1. Delivery and Financing of Dental Services in the Safety Net: an Overview Andrew Snyder Policy Specialist National Academy for State Health Policy June 24, 2008

2. The Big Picture Dental disease is the most prevalent chronic disease of childhood Low-income populations bear the burden of oral disease disproportionately Many barriers to accessing care – Low dentist participation in public programs – No dental in Medicare – Transportation, time off, translation

3. What I’ll discuss Recent UDS data on dental service delivery and staffing at health centers Funding streams: Medicaid and coverage expansions through state health care reform

4. Utilization

5. UDS Dental Encounters, 1996-2006

6. UDS Dental Users, 1996-2006

7. UDS Grantees Providing Dental Services On-Site, 2002-2006

8. Workforce

9. UDS Dental FTEs, 2000-2006

10. Source: Roger Rosenblatt, Holly Andrilla, Thomas Curtin, and Gary Hart. “Shortage of Medical Personnel at Community Health Centers,” Journal of the American Medical Association 295, No. 9 (2006): 1042-10491. Dentist Vacancy Rates at Health Centers (2004)

11. Source: American Dental Association, Survey Center. US Census Bureau (2001). Active Dentists per 100,000 Population (2000)

12. Dental HPSAs

13. Supply, Redistribution Strategies Loan repayment – National Health Service Corps, state programs – Often linked to service in HPSAs or CHCs Licensing strategies – Foreign dentists in safety net settings – Licensure by credential – Licensure after service, residency Increased use of non-dentists – “Public health” settings, “hub and spoke” arrangements – Using physicians, nurses to screen, educate, provide preventive measures

14. Financing

15. Medical and Dental Uninsurance Medical Insurance, 2006 (Source: www.statehealthfacts.org) Dental Insurance, 2004 (Source: MEPS Chartbook 17)

16. Overall Health Center Revenue, 2006

17. Dental services are less than 2% of Medicaid spending *Centers for Medicare and Medicaid Services. MSIS State Summary, FY 2004: Table 17, FY 2004 Medicaid Medical Vendor Payments by Service Category (CMS, June 2007).

18. Dental services are 5% of national health care expenditures **Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group. National Health Expenditure Accounts: Total Personal Health Care Spending, By Age Group, Calendar Years 1987, 1996, 1999, 2002, 2004 (Baltimore, MD: U.S. Department of Health and Human Services, 2004).

19. States with Full Medicaid Dental Benefits for Adults

20. States with Emergency or No Benefits for Adults in Medicaid

21. Status of Health Care Reform “Universal” plans under way: Maine, Massachusetts, Vermont Pieces of plan in action: Illinois, Washington, Pennsylvania, Wisconsin, Kansas Being debated in legislatures: New Mexico, Connecticut, California Commissions: Colorado, Minnesota, New York, Oregon

22. Status of Health Care Reform 2008 has seen slowdown in the rate of progress – Financial and housing crises – Deteriorating state budgets – Stalled SCHIP reauthorization – CMS interpretations of federal matching rules under Medicaid and SCHIP, especially for children over 250% FPL

23. Dental Care in Reform Could Mean… Setting up structure so people can purchase benefits Expansion of structures like SEHP, FEDVIP, or Medicaid Providing benefits to priority populations Paying attention to safety net, prevention, integration with medical care, to lower costs down the line.

24. ...But So Far, It Has Meant: No systematic addressing of dental uninsurance Dental benefits in Medicaid and CHIP expansions for kids Limited expansions for specific adults – Pregnant women, some parents Some investment in dental workforce, prevention

25. Massachusetts Reform established new independent public authority called “the Connector” which designs coverage and works with businesses, insurance companies, providers and consumers. Dental benefits are provided in MassHealth (Medicaid) and Commonwealth Care for all adults with income <100% FPL, and parents up to 133% FPL. Children up to 300% FPL continue to receive comprehensive oral health benefits. Funds added to “Health Safety Net Trust Fund” for safety net clinics to provide dental services for those without dental coverage between 100-300% FPL.

26. Maine State’s subsidized insurance plan – DirigoChoice – was implemented in January 2005. Focus on: chronic disease, the Maine Quality Forum (promoting quality and education), voluntary limits on growth of premiums, and electronic claims. Sliding scale for premiums and out-of-pocket expenses based on family income. Dental benefits only in MaineCare: comprehensive for under age 21, but only emergency/dentures for adults. Oral health improvement plan developed by the state was released in November 2007. – 13 goals around data, workforce, prevention, changing attitudes

27. Vermont Catamount Health created in May 2006 - provides subsidized coverage through private insurers for families up to 300% FPL. One plan (MVP) offers limited preventive and diagnostic coverage for kids under 19. Oral health will be addressed in reforms of chronic care management and care coordination programs. “Dental Dozen” – 12 targeted initiatives planned to improve oral health for all Vermonters. – Outreach, loan repayment, missed appointment reporting, involvement of physicians – Raised Medicaid reimbursement rates

28. Illinois “All Kids” program opens the state’s Medicaid program to all uninsured children, with Medicaid dental benefit, administered by Doral Efforts to introduce “Illinois Covered” expanded coverage for adults ran into legislative problems – Private “Choice” product included optional buy-in to dental insurance

29. Colorado Recommendations of blue-ribbon commission would provide CHP+ dental benefit to new enrollees, with $1000 annual cap, including adults Recommended loosening restrictions on dental hygienists’ ability to practice to full extent of their scope

30. Wisconsin “BadgerCare Plus” introduced in 2007 to expand health coverage to all uninsured children, and most uninsured adults “BC+ Benchmark Plan” modeled after commercial medical coverage, includes limited dental coverage for higher-income children and pregnant women – Coverage for diagnostic, preventive, and some restorative services – $200 deductible, 50% coinsurance, $750 maximum annual benefit

31. Kansas Expanded Medicaid coverage of routine dental services (including cleanings, restorative, perio) to pregnant women under 200% FPL Legislature previously approved $500,000 for development of health center “dental hubs”

32. Conclusion Dental service delivery through CHCs is growing, and an important part of many states’ strategies – Dental uninsurance more prevalent than medical uninsurance, – Medicaid is under-funded, and adult coverage is spotty

33. Conclusion CHC dental workforce is growing, but small, faces structural, geographic challenges – CHCs can serve as laboratories for new workforce approaches, integration with medical care Even though many states are opting not to address dental in health care reform, there are some positive moves afoot

34. Contact Andrew Snyder Policy Specialist National Academy for State Health Policy 1233 20 th Street, Suite 303 Washington, DC 20036 asnyder@nashp.org (202) 903-0101 http://www.nashp.org