EXECUTIVE SUMMARY

ROUNDTABLE ON ORAL HEALTH DISPARITIES

US Department of Health and Human Services, Office of Minority Health

In Collaboration with the National Dental Association

 June 30, 2009 

 The collaboration of the US Department of Health and Human Services, Office of Minority Health (OMH) and the National Dental Association on the Roundtable on Oral Health Disparities held on June 30, 2009 was a milestone in the discussion of oral health in America as an integral part of health care reform. The critical link of oral health to overall health is now, finally, indisputable. In fact, research has proven that dental care is medically necessary.  The Roundtable provided an unprecedented opportunity to bring together leaders of the dental community, in partnership with the Federal Government, to impart information that will educate and assist policy makers in their deliberations moving forward with health care reform.  Through the National Dental Association, the voices of the America’s most vulnerable populations were amplified.

 Despite advances in technology and research, the Surgeon General’s Report on Oral Health in America, and strategies set forth in the Call to Action, the health of Americans continues a downward spiral and health care costs continue to rise.  The dental safety net covers only 7 to 8 million of the 130 million adults and children who lack dental insurance, including 82 million who are dentally underserved. For nearly 100 years, the National Dental Association has been the voice of the underserved, the uninsured, and the underrepresented. In order to address the needs of our nation, the oral health care system must focus on solutions that will benefit society as a whole. 

 The purpose of the Roundtable is to buttress the knowledge that oral health is an integral part of overall health and to ensure that policy developers understand clearly the many dimensions and consequences of oral health disparities in America.  The hope is that understanding will bring clarity and a stronger resolve to rectify the problem.

Dr. Leslie E. Grant, NDA Past President and Chair of the Legislative Committee, served as the Moderator for the program. She opened session by recognizing several notable attendees, and extending personal thanks to Robert Johns, NDA Executive Director, and his staff for bringing this historic event to fruition.

She then introduced Capt. Arlene M. Lester, DDS, MPH, Regional Minority Health Consultant, Office of Minority Health, US Department of Health and Human Services (USDHHS).  Dr. Lester thanked everyone for coming to the joint meeting.  She then introduced Garth N. Graham, MD, MPH, Deputy Assistant Secretary for Minority Health, USDHHS.  She stated that Dr. Graham had supported the oral health policy meeting in February, 2009. She also said that “the push to eliminate disparities in oral health is not at all easy.”  Calling Dr. Graham to the podium she said: “YOU ARE APPRECIATED!”

Dr. Graham welcomed everyone on be half of the leadership of Office of Minority Health and the Department of Health and Human Services. He credited Dr. Lester with “pushing” the importance of oral health and including this area in policy development. He stated, “We have not paid enough attention to oral health; it is important that we pay more attention to it.” Dr. Graham recognized the limitations of working with inadequate critical information and asked the participants to bring forth ideas that would assist the DHHS in including oral health in the discussion. He thanked the NDA for being the leaders in bringing adequately into the open the ideas of the dental community.

He stated that he is part of leadership for Comparative Effectiveness Research in Health Care Reform; and informed the group that DHHS had released the report on June 29, 2009. Over the next months, $1.1 billion will be allocated for the Troubled Asset Relief Program (TARP) for health care research. He concluded his remarks by saying, “Through the prompting and pushing of Arlene and the NDA, we realized we were not listening and that we had to do a better job.  We have to address all of the challenges we are facing. Through the partnership that we are forging with the NDA this is the beginning of what we will do to highlight the discussions that revolve around oral health.  This is not us speaking to you, but you speaking to us.  We will be listening, and as we go through the follow up, you will keep us accountable.”

Dr. Grant then introduced the President of the NDA, Michael F. Battle, DDS.  Dr. Battle welcomed the participants and charged all attendees with helping to engage in vigorous conversations that will bring about solutions.

INNOVATIONS AND MODELS FOR CHANGE

Leslie then introduced Hazel J. Harper, DDS, MPH, Co-Founder and Project Director of the Deamonte Driver Dental Project.  Dr. Harper spoke about the project as a “NDA Model for Change”. It is a community partnership for children’s oral health in Prince George’s County, MD that was founded in 2008. The presentation detailed the development of the project, which was named in memory of Deamonte Driver, a 12 year old boy who died as a result of untreated tooth decay.  It is a school based mobile dental program to increase access and eliminate disparities.

The goals of the project are to:

• Increase access to quality oral health care
• Increase the number of dental Medicaid providers
• Increase the number of children connected to a dental home
• Establish a “Children’s Dental Hotline”
• Establish school based mobile dental clinic programs
• Identify children who are eligible, but not currently enrolled in Medicaid
• Increase awareness about the link between oral health and overall health

Volunteer dentists from the NDA utilize a mobile dental van to screen students at nine elementary schools.  It is a public-private partnership with a broad based community coalition.  The persistent efforts of NDA member, Dr. Belinda Carver-Taylor, project co-founder, resulted in the project receiving significant funding from the State of Maryland not only to purchase the mobile dental van, but also to manage the program.  This was made possible through the efforts and support of her patient, State Senator Ulysses Curry, Chairman of the Budget and Finance Committee in the State Legislature. The project has received recognition for its innovation and enthusiastic support from the state’s Governor, Martin O’Malley, elected officials, and members of Congress.

Dr. Grant then introduced Harry Goodman, DMD, MPH, Maryland State Dental Director, Maryland Department of Health and Mental Hygiene. Dr. Goodman brought greetings on behalf of Maryland Governor Martin O’Malley and Dr. John Colmers, Secretary of Maryland’s Department of Health and Mental Hygiene. He stated that he also represents the Association of State and Territorial Directors.

Dr. Goodman discussed innovative developments that have occurred in Maryland prior to and as a result of Deamonte’s passing.  He gave a historical perspective of Maryland’s progress in the area of oral health and stated that the work actually began ten years; but now there are many new partners to help lead the way.  In 1998, State Senator Gloria Lawlah helped introduce oral health legislation, but despite advances, there are still only 1 in 3 kids who receive oral health care.  In MD, only 17% of dentists accept Medicaid and less than 10% who bill for more than $10K per year. In 2003, Medicaid reimbursements were increased, and in 2007, after the death of Deamonte, the state’s Dental Action Committee (DAC) was formed under the direction of Secretary Colmers.

The DAC came up with a total of 60 recommendations with 7 main recommendations.  The main theme was public-private partnerships.  The goal was to develop the safety net and to “fix” the broken system. As a result, state funded increases will total $42 million over three years. In the past two years, many new dental clinics in public health facilities have been established throughout the state.  Hygienists are able to work alone to help in the newly established public health facilities. Other recommendations that have been implemented include:

• Carving out dental funding and using a single vendor to administer the Medicaid Program;
• Increasing the reimbursement rates;
• Simplifying the Medicaid application process and streamlining administrative processes to increase the number of providers; and
• Providing training to dental and medical providers to provide oral health risk assessment, educate parents/caregivers about oral health, and to assist families in establishing a dental home for all children.

Dr. Goodman reported that over 450 medical providers were trained in June (2009) for the fluoride varnish program; and that this model has been shared with many other state dental directors. He stated that “Although $2 million a year helps, we need so much more.  In fact, if all Medicaid children were able to take advantage of the dental program, we would not be able to accommodate

all of them.  We are now working on a surveillance model with an epidemiologist and a grant from CDC.”

He concluded his remarks by speaking about the public/private partnerships that have been effective in addressing disparities and access to care.  Instrumental in the efforts is the participation of the Maryland Dental Society and Maryland State Dental Association in the Maryland Dentists’ Day in Annapolis, where state legislators get information on issues that are germane to the dental profession.  He also spoke of the community partnerships that have come about as a result of the Deamonte Driver Dental Project.  The innovations occurring in Maryland are being studied nationwide to determine how they can be replicated to address issues of access and disparities.

RESULTS OF A HARRIS POLL: ORAL HEALTH IS A PRIORITY

Dr. Grant then introduced Gary Price, CEO of the Dental Trade Alliance (DTA). Mr. Price addressed Dr. Graham directly saying, “We hope that one day when we say ‘health care’, we will not also have to say ‘Oral Health’ care.  We hope that oral health will be automatically included.”  He noted that the room was filled with so many familiar faces in the dental profession, and issued a charge, “I urge each one of us here to bring a “new friend” someone who “gets it” but who is not already sitting “at the oral health table in these discussions”. 

He then began his presentation on the results of a recent Harris Poll supported by a grant from the DTA in collaboration with Oral Health America. (1,000 persons were interviewed)  He presented some of the highlights of the poll:

• The vast majority of adults know that lack of dental care leads to poor health.
• A significant number admit to having unmet dental needs.
• 1 of 6 reported holding off on seeing dentist because of job uncertainty
• 8 of 10 think it is important that universal dental health coverage be a part of health care reform
• Many feel that dental coverage should be extended to all persons.
• 4 of 5 agree that dental benefits are just as important as medical benefits
• 3 in 4 agree that all over 65 should have dental benefits even if the government has to provide them.
  

The poll indicates that the vast majority of Americans feel that oral health is a priority.

RACIAL DISPARITIES IN ACCESS, RESEARCH AND THE DENTAL WORKFORCE

Next on the program was Averette M. Parker, MD, President/CEO of the Access to Racial and Cultural Health Institute, Inc. Her topic was, “Racial Disparities and Access”. She posed the following questions, quoting from former Surgeon General Dr. David Satcher in May, 2000, “What is health justice?” Is health care fair across the board?  In answering, she stated that “there are clear racial and class disparities in the quality of health care provided.  Race based disparities in health is health injustice.  Health justice is equality in healthcare.”

Dr. Parker went on to say that “ Although the Office of Minority Health is an office that has been focused on a variety of things, when it comes to defining racial and ethnic healthcare disparities,  how much “in words” has REALLY impacted underserved communities?  She pointed out that Congresswoman Donna Christian-Christensen has said that” the elimination of health disparities is THE civil rights issue of the 21st century.”

Dr. Grant introduced Christopher Fox, DMD, DMSc, Executive Director of the International Association of Dental Research and American Association of Dental Research. He began his presentation by stating that “Oral health has not been mentioned in most of the reports that have come out of DHHS.” His presentation was entitled “Racial Disparities and Research”.  He brought out the fact that there are disparities in health care and more dental research is needed to determine the direction that should be taken to correct this.  Research is the basis for the justification of public policies. He stated that a decade ago, there were a number of findings that addressed the problems of disparities in the US, but that gaps in the research do not allow for proper analysis to formulate sound policy that addresses disparities and access to care.  He emphasized that research is the instrument to change the perceptions of policy makers and the public.

Currently the National Institute for Dental and Craniofacial Research (NIDCR) invests more than 11% of its funding for health disparities research. He stated that the NIDCR website lists all of the oral health disparities centers. The hope is that this research will give new policy some “teeth”.

Dr. Grant then introduced Jack Bresch, Associate Executive Director & Director of the American Dental Education Association (ADEA) Center for Public Policy and Advocacy, who spoke on “Dental Workforce Issues”.  Mr. Bresch began his presentation by stating that he supports the NDA position on Health Care Reform. He stated that of the approximately 180,000 dentists in the US, approximately 14% are non-white.  Native Americans make up .1%, Asian/Pacific Islanders 7%, African Americans 3.5%, and Hispanics 3.4%. In the US, these segments comprise 34% of the United States population.  In the last 20 years, Asian student’s enrollment has increased and all other ethnic groups have plateaued.

Currently, there are 4,091 Health Professional Shortage Areas (HPSAs) in the US representing 49 million people.  Mr. Bresch stated that 9,500 more dentists are needed to service these HPSAs. Of the 13,742 applications for dental school, 4,618 were enrolled.  At this rate, we will not meet the needs of the underserved populations, since only 13% of these enrollees belong to the underrepresented minority segment.

Also, surveys reveal that over 60% of African Americans dental professionals are not only willing to serve, but also want to serve in underserved communities.

GRASSROOTS INITIATIVES ANSWER THE CALL TO ACTION

Leslie introduced Robert Dennison, Dental Director of Health Delivery, Inc. from Saginaw, MI. Mr. Dennison presented information about how his successful model addresses access to care. He noted that even before the Surgeon General’s Report on Oral Health in America was released in 2000, it was known that there were racial barriers to health care.  In Saginaw, Michigan, the river divides the city. The East side of river is 86% racial minorities; 20% unemployed; 30,000 eligible for Medicaid; and 89% of children qualified for Medicaid. All those laid off have lost their health benefits. There are 153 practicing dentists in Saginaw County.  East of the river, only 3 of 5 will accept Medicaid.  Medicaid reimbursement rate was 23%.  The West side of the river, for the most part, is doing fine.

The “Smiles are Everywhere” program is a successful dental program that has been developed to address the needs of the underserved. The program utilizes mobile dental vans and portable dental units.  It promotes the “Dental Home” concept and that children should see a dentist by age 1. Fluoride varnish is also promoted for prevention. AmeriCorps workers are used as case managers to follow-up with children’s appointments and they have a 62% completion rate. “We are very proud of that” said Mr. Dennison.

Caswell Evans, Jr., DDS, MPH was the next speaker to be introduced. Dr. Evans is the Associate Dean, University of Illinois College of Dentistry, and Project Director and Executive Editor for the Surgeon General’s Report on Oral Health in America, 2000. \Dr. Evans began his remarks by reiterating the fact that “Health care is a right and not a privilege.”  He lauded the NDA for being an organization that does not make excuses, but “Walks the walk and tries to do the right thing.”

He then posed the question, “What changes have occurred since the Surgeon General’s Report?” and presented the following answers:

1. Oral health is a public issue, not just a private conversation between the dentist and the

    patient.

2. Oral health has its own validity separate from issues of dental practice.

3. Oral health means more than smiles and white teeth.  It means freedom from pain, and from

    deformities. Oral health defines our sense of self and defines who we are as well as our

    employability.  It is responsible for military preparedness and deployment.

4. We now know of associations between oral health and coronary disease, pulmonary

    disease, and low birth weight infants.

Regarding suggestions as to what DHHS should do, Dr. Evans stated,” First and foremost, to recognize that oral health is inseparable from health and thus should always be included. I am thankful that the report (2000) still has traction and will influence what changes come about as a result of the report years down the road. I think we are still at the starting point at the potential for changes.  I would like for Dr. Garth Graham and the DHHS leadership to go back and review the Surgeon General’s Report and the Call to Action, because many of the findings are still very relevant today.” 

“We are at a point in the debate of health reform where we still have reason to be optimistic.  There are several bills where oral health is included. We must make sure that in each bill, oral health comes from the same direction.  There are many foci of these bills. Successful programs are
worthy of assessment and replication. I will underscore the massive disparities of the minority profile of the minority practitioners in contrast to the percentage of the minority population. Until recently, the dental profession has maintained a monopoly on the service system; but also there is a monopoly of the problems that go along with it. 

In Illinois, the question has been asked about how are the dentists in IL [that were sent to dental school by IL taxes] working to help resolve the current problem in the state?  To what extent are dental schools training dentists to understand the problems of disparities and how are dental students being prepared to take action and play a part in the amelioration of these conditions?

I would suggest that DHHS look at the dental health infrastructure and question where does the dental health leadership come from today.  How many regional dental consultants are there now? I know of only ONE. In fact, there is presently no one representing oral health in the office of the Surgeon General.  This is an important issue that must be addressed and the appropriate recommendation made by someone in the federal government.

2020 goals are in draft and they will have oral health objectives. DHHS has a major role in making recommendations and I would like to ask Dr. Garth to take the lead on making sure that oral health issues are at the forefront.”

NDA POSITION ON HEALTH CARE REFORM

Dr. Michael Battle presented the organization’s position on Health Care Reform, which is based on the philosophy that “Health care is a right and not a privilege.” He stated that disparities are intolerable and that oral health care must be a part of any health care reform efforts.

“The NDA feels that the best way to address access to care is to increase the number of underrepresented minorities by recruiting and training health care providers with the qualifications, skills and commitment to improve access and eliminate disparities. We also feel that any health plan must provide universal access; provide basic primary oral health services for children and adults; and make oral health promotion and disease prevention a priority. We have programs that can be replicated, such as the Deamonte Driver Dental Project and the Student National Dental Association’s Impressions program. These programs promote cultural competency and community service, both of which must become core competencies in the dental curriculum. 

Our NDA members are on the front lines in underserved communities, but our providers need help to remain in these communities—loan forgiveness, small business tax credits, federally funded programs that provide reasonable reimbursement rates, and other financial incentives. We are prepared to pursue avenues to develop community driven business models for mobile dentistry; as well as to partner with local chapters of the American Dental Association in the Give Kids A Smile programs in an effort to increase access. We look forward to discussing the “bread and butter issues” and to determine which ways we can build better coalitions and collaborations.  We feel a strong need to be inclusive and to promote true coalitions.  The three main issues that the NDA wants to focus on are

• Universal health care coverage for ALL
• Access to care
• Increasing the number of underrepresented minorities to coincide with the percentage of the minority populations

ROUNDTABLE SYNTHESIS

Nathan Fletcher, DDS, Immediate Past President, served as the Roundtable Synthesizer and summarized the program as follows:

We need to take all that has been said to heart and change the ways we have been doing things.  When we look in the mirror, what do we see that can help us change the ways we have been doing things to make a difference in our America? We see that issues and solutions are community driven and we see how legislators respond to their communities.  We need DHHS to help us amplify the message: Oral health is critical to overall health. We need to take a closer look at how we frame our argument.  The issue of health disparities is indeed a civil rights issue.

Our practitioners cannot do what we need them to do, unless we get them some help.  I am very grateful to Jim Kitch [ADI-Mobile Health corporate partner] for all of the ways he has been instrumental in helping the NDA on the Corporate Round Table as well as with the Deamonte Driver Dental Project and the Dennison-“Smiles are Everywhere Project”, and many others across the nation. It is clear that these grassroots projects provide effective solutions for access.  It is equally clear that health care delivery at the local level is determined by policy at the federal and state levels.  Efforts on the part of the dental community must be addressed at each of these levels.

We know people who go out into the communities and serve who do not need or want the accolades.  They just want to serve. Caswell Evans is one of them.  Through his work on the Surgeon General’s report, he gave us a road map to follow.  Although it has been almost ten years since it was released, we continue to cite the report. There is no question that oral health is an integral part of overall health and that it must be included in any discussion about health care reform.  Assistance is needed to fund grassroots programs and assistance is needed to fund meaningful research to determine social aspects of disparities in health care.

The public perception is that all dental organizations are about dentists.  The NDA is about patients, and has been for 100 years. We must continue our commitment to community education and health literacy, as well as sustain our resolve to impact policy and influence policy makers.

Increasing the number of underrepresented minorities in the dental workforce is the key to improving access and eliminating racial and ethnic disparities. Summer Medical and Dental Enrichment Programs (SMDEP), loan repayment programs, expanded service assignments in HPSAs, increased Medicaid reimbursement, and increased funding for Title VII programs to train medical and dental professionals in rural and underserved areas are also important.

Public/private partnerships and collaborations, such as the multicultural Dental Mentorship Council, with funding from the National Pipeline Office and ADEA also serve to increase the numbers of minority dental professionals.

The National Dental Association is about patients. Patients are the constituents of policy makers.  Policy makers are elected to serve their constituents and according to the recent Harris Poll, 80% of their constituents believe that oral health care must be a part of health care reform.

The principles of civil rights and human rights must apply to every person in America; and every person has a right to health care.  Succinctly, health care, inclusive of oral health care is a must for children and adults, from cradle to grave. This health care must be universal. It must be NOW… and it must be without equivocation or compromise.

Nathan Fletcher, DDS

Hazel Harper, DDS, MPH

References:

National Dental Association Health Care Reform Position Statement, 2009

Harris Interactive Poll. Spring, 2009

Institute of Medicine of the National Academies, “The U.S. Oral Health Workforce in the Coming Decade”, Workshop Summary, February, 2009