[Congressional Record Volume 147, Number 149 (Thursday, November 1, 2001)]
[Senate]
[Pages S11380-S11386]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. BINGAMAN (for himself, Mr. Cochran, Mr. Daschle, Mrs. 
        Lincoln, Ms. Collins, Mrs. Carnahan, Mr. Hutchinson, and Mr. 
        Corzine):
  S. 1626. A bill to provide disadvantaged children with access to 
dental services; to the Committee on Finance.
  Mr. BINGAMAN. Mr. President, the legislation I am introducing today 
with Senators Cochran, Daschle, Lincoln, Collins, Carnahan, Hutchinson 
of Arkansas, and Corzine entitled the ``Children's Dental Health 
Improvement Act of 2001'' is designed to improve the access and 
delivery of dental health services to our Nation's children through 
Medicaid, the State Children's Health Insurance Program, SCHIP, the 
Indian Health Service, IHS, and our Nation's safety net of community 
health centers.
  The oral health problems facing children are highlighted in a 
landmark report issued by the Surgeon General and the Department of 
Health and Human Services, HHS, last year entitled Oral Health in 
America: A Report of the Surgeon General in which he observed that our 
Nation is facing what amounts to ``a `silent epidemic' of dental and 
oral diseases.''
  In fact, dental caries, which refers to both decayed teeth or filled 
cavities, is the most common childhood disease. According to the 
Surgeon General, ``Among 5- to 17-year olds, dental caries is more than 
5 times as common as a reported history of asthma and 7 times as common 
as hay fever.'' In short, dental care is, as the Surgeon General adds, 
``the most prevalent unmet health need among American children.''
  The severity of this problem is even greater among children is 
poverty. Poor children aged 2 to 9 have twice the levels of untreated 
decayed teeth as nonpoor children. Moreover, the Surgeon General has 
found that poor Mexican American children have rates of untreated 
decayed teeth that exceed 70 percent, a rate of true epidemic 
proportions.
  For these children, their personal suffering is real. Many of the 
oral diseases and disorders can cause severe pain, undermine self-
esteem and self-image, discourage normal social interaction, cause 
other health problems, compromise nutritional status, and lead to 
chronic stress and depression as well as incur great financial cost. 
Lack of treatment is estimated to result in a loss of 1.6 million 
school days annually, according to the National Center for Health 
Statistics.
  The General Accounting Office, GAO, in its April 2000 report, 
entitled ``Oral Health: Dental Disease is a Chronic Problem Among Low-
Income Populations,'' adds, ``Poor children suffer nearly 12 times more 
restricted-activity days, such as missed school, than higher-income 
children as a result of dental problems.''
  Incredibly, this could all be prevented. As the Surgeon General's 
report notes, prevention programs in oral health that have been 
designed and evaluated for children using a variety of fluoride and 
dental sealant strategies has the ``potential of virtually eliminating 
dental caries in all children.''
  Unfortunately, children do not get the dental services they need. 
According to the Surgeon General,'' Although over 14 percent of 
children under 18 have no form of private or public medical insurance, 
more than twice that many, 23 million children, have no dental 
insurance.'' The report adds, ``There are at least 2.6 children without 
dental insurance for each child without medical insurance.''
  One important provision in the bill would grant States flexibility to 
provide dental coverage to low-income children through the State 
Children's Health Insurance Program, just as States currently are able 
to do through Medicaid.
  Unfortunately, SCHIP law prohibits coverage of children for services 
unless they are completely uninsured. As authors Ruth Almeida, Ian 
Hill, and Genevieve Kenney of an Urban Institute report entitled Does 
SCHIP Spell Better Dental Care for Children? An Early Look at New 
Initiatives write, ``. . . many low-income children are covered by 
employer-based or other private health insurance for their medical 
care, but do not have a comprehensive dental benefit. Because these 
children are privately insured, they are not eligible for SCHIP and 
cannot avail themselves of dental coverage under SCHIP. Expanding SCHIP 
to furnish dental services on a wraparound basis to privately covered 
low-income children without dental coverage could help achieve broader 
improvements in children's oral health.''
  For low-income children with medical coverage but no dental insurance 
through the private sector, their only option would be to completely 
dump their private coverage for their children in order to access SCHIP 
coverage.
  Instead, the ``Children's Dental Health Improvement Act of 2001'' 
would create an option for states to provide low-income families with 
the ability to receive wrap-around dental coverage through SCHIP 
without having to completely drop their private insurance. This reduces 
the crowd-out of private insurance, which was a priority of the 
Congress during passage of SCHIP, and it provides low-income children 
with dental services that other children in the same economic 
circumstance are already receiving through SCHIP.
  In implementing such a change, I want to make it clear that I am in 
strong support of providing additional funding to SCHIP to ensure that 
these services are provided without reducing current levels of SCHIP 
funding. I am concerned about SCHIP funding in forthcoming years, 
particularly in those years referred to as the ``CHIP dip'' when 
funding levels drop from over $4 billion annually to around $3 billion. 
I have other legislation entitled, S. 1016, the ``Start Healthy, Stay 
Healthy Act of 2001,'' that addresses this very problem.
  With those additional funds, I strongly believe that SCHIP, just as 
Medicaid, should provide services to low-income children who are both 
uninsured and underinsured. Children need a comprehensive set of child 
health services, including dental services, to ensure their appropriate 
health and development.
  However, coverage for these services is often not enough. Even when 
children do have dental coverage, the access to care is often sorely 
lacking. Medicaid is the largest insurer of dental coverage to 
children. Yet, despite the design of the Medicaid program to ensure 
access to comprehensive services for children, including dental care, 
the Inspector General of the Department of Health and Human Services 
reported in 1996 that only 18 percent of children eligible for Medicaid 
received even a single preventive dental service. The same report shows 
that no State provides preventive services to more than 50 percent of 
eligible children. The factors are complex but the primary one is due 
to limited dentist participation in Medicaid.

[[Page S11381]]

  According to GAO, in its September 2000 report entitled Oral Health: 
Factors Contributing to Low Use of Dental Services by Low-Income 
Populations, ``Of 39 states that provided information about dentists' 
participation in Medicaid, 23 reported that fewer than half of the 
states' dentists saw at least one Medicaid patient during 1999.'' Even 
worse, a 1998 survey by the National Conference of State Legislatures 
indicates that fewer than 20 percent of dentists participate in the 
Medicaid program nationwide.
  The GAO concludes poor participation rates by dentists is due in 
large part to poor reimbursement rates in Medicaid. As the GAO points 
out, ``Our analysis showed that Medicaid payment rates are often well 
below dentists' normal fees. Only 13 states had Medicaid rates that 
exceeded two-thirds of the average regional fees dentists charged. . . 
.''
  Clearly, Medicaid is chronically underfunded with respect to dental 
care. The Surgeon General's report notes, ``On average, state Medicaid 
agencies contribute only 2.3 percent of their child health expenditures 
to dental care, whereas nationally, the percentage of all child health 
expenditures dedicated to dental care is more than 10 times that rate, 
almost 30 percent.''
  The good news is that many States, including New Mexico, are taking 
actions to improve the participation of dentists in the Medicaid 
program by raising low payment rates and reducing administrative 
requirements. These efforts were highlighted by the GAO in its 
September 2000 report. To further encourage such efforts, the 
``Children's Dental Health Improvement Act of 2001'' provides $50 
million annually as financial incentives and planning grants to states 
to undertake additional improvements in their Medicaid programs 
delivery of dental health services to children.
  In addition to Medicaid and SCHIP, the federal government administers 
other health care programs providing dental services or providers for 
low-income children and their families, including services administered 
by community health centers and the Indian Health Service, IHS. 
Unfortunately, both of these programs are underfunded and, as the GAO 
found, ``report difficulty in meeting the dental needs of their target 
populations.''
  For example, the GAO found that ``HHS and health center officials 
report that the demand for dental services significantly exceeds the, 
urban and rural health, centers' capacity to deliver it. In 1998 . . ., 
a little more than half of the nearly 700 health center grantees funded 
under this program had active dental programs.'' This is also true for 
public health departments across the country.
  To assist the health centers and public health departments with this 
need, the ``Children's Dental Health Improvement Act of 2001'' provides 
$40 million to community health centers and public health departments 
to expand dental health services through the hiring of additional 
dental health professionals to serve low-income populations.
  This is particularly a problem that needs to be addressed in areas 
with severe dental health professional shortages, such as New Mexico. 
For example, New Mexico ranked next to last in the Nation with just 
32.1 dentists per 100,000 population in 1998, according to HHS. This 
compares to the national average of 48.4 per 100,000. Moreover, the 
number of dentists in New Mexico declined by 7 percent between 1991 and 
1998 while the State's population grew 12 percent. The result was a 17 
percent decline in dentists per capita during the period.
  With regard to American Indian and Alaska Native populations, the 
need is so great and the funding so little that a comprehensive 
solution is requiring throughout the IHS system. With respect to the 
unmet need, the GAO notes that ``American Indian and Alaska Native 
children aged 2 to 4 years old have five times the rate of dental decay 
that all children have.''
  Unfortunately, the GAO adds, ``. . . about one-fourth of IHS' dentist 
positions at 269 HIS and tribal facilities were vacant in April 2000. 
Vacancies have been chronic at IHS facilities, in the past 5 years, at 
least 67 facilities have had one or more dentist position vacant for at 
least a year. According to IHS officials, the primary reason for these 
vacancies is that IHS is unable to provide a competitive salary for new 
dentists. . .''
  The GAO continues, ``The IHS' dental personnel shortages translate 
into a large unmet need for dental services among American Indians and 
Alaska Natives. IHS reports that only 24 percent of the eligible 
population had a dental visit in 1998. The personnel shortages have 
also reduced the scope of services that facilities are able to provide. 
According to IHS officials, available services have concentrated more 
on acute and emergency care, while routine and restorative care have 
dropped as a percentage of workload. Emergency services increased from 
one-fifth of the workload in 1990 to more than one-third of the 
workload in 1999.'
  To help alleviate this workforce shortage, the ``Children's Dental 
Health Improvement Act of 2001'' provides IHS with the authority to 
offer multi-year retention bonuses to dental providers offering 
services through the IHS and tribal programs.
  The bill also provides for some technical amendments to ensure that 
tribal organizations and community health centers are allowed to apply 
for school-based dental sealant funding from the Centers for Disease 
Control and Prevention, CDC.
  And finally, to help address this ``silent epidemic,'' HHS 
implemented what is referred to as the Oral Health Initiative, OHI, to 
coordinate dental health services in both the Health Resources and 
Services Administration, HRSA, and the Center for Medicaid and Medicare 
Services, CMS, formerly known as the Health Care Financing 
Administration. Despite the progress of the Initiative, it has no legal 
authority unlike other programs that target specific health needs of 
children, such as Emergency Medical Services for Children or the 
Traumatic Brain Injury Program. Because it lacks formal status and 
program control, the OHI is susceptible to future disruptions or 
dispanding.

  To ensure the continuation of the OHI, the ``Children's Health 
Improvement Act of 2001'' provides statutory authority for the OHI and 
authorized funding of $25 million to improve the oral health of low-
income populations served by both the public and private sector.
  The bipartisan legislation I am introducing today would improve the 
access and delivery of dental health services to our Nation's children 
through Medicaid, the State Children's Health Insurance Program, SCHIP, 
the Indian Health Service, IHS, and our Nation's safety net of 
community health centers. These problems are well-documented and call 
out for congressional action as soon as possible.
  I would like to thank the American Dental Association, the American 
Dental Education Association, the American Academy of Pediatric 
Dentistry, the National Association of Community Health Centers, Inc., 
the National Association of Children's Hospitals, the American Dental 
Hygienists' Association, and the Children's Dental Health Project for 
their outstanding support and/or their technical advice on this 
legislation. This bill is a result of their outstanding work.
  In particular, I want to thank Dr. Burt Edelstein and Libby Mullin of 
the Children's Dental Health Project for their vast knowledge and 
technical assistance on this issue. I want to thank Judy Sherman of the 
American Dental Association, Myla Moss of the American Dental Education 
Association, Dr. Heber Simmons and Scott Litch of the American Academy 
of Pediatric Dentistry, Karen Sealander of the American Dental 
Hygienists' Association, and Heather Mizeur of the National Association 
of Community Health Centers, Inc., for their valuable insight, 
technical advice, and support for this legislation. I look forward to 
working with them all to ensure that we achieve increased access to 
oral health care for our children.
  In addition to those organizations, I would like to thank the 
following groups for their support of the bill, including: Academy of 
General Dentistry, American Academy of Child and Adolescent Psychiatry, 
American Academy of Oral and Maxillofacial Pathology, American Academy 
of Periodontology, American Association of Dental Examiners, American 
Association of Dental Research, American

[[Page S11382]]

Association of Endodontists, American Association of Public Health 
Dentistry, American Association of Oral and Maxillofacial Surgeons, 
American Association of Orthodontists, American Association of Women 
Dentists, American College of Dentists, American College of Preventive 
Medicine, American Dental Trade Association, American Public Health 
Association, American Society of Dentistry for Children, American 
Student Dental Association, Association of Clinicians of the 
Underserved, Association of Maternal and Child Health Programs, 
Association of State and Territorial Dental Directors, Dental Dealers 
of America, Dental Manufacturers of America, Inc., Family Voices, 
Hispanic Dental Association, International College of Dentists, USA, 
March of Dimes, National Association of City and County Health 
Officers, National Association of Local Boards of Health, National 
Dental Association, National Health Law Program, New Mexico Department 
of Health, Partnership for Prevention, Society of American Indian 
Dentists, Special Care Dentistry, and United Cerebral Palsy 
Associations.
  I request unanimous consent that a Fact Sheet and the text of the 
bill be printed in the Record.
  There being no objection, the bill was ordered to be printed in the 
Record, as follows:

                                S. 1626

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

       (a) Short Title.--This Act may be cited as the ``Children's 
     Dental Health Improvement Act of 2001''.
       (b) Table of Contents.--The table of contents of this Act 
     is as follows:

Sec. 1. Short title; table of contents.

TITLE I--IMPROVING DELIVERY OF PEDIATRIC DENTAL SERVICES UNDER MEDICAID 
                               AND SCHIP

Sec. 101. Grants to improve the provision of dental services under 
              medicaid and SCHIP.
Sec. 102. Authority to provide dental coverage under SCHIP as a 
              supplement to other health coverage.

    TITLE II--IMPROVING DELIVERY OF PEDIATRIC DENTAL SERVICES UNDER 
  COMMUNITY HEALTH CENTERS, PUBLIC HEALTH DEPARTMENTS, AND THE INDIAN 
                             HEALTH SERVICE

Sec. 201. Grants to improve the provision of dental health services 
              through community health centers and public health 
              departments.
Sec. 202. Dental officer multiyear retention bonus for the Indian 
              Health Service.
Sec. 203. Streamline process for designating dental health professional 
              shortage areas.
Sec. 204. Demonstration projects to increase access to pediatric dental 
              services in underserved areas.

   TITLE III--IMPROVING ORAL HEALTH PROMOTION AND DISEASE PREVENTION 
                                PROGRAMS

Sec. 301. Oral health initiative.
Sec. 302. CDC reports.
Sec. 303. Early childhood caries.
Sec. 304. School-based dental sealant program.

TITLE I--IMPROVING DELIVERY OF PEDIATRIC DENTAL SERVICES UNDER MEDICAID 
                               AND SCHIP

     SEC. 101. GRANTS TO IMPROVE THE PROVISION OF DENTAL SERVICES 
                   UNDER MEDICAID AND SCHIP.

       Title V of the Social Security Act (42 U.S.C. 701 et seq.) 
     is amended by adding at the end the following:

     ``SEC. 511. GRANTS TO IMPROVE THE PROVISION OF DENTAL 
                   SERVICES UNDER MEDICAID AND SCHIP.

       ``(a) Authority to Make Grants.--In addition to any other 
     payments made under this title to a State, the Secretary 
     shall award grants to States that satisfy the requirements of 
     subsection (b) to improve the provision of dental services to 
     children who are enrolled in a State plan under title XIX or 
     a State child health plan under title XXI (in this section, 
     collectively referred to as the `State plans').
       ``(b) Requirements.--In order to be eligible for a grant 
     under this section, a State shall provide the Secretary with 
     the following assurances:
       ``(1) Improved service delivery.--The State shall have a 
     plan to improve the delivery of dental services to children 
     who are enrolled in the State plans, including providing 
     outreach and administrative case management, improving 
     collection and reporting of claims data, and providing 
     incentives, in addition to raising reimbursement rates, to 
     increase provider participation.
       ``(2) Adequate payment rates.--The State has provided for 
     payment under the State plans for dental services for 
     children at levels consistent with the market-based rates and 
     sufficient enough to enlist providers to treat children in 
     need of dental services.
       ``(3) Ensured access.--The State shall ensure it will make 
     dental services available to children enrolled in the State 
     plans to the same extent as such services are available to 
     the general population of the State.
       ``(c) Application.--A State shall submit an application to 
     the Secretary for a grant under this section in such form and 
     manner and containing such information as the Secretary may 
     require.
       ``(d) Authorization of Appropriations.--There are 
     authorized to be appropriated to make grants under this 
     section $50,000,000 for fiscal year 2002 and each fiscal year 
     thereafter.
       ``(e) Application of Other Provisions of Title.--
       ``(1) In general.--Except as provided in paragraph (2), the 
     other provisions of this title shall not apply to a grant 
     made under this section.
       ``(2) Exceptions.--The following provisions of this title 
     shall apply to a grant made under subsection (a) to the same 
     extent and in the same manner as such provisions apply to 
     allotments made under section 502(c):
       ``(A) Section 504(b)(6) (relating to prohibition on 
     payments to excluded individuals and entities).
       ``(B) Section 504(c) (relating to the use of funds for the 
     purchase of technical assistance).
       ``(C) Section 504(d) (relating to a limitation on 
     administrative expenditures).
       ``(D) Section 506 (relating to reports and audits), but 
     only to the extent determined by the Secretary to be 
     appropriate for grants made under this section.
       ``(E) Section 507 (relating to penalties for false 
     statements).
       ``(F) Section 508 (relating to nondiscrimination).
       ``(G) Section 509 (relating to the administration of the 
     grant program).''.

     SEC. 102. AUTHORITY TO PROVIDE DENTAL COVERAGE UNDER SCHIP AS 
                   A SUPPLEMENT TO OTHER HEALTH COVERAGE.

       (a) Authority To Provide Coverage.--
       (1) SCHIP.--
       (A) In general.--Section 2105(a)(1)(C) of the Social 
     Security Act (42 U.S.C. 1397ee(a)(1)(C)) is amended--
       (i) by inserting ``(i)'' after ``(C)''; and
       (ii) by adding at the end the following:
       ``(ii) notwithstanding clause (i), in the case of a State 
     that satisfies the conditions described in subsection (c)(8), 
     for child health assistance that consists only of coverage of 
     dental services for a child who would be considered a 
     targeted low-income child if that portion of subparagraph (C) 
     of section 2110(b)(1) relating to coverage of the child under 
     a group health plan or under health insurance coverage did 
     not apply, and such child has such coverage that does not 
     include dental services; and''.
       (B) Conditions described.--Section 2105(c) of the Social 
     Security Act (42 U.S.C. 1397ee(c)) is amended by adding at 
     the end the following:
       ``(8) Conditions for provision of dental services only 
     coverage.--For purposes of subsection (a)(1)(C)(ii), the 
     conditions described in this paragraph are the following:
       ``(A) Income eligibility.--The State child health plan 
     (whether implemented under title XIX or this XXI)--
       ``(i) has the highest income eligibility standard permitted 
     under this title as of January 1, 2001;
       ``(ii) subject to subparagraph (B), does not limit the 
     acceptance of applications for children; and
       ``(iii) provides benefits to all children in the State who 
     apply for and meet eligibility standards.
       ``(B) No waiting list imposed.--With respect to children 
     whose family income is at or below 200 percent of the poverty 
     line, the State does not impose any numerical limitation, 
     waiting list, or similar limitation on the eligibility of 
     such children for child health assistance under such State 
     plan.''.
       (C) State option to waive waiting period.--Section 
     2102(b)(1)(B) of the Social Security Act (42 U.S.C. 
     1397bb(b)(1)(B)) is amended--
       (i) in clause (i), by striking ``and'' at the end;
       (ii) in clause (ii), by striking the period and inserting 
     ``; and''; and
       (iii) by adding at the end the following new clause:
       ``(iii) at State option, may not apply a waiting period in 
     the case of child described in section 2105(a)(1)(C)(ii), if 
     the State satisfies the requirements of section 2105(c)(8) 
     and provides such child with child health assistance that 
     consists only of coverage of dental services.''.
       (2) Application of enhanced match under medicaid.--Section 
     1905 of the Social Security Act (42 U.S.C. 1396d) is 
     amended--
       (A) in subsection (b), in the fourth sentence, by striking 
     ``or subsection (u)(3)'' and inserting ``(u)(3), or (u)(4)''; 
     and
       (B) in subsection (u)--
       (i) by redesignating paragraph (4) as paragraph (5); and
       (ii) by inserting after paragraph (3) the following new 
     paragraph:
       ``(4) For purposes of subsection (b), the expenditures 
     described in this paragraph are expenditures for dental 
     services for children described in section 2105(a)(1)(C)(ii), 
     but only in the case of a State that satisfies the 
     requirements of section 2105(c)(8).''.
       (b) Effective Date.--The amendments made by subsection (a) 
     take effect on October 1, 2001 and apply to child health 
     assistance and medical assistance provided on or after that 
     date.

[[Page S11383]]

    TITLE II--IMPROVING DELIVERY OF PEDIATRIC DENTAL SERVICES UNDER 
  COMMUNITY HEALTH CENTERS, PUBLIC HEALTH DEPARTMENTS, AND THE INDIAN 
                             HEALTH SERVICE

     SEC. 201. GRANTS TO IMPROVE THE PROVISION OF DENTAL HEALTH 
                   SERVICES THROUGH COMMUNITY HEALTH CENTERS AND 
                   PUBLIC HEALTH DEPARTMENTS.

       Part D of title III of the Public Health Service Act (42 
     U.S.C. 254b et seq.) is amended by insert before section 330, 
     the following:

     ``SEC. 329. GRANT PROGRAM TO EXPAND THE AVAILABILITY OF 
                   SERVICES.

       ``(a) In General.--The Secretary, acting through the Health 
     Resources and Services Administration, shall establish a 
     program under which the Secretary may award grants to 
     eligible entities and eligible individuals to expand the 
     availability of primary dental care services in dental health 
     professional shortage areas or medically underserved areas.
       ``(b) Eligibility.--
       ``(1) Entities.--To be eligible to receive a grant under 
     this section an entity--
       ``(A) shall be--
       ``(i) a health center receiving funds under section 330 or 
     designated as a Federally qualified health center;
       ``(ii) a county or local public health department, if 
     located in a federally-designated dental health professional 
     shortage area;
       ``(iii) an Indian tribe or tribal organization (as defined 
     in section 4 of the Indian Self-Determination and Education 
     Assistance Act (25 U.S.C. 450b)); or
       ``(iv) a dental education program accredited by the 
     Commission on Dental Accreditation; and
       ``(B) shall prepare and submit to the Secretary an 
     application at such time, in such manner, and containing such 
     information as the Secretary may require.
       ``(2) Individuals.--To be eligible to receive a grant under 
     this section an individual shall--
       ``(A) be a dental health professional licensed or certified 
     in accordance with the laws of State in which such individual 
     provides dental services;
       ``(B) prepare and submit to the Secretary an application at 
     such time, in such manner, and containing such information as 
     the Secretary may require; and
       ``(C) provide assurances that--
       ``(i) the individual will practice in a federally-
     designated dental health professional shortage area; and
       ``(ii) not less than 33 percent of the patients of such 
     individual are--

       ``(I) receiving assistance under a State plan under title 
     XIX of the Social Security Act (42 U.S.C. 1396 et seq.);
       ``(II) receiving assistance under a State plan under title 
     XXI of the Social Security Act (42 U.S.C. 1397aa et seq.); or
       ``(III) uninsured.

       ``(c) Use of Funds.--
       ``(1) Entities.--An entity shall use amounts received under 
     a grant under this section to provide for the increased 
     availability of primary dental services in the areas 
     described in subsection (a). Such amounts may be used to 
     supplement the salaries offered for individuals accepting 
     employment as dentists in such areas.
       ``(2) Individuals.--A grant to an individual under 
     subsection (a) shall be in the form of a $1,000 bonus payment 
     for each month in which such individual is in compliance with 
     the eligibility requirements of subsection (b)(2)(C).
       ``(d) Authorization of Appropriations.--
       ``(1) In general.--Notwithstanding any other amounts 
     appropriated under section 330 for health centers, there is 
     authorized to be appropriated $40,000,000 for each of fiscal 
     years 2002 through 2006 to hire and retain dental health care 
     providers under this section.
       ``(2) Use of funds.--Of the amount appropriated for a 
     fiscal year under paragraph (1), the Secretary shall use--
       ``(A) not less than 75 percent of such amount to make 
     grants to eligible entities; and
       ``(B) not more than 25 percent of such amount to make 
     grants to eligible individuals.''.

     SEC. 202. DENTAL OFFICER MULTIYEAR RETENTION BONUS FOR THE 
                   INDIAN HEALTH SERVICE.

       (a) Terms and Definitions.--In this section:
       (1) Creditable service.--The term ``creditable service'' 
     includes all periods that a dental officer spent in graduate 
     dental educational (GDE) training programs while not on 
     active duty in the Indian Health Service and all periods of 
     active duty in the Indian Health Service as a dental officer.
       (2) Dental officer.--The term ``dental officer'' means an 
     officer of the Indian Health Service designated as a dental 
     officer.
       (3) Director.--The term ``Director'' means the Director of 
     the Indian Health Service.
       (4) Residency.--The term ``residency'' means a graduate 
     dental educational (GDE) training program of at least 12 
     months leading to a specialty, including general practice 
     residency (GPR) or an advanced education general dentistry 
     (AEGD).
       (5) Specialty.--The term ``specialty'' means a dental 
     specialty for which there is an Indian Health Service 
     specialty code number.
       (b) Requirements for Bonus.--
       (1) In general.--An eligible dental officer of the Indian 
     Health Service who executes a written agreement to remain on 
     active duty for 2, 3, or 4 years after the completion of any 
     other active duty service commitment to the Indian Health 
     Service may, upon acceptance of the written agreement by the 
     Director, be authorized to receive a dental officer multiyear 
     retention bonus under this section. The Director may, based 
     on requirements of the Indian Health Service, decline to 
     offer such a retention bonus to any specialty that is 
     otherwise eligible, or to restrict the length of such a 
     retention bonus contract for a specialty to less than 4 
     years.
       (2) Limitations.--Each annual dental officer multiyear 
     retention bonus authorized under this section shall not 
     exceed the following:
       (A) $14,000 for a 4-year written agreement.
       (B) $8,000 for a 3-year written agreement.
       (C) $4,000 for a 2-year written agreement.
       (c) Eligibility.--
       (1) In general.--In order to be eligible to receive a 
     dental officer multiyear retention bonus under this section, 
     a dental officer shall--
       (A) be at or below such grade as the Director shall 
     determine;
       (B) have completed any active duty service commitment of 
     the Indian Health Service incurred for dental education and 
     training or have 8 years of creditable service;
       (C) have completed initial residency training, or be 
     scheduled to complete initial residency training before 
     September 30 of the fiscal year in which the officer enters 
     into a dental officer multiyear retention bonus written 
     service agreement under this section; and
       (D) have a dental specialty in pediatric dentistry or oral 
     and maxillofacial surgery.
       (2) Extension to other officers.--The Director may extend 
     the retention bonus to dental officers other than officers 
     with a dental specialty in pediatric dentistry, as well as to 
     other dental hygienists with a minimum of a baccalaureate 
     degree, based on demonstrated need.
       (d) Termination of Entitlement to Special Pay.--The 
     Director may terminate, with cause, at any time a dental 
     officer's multiyear retention bonus contract under this 
     section. If such a contract is terminated, the unserved 
     portion of the retention bonus contract shall be recouped on 
     a pro rata basis. The Director shall establish regulations 
     that specify the conditions and procedures under which 
     termination may take place. The regulations and conditions 
     for termination shall be included in the written service 
     contract for a dental officer multiyear retention bonus under 
     this section.
       (e) Refunds.--
       (1) In general.--Prorated refunds shall be required for 
     sums paid under a retention bonus contract under this section 
     if a dental officer who has received the retention bonus 
     fails to complete the total period of service specified in 
     the contract, as conditions and circumstances warrant.
       (2) Debt to united states.--An obligation to reimburse the 
     United States imposed under paragraph (1) is a debt owed to 
     the United States.
       (3) No discharge in bankruptcy.--Notwithstanding any other 
     provision of law, a discharge in bankruptcy under title 11, 
     United States Code, that is entered less than 5 years after 
     the termination of a retention bonus contract under this 
     section does not discharge the dental officer who signed such 
     a contract from a debt arising under the contract or under 
     paragraph (1).

     SEC. 203. STREAMLINE PROCESS FOR DESIGNATING DENTAL HEALTH 
                   PROFESSIONAL SHORTAGE AREAS.

       Section 332(a) of the Public Health Service Act (42 U.S.C. 
     254e(a)) is amended by adding at the end the following:
       ``(4) In designating health professional shortage areas 
     under this section, the Secretary may designate certain areas 
     as dental health professional shortage areas if the Secretary 
     determines that such areas have a severe shortage of dental 
     health professionals. The Secretary shall, in consultation 
     with State and local dental societies and tribal health 
     organizations, streamline the process to develop, publish and 
     periodically update criteria to be used in designating dental 
     health professional shortage areas.''.

     SEC. 204. DEMONSTRATION PROJECTS TO INCREASE ACCESS TO 
                   PEDIATRIC DENTAL SERVICES IN UNDERSERVED AREAS.

       (a) Authority To Conduct Projects.--The Secretary of Health 
     and Human Services, through the Administrator of the Health 
     Resources and Services Administration and the Director of the 
     Indian Health Service, shall establish demonstration projects 
     that are designed to increase access to dental services for 
     children in underserved areas, as determined by the 
     Secretary.
       (b) Authorization of Appropriations.--There is authorized 
     to be appropriated such sums as may be necessary to carry out 
     this section.

   TITLE III--IMPROVING ORAL HEALTH PROMOTION AND DISEASE PREVENTION 
                                PROGRAMS

     SEC. 301. ORAL HEALTH INITIATIVE.

       (a) Establishment.--The Secretary of Health and Human 
     Services shall establish an oral health initiative to reduce 
     the profound disparities in oral health by improving the 
     health status of vulnerable populations, particularly low-
     income children, to the level of health status that is 
     enjoyed by the majority of Americans.
       (b) Activities.--The Secretary of Health and Human Services 
     shall, through the oral health initiative--

[[Page S11384]]

       (1) carry out activities to improve intra- and inter-agency 
     collaborations, including activities to identify, engage, and 
     encourage existing Federal and State programs to maximize 
     their potential to address oral health;
       (2) carry out activities to encourage public-private 
     partnerships to engage private sector communities of interest 
     (including health professionals, educators, State 
     policymakers, foundations, business, and the public) in 
     partnerships that promote oral health and dental care; and
       (3) carry out activities to reduce the disease burden in 
     high risk populations through the application of best-science 
     in oral health, including programs such as community water 
     fluoridation and dental sealants.
       (c) Coordination.--The Secretary of Health and Human 
     Services shall--
       (1) through the Administrator of the Centers for Medicare & 
     Medicaid Services (formerly known as the Health Care 
     Financing Administration) establish a Chief Dental Officer 
     for the medicaid and State children's health insurance 
     programs established under titles XIX and XXI, respectively, 
     of the Social Security Act (42 U.S.C. 1396 et seq. 1397aa et 
     seq.); and
       (2) carry out this section in collaboration with such 
     Administrator and Chief Dental Officer and the Administrator 
     and Chief Dental Officer of the Health Resources and Services 
     Administration.
       (d) Authorization of Appropriations.--There is authorized 
     to be appropriated to carry out this section, $25,000,000 for 
     fiscal year 2002, and such sums as may be necessary for each 
     subsequent fiscal year.

     SEC. 302. CDC REPORTS.

       (a) Collection of Data.--The Director of the Centers for 
     Disease Control and Prevention in collaboration with other 
     organizations and agencies shall annually collect data 
     describing the dental, craniofacial, and oral health of 
     residents of at least 1 State and 1 Indian tribe from each 
     region of the Department of Health and Human Services.
       (b) Reports.--The Director of the Centers for Disease 
     Control and Prevention shall compile and analyze data 
     collected under subsection (a) and annually prepare and 
     submit to the appropriate committees of Congress a report 
     concerning the oral health of certain States and tribes.

     SEC. 303. EARLY CHILDHOOD CARIES.

       (a) In General.--The Secretary of Health and Human 
     Services, acting through the Director of the Centers for 
     Disease Control and Prevention, shall--
       (1) expand existing surveillance activities to include the 
     identification of children at high risk of early childhood 
     caries;
       (2) assist State, local, and tribal health agencies and 
     departments in collecting, analyzing and disseminating data 
     on early childhood caries; and
       (3) provide for the development of public health nursing 
     programs and public health education programs on early 
     childhood caries prevention.
       (b) Appropriateness of Activities.--The Secretary of Health 
     and Human Services shall carry out programs and activities 
     under subsection (a) in a culturally appropriate manner with 
     respect to populations at risk of early childhood caries.
       (c) Authorization of Appropriations.--There is authorized 
     to be appropriated to carry out this section, such sums as 
     may be necessary for each fiscal year.

     SEC. 304. SCHOOL-BASED DENTAL SEALANT PROGRAM.

       Section 317M(c) of the Public Health Service Act (as added 
     by section 1602 of Public Law 106-310)) is amended--
       (1) in paragraph (1), by inserting ``and school-linked'' 
     after ``school-based'';
       (2) in the first sentence of paragraph (2)--
       (A) by inserting ``and school-linked'' after ``school-
     based''; and
       (B) by inserting ``or Indian tribe'' after ``State''; and
       (3) by striking paragraph (3) and inserting the following:
       ``(3) Eligibility.--To be eligible to receive funds under 
     paragraph (1), an entity shall--
       ``(A) prepare and submit to the State or Indian tribe an 
     application at such time, in such manner and containing such 
     information as the State or Indian tribe may require; and
       ``(B) be a--
       ``(i) public elementary or secondary school--

       ``(I) that is located in an urban area in which and more 
     than 50 percent of the student population is participating in 
     Federal or State free or reduced meal programs; or
       ``(II) that is located in a rural area and, with respect to 
     the school district in which the school is located, the 
     district involved has a median income that is at or below 235 
     percent of the poverty line, as defined in section 673(2) of 
     the Community Services Block Grant Act (42 U.S.C. 9902(2)); 
     or

       ``(ii) public or non-profit health organization, including 
     a grantee under section 330, that is under contract with an 
     elementary or secondary school described in subparagraph (B) 
     to provide dental services to school-age children.''.
                                  ____


      Fact Sheet--Children's Dental Health Improvement Act of 2001

       Senators Jeff Bingaman (D-NM), Thad Cochran (R-MS), Blanche 
     Lincoln (D-AR), Tom Daschle (D-SD), Susan Collins (R-ME), 
     Jean Carnahan (D-MO), Tim Hutchinson (R-AR), and Jon Corzine 
     (D-NJ) are preparing to introduce the ``Children's Dental 
     Health Improvement Act of 2001.'' The legislation seeks to 
     improve the access and delivery of dental care to children 
     across the country.


                         problems and solutions

                     Lack of Coverage for Children

       According to the Surgeon General's report, Oral Health in 
     America: A Report of the Surgeon General, that was issued in 
     2000, ``Although over 14 percent of children under 18 have no 
     form of private or public medical insurance, more than twice 
     that many, 23 million children, have no dental insurance.'' 
     The report adds, ``There are at least 2.6 children without 
     dental insurance for each child without medical insurance.''
       Moreover, according to the General Accounting Office in a 
     report entitled Factors Contributing to Low Use of Dental 
     Services by Low-Income Populations (Sept. 2000), AHHS and 
     health center officials report that the demand for dental 
     services significantly exceeds the [urban and rural health] 
     centers' capacity to delivery it. In 1998 . . ., a little 
     more than half of the nearly 700 health center grantees 
     funded under this program had active dental programs.''
       Legislative Proposal: The legislation would improve the 
     dental health of uninsured children by: Allowing states the 
     flexibility to utilize the State Children's Health Insurance 
     Program (SCHIP) to provide dental coverage to low-income 
     children below 200 percent of poverty that may have private 
     insurance for medical care but not dental services; and 
     providing $40 million to community health centers and public 
     health departments to expand dental health services through 
     the hiring of additional dentist health professionals to 
     serve low-income children.

                         Lack of Access to Care

       According to the GAO, ``While several factors influence the 
     access low-income groups have to dental care, the primary one 
     is limited dentist participation in Medicaid . . . Of 39 
     states that provided information about dentists' 
     participation in Medicaid, 23 reported that fewer than half 
     of the states' dentists saw at least one Medicaid patient 
     during 1999.''
       The GAO concludes this is due in large part to poor 
     reimbursement rates in Medicaid. As the GAO adds, ``Our 
     analysis showed that Medicaid payment rates are often well 
     below dentists' normal fees. Only 13 states had Medicaid 
     rates that exceeded two-thirds of the average regional fees 
     dentists charged. . ..''
       Legislative Proposal: The legislation seeks to improve 
     access to dental services for low-income children in the 
     Medicaid program by providing $50 million as financial 
     incentives and planning grants to states to improve their 
     Medicaid programs in terms of adequate payment rates, 
     access to care, and improved service delivery.

             Lack of Providers in Federally Funded Programs

       With respect to community health centers, the GAO notes, 
     ``HHS and health center officials report that the demand for 
     dental services significantly exceeds the [urban and rural 
     health] centers' capacity to delivery it. In 1998 . . ., a 
     little more than half of the nearly 700 health center 
     grantees funded under this program had active dental 
     programs.''
       With respect to the Indian Health Service (IHS) the GAO 
     adds, ``. . . about one-fourth of IHS'' dentist positions at 
     269 IHS and tribal facilities were vacant in April 2000. 
     Vacancies have been chronic at IHS facilities--in the past 5 
     years, at least 67 facilities have had one or more dentist 
     positions vacant for at least a year. According to IHS 
     officials, the primary reason for these vacancies is that IHS 
     is unable to provide a competitive salary for new dentists.''
       Legislative Proposal: The legislation seeks to improve 
     access to dental services for children served by community 
     health centers and the Indian Health Service by: Again, 
     providing $40 million to community health centers and public 
     health departments to expand dental health services through 
     the hiring of additional dental health professionals to serve 
     low-income children; and providing the Indian Health Service 
     with the authority to offer multi-year retention bonuses to 
     dental providers offering service through the IHS and tribal 
     programs.

            Need for Improved Coordination and Collaboration

       Despite Medicaid and SCHIP, dental care is the least 
     utilized core pediatric health service for low-income 
     children. There are 2.6 times more children lacking dental 
     coverage than health coverage and over a hundred million 
     Americans without dental insurance. Dental care is the most 
     frequently cited unmet health need of children, according to 
     their parents. In fact, the Health Interview Survey reveals 
     that the unmet need is three times greater than unmet need 
     for medical care, four times greater than unmet need for 
     prescription drugs, and five times greater than unmet need 
     for vision care. The third National Health and Nutrition 
     Interview Survey showed that dental caries [or dental decay] 
     is the most prevalent chronic disease of childhood.
       To help address this ``hidden epidemic,'' the Department of 
     Health and Human Services (HHS) enacted the Oral Health 
     Initiative (OHI) to coordinate dental health services in both 
     the Health Resources and Services Administration (HRSA) and 
     the Center for Medicare and Medicaid Services (CMS) (formerly 
     known as the Health Care Financing Administration).
       Despite the progress of the initiative, it has no legal 
     authority unlike other programs

[[Page S11385]]

     that target specific health needs of children (e.g., 
     Emergency Medical Services for Children and the Traumatic 
     Brain Injury Program). Because it lacks formal status and 
     program control, the OHI is susceptible to future disruptions 
     or disbanding.
       Legislative Proposal: The legislation provides statutory 
     authority for the OHI and authorized funding of $25 million 
     to improve the oral health of low-income populations served 
     by both the public and private sector.

                            Other Provisions

       In addition, the legislation contains the following 
     technical provisions:
       Dental Health Professional Shortage Area Designation: The 
     bill streamlines the process for the designation of dental 
     health professional shortage areas.
       Technical School-Based Sealant Provisions: The bill 
     includes technical provisions ensuring that entities eligible 
     for funding include both ``school-linked'' as well as school-
     based organizations, clarifies that an eligible entitle can 
     be a public or non-profit health organization or tribal 
     organization.
       Demonstration: The bill creates authority for HHS to 
     establish demonstration projects to increase access to dental 
     services for children in underserved areas.


                        endorsing organizations

       American Dental Association, American Dental Education 
     Association, American Academy of Pediatric Dentistry, 
     National Association of Community Health Centers, Inc., 
     National Association of Children's Hospitals, American Dental 
     Hygienists' Association, Academy of General Dentistry, 
     American Academy of Child and Adolescent Psychiatry, American 
     Academy of Oral and Maxillofacial Pathology, American Academy 
     of Periodontology, American Association of Dental Examiners, 
     American Association of Dental Research, American Association 
     of Endodontists, American Association of Public Health 
     Dentistry, American Association of Oral and Maxillofacial 
     Surgeons, American Association of Orthodontists, American 
     Association of Women Dentists, American College of Dentists, 
     American College of Preventive Medicine, American Dental 
     Trade Association, American Public Health Association, 
     American Society of Dentistry for Children, American Student 
     Dental Association, Association of Clinicians of the 
     Underserved, Association of Maternal and Child Health 
     Programs, Association of State and Territorial Dental 
     Directors, Dental Dealers of America, Dental Manufacturers of 
     America, Inc., Family Voices, Hispanic Dental Association, 
     International College of Dentists USA, March of Dimes, 
     National Association of City and County Health Officers, 
     National Association of Local Boards of Health, National 
     Dental Association, National Health Law Program, New Mexico 
     Department of Health, Partnership for Prevention, Society of 
     American Indian Dentists, Special Care Dentistry, and United 
     Cerebral Palsy Associations.
  Mrs. CARNAHAN. Mr. President, I would like to bring your attention to 
a hidden epidemic. This epidemic affects the overall health of 
children, especially children in low-income families. It has been 
called a ``hidden epidemic'' because it can be difficult to detect at a 
glance, and because it receives relatively little attention as a threat 
to children's health. But while this epidemic is ``hidden,'' it 
manifests itself every day in the smiles of America's children.
  The epidemic I am referring to is that of poor dental health. Dental 
decay, a major cause of tooth loss, is the most prevalent chronic 
disease of childhood. Each year, dental conditions cause children in 
the U.S. to miss more than 750,000 days of school. One in ten children 
between the ages of five and eleven has never visited a dentist. This 
is a shocking and distressing statistic. The unfortunate trend cannot 
be allowed to continue.
  States are working hard to offer dental health services through their 
Medicaid programs and the State Children's Health Insurance Program, 
but they need our help in meeting the challenge. The General Accounting 
Office reported that the biggest reason low-income people lack dental 
care is that not enough dentists participate in Medicaid. In Missouri, 
as in other states, some dentists simply choose not to accept Medicaid 
patients, while others cannot afford to accept them because Medicaid 
reimbursement is not sufficient to cover the costs of providing care. 
In Missouri, there are more than 1,000 children on Medicaid for every 
dentist willing to serve them.
  As a result, Medicaid patients must search far and wide to find a 
dentist and then face another challenge in traveling long distances to 
see that dentist. Often, this requires hours of planning to arrange for 
public or Medicaid-provided transportation, and several more hours of 
waiting after the visit to be picked up and returned home. For many 
lower-income parents, these hours away from work will severely cut into 
the family's income. Is it any wonder why so many children do not get 
the preventive dental care they need, and are not seen by a dentist 
until they are in intense pain or have infections so severe that their 
eyes have swelled shut? We cannot let this continue to happen to 
children in the United States.
  There are many reasons for protecting children's oral health. For 
instance, we know that when children have healthy smiles:
  They chew more easily and gain more nutrients from the foods they 
eat.
  They learn to speak more quickly and clearly.
  They look and feel more attractive improving self-confidence and 
willingness to communicate with others.
  They have better school attendance and pay more attention in class.
  They avoid extensive and costly treatment of dental disease.
  And they begin a lifetime of good dental habits.
  For all of these reasons, I am proud to join with Senators Bingaman, 
Cochran, Corzine, Collins, Daschle, Hutchison, and Lincoln in 
introducing the Children's Dental Health Improvement Act. This 
bipartisan bill would improve dental care for low-income children. I 
appreciate Senator Bingaman's leadership on this bill, and I am honored 
for the opportunity to work with him on this important issue. In order 
to make real improvements in our current situation, this legislation 
takes a multi-faceted approach that addresses each component of the 
problem.
  First, this bill would give States the option to provide dental 
coverage through the State Children's Health Insurance Program to low-
income children who may have private insurance for medical care but not 
for dental services. Part of the reason for the epidemic in dental 
health is a lack of insurance for dental services. For every child 
without health insurance, there are nearly three children who are 
uninsured for dental care. By providing more of these children with 
insurance, we can reduce their dental care costs--one of the many 
barriers that low-income families face in getting dental care for their 
children. Although the bill does not call for additional SCHIP funding, 
I support a separate funding increase for this program. This increase 
is essential to giving States the ability to expand coverage to dental 
services, especially States like Missouri, whose SCHIP programs are 
doing an excellent job and as a result spend all of their existing 
funding.
  Second, this bill would invest $25 million in and provide statutory 
authority to the Federal Oral Health Initiative. The Department of 
Health and Human Services initiated the Oral Health Initiative to 
coordinate its dental health services. These funds would be used to 
promote public-private partnerships and cooperation among Federal 
agencies in order to reduce the profound disparities in oral health 
among vulnerable populations. Low-income people are the hardest hit 
when it comes to dental disease. Compared to their counterparts in 
higher-income families, poor children have five times more untreated 
dental disease and poor teens are half as likely to visit a dentist 
annually. Giving legal authority to this Initiative will allow it to 
work on improving access to dental health without fear of future 
disruptions or disbanding and the increased funding will allow for the 
Oral Health Initiative's much-needed expansion.
  Third, this bill would offer States the opportunity to apply for $50 
million in Federal grants to assist them in improving dental coverage 
for children through Medicaid. The financial incentives and planning 
grants included in the bill would enable states to improve payment 
rates, access to care, and service delivery. It also includes an 
investment of $40 million for community health centers and public 
health departments to increase the number of dental health 
professionals who serve low-income children. With these funds, we can 
increase access to dental care for low-income children, shorten travel 
times and the wait for a dental appointment. This is especially 
important in rural areas, which generally face a greater shortage of 
providers.
  The Children's Dental Health Improvement Act has gained the support 
of over twenty dental health organizations, including the American 
Academy of Pediatric Dentistry and the

[[Page S11386]]

American Dental Association. Other supporters include the American 
Academy of Pediatrics, the National Association of Children's 
Hospitals, and the National Association of Community Health Centers. 
With their support, and the leadership of my fellow cosponsors of this 
bill, I hope that we can have a profound impact on dental health and 
ensure that America's low-income children will have healthy, beautiful 
smiles.
                                 ______