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
• “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)
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)
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
Solution
Expand access to care by
• Increasing insurance affordability
• Decreasing out-of-pocket costs
• Expanding access to providers and
• Maintaining high quality of care
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)
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
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
Comprehensive Dental Reform Act
Coverage
Access Points
Workforce
Education
Research
Access
Cost
Quality
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)
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
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
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
“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)
Unintended Consequences
• Financially unsustainable
• Lack of available providers
• Potential decrease in quality of care with
introduction of dental therapists
“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)
“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
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
Legislation Update
•
•
•
•
S. 3272 introduced June 7, 2012
Referred to Senate Finance Committee
Died in committee during the 112th Congress
Has not been re-introduced in current
Congress
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
References
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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
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/publichealth/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.pdf
Pew. A Costly Dental Destination: Hospital Care Means States Pay Dearly; February 2012. http://
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
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-dentaltherapist.html
American Public Health Association Letter to Sen. Bernard Sanders, Jun 6, 2012.
http://www.apha.org/NR/rdonlyres/3DEFCEF5-F959-4AF6-895E4422BAC4C383/0/120606APHALetterofSupport_ComprehensiveDentalReformAct2012.pdf
Press Release. American Dental Hygienist Association, June 6, 2012. http://www.adha.org/adha-supports-comprehensivedental-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