The Obama Agenda: In health care overhaul, dental care secondary
Dentists and oral health care providers have long felt maligned in the health care overhaul. While they point to several key measures in the two bills offered in the House and Senate expanding pediatric oral health coverage, they say their services have been overlooked as an essential component of health care.
"Dental health care remains outside the mainstream of medical care," said Dr. Ira B. Lamster, Dean of the Columbia University College of Dental Medicine. "That's a shame because so much of what happens in the mouth can affect other parts of the body."
The highly publicized death of Deamonte Driver, a 12-year-old who died just outside Washington, D.C., in 2007 from untreated tooth decay revealed access barriers Medicaid recipients face in seeking dental care. While Driver's condition could have been treated initially with an $80 procedure, his family was unable to find a dentist in Prince George's County, Md., who accepted the family's Medicaid plan. By the time Driver was able to see a dentist, the abscess had spread to his brain and he died from resulting complications.
News of the death spread throughout the dental community and then to Congress.
"It really felt like we were part of a third-world country," said Dr. Maitreya P. Padukone, past president of the New York County Dental Society and a practicing dentist in New York City.
Dental care and general health have long been separate entities in terms of financing and insurance, training and education, licensing, and regulation, and service delivery.
Under the legislation passed by the House on Nov. 7 and the bill pending in the Senate, more than 30 million uninsured Americans would receive health insurance. But millions of Americans would still be left without dental coverage.
A 2007 Census Bureau report estimated the number of people in the United States without health insurance at 47 million, or nearly 16 percent of the population. More than 85 million people are estimated to have lack dental coverage, according to the National Center for Health Statistics. There are twice as many children without dental coverage as there are without medical insurance.
The two proposals, "Affordable Health Care for America Act" passed by the House of Representatives on Nov. 7 and the "Patient Protection and Affordable Care Act" put forth by Senate Majority Leader Harry Reid (D-Nev.) on Nov. 18, include pediatric dental care but do not include adult dental care.
A 2008 survey by the Kaiser Family Foundation found that just 44 percent of employers who offer health care benefits also offer dental coverage.
Anyone who has existing dental coverage through an employer or private insurer would not see their benefits change. Those not covered by dental coverage now would be able to buy it through added cost.
While oral health advocates feel gains have been made, their work is cut out for them. Because medical and dental care are considered separate entities, dental health care is often relegated to a secondary, or less important, role in health care reform. Oral health care advocates must battle the perception of oral health and dental care as an optional and additional care.
The first step for oral health advocates is to raise awareness of the importance of oral health.
GAPS IN MEDICAID COVERAGE
The president's proposed $635 billion health care budget over 10 years virtually ignores dental care. About half of the budget would be raised through taxes and fees while the other half comes from cuts to Medicare and Medicaid, leaving dental care little room to grow.
A 2008 study by the National Academy for State Health Policy found that dental reimbursements range between 35 and 50 percent of set fees charged by dental care providers. Medicaid reimbursements vary from state-to-state.
"We are looking to increase Medicaid reimbursements, which can be woefully low for oral health care," said Jack Bresch, American Dental Education Association, associate executive director of the American Dental Education Association Center for Public Policy and Advocacy.
State Medicaid programs are required by federal law to cover comprehensive dental coverage to children, but adult coverage is optional. As of 2006, eight states and the District of Columbia provide comprehensive dental benefits for adults in Medicaid. Twenty states, including New York, provide only essential benefits, 16 states provide emergency-only care and six states provide no benefits for adults. The House proposal includes children under the age of 21 while the Senate bill has not yet defined the age of inclusion for children.
When state Medicaid programs must be cut, adult oral health coverage is often the first to go.
Of the states that offer comprehensive dental benefits to adults under Medicaid, many of them impose annual limits. Vermont caps its annual benefits at $495 while Hawaiians are limited to $500 per year under its Prevent Adult Dental Decay program.
Padukone said in addition to low Medicaid reimbursements, many dentists who once accepted Medicaid no longer due to too many patients who scheduled appointments and did not show up. While dentists often charge patients who cancel appointments with less than 24 hours' notice, there is no such recourse for Medicaid recipients who can not afford out-of-pocket payments. Dentists are then forced to take the hit of an unfilled schedule.
Neither the House nor the Senate health care proposals would provide any additional funding for dental Medicaid programs. The ADA is seeking an amendment that would increase Medicaid reimbursements to dentists as primary care providers. The House bill now increases Medicaid reimbursements only for primary care physicians.
GAINS FOR PEDIATRIC ORAL HEALTH
Driver's death spurred congressional hearings on Capitol Hill, just a few miles from where he died. Rep. Dennis Kucinich (D-Ohio), chair of a domestic policy subcommittee on the House Government Oversight Committee, held a number of hearings on Medicaid access.
Attorney Laurie Norris with the Public Justice Center had worked with the family to schedule an appointment for the Driver family.
"It took one mother, one lawyer, one helpline supervisor and three case-management professionals to make a dental appointment for one Medicaid child," Norris testified before Congress.
These hearings helped inform CHIPRA, the Children's Health Insurance Program Reauthorization Act, which was signed into law by President Barack Obama in February 2009.
Originally created under President Bill Clinton in 1997, the Children's Health Insurance Program (CHIP) is a state and federal partnership that provides low-cost health insurance coverage for children in families who earn too much income to qualify for Medicaid but cannot afford to purchase private health insurance.
Dr. Burton Edelstein, director of the Children's Dental Health Project and a professor of dentistry and public health at Columbia University, said CHIPRA corrected deficiencies in the original CHIP passed in 1997 in addition to extending the timeline.
CHIP served more than 7.3 million children in fiscal year 2008. CHIPRA extends this coverage through FY 2013. The Congressional Budget Office estimates that states will be able to provide coverage to an additional 4 million children who would otherwise be uninsured by this over the next four years.
Advocates would like to see this extended further. Bresch and the ADEA are pushing for an amendment which would extend the program until at least 2019.
"We don't want to kick kids out of a program we know that works," he said.
But pediatric oral health advocates are pleased with the provisions included in the health care proposals.
"The bill that passed the House is chockablock with children's health provisions - work force, safety net, dental education, surveillance, just a long list of meaningful oral health provisions," said Edelstein.
One of the biggest changes would be greater monitoring from Washington of state programs. The Senate health care bill would require Secretary of Health and Human Services Kathleen Sebelius to update national oral health care surveillance activities. States would be required to submit reports to the HHS Secretary every five years. In addition, all 50 states, territories and the District of Columbia will be required to participate in the Centers for Disease Control’s National Oral Health Surveillance System. Just 16 states participate today.
ADULTS LACK DENTAL CARE
While dental care advocates roundly praise the progress made in children's dental insurance, they continue to push for increased access to adult dental care.
"The health care reform still absolutely fails to address adults," said Edelstein.
The ADA lobbied for a provision to be included in the House health care bill, which passed Nov. 7, requiring Health and Human Services Secretary Kathleen Sebelius to submit to Congress the results of a study "determining the need and cost of providing accessible and affordable oral health care to adults as part of an essential benefits package." The ADA is working to get similar language included in the Senate bill.
Medicare does not cover any oral health insurance. Almost 70 percent of Americans over age 65 do not have any dental coverage.
"The challenge has always been to get it on the radar screen," said Bresch. "Essentially there are no oral health care benefits in Medicare. And if you're not in Medicare they don't know how important you are. It's a matter of raising the level of priority with them."
The absence of oral health coverage in Medicare isn't for lack of need.
"There are far more people who don't have dental insurance than do not have medical insurance," said Lamster. "For many people that becomes a real challenge, particularly those who have a history of disease or older adults. They're retaining teeth which have been in use for decades and the ability to pay for services just hasn't been there."
'BOTAX' WOULD HIT DENTISTS
Included in Senator Reid's 2074-page bill, H.R. 3590, is a proposed 5 percent excise tax on elective cosmetic surgery to help defray the cost of universal health care coverage. The Botax, as it has been dubbed, has become a source of contention for those in the medical and dental care industries.
The American Dental Association, which represents 157,000 member dentists across the country, opposes the tax on the grounds that it would limit coverage and access to heath care services but would also require dentists to act as tax collectors, interpreting and enforcing the law in their offices.
Sec. 5000B of H.R. 3590 imposes a 5 percent tax whether paid by insurance or out of pocket on "any cosmetic surgery or similar procedure which is performed by a licensed medical professional, and is not necessary to ameliorate a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or trauma, or disfiguring disease.
In a letter sent to Senate members dated Nov. 25, the ADA President Ronald L. Tankersley, D.D.S. and Executive Director Kathleen T. O'Loughlin, D.M.D., M.P.H. wrote, "Such a broad prohibition could exclude many Americans who, after neglecting their own oral health to their detriment, later seek corrective dental procedures in order to find gainful employment, personal comfort, and social acceptance. It seems counterintuitive to penalize people who are taking positive steps in their professional and personal lives, and feel corrective dental procedures are a necessary step in the direction of increased wages, comfort and social confidence."
Cosmetic dentistry treatments that could be subject to this tax include: fillings to correct tooth decay, composite bonding to correct chipped or broken teeth, teeth whitening, veneers, implants and gum surgery. A person who opts for a tooth-colored filling as opposed to a more visible silver or gold filling could be hit with a 5 percent tax.
The American Academy of Cosmetic Surgery said working women between the ages of 35 to 50 would be unfairly targeted by this tax. The group estimates a 5 percent tax would equate to $5 billion to $8 billion a year.
The provision would go into effect Jan. 1, which the ADA argues forces dental offices to comply under a burdensome timeline. Providers who do not enforce the 5 percent cosmetic tax would be held liable for the amount.
CHALLENGES LAY AHEAD
For oral health experts and dental care advocates, the focus remains on increasing the importance of oral health and increasing access to oral health care.
"I've been following this [health care reform] from the perspective of a health care consumer and a health care professional," said Lamster. "I fail to see how this is going to affect much of what we do."
One of the biggest challenges is intertwining medical and dental care. As in the case of Deamonte Driver who died when untreated tooth condition spread to his brain, research now shows links between untreated oral disease and an exacerbation of conditions such as diabetes, heart disease, and stroke. And oral cancer is responsible for more deaths in America than cervical cancer.
Provisions in the Senate health care bill include a five-year public education campaign to promote oral health, a $4 million program to train or employ alternative dental health care providers, expanding the Title VII dental workforce training program to include new programs and provide financial assistance and a dental faculty loan repayment plan. The bill would also establish a National Health Care Workforce Commission, which would coordinate with various Cabinets and serve as a resource the White House and Congress.
As a result of lobbying by the ADEA and other advocates, the Health Benefits Advisory Committee charged with determining basic packages of care in the House now includes an oral health care expert.
Advocates will be monitoring the Senate legislation and the melding of the two bills offered by the House and Senate. One of their primary concerns is a public option that would require health care providers to participate, which would also dictate fees for the private market.
"I don't think we - the people who promote oral health - have yet been successful in fully promoting the critical importance of oral health," said Edelstein. "It's only a half successful story so far."
