Dental News - Costs, as much as location, impede access to care

Robert Selleck, DTA

Fri. 8 June 2012

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WASHINGTON, DC, USA: On June 7, Sen. Bernard Sanders, I-Vt., and Rep. Elijah Cummings, D-Md., introduced the Comprehensive Dental Reform Act of 2012 in the Senate and House. The proposed legislation is titled "A bill to improve access to oral health care for vulnerable and underserved populations." In February, the Senate Subcommittee on Primary Health and Aging heard nearly 100 minutes of testimony at its hearing, “Dental Crisis in America: The Need to Expand Access.”

The hearing focused on how to serve the reported one-third of the U.S. population that is not receiving adequate dental care. Extensive and diverse written testimony was submitted as well.

Several witnesses at the hearing spoke in favor of creating a new licensing concept for midlevel care providers, such as the dental therapists practicing in Alaska and Minnesota, which to date are the only states to have passed laws creating such licensing. The Dental Reform Act proposes a similar concept.

The governor of Kansas last month signed a bill that expands treatment capabilities for dental hygienists, enabling them to pull loose primary teeth, manually scrape decay from teeth and place temporary fillings. The Kansas law was created in response to a dentist shortage in parts of the state and to improve dental care for other vulnerable and underserved populations. The law also includes a provision enabling retired dentists to treat low-income patients or patients living in underserved areas of the state.

The subcommittee’s investigation into access-to-care issues wasn’t limited to potential expansion of midlevel-practitioner licensing, a concept that has been opposed by both the American Dental Association and the Academy of General Dentistry. Those organizations’ advocacy components contend that opening certain treatment capabilities to midlevel practitioners with less training than dentists is not the best strategy from a patient-care standpoint to address access-to-care challenges.

Regarding other aspects of the proposed legislation, ADA President William R. Calnon, DDS, said in a news release, "We hope that our few areas of disagreement do not obscure our welcoming Sen. Sanders to this fight. His bill aims high, and that has long been needed. We fully support his intent, to help extend good oral health to all Americans."

The proposed legislation addresses much of what the subcommittee heard from witnesses in February. That testimony frequently focused on the costs of dentistry and dentistry education — and the impact such costs have on where dentists practice and the types of patients they most typically serve (those with dental insurance or other means of paying for care).

At the hearing's 90-minute mark Subcommittee Chairman Sanders said, “Generally speaking, dentists make a pretty good income. Why is it that we have a dental shortage in this country? Why do we not have enough dentists?”

In response, Shelly Gehshan, MPP, director of the Pew Children’s Dental Campaign, Pew Center on the States, based in Washington, D.C., said the supply of dentists ebbs and flows with the economy, with the 1970s and 1980s producing a large contingent of dental school graduates before recessions forced closure of a number of dental schools. As a result, today's large number of dentists retiring every year exceeds the annual number of dental school graduates.

Grant Whitmer, MSM, executive director at Community Health Centers of the Rutland Region, Rutland, Vt., said his organization just hired two recent dental school graduates, each of whom had more than $350,000 in debt from financing their educations. He said it was only because of the National Health Services Corps and loan repayment assistance that the two were able to take the positions, which focus on delivering care to underserved populations.

Burton Edelstein, DDS, MPH, professor of dentistry and health policy and management at Columbia University, New York, N.Y., said that dental training requires universities to fully fund their own operatories and high-end equipment purchases, unlike medical schools, which can rely on non-university hospitals for clinical training. Dentists opening their own private practices face similar expenses. The result: Providing dental services and/or training is a highly expensive proposition.

Gregory Folse, DDS, president of Outreach Dentistry in Lafayette, La., which is primarily a mobile concept serving the poor, disabled and elderly, praised the federal income tax system’s “incurred medical expense allowance,” which he said enables him to earn enough to focus his practice on underserved populations. But he acknowledged that his income places him in the lower 10 to 15 percent of the profession in earnings. He spoke in support of the Special Care Dentistry Act, which he said enables development of a stronger infrastructure for delivering treatment to underserved populations.

Subcommittee members repeatedly referred to the access-to-care issue as a crisis. Sanders said more that 130 million people in the United States lack dental insurance, and for those who have it, benefits typically are capped at $1,000 to $2,000 per year, which covers only basic services. He said 47 million people live in areas where it is a challenge to find dental care. “This is an issue of enormous importance, and does not get the attention it deserves,” Sanders said.

The proposed legislation references the need for nearly 9,500 additional dental providers to meet the nation's current oral health needs. Various witnesses and subcommittee members spoke of the growing body of research linking oral health to overall health. Also acknowledged were the financial impacts on hospitals that have seen increasing numbers of patients using emergency rooms as their only option for dental care, which typically means just immediate symptoms are being addressed, not underlying causes and prevention.

The proposed legislation takes a multipronged approach with a variety of programs that would make it more financially viable for dental professionals to provide care to people falling outside of current care-delivery models. “We’re going to shine a spotlight on an issue that is not much talked about and we are going to do our best to solve this problem,” Sanders said.

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