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