[Congressional Record Volume 147, Number 74 (Friday, May 25, 2001)]
[Senate]
[Pages S5701-S5704]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Ms. COLLINS (for herself and Mr. Feingold):
  S. 971. A bill to expand the availability of oral health services by 
strengthening the dental workforce in designated underserved areas; to 
the Committee on Finance.
  Ms. COLLINS. Mr. President, I am pleased to join my good friend and 
colleague from Wisconsin, Senator Russ Feingold, in introducing 
legislation to improve access to oral health care by strengthening the 
dental workforce in our nation's rural and underserved communities.
  Oral and general health are inseparable, and good dental care is 
critical to our overall physical health and well-being. Dental health 
encompasses far more than cavities and gum disease. The recent U.S. 
Surgeon General report Oral Health in America states that ``the mouth 
acts as a mirror of health and disease'' that can help diagnose 
disorders such as diabetes, leukemia, heart disease, or anemia.
  While oral health in America has improved dramatically over the last 
50 years, these improvements have not occurred evenly across all 
sectors of our population, particularly among low-income individuals 
and families. Too many Americans today lack access to dental care. 
While there are clinically proven techniques to prevent or delay

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the progression of dental health problems, an estimated 25 million 
Americans live in areas lacking adequate dental services. As a 
consequence, these effective treatment and prevention programs are not 
available in too many of our communities. Astoundingly, as many as 
eleven percent of our nation's rural population has never been to a 
dentist.
  This situation is exacerbated by the fact that our dental workforce 
is graying and the overall ratio of dentists to population is 
declining. In Maine, for example, there currently are 393 active 
dentists, 241 of whom are 45 or older. More than 20 percent of dentists 
nationwide will retire in the next ten years, and the number of dental 
graduates by 2015 may not be enough to replace these retirees.
  As a consequence, Maine, like many States, is currently facing a 
serious shortage of dentists, particularly in rural areas. While there 
is one general practice dentist for every 2,286 people in the Portland 
area, the numbers drop off dramatically in western and northern Maine. 
In Aroostook County, where I am from, there's only one dentist for 
every 5,507 people. Moreover, at a time when tooth decay is the most 
prevalent childhood disease in America, Maine has fewer than ten 
specialists in pediatric dentistry, and most of these are located in 
the southern part of the state.
  This dental workforce shortage is exacerbated by the fact that Maine 
currently does not have a dental school or even a dental residency 
program. Dental schools can provide a critical safety net for the oral 
health needs of a state, and dental education clinics can provide the 
surrounding communities with care that otherwise would be unavailable 
to disadvantaged and underinsured populations. Maine is just one of a 
number of predominantly rural states that lacks this important 
component of a dental safety net.
  Maine, like many States, is exploring a number of innovative ideas 
for increasing access to dental care in underserved areas. In an effort 
to supplement and encourage these efforts, we are introducing 
legislation today to establish a new State grant program designed to 
improve access to oral health services in rural and underserved areas. 
The legislation authorizes $50 million over 5 years for grants to 
States to help them develop innovative dental workforce development 
programs specific to their individual needs.
  States could use these grants to fund a wide variety of programs. For 
example, they could use the funds for loan forgiveness and repayment 
programs for dentists practicing in underserved areas. They could also 
use them to provide grants and low- or no-interest loans to help 
practitioners to establish or expand practices in these underserved 
areas. States, like Maine, that do not have a dental school could use 
the funds to establish a dental residency program. Other States might 
want to use the grant funding to establish or expand community or 
school-based dental facilities or to set up mobile or portable dental 
clinics.

  To assist in their recruitment and retention efforts, States could 
also use the funds for placement and support of dental students, 
residents, and advanced dentistry trainees. Or, they could use the 
grant funds for continuing dental education, including distance-based 
education, and practice support through teledentistry.
  Other programs that could be funded through the grants include: 
community-based prevention services such as water fluoridation and 
dental sealant programs; school programs to encourage children to go 
into oral health or science professions; the establishment or expansion 
of a State dental office to coordinate oral health and access issues; 
and any other activities that are determined to be appropriate by the 
Secretary of Health and Human Services.
  The National Health Service Corps is helping to meet the oral health 
needs of underserved communities by placing dentists and dental 
hygienists in some of America's most difficult-to-place inner city, 
rural, and frontier areas. Unfortunately, however, the number of 
dentists and dental hygienists with obligations to serve in the 
National Health Service Corps falls far short of meeting the total 
identified need. According to the Surgeon General, only about 6 percent 
of the dental need in America's rural and underserved communities is 
currently being met by the National Health Service Corps.
  In my State, approximately 173,000 Mainers live in designated dental 
health professional shortage areas. While the National Health Service 
Corps estimates that it will take 33 dental clinicians to meet this 
need, it currently has only three serving in my State.
  The bill we are introducing today would make some needed improvements 
in this critically important program so that it can better respond to 
our nation's oral health needs.
  First, it would direct the Secretary of Health and Human Services to 
develop and implement a plan for increasing the participation of 
dentists and dental hygienists in the National Health Service Corps 
scholarship and loan repayment programs.
  It would also allow National Health Service Corps scholarship and 
loan repayment program recipients to fulfill their commitment on a 
part-time basis. Some small rural communities may not have sufficient 
populations to support a full-time dentist or dental hygienist. This 
would give the National Health Service Corps additional flexibility to 
meet the needs of these communities. Moreover, some practitioners may 
find part-time service more attractive to them. This particularly may 
be the case for a retired dentist who may want to practice only part-
time, allowing this feasibility could in turn improve both recruitment 
and retention in these communities.
  Last year, after a 6-year hiatus, the National Health Service Corps 
began a two-year pilot program to award scholarships to dental 
students.
  This is a step in the right direction, however, these scholarships 
are only being awarded to students attending certain dental schools, 
not one of which is located in New England. Moreover, the pilot project 
requires the participating dental schools to encourage Corps dental 
scholars to practice in communities near their educational 
institutions. The problem is obvious. If none of these programs are in 
New England, and yet there is a requirement that the dentists 
participating in these programs practice in the surrounding 
communities, this is of no benefit to a State such as Maine that does 
not have a dental school and does not have a qualifying program. As a 
consequence, this program will do nothing at all to help relieve the 
dental shortage in Maine and other areas of New England.
  The legislation we are introducing today would address this problem 
by expanding the National Health Service Corps Pilot Scholarship 
Program so that dental students attending any of the 55 American dental 
schools can apply and require that placements for these scholars be 
based strictly on community need, not on whether or not they surround 
the dental school.
  It would also improve the process for designating dental health 
professional shortage areas and ensure that the criteria for making 
such designations provide a more accurate reflection of oral health 
needs, particularly in our rural areas where the problem is most acute.
  And finally, taxing the scholarships and stipends of students 
adversely affects their financial incentive to participate in the 
National Health Service Corps and to provide health care services in 
underserved communities. Our legislation would, therefore, exclude from 
Federal income tax the fees and related educational expenses to 
individuals who are participating in the National Health Service Corps 
scholarship and loan repayment programs.
  The Dental Health Improvement Act will make critically important oral 
health care services more accessible in our Nation's rural and 
underserved communities. I urge all of my colleagues to join me in 
supportin this legislation. I ask unanimous consent that letters 
endorsing my bill from the American Dental Association and the American 
Dental Education Association be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                  American Dental Association,

                                     Washington, DC, May 25, 2001.
     Hon. Susan Collins,
     Russell Senate Office Building,
     Washington, DC.
       Dear Senator Collins: On behalf of the American Dental 
     Association and our 144,000 member dentists, I am delighted 
     to endorse

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     the ``Dental Health Improvement Act,'' which you introduced 
     today. The Association is proud that the oral health of 
     Americans continues to improve, and that Americans have 
     access to the best oral health care in the world.
       Having said that, we agree that dental care has not reached 
     every corner of American society to the extent it has reached 
     the majority of Americans. For those Americans who are unable 
     to pay for care, and those with special needs, such as 
     disabled individuals, those with congenital conditions, and 
     non-ambulatory patients, obtaining dental care can be 
     difficult.
       Your legislation recognizes several of these problems and 
     goes a long way towards addressing them in a targeted and 
     meaningful way. The section on grant proposals offers states 
     the opportunity to be innovative in their approaches to 
     address specific geographical dental workforce issues. You 
     recognize the need to provide incentives to increase faculty 
     recruitment in accredited dental training institutions, and 
     your support for increasing loan repayment and scholarship 
     programs will provide the appropriate incentives to increase 
     the dental workforce in ``safety net'' organizations.
       The ADA is very grateful for your leadership on these 
     issues. Thank you for introducing this legislation. We want 
     to continue to work with you on dental access issues in 
     general and on this legislation as it moves through the 
     Congress.
           Sincerely,
                                               Robert M. Anderton,
     D.D.S., J.D., LL.M., President.
                                  ____

                                                   American Dental


                                        Education Association,

                                     Washington, DC, May 23, 2001.
     Hon. Susan Collins,
     U.S. Senate,
     Washington, DC.
       Dear Senator Collins, I am writing on behalf of the dental 
     education community to commend you for developing and 
     introducing the Dental Health Improvement Act. This 
     legislation, when enacted into law, will expand the 
     availability of oral health care services for the nation's 
     underserved populations, strengthen the dental workforce, as 
     well as maintain the ability of dental schools to produce the 
     necessary manpower to provide oral health care to all 
     Americans.
       The American Dental Education Association (ADEA) represents 
     the nation's 55 dental schools, as well as hospital-based 
     dental and advanced dental education programs, allied dental 
     programs and schools, dental research institutions, and the 
     faculty and students at these institutions. ADEA's member 
     schools are dedicated to providing the highest quality 
     education to their students, conducting research and 
     providing oral health care services to Americans from 
     medically unserved and underserved areas, the majority of 
     whom are uninsured or who are from low-income families. 
     Recent downward trends in student enrollment and a growing 
     shortage in dental faculty have caused ADEA serious concern 
     about our ability to fully and competently address these 
     responsibilities.
       Therefore, I was delighted to see that the Dental Health 
     Improvement Act directly responds to many of these concerns. 
     If implemented, the Act would expand access to oral health 
     care to thousands of Americans for the first time. When 
     enacted, the provisions of the bill can be instrumental in 
     helping the more than 31 million Americans living in ares 
     that lack access to adequate oral health care services. It 
     can provide much needed help to dental education institutions 
     as we seek to address faculty shortages.
       As you know, dental education institutions face a major 
     crisis in the graying of its faculty which threatens the 
     quality of dental education, oral, dental and craniofacial 
     research, and ultimately will adversely impact the health of 
     all Americans. Currently, there are approximately 400 faculty 
     vacancies. Retirements are expected to accelerate in both 
     private practice as well as teaching faculties in the 
     nation's 55 dental schools. There is a significant decrease 
     in the number of men and women choosing careers in dentistry, 
     teaching and research. Your personal experience in Maine is a 
     perfect example.
       Educational debt has increased, affecting both career 
     choices and practice location. Your bill will provide funds 
     to help with recruitment and retention efforts and helps 
     expand dental residency training programs to the 27 states 
     that do not currently have dental schools.
       Also important are the incentives you have proposed to 
     expand or establish community-based dental facilities linked 
     with dental education institutions. The need for this is 
     obvious. More than two-thirds of patients visiting dental 
     school clinics are members of families whose annual income is 
     estimated to be $15,000 or below. About half of these 
     patients are on Medicare or Medicaid, while more than a third 
     have no insurance coverage or government assistance program 
     to help them pay for their dental care.
       Dental academic institutions are committed to their patient 
     care mission, not only by improving the management and 
     efficiency of patient centered care delivery at the dental 
     school, but through increasing affiliations with and use of 
     satellite clinics. All dental schools maintain at least one 
     dental clinic on-site, and approximately 70% of U.S. dental 
     schools have school-sponsored satellite clinics. Delivering 
     patient care in diverse settings demonstrates professional 
     responsibility to the oral health of the public.
       Dental schools and other academic dental institutions 
     provide oral health to underserved and disadvantaged 
     populations. Yet more than 11 percent of the nation's rural 
     population has never been to see a dentist. This bill can 
     have a positive impact on this population by establishing 
     access to oral health care at community-based dental 
     facilities and consolidated health centers that are linked to 
     dental schools. 100 million Americans presently do not have 
     access to fluoridated water. The bill provides for community-
     based prevention services such as fluoride and sealants that 
     can cause a dramatic change for nearly a third of the 
     nation's population.
       Thank you again for taking such a leadership role in the 
     area of oral health. Please be assured that ADEA looks 
     forward to working closely with you to bring the far-reaching 
     potential of the Dental Health Improvement Act to fruition.
           Sincerely,
                                            Richard W. Valachovic,
                               D.M.D., M.P.H., Executive Director.

  Ms. COLLINS. Finally, Mr. President, I thank my principal cosponsor 
of this legislation, Senator Feingold of Wisconsin, for his 
contributions to this bill. We found that Maine and Wisconsin have many 
similar problems in ensuring that there is an adequate supply of 
dentists in our more rural parts of our State.
  It is our hope that this legislation will be considered and enacted 
this year.
  Mr. FEINGOLD. Mr. President, I rise today to join my friend from 
Maine, Senator Collins, to introduce the Dental Health Improvement Act. 
This legislation will improve access to dental services by 
strengthening the deal workforce in under-served areas.
  While the scope of the dental access problem is very wide reaching, 
this legislation takes an important step in the right direction by 
improving the dental workforce in under-served areas.
  According to the Surgeon General, an estimated 25 million Americans 
live in areas lacking adequate dental care services, and as many as 11 
percent of our Nation's rural population have never been to a dentist.
  This problem will only get worse since more than 20 percent of 
dentists will retire in the next 10 years, and the number of dental 
graduates by 2015 may not be enough to replace these retirees. While 
dentists have increased their productivity, they are still distribution 
problems in specific geographic areas.
  For too long, oral health has been overlooked and excluded from 
important public policy discussions of how to improve health and health 
care around the country. Some contend that oral health care has been a 
lower priority because advances in dentistry--most notably the expanded 
use of sealants and fluoridated water--are such that we are nearly a 
``cavity free society.'' Yet the truth is that while oral health has 
certainly improved dramatically among those who are insured, and those 
who have reliable access to a dentist, there is a tragic disparity in 
health status between the haves and the have nots.
  This disparity between the poor and everyone else exists in general 
medical health measures, such as infant mortality, low birth weight, 
blood lead levels and so on. But what I have learned since I first 
became interested in this issue is that the disparity is disturbingly 
stark in oral health.
  Surgeon General David Satcher framed this issue well at his May 2000 
release of his report, Oral Health in America, that ``Tooth decay 
remains the single most common chronic disease of childhood--five times 
more common than asthma.''
  While this fact is certainly true--that the prevalence of dental 
disease remains high among children--its burden within the population 
of US children has shifted dramatically.
  I would like to make sure that my colleagues are aware of this 
horrifying statistic that helps to outline the scope of the problem: 80 
percent of dental disease is found in the poorest 25 percent of 
children.
  This figure helps to illustrate the broad scope of the problem. And 
we all know that the problem is even more disturbing when we look at 
the ways these vulnerable children suffer from lack of dental care.
  Preschoolers living in poverty have twice the odds of having decaying 
teeth, twice the extent of decay when they have disease, and twice the 
pain experience of their most affluent peers.
  These children are already at a disadvantage in so many ways. And 
just

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the most basic dental care could make a difference in their lives. But 
our health care system allows this problem to fall through the cracks.
  Over the past few years these and similar statistics have been 
chronicled by numerous entities including the Surgeon General, the 
General Accounting Office, and the National Institutes of Health.
  This legislation will help strengthen the dental workforce that 
delivers vital oral health care services by improving the workforce in 
under-served areas. By providing States and communities with sufficient 
flexibility to address the unique needs of their under-served areas, I 
believe that this legislation will take an effective approach to 
meeting the needs of communities in Wisconsin and across the Nation.
  The first part of this legislation would establish a new State-based 
grant program to help states explore innovative ideas for increasing 
access to dental care in under-served areas.
  This grant program would be directed through the Health Resources and 
Services Administration at the Department of Health and Human Services 
and support the efforts of States to develop and implement innovative 
programs to address the dental workforce shortage that are appropriate 
to their individual needs.
  For example, States could tailor loan forgiveness and repayment 
programs for dentists practicing in areas designated as dental health 
professional shortage areas by either the Federal Government or the 
State.
  This program could also help with recruitment and retention efforts 
by providing grants or low interest loans to help practitioners in 
designated dental health professional shortage areas equip a dental 
office or share in the overhead costs of an operation.
  The second component of our legislation would increase participation 
of the dental workforce in the National Health Service Corps.
  According to the U.S. Surgeon General, the number of dentists and 
dental hygienists with obligations to serve in the National Health 
Service Corps falls far short of meeting the total identified need: 
only about 6 percent of the dental need is currently being met by this 
program, and outreach and development are critical to future 
opportunities for strengthening the dental workforce in designated 
under-served areas.
  Our legislation would develop and implement a plan for increasing the 
participation of dentists and dental hygienists in the National Health 
Service Corps scholarship and loan repayment programs and report back 
to Congress on their progress after three years.
  This legislation follows a series of recommendations by the American 
Dental Association and the American Dental Educators Association, who 
both strongly support this legislation.
  I hope my colleagues will join the Senator from Maine and me in our 
ongoing efforts to increase access to dental care and promote greater 
oral health.
  We must change America's approach to oral health, especially when it 
comes to some of the most vulnerable members of our communities--low 
income children. These kids deserve quality dental care. Right now, too 
many kids are suffering. It is my hope that Congress will work on a 
bipartisan basis to promote greater oral health.
                                 ______