[Senate Hearing 113-811]
[From the U.S. Government Publishing Office]









                                                       S. Hrg. 113-811

                       DENTAL CRISIS IN AMERICA:
                        THE NEED TO ADDRESS COST

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

                                HEARING

                               BEFORE THE

                SUBCOMMITTEE ON PRIMARY HEALTH AND AGING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                    ONE HUNDRED THIRTEENTH CONGRESS

                             FIRST SESSION

                                   ON

EXAMINING THE DENTAL CRISIS IN AMERICA, FOCUSING ON THE NEED TO ADDRESS 
                                  COST
                               __________

                           SEPTEMBER 12, 2013
                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions



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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                       TOM HARKIN, Iowa, Chairman

BARBARA A. MIKULSKI, Maryland        LAMAR ALEXANDER, Tennessee
PATTY MURRAY, Washington             MICHAEL B. ENZI, Wyoming
BERNARD SANDERS (I), Vermont         RICHARD BURR, North Carolina
ROBERT P. CASEY, JR., Pennsylvania   JOHNNY ISAKSON, Georgia 
KAY R. HAGAN, North Carolina         RAND PAUL, Kentucky  
AL FRANKEN, Minnesota                ORRIN G. HATCH, Utah 
MICHAEL F. BENNET, Colorado          PAT ROBERTS, Kansas
SHELDON WHITEHOUSE, Rhode Island     LISA MURKOWSKI, Alaska
TAMMY BALDWIN, Wisconsin             MARK KIRK, Illinois
CHRISTOPHER S. MURPHY, Connecticut   TIM SCOTT, South Carolina 
ELIZABETH WARREN, Massachusetts       
                                       

                      Pamela Smith, Staff Director
        Lauren McFerran, Deputy Staff Director and Chief Counsel
               David P. Cleary, Republican Staff Director

                               __________

                Subcommittee on Primary Health and Aging

                 BERNARD SANDERS, (I) Vermont, Chairman

BARBARA A. MIKULSKI, Maryland        RICHARD BURR, North Carolina
KAY R. HAGAN, North Carolina         PAT ROBERTS, Kansas
SHELDON WHITEHOUSE, Rhode Island     LISA MURKOWSKI, Alaska
TAMMY BALDWIN, Wisconsin             MICHAEL B. ENZI, Wyoming
CHRISTOPHER S. MURPHY, Connecticut   MARK KIRK, Illinois
ELIZABETH WARREN, Massachusetts      LAMAR ALEXANDER, Tennessee (ex 
TOM HARKIN, Iowa (ex officio)        officio)
                                       

                     Sophie Kasimow, Staff Director
               Riley Swinehart, Republican Staff Director

                                  (ii)

  



















                                CONTENTS

                               __________

                               STATEMENTS

                      THURSDAY, SEPTEMBER 12, 2013

                                                                   Page

                           Committee Members

Sanders, Hon. Bernard, Chairman, Subcommittee on Primary Health 
  and Aging, Committee on Health, Education, Labor, and Pensions, 
  opening statement..............................................     1
Baldwin, Hon. Tammy, a U.S. Senator from the State of Wisconsin..     4
Franken, Hon. Al, a U.S. Senator from the State of Minnesota.....    39

                               Witnesses

 Catalanotto, Frank A., DMD, Professor and Chair, Department of 
  Community Dentistry and Behavioral Science, University of 
  Florida College of Dentistry, and Vice Chair of the Board of 
  Directors, Oral Health America, Gainesville, FL................     6
    Prepared statement...........................................     8
Nycz, Greg, Executive Director, Family Health Center of 
  Marshfield, Inc., Marshfield, WI...............................    15
    Prepared statement...........................................    16
Stallings, Cathi, MSW, Social Worker, Falls Church, VA...........    31
    Prepared statement...........................................    32
Hughes, Debony R., D.D.S., Program Chief, Dental Health Program 
  and Deamonte Driver Dental Project, Prince George's County 
  Health Department, Cheverly, MD................................    33
    Prepared statement...........................................    35

                                 (iii)
 
          DENTAL CRISIS IN AMERICA: THE NEED TO ADDRESS COSTS

                              ----------                              


                      THURSDAY, SEPTEMBER 12, 2013

                                       U.S. Senate,
                  Subcommittee on Primary Health and Aging,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.

    The subcommittee met, pursuant to notice, at 10 a.m., in 
room SD-430, Dirksen Senate Office Building, Hon. Bernard 
Sanders, chairman of the subcommittee, presiding.
    Present: Senators Sanders, Franken, and Baldwin.

                  Opening Statement of Senator Sanders

    Senator Sanders. The hearing of the U.S. Senate 
Subcommittee on Primary Health and Aging is going to begin. I 
want to take this opportunity to thank all of the panelists who 
are with us today, and I want to thank CSPAN for putting this 
issue across the country. I also want to thank my colleagues, 
who I expect will be coming in and out for this hearing.
    In the last couple of years, we have had a lot of 
discussion in our country about a dysfunctional healthcare 
system in which some 50 million people have no health 
insurance. We have a crisis in primary care, and despite poor 
outcomes, we spend almost twice as much per person on 
healthcare as do the people of many other countries.
    Unfortunately, in the midst of the discussion about 
healthcare in general, we have forgotten and paid very little 
attention to an element of healthcare that is enormously 
important to all Americans, and that is dental care and the 
fact that we have a major crisis in dental care. And I'm glad 
that CSPAN is here. I'm glad that everybody is here, because 
this is an issue that needs a whole lot of discussion. It has 
been kind of pushed under the rug, and it's time that we 
brought it out into the sunlight.
    Last year, I held a hearing on dental care, where we 
learned that in the United States, we have a major crisis in 
terms of oral health. Simply put, we learned that people who 
need dental care the most are the least likely to get it, and 
that is low- and middle-income Americans, racial or ethnic 
minorities, pregnant women, seniors, individuals with special 
needs, and those who live in rural communities.
    For example, low-income kids are twice as likely as their 
higher income peers to develop cavities, and lower income 
adults are more than twice as likely as middle and higher 
income adults to have had all of their teeth removed. And what 
we know is, all over this country, there are kids who are home 
today, not going to school because they have serious 
toothaches. We know that this is a major problem that we are 
neglecting.
    What we also found is that in America today, millions and 
millions of people live in towns and cities where it is 
difficult to access dental care. Even if they might have some 
insurance, they can't find a dentist who will treat them.
    We learned that about 17 million low-income children 
received no dental care in 2009. We learned that--and this is a 
mind-blowing statistic--one-fourth of adults in the United 
States ages 65 or older have lost all of their teeth. What 
about that?
    We learned that low-income adults are almost twice as 
likely as higher income adults to have gone without a dental 
checkup in the previous year. We learned that bad dental health 
impacts overall health and increases the risk for diabetes, 
heart disease, and poor birth outcomes. We learned that there 
were over 830,000 visits to emergency rooms across the country 
for preventable dental conditions in 2009, a 16 percent 
increase over 2006.
    In other words, when people are in agony, their only 
alternative is to go into an emergency room, which, by the way, 
is very expensive. The people in the emergency room are not 
trained to deal with the dental problems. They deal with pain 
relief. And that's how we are spending money on dental care.
    We learned that almost 60 percent of kids age 5 to 17 have 
cavities, making tooth decay five times more common than asthma 
among children of this age. We learned that nearly 9,500 new 
dental providers are needed to meet the country's current oral 
health needs. However, there are more dentists retiring each 
year than there are dental school graduates to replace them.
    The dental crisis not only has high economic and financial 
costs to individuals in our country, but it comes with high 
social costs as well. Over $100 billion is spent every year on 
dental services in the United States. Over a third of these 
expenditures are paid out-of-pocket. Dental out-of-pocket 
spending is second to spending on prescription drugs.
    In addition to the billions that are spent, billions are 
lost in missed school days and lost economic opportunity and 
productivity due to dental pain. Tragically, sometimes people 
become extremely ill because of oral infections, and, on 
occasion, people die because they don't get the dental care 
they need.
    So let me be very clear. We are paying for this dental 
crisis now in an inefficient, ineffective, and unjust dental 
system where we spend money on those who come to our hospital 
emergency rooms suffering in pain. And yet we refuse to provide 
for people to get the care they need before it's too late. I 
believe that making sure that people can get to the dentist 
when they need to will prevent not only a lot of suffering, but 
at the end of the day, saves our country money as well.
    Interestingly enough, last year, I asked the people of 
Vermont and people all over the country to send me their 
stories about dental access problems. We were just blown away 
by the kind of response that we got. We had 1,200 responses. I 
think people are never asked to talk about it. What we heard 
was people who are in pain, who can't find a dentist, who worry 
about their kids. It was really quite something.
    I think we have a real problem that needs to be discussed. 
When we talk, by the way, about the concept of insurance, we 
usually mean that insurance covers the need. But I think most 
people understand that dental insurance often pays for a 
relatively small percentage of one's needs. The average benefit 
cap is just about $1,500 a year, and, as everybody knows, 
dental care is extremely expensive.
    I hope today our panel will help us to understand why 
dental care is so very expensive. If you have some serious 
dental problems, $1,500 is not going to do it. Despite these 
limits, people with dental insurance are far more likely to see 
a dentist than those who have no coverage at all. More than one 
out of every four Americans does not have any dental insurance.
    Traditional Medicare--and I see this every day. I don't 
know, Senator Baldwin, if you run into this as well. But 
seniors often come up to us and say, ``Why is Medicare not 
covering dental services?'' And it certainly does not.
    I am chairman of the Senate Committee on Veterans Affairs, 
and I can tell you that right now--and this is an issue we're 
working on--the VA does not cover dental care, except for 
service-connected problems, for our veterans. And States can 
choose whether their Medicaid programs provide coverage for 
dental care for lower income adults. Some do a good job. Many 
do not, which means that low-income Americans with Medicaid in 
nearly half of the States have no dental benefits or can 
receive services only in the case of a dental emergency.
    To my mind, it is unacceptable, but in our country, 
millions of people cannot get the care they need to live 
healthy lives. Dental problems, although entirely preventable, 
can lead to extreme pain.
    Another issue is the stigma of missing teeth. If I'm 
looking for a job, and I don't have my front teeth, what do you 
think my potential employer is going to say? He would say, 
``Actually, you're not the guy we want right here.'' So when 
you have no teeth in your mouth, it's like a P on your 
forehead, saying, ``This is a poor person. This is a person we 
don't want in our workplace.'' That's an issue that we have to 
address as well.
    The lack of access to dental care and the high cost of 
dental care are national problems. But as is often the case, 
the problems are far more acute for lower income Americans. For 
many people with Medicaid, for example, it is almost impossible 
to find a dentist who will see them.
    Medicaid is inadequate, but even if you do have Medicaid, 
it is, in many cases, impossible to find a dentist who will 
serve you. Only 20 percent of dentists accept Medicaid, and 
only a small percentage of dentists dedicate a significant 
portion of their practice for the underserved.
    When I ask about the high cost of dental care, I am often 
reminded that most dentists work in small private practices 
where the overhead is high, and dental school is extremely 
expensive. That is another very important issue that I hope we 
can touch upon, the outrageously expensive cost of dental 
school, people graduating with hundreds of thousands of dollars 
in debt.
    But in a report released today, just today, the Government 
Accountability Office, the GAO, found wide variations in fees 
charged by dentists. For eight of 24 common procedures the GAO 
examined, those charging at the high end charge more than 
double what those with average fees charge their patients. 
That's a whole other issue, why the cost of dental care is so 
expensive and the discrepancy in prices that we see all over 
the country.
    There is some good news out there, and we're going to hear 
some good news today. The good news is that we are making 
progress in expanding the number of locations where lower 
income people and working people can get access to dental care. 
FQHCs, Federally Qualified Health Centers, provide dental 
services to more than 4 million Americans across the country, 
regardless of their ability to pay.
    Under the Affordable Care Act, I and others worked very, 
very hard to expand FQHCs to the tune of some $12 billion or 
$13 billion and to put money into the National Health Service 
Corps so that we can help dentists get their student debts paid 
by the government so they can work in underserved areas.
    More than 90 percent of those that receive care at FQHCs 
have incomes that are 200 percent or below the Federal poverty 
line. I know in Vermont, we are having some success. We have 
about 25,000 people getting their dental care now through 
FQHCs.
    We have established school clinics, and they are working 
really well in at least two locations where there's a beautiful 
dental clinic right in the school. Kids are coming in. In some 
cases, adults are coming in. That's a concept that I like very 
much, and maybe we can talk about that.
    Later this month, I intend to reintroduce the Comprehensive 
Dental Reform Act. This bill addresses the dental crisis in 
America by expanding coverage to people with Medicare, 
Medicaid, veterans health benefits, and the Affordable Care Act 
to significantly increase the number of people with insurance, 
expanding the number of places where people can seek care, 
enhancing the workforce, and improving education to respond to 
the needs of the underserved.
    While this bill will, in fact, cost money--it is an 
expensive bill--it is worth repeating that we're already paying 
huge sums for dental care through emergency room visits, 
hospital stays, and lost wages and productivity. The bottom 
line is we have a crisis in this country in terms of dental 
care. We are wasting huge amounts of money, and it is time to 
make sure that every American gets the dental care he or she 
needs and to make sure that we especially take care of our 
kids.
    Senator Baldwin, I understand that you're going to have to 
be leaving us soon and you wanted to make an introduction of 
one of our panelists.

                      Statement of Senator Baldwin

    Senator Baldwin. If I could make an opening statement and 
then----
    Senator Sanders. Sure.
    Senator Baldwin. I can stay for a little while.
    Senator Sanders. Great. Great to have you.
    Senator Baldwin. So we can do it in the regular order you 
planned, Mr. Chairman.
    I want to thank you, Mr. Chairman, for holding this very, 
very important hearing.
    I appreciate the chairman's longstanding commitment to 
extending quality affordable dental care to all Americans. Far 
too many Americans do not have access to dental care. One of my 
constituents recently wrote to me and said that American dental 
care is unfortunately stratified into two buckets, the haves 
and the have nots. For those who currently lack access, the 
have nots, we must promote policy to expand coverage, including 
investing in Federally Qualified Health Centers.
    I'm pleased to have Mr. Greg Nycz here from the Family 
Health Center of Marshfield, WI. Mr. Nycz's center has been 
instrumental in expanding dental care to vulnerable populations 
in rural areas and tribal areas in the State of Wisconsin. He 
will shortly be offering some keen insight on the benefits of 
the health center model.
    For the haves, those Americans who currently have access to 
dental care, that care has grown significantly more expensive 
over recent years, putting a lot of stress on middle-class 
families' budgets. We have to do all that we can to address 
these increasing costs, because they ultimately threaten public 
health and economic security.
    But major opportunities exist at this moment. As we move 
forward with reforms to our underlying healthcare system, 
reforms that focus on delivering healthcare of higher quality 
at a lower cost, dental care must be an integral part of those 
changes and those reforms.
    First, ensuring access to dental care must be a major 
component of investing in preventative services so that we can 
save costs later by helping people avoid developing chronic 
diseases. Second, dental care should become more integrated 
into healthcare models. We need to tear down those artificial 
barriers that exist between dental and medical. They are 
artificial barriers. By delivering more integrated care, we 
will decrease cost and improve the quality of care.
    I look forward, Mr. Chairman, to the testimony of today's 
panel. I can remain a little longer and would love the 
opportunity to introduce my constituent when that moment 
arrives.
    Senator Sanders. Thank you very much, Senator Baldwin, for 
your hard work on this issue.
    Let me now take the opportunity to introduce our panelists. 
Our first witness is Dr. Frank Catalanotto.
    Dr. Catalanotto is a dentist and a professor and chair of 
the Department of Community Dentistry and Behavioral Science at 
the University of Florida College of Dentistry in Gainesville. 
He is also vice chair of the board of directors of Oral Health 
America.
    Senator Baldwin, do you want to introduce Mr. Nycz?
    Senator Baldwin. Thank you, Mr. Chairman. It is my great 
pleasure to introduce Mr. Greg Nycz. Mr. Nycz is the director 
of the Family Health Center of Marshfield, WI, which is a 
Federally Qualified Health Center. Mr. Nycz has been involved 
with the planning and operation of the Family Health Center for 
over 40 years.
    The Family Health Center of Marshfield is one of the 
largest FQHC dental practices in the Nation and the largest 
provider of dental services to Medicaid patients in the State 
of Wisconsin. I have always admired the work that the Family 
Health Center has done to increase access to care in my home 
State.
    Mr. Nycz, I will look forward to your testimony today.
    As you noted, Mr. Chairman, unfortunately, I'm going to 
have to leave midway through the testimony.
    But thank you so much for being here.
    Senator Sanders. Thank you.
    Our next panelist will be Cathi Stallings. Ms. Stallings is 
a social worker from Falls Church, VA, who has seen firsthand 
both personally, as I understand it, and professionally, the 
need to increase access to affordable dental care. She received 
her master's in social work from Virginia Commonwealth 
University.
    We thank you for being with us.
    Our final witness is Dr. Debony Hughes. Dr. Hughes has 
worked at the Prince George's County Health Department for 17 
years and has served as the Program Chief of Dental Health 
there since 2007. In this role, she oversees the Deamonte 
Driver Dental Project. She also serves on the Maryland Dental 
Action Coalition Board. She began her public health career as a 
dentist in Bristol, VT. But she left us.
    [Laughter.]
    Again, I want to thank all of you for being here. What we 
are trying to do and what this hearing is about is to focus 
attention on a crisis which does not get the discussion that it 
needs. It's going to be a long, hard fight, but that's what 
we're trying to do.
    Dr. Catalanotto, thank you for being here. Please make your 
presentation.

 STATEMENT OF FRANK A. CATALANOTTO, DMD, PROFESSOR AND CHAIR, 
   DEPARTMENT OF COMMUNITY DENTISTRY AND BEHAVIORAL SCIENCE, 
 UNIVERSITY OF FLORIDA COLLEGE OF DENTISTRY, AND VICE CHAIR OF 
  THE BOARD OF DIRECTORS, ORAL HEALTH AMERICA, GAINESVILLE, FL

    Mr. Catalanotto. Mr. Chairman, members of the subcommittee, 
thank you very much for the opportunity to talk about access to 
oral healthcare. My name is Frank Catalanotto, and I've spent 
almost 40 years in dental education but for the last 20 years 
have been advocating for a better way to deliver oral 
healthcare.
    There are several indicators about this access problem that 
I'd like to mention. First, dental care utilization has 
declined about 10 percent in the last decade among low-income 
people, primarily for cost.
    Second, we have made some good progress in the last decade 
to improve access to care for children. But we still have 
approximately 60 percent of Medicaid enrolled children who are 
not receiving proven, cost-effective, and preventive dental 
services. And, third, as the Senator said, hospital emergency 
room visits for dental problems have increased 16 percent to 
over 830,000 visits in 2009, a very significant wasted cost.
    What are the effects of this lack of access to care? Two 
examples: First, children who miss school because of dental 
problems do less well in school than other children. Education 
is the way out of poverty, but children in pain cannot learn.
    Second, a recent study from 2000 to 2008 showed that 61,000 
patients across the country were hospitalized for a preventable 
dental infection. And Deamonte Driver was not an isolated 
example. Sixty-six deaths were reported in this study at an 
estimated cost of $840 million. This is not a personal tragedy 
only. This is an economic loss.
    Let me mention dental schools. Dental schools are an 
important part of the dental safety net, with faculty and 
students that actually do provide care outside of the dental 
school in community-based settings accessible to the 
underserved. But dental education is very lengthy and 
expensive. That makes dentists a very expensive part of the 
healthcare team.
    The 165,000-plus dentists in the United States provide high 
quality dental care to those patients who can afford their 
services. Unfortunately, many of these dentists do not 
participate in the Medicaid program. There are many reasons for 
this, including low reimbursement rates. But no matter the 
reason, this significantly reduces access for many patients.
    Dentists provide significant pro bono care. However, I 
would remind you that while philanthropic care is wonderful, 
philanthropy is not a healthcare system and does little for 
long-term oral health care.
    Another concern I have and others have is that there are 
restrictive State dental practice acts that do very little to 
actually protect the health of the public and can specifically 
impede improving access to oral healthcare. I'll give two 
specific examples in a minute.
    What are some of the potential solutions to this access 
problem? I will only focus on workforce, although there are 
many others. A new dental workforce model, at least new to the 
United States, is the dental therapist.
    These therapists are members of the oral healthcare team 
who provide preventive and limited restorative care to their 
patients. They have been employed in over 50 countries for over 
90 years. They come from the ethnically and economically 
diverse communities they go back to serve.
    They are inexpensive to educate. They are cost-effective to 
hire. They are safe practitioners, no matter what else you may 
hear. They are currently employed in Alaska and Minnesota. 
There are at least 15 other States working to include them, but 
they are being blocked by restrictive dental practice acts at 
the State level and by the American Dental Association at the 
national level.
    Second, a more cost-effective location for delivering 
dental care is in a large group practice setting that employs 
multiple dentists and thus has lower overhead than the 
traditional dentist-owned single dental practices, thus 
reducing cost. One example you'll hear about in a minute. But 
another example is the not-for-profit Sarrell Dental Centers of 
Alabama that provide excellent comprehensive care. In the past 
8 years, they have grown from 15 sites to nearly 500,000, using 
a combination of a culture of caring, evidence-based practice, 
innovative business practices, marketing, and community 
outreach.
    Let me leave you with this last sentence, what Sarrell has 
done. They have reduced cost to the Medicaid program from an 
average annual cost in 2005 of $328 to $125 in 2012. This is a 
remarkable business model that takes care of patients.
    We need more of these around the country. We can't, because 
there are some States that have a restrictive dental practice 
act that will not allow a business like Sarrell to be owned by 
a non-dentist. This is ludicrous when the major hospitals in 
this country are run by MBAs.
    In closing, I'd like to point out that Congress is lobbied 
by many members of the dental industry, including dental 
academics. But who lobbies for the patient for increased access 
to care, for oral health services that prevent pain and 
suffering, for increased ability to learn and work, and for 
lower cost? I would suggest that we need you in your leadership 
roles in Congress to fight for those patients.
    Thank you very much, Senator.
    [The prepared statement of Mr. Catalanotto follows:]

            Prepared Statement of Frank A. Catalanotto, DMD

    Mr. Chairman, members of the subcommittee, thank you very much for 
the opportunity to speak with you this morning about access to oral 
health care in the United States. My name is Dr. Frank Catalanotto. I 
am a children's dentist who has spent almost 40 years in dental 
education and for the last 20 years, advocating for a better way to 
deliver oral health care. I am currently the Chair of the Department of 
Community Dentistry at the University of Florida College of Dentistry. 
I am here this morning to ask your assistance in improving access to 
oral health care in the United States.
   1. challenges facing the united states related to oral health care
    There are several indicators I can share with you that clearly 
illustrate the lack of access to oral health care in this country. 
First, Dental Care Utilization has declined among low-income adults 
over the past decade (ADA Health Policy Resource Center); over 35 
percent of low-income seniors have not seen a dentist in over 4 years, 
primarily because of costs. Second, while we have made significant 
progress in improving access to care for children, there are about 48 
percent of Medicaid enrolled children who are not receiving preventive 
dental services and about 77 percent of these children are not 
receiving restorative services. Third, according to a study released by 
the PEW Children's Dental Campaign in 2012, the number of Americans who 
have gone to hospital emergency rooms for dental pain and infections 
has increased 16 percent from 2006 to 2009; this included over 830,000 
such dental visits. Hospital dental emergency rooms are very 
expensive--in Florida in 2010, there were over 115,000 such visits 
costing over $88 million, and they are very inefficient since for most 
visits, the physicians prescribe antibiotics and pain medication and 
suggest the patient see a dentist the next day, something these 
patients cannot afford.
    What are the effects of this lack of access to oral health care?--A 
number of recent scientific reports, some by United Concordia 
Insurance, have shown that preventive dental care can reduce overall 
medical care costs for patients with diabetes and heart disease. 
Imagine if these benefits could be extended to the entire population 
and how that might help reduce overall health care costs in the United 
States. Second, several studies have now shown that children who missed 
school because of dental problems did less well in school than children 
who missed school for other reasons. Education is a way out of poverty, 
thus, to me; there is a clear economic advantage to having improved 
access to dental care. Third, a recently published study showed that 
over a 9-year period from 2000-8, a total of 61,439 patients were 
hospitalized because of a dental infection. More important, a total of 
66 patients died during these hospitalizations, all for lack of access 
to quality preventive dental care. This is a personal tragedy, not just 
an economic loss.
      2. the role of dental education in addressing lack of access
    Dental schools educate a highly competent workforce and conduct 
research to address the oral health needs of our county. Congress has 
recognized the importance of dental schools and funds HRSA to provide 
grants to support modernizing and reshaping dental education to meet 
the changing needs of the oral health workforce with a particular focus 
on health care disparities. Our team actually has several of these 
grants at the University of Florida and for that I am grateful. For 
example, dental schools across the country are working hard to recruit 
a dentist workforce that better mirrors the racial and economic 
diversity of our country. Dental schools are an important part of the 
dental safety net, providing much care in community-based settings such 
as federally Qualified Health Centers. But I would also add that dental 
education is very expensive, making dentists a very expensive part of 
the oral health care team.
     3. the role of the practicing dentist and the american dental 
                              association
    The 100,000 plus dentists in the United States provide high quality 
dental care to a large number of patients. Unfortunately, many of these 
same dentists do not participate in the Medicaid program; for example, 
in Florida, only about 12 percent of dentists see Medicaid patients. 
There are many reasons for this including low reimbursement rates and 
the very high overhead of dental practice making it somewhat cost-
inefficient, but, no matter the reason, this significantly reduces 
access for many patients.
    In addition, these dentists provide significant pro-bono care 
either in their offices or through such events as Missions of Mercy in 
which large numbers of dentist convene in a large facility or even 
tents and patients line up sometimes a day in advance to obtain some 
limited care. However, I would submit to you that while philanthropic 
care is wonderful, philanthropy is not a health care system and does 
little for long-term oral health. Another concern is restrictive dental 
practice acts that do little to help protect the health of the public 
and can really impede improving access to oral health care. I will give 
two specific examples at the end of my remarks.
      4. what are some potential solutions to this access problem?
    I categorize these potential solutions into three groups including 
in the accompanying Power Points including dental insurance, patient 
education and workforce. Because of the limited time, I will only focus 
my comments on workforce: Bottom Line--we need an oral health workforce 
that is less expensive than dentists to deliver routine dental services 
so that dentists can focus on more complex procedures and we need 
workforce locations that are more efficient and cost-effective than 
private dental practices with their high overhead.
    First, a comment about ``The Comprehensive Dental Reform Act of 
2013.'' This legislation extends dental insurance to millions of 
Americans. A number of other components will really help improve the 
oral health workforce in ways I will now address in my closing 
comments. But thanks for this legislation.
    A new dental workforce model--new to the United States--is the 
dental therapist. These therapists are members of the oral health care 
team who can provide preventive limited restorative dental care to 
patients under the supervision of a dentist. They have been employed in 
over 50 countries around the world for over 90 years. They are usually 
recruited from the ethically and economically diverse communities they 
return back to serve. They are inexpensive to educate and cost-
effective to hire. They are safe practitioners, no matter what else you 
may hear. They are currently employed in the United States in Alaska 
and Minnesota. There are at least 15 other States who are working to 
include dental therapists in the workforce but these efforts are being 
blocked by organized dentistry and the restrictive dental practice acts 
I mentioned earlier.
    Second, a more cost-effective location for delivering dental 
practices is a large practice setting that employs several dentists and 
other oral health care providers and thus has a lower overhead than the 
traditional dentist-owned single dentist practices. The recent Senate 
Report on Corporate Dentistry has illustrated some concerns about the 
profit-driven, equity-backed corporate model but there are excellent 
not-for-profit models such as the Sarrell Dental Centers of Alabama 
that provide excellent comprehensive preventive oriented care to low-
income patients. In the past 8 years, Sarrell has grown to 15 sites 
providing care to nearly 500,000 Medicaid recipients. Uses a 
combination of a ``Culture of Caring'', evidence-based dental 
practices, innovative business approaches, marketing and community 
outreach. Most importantly, they have demonstrated a decline in the 
average Medicaid reimbursement from $328 in 2005 to $125 in 2012. This 
is a truly unique model of dental practice. Unfortunately, many State 
dental practice acts across the country prevent dental practices from 
being owned and managed by non-dentists, something done across the 
country by medical groups and hospitals. We could use congressional 
help in expanding the Sarrell and similar models across the country.
    In closing, I would like to point out Congress is lobbied by many 
members of the dental industry including dentists, dental schools, 
dental industry, and insurance companies. But who lobbies for the 
patient for increased access to preventive and therapeutic oral health 
services that can prevent pain and suffering, increase ability to learn 
and work, and eventually help lower health care costs. I would suggest 
that we need you as elected Members of Congress to help these patients. 
THANK YOU!
                                 ______
                                 

               University of Florida College of Dentistry

         ``Dental Crisis in America: The Need to Address Cost''
                  frank a. catalanotto, dmd--who am i?
     Educated as a pediatric dentist, 39-year career in dental 
education, past president of the American Dental Education Association, 
former dean at University of Florida, now chair of Department of 
Community Dentistry and Behavioral Science (Public Health).
     Committed to improving access to oral health for all by 
education oral health services research, and advocacy.
     Vice chair, board of directors, Oral Health America.
     Chair, Leadership Council, Oral Health Florida.
     Viewpoint expressed this morning is my own and does not 
necessarily reflect the views of the University of Florida, Oral Health 
America or Oral Health Florida.
                     what can i cover in 5 minutes?
     Challenges to U.S. oral health care system.
     Role of Dental Education:

         educating workforce, and
         safety net provider.

     Role of the practicing dentist and the American Dental 
Association--Philanthropic Care, Regulation and Restrictive Dental 
Practice Acts.
     Consolidation in the dental industry. Role of:

         corporate/for profit models of dental practice; and
         large scale not-for-profit models (e.g., Sarrell).

     Potential solutions:

         insurance,
         new workforce models, and
         large, cost-effective not-for-profit dental practices.
      challenges: indicators of lack of access to oral health care
     Adults not seeking dental care.
     Children doing better but still a serious lack of access 
and utilization.
     Hospital Emergency Room for dental care is increasing; but 
hospital ERs do not solve the problem. ``Pay me now or pay me later.''
    who are these people with disparities of access and oral health?
The Culture of Poverty
    ``Many of us have no real understanding of what poverty is. We may 
be broke most of the time, in debt, unsure of how we'll pay the phone 
bill. But those particular definitions can apply to middle class. 
Poverty is something else. Missed meals, a reliance on government aide, 
homes without power or telephone services--these are the earmarks of 
the culture of poverty.''

     Those in POVERTY, patients on Medicaid, CHIP.
     Racial and Ethnic minorities.
     Traditionally, children, the elderly, rural, single 
mothers.
     The uninsured, including the working poor.
     Any who do not understand the importance of optimal oral 
health.
     Increasingly in this recession, lower middle-class and 
middle-class families. WORKING FAMILIES


Dental Care Utilization Declined Among Low-Income Adults and Increased Among PLow-Income Children in Most States
                                                 From 2000-2010
                                       (ADA Health Policy Resource Center)
----------------------------------------------------------------------------------------------------------------
                                                Children                                  Adults
                               ---------------------------------------------------------------------------------
                                   2000        2010         % Change        2000        2010         % Change
----------------------------------------------------------------------------------------------------------------
U.S. overall..................        27%         41%              53%         54%         48%             -10%
----------------------------------------------------------------------------------------------------------------
*Note both still below 50 percent.

                           adult dental care
     The decrease in adults seeking dental care cuts across 
economic groups with reductions in upper income, middle income and 6 
percent lower income groups. REASON--COSTS.
     Recent HARRIS--Oral Health America Poll. Almost half of 
older adults with incomes of $35,000 or less have not been to the 
dentist in 2 years and 35 percent of all lower income older adults have 
not sought dental care in the last 4 years. REASON--COSTS

  Table 4: Children Age 1-20 Enrolled in EPSDT for at Least 90 Continuous Days Who Received a Preventive Dental
                           Service, or a Dental Treatment Service in Fiscal Year 2011
----------------------------------------------------------------------------------------------------------------
                                                                                                      Percent
                                                  Total children      Percent     Total children     Children
                                                    receiving a      Children       receiving a     receiving a
                     REGION                         preventive      receiving a       dental          dental
                                                  dental service    preventive       treatment       treatment
                                                                  dental service      service         service
----------------------------------------------------------------------------------------------------------------
U.S. Overall....................................      13,550,097            42.2       7,466,214            23.3
----------------------------------------------------------------------------------------------------------------
Source: Fiscal Year 2011, CMS-416 Reports.

   A Costly Dental Destination--Hospital Care Means States Pay Dearly
             pew childrens dental campaign-issue brief 2012
     Preventable dental conditions accounted for 830,590 visits 
to ERs nationwide in 2009.

         a 16 percent increase from 2006.

     Emergency rooms are the first and last resort because 
their families struggle to find a dentist who either practices in their 
area or accepts Medicaid patients.
                       pay me now or pay me later
     Hospital ER visits do not provide ``treatment'' of the 
underlying dental problem, only relief of symptoms of pain and 
infection.
     Hospital ER visits cost money to Medicaid and insurance 
but for the uninsured, the hospitals usually absorb those costs. In 
other words, you/we are already paying for dental care for these 
patients.
     Makes more sense to pay up front for increased access and 
preventive and restorative dentistry.
     We need insurance and oral health professionals who are 
willing to work in underserved communities to provide these services to 
patients who cannot afford traditional dental services.
             effects of lack of access to oral health care
     Oral Health and overall body health.
     Effects on School Learning in children.
     Morbidity and Mortality.
                  oral health and overall body health
     New recently published reports showing lower annual health 
care (MEDICAL) costs for patients with chronic disease processes such 
as diabetes and heart disease if these patients have been treated 
successfully for periodontal disease and continued to maintain their 
periodontal health. The savings noted were significant.
     Visit the UCH Wellness Oral Health Study on United 
Concordia Web site to learn more.
Impact of poor oral health on children's school attendance and 
        performance \1\
---------------------------------------------------------------------------
    \1\ Jackson SL, Vann WF Jr, Kotch JB, Pahel BT, Lee JY. Am J Public 
Health. 2011 Oct;101(10):1900-6. doi: 10.2105/AJPH.2010.200915. Epub 
2011 Feb 17. PMID: 21330579 [PubMed--indexed for MEDLINE].
---------------------------------------------------------------------------
     Children who missed school days because of dental problems 
did less well in school than children who missed school for other 
reasons.
     outcomes of hospitalizations attributed to periapical abscess 
          from 2000 to 2008: a longitudinal trend analysis \2\
---------------------------------------------------------------------------
    \2\ J Endod. 2013 Sep;39(9):1104-10. doi: 10.1016/
j.joen.2013.04.042. Epub 2013 Jul 11.
---------------------------------------------------------------------------
    During the 9-year study period (2000-8), a total of 61,439 
hospitalizations were primarily attributed to dental/tooth infections 
in the United States. A total of 66 patients died in hospitals.
    This is not only a ``cost issue,'' this is a life and death issue!
                        role of dental education
     Academic Dental Institutions include dental schools and 
allied dental education programs.
     Educate and train a highly competent workforce and conduct 
research to address oral health needs of the country.
     Congress via HRSA has been very supportive of need for 
grants to support modernizing and reshaping dental education to meet 
changing needs of the oral health workforce with a particular focus on 
health care disparities.
     Academic Dental Institutions are a very important part of 
the safety net for underserved patients.
     Using our admissions policies to recruit a workforce that 
represents the diversity of the United States.
     University of Florida Statewide Network for Community Oral 
Health sends students out to work in community settings such as 
Federally Qualified Community Health Centers.
     HOWEVER, educating dentists is a very expensive component 
of the dental workforce.
   role of the practicing dentist and the american dental association
     The 100,000-plus dentists in the United States provide 
high quality care to a large number of patients.
     These dentists provide significant pro-bono care to the 
underserved in their practices, in philanthropic clinics, and in 
national events such as Give Kids a Smile days and Missions of Mercy 
(MOM) events.
                   dentists and medicaid patients \3\
---------------------------------------------------------------------------
    \3\ (*Published; **in preparation by my team.)
---------------------------------------------------------------------------
     Low Reimbursement* (but increasing rates does not always 
work).
     Administrative hassles* (this is real).
     Medicaid patients do not keep appointments* (but they 
can!).
     Do not want to mix Medicaid and other patients in waiting/
reception room.*
     Sense of Social Justice.*
     Social Stigma of being a Medicaid provider.**
                    philanthropy--missions of mercy

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]                    
                    


    While philanthropic care is wonderful, I would submit to you that 
philanthropic care is not a health care system and does little for 
long-term oral health.
   there is a body of literature on restrictive practices in dental 
                         licensing \4\ \5\ \6\
---------------------------------------------------------------------------
    \4\ Doyle, Roger, License to Work, Scientific American, 296:2, 
February, 2007.
    \5\ Kleiner, Morris and Kudrle, Robert, Does Regulation Affect 
Economic Outcomes? The Case of Dentistry, Journal of Law and Economics, 
43:2, 547-82, October 2000.
    \6\ Freund, Deborah and Shulman, Jay, Regulation of the 
Professions: Results from Dentistry, Advances in Health Care Economics 
and Health Services Research, 5:161-80, 1984.
---------------------------------------------------------------------------
     Purpose of regulation (State dental practice acts) is to 
safeguard the health of the public and promote competition.
     Substantial literature says this does not occur.
     In fact, the more restrictive the dental practice act, the 
higher the income of the practitioners and no demonstrable effect on 
the health of the public.
     Many State dental practice acts forbid a non dentist from 
owning a dental practice as will be discussed with a not-for-profit 
model in a few minutes.
     Such restrictive regulation negatively impacts access for 
the underserved.
                          potential solutions
     Insurance for oral health services

         Patients with insurance are healthier than patients 
        without insurance.

     Educate patients and change their behavior

         Evidence-based practices.
         Culturally competent practitioners.

     Workforce

         More dentists--a very expensive solution.
         Expanded work settings and reimbursement models for 
        dental hygienists.
         New workforce settings and business models.
         New models of oral health care professionals.
    insurance for oral health services--``the comprehensive dental 
                          reform act of 2013''
     Extends comprehensive dental health insurance to millions 
of Americans.
     A number of other components of this bill will really help 
improve oral health workforce and access to oral health care.
                new workforce models--dental therapists
     Dental Therapists are oral health care team members that 
can provide preventive and limited restorative care to patients under 
the direct supervision of dentists.
     Over 90 years of evidence in over 50 countries that they 
are safe and effective oral health care providers.
     Come from the local community, cultural competency.
     Excellent capacity for case management, patient education, 
restorative and limited surgical care. Inexpensive to educate and hire.
     Recent studies/reports in the United States clearly 
demonstrate quality, safety and cost effectiveness.
     Currently in use in Alaska and Minnesota. About 15 other 
States are considering this model of care.
     Being blocked by restrictive dental practice acts and 
vigorous opposition by organized dentistry.
     Training grants authorized by Congress but appropriations 
blocked in recent years.
     Native American Tribes in the ``lower 48'' would like to 
utilize Dental Therapists but are being blocked by Congress as a result 
of lobbying by dentists.
                      workforce--corporate models
     Senate Report on Corporate Models of Dental Practice.

          Corporate models are on the increase because of the 
        efficiency and cost effectiveness.
          Have the potential to provide lower cost care and 
        better access to the underserved.
          Senate report correctly drew attention to some 
        equity-backed corporate models that have a profit motivation to 
        over-treat patients.
          But we should not overlook the role of large, not-
        for-profit models that have an excellent track record of care.
                   sarrell dental centers of alabama
    A not-for-profit corporate model that works.

     In 8 years, have grown to 15 sites providing care to 
nearly 500,000 Medicaid recipients.
     Uses a combination of a ``Culture of Caring,'' evidence-
based dental practices, innovative business approaches, marketing and 
community outreach.
     Demonstrated a decline in the average Medicaid 
reimbursement from $328 in 2005 to $125 in 2012.
     So, why not expand this model across the United States?
     Strong opposition from the Alabama Dental Association that 
was only resolved by legislation and intervention by the FTC.
     Many dental practice acts across the country prevent 
dental practices from being owned and managed by non-dentists, 
something done across the country by medical groups and hospitals.
                         closing and thank you
     Congress is lobbied by many members of the dental industry 
including dentists, dental schools, dental industry, insurance 
companies.
     But who lobbies for the patient for increased access to 
preventive and therapeutic oral health services that can prevent pain 
and suffering, increase ability to learn and work, and eventually help 
lower health care costs.
     I would suggest that we need you as elected Members of 
Congress to help us as patients.

    Senator Sanders. Thank you very much.
    Mr. Nycz.

   STATEMENT OF GREG NYCZ, EXECUTIVE DIRECTOR, FAMILY HEALTH 
           CENTER OF MARSHFIELD, INC., MARSHFIELD, WI

    Mr. Nycz. Good morning, Senator Sanders.
    And thanks for the kind introduction, Senator Baldwin.
    I want to thank the subcommittee for the opportunity to 
testify today on a topic I am passionate about, the need to 
improve access to dental care in our country.
    I'm here representing Family Health Center of Marshfield, 
the center that serves a large region in Wisconsin 
approximately the size of the State of Maryland. About a third 
of our residents are poor or near poor.
    Twenty years ago, I served on the Wisconsin Dental 
Association's Access to Care Committee as their only non-
dentist. In that role, my phone number was listed as a resource 
for people seeking dental care. I took many calls.
    One day, I picked up the phone, and it was a young mother, 
failing to hold back the tears as her child screamed in pain 
and sobbed uncontrollably. The mother broke down. She had been 
trying for days, calling over 30 dental offices for help, 
someone who would stop her child's pain.
    Such conversations were not uncommon for me back then. But 
what made this conversation a life changer for me was that I 
came to realize as I spoke with her that she was not just 
bearing the burden of her child's pain, but also the self-
imposed pain that came with her conclusion that she was a 
failure as a mother.
    I'm proud of Wisconsin, and I'm proud of my country. But 
none of what that mother was enduring had to be, because it was 
all preventable, and there's really no mystery associated with 
how to fix it.
    After a decade of frustration, trying to improve the system 
and using traditional routes, my board said, ``Find another 
way. This is your top priority.'' Ten years later--and I 
brought a picture to show this--we've served nearly 100,000 
folks. Even we were surprised by the enormous response.
    Our patient origin map shows that in spite of the fact that 
we are located in northern Wisconsin, we've seen State 
residents from every county and 73 percent of our State's zip 
codes. Our patients tell us where we are needed.
    When we established our Park Falls clinic, over 1,000 
people traveled over 412,000 miles to get care with us at Park 
Falls, mostly from the Rhinelander area. Today, we have a 
clinic in Rhinelander as a result of that.
    The folks who lacked access, the elderly, those on 
Medicaid, and the uninsured poor, we knew about. But what 
surprised us was that veterans with limited incomes could not 
get care. Today, they now have a place to go.
    Those who journey the farthest are disproportionately 
people of all ages who have emergency dental needs and 
caregivers who bring their developmentally disabled loved ones 
for care at our sites--another group that is left behind.
    Recall the quote from Alice in Wonderland, ``If you don't 
know where you're going, any road will get you there.'' We knew 
to get to our preferred future, we would need societal 
investment. So we have been relentless in looking for ways to 
maximize the value of our efforts for the taxpayer, not just 
the patients we serve.
    We learned that we could improve the performance of our job 
placement agencies by making job seekers with horrible oral 
decay more presentable and employable. One of our counties with 
about 34,000 in population told us that they have about 100 
such adults every year.
    We learned that annual savings on the medical care side 
possibly in the range of $2,000 to $3,000 are possible for 
patients with diabetes if we give them proper dental care. And 
we learned we could be a real alternative to the emergency room 
and the hospital by opening our doors to patients with dental 
emergencies from across the State.
    I would like to leave you with three thoughts. First, 
success will require that we fundamentally work to change our 
Nation's perspective on the importance of oral health in its 
own right and the added value oral health brings to general 
health.
    Second, workforce matters. Over the next 20 years, 
Wisconsin may face 2.2 dentists retiring for each new dentist 
entering practice. And new graduates need to be better prepared 
to face more elderly patients with complex multiple medical 
conditions.
    Third and perhaps most importantly, at the community level, 
we are seeking to accomplish this by pursuing an integrative 
medical-dental model that leaves no one behind. This is the 
missions of all health centers. We are solving healthcare 
access problems one community at a time, and we're in 9,000 
communities.
    But the current demand for care is outpacing our growth. 
Over 300 of us applied for funding to meet unidentified unmet 
dental needs in 2011. Unfortunately, a last minute budget deal 
cut $600 million from planned health center funding, and there 
have been no opportunities to fund oral health expansion since 
then.
    Our Nation's health centers are your health centers. The 
health center model has what it takes to solve the oral health 
disparity problems for a growing number of our Nation's 
communities. And I appreciate Congress' past support of health 
centers and ask that you continue to invest in our Nation's 
health centers. Give us more work, for there is more work to be 
done.
    Thank you.
    [The prepared statement of Mr. Nycz follows:]

                    Prepared Statement of Greg Nycz

    Good morning Chairman Sanders, Ranking Member Burr, and 
distinguished members of the Subcommittee on Primary Health and Aging. 
My name is Greg Nycz and I want to thank you for the opportunity to 
testify today before the subcommittee. I am the executive director of 
Family Health Center of Marshfield, Inc. a federally and State-
supported community health center. Our Center serves a 10,354-square 
mile rural area in northern Wisconsin with 403,964 residents, 125,229 
of which have incomes at or below 200 percent of poverty. I greatly 
appreciate the opportunity you've extended to me to share insights 
accumulated over the last 20 years working with organized dentistry and 
then building our own dental capacity in an effort to assist our State 
in resolving significant oral health access problems for many of our 
residents.
    For most of the decade of the 1990s, I worked for change within 
organized dentistry in Wisconsin. The Wisconsin Dental Association, 
keenly aware of the access problems in the State's Medicaid program, 
convened a committee to explore ways to resolve access problems and 
enable more of our State's dentists to participate in the Medicaid 
program. They extended an invitation to me to serve on that committee 
as the only non-dentist in order to get the perspective of a community 
health center director. At the time, there was no lack of passion or 
commitment from the committee members. Wisconsin's Medicaid office 
staff were most helpful in streamlining some of the administrative 
impediments to greater dentist participation, and during the time of my 
tenure on the committee we were successful in obtaining an increase in 
State Medicaid rates. However, in spite of all these efforts, problems 
persisted and, following passage of the State Child Health Improvement 
Act and an annual stagnation in dental payment rates, access problems 
grew worse.
    In September 2001, shortly after the Surgeon General's report on 
the oral health of the Nation, my board faced the prospect of continued 
deterioration in access to oral health services for our Medicaid and 
uninsured patients. They directed staff to prioritize solving the oral 
health access and disparity problems throughout our extensive rural 
service area. As staff set about the task of fixing the system, we 
studied the problems more closely, which eventually led us to a 
question. How do we solve a problem that is pervasive at the State and 
national level? From a health center perspective the answer to this 
question is one community at a time. So that is what we set about 
doing. Our State welcomed our involvement as did our major partner, 
Marshfield Clinic. An expanded State rural dental clinic grant program 
provided us with resources to build our first dental center in 2003.
    Family Health Center has had a long-term partnership with 
Marshfield Clinic, relying on, rather than duplicating some of its core 
infrastructure. While Marshfield Clinic is a large regionalized health 
system with most specialties in medicine represented, they like many 
other health systems lacked any dental health professionals. Given 
their size, reputation, and our desire to promote the integration of 
dentistry and medicine, Family Health Center approached Marshfield 
Clinic to partner with us on our dental initiative. We provided them 
with information on what amounted to a public health crisis in 
Wisconsin affecting many Clinic and Family Health Center patients, and 
suggested that together we could have a much larger impact on the 
problem throughout our collective service area than our organization 
could do on its own. Recognizing the scope of the problem, Marshfield 
Clinic leadership unanimously voted to lend its infrastructure and 
later additional funding in support of our initiative to reduce oral 
health disparities throughout the region. This Marshfield Clinic 
decision enabled the rapid expansion of our dental system which by 
October 1, 2013, will also include a 9th dental clinic on Ho-Chunk 
Nation land near Black River Falls, WI.
    Because of State taxpayer investment in our program and also 
because of strong evidence that literally tens of thousands of 
Wisconsin residents were going to emergency rooms every year for 
treatment of non-traumatic dental pain, we committed to caring for 
patients with emergency dental conditions from across the State. Figure 
1 demonstrates that from the provision of our first dental service in 
temporary facilities in November 2002 through June 2013 we have cared 
for 95,535 unique patients. Strikingly, they have come from every one 
of Wisconsin's counties and from 73 percent of its zip code areas. We 
have treated patients from Wisconsin's largest cities who traveled, in 
some cases hundreds of miles, to get to a dental center in communities 
as small as Neillsville with a population of 2,443. Patient origin 
maps, like that of Figure 1, both illustrate the breadth and scope of 
the dental access problem in Wisconsin as well as provide us with 
information about communities in need. In essence, the underserved 
population's care seeking patterns inform us where we should consider 
placing our next dental center.
    To illustrate this point, we observed that within the first 15 
months of opening our Park Falls dental center, 1,000 patients had 
driven an estimated 412,000 miles to receive their dental care there 
from us. Many of these patients were traveling from the community of 
Rhinelander, which is 67 miles from Park Falls. We investigated this 
pattern with Rhinelander community leaders, including the mayor, and 
learned we were only seeing the tip of the iceberg as many people in 
need couldn't make the trip. A few years later we were able to open our 
8th dental center in Rhinelander bringing quality dental services 
closer to many of our patients and offering an opportunity for dental 
care to many others who previously couldn't make the trip.
    Our progress, and that of my health center colleagues in Wisconsin, 
has been spurred on by increased investment of State resources in the 
State rural dental clinic program, and through a doubling of our 
State's community health center grant. Our State grant focuses on 
supporting the mission of all of Wisconsin's 17 community health 
centers. This investment has paid huge dividends for State residents 
through greatly expanded access to dental care as shown in Figures 2 
and 3, which mark the progress and growth of Wisconsin's community 
health center dental facilities, patients served, and patient visits.
    The dramatic progress of Wisconsin's health centers in expanding 
oral health access to a growing number of Wisconsin residents is echoed 
in the steady progress health centers across the Nation have made in 
both incorporating oral health services into their programming and 
increasing the proportion of their patients who receive oral health 
services. In 2011, 78 percent of community health centers offered 
dental services at at least one site. This compares to Healthy People 
2020's baseline of 75 percent from 2007 with a nationally established 
target of 83 percent by 2020. The number of patients receiving dental 
services at health centers grew from 1.4 million in 2001 to over 4.0 
million in 2011, a 186 percent increase. Although this represented 20 
percent of total health center patients, more work remains to be done 
to meet the national goal of 33.3 percent of such patients by 2020. 
There is robust evidence that health centers stand ready to do this 
work as reflected in the fact that more than 300 health centers applied 
for funding to meet identified unmet dental needs in 2011. 
Unfortunately, a last minute budget deal to keep the Federal Government 
running that year included a $600 million cut to planned health center 
funding. As a result, none of the 300 applications were funded. Since 
then, there have been no subsequent Federal funding opportunities for 
dental expansion for health centers due to limited appropriations. 
Indeed, there have been no funding opportunities period for existing 
health centers to expand their services since the Recovery Act. While 
this was disappointing, our resolve is strong. The health center 
community is ready, willing and able to leverage investments from our 
States and Congress to meet State and national goals. Our integrative 
approach to health care can create offsetting savings by substituting 
quality dental services for more expensive emergency room and/or 
hospital-based treatments that now result from current access barriers. 
As the rest of my testimony will demonstrate, our approach can also 
improve health and indeed, save lives.
    As the preface to the Surgeon General's report stated,

          ``those who suffer the worst oral health are found among the 
        poor of all ages with poor children and poor older Americans 
        particularly vulnerable . . . Individuals who are medically 
        compromised or who have disabilities are at greater risk for 
        oral diseases and in turn oral diseases further jeopardize 
        their health.''

Our early experience confirmed the wisdom of this statement. At our 
ribbon cutting for our second dental center I read a short email to 
those in attendance. The author of the email reported things were going 
well, that they were grateful there was a dental clinic that would take 
their residents, and they were working on arrangements to send us some 
more patients. What made this short email remarkable was that the 
author was making arrangements to send his developmentally disabled 
residents to our dental center, which was 183 miles away.
    We quickly learned that accessing dental services for those with 
significant developmental or cognitive disabilities was even more 
difficult than the barriers faced by many low-income uninsured or 
publicly insured residents. Understanding the difficulties many 
disabled residents face in obtaining oral health services in our State, 
we entered into a Memorandum of Agreement with our State that in 
essence said ``we are open to and welcome the State's disabled 
population.'' Beginning with our second dental center, each dental 
center has been equipped with large treatment rooms and a wheelchair 
lift to help accommodate this high need population.
    We learned other lessons that surprised us. Local county Veteran's 
Affairs officers informed us that low-income vets uninsured for dental 
care had great difficulty accessing care. We learned that VA benefits 
extended to those who are 100 percent service disabled and that a State 
program provided some help, but many dentists did not participate in 
the program because of paperwork issues. We learned that one of the 
largest constituent complaints voiced to local legislative offices was 
the inability to get dental care, and we learned that many elderly were 
foregoing care because of its cost. When we build a dental center and 
open our doors, our local legislators report that the phones fall 
silent regarding complaints on access to dental care. Our vets, the 
disabled, and the poor of all ages have a place to go. Access to dental 
care is no longer the issue it once was. The health center model leaves 
no one behind.
    It is our belief that any organization that accepts Federal or 
State taxpayer funds has a huge stewardship responsibility and a 
requirement to be accountable for the expenditure of funds. One of the 
ways we try to be accountable is to look for targets of opportunity to 
add value. To avoid increased emergency room use for non-traumatic oral 
pain, we work in many emergency patients from all over the State on a 
daily basis at all of our dental centers. We also believe one of the 
best services we can provide to our State is to assist our patients in 
leaving the Medicaid program altogether through job attainment or job 
promotion. To achieve this goal we accept referrals of job seekers from 
job placement agencies. Many individuals being retrained for 
predominantly service sector jobs have a difficult time getting hired 
or promoted if they have significant oral health problems. We eagerly 
accept such referrals in the hope that we increase such individuals' 
opportunities to achieve gainful employment or promotion and leave 
Medicaid in favor of private employment-based insurance. In addition we 
have historically prioritized low-income pregnant women. The reason for 
this is evidence that periodontal disease may contribute to poorer 
birth outcomes. While the scientific community is still debating this 
topic, for the sake of these unborn children, we prefer to do 
everything possible that might help lead to a better birth outcome.
    We have made demonstrable progress. As Figure 4 shows, while 
Wisconsin was second to last in 2008 among all States in children on 
Medicaid who received a dental service, the three counties with our 
dental centers had access rates equivalent to those in the Nation's top 
performing States. Unfortunately we are far from declaring victory. Our 
accountabilities to our supporters, including taxpayers and the 
communities we serve, demand that we do more to generate societal 
savings to help offset the cost of dental care to those who previously 
went without that care. What are our options to do better?
    There is a tremendous prevention potential in dentistry. We believe 
there is also a tremendous potential to improve health and reduce costs 
overall if we can bridge the chasm that exists between medicine and 
dentistry. We believe the bridge is through closer integration of 
medicine and dentistry using 21st century technology that can support 
virtual teaming between our health professionals and their staffs, and 
through practice changes that reinforce shared professional interests 
in patients and their health. We have begun acting on these beliefs and 
received support from like-minded partners. To this end I wish to 
acknowledge the significant support we have received from Delta Dental 
of Wisconsin in helping us create an integrated medical/dental 
electronic record to provide a platform to allow virtual teaming on 
patients. Delta Dental of Wisconsin has also provided support for oral 
health research and education initiatives at Marshfield Clinic's 
Education and Research Divisions. I also wish to acknowledge the 
DentaQuest Foundation for their support in helping us learn about best 
practices for engaging our patients with diabetes and encouraging them 
to seek regular dental care.
    We have come to the conclusion that to get to a preferred future we 
have to fundamentally change how we view dentistry within the larger 
health care system. To illustrate this point, let's consider a series 
of questions involving dermatology, a specialty that deals with 
problems of the skin:

          Why do we think we can afford adult dermatology in our 
        Nation's Medicaid program but not adult dental? Why is it that 
        we don't have separate dermatology insurance like we do for 
        dental insurance? Why is it that we include dermatological care 
        in our medical records but not dental care? Why do most medical 
        care systems, many who tout most if not all medical 
        specialties, exclude dentistry? Why do medical schools teach 
        our future physicians to be concerned about infections anywhere 
        in the body but the oral cavity? Why in Wisconsin, in spite of 
        very low payment rates to physicians and dentists, do most 
        physicians continue to treat Medicaid patients while most 
        dentists do not?

    Other policy-oriented examples are the exclusion of dental benefits 
in Medicare and the limitations on dental benefits in the VA. A more 
recent example is the promotion of ``primary care medical homes'' a 
terminology that excludes dental. Why not ``primary care health homes'' 
which is a much more inclusive concept? (Incidentally, most federally 
qualified health centers would rightly consider themselves to be 
integrated primary care health homes). The separate and stark contrast 
between dentistry and medicine beginning with training and continuing 
through insurance and practice policies should increasingly be 
questioned in light of a growing body of scientific evidence linking 
oral and systemic health.\1\
---------------------------------------------------------------------------
    \1\ Powell V, Din F, Acharya A, et al., Project on Clinical Data 
Integration Page 20, Contact points between medical and dental care/
research--Version J: Categories (1-29) and references).
---------------------------------------------------------------------------
    Everyone is united in wanting our country to derive even more value 
from our health care system, with better quality at a lower price 
point. If that is the case, then why is there such reluctance to act? 
We can debate whether we can afford to have dental benefits covered 
under our Medicare program or whether all States should offer dental 
benefits to adults in their Medicaid programs. But if cost is the 
central issue holding us back, if cost is the driver in much of our 
decisionmaking, why don't we act to lower costs when an evidence-base 
outlining on how it could be done exists? Consider the following. As a 
nation we fund medical research through the National Institutes of 
Health. That societal investment has helped us understand that 
connections exist between diabetes and periodontal disease and to treat 
one without treating the other does have health and cost consequences. 
(Please refer to Attachment 1 for a concise summary of some evidence 
regarding periodontal disease and diabetes.) The value of our 
investment in research to our Nation's taxpayers is magnified when we 
put the results of that research into practice.
    The private sector has responded and is attempting to leverage this 
knowledge: the public sector should as well. What seems to have driven 
the private sector to act was the emerging evidence, mostly from the 
past 10 years, that individuals with selected chronic health conditions 
or combinations of them benefit from improved oral health, specifically 
improved periodontal status, and that potentially large reductions in 
medical care costs associated with their chronic condition(s) follow 
closely and appear to be sustainable as long as good oral health is 
maintained. The emerging evidence appears strongest for individuals 
with diabetes (only) or in combination with cardiovascular disease, 
kidney disease or congestive heart failure. Savings of approximately 10 
percent annually for individuals with diabetes receiving periodontal 
care were reported in a multi-year Michigan Blue Cross Blue Shield 
study. That study also found annual medical cost reductions ranging 
from 20-40 percent for individuals with diabetes and at least one other 
chronic condition previously noted.\2\
---------------------------------------------------------------------------
    \2\ http://www.bcbsm.com/pr/pr_08-27-2009_71090.shtml.
---------------------------------------------------------------------------
    A 2006-8 CIGNA study of 46,094 individuals with diabetes estimated 
annual medical cost savings of $2,483/person (23 percent) in year 3 for 
those who received dental care. Notably, study results suggested 
increasing annual cost savings as a function of continuing better oral 
health among those individuals with diabetes that received periodontal 
care at baseline (2006) and continued maintenance oral health care 
annually compared to those individuals that did neither.\3\
---------------------------------------------------------------------------
    \3\ Jeffcoat M, et al. CIGNA, Does Treatment of Oral Disease Reduce 
the Costs of Medical Care? Medscape Today. October 19, 2011. On-line: 
http://www.medscape.com/viewarticle/751609.
---------------------------------------------------------------------------
    United Concordia and Highmark, Inc. reported average medical care 
cost savings of $1,814 per year over 3 years for individuals with 
diabetes who sought periodontal treatment and subsequent regular dental 
care during the 2007-9 study compared to individuals with diabetes who 
did not receive dental care during the study period. Another important 
study result was additional estimated cost savings of $1,477 per person 
per year among individuals with diabetes after they completed seven 
periodontal treatments and/or oral health maintenance visits. In 
subsequent analyses that examined the relationships between gum disease 
and other medical conditions, annual medical cost savings from reduced 
hospitalization and office visits associated with periodontal treatment 
were found for heart disease ($2,956), cerebrovascular disease 
($1,029), rheumatoid arthritis ($3,964) and pregnancy ($2,430).\4\
---------------------------------------------------------------------------
    \4\ https://secure.ucci.com/ducdws/dental.xhtml?content=dhc-
conditions&s1=ucwellness-oral-health-study&s2=results-ucwellness-oral-
health-study.
---------------------------------------------------------------------------
    A recent study in an HMO population provides further insight into 
the potential sources of savings associated with better oral health 
status among individuals with diabetes. Diabetes-specific hospital 
emergency department visits rates were more than 60 percent higher 
(16.2 percent vs. 10.1 percent) and diabetes-related hospitalization 
rates were more than 75 percent higher (14.8 percent vs. 8.3 percent) 
among individuals with diabetes who did not seek dental care compared 
to individuals that had two or more periodontal or prophylactic 
treatments annually for 3 years.\5\
---------------------------------------------------------------------------
    \5\ Mosen D, Pihlstrom D, Snyder J, Shuster E. Assessing the 
association between receipt of dental care, diabetes control measures 
and health care utilization. JADA January 2012 143(1): 20-30.
---------------------------------------------------------------------------
    There is clear evidence that health insurers are ramping up their 
oral health programs that many established in 2005-7. Several major 
insurers have announced expanded oral health-related programs for their 
insureds that are pregnant and those with kidney disease, 
cerebrovascular (stroke) conditions, head and neck cancer and organ 
transplants.\6\ Leading health insurers seem to have concluded that 
supporting and even incenting better oral health access and care is 
good business. It should be so for our publicly supported programs as 
well. The taxpayers of this country should demand it.
---------------------------------------------------------------------------
    \6\ http://newsroom.cigna.com/article_display.cfm?article_id=1287.
---------------------------------------------------------------------------
    I urge the subcommittee to consider following the lead of these 
insurers by capitalizing on our Nation's investment in the National 
Institutes of Health, and institute policy changes that would enable 
Medicare and Medicaid enrollees with such chronic conditions to access 
appropriate high quality oral health treatments.
    Another key point for the subcommittee to consider is that it is 
not enough to simply establish coverage or even more dental clinics, as 
many low-income Americans do not seek dental care until they have oral 
pain. While addressing pain and suffering is meritorious in its own 
right, avoiding that pain and suffering and more expensive treatment 
interventions is our goal. The undervaluing of oral health in America 
is, from our perspective, one of the greatest health literacy 
challenges we have. Our health center is involved in a generational 
effort to address health literacy issues that shape the current 
practice among many high-risk, low-income populations. A major 
initiative is needed to help convince our residents of the importance 
of oral health to general health and of the importance of regular 
dental checkups in maintaining good oral health. Developing more 
reliable and internally consistent estimates of population access to 
oral health services should be considered part of that effort. I make 
this point because it appears that the proportion of children, 
adolescents and adults who use the oral health care system in the past 
year is actually well below what many people believe. The percent of 
residents aged 2 and older who received a dental service in 2007 is 
estimated by Healthy People 2020 to be 44.5 percent. Our national goal 
for 2020 is 49 percent. However, widely cited estimates based on health 
interview survey data using self-reported information is in the range 
of 20 percentage points higher. Although such widely diverse estimates 
cannot be reconciled without further work, I note that the higher 
estimate is based on self-report data that requires recall on long past 
events making such estimates generally less reliable than those based 
on observed expenditures. I urge the subcommittee to explore this 
information further as it has significant implications for dental 
workforce projections, as well as understating the need to integrate 
medicine and dentistry to help address the oral health literacy issue.
    We must strive for a future where people better understand the 
importance of daily oral hygiene, proper nutrition, and regular dental 
checkups not just to their oral health but to their overall health as 
well. We believe success in this effort is tied to convincing our 
medical colleagues to help educate their patients on the importance of 
good oral health care and regular dental checkups. This is made more 
difficult by the fact that our Nation's medical schools by and large 
pay little attention to the oral cavity in medical student training. 
This is evidenced by the response to 2012 survey question by the AAMC 
of our Nation's graduating medical students on, ``How well do you feel 
that your medical school has trained you to address oral/dental health 
topics?'' Apparently, students were underwhelmed as 32.4 percent of the 
Nation's graduates checked ``not well trained at all'' and only 1.3 
percent checked ``very well trained.'' Our vision for the future is 
that our physician community treat the importance of regular oral 
health checkups on a par with their counseling of patients on the need 
to be immunized, receive clinical preventive services, exercise, and 
eat right. In addition to the virtual teaming I mentioned earlier, our 
dental teams should be aided by an integrated electronic medical 
record, to engage patients on the importance of receiving clinical 
preventive services in medicine. Currently we do blood pressure checks 
and non-fasting blood sugars under protocols in our dental centers. 
These efforts can have a direct impact on morbidity and even mortality 
in our patients as evidenced by a recent message one of our hygienists 
received from a dental patient:

          ``You know I thought that it seemed dumb that you would take 
        blood pressure at the dentist office until I had a friend of 
        mine come here and you guys took his blood pressure in hygiene 
        and wouldn't even see him. You sent him right over to the 
        emergency room. Good thing you did, they took him into 
        emergency surgery. I guess they said he was ready to pop.''

    We should expect this type of coordination in our health care 
system. Additional examples of teaming across medicine and dentistry 
are provided in Attachment 2.
    I'd like to conclude my testimony by sharing some observations 
regarding dental workforce and dental education issues. Early on, we 
recognized that to be successful in our dental initiative we could not 
ignore workforce and dental education issues that might confound our 
progress. Figure 5 indicates that given current rates of dental school 
production, the age distribution of dentists in Wisconsin portends a 
shortage of dentists. Over the next 20 years, 2.2 dentists are likely 
to retire for each new dentist entering practice. As if this is not bad 
enough, two factors may further aggravate the situation for northern 
rural communities. First, there currently exists a marked preference of 
dentists to locate in suburban or urban areas of our State relative to 
the less populated communities. Second, retiring dentists are 
predominantly male, while new graduates are gender balanced and female 
dentists in Wisconsin have shown an even more marked preference for 
suburban or urban practices. Rural Wisconsin loses on both of these. We 
are hoping to meet this challenge by establishing, in partnership with 
Marshfield Clinic, a dental residency program and by providing 
dedicated space within our dental facilities for dental students.
    As we continue to grow our dental system to enlist nearly 50 
dentists in this work by years end, we can reflect on the opportunity 
we have had to hire dentists trained in over a dozen dental schools 
across the country. Most dental schools are urban-based and specialty-
oriented. Most provide students with less exposure than we would like 
to treating developmentally disabled patients and young children. 
Nationally, as I speak with my health center colleagues, not enough 
graduates are interested in careers in the safety-net. Ed O'Neil, 
director, UCSF, Center for the Health Professions, Center on 
Recommendations for Reform (3/7/07) said it best:

          ``For instance, in many specific locations the Nation is 
        experiencing a raging epidemic of pediatric dental disease. In 
        face of this reality, does it make sense to prepare more young 
        men and women with the skills to serve the bungalow-based smile 
        clinics that serve the suburbs? Instead, shouldn't we align the 
        training with the needs of community clinics to organize and 
        deliver a broad range of preventative and therapeutic services 
        to the population that is experiencing the epidemic?''

    As a nation we should not lose sight of the importance of oral 
health to general health, and the importance of oral health in its own 
right. What some of us take for granted is currently beyond the reach 
of many. Discussions I have had with many well-educated people on the 
problems lower income people face obtaining dental care usually result 
in surprise. They didn't know. There is a reason the Surgeon General 
referred to this problem as a ``silent epidemic.''
    I thank the subcommittee for this opportunity for me to share what 
we've learned and most importantly for taking up this subject, it may 
still be an epidemic but let it be silent no longer.

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                                 ______
                                 
Attachment 1.--A Brief Summary of the Evidence Base for Intervention to 
          Improve Oral Health Among Individuals with Diabetes
              diabetes as a pandemic threat to oral health
    Physiology does not respect the disciplinary divide that separates 
the medical from the dental care of the diabetic patient. Diabetes (DM) 
is a pandemic in the United States: in many counties, over 10 percent 
of people over 20 years old are affected.\1\ The disease is accompanied 
by wide-ranging health consequences that worsen if it is poorly 
controlled. To use the legal vernacular, it is established beyond a 
reasonable doubt that DM has a deleterious effect on periodontal 
disease (PD) and the evidence is mounting on the impact of periodontal 
health on diabetic control.\2\ The evidence supporting a link between 
PD and DM is so strong that PD has been classified as the 6th 
complication of diabetes.\3\ DM now affects nearly 26 million Americans 
and over the next decade, an estimated 40 million more adults could 
develop the condition, and its complications are expensive. Absent 
changes, the surge in new cases could add an estimated $512 billion to 
annual health care spending by 2021 . . . ''.\4\ In spite of this 
knowledge, only 55.6 percent of the U.S. population aged 2 years and 
older with diagnosed diabetes had been to the dentist in the past 
year.\5\ Moreover, severe disparities exist in dental access based on 
income, insurance status, educational attainment and race.
  comprehensive description of the model and supporting evidence base
    The Institute of Medicine (IOM), National Academy of Sciences, 
released a report, ``Dental Education at the Crossroads: Challenges and 
Change,'' in January 1995, calling for greater collaboration between 
medicine and dentistry. The report said closer integration was needed 
between dentistry and medicine on all levels of the health care system: 
research, education and patient care. In 2000 Surgeon General David 
Satcher's report entitled ``Oral Health in America'' was released. The 
report focused attention on a national problem which had gone largely 
unrecognized for decades: the oral health crisis. Dr. Satcher 
emphasized that oral health does not only encompass teeth. He 
underlined the importance of recognizing the integration between oral 
and systemic health and the profound mutual impact that one has on the 
other, stating that one cannot have systemic health in the absence of 
oral health. To emphasize this point, he summarized the existing 
evidence that points to important links between oral disease, such as 
PD, and systemic diseases such as DM, heart disease and stroke, 
respiratory health and fetal health (miscarriage and stillbirth). The 
Surgeon General further exposed disproportionate access to dental 
health care encountered by disparity-prone populations including low-
income individuals, those with no insurance, children, the elderly, 
handicapped and institutionalized patients who experience what he 
dubbed the ``silent epidemic'' when referencing the high rate of oral 
disease prevalent among these populations.
    The report revealed how a struggling and stagnated dental industry 
that was experiencing workforce shortages exacerbated the problem by 
denying access to vulnerable populations without the ability to pay 
for, or access services. His report revealed how, in addition to the 
systemic ramifications of poor oral health, far reaching consequences 
were inflicted on those with limited or no access, including high 
social and economic cost to the individual, negative impact on quality 
of life and the burden this also placed on society. Importantly, the 
Surgeon General emphasized that this trend was reversible and 
preventable and pointed to the importance of bringing education and 
research to bear on the problem as actionable ways to advance oral-
systemic health. Dr. Satcher called for further investigations into 
oral-systemic health connections, health disparity research, community-
based, public health and behavioral health initiatives, health services 
research, and an expansion in diagnostic and treatment options which 
would emphasize proactive disease prevention. His report emphasized 
that for three decades improvement in oral health had been a focus area 
of U.S. Department of Health and Human Service's Healthy People 
initiative and that solving the problem would require a concerted 
effort between the health care industry including professionals and 
health care entities, academia, the government, health insurers and 
patients. Notably, 13 years later, oral health remains a priority focus 
in Healthy People 2020, with many objectives remaining to be 
achieved.\6\
    A chasm currently exists between our perceptions, financing, and 
delivery of oral health services and general medical services. It 
persists despite mounting evidence that it should not. Yet today, 
proportionately fewer of us annually access oral health services than 
medical services. Our oral health record for some of our most 
vulnerable citizens is abysmal. The elderly, where chronic disease is 
more prevalent, have the lowest rate of dental insurance of any age 
group.\7\ Poor children on Medicaid/CHIP have public dental insurance, 
but low reimbursement rates and other problems have left most without 
annual oral health services. Poor adults have even less coverage and 
access.
    This trail leads to an important question, ``If the future is 
medical homes and ACOs, where is oral health in that calculus? Why 
isn't it more prominent when evidence exists to support its inclusion 
in these new models/systems.''
                   brief summary of the evidence base
    PD is a broad term encompassing a complex disease initiated by a 
variety of pathogens, largely anaerobic bacteria which establishes a 
niche in dental plaque that they lay down to protect themselves from 
exposure to oxygen. The disease is not a single entity and may, or may 
not exhibit a familial pattern of inheritance. PD may range from its 
mildest manifestation, gingivitis, a self-limited condition, to severe 
periodontal disease that is associated with pain, gum erosion, 
loosening of teeth (attachment loss) and bone loss below the affected 
tooth and eventually, if untreated, loss of the tooth. PD may be acute 
and resolve with appropriate treatment (scaling and root planing, 
sometimes supplemented by antibiotic therapy, and proper oral hygiene) 
or in a subset of patients, establish chronicity and refractoriness to 
treatment. PD is a highly prevalent condition among adults in the 
United States with an estimated 40 percent prevalence rate of moderate 
to severe disease.\8\ Research examining exacerbation of systemic 
disease in the presence of oral disease and vice versa has produced 
substantive evidence that such connections are real.\9\ \10\ Much 
research in the past two decades has explored the validity of the 
``focal infection theory'' that promotes the possibility that organisms 
present at a focal infection site or their products may gain systemic 
access and become associated with promulgating other disease processes. 
PD represents such a focal infection and risks for systemic 
manifestations increase with establishment of chronicity. Of importance 
here is that with proper hygiene and regular dental care and education, 
this disease is largely preventable and its prevention and control 
could exert considerable far reaching impact on promoting systemic 
health at multiple levels.
    An extensive evidence base exists to support the reintegration of 
the mouth into the body for everyone.\11\ The impact of DM on PD was 
recognized nearly 50 years ago \12\; Moreover, mounting evidence 
substantively supports mutual bidirectional exacerbation of these two 
conditions.\13\ \14\ \15\ In a systematic review of 48 studies 
undertaken since the 1960s, 44 studies reported increased prevalence, 
extent, severity or progression of PD in patients with DM.\16\ 
Interestingly, the observation by two independent studies in 1989 \17\ 
\18\ reported that infectious processes can establish insulin 
resistance in non-diabetics that can persist for 3 months following 
resolution of the infectious process, promoted the concept that PD also 
contributes to diabetic status. Notably, PD is also a risk factor for 
stimulating diabetes-associated complications.\19\ \20\ \21\ Adjusted 
for other risk factors, mortality risks related to ischemic heart 
disease and diabetic nephropathy were 2.3 and 8.5 times higher, 
respectively, for individuals with DM and severe PD compared to those 
with no PD; overall mortality risk from cardio-renal pathology was 3.5 
times higher for those with DM and PD compared to subjects with no 
PD.\20\
    The mechanism underlying this bacterial impact on glycemic control 
is attributed to dysregulation of insulin-mediated glucose uptake at 
the skeletal muscle level, inducing a state of systemic insulin 
resistance.\22\ Studies among Pima Indians with a high rate of DM \23\ 
and in a population of Japanese patients with DM \24\ strongly suggest 
that DM is a risk factor for PD, likely due to increased susceptibility 
of diabetic patients to infectious processes due to compromised 
immunocompetence related to irreversible formation of advanced 
glycation end products. Proteins mediating immunological functions 
become compromised due to non-enzymatically mediated glycation and 
multiple pathological mechanisms converge to induce what manifests as a 
heightened chronic proinflammatory state that simultaneously 
exacerbates both the DM and PD pathophysiological processes.\22\ \25\ 
\26\ Chronic systemic micro-inflammatory processes have been implicated 
as a common factor underlying both DM and PD, driving chronicity, 
progression and mutual exacerbation of these conditions in the absence 
of intervention. Importantly, micro-inflammatory processes which 
contribute to disease chronicity appear to be modifiable risk factors 
responsive to PD treatment and regular dental care as well as more 
advanced therapeutic regimes.\27\
    Poor glycemic control is an important factor in PD progression and 
severity.\28\ \29\ Notably, outcomes of four recent systematic reviews 
and meta-analyses support the position that glycemic control improves 
periodontal health, and, conversely, improvement in periodontal health 
impacts positively on glycemic control. \30\ \31\ \32\ \33\ \34\ 
Collectively, these results strongly support potential for simultaneous 
stemming of epidemic prevalence of both PD and DM through cross 
disciplinary efforts that systematically target glycemic control and 
good oral care. Promoting interdisciplinary care processes is pivotal: 
studies evaluating dentists' understanding of DM-PD bi-directional 
relationship showed that 60 percent promoted this with patients; 
physician awareness of PD/DM complications was low.\34\ Strikingly, 
interactions between dentists and physicians on oral-systemic patient 
management were measured at <15 percent in a 2006 U.S. study.\35\
                               References
    1. Centers for Disease Control and Prevention. National Diabetes 
Surveillance System. 2009 [cited 2013 April 02]; Available from: http:/
/apps.nccd.cdc.gov/DDTSTRS/default.aspx.
    2. Taylor, G.W. and W.S. Borgnakke, Periodontal disease: 
associations with diabetes, glycemic control and complications. Oral 
Dis, 2008. 14(3): p. 191-203.
    3. Loe H. 1993. Periodontal disease. The sixth complication of 
diabetes mellitus. Diab Care 16:329-34.
    4. Vojta D, De Sa J, Prospect T, Stevens S, Effective Interventions 
for Stemming the Growing Crisis of Diabetes and Prediabetes: A National 
Payer's Perspective. Health Affairs, 31, No 1 (2012): 20-6.
    5. Healthy People 2020, Summary of Objectives, Diabetes, D-8, 
Annual dental examinations.
    6. Koh, H. 2010. A 2020 vision for Healthy People. NEJM 362: 1653-
56.
    7. MEPS Chartbook No. 17, Dental Use, Expenses, Dental Coverage, 
and Changes, 1996 and 2004, AHRQ, DHHS.
    8. Fuster V, Badimon L, Badimon JJ, 1992. The pathogenesis of 
coronary artery disease and the acute coronary syndromes NEJM 326: 242-
50.
    9. Kim J and Amar S. 2006 Periodontal disease and systemic 
conditions: a bidirectional relationship. Odontol 94: 10-21.
    10. Pizzo G, Guiglia R, Lo Russo L, Campisi G. 2010. Dentistry and 
internal medicine: from the focal infection theory to the periodontal 
medicine concept. Eur J Internal Med 21: 496-502.
    11. Powell V, Din F, Acharya A, et al., Project on Clinical Data 
Integration Page 20, Contact points between medical and dental care/
research--Version J: Categories (1-29) and references.
    12. Belting SM, Hiniker JJ, Dummett CO. Influence of diabetes 
mellitus on severity of periodontal disease. J Periodontol 1964 35:476-
80.
    13. Mealey BL, Rose LF. Diabetes mellitus and inflammatory 
periodontal diseases. Curr Opin Endocrinol Diabetes Obes. 2008;15:135-
41.
    14. Taylor GW, Borgnakke WS. Periodontal disease: associations with 
diabetes, glycemic control and complications. Oral Dis. 2008;14:191-
203.
    15. Nagasawa T, Noda M, Katagiri S, Takaichi M, Takahashi Y, Wara-
Aswapati N, Kobayashi H, Ohara S, Kawaguchi Y, Tagami T, Furuichi Y, 
Izumi Y. Relationship between periodontitis and diabetes--importance of 
a clinical study to prove the vicious cycle. Intern Med. 2010;49:881-
85.
    16. Taylor GW, Burt BA, Becker MP, Genco RJ, Schlossman M, Knowler 
WC. 2001 Severe periodontitis and risk for poor glycemic control in 
patients with non-insulin dependent diabetes mellitus. J Periodontol 
67: 1085-93.
    17. Sammalkorpi K. 1989. Glucose intolerance in acute infections. J 
Int Med 225: 15-19.
    18. Yki-Jarvinen H, Sammalkorpi K, Koivisto VA, Nikkila EA. 1989 
Severity, duration and mechanisms of insulin resistance during acute 
infections. J Clin Endocrinol Metab 69: 317-23.
    19. Jepsen S, Kebschull M, Deschner J. Relationship between 
periodontitis and systemic diseases. Bundesgesundheitsblatt 
Gesundheitsforschung Gesundheits
schutz. 2011;54:1089-96.
    20. Saremi A, Nelson RG, Tulloch-Reid M, et al. Periodontal disease 
and mortality in type 2 diabetes. Diabetes Care 2005;28:27-32.
    21. Shultis WA, Weil EJ, Looker HC, Curtis JM, Shlossman M, Genco 
RJ, Knowler WC, Nelson RG. Effect of periodontitis on overt 
nerphropathy and end-stage renal disease in type 2 diabetes. Diabetes 
Care. 2007 30: 306-11.
    22. Grossi SG, Genco RJ. 1998. Periodontal disease and diabetes 
mellitus: a two-way relationship. 3: 51-61.
    23. Nelson RG, Shlossman M, Budding LM, Pettitt DJ, Saad MF, Genco 
RJ, Knowler WC. 1990 Periodontal disease and NIDDM in Pima Indians 
Diabetes Care. 13: 836-40.
    24. Nishimura F, Kono T, Fujimoto C, Iwamoto Y, Murayama Y. 2000. 
Negative effects of chronic inflammatory periodontal disease on 
diabetes mellitus. J Int Acad Periodontol. 2: 49-55.
    25. Genco, R.J., Glurich, I., Haraszthy, V., Zambon, J., DeNardin, 
E. 1998. Overview of Risk Factors for Periodontal Disease and 
Implications for Diabetes and Cardiovascular Disease. Compendium of 
Continuing Education in Dentistry (Symposium Proceedings) 19: 40-4.
    26. Collin, HL, Uusitupa M, Nisanen L, Kontturi-Narhi V, Markkanen 
H, Koivisto AM. 1998, Periodontal findings in elderly patients with 
non-insulin dependent diabetes mellitus. J Periodontol 69: 962-66.
    27. Lalla E and Papapanou PN. Diabetes mellitus and periodontitis: 
a tale of two interrelated diseases. Nat Rev Endocrinol 2011 Jun 28 
Epub ahead of print.
    28. Weidlich P, Cimoes R, Pannuti CM, Oppermann RV. Association 
between periodontal diseases and systemic diseases. Braz Oral Res. 
2008;22 Suppl 1:32-43.
    29. Chavarry NG, Vettore MV, Sansone C, Sheiham A. The relationship 
between diabetes mellitus and destructive periodontal disease: a meta-
analysis. Oral Health Prev Dent. 2009;7:107-27.
    30. Darre L, Vergnes JN, Gourdy P, Sixou M. Efficacy of periodontal 
treatment on glycaemic control in diabetic patients: A meta-analysis of 
interventional studies. Diabetes Metab. 2008;34:497-506.
    31. Janket SJ, Wightman A, Baird AE, Van Dyke TE, Jones JA. Does 
periodontal treatment improve glycemic control in diabetic patients? A 
meta-analysis of intervention studies. J Dent Res. 2005;84:1154-59.
    32. Simpson TC, Needleman I, Wild SH, Moles DR, Mills EJ. Treatment 
of periodontal disease for glycaemic control in people with diabetes. 
Cochrane Database Syst Rev. 2010:CD004714.
    33. Teeuw WJ, Gerdes VE, Loos BG. Effect of periodontal treatment 
on glycemic control of diabetic patients: a systematic review and meta-
analysis. Diabetes Care. 2010;33:421-27.
    34. Al-Khabbaz AK, Al-Shammari KF, Al-Saleh NA. Knowledge About the 
Association Between Periodontal Diseases and Diabetes Mellitus: 
Contrasting Dentists and Physicians. J Periodontol. 2011;82:360-66.
    35. Kunzel C Lalla E Lamster IB. Management of the patient who 
smokes and the diabetic patient in the dental office. J Periodontol 
2006 77: 331-40.
Attachment 2.--Examples of the value to patients of better coordination 
                     between medicine and dentistry
    Case example: A Family Health Center patient living in Clark County 
was referred to the Ladysmith Dental Center by his Marshfield Clinic 
Oncologist. His cancer treatments were negatively impacting on his oral 
health status, and as a result he began losing weight. The patient was 
initially scheduled for an emergency visit and followup dental care. 
All of his teeth needed to be extracted and he was fitted for dentures. 
To date, the patient has improved oral health and has gained 10 pounds.
    Case example: An elderly woman on Medicare presented at our 
Ladysmith Dental Center with severe diabetes, which was not controlled 
well due to the condition of her teeth. She had driven over 4 hours 
one-way to get to our clinic. She had only a few teeth, which had to be 
extracted. Over several visits we were able to provide her with 
dentures and in a subsequent visit she reported that she is now eating 
better and has her diabetes under better control.
    Case example: Another diabetic patient presented at our Ladysmith 
Dental Center. The patient was jaundiced and very ill and had a large 
lesion on his leg for the past 4 years that would not heal. He also had 
severe oral health disease. Following a full mouth extraction and 
dentures, this patient has been back for routine care. He reports his 
blood glucoses are under control, he has good skin color, his skin 
lesion is healed and he is very happy.
    Case example: A 20-year-old female with no income presented as 
unemployed and depressed with very poor oral health. We provided 
extractions and dentures. She now has an improved self image and a job.
    Case example: A patient presented at our Ladysmith Dental Center as 
an emergency. She was in high school at the time of her first visit and 
she qualified for a full discount under our sliding-fee program. Due to 
the extensive dental care needed and her family's inability to afford 
that care, she was not able to find a dentist that would see her. Her 
extensive dental care included root canals, crowns, and major fillings 
in the majority of her top teeth. To date, the cost of her care exceeds 
$5,000. She is now an established patient with the dental center and 
the majority of the work was completed in time for her senior picture.
    Case example: A teenage child with spina bifida presented to clinic 
to establish care with a new pediatrician. The examination revealed 
multiple severe dental caries requiring extraction and repair. This 
child had just been hospitalized for many months to repair and heal her 
third sacral decubitus. Pediatrician requested prompt dental treatment 
to decrease the potential for additional infections that could 
jeopardize skin integrity. Pediatric care coordinator and special needs 
dental coordinator worked together to arrange dental treatment under 
anesthesia with appropriate skin pressure relief measures in place to 
prevent possible skin breakdown. Dental health was achieved, skin 
integrity was maintained and potential for additional infections due to 
decay and gum disease reduced. This child also had improved self-esteem 
and improved social interactions with peers.
    Case example: A teenage patient with special needs presented to the 
pediatrician for a well-check. Patient has profound cognitive 
impairment, no speech, aggressive behavior and is completely 
uncooperative with examinations. Patient had previously received dental 
care and treatment under anesthesia and was in need of a dental exam 
with cleaning again. Pediatrician requested additional specialty care 
examinations and procedures be done in conjunction with the scheduled 
dental service. Pediatric care coordinator and special needs dental 
coordinator were able to arrange eye exam, gynecological exam, ENT 
exam, blood draw for lab testing and vaccinations to take place while 
patient was anesthetized for the dental procedure.

    Senator Sanders. Thank you very much, Mr. Nycz.
    Ms. Stallings.

      STATEMENT OF CATHI STALLINGS, MSW, FALLS CHURCH, VA

    Ms. Stallings. Good morning, Chairman Sanders and 
distinguished members of the subcommittee. My name is Cathi 
Stallings, and I am a social worker from Falls Church, VA. I am 
here as someone who knows firsthand that dental care is a 
luxury that many millions of us in America cannot afford. I 
have paid thousands of dollars for dental work and need much 
more.
    I, personally, am focused on this issue because I am not 
able to afford to pay the exorbitant cost for the dental work 
that I need. Since finding out the extent of my dental needs, I 
have spent many dark hours wondering how I will afford my 
future.
    Several years ago, I took out a bank loan to pay for a 
bridge that I needed. I was told a few months ago that the 
bridge needs to be replaced. I was quoted the price of $7,000 
for this. The periodontist said he would give me a discount, 
but it didn't matter. I couldn't afford that, either.
    I have quite a few other dental issues. The insurance 
coverage with my job covers $1,290 per year, which doesn't 
cover even one of the crowns I need, let alone anything else. 
Crowns have been quoted to me up $2,000 each. In the past 2 
months, I've needed scaling and root planing for gum disease, 
as well as an emergency crown when one of my teeth cracked.
    As a social worker, I work with severely mentally ill 
clients, most of whom have not been able to afford to go to a 
dentist in many years. One issue for them is that numerous 
medications cause dry mouth, but with psychotropic medications, 
there can be a more severe effect, as it usually takes more 
than one medication to treat the mental health symptoms. Saliva 
helps in preventing dental pathologies, like cavities and gum 
disease, by the cleansing and antibacterial action.
    One of my clients has very few teeth left. He found out 2 
weeks ago that he has three abscesses in his remaining teeth. 
His Medicaid benefits only provide extractions of teeth, but no 
dental services. If more of his teeth are pulled, he said he 
doesn't know how he'll be able to eat.
    Another one of my clients receives general relief funds of 
$220 per month to live on. I gave her information about a 
dentist who was providing a free emergency exam and x-rays. She 
went and found out that she needs scaling and root planing for 
her gum disease. The total price that was quoted to her for 
this procedure was $1,600. I then directed her to a lower cost 
dental service this summer, and she was told that they may have 
an opening in November, since there is such a long waiting 
list.
    This week, I was told by another client that he was told in 
1999 that he had 11 cavities. He has never been treated for any 
dental work in all these years. He said, ``I guess I'm on my 
way to a root canal, because I do feel a sensation in my 
mouth.''
    I had an extremely unusual birthday this year. As I was 
preparing to go out and celebrate with my mother, I heard on 
the news about the Maryland Mission of Mercy clinic, where free 
dental services were being provided. Immediately, I ran out of 
my home, met my mom outside and told her, ``We have to cancel 
my birthday. I have to go to Laurel, MD.''
    We went and were told they were full for the day, but that 
I could try again tomorrow. I knew that dental care was much 
more crucial than celebrating my birthday. So that evening, I 
went back to Laurel and arrived around 8 p.m. I was No. 2 in 
line. I was thinking that I wish I could have brought all my 
clients with me.
    Many others started to show up as time went on. We shared 
our stories of dental nightmares. I spent the night on the 
sidewalk, but I didn't mind, because I was getting a great 
birthday gift. It turns out that the gift was seeing over 400 
volunteers in action, giving their time and hearts to provide 
over $750,000 worth of free dental work that weekend.
    I wasn't able to get the dental services I was hoping for, 
as they weren't able to do specifically what I needed. But I 
came away with a scene that I will never forget--men and women 
of every race, creed, and color lined up for what seemed like a 
mile, in dire need, with the hope of being helped. It was truly 
heart-breaking for me to see.
    I have learned that the lack of adequate dental care can 
lead to diabetes, chronic heart disease, and strokes. These 
risks are scary for me and so many others. But you have the 
solution in your hands.
    I am a social worker. These are my clients. But on this 
issue, all of us are standing together in the same line, 
looking for help. I beg you to pass this legislation so that 
help can be provided to all.
    Thank you for your valuable time and attention to this 
critical matter.
    [The prepared statement of Ms. Stallings follows:]

               Prepared Statement of Cathi Stallings, MSW

    Good morning Chairman Sanders and prestigious members of the 
subcommittee. I appreciate the opportunity to speak before you today. 
My name is Cathi Stallings, and I am a social worker from Falls Church, 
VA.
    I am here as someone who knows firsthand that dental care is a 
luxury that many millions of us in America cannot afford. I have paid 
thousands of dollars for dental work and need thousands more.
    I personally am focused on this issue because I am not able to 
afford to pay the exorbitant cost for the dental work that I need.
    Since finding out the extent of my dental needs, I have spent many 
dark hours wondering how I will afford my future. Several years ago I 
took out a bank loan to pay for a bridge that I needed. I was told a 
few months ago that that bridge needs to be replaced. I was quoted the 
price of $7,000 for this, but the periodontist said he would give me a 
discount.
    I have quite a few other dental issues. The insurance provided with 
my job covers only $1,290 per year, which does not cover even one of 
the crowns I need, let alone anything else (they have cost me about 
$2,000 each). In the past 2 months, I've needed scaling and root 
planing for gum disease, as well as an emergency crown when one of my 
teeth cracked.
    As a social worker, I work with severely mentally ill clients, MANY 
of whom have not been able to afford to go to a dentist in years. 
Numerous medications cause dry mouth, but with psychotropic medications 
there can be a more severe effect, as it usually takes more than one 
medication to treat the mental health symptoms. Saliva helps in 
preventing dental pathologies, like cavities and gum disease, by the 
cleansing and antibacterial action.
    One of my clients has very few teeth left. He found out 2 weeks ago 
that he has three abscesses in his remaining teeth. His Medicaid 
benefits provide only extractions of teeth--no dental services. If more 
of his teeth are pulled, it will become increasingly difficult for him 
to eat.
    Another one of my clients receives General Relief funds of $220 per 
month to live on. I gave her information about a dentist who was 
providing a free emergency exam and x-rays. She went and found out that 
she needs scaling and root planing for her gum disease. The total price 
quoted to her for this procedure was $1,600. I then directed her to a 
lower cost dental service this summer, and she was told that they may 
have an opening in November, since there is such a long waiting list.
    Every day my clients pay for the consequences of their illness and 
their inability to support themselves.
    I had an extremely unusual birthday this year. As I was preparing 
to go out and celebrate with my mother, I heard on the news about the 
Maryland Mission of Mercy clinic, where free dental services were being 
provided. Immediately, I ran out of my home, met my mom outside and 
told her, ``We have to cancel my birthday. I have to go to Laurel, 
MD.''
    We went and were told they were full for the day, but that I could 
try again tomorrow. I knew that dental care was much more crucial than 
celebrating my birthday. So that evening, I went back to Laurel and 
arrived around 8 p.m. I was No. 2 in line.
    Many others started to show up as time went on. We shared our 
stories of dental nightmares. I spent the night on the sidewalk, but I 
didn't mind, because I was getting a great birthday gift. It turns out 
that the gift was seeing over 400 volunteers in action giving their 
time and hearts to help give over $750,000 worth of free dental work 
that weekend.
    I wasn't able to get the dental services I was hoping for, as they 
weren't able to do specifically what I needed. But I came away with a 
scene that I will never forget--men and women of every race, creed and 
color lined up for what seemed like a mile--in dire need, with the hope 
of being helped. It was truly heart-breaking for me to see.
    I have learned that the lack of adequate dental care can lead to 
diabetes, chronic heart disease and strokes. These risks are scary . . 
. for me and so many others. But YOU have the solution in your hands.
    I am a social worker. These are my clients. But on this issue ALL 
of us are standing together in the same line, looking for help.
    I beg you to pass this legislation so that help can be provided. 
Thank you for your valuable time and attention to this critical matter.

    Senator Sanders. Ms. Stallings, thank you very much.
    Dr. Hughes.

 STATEMENT OF DEBONY R. HUGHES, D.D.S., PROGRAM CHIEF, DENTAL 
   HEALTH PROGRAM AND DEAMONTE DRIVER DENTAL PROJECT, PRINCE 
        GEORGE'S COUNTY HEALTH DEPARTMENT, CHEVERLY, MD

    Ms. Hughes. Good morning. I am a public health dentist. As 
Senator Sanders stated, I began my career in public health 21 
years ago in Vermont, and for the past 7 years, I have been the 
program chief of the dental health program for Prince George's 
County Health Department. Last fiscal year, we provided more 
than 3,200 clinic visits to children and pregnant women.
    In addition, we provide oral health education across the 
county and work with community organizations. Working with 
patients, clinicians, health administrators, and community 
organizations has given me insight on the state of oral health 
both locally and nationally.
    I would like to thank Chairs, Senator Sanders and Senator 
Burr, and committee members for this opportunity to share 
information about the climate and landscape of dental access 
and cost issues in my jurisdiction.
    Let me begin by telling you about some experiences that 
influence my remarks today and inspire my work. In Vermont, I 
lived in a small town with a population of approximately 8,000, 
and there were four private dental offices. At that time, 
Vermonters eligible for Medicaid did not have access to any of 
those four dental offices.
    With the help of a community organization, we were able to 
provide care and expand access to Medicaid-eligible residents. 
In Prince George's County, the Health Department provides a 
similar safety net for dental care.
    Recently, I participated in my first Mission of Mercy. This 
2-day, large-scale event provided free dental care to uninsured 
adults. Men and women camped out overnight, waiting to be 
served. Many received quality care, but patients should not 
have to endure such conditions to receive treatment.
    This experience affirmed my belief that dental care is not 
a luxury, but rather a necessity, and we must make it 
accessible to all adults. But achieving this goal will be 
difficult if we are unable to address rising operational costs 
of dentistry.
    Of course, we cannot talk about the high cost of dentistry 
without acknowledging the cost of dental education. It's not 
uncommon for a dentist to graduate with a debt of over 
$200,000, and, arguably, education costs play a role in access 
and driving cost.
    But operating a practice is the true cost driver. For 
example, building out a dental office can cost up to $500,000 
for equipment alone. Coupled with the escalating costs of staff 
salaries, insurance premiums, dental supplies, laboratory fees, 
and equipment upkeep, which are largely unknown to those 
outside the field of dentistry, a practice can experience 
staggering costs. My clinic recently had repairs on an x-ray 
unit, and the labor fee alone was $295.00 per hour.
    For many consumers who have neglected their dental care, 
extensive treatment is often required, and it can be expensive. 
For example, according to the American Dental Association's 
2011 survey of dental fees in the South Atlantic Region, the 
average cost of a root canal is $1,075. Add in the cost of a 
crown, and the fee increases an additional $1,079.00. Of 
course, the less expensive option is to have the tooth pulled, 
but this choice can lead to problems with chewing, speech, and 
appearance.
    Can dental costs be contained? This is a question I cannot 
answer. But it is important for consumers to know what drives 
their cost. As a public health dentist, I think about 
education, prevention, outreach, and obtaining more resources 
to provide increased accessibility to care.
    In Prince George's County, there is an established mobile 
health fleet that provides medical and dental care to public 
schools. The county health department operates the Deamonte 
Driver Dental Project, which is a mobile dental unit funded by 
the Maryland Office of Oral Health, providing care to children.
    We address the emergent needs and provide resources for 
families to establish a dental home. We work with volunteer 
dentists in the neighborhoods of the schools we service to 
provide a resource for families that will continue the efforts 
to make dental care easily accessible.
    Last fiscal year, the project provided care to more than 
2,300 children on a budget of $180,000. Mobile units are not a 
panacea for treatment, but they are certainly a model for 
providing affordable dental care.
    Prevention is an important aspect of reducing costs for 
dental treatment. After the death of Deamonte Driver, Governor 
O'Malley assembled the Dental Action Committee. One of the 
recommendations was to institute school-based oral health 
screenings program. The Maryland Dental Action Coalition, 
formed from the original Dental Action Committee, received 
$172,000 from the Kaiser Foundation to develop a demonstration 
project to determine the feasibility of this type of program in 
Prince George's County.
    The results of the project showed that it is vital to have 
a presence in the schools. Of 3,000 children screened, 200 were 
in the A category, potential Deamonte Drivers, which indicated 
that they had an immediate need, either infection or multiple 
decayed teeth.
    It is these types of programs that will address affordable 
accessibility. We need a stronger financial commitment to 
support the public health infrastructure so that the dental 
needs of all Americans can be met.
    Thank you again for the opportunity to address this crisis.
    [The prepared statement of Ms. Hughes follows:]

             Prepared Statement of Debony R. Hughes, D.D.S.

    Good morning. My name is Dr. Debony Hughes and I am a public health 
dentist. I began my career in public health 21 years ago in Vermont and 
for the past 7 years I have been the Program Chief of the Dental Health 
Program for Prince George's County Health Department in Maryland. Last 
fiscal year, we provided more than 3,200 clinic visits to children and 
pregnant women. In addition we provide oral health education across the 
county and work with community organizations. Working with patients, 
clinicians, health administrators and community organizations has given 
me insight on the state of oral health both locally and nationally.
    I would like to thank chairs Senator Sanders and Senator Burr and 
committee members for this opportunity to share information about the 
climate and landscape of dental access and costs issues in Prince 
George's County.
    Let me begin by telling you about some experiences that influence 
my remarks today and inspire my work in Prince George's County.
    In Vermont, I lived in a small town with a population of 
approximately 8,000 and there were four private dental offices. At that 
time, Vermonters eligible for Medicaid did not have access to any of 
those four dental offices. With the help of a community organization, 
we were able to provide care and expand access to Medicaid eligible 
residents. In Prince George's County, the Health Department provides a 
similar safety net for dental care.
    Recently, I participated in my first Mission of Mercy, a large-
scale event providing free dental care to uninsured adults. For 2 days 
dental professionals treated hundreds of adults each day. I was 
overwhelmed to see so many amassed to receive treatment. People slept 
overnight in hopes to receive care. Many received quality care but I 
believe patients should not have to endure those types of conditions to 
receive treatment.
    These experiences reminded me that quality dental care is not a 
luxury, it is a necessity and we need to make it accessible and 
affordable for adults to receive the care they need and deserve.
    These experiences also tell me that this task will remain difficult 
if we are unable to address the escalating costs of dental education 
and the escalating operational costs of dentistry.
    There are several factors that influence the correlation of dental 
insurance coverage and utilization, access to care, and high costs of 
dental care which leads to more extensive and expensive treatments.
    Providing dental care is costly. When we talk about the high cost 
of dentistry, we need to look at the several aspects of care. First, 
let us consider the costs of a dental education. It is not uncommon for 
dentist to graduate with a debt of over $200,000. Establishing an 
office can cost up to $500,000 for equipment alone. The escalating 
costs of staff salaries, insurance premiums, dental supplies, 
laboratory fees and equipment upkeep are staggering and largely unknown 
to those outside the field of dentistry. Our clinic recently had a 
repair done on an X-ray unit. The labor fee alone was $295.00 per hour.
    For many people who have neglected their dental care for a variety 
of reasons, extensive treatment may be required. For example, a root 
canal, a procedure that requires removing the infected nerves in the 
root of a tooth can cost on average, of $1,075 according to the 
American Dental Association's 2011 Survey of Dental Fees in the South 
Atlantic Region. This fee does not include the cost of the crown, which 
averages $1,079.00. The less expensive option is to have the tooth 
pulled which can lead to other problems that can affect chewing, speech 
and appearance.
    With these types of exorbitant costs to maintain a quality 
practice, the costs for dental procedures have to stay competitive with 
the supporting costs of the practice. Can these costs be contained? I 
am not in the position to answer this but it is important for consumers 
to know what drives the costs in dentistry.
    As a public health dentist, I think about education, prevention, 
outreach and obtaining more resources to provide increased 
accessibility to care. In Prince George's County, there is an 
established mobile health fleet that provides medical and dental care 
to the public schools. The county health department operates the 
Deamonte Driver Dental Project (DDDP), which is a mobile dental unit. 
This project honors the legacy of Deamonte Driver by providing dental 
care to Title I schools, which includes the school he attended. The 
project, funded by the Maryland Office of Oral Health, allows us to 
provide care to insured and uninsured children. We address the emergent 
needs and provide resources for families to establish a dental home. We 
work with volunteer dentists in the neighborhoods of the schools we 
service to provide a resource for families that will continue the 
efforts to make dental care easily accessible. Last fiscal year the 
DDDP provided care to more than 2,300 children on a budget of $180,000. 
Mobile units are not a panacea for treatment but they are certainly a 
model for providing affordable dental care.
    Prevention is an important aspect of reducing costs for dental 
treatment. After the death of Deamonte Driver, Governor O'Malley 
assembled the Dental Action Committee (DAC). One of the recommendations 
was to institute school-based oral health screening programs. The 
Maryland Dental Action Coalition, formed from the original DAC, 
received $172,000 from the Kaiser Foundation to develop a demonstration 
project to determine the feasibility of this type of program in Prince 
George's County. The results of the project showed that it is vital to 
have a presence in the schools. Of 3,000 children screened, 200 were in 
the A category which indicated that they had an immediate need, either 
infection or multiple decayed teeth. This indicated 200 more potential 
Deamonte Drivers.
    It is these types of programs that will address affordable 
accessibility. We need a stronger financial commitment to support the 
public health infrastructure so that the dental needs of all Americans 
can be met.
    Thank you again for the opportunity to address this crisis.

    Senator Sanders. Thank you very much, Dr. Hughes, and come 
back to Bristol. We can use you.
    There's a lot to go over. What I propose is that we can do 
this kind of informally. I would like to ask each of you 
questions, but at the end of the response, if others want to 
jump in and comment, that would be great.
    Let me tell you a little story about Vermont. About 45 
years ago, I moved to a small town in rural Vermont in what we 
call the Northeast Kingdom. I saw a kid there, a neighbor of 
mine. I'd never seen anything like it in my life. He was maybe 
10 years of age, and all of his teeth were rotting in his 
mouth. I'd never seen anything like that in my life.
    It turned out that he was certainly not unique. We had a 
major problem in Vermont then. Over the years, in our State, we 
have made some significant progress, and we've done it 
primarily through the establishment of Federally Qualified 
Health Centers around the State. We now have 43 locations, 
eight FQHCs, and in our small State, about 25,000 people are 
getting treated, regardless of income, at the community health 
centers.
    We have established--and this is really a source of great 
satisfaction. In low-income areas, way up in the Northeast 
Kingdom--Dr. Hughes, you may remember--in the towns of 
Richford, in Plainfield, in Burlington, we have state-of-the-
art dental clinics that I think are fairly cost-effective, 
because we have a number of dentists and dental technicians who 
are practicing there. We have a long way to go.
    Now, let me at least start off by saying this. What we have 
learned in Vermont is that every time you build--it's like, 
``If you build it, they will come.'' It's like the baseball 
fields. What we have learned is you build a dental clinic, and 
guess what? People come.
    Dr. Catalanotto, is that your impression, that the need is 
out there, and if we build it, people will come?
    Mr. Catalanotto. Absolutely. I look at my own examples in 
Florida. At our dental school, which is very large, we have 
patients who travel 2 hours away, because they can't find 
affordable care in their communities. When I went to Gadsden 
County next to the State capital of Tallahassee, on the day we 
did a school exam, one in five children reported pain that day 
of the exam.
    Senator Sanders. One in five children?
    Mr. Catalanotto. One in five children on the day of the 
exam--this was about 5 years ago--reported pain, one in five, 
Senator. A young graduate of ours went to the county health 
department and took a job. She's a pediatric dentist who gave 
up what she could have made in private practice to work in the 
county health department. Overnight, she made it a major 
success with large numbers of patients. So, yes, the need is 
out there. People will come if provided access to the services 
at an affordable cost.
    FQHCs are a wonderful partner in doing this. I will tell 
you, as an example, all of my dental students at the University 
of Florida spend approximately 6 weeks of their clinical year 
in an FQHC. Why do the FQHCs love that? It's not the short-term 
labor they get. It's that these students finally figured out, 
``This is a place I might practice.'' It's no longer the 
private practice model. They see the opportunity, sir.
    Senator Sanders. Let me ask you a tough question, but it's 
just between you and me.
    Mr. Catalanotto. Yes, sir.
    Senator Sanders. I have the impression today that maybe 
there are some great dentists out there who see their job as 
treating people in need. But it is also no secret that there 
are a lot of dentists who graduate dental school deeply in 
debt--and I want to talk about that in a moment--who are making 
a pretty penny by treating the upper middle class. If you look 
in the Yellow Pages, they've got a beautiful smile, and they do 
all the cosmetic dentistry. So we have a lot of dentists 
practicing cosmetic dentistry when kids are in pain.
    Mr. Catalanotto. Yes.
    Senator Sanders. What do we do? What ideas do you have? And 
I should tell you we've tried substantially increasing funding 
for the National Health Service Corps, which you're familiar 
with. What do we do to create the kind of dental workforce that 
we need so that we don't have to be embarrassed that there are 
huge places in America where people--either there are not 
enough dentists, or there are not enough dentists treating low- 
and moderate-income people? What's your ideas on that?
    Mr. Catalanotto. I can give you three answers. We do need 
to improve Medicaid reimbursement. In Florida, we have the 
worst Medicaid reimbursement in the United States. The result 
is that only 10 percent, approximately, of Florida dentists are 
accepting Medicaid.
    Senator Sanders. Say that again. I want everybody to hear 
that. You have Medicaid, but only 1 in 10 dentists will take 
Medicaid patients.
    Mr. Catalanotto. That is all, but it's because we have some 
of the lowest Medicaid reimbursements in the United States. No. 
2, I think there is very clear data that things like National 
Health Service Corps scholarships and loan forgiveness programs 
are wonderful. There are some States that have them.
    We do not have them in Florida. I am happy to say that the 
Florida Dental Association has lobbied our State legislature, 
but our State legislature is just too cheap to do it.
    Third--and this is the longer-term solution--HRSA Title VII 
funding provides grants to dental schools. The newest set of 
grants is to help change the culture of the dental school and 
the culture of dental students. They focus on healthcare 
disparities.
    I am the principal investigator of one of those grants to 
the University of Florida College of Dentistry. And what we are 
doing is revamping our curriculum to produce students who are 
more culturally competent and sensitive to the needs of the 
underserved patients. They have more public health experience. 
I've been able to hire a public health dentist to add to my 
faculty.
    So now second-year dental students go out into a school-
based setting, where they understand. They go into schools of 
poverty. They see the picture early in their dental education. 
Our goal and our hope is that they will become more sensitive 
to this issue after they graduate.
    Senator Sanders. And are you finding--and we have the same 
issue--we had a hearing here on primary healthcare, getting 
doctors, young medical students, involved in primary 
healthcare. Are you finding that, given the opportunity, and if 
there were decent reimbursement rates, we would be able to 
attract more young people to serve lower income folks?
    Mr. Catalanotto. Yes. There's no doubt. What I hear from 
the FQHCs is,

          ``Frank, you're sending the students to work for us. 
        They are seeing the problem. They get a better 
        appreciation of the needs of these kinds of patients, 
        and they are going into those settings.''

    Yes, sir.
    Senator Sanders. Thank you very much.
    Senator Franken has joined us, and I wanted Al to be able 
to give his opening remarks, if he'd like.

                      Statement of Senator Franken

    Senator Franken. There hasn't been testimony yet?
    Senator Sanders. Yes, everybody has testified, first round. 
But if you want to jump in and just----
    Senator Franken. Yes, I actually want to followup. Thank 
you, by the way, Mr. Chairman, for inviting me to attend this 
hearing. It's a very important hearing. And I want to pick up 
where you were on dental care.
    In Minnesota, we became the first in the Nation to create a 
license for an advanced practice dental provider called a 
dental therapist. This was actually first started in the United 
States in Alaska to address the native population there, 
because in Alaska, to get a dentist, you would really only get 
a dentist once a year, who would fly in for a couple of days.
    But now they have dental therapists. Other OECD countries 
have dental therapists. I guess the ones who are in Alaska were 
trained in New Zealand or something.
    Dr. Catalanotto, in your written testimony, you emphasized 
the financial impact of the national dental care crisis, and 
you were just talking about the limited access to dental care 
and how it leads to wasteful spending. The GAO report released 
this morning notes that only 62 percent of Americans have 
dental coverage, and only about 40 percent of people have a 
dental visit in any given year.
    You also noted in your testimony that one important way to 
expand access to dental care would be for States to consider 
dental therapists, like Minnesota. Could you elaborate on that? 
And what can we in Congress do to support the expansion of that 
program and the expansion of the number of dental therapists?
    Mr. Catalanotto. Thank you, Senator. It's a great question. 
Just by way of background, I have been to Alaska three times, 
looking at the dental therapist model. I have talked 
extensively with the folks in Minnesota that have both trained 
these dental therapist and then employed these dental 
therapists.
    Last week, I testified to the New Mexico legislature about 
dental therapists, and with me was one of the folks who employs 
dental therapists in Minnesota. I have read most of the 
literature on this. I am absolutely convinced that this is a 
cost-effective, safe, wonderful model to deliver care to people 
in need.
    The beauty of dental therapists is that they can do the 
kinds of simpler procedures that a dentist might do, but that 
allows the dentists to work at the top of the scope of their 
practice instead of at the bottom of the scope of their 
practice. They are inexpensive to educate. They usually come 
from the communities they go back to serve--underserved ethnic 
minority groups. They are a wonderful solution.
    The difficulty comes from the opposition at the State level 
and then the national level, which I think was your question. 
At the State level, it's restrictive dental practice acts that 
forbid these individuals. There are approximately 15 to 20 
States that are now this close to legislation to get dental 
therapists in their States.
    But I would also add that it's not just dental therapists. 
These restrictive dental practice acts also prevent dental 
hygienists who are excellent at providing some of the primary 
services needed--these dental practice acts restrict them from 
working at the top of their skill across many States.
    At the Federal level, the impediment that currently exists 
is that language was inserted into the health service 
reauthorization just a couple of years ago that prevents the 
first nation folks across this country who want to implement 
dental therapists--it prevents them from doing it because 
there's language that says they cannot use Federal funds. This 
is a travesty. This is an affront to the sovereignty of the 
first nations. That is something that you could do at the 
Federal level. There's not much you can do at the State level 
because of the individuality of dental practice acts.
    Senator Franken. I just think this is incredible.
    Mr. Nycz, in Wisconsin, you would hire a dental therapist. 
Dental therapists, in studies, do the task they're allowed to 
do as well as dentists. Am I right?
    Mr. Nycz. Yes, that's what the evidence shows. But, again, 
because of these State laws, we do not have access. And, of 
course, there are not many of them that have been minted.
    I'd like to circle back to the chairman's point about, ``If 
you build it, they will come.'' The map that we showed shows 
that we're taking care of close to 100,000 people who have come 
from all over the State. And I would add that maybe 140 to 150 
from the good State of Minnesota have come to us for dental 
care.
    When we see people, when we open up a clinic--and this is 
why this is a little nuance--we get people with such horrible 
dental disease that young men and women just coming out of 
their dental training--many of them are kind of daunted by the 
task in front of them. We've had one dentist leave after 6 
months, saying they're not prepared for this kind of work.
    We had another dentist come and say, ``You know, I'm not 
prepared for this.'' She went back and got a year residency, 
and now she's going to work for us starting October 1st. So 
there's a training aspect.
    Dr. Michael McGinnis once wrote about the dirty dozen 
reasons why we don't do prevention. One of his points was the 
primacy of the rescue. So I would say as it relates to dental 
therapists that we have dentists who can't even do the job we 
put in from of them when they come right out of training, 
because they're not used to that.
    But as a health center director, that's what we're faced 
with now, that primacy of the rescue. So I need well-trained 
dentists, trained even more than they get in their 4-year 
schools, to tackle that problem.
    But I want to get over the top of that hill, and I want to 
have our population find that they can experience the same oral 
health level that more affluent people have. And it's at that 
time, as our population gets healthier, that we have a 
responsibility to the taxpayers as well. We've built group 
dentistry practices, with five dentists, 10 dentists, with 
hygienists.
    And what I see over time is as our population gets 
healthier, we need to substitute in other providers who can 
handle the more routine things to allow our dentists to 
continue to handle and help out on those emergencies and the 
more complicated cases. So I see this more in our future, if 
these problems that we discussed can be resolved.
    Senator Sanders. Let me jump in.
    Senator Franken. I wanted to end on it, Mr. Chairman, if I 
might, because I have to go back to Judiciary. When we had 
testimony on this, we had a dental therapist who worked in a 
native village, in her own village. And she said that she was 
able to--because she had been from the village, when she would 
see kids in the village at the store or somewhere else, she'd 
say, ``Brush your teeth every day.''
    So when you're talking about this prevention piece, I think 
that it's actually key that we have people who are more likely 
to go back to where they live. And I think that this is 
something I would really like to continue to pursue.
    Thank you, Mr. Chairman.
    Senator Sanders. Thank you.
    Let me pick up where Senator Franken left off. What we're 
really talking about is the workforce, in general, whether it's 
dental therapists or dentists or hygienists. And let me throw 
this out to Dr. Hughes.
    What ideas do you have? Dr. Catalanotto made some 
suggestions, but is it your experience that we are not 
attracting the kind of practitioners that we need to take care 
of a population that has a whole lot of needs out there?
    Mr. Hughes. Actually, in Maryland, we have seen an increase 
in providers participating in Medicaid. We currently have over 
1,600 providers. Our access issues deal more with adults not 
having coverage. And for those adults that do have Medicaid, 
the benefits are so limited that they cannot find a provider.
    Senator Sanders. So what happens to them?
    Mr. Hughes. They don't get seen.
    Senator Sanders. And when they're in pain, what happens to 
them?
    Mr. Hughes. They go to the emergency room, and then they 
are referred to the health department, and that's my other 
issue. There's not enough funding for public health 
infrastructure. Right now, I could easily have an adult program 
in the health department. But when there were budget cuts, one 
of the first things that was cut was the money for a dentist 
that was seeing the uninsured adult population.
    So we don't have funding. We have the capacity, but we 
don't have funding. We don't have problems finding providers, 
but because we don't have the funding, we can't offer the 
services.
    Senator Sanders. Moving to what Ms. Stallings talked about. 
I think we have all seen pictures, whether it's healthcare or 
dental care, of doctors who volunteer their time, pro bono, to 
treating folks who don't have access.
    Actually, one of my staff members, Erica--I think it was 
last year you were in southern Virginia--and, Ms. Stallings, 
you mentioned something similar--where it really looked like a 
third-world country or maybe a fourth-world country, where 
there were people who had terrible health and dental problems 
and couldn't find access to a doctor or dentist.
    It was hard to believe that this was the United States of 
America, where people were spending the entire night, waiting 
in line in order to get a tooth extracted or get a basic 
checkup to find out whether they had cancer or whatever it may 
be. It really did not look like America.
    Ms. Stallings, I gather you are familiar with that reality. 
Yes?
    Ms. Stallings. Oh, yes, definitely.
    Senator Sanders. If you are a lower income American. You're 
on Medicaid, but you don't have access--Medicaid does not pay 
for a dentist. What happens to you? What do those people go 
through?
    Ms. Stallings. We have an office. One day, I had a client 
who was in severe pain. I took her to our main office. We got 
her an appointment. I believe it was in a couple of days. And 
we were told that they would pay up to $200.
    They have very limited funds, and, many times, the only 
option is clients waiting months on this waiting list to be 
able to be seen in the clinic where people are donating their 
time in their free off hours. But the wait list is incredibly 
long, and they have to wait for a long time often.
    Senator Sanders. So many of your clients are going through 
their days in pain.
    Ms. Stallings. Well, it's more--when they're in severe 
pain, we definitely take action to get any treatment that we 
can possibly get. A lot of our clients do lose teeth, do have 
extractions, quite a few. If someone is really in pain, we try 
to do everything we can with the limited opportunities we have.
    Senator Sanders. Let me go back to anybody here.
    Dr. Catalanotto, you raised this issue.
    We have a crisis. We don't have the workforce to address 
the crisis. What role does the ADA, the American Dental 
Association, play in all this? And, by the way, we invited the 
ADA to be with us today, and they were going to be with us, but 
at the last minute they chose not to be here. Are they stepping 
up to the plate and addressing the issues that we're talking 
about today?
    Mr. Catalanotto. In my opinion, in the last couple of 
years, there has been a shift in the national picture of the 
American Dental Association, in the leadership, and they are 
calling more and more attention to the access issue. But one of 
my arguments back to them would be, you need to lobby equally 
as hard for these access issues as you do for the business 
issues that concern you. I'm still not necessarily seeing that 
at this particular point.
    The State level is totally different. The State 
organizations are very independent of the national 
organization. So one example would be the American Dental 
Association has policies on better licensing procedures. They 
support the policies that most dental education does. But at 
the State level, that's not particularly happening.
    So easier reciprocity between the States is a national 
policy of the American Dental Association. It's still impeded 
in some States, but it is getting better. I want to be positive 
about that.
    Senator Sanders. Mr. Nycz, let me ask you a question. You 
guys are doing very well. I think we are doing well in Vermont 
as well in expanding access. If you had your druthers, have you 
done any computations as to what it would take in a State like 
Wisconsin--how many more facilities that you would need, how 
much more money you would require to provide, in a sense, 
universal dental care to the people in need?
    Mr. Nycz. It is a big number. Our State asked us could our 
State's health centers help them solve this problem, and how 
would we help them solve this problem. We said yes, if we 
stepped up and we had the resources, we could do that.
    When Governor Doyle came to one of our ribbon cuttings, he 
said that the approach we're taking is building these group 
dental clinics. Many of my private sector dentist colleagues 
tell me that you're never going to solve the problem by trying 
to get a dentist to establish a practice in this town of 1,000 
and this town of 300 and so forth. You need to really somehow 
centralize that, usually to the county seat or a place where 
people can come.
    So that way, we can gain some efficiencies in a group 
practice kind of setting. It's easier to recruit and easier to 
retain. Governor Doyle said to me when he shook my hand,

          ``I love this model. I'm wondering about how many of 
        these we need. Could we have them within 50 miles apart 
        so nobody goes more than 25 miles, or should it be 40 
        miles?''

    When we simulated this, it does cost a lot of money to do 
this. I mean, we were up in the $100 million range. He was a 
former attorney general, and he just said, ``Well, these folks, 
particularly the folks on Medicaid, have a legal right to these 
services, and we've got to find a way to do that.''
    We've made great progress, as that map shows. In my written 
testimony, I show what, collectively, we've done in the State 
of Wisconsin, and Wisconsin has been a wonderful partner to 
this day. But the fundamental question you're asking about 
cost--it is costly because we've neglected this, because we've 
had a population that does undervalue oral health and doesn't 
fully understand the importance of oral health to general 
health.
    And we have the point that you made that around 42 percent, 
43 percent visit a dentist every year. It should be more. In 
the model that we're trying to do--how do you capture savings? 
You can talk about people coming out of school with certain 
income targets and having to price things and all that. But the 
real savings on this is to raise the oral health profile of the 
American people.
    The prevention potential in dentistry is gigantic. All of 
this stuff can be prevented. So we're engaged in this 
generational effort to try to make that difference. And places 
that could be helpful--we're grateful in Wisconsin that we have 
adult dental in Medicaid.
    I've been saying, why don't all States have adult dental? 
Why don't we have adult dental in the exchanges? People say we 
can't afford it. But then I ask back and say, ``Well, how do we 
afford adult dermatology?'' We have to totally change our 
thinking and integrate these things.
    Senator Sanders. You're absolutely right, and that's why 
we're holding hearings like this, just to raise that 
consciousness. And you made the point, which is true, that if 
you expand access to dental care, it is an expensive 
proposition. But if you don't expand access, it is an equally 
or perhaps more costly proposition.
    Who wants to say a word about people walking into an 
emergency room and how much that costs?
    Mr. Catalanotto. Senator, we did our own emergency room 
report in Florida. In 2010, 115,000 dental visits to the 
emergency room at a cost of $88 million. It prompted me to 
write an editorial. It was entitled, ``Pay Me Now or Pay Me 
Later.'' We're paying for this. We are paying for this today, 
every day.
    Just the Medicaid cost alone from that $88 million was 
approximately $30 million to $35 million. I did a rough 
calculation based on Florida Medicaid fees. I could have 
purchased 495,000 preventive visits, 495,000 preventive visits, 
rather than a wasted visit in a hospital emergency room where 
all they get is an antibiotic and pain medication, and they're 
told to go see a dentist tomorrow. Well, they can't find a 
dentist.
    Senator Sanders. Which is why they're there in the first 
place.
    Mr. Nycz.
    Mr. Nycz. We're opening a clinic in Black River Falls, WI, 
on Ho-Chunk Nation land in a few weeks. The reason we're there 
is because 1,000 folks were leaving that community to go to our 
dental clinics in other communities. We are grateful for 
Federal funds through the Community Health Center Program, 
which you have something to say about, that got us money to 
help build and equip that center.
    When we asked the public health department for a letter of 
support, they sent me a letter that said we have this 28-year-
old--and this gets to the point that it's not just the Medicaid 
program, and it's one of the reasons why I think the health 
center model is so good. It's the leave-no-one-behind model.
    A lot of this evolves into a talk about Medicaid. But as 
other panelists have pointed out, there are many people who 
don't have Medicaid, or they have Medicaid with no dental 
coverage, or they have health insurance with no dental 
coverage.
    This 28-year-old who worked in the woods--no insurance, 
paycheck to paycheck, nothing in the bank--starts getting 
sicker and sicker and sicker. His sister starts to worry about 
him, and he's just going downhill. She's thinking he's got a 
job in the woods, so he must have Lyme disease.
    They call the local clinic, and they say, ``I'd like to 
make an appointment.'' ``Does he have insurance?'' ``No.'' This 
is for physician care. They want a Lyme test. ``Does he have 
any money for a down payment?'' ``No, he doesn't.'' ``Well, we 
can't give him an appointment.''
    He gets worse. She takes him to the public health 
department. They go, ``Oh, my goodness. We've got to get you 
right to the hospital.'' The hospital folks said he probably 
wouldn't have survived another 12 hours--advanced jaw cancer, 
three abscesses, sepsis. He's alive today, thankfully. But how 
much money had to be spent in the system?
    And what haunts me is in that letter of support at the end, 
they said, ``Both his sister and I agree that had you had one 
of these dental clinics here, this would not have happened.''
    Senator Sanders. What we know--and it's true of dental care 
and it's true of healthcare as well--is if a Medicaid patient 
needs primary care, can't find a primary healthcare provider 
and walks into an emergency room, it costs 10 times more than 
walking into a community health center. And I suspect the 
numbers are similar--but it's not even similar, because, as Dr. 
Catalanotto pointed out, the emergency room in a hospital, in 
most cases, doesn't really treat the dental problem as well, 
but just eases the pain and deals with the infection.
    Let me get back to one other issue--and, Dr. Hughes, jump 
in if you want to here. The cost of dental school is kind of 
off the charts. I remember last year in Rutland, VT, talking to 
two young dentists. One of them had graduated from Tufts, I 
think--well over $200,000 in debt. What are we going to do 
about that?
    Ms. Hughes. How do we reduce dental school tuition?
    Senator Sanders. If I graduated with $200,000 in debt, I 
probably would not be running to a community health center to 
make whatever I would make there. I'd probably figure out how 
I'm going to make as much money as I possibly can. Is that a 
fair statement?
    Ms. Hughes. It is. However, if you work at the community 
health center, you're likely eligible for loan repayment. 
That's what we need to--I think it's important to establish 
more of these types of programs. In Prince George's County, we 
have a population of over 800,000 people. We only have one 
Federally Qualified Health Center and one Safety Net Clinic.
    Senator Sanders. That's all you have?
    Ms. Hughes. That's all we have. And there is only one 
dental shortage designation area in the county. So it is a 
daunting task to try to establish an area as a dental health 
shortage area, because it requires that you have surveys of all 
the dentists in the area and how they practice. That's hard 
information to get. They get a survey, and they toss it to the 
side. So we have to improve that process.
    But I don't know how to answer that question, how we reduce 
dental school cost. It's costly to go to school. I mean, in 
dental school, we're doing procedures. There's the cost for the 
equipment. We're not just sitting in lecture halls. We're 
actually doing procedures. So that's why the cost is elevated.
    Senator Sanders. I want to get back to Dr. Catalanotto for 
a second. You raised an issue that we are familiar with, and 
that is the Sarrell situation in what, Alabama?
    Mr. Catalanotto. Yes, in Alabama, sir.
    Senator Sanders. You see that as a potential model to 
provide cost-effective, quality dental care. Yes?
    Mr. Catalanotto. Yes, I do.
    Senator Sanders. Say a few words about that.
    Mr. Catalanotto. They've grown from 1 to 15 clinics in 
about 9 years with no grants, only on Medicaid fees. They do it 
because, first of all, the culture of caring. I can talk about 
that, but that's not the business issue. The business issue is 
they run it with a ruthless business model. The CEO was a 
Fortune 500 company president at the age of 31. He did this as 
a volunteer activity in his community, but now it has turned 
into a major not-for-profit business.
    Senator Sanders. You're convinced the quality is good?
    Mr. Catalanotto. I have been there three times. I have free 
rein to get up from my meeting and walk down the hall and walk 
into a clinic. Every time I walk in, the parent is in the room. 
Just before each visit, they take height, weight, blood 
pressure, and temperature and report it back to the parent.
    I walk into the room and I see toothbrush--I don't see 
procedures being generated. I see prevention being emphasized. 
That's the only way they could have reduced care from over $300 
to $125 annually.
    But what do they do? They use their facilities 50 hours, 60 
hours a week. They have mass purchasing power from 15 clinics, 
so they're able to get the most cost-effective pricing. They 
have a call center.
    Senator Sanders. And how do they pay their dentists, 
reasonably well?
    Mr. Catalanotto. They pay their dentists very well, but not 
on production. The dentists are paid a straight salary, whether 
they do 15 amalgams or restorations in a day or whether they do 
five.
    They use this interesting model. The call center staff may 
get a bonus for keeping the chairs filled, because they call 
their patients. They treat their patients with dignity. There's 
a common claim--oh, those Medicaid patients don't keep their 
appointments. Sarrell Dental Center has a chair utilization 
rate of 99 percent, because they treat their patients with 
dignity. They treat them with respect. They make them feel----
    Senator Sanders. You're telling me that they are making 
money?
    Mr. Catalanotto. They are making money. Now, they're a not-
for-profit, so they plow the money back into a new clinic. They 
just recently got themselves equipped to do some tele-
dentistry. They do community service. They have great community 
outreach. Each clinic has a community person who goes out into 
the community, promoting care, promoting getting patients to go 
to the clinic and get their dental care. It's a wonderful 
model.
    Senator Sanders. And their staff feels good about working 
there?
    Mr. Catalanotto. The staff feels good. So many of their 
dental assistants, for example, are college-educated young men 
and women because of the economic situation. They care. Sarrell 
has now started--there's just one or two--if you want to go to 
dental school, if you want to go to dental hygiene school, we 
will pay your way if you offer to come back and work here.
    Senator Sanders. So they're doing their own National Health 
Service Corps.
    Mr. Catalanotto. They have their own National Health 
Service Corps. And I can tell you I'm on their board, unpaid, 
on their board of directors. They want to expand out of State. 
They are restricted from doing this because the CEO is an MBA.
    Senator Sanders. Mr. Nycz, is there anything in that model 
we can learn from?
    Mr. Nycz. I think health centers probably could learn from 
this model as well. But the task we're faced with, though, is 
not just taking care of Medicaid on dental. We have to contend 
with adults. We have to contend with people with psychiatric 
problems. We have to contend with people with disabilities. So 
we have to be a little bit more well-rounded.
    For example, we could make our site more efficient if we 
didn't include large treatment rooms and wheelchair lifts. We 
could make our site more efficient perhaps if we didn't include 
space for training. So I think that we can learn from them, but 
their model is still fairly focused on a distinct population, 
and we have responsibility for everyone.
    Senator Sanders. Is Sarrell mostly focused on kids?
    Mr. Catalanotto. It is only focused on kids because there 
are no adult benefits in the State of Alabama. So they only do 
children. He is absolutely right. It is a little different 
model. Now, they do some developmentally disabled. They have 
recently hired an oral surgeon. They have several pediatric 
dentists who can take children to the hospital.
    Senator Sanders. But only treating kids.
    Mr. Catalanotto. But they only treat children through age 
20.
    Senator Sanders. Let me just say to Mr. Nycz and to 
everybody here that we're going to do our best to focus more 
and more attention on this issue--why this hearing is so 
important. We're going to do our best to fight for more money 
for the community health centers.
    We're going to take a look at the issue of dental 
therapists. We are going to take a look at models which seem to 
be high quality and cost-effective. We want to deal with that. 
I think your point about philanthropy is great, that it is not 
a solution to a major, major crisis in this country.
    Dr. Hughes is here today, and she oversees the Deamonte 
Driver Dental Project. Maybe we'll conclude--Dr. Hughes, tell 
us--because some people may have forgotten--who Deamonte Driver 
is and why the project is named after him.
    Ms. Hughes. Deamonte Driver was the 12-year-old that died 
in Prince George's County from an abscess. His parent was 
unable to access dental care. His Medicaid had lapsed, and she 
could not find a dentist to treat the child. He was taken to an 
emergency room and given treatment for sinusitis and other 
things and released, and then was rushed back to the hospital 
and had to have immediate surgery when they found that the 
bacteria had spread to his brain.
    Deamonte Driver died February 27, 2007. As a result, the 
Governor of Maryland said, ``This cannot happen again.'' The 
Dental Action Committee was formed, and seven recommendations 
were made. Also, from their actions, the Deamonte Driver 
Project was initiated. It is a mobile dental unit that goes to 
Title I schools throughout the county. We treat all children, 
insured and uninsured.
    One thing that we really don't talk about is the children 
that are uninsurable. We have a large population, in the county 
and in the State, of children that are uninsurable, and we see 
those children as well.
    By definition, a mobile unit in Maryland cannot be a dental 
home, and that is not our purpose. We work with families 
through case management to ensure that all children are in a 
dental home. We are there to treat emergent needs so that we 
don't have another Deamonte Driver.
    As I talked about earlier, in our process, we are trying to 
establish statewide school screenings. Children are required 
when they go to school to have immunizations. Why are they not 
required to be seen by a dentist?
    So in our demonstration project, we saw that there were a 
number--it was vital that we were there. There are a number of 
children who, had we not seen them, could possibly be Deamonte 
Drivers. So we honor the legacy of Deamonte Driver by being in 
the schools. We also provide treatment at the school he 
attended. The program has been very successful, and it is 
welcomed by all the schools that we attend.
    Senator Sanders. Dr. Hughes, thank you for the work that 
you do on that. I think to remember Deamonte Driver, our job is 
to dedicate ourselves to make very, very significant 
improvements to our dental care system so we never see another 
Deamonte Driver situation again in this country.
    I want to thank you all, not only for being here today, but 
each in your own individual way for playing such an important 
role in addressing this issue. Thank you very much.
    With that, let's adjourn the hearing.

    [Whereupon, at 11:20 a.m., the hearing was adjourned.]

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