[Congressional Record Volume 149, Number 78 (Friday, May 23, 2003)]
[Senate]
[Pages S7137-S7142]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. BINGAMAN (for himself, Mr. Cochran, Mrs. Lincoln, Ms. 
        Collins, Mr. Daschle, Mr. Jeffords, Ms. Cantwell, Mrs. Clinton, 
        and Mr. Johnson):
  S. 1142. 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, Lincoln, Collins, Daschle, Jeffords, Clinton, 
Cantwell, and Johnson is entitled the Children's Dental Health 
Improvement Act of 2003. This legislation 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 Services, 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, in 2000 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-years 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.''
  I was pleased to chair a hearing in the Health, Education, Labor and 
Pensions Committee on June 25, 2002, entitled ``The Crisis in 
Children's Dental Health: A Silent Epidemic'' in which the Surgeon 
General, Dr. David Satcher, testified. Dr. Satcher's testimony was 
strong and compelling.
  In his words, ``Over 108 million children and adults lack dental 
insurance, which is over 2.5 times the number who lack medical 
insurance.'' Dr. Satcher also highlight the following information 
specific to the oral health problems in children:
  There are striking disparities in dental disease by income. Poor 
children suffer twice as much dental cries as their more affluent 
peers, and their disease is more likely to be untreated. These poor-
nonpoor differences continue into adolescence. One out of four children 
in America is born into poverty, and children living below the poverty 
line--annual income of $17,000 for a family of four--have more severe 
and untreated decay.
  Other birth defects such as hereditary ectodermal dysplasias, where 
all or most teeth are missing or misshapen, cause lifetime problems 
that can be devastating to children and adults.
  Unintentional injuries, many of which include head, mouth, and neck 
injuries, are common in children.
  Intentional injuries commonly affect the craniofacial tissues.
  Tobacco-related oral lesions are prevalent in adolescents who 
currently use smokeless--spit tobacco.
  Professional care is necessary for maintaining oral health, yet 25 
percent of poor children have not seen a dentist before entering 
kindergarten.
  Medical insurance is a strong predictor of access to dental care. 
Uninsured children are 2.5 times less likely than insured children to 
receive dental care. Children from families without dental insurance 
are three times more likely to have dental needs than children with 
either public or private insurance. For each child without medical 
insurance, there are at least 2.6 children without dental insurance.
  Medicaid has not been able to fill the gap in providing dental care 
to poor children. Fewer than one in five Medicaid-covered children 
received a single dental visit in a recent year-long study period. 
While recent CMS data indicate progress in this area with 1 million 
more Medicaid-eligible children now receiving annual dental care than 
was the case in 1996, there is still a long way to go to ensuring 
greater access. Although new programs such as the State Children's 
Health Insurance Program, SCHIP, may increase the number of insured 
children, many will still be left without effective dental coverage.
  The social impact of oral diseases in children is substantial. More 
than 51 million school hours are lost each year to dental-related 
illness. Poor children suffer nearly 12 times more restricted-activity 
days than children from higher income families. Pain and suffering due 
to untreated diseases can lead to problems in eating, speaking, and 
attending to learning.
  Over 50 percent of 5- to 9-year-old children have at least one cavity 
or filling, and that proportion increases to 78 percent among 17-year-
olds. Nevertheless, these figures represent improvements in the oral 
health of children compared to a generation ago.
  The Senate also heard the testimony of Dr. Burton Edelstein, founding 
director of the Children's Dental Health Project; Dr. Gregory Chadwick, 
president of the American Dental Association; Dr. Lynn Douglass 
Moundon, director of oral health in the Arkansas Department of Health; 
Ed Martinez, chief executive officer at San Ysidro Health Center in 
California; and, Dr. Timothy Shriver, president and chief executive 
officer of Special Olympics, Inc.
  Dr. Edelstein underscored the need for more attention to this issue. 
As he said, ``The too-widespread belief that childhood dental disease 
has been vanquished states in contrast to the thousands upon thousands 
of toothaches and acute abscesses experienced daily by America's 
children--many as young as 2 years of age.''
  In endorsing this legislation, Dr. Chadwick added, ``. . . we cannot 
forget the fact that millions of people in this country--particularly 
children--aren't getting even basic preventive and restorative dental 
care. These children are out there suffering.''

  The Children's Dental Health Improvement Act of 2003 seeks to end 
that suffering. One important provision in the bill would grant States 
flexibility

[[Page S7138]]

to provide dental coverage to low-income children through the State 
Children's Health Insurance Program, or SCHIP, 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 private 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 2003 creates 
an option for States to provide low-income families with the ability to 
receive wraparound 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. 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 dental participation in Medicaid.
  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, have taken 
recent 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 2003'' 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, or 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 2003 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 decay that 
all children have.''
  Unfortunately, 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 . . .''
  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 2003 provides IHS with the authority to offer 
multiyear 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, or CDC.

[[Page S7139]]

  The legislation also has a new provision that addresses a technical 
and unintended problem with the implementation of provisions changing 
the way Medicare graduate medical education, or GME, is funded. As 
background in the Balanced Budget Act of 1997, or BBA, Congress 
recognized the unfairness of subjecting dentistry to GME policies based 
on the oversupply of physician specialists by exempting dental 
residency positions from caps placed on the number of residents 
supported by Medicare GME.
  However, the two provisions in that law--both enacted primarily to 
alleviate the impact on hospitals that decrease physician slots--have 
had the opposite impact on hospitals that increase their dental 
residency positions. While successful in achieving the purpose of 
reducing the number of physicians being trained, these provisions have 
hurt dentistry and access to oral health care in the United States and 
are contrary to the congressional goal in 1997 to increase the number 
of postgraduate dental residency slots. As a result, the legislation 
would exempt dental residency training positions from the 3-year 
rolling average provision used to calculate the number of residents for 
Medicare GME payments.

  The bipartisan legislation I am introducing today would improve the 
access and delivery of dental health services to our Nation's children 
through Medicaid, SCHIP, 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, Libby Mullin, and 
Ann De Biasi 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 and Jack Bresch 
of the American Dental Education Association, Dr. Herber Simmons and 
Scott Litch of the American Academy of Pediatric Dentistry, Karen 
Sealander of the American Dental Hygienists' Association, Dr. Jim 
Richeson and Judy Kloss Bynum of the Academy of General Dentistry, Dr. 
Stephen Corbin of Special Olympics, Inc., and Dan Hawkins, Chris 
Koppen, and Roger Schwartz of the National Association of Community 
Health Centers, Inc., for their valuable insight, technical advice, and 
continued 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, whether in the past 
session of Congress or this year. They include: the 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 for 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.
  Mr. President, I ask unanimous consent for the text of the bill to be 
printed in the Record.
  There being no objection, the bill was ordered to be printed in the 
Record, as follows:

                                S. 1142

       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 2003''.
       (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. State option to provide wrap-around SCHIP coverage to 
              children who have other health coverage.

    TITLE II--CORRECTING GME PAYMENTS FOR DENTAL RESIDENCY TRAINING 
                                PROGRAMS

Sec. 201. Limitation on the application of the 1-year lag in the 
              indirect medical education ratio (IME) changes and the 3-
              year rolling average for counting interns and residents 
              for IME and direct graduate medical education (D-GME) 
              payments under the medicare program.

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

Sec. 301. Grants to improve the provision of dental health services 
              through community health centers and public health 
              departments.
Sec. 302. Dental officer multiyear retention bonus for the Indian 
              Health Service.
Sec. 303. Demonstration projects to increase access to pediatric dental 
              services in underserved areas.
Sec. 304. Technical correction.

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

Sec. 401. Oral health initiative.
Sec. 402. CDC reports.
Sec. 403. Early childhood caries.
Sec. 404. School-based dental sealant program.
Sec. 405. Basic oral health promotion.

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, 
     including children with special health care needs, 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) Use of Funds.--

[[Page S7140]]

       ``(1) In general.--Funds provided under this section may be 
     used to provide administrative resources (such as program 
     development, provider training, data collection and analysis, 
     and research-related tasks) to assist States in providing and 
     assessing services that include preventive and therapeutic 
     dental care regimens.
       ``(2) Limitation.--Funds provided under this section may 
     not be used for payment of direct dental, medical, or other 
     services or to obtain Federal matching funds under any 
     Federal program.
       ``(d) 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.
       ``(e) Authorization of Appropriations.--There are 
     authorized to be appropriated to make grants under this 
     section $50,000,000 for fiscal year 2004 and each fiscal year 
     thereafter.
       ``(f) 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. STATE OPTION TO PROVIDE WRAP-AROUND SCHIP COVERAGE 
                   TO CHILDREN WHO HAVE OTHER HEALTH COVERAGE.

       (a) In General.--
       (1) SCHIP.--
       (A) State option to provide wrap-around coverage.--Section 
     2110(b) of the Social Security Act (42 U.S.C. 1397jj(b)) is 
     amended--
       (i) in paragraph (1)(C), by inserting ``, subject to 
     paragraph (5),'' after ``under title XIX or''; and
       (ii) by adding at the end the following:
       ``(5) State option to provide wrap-around coverage.--A 
     State may waive the requirement of paragraph (1)(C) that a 
     targeted low-income child may not be covered under a group 
     health plan or under health insurance coverage, if the State 
     satisfies the conditions described in subsection (c)(8). The 
     State may waive such requirement in order to provide--
       ``(A) dental services;
       ``(B) cost-sharing protection; or
       ``(C) all services.
     In waiving such requirement, a State may limit the 
     application of the waiver to children whose family income 
     does not exceed a level specified by the State, so long as 
     the level so specified does not exceed the maximum income 
     level otherwise established for other children under the 
     State child health plan.''.
       (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 wrap-around coverage.--
     For purposes of section 2110(b)(5), 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, 2002;
       ``(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) No more favorable treatment.--The State child health 
     plan may not provide more favorable coverage of dental 
     services to the children covered under section 2110(b)(5) 
     than to children otherwise covered under this title.''.
       (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:
       ``(iii) at State option, may not apply a waiting period in 
     the case of a child described in section 2110(b)(5), if the 
     State satisfies the requirements of section 2105(c)(8).''.
       (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:
       ``(4) For purposes of subsection (b), the expenditures 
     described in this paragraph are expenditures for items and 
     services for children described in section 2110(b)(5), but 
     only in the case of a State that satisfies the requirements 
     of section 2105(c)(8).''.
       (3) Application of secondary payor provisions.--Section 
     2107(e)(1) of the Social Security Act (42 U.S.C. 
     1397gg(e)(1)) is amended--
       (A) by redesignating subparagraphs (B) through (D) as 
     subparagraphs (C) through (E), respectively; and
       (B) by inserting after subparagraph (A) the following:
       ``(B) Section 1902(a)(25) (relating to coordination of 
     benefits and secondary payor provisions) with respect to 
     children covered under a waiver described in section 
     2110(b)(5).''.
       (b) Effective Date.--The amendments made by subsection (a) 
     shall take effect on January 1, 2003, and shall apply to 
     child health assistance and medical assistance provided on or 
     after that date.

    TITLE II--CORRECTING GME PAYMENTS FOR DENTAL RESIDENCY TRAINING 
                                PROGRAMS

     SEC. 201. LIMITATION ON THE APPLICATION OF THE 1-YEAR LAG IN 
                   THE INDIRECT MEDICAL EDUCATION RATIO (IME) 
                   CHANGES AND THE 3-YEAR ROLLING AVERAGE FOR 
                   COUNTING INTERNS AND RESIDENTS FOR IME AND 
                   DIRECT GRADUATE MEDICAL EDUCATION (D-GME) 
                   PAYMENTS UNDER THE MEDICARE PROGRAM.

       (a) IME Ratio and Rolling Average.--Section 
     1886(d)(5)(B)(vi) of the Social Security Act (42 U.S.C. 
     1395ww(d)(5)(B)(vi)) is amended by adding at the end the 
     following new sentence: ``For cost reporting periods 
     beginning during fiscal years beginning on or after October 
     1, 2003, subclauses (I) and (II) shall be applied only with 
     respect to a hospital's approved medical residency training 
     program in the fields of allopathic medicine and osteopathic 
     medicine.''.
       (b) D-GME Rolling Average.--Section 1886(h)(4)(G) of the 
     Social Security Act (42 U.S.C. 1395ww(h)(4)(G)) is amended by 
     adding at the end the following new clause:
       ``(iv) Application for fy 2004 and subsequent years.--For 
     cost reporting periods beginning during fiscal years 
     beginning on or after October 1, 2003, clauses (i) through 
     (iii) shall be applied only with respect to a hospital's 
     approved medical residency training program in the fields of 
     allopathic medicine and osteopathic medicine.''.

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

     SEC. 301. 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));
       ``(iv) a dental education program accredited by the 
     Commission on Dental Accreditation;
       ``(v) a community-based program whose child service 
     population is made up of at least 33 percent of children who 
     are eligible children, including at least 25 percent of such 
     children being children with mental retardation or related 
     developmental disabilities, unless specific documentation of 
     a lack of need for access by this sub-population is 
     established; and
       ``(B) shall prepare and submit to the Secretary an 
     application at such time, in such manner, and containing such 
     information as

[[Page S7141]]

     the Secretary may require, including information concerning 
     dental provider capacity to serve individuals with 
     developmental disabilities.
       ``(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; or
       ``(ii) not less than 25 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 2004 through 2008 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 65 percent of such amount to make 
     grants to eligible entities; and
       ``(B) not more than 35 percent of such amount to make 
     grants to eligible individuals.''.

     SEC. 302. 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. 303. 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.

     SEC. 304. TECHNICAL CORRECTION.

       Section 340G(b)(1)(B) of the Public Health Service Act (42 
     U.S.C. 256g(b)(1)(B)) is amended by striking ``and'' at the 
     end and inserting ``or''.

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

     SEC. 401. 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 and children with developmental disabilities, 
     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--
       (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;
       (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; and
       (4) carry out activities to improve the oral health 
     literacy of the public through school-based education 
     programs.
       (c) Coordination.--The Secretary of Health and Human 
     Services shall--
       (1) through the Administrator of the Centers for Medicare & 
     Medicaid Services, establish the 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.);
       (2) through the Administrator of the Health Resources and 
     Services Administration, establish the Chief Dental Office 
     for all oral health programs within the Health Resources and 
     Services Administration;
       (3) through the Director of the Centers for Disease Control 
     and Prevention, establish the Chief Dental Officer for all 
     oral health programs within such Centers; and
       (4) carry out this section in collaboration with the 
     Administrators and Chief Dental Officers described in 
     paragraphs (1), (2), and (3).
       (d) Authorization of Appropriations.--There is authorized 
     to be appropriated to carry out this section, $25,000,000 for 
     fiscal year 2004, and such sums as may be necessary for each 
     subsequent fiscal year.

[[Page S7142]]

     SEC. 402. CDC REPORTS.

       (a) Collection of Data.--The Director of the Centers for 
     Disease Control and Prevention, in collaboration with other 
     organizations and agencies, shall collect data through State-
     based oral health surveillance systems describing the dental, 
     craniofacial, and oral health of residents of all 50 States 
     and certain Indian tribes.
       (b) Reports.--The Director of the Centers for Disease 
     Control and Prevention shall compile and analyze data 
     collection under subsection (a) and annually prepare and 
     submit to the appropriate committees of Congress a report 
     concerning the oral health of States and Indian tribes.

     SEC. 403. 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, including sub-populations such as children with 
     developmental disabilities;
       (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. 404. 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 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 organization, including a 
     grantee under section 330 and urban Indian clinics under 
     title V of the Indian Health Care Improvement Act, that is 
     under contract with an elementary or secondary school 
     described in subparagraph (B) to provide dental services to 
     school-age children.''.

     SEC. 405. BASIC ORAL HEALTH PROMOTION.

       (a) In General.--The Secretary of Health and Human 
     Services, acting through the Director of the Centers for 
     Disease Control and Prevention and in consultation with 
     dental organizations (including organizations having 
     expertise in the prevention and treatment of oral disease in 
     underserved pediatric populations), shall award grants to 
     States and Indian tribes to improve the basic capacity of 
     such States and tribes to improve the oral health of children 
     and their families.
       (b) Requirements.--A State or Indian tribes shall use 
     amounts received under a grant under this section to conduct 
     one or more of the following activities:
       (1) Establish an oral health plan, policies, effective 
     prevention programs, and accountability measures and systems.
       (2) Establish and guide coalitions, partnerships, and 
     alliances to accomplish the establishment of the plan, 
     policies, programs and systems under paragraph (1).
       (3) Monitor changes in oral disease burden, disparities, 
     and the utilization of preventive services by high-risk 
     populations.
       (4) Identify, test, establish, support, and evaluate 
     prevention interventions to reduce oral health disparities.
       (5) Promote public awareness and education in support of 
     improvements of oral health.
       (6) Support training programs for dental and other health 
     professions needed to strengthen oral health prevention 
     programs.
       (7) Establish, enhance, or expand oral disease prevention 
     and disparity reduction programs.
       (8) Evaluate the progress and effectiveness of the State's 
     oral disease prevention and disparity reduction program.
       (c) Authorization of Appropriations.--There is authorized 
     to be appropriated to carry out this section, such sums as 
     may be necessary for fiscal year 2004 and each subsequent 
     fiscal year.
                                 ______