The death of twelve-year-old

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1 Essay Foundations Role In Improving Oral Health: Nothing To Smile About A call for foundations to fund more oral health policy grants to effect system change. by Shelly Gehshan ABSTRACT: Dental care is the largest unmet health need among low-income children, yet it garners relatively little attention from policymakers and grantmakers. Foundation giving for dental education and dental care totaled $55.6 million in 2005 a mere 1.6 percent of total health grant making and 0.34 percent of total foundation giving. Health foundations have played a critical role in advancing the U.S. health care system. The need for investments from grantmakers to spur innovation and change in the dental care system is great. This paper describes a range of ideas for strategic grant making to improve oral health in the United States. [Health Affairs 27, no. 1 (2008): ; /hlthaff ] The death of twelve-year-old Deamonte Driver in February 2007 from a dental infection that had spread to his brain sent shock waves through the health policy community. Congress held hearings, dental organizations and advocates debated what went wrong and how to make it right, states looked for new ways to improve access, and a number of grantmakers added oral health to their agendas. 1 Experts were deeply saddened but not surprised by the tragedy, because dental care remains the largest unmet health need among low-income children, yet it garners relatively little attention. 2 It has been several years since the 2000 U.S. surgeon general s report called poor oral health a silent epidemic that inflicts needless pain and suffering and financial and social costs disproportionately on low-income people. 3 Yet very little tangible progress has been made to improve access and prevent more such tragedies from occurring. Who Is Left Out? Although oral health in the United States has improved greatly from decades ago, important disparities exist. Dental caries the infectious disease that causes cavities is nearly universal. Unlike most common physical ailments, which eventually resolve themselves with rest and self-care, dental caries will continuetoprogressunlessitistreatedand,as Driver s death shows, can be life-threatening. Access to dental care is worse for people facing geographic, physical, developmental, financial, and language barriers: that is, low-income and uninsured people, those in rural areas, immigrants, and minorities. One of the clearest class markers in America is missing or visibly decayed teeth. Across the lifespan, the groups with the worst access are our most vulnerable: young children, pregnant women, the elderly, and the disabled. In dental care more than in medical care market forces prevail. Since most care is Shelly Gehshan (sgehshan@nashp.org) is a senior program director at the National Academy for State Health Policy s (NASHP s) Washington, D.C., office. She is also vice chair of the Children s Dental Health Project. HEALTH AFFAIRS ~ Volume 27, Number DOI /hlthaff Project HOPE The People-to-People Health Foundation, Inc.

2 delivered in private dental offices, lack of ability to pay, either out of pocket or through insurance, is correlated with lack of access. Unfortunately, though, if a person cannot pay or has no dental home, there are no dental emergency rooms. What safety net does exist is critical community health centers with dental capacity, hospitals with dental clinics or training programs, and dental and dental hygiene school clinics but that safety net reaches fewer than eight million of the eightytwo million Americans who are underserved for dental care. 4 The majority of dentists donate at least some free or reduced-cost care at their offices or in free clinics, but their generosity does not replace the need for a permanent, accessible system of care. 5 For children, untreated dental decay means difficulty eating, sleeping, playing, learning, and thriving normally. For adults, poor oral health carries the same weight but also makes it hard to get and keep a job and results in lost work time. As a new wave of state health reforms sweeps the country, dental benefits have been largely left out. Who Pays For Dental Care? Financing for dental care has long been inadequate and unstable. Although roughly 10 percent of children lack health insurance, 23 percent lack dental insurance. 6 Full dental benefits are required for children in Medicaid; however, in 2004 only about 20 percent of children ages 0 5 and 30 percent of all childrenwhowereenrolledinmedicaidreceived dental services. 7 Dental care is out of reach for many adults as well. Since its peak in the mid- 1980s, dental insurance for adults has been dropping; fewer than half of private-sector workers are now offered dental insurance, and only about one-third of those offered insurance take it up. 8 Although Medicaid insures the poorest and most vulnerable Americans, states are not required to provide dental benefits to adults. As of 2006, twenty-two states provided either no benefits or emergency benefits only to adults; twenty provided limited benefits; and only eight, plus the District of Columbia, offered full dental benefits. 9 Dental benefits, since they are optional, are often the first thing on the chopping block when budgets get tight. Medicare does not provide dental benefits, except oral surgery needed to treat serious medical conditions, leaving the population age sixty-five and older to its own devices when it comes to affording care. Since dental insurance is so spotty and private coverage involves a substantial amount of cost sharing, 44 percent of care provided in dental offices is paid for out of pocket. 10 Prospects for Medicaid expansions and increases in state funding are dim. As a new wave of state health reforms sweeps the country, dental benefits have been largelyleftout.maine,massachusetts, and Vermont included dental benefits in their revamped, expanded systems only for people below the federal poverty level and those eligible for traditional Medicaid. 11 Challenges Ahead Many states are grappling with current or impending shortages of dentists and other providers. Dentistry is an aging profession. Of the nation s roughly 162,000 practicing dentists, 22.5 percent were ages 55 64, and 10 percent were age sixty-five and older in Policymakers are just beginning to pay attention to the fact that in 2014, the number retiring will exceed the number graduating and entering practice. Even now, all states face shortages in some dental specialties and have too few dentists practicing in rural areas. The Bureau of Health Professions says that 6,701 9,138 dental providers are now needed to serve 3,724 designated shortage areas in which more than thirty million underserved people live. 13 A growing population and the aging of the babyboom generation will put even greater demands on a system that already leaves out many millions of people. As policymakers, states, and communities look for solutions, many obstacles await them. Dentistry has operated much the same way for 282 January/February 2008

3 decades most dentists work for themselves in solo practices and it has been remarkably resistant to change. State corporate practice laws that bar dentists from being employed by nondentists are designed to keep it that way. Managed care is still a small part of the dental world. Dentists, as other health provider groups have done, have strongly resisted attempts by allied providers to encroach on their turf, by opposing dental hygienists efforts to expand their scope of practice or loosen supervision requirements. 14 There are no mid-level dental providers similar to physician extenders, such as nurse practitioners or physician assistants. Dentists have fought expensive legal battles to stop the deployment of new midlevels in Alaska because of concerns about the scope of services they provide. Dental school infrastructure is aging, too, and faces a chronic faculty shortage that makes increasing class sizes difficult. Given the structure of state professional regulation, dentists have influence over increases in supply that puts the interests of members of the profession above the needs of the public. However, dental societies at the national and state levels are deeply concerned about access problems, are working in new ways to address them, and are more open to change than they were in the past. Common Misperceptions Part of the reason that oral health disparities persist and the response to them has been so tepid is widespread public perceptions that devalue oral health and public responses to it. Research has shown that most people equate the consequences of neglected oral health among children with poor diet and nutrition or cosmetic problems such as appearance and self-esteem. 15 Ignoring dental problems is not seen as serious. Dental services are seen as optional, not as core primary health services. For thegeneralpublic,deamontedriver sdeath was either a rude awakening or an aberration that did not warrant further thought. Researchers also found that most people consider poor oral hygiene to be a personal or family responsibility, with the oral health of children under the purview of parents. 16 This line of thinkingleadstolittleornopublicsupportfor public- or private-sector programs to address dental problems, and much blame goes to parents who fail to teach and enforce good diet andoralhygieneandgettheirchildrentothe dentist. Many people, then, do not understand or support the public programs that have played a huge role in improving oral health. Water fluoridation was one of the crowning public health achievements of the twentieth century, and much progress has been made, yet 33 percent of the population with community water systems still lacks it. 17 School-based programs to provide dental sealants for at-risk children work wonders in preventing cavities and lowering treatment costs, yet as of 2002 only twenty-nine states had them. 18 Policymakers and foundations may perceive that dentists are part of the problem, rather than part of the solution, and this may also contribute to the weak response. Research completed for the Robert Wood Johnson Foundation (RWJF) found that some people express resentment that dentists behave more like business owners than health care providers and should have more concern about needy individuals and the health of the public. There are legislators and state officials who view dentists as uncooperative, greedy and lacking in empathy. 19 Another complicating factor is that most stakeholders interviewed for the RWJF project were unaware of how the economics of a dental practice differs from that of a medical practice. (Overhead is higher in dental practices than in physicians offices, so Medicaid reimbursement rates that fail to at least cover costs are a primary barrier to dentists participation.) 20 These beliefs undermine support for increasing reimbursement rates, a key strategy to improve access for low-income people since the beneficiaries of increased rates are thought to be dentists, who are perceived by some as greedy, rather than the low-income, underserved people whom they treat. 21 These beliefs may also undermine foundation investment in improving oral health, because there is no point in investing in change if it means taking on a powerful constituency that is satisfied with the status quo. HEALTH AFFAIRS ~ Volume 27, Number 1 283

4 If dentists do not want to treat the millions of people who now lack access and they fight to prevent other providers from doing so, foundations have little incentive to help. The Foundation Response Foundation investments in oral health have been very limited, compared with both the need and total grant making. Foundation giving for dental education and dental care totaled$55.6millionin This was a mere 1.6 percent of total health Funding the provision of direct services or government functions such as water fluoridation, although laudable, would fail to achieve any system change. grant making and a barely noticeable 0.34 percent of total foundation giving. By comparison, in 2005, foundations invested $225.7 million for mental health and $747.5 million for public health, representing 6.6 percent and 21.8 percent of their health spending, respectively. 23 Besides, almost half of the oral health funding in 2005 was in support of one program: Pipeline, Profession, and Practice: Community-Based Dental Education, supported by the RWJF and the California Endowment. The Pipeline initiative, a collaborative of fifteen dental schools, seeks to reduce oral health disparities by attracting and training minorities to be dentists and establishing community rotations during dental school in the hope that graduates will serve more low-income patients. Without this program, national foundation investments in oral health would have been negligible. Many state and local funders made valuable contributions in 2005 in their geographic areas. These were aimed primarily at increasing the supply of dental services or providers or at building capacity and expertise to serve special populations. The following are just a few of the efforts. The Duke Endowment funded a range of projects, including start-up costs for a new pediatric dental clinic, a mobile dental van, a pediatric dental residency program, and a center to train dental providers and offer care for lowincome people. The Kate B. Reynolds Charitable Trust provided six grants to improve dental access, including funding to establish a new training program for dental hygienists and a grant to begin a volunteer restorative care clinic for uninsured adults. The John S. and James L. Knight Foundation gave a number of creative grants to improve the care delivery system: One grant will fund efforts to link children with services, another will fund training for child care providers about oral hygiene routines for children, andathirdwillfundefforts to organize visits to a mobile dental van. The Virginia G. Piper Charitable Trust funded the purchase of dental equipment to treat disabled children and adults and expansion of a clinic s services so as to serve homeless adults at a shelter. The San Francisco Foundation made eight oral health grants to improve service delivery and access, conduct advocacy and reform efforts, and educate policymakers and thepublicabouttheimportanceoforalhealth. How Could Foundations Make A Difference? Health foundations have played a critical role in advancing the health care system in this country. For example, strategic investments by foundations in start-up grants, demonstration programs, and evaluations brought schoolbased health centers from an idea to a reality across the country. Also, over several decades, private foundations and the federal government funded the development of curricula, faculty training, and planning and implementation grants for two new types of health care providers nurse practitioners and physician assistants who are now numerous, widely used, and well integrated into the system. Foundations can spur improvements in oral health in many ways. Funding the provision of direct services or government functions such as water fluoridation, although 284 January/February 2008

5 laudable, would fail to achieve any system change. The need for innovative thinking and system change to improve access to dental care is great, but the scarcity of foundation investments in the past means that there is a need for groundwork to be laid. According to a wellknown theory, three streams of activity need to converge to achieve policy change: problems, policies, and politics. 24 The work of defining policy problems essentially consists of research, advocacy, and communication to spur public dialogue and generate consensus. Developing policy proposals requires generation of ideas, policy research, demonstration programs, and evaluations. Building political support requires education, leadership development, and coalitions of stakeholders. Defining the problem. One of the difficulties in advancing an oral health agenda is disagreement about the nature of the problem. Is there sufficient capacity but inadequate financing for services? Is there a shortage or simply a maldistribution of dentists and dental hygienists? Do low-income children lack access to preventive care and oral health education as well as to restorative care? Is the problem that too few dentists will treat lowincome patients, or that the capacity of safetynet clinics is much too small? Grantmakers can fund the research and policy work needed to answer the critical questions facing states and communities and define the problems facing policymakers and stakeholders. Once problems are defined, funderscouldinvestinframingthemandin communications to assist stakeholders in building a constituency. Grantmakers can promote public dialogue in task forces, commissions, and other forums and can support work to frame the problem and communicate priorities to policymakers and the public. If there is no agreement on the nature of the problem or whatmightsolveit,itisdifficulttobuildpolitical support for a solution. Developing policy solutions. Very little Perhaps the best investments would be those aimed at bringing more choices to the dental delivery system. funding has been devoted to developing new ideas, solutions, strategies, or models for improving oral health. As a result, few researchers or policy centers focus on it. For example, would more widespread, affordable, private dental insurance improve access among lowincome workers? How can we make proven programs, such as community water fluoridation and sealant programs, universal? How can risk-based care, early intervention, and disease management be applied to oral health? Are new and different types of dental providers needed to treat underserved groups? Are state bans on the corporate practice of dentistry stifling innovative service-delivery models? Would lowincome people be more likely to seek dental care if it were co-located with medical care? Foundation funding of program evaluation and analysis of demonstration projects or new approaches could help enormously to build support for replicating successful interventions. Similarly, objective research and analysis are critical to helping policymakers evaluate workforce models. Much more work is needed, such as a 2007 survey of dental hygienists in California, which can be used to help inform moves toward independent practice by hygienistsandtheiruseinunderservedsettings. 25 Perhaps the best investments would be those aimed at bringing more choices to the dental delivery system. New mid-level providers could improve the efficiency of the dental team in private dental offices and safety-net clinics and assist in prevention. Although private dentists are fearful of such change, strategic research and evaluation might show potential benefits to dentists of having new providers in the system. Examinations of dental practice economics and how new providers would affect it would be particularly helpful in allaying fears. Several models are being discussed for new mid-level practitioners, including dental health aide therapists (DHATs), eleven of whom were trained in New Zealand HEALTH AFFAIRS ~ Volume 27, Number 1 285

6 and now practice in Alaska at Indian Health Service sites. There are other new workforce models now being proposed, including the advanced dental hygiene practitioner, community dental health coordinator, and pediatric oral health therapist. 26 In 2007 the W.K. Kellogg Foundation gave $2.8 million to establish a training program for DHATs in Alaska. The University of Washington Medex Physician Assistant Training Program will develop this ground-breaking program to train DHATs in Anchorage. Other foundation support could be used to determine which models best fit state needs, develop curricula, and establish training programs. Also, foundation support could be used to push for the policy changes needed before new providers can be licensed and deployed. Grantmakers also could invest in helping to bridge the chasm between general health and dental health care. Given the inaccessibility of dental care and increasing evidence of the link between systemic and oral health, more physicians are being enlisted to provide oral health education, visual screening, fluoride varnish, and referrals to dentists. North Carolina pioneered this approach, and many states are considering it. Funds are needed to evaluate these approaches, disseminate lessons learned, and engage payers and policymakers in how to better integrate oral health care into general health care. More work is needed such as the Interfaces project, funded by the federal Maternal and Child Health Bureau. Here, the Children s Dental Health Project, a policy research and advocacy group, and the American Academy of Pediatric Dentistry partnered to explore ways to integrate oral health into pediatric care. At the state level, the UniHealth Foundation provided two grants in 2005 to integrate primary care with community-based dental care in California. Building political support. Finally, foundations could fund organizations that take on the important task of building political support for policy change among legislators, governors, state officials, and the provider community. Consensus building across all stakeholders can help define areas of common ground and break the logjam that often seems to appear when policy change threatens the status quo. It is particularly important to work with organized dentistry and purchasers of services (Medicaid, employers, citizens), which are both critical to the success of reforms. Foundations can also fund efforts to educate elected officials about oral health, develop new leaders, and groom champions to take on the issue. The United Methodist Health Ministry Fund in Hutchinson, Kansas, hasinvestedinoralhealthsince1998.itssupport for Oral Health Kansas (a coalition in that state) and for other efforts has greatly improved the landscape for oral health there. The California Wellness Foundation and the California Endowment fund that state s broadbased, active Oral Health Action Council. Deamonte driver s death from a condition that was completely preventable has been a wake-up call for policymakers. Although oral health has improved for most Americans, serious and persistent disparities exist among low-income people and many vulnerable groups, and nearly eighty-two million people lack access to dental care. With a few exceptions, foundations have largely stayed on the sidelines of this issue. Given the relative scarcity of foundation investment in the past and the enormous need, the field is ripe for innovation and advancement. Although the dental care delivery system has remained virtually unchanged for decades, and private dentists are resistant to change, organized dentistry has demonstrated increasing willingness to confront access problems. New, strategic foundation investments are needed to help states and communities define problems, set priorities, achieve consensus around policy solutions, and implement them. Foundations have spurred enormous changes in other systems in the past. Their attention to the oral health of millions of underserved Americans is needed to move the field forward so that needless tragedies do not happen again. 286 January/February 2008

7 The author thanks Burton Edelstein of the Children s Dental Health Project, Alan Weil of the National Academy for State Health Policy (NASHP), and Andy Snyder of NASHP for reviewing drafts of this paper, and Sara Sills for research assistance. NOTES 1. Children s Dental Health Project, CDHP News Bytes March CDHPPubs/NewsBytesDatabaseandArchives.asp (accessed 11 October 2007); and author s conversations with foundation staff. 2. P.W. Newacheck et al., The Unmet Health Needs of America s Children, Pediatrics 105, no. 4, Part 2 (2000): U.S. Department of Health and Human Services, Oral Health in America: A Report of the Surgeon General (Rockville, Md.: National Institute of Dental and Craniofacial Research, 2000), H. Bailit et al., Dental Safety Net: Current Capacity and Potential for Expansion, Journal of the American Dental Association 137, no. 6 (2006): Kathleen Roth, former president, American Dental Association, testimony before the House Energy and Commerce Subcommittee on Health, 27 March 2007, C. Lewis et al., Dental Insurance and Its Impact on Preventive Dental Care Visits for U.S. Children, Journal of the American Dental Association 138, no. 3 (2007): ; and Bureau of Labor Statistics, National Compensation Survey: Employee Benefits in Private Industry in the United States, March 2006, August 2006, ebsm0004.pdf (accessed 11 October 2007). 7. S. Gehshan and M. Wyatt, Improving Oral Health Care for Young Children (Washington: National Academy for State Health Policy, April 2007), BLS, National Compensation Survey, Employee Benefits in Private Industry, ADA, Adult Dental Benefits in Medicaid: FY , as of 11 June 2007 (Unpublished document, ADA, Government Affairs Division, 2007). 10. Centers for Medicare and Medicaid Services, National Health Expenditure Accounts data, Table 10,PersonalHealthCareExpenditures,byType of Expenditure and Source of Funds: Calendar Years , tables.pdf (accessed 1 November 2007). 11. A. Snyder and S. Gehshan, Kansas Health Reform: Options for Adding Dental Benefits (Washington: NASHP, October 2007). 12. ADA Survey Center, Table 9a in Distribution of Dentists in the United States by Region and State, 2005 (Chicago: ADA, 2005). 13. Health Resources and Services Administration, Bureau of Health Professions, Selected Statistics on Health Professional Shortage Areas, as of 30 June 2007 (Rockville, Md.: HRSA, 2007). 14. See A. Berenson, Boom Times for Dentists, but Not for Teeth, New York Times, 11 October S.N. Bales, Framing Children s Oral Health for Public Understanding and Support: A Frameworks Message Memo (Washington: Frameworks Institute, December 1999), Ibid. 17. Centers for Disease Control and Prevention, Fluoridation Statistics 2002: Status of Water Fluoridation in the United States, (accessed 13 October 2007). 18. CDC, Preventing Dental Caries with Community Programs, Fact Sheet, oralhealth/factsheets/dental_caries.htm (accessed 13 October 2007). 19. S. Gehshan and T. Straw, Access to Oral Health Services for Low-Income People: Policy Barriers and Opportunities for Intervention for the Robert Wood Johnson Foundation (Washington: National Conference of State Legislatures, October 2002), S. Gehshan, P. Hauck, and J. Scales, Increasing Dentists Participation in Medicaid and SCHIP, Promising Practices Issue Brief (Washington: NCSL, 2001). 21. Gehshan and Straw, Access to Oral Health Services. 22. Foundation Center, research commissioned by NASHP, Foundation Center, Distribution of Grants by Subject Categories, circa 2005, foundationcenter.org/findfunders/statistics/pdf/ 04_fund_sub/2005/10_05.pdf (accessed 13 October 2007). 24. J. Kingdon, Agendas, Alternatives, and Public Policies, 2d ed. (New York: Longman, 2002). 25. B.Mertz,K.Grumbach,andD.Keane,California Survey of Dental Hygienists : Descriptive Findings (San Francisco: Center for the Health Professions, University of California, San Francisco, March 2007). 26. The American Dental Hygienists Association is developing the advanced dental hygiene practitioner. The ADA is developing the community dental health coordinator. David Nash, a professor at the University of Kentucky School of Dentistry, has promoted the concept of a pediatric oral health therapist. HEALTH AFFAIRS ~ Volume 27, Number 1 287