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

                           OF DEAMONTE DRIVER



                               before the


                                 of the

                         COMMITTEE ON OVERSIGHT
                         AND GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION


                           FEBRUARY 14, 2008


                           Serial No. 110-164


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

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

                    Subcommittee on Domestic Policy

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

                            C O N T E N T S

Hearing held on February 14, 2008................................     1
Statement of:
    Smith, Dennis, director, Center for Medicaid and State 
      Operations; Dr. Jim Crall, director, Oral Health Policy 
      Center, professor and Chair, Section of Pediatric 
      Dentistry; and Dr. Burton Edelstein, founding Chair, 
      Children's Dental Health Project, professor and Chair, 
      Social and Behavioral Sciences, Columbia University College 
      of Dental Medicine.........................................    16
        Crall, Dr. Jim...........................................    30
        Edelstein, Dr. Burton....................................    45
        Smith, Dennis............................................    16
Letters, statements, etc., submitted for the record by:
    Crall, Dr. Jim, director, Oral Health Policy Center, 
      professor and Chair, Section of Pediatric Dentistry, 
      prepared statement of......................................    34
    Cummings, Hon. Elijah E., a Representative in Congress from 
      the State of Maryland, prepared statement of...............   100
    Edelstein, Dr. Burton, founding Chair, Children's Dental 
      Health Project, professor and Chair, Social and Behavioral 
      Sciences, Columbia University College of Dental Medicine, 
      prepared statement of......................................    47
    Kucinich, Hon. Dennis J., a Representative in Congress from 
      the State of Ohio:
        Letter dated October 2, 2007.............................    54
        Prepared statement of....................................     6
        Various letters..........................................    60
    Smith, Dennis, director, Center for Medicaid and State 
      Operations, prepared statement of..........................    19
    Watson, Hon. Diane E., a Representative in Congress from the 
      State of California, prepared statement of.................    28

                           OF DEAMONTE DRIVER


                      THURSDAY, FEBRUARY 14, 2008

                  House of Representatives,
                   Subcommittee on Domestic Policy,
              Committee on Oversight and Government Reform,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 3:15 p.m., in 
room 2154, Rayburn House Office Building, Hon. Dennis J. 
Kucinich (chairman of the subcommittee) presiding.
    Present: Representatives Kucinich, Cummings, Watson, Issa, 
and Shays.
    Staff present: Noura Erakat, counsel; Jean Gosa, clerk; 
Emily Jagger, intern; and Vic Edgerton, legislative director, 
Office of Congressman Dennis J. Kucinich.
    Mr. Kucinich. The subcommittee will come to order.
    Just for the attention of those who are in the audience and 
those who are here to testify, the House is in session right 
now. We have a series of votes. There has been a brief 
interruption for a motion of personal privilege. That 
discussion could go on for a while.
    So in the interest of expediting this hearing and 
respecting the schedules of the witnesses, I have come here to 
start the hearing. At some point my colleague, Mr. Issa, will 
join us. I want to proceed right now, though, given the hour 
and the fact that the House will be finished when it completes 
this series of votes. I just want to make sure that we respect 
your time.
    This is the Domestic Policy Subcommittee of the Oversight 
and Government Reform Committee, a hearing on Reform of Dental 
Care in Medicaid.
    [Slide shown.]
    Mr. Kucinich. One year ago, a 12-year-old boy, Deamonte 
Driver, died of a brain infection caused by an untreated tooth 
decay. Deamonte lived in Prince George's County, Maryland, and 
was eligible for Medicaid, but he hadn't seen a dentist in more 
than 4 years.
    In May 2007, my subcommittee held a hearing to examine the 
circumstances that led to Deamonte's preventable death. Today 
we will examine what corrective actions the Center for Medicaid 
and State Operations [CMS], has taken since Deamonte's death to 
reform the pediatric dental program for Medicaid-eligible 
    During our hearing last May, we learned that Deamonte's 
mother, Alyce Driver, tried to obtain oral health services for 
her son and his brothers. But there was a problem: there were 
no dentists available for her Medicaid-eligible children 
enrolled by United HealthCare Co. [United]. According to Laurie 
Norris, the Driver family lawyer and a witness at last year's 
hearing, ``it took one mother, one lawyer, one help line 
supervisor, and three case management professionals to make a 
dental appointment for one Medicaid child.''
    After the hearing, I instructed my subcommittee staff to 
investigate the adequacy of the dental provider network 
available to Medicaid-eligible children enrolled in the same 
managed care company that was responsible for Deamonte.
    My subcommittee investigated United's dental network and 
records of claims submitted for services rendered to United 
beneficiary children in 2006. Our staff found that Deamonte was 
far from the only child in Maryland who hadn't seen a dentist 
in 4 or more consecutive years. In fact, nearly 11,000 Maryland 
children enrolled in United had not seen a dentist in four or 
more consecutive years, putting them in the same precarious 
position that Deamonte was at the time of his death.
    The investigation also revealed that United's dental 
provider network was not nearly as robust as they had claimed. 
We discovered that 55 percent of all dental services rendered 
in 2006 in the county where Deamonte resided were conducted by 
only seven dentists. We also discovered that 19 of the dentists 
listed in the dental provider network in the county provided 
zero services to Medicaid-eligible children in 2006.
    United has concurred with all of the subcommittee's 
findings and they are cooperating with the subcommittee's 
broader investigation as well.
    There is no dispute that Federal law, specifically Section 
1902 of the Social Security Act, mandates that Medicaid-
eligible children are entitled to routine dental services and 
any necessary treatment on a periodic basis. Why, then, were 
there no dentists available to deliver that care to Deamonte? 
More importantly, why didn't CMS, the Federal agency 
responsible for administering Medicaid, do something about it?
    At our hearing last May, we asked Mr. Dennis Smith, the 
Director of CMS, that question. We asked him why he did not 
take any action in Maryland after he learned that only 24 
percent of its children got any dental care in 2004, and he 
responded. And I think some of you are familiar with the 
quotes, but here they are.
    [Slide shown.]
    Mr. Kucinich. ``The enforcement tools . . . are to sanction 
the State financially. . . . I have not sanctioned States for 
the access issue in dental care.''
    [Slide shown.]
    Mr. Kucinich. He went on to say: ``Enforcement is about 
taking financial penalties against states.''
    But financial sanctions are absolutely not the only 
enforcement tools available to CMS. The Director of CMS has 
many enforcement tools available to him, and in a May 17, 2007 
letter that Congressman Cummings of Maryland and I sent to Mr. 
Smith, we enumerated just a few of them.
    [Slide shown.]
    Mr. Kucinich. We suggested that CMS--and these are our 
suggestions: Conduct a critical incident review of Deamonte 
Driver's death; make children's access to dental care a CMS 
enforcement priority and communicate this priority to all 
States; establish a standard or goal for the percentage of 
eligible children to receive preventive dental services; 
improve current reporting requirements, namely, make the CMS 
416 forms more reliable and accurate; identify the poorest 
performing States and assess why those States are performing 
poorly and suggest ways they can improve their performance; 
rank the States in order of performance vis-a-vis the provision 
of dental care; ensure that administrators of Medicaid programs 
have ready access to the policy guidance they need in order to 
cover children's dental services with respect to reimbursement 
rates and managed care oversight; issue a letter to State 
Medicaid directors reminding them of their legal obligations 
and ask them to submit plans of action for ensuring that 
children will have adequate access to dental services; assess 
civil money penalties against any managed care organization 
that has contracted with a Medicaid agency and has failed to do 
    What a difference a year makes. Since our hearing, Medicaid 
has indeed used several tools to enforce Federal law. We will 
learn about some of these actions today.
    But time doesn't heal all wounds. In important ways, 
Medicaid still hasn't learned the most important lessons from 
the preventable death of Deamonte Driver.
    According to experts, one of the most important things that 
CMS can do is address the issue of reimbursement rates at a 
national policy level.
    In 2000, CMS contracted with the American Association of 
Pediatric Dentists [AAPD] to draft a Guide to Children's Dental 
Care in Medicaid. This contract stipulated that the Guide was 
to provide policy guidance to the State Medicaid agencies about 
implementing and managing Medicaid's Early and Periodic 
Screening, Diagnostic, and Treatment [EPSDT] system.
    [Slide shown.]
    Mr. Kucinich. The AAPD submitted the completed Guide to CMS 
in 2001. However, CMS did not publish it until 2004, and when 
it finally did publish it, under the authority and leadership 
of Mr. Smith, the entire policy section on reimbursement rates 
and managed care oversight was redacted.
    [Slide shown.]
    Mr. Kucinich. Now, I don't understand why Mr. Smith would 
do that, when, at our hearing last year, he himself said, ``The 
key to improving access principally from the provider 
perspective is to increase reimbursement rates.''
    Clearly, Mr. Smith understands the nature of the problem, 
as well as a cornerstone to its solution. Yet, as Director of 
CMS, we have not seen sufficient evidence that he would use his 
understanding to solve that problem or, at the very least, to 
improve it.
    In our letter to him, Mr. Cummings and I urged Mr. Smith to 
revise the Guide and incorporate information relating to 
provider reimbursement and managed care oversight that was 
edited out of the 2004 version. Alternatively, we asked him to 
send a State Medicaid Director letter that provided this 
critical policy information.
    [Slide shown.]
    Mr. Kucinich. We have not received cooperation on our 
request. Mr. Smith explained, in slide 7: ``States have ready 
access to all Medicaid policy on reimbursement and managed care 
oversight through existing Federal publications and 
documents.'' That answer that we received is not acceptable.
    In Georgia, that information was available when its three 
managed care organizations cut their reimbursement rates and 
limited their dental services in 2006. That was a profit-
boosting move on their part. In Maryland, that information was 
available when Deamonte died of a brain infection caused by 
untreated tooth decay.
    In the District of Columbia, Virginia, and 20 other States, 
that information has been available as Small Smiles--an 
abusive, possibly criminal, multi-State dental provider--preys 
on Medicaid-eligible children to generate a profit. Because 
inadequate reimbursement rates are often insufficient to cover 
even an honest dentist's costs, Small Smiles conceived of 
another way to make a profit: a predatory mill where multiple, 
sometimes unnecessary, procedures are imposed, assembly-line 
style, on children with little regard for their welfare or 
proper dental practice.
    Small Smiles routinely barred parents from their children's 
side during dental procedures, and in separate instances 
performed more than a dozen root canals on a child's baby 
teeth, and, in Arizona, fatally overdosed a child with 
anesthesia. While CMS certainly doesn't condone these 
unscrupulous and horrific practices, the silence on 
reimbursement rates creates economic incentives for these kind 
of practices to flourish.
    CMS's role as Federal administrator of Medicaid is not just 
to have information available, but to make sure that the States 
have and use that information and comply with Federal law.
    Prior to Mr. Smith's taking the reins at CMS, the former 
CMS director understood this concept and issued a State 
Medicaid Director letter requesting information on State 
efforts to ensure children's access to dental services under 
Medicaid. The letter indicated that CMS would undertake 
intensive oversight of States whose dental utilization rates, 
as indicated on the CMS-416 annual reports, were below 30 
percent, including site visits by regional office staff.
    States with utilization rates between 30 and 50 percent 
would be subject to somewhat less stringent review. All States 
were asked to submit ``Plans of Action'' detailing how they 
would improve access to oral health care within 3 years. The 
letter not only sent a message to States that oral health was a 
Medicaid priority but, that as a provider of half of the 
States' Medicaid budgets, CMS was monitoring their performance 
    Significantly, Maryland was among the States with 
utilization rates below 30 percent. But between 2001, when 
Maryland submitted the information to CMS, and February 2007, 
when Deamonte died, CMS, under the leadership of Mr. Smith, 
hasn't done anything to followup with these poorest performing 
    The new administration in Maryland under Governor O'Malley 
has laudably taken initiative since Deamonte Driver's death. 
Maryland's Medicaid Administration has taken a number of 
significant actions. They did that on their own in light of all 
the local attention Deamonte's tragic death earned. But what 
has CMS done nationally, in other States besides Maryland, to 
prevent the situation that led to Deamonte's death? Today we 
are going to find out.
    [The prepared statement of Hon. Dennis J. Kucinich 


    Mr. Kucinich. With that, I am going to go and vote. I will 
be back and we will continue the hearing.
    Mr. Kucinich. The committee will resume.
    Mr. Smith, Dr. Crall, Dr. Edelstein, thank you for being 
here. I ask that you proceed. Thank you.


                   STATEMENT OF DENNIS SMITH

    Mr. Smith. Thank you, Mr. Chairman. I am happy to be with 
you again this afternoon. I will be very brief. We have a 
statement for the record, so I won't go through all of the 
detail that we have provided in terms of the steps that we have 
taken since the subcommittee hearing in may of 2007.
    In the President's budget that came out last week, Medicaid 
spending, Federal and State combined, is estimated to exceed 
$347 billion in fiscal year 2009, $2 trillion over the next 5 
years, $5 trillion over the next 10 years. Total Medicaid 
spending on children will exceed $400 billion over the next 5 
and $1 trillion over 10, which is approximately 20 percent of 
Medicaid's spending on children. We serve more than 29 million 
children in Medicaid. In 2009, the estimated per capita cost 
for a child for a full year on Medicaid is nearly $2,900.
    Medicaid is directly administered by the States. States 
enroll providers at reimbursement rates and negotiate managed 
care contracts. Medicaid is a matching program; Federal dollars 
follow State dollars. In general, we do not have separate 
authority to make direct grants to States for different 
activities, although Congress has periodically created specific 
grant programs, such as the Medicaid Transformation Grants 
under the Deficit Reduction Act of 2005, and the Real System 
Change Grants previous to that.
    In terms of our response to the issues in Maryland 
specifically, as you are aware, we did perform a focused review 
of Maryland dental services that we began in October of last 
year. We have completed that review and submitted that to the 
subcommittee for its review. In general, CMS found that 
although Maryland took steps in 2007 to hold managed care 
organizations responsible for providing dental services, 
additional accountability and oversight was needed. The draft 
findings were issued on November 28th of last year, which 
included six findings and recommendations for the State to 
respond to.
    Those recommendations centered on ensuring the individual 
that information provided to beneficiaries on accessing dental 
services was easy to find and culturally appropriate; 
establishing an internal service to independently verify MCO 
dental provider directories; instructing MCOs to track and 
report on children not receiving dental services and to 
escalate steps to reach such children; documenting the oral 
health needs of special needs children and the adequacy of 
dental specialists to meet their needs; requiring MCOs to 
monitor and report on dental provider utilization; and 
conducting appropriate reviews to determine the need to 
initiate appropriate corrective actions, including sanctions, 
against any MCO not meeting its contractual obligations.
    In particular to the quote from the May hearing, I am 
concerned that the quote left the impression that we would not 
pursue sanctions. I want to assure you that we had--my 
recollection is--a general discussion, conversation with Mr. 
Waxman about it. If I gave the impression that we were taking 
sanctions off the table, I certainly did not mean to give that 
impression. We specifically raised the issue of sanctions in 
particular on the MCOs with Maryland and Maryland specifically 
needed to address whether or not sanctions needed to be taken. 
Maryland ultimately recommended that sanctions not be taken in 
the corrective actions of the MCOs in general and the work of 
the Dental Action Committee.
    Maryland formed a Dental Action Committee last June with a 
broad variety of community leaders. I understand that Dental 
Action Committee has submitted a report to the Maryland General 
Assembly, which is ultimately responsible for providing the 
necessary funding to support the recommendations for increased 
    We will not be stopping with our work in Maryland. Although 
we have seen progress in the utilization of dental care for 
children in Medicaid, in 1996 only one in five children in 
families with income below 200 percent of the Federal poverty 
level had a dental visit the previous year. Our current CMS 
Form 416 data for 2006 showed that one in three individuals 
under age 21 received a dental service. That is an increase of 
10 percent over 2003, 22 percent increase from 2000. But we 
agree that, certainly, further progress is needed.
    In that respect, in our oversight role, we began a series 
of EPSDT dental reviews this week that will occur in 15 States 
between now and early April. CMS Central Office and Regional 
Office Staff----
    Mr. Kucinich. Mr. Smith, excuse me. I am sorry to interrupt 
your testimony, but since we have been joined by our ranking 
member, Mr. Issa, and since his presence now makes this an 
official meeting, what I would like to do is to ask you and all 
the others to stand and be sworn. You continue with your 
testimony and then if Mr. Issa has anything after Mr. Smith is 
complete, we will ask Mr. Issa to enter his statement.
    So would you raise your right hands?
    [Witnesses sworn.]
    Mr. Kucinich. Let the record show that the witnesses have 
answered in the affirmative. I thank you for your cooperation.
    You may proceed, Mr. Smith.
    And I thank Mr. Issa for his presence here.
    Mr. Issa. Thank you. And I apologize for not being here 
    Mr. Kucinich. Listen, we are both in a tight schedule 
today, so it means a lot that you are here.
    Mr. Smith, you will proceed. Then I will come back to Mr. 
Issa and then the other two witnesses. Go ahead.
    Mr. Smith. Thank you, Mr. Chairman.
    As I just mentioned, we began a review that will occur 
between now and early April for 15 States. We have developed, 
and staff in the central office and the regional offices have 
now been trained, on a dental review protocol that will be used 
to assess States in seven key areas: informing families, 
periodicity schedules and inter-periodic services; access to 
dental services; diagnosis and treatment services; support 
services; coordination of care; and data collection, analysis, 
and reporting. These 15 States have been identified and, as I 
said, we began this week and we expect to issue final reports 
to the States during the summer.
    In my testimony, I have a list of a number of activities 
that we have undertaken. I won't go through all of those now, 
but they, I believe, demonstrate that we have taken action on 
the area of dental access and I believe that we have engaged 
the States appropriately in improving services to children, 
improving access to the dental care.
    We believe that we have expanded both the use of the dental 
services among children and our ability to report on that 
progress, and this is an area that we often find ourselves in 
terms of gaps and information in our reporting systems. We are 
not always able to provide the data that policymakers and the 
subcommittee would like to have, and I have personally 
expressed my frustration many times on our ability to be able 
to report timely, accurately, and in the various different ways 
that we would want to to be able to measure the real progress 
that we have taken.
    I also, in terms of being able to respond to--the chairman 
raised an issue of practices that we have now seen in terms of 
inappropriate care of children, providing care that is not 
medically necessary and, in fact, may in fact lead to 
detrimental impact on children's health. We are very much aware 
of those and we are participating in those reviews, and I 
assure you that our program integrity group, in cooperation 
with Medicaid fraud control units and the Department of Justice 
are participating in those reviews.
    Thank you again for inviting me this afternoon.
    [The prepared statement of Mr. Smith follows:]


    Mr. Kucinich. Thank you very much, Mr. Smith. I appreciate 
your presence here and your willingness to cooperate with us. 
Thank you.
    Mr. Issa.
    Mr. Issa. Thank you, Mr. Chairman. Once again, I would like 
to apologize for the overlapping schedule of multiple 
committees. Mr. Chairman, I want to personally thank you for 
doing what this committee should do, which is to hold hearings, 
shed light on a problem that exists, particularly within 
Government-managed programs, and then give Government 
management an opportunity to work on those problems, and last, 
as today, to come back and tell us what they have done to see 
whether or not we need to address it further.
    Certainly, I think that this will not be the last visit on 
health care, Government-sponsored health care before this 
committee. I am confident that as we seek to deal with the 
problems not just of S-CHIP and other Federal programs, but the 
broader problem of health care availability in this country 
and, as Mr. Smith said,--and I couldn't agree with you more--
the fact that under-medication and over-medication can occur 
separate from whether or not there is insurance. These problems 
and more need the constant attention of professionals at the 
front line and then periodic review by this committee and 
    So I want to thank the chairman for bringing this up today. 
This is an issue that we are both passionate about. We both, 
sadly enough, are Clevelanders and come from an area that today 
is suddenly in greater need of these kinds of services and 
    So with that, Mr. Chairman, I would ask unanimous consent 
to put my entire opening statement in the record and go on to 
the rest of the hearing.
    Mr. Kucinich. I appreciate that. I look forward to having 
your entire statement in the record. And, again, the Chair 
wants to state how much I appreciate our working partnership 
here in the public interest. Thank you.
    Before we move on, does the gentlelady from California have 
anything that she wants to say?
    Ms. Watson. I want to thank the chairman for holding this 
important hearing on reforming the pediatric dental program for 
Medicaid-eligible children.
    In 2007, the subcommittee held a hearing on the unfortunate 
death of Deamonte Driver, a 12-year-old boy from Prince 
George's County, Maryland, who died of a brain infection caused 
by tooth decay. Deamonte's death shines light on our Nation's 
Medicaid program that has become increasingly unglued due to 
the fact that fewer and fewer dentists are willing to take 
Medicaid patients. As noted in the 2007 hearing, Prince 
George's County has approximately 45,00 to 50,000 child 
Medicaid participants, some 200 dental offices that are listed 
as Medicaid providers. But, in reality, only 25 percent, or 50 
offices actually see child Medicaid patients. The ratio of 
patients to providers is obviously unacceptable.
    It pleases me that the subcommittee has continued its 
oversight of the Center for Medicaid and State Operations since 
the 2007 hearing and has provided the members of the 
subcommittee with a brief update on its ongoing investigation. 
The committee memorandum notes, quite disturbingly, ``On 
October 2nd, 2007, the subcommittee issued its review of 
United's documents and revealed that nearly 11,000 Maryland 
children enrolled in the United had not seen a dentist in four 
or more consecutive years, putting them in the same precarious 
position that Deamonte was in at the time of his death.''
    The review also revealed that United Health Group 
Companies, the health company that manages the CMS program, 
dental provider network was not nearly as robust as they had 
claimed. Fifty-five percent of all dental services rendered in 
2006 in the country were conducted by only seven dentists.
    So, Mr. Chairman, we see, in 1 year, that the basic 
situation has not changed that much. Thousands of children in 
Maryland alone--and undoubtedly hundreds of thousands of 
children across the Nation--are in danger of having their 
health systems seriously compromised at a young age due to lack 
of access to dental care. So I look forward to the hearing and 
to hearing from the witnesses as to how we go about fixing a 
serious problem that will have health consequences for many of 
these same children who reach adulthood decades later. The age-
old adage by Ben Franklin ``an ounce of prevention is worth a 
pound of cure'' is certainly applicable to the situation we 
have before us today. So thank you so very much.
    [The prepared statement of Hon. Diane E. Watson follows:]


    Mr. Kucinich. I want to thank the gentlelady from 
California for her participation and let you know that Mr. 
Smith had already given his testimony when Mr. Issa arrived. 
Out of fairness, I wanted to make sure that you had a chance to 
submit your statement, and you have, and I am grateful for 
    We are going to proceed with Dr. Crall, and you are welcome 
to stay as long as you would like, of course.
    Dr. Crall, you may proceed, and thank you.

                   STATEMENT OF DR. JIM CRALL

    Dr. Crall. Thank you, Mr. Chairman and members of the 
subcommittee for the opportunity to participate. My testimony 
is organized into three sections corresponding to requests in 
your letter of February 4, 2008.
    I will begin with a quick overview of the significance of 
oral health to overall health, which has been extensively 
documented in scientific publications, governmental reports, 
including the Surgeon General's Report on Oral Health.
    Oral diseases and developmental disturbances are common 
afflictions for children and adults. Tooth decay, often 
referred to as dental caries, is the most common chronic 
disease of childhood. Over 50 percent of U.S. children 
experience tooth decay by the time they enter kindergarten and 
nearly 80 percent by late adolescence. Children covered by 
Medicaid and other public programs acquire this disease early 
in life, have higher rates of caries and more severe forms of 
the disease and greater unmet treatment needs. The early onset 
of caries, especially in low-income children, underscores the 
importance of providing ongoing dental care and what we refer 
to as a dental home beginning early, that is, by age one.
    Gingivitis, inflammation of the gums, also common in 
children, can progress to periodontal disease, which is an 
inflammatory disease that destroys bone and spreads infection. 
Infants, children, and adults also experience a wide variety of 
developmental abnormalities, such as cleft lip and cleft palate 
and abnormal formation of teeth and jaws. Also, in adults, oral 
and pharyngeal cancers are relatively common.
    The consequences of oral diseases and development 
disturbances can be profound for overall health and quality of 
life. The infectious disease that causes tooth decay can spread 
to the bloodstream and lymph system. These infections cause 
pain, swelling, loosening of teeth, and can spread to other 
areas of the body, such as the brain, heart, and lungs; and 
they can trigger serious co-morbidities. The death of Deamonte 
Driver is a tragic reminder of the potential consequences of 
untreated tooth decay. Periodontal disease is also caused by 
bacteria that can spread throughout the body and has been 
associated with a variety of conditions, including 
cardiovascular disease, type 2 diabetes, adverse pregnancy 
outcomes, pneumonia, and osteoporosis. Developmental 
disturbances such as cleft lip and cleft palate and oral 
cancers have obvious impacts on individuals' ability to speak, 
eat, their appearance, self-esteem, and social interactions, as 
can tooth decay and periodontal disease, especially for 
individuals of low, socio-economic status.
    The messages of the Surgeon General's Report on Oral Health 
have not been effectively translated into public policy or 
public programs. Despite Federal EPSDT statutes, access to 
dental services for children covered by Medicaid remains a 
significant chronic problem. Most States and Medicare do not 
coverage for basic restorative dental services for adults. 
Failure to implement the Surgeon General's findings in public 
programs via legislative authority and appropriations, 
regulatory oversight, and effective program implementation 
remains a significant detriment to overall health and quality 
of life for millions of U.S. children and adults.
    Next, I would like to turn to the importance of 
reimbursement rates to ensuring access to dental care among 
Medicaid beneficiary children. Regular dental care is one of 
three key elements considered to be central to sustaining good 
oral care. The other two have to do with dietary practices and 
what we call oral hygiene or self-care routines. Access to 
ongoing dental care is especially important for children at 
elevated risk for common dental diseases, that is, children in 
low-income families and children with special health care needs 
who generally are covered by Medicaid.
    Reimbursement that is sufficient to engage in adequate 
number of dental professionals having the knowledge and skills 
to meet the full range of dental care needs of Medicaid 
children is fundamental to ensuring access and sustaining good 
oral health. Approximately 24 million children were enrolled in 
Medicaid each month in 2007. Providing access to ongoing dental 
services for this large number of children requires that a very 
substantial number of private sector dentists--who provide over 
90 percent of dental services--as well as public sector--often 
referred to as safety-net dentists--be engaged as Medicaid 
participating providers in each State.
    Could I have the first slide, please?
    [Slide shown.]
    Dr. Crall. Studies conducted by Federal agencies report 
that inadequate reimbursement is the most significant reason 
why dentists do not participate in Medicaid. GAO reports note 
that Medicaid payment rates often are well below dentists' 
prevailing fees and that, as expected, payment rates closer to 
dentists' full charges appear to result in improvement in 
service use.
    [Slide shown.]
    Dr. Crall. This slide shows trends in total U.S. dental 
expenditures and Medicaid dental expenditures following 
enactment of Federal Medicaid legislation in 1965. The dark 
blue line depicts total U.S. spending on dental services. The 
yellow line represents aggregate public expenditures for dental 
services, largely Medicaid.
    With a few recent exceptions, chronic under-funding over a 
period of several decades has translated into reimbursement 
rates that provide limited or no financial incentives for most 
dentists to participate as Medicaid providers in most States.
    Medicaid programs frequently base reimbursement schedules 
on a fundamentally flawed application of the concept of usual, 
customary, and reasonable fees, which does not provide a valid 
reflection of market-based dental fees for several reasons, 
which are detailed in my written testimony. Moreover, most 
Medicaid programs have no provisions for updating fee 
structures on a regular basis for inflation.
    And if I could have the next slide.
    [Slide shown.]
    Dr. Crall. This slide illustrates a 50 percent loss in 
purchasing power over a 14-year period. Unfortunately, it is an 
interval which is not uncommon for Medicaid rate adjustments in 
many States, with a 5 percent annual inflation rate.
    [Slide shown.]
    Dr. Crall. Next slide shows the effects of applying 
discounts of 17 percent or 35 percent to dentists' average 
charges. The results are reimbursement rates that are below, 
and often substantially below, the usual charges of 75 percent 
to 90 percent of dentists. And, beyond that, discounts of over 
50 percent off of average charges are not uncommon in State 
Medicaid programs.
    Next slide, please.
    [Slide shown.]
    Dr. Crall. Beginning in the late 1990's, following a series 
of oral health policy academies organized by the National 
Governors Association, several States moved to increase 
Medicaid reimbursement rates to levels consistent with market-
based approach. As the GAO noted, Medicaid payments that 
approximate prevailing private sector market fees did result in 
substantial increases in dentists' participation in Medicaid, 
as shown on this slide.
    [Slide shown.]
    Dr. Crall. More directly to the point, the next slide shows 
data from CMS 416 reports illustrating substantial increases in 
utilization in five States subsequent to rate increases that 
approach market-base levels.
    [Slide shown.]
    Dr. Crall. And my final slide provides a comparison of one 
State's Medicaid payment rates for illustration. This State's 
Medicaid program paid $18.08 for a periodic examination, an 
amount that only 2 percent of dentists in this State would see 
as equal to or greater than their current charges. It is the 
second percentile of fees.
    Of particular note, for 9 of the 15 selected procedures on 
this slide, the respective Medicaid payment rates are less than 
the usual charges reported by any dentist in this State. They 
are less than the first percentile of fees. From an economic 
perspective, these payment levels would not provide adequate 
incentives for dentists to participate in Medicaid.
    Finally, I was asked to comment on CMS's redaction of the 
section on policy guidance relating to provider reimbursement 
and managed care oversight in the Guide to Children's Dental 
Care in Medicaid that I authored for the American Academy of 
Pediatric Dentistry. I will just point out that the entire 
section of the document that AAPD submitted to what was then 
HCFA, now CMS, on program financing and payments, Section C in 
the submitted table of contents, was deleted from the published 
version of the Guide. That material primarily related to the 
previous statements on reimbursement.
    Additional information was provided in the redacted 
sections on relevant actuarial studies, which showed that 
roughly $14 to $17 in 1998 or 1999 dollars per enrolled 
beneficiary, often referred to as PMPM, would be necessary to 
pay for dental services for children enrolled in Medicaid at 
market rates comparable to those used by commercial dental 
benefit plans for employer-sponsored groups, or $17 to $20 PMPM 
for administering a Medicaid dental benefits program.
    This information was included to provide a guide or 
benchmarks that State Medicaid programs could use to assess 
their current allocation levels for dental benefits for 
children enrolled in Medicaid. Available information suggests 
that many States allocate only a small fraction of the 
financial resources suggested by these actuarial studies. Some 
were on the order of $5 to $7 per child per month.
    Other sections that were redacted included information on a 
number of topics that have potential relevance to the program 
administration and managed care organizations, such as 
legislative and regulatory requirements; basic program 
requirements; screenings and referrals for diagnosis and 
treatment; reimbursement for behavior management; integration 
of dental services and EPSDT screening services; continuity of 
care and case management; and contracts, development, and 
    Two appendices on actuarial estimates and a document 
developed by a joint HCFA-HRSA-supported Maternal and Child 
Health Technical Advisory Group on Policy Issues in the 
Delivery of Dental Services to Medicaid Children and Their 
Families also were not included.
    These sections were included in the version submitted by 
AAPD because, at the time, information on these topics, as well 
as differences between how medical and dental benefits are 
organized and financed, were not well known or understood by 
State policymakers, especially those who are not dental 
professionals. This information could have helped State 
officials understand important aspects of the dental care 
delivery system and how it relates to Medicaid policies, 
especially in the absence of regulations corresponding to 
changes made in OBRA 1989 that were never carried out.
    Thank you, Mr. Chairman.
    [The prepared statement of Dr. Crall follows:]


    Mr. Kucinich. I thank the gentleman.
    Dr. Edelstein, thank you. Proceed.


    Dr. Edelstein. Mr. Chairman and members of the 
subcommittee, I appreciate the opportunity to address the issue 
of children's dental services in Medicaid.
    In my role now as a professor of health policy, I teach my 
students that public policymaking is that process that you 
folks exercise in allocating resources to competing interests, 
and we can't help but note how poorly dental tends to fare in 
that competitive arena. We observe that it not only fares 
poorly, but, objectively, it fares poorly in that only one in 
three children now is obtaining dental services in Medicaid, 
contrasted with nearly two in three in commercial coverage.
    And, yes, I do appreciate that there has been a significant 
increase since so many of us committed so much effort, starting 
in 1998, to improve the proportion of children who do receive 
care in Medicare, but the assertion that it has come as a 
result of CMS action, that CMS has been able to expand dental 
services is one that I hope I will have an opportunity to 
discuss during the question period.
    We also recognize that CMS has many options available to it 
to improve the situation, and I would suggest that there are 
three such options: exercising leadership, providing technical 
assistance, and holding States accountable to required 
    When we look at dental care in Medicaid, my students and I 
can't help but notice how little, how infrequent, and how 
inadequate are those Federal efforts to ensure that children 
have the basic coverage that they need for their essential 
growth, health, and function. Most surprising has been the 
paucity of new action in this last year, given that it is 
almost now the first anniversary of Deamonte Driver's death.
    As a consultant to the Department of Health and Human 
Services from 1998 to 2000, I came to know the dental Medicaid 
through a formal HRSA-CMS dental access initiative. Under the 
two prior national Medicaid directors, a 10-year vacancy in the 
CMS chief dental officer position was filled, and it was filled 
with a person who had direct reporting authority to the 
Medicaid director, a place that no longer is true; a joint 
technical advisory group [TAG], was formed; the regional office 
capacities to assist the States was bolstered; CMS and HRSA 
joined forces with the Governors Association and the National 
Conference of State Legislatures to work with the States; CMS 
funded demonstrations in prevention that proved that you could 
have better outcomes at lower costs; the Medicaid Guide was 
commissioned; the 416 Report was strengthened; States were 
required to report to CMS on their efforts. A variety of things 
were done and, as we now know, not one of these efforts was 
followed through in the last 7 years, until the recent 
announcement of the reinstitution of the TAG and the 
reinstitution of the focused reviews.
    However, before coming to my consultancy with Government, I 
was a participating pediatric dentist, a clinician, and it was 
in that role that I personally came to understand this 
poisonous mix of low payment and unnecessarily burdensome 
administration. Parents continue to struggle to find 
participating providers. Yet, my practice experience with 
another governmental program, the Tricare program for children 
who are military dependents, is very different, and it shows 
that when Government does seek to truly provide dental 
services, it can find a way.
    Now, I understand that Medicaid kids are a different 
population than are the dependent children in the military, but 
the programs function so differently that I think it is telling 
about differences in priorities and commitments that the 
government has to these two different groups of children.
    So, in brief, I would suggest there are three things that 
CMS could be doing now that would make a significant difference 
and continue to move us toward the two in three children 
receiving dental services instead of the one in three.
    First, CMS could exercise definitive leadership. CMS could 
assure that the CMS staff, the staff in all of the regional 
offices, the State Medicaid directors all know that dental care 
is not only required under EPSDT, but is a priority of the 
administration. It could promote evidence-based early 
intervention that starts dental care well before the disease 
begins by focusing on that periodicity schedule from OBRA 1989 
that never got moved. With little expenditure of time and 
money, CMS could partner with HRSA again, but also with CDC, 
ARQH, NIH, IHS, WIC, Head Start, private organizations, 
foundations, professional associations to really use its bully 
pulpit, its leadership, to leverage the capacities of others.
    Second, CMS could provide meaningful technical assistance. 
CMS could provide intensive and extensive technical assistance, 
best practices, guidance, release of the Guide, release of the 
TAG findings from all those years ago, develop and disseminate 
model contracts, convene States again to learn from one 
another, ensure that there is a competent cadre of people in 
the regional offices who can really help the States, make 
suggestions about what can be done under HIFA and DRA to 
improve dental services. And when problems flare up, as they 
did in this last year in Georgia and now in Connecticut, CMS 
could be there to broker solutions and to provide technical 
assistance to the States.
    Last, I would suggest that CMS could more substantially 
exercise meaningful oversight. CMS has clearly demonstrated its 
willingness and its capacity to act forcefully on a number of 
issues, including, for example, the August 17th stringent 
guidance on State program expansions. Why CMS has not acted as 
forcefully on dental issues is inexplicable unless one believes 
that even the death of a child does not sufficiently highlight 
the importance of basic dental care. A Federal directive to 
States that compliance with reporting and service requirements 
under the law is of serious import to the agency would go a 
long way.
    So, taken together, I would suggest that leadership, 
technical assistance, and oversight could bring dental care to 
the forefront, it could honor Deamonte Driver's life, and it 
could assist the millions of children in Medicaid who currently 
have so little access to essential dental services. Thank you.
    [The prepared statement of Dr. Edelstein follows:]


    Mr. Kucinich. Thank you very much.
    Before I begin with my questioning, did you have an opening 
statement? OK. All right. If you would like, you could submit 
one for the record at any time.
    Mr. Shays. The only statement I would make, since you have 
invited that, is to thank our witnesses for coming and to thank 
you for having this hearing. This issue presented itself in a 
very shocking way and, frankly, I was stunned that--and I plead 
ignorance--that bad dental care could result in what it 
resulted in in the case of the young man, Mr. Driver.
    Mr. Kucinich. I thank my colleague.
    A subcommittee investigation revealed that there are 10,780 
Medicaid beneficiary United enrollee children in Maryland who 
have not received dental services in at least four consecutive 
years, so I would like to begin this discussion with Mr. Smith.
    What is the total number of Medicaid beneficiary children, 
those that are enrolled in the Medicaid managed care 
organizations, in Maryland who have not received dental 
services in at least three consecutive years?
    Mr. Smith. Mr. Chairman, we don't have the data at this 
point to be able to track individuals. The data that comes to 
us on the 416, for example, is dated that is in the aggregate. 
To track specific individuals, the States have that 
information; they are the ones that process the claims, etc. 
But under our current data collection systems and the capacity 
that we have, we don't track individual claims.
    Mr. Kucinich. Do you think it would be helpful if--for 
example, do you have anybody on your staff that would pick up a 
phone and say, hello Maryland, what is the total number of 
Medicaid beneficiary children who haven't received dental 
services? Do you ever do that? Do you collect data in that way? 
Do you do it informally if the formal systems aren't working?
    Mr. Smith. Mr. Chairman, our lack of data collection is a 
great frustration to me. Yes, we can--and oftentimes, 
unfortunately, that is what we end up doing, responding to all 
types of requests for data, but that is what we are left with, 
is picking up the phone, calling, oftentimes--and, again, even 
in the 416. The 416 we still have five States outstanding to 
where we don't have two States still have not even submitted 
the data yet from 2006. The other three States we are not 
satisfied that they are reporting accurately. So accurate 
reporting and our data systems, although I believe we have 
great improvement over previous years, we are still a long ways 
from what is satisfactory.
    Mr. Kucinich. I understand your frustration. I want to 
point something out, that our staff actually contacted Maryland 
and found out that approximately 22,555 children ages 5 to 14 
have not received care in three consecutive years, and the 
numbers would be even greater if we considered the CMS 416 
standards, which are children ages 4 to 20; it widens out the 
age groups.
    I would just like to submit to you that as a Federal 
administrator, in addition to whatever data base issues exist 
here, it might be helpful if you could find a way for your own 
staff to be able to access the kind of information that a 
relatively small congressional staff has been able to get. It 
occurs that during your EPSDT review in Maryland, you may have 
been able to find that out, and I just want to point out that 
another way of getting this information is by asking the 
Medicaid managed care organizations.
    As part of our investigation of United, my staff asked them 
how man of their beneficiary children had not seen a dentist in 
1, 2, 3, 4, 5 consecutive years, and we have a letter somewhere 
that I want to enter into the record by unanimous consent. As I 
mentioned earlier, there are nearly 11,000 children enrolled in 
United that have not seen a dentist in 4 consecutive years, 
putting them in the same position that Deamonte was when he 
died. So, without objection, this will go into the record.
    [The information referred to follows:]


    Mr. Kucinich. Now, in addition to Maryland, there were 14 
States that had less than a 30 percent utilization rate in 
2001. They reported their utilization rates in response to the 
January 18, 2001 State Medicaid letter, and I just wondered if 
you could help us and tell us, in each of these States, what is 
the total number of Medicaid-eligible children that have not 
received dental services in at least three or four consecutive 
years, if you have any of this information. I am going to go 
over a list, and just tell me if you have any information. If 
you don't, we would like you to get it. We think these figures 
exist. We are looking for Alabama. Do you have that?
    Mr. Smith. Mr. Chairman, I don't have--as I responded 
earlier, we have data in the aggregate. We can go back to the 
States that you would like to----
    Mr. Kucinich. OK, our staff is going to provide you with a 
list. I didn't invite you here to embarrass you, I just want to 
point out that we have some difficulties that exist, I think, 
that perhaps are impediments to the efficient management at a 
Federal level to permit higher rates of utilization. I am going 
to ask staff to present this list.
    OK we have correspondence from Maryland, North Carolina, 
and from CMS that we are going to put into the record with 
unanimous consent.
    [The information referred to follows:]


    Mr. Kucinich. We have eight States which have a utilization 
rate below 30 percent, and that is 5 years after that first 
report in 2006, after this was first addressed. Five States 
still have utilization rate below 30 percent, which means that 
those young people eligible for those services, there is only 
30 percent of all the eligible children are getting care, or 
less than that, in these States: Arkansas, Delaware, Florida, 
Michigan, Missouri, Nevada, New Jersey, and Wisconsin. We 
really need to find out these numbers and to submit those, and 
I would like you to help us and get these numbers and submit 
them to the subcommittee.
    Mr. Smith. Mr. Chairman, we would be happy to work with you 
to track down the numbers from the States. We will try to get 
you the data and will assist in collecting the information from 
the States.
    Mr. Kucinich. I want to just share something with Mr. Shays 
before I turn this over to him.
    We are trying to work with Mr. Smith in a cooperative way 
so that he can produce this information. I met with him 
yesterday, and he has indicated his frustration in the way 
these information systems are set up, but CMS not being aware 
of it is really a barrier to being able to make sure that these 
services get delivered. I mean, that is just one of the issues. 
So I thank my friend. If you would like to join in, I would 
appreciate it.
    Mr. Shays. I would like to ask a few questions. Again, Mr. 
Chairman, thank you.
    When this story came out, I was stunned, frankly, because I 
had not heard of how debilitating and then life-threatening the 
lack of care of your own teeth could be in your mouth, and I 
want to ask was this a really isolated case? I mean, like, was 
this one out of a few or does this young man represent tens of 
children in each State? So tell me that. And I throw it open to 
any of you.
    Dr. Edelstein. Mr. Shays, it is an excellent question, and 
it is something that has not been thoroughly researched. What 
we do know--I am currently working with a dental resident who 
is looking just at greater metropolitan New York City hospital 
records. What we have learned so far is that the frequency of 
head and neck-associated brain abscesses is really quite a bit 
higher than any of us had anticipated. What we are trying to 
sort out now is how many of those are related specifically to 
dental origin.
    It turns out that, talking to the neurologists and 
neurosurgeons, what was really different about Deamonte Driver 
is that he succumbed to a brain infection. So it is not the----
    Mr. Shays. So the answer is that this is something that we 
are checking out. So you are not coming back to me and saying, 
hello, Mr. Shays, we have 100 of these in each State or 
something like that, cases like that. That is not the case 
right now.
    Dr. Edelstein. Well, actually, I think----
    Mr. Shays. We just don't know.
    Dr. Edelstein. Well, we don't know. What we do know is that 
there are many, many brain infections, airway infections, and 
major facial infections.
    Mr. Shays. And so what is causing that, is it a dental 
    Dr. Edelstein. That are from teeth, yes.
    Mr. Shays. Great.
    Dr. Crall.
    Dr. Crall. I was going to say that shortly after Deamonte's 
death, many of us are on a variety of listservs, and certainly 
in the dental public health world it lit up over individuals 
who, over the years, had accumulated files of similar types of 
death, and in the same week a youngster died on a school bus in 
Mississippi from a dentally related condition.
    Mr. Shays. I mean, it is clearly something we should look 
at, and that I am not trying to minimize, but what it is saying 
is, as you are pointing out, we need statistics and 
    I have seen adults with teeth that are rotting, and I 
realize I pass judgment like, you have to be a real fool taken 
care of, but then I think, I would sooner die than you stick me 
in an MRI in a tube, where I am--I would not do it; you would 
have to knock me out to get me to do it. So some of the 
problem, just a phobia about sitting in a dental chair and that 
simply people just are deathly afraid to have that kind of 
experience. In other words, is the fear that I have of being 
claustrophobic, which would keep me from doing things that 
could help me, is that the same kind of fear that somebody has 
when they have to sit in a dental chair?
    You are looking at me, Mr. Smith, like what the hell is he 
asking. I am not communicating with you. I know adults who are 
so afraid to go to the dentist they would sooner let their 
teeth rot. I have no sympathy for that. And yet I think, well, 
you know what, there are certain things I wouldn't do because 
of a phobia I might have.
    Dr. Crall. I think I would make two responses to that. One 
is that, yes, it is true that some adults actually really have 
a serious phobia about going to the dentist, but situations 
like that are much more common when they have had bad 
experiences early on, and that is generally from the not 
getting care in a timely way. So that the experience going to 
the dentist is not the routine experience that most of us 
happen to experience. That is why we really try to emphasize 
the importance of the ongoing care and the routine care, 
because even as unpleasant as some people may feel getting a 
filling or a restoration is, it really is a substantial issue.
    The other is the financial side of things. I used to be at 
the University of Connecticut. We did a study for NIH that 
looked at the reasons for tooth loss in adults, and it was very 
clear that there are many, many salvageable teeth, as well as 
lots of unsalvageable teeth----
    Mr. Shays. I do have a few more questions.
    With your permission, if I could continue for two or three 
more minutes. Is that all right?
    Is the threat of bad dental care more severe to a child 
versus an adult? In other words, can an adult have bad teeth 
and not have them affect him or her the same way as if he were 
a child? Is the outcome the same and is it as quick in terms of 
    Dr. Edelstein. It is not as quick in terms of 
deterioration. The adage about children is that they get sicker 
faster, they get better faster.
    Dr. Crall. But blindness, death, all of those things are 
consequences that can occur in adults as well as children.
    Mr. Shays. The technology has improved. I happen to visit 
the dentist more than I would like, so I feel like I am an 
expert on new technologies. It is pretty impressive. Is that 
technology not available as much for a child under Medicaid, 
given that those who are poorer may not be able to go to 
doctors who have the best technology, or is that not an issue?
    Dr. Edelstein. I believe that the technology that is 
available to children, if they can find their way into a dental 
office, is equivalent. The problem is getting into the dental 
    Mr. Shays. We have community-based health care clinics in 
our district that are stunning and serve the whole community. 
Is that one way to really start to reach more young people?
    Dr. Edelstein. Without question, the safety net is an 
important place that needs to be bolstered. If you take a look, 
though, at the dental programs in, for example, FQHCs, there 
are many FQHCs that have no dental facilities and many dental 
facilities in FQHCs that have no dentists.
    Mr. Shays. Finally, let me just make this point.
    Thank you, Mr. Chairman.
    Our staff has written some excellent questions that I 
didn't choose to go to because I was so curious about my own, 
but if they could extend a few questions that you might be 
willing to respond in writing, that would be helpful.
    Again, Mr. Chairman, thank you. I am going to get on my 
way, but I thank you very much.
    Mr. Kucinich. The Chair would like to associate himself 
with your request.
    So we would appreciate your cooperation in responding to 
Mr. Shays' questions. And the point that you made, even beyond 
the statistics, there is the human factor here about children's 
lives being put at risk, which is why these hearings become 
very important.
    The person who has been one of our partners on this is Mr. 
Cummings from Maryland, who is very familiar with this case. I 
am going to ask Mr. Cummings to continue this hearing and to 
take the chair, and we will proceed shortly.
    Mr. Cummings [presiding]. Thank you very much. I want to 
thank you all for being here this evening. Hopefully, we won't 
hold you too much longer.
    But I must say that when we held our hearing last May, we 
invited three major stakeholders to testify before us: Mr. 
Dennis Smith, from the Centers for Medicaid and Medicare 
Studies; Ms. Susan Tucker, from the Maryland Department of 
Health and Mental Hygiene; and Dr. Alan Finkelstein, from the 
United Health Group. Only one of those individuals sits before 
us today, and that is Mr. Smith, and this is not without 
reason. In the intervening months since our May hearing in the 
year since Deamonte's death, the State of Maryland has stepped 
up to the plate in its efforts to improve children's access to 
dental health.
    Governor O'Malley, who I was just with a few minutes ago--
and that is the only reason I am late, because we had a 
delegation meeting--convened a Dental Action Committee which 
developed seven recommendations to better serve our children, 
including: raising reimbursement rates for dental services; 
initiating a single State-wide vendor for dental services; 
spending $2 million per year to enhance the dental health 
infrastructure; providing dental screenings for children; 
creating a new dental hygienist position; improving education 
for dental students; and crafting a public education campaign 
on oral health. The Governor included the first three items in 
his 2009 budget and he is currently working with the Dental 
Action Committee to implement the others, and I certainly 
applaud him for that.
    Similarly, the United Health Group has stepped up to the 
plate to do its part. Following our hearing in May, the company 
invested $170,000 for a program at the University of Maryland 
Dental School to improve children's access to dental care in 
Baltimore City, including more than $30,000 to hire a pediatric 
dentistry case manager, more than $60,000 to hire a pediatric 
dentistry fellow, $30,000 to establish a mini pediatric 
dentistry clinic, and $15,000 to provide continuing education 
to pediatric and family practice residents.
    The company is now working to develop a similar partnership 
with Howard University that will reach across the Maryland 
border to Deamonte's hometown in Prince George's County.
    I wish I could say that our Federal partners have been as 
cooperative as our State and private sector ones have been. 
Sadly and painfully, I cannot.
    In our May hearing, Mr. Smith, you repeatedly implied that 
you had no enforcement tool for ensuring that children get 
access to dental care under the Medicaid program. So we sent 
you a seven page letter outlining the various steps you could 
take. To be sure, you have taken some of these steps, but I am 
significantly underwhelmed by your lack of urgency. Our 
children simply cannot wait. They can't wait.
    I understand that since our last meeting CMS has completed 
an audit of the State of Maryland and is currently planning to 
audit 15 other States. Notably, the Maryland audit was 
completed in October, but CMS did not finalize it until 
February, after the subcommittee informed CMS of our intention 
to hold this hearing. In addition, target dates for the other 
15 States range from February 11th to April 7th of this year, 
all after CMS received notice that this hearing would take 
place. I find it extremely troubling that CMS failed to 
initiate this investigation without pressure from this 
    Further, I understand that you, Mr. Smith, met with the 
chairman and staff yesterday to discuss CMS's work on this 
issue and did not know the answers to even the simplest 
questions about what the agency has done. I can't even begin to 
tell you what I am feeling with regard to the job that you are 
doing. Your own lack of knowledge illustrates the priority with 
which you treat this issue. I certainly hope that you are 
better prepared to answer questions today.
    On that light, can you tell me more about the investigation 
and why it did not begin sooner? And then I have a whole series 
of questions.
    Mr. Smith. Thank you, Mr. Cummings. I think we began the 
review in October. That review included issuing a draft to the 
State of Maryland, giving them the opportunity to respond, 
which we received in mid-December. And we wanted to have their 
response before we completed the review, which is why, the day 
after we sent the review to Maryland, we sent it up to the 
subcommittee as well.
    Mr. Cummings. Mr. Smith, as we understand it--and you 
correct me if I am wrong--CMS played a negligible role in 
Maryland's reform. In fact, Maryland's Department of Health and 
Mental Hygiene wrote a letter to Chairman Kucinich on this 
    The letter makes it very clear that CMS had nothing to do 
with Maryland's dental reforms. Mr. John Colmers, Maryland's 
DHMH Secretary, explains that he initiated the Dental Action 
Committee in June 2007 and that CMS did not even begin its 
audit in Maryland until October 2007, and only finalized its 
findings early in February of this year. And I understand what 
you just said about December.
    In fact, Mr. Smith, rather than help Maryland enact those 
reforms, you may have hindered their efforts. Let me explain.
    According to your final report on Maryland's EPSDT program, 
with the focus on dental services for children--which I would 
like to enter into the record by unanimous consent--Maryland's 
DHMH states that it funds an outreach and care coordination 
unit in each local health department to provide outreach and 
education for the hard-to-reach non-compliant patients.
    However, you informed Maryland that ``This is no longer 
considered an appropriate Medicaid administrative activity, so 
Federal matching funds will no longer be available for these 
local health department programs that have been providing 
assistance since health choice began 10 years ago.'' Are you 
familiar with that?
    Mr. Smith. I am familiar, sir.
    Mr. Cummings. Can you explain that to me so I can have a 
better understanding?
    Mr. Smith. I would be happy to. I think what the State was 
referring to was an entirely separate regulation on school-
based administrative costs. For the State of Maryland to send 
in employees of the State to go in and to do outreach, to do 
enrollment, those are all reimbursable administrative expenses 
that the Federal Government would match. The issue of the 
school-based administrative claiming guide was due to issues 
that have dated back a number of years regarding abuses in the 
system in schools to where many different things were being 
billed to the Medicaid program, including school construction. 
Again, I certainly am not taking issue with the importance of 
school construction, but we don't believe that is properly 
billed to the Medicaid program.
    Mr. Cummings. Well, what have you done to help Maryland?
    Mr. Smith. I'm sorry?
    Mr. Cummings. What have you done to help Maryland? To me, 
it seems like you--well, it appears that there are roadblocks, 
but what have you done to help them, Maryland?
    Mr. Smith. Well, I would like to think that our review did 
help Maryland in terms of----
    Mr. Cummings. How so?
    Mr. Smith. In terms of helping to identify areas that we 
believed were weaknesses in the program, that they agreed were 
weaknesses in the program, and I would like to think that we 
are working with Maryland as good partners. John Folkemer, who 
is the Director, used to work in our agency. We have a good 
relationship with Maryland. I would like to think that we 
continue to have a good relationship.
    Mr. Cummings. Now, the things that you came out with, did 
those come out after the recommendation of the Dental Action 
    Mr. Smith. The Dental Action Committee made their report 
prior to our review.
    Mr. Cummings. And so, what, are you trying to take credit, 
in part, for what the Dental Action Committee had already done?
    Mr. Smith. No, sir, I am not trying to take credit for it.
    Mr. Cummings. And the reason why I say that is because the 
Dental Action Committee, I think, has done an outstanding job. 
And I guess what I am getting at is I want to make sure the 
Federal Government is doing its part to help States. I just 
left Governor O'Malley, and one of the things that he was 
saying to us in the delegation is that he wanted the Federal 
Government to step up to the plate not just in this, but in 
general, to help States accomplish the things that they need to 
    And I am just wondering are there other things that you see 
that you might be able to do to help Maryland?
    Mr. Smith. Well, as I said, I hope that our review was 
helpful to Maryland.
    Mr. Cummings. Anything beyond the review, Mr. Smith?
    Mr. Smith. Specifically, Mr. Cummings, we match State 
dollars, so the State puts up its money first, and then we 
match that. I think what Maryland did in terms of the review 
and the Dental Action Committee, they have a good plan. We 
    Mr. Cummings. Is it one of the better plans that you have 
seen throughout the country? Are you familiar with other plans 
in other States?
    Mr. Smith. A number of States previously had plans. We are 
going out to review 15 States between now and April to look at 
what they are doing and, certainly, we share information 
between what we see are best practices. We have on our Web site 
now three States that we identify as best practices 
specifically in the dental area. States have a tendency to 
learn from each other, to pick up the information from each 
other. We have re-instituted the Oral Technical Assistance 
Group that we are working with the American Public Health 
Association. The Medicaid directors work through APHSA. They 
had some turnover on their staff, but we are discussing with 
them re-instituting the oral health TAG.
    We have a number of different things going on with the 
dental officers themselves, the medical directors, that we hope 
will bear fruit from those discussions. The Association for 
Community-Affiliated Plans, which are kind of the not-for-
profit managed care organizations, we have had discussions with 
them to help identify, again, good practices and how to spread 
that among the different States.
    Mr. Cummings. Do you believe that every child ought to have 
appropriate dental care?
    Mr. Smith. Yes, Mr. Cummings.
    Mr. Cummings. And do you believe your agency is doing 
everything in its power to work with the States to make that 
    Mr. Smith. I think, Mr. Cummings, that it is a shared 
responsibility and a shared role. I think that what we have--I 
think the focus on dental benefits in particular over the last 
several months are very important. We are happy to be a partner 
of that.
    Mr. Cummings. Do you----
    Mr. Smith. If I may, you mentioned the Dental Action 
Committee report in Maryland, which is a great example, but if 
the Maryland General Assembly doesn't fund it, they can't get 
Federal dollars if they don't put up their dollars.
    Mr. Cummings. Well, did you encourage States to increase 
rates when you redacted the section from the Guide? Remember we 
had that discussion about the Guide?
    Mr. Smith. We did have that discussion, Mr. Cummings. 
Again, I tried to explain. I thought it simply didn't belong in 
to what was a clinical guide.
    Mr. Cummings. So did you encourage the States to increase 
the rates? Did you encourage them?
    Mr. Smith. I'm sorry?
    Mr. Cummings. Did you encourage the States to increase the 
    Mr. Smith. As I said at the previous hearing, and what we 
have said subsequent to that, I think there is a widespread 
recognition that reimbursement rates in Medicaid are low and 
they are behind. Again, I guess I am struggling a little bit 
when I have clearly said I understand that rates are low and I 
have clearly said that there are a couple of key areas about 
gaining access, and reimbursement is certainly one of those key 
    But the Guide itself, it was my judgment that it just 
didn't belong in what I thought was a clinical--I mean, I can 
understand the concern if I were saying the opposite and I 
wanted to take something out that I didn't agree with, but I 
clearly have been saying that reimbursement in Medicaid is low 
and that is one of the major barriers to access.
    Mr. Cummings. Do you believe that some children ought to be 
left behind?
    Mr. Smith. No, sir.
    Mr. Cummings. Because you know that is what is happening, 
    Mr. Smith. All Medicaid children should be receiving the 
care that they get. I believe that we have made progress. I 
think there is certainly more progress to be made, and the 
children on Medicaid should not have any less access than any 
other child. It is complicated, though, in terms of 38 
percent--I believe the percentage of 38 percent of rural 
counties in America have no dentist. So I can't produce a 
dentist in a rural county for a Medicaid child if there is not 
a dentist for any other child as well. Those types of things 
that we find are, again, to overcome those takes a partnership, 
it takes, again, in many respects, in the Medicaid program it 
comes from the States putting up their share of the dollars.
    If I may, the Federal Government funds direct grants. 
Congress has given money to CDC; Congress has given money to 
HRSA. When you hear about conferences or special initiatives, 
it is because that is where the money has gone to.
    In Medicaid, we don't have direct grant-making authority 
for those types of activities all on our own. We spend money 
because the States have spent money.
    Now, there have been some exceptions to that. Congress 
specifically created, for example, the Real Systems Change 
Grants, helping people to get out of institutions and back into 
their own homes. But Congress specifically appropriated that, 
created that fund and funded the dollars for it. The Children's 
Health Act of 2000, where Congress again created grants. 
Unfortunately, funding was never appropriated for those 
specific grants. I believe it was $10 million a year. But those 
dollars were not appropriated.
    So, generally, when Congress has set out funding, they have 
put it in the public health service rather than CMS.
    Mr. Cummings. Did you have a comment, Dr. Edelstein? I saw 
you scribbling.
    Dr. Edelstein. A couple of thoughts. One is that the 
example of rural access is absolutely true, but an absolutely 
marginal issue. Children in areas where other children have 
ready--children in Medicaid in other areas where the children 
not in Medicaid have ready access to dental care also don't 
have access to dental care. In other words, the majority of 
places where children do readily access care, Medicaid children 
cannot. So it is not a question of whether there are enough 
dentists out there, period; it is a question of whether there 
are enough dentists whose offices are open to the children.
    On the issue of CMS taking a leadership role in 
demonstrations, I don't know the internal financing and working 
of CMS--nor do I believe I should be expected to--but I do know 
that it was CMS that funded the demonstration in North Carolina 
that proved through the Into the Mouth of Babes program that 
you can enjoy better health outcomes at lower costs. And that 
was funded entirely by CMS, to the best of my knowledge.
    Mr. Cummings. Do you think we can do more of that, Mr. 
    Mr. Smith. Mr. Cummings, if I may----
    Mr. Cummings. First of all, do you know if it was funded by 
you all?
    Mr. Smith. We funded it for 2 years. HRSA picked it up and 
they are funding it. So, again, we see it as a partnership with 
other partners that are involved.
    Mr. Cummings. And that money comes out of a certain pot? 
How does that work?
    Mr. Smith. I don't know what they are using.
    Mr. Cummings. Dr. Crall, did you have a comment?
    Dr. Crall. I believe CMS has funded demonstrations on a 
variety of issues, continues to fund demonstrations on a 
variety of issues, which I think would be very helpful in this 
case, as well as evaluation dollars, other types of things that 
could really identify key elements and programs that are 
working, elements and programs that are working better in some 
States than in others.
    Mr. Cummings. I look at this agreement that we were able to 
work out in Maryland with United. I mean, it is not a lot of 
money, it really isn't, $170,000. I mean, that is not a lot of 
money, but you are able to do a whole lot with it. I kind of 
think that we just need to have not only the will to do these 
things, but we have to make them happen.
    When I see that little boy's face, I am just reminded of 
the way, Mr. Smith, that we get reports constantly from the 
University of Maryland that they are working with these young 
people, and they tell us that there are more and more kids that 
are just shy of where Deamonte was before he got real sick, in 
other words, that they are coming in to the dental chair and 
they have infections, some of them, and the infection goes to 
the eye, as I understand it, and it has not gotten to other 
    But the fact is that these children are in trouble. And, 
fortunately, a lot of them are caught before that time, but 
this is America, this is the United States, and I think we can 
do better.
    And I think that one of the things that has concerned me 
overall--and it is just not in this area, but generally--is 
that I think we are operating in a culture of mediocrity, where 
we kind of allow people to fall to the wayside as if it is OK. 
But it is not OK, because if it were your child, I am sure that 
you would do everything in your power to make sure that child 
had the kind of care that child needs. I just think that we 
could probably be a little bit more innovative and do a little 
bit more so that we can touch these children before they leave 
    Before I get to Ms. Watson, one of the things that I am 
always thinking about is how we, as adults, have a 
responsibility to our children to make sure that they are OK, 
and I just think we can do more. I just really do. And I think 
that if we cannot do more, then we don't need to be in the jobs 
that we are in. We really don't. We need to go and do something 
else, and let somebody else come in who can do those jobs so 
that we don't leave children behind with infections going to 
their eye sockets. I mean, this is not some Third World 
country, and you are the man, you know?
    Mr. Smith. Mr. Cummings, if I may, I provided in my opening 
    Mr. Cummings. I am sorry I missed it. I am sure it was 
    Mr. Smith. Medicaid will spend $2,900 per child for a full 
year. And, again, the general impression kids are healthy, they 
don't cost much because they are healthy, I think that is 
generally true, but Medicaid will be spending $2,900. I mean, I 
agree with you passionately, why aren't we getting better value 
for the investment that we are making and the dollars that we 
are spending? And I think the health care spending in general--
and Medicaid is going to be similar to what else is going on--
but health care spending is driven by under-utilization and 
over-utilization, and to get them right is the optimum dollars. 
I mean, we do talk a great deal about the cost of health care 
in the United States, about how much we spend more than any 
other country.
    Mr. Cummings. Let me go to Ms. Watson. My time has been up. 
And then we will come back to revisit this.
    Ms. Watson.
    Ms. Watson. Thank you so much. I must apologize for going 
out. While Representative Kucinich was here, I know that he was 
hoping that I would raise some of the issues that he would like 
to raise.
    If I am repeating the questions that have already been 
asked, would you stop me, please?
    I am going to address Mr. Smith, because I know that you 
are aware of the Omnibus Budget Reconciliation Act of 1989, and 
it significantly revised the EPSDT benefits as enumerated in 
the Social Security action with regard to dental care, the OBRA 
exempted dental services from requirements of the general 
health screening services, and created a separate regulatory 
scheme for them.
    Among other changes, the OBRA mandated that each State 
develop its own periodicity schedule for dental services and 
examinations, and I know you are aware of that. Regulations 
outlining the OBRA amendments were never promulgated. Instead, 
the then existing HCFA wrote Part 5 of the State Medical 
Manual, which is only guidance and does not have the force of 
regulation. So, today, Federal law is contradictory, because 
whereas the statute requires that each State must develop a 
periodicity schedule, existing regulations say that dental 
schedules will be federally set and dental referrals must be 
made by a physician at the age of 3. That is for a child.
    So this is rather confusing, Mr. Smith, and does not make 
clear what the law is. So my question is, to you, how many 
States have developed a specific dental periodicity schedule in 
consultation with the dental professional organizations, are 
you aware?
    Mr. Smith. Ms. Watson, we do expect every State to have 
their periodicity tables. That is one of the things that we 
will be checking on our review to make certain that they have 
the periodicity tables.
    Ms. Watson. As I understand, there are only two States that 
have such schedules. Is that true?
    Mr. Smith. I don't think that--we would have to check. That 
doesn't sound----
    Ms. Watson. Well, if my information is true, that means 
that 48 States have not complied with Federal law, and this may 
be in part the results of lack of clarity on the CMS plans. And 
I would like you to look into it so you can get back to us. I 
think we are seeing the results of States not having these 
plans, and my colleague would agree, because--did Deamonte live 
in your district?
    Mr. Cummings. No, he didn't, but, Congresswoman Watson, 
Maryland is a small State, so I guess he would be about 40 
minutes away from me. He was more like in Wynn's district, 
closer to Washington.
    Ms. Watson. So it is very important to us--and one of the 
reasons why we are having this hearing--to explain, because it 
is a contradiction and we need to see that all States have such 
    Mr. Smith. I agree, Ms. Watson. If I may expand a little 
bit. The law itself under EPSDT makes it clear that a Medicaid 
child does have the benefit of preventive care, restorative 
care, etc. So, in many respects, whether the State--the current 
periodicity table is--the child, if they need care, is entitled 
to that benefit regardless of whether the State ever did a 
periodicity table.
    Ms. Watson. Well, maybe we should clarify that.
    Dr. Crall.
    Dr. Crall. Yes, Ms. Watson. In my opinion, the real value 
of periodicity schedules are that they not only deal with the 
broad rights of the child under a program, but they are 
definitive in terms of accommodating professional guidelines 
about when children should receive certain types of services 
and what services they should receive on an ongoing basis. 
Those are incredibly important for States translating that 
information into coverage decisions and also just sending the 
message about the need for early care and ongoing care for 
children, and periodicity schedules do that. And they do not 
exist in----
    Ms. Watson. You are from UCLA, aren't you?
    Dr. Crall. Yes, ma'am.
    Ms. Watson. That is my alma mater. I was in California in 
the State senate and I chaired the Health and Human Services 
Committee for 17 years. I have been away from there since 1998. 
Do the math. Ten years. And one of the things I did was to be 
sure that every patient walking into a dental office would be 
aware of amalgams. Do you know they did not do that? I had to 
hold hearings here. I have been away a long time. I came here 
in 2001. And we had to have hearings to force some leadership.
    So what I would like to say, Mr. Smith, is that we need 
leadership. We need you to stay on these States, the 48. I will 
give that two States have promulgated the--and really 
understand what the mandate is. For your leadership to be 
effective, you need to see that they follow through. We can't 
have another death like we experienced with Deamonte. That is a 
shame on all of us. So I wish you would followup with that.
    Will you be doing anything to come up with new regulations 
in accordance with OBRA?
    Mr. Smith. OBRA 1989?
    Ms. Watson. Yes.
    Mr. Smith. At this time, we don't have plans to do further 
regulations on OBRA 1989. Again, one of the things that we are 
doing in the review of the 15 States that we started this week 
and will be doing through April, I think that we have a number 
of different areas that we are looking at from support and 
coordination, beneficiary information, that sort of thing. So I 
think what we are--the strategy that we are really using is to 
be able to do those reviews and, as Maryland responded through 
the Dental Action Committee, where deficiencies were 
acknowledge and owned up to and the State came up with a plan 
to make those improvements, I believe we will see those same 
types of strategies take place.
    Ms. Watson. I see that Dr. Edelstein might want to add to 
this discussion.
    Dr. Edelstein. Ms. Watson, if I could. I would like to 
relate the tremendous importance of OBRA 1989, which, as you 
note, was never acted upon. Eighteen years now. I would like to 
relate that to prevention, because the real answer to improving 
children's health--not just whether or not they get a dental 
visit, but whether they are healthier than they are now--relies 
on prevention and disease management.
    In those 18 years, the professional guidance on the 
appropriate age to start dental services has changed. With the 
recognition that tooth decay is an infectious disease that is 
established before age 2, periodicity schedules that call for 
starting at age 3 are, on the face of it, inappropriate. You 
can't start doing preventive services the year after a child 
acquires a disease.
    So the importance of OBRA 1989 enactment--and now the 
regulations that need to follow from that--is that a clear 
message would be sent to the medical community, to the dental 
community that Medicaid is up to speed with what the science 
says about the importance of starting early. And having a 
periodicity schedule that calls for anything less than age 3 
should be rejected by CMS based on the science.
    Thank you.
    Ms. Watson. Mr. Sherman, I am just reminded of the hearings 
that you participated in with such leadership yesterday, when 
we were looking at the use of these enhancing drugs and 
steroids and so on, and what I saw as the purpose was to send a 
message out to young people, because we are involved with 
wellness. Dr. Smith, if we would keep people well, then the 
cost of Medicaid and Medicare would start to diminish. And, you 
see, America has to start looking at wellness, how to prevent 
illness, kind of like the Chinese system, where they pay the 
doctors to keep their patients well; and when they become ill, 
they must provide the health care free. We work the other way 
around and we pay the medical professionals big bucks after a 
person becomes acutely ill.
    So we have to change our way of thinking. I am going to ask 
you, Mr. Smith, if you will look at at least checking to see 
what happened to those other 48 States that have not 
promulgated the regulations and get back to this committee in 
    Mr. Smith. We will do that, Ms. Watson.
    Ms. Watson. Please.
    Mr. Smith. Again, that is specifically a part of our 
protocol as we go out to the 15 States.
    Ms. Watson. Good. And I did hear you say the cost, and it 
is our responsibility, and we are dealing with a budget 
proposal for 2009, and one of the things I want to see, Mr. 
Chairman, is that we really look at Medicaid, Medicare and how 
we then start to put the dollars in, because we talk about 
homeland security. It is not about the land, it is about the 
people on the land, and we have to start with our young people 
and keep them healthy.
    So thank you so much, and I want to thank the witnesses for 
being here. And thank you, Mr. Chairman, for giving me all this 
    Mr. Cummings. Thank you very much, Ms. Watson. I just want 
to pick up where you left off.
    To you, Mr. Smith, in looking over the fiscal year 2009 
budget, I was surprised to see there are no increases for 
dental care, and I am trying to figure out why not additional 
funds, particularly when we know that there is such a 
tremendous need, Mr. Smith.
    Mr. Smith. Mr. Chairman, there will be an increase in 
funding as the services show up in the service categories. So 
it is all put together into medical assistance, it is not 
broken out separately. But Medicaid spending on dental care 
continues to increase every year.
    Mr. Cummings. OK. And how much did it increase over the 
last 2 years?
    Mr. Smith. I don't know offhand, Mr. Cummings, but we can 
provide that.
    Mr. Cummings. Can you get that to me?
    Mr. Smith. There is--the spending would be both on the fee-
for-service side and the managed care side. On the fee-for-
service side, that shows up because of their individual claims 
are submitted, but under a risk-based managed care it wouldn't 
show up because it would have been built into the rate that was 
paid to the managed care. So what we would provide would only 
be on the fee-for-service side, it would not include the 
managed care side.
    Mr. Cummings. Dr. Crall, in your testimony you talked about 
the importance of reimbursement rates to improving children's 
access to dental care. I want to turn our conversation to the 
State of Georgia. In your testimony, you have a table that 
shows that reimbursement in the State was raised to the 
seventy-fifth percentile and dentist participation went up. Is 
that correct?
    Dr. Crall. That is correct, Mr. Cummings.
    Mr. Cummings. So it went up about five, five and a half 
times, is that right?
    Dr. Crall. Yes.
    Mr. Cummings. But that is not the end of the story. Then we 
had the folks trying to pull out, is that right? Can you 
explain that, what happened, what you think happened?
    Dr. Crall. I will explain it to the extent that I am aware 
of the situation.
    Mr. Cummings. And then, Mr. Smith, you can tell us what you 
did about this.
    Dr. Crall. My understanding is that Georgia was using a 
global managed care arrangement and, therefore, payments were 
going to managed care organizations, who then would subcontract 
with other organizations to provide the dental services. And 
decisions were made to actually curtail and to reduce a number 
of significant providers of dental services within Georgia. I 
presume that was related to budgetary considerations, but that 
is typical of what often happens in a State where the 
significant changes are made in the rate structure.
    The first thing that is going to happen is that the 
expenditures are going to go up. And if someone doesn't 
prioritize dental services and have a commitment to maintaining 
the effectiveness in increasing utilization that ensues because 
of those increases, what typically happens in States is they go 
through and they will cut dental expenditures along with many 
other programs. And dentists are aware of that situation and 
are very reluctant to join in to Medicaid because they get 
whipsawed around on this payment approach.
    Now, we realize that many State budgets are under a fair 
amount of strain, but there are examples of other States--South 
Carolina and most recently in Texas and even in Connecticut--
where they have recognized that the importance of giving their 
Medicaid rates into the market for dental services and have 
found ways to at least ensure that a solid core of limited--and 
not too limited, but a core of somewhere between the range 
typically goes from 45 to 80 procedures at least that cover 
basic dental services that children need to take care of their 
disease are at a level that dentists will find to be 
    So what happened in Georgia is typical of what has 
occasionally happened in other States, that the changes made, 
the increase in utilization ensues, expenditures go up, but 
then, all of a sudden, the rug is pulled out from under the 
program and that sends a very poor signal to other providers in 
the State about participating in Medicaid.
    Mr. Cummings. Do you want to comment on that, Dr. 
    Dr. Edelstein. I would only add that Georgia is a 
particularly good example of how inappropriate contracting 
practices led to a squeeze on profits for for-profit Medicaid 
providers such that their only solution to protect their 
profits was to undo the very success that the program was 
intended to produce. The program is intended to produce care 
for children.
    Mr. Cummings. Right.
    Dr. Edelstein. In doing that, it costs too much for not the 
State, but the managed care company that was caught in the 
    Mr. Cummings. Right.
    Dr. Edelstein. They, therefore, cut services; the exact 
opposite of what the program is for.
    Now, my question, and what I added in my testimony, was 
where was CMS at that time.
    Mr. Cummings. Yes. That is a good question.
    Mr. Smith. Mr. Cummings----
    Mr. Cummings. Well, I want you to know I was going to ask 
that question, but Dr. Edelstein beat me to the punch.
    Mr. Smith. In terms of Georgia specific, I would have to go 
back and find out the specifics on Georgia. In general, I know 
a couple of things have happened in Georgia. Georgia did switch 
to managed care, they switched into their S-CHIP program as 
well, and, as a result, Georgia expenditures have increased 
    Part of the reason why Georgia went to managed care was a 
loophole in the law that allowed managed care entities to pay a 
provider tax that, in essence, was paying the funding of the 
State appropriations. So the underlying finance of the Medicaid 
program created an incentive for Georgia to adopt almost a 
self-financing model, things like that which we have been 
trying to close off.
    In managed care, though, in general,--and certainly my 
colleagues here can talk more sort inside the association than 
I can--dentists tend not to like managed care, regardless of it 
is in Medicaid or not. So Medicaid, yes, there is a piece of it 
there, but there is also something bigger than just Medicaid in 
terms of those relationships.
    Mr. Cummings. Yes, Dr. Crall.
    Dr. Crall. I certainly agree with the statement about 
dentists' hesitation about getting involved in managed care 
arrangements. Some of that stems from the fact that in the 
world of Medicaid dental services there have been managed care 
rates as low as $2 to $3 per child per month to provide care 
for Medicaid beneficiaries. No self-professionally respecting 
dentist would enter into any such arrangement. The only way 
that kind of an arrangement can work is to minimize children 
getting services, so that you inadequate collect payments for 
each child, but collectively allow them to work on the few 
children that you treat.
    So I think that while that is very true, I think that it 
also highlights the fact that when States learn about that and 
when they come to understand the way the systems work and the 
way the providers work, that has led many States to go to 
carve-outs from these managed care arrangements, to take their 
dental programs out of these global managed care arrangements 
and to deal with that particular issue.
    And, in fact, it also reminds me of comments I made in my 
testimony about the series of policy academies that the 
National Governors Association initiated in the late 1990's. 
That gave us a great opportunity--and there was strong demand 
from the States; over 30 States applied for those. But it gave 
us the opportunity to really spend some time with some State 
officials to help them understand the fundamental issues, and I 
would say that every State that is on that list that I provided 
of States that made substantial changes and where we saw the 
increases in dentist participation and utilization, those 
States were States that participated in those processes. So 
anything that can be done to make it a priority within the, 
State to get the State officials involved, strong leadership 
State officials involved, and to work with Federal partners to 
make that happen, I think we have a truncated track record of 
where that process can work.
    Mr. Smith. And, Mr. Cummings, if I may, we have had 
discussion with the Medicaid directors in terms of their 
managed care plans overall. We do believe that States need 
greater expertise in developing their managed care contracts, 
etc. Again, you often find you have a policy. The policy is 
just fine, but if you can't operationalize it correctly, then 
you have other problems. We did managed care in Virginia, and 
on the medical side, at the very least, managed care was very 
good for Medicaid beneficiaries in terms of the great increase 
in access, especially to specialists. That was lacking in the 
fee-for-service world.
    So I don't want to just--managed care has a place. It needs 
to be done correctly and States need the expertise to be able 
to do good bids, to make certain there are actuarially sound 
rates. If those rates are actuarially sound, if they are built 
off solid data, if they are built off service utilization, then 
those should be good rates. But if you don't have that 
component, then you are going to end up with rates, and then 
your networks are going to fall apart.
    Mr. Cummings. All right, Ms. Watson.
    Ms. Watson. Thank you, Mr. Chairman.
    We understand that CMS is preparing to re-institute the 
TAGs, and these are the technical advisory groups, the Oral 
Health Technical Advisory Groups. Is that so?
    Mr. Smith. Yes. We already have a number of TAGs, and we 
are in discussions with the Medicaid Directors Association. 
They need to be able to support it from their side. We have 
told the Medicaid directors we would like----
    Ms. Watson. So there is no guaranteed funding for them.
    Mr. Smith. We have contracts with APHSA currently. We 
probably have to add a little bit more to that, but we have 
expressed an interest and willingness on our end to do so. And 
they have expressed a willingness also. They have had a 
transition and turnover in their staff.
    Ms. Watson. I see. But you do see a way to fund these TAGs 
through some kind of arrangement?
    Mr. Smith. The oral health TAG?
    Ms. Watson. Yes.
    Mr. Smith. That is our intent, to re-institute the TAG.
    Ms. Watson. And I understand in the 1990's and in 2000 that 
the oral health TAG was convene to respond to questions from 
the States and from providers, but, to our knowledge, the 
findings have never been released. Can you comment why the 
findings that came out of the TAGs have not been released?
    Mr. Smith. I am not certain of what happened in the 1990's. 
The TAGs----
    Ms. Watson. In 1999, 2000.
    Mr. Smith. The TAGs themselves are a way to raise issues 
and they are a kind of ongoing discussions. I don't know that 
the TAGs themselves produced specific documents that would be 
    Ms. Watson. Well, I would say that there should be an 
accounting of those discussions so that we could then fix the 
oral health system where there are failures, and that is 
another thing I would like you to look into for our knowledge, 
what yet needs to be done. Those TAGs were set up to have that 
two-way dialog, and I would hope that there would be some 
reporting as to what was found, what was learned, what we need 
to address. And if you could go back into the records, it would 
be very helpful to us.
    Mr. Smith. I would be happy. Again, we have 10 or 11 or 12 
TAGs already.
    Ms. Watson. Yes, but what happened back when they were put 
together in the end of the 1990's?
    Mr. Smith. But in terms of the format, I don't know that 
they produced minutes, even. I would have to go back and find 
    Ms. Watson. Dr. Edelstein, can you enlighten us on this?
    Dr. Edelstein. I would be happy to. I was privileged to 
serve as a technical advisor to the oral health TAG when it was 
formulated in 1999. The express purpose of the TAG at that time 
was to collect questions from the States regarding technical 
issues in the administration of Medicaid dental programs and, 
therefore, to share the responses of the experts back to the 
States. The first part happened; the second part never did.
    Ms. Watson. All right. So there is a collection, wouldn't 
you say?
    Dr. Edelstein. There is a document----
    Ms. Watson. A document.
    Dr. Edelstein [continuing]. That has each of the questions 
raised by the States and the answers responded to by the TAG.
    Ms. Watson. What was the title? What was the document 
title, do you remember? It would be TAG something.
    Dr. Edelstein. It is the report of the oral health TAG.
    Ms. Watson. OK.
    Dr. Edelstein. And Dr. Crall was also involved.
    Ms. Watson. Dr. Crall.
    Dr. Crall. Yes. The questions and the answers from that TAG 
can be found in Appendix D, I believe, of the material that the 
American Academy of Pediatric Dentistry submitted to CMS as 
part of the dental guide. If it was not seen fit to publish 
that material in that form, I wholeheartedly concur with you 
that information does need to be made in some sort of public, 
ongoing basis--internet, CMS internet site, wherever.
    Of course, as regulations change over time, the answers to 
those questions need to be adapted to reflect current policy, 
and I would really encourage CMS to make that an ongoing 
dynamic set of information that someone could go to and know 
the questions won't change that much. It is the answers that 
change as regulations and program changes. But the questions 
are the fundamental questions that people administering these 
programs in the State need to know to be able to operate their 
programs consistent with current policy.
    Ms. Watson. Through the Chair, I would ask Mr. Smith--and I 
am sure you have staff sitting behind you--if you could find 
that report. Good, you have already made--and I am going to ask 
my staff to make a note so I can raise this question in the 
full committee, Mr. Chairman, because I think that it would be 
very, very helpful to dentistry and to the practitioners and to 
us, as we plan ahead and as we budget, to know what the dialog, 
what the questions were, what the input was, what the 
assessment of all that was, from the TAG. And this is the 
reason why it was set up, so we will know what the dentists and 
I guess the patients, too--there will be some reference to 
patients, as well.
    And if you could find that document and share it with us. 
And I think that needs to go out publicly, and we need to show 
that we are working to improve dental services to Americans, 
particularly to our children. So we want to know just what 
comes out of those advisory groups and how we can move forward 
with this.
    So if it can be relayed to the subcommittee Chair, Mr. 
    Mr. Cummings. I have it. We will take care of that. I 
promise you.
    Ms. Watson. OK, good. Thank you so much.
    Mr. Cummings. I am just going to take two more minutes. 
First of all, I want to thank you all for your patience. I know 
you all have had a long day.
    I have a request of you, Mr. Smith. We are concerned about 
Georgia and its recent cut in reimbursement rates. We want to 
find out if they are in violation of Federal law. Can you find 
that out for us?
    Mr. Smith. We will, Mr. Cummings.
    Mr. Cummings. What would be the procedure for accomplishing 
    Mr. Smith. We will have to go back to see. If Georgia is 
not on our list, we will put them on our list and find out what 
    Mr. Cummings. So you have a list of States that you are 
trying to determine whether or not they are in violation of 
Federal law, is that what you are trying to tell me?
    Mr. Smith. We have a list of the 15 States to which we are 
starting to do our reviews.
    Mr. Cummings. Are you questioning whether or not they 
violated Federal law?
    Mr. Smith. I think that we would make that assessment based 
on the review.
    Mr. Cummings. OK. I just didn't know whether that was one 
of the reasons why you were looking at the 15 States. Do you 
follow what I am saying?
    Mr. Smith. I think there are seven different areas that we 
are looking at in the protocol.
    Mr. Cummings. OK. All right. The other thing I guess that I 
am concerned about, I just want to make sure that we are doing 
all that we can. You send all these guidelines out and you make 
all these requests of the various States, telling them what 
they can't do. I guess what I am hoping is that you will do 
more of telling them what they can do so that they can help 
kids. But it just seems to me like that is so much that is done 
to try to put the limitations on, but at the same time there 
doesn't seem to be a lot done to push them along to get them to 
do more. You follow me? And I know you may disagree with that. 
Talk to me.
    Mr. Smith. I think, again, as I said, we are spending 
$2,900 per child, and if we are not communicating the value 
that we are getting for that in the Medicaid program, or if we 
are not doing an adequate job communicating what we think that, 
as we have laid out in our testimony and our strategy, we do 
believe that those will lead to increased quality and increased 
access. Clearly, the conclusions of the reports for the 
individual States we will certainly share with the 
subcommittee. We believe that we are pursuing strategies that 
involve multiple partners--not just the States, but the 
associations as well--and we believe that will be a successful 
    Mr. Cummings. It is interesting that you cut guidance on 
how to oversee MCOs from the Guide. Are you familiar with that? 
Do you know that?
    Mr. Smith. Going back to the dental guide discussion we 
had, yes.
    Mr. Cummings. Yes. Because you had these philosophies about 
what shouldn't be in the Guide and what should be in the Guide, 
and I guess what I am trying to say is that some kind of way, 
Mr. Smith--and I say this with all the humility I can muster--I 
just think you could do a better job. I really do. And it pains 
me to even say that. But you are the person who has been put in 
a certain place at a certain time, and that position is to take 
care of a lot of human beings who may not have even been 
conceived six or 7 years ago.
    Let me finish.
    And I guess, I tell my staff that we are all given certain 
positions at certain points in our lives, and we are put there 
specifically to carry out a task and be effective and 
efficient. And if we can't do it, for whatever reason,--and I 
say this over and over again--do something else. Go play golf. 
Do something. But let somebody else come in there who will make 
a difference.
    Because I don't want anymore Deamontes. And I say that. 
They live in my neighborhood. There are little Deamontes and 
little Chantes walking around in my neighborhood right now. 
When you go and eat dinner and celebrate Valentine's Day with 
your wife, they are going to be still in vulnerable positions 
    So I just think that we, as a country, can do better, and 
your organization has certain responsibilities. And Dr. Crall 
and Dr. Edelstein, I know, just listening to them, they have--I 
can hear it--a level of frustration, and I guess it is very 
frustrating to me, because I just think that this is our watch. 
This is our adult watch.
    So I am going to end there. Did you have anything else, Ms. 
    Ms. Watson. No.
    Mr. Cummings. All right, thank you all very much. Unless 
you all wanted to say something else. I apologize. Did you have 
something else you wanted to say, Dr. Crall?
    Dr. Crall. Well, I would just close in saying that of the 
$2,900 per child that is being spent, there are three actuarial 
studies that I am aware of that could send a signal to the 
States about the amount of resources that they ought to be 
putting into their dental programs. And I think that anything 
along those lines, as well as the periodicity schedules, that 
would send a clear message about exactly the types of services 
that children are supposed to receive and when they should 
receive that, those kind of signals need to be out there on an 
ongoing basis to emphasize this. And I couldn't agree with you 
more, we don't need anymore Deamontes.
    Mr. Cummings. If there are things, by the way, that you all 
feel that we need to be doing, you can get them to us in 
writing. We, hopefully--well, not hopefully. Next year there 
will be a new administration, and we may have to start there to 
try to get the new administration to begin to push on these 
things so that we can get some things done. But we welcome your 
advice because you all have dedicated your lives to touching 
these young people and you are where the rubber meets the 
road--you are there--and you do it everyday, so we want that 
information. So any recommendations that you would have for us, 
please pass them on, please.
    Dr. Edelstein.
    Dr. Edelstein. I only wish to say that it is nearing the 
first anniversary of Deamonte Driver's death, and I wanted to 
recognize, on behalf of all the children who you and others are 
helping, how much you have not let down one moment in this year 
to highlight the importance of children's oral health, and we 
are anxious, all of us are anxious to work with you to continue 
to help to provide the technical information that will make it 
possible for you to do that. Thank you.
    Mr. Cummings. Again, as you have heard me say, Dr. 
Edelstein, when I was growing up, we expected to have cavities 
in our mouths. Low expectations. But a lot of our parents 
didn't know any better. But this is 2008 and we can do better 
as a Nation. We can do better.
    Thank you, Ms. Watson. I know you had a long flight.
    Thank you all. Happy Valentine's Day.
    [Whereupon, at 5:55 p.m., the subcommittee was adjourned.]
    [The prepared statement of Hon. Elijah E. Cummings and 
additional information submitted for the hearing record