1. The Need for Comprehensive Dental Reform Matthew Montgomery DO, MBA, MPH Training in Policy Studies Fellow 2012 – 2013 AOA Health Policy Forum September 20, 2013

2. “Indeed, what amounts to a ‘silent epidemic’ of dental and oral diseases is affecting some population groups. This burden of disease restricts activities in school, work, and home, and often significantly diminishes the quality of life.” -David Satcher MD., PhD U.S. Surgeon General 1998-2002 Oral Health in America (2000)

3. Sen. Bernard Sanders (I-VT) “When we talk about the health care crisis in America we often ignore a very important aspect of that crisis. And that is that tens of millions of Americans are unable to access affordable dental care – and they suffer as a result of that. Today, by introducing what we believe is the most comprehensive dental care legislation in American history, we start addressing that issue.” -Policy Brief (June 7, 2012)

4. Issue at a Glance Oral health correlated with other systemic medical problems Mantra of oral health is prevention Increasing costs and decreasing provider availability have decreased access to care and overall oral health outcomes Disproportionally affects poor, vulnerable, and minority populations

5. Solution Expand access to care by Increasing insurance affordability Decreasing out-of-pocket costs Expanding access to providers and Maintaining high quality of care

6. History and Background Dental caries: one of the most common chronic diseases – 60% of children aged 5-17 (greater than asthma) – 25% of Adults > 65 y/o lost all teeth Disparities in outcomes along racial/ethnic background, socioeconomic status, geographic distribution 51 hrs of school; 164 hrs of work lost d/t dental disease 830,000 ER visits for preventable dental conditions (2009)

7. Barriers to Access Insurance and Cost 130 M Americans w/o dental insurance Limited coverage from Medicare and Medicaid Medicaid expansion under PPACA provide care for 5M more children $108.4B total dental expenditures (2011) – 4% of NHE – 41.6% in out-of-pocket costs ($45.1M) 14% of out-of-pocket cost of NHE Workforce 190,000 licensed dentists Concentrated in suburban areas – 47M people live in 4,400 Health Professions Shortage Areas (HPSAs) 6,600 additional providers needed More dentist retiring each year then there are graduates to replace them

8. Comprehensive Dental Reform Act of 2012 (S.3272) Amend titles XVIII (Medicare) and XIX (Medicaid) of Social Security Act to cover dental services Amend Public Health Service Act to better integrate dental and medical services Remove restrictions on VA to provide more resources for dental benefits Establish demonstration programs to train and employ alternative providers Develop grants to target “at risk” populations and coordinate care

9. Comprehensive Dental Reform Act CoverageAccess Access Points Workforce Cost Education ResearchQuality

10. Access and Quality Access to Coverage Extend coverage to Medicare/Medicaid and VA 10% increase in FMAP for states Increase funding for integration of services in various setting Provide funding for case management grants for specific populations Access to Workforce Provide incentives to practice in rural and underserved areas Promote alternative dental care providers (dental therapists)

11. Dental Therapists Alternative dental care providers – Function between a dentist and dental hygienist History of working in rural areas Currently practice privileges in multiple countries including U.S. (Alaska, Minnesota) Scope of practice varies but generally includes – Diagnostic exams, Xray, cleanings, sealants, fillings, tooth extractions

12. Cost No estimate of cost from CBO Sanders Bill proposed 0.025% excise tax on securities – Stocks, partnership interest, notes, bonds, debentures, derivatives – Any transaction occurring on US trading floor or involving a US citizen

13. Intended Consequences Medicare, Medicaid, VA insurance expansion and increased provider availability increase access to care Decrease health disparities Improve quality of care through funding in prevention and systems level research

14. “Oral health is an integral part of overall health and well-being…the Comprehensive Dental Reform Act will drive down health disparities and improve public health.” -Georges C. Benjamin MD, FACP, FACEP Executive Director, APHA “…the Comprehensive Dental Reform Act seeks to raise the public’s awareness of the importance of oral health and expand the dental workforce to include millions more Americans…” -ADHA Press Release (June 6, 2012)

15. Unintended Consequences Financially unsustainable Lack of available providers Potential decrease in quality of care with introduction of dental therapists

16. “Only dentists can diagnose, develop treatment plans, and provide complex treatment. It would be detrimental to patients to dilute the very scarce pool of resources…” -William Calnon D.D.S., President ADA June 2012 “Oral health is an integral part of overall health and well-being…the Comprehensive Dental Reform Act will drive down health disparities and improve public health.” -Georges C. Benjamin MD, FACP, FACEP Executive Director, APHA “…the Comprehensive Dental Reform Act seeks to raise the public’s awareness of the importance of oral health and expand the dental workforce to include millions more Americans…” -ADHA Press Release (June 6, 2012)

17. Other Stakeholders Pro – American Association of Public Health Dentistry – National Rural Health Association – National Association of Community Health Centers – Veterans for Common Sense Con – American Dental Association – Wall Street Groups – Internal Revenue Service

18. Legislation Update S. 3272 introduced June 7, 2012 Referred to Senate Finance Committee Died in committee during the 112 th Congress Has not been re-introduced in current Congress

19. Recommendation Good Policy with reservation and political baggage which should be re-introduced Needs Amendments – Await CBO Estimate of cost – Earmark raised revenue for bill financing – Strictly define roles and practice area of dental therapist – Funding for awareness campaign on oral health

20. References U.S. Department of Health and Human Services [DHHS]. Oral Health in America. A Report of the Surgeon General; 2000. http://silk.nih.gov/public/hck1ocv.@www.surgeon.fullrpt.pdf http://silk.nih.gov/public/hck1ocv.@www.surgeon.fullrpt.pdf Policy Brief. Sen. Bernard Sanders [June 7, 2012] (Accessed Feb 2013) Institute of Medicine [IOM]. Advancing Oral Health in America; 2011. http://www.hrsa.gov/publi- chealth/clinical/oralhealth/advancingoralhealth.pdfhttp://www.hrsa.gov/publi- chealth/clinical/oralhealth/advancingoralhealth.pdf Centers for Disease Control and Prevention [CDC]. Oral Health: Preventing Cavities, Gum Disease, Tooth Loss, and Oral Cancers; 2011. http://www.cdc.gov/chronicdisease/resources/publications/ aag/pdf/2011/Oral-Health-AAG-PDF-508.pdf Haley J et al. “Access to Affordable Dental Care: Gaps for Low-Income Adults.” Kaiser Low Income Coverage and Access Survey; July 2008. http://www.kff.org/medicaid/upload/7798.pdfhttp://www.kff.org/medicaid/upload/7798.pdf Pew. A Costly Dental Destination: Hospital Care Means States Pay Dearly; February 2012. http:// www.pewcenteronthestates.org/dental www.pewcenteronthestates.org/dental U.S. Committee on Health, Education, Labor & Pensions. Dental Crisis in America: The Need to Expand Access. [Feb 29, 2012] Library of Congress Summery, Comprehensive Dental Reform Act of 2012. http://www.govtrack.us/congress/bills/112/s3272#summary/libraryofcongress http://www.govtrack.us/congress/bills/112/s3272#summary/libraryofcongress Center for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group British Association of Dental Therapist. History of Dental Therapist. http://www.badt.org.uk/public/history-dental- therapist.htmlhttp://www.badt.org.uk/public/history-dental- therapist.html American Public Health Association Letter to Sen. Bernard Sanders, Jun 6, 2012. http://www.apha.org/NR/rdonlyres/3DEFCEF5-F959-4AF6-895E- 4422BAC4C383/0/120606APHALetterofSupport_ComprehensiveDentalReformAct2012.pdf http://www.apha.org/NR/rdonlyres/3DEFCEF5-F959-4AF6-895E- 4422BAC4C383/0/120606APHALetterofSupport_ComprehensiveDentalReformAct2012.pdf Press Release. American Dental Hygienist Association, June 6, 2012. http://www.adha.org/adha-supports-comprehensive- dental-reform-act-of-2012http://www.adha.org/adha-supports-comprehensive- dental-reform-act-of-2012 American Dental Association Letter to Sen. Bernard Sanders, June 5, 2012. http://www.vsds.org/_ah/editor/documents/ADA%20Letter%20to%20Senator%20Sanders.pdf http://www.vsds.org/_ah/editor/documents/ADA%20Letter%20to%20Senator%20Sanders.pdf