[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]




 
 MEDICAID'S EFFORTS TO REFORM SINCE THE PREVENTABLE DEATH OF DEAMONTE 
                       DRIVER: A PROGRESS REPORT

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

                                HEARING

                               before the

                    SUBCOMMITTEE ON DOMESTIC POLICY

                                 of the

                         COMMITTEE ON OVERSIGHT
                         AND GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                            OCTOBER 7, 2009

                               __________

                           Serial No. 111-129

                               __________

Printed for the use of the Committee on Oversight and Government Reform


         Available via the World Wide Web: http://www.fdsys.gov
                     http://www.oversight.house.gov



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              COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM

                   EDOLPHUS TOWNS, New York, Chairman
PAUL E. KANJORSKI, Pennsylvania      DARRELL E. ISSA, California
CAROLYN B. MALONEY, New York         DAN BURTON, Indiana
ELIJAH E. CUMMINGS, Maryland         JOHN L. MICA, Florida
DENNIS J. KUCINICH, Ohio             MARK E. SOUDER, Indiana
JOHN F. TIERNEY, Massachusetts       JOHN J. DUNCAN, Jr., Tennessee
WM. LACY CLAY, Missouri              MICHAEL R. TURNER, Ohio
DIANE E. WATSON, California          LYNN A. WESTMORELAND, Georgia
STEPHEN F. LYNCH, Massachusetts      PATRICK T. McHENRY, North Carolina
JIM COOPER, Tennessee                BRIAN P. BILBRAY, California
GERALD E. CONNOLLY, Virginia         JIM JORDAN, Ohio
MIKE QUIGLEY, Illinois               JEFF FLAKE, Arizona
MARCY KAPTUR, Ohio                   JEFF FORTENBERRY, Nebraska
ELEANOR HOLMES NORTON, District of   JASON CHAFFETZ, Utah
    Columbia                         AARON SCHOCK, Illinois
PATRICK J. KENNEDY, Rhode Island     BLAINE LUETKEMEYER, Missouri
DANNY K. DAVIS, Illinois             ANH ``JOSEPH'' CAO, Louisiana
CHRIS VAN HOLLEN, Maryland
HENRY CUELLAR, Texas
PAUL W. HODES, New Hampshire
CHRISTOPHER S. MURPHY, Connecticut
PETER WELCH, Vermont
BILL FOSTER, Illinois
JACKIE SPEIER, California
STEVE DRIEHAUS, Ohio
JUDY CHU, California

                      Ron Stroman, Staff Director
                Michael McCarthy, Deputy Staff Director
                      Carla Hultberg, Chief Clerk
                  Larry Brady, Minority Staff Director

                    Subcommittee on Domestic Policy

                   DENNIS J. KUCINICH, Ohio, Chairman
ELIJAH E. CUMMINGS, Maryland         JIM JORDAN, Ohio
JOHN F. TIERNEY, Massachusetts       MARK E. SOUDER, Indiana
DIANE E. WATSON, California          DAN BURTON, Indiana
JIM COOPER, Tennessee                MICHAEL R. TURNER, Ohio
PATRICK J. KENNEDY, Rhode Island     JEFF FORTENBERRY, Nebraska
PETER WELCH, Vermont                 AARON SCHOCK, Illinois
BILL FOSTER, Illinois
MARCY KAPTUR, Ohio
                    Jaron R. Bourke, Staff Director


                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on October 7, 2009..................................     1
Statement of:
    Edelstein, Burton, D.D.S., M.P.H., Chair, Children's Dental 
      Health Project; Mary McIntyre, M.D., M.P.H., medical 
      director, Office of Clinical Standards and Quality, Alabama 
      Medicaid Agency; Joel Berg, D.D.S., M.S., Chair, Department 
      of Pediatric Dentistry, University of Washington; and Frank 
      Catalanotto, D.M.D., professor and Chair, Department of 
      Community Dentistry and Behavioral Sciences, University of 
      Florida, College of Dentistry, representing American Dental 
      Education Association......................................    58
        Berg, Joel...............................................    83
        Catalanotto, Frank.......................................    88
        Edelstein, Burton........................................    58
        McIntyre, Mary...........................................    68
    Iritani, Katherine, Assistant Director, Health Issues, U.S. 
      Government Accountability Office; and Cindy Mann, Director, 
      Center for Medicaid and State Operations...................    10
        Iritani, Katherine.......................................    10
        Mann, Cindy..............................................    23
Letters, statements, etc., submitted for the record by:
    Berg, Joel, D.D.S., M.S., Chair, Department of Pediatric 
      Dentistry, University of Washington, prepared statement of.    85
    Catalanotto, Frank, D.M.D., professor and Chair, Department 
      of Community Dentistry and Behavioral Sciences, University 
      of Florida, College of Dentistry, representing American 
      Dental Education Association, prepared statement of........    90
    Edelstein, Burton, D.D.S., M.P.H., Chair, Children's Dental 
      Health Project, prepared statement of......................    61
    Iritani, Katherine, Assistant Director, Health Issues, U.S. 
      Government Accountability Office, prepared statement of....    12
    Kucinich, Hon. Dennis J., a Representative in Congress from 
      the State of Ohio:
        Letter dated December 15, 2008...........................    52
        Letter dated October 7, 2009.............................    50
        Prepared statement of....................................     5
    Mann, Cindy, Director, Center for Medicaid and State 
      Operations, prepared statement of..........................    26
    McIntyre, Mary, M.D., M.P.H., medical director, Office of 
      Clinical Standards and Quality, Alabama Medicaid Agency, 
      prepared statement of......................................    70


 MEDICAID'S EFFORTS TO REFORM SINCE THE PREVENTABLE DEATH OF DEAMONTE 
                       DRIVER: A PROGRESS REPORT

                              ----------                              


                       WEDNESDAY, OCTOBER 7, 2009

                  House of Representatives,
                   Subcommittee on Domestic Policy,
              Committee on Oversight and Government Reform,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 2:40 p.m., in 
room 2154, Rayburn House Office Building, Hon. Dennis J. 
Kucinich (chairman of the subcommittee) presiding.
    Present: Representatives Kucinich, Cummings, Watson, and 
Jordan.
    Staff present: Jaron R. Bourke, staff director; Tom Mulloy, 
Office of Representative Kucinich; Jean Gosa, clerk; Charisma 
Williams, staff assistant; Carla Hultberg, chief clerk, full 
committee; Leneal Scott, IT specialist, full committee; Adam 
Hodge, deputy press secretary, full committee; Ashley Callen, 
minority counsel; Molly Boyl, minority professional staff 
member; and Adam Fromm, minority parliamentarian/Member 
services coordinator.
    Mr. Kucinich. The Domestic Policy Subcommittee of Oversight 
and Government Reform will now come to order.
    I want to thank the witnesses and those in the audience and 
my colleague, Ranking Member Jordan, for your patience. The 
House had in consideration a bill that I was the author of, and 
so I had to be there to present it. It's good to be here with 
you as we start this hearing.
    This hearing is going to be the fourth in a series on 
access to pediatric dental services in Medicaid. The 
subcommittee has focused on this issue since the death of 
Deamonte Driver in February 2007; and that's Deamonte Driver's 
picture. His death highlighted the inadequacy of dental 
services for Medicaid and rural children in Maryland.
    Without objection, the Chair and the ranking minority 
member will have 5 minutes to make opening statements, followed 
by opening statements not to exceed 3 minutes by any other 
Member who seeks recognition.
    Without objection, Members and witnesses may have 5 
legislative days to submit a written statement or extraneous 
materials for the record.
    On February 25, 2007, Deamonte Driver, a 12-year-old boy 
from Prince George's County, Maryland, died from a brain 
infection caused by untreated tooth decay. Deamonte's tragic 
death could have been easily prevented by access to dental 
care, dental care he was entitled to and should have received 
through United HealthCare, Maryland's Medicaid dental provider.
    Unfortunately, that company failed to meet its obligation 
to provide beneficiaries with access to dental providers. So 
onerous were the administrative barriers that United HealthCare 
had created, ``it took one mother, one lawyer, one online help 
supervisor, and three case management professionals to make a 
dental appointment for one Medicaid child,'' according to 
testimony we received from Laurie Norris, a legal advocate who 
worked with the Driver family.
    In the 2\1/2\ years since Deamonte's preventable death, 
this subcommittee has been conducting an inquiry into the 
adequacy of efforts on a State level to ensure access to 
pediatric dental services under Medicaid, as well as the 
actions that the Center for Medicaid and State Operations, CMS, 
to conduct oversight of State systems.
    At our first hearing in May 2007, we learned that Deamonte 
Driver was not the only Maryland youth who wasn't receiving 
dental care to which he was entitled by Medicaid. In fact, our 
investigation of United HealthCare found that approximately 
11,000 Maryland children in United HealthCare's Medicaid 
operation had not seen a dentist in at least 4 years. We found 
that United HealthCare provided information to Medicaid 
beneficiaries that was so inaccurate and outdated it would have 
been virtually impossible to find a dental care provider.
    We also learned that CMS did virtually nothing to address 
the problems in poorly performing State systems. Dennis Smith, 
director of CMS at the time, argued that financial sanctions 
are the only tool CMS has to enforce compliance; and he was 
unwilling to hand down financial sanctions because he said the 
cost was ultimately borne by the patient.
    Simply put, this is not the case; and in a letter to Mr. 
Smith the subcommittee outlined nine actions that CMS could 
take that would serve to enforce the statutory responsibilities 
that States have to ensure that Medicaid-eligible children have 
access to dental services.
    Our second hearing focused on CMS's response to this letter 
and actions taken by them in the years since Deamonte Driver's 
death to address the deficiencies in its oversight 
responsibilities. While they did take some action, their 
efforts, unfortunately, fell short of effecting any real 
change. In fact, the hearing revealed that most of the progress 
of the State of Maryland was made despite CMS, that the agency 
was not actively involved in the State's efforts and provided 
almost no guidance.
    Additionally, CMS continued to neglect the issue of 
provider reimbursement rates, despite hearing testimony about 
the importance of them to effecting system-wide reform. 
Astoundingly, Mr. Smith even acknowledged as such during our 
first hearing, but stubbornly, stubbornly continued to avoid 
the issue. Mr. Smith resigned from his post not long after our 
second hearing.
    After that, things began to change. A GAO report, the first 
of its kind since 2000, revealed that millions of Medicaid-
enrolled children suffer from tooth decay, almost one-third of 
the total Medicaid population. Medicaid children are roughly 
twice as likely as privately insured children to suffer from 
tooth decay.
    Moreover, this pattern has persisted for years. Very little 
has been done to improve access to and utilization of dental 
services. In a sense, the problem of tooth decay is getting 
worse, because the rate of decay in the teeth of children aged 
2 to 5 has increased in recent years.
    Now our third hearing on the issue demonstrated that 
improvement is possible. Under new leadership and continued 
congressional scrutiny, CMS began to turn a corner. The interim 
director of the Center for Medicaid and State Operations 
outlined a number of actions that they had taken to engages 
States actively in reform as well as to improve their own 
oversight functions. They conducted 17 reviews of State systems 
with utilization rates below 30 percent and provided each State 
with its own report and recommendations, worked with States to 
develop oral health schedules that met Federal guidelines, and 
formed an Oral Health Technical Advisory Group with State 
Medicaid directors.
    We also learned that the State of Maryland, where this 
whole journey began, continued making considerable progress. 
The dental action committee that they formed developed seven 
recommendations to improve access to dental care for Maryland's 
children. Two ended up in a budget submitted by Martin 
O'Malley, the Governor of Maryland, and another was passed by 
the State legislature.
    Today, the GAO will share the findings of their most recent 
report, commissioned at the request of myself and Mr. Cummings, 
on the adequacy of pediatric dental oversight at the State and 
Federal level. I am thankful to GAO for their hard work and 
dedication in studying this problem.
    We will also hear, for the first time, from the new 
director of the Center of Medicaid and State Operations. I am 
looking forward to their report on the progress they have made 
and how they plan to use that momentum to address the gaps that 
remain as identified in the GAO report.
    Additionally, we are going to hear from State Medicaid 
officials and researchers who have studied and implemented 
successful initiatives to increase access to and utilization of 
dental services, as well as to improve provider participation.
    I believe and hope that CMS has turned a corner in their 
oversight of pediatric dental services since the death of 
Deamonte Driver. But the magnitude of the underlying problem is 
great, and even today there are millions of children just like 
Deamonte entitled to dental care but not receiving it. The 
urgent job of everyone here today is to move quickly to prevent 
another one of them from dying from preventable dental disease.
    Finally, I just want to share with my colleagues, you know, 
people ask me when Deamonte's death was first announced, why 
are you so interested? It's just 1 person out of 300 million. 
You know, these things happen.
    I remember growing up in the inner city. I was the oldest 
of seven. My parents never owned a home and lived in 21 
different places by the time I was 17, including a couple of 
cars. And one of the things we didn't have was dental care. I 
mean, I can remember chewing on gum balls and having them just 
breaking off--my teeth breaking off into the gum balls. And I 
can remember having dental problems that didn't get treated for 
a long, long time.
    And I don't want to get too graphic about it, but for those 
who have experienced being a child without access to dental 
care, you know what a nightmare it can be.
    Deamonte Driver, that's me. That's me as a young boy. His 
life was sacrificed to an uncaring system. We can't have any 
more Deamonte Drivers out there.
    Look at his face. I mean, he is just--he is really asking 
us, what we are going to do about this? Are we going to take a 
stand to make sure that the children of America get the dental 
services that they are entitled to?
    That's the challenge we have, and I will not rest. I know 
there are colleagues like Mr. Cummings and Mr. Jordan, we have 
very powerful feelings about this as well.
    But I will not rest until we have caused the death of 
Deamonte Driver to be a driver of a new day in delivering 
dental services to the children of this country and 
particularly those who are served by Medicaid.
    I want to thank you for your indulgence, Mr. Jordan.
    With that, I yield to the ranking member of this committee, 
Mr. Jordan, for his opening statement.
    [The prepared statement of Hon. Dennis J. Kucinich 
follows:]

[GRAPHIC] [TIFF OMITTED] T4919.001

[GRAPHIC] [TIFF OMITTED] T4919.002

    Mr. Jordan. I thank the chairman for his work and for 
calling this hearing as well and for continuing to highlight 
the importance of access to dental care for children. I look 
forward to hearing from our witnesses about what has been done 
to enhance pediatric dental services and improve access, since 
these issues were first looked at by the subcommittee following 
the tragic death of Deamonte Driver in 2007.
    Barriers to care, including low reimbursement rates for 
dentists, lack of understanding of the importance of our oral 
health, and excessive administrative burdens for patients and 
providers all contribute to the problem. According to the 
report the GAO released today, State Medicaid programs have 
taken steps toward improving access, but gaps remain that must 
be addressed.
    Likewise, CMS has worked to improve its oversight of 
pediatric dental issues in Medicaid. More progress certainly is 
necessary. In 2008, GAO estimated that one in three children on 
Medicaid had untreated tooth decay. I hope our witnesses today 
will tell us what is being done to fill these gaps and treat 
these children.
    Unfortunately, the issue of access to care is not unique to 
pediatric dentistry for Medicaid enrollees but a problem across 
the health care spectrum. The problems of access to care are 
prevalent in our existing government-run programs, including 
Medicaid, Medicare, and SCHIP. Low reimbursement rates set at 
the State level for Medicaid and the national level for 
Medicare lead to a low participation of providers in these 
programs. In this respect, the terrible story of Mr. Driver can 
prove to be a lesson as we move through health care reform and 
evaluate the different options for ensuring a healthy America.
    With that, Mr. Chairman, I yield back the balance of my 
time.
    Mr. Kucinich. I thank my colleague from Ohio; and the Chair 
recognizes Mr. Cummings from Maryland, who has been working on 
this issue from the time that it was first known. I want to 
thank him for his dedication.
    Mr. Cummings. Thank you very much, Mr. Chairman.
    I really do thank you for your interest in this issue, and 
I thank you--as I listened to you just a moment ago, I am 
reminded that what you have done is you have taken some of your 
experiences in life as a child and turned them around and used 
them as a passport to help others, and that says a lot. So 
often people want to bury what happened in their past. However, 
you take it and you raise it up to remind us that this could 
happen to anybody. So I do--but not only do you do that, you 
then lay out a mission to correct it. So I really do appreciate 
you doing this.
    You know, Deamonte died on February 25, 2007, and I know 
that the chairman has already talked about it, but I think 
about it every day, just about. And when I think about an 
untreated tooth and an infection spreading to a child's brain, 
$80 worth of dental care might have saved his life, but 
Deamonte was born, he never made it to the dental chair.
    Mr. Chairman, you recall we first held a hearing on this 
topic at my request back on May 2, 2007, in an effort to 
identify the critical breakdowns in our Medicaid system's 
provision of dental care to children. As our dental health 
professionals here today know, oral health is an often 
overlooked but vital component of health care. Preventive 
dental care, especially for our children, is a fundamental need 
for their healthy development into adulthood.
    In fact, tooth decay is the most common childhood disease. 
It is five times as common as asthma and seven times as common 
as hay fever. This has the most detrimental impact on low-
income communities. Eighty percent of cavities occur in only 25 
percent of children, predominantly low-income children. Low-
income children suffer twice as much from tooth decay as do 
more affluent children. Millions of school hours are lost each 
year to dental-related illness. Poor children suffer nearly 12 
times more restricted activity days than children from more 
affluent families due to dental-related illness.
    Our previous hearings on this matter revealed woeful 
failures of the Centers for Medicaid & Medicare Services and 
its State partners to comply with section 1905(r)(3) of the 
Social Security Act, which ensures that every child--every 
Medicaid-eligible child will have access to medically necessary 
dental care under the Early Periodical Screening, Diagnostic, 
and Treatment [EPSDT], provision. We found that Medicaid fell 
glaringly short of meeting this mandate and was given 
directives to address these disparities. I am eager to hear 
today about efforts that they have partaken in to address the 
disparities.
    Since Deamonte's death, my home State of Maryland has 
resolved to do everything possible to prevent such an avoidable 
tragic loss; and we have made significant gains to improve 
children's access to dental care. In just 2 years, Mr. 
Chairman, 41,000 more children in Maryland received Medicaid-
funded dental service than those who received such service in 
2007. In 2009 alone, Maryland is making an overall $81\1/2\ 
million investment in Medicaid dental care services Statewide.
    Governor Martin O'Malley, to his credit, also 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 2000 budget, and he is 
currently working with a dental action committee to implement 
the others.
    Similarly, the UnitedHealth Group has stepped up to the 
plate to do its part. It 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 access to education to pediatric and family 
practice residents.
    As I close, the company is now working to develop a similar 
partnership with Howard University that will reach across the 
Maryland border to Deamonte's home county, Prince George's.
    All of these actions are commendable. However, they are 
being implemented solely on a State level. In order for us to 
see monumental gains, changes must be made Nationwide. We have 
been anticipating a review of CMS's since our last hearing to 
learn what has been accomplished at the Federal level. We were 
sorely disappointed regarding the lack of demonstrable effort 
between our first and second hearings, so GAO's report has been 
eagerly awaited. I am hopeful that we are turning the page to a 
new day.
    With the leadership of Ms. Cindy Mann, CMS will work to 
create innovative reforms to address the concerns raised in 
GAO's report, and these reforms will incorporate the effective 
and efficient programs that are already working on a State 
level.
    Mr. Chairman, a child died because of our failure as 
adults, of our failure as adults to discharge this mandate. For 
Deamonte Driver and for every child and adult like him, we must 
proceed with a sense of great urgency and with an unfailing 
determination to see our efforts to completion. It is their 
turn. It is their turn to grow up. It is their turn to be 
healthy children. It is their turn to deliver and develop the 
gifts that they have been given to deliver to us. But if they 
are not healthy and if their teeth are rotting and if we are 
not doing anything about it, shame on us.
    Thank you very much, Mr. Chairman. With that, I yield back.
    Mr. Kucinich. Thank you, Mr. Cummings, for your commitment, 
your statement, your heart, your passion, and your willingness 
to take a stand.
    We are now going to go to the witnesses. There are no 
additional opening statements. The subcommittee will receive 
testimony from the witnesses before us today.
    I would like to start by introducing our first panel:
    Ms. Katherine Iritani is Acting Director for Health Issues 
at the U.S. Government Accountability Office. In her 27-year 
career with GAO, she has helped plan and execute a wide variety 
of program and evaluation assignments. In recent years, she has 
overseen multiple evaluative studies on Medicare financing and 
access issues, including children's access to preventive and 
dental services. Ms. Iritani currently works in GAO's Seattle 
field office and has a business administration degree from the 
University of Washington.
    Next, Ms. Cynthia Mann. Ms. Mann was appointed director of 
the Center for Medicaid and State Operations [CMSO], in June 
2009, where she is responsible for the development and 
implementation of national policies governing Medicaid, the 
State Children's Health Insurance Program, survey and 
certification, Medicaid Integrity Program, and the Clinical 
Laboratories Improvement Amendments. CMSO, the Center for 
Medicaid and State Operations, also serves as the focal point 
for all CMS interactions with States and local governments.
    Prior to her return to CMS in 2009, Ms. Mann served as a 
research professor at Georgetown University Health Policy 
Institute and executive director of the Center for Children and 
Families at the Institute. Her work at Georgetown focused on 
health coverage, financing, and access issues affecting low-
income populations. Previously, she served as director of the 
Family and Children's Health Programs at CMSO from 1999 to 
2001, where she played a key role in implementing Medicaid and 
the SCHIP program.
    Before joining the government in 1999, Ms. Mann led the 
Center on Budget and Policy Priorities, Federal and State 
health policy work. She also has extensive State-level 
experience, having worked on health care welfare and public 
finance issues in Massachusetts, Rhode Island, and New York.
    Thank you both for appearing before this subcommittee 
today.
    It's the policy of the Committee on Oversight and 
Government Reform to swear in our witnesses before they 
testify. I would ask that you rise.
    [Witnesses sworn.]
    Mr. Kucinich. Let the record reflect that each witness 
answered in the affirmative.
    I would ask that each of the witnesses now give a brief 
summary of your testimony. I ask that you keep this summary 
under 5 minutes in duration. Your complete written statements 
are going to be in the record; and that's what we are here to 
do, to have you amplify on that in your time that you will be 
presenting.
    So I would like you, Ms. Iritani, to be our first witness. 
You may begin.

  STATEMENTS OF KATHERINE IRITANI, ASSISTANT DIRECTOR, HEALTH 
ISSUES, U.S. GOVERNMENT ACCOUNTABILITY OFFICE; AND CINDY MANN, 
       DIRECTOR, CENTER FOR MEDICAID AND STATE OPERATIONS

                 STATEMENT OF KATHERINE IRITANI

    Ms. Iritani. Mr. Chairman, Ranking Member Jordan, and 
members of the subcommittee, I am pleased to be here to discuss 
children's access to Medicaid dental services, a longstanding 
concern.
    As you noted in your opening remarks, an estimated one of 
every three children in Medicaid has untreated tooth decay. One 
in nine have it in three or more teeth. This is about twice the 
rate experienced by privately insured children and translates 
to millions of Medicaid children in need of dental care. In too 
many cases, this need is urgent.
    My statement is based on GAO's report that you are 
releasing today. This report summarizes at a national level 
efforts of States and CMS to improve Medicaid dental services 
for children. In summary, we found that State Medicaid programs 
and CMS have taken a number of actions to monitor and improve 
children's access to dental services, but problems with access 
persist and gaps in CMS oversight remain.
    First, let me share highlights of States' actions from our 
Web-based survey of State Medicaid programs. All States 
reported monitoring children's access to dental services, and 
nearly all States had implemented one or more initiatives to 
improve access through actions to reach out to families such as 
establishing hotlines to help them find a dentist and 
initiatives such as raising reimbursement rates to encourage 
more dentists to serve Medicaid children.
    Nonetheless, States reported multiple barriers to improving 
access. These barriers are well-known and longstanding, for 
example, for families finding a dentist to treat their 
children; for providers, concerns remain about families missing 
their appointments, low reimbursement rates and administrative 
burdens. These barriers persist, despite States actions to 
address them.
    Of significance, most States indicated their initiatives to 
improve access had not met their expectations; and two-thirds 
of the 21 States that reported contracting with managed care 
organizations to provide dental services said those 
organizations were not meeting the States' access standards.
    The bottom line, children's access to Medicaid dental 
services has been improving but remains low. States report that 
only about 35 percent of Medicaid children nationally received 
any dental service in 2007, as compared to HHS's goal of 66 
percent of low-income children receiving a preventive dental 
service by 2010.
    Now let's turn to actions of CMS. CMS has improved its 
oversight of State programs in several ways, but more can be 
done.
    Two observations: First, CMS has focused dental reviews of 
17 States with low dental access rates, identified significant 
problems, including concerns in eight States that managed care 
organizations had inadequate numbers of dentists in their 
networks. CMS did not, though, require corrective action plans 
of States or have plans to review other States with low dental 
access rates.
    Second, CMS has improved its guidance to and communications 
with States. For example, CMS posted descriptions of four 
States promising practices for improving access on its Web 
site, but nearly every State, 49 in all, reported to us that 
they need more from CMS. States reported, for example, that 
they need specific guidance in areas such as establishing 
appropriate dental payment rates and improving billing 
policies.
    Notably, when we ask States how CMS could help them, most 
States answered that CMS should provide more information on 
what was working in other States. Twenty-six States reported to 
us that they believe their State had one or more best practices 
for delivering dental services that could be shared with 
others.
    In conclusion, CMS and States have taken noteworthy steps 
to improve children's access to Medicaid dental services. 
Concerted and continued efforts and, in these challenging 
fiscal times, innovative solutions will be needed to address 
the multiple and longstanding barriers to improving children's 
oral health. For its part, CMS can help through ongoing 
assessment, guidance, and support of States' efforts, building 
upon the steps the agency has recently undertaken. We have made 
several recommendations to CMS toward this end and have ongoing 
work for the Congress further examining these issues.
    Mr. Chairman, this concludes my statement. I would be happy 
to answer any questions.
    Mr. Kucinich. I thank the gentlewoman.
    [The prepared statement of Ms. Iritani follows:]

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    Mr. Kucinich. The Chair recognizes Ms. Mann. You may 
proceed.

                   STATEMENT OF CYNTHIA MANN

    Ms. Mann. Good afternoon, Chairman Kucinich, Ranking Member 
Jordan, and members of the subcommittee. I, too, appreciate the 
opportunity to be with you today to talk about how children are 
faring receiving needed dental services under the Medicaid 
program; and I want to begin by commending you, Mr. Chairman, 
for your sustained interest in this area.
    I have been the director for the Center for Medicaid and 
State Operations for a little less than 4 months, and I have 
not been a witness to the prior hearings. However, in my 
position at Georgetown University, I closely followed the 
proceedings. And now that I am director of CMSO and have taken 
stock of what we have done in the past period of time, it is 
clear to me that the activity that has happened was triggered 
in large part by the activity of this committee and by your 
interest in this area and that you have been able to plant the 
seeds for a renewed commitment on this very important matter.
    While I am new to CMS, I am not new to this issue. As you 
noted in your introduction of me, I have worked on children's 
access issues for many years; and I would note that in my 18 
months at CMS in 1999 and 2001 I helped author the letter that 
was issued in January 2007, which you referred to in your first 
hearing, which called for every State to conduct a dental 
access review.
    Since that time, many States have made progress narrowing 
dental access gap for children. But, as the GAO correctly 
points out, significant gaps remain. We know from the research 
that there's an inextricable link between oral health and 
overall health and that every child needs dental care, 
preventive care, and treatment when appropriate.
    Sadly, our country's record in assuring our kids have the 
dental care they need, both in private coverage as well as in 
public coverage, is not good; and the record is particularly 
poor for low-income children. I can assure you, Mr. Chairman 
and members of the committee, that Secretary Sebelius and I 
share a firm belief that we have a responsibility to do much 
more to assure that every child enrolled in Medicaid receives 
the dental care they need.
    The data show that about 36 percent of all Medicaid-
eligible children used dental services over a year's period of 
time. With that data, there can be little doubt that 
improvements are necessary.
    States administer the program, they enroll the providers, 
they set the provider rates, but CMS plays a critical role, and 
we are intent on using all of the tools available to us to 
assure that every child covered by Medicaid is as healthy as he 
or she can be.
    My written testimony lists a number of actions that CMS has 
taken over the past period of time since the last hearing. I am 
just going to review a few of those activities.
    In policymaking activity, we are now actively involved in 
providing guidance in the area of children's health insurance 
coverage and the new CHIPRA provisions that expanded dental 
benefits for children in a number of different ways. In fact, 
today we released our guidance to States on the new CHIP dental 
health benefit and the supplemental insurance option that's now 
available to States to provide dental coverage to children who 
have other sources of care.
    CHIPRA also included several other provisions that we are 
working on. One was a provision that required the Secretary to 
publish the names of the dentists serving children in the 
Medicaid program in every State around the country, Medicaid 
and the CHIP program. We launched that Web site on August 4th 
and have those dental providers listed at this point. That Web 
site, I will say, is a work in progress.
    We think that there's a number of improvements that we want 
to continue to make. We have had a number of--a lot of activity 
on that Web site, about 43,000 hits to the page, but there are 
improvements that can be done; and we think we can use that Web 
site not only to ultimately share information with families 
like Deamonte Driver's family about where to get dental care 
but also for us to use as a monitoring tool to be able to see 
what the numbers of dentists are in each Medicaid program, how 
many are taking new patients, and what that access looks like 
over time.
    We also are intent on changing our data reporting system. 
We want to change the so-called CMS-416, which is our EPSDT 
reporting form, to include information about other providers 
that are providing oral health care, as well as to improve, to 
make other improvements to the 416; and we are planning to do 
that by the spring of this year. There were a number of 
requirements to changes in the 416 that were part of CHIPRA, so 
we want to consolidate those changes and put those out in the 
spring.
    We are also partnering right now with the Agency for Health 
Quality and Research to come up with dental health quality 
standards as part of the overall initiative to come up with 
children's health standards. We believe that those health 
standards, those dental quality standards themselves, which 
will be reported by States, hopefully--it's a voluntary 
reporting by States--will again give us another window to 
assure that children are getting the care that they need and 
get States to pay continued attention to the need for oral 
health services.
    We are also helped, as you noted, in your introductory 
remarks, Chairman Kucinich, by a new oral health and technical 
advisory group that's going to help us move forward in our 
policymaking. But a second area of----
    Mr. Kucinich. The gentlewoman's time has expired, but I 
will let you make a concluding statement.
    Ms. Mann. Let me conclude by saying our two other areas 
that we are focusing on, besides policymaking, is identifying 
best practices, sharing those widely with States, meeting with 
States on best practices and then the issue of oversight.
    On those 16 State reviews, on August 27th, I issued a 
letter to all of those States, saying that we wanted to know 
the results of those recommendations and those reviews. Our 
regional offices are now working with each of those States, and 
we will look at those reviews and also assess whether 
additional reviews are needed.
    Thank you. I wanted to just close by saying that we are 
committed to continuing to make this a focus of our work as we 
go forward and always welcome your insights and your 
suggestions in terms of moving forward.
    Mr. Kucinich. I thank the gentlewoman.
    [The prepared statement of Ms. Mann follows:]

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    Mr. Kucinich. We are going to go to questions of the 
witnesses. The Chair and the ranking member will have 10 
minutes for questions and followed by 5 minutes from other 
Members' questions. We will see how we go in the rounds, 
whether we go one rounds or two rounds.
    I will begin by asking Ms. Iritani, does GAO have an 
estimate of the number of Medicaid-eligible children who did 
not receive a single dental service?
    Ms. Iritani. Yes, we do.
    Mr. Kucinich. How many?
    Ms. Iritani. That would be 12.6 million on the basis of 
nationally representative surveys.
    Mr. Kucinich. Thank you.
    What percent of children does that work out to be?
    Ms. Iritani. That's 66 percent of Medicaid children.
    Mr. Kucinich. So the reality is that--you say 66 percent of 
the eligible children do not receive dental services. 
Meanwhile, the Department of Health and Human Services has 
established a national goal of achieving 66 percent of eligible 
children who do receive dental services by next year. So we've 
got 66 percent not receiving, and the goal is 66 percent who 
will receive the preventative dental services. That is, to 
achieve the national goal, we're essentially going to have to 
turn the current statistics on their head.
    Now, Ms. Mann, you've inherited an agency that, for the 
better part of a decade, has been held back from making 
progress toward this goal.
    For instance, when we asked the official who preceded you 
what it was going to take to increase access to dental 
services, he indicated there wasn't much he could do. He didn't 
believe that he could require corrective actions of the States. 
What do you believe?
    Ms. Mann. I think there's a great deal that we can do, 
Chairman. I believe it's a multi-pronged problem, and we have 
an obligation to have a multi-pronged solution. I think it's 
both----
    Mr. Kucinich. Excuse me. Those are words.
    Ms. Mann. I think we have to give some guidance to States. 
If they're looking for guidance on how to set dental rates, we 
will provide that guidance on how to set dental rates. I 
believe we need to do oversight. As I mentioned, we are 
following up with each of the 16 States that we did the initial 
reviews. There had not been followup till I got back--until I 
came on at CMSO, and we will assess whether additional State 
reviews are necessary. What I want to do is focus on these 16 
States, see where we are, see what progress has been made.
    I do think that CMS can do corrective action plans. We plan 
on doing it in a number of different areas where it's 
necessary. I'd like to work with States and share best 
practices. These are complicated areas. These are troubling.
    Mr. Kucinich. OK. We're going to get into the corrective 
action in a little bit. I want to go back to Ms. Iritani--
excuse me--and thank you. We're, you know, trying to create a 
dialog here.
    Ms. Iritani, in your testimony, you mentioned that more 
than half of the 21 States that provide dental services through 
managed care organizations have reported that MCOs in their 
State do not meet any--or only meet some of the State's dental 
access standards.
    Approximately how many children are going without dental 
services in those States?
    Ms. Iritani. That's a difficult question to answer, 
because, unfortunately, the data by delivery system is not 
reliable. So the 416 that captures the data on access by 
delivery system, we have found, does not break out managed care 
versus fee for service for access, and those States do not have 
managed care throughout the State.
    Mr. Kucinich. OK. If we're looking at achieving a goal 
then, we need to really have some quantitative assessment of 
where we start. Do you have any guess at all? Do you have a 
best guess of what that number would be as to how many children 
are going without dental services in the States?
    Ms. Iritani. In the States that have managed care?
    There are 21 States that reported that they have managed 
care----
    Mr. Kucinich. We know that.
    Ms. Iritani [continuing]. But in some of those States, the 
managed care penetration rate--that is the number of children 
that were receiving dental services through managed care--was 
very low.
    Mr. Kucinich. OK.
    Ms. Iritani. So we can't answer that question, 
unfortunately.
    Mr. Kucinich. We're going to work with you to help get the 
breakdown so we know where the targets are in terms of the 
goals that we have to reach. We have to know where we're 
starting and since it is on a State-by-State basis, so we're 
going to need your help on that.
    Now, Ms. Mann, this subcommittee found that 
UnitedHealthcare, as an inadequate dental provider network, was 
a contributing factor to the preventable death of Deamonte 
Driver. As you know, CMS recently conducted a significant 
review of dental services in 17 States, and you identified 
eight States where Medicare managed care organization provider 
networks were not assured of being adequate to provide access 
to dental services.
    Ms. Mann, do you believe that inadequate dental provider 
networks in Medicaid managed care organizations are a 
significant barrier for children to receive dental care?
    Ms. Mann. Chairman, I think there's an access problem 
inside managed care and outside managed care, and actually----
    Mr. Kucinich. Well, let's talk about inside managed care. 
What do you believe?
    Ms. Mann. I think it depends on each State, and in some 
States, their managed care organizations are not providing a 
sufficient network.
    Mr. Kucinich. OK. So what are you saying? It depends on 
each State. That's not--I need something more specific here. 
You're giving me answers that are interesting, but they're very 
general, and the way that this committee works is we learn by 
getting specific answers.
    Can you be specific?
    Ms. Mann. Each State is different, Chairman, so I can't 
tell you that there is--it's not that inherently managed care 
is a problem. It is that every State has an obligation to make 
sure that network is sufficient. In those eight States, we're 
following up specifically to look at what steps those States 
have taken to ensure----
    Mr. Kucinich. OK. Now, each State is different. Thank you. 
Now I'm focusing on Medicaid managed care organizations because 
they behave like a traditional HMO in the Medicaid context, 
retaining the risk in exchange for capitation fees. Under 
Medicaid, they make money when their enrollees don't get 
medical and dental care.
    This subcommittee held a hearing last month on the health 
insurance industry and the industry spending--on numbers, 
health care is known as medical losses, and insurance company 
executives try hard to keep those losses to a minimum. 
Obviously, one of the ways a for-profit Medicaid managed care 
organization can please Wall Street and can keep their medical 
losses to a minimum is by making it difficult for people who 
are covered to find a dentist who will accept Medicaid.
    In your opinion, have you seen any evidence that dental 
utilization rates differ according to whether a State relies 
upon for-profit Medicaid managed care organizations to provide 
coverage?
    Ms. Mann. The study that I have seen is the study that 
actually you asked for, Chairman, in the CRS report, and it 
certainly showed dental access problems. I have not seen a more 
broad across-the-board study of it. I think that the evidence 
is that, in risk-based contracts, there can be a greater 
propensity for denial of care, and therefore there is a greater 
obligation, if the State chooses to set up its system that way, 
to oversee and make sure that care is sufficient. Medicaid 
obligations----
    Mr. Kucinich. OK. Now we're making some progress here. I 
would like to ask that you and your staff consider 
correspondence received by my staff from Dr. Burton Edelstein 
in which he finds evidence for a correlation between Medicare 
managed care organizations and lower dental utilization rates. 
Did you collect data from the States which would allow you to 
determine if this is a factor, if there is a correlation 
between Medicaid----
    Ms. Mann. You asked about for-profit managed care 
organizations. I have not looked at data looking at for-profit 
managed care organizations. We can look at that more closely, 
Chairman, and I'd be glad to look at that more closely.
    Mr. Kucinich. Good. Thank you.
    Ms. Mann. I will say that we have a real problem in the 
fee-for-service area as well, and so I think that----
    Mr. Kucinich. Well, that's not what this hearing is about, 
though, is it?
    Ms. Mann. I thought the hearing is about Medicaid access 
for children.
    Mr. Kucinich. OK. Ms. Mann, do you believe that inadequate 
dental provider networks, where they're connected to this for-
profit motive, are one of the reasons why so many of these 
children are not getting health care? Is it because of the way 
the system is structured?
    Ms. Mann. I think that Medicaid managed care organizations 
can make it worse or can make it better depending upon what the 
financing looks like, what the incentives are and what the 
oversight is.
    Mr. Kucinich. I want to ask you about one of GAO's findings 
that troubles me.
    In testimony before this subcommittee in September 2008, 
interim director Herb Kuhn testified: CMS will require 
corrective actions for those States not in compliance with 
Federal regulations.
    However, you told GAO that you will only followup with 
States but had no plans to require action from them. As you 
wrote in a cover letter, ``These were programmatic reviews, and 
as such, formal, corrective action plans,'' were not required.
    I'm wondering if CMS has backed down from its earlier 
commitment to this subcommittee to require corrective actions 
from the States?
    Ms. Mann. As I stated a moment ago, we believe the 
corrective action plans are part of our toolkit in terms of 
moving forward on the Medicaid program. These reviews were 
done, as you noted, before I came, and they were set up as 
technical assistance reviews.
    Mr. Kucinich. So you plan to require corrective action 
plans?
    Ms. Mann. Can--if I could finish?
    Mr. Kucinich. Well, just can you answer that question, 
though?
    Ms. Mann. If there--when we complete these reviews back 
from the regional offices, if we still see problems, then we 
will move forward in a separate action for corrective action 
plans, yes.
    Mr. Kucinich. So you're not adverse to corrective action 
plans?
    Ms. Mann. Absolutely not.
    Mr. Kucinich. And you'll be letting this committee know 
about timeframes for the component of that requirement?
    Ms. Mann. Sure.
    Mr. Kucinich. OK. Thank you very much.
    The Chair recognizes Mr. Jordan.
    Mr. Jordan. Thank you, Mr. Chairman.
    Let me pick up where the chairman was.
    The first question or the first point he made was only a 
third of children--this, I guess--I think--I assume he got his 
information from the same place I did--from a GAO study last 
year. Only one in three children are getting treatment for 
tooth decay and other dental problems. So I just want to, I 
guess, cut to the chase.
    Have you seen an improvement in the past year? Is it better 
now? What is the status? And I understand that this is last 
year's study, but here we are late in 2009. What kind of 
improvement have we seen in helping these kids?
    I'll go to Ms. Mann first.
    Ms. Mann. The data from the last 2 years shows a slight 
improvement from 33 percent to 36 percent of kids having a 
dental visit in the past year. So we're--nationwide, we're 
moving, albeit very slowly, in the right direction.
    Mr. Jordan. I would say most people would say that's really 
slowly in the right direction. OK.
    Ms. Iritani, do you want to comment?
    Ms. Iritani. Yes, and we've seen the same data.
    Mr. Jordan. OK. Let me just bring up something to Ms. 
Iritani.
    You talked about one of the things that States have 
reported is this rather heavy administrative burden. In fact, I 
remember my days working at the Statehouse, and you talk to 
local officials. It's always, you know, dealing with the 
Federal Government--dealing with county government, dealing 
with the State government and the Federal Government.
    So, A, is it true? Do you feel like there's a big burden 
you've placed--that has been placed by the Federal Government 
on States, and you know, what ways can States better navigate 
this and better deal with this situation?
    We'll let both of you go at it.
    Ms. Iritani. We asked States about the barriers in their 
States to providers serving more children. Most States actually 
reported broken appointments--patients missing appointments as 
a major barrier. Administrative requirements was reported as a 
major barrier to providers serving more children by about 28 
States, so not as much of an issue.
    Mr. Jordan. Would you be supportive of--and it's one of the 
things I worked on in my days at the Statehouse because of the 
whole welfare reform thing. Would you be supportive of some 
kind of penalty for--I'm just curious--for parents who--the 
appointment has been made. You know, it's in place. Would you 
be in favor of some kind of penalty for families who don't 
bring their child for that appointment?
    Ms. Iritani. We asked States about model practices, and I 
think there are States that are actually dealing with the 
broken appointment issue without a penalty situation. Virginia, 
for example, reported on a broken appointment initiative 
whereby they tracked broken appointments and tried to help 
patients get to their appointments.
    Mr. Jordan. OK. Go ahead. I interrupted you. Go ahead. What 
other actions are being taken to help States deal with the 
administrative burden?
    Ms. Iritani. Our report didn't look at those issues.
    Mr. Jordan. Ms. Mann.
    Ms. Mann. Representative, just to be clear, the Federal 
Government does not in this instance require any paperwork that 
the States use to enroll their providers. So there--I have 
been--as GAO has reported, 28 States identify and providers 
often have identified that paperwork is a problem. If so, it's 
a State-initiated problem, and it's one of the things that, I 
think, is routinely on States' lists to try and address, and I 
think some of the States here to testify today will talk about 
what they've done to----
    Mr. Jordan. It's an internal issue?
    Ms. Mann. It's a State--it's a State issue.
    Mr. Jordan. OK. OK.
    Ms. Mann. It's--to the extent that it's causing barriers, 
we regard it as a CMS issue--an oversight issue, but it's not 
requirements that we put on States.
    Mr. Jordan. OK. OK.
    Let me ask you--one of the things I remember--and this is, 
oh, probably 15, 20 years ago--I guess 15, 18 years ago--and 
maybe it would be better for the second panel, but in Ohio--
this was way back when I was just--when I was assistant 
wrestling coach at Ohio State University. One of the programs 
they had in place was the dental school would--we knew about it 
because I was, you know, employed at Ohio State, but you know, 
we had four children, so we were looking to get the cheapest 
care possible for our kids.
    We took them to the dental college--the dental school, and 
we were very pleased, and it was very--you know, very 
inexpensive. I don't know what it cost, but I just know, when 
you're, you know, a young couple and you've got four kids--or 
maybe at the time we only had three--you're looking to save 
dollars wherever you can. It seemed to work. It seems to me 
that's a concept where, you know, here is a State institution 
receiving all kinds of taxpayer support already, many times in 
large metropolitan areas. That's something that we should be 
encouraging, and again, I was looking ahead in my briefing book 
here. I think we're going to hear from one of our witnesses 
about this issue, but--about this type of program. That makes 
all the sense in the world to me. It may be a little more 
difficult in rural areas where there may not be a dental school 
as close, but you've got to believe that's a way to help meet 
this need and not cost the taxpayers more money, which is 
obviously something that I know I'm concerned about, and I 
assume--and I think the rest of the committee is as well.
    So, if you could, talk about that concept and what's going 
on already and how we can encourage more----
    Ms. Mann. I think there are a number of dental schools that 
are providing direct services. Also, there are some new 
programs being involved, and we are trying to think of 
partnering with them in order to provide some payment for 
training, so--and also some loan repayment programs so that the 
dental students that get trained go out into low-income 
communities. There's also county health departments that are 
providing dental health services and a lot of federally 
qualified health centers.
    So, I think, looking at all of those avenues to build our 
work force in terms of oral health providers is right.
    I was just talking to a State legislator yesterday from 
Kansas. They don't have a dental school in Kansas, so that's 
why each--you know, each State you need to think about the 
different--the landscape and what can work, but I think the 
dental schools have been--can be very critical.
    Mr. Jordan. Do either of you know how many States are 
implementing such an approach right now with one of their 
dental schools or, maybe, with their single dental school?
    Ms. Mann. I don't know, but we can find that out and get 
that information to you.
    Mr. Jordan. It seems to me if it's like--look, if that's 
working and, you know, many States have dental schools----
    Ms. Mann. Sure.
    Mr. Jordan [continuing]. It's certainly something we should 
be doing; and again, not reinventing the wheel, we're always 
talking about the reimbursement rates and what providers--these 
are dental students. They need patients to learn their craft 
on, so it makes sense to me.
    Ms. Iritani, did you want to comment? Do you have any 
idea----
    Ms. Iritani. I think that there are many States that have 
innovative practices such as that, and we recommended to CMS 
that they develop more ways for sure.
    Mr. Jordan. You don't know the number, though? OK. OK.
    Mr. Chairman, I'll yield back the balance of my time.
    Mr. Kucinich. I thank the gentleman.
    The Chair recognizes Mr. Cummings. He may proceed.
    Mr. Cummings. Thank you very much, Mr. Chairman.
    I want to thank you both for your testimony.
    I must admit that, Ms. Mann, I'm feeling a feeling of deja 
vu in that, under the previous administration with CMS, so 
often this committee felt like we were getting the rope-a-dope, 
and I want to be specific because I'm talking about the lives 
of children. You said that there were things that you were 
willing to do.
    Mr. Chairman, I hope you will understand what I'm about to 
say. I want to make sure that Ms. Mann is held accountable, and 
I want specific commitments for these children. We've been 
through a process, Mr. Chairman, as you will recall, where we 
were told things, and nothing happened. Now, either we're going 
to get some specifics as to what is going to happen and address 
these children's needs as the urgency of now, to borrow 
President Obama's words--because it is the urgency of now when 
only one-third of our children are getting what they need so 
that they can grow up and be able to sit at a table like that, 
to be able to go to school without pain, to be able to live a 
healthy life or we need to do something different. We need to 
be specific.
    Ms. Iritani, you said here that CMS agreed to three of the 
four recommendations--is that right?--and partly the fourth; is 
that correct?
    Ms. Iritani. That's correct.
    Mr. Cummings. And which ones did they partly agree to?
    Ms. Iritani. They agreed, in part, with our recommendation 
to conduct reviews in all States with low dental access rates. 
They indicated that they would consider conducting additional 
reviews in the context of other programmatic reviews.
    Mr. Cummings. All right.
    Ms. Mann, you said that there were things that you all were 
going to do. Can you go down each one of the things that you 
said you're going to do or are doing and give us timetables 
now? Because the way we like to operate is we like to bring you 
back on the date within a week or two after you say it's going 
to be done so that we can make sure it's done. See, we have a 
limited amount of time to be in these jobs. We may not win the 
next election, and so we have to be--we want to make sure that 
we are effective and efficient while we are here. Other than 
that, we might as well go and play golf. So the question 
becomes:
    What are you willing to do? When are you going to do it?
    Mr. Chairman, you set the schedule, but I would like for 
that--so that we can come back and check with Ms. Mann as to 
what--if she makes a commitment that we be able to have her 
come before us and let us know that the commitment has been 
completed.
    Mr. Kucinich. Will the gentleman yield?
    Mr. Cummings. Yes, of course.
    Mr. Kucinich. This is our fourth hearing, and you've been 
instrumental in creating every one of these hearings; and as I 
indicated in my opening remarks, we are going to stay on this. 
So we're going to get to know each other real well, and we're 
going to have a chance to be able to compare notes and 
establish metrics, timetables, completion of items because look 
where we are--66 percent are not getting the dental services to 
which they are entitled; and the goal is for 66 percent of 
children to get it.
    So, with your persistence and in working with Mr. Jordan 
and our subcommittee, I think we've got a long way to go, but 
Ms. Mann is now on that road with us, so we'll look forward to 
working with you.
    Now I yield back to Mr. Cummings.
    Mr. Cummings. I just want to go through the things that 
you--the action that you are going to take and when you expect 
to have it done. That's all. I mean, you can be brief. You 
talked about it a little bit already, but I just want to know 
exactly what you're going to do to correct this situation to 
get to that goal.
    Do you agree with the goal, first of all?
    Ms. Mann. Absolutely.
    Mr. Cummings. OK. Just tell us what you plan to do.
    Ms. Mann, don't take this personally.
    Ms. Mann. I'm not.
    Mr. Cummings. I'm serious. I'm speaking about the kids. You 
know, the chairman talked about himself. I was the same little 
kid who got all kinds of dental treatment later in my life. 
I've got kids right now in Baltimore who are going to the 
University of Maryland Dental School because of Deamonte 
Driver, in part, and they're discovering that the infection has 
gone to their eyes. See, apparently--I don't know that much 
about dentistry. Apparently, it goes to your eye before it goes 
to your brain, and I'm talking out for those little kids 
because I want them to grow up.
    So that's why I'm kind of pushing hard on this because I 
don't want us to be making these same arguments a year from now 
or 2 years from now, and then some kid who only has, by the 
way, a limited amount of time to be a child--I don't want to be 
in the situation where that child is either harmed because we 
did not do what we could have done. I want every child--I think 
it was Masloff that says we must be what we can be, and I want 
every child to be what he or she can be.
    So you can go ahead and tell us when you're going to do 
what you're going to do, what you're going to do, and then I'm 
sure the chairman will deal with scheduling hearings 
appropriately so that we can measure our progress.
    Ms. Mann. There are a number of actions already underway.
    As I noted on August 27th, I wrote to each of the States 
that had 16--the 16 States that had reviews. The regional 
offices are currently engaged with those States. I can commit 
to you that, in 30 days, we can tell you a response from those 
followup reviews from the regional offices and let you know 
where we stand on each of those reviews.
    We have a listening session on EPSDT and where we should go 
on EPSDT, which is, as you know, the children's benefit package 
in Medicaid, scheduled for October 16th. That's the first. We 
plan to have a few in that series to help guide us on one of 
the most important actions we can take going forward. I'm happy 
to commit to you the week after that October 16th listening 
session to let you know exactly what the recommendations were 
going forward.
    We plan to do dental reviews in each of the States that are 
at the top of the list to identify, as the GAO has recommended, 
what those best practices are, and I can commit to you to 
provide you that information in the next--I have to figure out 
exactly when we can do those reviews, but I can followup and 
give you an exact date as to when we can do those and when we 
can provide that information.
    Mr. Cummings. Can you give me an outside date?
    Ms. Mann. Sure. I would say by December.
    Mr. Cummings. OK.
    Ms. Mann. We have committed to do the change in the 416 
report by the spring of this year. We have a number of changes 
that we've already developed; and then there's new legislation 
in CHIPRA that we want to incorporate in those changes, and we 
want to do some consultation with experts. So we are having 
that consultation. That's part of the listening session that's 
scheduled for October 16th. We are doing that consultation this 
fall. We are going to be doing those changes this spring in the 
416, which is to improve some of the data collection issues so 
that we can give you the numbers that you're looking for so 
that we can have a better idea and a more accurate idea, 
whether it's in managed care or fee for service, how many kids 
are or aren't getting the services that they need.
    Mr. Cummings. I see my time has expired.
    Thank you, Mr. Chairman.
    Mr. Kucinich. I think, Ms. Mann, you can tell by Mr. 
Cummings' remarks that this committee needs your cooperation 
and that we are not going to stand by and watch any more little 
kids dying. Don't take this personally, but it's your job now; 
it's your responsibility, and so whoever was sitting in that 
chair is going to hear the same thing from members of this 
committee about your obligation to these children.
    These aren't statistics. This was a child who was full of 
promise like every child, and the system let this happen to 
this child; and I see from your background that you have 
concerns about people in these lower economic situations. 
That's where I come from, and I identify with Deamonte, so 
that's why I will not give you or any witness who comes from 
the administration any wiggle room on this question. You will 
not have it. Just know that.
    You know, with all due respect--because you know what? A 
child died. Now, I want--one of the significant reforms that 
could, in theory, increase the number of children who receive 
some preventative dental services is allowing pediatricians to 
apply fluoride varnishes. However, this subcommittee has heard 
that the administrative barriers to reimbursement for providing 
those services are discouraging doctors from doing it. My staff 
has received this correspondence from the Maryland Chapter of 
the American Academy of Pediatrics on this topic, and I ask 
unanimous consent to put this in the record.
    [The information referred to follows:]

    [GRAPHIC] [TIFF OMITTED] T4919.029
    
    Mr. Kucinich. Can you do anything about streamlining 
reimbursement for this procedure?
    Ms. Mann. We do--thank you.
    The Medicaid program does--will--does already in many 
States reimburse many pediatricians for providing sealants, and 
if there's any question that States have about their ability to 
claim Medicaid reimbursement for that procedure, we can 
certainly clarify that immediately.
    Mr. Kucinich. Great. If you'd study that letter, it would 
be very helpful, and maybe you could respond to it and send us 
a copy.
    Ms. Mann. I would be glad to do that.
    Mr. Kucinich. In a letter to the subcommittee, Dr. James 
Crall, who has testified before us on two occasions, 
recommends, ``A uniform program oversight and performance 
assessment regardless of State of residence.''
    I ask unanimous consent to insert the entire text of Dr. 
Crall's correspondence into the record.
    [The information referred to follows:]

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    Mr. Kucinich. Ms. Mann, what can CMS do to fix the 
patchwork of oversight at the State level and to create a 
uniform system of oversight and assessment.
    Ms. Mann. I think we can do a uniform system of assessment, 
Chairman. I think that the responses aren't uniform because the 
problems aren't uniform, and that's--if I could wave the wand 
and get that 66 percent and make it all happen by doing reviews 
tomorrow, I would do that. We don't have providers in many 
States and in many parts of the country that are willing to 
take Medicaid beneficiaries. We have a participation rate--a 
utilization rate in private health insurance of about 59 
percent right now. We've got a multitude of problems in terms 
of getting oral health care to children both in and outside of 
the public systems. It is not an overnight problem.
    We will commit, and we are committed to doing everything we 
can to make the Medicaid program work for every child and to 
make sure that dental care is there; but it is a multi-pronged 
problem, and I don't say that to try and get around our 
responsibilities. I say that to say that we're rolling up our 
sleeves, and it is not a simple solution. If I could do the 
oversight of 50 States tomorrow and say that would solve it, I 
would do the oversight of 50 States tomorrow. It won't solve 
it, but it will get us farther along, and we're willing to do 
that, of course, and to be as aggressive as we can.
    Mr. Kucinich. I think the watch words would be ``corrective 
action'' here, wherever there is action to be taken, that you 
don't stand by and figure they'll solve their own problems.
    Ms. Mann. I agree. I agree. But when we have States come to 
us and say they don't have a dental provider within, you know, 
five counties of their State, corrective action plans won't get 
the child the dental care.
    Mr. Kucinich. But Deamonte Driver died. He had a provider, 
all right.
    Ms. Mann. You're absolutely right, and that would have been 
a very different story. That's exactly right.
    Mr. Kucinich. So we understand that there are certain 
circumstances where you have to become involved in encouraging 
States with respect to their--to provider networks, but there 
are areas where they have providers, and we're wondering about 
corrective action in those areas.
    Now, Dr. Crall's letter also recommends uniform eligibility 
and benefits regardless of State of residency.
    Could you tell us what challenges CMS faces to creating 
such a system?
    Ms. Mann. In the Medicaid program, actually, there is 
uniform benefit eligibility for children. That is the EPSDT 
program, and it is the guarantee that every child get that 
uniform eligibility, which is, simply stated, all the medical 
care that they need, that's deemed necessary. So we have a lot 
of variations for adults in Medicaid but not for children.
    The question is do we get it enforced, and do we have 
providers taking the children, and do families know about the 
availability; and that's why we're setting up this listening 
session and doing this EPSDT work group. We have a problem 
beyond oral health. We have a larger problem making sure that 
EPSDT benefit is observed for every child in the Medicaid 
program.
    Mr. Kucinich. Thank you very much.
    Mr. Jordan.
    Mr. Jordan. Thank you, Mr. Chairman.
    Just a couple of basics I was curious about.
    What is the average time a child is enrolled in Medicaid?
    Ms. Mann. Generally, in any given year, about 9 months.
    Mr. Jordan. So they're in 9 months, out? I mean, is there a 
back-and-forth a lot? Just tell me the typical scenario.
    Ms. Mann. There's a fair amount of back and forth. If you 
look at----
    Mr. Jordan. Over their lifetime, what is the average? I 
mean, the lifetime of the child from 0 to 18. What's their 
lifetime?
    Ms. Mann. I don't know. Over the lifetime, if you look at a 
cohort of uninsured children, about a third of them have 
actually been on Medicaid in the last year or so. So there's a 
lot of turning in and out, and one of the important advances, I 
think, that we can do to help children get access to care is to 
keep that coverage continuous.
    Mr. Jordan. But my point is--so some of these kids who 
aren't getting coverage--I mean do your numbers account for 
this one-third we've determined that are getting the dental 
care? Is it because--could they be, in fact, moving out of 
Medicaid and getting care from a private--you know, a private 
source?
    Ms. Mann. They could be moving out of care and getting care 
from private sources. They could be moving out of coverage in 
Medicaid and simply being uninsured, but not have a card to 
then go to the dentist; and for Medicaid patients, it's 
probably more the latter, but it could be either.
    Mr. Jordan. What's the percentage of eligible Medicaid 
children, the percentage who are eligible who aren't enrolled--
or the number? Give me those numbers.
    Ms. Mann. About 7 out of 10 of all uninsured children are 
eligible for either Medicaid or CHIP but not enrolled. Some 
have been enrolled in the past, but they've been churned 
through the program; but at any given time, about 7 out of 10 
of eligible children--of uninsured children--could be enrolled 
through either Medicaid or CHIP. They're eligible.
    Mr. Jordan. OK.
    Ms. Mann. That's why enrollment and continuous enrollment 
is a very important piece of the quality puzzle.
    Mr. Jordan. OK. OK.
    Thank you, Mr. Chairman.
    Mr. Kucinich. I thank the gentleman.
    The Chair recognizes Mr. Cummings.
    Mr. Cummings. Ms. Mann, the Government Accountability 
Office reported in September 2008 that the extent of dental 
disease in children had not decreased between 1994-2005, which 
means that kids were estimated to have untreated tooth decay. 
Information from that report showed that about one in three 
children ages 2 through 18 in Medicaid had untreated tooth 
decay, and one in nine had untreated decay in three or more 
teeth.
    Compared to children with private insurance--and you know, 
you know the stats--how much funding was lacking and what was 
the cause of unavailability, do you know?
    In other words, what is CMS doing about the urgency of the 
need for the treatment of these children, some of whom may be 
adults now, and how are we addressing that? How do you plan to 
address that?
    Ms. Mann. I'm sorry. The treatment of adults?
    Mr. Cummings. Yes.
    Ms. Mann. In the Medicaid program under Federal law, 
coverage of dental services for adults is optional with the 
States, and as you look through what's going on in the States 
now and during a recession, it's one of the first set of 
benefits that States will cut out if they're looking to reduce 
their Medicaid budgets, so it is not a requirement nor is the 
standard, even once they cover an adult in Medicaid, nearly as 
robust as the standard is for children.
    Mr. Cummings. Ms. Iritani, you were talking about barriers 
and what the State folks said were the barriers, and you said 
that one of the things that was talked about the most was the 
failure to make appointments; is that right?
    Ms. Iritani. That's correct.
    Mr. Cummings. Did you all have any recommendations as to 
how to deal with that?
    Ms. Iritani. Our recommendations aimed at CMS were to 
conduct more reviews of the States with low access rates. 
They--CMS' reviews looked at a number of different access-
related problems, including inadequate provider networks, and 
we also advised CMS that they should take action to ensure that 
any State found with an inadequate provider network to 
corrective action.
    Mr. Cummings. Ms. Mann, you know, when Ms. Iritani was 
talking about this earlier, I was thinking about how important 
it is that parents understand the relationship between teeth 
and the rest of the body. I think a parent--any parent wants 
their kid to be healthy, but I don't think a lot of parents 
have a clue of the relationship between the teeth and the body; 
and I'm just wondering did you have any thoughts on that with 
regard to making sure that we get that information out there?
    We--well, I was the author of an amendment to SCHIP where 
we were able to do some things in that regard, but I'm just 
wondering: Is that on your list? Because, you know, that's one 
of the things that--it might cost some money getting the 
information out, but the benefits would be phenomenal compared 
to the money that we put out because then you'd have all these 
agents call parents, who--you know, it's just like I think of a 
parent who thought that their kid had a fever. They would do 
everything in their power to address that when, certainly, 
tooth decay could lead to something far worse than a fever, and 
so I'm just wondering what your feeling is on that.
    Ms. Mann. I think you're absolutely right. Prevention is a 
key to moving forward. There is a provision--and perhaps this 
is the one you're referring to--in the CHIP legislation that 
requires education for pregnant women and parents of newborns, 
and we are working on developing an education campaign. We're 
partnering--we plan on partnering with the Centers for Disease 
Control. We've been reaching out to some of the philanthropic 
organizations around the country and to look at other 
mechanisms to get information out to pregnant women and to 
newborns about what they can do.
    We also find that the dental utilization rate is much lower 
for adolescents, and I think that's also a lack of information 
about how important dental care is for teenagers, so I think 
coming up with a campaign that helps to provide some 
information to parents as well as to teenagers, themselves, 
will be really important.
    Mr. Cummings. Can you assume--give us a deadline on that, 
give us some type of timetable on that since it's such an 
important and potentially beneficial and cost-saving thing? We 
want to really followup on that, and I have a tremendous 
personal interest in that, all right?
    Ms. Mann. I would be glad to provide you with a plan and a 
timetable attached to it.
    Mr. Cummings. Very well.
    Thank you, Mr. Chairman.
    Mr. Kucinich. I thank the witness for her responsiveness 
and the GAO for their report. This committee appreciates your 
attendance, and we will be in touch with you regarding our next 
meeting. Thank you very much.
    The first panel is dismissed. We will now go to the second 
panel.
    While our staff is concluding its work, this is the 
Domestic Policy Subcommittee of Oversight and Government 
Reform. Today is Wednesday, October 7, 2009. The title of 
today's hearing is ``Medicaid's Efforts to Reform since the 
Preventable Death of Deamonte Driver.''
    We have heard from witnesses from the GAO and also from the 
new director for the Center for Medicaid and State Operations. 
We are fortunate to have an equally outstanding group of 
witnesses on our second panel.
    Burton L. Edelstein, who is a D.D.S. and an M.P.H., is a 
professor of Clinical Dentistry and Clinical Health Policy and 
Management at Columbia University's College of Dental Medicine 
and Mailman School of Public Health. He is founding director 
and board Chair of the Children's Dental Health Project--a 
D.C.-based nonprofit policy and strategic consulting 
organization that advances policies to improve children's oral 
health.
    Mary G. McIntyre, M.D. and M.P.H., is medical director of 
the Office of Clinical Standards and Quality for the Alabama 
Medicaid Agency. She received an award from the Alabama Dental 
Association's House of Delegates in 2004 for outstanding 
leadership and championing the cause for improved oral health 
for Alabama's children. Dr. McIntyre served as chairman of the 
Robert Wood Johnson Foundation National Advisory Committee 
State Action for Oral Health Access.
    Joel Berg, D.D.S. and M.S., is professor and Lloyd and Kay 
Chapman Chair of the Lloyd and Kay Chapman Chair for Oral 
Health. He serves as the Chair of the Department of Pediatric 
Dentistry at the University of Washington and dental director 
at Seattle's Children's Hospital. He is author of a multitude 
of manuscripts, abstracts and book chapters regarding a variety 
of subjects, including restorative materials for children and 
other work related to bio materials and is coeditor of a 
textbook on early childhood oral health.
    We have Doctor--or Frank Catalanotto; is that right?
    Dr. Catalanotto. Yes.
    Mr. Kucinich. D.M.D. He is professor and Chair of the 
Department of Community Dentistry and Behavioral Sciences, 
University of Florida College of Dentistry. He has chaired a 
number of committees in the American Academy of Pediatric 
Dentistry. He has served on the editorial board of the 
Academy's journal, ``Pediatric Dentistry.'' In addition, he was 
a member of the National Affairs Committee of the American 
Association for Dental Research from 1989 to 1995. This 
committee works with the Federal congressional delegation to 
increase funding for dental research, particularly for the 
National Institute of Dental Research. He is currently a member 
of the Legislative Affairs Committee of the American Dental 
Education Association, which advises and lobbies on Federal 
policies and appropriations related to dental education and 
practice.
    I want to thank all of you for appearing before our 
subcommittee. It's the policy of our Subcommittee on Domestic 
Policy of the Committee of Oversight and Government Reform to 
swear in all witnesses before they testify.
    I would ask that you rise and raise your right hands.
    [Witnesses sworn.]
    Mr. Kucinich. Thank you very much.
    Let the record reflect that each of the witnesses answered 
in the affirmative.
    As with panel one, I would ask each witness to give an oral 
summary of his or her testimony. Please keep this summary under 
5 minutes in duration, and your complete statement will be 
included in the hearing record.
    Again, thanks to each and every one of the witnesses for 
being here. I would like Dr. Edelstein to begin as the first 
witness on this panel.
    You may proceed, sir.

    STATEMENTS OF BURTON EDELSTEIN, D.D.S., M.P.H., CHAIR, 
CHILDREN'S DENTAL HEALTH PROJECT; MARY McINTYRE, M.D., M.P.H., 
  MEDICAL DIRECTOR, OFFICE OF CLINICAL STANDARDS AND QUALITY, 
   ALABAMA MEDICAID AGENCY; JOEL BERG, D.D.S., M.S., CHAIR, 
 DEPARTMENT OF PEDIATRIC DENTISTRY, UNIVERSITY OF WASHINGTON; 
AND FRANK CATALANOTTO, D.M.D., PROFESSOR AND CHAIR, DEPARTMENT 
 OF COMMUNITY DENTISTRY AND BEHAVIORAL SCIENCES, UNIVERSITY OF 
  FLORIDA, COLLEGE OF DENTISTRY, REPRESENTING AMERICAN DENTAL 
                     EDUCATION ASSOCIATION

                 STATEMENT OF BURTON EDELSTEIN

    Dr. Edelstein. Thank you, Mr. Chairman, Ranking Member 
Jordan and members of the subcommittee. I appreciate the 
opportunity to come before you today to testify about the 
Federal Government's role and responsibilities in ensuring that 
children in Medicaid have access to the dental care that is 
entitled to them by Federal law.
    I am Dr. Burton Edelstein, Columbia University professor 
and Chair of Children's Dental Health Project here in D.C.
    The founding of the Children's Dental Health Project in 
1997 was a direct response to congressional enactment of the 
State Child Health Insurance Program because I, as a pediatric 
dentist who treated children on a daily basis, was shocked by 
the lack of attention that in 1997 was given to children's oral 
health. It was not until the death of Deamonte Driver that so 
much attention has been brought to this issue, and the 
subsequent work by this subcommittee and others has ensured 
that policymaking simply, as you've demonstrated today, will 
not leave this issue to fester any longer.
    The result of the attention that you have brought to this 
issue led to significant improvements in provisions in CHIP 
through CHIPRA. I commend the chairman and the committee on 
this issue, and I cannot think of a better example of how far 
we have come than to have Cindy Mann as the CMSO director with 
her personal commitment to children and to children's oral 
health.
    Clearly, Mr. Cummings, I agree with the statement you made 
earlier that we may need to do something different, and I think 
we need to explore the limits of what CMS can and cannot do as 
well as what it can do in partnership with other agencies 
across the Federal Government.
    Clearly, all of the progress that has been made has still 
left a number of challenges. So, 2\1/2\ years after the 
subcommittee launched its investigation, we still have Deamonte 
Drivers out there, and we need to consider some of the more 
structural and fundamental issues that limit the access to 
health care.
    At the time that CDHP was founded, subsequent to SCHIP, the 
vast majority of advocacy on behalf of oral health for children 
was made by organizations of dentists. This makes sense, of 
course, because it's dentists who are on the front line of 
providing care to children. However, dentists, parents and the 
program all both contribute to and can help solve the woeful 
inadequacy that you've highlighted today.
    When asked about how to improve the program, dentist 
organizations typically respond with the very items that we 
heard featured today: low payments, complex paperwork and 
noncompliant patients. Unfortunately, we have seen in States 
across the Nation that addressing these three issues alone--and 
many States have taken significant actions on these three 
issues--has not led to the kinds of increases that we would 
hope for. Research has shown that increasing reimbursement 
absolutely is a necessary but not a sufficient condition for 
improving dental access.
    For example, an analysis done by the California Health Care 
Foundation in four States shows that raising reimbursements did 
significantly kick up the percentage of kids receiving care but 
only from a quarter of children to a third, which is that level 
that we're stagnating at today.
    Studies currently underway by my research group at Columbia 
University indicate that, during the period 1999 to 2006, 41 
States did increase fees; 25 showed no increase in utilization 
primarily because those increases didn't bring them into the 
market. However, amongst the 25 that did have an increase in 
both fees and utilization, about half--13--still only reached a 
level of 33 percent or more. Overall, in 2006, 20 of our States 
still provided care to fewer than one-third, and no State has 
broken the 50 percent level yet. A variety of factors 
contribute to this problem, which I've detailed further in my 
written testimony.
    Based on the complexity of this issue, CDHP has advocated 
for a holistic approach to improving children's oral health--an 
approach that combines both public health and patient-focused 
interventions. In my written testimony, I lay out solutions 
that can be pursued by a variety of agencies--by CDC, NIH, 
HRSA, WIC, Head Start, AHRQ, as well as CMS.
    CMS, of course, plays a particularly pivotal role because 
it is both the funder and the regulator of so much of this 
care, and the suggestions that we've made fall under the three 
categories that have been featured already today--leadership, 
technical assistance and oversight--which I believe CMS is now 
fully committed to pursue. My colleagues and I at the 
Children's Dental Health Project look forward to continuing to 
work with this committee, with CMS and with all who are 
concerned about dental care for Medicaid beneficiaries.
    When CDHP was founded, we called it ``a project.'' We 
specifically called it ``a project'' with the realization that 
the problem we're addressing is solvable. Tooth decay in 
children is preventable. The irony is that we're putting so 
much effort into chasing after disease that can be prevented in 
the first place.
    I look forward to continuing to work with you and with all 
who care about children's oral health to solve this problem. 
That concludes my testimony. I look forward to your questions.
    Mr. Kucinich. Thank you very much, Dr. Edelstein.
    [The prepared statement of Dr. Edelstein follows:]

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    Mr. Kucinich. Dr. McIntyre, you may proceed for 5 minutes.

                   STATEMENT OF MARY McINTYRE

    Dr. McIntyre. Mr. Chairman, Ranking Member Jordan and 
members of the subcommittee, thank you for the opportunity to 
speak on behalf of the Alabama Medicaid Agency and the 
population that we serve.
    My name is Dr. Mary McIntyre, and I serve as medical 
director, and I'm not a dentist, but a physician, board 
certified in public health and general preventative medicine. I 
appreciate the opportunity to testify before you today on the 
progress that we have made. This has been a 10-plus-year 
journey, and it isn't over yet. The vision statement for our 
State Oral Health Coalition and for our Smile Alabama! 
initiative is to ensure every child in Alabama enjoys optimal 
health by providing equal and timely access to quality, 
comprehensive oral health care, where prevention is emphasized, 
promoting the total well-being of the child.
    I have been asked to address the programmatic aspects of 
the Smile Alabama! initiative that have, No. 1, improved access 
to and the utilization of pediatric dental services and, No. 2, 
increased provider enrollment and participation.
    More than 10 years ago, the Alabama Medicaid Agency 
recognized that significant growth in the number of children 
eligible for Medicaid dental services and a decrease in dental 
provider participation in the Medicaid dental program had 
combined to create a dental access crisis. The dental 
utilization rate in 1998 was approximately 25 percent, due 
largely to the low number of Medicaid participating providers 
but also because of the widespread belief that preventative 
dental care for children, especially very young children, was 
unimportant. Providers complained of low reimbursement rates, 
uncooperative patients and families, and a cumbersome claims 
filing process.
    A decade later, Alabama Medicaid's dental utilization is up 
by more than 62 percent, and there has been a 216 percent 
increase in the number of dentists who see more than 100 
patients per year. There is greater public awareness that good 
oral health is essential to overall health.
    What made this possible is the collective determination of 
many people in both the public and the private sectors to find 
solutions and the willingness of dental providers, State 
leaders and others to implement steps necessary to bring about 
meaningful change.
    While the initiative known as Smile Alabama! was the 
primary catalyst to this important public health achievement, 
there were several important milestones that laid the 
groundwork for its success. These include the formation of a 
dental task force, increases in the dental reimbursement rate, 
major claims processing changes, dental outreach efforts, 
formation of a public-private alliance, creation of an oral 
health strategic plan and policy leadership team, convening of 
two State dental summits, and finally, the successful funding 
and implementation of the Smile Alabama! initiative.
    In February 2001, the Alabama Medicaid Agency received a 
grant of $250,000 to enhance dental outreach efforts through 
the Smile Alabama! initiative. Funding for the grant was 
provided through the Robert Wood Johnson Foundation's 21st 
Century Challenge Fund--a component of the Southern Rural 
Access Program--and was matched by Federal, State and private 
funds to total more than $1 million.
    In summary, the Smile Alabama! initiative was composed of 
four components--a dental reimbursement increase, claims 
processing simplification, patient outreach in education and 
provider outreach.
    In conclusion, in order to improve access to and the 
utilization of oral health care services, a focus on prevention 
and early care is important. A multi-pronged approach must be 
taken for a complex multifaceted issue. Efforts must be 
ongoing. None of us want any child to suffer. I, personally, 
know what it is to be a child in severe pain from a dental 
abscess because my parents lacked the means to obtain care.
    States are struggling to maintain services in the light of 
severe budget shortfalls. We are currently experiencing 
increased enrollment due to the present state of the economy, 
with shrinking budgets, while trying to increase utilization. 
These factors will limit our ability to push utilization up, 
and must be considered in any discussion surrounding finding 
the solution to the dental access issue.
    It is important that everyone understand that improving the 
oral health status of this most vulnerable population will 
require an understanding of all of the factors that result in 
underutilization.
    Thank you for this opportunity to speak today on behalf of 
the Alabama Medicaid Agency and the recipients that we serve.
    Mr. Kucinich. Thank you, Dr. McIntyre.
    [The prepared statement of Dr. McIntyre follows:]

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    Mr. Kucinich. Dr. Berg, you may proceed.

                     STATEMENT OF JOEL BERG

    Dr. Berg. Good afternoon, Mr. Chairman and members of the 
subcommittee. I thank you for the invitation to testify today.
    My name is Joel Berg, and I am the Chair of the Department 
of Pediatric Dentistry at the University of Washington, dental 
director at Seattle Children's Hospital, as well as the 
secretary-treasurer of the American Academy of Pediatric 
Dentistry. I am a practicing pediatric dentist, and I care for 
a large number of Medicaid eligible children. I am honored to 
appear before you today to represent and to share the success 
of Washington State's Access to Baby and Child Dentistry [ABCD] 
program.
    The goal of ABCD is to expand access to oral health 
services by Medicaid eligible children from birth through their 
6th birthday. More than a dozen nationally publicized articles 
and published articles have clearly demonstrated that early 
prevention reduces future dental costs and that ABCD is an 
effective, cost-saving method of improving the oral health 
status of children enrolled in Medicaid. The first ABCD program 
was established in 1995 in Spokane, Washington as a 
collaborative effort between public and private sectors. The 
community agreed that something needed to be done to address 
the severe lack of dental access among high-risk, low-income 
preschool children.
    ABCD programs are locally administered by a health 
jurisdiction or a community agency that contracts with the 
local health department. The administrator then works with an 
identified ABCD dental champion, who is a leading pediatric 
dentist or general dentist who is selected and trained by the 
University of Washington to identify, recruit, train, and 
mentor other local general dentists. ABCD encourages general 
dental offices, not just pediatric general offices, to provide 
a positive dental experience and a dental home by age 1. The 
ABCD program is embedded in many local Head Start and Early 
Head Start programs, now both under the American Academy of 
Pediatric Dentistry Leadership.
    In Washington State, ABCD is a collaborative effort of 
Washington Dental Service Foundation, the University of 
Washington School of Dentistry, the Department of Social and 
Health Services, the Washington State Dental Association, the 
Department of Health, local dental societies, and local health 
jurisdictions.
    ABCD-certified dentists receive enhanced Medicaid 
reimbursement for selected procedures on enrolled children. 
Dental office staff receive training and communication in 
culturally appropriate followup with families, and the billing 
staff learns how to work with the Medicaid program.
    With the growth of the ABCD program, an increasing number 
of Washington physicians is now addressing oral health during 
well child checks because ABCD-trained dentists serve as 
referral sites. Medicaid reimburses trained and certified 
primary care providers for delivering oral screenings, health 
education, employed varnish applications during well child 
checks, and they make the necessary referrals to dentists.
    Today, 31 of Washington's 39 counties--more than 1,000 
dentists--participate in ABCD, and several other States have 
expressed interest in adopting this successful program. ABCD 
has more than doubled the number of young Medicaid children in 
Washington to receiving dental care from 40,000 to 107,000--a 
utilization increase from 21 to 39 percent.
    The ABCD program is reducing overall dental costs. 
Education/prevention is most cost-effective during the first 2 
years of life, and ABCD is making progress toward increasing 
the number of children who receive care before their 2nd 
birthday. In 2008, nearly 22,000 children under age 2--19 
percent of eligible children--received dental services. When 
the program began in 1997, only 3 percent, close to what is 
probably the national average today of eligible infants and 
toddlers, received dental care.
    While targeted enhanced reimbursements for increased 
frequency of preventative interventions for young Medicaid 
children are extremely important, other elements must be 
present to ensure the success of ABCD. The Washington Dental 
Service Foundation coordinates the program at the State level, 
and provides 3-year startup grants to launch the program 
locally so that outreach to families, case management, support 
services for the dentists, and other critical activities are 
included.
    In the years ahead, the ABCD program will be expanding the 
use of risk assessment tools as exciting technologies are 
emerging. This combined with increasing incentives for earlier 
intervention and for higher risk children, an expanding 
partnership to refer the highest risk children--the highest 
risk and low-income children--to a dentist as early in life as 
possible will further improve the oral health of the program's 
children.
    We must combat the growing crisis in childhood dental 
disease and increase access to care to some of our country's 
most vulnerable patients. ABCD is a proven best practice that 
is working in Washington State. I thank you for the opportunity 
to share the success, and we look forward to working with 
others States across the country to increase access to dental 
care.
    Thank you.
    Mr. Kucinich. Thank you, Dr. Berg.
    [The prepared statement of Dr. Berg follows:]

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    Mr. Kucinich. Dr. Catalanotto, you may proceed.

                 STATEMENT OF FRANK CATALANOTTO

    Dr. Catalanotto. Thank you.
    Good afternoon, Mr. Chairman and Ranking Member Jordan and 
members of the committee.
    My name is Dr. Frank Catalanotto. I am Chair of the 
Department of Community Dentistry and Behavioral Science at the 
University of Florida College of Dentistry. I am here today on 
behalf of the American Dental Education Association [ADEA].
    ADEA's membership consists of academic dental institutions 
who serve as dental homes for a broad array of racially and 
ethnically diverse patients, many of whom are uninsured, 
underinsured or reliant on public programs such as Medicaid and 
the Children's Dental Health Program.
    The American Dental Education Association is grateful for 
the opportunity to share our perspectives and recommendations 
for improving the children's dental program and Medicaid.
    First, a couple of comments about academic dental 
institutions as safety net providers, and this is the answer to 
some of your questions, Mr. Jordan.
    Academic dental institutions include dental schools and 
dental hygiene schools that provide dental care reduced fees 
and provide millions of dollars of uncompensated care in our 
clinics each year.
    All 59 U.S. dental schools and over 200 schools of dental 
hygiene operate clinics that teach students how to treat a 
broad array of patients and conditions as part of our 
educational mission.
    On average, over 53,000 patient visits were conducted 
annually at each U.S. dental school, totaling more than 3 
million patient visits; and over 50 percent of those patients 
were on public assistance programs. At the University of 
Florida college clinics, we had over 101,000 patient visits in 
2008; and 76 percent of those patients were at 200 percent of 
the poverty level or below.
    A couple of comments about Medicaid dental benefits and 
academic dental institutions.
    Safety net dental programs and community health centers, 
local departments and academic dental clinics operating at full 
capacity are only able to meet about 8 percent of all the unmet 
dental needs in this country. There are few public subsidies 
that are available to academic dental institutions to help pay 
for the uncompensated care we provide.
    Medicaid dental reimbursement levels have also been 
historically low. On average, they equal the lowest 10 percent 
of market rates in many States. In Florida, for example, our 
Medicaid reimbursement fees rank at 49th of the States. 
Therefore, 74 percent of the 18,000 children we saw in the 
University of Florida college and university clinics were at or 
below poverty level. In other words, they were on Medicaid. And 
the low reimbursement rates we receive put considerable strain 
on our ability to continue providing these services.
    I would like to give you two examples of how academic 
dental institutions can help improve access to care in the 
United States.
    The University of Florida College of Dentistry has a 
Statewide network for community oral health that operates five 
dental clinics and is affiliated with nine other clinics 
throughout the State of Florida, from Miami to the border of 
the western part of the State; and these partners include 
federally qualified community health centers, county health 
departments, and a mobile dental van. The network serves 
Florida's most vulnerable populations and provides 
comprehensive dental care in the areas of greatest need around 
the State.
    The second example, in 2002, the Robin Wood Johnson 
Foundation and the California endowment funded a program to 
promote community based dental education in 23 dental schools 
with grants totaling approximately $38 million. One of the 
dental schools funded was the Ohio State University College of 
Dentistry. The College's goal with the Robin Wood Johnson money 
was to reach populations in need of dental care across the 
State. Starting in 2003, when they first received the grant, 
the dental school had 10 community based sites. By 2007, they 
had expanded to 46 sites where their dental students and 
residents provide dental care to underserved and low-income 
minority income patients.
    So what are the recommendations we have? My written 
testimony provides eight specific recommendations that ADEA 
would suggest, but I would like to focus on just three of them.
    First, fund the expansion of community based dental 
education learning programs with academic dental institutions, 
and the Robin Wood Johnson pipeline project is an example of 
the kind of funding that maybe could be provided at both the 
Federal and at the State level.
    Second, develop standards and protocols for models of care 
that allow other primary care professionals to help gather 
data, detect clinically pathological conditions, dental 
conditions, triage, and refer patients to appropriate dental 
professionals for care.
    One of the questions asked earlier was about the role of 
physicians in providing oral health services. You may have 
noticed in my background that I have a grant from HRSA to 
actually train physicians to provide such care to provide oral 
health preventive services that are funded by Medicaid, and 
involving other members of the health care team is a critical 
step in this process of addressing access to care.
    No. 3, provide Federal funds to States for school-based 
oral health promotion, education, and prevention programs. 
School-based sealant programs are another example. In other 
words, bring care to the K-12 school system where the children 
are.
    In conclusion, the American Dental Education Association 
believes it is critical for Congress to preserve basic medical 
services for Medicaid beneficiaries and safeguard essential 
Medicaid dental benefits in any reform of the U.S. health care 
system. ADEA and its member institutions are prepared to work 
with Congress and other health care advocates to identify 
programs and policies that will increase access to care for 
underserved patients in Medicaid.
    That is my testimony. Thank you very much.
    [The prepared statement of Dr. Catalanotto follows:]

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    Mr. Kucinich. Thank you, Doctor.
    Now you gave us three out of eight.
    Dr. Catalanotto. There were two, sir--my apologies--two of 
the ones I wanted to assess. My error.
    Mr. Kucinich. I just wanted to make sure that you feel that 
you communicated your major points.
    Dr. Catalanotto. The other six are provided in detail in 
the written testimony.
    Mr. Kucinich. OK. I just want to make sure that you had a 
chance to note that. It sounded like you were on a roll there. 
I didn't want to cut you off.
    Dr. Catalanotto. Thank you.
    Mr. Kucinich. Let's go to questions for the witnesses.
    Dr. Edelstein, in your prepared testimony, you address the 
situation that occurred in Georgia where vendors cut providers 
from their networks to ward off utilization increases imposed 
by the States. This is clearly an unintended consequence of 
reform that was intended to increase access to care.
    In your opinion, what does the evidence suggest about the 
consequences of relying upon Medicaid managed care 
organizations to provide dental coverage to children?
    Dr. Edelstein. What I am referencing there is specifically 
placing managed care companies at financial risk. And, as was 
mentioned earlier, depending upon the quality of the contracts 
and the degree of oversight, it is possible to have a variety 
of relationships between a State and a managed care company and 
still have a satisfactory outcome.
    However, in the case of dentistry per se, there is very 
little that managed care companies concurrently do to manage 
the care in order to effectuate savings; and so the primary 
technique that they have left to rely upon in order to protect 
their profit line--because these are for-profit at-risk 
companies--is to control utilization. And that means that 
there's a perverse incentive built into the concept with regard 
to dentistry, because there's very little else that the managed 
care company can do to protect its bottom line.
    Mr. Kucinich. Thank you, Doctor.
    Drs. Berg and McIntyre, if you could both give a try at 
answering this one.
    Patient compliance is often cited as a barrier to improving 
outcomes in State Medicaid dental programs. Both of your 
programs have a case management component. And what are some of 
the specific interventions of case management?
    Before you answer that question--Ms. Mann, I just want to 
note something. First of all, you may be one of the only 
administration official who has actually stayed to hear 
witnesses on the next panel. It's very rare and refreshing. 
Thank you.
    So, Dr. McIntyre and Dr. Berg, what are some of the 
specific interventions of case managers in your programs that 
increased patient compliance?
    Dr. McIntyre. I want to start first with a regional--
because we kind of redesigned things with our First Look 
Program, but we originally wanted to address the issues that 
the providers themselves talked about, which was the missed 
appointment. And what the care coordinators provided was the 
means of actually contacting patients to assist them with 
getting into their providers' offices. You know, they address 
issues such as the care of the other children, which is 
something that a lot of times people didn't think about. Well, 
what did they do with the other kids when they really have an 
appointment to see the dentist for maybe one or two of those 
children, issues such as transportation to the dental office.
    And sometimes there were issues that didn't have anything 
to do with the transportation. There were issues concerning, 
well, I don't know how I am going to pay rent tomorrow, so I am 
not really worried about keeping a dental appointment next 
week. So that the care coordinators had to get into not just 
the issues of the dental appointment themselves but also the 
other issues that were surrounding the reasons why these 
patients wouldn't keep appointments.
    And then one of the things we had to deal with was also to 
address the dental provider's problem about behavior in the 
office, and we did that also as part of this program. We are 
trying to educate them on, you know, taking one child and 
making sure that you are on time for your appointments.
    Mr. Kucinich. Thank you, Dr. McIntyre.
    Dr. Berg, would you like to respond?
    Dr. Berg. Yes, Mr. Chairman.
    I think you were pointing out that one of the most 
important aspects of the ABCD is the local ABCD coordinator. It 
is a county specific--or local health jurisdiction specific 
program. And we found, indeed, that in the smaller local health 
jurisdictions it's easier to get access to care through the 
ABCD program because it's easier in the smaller communities to 
coordinate efforts. We found, actually, that we had lower no-
show rates than some of the ABCD programs in most jurisdictions 
then with the non-Medicaid populations. We have evidence to 
show that.
    So these care coordinators are absolutely critical in the 
scheme of things to make things work. We have evidence of that 
in different counties.
    Mr. Kucinich. Thank you, Dr. Berg.
    The GAO study reveals that States overwhelmingly would like 
additional guidance from CMS. So if we could again hear from 
Drs. McIntyre and Berg, from the State perspective, what 
specific suggestions do you have for CMS to improve the 
guidance they provide to State Medicaid systems?
    Dr. McIntyre. Well, as a State that I think we had a 
relatively--what could I say--a very good relationship with our 
regional office when it came down to getting assistance, we 
didn't have any problems recalling. But specifically when it 
comes down to recommendations, the main thing is to communicate 
specifically what we can and cannot do from a State standpoint. 
And I think a lot of times States are under the, I guess, 
misinformation as far as with misunderstandings about what 
policies will allow them to do or not do.
    But we didn't have it, that particular issue, because we 
got clear communication about, well, you know, when it came 
down to Smile Alabama!, no one told us that we couldn't go 
after outside funding, so we did. We did a check, and it was 
OK. So we went after funding in order to do the program.
    But I think there's something that other States need to 
know, that you don't have to deal with just the money that you 
have, you know, within the State coffers, that you can look 
beyond that and identify private-public partnerships in order 
to do some of the programs that you want to do from a State 
standpoint.
    Mr. Kucinich. Thank you, Doctor.
    Dr. Berg, if you could answer. My time has expired, but 
please just give a brief answer.
    Dr. Berg. Yes, please. I will give specific 
recommendations.
    The State of Montana just adopted an ABCD-like program 
modeled after Washington State's program. They actually did 
what we would have liked to have done this year, but it wasn't 
fundable in the current legislature, and that is to incentivize 
earlier intervention where we can separate the highest-risk 
children.
    We know that, as was stated earlier, 80 percent or 
something of the cost is spent on 25 percent of the children, 
and that starts at about age 2\1/2\ or 3. If at age 1 we can 
identify who they were and segregate them and have more 
aggressive intervention for the higher-risk children, we can 
save money. We have actually done an economic modeling of this 
through our health economist and have shown that it can work.
    So I would absolutely look right now at earlier 
intervention, incentivizing earlier intervention, incentivizing 
higher risk, more aggressive interventions.
    Mr. Kucinich. Thank you very much.
    The Chair recognizes Mr. Jordan.
    Mr. Jordan. Thank you, Mr. Chairman.
    Let me thank the witnesses, too, and for your commitment 
for helping these children.
    You know, the goal is, as Dr. Berg just said, to treat them 
as early as possible so we save on costs in the long term and, 
obviously, hopefully avoid any type of tragedies like with 
Deamonte. And I appreciate the work that the universities are 
doing. It was great to hear that. I think I got the numbers, 3 
million you said.
    Dr. Catalanotto. Three million dental visits across the 59 
dental schools. That does not include any visits that might 
have occurred at----
    Mr. Jordan. In a year.
    Dr. Catalanotto [continuing]. Dental hygiene programs.
    Mr. Jordan. Wow. You said at your university you had 
100,000 last year.
    Dr. Catalanotto. 100,000 visits, 76 percent of which were 
patients at 200 percent of the poverty level or below.
    Mr. Jordan. 100,000 children?
    Dr. Catalanotto. No, 100,000 dental visits. There were 
26,000 children of that 100,000.
    Mr. Jordan. We appreciate all that.
    Dr. Edelstein, in your comments you said three things--
paperwork, low reimbursement rates, and noncompliant patients--
make it tough for certain providers to do this care. Which of 
the three is the one that--if you had to rank order those 
three, which is the one that is the most difficult for dentists 
to deal with?
    Dr. Edelstein. The one that is perceived and reported to be 
the most difficult is the low reimbursement, and the point I 
had hoped to make clear is that sufficient funding is a 
necessary but not sufficient condition.
    Mr. Jordan. Would it help--let me ask you this question. I 
am going to ask some fundamental questions here.
    Would it help if dentists would be able to--for those 
families who can pay something, would it help if they could 
say, OK, Medicaid covers this much and would you as a family be 
willing to pay X amount of dollars to cover the cost of the 
care? Would that help?
    Dr. Edelstein. I have no idea, except to suggest that it 
would create a significant--as small business people, it would 
create significant billing hassles and problems trying to deal 
with the copayments. As a practitioner who actively 
participated in both Medicaid and CHIP in Connecticut where 
copays were allowed for some CHIP patients in Connecticut, we 
did confront significant problems with trying to manage that 
cost-sharing portion.
    Mr. Jordan. OK.
    So, again, you started--I think you were starting to say 
that what you hear typically is low reimbursements is the 
single biggest reason given for not accepting these patients. 
But it sounds to me like that's not what you believe. What do 
you believe?
    Dr. Edelstein. Well, the ``but'' was that our study nearing 
completion now tried to assess the impact of different levels 
of fee increase on utilization; and what we discovered were a 
couple of things. First off that with the increases, generally, 
you have the same providers who were already seeing Medicaid 
patients seeing many more Medicaid patients, rather than 
bringing a lot of new providers into the actual provision of 
care.
    Now, that's when fees are the primary intervention. As Dr. 
McIntyre mentioned, in Alabama, there was additionally some 
case management and reductions in paperwork with prior 
authorizations. So a multi-pronged approach did help.
    On the other hand, even in Alabama, with all of its 
tremendous effort, we see that relative increase was 
tremendous, but we still hit the same sort of barrier, hitting 
the top levels that any States have hit in the 40 to 45 percent 
range. And it's tempting to think that barrier really 
represents parents' failure to pursue care, but, in fact, 
parents are able to obtain significantly higher levels of 
medical care, raising the question about whether the doors to 
the dental offices are truly open.
    Mr. Jordan. OK. What--you mentioned noncompliant patients 
as one thing here. Do you think that's a real problem or not?
    Dr. Edelstein. Well, the noncompliance has to do with 
appointment keeping; and I think Dr. McIntyre explained how 
complex some of these individuals' lives are. But there's an 
excellent example that I cite in my written testimony from New 
York State, Tompkins County, where a county level care 
coordinator liked what the American Dental Association has 
suggested, as the community dental health coordinator acted as 
a case manager.
    Mr. Jordan. Let me just ask this question of all of you and 
see what you thought. And I brought this up, I think, in the 
very first round of our first panel.
    You know, there are all kinds of taxpayer assistance that 
the typical Medicaid-eligible family receives. I kind of come 
from the school of thought that says, if you want responsible 
behavior, you should reward it and irresponsible behavior, 
there should be some kind of penalty for it.
    Do you think it would make some sense if, in fact, parents 
aren't complying with the appointments that they have, aren't 
doing what needs to be done for their kids relative to dental 
care, if there was some kind of sanctioning or some kind of 
penalty in--you know, typical families getting nine or ten 
different types. They are getting TANF. They are getting 
housing. They are getting food stamps. On and on it goes.
    Some kind of sanctioning process, do you think that would 
be helpful, along with what Dr. McIntyre, I think, and Dr. Berg 
referred to in a previous answer, the care coordinator and the 
case manager approach as well?
    Let's go down the line.
    Dr. Edelstein. I personally am more of a carrot than a 
stick person, thinking that as soon as there is a clear 
understanding of what the child's needs are that there be an 
effort to engage the family in a positive way. My concern is 
the child and recognizing the complexity of some of these lives 
to get to whatever benefits the children.
    Mr. Jordan. Yes. It seems to me--look, I know we did well 
for reform in the State of Ohio. I was the guy who did the 
language on the time limits component, and we said we are going 
to make sure kids get health care. We are going to make sure 
kids get, you know, the food they need. But at some point, if 
an individual is not willing to work and they are an able-
bodied adult, they are no longer going to receive cash from the 
taxpayers. And it was a long period of time, and we gave them 
job training and everything else.
    But at some point if you don't have that deadline, if you 
don't have--I would say deadlines influence behavior. And if 
you don't have that out there as some kind of thing that 
everyone has to think about--we all have to function. Everyone 
in the world has to function under those kinds of responsible 
things and those kinds of deadlines. It seems to me there might 
be an approach in there that can work and still make sure that 
these kids get what they need.
    Dr. Edelstein. Perhaps when dental access is readily 
available, when those office doors really are open and parents 
can have success in pursuing their desire to find treatment for 
their kids, then perhaps it would be time to think about the 
sticks.
    Mr. Jordan. Mr. Chairman, if I could, real quick----
    Mr. Kucinich. If you can give a quick answer.
    Mr. Jordan. I thank the chairman's indulgence.
    Real quick----
    Mr. Kucinich. Just give a brief answer.
    Dr. McIntyre. From the standpoint--I am like Burt. I look 
at the carrot versus the stick. And the reality is that 
sanctions will really hurt the children. Because what we are 
looking at is you are sanctioning the parents for behavior that 
the kids have no control over. And then what happens is they 
don't get into care. So really it would only hurt them.
    Mr. Jordan. The only thing I would say is----
    Dr. Berg. I would agree with the last part of Dr. 
Edelstein's statement as well, that when the access problem is 
solved and there is much more readily available access, then we 
could look at some pilot projects perhaps to study that. I 
think we don't have enough information to know if it's 
effective or not. I would want to study it on a small scale to 
see what kind of effectiveness we have.
    Dr. Catalanotto. Just to emphasize that, in Florida, for 
example, only 10 percent of Florida dentists see Medicaid 
patients. Our numbers are worse than the rest of those States. 
We only have 25 percent of children achieving any kind of 
dental visit.
    So until you solve the access problem, it's not--I don't 
think it's appropriate to talk about punishment for the 
parents, which ultimately punishes the child. We need to fix 
the access problem first.
    Mr. Kucinich. I thank the gentleman.
    The Chair recognizes Mr. Cummings.
    Mr. Cummings. Dr. McIntyre--thank you, Mr. Chairman.
    Tell me, what part did--first of all, the folks who you all 
hire, are these a lot of community people? In other words, that 
have the kind of sensitivity that you are talking about?
    I think they first have to understand--it really reminds me 
of Healthy Start. In other words, you have people who 
understand the complexity of people's lives. They understand 
that punishment is--I could have answered that question. That's 
not going to get it, because then they will drop out of the 
system.
    Dr. McIntyre. They will.
    Mr. Cummings. But so you must be--you must look at a 
certain type of worker who has a certain level of sensitivity.
    Dr. McIntyre. We didn't hire anyone. Let me get that 
straight. This is--remember when I talked about public-private 
partnerships? We actually worked with the Health Department to 
get care coordinators in the community.
    Mr. Cummings. I see.
    Dr. McIntyre. So that many of these people were folks that 
knew people already, that people were comfortable with. They 
were at the community level. They were on a county level. So 
that when you are calling to get a child in that a lot of times 
these people really know who the children are.
    Mr. Cummings. I see.
    Dr. McIntyre. So I think in that standpoint we didn't go 
out and hire a bunch of people. We worked with the Health 
Department to get care coordinators at the county level in 
order to work to put this program into place.
    And that's the whole thing about working together with all 
of the different entities within the State. It's not just a 
Medicaid issue. It's an issue that involves the entire State, 
and it involves all the people that are there coming together 
to try to come up with a solution.
    Mr. Cummings. Dr. Edelstein, we were talking about the 
whole idea of--you were here earlier when we talked with the 
other panel about this whole idea of a campaign to educate 
parents with regard to the significance of dental care for 
their children. Tell us, how do you feel about that? I mean, do 
you think that is very significant?
    Dr. Edelstein. Yes. The parents clearly have a critical 
role, particularly, as Dr. Berg mentioned that the disease 
onset is very early in life. And so we need to get to parents 
very early in life, as required now by CHIPRA.
    But one of the roles for the parents is the day-to-day, 
moment-to-moment decisions that they make that either 
predispose their kids to have this problem or predispose their 
kids to avoid this problem. And so the education needs to be 
about more than dental care but has to be about managing the 
risk factors for developing the disease in the first place.
    Mr. Cummings. You know, I visited Kennedy Krieger in my 
district. They have this clinic for severe dental problems for 
kids, and they showed me some kids who had had phenomenal 
damage as little kids. I mean, who literally had to go through 
major surgery as a little kid--I mean, like 3 years old--
because of things like a bottle with sugar, like juice bottles, 
and the sugar gets to the tooth. And a lot of people don't 
realize how significant those little things are. And I just 
think that education is so significant.
    The other thing I was going to ask you about is these 
federally qualified health centers. One of the things that I 
pushed hard for is making sure that they could contract with 
dentists. Because a lot of times that's a missing piece, and 
those help centers are located smack dab in the middle of 
places where people would not normally be able to get health 
care.
    You might want to comment on that, too, Dr. McIntyre----
    Dr. Edelstein. Well, if I might reflect on the value of 
that contracting, it has so many values. The first is that it 
allows dental practitioners who are not Medicaid providers to 
contract with FQHCs to see Medicaid patients and thereby become 
familiar with the patients as people, as patients who they can 
become more comfortable with and discover really face the same 
kinds of dental issues that others do and can be readily 
accommodated in their practices.
    The second is that it expands the capacity of the federally 
qualified health center. So many of the health centers are 
limited either by not having dental facilities themselves or 
having facilities and no dentists, because there is a shortage 
in the FQHC system. So that allows them to contract with 
dentists to expand their capacity.
    So, on both sides, it benefits the patients, it benefits 
the dentist, it benefits the health centers. And we anticipate 
that experience the dentists will have will lead them more 
likely to become active Medicaid providers.
    Mr. Cummings. Dr. McIntyre, did you have a comment on that? 
And thank you.
    Dr. McIntyre. Yes, I wanted to comment that, in looking at 
the public-private partnership, the FQHCs are vital in making 
sure that we identify all of the resources available.
    And some of the things we did was also identify not just 
the Medicaid dentists per se but also for uninsured--because a 
lot of our uninsured go on and off, you know, their own 
Medicaid; then they have no insurance at all--to make sure that 
those resources are available for them.
    But there is a shortage. When we talk about addressing 
access issues, one of the things I wanted to bring out was 
this: Overall, in our State, as of May, we had a shortage of 
288 dentists. Now this is not Medicaid dentists. This is a 
shortage in dentists in the counties.
    So, in addressing the issue, we have to address the work 
force in order to--like, he was talking about are their doors 
really open? Well, the doors are open, but who gets in it to 
see is something that you have to consider when you are looking 
at that. Because the work force itself is part of this problem.
    Mr. Cummings. Thank you.
    Mr. Kucinich. I thank the gentlewoman.
    The Chair recognizes Mr. Issa.
    Mr. Issa. I thank the gentleman.
    I thank the chairman for holding this hearing, because I do 
believe it is important that we as a committee that looks at 
waste, fraud, and abuse also look at government efficiency; and 
that's, I think, a great deal of what we want to work on here 
today.
    Before I do my comments, I would like to yield to the 
gentleman from Ohio for his question.
    Mr. Jordan. Well, just a quick comment, and I do have to 
run to an RC thing.
    I could tell the panel didn't particularly like my 
suggestion about holding parents more accountable. But I would 
just point out this. We heard from the previous panel that the 
number was one in three kids, 33 percent, were getting the 
treatment, according to the study done in 2008. And since that 
time Ms. Mann's answer was it has been improved all the way up 
to 36 percent now.
    So, obviously, what we are doing isn't working. Maybe it 
makes sense, you know, to try the same old, same old, giving us 
the big increase of 3 percent. Maybe it makes sense to try 
something different and go the route that I suggested. That's 
my only point. I know it's worked in other parts of welfare 
reform. It has worked in the State of Ohio.
    So I would just offer that and thank the gentleman for 
yielding me a few seconds.
    Mr. Issa. Now I am going to take a slightly different line 
of questioning.
    I guess I have an MD, a DMD, and two DDSs, so that probably 
gives me all of the passel of opinions.
    When I was growing up in Cleveland, Ohio, right next to but 
slightly down the street from the chairman, we still had a 
great deal of, if you will, the public health care system; and 
a lot of the services at that time were delivered through 
nonprivate means if they were going to be delivered. I got my 
shots through the public system and so on. And that delivery 
system for the working poor and even up tiptoeing through the 
middle class and certainly for what we would call the most 
indigent among us today was an accepted part of society.
    It appears to me as though, as we have divested ourselves 
of that, and the Medicaid system has been about money being 
delivered, often, often not at the same rate, haven't we moved 
away from--at least germane to today--if preventive medicine, 
recognizing that dentistry expands to fill the amount of money 
you have, that if you have enough money--and we here on the 
dais don't have a dental plan--or at least it's not standard in 
our program. If you have enough money, you don't get amalgam. 
If you have enough money, you don't get false teeth; you get 
implants. If you have enough money, you go through a series of 
much more expensive levels of care. And I think you are all 
aware of just how phenomenal dentistry can be if you have the 
dollars for it.
    But aren't we here today talking fundamentally about the 
least--trying to find the most efficient, least expensive, most 
universal for the poor delivery of evaluation, cleaning, and 
prevention? And isn't our system somewhat broken in that if 
that's what you wanted to provide, would you provide it the way 
you do today? And this is regardless of 3 percent more money, 6 
percent less money.
    I would like your comments on that. Because, for this 
committee, we do try to think in the sense of organization of 
government.
    I will go right down the line. Thank you, Doctor.
    Dr. Edelstein. Interestingly, this problem is not unique to 
the United States; and underserved populations having lack of 
dental care is a global phenomenon. So if we look at other 
countries like ours--Great Britain, New Zealand, Australia, the 
Netherlands--to see how they have approached this, they do it 
primarily with the advent of different kinds of providers. I 
wouldn't say that it's necessarily a public delivery system, as 
opposed to a private delivery system, but it's a more readily 
accessible, more limited in scope provider who is more like the 
vulnerable population being treated.
    And there are a number of ideas, from the American Dental 
Hygienists Association, the American Dental Association, new 
legislation in Minnesota, experiments and new programs in 
Alaska, a variety of approaches that bring dental therapists to 
increasing the capacity for the delivery of services. So, 
looking at other countries, that might be one direction of 
particular value.
    Mr. Issa. As you go down the list, the reason I said 
``public'' is that I understand that dental practice and State 
regulations tend to predetermine certain things such as a 
hygienist being able to work on their own or not, an assistant 
work on their own or not. I used the term ``public'' because 
it's a preemption for the poor potentially that would allow us 
to find the most efficient way to provide preventive medicine 
that might not be universally available in some States. Being 
in California now, I am aware of that.
    Please, Doctor.
    Dr. McIntyre. Well, as a physician, one of the things that 
I started out with our group, when we first formed our task 
force in our coalition, was that the mouth is part of the body 
and that for some reason we have kind of separated it out and I 
think a lot of problems came from that.
    But we have actually started using our primary care 
providers, physicians, more because dental caries is a disease 
and, like any disease, in order to get away from the disease 
later, we have to prevent it. So if we can start early, when 
children first get their teeth--you know, when they get those 
first two in the mouth, even before they get their teeth, we 
start educating mothers when they are pregnant about what they 
need to do. They get brochures and information from the care 
managers about how to take care of the teeth and the babies 
aren't here. They are more likely to listen before the babies 
are born. Then when they get here, then doctors who see 
children and give them their shots is an ideal opportunity to 
educate, assist, and refer; and that's what we are trying to do 
to utilize the system.
    Mr. Issa. If we could narrow the answer just to the 
organizational one, because I am testing the chairman.
    Mr. Kucinich. Please respond, the gentleman's time has 
expired.
    Dr. McIntyre. And that is part of the organization.
    Mr. Issa. Thank you.
    Dr. McIntyre. Using physicians to do part of the work, OK.
    Dr. Berg. My comment is a summary of what has been stated 
before. That dental caries, cavities in kids is almost entirely 
preventable; and the earlier you intervene, the more 
preventable it is. And the other nondental providers who aren't 
treated in the surgical aspects of dentistry can assist us in 
the risk assessment of prevention. You know, the fluoride 
varnish is not the cure. But the risk assessment, determining 
who is at greatest risk and providing more aggressive and 
frequent interventions, that is the solution.
    So I think we need to segregate the surgery and not think 
about dentistry as surgery. We have dentists who can do 
surgery. We need some assistance in the earlier intervention 
for those folks, as mentioned, who do see the children earlier.
    Mr. Issa. Thank you. Please.
    Dr. Catalanotto. The other part that I would mention about 
this is that there is a fundamental problem, though, in the 
dental public health infrastructure. What I mentioned in my 
testimony is that, assuming you had, at full capacity, the 
existing public health infrastructure, the dental institutions, 
county health departments, federally qualified community health 
centers, they can only address about 8 percent of the dental 
need that's out there.
    So part of your solution that you need to look at is 
improving the dental public health infrastructure.
    Mr. Issa. Thank you. Thank you for your indulgence, Mr. 
Chairman.
    Mr. Kucinich. Thank you.
    The Chair recognizes Ms. Watson.
    Ms. Watson. Thank you very much, Mr. Chairman.
    I want to address this particularly to Dr. McIntyre and Dr. 
Berg. I think your two States have participated in some 
promising practices that were posted by CMS; and, in a survey 
that was taken by GAO, there were 37 States who indicated a 
need for more information on other States' efforts. And have 
you then shared that information? Have you been part of it, 
Promising Practices, that was initiated by CMS? And can that 
Web site then be promoted to other States that need this 
information?
    Dr. McIntyre.
    Dr. McIntyre. Well, we have actually provided information 
to a number of people, including CMS.
    Now, as far as whether it's part of the Promising, I know 
that we have actually published articles. We put out 
information on our Web site. We mailed out brochures to all 50 
States. It's, you know, basically in the past, to actually give 
them the information about what we were doing. So--and we 
actually put the information where it is accessible, and we are 
willing to share it with anyone.
    Ms. Watson. One of the things that concerns me is that many 
of the dentists kind of look at the Medicaid beneficiaries and 
say, I really don't want them. What's with that attitude?
    Dr. McIntyre. I mean, I think that's a matter of education 
as well; and it goes on both sides. Part of what we did as part 
of our provider education and outreach was to educate providers 
that it was a two-way street. And that in order to receive, you 
know, the behavior that they were expecting, they also needed 
to be willing to treat people with respect. So we came up with 
a dental rights and responsibilities sheet that addressed the 
provider on what they could expect and what the patient could 
expect from the provider and for both of them to sign it.
    And the reason for that is--and I am saying this because, 
as a child who grew up with no insurance and no access to 
health care, OK, and people a lot of times are looking down on 
people just because of their income levels, is something that 
we have to go beyond. And that is one of the things that we 
address with the providers, that, you know, if you expect 
people to behave a certain way, you have to treat them so that 
they will behave that way. If you expect bad behavior, you will 
get bad behavior. So that's part of the education that we deal 
with our dental task force.
    Ms. Watson. Dr. Berg.
    Dr. Berg. Yes, I think, part of the success of ABCD is 
training and cultural sensitivity. That's a big part with the 
staff, and it's effective. You know, that there are unique 
needs of this different population, their circumstances are 
different, and that has been critical to the success. So I will 
just add that statement.
    Ms. Watson. Well, let me give you a pet peeve of mine.
    I had a bill for the last 8 years to look at dental 
amalgams. Amalgams are, as you know silver fillings. They are 
50 percent mercury. Mercury is the No. 1 toxic element. And I 
have been getting to the dentists. In fact, the minority 
dentists came in, and they are adamantly opposed to it because 
they say it's cheaper to put an amalgam filling in.
    Well, the research shows that when you have mercury in your 
fillings, it is constantly--gases are constantly escaping, 
particularly with children. So I find a real problem with the 
dentist that says to me, it's a matter of cost. And, you know, 
we have now, in your States, Medicaid providing dental health 
care; and then we don't have this kind of patient result. 
However, when you get the industry saying to you, it's a matter 
of cost, black people don't like to go to the dentist, so this 
is the cheapest we can give, I think that's a violation of 
ethics. How do we continue to educate these dentists? Anybody 
want to take a swipe at that?
    Dr. Berg. You are talking about the amalgam question 
specifically?
    Ms. Watson. Yes.
    Dr. Berg. I think, first of all, to remind them that only 
about 6 percent of their total cost is materials, including 
amalgam and other materials; and the real cost is how efficient 
they are at running their practice. And I think there are best 
practices and ABCD has an annual meeting where our champions 
come together and talk about how do I run efficiently in my 
office. And by changing those behaviors in their office, they 
can do well by doing good and be much more efficient. So I 
think that's the focus we give.
    By the way, I think, in our State, I wouldn't say there's 
any differentiation in any population in terms of who gets 
what, restorative procedure. We don't happen to do many 
amalgams, because there are alternatives today. Some do. But I 
think we like to educate that it's the efficiency of running 
the practice where they are going to save the money, not--
difference of materials are really minuscule compared to staff 
costs and other costs in the practice.
    Ms. Watson. Thank you.
    Thank you, Mr. Chairman.
    Mr. Cummings [presiding]. Thank you very much.
    We are going to conclude this hearing. But I want to thank 
all of you for your testimony.
    As a representative from the State where Deamonte Driver 
died, this hearing means a lot. I have often said that Deamonte 
Driver was a little boy who was suffering from an infected 
tooth, and he died in one of the richest States in one of the 
richest counties in one of the richest countries in the world. 
There is something wrong with that picture, and we can do 
better.
    Dr. McIntyre, I was just thinking, as you were talking 
about this whole idea of people just getting respect, a lot of 
times people don't realize it, but people feel so often that 
folks are talking down to them, and they don't--so they don't--
they feel that they are not respected.
    When we look at health care disparities, for example, one 
of the things that is clear is that there is a divide and some 
type of misunderstanding between, sometimes, those people who 
are trying to treat and those who need treatment. And so I 
think it's very important that, when we look at the Deamonte 
Drivers, we look at all the kinds of things you have talked 
about here today.
    And I was glad that Ms. Mann stuck around to hear some of 
this.
    One of the things that Ms. Mann said was--not Ms. Mann but 
our gentlelady, Ms. Iritani, said was that they wanted--these 
other States wanted to know best practices. Duh. I mean, this 
is not rocket scientist stuff. This is basic common sense and 
trying to work things out and treating human beings as human 
beings.
    So I just kind of think--I know we made a lot of headway, 
but I just wanted to take the time to thank all of you all 
every day because you are affecting children.
    I mean, and I say over and over again, children come on 
this Earth with gifts. They bear gifts. Every one of them bears 
gifts. They are born on the day that they are born to deliver 
gifts at certain points in their lives. But what happens is 
that, if we don't treat them right and we don't nurture them 
and nourish them and help them develop, they will never deliver 
those gifts. And if they are sitting, as I did as a little boy, 
sitting in elementary school thinking that cavities was a part 
of life. It wasn't a question of--it was like a headache. You 
are supposed to have cavities. And a lot of people are still 
thinking that today.
    That's why this whole education thing is so significant, 
letting people know. And that whole idea of letting them know 
there is a direct relationship between the body and teeth, they 
don't think it.
    So I think all of us--I mean, the testimony that you all 
have provided today is basics. And, hopefully, somebody is 
listening, somebody will come to you all--because you all seem 
to know where you are going, and you are on the right path--and 
allow you to help others to get it.
    Now, the question becomes sometimes not whether people get 
it but whether they want to get it, whether they have the will 
to do what's necessary; and that's where we are going to come 
in. We are going to try to do everything in our power to make 
sure that our children, that the providers, that the States, 
and that all others have the kind of information they need so 
they can touch our children in a positive way and look out for 
generations yet unborn.
    Finally, let me say this. This is about--this is bigger 
than us. This is bigger than us. When you were talking--Dr. 
McIntyre talked--you know, it's a great idea to educate mothers 
before they give birth. Because, you know, all that excitement 
you have when you find--you know, I am not a woman, so I don't 
know, but folks get real excited about their first birth in 
particular. And they go and they prepare the room and all that 
kind of good stuff.
    And then the question becomes, you know, shouldn't part of 
that preparation be making sure that you are prepared for the 
teeth of that child and the dental health?
    And what I was telling my aide, you know, was that the 
wonderful thing about it was that if you then educate, first, 
the mother delivering the first child, then that sets a pattern 
for the other children that may come. But it does something 
else. It then teaches the child as the child grows up how to 
take care of their teeth and then hopefully generations--you 
have generational cycles of good teeth, taking good care of 
your teeth. That's what it's all about.
    So thank you all very much. This hearing is now adjourned.
    [Whereupon, at 5:05 p.m., the subcommittee was adjourned.]
    [Additional information submitted for the hearing record 
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