Oral Health

Recently Passed Federal Public Health Legislation

Congress has passed several bills in the last few weeks related to public health.  Here’s a quick summary and links to the laws.

Improving Access to Maternity Care HR 315

This bill requires HRSA to identify maternity care health professional target areas and publish data comparing the availability of and need for maternity care health services in health professional shortage areas and areas within those areas.

Preventing Maternal Deaths Act of 2018 HR 1318

This bill authorizes HHS grants to states to review maternal deaths, publish reports with the results.

PREEMIE Reauthorization Act of 2018  S 3029

This bill increases federal research on preterm labor and delivery, improve the care, treatment, and outcomes of preterm birth and low birthweight infants. 

Agriculture Improvement Act of 2018 – The Farm Bill HR 2

The Farm Bill reauthorizes food security programs through FY23 including Supplemental Assistance Program (SNAP) and SNAP nutrituon education.  It also removes hemp from the Controlled Substances Act, which would legalize hemp production and therefore changes how CBD is regulated.

State Offices of Rural Health Reauthorization Act: S 2278

This bill reauthorizes $12.5M annually through FY22 for the Federal Office of Rural Health Policy to make grants to each state office of rural health to improve health care in rural areas. This bill was approved by both the House and Senate but is not yet signed.

The Action for Dental Health Act of 2018

This bill provides an opportunity to improve oral health across the country.  The bill will provide additional resources to the CDC to increase funding for groups and organizations to qualify for federal grants that develop programs and expand access to oral health education and care in states and tribal areas

CDC will still need to flesh out the grant guidance in the coming months before they put out their announcement with the application and expectations. 

PEPFAR Extension Act of 2018  HR 6651

This bill extends certain provisions of the U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003.

Sickle Cell Disease Research, Surveillance, Prevention, and Treatment Act of 2018  S 2465

This bill reauthorizes a sickle cell disease prevention and treatment program and to authorizes funding for grants for research, surveillance, prevention, and treatment of heritable blood disorders.

Infrastructure for Alzheimer's Act S 2076

This bill would create an Alzheimer's public health infrastructure across the country to implement effective Alzheimer's interventions focused on public health issues such as increasing early detection and diagnosis, reducing risk and preventing avoidable hospitalizations.

Action for Dental Act Passed

The Action for Dental Health Act of 2018 was overwhelmingly passed by congress last week providing an opportunity to improve oral health across the country.  The bill will provide (once signed by the President) additional resources to the CDC to increase funding for groups and organizations to qualify for federal grants that develop programs and expand access to oral health education and care in states and tribal areas.

Grantees are expected to include dentistry and hygiene programs working in rural and underserved areas as well as organizations helping to increase oral health literacy and disease prevention in low-income and minority communities.  The Bill is expected to a=invest an additional $133M over the next four years.

CDC will be entering into contracts with state, county, or local public officials and other stakeholders to develop and implement initiatives to: (1 improve oral health education and dental disease prevention;  2) reduce geographic barriers, language barriers, cultural barriers, and other similar barriers in the provision of dental services; 3) establish dental homes for children and adults; 4) reduce the use of emergency departments by individuals who seek dental services more appropriately delivered in a dental primary care setting; or 5) facilitate the provision of dental care to nursing home residents.

CDC will still need to flesh out the grant guidance in the coming months before they put out their announcement with the application and expectations.

Approaches for Improving Oral Health

Poor oral health is a health disparity for low-income people and people with disabilities.  Dental illnesses significantly increase the risk of chronic health conditions, result in missed days of work and school, and negatively affect employability. According to an American Dental Association survey, approximately 33% of Americans who have income lower than 138% of federal poverty level struggle to get employed because of the condition of their mouth and teeth. 

Poor oral health can easily compound the effects of preexisting conditions and aggravate already fragile socioeconomic well-being, both at the individual and population levels. However, oral health care delivery and services can be improved through innovations in programming, financing, and workforce training. Using the population health framework, states can make significant strides towards improving their population's overall health by improving dental care access and delivery.

Below are some examples of public health policy interventions underway in the U.S in various states to address this important health disparity.

Impact of Medicaid on Access to Oral Health Services

State Medicaid programs including AHCCCS are mandated to provide comprehensive dental coverage for Medicaid-enrolled kids - but aren’t required to offer dental coverage to Medicaid‐enrolled adults. Nationally there’s an uneven patchwork of dental care coverage that impacts access to dental services. 

Arizona provides emergency dental services to all enrolled adults up to a $1,000 annual cap. But coverage alone isn’t enough to actually get care.  Many dental providers don’t  accept Medicaid coverage and nearly 49 million people are living in dental health professional shortage areas (HPSAs) across the country (HPSAs are geographic regions, populations, or facilities that are lacking sufficient healthcare providers).

Many states have used Medicaid waivers demonstrations to improve dental care. For example, California developed a Dental Transformation Initiative to increase dental care access and address the specific oral health needs of children by providing incentive payments to dental providers for achieving state-defined targets.  Here are some examples that are being implemented across the country:

Alignment with Population Specific Services

Oral health programs or pilots can also be aligned with current services provided by the state for increasing access to oral health services for specific populations.  For example, New Hampshire created a pilot program held at local WIC sites to integrate preventative oral health care for low-income women and children into existing safety net programs. It included a weekly dental clinic at each WIC site at which dental hygienists and dental assistants provided preventative care and referred participants to local Medicaid-enrolled dental providers for follow-up care.

Workforce Innovation

Last legislative session Arizona lawmakers approved a new class of dental professionals called Dental Therapists who, over time, will be about to meet some of the workforce demands in Arizona’s rural and underserved areas.  The Board of Dental Examiners still needs to develop the Administrative Code (Rules), but dental therapists will be practicing on the horizon, providing a potentially important access point in rural and other underserved areas.

Care Delivery Innovations

Advances in telehealth can also be promising avenues for improving access to oral health care too. For example, Alaska used telehealth to address its oral health needs. Given the lack of access to oral healthcare that affects their rural residents, they established the practice of mid-level oral health providers known as dental health aide therapists. Telehealth (specifically live videoconferencing) allows these aides to connect with supervising dentists in hub locations who are then able to provide professional oversight and supervision virtually. 

Families USA Issue Brief: Adult Dental Services

States have great latitude to determine the scope of dental benefits they cover for adults through their Medicaid programs. Some states cover comprehensive benefits, others cover emergency dental care and some none (AZ provides emergency coverage up to $1000 per year for all adults and comprehensive coverage for kids).  This variation in coverage matters. Without adequate dental coverage, people face barriers to getting care they need to stay healthy.

To better understand the consequences of insufficient dental coverage, Families USA conducted a survey of states that cover emergency-only dental services.  In the issue brief Families USA found:

  • States that cover emergency dental services generally cover some services to address severe pain including extractions. But most don’t provide restorative care nor cleanings that would address underlying disease.
  • In some states, Medicaid managed care plans provide plan-specific “value added” benefits.
  • State Medicaid programs pay for hospital emergency department visits when appropriate dental services are not available.
  • More comprehensive benefits and fewer prior authorization requirements would encourage provider participation.
  • Low-income seniors and people with disabilities who rely on Medicaid and Medicare for health coverage are among those affected by the lack of dental coverage.

The Families USA Issue Brief concludes that emergency-only dental coverage is a start, but states should invest in comprehensive Medicaid dental coverage for adults if they want to effectively keep their populations healthier and reduce other health care costs. Here’s the full the full issue brief.