development and 
health programs, in addition to a $200 million increase for 
voluntary full-day kindergarten programs championed by Governor 
Janet Napolitano
      Minnesota Governor Tim Pawlenty has proposed 
$4000 per child for high quality early learning programs for 
at-risk 4 year olds.

                        State Health Care Reform

    The State of Hawaii enacted universal health care access in 
1974. From that point until 2003, neither the Federal 
Government nor States made very much process in covering the 
uninsured. In 2003, the State of Maine enacted a comprehensive 
proposal with the goal of universal coverage by 2009. This was 
quickly followed by Vermont and Massachusetts, who enacted 
plans in 2006 with ambitious goals to cover all of the 
uninsured. What is of particular note of all three of these 
plans is that they were bipartisan and subsidized coverage for 
families up to 300 percent of the Federal poverty level. It is 
also true that these States had relatively low rates of 
uninsured prior to enacting reforms. While the three States 
face significant challenges to implement their plans, the early 
success in developing a State consensus for reforms has 
stimulated major reforms in another 20-25 States.
    There are about four States that have committed to 
universal coverage while another ten are developing proposals 
for universal access to coverage. Several others are focused on 
universal care for all children and many others are pursing 
more incremental reforms. There are a number of common elements 
in these reforms as follows:
    State Coverage Extensions. To address the problem of the 
uninsured, States have enacted plans or are considering 
proposals to increase coverage and access for many Americans. 
These initiatives include reforming the individual insurance 
market, requiring individual or employer participation in 
health insurance, ensuring that all individual who are eligible 
for S-CHIP or Medicaid are enrolled and direct subsidies to 
low-income individuals.
    Connectors. A ``connector'' or ``exchange'' model offers 
health coverage through a quasi-governmental authority that 
negotiates with health insurers to offer a minimum standard of 
benefits within a certain premium range. The connector pools 
individuals together to offer affordable, private insurance 
options. Most ``connectors'' consolidate the small group and 
individual markets into the pool. Many States are offering 
subsidies for low-income individuals to purchase health 
insurance through the ``connector.'' A choice of plans is 
provided and portability is a major benefit.
    Tax Incentives. Section 125 of the IRS tax code permits 
tax-free deductions of health insurance premiums from workers' 
paychecks, saving money for both the employer and employee. 
Many health reform plans are requiring employers to set up the 
option for their workers to deduct health insurance premiums 
tax-free. This option is generally paired with a connector 
model to ensure minimal administrative burdens for employers.
    Employer Mandates. Some States have required employers to 
either offer insurance to all of their uninsured workers or pay 
a fee for each uninsured employee. The employer mandate is seen 
as encouraging employers to continue to offer coverage and 
helping to fund the coverage expansion in the State. Generally, 
those States requiring employer contributions are those aimed 
at achieving universal coverage.
    Individual Mandates. Some States are moving toward a 
requirement on individuals to have health insurance coverage. 
Through State income tax filings, individuals who can afford 
coverage and are found not to have insurance will be fined. An 
individual mandate is being paired with mechanisms to make 
coverage more affordable for all residents, so individuals have 
the opportunity to meet the mandate without facing a financial 
hardship.
    Quality Improvements and Measurements. Using coverage 
expansions and Medicaid redesigns as vehicles, many States have 
incorporated quality improvement and measurement into their 
health reform plans to improve efficiency and patient care. 
Many States are using disease management programs, applying 
quality measures for doctors and hospitals, and taking steps 
toward interoperability with electronic data systems.
    Benefit Packages. Here, States are negotiating with 
providers to make a basic benefit package available to current 
low-income individuals and small businesses. Some of these may 
be paired with health savings accounts. The benefit package is 
then offered through the connector.
    The question now is how does a mandate for dental health or 
any other mandate on the Medicaid of S-CHIP benefit package 
relate to these reform efforts. I would argue that it could 
well be an obstacle in the following two ways.

     Requires States to spend more money per person in 
these programs, which redirects funds from eligibility 
expansions; and
     Limits State efforts to create affordable 
consolidated insurance markets.

    The goal of State actions is universal coverage or 
universal access. To attain this goal, States use a combination 
of existing programs, including Medicaid and S-CHIP, and new 
mechanisms to expand affordable health insurance. If States are 
required to meet new Federal benefit mandates in either 
Medicaid or S-CHIP, they will have to spend more money per 
individual currently covered in these programs. Efforts to 
enroll eligible uninsured individuals and many planned 
expansions of these programs will be more expensive for sates. 
These increased costs will force States to redirect funds that 
could have been used to fund other affordable health insurance 
initiatives. Reducing flexibility in these programs is a real 
obstacle both to maintaining existing coverage as well as 
coverage expansion.
    New mandates on Medicaid and S-CHIP is also a potential 
obstacle to State efforts to create affordable consolidated 
insurance markets. Most State coverage efforts include 
negotiation, with providers to develop basic benefit packages 
that would be subsidized by States and offered through the 
connector. Often this would be the same benefit package that is 
offer by the managed care or other major providers, which is 
often the same as that provided to State employees. 
Essentially, the connector consolidates the small group and 
individual markets into a pool. It then matches providers who 
are offering benefits with the demand for health care by States 
via State employees, S-CHIP and Medicaid, as well as small 
business, State subsidized previously uninsured and other 
individuals with COBRA or similar needs.
    This approach spreads risk, lowers cost, and stabilizes 
this market. Essentially, mandates that change this benefit 
package will become an obstacle to the efficiency of these 
pools. Rather than allow Federal programs to be integrated into 
the health care system, S-CHIP and Medicaid will continue as 
separate more expensive programs.
    Mr. Chairman, we urge you not to impose any additional 
mandates on States. Instead Congress should work with States to 
support current health reform efforts.

                 Medicaid vs. Other Domestic Priorities

    Governors prefer maximum flexibility in administering 
almost all Federal programs. This allows States not only to 
tailor their programs to the specific needs of their citizens, 
but increases the efficiency of programs.
    Governors and States now have about 40 years experience 
with Medicaid. It is the Nation's critical safety net health 
coverage program for low-income individuals and families. It 
covers 40 percent of non-elderly Americans living in poverty. 
It also covers more than 7 million in Medicare of the almost 44 
million enrollees, as well as 28 million children or 1 in every 
4. Finally, it covers long-term care coverage for 8 million 
low-income Americans with disabilities and chronic illness. In 
total, the program now covers 53 million Americans and costs 
about $317 billion in 2005.
    Unfortunately, Medicaid has grown almost 11 percent per 
year over that last 25 years. It now totals 23 percent of the 
average State budget, more than States spend on all elementary 
and secondary education. In States like Tennessee and Missouri 
it constitutes about 35 percent of their State budgets.
    With State revenues growing only about 5-6 percent per 
year, Medicaid has been funded by cutting virtually all other 
components of State spending. The stark reality of this in 
terms of total State spending is as follows:

      Between 1988 and 2005, a 17-year period, Medicaid 
has grown from 11.5 to 22.9 percent of State budgets. All 
components of State budgets have been cut to accommodate this 
increase.
      Elementary and secondary education went from 23.9 
percent to 21.8 percent, while higher education went from 12.8 
percent to 10.8 percent over the same period. The rest of the 
cuts came from welfare, economic development, environmental, 
and infrastructure programs.

    Providing health care benefits to all Americans--while 
critical--is not the only challenge facing State governments. 
The new world marketplace will challenge our standard of 
living. The United States used to compete with high wage, high 
technology countries in the developed world or low wage, low 
technology countries in underdeveloped countries. Now the 
United States competes with high technology, low wage emerging 
nations. Some of these emerging nations are rapidly growing 
large countries--such as India and China--while others are the 
smaller Pacific Rim countries, like Taiwan, Korea, and 
Singapore. But this list also includes many of the nations of 
Eastern Europe and emerging regions in South America as they 
join the world marketplace.
    Some of these countries compete with the United States in 
the production of manufacturing goods, from textiles to 
electronics to automobiles, while others are challenging the 
United States in Web construction, call centers, software 
development, and electronic products. Essentially, the changing 
world market has eliminated most safe havens where a nation's 
output and jobs are not threatened by increased competition.
    The United States' ability to compete in this new 
knowledge-based highly competitive world economy will depend on 
its ability to innovate, which in turn depends upon the 
education and training of our workforce. The economic cost of 
not being able to innovate will be reflected in the reduction 
of real wages and real incomes of United States citizens. This 
may not lead to any crisis in the short term, but reductions in 
real wages of 1-2 percent a year over the next decade can have 
a dramatic impact, particularly on low and middle income 
Americans. Further, reductions in this standard will create 
tensions among the various groups and societal institutions.
    While the United States has witnessed cyclical downturns 
when real wages have fallen, the trend over the last 200 years 
has generally been upward. The choice going forward, however, 
is between reductions in real wages or accelerating the rate of 
innovation. It is not possible to reestablish trade barriers to 
protect our current standard of living.
    In order to compete in the new emerging global marketplace, 
we have to dramatically upgrade the education and training of 
our labor force. To date, our education performance has been 
less than stellar.

      U.S. 15 year-olds ranked 24 out of 39 countries 
on the Program for International Student Assessment (PISA) of 
students' ability to apply mathematical concepts to real world 
problems.
      In 2004, the U.S. produced 137,000 new engineers 
while India provided 112,000 and China produced $352,000 
adjusted for quality.

    Mr. Chairman, at this time States spend about one-third of 
their revenues on health care and about one-third on education. 
However, the double digit growth in State health care spending 
may not be sustained in the future. If the past is a good 
indication of the future, it would be financed by cuts in 
education. Future cuts in education, however, will lead to 
declines in our standard of living.
    Health care and education are our two major domestic 
challenges as we go forward as a nation. It is important to 
have universal health care or universal access. But it is also 
important to increase our standard of living, which requires 
additional spending on education. Governors are attempting to 
find the appropriate balance between these two challenges.
                              ----------                              

    Mr. Pallone. Thank you very much.
    Ms. Farrell.

STATEMENT OF CHRISTINE FARRELL, R.D.H., M.P.A., MEDICAID POLICY 
 SPECIALIST, MICHIGAN DEPARTMENT OF COMMUNITY HEALTH, MEDICAL 
                    SERVICES ADMINISTRATION

    Ms. Farrell. Good morning, Chairman Dingell, Chairman 
Pallone and Ranking Member Deal and the members of the 
Subcommittee on Health. My name is Christine Farrell and I am 
employed with the Michigan Department of Community Health, 
Medical Services Administration, the agency that administers 
the Michigan Medicaid program. For the past 15 years, I have 
been the dental policy specialist with the responsibility of 
managing the Medicaid dental benefit. Since 2000 I have served 
as the contract manager for the Healthy Kids Dental program and 
this is our partnership with the Delta Dental Plan in Michigan. 
In addition, I am also a part of the dental team. I am a 
registered dental hygienist.
    Apart from my State role, I also have a national role. I am 
the national chairperson of the Medicaid/SCHIP Dental 
Association. We are an association of dental program managers. 
As an association, we hope to have a more effective voice for 
the delivery of oral health care to the Medicaid and SCHIP 
populations since we all share the goal of trying to provide 
access to oral health services for our beneficiaries. Medicaid/
SCHIP Dental Association has worked to promote oral health 
awareness within our respective programs and we are also 
working with other oral health advocacy groups, with the 
Centers for Medicare and Medicaid Services, the National 
Association of State Medicaid Directors and the National 
Academy for State Health Policy.
    My primary purpose today is to highlight the Michigan 
Medicaid program and how we are addressing the issue of access 
to oral health care for Medicaid beneficiaries under the age of 
21 through our Healthy Kids Dental program. This is our 
partnership with Delta Dental Plan of Michigan and it began on 
May 1, 2000, and continues today. In 1999, the Michigan 
Legislature appropriated an additional $10.9 million to address 
the issue of access to oral health services for Medicaid 
beneficiaries, especially those in rural areas. As a result of 
dental taskforce recommendations, Michigan chose to use half of 
these monies to provide infrastructure grants to safety-net 
providers such as community health centers, local health 
departments, hospitals and universities. The additional monies 
went to develop a demonstration project similar to our MIChild 
dental program, which is our SCHIP program which provides a 
dental insurance product to enrollees. We set out to contract 
with a dental insurance carrier to administer the Medicaid 
dental benefit through a statewide network of dental providers, 
and Delta Dental Plan answered that call.
    The Healthy Kids Dental program was implemented on May 1, 
2000, in 22 counties providing access to oral health care 
services for 50,000 Medicaid beneficiaries. The program was 
expanded to 37 counties in October 2006 and increased the total 
beneficiaries to over 100,000. On May 1, 2000, the program 
expanded to an additional 22 counties, providing access again 
to another 50,000 beneficiaries. Today it is in 59 of our 83 
counties. The majority of these counties are rural. They have 
dental care health professional shortage areas and have little 
or no dentist participation in the traditional Medicaid 
program. Some of these counties have no dentists or one or two.
    The Healthy Kids Dental program is designed to mirror an 
employer-sponsored plan. By partnering with Delta Dental Plan 
of Michigan, we gained access to their statewide network 
because approximately 95 percent of the dentists in Michigan 
participate with Delta Dental whereas less than 20 percent of 
the practicing dentists are Medicaid providers. By using this 
network, we provide an immediate benefit to our Medicaid 
beneficiaries. We offer them greater access to dentists and the 
ability to develop a dental home. Another advantage is that 
they are mainstreamed into the entire population of Delta 
subscribers and they do not have the stigma of public 
assistance, and as long as a dentist participates with Delta 
Dental, they can't refuse to treat Medicaid beneficiaries.
    While Delta administers the Medicaid dental benefit, the 
advantage to their network dental providers is that Delta 
administers the benefit according to their policies and 
procedures. Providers submit claims directly to Delta and 
receive reimbursement from Delta. Initially they were 
reimbursed at the Delta premier rate, which may be commonly 
referred to as their usual customary charge. In January 2006, 
due to budget considerations, Delta Dental and the Medicaid 
program initiated a reimbursement change to a fixed fee 
schedule. While this fixed fee schedule is less than their 
premier rate, it is still higher than our standard Medicaid 
rate. We were initially concerned that this decrease in 
reimbursement would impact the network of participating 
providers and decrease access. This fear was unfounded. We have 
monitored the provider network and we have retained over 86 
percent of the participating dental providers. We attribute 
this success to the fact that Delta Dental has a strong 
relationship with their dental network and is a highly 
respected company by the Michigan Dental Association and its 
members.
    We have contracted with a University of Michigan 
researcher, Dr. Stephen Eklund, to assess the results of the 
Healthy Kids Dental program and we have just released a study 
showing that 5 years of operation where it shows that dental 
visits are 50 percent higher for children enrolled in the 
Healthy Kids Dental program compared to our traditional 
Medicaid dental program. Additional results show that travel 
distance has also been cut in half from the traditional 
Medicaid beneficiary experience. In addition, many Healthy Kids 
dental beneficiaries have established a dental home and are 
developing routine dental recall patterns. The results are 
impressive and we are very excited about them.
    In addition, Delta Dental Plan recently conducted a survey 
of Healthy Kids Dental participants and the majority of them 
are also satisfied.
    The goal of the Healthy Kids Dental program is to increase 
access to oral----
    Mr. Pallone. Ms. Farrell, I am going to have to ask you to 
summarize too.
    Ms. Farrell. Oh, I am sorry.
     We think we have demonstrated success and Michigan would 
welcome additional Federal assistance to assist us in further 
expanding the Healthy Kids Dental program and we are in 
challenging economic times and we continue to look at 
innovative ways to increase our oral health care access.
    [The prepared statement of Ms. Farrell follows:]

                     Testimony of Christine Farrell

     Good morning Chairman Dingell, Chairman Pallone, Ranking 
Member Deal and the members of the Subcommittee on Health.
     My name is Christine Farrell and for the past 19 years I 
have been employed by the Michigan Department of Community 
Health, Medical Services Administration (the agency that 
administers the Michigan Medicaid Program). For the past 15 
years, I have been the dental policy specialist with the 
responsibility of managing the Medicaid dental benefit. Since 
2000, I have served as the contract manager for the Healthy 
Kids Dental program; this is our partnership with the Delta 
Dental Plan of Michigan.
     Apart from my State role, for the past 3 years, I have 
been the national chairperson of the Medicaid/SCHIP Dental 
Association (MSDA). This association was formed 3 years ago at 
the National Oral Health Conference by Medicaid and SCHIP 
dental program managers. As an association, we hope to have a 
more effective voice for the delivery of oral health care to 
the Medicaid and SCHIP populations. Our mission is to provide a 
support system and promote collegiality among State Medicaid 
and SCHIP programs since we all share the goal of trying to 
provide access to oral health services for our beneficiaries. 
Since forming this association, the MSDA has worked to promote 
oral health awareness and to increase access to oral health 
services for Medicaid and SCHIP beneficiaries within our 
respective State programs, with the Centers for Medicare and 
Medicaid Services (CMS) Chief Dental Officer, with national 
policy groups such as the National Association of State 
Medicaid Directors (NASMD), the National Academy for State 
Health Policy (NASHP), and other oral health advocacy groups. 
Our Association seeks the opportunity to provide State and 
national leadership in the development of Medicaid/SCHIP oral 
health policy, encourage innovation and collaboration among 
State Medicaid programs, and to promote the integration of oral 
health and primary care in Medicaid/SCHIP programs.
     My primary purpose today is to highlight the Michigan 
Medicaid Program and how we are addressing the issue of access 
to oral health care for Medicaid beneficiaries under the age of 
21 through our Healthy Kids Dental program. The Healthy Kids 
Dental program is our partnership with the Delta Dental Plan of 
Michigan. This partnership began on May 1, 2000 and continues 
today.
     In 1999, the Michigan legislature appropriated an 
additional $10.9 million dollars to address the issue of access 
to oral health services for Medicaid beneficiaries, especially 
those in rural areas. As the result of Dental Task Force 
recommendations, Michigan chose to use half of the monies to 
provide infrastructure grants to safety-net providers, such as 
community health centers, local health departments, hospitals 
and universities. The additional monies went to develop a 
demonstration project similar to the MIChild dental program 
(Michigan's SCHIP program) which provides a dental insurance 
product to enrollees. We (Medicaid) sent out a proposed 
bulletin announcing the intent to contract with a dental 
insurance carrier to administer the Medicaid dental benefit 
through a statewide network of dental providers.
     The Healthy Kids Dental program was implemented on May 1, 
2000, in 22 counties providing access to oral health care 
services for 50,000 Medicaid beneficiaries under the age of 21. 
The program was expanded to 37 counties in October, 2006, and 
increased the total beneficiaries enrolled to over 100,000 
enrollees. On May 1, 2006, the program expanded to an 
additional 22 counties providing access to another 50,000 
beneficiaries. Today, it is in 59 of the 83 Michigan counties 
providing access to oral health care services for over 200,000 
beneficiaries. The majority of these counties are rural, are 
Dental Care Health Professional Shortage Areas, and have little 
or no dentist participation in the traditional Medicaid 
Program.
     The Healthy Kids Dental program is designed to mirror an 
employer-sponsored plan. By partnering with Delta Dental Plan 
of Michigan, we have gained access to their statewide network. 
Approximately 95% of the practicing dentists in Michigan 
participate with Delta Dental whereas, less than 20% percent of 
the practicing dentists are Medicaid providers. By using this 
network, we provide an immediate benefit to our Medicaid 
beneficiaries by offering them greater access to dentists and 
the ability to develop a dental home. Another advantage for the 
beneficiaries is that they are mainstreamed into the entire 
population of Delta subscribers by receiving a Delta Dental 
card; they do not have the stigma of public assistance. As long 
as the dentist participates with Delta Dental, they cannot 
refuse to treat Medicaid beneficiaries unless the office is 
closed to all new patients.
     While Delta administers the Medicaid dental benefit, the 
advantage to their network dental providers is that Delta 
administers the benefit according to their policies and 
procedures, providers submit claims directly to Delta and 
receive reimbursement from Delta. Initially, the dentists were 
reimbursed at the Delta Premier rate (may be commonly referred 
to as their Usual & Customary Charge). In January 2006, due to 
budget considerations, Delta Dental and the Medicaid Program, 
initiated a reimbursement change from the Premier rate to a 
fixed fee schedule. While this fee schedule is less than the 
Premier rate, the rate is still higher than the standard 
Medicaid fee schedule. We (both Medicaid and Delta Dental) were 
initially concerned that this decrease in reimbursement would 
impact the network of participating providers and decrease 
access. This fear was unfounded. We have monitored the provider 
network and have retained over 86% of the participating dental 
providers. We attribute this success to the fact that Delta 
Dental has a strong relationship with their dental network and 
is a highly-respected company by the Michigan Dental 
Association and its members.
     A University of Michigan researcher, Dr. Stephen A. 
Eklund, was contracted to assess the results of the Healthy 
Kids Dental program. A study using data from the first 5 years 
of operation has just been completed and the results are 
impressive. Results show that dental visits are 50 percent 
higher for children enrolled in the Healthy Kids Dental program 
compared to children enrolled in the traditional Medicaid 
dental program. Additional results show that the travel 
distance for beneficiaries has been cut in half from 
traditional Medicaid experience. The median distance traveled 
is 7.6 miles for Healthy Kids Dental beneficiaries, whereas 
beneficiaries in the traditional Medicaid Program normally 
travel twice that distance. In addition, many Healthy Kids 
Dental beneficiaries have established a dental home and are 
developing routine dental recall patterns. The results of the 
study are impressive and we (both Medicaid and Delta Dental) 
are excited about them. It demonstrates that the partnership 
with Delta Dental is working.
     In addition, Delta Dental Plan recently conducted a survey 
of Healthy Kids Dental participants. Of the respondents, nearly 
99 percent are satisfied with the program and 92 percent 
indicated that their child's health has improved due to the 
Healthy Kids Dental program.
     In 2004, the American Dental Association designated the 
Healthy Kids Dental program as one of five national models for 
improving access to oral health services for Medicaid 
beneficiaries.
     The goal of the Healthy Kids Dental program is to increase 
access to oral health services for Medicaid beneficiaries and 
to eliminate barriers. We believe that the program has 
accomplished this goal through our partnership with Delta 
Dental Plan of Michigan. We have addressed the three most 
common complaints typically reported about the Medicaid 
Program: low reimbursement rates, administrative burden and 
beneficiary no-show rates. We have also improved the health of 
the beneficiaries by crafting a new model that is working in 
Michigan.
     While this program has demonstrated success, Michigan 
would welcome additional Federal assistance to assist us in 
further expanding the Healthy Kids Dental program statewide. We 
are in challenging economic times in Michigan and we continue 
to look at innovative ways to improve access to oral health 
care. Additional Federal support would assist Michigan, and 
other States, in crafting solutions to improve and expand 
access to this critical benefit for children.
                              ----------                              

    Mr. Pallone. Thank you. I would also say you can submit 
your full statement for the record too. We are just trying to 
get you to summarize your comments within the minutes or so.
    Next is Dr. Mosca.

 STATEMENT OF NICHOLAS G. MOSCA, D.D.S., CLINICAL PROFESSOR OF 
     PEDIATRIC AND PUBLIC HEALTH DENTISTRY, UNIVERSITY OF 
                MISSISSIPPI SCHOOL OF DENTISTRY

    Dr. Mosca. Good morning, Mr. Chairman and members of the 
committee. My name is Dr. Nicholas Mosca. I am clinical 
professor of pediatric and public health dentistry at the 
University of Mississippi School of Dentistry and also serve as 
State dental director for Mississippi. It is an honor to 
testify on behalf of two organizations, the American Dental 
Education Association, which represents over 21,000 members at 
more than 120 academic dental institutions including 56 schools 
of dentistry in 34 States, the District of Columbia and Puerto 
Rico, and the American Association for Dental Research, which 
represents 5,000 individual and 100 institution members.
    Each year about 4,500 pre-doctoral dental students graduate 
from dental school. Fourteen thousand dental hygienist students 
graduate. Eight thousand dental assistants and 800 dental 
laboratory technologists graduate. Many of these students are 
trained in clinical environments where dental care is provided 
to underserved low-income populations including individuals 
covered by Medicaid and the State Children's Health Insurance 
Program.
    Let me share with you, as did New Mexico, Utah and 
California, a snapshot of Mississippi. During the 2004-05 
school year, 7 in 10 third-grade children experienced tooth 
decay. Two in five had untreated dental disease, and 1 in 10 
had urgent need for dental care, which means that over 3,800 
children had urgent need for care. Almost twice as many 
African-American children were in need of urgent care because 
of pain or infection.
    On March 23, at a Head Start program in Clarksdale, 
Mississippi, the birthplace of the blues, I saw a 4-year-old 
child with an acute dental abscess. We have all been talking 
about the untimely death of Diamonte Driver but let me also 
share another example of an access issue. A week ago in USA 
Today, it was reported that a routine dental visit revealed a 
cancerous tumor in the mouth of North Carolina football coach 
Butch Davis. Coach Davis is now undergoing chemotherapy for 
non-Hodgkin's lymphoma. His access to oral health care in 
combination with dental insurance played a critical role in 
saving his life. These two examples reveal opposing sites of 
access to dental care in America. One individual lacked 
consistent care while the other was well insured and had timely 
care.
    Once upon a time, access to dental care meant the removal 
of bad teeth and the fabrication of dentures. Dental care is no 
longer akin to making hearing aids or eyeglasses. In other 
words, we must work to prevent most infection and pain from 
occurring in the first place. Healthy adult mouths have 32 
teeth which are supplied by blood vessels, just like our 
fingers. How can we afford to allow our children's fingers to 
become infected? How many fingers could you afford to lose? The 
real tragedy is that we know how to prevent most tooth decay in 
most populations. We only need to act on our knowledge.
    Prevention of disease such as by public water fluoridation 
or school-based dental sealant programs is essential to contain 
the higher costs associated with care. Children who receive 
early preventive care are more likely to continue using 
prevention services and those who wait to visit a dentist are 
more likely to have a costly health problem or require an 
emergency room visit.
    Our U.S. academic dental institutions act to mitigate these 
emergency room visits by serving as safety-net providers to 
provide comprehensive care at reduced costs and we serve 
racially and ethnically diverse populations including low-
income, elderly, migrant individuals, home-bound individual, 
mentally, medically and physical disabled individuals. As 
providers of services to underserved populations, academic 
dental institutions may also enhance Government initiatives to 
expand access to prevention and dental care. Schools can work 
with State oral health programs to support school-based dental 
programs, sealant programs, and schools can conduct research to 
evaluate the dental workforce capacity needed to adequately 
serve those in Medicaid, Ryan White HIV dental clinics and 
other public assistance programs.
    Here are some fairly straightforward ways in which Congress 
can immediately act to enhance access to vital preventive and 
restorative services. We urge Congress to adopt the following 
recommendations for the reauthorization of the SCHIP program, 
establish a Federal guarantee for dental coverage in SCHIP, 
develop a dental wraparound benefit in SCHIP, facilitate 
ongoing outreach efforts to enroll all eligible children in 
SCHIP and Medicaid, and ensure reliable data reporting on 
dental care in SCHIP in Medicaid. We further urge Congress to 
ensure that there is adequate funding of the Federal programs 
that increase access to oral health care and improve oral 
health infrastructure and dental research and bolster the oral 
health care workforce for the Nation. You already had many of 
these programs named and so I just want to reiterate that we 
know how to prevent most disease in most populations. We only 
have to act on this knowledge.
    Thank you, and I am happy to field any questions that you 
may have.
    [The prepared statement of Dr. Mosca follows:]

                 Statement of Nicholas G. Mosca, D.D.S.

    Mr. Chairman and members of the committee, I am Dr. Nick 
Mosca, Clinical Professor of Pediatric and Public Health 
Dentistry at the University of Mississippi School of Dentistry 
and Dental Director for the State of Mississippi. I am a member 
of the American Dental Education Association (ADEA) and the 
American Association for Dental Research (AADR). This morning I 
am testifying on behalf of both organizations.
    The ADEA represents over 120 academic dental institutions 
as well as all of the educators, researchers, residents and 
students training at these institutions and AADR represents 
over 5,000 individual members and 100 institutional members. 
The joint mission of ADEA and AADR is to enhance the quality 
and scope of oral health, advance research and increase 
knowledge for the improvement of oral health, and increase 
opportunities for scientific innovation. Academic dental 
institutions play an essential role in conducting research and 
educating and training the future oral health workforce. These 
institutions provide dental care to underserved low-income 
populations, including individuals covered by Medicaid and the 
State Children's Health Insurance Program.
    I thank the committee for this opportunity to testify about 
access to oral health care, the role academic dentistry plays 
in providing care for underserved populations and the role we 
play in educating a competent and diverse oral health care 
workforce for the Nation.
    Preventive Care is Essential to Eradicate Oral Health 
Disparities and Contain Costs
    Americans spend millions of dollars annually in treatment 
of dental caries (cavities) and tooth restoration. Despite 
tremendous improvements in the Nation's oral health over the 
past decades, the benefits have not been equally shared by 
millions of low-income and underserved Americans.
    As the Surgeon General's report on oral health in America 
told us 7 years ago, there are "profound and consequential oral 
health disparities within the population," particularly among 
racial and ethnic minorities, rural populations, individuals 
with disabilities, the homeless, immigrants, migrant workers, 
the very young, and the frail elderly." At the time of 
publication of the Surgeon General's Report there were 108 
million Americans lacking dental insurance, of which 23 million 
were children.
    Children in households below 200 percent of poverty have 
three times the tooth decay of children from affluent homes. 
Their disease is more advanced and is less likely to be 
treated. Eighty percent of untreated dental caries (tooth 
decay) is isolated in roughly 25 percent of children. The 
majority of these children are from low-income and other 
vulnerable groups--the same groups that rely upon public health 
programs for their care. Most adults, particularly as they age 
show signs of periodontal or gingival disease. Fourteen percent 
of people age 45 to 54 have severe periodontal disease and that 
number grows to almost a quarter (23 percent) for people age 65 
to 74. Tragically one-third of adults (30 percent) are 
completely toothless (edentulous).
    Access to oral health care can be a matter of life and 
death. Those of us who read the Washington Post were reminded 
of that recently with the untimely death of Deamonte Driver, a 
12-year-old boy with an abscessed tooth, part of an uninsured 
and sometimes homeless family whose Medicaid coverage had 
lapsed. Deamonte's tooth infection spread to his brain. After 
two brain surgeries and six weeks in the hospital (and tens of 
thousands of dollars in medical expenses), he died. A week ago 
USA Today reported that a routine dental visit revealed a 
cancerous tumor in the mouth of North Carolina football coach 
Butch Davis. Coach Davis is now undergoing chemotherapy for 
non-Hodgkin's lymphoma. His access to oral health care, in 
combination with dental insurance played a critical role in 
saving his life.
    America's most prevalent infectious disease is dental decay 
(caries) for all ages. It is five times more common than asthma 
and seven times more common than hay fever in children. Early 
childhood caries is dental decay found in children less than 5 
years of age. It is estimated that 2 percent of infants 12-23 
months of age have at least 1 tooth with questionable decay 
whereas 19 percent of children 24-60 months of age have early 
childhood caries in the United States. \1\
---------------------------------------------------------------------------
    1 ``Early Preventive Dental Visits: Effects on Subsequent 
Utilization and Costs,'' Matthew F. Savage, DDS, MS, Jessica Y. Lee, 
DDS, MPH, PhD, Jonathan B. Kotch, MD, MPH, and William F. Vann, Jr., 
DMD, PhD, Pediatrics Vol. 114, No. 4, October 2004.
---------------------------------------------------------------------------
    Preventative care is essential to contain costs associated 
with oral health care treatment and delivery. Children who have 
early preventive dental care are more likely to continue using 
preventive services. Those who wait to visit a dentist are more 
likely to visit for a costly oral health problem or emergency. 
The average cost for a dental visit before age one was $262. 
This doubled to $546 when a child's first visit wasn't until 
ages 4 to 5 \2\
---------------------------------------------------------------------------
    2 Ibid
---------------------------------------------------------------------------
    Dental caries is a chronic, infectious disease process that 
occurs when a relatively high proportion of bacteria within 
dental plaque begin to damage tooth structure. If caries can be 
diagnosed before irreversible loss of tooth structure occurs, 
it can be reversed using a variety of approaches that 
``remineralize'' the tooth. In addition to improved 
diagnostics, researchers are working to develop a vaccine to 
prevent tooth decay while others use new methods to 
specifically target and kill the decay-causing bacteria.

            Academic Dental Institutions and Access to Care

    U.S. academic dental institutions (dental schools, allied 
dental programs and postdoctoral/advanced dental education 
programs) are safety net providers increasing access to care. 
These institutions are dental homes for a broad array of 
racially and ethnically diverse patients including low-income 
non-elderly and elderly individuals; migrant individuals; 
homebound individuals; mentally, medically or physically 
disabled individuals; institutionalized individuals; HIV/AIDS 
patients; Medicaid and SCHIP children and uninsured 
individuals.
    All U.S. dental schools operate dental clinics and most 
have affiliated satellite clinics where preventative and 
comprehensive oral health care is provided as part of the 
educational mission. All dental residency training programs 
provide care to patients through dental school clinics or 
hospital-based clinics. Additionally, all dental hygiene 
programs operate on-campus dental clinics where classic 
preventive oral health care (cleaning, radiographs, fluoride, 
sealants, nutritional and oral health instruction) can be 
provided 4-5 days per week under the supervision of a dentist. 
All care provided is supervised by licensed dentists as is 
required by State practice acts. All dental hygiene programs 
have established relationships with practicing dentists in the 
community for referral of patients. Millions of dollars of 
uncompensated care are provided by academic dental institutions 
each year.
    As major providers of services to underserved populations, 
academic dental institutions also play a major role in 
enhancing private sector initiatives that support expanded 
access to dental care. They support school-based sealant 
programs that reduce the incidence of tooth decay in children; 
and they evaluate the dental workforce capacity needed to 
adequately serve those in Medicaid, Ryan White HIV/AID clinics 
and other public assistance programs.

           Educating the Nation's Oral Health Care Workforce

    Oral health care is important for all Americans including 
those living in inner cities and in rural underserved areas. 
There are presently more than 3,400 designated dental health 
profession shortage areas, in which 45.3 million people live. 
It is doubtful that many of these areas can financially support 
a dentist or attract a dentist by virtue of their 
infrastructure or location. But the issue remains. There are 
unserved and underserved communities and populations, as well 
as a growing desire in society to have equitable access to 
health care and dental care for all. The challenge to dentistry 
is not only to expand the capacity of the dental workforce; it 
must also improve its distribution and access to oral health 
care. In order to achieve these objectives it is the mission of 
academic dental institutions to educate and train the U.S. 
dental health care workforce.
    Predoctoral Dental Education. Upon successfully completing 
dental school and passing a State licensure exam graduates may 
enter private practice as general dentists. Graduate also have 
the option to pursue advanced and specialty training.
    At the present time about 4,500 predoctoral dental students 
graduate annually after 4 years of dental school. The high 
water mark for dental student enrollment occurred in the late 
1970's with 6,300 students. Enrollment increased during the 
1960's and 1970's due to surges in both the baby boomers coming 
of college age and the percent of college age adults enrolling 
in college. Also, there was broad support for expanding the 
number of health care providers during that time which led to 
Federal student loan and scholarship programs, as well as 
Federal construction and capitation grants to schools to 
support enrollment increases. Then during the late 1970's and 
through the 1980's there were declines in enrollment which can 
be attributed to a strongly voiced perception of an oversupply 
of dentists, periods of economic inflation and stagnation, and 
termination of Federal support for further expansion in the 
numbers of health care providers. During the mid-1990's, 
applicants to dental school increased as dentistry was once 
again perceived to be a challenging and financially rewarding 
profession. However, enrollment increased only slightly. It 
should be noted that there is limited capacity within the 
current dental education infrastructure to accommodate much of 
an enrollment increase. And until recently, there was not 
support or need to do so nationally.
    At the present time there are 56 U.S. dental schools in 34 
States, the District of Columbia and Puerto Rico. Growing 
demand for dental care in certain areas of the country has 
precipitated the opening of six new dental schools. In 2003 the 
Arizona School of Health Sciences, the University of Nevada Las 
Vegas in 2002, and the Nova Southeastern University in Florida 
in 1997. In near future East Carolina University in Greenville, 
North Carolina plans to open a dental school with a focus on 
rural dentistry. The school plans to operate 10 student dental 
clinics in under-served communities throughout the State 
enrolling 50 students per class. Midwestern University in 
Glendale, Arizona will open a dental school in August 2008 with 
an enrollment of 100 students per class. The dental school is 
part of Midwestern's expansion plan to address the State of 
Arizona's health care workforce shortages. Western University 
of Health Sciences in Pomona, California plans to open a dental 
school in the next few years. The University is in the 
preliminary phase of the accreditation process.
    Prior to these openings, significant growth took place from 
1960-1978 with the number of dental schools increasing from 47 
to 60. This increase of 13 was during a time of Federal 
construction grants and a widely perceived need to expand the 
number of all health care professionals, including dentists. 
Between 1986-2001, seven dental schools closed, all private or 
private/State-related dental schools.
    Dental Residency Training. Approximately 2,800 new 
graduates and other dentists who have been in practice choose 
to specialize or advance their training in general dentistry by 
enrolling in dental residency training programs. There are nine 
recognized dental specialties: oral surgery, oral radiology, 
oral pathology, orthodontics, endodontics, periodontics, 
pediatric dentistry, dental public health as well as two 
programs in general dentistry, general practice residency and 
advanced education in general dentistry. Dental residency 
training programs last from a minimum of 14 months for Dental 
Public Health up to maximum of 54 months for oral surgery. 
Dental residency programs increase access to oral health care 
for a broad array of patients. Dentists may not practice a 
dental specialty without having successfully completed the 
required training.
    In 1995, the Institute of Medicine called for the creation 
of a number of graduate dental education residency positions 
sufficient to accommodate all graduates by 2005. In 1999, the 
Journal of Dental Education published a series of articles in a 
special issue that set forth a focused and compelling rationale 
for a mandatory, post-graduate year of dental residency 
education (PGY-1). The most recent call for a PGY-1 was in 
December 2006 at the ADEA Summit on Advanced Dental Education. 
Delaware has long required a residency before dentist could 
begin practice in the State. Beginning this year the State of 
New York requires a PGY-1 for initial licensure.
    Allied Dental Education There are about 300 dental hygiene 
programs in all 50 States and the District of Columbia. Most 
dental hygiene programs grant an associate degree, others offer 
a certificate, a bachelor's degree, or a master's degree. 
Dental hygienists rank among the fastest growing occupations. 
Each State has its own specific regulations regarding dental 
hygiene responsibilities thus services provided varies from 
State to State. Nearly 13,900 dental hygienists graduate 
annually.
    There are 272 dental assisting programs located in 47 
States and Puerto Rico. Dental assistants enhance the capacity 
of a dental office to treat patients by assisting dentists with 
a variety of treatment procedures. About 8,000 dental 
assistants graduate each year.
    Eight hundred students graduate annually from the 20 dental 
laboratory technology programs located in 16 States. These 
individuals create replacements for natural teeth and 
corrective devices; fabricate dentures, bridges, crowns and 
orthodontic appliances and work with a variety of materials 
such as waxes, plastics, precious and non-precious alloys, 
porcelains and others to fabricate dental restorations and 
tooth replacements.

                           Medicaid and SCHIP

    More than 9 million children lack medical insurance and 23 
million children lack dental insurance. Medicaid plays a 
critical role in children's access to dental services. In fact, 
Medicaid pays for 25 percent of all dental expenses for 
children under 6 years of age. Also, Medicaid covered 66 
percent of the dental expenses incurred for all people with 
public insurance.
    All 25 million children in Medicaid under age 21 are 
eligible for needed dental care through the Early Periodic 
Screening, Diagnosis and Treatment program (EPSDT). Dental 
services were among the first three preventive health care 
services included in EPSDT. Although all children enrolled in 
Medicaid qualify for EPSDT services, less than one in four 
children on Medicaid receive them.
    State Medicaid programs are required to ensure that dental 
services are available and accessible and to provide services 
if a problem is identified that requires treatment. States must 
also inform Medicaid-eligible persons about the availability of 
EPSDT services and assist them in accessing and utilizing these 
services. Services include regular screenings and dental 
referrals for every child at regular intervals meeting 
reasonable standards of dental practice established by States 
in consultation with the dental profession. States must 
provide, at a minimum, services that relieve pain and 
infection, restore teeth, and maintain dental health.
    The State Children's Health Insurance Program (SCHIP) plays 
a critical role in providing access to dental care for covered 
children. Although States have the option to include dental 
coverage (presently all States have some level of dental 
benefits) the fact that they do so is a significant factor in a 
parent's decision to enroll their children in SCHIP.
    As Congress deliberates the reauthorization of the SCHIP, 
ADEA/AADR urges Congress to immediately enact legislation that 
would enhance SCHIP insurance coverage and enhance access to 
dental care. We recommend that Congress enact following 
recommendations to improve the system of care: (1) Establish a 
Federal guarantee for dental coverage in SCHIP; (2) Develop a 
dental wrap-around benefit in SCHIP; (3) Facilitate ongoing 
outreach efforts to enroll all eligible children in SCHIP and 
Medicaid; and (4) Ensure reliable data reporting on dental care 
in SCHIP and Medicaid.
    Dental care for adults under Medicaid is optional. As a 
result, many States often reduce or eliminate funding for adult 
dental programs during difficult economic times
     Today, most States have caps or limits on spending for 
adult oral health and dental services. Forty-one States offer 
only emergency care. As States begin to recover from the recent 
economic recession, some are reinstating limited oral health 
and dental services for adults; however, only a relatively few 
States provide comprehensive adult services. For many Medicaid-
eligible adults this is the only insurance coverage they have 
for oral health and dental care.

   Federal Programs That Help To Address Oral Health Workforce Issues

    The Dental Health Improvement Act, a Federal grant program 
for States, awarded the first 18 grants to States last October 
to help develop innovative dental workforce programs. The first 
grants are being used for a variety of initiatives including: 
increasing hours of operation at clinics caring for underserved 
populations, recruiting and retaining dentists to work in these 
clinics, prevention programs including water fluoridation, 
dental sealants, nutritional counseling, and augmenting the 
State dental offices to coordinate oral health and access 
issues.
    The Title VII General and Pediatric Dentistry Programs are 
essential to building the primary care dental workforce are 
effective in increasing access to care for vulnerable 
populations including patients with developmental disabilities, 
children and geriatric patients. These primary care dental 
residency programs generally include outpatient and inpatient 
care and afford residents with an excellent opportunity to 
learn and practice all phases of dentistry including trauma and 
emergency care, comprehensive ambulatory dental care for adults 
and children under the direction of experienced and 
accomplished practitioners.
    The Centers for Disease Control and Prevention Oral Health 
Program expands the coverage of effective prevention programs 
by building basic capacity of State oral health programs to 
accurately assess the needs in their State, organize and 
evaluate prevention programs, develop coalitions, address oral 
health in State health plans, and effect allocation of 
resources to the programs. CDC provides technical assistance to 
States that is essential to help oral health programs build 
capacity.
    Congress designated dental care as a ``core medical 
service'' when it reauthorized the Ryan White Modernization and 
Treatment Act in 2006. Seventy-five percent of the funding for 
titles I and II must be devoted to core medical services. This 
should result in many more afflicted patients receiving the 
dental care they need. The Dental Reimbursement Program 
provides access to quality dental care to people living with 
HIV/AIDS while simultaneously providing educational and 
training opportunities to dental residents, dental students, 
and dental hygiene students who deliver the care. The Dental 
Reimbursement Program is a cost-effective Federal/institutional 
partnership that provides partial reimbursement to academic 
dental institutions for costs incurred in providing dental care 
to people living with HIV/AIDS. The Community-Based Dental 
Partnership Program fosters partnerships between dental schools 
and communities lacking academic dental institutions to ensure 
access to dental care for HIV/AIDS patients living in those 
areas.
    The under representation of minorities poses a challenge to 
the U.S. health care workforce, including dentistry, especially 
as immigration trends contribute to increased numbers of 
minorities in the population. Title VII Diversity and Student 
Aid programs play a critical role in helping to diversify the 
health professions student body and thereby the health care 
workforce. Of paramount importance are the Health Careers 
Opportunity Program, the Centers of Excellence and the 
Scholarships for Disadvantaged Students. These programs are key 
drivers in recruiting and retaining students in the health 
professions. For the last few years these grant programs have 
not enjoyed an adequate level of support to sustain the 
progress that is necessary to meet the challenges of an 
increasingly diverse U.S. population.

              Academic Dental Institutions Recommendations

    Oral disease affects individuals, families, the community 
and society. Poor oral health can lead to pain and infection, 
missed work or school and disruptions of vital functions such 
as speech and eating, and other productive activities. Oral 
disease not only poses a risk to general health it can 
complicate other existing medical conditions.
    While dental care demands are higher than many other health 
care demands, many people in the U.S. do not receive basic 
preventive dental services and treatment. Most oral diseases 
are preventable if detected and treated promptly. Yet millions 
of Americans face unacceptable conditions in oral health living 
daily with pain and disability without treatment. The major 
reason for not obtaining dental services is financial. Since 
few oral health problems in their early stages are life-
threatening, people often delay treatment for long periods of 
time. Often, it is hospital emergency rooms to which they turn 
once they can no longer stand the pain or their condition has 
worsened to the point where they can no longer postpone 
treatment.
    ADEA/AADR urges Congress to adopt our SCHIP recommendations 
as set forth in this testimony that will greatly enhance access 
to vital preventive and restorative oral health care services: 
(1) Establish a Federal guarantee for dental coverage in SCHIP; 
(2) Develop a dental wrap-around benefit in SCHIP; (3) 
Facilitate ongoing outreach efforts to enroll all eligible 
children in SCHIP and Medicaid; and (4) Ensure reliable data 
reporting on dental care in SCHIP and Medicaid.
    Furthermore, we urge Congress to ensure adequate funding of 
the Federal programs outlined above, namely Medicaid and SCHIP, 
the Dental Health Improvement Act, Title VII General and 
Pediatric Dentistry Programs, the Centers for Disease Control 
and Prevention Oral Health Program, the Ryan White 
Modernization and Treatment Act and the title VII diversity and 
student aid programs which include the Health Careers 
Opportunity Program, the Centers of Excellence and the 
Scholarships for Disadvantaged Students.
                              ----------                              

    Mr. Pallone. Thank you, Dr. Mosca.
    Dr. Corbin.

  STATEMENT OF STEPHEN B. CORBIN, D.D.S., M.P.H., SENIOR VICE 
PRESIDENT OF CONSTITUENT SERVICES AND SUPPORT, SPECIAL OLYMPICS 
                         INTERNATIONAL

    Dr. Corbin. Good morning, and thank you again for having us 
here to share information on a very important topic, and a lot 
of verbal and written information will come across these tables 
and it will go into the record, but I think it is important 
that we get back to what this is all about. If you look to your 
left or your right and you see on your screen, you will see 
examples of very serious early dental infections in young 
children, as young as 3 or 4 all the way up to 6 or 7. So at 
the end of the day Diamonte Driver is a statistic, a dead child 
who should still be alive, and again, he is not the exception. 
There are many children out there that have these problems.
    There is one barrier we need to get over right in the 
beginning and it is not micromanaging the reimbursement levels 
or anything like that. It is a conceptual barrier. A decade 
ago, C. Everett Koop said if you don't have oral health, you 
are not healthy. Medical and dental science over the past 
decade has advanced and shown that Dr. Koop was indeed right 
and we know that to be the case today. At the same time, 15 
years ago, I heard for the first time in a State legislature 
this quote, or this is a paraphrase that is close to a quote: 
sure, it would be nice to save the dental program but let us 
face it, no one really dies from a toothache. This was not a 
single legislature. This is going on over and over, over the 
past 15 years, and it really strikes the contrast, the balance 
about is dentistry about filling holes in teeth that happen and 
can happen now or a year from now or is it about ongoing health 
care and well-being for children, adolescents and adults, and I 
think you will agree with me, it is the latter. There are many 
points along the way where we could have intervened in the 
death march that took Diamonte Driver to a way-too-premature 
end to his life.
    I am a board-certified public health dentist. It is a rare 
breed. You won't find another one probably within--oh, other 
than Burt. Are you certified? I don't know. I work with Special 
Olympics International. We have a global health program now. We 
have a global health program because the people who work in 
health and not sports were not getting the job done for our 
population. We do 130,000 free health screenings a year. We 
have a program called Special Olympics Special Smiles and based 
on 5,500 screenings of our athletes, half of whom are under the 
age of 21, consider these statistics. Twelve percent report 
pain in their mouths at the time we are doing the screening. 
More than a third have obvious signs of gingival infection. 
That means when you look at it, you can see it. You don't need 
a microscope. A fourth have obvious dental decay. No X-rays, no 
taking a sharp pick and sticking it into the tooth. You look 
and you see it. A quarter are missing teeth. Missing teeth, 
that is a reflection of a lack of continuous comprehensive and 
early preventive and treatment care. Most of them, at least 
half, have dental plaque that leads to oral infections of the 
soft and hard tissues. Too many families say that they just 
don't have access to regular dental care for their children. 
One of ten of their children is in need of urgent care.
    We have also done some research into the issue of training 
health professionals, physicians and dentists. We did a 
national survey of dental and medical schools and post-graduate 
programs. The vast majority of dental and medical students say 
they don't feel prepared to deal with the population of 
intellectual disabilities when they graduate, and half or more 
of the deans tell us their students are not prepared to treat 
this population when they graduate, so that obviously begs the 
question of what needs to be done in terms of professional 
education.
    One of my most recent disappointments, a year and a half 
ago, we started a Web-based provider directory where providers 
could self-identify as willing to speak to people with 
intellectual disabilities or their parents about care, not a 
guarantee of treatment, not a guarantee of price, just the 
willingness to speak about care. There are well over a million 
health professionals in the United States and over 150,000 
dentists in the United States. We contacted the organizations 
in writing. We followed up by telephone calls. We got a few 
articles in some magazines and journals but I got to say, a 
year and a half later it is one of my greatest disappointments. 
Less than 1,000 people have signed up for this 
multidisciplinary provider Web site out of well over a million 
providers, and I think at last count there was about 258 
dentists that had registered for this. This is certainly very, 
very disappointing for a family who has a child with an 
intellectual disability.
    Now, if I could show you one more picture here.
    [Slide]
    This is Mr. James Pearce. He is from Kentucky. He showed up 
at a clinic in Lexington, Kentucky, looking like what he looks 
like on the left. That reflects obvious dental disease, and 
even up on the screen you don't have to be a specialist to see 
that there are some serious problems there, infected teeth, 
missing teeth, grossly infected soft tissues. James is ill. He 
has swelling around the eye there. James in that picture is 
barely alive to a lot of people, and James in that picture on 
the left is somebody who is not going to be out in the front 
working in a business serving customers but thanks to Dr. Henry 
Hood, a developmental medicine dentist who took James on, they 
were able to do a very good job of dealing with James' dental 
needs. As I said, he has a moderate intellectual disability. 
James is doing very well now. James can stand out in front. 
James is somebody who you could say, I could be a friend to 
James. So I think you can see that what happened on the left 
didn't happen overnight. That started clearly in his youth, 
went through his adolescence, young adulthood and that is what 
we get. And this is one of the problems with this population.
    Mr. Pallone. I am going to have to ask you to wrap up again 
because you are over a minute too.
    Dr. Corbin. Then I will wrap up and say I endorse many of 
the recommendations that I have heard here about how we can 
maintain an enhanced coverage for this population.
    One thing I would really like you to look into is tell me 
why people with ID are not considered by the Federal Government 
to be a medically underserved population and tell me why when a 
person with intellectual disability in the fifth-grade 
intellectual level gets kicked out of the EPSDT program when 
that person turns 21. It makes absolutely no sense.
    [The prepared statement of Dr. Corbin follows:]

                      Testimony of Stephen Corbin

    ``Sure, it would be nice to save the dental program, but, 
let's face it: No one really dies from a toothache.'' I start 
out my testimony today paraphrasing a common misperception that 
State legislatures have debated over the past three decades 
about Medicaid dental programs. As you will see, this statement 
is both prescient and false and underlies much of what is wrong 
with public dental programs in the country today.
    Good morning. I am Dr. Stephen Corbin, senior vice 
president for Constituent Services and Support at Special 
Olympics International. I am honored to be invited to 
participate in this important hearing on access to dental care. 
This is a matter to which I have dedicated years of study and 
service and, I am loathe to admit, have not seen the 
breakthrough progress that is so badly needed.
    I understand that the recent tragic death of 12-year-old 
Deamonte Driver from the complications of untreated dental 
decay has heightened awareness all the way up to the halls of 
Congress that action is essential so that such a tragedy never 
happens again. As with so many things in society that are 
unjust and preventable, it often takes a sudden tragedy to 
garner attention on long-standing tragedies. It appears that 
this may be such a case. If we can use the moment 
constructively, we can honor the memory of a young child who 
became the victim of a failed system. He and his family were 
ill-served. They did not have any control over the office 
policies of any healthcare providers or payment policies of a 
public financing system.
    What we all need to realize is that Deamonte Driver not 
only died as a result of the passive complicity of a failed 
system, but he suffered for months, possibly unaccounted years, 
from the chronic pain of infections that invaded his teeth and 
eventually spread to supporting structures, his blood stream 
and his brain. Was this some exotic new infectious invader 
unknown to medical science? Was this a unique case, such as had 
never been seen before? Was this a clinical condition for which 
there is no known treatment? Sad to say, the answers to these 
questions are ``no, no and no!''
    If you were to track back to the cause of death in this 
instance, one could say that the immediate cause of death was 
heart failure, precipitated after an infection of the brain, 
arising out of a blood-borne infection, that moved from an 
infected pulp of a tooth, that had been preceded by a deep 
carious lesion of the dentin of the tooth, that was preceded by 
an extensive carious lesion of the enamel, that was preceded by 
a minimally invasive carious lesion of the enamel, that was 
preceded by a barely detectable lesion of the enamel, that was 
preceded by an insensitive, incomplete and under funded medical 
system that never gave Deamonte Driver the chance he needed. 
The chance that he needed to recover and survive.
    The bottom line is there were numerous points along the way 
where this death march could have been halted; where the 
infection could have been prevented or intercepted early, or if 
late, still could have been tackled. And, a young life could 
have been saved. Why did Deamonte Driver have to die from 
probably the most common childhood affliction, from a disease 
that we have known how to prevent and treat for more than 100 
years? The answer to this question is complex, and I hope that, 
by the end of this hearing, we will know enough to be able to 
move forward with specific actions to change this situation 
permanently.
    While I am a dentist and a Board Certified Public Health 
Dentist (a rare breed indeed), I currently lead a global multi-
disciplinary health program for persons with intellectual 
disabilities, some 2.25 million Special Olympics athletes 
worldwide, more than half under the age of 21. Special Olympics 
has stepped forward as a global leader to address the burden of 
unmet health needs for the more than 170 million persons around 
the world, including 6 million in the United States, with 
intellectual disabilities. Not because we were inclined to, as 
a sports organization, but because we really had no choice. 
Where those who should have taken care of this have failed to 
do so, Special Olympics stepped up. If you are not healthy, how 
can you successfully compete as an athlete at any level?
    Our athletes have this in common wherever they live around 
the world: they all have a permanent intellectual disability; 
they all demonstrate courage on the athletic field and 
acceptance of others; they all get sick on occasion and have 
health challenges like everyone else; they care whether they 
are well or sick; when they get sick, they need care; when they 
have tooth infections they hurt, even if they don't complain; 
when they get sick and can't get the care they need, they 
suffer and get sicker; when they finally do get care, too often 
it is as a last resort when their options aren't particularly 
good.
    The way they differ from other people is that they tend to 
have few available resources for assistance; be underemployed 
or unemployed--thus, they tend not to have private medical 
care, including dental insurance; no one expects them to be 
pretty or handsome; no one expects that they need to have a 
bright white smile; no one really worries if they are missing 
some of their front teeth; no one knows if they have dental 
infections; no one knows if they are in pain from dental 
disease; no one, or hardly anyone, feels responsible for 
helping them to achieve oral health.
    Allow me to lay out some hard facts for you. Special 
Olympics, through its Healthy Athletes' Program, provides free 
health assessments and some care to more than 130,000 Special 
Olympics athletes each year. We conduct more than 600 health 
screening events in some 70 countries through the volunteer 
efforts of 13,000 healthcare professionals and students, 
supported through the generosity of the U.S. Centers for 
Disease Control and Prevention, Lions Clubs International and 
several corporate and academic partners. And let me thank the 
U.S. Congress for appropriations directed to our Healthy 
Athletes Program over the past 5 years that makes this broader 
largesse possible.
    We have accumulated across our seven Healthy Athletes 
screening disciplines, without a doubt, the largest database of 
health status and health needs of persons with intellectual 
disabilities that has ever existed. Our Special Smiles' 
screening protocol, one of the first disciplines implemented by 
Special Olympics, was established and validated by the U.S. 
Centers for Disease Prevention and Control nearly a decade ago. 
Over the past 5 years alone, Special Olympics has conducted 530 
Special Smiles screening events around the world. More than 
half of them have taken place in the United States. We have 
provided about 12,500 dental screenings at those events to 
athletes age 8 years and older.
    In this day and age, where dental art and science can 
produce almost any smile one could wish, consider the 
following. Of Special Olympics athletes (n=5447; average age 24 
years) volunteering to participate in the Special Smiles 
Program in the United States:

     Some 12 percent report pain in their mouths at the 
time of the screening;
     More than a third have obvious signs of gingival 
(gum) infection;
     Nearly a fourth have obvious dental decay (without 
probing or x-rays);
     One quarter are missing teeth, reflecting end-
stage treatment of common dental diseases (like Deamonte 
Driver);
     Too many have extensive dental plaque that leads 
to infection of oral tissues, hard and soft, and ultimately, 
loss of teeth;
     And, too many athletes and families report that 
they have never been able to secure a regular source of dental 
care for their child, even as nearly one in ten are in need of 
``urgent'' dental care.

    Further, Special Olympics, the sports organization, has 
done research into the preparation of dental and medical 
students in the United States to understand the scope and 
quality of their professional education in dealing with the 
health needs of people with intellectual disabilities. What did 
we find? The vast majority of dental and medical students do 
not feel adequately prepared to work with this population when 
they graduate from school. They say they want to be prepared, 
they just are not. Further, the deans of dental and medical 
schools and graduate medical and dental programs acknowledge 
that their graduates are unprepared to deal with the needs of 
this population. If you survey a listing of continuing 
professional education courses that address the needs of the 
intellectual disabilities population, you would be hard pressed 
to find any.
    So, if healthcare professionals aren't trained during their 
basic professional preparation, and there is no marketplace for 
continuing professional education in this area, should we be 
surprised that people with intellectual disabilities and their 
families have difficulty in securing reliable, receptive, 
qualified sources of dental and other healthcare for their 
children?
    Here is one of my most recent disappointments. In September 
2005, Special Olympics created a Web-based directory of 
healthcare providers nationwide. That is, we created a user-
friendly way for clinical providers in virtually all health 
disciplines to identify themselves to persons with intellectual 
disabilities and their families as willing to speak with them 
about the opportunity to receive health care. Not a guarantee 
to health care! Not a guaranteed price for health care! Just 
the opportunity to discuss the opportunity for healthcare.
    After a year and a half of proactive outreach to 
professional organizations, we have fewer than 1,000 of the 
more than 1 million U.S. health professionals registered. 
Regarding dentistry, we have only 248 names listed (as of 
February 20, 2007) out of more than 150,000 dentists in 
America. If you were a person with intellectual disabilities 
seeking a chance to be healthy or a family with a child with 
intellectual disabilities, whom you worried about in terms of 
their health care, how would all of this look?
    I can tell you that Special Olympics Healthy Athletes is 
special its own right. It is a place that athletes know is 
their place. And it is a place for volunteer healthcare 
professionals where, for example, a 40-year veteran of clinical 
healthcare delivery can say tearfully and happily, ``Now I know 
why I invested 10 years in my professional education and all of 
that money learning how to care for people.'' In the end, one 
can say that it ``ain't'' brain surgery. But, for Deamonte 
Driver, it was brain surgery when it didn't have to be. When we 
do our Special Smiles dental screenings, in addition to 
examining the teeth and oral cavity, providing dietary and oral 
hygiene education, constructing mouth guards where appropriate 
and providing preventive supplies, we also provide our athletes 
with a report card on their health, as well as referral 
information for follow up where needed. Additionally, we 
provide lists of community dental providers--lists that are 
always too short or where the providers are not conveniently 
located. We do our best to get athletes connected with locally-
based providers for follow-up care but, sadly, our lists fall 
short of provider information despite all our efforts.
    Now, I need to share a compelling image with you. This is 
Mr. James Pierce. James is a person with a moderate 
intellectual disability. I can show you this picture because 
James gave us permission. James went to the dentist, Dr. Henry 
Hood of the Underwood and Lee Clinic in Lexington, Kentucky, a 
special dentist and friend of mine, with what you see. One does 
not have to be a dental professional to look at the picture of 
James and see that he is sick. There is obvious extensive 
dental disease, swelling around the eye, a contorted barely 
alive look. James did not get this way overnight. This is the 
accumulated neglect of years of lack of proper dental care 
combined with a lack of proper self care. Likely these problems 
started in childhood or adolescence and just perpetuated. The 
bottom line is that James was generally sick from dental 
infections. Is this a person who an employer would let interact 
with customers, or is this a person that ``belongs in the 
back,'' if anywhere at all.
    Look at James today and tell me what you see. Is this 
someone who can be confident in meeting people; someone who 
could work out in front? Is this someone who could succeed at 
some level? Is this someone you might be interested in knowing? 
Dr. Hood, a knowledgeable and caring dental professional, took 
the time to do an overall assessment of James and his oral 
health prognosis and provided the appropriate care. James is 
doing well and is employed. If James were your son, brother, 
friend, which treatment and care would you have preferred? I 
don't think we need to count the votes.
    Can we muster the backbone to do what is right; to match 
our scientific knowledge with our social responsibility? Would 
we allow or condone those of minimal means to drive cars 
without seat belts because we might have to pay for them? Of 
course not.
    Why would we sacrifice childhoods and even lives for 
failure to implement the most obvious of solutions?
    Here are some suggestions that could help prevent future 
dental tragedies:
    1. Change the culture around dental care for children. It 
should be as important as getting kids immunized or making sure 
they wear seat belts in cars. Dental care for children is 
universally needed.
    2. The marketplace is not sensitive to many underserved 
populations as desirable business targets. That is, 
reimbursement levels in public programs have not been adequate 
to attract a significant increase in willing providers. In 
general, enhancements in public dental program reimbursement 
rates have been inadequate to achieve the behavior change in 
providers that is necessary. Reimbursement levels need to be 
enhanced to where they are market rational. Thus, we need to 
work to build opportunities that work toward full access to 
dental care for children. Strategies could include incentive 
payments for individual providers or community-based programs 
such as health centers when they reach target goals for 
providing care to high-risk populations.
    3. Public oral health programs that are operated by 
government entities need to be designed to be proactive, not 
residual or reactive. It is not enough that a child is eligible 
to have dental care paid for. There must be a premium on 
children getting in for early and regular oral health care. 
Thus, public programs need additional resources, not just to 
pay dentists for care, but to provide a solid underpinning for 
a program that can produce real results in increasing access 
and reducing the prevalence of dental need.
    4. Expand eligibility for children needing oral health 
care. Dental services should not be elective for States under 
SCHIP. And, programs should be designed with enough flexibility 
so that children are not constantly bounced off eligibility 
roles because of ``hair trigger'' provisions.
    5. For special high risk populations, such as people with 
developmental disabilities, extra efforts are needed, including 
training of clinical providers and enhanced reimbursement 
provisions that reflect the additional time that is sometimes 
required in patient management and treatment. And, while we are 
at it, why is it that the population with developmental 
disabilities is not considered a ``medically underserved'' 
group by the Federal Government. That warrants some close 
follow up and future discussions by this committee. How is it 
that when a child with an intellectual disability hits a 
certain age, even though their disability condition is 
permanent, they ``age out'' of their Medicaid (EPSDT) dental 
benefits in most States to dramatically reduced ``adult'' 
service levels, if they are even available. Children with 
intellectual disabilities who are fortunate to receive care 
under Medicaid or SCHIP, all of a sudden get pushed out of the 
system--after years worth of investment of public resources in 
their care. This makes no sense at any level.
    6. Provide needed quality oversight, research and 
evaluation of policies concerning dental care for children and 
vulnerable groups. This should be an ongoing responsibility of 
government. It is not enough to be responsive when a highly 
publicized tragedy takes place.
    These suggestions are not complete, but, hopefully, can 
help point our collaborative efforts in the right direction.
    ``Deamonte Driver Saved''--``DDS.'' It is possible if we 
commit ourselves to the right actions. Thank you.
                              ----------                              

    Mr. Pallone. Thank you. Thanks a lot really for your 
testimony and for your insight.
    That concludes our statements by the witnesses, so we are 
now going to now go to questions of the panel, and I will 
recognize myself to begin with that for 5 minutes.
    We know that this hearing was brought about because of the 
story of Diamonte Driver in the Washington Post recently a few 
weeks ago and I think we all noted that this was a young boy 
who died from an infection that spread to his brain after his 
infected tooth went untreated. We also heard about another 6-
year-old boy in Mississippi who recently died as well due to an 
infection that spread from an untreated infected tooth. Now, 
the pain that these families have to feel from losing a child 
is obviously enormous but our job is to make sure other 
families don't have to experience this tragic loss, and many of 
you have commented on that. I don't know all the details of 
Diamonte Driver but I know that his Medicaid coverage had 
lapsed and so certainly one of the issues would be about gaps 
in coverage. Some of you have talked about gaps in coverage and 
the need to shore up existing public programs. Others have 
talked about the lack of reimbursement rate. There are many 
factors that go into the problems that we are dealing with 
here.
    I was going to ask Dr. Edelstein, I know you are a little 
bit familiar with Diamonte, if you could give us your 
assessment of how systems broke down to serve him and what 
could have been done to prevent this from happening by 
reference to him.
    Dr. Edelstein. Thank you for your question. The obvious and 
first-line systems failures are the ones that you have noted. 
Continuous eligibility would have made it possible for him to 
retain his Medicaid benefit even while in a homeless shelter. 
Care assurance systems that make sure that dental care is 
actually available and not just covered would have made sure 
there were places he could have gone, and all the various 
people who came in contact with him, the lawyers, social 
workers, people at the homeless shelter as well as school 
nurses, teachers and others who have come in contact with him 
could have made referral, if there were a coordinated system of 
care in place that is already required by EPSDT legislation.
    But then there is a secondary level of systems failures 
that are not as obvious, educational systems failures. So few 
parents yet know what NIH discovered 40 years ago, that tooth 
decay is an infectious and transmissible disease acquired by 
age 1 or 2 and that real prevention needs to start very early. 
Public information systems, work force systems many of you have 
mentioned that there is need for additional training. HRSA for 
example in its title VII program that Ms. DeGette mentioned 
does train pediatric dentists but it does not, as it does for 
physicians, allow curriculum development and faculty support, 
so those are systems that would address the problem Dr. Corbin 
mentioned about preparedness of our future dentists.
    Early intervention systems--HRSA supports an early child 
comprehensive system that Mr. Scheppach mentioned relates to 
early childhood development. There is a place for early 
childhood oral health care there. And lastly, safety-net 
systems of care. The rural health centers, the community health 
centers, the school-based health clinics, they are all very, 
very small and the local community emergency room does not 
provide definitive care. So all of these systems had to come 
together for this monumental failure for these children.
    Mr. Pallone. Now, he was in a homeless shelter and their 
Medicaid coverage had lapsed from what I understand. I know 
they were covered by Medicaid. So this whole idea of continuous 
health coverage under Medicaid or SCHIP, breaks in coverage due 
to changes in income or whatever, I think that would come into 
play. I was just going to ask Dr. Roth because I know my time 
is running out, do you have any recommendations about 
maintaining coverage? We talk about continuous eligibility, a 
guarantee of coverage for a full year or presumptive 
eligibility, allowing a predetermination of eligibility. Did 
you want to comment on those gaps in coverage or ways to 
prevent that?
    Dr. Roth. There certainly are ways. It doesn't take anyone 
to figure out that you need to be continuously in a dental home 
to have good oral health and maintain your oral health. We 
strongly believe that a family has to become part of a dental 
system and you need to train the parents as well as get the 
children in for ongoing dental care. So it is simple. It needs 
the dollars to support the system and patients need access to 
get into that dental system.
    Mr. Pallone. You mentioned the reimbursement rate under 
Medicaid. Did you just want to comment briefly on that, I mean, 
because in his case, Diamonte's, it seems like there was a 
dentist that was able to take him but there was no coverage, 
but you seem to feel that there are other cases where the 
reimbursement rate becomes a block.
    Dr. Roth. Well, you do have many dentists around the 
country that are not Medicaid providers and the biggest reason 
for that is the reimbursement level is so low, it doesn't even 
cover the cost of overhead to provide the dental care. So I 
would encourage Congress to provide adequate funding of dental 
programs. And we are looking to expand the system to provide 
another person on the dental team, the community health 
coordinator, which is simply a social worker, if you want to 
think of it that way, a person to go into the community that 
can do the social skills needed to educate the public as well 
as some clinical skills to their skill sets, if you will. So I 
would encourage you to look at our community dental health 
coordinator as another mid-level provider that can really 
answer the access issue from the community level as well as 
from providing care and clinical skills.
    Mr. Pallone. Thank you.
    Mr. Deal.
    Mr. Deal. Thank you, Mr. Chairman.
    I am going to move quickly and I would ask my witnesses to 
do the same, so if they could. First of all, Mr. Scheppach, the 
Governors I know supported the provision that was in the DRA 
allowing them the flexibility to provide benchmark plans for 
their Medicaid population. Recently the members of this 
committee received a letter from Governor Ernie Fletcher of 
Kentucky concerned about a provision that was originally in the 
Iraq supplemental and I think it was taken out in the final 
version that he felt would jeopardize that ability and that 
flexibility for Governors. Is that still an important issue, 
and if so, why?
    Mr. Scheppach. Well, yes, it is. I think we had a number of 
States, West Virginia, Idaho as well as Kentucky who have 
actually taken that provision and really tried to do some 
preventive care so that they can better manage long-term 
chronic illnesses, so that flexibility is still an important 
issue to Governors.
    Mr. Deal. Thank you.
    Mr. Chairman, I would unanimous consent that the letter 
from Governor Fletcher be made a part of the record. I think we 
have all received copies of it.
     Let me quickly move to highlight what I consider to be 
important here. Diamonte Driver is the case that we all cite as 
the reason we are here and I have heard a variety of things. I 
have read your testimony as I have heard your testimony. It all 
generally starts out with the system failed him, the systems 
failed him. I believe Dr. Edelstein just enumerated who failed 
him, the lawyers, the teachers, the social workers, the 
homeless shelter workers and everyone. I never heard the mother 
or the parents mentioned as the ones who failed him. In most of 
our households, we assume that responsibility as parents. If it 
lapsed, then whose fault was it? It wasn't the child's fault. 
It was the parents' fault for not signing up an eligible child. 
I wonder if we had had Diamonte dying from an internal bleeding 
that had occurred because he fell while he was in the mother's 
presence and he had died from that, we would have probably had 
a child abuse case brought against the mother but here we blame 
the systems. We never put personal responsibility in the 
equation, and I think it is an important ingredient that has 
been overlooked.
    But let me hit some of the things I thought you ought to 
maybe elaborate on if we have time to do it. First of all is, 
we have heard reimbursement rates under Medicaid, under SCHIP, 
et cetera. One question I would have, are the reimbursement 
rates for dentists disproportionately less than for doctors 
treating in the medical environment, and is the ratio of 
dentists who are signed up in the Medicaid programs 
disproportionately low as a percentage of the dental population 
versus the medical enrollment there? Who would care to comment 
on that? Dr. Edelstein.
    Dr. Edelstein. I would be happy to. The answer to both of 
your questions is yes. The rates are lower relative to other 
providers but there are problems with Medicaid payments across 
the board. If you compare Federal Government rates for 
physicians in Medicare with the same services in Medicaid, you 
can see that differential.
    But I want to take a moment to agree with you 
wholeheartedly about parental responsibility. There is no 
question. The question becomes when parents then do seek care, 
which is perhaps not the case we were addressing today but when 
parents then do seek care, are they able to obtain it. Too 
often the answer is no.
    Mr. Deal. Let me go to that because I think that is the 
next thing. The number of available dentists, I think Dr. 
Mosca's testimony is very informative as to dental schools, the 
number that are there, the number that are producing. I used 
the statistic in my State, we have 240 retiring every year, 
only producing 60 in my State dental schools, as I understand 
it. That is a huge problem, the number of available dentists. 
What do we do about that? Dr. Mosca, you are probably an expert 
on that.
    Dr. Mosca. Well, let me just make an additional comment. 
The child that I mentioned in Clarksdale who had the dental 
abscesses this past Friday actually had access to the care 
system but did not receive the treatment that the child needed, 
and so I would have to agree with Dr. Edelstein that----
    Mr. Deal. In fact, you point out that EPSDT mandates dental 
coverage for children and that only one out of every four 
children under Medicaid actually receives those services. Is 
that right?
    Dr. Mosca. Correct.
    Mr. Deal. OK.
    Dr. Mosca. But I think that in terms of the numbers, I 
think that the other layer that we add on to this is the 
knowledge and skills. For example, when managing the youngest 
and the oldest populations, we rely on the title VII residency 
training programs to impart that type of educational 
experience. It is important to understand how to treat young, 
young kids and elders because there are some issues that 
interface with the level of skills.
    Mr. Deal. My time is running out. Let me just enumerate 
some other things I think are important. The geographic 
distribution of dentists, many of you have alluded to that. The 
number of dentists who are available in community health 
settings or other clinic settings, I think all of those at 
distribution of services is a key ingredient and unfortunately, 
my time is up.
    Mr. Pallone. Mr. Green.
    Mr. Green. Thank you, Mr. Chairman, and following up our 
ranking member, I think the actual case we are talking about, I 
think the mother did apply for the Medicaid extension. She lost 
it because she was in a homeless shelter and I think the 
paperwork may have gone back to a homeless shelter instead of 
her new residence. Again, my concern is that I have seen what 
happens. They are trying to expand Medicaid programs and SCHIP 
in a lot of our States and they cut that expansion because they 
really don't want to sign up in the name of flexibility a lot 
more children.
    Let me talk about, I am a longtime supporter of health 
centers programs and we have introduced legislation to 
reauthorize it until 2012. One of the key Federal requirements 
of health centers is they provide a full range of primary and 
preventive care including dental care. In fact, in 2005, health 
centers encountered 1.7 million visits for preventive dental 
exams. While the requirement to provide access to dental care 
can be met through referral arrangements, 73 percent of the 
health centers provide preventive dental care either onsite or 
through contracting arrangements.
    Ms. Farrell, you mentioned health centers as recipients of 
infrastructure grants resulting from Michigan's dental 
taskforce recommendations. Can you or the other witnesses speak 
to the role health centers play in a safety-net dental 
provider?
    Additionally, Dr. Edelstein, can you speak to the 
effectiveness of contracting arrangements between dentists and 
health centers and any recommendations you would have.
    And lastly, Dr. Roth, when you talk about the community 
health coordinator in your testimony, that is not just a social 
worker, that is actually a provider that is licensed by the 
State to be able to do exams and things like that but also go 
out and do preventive health care. So it is a long question 
about how we can we better relate to health FQHCs with the 
dental requirement because my FQHCs, the few we have, it is 
typically pediatrics, a lot of children, and the children are 
the ones who need the dental care. You will have 3 minutes to 
answer that long question.
    Ms. Farrell. Yes. Along with my dental responsibilities, 
one of my responsibilities is also our community health 
centers, all our cost-based reimbursement policies, our safety-
net providers, so I am very aware of the community health 
centers in the State of Michigan. I believe we have 27 
federally qualified health centers with 155 sites throughout 
the State. Some of them are rural, some of them are urban, but 
the majority of them do offer dental care. When we offer these 
infrastructure grants, we did 32 sites. Out of those 32 sites, 
15 of them went to, the grants went to community health centers 
so they expanded their dental operatories and we have our 
Medicaid population and the uninsured in our SCHIP, they treat 
all three of those. In addition, we have also partnered with 
University of Michigan and the dental students and we rotate 
students through community health centers to make them aware of 
what is available so we can try to get them to treat and come 
back and be providers into that community, which has developed 
into a win-win situation where we have had at least five or six 
dental students from the University of Michigan become 
providers at community health centers.
    Mr. Green. Dr. Edelstein?
    Dr. Edelstein. Mr. Green, you mentioned that 73 percent of 
community health center grantees have dental programs but in 
fact it is far fewer sites that actually have programs and many 
of the sites----
    Mr. Green. Mostly contracting, in all honesty.
    Dr. Edelstein. Right, and so what we end up with is a fair 
number of community health center sites that don't actually 
have the capacity to deliver care, and you mentioned 
contracting as a solution for that. CMS, then HCVA, HRSA, the 
American Dental Association and the National Association of 
Community Health Centers worked on developing a contracting 
manual that would allow private dentists to provide services to 
community health center patients. What Congress needs to do is 
to clarify with the agencies that that in fact is legal to do 
because there has been controversy amongst the primary care 
associations. So with that clarification, that approach that 
you have recommended could expand dramatically.
    Mr. Green. Dr. Roth, on the community health coordinator, 
and I know in your answer to another question you talked about 
a social worker, which is great, but also it is a provider. 
This person would be a provider?
    Dr. Roth. That person would provide clinical skills so they 
will do some--very many preventive services. They are not going 
to be a licensed provider so it is not another level of a 
dental hygienist or a dentist. It is not a licensed person. It 
is a person that will work under the scope and under the 
auspices of a dentist. In a community health center, they can 
work offsite so they don't need to have a dentist onsite 
necessarily to work. But they are not licensed, and I want to 
make that clear right from the start.
    Mr. Green. OK.
    Dr. Roth. They will have an educational program that takes 
about 2 years and we have that ready to start this fall. So we 
are looking to pilot those community health coordinators and 
get them into community health centers and into schools 
beginning this fall in their educational programs. I would 
encourage Congress to look at possibly funding some of those 
pilot sites that we are looking to do. It is not a lot of money 
but it certainly will make an enormous impact in expanding the 
efficiencies of dental care that has reached into the 
communities as well as expanding the dental network of people 
that can provide care.
    If I can just answer the community health center issue, 
less than 1 percent of all the practicing dentists, which is 
162,000 practicing dentists in the country, are employed in a 
community health center. If we can expand that network by 
providing the dentistry that needs to be done by going into the 
communities and partnering and contracting out, as Dr. 
Edelstein promoted, that really is an answer to using a dental 
workforce that is out there available. They need to be 
compensated and need to be able to work, the work is the 
problem.
    Mr. Pallone. Next is Dr. Burgess.
    Mr. Burgess. Thank you.
    Just to follow up on that, Dr. Roth, Mr. Deal referenced 
the large number of dentists that are retiring in Georgia every 
year. If we modify the Federal Tort Claims Act somewhat to 
allow those retired dentists to come into the community health 
centers and practice, would that not be a beneficial thing? Yes 
or no will suffice.
    Dr. Roth. Absolutely.
    Mr. Burgess. Thank you.
    Let me ask Dr. Mosca a couple of questions because I really 
appreciate your testimony. I thought it was so critical and of 
course, Baylor College of Dentistry is down near my--not in my 
district but near my area. They, as I understand, provide a 
significant amount of low-cost or free care, not just to 
children but to all patients, to all comers. Other schools 
provide the same service, I would assume? Dr. Mosca?
    Dr. Mosca. I am sorry. I thought you were talking to Dr. 
Roth.
    Mr. Burgess. The care provided by the colleges of 
dentistry, they play a big role I know in the Dallas area, 
Baylor College of Dentistry does and I have even heard from 
members of your profession coming to talk to me about nursing 
home patients who also pose some of these same problems and are 
typically underserved but a lot of this falls to the dental 
school. Is that not correct?
    Dr. Mosca. That is correct.
    Mr. Burgess. Well, do we have enough?
    Dr. Mosca. Do we have enough dental schools?
    Mr. Burgess. Correct.
    Dr. Mosca. Well, we actually have----
    Mr. Burgess. I asked you first.
    Dr. Mosca. We actually have a number of schools. There have 
actually been six new dental schools that are in the process of 
opening. The Arizona School of Health Services, the University 
of Nevada-Las Vegas opened in 2002, Nova Southeastern 
University in 1997, and actually there is a predicted decrease 
in services up until I think 2020 and then at that point there 
will actually be an increase in providers, and that is because 
of closing of schools that occurred a while back, so we are 
kind of trying to catch up with the closure of the previous 
school but these new schools should add to the workforce.
    Mr. Burgess. We have reached the nadir, but of those people 
that are going to be entering the workforce, do we have a 
concept of how many will be entering pediadontics and general 
dentistry as opposed to the higher reimbursement subspecialties 
of dentistry?
    Dr. Mosca. About half of the graduates, I mentioned that 
4,500 graduates are released each year, and about half, or 
2,800, go into either general dentistry or some specialty 
training.
    Mr. Burgess. Tell me this----
    Dr. Mosca. The title VII funding actually does allow the 
dental schools to increase and support that type of training.
    Mr. Burgess. My observation has been that most people go 
into the practice of medicine close to where they trained 
because they know the community and they know the other 
providers in the area. Is the same true of where dentists 
choose to practice?
    Dr. Mosca. In Mississippi, about 70 percent of our schools' 
graduates have stayed in the State.
    Mr. Burgess. So they do tend to stay close to home. What 
type of location decisions are made based on the prospects of 
perhaps low reimbursement or a population of low health 
literacy where the outcomes may not be as good?
    Dr. Mosca. That is actually an issue that we are trying to 
solve within the State of Mississippi. By working with 
community partners, we are trying to incentivize providers to 
locate in various areas. I was just at a meeting 2 weeks ago--
--
    Mr. Burgess. If I can interrupt you, how do you do that? 
How do you provide that incentive?
    Dr. Mosca. At the meeting I was at 2 weeks ago, we had the 
mayor, we had the county supervisor. We convened the local 
civic leadership to actually----
    Mr. Burgess. So the community provides some of that 
incentive?
    Dr. Mosca. To try to, right, for----
    Mr. Burgess. Pardon me for interrupting, but the chairman 
has an iron fist with that gavel and I have to ask some other 
questions.
    You were starting to reference data reporting in your 
testimony. What type of data do you want to see and what will 
you do with the data as you collect it?
    Dr. Mosca. Well, the data that we have collected has been 
very helpful in promoting discussions around policy and I would 
have to concur with Dr. Edelstein that we need to look at the 
outcomes of the SCHIP programs and capture that data.
    Mr. Burgess. And when will that type of data be available 
to us here on this side of the dais?
    Dr. Mosca. I can't answer that question but I could 
certainly provide that answer for you.
    Mr. Burgess. And I think the committee would genuinely 
appreciate that.
    Let me go with what little time I have left to Dr. 
Scheppach. Governor Warner sat at that very table about a year 
and a half ago and said that Medicaid was on the road to a 
meltdown because of the costs and the expansion of costs of the 
Medicaid program. Do you think that statement is still valid 
today or have we fixed it?
    Mr. Scheppach. Yes, I do. Even though the growth in 
Medicaid----
    Mr. Burgess. We fixed it?
    Mr. Scheppach. No, we did not fix it.
    Mr. Burgess. And you talked about some of the coverage 
initiatives that are going on in States to affordable health 
insurance and you kind of ran out of time there and you are 
going to run out of time again, but can you kind of explain how 
Medicaid and SCHIP fit into these State initiatives?
    Mr. Scheppach. Well, I think it is important to maintain 
the flexibility that we currently have because I think the key 
component of this is that the States are creating connectors 
for the small market.
    Mr. Burgess. And do you think that the flexibility that we 
provided has allowed those States, Massachusetts, California, 
to some degree even Texas to begin to tinker with those and 
provide those types of benefits?
    Mr. Scheppach. That is right, and that is a benefit that 
you can also provide to small business and so on. You can 
stabilize that small market. If you start doing independent 
additional benefits, it is going to create an obstacle.
    Mr. Burgess. Thank you.
    Mr. Pallone. Thank you, Dr. Burgess.
    Ms. DeGette.
    Ms. DeGette. Thank you very much, Mr. Chairman.
    I was sitting here thinking about how important pediatric 
dental care is and how it can really prevent so many bigger 
problems, not just in the long run but immediately, so I had my 
staff pull the SCHIP statute. It is always dangerous when the 
members of Congress start actually reading the statutes, and 
one of the required coverages right now under SCHIP is well-
baby and well-child care including age-appropriate 
immunizations. That is required in all 50 States right now. And 
so when I look at that, it seems to me that dental care should 
be included in that, and so then I was reading Mr. Scheppach's 
testimony about how you think that flexibility should be 
maintained with the States in pediatric dental care under 
SCHIP. I wanted to ask you a couple of questions about that, 
because in reading your testimony, it seems that the main 
flexibility you are talking about, Mr. Scheppach, is 
flexibility in how that dental care is offered. Would that be 
accurate? I mean, you are not really saying on behalf of the 
Governors that we should allow States flexibility in whether to 
offer pediatric dental care, just in how they deliver that?
    Mr. Scheppach. Well, I think right now it is an optional 
benefit, and I think what we are saying, it should probably 
continue as an optional benefit.
    Ms. DeGette. Well, it is an optional benefit right now but 
all of the States up until now have offered dental care, 
correct?
    Mr. Scheppach. That is right, but they have different 
restrictions essentially on how much they are willing to do, 
the number of treatments and that type of thing.
    Ms. DeGette. Right, but Mr. Green and I are both concerned 
about this because his State of Texas is now talking about 
dropping dental care for cost concerns and other States like 
Colorado and others have talked about it too. So I think we can 
all agree, all the whole panel agrees that pediatric dental 
care can be very cost-effective as well as humane for the kids, 
right?
    Well, I will ask you, Dr. Edelstein. Pediatric dental care 
can be very cost-effective and also humane for the kids?
    Dr. Edelstein. Cost-effective, humane and essential. I 
cannot understand how the mouth can be carved out of the rest 
of the body and put restrictions on how much care. It is like 
saying that we can diagnose a problem but not treat it. We can 
do $175 worth of your appendicitis but we are going to stop 
there and just close you up because we have hit the benefit. It 
is the only service that is treated as though it weren't part 
of the child's body.
    Ms. DeGette. Well, and actually that is the other thing. 
Just getting back to Mr. Scheppach though, I understand your 
point about flexibility and how you offer it but if all the 
States are doing it now, I don't suppose there would be a big 
objection by the Governors if we just said you have to offer 
dental care under SCHIP but still allowed from flexibility.
    Mr. Scheppach. Well, I think what would happen essentially 
is that wouldn't allow flexibility, you would set certain 
standards around that benefit package and that would be 
relatively costly and it would be hard to package it in managed 
care and combine it with health care benefits so it is not--I 
don't think the legislation would ever say provide health care 
benefits. You would put certain standards around it in terms of 
the numbers of visits and what is applicable.
    Ms. DeGette. Well, all the States offer dental so there is 
going to be conditions around that. Now, I would really hope 
the Governors association would work with us as we reauthorize 
SCHIP because if everybody is offering dental and if what Dr. 
Edelstein says is true, and we all believe it, which is dental 
care is essential to this and it is also cost effective, I 
think it would be my inclination and I bet you I can speak for 
a lot of my fellow panel to include it but we do want to allow 
the States flexibility to make it work.
    Dr. Edelstein, I wanted to ask you another question, which 
is related to what you just said about the idea of dentistry 
being related to the whole body. I think maybe based on my 
experiences, the mother of two--I was watching Mr. Pallone's 
kids. We have had many investments not only into pediatric 
dentistry but also orthodontia, which are ongoing to this date, 
but I think a lot of parents even in my socioeconomic bracket 
don't realize the importance of pediatric dentistry and of 
taking their kids to the dentist on a regular basis. Would you 
agree with that?
    Dr. Edelstein. It does vary significantly across 
populations by education and by opportunity and by their own 
experience but certainly the value of pediatric dental care is 
something that has only grown in awareness in recent years.
    Ms. DeGette. So for someone to blame the mother of this 
young boy who died from an abscessed tooth who was living in a 
homeless shelter, I think that is kind of an unfair placement 
of the blame. I don't know if you have a comment on that.
    Dr. Edelstein. The only comment I have is specific to this 
particular child and that is that his presentation was one that 
did not scream out initially dental abscess. It took the skills 
of diagnosticians of dentists and physicians together to 
identify the original cause of this problem and that is an 
indication of how complex it can be and how the teeth are 
indeed part of the body. Symptoms can show up differently than 
expected.
    Ms. DeGette. And I would also say I think we need to have a 
global--this is a topic for maybe later today or another day. 
We need to have much more public awareness of the importance of 
pediatric dentistry across all socioeconomic groups.
    Dr. Edelstein. Particularly starting at age 1 as 
recommended by the pediatricians and by the pediatric dentists 
because that is when the disease begins.
    Ms. DeGette. Right. Thank you very much.
    Mr. Pallone. Thank you.
    Mr. Murphy of Pennsylvania.
    Mr. Murphy. Thank you, Mr. Chairman.
    A couple quick questions. I know in my role as a 
psychologist for many years I would sometimes be contacted by 
dentists who felt that a child because of their substantial 
learning problems or behavior problems might require some extra 
care in preparation for a dental visit, but I must admit I am 
not clear on whether or not these things are handled 
appropriately by any payments in the SCHIP program or Medicaid 
or anything else. Can someone comment on these sorts of needs 
and is that something that the reimbursement rates are also not 
adequate to handle?
    Dr. Roth. I can comment on that. You are right, there are 
some children that do have special needs whether it is 
hospitalization for extensive dental care or simply a mild 
sedative to make the procedures easier, and there is not 
coverage for that in most States.
    Mr. Murphy. So that is an expense the dentists themselves 
have to take care of out of their own pocket in order to do 
that?
    Dr. Roth. Yes, or the parents choose not to use comfortable 
means to deliver the dental care.
    Mr. Murphy. Which of course can mean child's dental care is 
even more aversive.
    Second, there have been some things written in the paper 
about the amount of paperwork and bureaucracy that is necessary 
for a dentist to fill out if they want to participate in these 
programs. Are these really mountains of paper? Can someone 
comment on that? What do we have and is there a way of making 
it more effective? I see Ms. Farrell reaching for her button. 
Yes?
    Ms. Farrell. We have heard those complaints for a number of 
years in Michigan. We have tried to address that administrative 
burden. We have streamlined our provider enrollment form. Of 
course, with HIPAA and the administrative simplifications, we 
have had to go to national code sets. We are going to national 
claim forms, which is the ADA claim form, the paper claim form 
or electronic version. So there are lots of steps that we have 
tried to, and I would say the majority of States speaking also 
in my Medicaid/SCHIP dental association role. We have all 
looked at trying to decrease that administrative burden on the 
dentists to try to get them to become participants.
    Mr. Murphy. I would hope that could all be simplified.
    Dr. Roth?
    Dr. Roth. Well, if I can just add to that quickly. It is 
not simply signing up to be a Medicaid provider but it is the 
claim forms that you have to fill out when you try to provide 
the services. They are not using the standard ADA claim form, 
which I use for all my other insurance company forms, so they 
make the system much more difficult than it needs to be.
    Mr. Murphy. Do they allow for any electronic forms on 
this----
    Dr. Roth. They do, but it is also very difficult to get 
into that entire system from the Medicaid system itself.
    Mr. Murphy. I know whenever I would fill out forms too, I 
would always ask myself how much of this information is really 
necessary to make a decision on whether or not to cover this 
child, and outside of the name, I am not sure how much anybody 
really reviewed.
    Let me ask another question here. A comment was made 
earlier about 73 percent of community health centers offer 
dentistry in them. How much of this is really--I mean, just to 
have someone there doesn't necessarily mean they can take care 
of all the demands and needs.
    Dr. Edelstein, can you perhaps comment on, I had seen 
previous studies that talked about a shortage of psychiatrists, 
internists, family physicians and OB/GYNs at community health 
centers. What is the shortage of the demands versus what we 
have needs for there with dentists at community health centers?
    Dr. Edelstein. Yes, let me please clarify that 73 percent. 
That is 73 percent of health center grantees but many grantees 
have multiple sites so if one site has a dental program and 
five or six additional sites do not----
    Mr. Murphy. So that could actually be a skewed upward 
number?
    Dr. Edelstein. Very much so.
    Mr. Murphy. OK.
    Dr. Edelstein. And it is really estimated that it is closer 
to half of community health centers have a dental program----
    Mr. Murphy. So they may have a dentist there but can they 
fill the needs of the patients who need them?
    Dr. Edelstein. Absolutely not. The community health centers 
have prioritized relative to children. The community health 
centers in many States have chosen to prioritize uninsured 
adults who have no other recourse whereas children do have 
Medicaid coverage. Medicaid coverage for adults does not 
include dental services in the majority of States so the 
community health centers become the site of service of last 
resort for adults. That has crowded out the kids.
    Mr. Murphy. One of the things that I love about community 
health centers is unlike I think any other thing we have in 
pediatrics, it is in one building where everybody knows each 
other, where at the moment a pediatrician, for example, can be 
meeting with the family, he can say let me introduce you to the 
dentist who we are going to make another appointment for or the 
psychologist or social worker or someone else to do that, which 
is a huge asset. I had mentioned my bill before, H.R. 1626. I 
doubt if you have had a chance to read it, but I hope you would 
take a look at that in that it really does allow physicians and 
dentists and others to volunteer. Have you ever taken a poll of 
how many dentists semi-retired or active would be willing to 
give some of their time? Does anyone know that?
    Dr. Edelstein. I don't think that figure is known but it is 
part of the volunteer solution, but as we recognize, charitable 
care and volunteer care is not a system of care but it can be 
part of a gateway into contract care in private offices that 
would work very well for the majority of FQHC patients.
    Mr. Murphy. Thank you very much.
    Mr. Chairman, thank you so much.
    Mr. Pallone. Thank you.
    Mrs. Capps.
    Mrs. Capps. Thank you again. This has been a very fruitful 
panel. I just hope we can pick up on a lot of these things. Our 
ranking member asked some very pointed questions about parental 
responsibility, which I appreciate, and that is one of the 
topics, the areas that I think we should go into. I just recall 
from my days as a school nurse with parents so concerned about 
what to do about this child in pain crying out in the night. 
That certainly was a high priority for them. In many parts of 
my district, most of my district at that time, it was over 100 
miles to go to a dentist who would take Medicaid. A pediatric 
dentist was even further and the waiting lists were months and 
months long. I know some steps have been taken to remediate 
that but I also know parents would be so motivated, they would 
take whatever cash they had and go to the dentist in the Yellow 
Pages and wouldn't have enough and then it is rent or food. I 
mean, these are really tough choices for many of our families.
    Dr. Edelstein, I wanted to give you a chance to expand on 
your points about prevention, overall well-being and the cost-
effectiveness of early dental care for children. It always 
pained me as a school nurse to see kids losing so much valuable 
class time and not able to concentrate on their studies. Can 
you share any information about how often oral disease accounts 
for absenteeism, and the reverse, what are the ways that you 
can document that it is important to a child's participation in 
education?
    Dr. Edelstein. I think your point earlier that many 
children are in the classroom but distracted, they are in the 
classroom but unable to focus, they are in the classroom but 
feeling dental pain intermittently that really does cause them 
to act out and not perform well as students, and that dental 
pain doesn't go home when they go home from school. It only 
becomes a problem throughout the day, and that kind of chronic 
distraction long before we get to the kind of infection that we 
have been talking about earlier.
    But you did mention cost-effectiveness of prevention and I 
wanted to cite a couple of statistics about the tremendous 
cost-effectiveness so that the Governors and others will 
consider how much benefit can be gained and cost savings can be 
made rather than new expenditures in the Medicaid and SCHIP 
program. One recent study from the University of North Carolina 
pointed out that children who start care at age 1 as currently 
recommended by pediatricians and pediatric dentists, over the 
next 5 years consume 40 percent less cost for care than had 
they not started at age 1 and they utilize the emergency room 
less. That is dramatic. Children with coverage are 30 percent 
more likely to get preventive care, and routine care instead of 
emergency care. That Texas study that was illustrated in my 
slide shows that the average cost for an admission over a 
period of multiple years in Texas at discounted rates paid to 
the hospital by Medicaid was $6,500. The emergency room visits 
were $230 for the same kind of presentation but resulted in no 
definitive care, and the same kind of care could have been 
provided in a dental office for somewhere between $50 and $80. 
So the opportunity to utilize the lowest cost, most effective, 
most preventive site is often overlooked.
    Mrs. Capps. Just to wrap this up, we have this opportunity, 
a unique one as we reauthorize SCHIP, I don't want us to lose 
that change. This is the kind of data then that we can have to 
help us understand that access to dental care is really cost-
effective. Do you want to just expand further and then I will 
open it up if there is----
    Dr. Edelstein. Well, it is our pleasure at the Children's 
Dental Health Project to provide these kinds of data. Almost 
all of them are derived from Federal studies. Those that are 
not are derived from State studies and some from university 
studies. We have well-reliable information that can help make 
sound policy.
    Mrs. Capps. Anyone else want to pick up on that for the 
last 45 seconds? Thank you.
    Dr. Roth. I would just like to encourage you to have States 
look at those models of care that are successful. You have got 
the Michigan model and you have got Smile Alabama and TennCare. 
You have got some great programs out there that are working and 
working very well for the children and the providers in the 
States. It doesn't take that much more money but it is money 
that is used wisely in combination with government and the 
dental community all coming together. So I would encourage you 
to make that part of your mission, adequate funding, and then 
look at the models that work.
    Mrs. Capps. Thank you very much. I will yield back.
    Mr. Pallone. Thank you.
    The gentlewoman from Tennessee.
    Mrs. Blackburn. Thank you, Mr. Chairman, and thank you to 
each of you for your time today.
    Dr. Scheppach, I would like to come to you, if I may, 
because I appreciated your testimony, and even though your 
testimony ran long, I love the fact that you have a great 
enthusiasm for what you do and that you seem to have such a 
heart for being certain that the programs work well for our 
State. I think that that is the area where the rubber meets the 
road and our States and our health care agencies within our 
States are the ones that are working with those local 
communities and keeping the focus on how we preserve access to 
health care and how we preserve access to those components of a 
healthy lifestyle that our constituents all want, and I noted 
in your testimony, you had made a statement, if the States are 
required to meet new Federal benefit mandates in either 
Medicaid or SCHIP, they will have to spend more money per 
individual currently covered in these programs. Increased costs 
will force the States to redirect funds that could have been 
used to fund other affordable health insurance initiatives, and 
many times I think those of us at the Federal level who look at 
how we structure a program forget that any time there is a 
mandate that goes out, that is paperwork for the provider, it 
is paperwork for the insurance company, it is paperwork for the 
State that is the conduit to those funds, and when you put that 
money into paperwork, it is not going into health care, and 
what I want to do is have you speak a little bit to flexibility 
and your concerns about reducing flexibility in these programs 
and the impact you see that a reduction in flexibility and 
increases in mandates, what that would do to our States and 
some of the innovative programs.
    Mr. Scheppach. Well, as I indicated before, I think we are 
at a basic tipping point with respect to States moving forward 
and actually doing comprehensive health care reform. I think 
that within the next 2 to 3 years, we have already had four who 
have enacted it, I think we will have 6, 8, 10 more that will 
enact it. Some of those will be big States. We will begin to 
find out whether personal mandates work. We will begin to find 
out whether employer mandates work, whether connectors work and 
so on. I think that the root to national reform is through the 
50 State houses and we are only going to be able to get Federal 
reform after we prove what works at the State level.
    With respect to the mandates, again, you would like to make 
a basic public policy decision, are we going to try to have a 
basic benefit package for the entire population, get everybody 
in with some level of coverage or are we going to make a 
decision to leave a whole bunch of people out and create a more 
robust benefit package for certain populations. We talk a lot 
about quality in these particular programs. I think we need 
quality standards across the board in health care and dental, 
not necessarily for the SCHIP program but for the entire thing. 
What we are doing is setting standards around individual 
programs, which means we keep selective programs operating 
rather than trying to get at an efficient market. What we need 
to do is let the States move forward, help them to get 
everybody in the system, work out the bugs, because I think 
they will give a direction for national health care reform. 
When you put on specific benefit mandates, States aren't going 
to be able to get universal care. So I think you have to make a 
policy choice: are we going to get to universal more quickly 
and allow the States to provide the leadership or are we going 
to provide more robust benefits for certain populations.
    Mrs. Blackburn. So what you are saying is, we have got the 
four States that have programs out there that are exercising 
some innovation and you have got six to eight States that you 
feel like are going to be ready to move forward and implement 
programs but if we come in with the mandates and change the 
structure, then all of that work just goes out the window?
    Mr. Scheppach. I would say it makes it more difficult. I 
think there are other places that the Congress can help. I 
think we need help on sort of setting up alliances or 
connectors. I think we need help on sort of quality measures, 
price transparency, health IT. We need to set up an 
infrastructure so that consumers can make decisions around this 
rather than concentrating on expanding an individual program.
    Mrs. Blackburn. Those initiatives that you just mentioned, 
those items that you just listed where you need help, are any 
of the States leading on innovation in those specific areas?
    Mr. Scheppach. A lot of States are. Yes. I mean, the health 
IT, we have been working with HHS. We have made contracts to 35 
States to work with their stakeholders in those particular 
States so that they can deal with the security issues, the 
confidentiality issues and so on. So all of these areas we have 
got States moving: quality, price transparency, health IT.
    Mrs. Blackburn. Anybody else want to add something to that 
before we leave that? My time is about up.
    Dr. Edelstein, go ahead.
    Dr. Edelstein. Yes, I appreciate the opportunity. Thank 
you. I completely agree with Mr. Scheppach and with the 
Governors that basic health care should be the goal, basic 
health care and not extra benefits. I am simply saying as we 
discussed yesterday that dental care is a component of basic 
health care and agreeing with Ms. DeGette that well-child, 
well-baby care inherently must include oral health care.
    Mrs. Blackburn. I yield back.
    Mr. Pallone. Thank you. And that concludes all questions 
for the first panel. I want to thank you all. I thought it was 
very insightful and thank you for your participation. We 
appreciate it.
    I would ask the next panel to come forward. I am going to 
ask our second panel to be seated so we can continue. And 
again, I am going to introduce you all. Welcome. From left to 
right, we will get all our signs in place. First on my left is 
Dr. David Krol, who is the associate professor of pediatrics 
and chair of the Department of Pediatrics at the University of 
Toledo College of Medicine in Ohio, and second is Dr. Jack 
Chapman, who is president of Health Access Initiative from 
Gainesville, Georgia, and then last but not least is Ms. Chris 
Koyanagi, who is policy director for the Bazelon Center for 
Mental Health Law here in Washington, DC.
    I think you heard before that we are going to ask each of 
you to speak for 5 minutes. You can include your written 
statement for the record and we of course may ask for 
additional written questions to follow up afterwards as well. 
So I will start with Dr. Krol, if you would, for 5 minutes. 
Thank you.

 STATEMENT OF DAVID M. KROL, M.D., M.P.H., F.A.A.P, ASSOCIATE 
   PROFESSOR OF PEDIATRICS, CHAIR, DEPARTMENT OF PEDIATRICS, 
            UNIVERSITY OF TOLEDO COLLEGE OF MEDICINE

    Dr. Krol. Thanks very much.
    As a pediatrician, a general pediatrician who has worked 
very closely with dentists and mental health professionals, as 
the chair of the department of pediatrics and as a member of 
the American Academy of Pediatrics, I and we consider 
children's dental and mental health an integral part of well-
child care and ensuring the bright futures process. We applaud 
the committee for holding this hearing.
    The prevailing adult acute care model of coverage 
inappropriately limits preventive and other types of services 
that are of critical importance for children and adolescents 
because of their unique characteristics and environments. If we 
as a society can commit more than $2 trillion of our 2007 GDP 
to health care, there is no excuse or plausible explanation why 
our youngest citizens cannot have the best we have to offer 
that utilizes the clinical values of pediatric health care, 
training and research in its ultimate development. Because many 
adult diseases appear in childhood, investing in preventive 
benefits for children is also cost-effective. However, this 
return on investment can take many years to become apparent.
    Through regular contact with parents or guardians, 
pediatricians and other child health care providers can assess 
and monitor a child's development and screen for developmental 
problems and risk behaviors. Although each child develops at 
his or her own pace, all children progress through an 
identifiable sequence of physical and emotional growth and 
change. Age-appropriate health care visits foster positive 
parenting behaviors, help promote optimal development and 
initiate early intervention when problems appear imminent.
    The major risks to children's health and development, 
particularly after infancy, are largely preventable. Well-child 
care or health supervision provides a vehicle for health 
professionals to promote healthy lifestyle choices, monitor 
physical and behavioral pathology and provide age-appropriate 
counseling or anticipatory guidance.
    Because of the prevalence of obesity, dental caries, 
attention deficit disorder/hyperactivity, depression and the 
stresses faced by parents, experts have noted that the term 
``well-child care'' is applicable to fewer and fewer children. 
Pediatricians reported in a national survey that they face an 
array of obstacles to providing quality well-child care: time 
constraints, low levels of payment for preventive pediatric 
care and lack of payment for specific developmental services.
    Optimal relationships between pediatrician, their patients 
and the patient's family occur in a medical home. A medical 
home is not a building, house or hospital but rather an 
approach to providing comprehensive primary care. A medical 
home is primary care that is accessible, continuous, 
comprehensive, family-centered, coordinated, compassionate and 
culturally effective. The physician should be known to the 
child and family and should be able to develop a partnership of 
mutual responsibility and trust with them.
    In contrast to care provided in a medical home, care 
provided through emergency departments, walk-in clinics and 
other urgent care facilities, though sometimes necessary is 
more costly and often less effective. Children from low-income 
families are more likely than other children to have serious 
health problems. There is also an inverse correlation between 
poverty and education needed to manage these problems. While 
most pediatricians provide care for such families in their 
practices, financially they are being forced to limit the 
number that they can continue to see. One such practice in my 
home State of Ohio also takes care of 500 Medicaid children 
from Indiana. They have just notified Indiana that they are 
dropping their patient caseload to 90. While they are retaining 
the patients that have the most complex problems, the others 
will need to be reassigned. The reality is that having a 
Medicaid/SCHIP card does not guarantee access to quality 
pediatric care in a timely fashion. Needed modifications in 
payment could quickly rectify this situation.
    The knowledge and science of healthy child development is a 
rapidly evolving field and the practice of pediatrics changes 
accordingly. Launched by the Health Resources and Services 
Administration's Maternal and Child Health Bureau in 1990, 
Bright Futures is a national child health promotion and disease 
prevention initiative that provides principles, strategies and 
tools that can be used to improve the health and well-being of 
all children. A comprehensive revision of Bright Futures is 
near completion by the American Academy of Pediatrics. The 
experts drafting the recommendations have established 
priorities for each well-child care visit to use as a guide in 
discussing health promotion and disease prevention with 
families. The first priority for every visit is addressing the 
concerns of the family around the health and development of 
their child.
    Dollar for dollar, providing better health care for 
children represents one of the best returns on investment 
available. This wise investment means ensuring that health care 
systems including safety-net providers and health insurers are 
responsible to the unique health needs of children. As a 
Nation, we must invest in improving children's access to 
quality care. Just as coming events cast their shadows before 
them, so does the health of a nation's children foreshadow the 
health of its future.
    Thank you for the opportunity.
    [The prepared statement of Dr. Krol follows:]
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    [GRAPHIC] [TIFF OMITTED] T9877.002
    
    [GRAPHIC] [TIFF OMITTED] T9877.003
    
    Mr. Pallone. Thank you, Dr. Krol.
    Dr. Chapman, I know it says Mr. Chapman but it also says 
you are a doctor so I am going to use that. You are a medical 
doctor, correct?
    Dr. Chapman. Yes, sir. That is correct.
    Mr. Pallone. Thank you.

   STATEMENT OF JACK CHAPMAN, M.D., PRESIDENT, HEALTH ACCESS 
                           INITIATIVE

    Dr. Chapman. Mr. Chairman, honorable members of the 
committee, thank you for allowing me the opportunity to address 
you today. My name is Dr. Jack Chapman. I am president of the 
Health Access Initiative in Gainesville, Georgia. I am also in 
the private practice of ophthalmology and I currently serve as 
president-elect of the Medical Association of Georgia.
    I come before you today to share the story of how we are 
providing for the health of the low-income uninsured in Hall 
County, Georgia, especially children. We have a collaborative 
effort between private physicians, the Good News Clinic, the 
Hall County Health Department, the Health Access Initiative and 
the Northeast Georgia Medical Center.
    What I would like to convey to you is how the old model 
worked and explain the new model now operating in our 
community.
    Good News Clinics was founded in the early 1990's. It is 
the largest free clinic in the Southeast and one of the top 10 
free clinics in the Nation. Largely with volunteer physicians, 
they provide free medical and dental care including medications 
to low-income uninsured patients. This is accomplished through 
a freestanding pharmacy staffed by a full-time pharmacist. In 
2006, there were 8,843 medical clinic patient visits, 7,440 
dental clinic visits and 66,451 pharmacy visits. The 
medications they provided to the patient at no charge had a 
retail value of $3.8 million. Hall County has a population of 
over 170,000.
    The Hall County Health Department provides a prenatal 
program in conjunction with the Longstreet Clinic, a private 
multispecialty group. Prenatal care helps decrease infant 
mortality and infants' risk of health problems that would cost 
far more without prenatal intervention. In 2004, Hall County's 
infant mortality rate was 5.5 percent compared to 8.5 percent 
for the State of Georgia.
    The Hall County Health Department also provides clinical 
services with 29,737 clients served in 2006.
    In collaboration with community partners, Health Access 
Initiative provides access to health care for uninsured 
patients. Health Access is a consortium of partners including 
over 150 physicians, the local hospital, health department, 
free clinic, federally qualified clinic, United Way 2-1-1, 
chamber of commerce and other partners. This group came 
together to primarily fill the need for the specialty surgical 
care for the uninsured indigent.
    Health Access adds value to the existing resources in the 
community by providing specialty and surgical needs in a 
seamless manner. Under the old model, when someone needed 
surgery, the physician seeing the patient at the Good News 
Clinic or the health department would be in a predicament. The 
physician would have to stop what he or she was doing and take 
the time to make a number of phone calls in order to find a 
specialist surgeon that would do a favor for the clinic. If 
surgery was indicated, the physician who was doing the clinic a 
favor would have to call an anesthesia friend and ask that 
physician to do a favor for him. If radiology was needed, then 
the same would take place. Of course, the hospital operating 
room would need to be contacted as well, and this does not 
include the challenge if more than one specialty surgeon is 
needed as well. Under the old model, it was a cumbersome, time-
intensive process without structure, organization or 
measurement.
    Health Access arose out of the Hall County Medical Society. 
What it accomplished under the new model is to bring all the 
participants together in a more coordinated fashion. We have 
the physicians, hospital, X-ray and labs all agree to provide 
the care for qualified patients on the front end. This way when 
a patient is seen in the Good News Clinic that requires 
specialty care surgery, the physician there makes the 
determination and writes the order. In the new model, Health 
Access is notified and contacts the patient to make all the 
arrangements. A photo ID is issued to the patient to identify 
them as the Health Access patient using a customized software 
tracking program. If anesthesia is required for surgery, they 
are already committed to provide the care. The hospital is 
already on board to provide labs and OR. Also, the radiologist 
is on board. The new model is seamless and user-friendly. It is 
also less of a burden for the volunteer physician and allows 
the physician to see more patients.
    To track this, the physician's office providing the care 
sends a health claim form over to Health Access with the CPT 
code, the ICD9CM code, and the amount of services or care 
provided. We then enter this into our client tracking program 
so that we can track the care provided as well as how much was 
provided. We make sure that the patients keep all appointments 
and follow-up visits. Last year we documented a 90 percent 
compliance rate with patients keeping their appointments in the 
physicians' offices. According to the code, we track the value 
of services provided. In 2006, Health Access Initiative 
physicians in Hall County provided over $815,000 in donated 
care.
    The emergency room is another entry point into our system. 
Our ER in Hall County is the third busiest in the State of 
Georgia with over 95,000 visits last year. When you think of an 
ER, you think of trauma, motor vehicle accident, heart attack. 
However, the No. 1 diagnosis in our ER is earache. The ER is 
used as a clinic. The cost of taking care of a patient in the 
ER as opposed to the office/clinic setting is three times. The 
Good News Clinic has data that shows their cost of care for a 
patient is $34 as compared to $221 for the same patient in the 
ER. The Andrew Young Health Policy Center at Georgia State 
University----
    Mr. Pallone. Dr. Chapman, you are about a minute over, so 
if you could summarize.
    Dr. Chapman. In closing, as you can see, it takes a lot of 
collaboration to make this work. The new model accomplishes 
this task. In fact, the Health Access Initiative was honored 
for this.
    I hope that you will recognize that individual communities 
can step up to the plate to provide their citizens in need. I 
hope you will continue to encourage and assist as possible. The 
donated care model is not the answer to the problem of 
providing health care but is part of the answer.
    I thank you again for allowing me to be here today and I 
thank you for your time, service and attention you are giving 
to this very important issue.
    [The prepared statement of Dr. Chapman follows:]

                 Testimony of Jack M. Chapman Jr., M.D.

    Mr. Chairman, honorable members of the committee, thank you 
for allowing me the opportunity to address you today. My name 
is Dr Jack Chapman. I am President of the Health Access 
Initiative in Gainesville, GA. I am also in the private 
practice of Ophthalmology and I currently serve as President-
elect of the Medical Association of Georgia.
    I come before you today to share the story of how we are 
providing for the health of the low income uninsured in Hall 
County Georgia, especially children. We have a collaborative 
effort between private physicians, the Good News Clinic, the 
Hall County Health Department, the Health Access Initiative, 
and the Northeast Georgia Medical Center.
    What I would like to convey to you is how the old model 
worked and explain the new model now operating in our 
community.
    Good News Clinics (GNC) was founded in the early 1990's. It 
is the largest free clinic in the Southeast and one of the top 
10 free clinics in the nation. Largely with volunteer 
physicians, they provide free medical and dental care including 
medications to low income, uninsured patients. This is 
accomplished through a free standing pharmacy staffed by a 
full-time pharmacist. In 2006 there were 8843 medical clinic 
patient visits, 7440 Dental Clinic visits and 66,451 pharmacy 
visits. The medications they provided for - all at no charge to 
the patient - had a retail value of $3.8 million. Hall County 
Georgia is located in Northeast Georgia and has a population of 
over 170,000.
    The Hall County Health Department (HCHD) provides a 
prenatal program in conjunction with The Longstreet Clinic, a 
private multispecialty group. Prenatal care helps decrease 
infant mortality and infants' risk of health problems that 
would cost far more without prenatal intervention. In 2004, 
Hall County's infant mortality rate was 5.5 percent, compared 
to 8.5 percent for Georgia.
    The Hall County Health Department also provides clinical 
services with 29,737 clients served in 2006.
    In collaboration with community partners, Health Access 
Initiative (HAI) provides access to healthcare for uninsured 
patients. HAI is a consortium of partners including over 150 
physicians, the local hospital, health department, free clinic, 
federally qualified clinic, United Way 2-1-1, Chamber of 
Commerce, and other partners. This group came together to 
primarily fill the need for specialty/surgical care for the 
uninsured/indigent.
    HAI adds value to the existing resources in the community 
by providing specialty and surgical needs in a seamless manner. 
Under the old model, when someone needed surgery, the physician 
seeing the patient at the GNC or the HCHD would be in a 
predicament. The physician would have to stop what he or she 
was doing and take the time to make a number of phone calls in 
order to find a specialist/surgeon that would do a favor for 
the clinic. If surgery was indicated, the physician who was 
doing the clinic a favor would have to call an anesthesia 
friend and ask that physician to do a favor for him. If 
radiology was needed then the same would take place. Of course, 
the hospital/operating room would need to be contacted as well 
and this does not
     Include the challenge if more than one specialty surgeon 
is needed. Under the old model it was a cumbersome time 
intensive process without structure, organization, or 
measurement.
    HAI arose out the Hall County Medical Society. What is done 
under the new model is to bring all of the participants 
together in a more coordinated fashion. We have the physicians, 
hospital, x-ray, and labs all agree to provide the care for 
qualified patients on the front end. This way, when a patient 
is seen at the GNC that requires specialty care/surgery, the 
physician there makes the determination and writes the order. 
In this new model, HAI is notified and contacts the patient to 
make all the arrangements. A photo ID card is issued to the 
patient to identify them as an HAI patient using a customized 
software tracking program. If anesthesia is required for 
surgery, they are already committed to provide the care for 
HAI. The hospital is already on board to provide labs and OR as 
needed. Also, the Radiologist is on board as well. The new 
model is seamless and user friendly. This also lifts the burden 
from the volunteer physician and allows the physician to see 
more patients.
    To track this, the physician's office providing the care 
sends a health claim form over to HAI with the CPT code, the 
ICD9CM code, and the amount of services or care provided. We 
then enter this into our client tracking program so that we can 
track that the care was provided (i.e. the patient kept the 
appointment), as well as how much was provided. We make sure 
that the patient keeps all appointments and follow-up visits. 
Last year we documented a 90 percent compliance rate with 
patients keeping their appointments in the physician's offices. 
According to the code, we track the value of services provided. 
In 2006, HAI physicians provided over $815,000 in donated care.
    The emergency room (ER) is another entry point into our 
system. Our ER in Hall County Ga is the third busiest in the 
State of Georgia with over 95,000 visits last year. When you 
think of an n ER, you think of trauma, MVA, or heart attack. 
However, the number one diagnosis in our ER is earache. The ER 
is used as a clinic. The cost of taking care of a patient in 
the ER as opposed to the office/clinic setting is three times. 
The GNC has data that shows their cost of care for a patient is 
$34 as compared to $221 for the same patient in the ER. The 
Andrew Young Health Policy Center at Georgia State University 
has similar data.
    We have been too successful in getting people to go to the 
hospital/ER for care. The ERs have become clinics. At HAI, we 
work to keep the patient out of the ER. We want the patient to 
have a medical home that they use for their care. In fact, as 
part of our partnership, we are sent a daily report from the 
hospital notifying us if a patient in the HAI program was seen 
in the ER the day before. We then contact the patient to find 
out if the visit to the ER was the appropriate place to access 
the care that they needed. If not, then the patient is 
counseled on the appropriate or better way to obtain the care 
they need and we make sure they have a follow up appointment 
with their primary care provider if needed. We are trying to 
change the habits as well as the behavior as it relates to 
going to the ER.
    Another important aspect to providing care and keeping 
healthcare resource utilization and cost down is to keep the 
patient from bouncing back and forth into the hospital. This 
requires the patient to have the medications needed available. 
If a patient does not obtain the medication required then they 
will have a difficult time improving and most likely will 
become worse with a more complicated illness that will be much 
more expensive and require much more in resources to treat. 
Through our partnership with GNC, HAI staffs a pharmacy tech to 
help provide free medications to meet acute needs. The 
medication assistance programs are used to meet chronic needs.
    As you can see, it takes a lot of collaboration to make 
this work. The new model accomplishes this task. In fact, the 
HAI was honored by the Healthcare GA Foundation with the 
Community Service Collaborative of the Year Award for 2006.
    In closing, I hope that you will recognize that individual 
communities can step up to the plate to provide for their 
citizens in need. I hope that you will continue to encourage 
and assist as possible, communities to start collaboratives 
like HAI and GNC. It really takes all parties coming together 
and working in a coordinated manner to provide for this 
problem.
    This donated care model I have described is not THE answer 
to the problem of providing healthcare for those who are low 
income and uninsured, but it can be a PART of the answer and 
can go a long way in helping many people who could not 
otherwise obtain the healthcare they need.
    Thank you again for allowing me to be here today. Thank you 
for the time, service and attention you are giving to this very 
important issue.
                              ----------                              

    Mr. Pallone. Thank you.
    Ms. Koyanagi.

 STATEMENT OF CHRIS KOYANAGI, POLICY DIRECTOR, BAZELON CENTER 
                     FOR MENTAL HEALTH LAW

    Ms. Koyanagi. Thank you, Mr. Chairman. I appreciate the 
opportunity to testify today on children's mental health.
    I think for policy purposes, it is really helpful to think 
of children who need mental health services in some different 
groupings. First of all, one in five children in this country 
have a diagnosable mental disorder that requires treatment. 
Eleven percent of children have a mental disorder that also is 
accompanied by a significant functional impairment. Obviously 
those children need more-intensive services. And 5 percent of 
children have a mental disorder which causes extreme functional 
impairment and those children need a wider array of services as 
well as more-intensive services.
    And unfortunately for most children, access to mental 
health care is pretty abysmal. First of all, obviously children 
who are uninsured have little recourse, and what that is not 
the topic today, I do hope the committee will focus on the 
issue of uninsured children. But our public mental health 
systems are now so overburdened that they really cannot accept 
people who don't have either public insurance or private 
coverage.
    But children who have private coverage through employer-
based plans also have limits on their mental health services. 
Typically these plans only cover basic mental health, 
outpatient therapy, medications and hospitalization, and also 
there are limits on the array of those services, typically 30 
inpatient days or 20 outpatient sessions is what you will find 
in most policies. Legislation introduced by Representatives 
Kennedy and Ramstad, the Mental Health Parity Act, would 
address this problem. We certainly urge the Congress to enact 
that bill.
    But unfortunately, these limits in private plans have also 
been imported into SCHIP and Medicaid. SCHIP permits States to 
use benchmark plans, private plans as their models for SCHIP 
and many States do, and also now through the Deficit Reduction 
Act, Medicaid populations can also be placed into these kinds 
of benchmark plans which brings all these limits on mental 
health services into these public programs so many low-income 
children also cannot receive the course of mental health 
treatment that they need.
    We would urge Congress to address this in SCHIP by 
requiring equity in the mental health benefits and also perhaps 
to either repeal the benchmark provision in Medicaid or at 
least require those benchmark plans include a reasonable mental 
health package.
    In addition, SCHIP has a further problem for us in terms of 
mental health coverage because States may choose to cover only 
75 percent of the actuarial value of the mental health benefit 
in the benchmark. So first your benchmark has limits and then 
under SCHIP, States can reduce even further and 
have even tighter limits. Chairman Dingell has introduced a 
bill, the Children's Health First Act, which would rectify that 
problem and we would urge the committee to take a look at that.
    For children who have more severe mental health disorders, 
not only are the limits in the private plans and SCHIP 
inadequate but so is the range of services. These children 
require intensive community-based services such as in-home 
services, services in school. Their parents need help in 
understanding the disorder and how to respond when crises are 
emerging. These children need case management to meld these 
services together and various comprehensive programs, and a 
point of fact, we generally see that those services are only 
available under Medicaid.
    The gaps in coverage can be disastrous for families. There 
are many families who are advised by public officials to give 
up custody of their child to a public agency in order to ensure 
that the child has access to these kinds of comprehensive 
services. The GAO found almost 13,000 such children in just 19 
State child welfare agencies and 30 county juvenile justice 
systems but GAO pointed out that these data grossly understate 
the problem because so few States keep the data.
    So the bottom line is that Medicaid is the critical safety 
net for children with the most serious mental disorders and the 
only program that covers all the array of services that they 
need.
    I would like to alert the committee that we are extremely 
concerned that the Medicaid community mental health services 
package is being amended by CMS, which is both having some 
audits conducted of these programs including I think an audit 
that is going on now in Georgia and also considering amending 
its regulations to reduce coverage of the community services. 
This is ironic because these community-based services are the 
least costly and because they enable children to stay with 
their own families or in alternative family-like settings, they 
are the most effective and the most likely to have long-lasting 
effects rather than placing children in institutions far away 
from their home.
    The Surgeon General in 1999 and the President's Commission 
on Mental Health in 2003 have both made clear that we have now 
extremely effective treatments for mental health disorders but 
that these are far too frequently unavailable. America's 
children deserve a healthy start in life and that would include 
having early and effective access to treatment for their mental 
disorders.
    Thank you, Mr. Chairman.
    [The prepared statement of Ms. Koyanagi follows:]

                      Testimony of Chris Koyanagi

     Good morning Chairman Pallone, Representative Deal and 
members of the Subcommittee. My name is Chris Koyanagi. I am 
the policy director for the Judge David L. Bazelon Center for 
Mental Health Law. The Bazelon Center is the leading national 
nonprofit, legal-advocacy organization representing people with 
mental disabilities. The Center works to define and uphold the 
rights of adults and children with mental disabilities who 
primarily rely on public services to ensure that they have 
equal access to health and mental health care, education, 
housing and employment.
     Thank you for the opportunity to share our insights 
regarding mental health care for children in the public and 
private sector, including barriers to care, the consequences of 
inadequate access to care, and opportunities for Congress to 
improve access and provide a healthy start for children with 
mental health needs. It is our hope that this hearing will 
result in increased support for specific legislative proposals 
that will provide appropriate and timely access to mental 
health services and supports in both the public and private 
sectors.
    During my testimony, I will describe opportunities within 
the committee's jurisdiction to address shortcomings in health 
care coverage for children with mental health needs such as 
approving the bipartisan Paul Wellstone Mental Health and 
Addiction Equity Act, enacting the bipartisan Keeping Families 
Together Act, eliminating the discriminatory limits on mental 
health care in State Children's Health Insurance Program 
(SCHIP), and preserving and strengthening the public sector 
Medicaid program.

                  Overview of Children's Mental Health

     Mental disorders affect about one in five American 
children and five to nine percent experience serious emotional 
disturbances that severely impair their functioning. Children 
from low-income households are at increased risk of mental 
health problems and research has indicated that children in 
Medicaid and SCHIP have a much higher prevalence of mental 
health problems than other insured children or even uninsured 
children. Tragically, a large majority of children struggling 
with these mental disorders (79 percent by some estimates) do 
not receive the mental health services they need. Not 
surprisingly, uninsured children have a higher rate of unmet 
need than children with public or private insurance.
     More than just a problem for the uninsured, children 
covered by private or public health plans have serious coverage 
gaps that prevent them from obtaining needed mental health 
services. For instance, private health plans set arbitrary 
limits on mental health coverage, such as caps on the number of 
times a child may be seen by a therapist over the course of a 
year. Approximately 68 percent of Americans under the age of 18 
are covered by private insurance, while public programs (such 
as Medicaid and SCHIP) cover about 19 percent.
     Within the public sector, discriminatory limits on mental 
health services in SCHIP that would not be permissible in 
Medicaid have restricted access to care for children and 
adolescents. Additionally, current Administrative activities 
that restrict reimbursement under the Medicaid rehabilitative 
services option limit access to a range of critical community-
based services for children and adults that help them remain in 
the community--a goal supported by the President's Commission 
on Mental Health.
     Without early and effective identification and 
intervention, childhood mental disorders can lead to a downward 
spiral of school failure, poor employment outcomes, and, later 
poverty in adulthood. Untreated mental illness may also 
increase a child's risk of coming into contact with the 
juvenile justice system, and children with mental disorders are 
a much higher risk of suicide. According to the Surgeon 
General, an estimated 90 percent of children who commit suicide 
have a mental disorder.
     Fortunately, poor outcomes for children with mental health 
needs can be prevented with access to appropriate services.

  Insurance Reform Needed to Improve Access and Avoid Tragic Outcomes

     Mental health treatment can be very expensive and most 
families rely upon insurance to help cover the cost of these 
services. For example, one outpatient therapy session can cost 
more than $100. Residential treatment facilities, which provide 
24 hours of care, seven days a week, can cost $250,000 a year 
or more. However, employer based coverage often restricts 
access to mental health services for children and adults by 
placing limits on mental health coverage that they do not place 
on medical/surgical care. Limits on mental health coverage 
includes lower outpatient office visit limits, lower hospital 
stay limits, higher outpatient office visit co-payments, and 
higher outpatient office visit co-insurance. Data show that 94 
percent of health maintenance plans and 96 percent of other 
plans have these restrictions. Families that face health 
insurance restrictions or exhaust their health insurance 
benefits are left without options.
     Enacting mental health parity legislation (sponsored by 
Representatives Patrick Kennedy and Jim Ramstad) would be an 
essential first step to improving access in the private sector. 
Comprehensive parity legislation would help by prohibiting 
private insurers from denying access to needed services because 
of stigma and discrimination through current limitations and 
restrictions on mental health care that are not placed on 
general health care. Additionally, this Federal legislation 
would extend parity protections to the many self-funded 
employer-sponsored plans, that are currently exempt from any 
State mental health parity laws.
     Gaps in services and limits in coverage can be disastrous 
and could lead to custody relinquishment whereby parents of 
children with mental disorders forgo custody of their children 
so they can become wards of the State and eligible for medical 
assistance. It is clear that across the country, children 
needing intensive mental health treatment are not receiving the 
care they need early on to prevent a host of adverse outcomes, 
including custody relinquishment. According to a General 
Accounting Office (GAO) report of April 2003, at least 12,700 
children were placed in child welfare or juvenile justice 
system in 2001, solely to access State-funded mental health 
services. But this finding grossly understates the extent of 
the problem. GAO also found that most States and counties do 
not track how often custody relinquishment occurs and the 
12,700 figure only reflects data from 19 child welfare 
departments and 30 county-level juvenile justice systems.
     Legislation entitled the Keeping Families Together Act 
(H.R. 687-S. 382) has been introduced to help prevent parents 
from having to choose between custody and care by funding 
State-level interagency systems of care to improve mental 
health sources for children with mental disorders at risk of or 
already subjected to custody relinquishment. This legislation 
is sponsored by Representatives Patrick Kennedy, Jim Ramstad, 
and Pete Stark and Senators Susan Collins and Tom Harkin. It 
has been referred to the Energy and Commerce Committee and we 
urge the committee to approve this crucial piece of legislation 
as soon as possible.
     Many families cite gaps in private insurance coverage as a 
major factor in their decisions to relinquish custody of their 
children. Private insurance plans do not cover the full array 
of intensive, community-based rehabilitative services that 
children with the most severe mental or emotional disorders 
need'services that would be covered under Medicaid.

        Medicaid Provides Vital Access to Mental Health Services

     Medicaid is a critical source of support for mental health 
care, accounting for 20 percent of all mental health spending. 
Thanks in large part to the Early and Periodic Screening, 
Diagnosis, and Treatment (EPSDT) benefit. Medicaid covers a 
comprehensive array of mental health services for children, 
including intensive services in the community that offer the 
greatest potential for avoiding costly institutional care. 
Medicaid is the only source of coverage that finances a full 
range of the rehabilitative services needed by children with 
mental disorders.
     Last Congress, the bipartisan Family Opportunity Act was 
enacted as part of the Deficit Reduction Act to give States the 
option of allowing families with children with disabilities to 
buy Medicaid coverage for their children. This new law also 
created a demonstration program to provide home and community- 
based services to children with serious emotional and 
behavioral disorders as alternatives to psychiatric residential 
treatment. Enactment of these important provisions were a 
significant step in strengthening the Medicaid program by 
enabling families to meet their children's serious health and 
mental health needs while still keeping their families intact.
     Further steps that must be taken include strengthening the 
Medicaid EPSDT benefit so that all children served by Medicaid, 
including those with mental health disorders, receive 
comprehensive screening. Non-compliance with EPSDT leads to 
reduced access to services and puts children in need of 
treatment at great risk of experiencing a host of other adverse 
consequences.
     Medicaid coverage of community-based services through the 
rehabilitative services option is also critically important for 
children with mental health needs, especially children with 
serious disorders. These intensive rehabilitative community-
based services for kids include multisystemic therapy, 
intensive home-based services for children and adolescents, 
therapeutic foster care, and behavioral aide services. These 
services are effective alternatives to institutional care for 
children and adults with severe mental disorders and are 
critical to promoting resiliency and recovery from mental 
illness. Medicaid is generally, the only source of coverage for 
them, specifically through the rehabilitative services option.
     Unfortunately, the administration has indicated it will 
narrow coverage under the rehabilitative services option 
through regulatory changes. During the Deficit Reduction Act 
deliberations last Congress, Members deliberately rejected the 
administration's proposed changes to Medicaid coverage of 
rehabilitative services. Nonetheless, the administration is 
currently going forward with narrowing the scope of the 
rehabilitation option through the regulatory process as well as 
changes in coverage policy implemented through audits by the 
Health and Human Services Office of the Inspector General. The 
integrity of the Medicaid program and the standards set by 
Congress regarding the scope of optional service programs must 
be maintained. The back door approach being used by the 
administration, and shunned by Congress in the recent past, 
would drastically affect specific interventions that enable 
children and adults with serious mental disorders to function 
independently, learn in school, socialize age appropriately and 
experience symptom reduction.

   SCHIP Changes Required to Eliminate Disparities and Improve Access

     SCHIP has generally been very successful in expanding 
health care coverage to millions of previously uninsured 
children, and States that simply expanded their Medicaid 
programs to cover these additional children offer comprehensive 
mental health services. However, States have the option to 
establish stand-alone SCHIP plans that are separate from their 
Medicaid programs and modeled after private insurance benchmark 
plans. Unfortunately, many States have adopted into these 
separate SCHIP plans private-insurance style limits on mental 
health services that would not be permissible in Medicaid, 
including caps on inpatient and outpatient care.
     A study of SCHIP managed care plans found wide variations 
in the scope and limits of mental health treatment, with many 
States limiting outpatient services to 20 visits and inpatient 
days to 30 or less. These limits are not based on the medical 
needs of beneficiaries or best practice guidelines and result 
in coverage that is wholly inadequate for children with mental 
disorders. Another study found that children with complex 
mental health needs would have access to full coverage of 
needed services in only approximately 40 percent of States due 
to limited benefits in SCHIP plans.
     Mental health services are key components of the range of 
services children need for healthy development, and children 
enrolled in separate SCHIP plans deserve comprehensive coverage 
for their mental health needs For these children to have access 
to appropriate range of services, the law must be amended to 
ensure that all SCHIP plans provide mental health coverage that 
is equivalent to the coverage provided for general health care.
     On February 28, 2007, over 40 national organizations 
representing children in the child welfare and mental health 
system sent a letter urging you to use this critical 
opportunity afforded by the SCHIP reauthorization process to 
prohibit disparate limits on mental health care for children in 
separate SCHIP plans.
     Furthermore, language in the SCHIP statute even allows 
States to provide significantly less mental health coverage in 
their separate SCHIP plans than is covered in the benchmark 
plan they select. The law allows States that opt to create a 
separate plan to reduce the actuarial value of the mental 
health benefit by 25 percent--that is, the mental health 
benefit in SCHIP need only be actuarially equivalent to 75 
percent of the benefit in the benchmark plan itself. This 
statutory provision authorizes States to establish SCHIP 
benefit packages that are totally inadequate for treating the 
great majority of childhood mental disorders.
     This provision allowing the reduction of mental health 
benefits to 75 percent of the mental health benefits in the 
benchmark plans must be eliminated, and we commend Chairman 
Dingell for including a provision to do just that in his bill 
entitled the Children's Health First Act.
     In conclusion, it is clear that many parents face 
tremendous barriers to accessing adequate mental health 
services for their children. Both the President's Commission on 
Mental Health and the Surgeon General have declared children's 
mental health coverage to be in crisis. It is unthinkable that 
a child with asthma would enter the child welfare system solely 
to access treatment. But, for children with mental health 
needs, this is precisely what does happen across the country.
     I urge you to take advantage of all legislative 
opportunities to improve access to mental health services and 
supports for children. Proposals before the committee to remedy 
the failings of the private and public sector serving children 
with mental health needs must be seized to offer these children 
a fair chance at overcoming the extra challenges they face.
     I thank you for holding this vital hearing and would be 
happy to answer any questions you might have.
                              ----------                              

    Mr. Pallone. Thank you very much, and I want to thank all 
the panelists and we will now have some questions. I recognize 
myself for 5 minutes for questions.
    I am going to start with Dr. Krol. On the first panel, our 
ranking member, Congressman Deal, mentioned some technical 
changes to the Deficit Reduction Act which are needed to 
protect the children's benefit in Medicaid EPSDT, or Early 
Periodic Screening, Detection and Treatment, and then Mr. 
Scheppach described these changes as limiting flexibility, but 
my understanding is the technical change doesn't affect 
flexibility, it merely clarifies that this important children's 
benefit is unaffected. In fact, Senators Grassley and Baucus 
and Congressman Barton have acknowledged that the Deficit 
Reduction Act was not intended to affect the EPSDT benefit for 
children and I believe the American Academy of Pediatrics 
supports this technical change.
    So I just wanted to ask you, Dr. Krol, why is EPSDT so 
important for children and why is this technical change needed 
to protect children's coverage, if you will?
    Dr. Krol. Thank you for that question. First of all, the 
American Academy of Pediatrics does support that technical 
change wholeheartedly. I can speak as a pediatrician that takes 
care of kids and tell you a little bit of why EPSDT is so 
important to me and the children that I take care of, and I 
sometimes cringe when I hear the acronym rather than saying it 
all out because we lose what it actually means when we just say 
EPSDT. It makes it a little easier on us. But the first part is 
early. What it allows me to do is, I can assess children as 
early as possible. When they walk into my door--well, they are 
not walking in the door at a week of age but they are brought 
into my door and I see these parents and I can assess risk in 
this child for a variety of different things and it gives me 
the opportunity to connect with my colleagues or my mental 
health colleagues if I need a referral. That is the first part. 
The periodicity is very important. Over time kids change, their 
circumstances change and the science changes over time, and I 
need that ability to over time assess a child. That 
relationship between me and that family is extremely important 
and EPSDT allows me to do that. But what it really allows me to 
do is to screen. It allows me to provide age-appropriate 
screening, trying to prevent disease before it happens rather 
than waiting until the disease comes and treating the disease. 
My goal is to have a child go 18 years through my office, 21 
years through my office, sometimes 24 years through my office, 
and all I am doing is telling parents what is coming up, here 
is what is going to happen with your child, here is what is 
going to be going on rather than a child coming in and having 
some sort of issue that I am going to have to deal with as far 
as an illness. What EPSDT allows me to do is to prevent 
disease, ameliorate needs, address concerns of families and 
children, especially when they are adolescents, and it allows 
me to collaborate to address the disease if they do have that. 
I think that technical change is needed to maintain that.
    Mr. Pallone. Do you want to explain that a little more 
though, the technical change? What is it going to do?
    Dr. Krol. Well, what I think it will do is, it will allow 
me to do these, all of these things that I think are required 
to help me take care of kids in a better way, to help them live 
healthy and happy lives. By taking away these benefits, by 
removing these benefits, we just can't do the job that we are 
doing right now.
    Mr. Pallone. OK. Let me also ask you, you mentioned obesity 
in your statement and I mentioned it in my opening statement 
and most people are aware the rates of childhood obesity are 
rapidly increasing. Can you comment on the impact that that 
trend is having on children and maybe on steps that 
pediatricians could take to combat the epidemic and also what 
types of things you think Congress could do to address the 
childhood obesity problem?
    Dr. Krol. It is a significant epidemic and a difficult 
question to answer for a variety of reasons, not the least of 
which is so many things impact obesity. The simplest way to 
look at it is calories in versus calories out, and if you want 
to affect obesity, you affect one or the other and ideally 
both. So on the front end, working with families and children 
on what they are taking in as far as what kind of foods are 
healthy, amounts, portion size, not sucking down a two-liter 
bottle of your favorite soft drink or sugared substance, and 
just to bring up the sugared substances, they are common risk 
factors to obesity and oral health issues, so there is an 
opportunity there to make a difference, not only in obesity but 
also in oral health. On the other side of the equation, 
affecting the calories that are expended, getting children more 
active, helping families work with kids because the reality is, 
if I am going to make a change in a child, it has to happen 
within the family. If I tell a family or if I tell a child you 
got to eat better, you got to exercise more, but the 
environment they live in, they have food instability where they 
are not quite sure where their next meal is going to be coming 
from and they are buying from their favorite fast-food 
restaurant because of 99-cent meals or they live in a 
neighborhood where they can't access physical activity or they 
go to a school that has removed physical activity, physical 
education from the program or they have a school lunch which 
they may qualify for a free school lunch but junk-food machines 
are open at the same time and they take their money and they 
spend in a junk-food machine rather than in the healthier 
lunches. I think there are a lot of barriers that we have to 
address. Some of these I can do in my office but some of these 
have to happen on a community level that I can help impact but 
it really takes a team to address those issues.
    Mr. Pallone. Thank you. Since my children left, I can say 
that they are still even today trying to go to McDonald's 
whenever possible and I have to constantly tell them that there 
are alternatives to McDonald's when we go out to eat.
    Dr. Krol. There are.
    Mr. Pallone. Thank you.
    Mr. Deal.
    Mr. Deal. Thank you, Mr. Chairman. With regard to 
clarifying the question that came up in the earlier panel and 
your question now with regard to the language that was in the 
Deficit Reduction Act about the flexibility and the benchmark 
plans of the States we have heard from the representative of 
the Governors' office, I would like to ask permission to insert 
in the record letters from Dr. McClellan and Secretary Leavitt 
indicating that they would never approve a State plan that did 
not include the EPSDT provision, and if that needs further 
clarification to satisfy provider groups or the Governors, 
maybe you and I should have a meeting with Secretary Leavitt or 
perhaps even a hearing in the subcommittee. So I think that is 
a clarification.
     With regard to that issue of State benchmarks though, I 
know that one of our witnesses said they don't like those but 
the reality is that a State benchmark says that your plan has 
to include, first of all, the EPSDT screening provisions but it 
also has to be modeled by what you provide to your State 
employees and the most prominent private health insurance plan 
in your State. Now, what taxpayers are objecting to is that in 
almost every instance we find that the Government programs, 
whether it be Medicaid or whether it be SCHIP, provide better 
benefits than the average taxpayer who is paying for those are 
able to buy in their own plans. Now, that is the consideration, 
and if you are not aware of that consideration, then you are 
not hearing what the public is saying on these issues.
    Let me address my remarks to Dr. Chapman, and Mr. Chairman, 
he is not only a doctor, he is a doctor two times over. He came 
to our community as an optometrist, practiced as an optometrist 
for a number of years, decided he wanted to take the next step 
up, went back to medical school and now came back and he is an 
ophthalmologist, a medical doctor and the president-elect of 
our State medical association, so he is indeed a fine member of 
our community.
    Let me draw some contrast though as to what we have heard 
in this hearing today. First of all, we heard in the first 
panel about the limitations on dental care, limitations that 
dealt with the available number of dentists out there, the 
reimbursement rates that are perhaps not what they should be, 
the number of dentists available in community health centers, 
et cetera. We have heard from Dr. Krol, who is saying that 
pediatricians need more money, that the plans don't pay enough. 
Children of course are perhaps the most mandated covered 
population group that we have in our country by virtue of all 
the Government programs that are out there. But let me contrast 
that with what Dr. Chapman is talking about. He is talking 
about in my community, which I am very proud and I appreciate 
him coming here to talk about it. My community, what happened 
to Diamonte Driver would never have happened in my community 
because it wasn't a question of whether or not he was Medicaid-
eligible. It wasn't a question of whether he was SCHIP-
eligible. He is talking about providing health care, dental and 
health care, without cost, without Government programs, without 
anything other than a medical and dental community and a 
community as a whole that is interested in providing these 
kinds of services. Now, there are impediments, first of all, 
with regard to the Hall County Health Access.
    Now, Dr. Chapman, if I am correct, this is what, in 
collaboration with the medical community and the hospital, you 
are attempting to provide people who come in and don't have a 
medical home, don't know where to go other than the emergency 
room, a way of getting them appointments with doctors, 
including specialists. Is that correct?
    Dr. Chapman. That is correct. The problem that a lot of the 
clinics have when they come, they get a few doctors that are 
really interested in going and providing the care, then they 
get in there with a patient and then the patient needs a 
gallbladder surgery or needs some kind of other extra care. 
They look around, there is nobody there. Now when they turn 
around, we have somebody there.
    Mr. Deal. Of those 150 physicians, I believe you have every 
specialty covered except maybe one. Is that right?
    Dr. Chapman. Yes, sir, we have them all covered.
    Mr. Deal. All right. You have them all covered. And then 
you mentioned the component of Good News Clinics. Now this once 
again is a totally free clinic. Is that correct?
    Dr. Chapman. It is totally free. That is correct.
    Mr. Deal. And it is staffed by both active physicians and 
active dentists as well as retired physicians and retired 
dentists make up their service providers. Is that correct?
    Dr. Chapman. That is correct.
    Mr. Deal. They don't receive any Federal money?
    Dr. Chapman. No Federal money.
    Mr. Deal. No State money?
    Dr. Chapman. No State money.
    Mr. Deal. They have community chest and local voluntary 
charities that provide support, churches, et cetera.
    Now, with regard to the first one, the Health Access where 
you have doctors who are willing to give their time free of 
charge, if you wanted to make a $10,000 contribution to that 
Health Access, you could write that off as a deduction, 
couldn't you?
    Dr. Chapman. That is correct.
    Mr. Deal. Can you write off your services that you provide 
free of charge in any form or fashion?
    Dr. Chapman. No, I cannot.
    Mr. Deal. Do you still have to provide malpractice 
insurance if you want to be covered?
    Dr. Chapman. I do.
    Mr. Deal. And the retired doctors and dentists in the Good 
News Clinic, they can't write off anything for their services, 
can they?
    Dr. Chapman. No, they cannot.
    Mr. Deal. And if they want liability protection, they have 
to pay for it out of their pocket. Is that right?
    Dr. Chapman. That is correct.
    Mr. Deal. Thank you, Mr. Chairman.
    Mr. Pallone. Mrs. Capps.
    Mrs. Capps. Thank you, Mr. Chairman.
    Dr. Krol, I want to make sure I have time to ask you a 
question further to explain about well-child visits and the 
importance of a medical home or primary provider. I am very 
interested in that.
    But I want to start, Ms. Koyanagi, with you to speak about 
community-based services which is also dear to my heart. I want 
to clarify something for the record. On the values of mental 
health coverage and private plans as compared to SCHIP, it is 
my understanding that Congress required when SCHIP was passed 
in 1997 to provide coverage equaling 75 percent of the value of 
mental health coverage offered in private plans that were used 
as the, quote, benchmark. Is that correct?
    Ms. Koyanagi. That is correct.
    Mrs. Capps. I want to make sure that is on the record. You 
talked about home- and community-based service for children 
with emotional and behavioral disorders. As one who spent a 
career in a school setting where a lot of this first comes to 
light and families are identified through the IEP process or 
screening process, the role of the endangered professional that 
I represent, which is a school nurse, that there are roles that 
are played there at that kind of place where all children come 
that then can be seen as part of the early diagnosis or 
assessment or picking up these kind of things to refer and also 
then some about the wraparound services that could be available 
to support a family with a mental health issue in a child.
    Ms. Koyanagi. That is correct. Schools in fact provide a 
significant amount of the mental health services that children 
receive and many children only receive mental health services 
through schools. So they are a very integral part of a 
community mental health network.
    Mrs. Capps. And are there ways that we can in Congress 
ensure that this continues or that we build the strength of one 
community-based and include the school base include the 
community base?
    Ms. Koyanagi. Well, there are many ways, yes. The 
integration of mental health services with school-based 
services is one way that the Substance Abuse and Mental Health 
Services Administration promotes. Medicaid could pay more 
effectively for school-based health services and mental health 
services. There are barriers there that could be eliminated 
that would make it easier for these services to be paid for 
within the schools.
    Mrs. Capps. And we could provide some incentives for that 
happening here in Congress because some of those barriers are 
Federal. Am I right?
    Ms. Koyanagi. Absolutely.
    Mrs. Capps. I know firsthand that when we can see the 
school and the community together as part of a referral and 
also a treatment facility, that I think it is a win-win. Am I 
correct?
    Ms. Koyanagi. Yes, that is correct.
    Mrs. Capps. Thank you.
    Dr. Krol, I also agree very much with your emphasis on the 
importance of regular well-child visits and the importance of a 
medical home or a health provider where multidisciplinary 
services could be centered. Can you explain about that? Should 
we have, for example, mental health services as a part of early 
periodic screening service and should mental health 
professionals be part of the medical home?
    Dr. Krol. There is no question that mental health should be 
a part of that. Just as we mentioned the mouth is part of the 
body, the brain is a part of the body as well. There is no way 
around that. And in fact, development and mental health issues 
in younger children is extremely important. I can tell you in 
my own community in Toledo, Ohio, we have been talking 
considerably about the issue of autism and about trying to find 
ways to get to kids earlier in life to help families deal with 
this, which for many families is an overwhelming diagnosis 
anywhere on that spectrum and trying to find ways to include 
that within our medical home, within the services that we 
provide as a pediatrician but also making the connection out 
into the community because we cannot do it all in our office. 
We have to depend on our colleagues in the community as well as 
in the school, and I think what you pointed out is a 
significant barrier sometimes to many communities is the 
connection to mental health services. So you are exactly right. 
Mental health should be a significant part of the medical home.
    Mrs. Capps. Some of the symptoms, speaking of autism, come 
about with the early toddler care programs, Head Start 
programs. It is when parents become aware that there is 
something that needs to be looked into further.
    Dr. Krol. You are exactly right, and in my office I depend 
a lot on what parents tell me. When a parent tells me that 
something is wrong with their child, I take that very seriously 
and I pursue that to the point where I feel comfortable and the 
family feels comfortable that there either is or isn't 
something wrong with their child and so making that a 
significant and important part of the services that EPSDT 
provides and the services that I provide as a pediatrician in a 
medical home are very important.
    Mrs. Capps. Thank you both very much. I yield back.
    Mr. Pallone. Thank you.
    Dr. Burgess.
    Mr. Burgess. Thank you again, Mr. Chairman.
    Dr. Krol, let me ask you, if I could, about the issue of 
medical devices in regard to children. Of course, adult 
populations' medical devices have achieved a good deal of 
success but as the late Dr. Benji Brooks down in Houston where 
I trained in medical school, the patron saint of pediatric 
surgery, used to drill on us in medical school that kids are 
different. They are not just little people. So as far as 
medical devices are concerned, we talk about things like 
shunts, stents and pacemakers and that sort of thing. They have 
to be designed specifically for children. Is that correct?
    Dr. Krol. That is entirely correct, and while I am a 
general pediatrician, I depend significantly upon my surgical 
colleagues and they bring that to me all the time, the issues 
that they face regarding trying to adapt adult devices to kids 
if they can possibly do that, and the fact is that you can't. 
They aren't little adults.
    Mr. Burgess. Well, has the American Academy of Pediatrics 
conducted a study to determine if there is an unmet need for 
pediatric devices and what that unmet need might be?
    Dr. Krol. I have to admit that I don't know for sure but I 
can definitely provide you with that information for your 
office. My thought is that we were looking into that 
considerably. We have surgical members of our academy that 
address these issues and face these issues all the time so I 
would not be surprised if our academy has addressed that but I 
don't know the specific policy that we have on it.
    Mr. Burgess. If you find it and you can make it available 
to the committee, that would be super.
    We of course hear a lot on this committee about things like 
health literacy, low health literacy, health disparities. So 
what steps can be taken to coordinate care and ensure that 
children or in this case the children's parents actually follow 
up and take the physician's advice and follow up on the care 
recommended by the physician and do their appropriate follow-up 
visits?
    Dr. Krol. Well, you pointed out one of the many significant 
barriers to quality health care for children is the 
communication that we have with the parents specifically and a 
lot of that has to do with the literacy level, not just health 
literacy but literacy in general. So trying to find ways to 
make information and some of this very technological 
information that is easy for me to talk with you about as 
physicians but to bring that to a level where a family can 
understand that and a family that may have a fifth-grade, 
sixth-grade, eighth-grade reading level is sometimes very 
difficult. So trying to find ways to make information available 
to these families in a way that they can digest it, understand 
it, feel informed about it, able to make competent decisions 
for their kids is extremely important. So finding any way where 
we can do that, we work very hard on trying to do that, not 
only on a health literacy level but also on a language level 
with families that speak different languages that come into our 
communities. It is a significant barrier to health care and 
also a significant barrier to quality. Making sure that what I 
am saying is what the family is hearing is very important.
    Mr. Burgess. And along the same lines of the medical 
devices, if you have information that any study that the 
American Academy of Pediatrics has done regarding levels of 
health literacy and levels of compliance, again I think the 
committee would be interested in that.
    In your testimony, you say that dollar for dollar, 
providing better health care for children represents one of the 
best returns on investment available and obviously we do have 
to be concerned about return on investment when we are talking 
about the taxpayer's dollar. So in a program like SCHIP, for 
example, that was specifically designed for children, has 
children as one of the capital letters in the acronym, would it 
not make sense to focus on providing care to children rather 
than providing care to adults in the SCHIP program?
    Dr. Krol. I can say this: As a pediatrician, taking care of 
a child is not just about taking care of the child. It is about 
taking care of the family that is taking care of that child. It 
is about an interaction and a relationship with the family. We 
can't pull the child away from that family and take care of 
them individually. When they leave my office, they go back to a 
home environment and go back to family members, siblings, aunts 
and uncles, grandmas and grandpas. We have to approach child 
health in some ways as family health, and as far as a specific 
benefit for parents, I will say that we can't ignore the fact 
that children live in families and they can't survive on their 
own without families, and the care that I provide includes care 
for families and not just children.
    Mr. Burgess. But again, as a dollar for dollar return on 
investment, a dollar invested in a child's health is going to 
go farther than a dollar invested in an adult's health. Is that 
a fair statement?
    Dr. Krol. I would say that yes, the money that is spent on 
children is definitely a great investment. I can't say that it 
is necessarily better or worse.
    Mr. Burgess. Well, if we need to develop other programs to 
take care of family members who are not children, I mean, it 
seems to go beyond the scope of the SCHIP program.
    Mr. Chairman, I am going to yield back but I do want to 
make one general commercial announcement. We are going to have 
our trauma bill up on the floor later today, and of course, as 
a shameless tie-in to the issue that is before us today, the 
leading cause of death for children over the age of 1-year is 
injury, specifically motor vehicle crashes, firearms and 
drownings, so our trauma bill that we are going to have on the 
floor today is extremely important and germane to this 
discussion.
    I will yield back.
    Mr. Pallone. Thank you. It is not a commercial announcement 
though, but thank you.
    That concludes our questions. I want to thank all of you 
for being here today and for bearing with us as we ask 
questions.
    I would just remind Members that you may submit additional 
questions for the record to be answered by the relevant 
witnesses and the questions should be submitted to the 
committee clerk within the next 10 days. The clerk will notify 
your offices of the procedure so obviously we may give you 
additional written questions and I hope you bear with us.
    Thank you very much, and without objection, this meeting of 
the subcommittee is adjourned.
    [Whereupon, at 1:10 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]

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Statement by Mark B. McClellan, M.D., Ph.D, Administrator, Centers for 
                      Medicare & Medicaid Services

    Questions have been raised about the new section 1937 of 
the Social Security Act (SSA) (as added by the Deficit 
Reduction Act of 2005) that permits states to provide Medicaid 
benefits to children through benchmark coverage or benchmark 
equivalent coverage. If a State chooses to exercise this 
option, the specific issue has been raised as to whether 
children under 19 will still be entitled to receive EPSDT 
benefits in addition to the benefits provided by the benchmark 
coverage or benchmark equivalent coverage. The short answer is: 
children under 19 will receive EPSDT benefits.
    After a careful review, including consultation with the 
Office of General Counsel, CMS has determined that children 
under 19 will still be entitled to receive EPSDT benefits if 
enrolled in benchmark coverage or benchmark equivalent coverage 
under the new section 1937. CMS will review each State plan 
amendment (SPA) submitted under the new section 1937 and will 
not approve any SPA that does not include the provision of 
EPSDT services for children under 19 as defined in section 
1905(r) of the SSA.
    In the case of children under the age of 19, new section 
1937 (a) (1) is clear that a state may exercise the option to 
provide Medicaid benefits through enrollment in coverage that 
at a minimum has two parts. The first part of the coverage will 
be benchmark coverage or benchmark equivalent coverage, as 
required by subsection (a) (1) (A) (i), and the second part of 
the coverage will be wrap-around coverage of EPDST services as 
defined in section 1905(r) of the SSA, as required by 
subsection (a) (1) (A) (ii). A State cannot exercise the option 
under section 1937 with respect to children under 19 if EPSDT 
services are not included in the total coverage provided to 
such children.
    Subparagraph (C) of section 1937 (a) (1) permits states to 
also add wrap-around or additional benefits. In the case of 
children under 19, wrap-around or additional benefits that a 
state could choose to provide under subparagraph (C) must be a 
benefit in addition to the benchmark coverage or benchmark 
equivalent coverage and the EPSDT services that the state is 
already required to provide under subparagraph (A) of that 
section. Subparagraph (C) does not in any way give a state the 
flexibility to fail to provide the EPSDT services required by 
subparagraph (A) (ii) of section 1937 (a) (1).
                              ----------                              


               The Secretary of Health and Human Services

    August 25, 2006

    The Honorable Joseph Barton
    Chairman
    Committee on Energy and Commerce
    House of Representatives
    Washington, DC 20515

    Dear Mr. Chairman:

     Thank you for your letter regarding the Deficit Reduction 
Act of 2005 (DRA) and congressional intent with regard to 
sections 6041 and 6044 of the DRA.
     Section 6041 of the DRA created a new section 1916A of the 
Social Security Act (the Act) in which States can choose 
alternative premiums and cost sharing for certain Medicaid 
beneficiaries. On June 16, 2006, we issued guidance to the 
States on cost sharing. As stated in that guidance, for persons 
with family income at or below 100 percent of the Federal 
poverty level, we plan to apply the limitations of section 1916 
of the ACT so that States may not impose alternative premiums 
and cost sharing under section 1916A for this group.
     Section 6044 of the DRA provides that States can choose to 
implement benefit flexibilities authorized by a newly created 
section 1937 of the Act. However, the statute prohibits States 
from requiring enrollment in an alternative benefit package for 
our most vulnerable populations; i.e., pregnant woman; certain 
low-income parents, adults, and children with disabilities; 
dual eligibles; certain other aged and disabled individuals in 
need of long-term care; and adults and children with special 
needs.
     Regarding Early and Periodic Screening, Diagnostic, and 
Treatment (EPSDT) services, our guidance to States issued on 
March 31, 2006, makes it clear that States that choose to offer 
benchmark plans must provide EPSDT to all eligible children.
     I look forward to working with you to improve health care 
for our most vulnerable populations and to implement these 
critical DRA provisions. Please call me if you have further 
concerns or questions. I will also provide this response to the 
cosigner of your letter.

    Sincerely,


    Michael O. Leavitt
    Secretary