Public programs: medicaid and state children’s health insurance program

There has been a plethora of studies, issue briefs, and reports released in 2008 questioning the availability of access to oral care by the uninsured, the underinsured, and those in public programs. Medicaid is a shared state and federal program covering health care costs for populations with limited income and assets. Although the federal government provides matching funds to finance Medicaid and sets certain coverage and benefit rules, states manage the day-to-day operation of the Medicaid program. A state can run the program directly, contract with a private insurer, or use a hybrid of the two. An additional public program is the State Children’s Health Insurance Program (SCHIP) passed in 1997 as part of the Balanced Budget Act to assist in covering low-income children in families with incomes too high to qualify for Medicaid but not enough to purchase private insurance. “In general, this program builds on Medicaid by providing federal matching funds that allow states to provide health insurance coverage to certain uninsured low-income children either under Medicaid, under a separate SCHIP program, or a combination of both approaches.”

In 2005, one third of all children living below 200% Federal Poverty Level (FPL) did not visit a dental provider. As reference, a family of four at the FPL would have an income of $21,200 (at 200% is $42,400). In recent testimony to the US Congress, Centers for Medicare and Medicaid Services (CMS) explained states with lower use of children’s dental services frequently require improvements in the following areas:

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  Clear information for beneficiaries that is linguistically and culturally appropriate regarding the availability and importance of dental services and how to access the services

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  Process to remind beneficiaries that recommended visits are due

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  Updated dental provider listings

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  Processes to track whether recommended visits occurred

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  Availability of dental providers, particularly in more rural portions of the State

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  Availability of specialists for referrals

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  Availability and reliability of transportation to dental services.

As CMS highlights, and states’ experience confirms, it is difficult to get dentists to accept Medicaid patients, and in some geographic areas it can be very difficult to find any dentists. Dentists cite three primary reasons for their low participation in state Medicaid programs: (1) low reimbursement rates, (2) burdensome administrative requirements, and (3) problematic patient behaviors. The American Dental Association (ADA) has encouraged federal legislation, which addresses dental workforce needs by providing grants to dental schools and qualified hospitals to increase the pursuit of pediatric dentistry. ADA also cites the Healthy Kids Dental program in Michigan as an example of a successful public program, as it provides Medicaid beneficiaries with the same Delta Dental private sector coverage that is widely accepted by most dentists in the states. Nonetheless, access to dental services for both children and adults in low-income brackets can be difficult to attain.

In the Medicaid program, a child’s EPSDT (Early Periodic Screening, Diagnosis, and Treatment) benefit requires that state programs pay for regular health items, treatment found to be medically necessary, hearing, vision screening, and comprehensive dental. SCHIP does not include the same requirements of coverage as Medicaid, and states are federally required only to include well-child services, immunizations, and emergency services. “Currently 14 states with separate SCHIP programs offer children the same benefits Medicaid provides; other states provide more limited benefits modeled after private insurance, with seven capping annual dental expenditures or limiting the number of dental services allowed per year. Today, all states except Tennessee cover some dental services under SCHIP.” Experts suggest that “The funding structure for SCHIP is both successful and flawed,” noting that, “It has succeeded in meeting its goal of encouraging state expansions while limiting federal liability, with a matching rate sufficient to encourage all states to expand coverage. However, the program’s success in enrolling children has come up against its federal funding limits. Congress has acted six times in SCHIP’s brief history to modify the program’s rules.”

In 2007, the SCHIP program was due to be reauthorized; however, the size and scope of proposals to expand the program generated controversy. Some policymakers viewed reauthorization as an opportunity to grow the program in ways that would better ensure that it reached the millions of children who remain uninsured in America. Others preferred limiting reauthorization to a simple continuation of the existing program with modest financing improvements. Ultimately, the debate centered on several points of disagreement, including how much to spend on reauthorization, how to define the upper income limit for program eligibility, and how to address the actions by some states to include parents and other adults in their SCHIP populations.

As debate on these contentious issues continued, bipartisan efforts were underway to include a provision in the reauthorization bill requiring dental coverage for children enrolled in SCHIP. The dental provision enjoyed strong support in the dental community, among children’s advocates, and with bipartisan policymakers. It was adopted in the compromise bill approved by the US House of Representatives and the US Senate. However, unhappy with the outcome of several of the other more contentious issues, President Bush vetoed the bill. Congress did not have the votes to override the President’s veto, and efforts to pass a full reauthorization bill were abandoned in favor of simply extending current law through early 2009. Congress is set to revisit SCHIP in 2009 with the new Obama Administration.

Amidst the SCHIP federal debate, the Director of CMS sent letters to the lead health officials of each state indicating that for states to expand SCHIP eligibility to children in families with incomes above 250% of the federal poverty level, they must guarantee that they have enrolled at least 95% of the children in their state below 200% of the federal poverty level. Some states, mainly those with higher costs of living, had begun raising their income eligibility levels for the program to 300% of poverty. As of May 2007, one state, New Jersey, had set eligibility at 350% of the FPL ($74,200). Many states and children’s health advocates argued that the enrollment standards established by the federal government in this directive were unattainable and therefore an attempt to forestall states’ efforts to reach children in lower income families without health insurance. States with high-cost metropolitan areas such as New York City and San Francisco were extremely concerned. Others believed that the Administration’s move would focus the program on its target population and reduce the threat that public program dollars would be used to replace coverage children may already have through private means, including their parents’ employer-sponsored coverage.

“Crowd-out” is defined as an enrollee dropping private insurance to participate in a free or subsidized health program administered by the state. “The crowd-out of private coverage can occur through various avenues. For example, some parents who would have otherwise had family coverage through their employer might decline it for their children—or might decline coverage altogether—if their children are eligible for SCHIP. Estimates vary about the extent to which SCHIP has resulted in the reduction of private coverage. Federal law requires that the states have procedures in place to prevent people from substituting SCHIP for employer-sponsored insurance. However, on the basis of a review of the available studies, the Congressional Budget Office concluded that the reduction in private coverage among children is most probably between a quarter and a half of the increase in public coverage resulting from SCHIP. That is, for every 100 children who gain coverage as a result of SCHIP, there is a corresponding reduction in private coverage of between 25 and 50 children.” Although there have been extensive studies and issue briefs regarding public program expansions on employer-sponsored medical insurance, there have been no reports on how crowd-out may affect the dental marketplace. Although increasing access to oral health care is necessary, crowd-out is certainly a factor that could impact the overall oral health of the nation if adult coverage is abandoned when shifting children to public programs.

Stakeholders and workforce models

There are several key members of Congress who are actively promoting oral health care legislation, likely prompted by the Driver case and growing concern about the extent of the dental access problem in public programs like Medicaid and SCHIP. The attention of lawmakers has increased as they continue to learn about both the prevalence of dental caries (tooth decay) and the increasing evidence that oral and overall health are correlated. Tooth decay remains the most prevalent chronic disease in both children and adults, even though it is largely preventable. Federal and state legislators have been investigating additional opportunities to enhance dental care. Legislation has been introduced in 2007 and 2008 to better coordinate federal efforts to improve oral health by expanding dental services to underserved populations and strengthening the dental workforce.

There are a variety of viewpoints on access to dental providers, and although stakeholders agree there currently is a severe maldistribution of dental providers, whether a shortage of dentists currently exists or will occur in the future is being debated. Whichever your viewpoint or stance, government officials are looking for solutions. Approaches to expanding access to oral health care through legislation vary; however, they tend to focus on two areas—augmenting the reimbursement of providers of oral care and increasing funding for oral health programs. Beginning in 1998, 14 states have passed legislation in which they can directly reimburse dental hygienists for services under the Medicaid program. Over half of the states allow dental hygienists to initiate treatment based on the their assessment of patients’ needs without the specific authorization of a dentist, and some states go further by allowing the treatment of the patients without the presence of a dentist. Several of these statutes were initiated to allow dental hygienists to practice in underserved areas, such as in nursing homes or Indian reservations. Although the American Dental Hygienists Association (ADHA) has supported and likely initiated some of these statutes, lawmakers viewed these measures as a step forward in increasing access to areas in need of oral care.

NADP released a position on the access and workforce issue, taking its lead from the U.S. Surgeon General’s 2000 report, “Oral Health in America.” The Surgeon General’s report brought national attention to the issues regarding access to dental care and the importance of dental care to overall health. “The nation’s capacity to provide care that is accessible and acceptable to address the oral health needs and wants of Americans in the next century is challenged….” That report also recommended use of “public–private” partnerships to address these important issues. NADP supports the principle of public–private partnerships and commits to (and its member organizations) both dialog and partnership with organized dentistry, dental education, government agencies, and organizations representing allied dental personnel to examine and implement a mix of responses to improve the nation’s capacity to provide oral health care. NADP also suggests initial examination of the following mix of responses:

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  Expansion of dental school classes

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  Expansion of education and awareness for current and emerging members of the dental profession on ways to increase productivity of the dental workforce, particularly through the use of allied dental personnel

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  Enhanced practice mobility between states, reciprocity between state licensure, and simplification of the licensure process on a national basis

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  Expansion of delegated duties to qualified allied dental personnel where allowed by local laws and supported by education and accountability

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  Incentives for (a) Increased availability of education and training for allied dental personnel, to insure that delegated duties are delivered without diminished quality; (b) allied dental personnel to seek that continuing education, with the goal of increased productivity and enhanced career satisfaction; (c) qualified applicants to enter dental schools, obtain relief of student debt, and obtain assistance in the formation of new practice opportunities; (d) dentists to remain in the workforce as long as they can contribute, rather than opting for full retirement; (e) quality faculty candidates to seek affiliation with dental schools; (f) research for evidence-based dentistry that can identify ways to intervene in the dental disease process before major restoration is required; (g) the development of technology that increases the productivity of a dentist in his or her practice.

NADP must play a balanced role in the access debate. Dental plans must prove to their customers (employers and other groups that provide benefits) as well as to state regulators that they provide adequate access in all areas in which the dental plan has enrollees. The plans must also provide enough business to dentists to maintain a positive relationship. Although NADP supports the availability of additional allied dental personnel, the organization has not endorsed a one-size-fits-all practitioner approach to expanding the dental workforce.

Both ADHA and ADA have introduced new models for allied dental personnel to lawmakers whom they believe would increase access to oral care. ADHA has proposed the Advanced Dental Hygiene Practitioner (ADHP), a midlevel oral health provider educated and licensed to provide both preventive and limited restorative services to meet identified patient needs. Similar to a nurse practitioner, the ADHP type of provider is used in many other countries. Although both organizations have been careful in their public testimony related to the ADHP, the ADA has been opposed to the new position. Dentists cite the potential for a decrease of quality in patient care, as the yet-to-be-developed education of the ADHP may not be enough for the duties the position requires. The ADHA posits the ADA is concerned about diminishing of business from the new practitioner and notes the success of the ADHP position in other countries and similar positions in the medical community.

Although ADA states there is not a shortage of dentists, they do agree there is a maldistribution limiting the availability of dentists in certain geographic regions. ADA notes that even with an influx of dentists, providers would not necessarily practice in underserved areas. The ADA proposes the Community Dental Health Coordinator (CDHC) workforce model to remedy the need for oral care in underserved areas. The CDHC, under a dentist’s supervision, will provide preventative dental services, such as basic cleanings and sealants and in addition will collect information to assist the dentist in the triage of patients and address the social, environmental, and health literacy issues facing the community population. Another facet of the CDHC will be educating community members on preventive oral health care and assisting them in developing goals to promote and manage their own personal oral health. Linking patients to avenues of oral health care will also be an important role for the CDHC in working with underserved populations going through the maize of the health and dental care systems. The ADA has funded grants in three underserved areas to pilot the CDHC program.

In 2008, the Minnesota Legislature proposed a bill allowing for a new type of practitioner, similar to the ADHP. After months of debate between the Minnesota dental hygienists and the Minnesota Dental Association, the final legislation included a compromise that established a new oral health practitioner discipline, licensed by the Board of Dentistry, and working under the supervision of a dentist. The legislation created a work group (comprised of all stakeholders of the dental community) to advise the commissioner of health on recommendations and legislation to specify the training and practice details for these new oral health practitioners and report back to the 2009 Legislature.

In meetings with certain lawmakers and the various dental stakeholders, ADA has fielded tough questions about how their model would address growing concerns surrounding oral health access issues. The tone of legislators comments and inquires indicates the CDHC workforce model is not viewed as an adequate solution.

As the access debate continues, the education of any new oral health provider will take time to evolve, and the American Dental Education Association (ADEA) has been involved as the voice of dental educators. As ADEA stated in Congressional testimony, “Some say we have a dental shortage. Others say we have a maldistribution of dentists to meet the nation’s oral health needs. No matter how one defines it, there can be no doubt that there is a significant access problem for millions of Americans. We must acknowledge that the current dental workforce is unable to meet present day demand and need for dental care…. The math is simple on this equation. There is an increasing need and demand for dental care. There is a current shortage of dental faculty to educate and train the future dental workforce. Several new dental schools are scheduled to open across the country to meet individual state workforce and access needs. We face a crisis if resources are not dedicated to help recruit and retain faculty for the nation’s dental schools.” This statement introduces a new facet to the access issue, a workforce shortage within dental teaching institutions.

ADEA has proposed 18 recommendations to address dental workforce challenges. The proposals range from increasing funding for oral care in Medicaid and SCHIP, including dental, in certain educational block grants, bolstering prevention and education regarding dental caries, and passing federal legislation as explained in the next section.