Too many children have too much oral disease

While many children in the United States enjoy remarkably good oral health according to Burton Edelstein, founding director of the Children’s Dental Health Project of Washington, DC, and director of the Division of Community Health at the Columbia University School of Dental and Oral Surgery, there remains a significant problem in a subset of the nation’s children.

"We have a reasonably firm estimate that 4 million to 5 million kids suffer dental disease bad enough that they have functional impairments from dental pain like not sleeping well, not eating well, problems attending to schoolwork, or problems just getting along with other people," Mr. Edelstein tells State Health Watch. "Tooth decay is the most prevalent childhood disease — five times more common than asthma, according to the U.S. surgeon general. But 80% of the tooth decay occurs in 20% of the kids. And 25% of that 20% have really extensive disease. What hurts is that we know that this disease is overwhelmingly preventable."

There is a delivery issue, according to Mr. Edelstein, in that the children with the highest levels of disease have the lowest level of treatment, primarily those covered by Medicaid and the State Children’s Health Insurance Program or not covered at all. "Medicaid is essentially dysfunctional in a majority of the states in terms of delivery of dental services to children. CMS’ [the Centers for Medicare and Medicaid] most recent data show that in 32 states, less than 30% of covered kids received a dental visit in a year’s time," he says.

"And that’s true even though dental care is required under [Early and Periodic Screening, Detection, and Treatment]," he adds.

A related public health problem, Mr. Edelstein says, is inadequate delivery of prevention services, including an inadequate general availability of fluoride and less than optimal delivery of sealants. "Politically, this issue has traction, There is concern from key policy-makers and organizations like the National Governors Association and National Conference of State Legislatures," he says.

At a June 25 hearing of the U.S. Senate’s Health, Education, Labor, and Pensions Committee, Arkansas’ director of the Office of Dental Health, Lynn Mouden, called for approval of the Children’s Dental Health Improvement Act of 2001. Mouden said there is an oral health crisis in this country because to date, oral health has not been a national priority. "Unfortunately, we live in a country where decision makers and insurance companies have decided that health care ends at the neck. For some reason, dental, mental, and vision seem to be in a different category than the rest of the body. We will never achieve optimum oral health until we correct those beliefs," she stated at the hearing.

Ms. Mouden reported that more than 40% of Arkansas children attend school with untreated cavities and one in 12 have emergency dental needs. "Insufficient funding of Medicaid continues to plague Arkansas. Arkansas Medicaid pays approximately 50% of a participating dentist’s usual fees. In a profession where overhead typically is 70% of income, it is amazing that dentists are put into the unique position of having to subsidize their services by providing dental care at less than cost. And increased funding for Medicaid is not the whole answer, because dentistry’s commitment to the underserved is well documented. In Arkansas alone, dentists donate more than $8 million each year in free dental care. It is often the bureaucratic barriers that can make participation in Medicaid an administrative nightmare for dentists, most of whom are in solo private practice."

Ms. Mouden said the Children’s Dental Health Improvement Act of 2001 (SB 1626 and HR 3659) would provide grants to states to improve Medicaid programs and to address issues of training, public health, and service delivery. It also contains an initiative to support oral health promotion and disease prevention. The bill is gaining bipartisan support in Congress and a House hearing is expected early in the next Congress.

Mr. Edelstein tells State Health Watch that in some states, positive actions are being taken. In Wash-ington, for instance, a group of concerned dentists, dental educators, public health agencies, the state dental association, the Washington Dental Foundation, and state Medicaid representatives developed the Access to Baby and Child Dentistry (ABCD) program that focuses on preventive and restorative dental care for Medicaid-eligible children from birth to age 6. Under the program, dentists are able to receive enhanced reimbursement for selected Medicaid preventive service codes for enrolled children by receiving continuing education in early pediatric dental techniques. In addition, dental office staff are trained in communications and culturally appropriate follow-up with client families, and enrolled families are coached in the need for early and preventive dental care and appropriate behavior in dental offices, including the need to keep appointments. Organizers say the education and support encourages dentists in private practice to increase their commitment to expanding dental access in the community.

According to the ABCD web site (www.abcd-dental.org), for such a program to succeed, states need a supportive Medicaid program able to pay the enhanced dental fees and contract with a local government agency to draw down federal match funds for program operations; a local dental society and state dental association that will encourage its members to participate; a dental school pediatric dentistry department willing to develop and deliver the training, certification, and ongoing monitoring of dentists; a local government entity to provide outreach and case management and be eligible for federal matching funds; an oversight task force of representatives from each of the involved entities; and support of a community oral health coalition and other child health advocates who recognize a need for action.

States that are operating successful programs on their own, according to Mr. Edelstein, include Michigan, with a multicounty demonstration contract with a managed care vendor that intends to make the program equal to high quality private care; South Carolina’s payment of market rates to dentists; Tennessee, in which TennCare carved children’s dental care out of managed care to a single administrative-services-only vendor; and Indiana, which was the first state to pay market rates. he reports that Indiana hasn’t been able to continue indexing its rates, however, and thus access has stagnated. Other states making progress are Alabama, Georgia, and Delaware.

On another front, the Reforming States Group, supported by Milbank Memorial Fund, has proposed a public-funded dental insurance program for states that targets children in need and takes full advantage of prevailing dental financing and delivery systems in the context of SCHIP. Backers say the program would promote access to continuous primary dental care; encourage dental provider participation; assure accountability without undue administrative burden; achieve more cost-effective use of resources; target higher-needs children; provide comprehensive dental care; and lead to improved oral health outcomes.

There would be coverage for four levels of dental treatment that children need: diagnostic, preventive, and disease management services; basic restorative care; advanced restorative care; and catastrophic care.

Actuarial studies say estimated costs for the proposed program are approximately $14.50 per enrolled member per month for direct services and $2.50 per member per month for administrative costs.

"The United States public spends 25% to 30% of its child health care dollars on oral health," Mr. Edelstein says. "But Medicaid nationally spends only 5% on dental care, and if nursing home expenditures are included, the figure drops to something like 0.5%."

In one of the last actions of the Clinton administration, then Timothy Westmoreland, Medicaid director issued a letter to state Medicaid directors on Jan. 18, 2001, quoting a surgeon general’s report on children’s dental health that said that "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." Mr. Westmoreland said the agency intended to review state actions in four areas: outreach and administrative case management for children, adequacy of Medicaid reimbursement rates, increasing provider participation, and claims reporting and processing. States also were asked to submit a plan of action for improving children’s access to oral health services. Although action on that letter seems to have stalled in the new administration, advocates hope that its intent will be revived.

Mr. Edelstein says that even in a time of state budget problems, there are things states can do to help address the problem:

  • simplify Medicaid dental program administrative requirements on dentists;
  • ensure that existing "enabling services" such as transportation and follow-up extend to dental care;
  • conduct small demonstration projects that can be expanded when the economy improves;
  • implement coordinated efforts through active coalitions such as Washington’s ABCD program;
  • develop plans for a significant reform effort when an opportunity occurs.

[Contact Mr. Edelstein at (202) 833-8288. To download the Milbank Reforming States Group proposal, go to: www.milbank.org/reports/99071 6mrpd.html. To download the Westmoreland letter, go to: www.cms.gov/states/letters/smd118a1.pdf.]