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INSURING BRIGHT FUTURES: IMPROVING ACCESS

TO DENTAL CARE AND PROVIDING A HEALTHY

START FOR CHILDREN

HEARING

BEFORE THE

SUBCOMMITTEE ON HEALTH

OF THE

COMMITTEE ON ENERGY AND

COMMERCE

HOUSE OF REPRESENTATIVES

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

MARCH 27, 2007

Serial No. 110–25

(

Printed for the use of the Committee on Energy and Commerce

energycommerce.house.gov
COMMITTEE ON ENERGY AND COMMERCE

JOHN D. DINGELL, Michigan, Chairman

HENRY A. WAXMAN, California

EDWARD J. MARKEY, Massachusetts

RICK BOUCHER, Virginia

EDOLPHUS TOWNS, New York

FRANK PALLONE, JR., New Jersey

BART GORDON, Tennessee

BOBBY L. RUSH, Illinois

ANNA G. ESHOO, California

BART STUPAK, Michigan

ELIOT L. ENGEL, New York

ALBERT RUSSELL WYNN, Maryland

GENE GREEN, Texas

DIANA DEGETTE, Colorado

Vice Chairman

LOIS CAPPS, California

MIKE DOYLE, Pennsylvania

JANE HARMAN, California

TOM ALLEN, Maine

JAN SCHAKOWSKY, Illinois

HILDA L. SOLIS, California

CHARLES A. GONZALEZ, Texas

JAY INSLEE, Washington

TAMMY BALDWIN, Wisconsin

MIKE ROSS, Arkansas

DARLENE HOOLEY, Oregon

ANTHONY D. WEINER, New York

JIM MATHESON, Utah

G.K. BUTTERFIELD, North Carolina

CHARLIE MELANCON, Louisiana

JOHN BARROW, Georgia

BARON P. HILL, Indiana

JOE BARTON, Texas

Ranking Member

RALPH M. HALL, Texas

J. DENNIS HASTERT, Illinois

FRED UPTON, Michigan

CLIFF STEARNS, Florida

NATHAN DEAL, Georgia

ED WHITFIELD, Kentucky

BARBARA CUBIN, Wyoming

JOHN SHIMKUS, Illinois

HEATHER WILSON, New Mexico

JOHN B. SHADEGG, Arizona

CHARLES W. ‘‘CHIP’’ PICKERING,

Mississippi

VITO FOSSELLA, New York

STEVE BUYER, Indiana

GEORGE RADANOVICH, California

JOSEPH R. PITTS, Pennsylvania

MARY BONO, California

GREG WALDEN, Oregon

LEE TERRY, Nebraska

MIKE FERGUSON, New Jersey

MIKE ROGERS, Michigan

SUE WILKINS MYRICK, North Carolina

JOHN SULLIVAN, Oklahoma

TIM MURPHY, Pennsylvania

MICHAEL C. BURGESS, Texas

MARSHA BLACKBURN, Tennessee

PROFESSIONAL STAFF

DENNIS B. FITZGIBBONS, Staff Director

GREGG A. ROTHSCHILD, Chief Counsel

SHARON E. DAVIS, Chief Clerk

BUD ALBRIGHT, Minority Staff Director

(II)
(III)

SUBCOMMITTEE ON HEALTH

FRANK PALLONE, JR., New Jersey, Chairman

HENRY A. WAXMAN, California

EDOLPHUS TOWNS, New York

BART GORDON, Tennessee

ANNA G. ESHOO, California

GENE GREEN, Texas

Vice Chairman

DIANA DEGETTE, Colorado

LOIS CAPPS, California

TOM ALLEN, Maine

TAMMY BALDWIN, Wisconsin

ELIOT L. ENGEL, New York

JAN SCHAKOWSKY, Illinois

HILDA L. SOLIS, California

MIKE ROSS, Arkansas

DARLENE HOOLEY, Oregon

ANTHONY D. WEINER, New York

JIM MATHESON, Utah

JOHN D. DINGELL, Michigan (ex officio)

NATHAN DEAL, Georgia,

Ranking Member

RALPH M. HALL, Texas

BARBARA CUBIN, Wyoming

HEATHER WILSON, New Mexico

JOHN B. SHADEGG, Arizona

STEVE BUYER, Indiana

JOSEPH R. PITTS, Pennsylvania

MIKE FERGUSON, New Jersey

MIKE ROGERS, Michigan

SUE WILKINS MYRICK, North Carolina

JOHN SULLIVAN, Oklahoma

TIM MURPHY, Pennsylvania

MICHAEL C. BURGESS, Texas

MARSHA BLACKBURN, Tennessee

JOE BARTON, Texas (ex officio)

(V)

C O N T E N T S

Page

Allen, Hon. Tom, a Representative in Congress from the State of Maine,

opening statement ................................................................................................ 12

Blackburn, Hon. Marsha, a Representative in Congress from the State of

Tennessee, opening statement ............................................................................ 6

Burgess, Hon. Michael C., a Representative in Congress from the State of

Texas, opening statement .................................................................................... 8

Capps, Hon. Lois, a Representative in Congress from the State of California,

opening statement ................................................................................................ 9

Deal, Hon. Nathan, a Representative in Congress from the State of Georgia,

opening statement ................................................................................................ 3

DeGette, Hon. Diana, a Representative in Congress from the State of Colorado, opening statement ...................................................................................... 6

Prepared statement .......................................................................................... 7

Dingell, Hon. John D., a Representative in Congress from the State of Michigan, prepared statement ...................................................................................... 18

Engel, Hon. Eliot, a Representative in Congress from the State of New York,

opening statement ................................................................................................ 17

Eshoo, Hon. Anna G., a Representative in Congress from the State of California, prepared statement ...................................................................................... 19

Green, Hon. Gene, a Representative in Congress from the State of Texas,

opening statement ................................................................................................ 4

Hooley, Hon. Darlene, a Representative in Congress from the State of Oregon,

opening statement ................................................................................................ 14

Matheson, Hon. Jim, a Representative in Congress from the State of Utah,

opening statement ................................................................................................ 15

Murphy, Hon. Tim, a Representative in Congress from the Commonwealth

of Pennsylvania, opening statement ................................................................... 11

Pallone, Hon. Frank Jr., a Representative in Congress from the State of

New Jersey, opening statement .......................................................................... 1

Solis, Hon. Hilda, a Representative in Congress from the State of California,

opening statement ................................................................................................ 13

Towns, Hon. Edolphus, a Representative in Congress from the State of New

York, opening statement ...................................................................................... 16

Wilson, Hon. Heather, a Representative in Congress from the State of New

Mexico, opening statement .................................................................................. 13

WITNESSES

Chapman, Jack, M.D., president, Health Access Initiative, Gainesville, GA ..... 81

Prepared statement .......................................................................................... 83

Corbin, Stephen B., D.D.S., senior vice president, constituent services and

support, Special Olympics International, Washington, DC .............................. 56

Prepared statement .......................................................................................... 58

Edelstein, Burton L., D.D.S., founding director, Children’s Dental Health

Project, Washington, DC ..................................................................................... 19

Prepared statement .......................................................................................... 21

Farrell, Christine, Medicaid policy specialist, Michigan Department of Community Health, Lansing, MI ............................................................................... 45

Prepared statement .......................................................................................... 47

Koyanagi, Chris, policy director, Bazelon Center for Mental Health Law,

Washington, DC ................................................................................................... 84

Prepared statement .......................................................................................... 86

Krol, David M., M.D., associate professor, pediatrics, University of Toledo

College of Medicine, Toledo, OH, on behalf of the American Academy of

Pediatrics .............................................................................................................. 76
Page

VI

Krol, David M., M.D., associate professor, pediatrics, University of Toledo

College of Medicine, Toledo, OH, on behalf of the American Academy of

Pediatrics—Continued

Prepared statement .......................................................................................... 78

Mosca, Nicholas G., D.D.S., clinical professor, pediatric and public health

dentistry, University of Mississippi School of Dentistry, Jackson, MS, on

behalf of American Dental Education Association ............................................ 49

Prepared statement .......................................................................................... 51

Roth, Kathleen, D.D.S., president, American Dental Association, Washington,

DC .......................................................................................................................... 24

Prepared statement .......................................................................................... 26

Scheppach, Raymond C., executive director, National Governors Association,

Washington, DC ................................................................................................... 40

Prepared statement .......................................................................................... 41

SUBMITTED MATERIAL

Hoyer, Hon. Steny, a Representative in Congress from the State of Maryland,

statement .............................................................................................................. 98

Fletcher, Hon. Ernie, Governor, Commonwealth of Kentucky, letter of March

15, 2007 to the Committee on Energy and Commerce ...................................... 100

‘‘For Want of a Dentist,’’ article from the Washington Post of February 28,

2007, by Mary Otto. ............................................................................................. 101

McClellan, Mark B., M.D., Administrator, Centers for Medicare and Medicaid

Services, statement, submitted by Mr. Deal ...................................................... 107

Leavitt, Michael O., Secretary, Department of Health and Human Services,

letter of August 25, 2006 to Mr. Barton, submitted by Mr. Deal .................... 107
(1)

INSURING BRIGHT FUTURES: IMPROVING

ACCESS TO DENTAL CARE AND PROVIDING

A HEALTHY START FOR CHILDREN

TUESDAY, MARCH 27, 2007

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE ON HEALTH,

COMMITTEE ON ENERGY AND COMMERCE,

Washington, DC.

The subcommittee met, pursuant to call, at 10:10 a.m., in room

2123 of the Rayburn House Office Building, Hon. Frank Pallone,

Jr. (chairman) presiding.

Members present: Representatives Towns, Green, DeGette,

Capps, Allen, Baldwin, Engel, Solis, Hooley, Matheson, Deal, Murphy, Burgess, Blackburn and Wilson.

Staff present: Elizabeth Ertel, Yvette Fontenot, Brin Frazier,

Amy Hall, Christie Houlihan, Bridgett Taylor, Lauren Bloomberg,

and Robert Clark.

OPENING STATEMENT OF HON. FRANK PALLONE JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY

Mr. PALLONE. I want to call the subcommittee to order.

Today we are having a hearing on ‘‘Insuring Bright Futures: Improving Access to Dental Care and Providing a Healthy Start for

Children.’’ I now would recognize myself for an opening statement.

I would like to thank our witnesses for appearing before the subcommittee today and I am certain that we will learn much from

your expertise. Today’s hearing was brought about after a 12-yearold Maryland boy lost his life because he was unable to access the

dental care he needed to treat an abscessed tooth. What started out

as a simple toothache quickly developed into a far worse problem

that cut the boy’s life far too short. When news of this tragedy

spread throughout the country, many people were shocked. It was

unimaginable to think that something as minor as a toothache

could have such dire consequences.

Indeed, for most of us, we take for granted the convenience of

going to see a dentist, but the truth of the matter is, for millions

of Americans, proper dental care is often out of reach and sadly,

most of those people are children. Indeed, the truly frightening

thing about Diamonte Driver’s death is the number of American

children who are at risk of a similar fate. The problem of poor oral

health is nationwide and impacts millions of children. There has al-
2

ready been another boy in Mississippi who died because of delayed

dental care.

Now, the question is: just how big is this problem? Statistics

show that chronic infectious disease that causes cavities remains

second only to the common cold in terms of prevalence in children.

Unlike a cold, however, tooth decay does not go away; it only gets

worse. Pain from untreated dental disease can make it difficult for

children to eat, sleep, pay attention in school, and it can affect

their self-esteem. Poor children are more than twice as likely to

have cavities than children who come from wealthier households.

Medicaid is able to provide comprehensive dental care to many lowincome children through its early periodic screening, diagnosis and

treatment benefits. Similarly, many States provide dental benefits

as part of their children’s health insurance programs, and I have

no doubt that if it were not for these two programs, the problems

that our children face in securing primary dental care would be exponentially worse.

But clearly, we need to do more. There are many children who

are eligible for Medicaid or SCHIP who are not enrolled. That

means that there are millions of children who should be receiving

dental care but are not, and we need to invest more funds to improve enrollment in these important programs and provide the financial resources to ensure that they can access the benefits once

they are enrolled. But there are many children who are not eligible

for public health insurance programs who are unable to also receive proper dental care.

When I am home in New Jersey and I am visiting a community

health center or a hospital clinic, I see firsthand how difficult it is

for low-income families to obtain primary dental care. The community health centers that I talk to describe the difficulty they have

in securing dentists to provide care to their patients, and I look forward to hearing from our witnesses about their recommendations

on how Congress might be able to encourage dentists to provide

care in many of these underserved communities. But the problem

of access to dental care goes even further. For millions of Americans who have health insurance, dental benefits are often not included. Indeed, millions of families who obtain their health insurance from their employers do not have policies that cover dental

care, leaving them with few places to seek care.

I truly believe that we are seeing a crisis when it comes to dental

care for kids but poor oral health is just the tip of the iceberg. It

certainly is not the only health care problem affecting our Nation’s

children. Obesity, for example. Obesity rates among adolescents

have doubled in the past two decades and now affects 16 percent

of children ages 16 to 19. When compared with other developed

countries, it is very clear that our fragmented health system is failing our children, and as a consequence, our children are suffering.

The United States maintains higher rates of infant and child mortality, higher prevalence of asthma, and injuries and rapidly increasing rates of mental health problems with a limited ability to

respond. Congress can and should do more to address these problems. Unfortunately, over the years, the interest of our children

has often taken a back seat to more politically powerful interests.

Unfortunately, I think that it has been too easy for previous Con-
3

gresses to overlook the needs of our children simply because they

lack the political voice that other groups might have, and that

clearly needs to change. Our Nation’s children can no longer wait

for Congress to act on this pressing health issue. The longer we

wait, the more children we put at risk.

A Nobel laureate and poet, Gabrielle Mistral, said, and I quote,

‘‘Many things we need can wait. The child cannot. Now is the time.

His bones are being formed, his blood is being made, his mind is

being developed. To him, we cannot say tomorrow. His name is

today.’’ And I don’t know if it is proper but I will say that because

this is so important, I have my own wife and children here today

listening to the hearing, at least in the beginning, and I mention

that only because I can relate to the problems that these kids face

and it is one of the reasons that I am particularly interested in it

because I have children of my own.

So with that, I will yield back my time and recognize the ranking

member, Mr. Deal, for an opening statement.

OPENING STATEMENT OF HON. NATHAN DEAL, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF GEORGIA

Mr. DEAL. Thank you, Mr. Chairman, and welcome to our panelists and to our guests, and I am pleased to see Mr. Pallone’s family

here too and I see at least one set of braces over there so he is contributing to the industry, I might add.

I understand we have some special guests in our audience today,

Mr. Chairman, some members of the American Dental Association.

If it would be appropriate, I would like to see them if they would

raise their hands, please. Don’t be bashful. Oh, there they are. Oh,

they are everywhere. I thought they were a bigger crowd than that.

Well, let me thank you for being here. Certainly this is an important component of addressing the future needs of dental services in

our country. My State, I am told, that we have about 240 dentists

every year who are retiring and we are only graduating about 60,

as I understand it, from our dental schools. So it is important for

you to continue in your educational pursuits, and we thank you for

coming today.

Our hearing today is an essential element of focusing on essential elements of children’s care and that is their dental care, and

I would thank our witnesses and I look forward to their testimony.

Our witnesses, I am sure, today will tell us that there are a number of barriers to proper oral health care despite the fact that all

States must provide dental services as a part of their Medicaid programs and every State with an SCHIP program includes dental

benefits. It seems that the impediments to adequate coverage in

the public programs exist not necessarily because the benefit does

not exist. For instance, many dentists choose not to participate in

the public programs. In 2000, only about a quarter, 26.3 percent,

of dentists participated in the Medicaid program. Also in my conversations with dentists, many cite the overwhelming administrative burden of providing services through the public programs. I believe it is shortsighted to point only to reimbursement levels when

dentists will choose to provide their services on a pro bono basis

rather than participate in the public programs. Moreover, many

people do not recognize the importance of oral health and simply
4

fail to take advantage of the benefits that are available to them.

This is true for both individuals covered by private and public insurance. Dental services are certainly an important component of

health care coverage but encouraging individuals to take advantage

of provided benefits seems equally important. At some point, people

must take responsibility for their oral health on a regular basis.

I am afraid that many in our committee have an interest in creating mandates with SCHIP like the dental benefit in Medicaid

which would make it more difficult for States to provide health coverage appropriate to the needs and conditions of the individual

States. The Governors’ frequent frustration with the rigid structure

of the Medicaid program helped inform the steps we took in the

Deficit Reduction Act to provide benefit flexibility to the States in

Medicaid. This flexibility allows Governors to design effective programs which meet the specific needs of their State. Dr. Scheppach

will tell us how the flexibility of the SCHIP program contributes

significantly to its success. I fear that if we remove the flexibility

of SCHIP, we will seriously hamper the States’ ability to design innovative health care reform proposals to cover their uninsured.

In these discussions about SCHIP and Medicaid, it is also too

easy to lose sight of the role played by free clinics, health centers

and collaborations like the Health Access Initiative in my hometown, and we will have a speaker on the next panel to talk about

it. These organizations provide an effective way to bring health

care to the uninsured. For instance, in the case of dental care, dentists who may want to avoid the administrative burden of the Federal programs but still want to help meet the needs of their local

community could volunteer their time at a clinic. I hope the committee will spend time examining ways to make these initiatives

and institutions more effective, perhaps through liability reform or

even providing a tax deduction to physicians who provide their

services for free in a clinic setting.

I look forward to the testimony of the witnesses today and to

their insights into this very distinct and unique problem, and I am

sure that we will be informed by your testimony. Thank you for

being here.

Thank you, Mr. Chairman.

Mr. PALLONE. Thank you, Mr. Deal.

I now recognize our vice chair, Mr. Green from Texas.

OPENING STATEMENT OF HON. GENE GREEN, A

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS

Mr. GREEN. Thank you, Mr. Chairman, for holding this hearing

on access to dental care for our Nation’s children.

I am glad that one of our early hearings on access issues will

highlight dental care because it is such an important component of

children’s health care. Tooth decay remains the most prevalent

chronic health care condition faced by our children today, which is

why dental issues should be part of our discussion involving increased access to health care. A lack of access to dental care is no

different from other health care since the effect of inaction is the

same. Without preventive dental care, dental problems are often

left untreated until they reach emergency proportions and the patient arrives in the hospital emergency room with a condition that
5

could have been treated earlier and at much lower cost. In fact,

Medicaid statistics show that the cost of managed dental problems

through preventive dental care is 10 times less costly than inpatient dental treatment in hospital ERs. Despite the obvious benefit

of preventive dental care, we have serious uninsured problems with

dental benefits that restrict access to care. In fact, for every child

who goes without health insurance, there are three children who

lack dental insurance. This discrepancy leaves children without insurance being five times as likely to have unmet dental needs than

their classmates who have insurance.

Unfortunately, Congress contributed to this disparate treatment

of dental and health insurance when it created the State Children’s

Health Insurance Program in 1997. While States that use SCHIP

dollars to expand their Medicaid programs had to include the full

range of dental benefits provided to the traditional Medicaid population, Congress made the dental benefit optional for States like

Texas, who have separate SCHIP programs. The result, when funding got tight and State legislators got a little uncomfortable about

balanced budgets, the SCHIP dental benefit found itself on the

chopping block and I am sorry to say that is exactly what the

Texas Legislature did in 2003 when it was the first State in the

country to eliminate the SCHIP program’s dental benefit. I understand the State of Georgia is considering a similar tactic and I assure my friends in Georgia that the elimination of this critical benefit is a misguided health policy. In fact, we may have an amendment we might call the Charlie Norwood amendment since Dr.

Norwood served on our committee a very long time and passed

away recently and was a dentist in Georgia.

In Texas, public outrage over SCHIP dental policy and other cuts

led the State legislature to restore the benefit in 2005. Unfortunately, the Texas children got only half a loaf with the Texas

SCHIP program imposing $175 annual cap on preventive and diagnostic services and a $400 cap per enrolled child on therapeutic

services like tooth extractions and root canals. Despite being

passed in 2005, the benefit only became available to Texas children

in the beginning of April 2006, meaning that too many of the

300,0000 Texas children that remain on SCHIP rolls went far too

long without dental checkups and preventive services.

The recent news of the 12-year-old child in Maryland who died

tragically and needlessly from complications of untreated dental infection sheds an unmistakable light on our children’s needs for increased access to dental care. Sadly, the problem is not limited to

Maryland. In fact, 46 counties out of our 254 in my State of Texas

do not have a practicing dentist. Without access to dental care, the

children living in these counties and similar communities throughout the country have little more than hope to ensure that their

dental health does not deteriorate into irreversible health problems.

I want to thank the chairman for drawing attention to this as we

focus on improving access to health care and specifically the SCHIP

reauthorization. I hope that we will take the opportunity to address

the dental needs of our children and do everything possible to increase their access to critical dental care, and again, I thank our

witnesses on our two panels today, and I yield back my time.
6

Mr. PALLONE. Thank you, Mr. Green.

I recognize the gentlewoman from Tennessee, Mrs. Blackburn.

OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF TENNESSEE

Mrs. BLACKBURN. I thank the chairman for holding this hearing

today and I want to extend my welcome to your family. Also, I appreciate the panel that is before us. I am delighted that we have

a diverse panel of witnesses who have assembled for us today.

I think we all agree that lack of access and lack of knowledge of

how to use that access when it comes to dental health services for

children is a serious problem. It is also a frustrating problem and

it is one that could be remedied and should be remedied with some

commonsense, practical solutions. We all know the Centers for Disease Control numbers that nearly 25 percent of our children under

age 5 are affected by dental decay and half of our children age 12

to 15 are affected. We know that low-income children are the hardest hit and that about half of those 6 to 19 have untreated decay,

absolutely phenomenal numbers when you think about this being

2007. We also know that these untreated cavities can cause pain,

dysfunction, absence from school, underweight, poor appearance,

all items that greatly affect a child’s ability to be successful in their

current life and in their future life, and these facts are disturbing

to all of us.

At a time when we are shifting from responsive medicine to preventative medicine, there is no excuse for allowing the problem to

continue. We all had grandmothers who would quote to us, ‘‘an

ounce of prevention is worth a pound of cure.’’ We should apply this

to the problem of children’s dental health. Not only is proper oral

care common sense, it is also extremely cost-effective and provides

significant savings of health care dollars during an individual’s entire lifetime.

I am looking forward to hearing the testimony today and working

with all of you on how we can best address the situation, how we

consider SCHIP, how we allow States flexibility, and how we continue and allow health care innovation. I am looking forward to a

thoughtful consideration of the options before us.

I yield back.

Mr. PALLONE. Thank you.

I recognize the gentlewoman from Colorado, Ms. DeGette.

OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF COLORADO

Ms. DEGETTE. Thank you, Mr. Chairman. I would ask unanimous consent to put my full statement in the record and simply

point out that as we consider the need for dental coverage for children, we also need to think about the need for more dental providers to give those children care.

The title VII primary medicine and dentistry cluster plays a critical role in our Nation’s health care safety net. Programs supported

by title VII produce an essential pipeline for a number of essential

medical providers, general and pediatric dentists who go on to work
7

in community health centers, rural health clinics, inner city urban

clinics, hospitals and dental school clinics, exactly the providers

that serve the populations we are talking about today. These are

the places where the SCHIP kids are enrolled and other indigent

kids who don’t have any other recourse to dental care. Funding for

all of title VII has been drastically cut in the last few years, which

severely constricts our pipeline for dentists. I hope the witnesses

today will talk with us about the challenges faced in States to meet

the demand for dentists, because if we don’t have dentists, it is

going to be hard to see how we can give all of our kids dental care.

One other issue I want to mention, as we look at the reauthorization of SCHIP, we need to examine, as Mr. Pallone says, the holistic needs of the child, not just the dentistry, not just the medical

needs, but we also need to look at mental health for the kids and

I think that is widely underestimated. I also serve on the Oversight

and Investigation Subcommittee which had a hearing last week

about the medical infrastructure of New Orleans and trying to rebuild after Hurricane Katrina. Over and over again, we heard from

providers in community health centers about the unbelievable need

for mental health services. This is particularly true for children

who have lost everything, who are depressed and who in many

cases have suffered post-traumatic stress disorder yet while we

know the need for mental health care services is severe in the hurricane-affected regions, the need is no less acute for other children

around the country. Many face mental and behavioral health problems as well as developmental disabilities that require extensive

care and that is care that they are currently unable to afford. I

know the primary purpose of this hearing is dentistry but on the

second panel we have witnesses who can help us talk about these

other challenges for children and how we can use SCHIP more effectively to address their needs.

Mr. Chairman, reauthorization of SCHIP is of paramount importance both to myself and to this committee in the next few months.

As we do so though, we need to make sure that we carefully consider all of the health needs of those children and how we can best

meet them.

I yield back the balance of my time.

[The prepared statement of Ms. DeGette follows:]

PREPARED STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN CONGRESS

FROM THE STATE OF COLORADO

Mr. Chairman, thank you for calling this hearing today. As we prepare to reauthorize the State Children’s Health Insurance Program (SCHIP) it is critical that

we ensure that the benefits provided through this program effectively meet the

health care needs of the children enrolled.

As we have all heard, two young boys—one in Maryland, one in Mississippi—recently lost their lives when an infection from an abscess tooth spread into their

blood. In both cases, each boy lacked health insurance with dental coverage. Instead

of a minor procedure in a dentist’s office, the boys were rushed to the emergency

room, underwent extensive surgery, and eventually died. In the case of the boy in

Maryland, $250,000 worth of care was spent to keep him alive. Covering this boy

in SCHIP with proper dental coverage would have prevented this from occurring.

As we consider the need for dental coverage for children, I hope that we can also

discuss the need for more dental providers to give care. The Title VII Primary Medicine and Dentistry cluster plays a critical role in our Nation’s health care safety net.

Programs supported by title VII produce an essential pipeline for a number of essential medical providers, general and pediatric dentists who go on to work in community health centers, rural health clinics, inner city urban clinics, hospitals and den-
8

tal school clinics. These are the very places that provide much of the dental care

to those children enrolled in SCHIP. Funding for all of title VII has been drastically

cut in recent years, severely constricting our pipeline for dentists. I hope that our

witnesses will be able to share with us today the challenges faced in states to meet

the demand for dentists.

Mr. Chairman, in addition to the Health Subcommittee, I also serve on the Oversight and Investigations Subcommittee. We recently held a hearing about rebuilding

the medical infrastructure of New Orleans after Hurricane Katrina. Over and over

again, we heard from providers in community health centers about the need for

mental health care services. This is particularly true for children, who have lost everything, who are depressed, and in many cases have post-traumatic stress disorder.

Yet, while we know the need for mental health care services is severe in the hurricane affected regions, the need is no less acute for some children throughout the

country. Many face mental and behavioral health problems, as well as developmental disabilities, that require extensive care—care that they are currently unable

to afford. I look forward to hearing from the witnesses on our second panel today

about the need to help children with these challenges and ideas about how we can

use SCHIP more effectively to address their needs.

Mr. Chairman, reauthorization of SCHIP is certainly of paramount importance

during the next several months. However, as we do so we need to make sure that

we carefully consider all of the health care needs of those who are and will be covered.

I yield back the balance of my time.

Mr. PALLONE. Thank you, and if I could just mention, as you

know, the supplemental has I guess about $730 million for SCHIP

for the rest of this fiscal year and the budget that came out of committee has a $50 billion reserve fund for the next 5 years, and

when we come back after the break, we will start the process of reauthorizing SCHIP. So I just want all of you to know that we are

on top of that, and through all your help, through all the members

of the committee.

Dr. Burgess.

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS

Mr. BURGESS. Thank you, Mr. Chairman.

I want to thank my friend from Texas, Mr. Green, for invoking

the spirit of Charlie Norwood, certainly the dental conscience of our

committee. Charlie was a tireless advocate for improved health

care in the United States. He was a tireless advocate for making

the system work for everyone for whom it was supposed to work,

and Charlie of course was famous for being a straight talker, and

in fact today I hope that we can all engage in a little straight talk

about this problem because the Maryland case of about a month

ago is why we are here today. That tragic story has called attention

to the fact that the system failed a family multiple times, and the

question before us today is, what do we do about it.

Congress is reauthorizing the SCHIP program and we need to

decide in which direction to take the program. Now, certainly we

could mandate dental coverage under SCHIP but the fact is that

several States already do offer at least some level of dental coverage. Seventy-three percent of federally qualified health centers

offer children’s dental coverage. So the question is, is that somewhat redundant? Certainly we could allocate more funding to

SCHIP but there are some of us who believe that a return on investment for additional funding is sometimes not what we would

envision. We could have the Government take over the entire sys-
9

tem but the Government programs we already have in place face

some serious issues.

I would like to refer to a Washington Post article today that

quotes a dentist, Aldred Williams. He is the lead dentist at Small

Smiles, a district clinic that services Medicaid-qualified children

and young adults. His quote is, ‘‘There are so many barriers to

treating these kids covered by Medicaid including lower reimbursement rates and the bureaucracy. Private practices often end up

paying out of pocket to cover the full cost of care.’’ That is why the

penetration of private providers in this program are only at about

17 percent. Doctors don’t want to see Medicaid patients because

they don’t get paid fairly and we can’t seem to figure out how to

pay for all the services we would like to see, so forgive me if I am

skeptical that we will improve anything by expanding programs already plagued by irreconcilable systemic problems.

Instead, I believe we should actually address the underlying

problems, so I am very interested in the ADA’s report on improving

access to dental care. I would like to talk about improving Medicaid

reimbursement, streamlining the bureaucracy and improving

health literacy so that doctors and their patients can navigate the

health care system without needing an advanced degree in medical

administration or public health policy administration and so that

doctors have an incentive to treat indigent patients beyond just the

goodness of their hearts. I would like to hear more about the public-private partnership in Michigan and I would like to hear their

thoughts on what has made it successful. I would like to hear their

ideas for education and prevention so we can encourage Medicaid

patients to actually get the care the program covers.

As a physician, I have always tried to make decisions based on

what I would want for myself and for my family, and were I homeless and were my family homeless, I would want Medicaid and

SCHIP to work and work effectively and work properly but I also

wouldn’t want to be on it for the rest of my life. I would want the

safety net to function as a safety net instead of staying on a

minimalist Government program that always falls just short of

what was really intended. I would want the knowledge and education that allowed me to navigate the system and make my own

appropriate decisions for myself and my children and I would want

the power to determine my own fate and the power to change the

situation.

Mr. Chairman, you have been very kind in letting me go over but

that is what I would be interested in hearing our panel address

today, and I will yield back the balance of my time.

Mr. PALLONE. Thank you, Doctor.

I next recognize for an opening statement the gentlewoman from

California, Mrs. Capps.

OPENING STATEMENT OF HON. LOIS CAPPS, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA

Mrs. CAPPS. Thank you, Chairman Pallone, and welcome to your

children and good testimony to the topic at hand today.

I am very pleased that we are here to discuss the importance of

providing children with an early healthy start to their lives. For me

it is an issue I have dedicated my whole life to as a public health
10

nurse, a school nurse, for 20 years and now as a public servant,

and I waited a long time ever since being in Congress for this hearing today. We are going to have the opportunity to focus on two

areas of health care too often overlooked but so critically important

to ensuring the health of children.

Again, I will just mention the name Diamonte Driver, a tragic reminder of our duty to protect and preserve children’s health. Unfortunately, there are many Diamontes in classrooms today with abscesses in their teeth across this country. I think it is nothing short

of a miracle that more of them don’t end up with involving their

brain, a stark reminder of the consequences of failing to provide access to preventive health care so cost effective, so important in its

results including dental and mental health care. I have been advocating, as I said, for improved children’s dental health for years.

Children are already vulnerable as a group but children from lowincome households are particularly vulnerable. Every school in the

country today when a child comes with a swollen jaw and can’t eat,

can’t study, somebody in the school is going to scramble around trying to find some pro bono care, trying to find a provider, and that

is health care in our country today. These low-income children are

twice as likely to suffer from dental caries than children from higher income families because they are more likely to lack access to

dental health care.

In my district, there is a wonderful nonprofit organization that

provides a well-run mobile dental clinic to many of the migrant

families in my area. Ironically, it is a nonprofit organization designed to provide medical services to Third World countries. They

find lots of people to assist right in my backyard.

A few years ago I was honored, it has been mentioned already,

to introduce the Children’s Dental Health Preservation Act with

our late colleague, Charlie Norwood, a bill seeking to identify children at risk for developing cavities as well as to train health care

professionals, already been referred to, to educate patients on the

importance of preventive health care, dental care, and I think it

would be a fitting memorial to our colleague to name this legislation that I hope will result for him. And with SCHIP reauthorization covering the uninsured at the forefront of this committee, I am

hopeful we can finally make progress.

Of course, children’s mental health is equally as important.

Again, I have seen so many children lagging behind their peers because they are not afforded proper treatment or identification of behavior problems which are really mental health issues. Not only

are school nurses not equipped to provide comprehensive mental

health services, there is a dire shortage of school nurses to identify

and refer out and a dire shortage of places for young children to

get the kind of treatment that early in life is so effective in changing and responding to this situation.

I hope our witnesses today will help provide us the tools to formulate the kind of policies that will put in place the best models

of dental and mental health care for our children, and I yield back.

Mr. PALLONE. Thank you, Mrs. Capps.

I recognize Mr. Murphy of Pennsylvania.
11

OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

Mr. MURPHY. Thank you, Mr. Chairman, and thank you for your

leadership on making sure this issue is addressed by this committee and Congress.

We all know in the comments made so far we have talked about

how preventive dental care reduces disease and risk before symptoms appear, and I know even in my role as a psychologist, many

times kids that I would be seeing, young children we would note

as part of their medical concerns that many of them had dental

problems that needed to be addressed and so too it was that I

worked with families, helping them to search through the bureaucracy to find ways of getting that care. Luckily, there are clinics

around for children but many times families are not aware of this

and they put off the care and we can see just how bad this can get

on something we take for granted that can really lead to infections

and to terrible tragedies.

Of course, part of the problem is that many families don’t have

a medical home and there doesn’t seem to be enough available dentists as part of that. I would like to point out that one solution that

I have offered is legislation that would help us expand children’s

access to community health centers and free clinics, community

health centers in particular which are nonprofit community-supported health care providers who offer primary and preventive

health care services to low-income, underinsured and uninsured

families. There are a number of these in the country. Unfortunately, we need many more, but one of the problems is that there

is just a vast shortage of many medical providers at these clinics,

10 to 15 to 20 percent shortages of everyone from family physicians, OB/GYNs, pediatricians, et cetera.

Now, one of the things that I know in working with dentists too

is that many of them would love to have an opportunity even to

volunteer some time. One fellow said to me, if I am going to offer

pro bono work, I would like to do it at some other office or clinic

where I can do that and give a day or two a month to do that. Unfortunately, the way our bureaucracy is set up, that if someone

works at a community health center, they are covered under the

Federal Torts Claim Act. If they want to volunteer their time, they

are not, and so what they find themselves dealing with is high

medical malpractice insurance when all they wanted to do was give

some of their time and help children in their community. So I introduced H.R. 1626, which is the Family Health Care Accessibility

Act, which extends the Federal Tort Claims Act coverage to volunteer doctors and dentists who want to volunteer at community

health centers. I am hoping at some point this committee and subcommittee can take up those issues.

But what is being pointed out, and I look forward to hearing

some of the testimony today from the dental association, is just

what is this wall of bureaucracy. I hear legends of pages and pages

and pages that dentists have to fill out if they even want to work

with children, and it comes to the point that the time demands of

dealing with the bureaucracy is so much so that they see this as

a problem and that is why reading the article in Maryland, there
12

are only a few hundred dentists out of the thousands which are

available who actually work with Medicare.

I look forward to hearing this information today, and again,

thank you, Mr. Chairman, for your leadership on this.

Mr. PALLONE. Thank you.

I recognize Mr. Allen of Maine.

OPENING STATEMENT OF HON. TOM ALLEN, A

REPRESENTATIVE IN CONGRESS FROM THE STATE OF MAINE

Mr. ALLEN. Thank you, Mr. Chairman. Thank you for calling this

hearing today to examine the critical issue of improving access to

dental care and mental health services for America’s children.

Dental decay is the most common chronic childhood disease but

it is also the most preventable. We know that dental problems can

have a profound impact on children’s ability to learn and advance

in school. It can also hinder their ability to speak and eat. Left untreated, it can lead to chronic disease and even death.

I am pleased to support Chairman Dingell’s Children’s Health

First Act which would expand and significantly increase funding

for the SCHIP program. The lack of adequate access to dental care

is particularly acute among children from low-income families.

Therefore, the bill would require States to offer dental coverage

under SCHIP in virtually all cases. It would also require the benefit to mirror the Medicaid early periodic screening, diagnosis and

treatment benefit if a State designs its own SCHIP plan rather

than simply expanding Medicaid to cover SCHIP children. States

would be able to offer SCHIP dental coverage as a wraparound

benefit to children who meet the income requirements but who

have private medical coverage.

Medicaid patients often don’t receive timely dental care because

there are not enough dentists participating in the Medicaid program. In rural States like Maine, there is a severe shortage of oral

health professionals, particularly pediatric dentists. Maine has approximately 600 dentists but only 278 participate in the Medicaid

program. Of these dentists, only nine are pediatric dentists. We

need to strengthen the title VII health professions training programs including the pediatric dentistry program. That program

provides seed money for startup or expansion of pediatric dentistry

residency programs that focus on underserved populations. Investing in children’s oral health makes economic sense. For every dollar spent on preventive care, between $8 and $50 can be saved in

emergency treatment.

I want to commend the dentists, dental hygienists and other oral

health professionals who volunteer their services and give free care

to needy individuals, both children and adults. The ADA’s Give

Kids a Smile Day and innovative State-based public-private partnerships like No Cavities Maine, which reaches children and senior

citizens through the YMCA, go a long way to improve access to

dental services for low-income individuals. But as one dentist in

Maine told me recently, it is not just about 1 day of service or one

weekend of volunteering but a daily commitment to provide care

for the needy. I want to thank you all for your service.
13

I look forward to hearing from our distinguished panel on ways

we can improve children’s access to health care services, and with

that, Mr. Chairman, I yield back.

Mr. PALLONE. Thank you.

I recognize Mrs. Wilson of New Mexico.

OPENING STATEMENT OF HON. HEATHER WILSON, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW MEXICO

Mrs. WILSON. Thank you, Mr. Chairman. I appreciate your holding this hearing today.

In New Mexico, we have a very serious problem with access to

dental care for our population as a whole but particular this is a

significant problem with children, and particularly those who are

low-income and uninsured in rural areas in Indian country, and it

is something we have to address. It is something that I saw as a

State official responsible for foster children. Sixty-four percent of

third graders in New Mexico have tooth decay and 34 percent have

untreated tooth decay. So in a classroom of 30 kids, 10 of them are

having problems with their teeth. New Mexico ranks 49th among

the States in dentists per capita and we have a similar shortage

of dental hygienists. Part of our problem is that 21 percent of our

population is eligible for Medicaid. Part of it is that we are a very

rural State and it has been difficult to attract dentists to New Mexico. We also in the entire State of New Mexico, the fifth largest by

land area State in the country, we do not have a school of dentistry, so New Mexicans who want to become dentists go out of

State and oftentimes we never see them come back.

This problem is something I think we need to address systemically, and unfortunately, our State government is not particularly

interested in addressing this problem. In the Department of

Health, they don’t even have a dentist who is focused on oral

health.

I appreciate your having this hearing today so that we can look

at innovative ways and look at the problem in its entirety of scope.

It doesn’t matter if you have insurance or it is included under Medicaid if you can’t find a dentist or if the dentist you can find won’t

take Medicaid because the bureaucracy and the paperwork is such

a terrible nightmare. We need to address these problems so that

kids get access to care no matter where they live.

Thank you, Mr. Chairman.

Mr. PALLONE. Thank you.

I recognize next Ms. Solis of California.

OPENING STATEMENT OF HON. HILDA L. SOLIS, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA

Ms. SOLIS. Thank you, Mr. Chairman, and I want to also applaud

you for having this very important hearing this morning.

Oral health is closely linked to overall physical health and I believe oral health has to be a big priority for us both at the local

level, the State level and the Federal level and that is why I am

glad we are having the hearing today.
14

The California Oral Health Needs Assessment revealed that

three out of every 10 Californian third graders had untreated tooth

decay. These numbers are particularly troublesome for children in

minority and underrepresented communities. Latinos along with

African-Americans and Native Americans have the poorest dental

health of any racial group in the United States, and in California,

the State that I represent, Latino kindergarteners were 2.4 times

more likely to have untreated tooth decay than white children.

Their oral health dramatically affects their ability to lead active

lives. For example, Latino children are more likely to miss school

due to oral health problems, and we are all aware of the problems

associated with the lack of medical insurance yet the situation for

dental coverage is equally important. For every child who lacks

health insurance, approximately three children lack dental health

care. In California, 25 percent of our children lack dental insurance, which decreases the likelihood that they will receive regular

checkups and treatment. Low reimbursement rates add to the problem for programs like Denti-Cal, the California dental Medicaid

program, and the lack of providers willing to take on Medicaid patients also poses a major obstacle to accessing dental care, and

more and more families are unable to afford health insurance.

Many of our children do not receive the proper health and dental

care they deserve, and I hope that through SCHIP and Medicaid

we will address the critical need for dental services and improve

dental coverage overall. We must work closely with our schools and

with our public health clinics to expand care so that our families

are all served.

In my district in California, the 32d, I worked very hard to partner with L.A. Unified in one of our middle schools to provide a dental clinic there to help provide wraparound services, mental health

services and daily checkups, not just for the students attending the

school but the outlying community that could also benefit from that

help. I am also proud to say that one of our local clinics that was

just reopened in the city of Azusa in L.A. County is now beginning

to look at offering dental services for residents in Azusa who are

primarily Latino, about 70 to 80 percent, and have incomes below

$30,000.

So I am pleased that we are having this discussion and debate

and I also want to mention that the Congressional Hispanic Caucus, as task force chair during the past few years we were able to

work closely with Univision, one of the major Spanish language

networks, to create public awareness programs in Spanish to provide briefings and better understanding about dental care and we

did it in conjunction with the dental association. So I want to

thank them for that. I look forward to your testimony today and

look forward to seeing the expansion of dental care services for our

children.

Thank you. I yield back the balance.

Mr. PALLONE. Thank you.

I now recognize Ms. Hooley of Oregon.

OPENING STATEMENT OF HON. DARLENE HOOLEY, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF OREGON

Ms. HOOLEY. Thank you, Mr. Chairman.
15

Like my colleagues, I was shocked and deeply saddened to hear

about the death of 12-year-old Diamonte Driver. The death of a

child is always a terrible event. However, Diamonte’s passing is

particularly distressing because we know that his death could easily have been prevented with low-cost dental care. Most Americans

including myself were shocked that a child could die in the United

States for want of such a basic dental service.

While we should shine a light on the heart wrenching tragedy of

Diamonte’s death, it is also important to remember that poor oral

health has other consequences that are less severe but still detrimental to a child’s well-being. As a former schoolteacher, I can attest to the fact that a child’s toothache can have a very disruptive

effect on the learning process. Not only is the child in pain, unable

to learn, but a child in pain is often a disruptive force that hampers the ability of other children to focus and participate in class.

That challenge to effective learning is unfortunately only part of

the overall harm. In addition, more than 850,000 school days each

year are missed by students because of dental-related illness. A

child who is not in class obviously cannot learn. At a time when

there is a strong emphasis on student achievement, I hope we can

take an expansive view of what impacts learning. I think oral

health is one of those factors that should get a lot more attention.

The mental health problems of children often similarly do not receive the focus that they warrant. Again from my years as a teacher, I know that there is nothing more frustrating than seeing a

child struggle who could flourish if he or she received appropriate

mental health services. I look forward to discussing access issues

resulting from the lack of mental health providers or too few participating providers.

Mr. Chairman, again I thank you for holding this hearing on

these very important but often unappreciated issues. Thank you.

I yield back.

Mr. PALLONE. Thank you.

The gentleman from Utah, Mr. Matheson.

OPENING STATEMENT OF HON. JIM MATHESON, A

REPRESENTATIVE IN CONGRESS FROM THE STATE OF UTAH

Mr. MATHESON. Thank you, Mr. Chairman. Thank you for holding this hearing today. It is an issue that is very important to our

national health care debate. Although I am saddened by the events

that have brought us together, I feel we have an opportunity to

honor the memories of these two boys by examining how our Nation’s uninsured children are accessing dental care.

In my State, children without dental insurance receive most of

their services in safety-net clinics such as community health centers, donated dental services and primary children’s medical centers. We have a program called the Utah Oral Health Program and

it has completed an oral health survey of 6- to 8-year-old children

in the fall of 2005. Of those surveyed, 25 percent indicated they

had no dental insurance, 20 percent indicated they had not seen a

dentist in the past year, and 10 percent indicated they needed dental care in the past year but could not get it. Of those surveyed,

21 percent had obvious dental decay. These are troubling statistics

and ones that we are working hard to address.
16

In an effort to educate Utahans on the importance and far-reaching impact of preventive dental care for children, we have been

proactively promoting preventive oral health care throughout the

State in a number of ways. For example, the statewide campaign

by the Utah Dental Association emphasized the importance of the

early diagnosis of oral cancer. The Baby Your Baby campaign includes information on the relationship between periodontal disease

and low birth weight pre-term births. In addition to the oral health

program, the Utah Dental Association and the Utah Dental Hygienists Association have completed several activities throughout

the State to promote the first dental visit for children by age 1 or

within 6 months of the first tooth erupting. Outreach to Utahans

has included visits to local dental societies, presentations to local

health departments, presentations to conferences, newsletter articles and brochures. That is a quick list of the outreach we try to

do in our State.

I mentioned to this committee before that my wife is a pediatric

infectious disease doctor at the Primary Children’s Medical Center

in Salt Lake. I have heard very much around the dinner table stories about the importance of preventive care in terms of oral

health. Access to care is such a critical issue for our country. I look

forward to hearing the suggestions of the committee and the witnesses on identifying responsible ways to improve access to dental

care for our kids.

Mr. Chairman, I will yield back.

Mr. PALLONE. Thank you.

Next is the gentleman from New York, Mr. Towns.

OPENING STATEMENT OF HON. EDOLPHUS TOWNS, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW

YORK

Mr. TOWNS. Thank you very much, Mr. Chairman, for holding

this hearing. I think this is a very important hearing.

Eighty percent of all tooth decay is found in 25 percent of children. Despite the magnitude of need, dental coverage remains an

optional benefit in SCHIP. All States have recognized that poor

oral health affects children’s general health and have opted to

make dental coverage an option. However, dental coverage is often

the first benefit cut when States seek budgetary savings. I believe

that Congress must stabilize access to dental care for children by

establishing a Federal guarantee for dental coverage in SCHIP.

In addition, the National Dental Association and the National

Dental Hygienists Association, which represents African-American

dentists and dental hygienists, believe we must substantially increase the number of minorities entering the field of dentistry and

other allied oral health fields if we are to turn around the tragedy

related to underserved communities and oral health.

It is also time we stopped punishing parents with moderate incomes whose children receive medical, but not dental, benefits

through employer-sponsored health plans. Many of these parents

and their children cannot afford dental coverage. We need to develop a dental wraparound benefit in SCHIP that allows these parents to purchase dental insurance if they meet other eligibility

standards. It is time we commit ourselves to quality dental care for
17

all because it is less expensive to prevent advanced oral problems

than to deal with them in an emergency room. I think Dr.

Ellerman is right when she said that we must now begin to think

of our children. They are 25 percent of the population but 100 percent of our future. I am sure that our witnesses this morning will

be able to shed some light on the issue of dental care under SCHIP

and that we will be able to do a much better job on behalf of our

children.

On that note, Mr. Chairman, I yield back.

Mr. PALLONE. Thank you.

And our other gentleman from New York, Mr. Engel.

Mr. ENGEL. Thank you, Mr. Chairman. When you said the gentleman from New York for Mr. Towns, I started to push my button.

Mr. TOWNS. It would have been OK.

OPENING STATEMENT OF HON. ELIOT L. ENGEL, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW

YORK

Mr. ENGEL. But I agree with everything Mr. Towns said, and I

want to thank you for holding this hearing. It shouldn’t take a

tragedy to call attention to the need for comprehensive accessible

health care but that certainly is what the senseless death of

Diamonte Driver has done this month, a 12-year-old who died of

a brain infection initially caused by an infected tooth and had been

covered by Medicaid, which would have covered his health problems. A series of events led to the loss of his coverage though,

which certainly highlights the need for presumptive eligibility. A

simple dental procedure that could have cost $80 to cover went untreated and manifested in a serious brain injury requiring nearly

a quarter of a million dollars in care which ultimately could not

save this child.

Considering that dental care is the most prevalent unmet health

need among American children, and that is a quote according to

the U.S. Surgeon General, it simply makes sense to shore up our

public programs that provide dental care to low-income children.

While the Medicaid program provides comprehensive coverage for

children’s dental care through the Early Periodic Screening Detection and Treatment benefit, access to care is hampered by low Medicaid reimbursement rates. States that can compensate dental care

providers with rates closer to market-based fees have been able to

enroll more providers in the Medicaid program and in turn successfully treat more children. The SCHIP program by contrast does not

even require that children be entitled to dental care. While all

States have elected to provide some coverage, the benefits and access to treatment varies widely from State to State. As we move

to authorize the SCHIP program, I believe we should modernize it

to establish a Federal guarantee for dental coverage. We should

also strongly consider developing a dental wraparound benefit in

SCHIP to support families with low to moderate incomes covered

in the private market who do not receive dental coverage for their

children.

Mr. Chairman, while all the witnesses on the two panels are impressive, I would like to extend a warm welcome to Dr. Edelstein

of the Children’s Dental Health Project and Columbia University in
18

New York City, where I am from. The Columbia University teaching clinic offers outstanding primary and specialty oral health care

at reduced cost to patients. At the onsite dental clinic, general oral

health and specialty practitioners handle more than 80,000 patient

visits each year. It is a great service to the community and I commend Columbia for this work.

Mr. Chairman, there is no question that well-child care should

include comprehensive dental care. I am pleased that you have convened this hearing to discuss these important issues and look forward to the witnesses’ testimony today, and I yield back the balance of my time.

Mr. PALLONE. Thank you.

That concludes the opening statements by members of the subcommittee, and I would ask unanimous consent any other statements be included in the record at this time.

[The prepared statements follow:]

PREPARED STATEMENT OF HON. JOHN D. DINGELL, A REPRESENTATIVE IN CONGRESS

FROM THE STATE OF MICHIGAN

Today’s hearing will focus on providing a healthy start for children. It is common

sense that keeping children healthy and treating illness early is a wise investment.

Children who are healthy do better in school. They are at lower risk for developmental problems. And their future healthcare costs are likely to be less.

Medicaid and the State Children’s Health Insurance Program (S-CHIP) provide

the health insurance and a healthy start for nearly a quarter of U.S. children. These

two programs are primarily responsible for preventing these children from joining

the increasing number of those who are uninsured. Our Nation has made good

progress in getting children immunized against disease, but progress has been slower on dental care and mental health care. Clearly more needs to be done.

Medicaid’s coverage of dental and mental health benefits is exemplary. And many

States meet Medicaid’s standard of coverage under SCHIP, as well. But many do

not. And that means many children still have unmet needs in these two areas.

Dental disease is the most common childhood disease—more prevalent than asthma and diabetes. It is also the most easily prevented. Proper care, however, must

start in infancy, including oral checkups, preventive care, sealants, fluoride, and at

home oral care.

If left untreated, however, dental disease can be deadly. Sadly, the Nation learned

this recently from the much-publicized case of a 12-year-old child from Maryland

named Deamonte Driver. In Mississippi, there was recently an equally tragic and

equally preventable death that would have been prevented if action had been taken

sooner. Six-year-old Alexander Callendar died due to untreated dental disease.

The need for action exists on several levels. The Congress has a role to play in

ensuring States have sufficient resources in Medicaid and SCHIP to address the

unmet dental need among children. The Federal Government needs take steps to

prevent future tragedies from occurring. We need to play a role in training and education of dentists. And we have a role to play in ensuring access in all communities.

I will soon introduce a bipartisan bill that will move us forward toward addressing many of these issues. I hope that my colleagues on the committee will join me

in cosponsoring this legislation. It should be a national priority.

Likewise, children’s mental health care is also a significant challenge for families,

especially the uninsured or under-insured. Private insurance coverage is limited or

inadequate for those with the greatest need. Under Medicaid and SCHIP we need

to do more to make community-based mental health care an option. There are more

than 12,000 children across the country who are on waiting lists because existing

programs lack space. In addition, the Centers for Medicare and Medicaid Services

(CMS) has recently initiated efforts that would restrict or even eliminate States’

ability to manage the care of children with the most severe mental illnesses. We

need to be assisting children and States in this area, not further restricting access

for children to receive needed care. CMS’s actions are unacceptable and this is

something we will explore in the near future.

I thank Chairman Pallone for this hearing. It is timely. It is necessary. I look forward to working with my colleagues on these important health priorities.
19

PREPARED STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN CONGRESS

FROM THE STATE OF CALIFORNIA

Thank you, Mr. Chairman, for holding this hearing on the role of early health

care interventions to ensure that children have a chance for a healthy start in life.

Two health care benefits most often overlooked are dental and mental health care.

Tooth decay is the most common childhood disease, affecting five times more children than asthma, and seven times more children than hay fever. In February and

March of 2007, untreated dental problems caused the deaths of two children in Mississippi and Maryland. Had these children had access to preventive dental care,

they would be alive today.

Mental health care is also an important benefit for children. The Urban Institute

estimates that at least one-tenth of children suffer from a serious mental health

problem that causes impairment. Poor children have more mental health problems

than other children, yet they have fewer options for mental health screening and

care.

Programs like Medicaid and the State Children’s Health Insurance Program

(SCHIP) play an important role in providing preventive health services to low-income children. Medicaid is widely considered the largest provider of funds for mental health services for children and it also provides comprehensive coverage for children’s dental care needs. However, due to differences in how States operate their

SCHIP programs, access to mental health and dental care benefits vary geographically.

Childhood is the most important time in a person’s life for preventive screening

and treatment of mental and physical ailments. We must assure that children and

their families have access to resources and services that promote positive early

health and development.

I urge my colleagues on this subcommittee and in Congress to ensure that children have access to important, preventive health care which includes comprehensive

dental and mental health benefits. We can do this by including these benefits in our

reauthorization of the State Children’s Health Insurance Program later this year.

Thank you, Mr. Chairman, and I look forward to hearing the testimony of our expert witnesses.

Mr. PALLONE. I will now turn to our witnesses, and our first

panel is already there. I want to welcome you again. Let me introduce each of you, starting from my left to right. First we have Dr.

Burton Edelstein, who is founding director of the Children’s Dental

Health Project. Second, we have Dr. Kathleen Roth, who is president of the American Dental Association. And then we have Mr.

Raymond Scheppach, who is the executive director of the National

Governors Association, and then we have Christine Farrell, who is

the Medicaid policy specialist with the Michigan Department of

Community Health, Medical Services Administration. And next is

Dr. Nicholas Mosca, who is clinical professor of pediatric and public

health dentistry at the University of Mississippi School of Dentistry, and last is Dr. Stephen Corbin, who is senior vice president

of Constituent services and support for the Special Olympics International.

Thank you again for being here. We are going to have 5-minute

opening statements from each of you. Those statements will be

made part of the hearing record and each witness may in the discretion of the committee submit additional briefs and pertinent

statements in writing for inclusion in the record. And I will start,

again from my left, and recognize Dr. Edelstein for an opening

statement.

STATEMENT OF BURTON L. EDELSTEIN, D.D.S., M.P.H., FOUNDING DIRECTOR, CHILDREN’S DENTAL HEALTH PROJECT

Dr. EDELSTEIN. Thank you, Mr. Pallone.
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My name is Burton Edelstein. I am a pediatric dentist who has

been involved with dental coverage for poor and low-income children as a student, clinician, educator, researcher and policy analyst

for 37 years, nearly as long as the Medicaid EPSDT benefit that

so many of you mentioned. I speak to you today as founding director of Children’s Dental Health Project, a DC-based nonprofit policy

organization committed to improving children’s oral health in

America. My testimony has also been endorsed by my professional

association, the American Academy of Pediatric Dentistry.

The committee has shown a strong command of the issue and

has so well described the problem. I seek today to pull much of

what you said together and make some recommendations for solutions. I thank the committee for addressing children’s oral health,

an issue highlighted tragically by the death of Diamonte Driver

that has been noted. I dedicated my testimony today to him but

also to the hundreds of thousands of other children who suffer significantly and unnecessarily from completely preventable dental

problems.

My testimony is grounded in three straightforward facts. First,

that tooth decay is virtually preventable, almost completely preventable, yet ironically, as you note, it remains the single-most

common chronic disease of childhood in the United States and is

present in one-quarter of all 2- to 5-year-olds. Second, dental care

is essential to overall health, yet for reasons that make neither biologic sense nor policy sense, dental care has been legislated as an

optional service as though the mouth were not integral to the body.

Third, preventive care is cost-effective yet far few children obtain

the kinds of routine care that would prevent pain, infection, sleepless nights, missed meals and poor school performance that you

have noted.

Medicaid itself, as envisioned by Congress, is tremendously valuable. It is appropriately designed and it is fully accountable. In the

handful of States that have taken their dental Medicaid programs

seriously and reformed them well, Medicaid has been shown to

work for dentists, for children, for families, and the number of dentists participating has increased dramatically, twofold, threefold,

fourfold. These States have been creative and they have taken advantage of flexibility that already exists in the program. But in too

many States, there has not been attention to the opportunities in

Medicaid and the programs have been allowed to fail, fail children

and fail the providers who care for them. Congress can play a

stronger role in assuring that Medicaid works for all children

across the country by helping States, by enhancing your oversight,

by providing grants to support State program improvements, by offering technical assistance, by promoting best practices and by

holding States accountable for the performance that is already required by Medicaid law.

SCHIP is a different story. It is now 10 years old and due up for

reauthorization, which provides a terrific opportunity for Congress

to do many of those things that you spoke of. With the three recommendations that I make now, I am speaking for 12 national dental membership organizations including all of those present at this

table as well as organizations of pediatric and general dentists,

Hispanic and black dentists, dental hygienists, dental researchers,
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State dental officers and dental students. Together we ask you to

do three things with SCHIP.

Firstly, put the mouth back into well-child care. Recognize with

us that the mouth is integral to the body and that dental care cannot be considered an optional service, and because States are already significantly involved in providing dental care, this can occur

at very little cost. Second, allow States to offer that wraparound

dental coverage that some of you have mentioned. This will

incentivize poor and working-class families to retain their private

medical coverage and not drop it so that they obtain their medical

and dental coverage together through SCHIP. And third, require

States to report on their dental program performance in SCHIP.

After 10 years, we know almost nothing about the performance of

SCHIP for dental coverage while we know a great deal in Medicaid.

Similar reporting in SCHIP would help you and help children gain

the benefit that they already have available to them.

With these few Medicaid and SCHIP fixes, the benefit of cost-effective prevention can bring savings to Government and better

health to children. This is unusual, to be able to have both better

health and cost savings at the same time. For example, Diamonte

could have received preventive care for 12 years. He could have

had a sealant. He could have had a filling. He could have had a

root canal. He could have had a number of dental treatments, no

one of which would have cost more than one one-thousandth of

what his hospital stay cost.

The problem of childhood tooth decay is also global. The U.S. has

recently joined with other nations representing half of the world’s

population to eliminate childhood dental caries. Unlike most of the

partner nations, the U.S. has no Federal entity that coordinates

and integrates the various programs across its agencies. We in the

U.S. would benefit greatly if Congress were to charge the Department of Health and Human Services to develop an interagency

taskforce on children’s oral health with strong leadership and

strong Congressional support. In this way, the U.S. could set the

international standard for children’s oral health.

On behalf of America’s children, I urge you and the committee

to continue attending to pediatric oral health, to continue beyond

this hearing, to maximize opportunities for cost-effective prevention, to ensure that dental care is never again considered an optional service as though it didn’t matter, and to integrate oral

health into each and every Federal program that addresses children’s health and well-being. Diamonte is sadly only one example

of what happens when we fail as a nation to sustain attention to

children’s oral health. The problem with childhood oral health is

fixable and fixable at low cost. Let us work together to enhance

Medicaid and SCHIP, to do more to educate the public, to improve

training of dental professionals and to care for young children for

the benefit of prevention for all.

Thank you so much.

[The prepared statement of Dr. Edelstein follows:]

TESTIMONY OF BURTON L. EDELSTEIN, D.D.S.

Good morning. My name is Burton Edelstein. I am a pediatric dentist who first

cared for a child with Medicaid coverage 37 years ago—just 3 years after Congress
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mandated dental services for children in Medicaid. Since that time I have been actively engaged in Medicaid and SCHIP as a private practice clinician in Connecticut,

as a dental educator now at Columbia University, and as founder of the Children’s

Dental Health Project—a DC-based independent policy organization committed to

improving children’s oral health in America.

I have learned about publicly financed dental coverage from my patients and their

families, from students and colleagues, and from working with Congress and the Department of Health and Human Services. I have also observed much from the

public’s response to the tragic and completely avoidable death of Deamonte Driver,

the Maryland 12 year old who died just up North Capitol Street from here at National Children’s Medical Center from complications of a dental infection. Sadly,

Deamonte represents the worst case scenario of multiple systems failures. I dedicate

my testimony to him and to the hundreds of thousands of other children who suffer

significantly and unnecessarily from preventable dental problems.

My testimony today reflects the totality of this experience. It is based on three

facts:

• first, that tooth decay is overwhelmingly preventable;

• second, that dental care is essential to children’s overall health and wellbeing;

and• third, that dental care is cost effective.

All three qualities have strong implications for the committee’s oversight of Medicaid and the State Child Health Insurance Program.

Regarding Medicaid: Medicaid dental coverage for children as envisioned by Congress is tremendously valuable, appropriately designed, and fully accountable. The

handful of States that have implemented Medicaid dental coverage well have demonstrated that this program works for children, their families, and their caregivers.

But in the majority of States, Medicaid dental coverage is little more than an

unfulfilled promise—adequate coverage but inadequate services. Congress has many

options to further strengthen dental Medicaid performance across the Nation

through improved oversight; incentives and sanctions, Federal grants to States for

program improvements, and beneficiary empowerment by granting legal standing to

beneficiaries when the program fails them.

Regarding SCHIP: In the aftermath of Deamonte’s death which so clearly demonstrated that the teeth and mouth are an integral part of the body, dental coverage

can no longer be considered an ‘‘optional service’’ in SCHIP. Just as the mouth is

integral to the body, so too must dental care be legislated as an integral component

of well baby and well child care. With SCHIP reauthorization now underway, Congress can take steps to stabilize and improve dental coverage in SCHIP by requiring

that it provides both dental preventive and dental treatment services. Congress can

enact ‘‘wrap around’’ dental coverage in SCHIP for those children from working-poor

families who have medical but no dental coverage and it can require dental performance information from States so that they are accountable to both the Federal Government and to the children.

The fact that dental care is prevention oriented, essential to children’s health, and

cost effective also makes it a very favorable healthcare service from a public insurance perspective. A small upfront investment in comprehensive dental care for all

children would pay considerable dividends in both health outcome and dollars saved.

But effective preventive dental care requires that children receive care early and periodically in a dental home—an identified source of ongoing care that provides complete oversight and care coordination for each child. For example, if Deamonte Driver had had a dental home starting with the recommended age-one dental visit, his

disease may well have been prevented through health education and counseling, fluoride treatments, and placement of dental sealants. Had this level of treatment been

insufficient and he still developed cavities, they would have been found early and

treated at low cost. Rather than a quarter million dollar bill to Maryland Medicaid

for neurosurgery, he could have been treated with a sealant, a filling, or, if necessary, an extraction—any one of which would cost the State less than $150.

Dental disease matters: Ordinary tooth decay needs no longer be the single most

common chronic disease of childhood in America. As a nation, we can reach our elusive Healthy People 2010 goals for children’s oral health and can reverse the recent

upswing in tooth decay reported by CDC for our youngest children. CDC reported

in August 2005 that more than a quarter (28 percent) of 2–5 year olds already have

cavities in their baby teeth and half (49 percent) of children ages 6–11 have cavities

in their adult teeth. Toothaches that distract from eating, sleeping, and attending

to schoolwork are completely preventable and—when they do occur—are completely

treatable at low cost. Dental abscesses that lead to swollen faces like that shown

in the photograph before you, and even to head and neck infections that can proceed
23

1 Pettinato ES, Webb MD, Seale NS. A comparison of Medicaid reimbursement for non definitive pediatric dental treatment in the emergency room versus periodic preventive care. Pediatric

Dentistry, 2000

to cause significant morbidity and occasional mortality are similarly avoidable—and

when they occur—treatable at low cost. Yet many children insured through Medicaid seek relief of toothaches in the emergency rooms of our community hospitals because of difficulty accessing dental care in private and safety-net offices. One Texas

study reported that the cost to Medicaid is three times greater for emergency room

care—care that doesn’t solve the underlying dental problem—than the total cost of

preventive care would have been to assure oral health in the first place 1

Dental coverage matters. Federal data confirm that children with dental coverage,

whether in Medicaid, SCHIP, or employer-based insurance, obtain more dental care

than similarly situated children without coverage. Yet Medicaid and SCHIP have

not realized their full potential in most States as far fewer children in these programs are able to access care than children in commercial coverage. According to

the most recently available CMS data on Medicaid program performance, only 30

percent of children enrolled in Medicaid at any time during the year had at least

one dental visit and only 25 percent had at least one preventive dental visit—less

than half the rate of services obtained by commercially insured children. State-byState performance varies greatly—ranging as low as 13 percent in one State to as

high as 47 percent in another. We know far less about SCHIP effectiveness because

Congress has not to date required systematic dental performance reporting in

SCHIP.

Effective Medicaid and SCHIP dental coverage matters. According to a HRSA report, young children in poor and working poor families (<200 percent FPL) eligible

for Medicaid and SCHIP are five times more likely to have cavities than children

in higher income families (>300 percent FPL). They have three times more teeth decayed and are twice as likely to seek a dental visit for pain relief—but are only half

as likely to obtain a dental visit in a year. These disparities can be well addressed

by effective SCHIP and Medicaid administration in the States and by working collaboratively with families, dentists, and government to ensure that the program

meets diverse needs and constraints.

Prevention matters: CDC promotes prevention programs including community

water fluoridation that continues to effectively dampen decay experience in America

and sealant programs that protect permanent teeth that are most susceptible to

decay—like the tooth that ultimately led to Deamonte’s demise. The Maternal and

Child Health Bureau’s focus on the oral health of young children in Head Start and

on children with special health care needs promotes early and timely prevention.

NIH-sponsored research over the past 40 years has well established that tooth decay

is an infectious disease that is typically transmitted from mothers to children during

a child’s first years of life. This and other scientific knowledge about the nature of

the disease provide a number of options for ‘‘providing a healthy start’’ for all children through universal acceptance of the age-one dental visit, parent and provider

education, and regular dental care in a dental home. Lacking only in these Federal

programs is sufficient support, coordination, and dissemination of best practices to

realize tremendous financial and health returns for our children.

Global perspective: Childhood tooth decay is a global problem. Pediatric oral

health activists in the US from inside and outside of Federal Government have recently engaged in a global campaign to reduce childhood tooth decay through both

prevention and treatment approaches. With sufficient ongoing Congressional attention to dental care for our children—particularly for those who are eligible for Medicaid and SCHIP—the US can set the standard of good oral health for children and

can become the international leader among the 11 participating nations that represent half of the world’s child population.

On behalf of America’s children, I urge you and your committee to continue attending to pediatric oral health, to maximize opportunities for cost-effective cavity

prevention, to ensure that dental care is never again considered optional in SCHIP,

and to integrate oral health into each and every Federal program that addresses

the health and welfare of our Nation’s children. You have before you many policy

options and opportunities for ‘‘improving access to dental care and providing a

healthy start for children.’’ My colleagues and I look forward to your questions today

and to providing ongoing assistance in your efforts to ensure ‘‘bright futures’’ for all

children.

Thank you.

Mr. PALLONE. Thank you, Doctor.
24

I am going to ask Dr. Roth to speak next. I know that it is hard

to keep to the 5 minutes, but if you can, I would appreciate it because we do have a lot of people. Thank you.

STATEMENT OF KATHLEEN ROTH, D.D.S., PRESIDENT,

AMERICAN DENTAL ASSOCIATION

Dr. ROTH. Yes. Good morning, Mr. Chairman and members of the

subcommittee. I am Kathleen Roth from Wisconsin, a practicing

dentist and currently the president of the American Dental Association. I have participated in Medicaid and SCHIP. I have firsthand knowledge of providing care to those underserved children so

severely in need of dental care and I understand the havoc that no

care can really cause in a child’s mouth.

Like all of us, I was very shocked at the death of 12-year-old

Diamonte Driver, who lived just a short distance from here. I believe that we have an obligation to honor this child and his family

by saying no more: no more children unable to eat and sleep properly, no more needless deaths, no more unable to pay attention in

school and no more unable to smile because of severe dental disease that could so easily be prevented and treated. If we do not resolve to reform the system now, we are ignoring the warning that

this tragedy is sending us and the Nation’s children will continue

to suffer the consequences. It is not just the poor that are affected.

As you will hear from Dr. Corbin in his descriptions, mentally disabled children and adults also face severe barriers to receiving oral

health care.

I have provided care to the underserved in my community for

many years. Every dentist I know provides some free or discounted

care to people who need it and otherwise would not be able to get

it. We do this both individually and collaboratively. One study published in the mid–1990’s estimated that dentists deliver $1.6 billion

in free or discount care in a single year, but the sad fact is that

all of our volunteerism and charitable efforts are not enough and

they never will be enough because charity is not a healthcare system.

Wisconsin is an all-too-typical example of how the so-called safety net is anything but. The Badger Care reimbursement schedule

is so meager that in most cases it does not even cover dentist overhead. The paperwork is onerous and confusing. The entire process

is actually so frustrating that it discourages dentists from participating in the program at all.

It is critical that we build a preventive infrastructure that ultimately will be the only way that we will end what the former surgeon general, David Satcher, famously titled the silent epidemic.

To that end, every child should see a dentist within 6 months of

the appearance of that first tooth and certainly no later than the

first birthday. We need more community-based initiatives such as

water fluoridation and the broader availability of dental sealants

and topical fluorides.

We must embrace innovations in the dental workforce. The ADA

has modeled a new type of an allied dental provider, the community dental health coordinator, which will greatly enhance the productivity of a dental team by extending our reach into underserved

communities. The CDHC model is unique in that it combines the
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provision of preventive services along with triage, case management and referral to qualified dentists when care is needed.

Ninety percent of the Nation’s dentists are in private practice.

We need to make it possible for more of them, many more of them,

to participate in Medicaid. Several States have refined their Medicaid programs to do that. You will hear about Michigan’s program

in a moment. Tennessee has reformed TennCare, and Smile Alabama is an excellent example. In some cases programs have succeeded in enrolling Medicaid beneficiaries into existing and very

well-designed private sector dental plans. Congress can do a great

deal to encourage and make it possible for more States and communities to take similar measures through grants and other means.

Chairman Dingell has been a leader in this area and working with

Congressman Mike Simpson, who is also a dentist, as well as many

of you members on this committee who are sponsoring the Children’s Dental Health Improvement Act.

Mr. Chairman, the most vulnerable amongst us, especially the

children, deserve much better, better than the fate that befell

Diamonte Driver, and better than the untold numbers of children,

someone within a few blocks of where we are today, who are suffering from untreated dental disease. Dentists can do more but only

if the State and Federal Governments will give us the support that

we need to do that. We call upon our many friends here in Congress to work with us to ensure that every American child can face

his or her future with a smile.

Thank you.

[The prepared statement of Dr. Roth follows:]
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Mr. PALLONE. Thank you, Dr. Roth.

And next we have Mr. Raymond Scheppach.

STATEMENT OF RAYMOND C. SCHEPPACH, EXECUTIVE

DIRECTOR, NATIONAL GOVERNORS ASSOCIATION

Mr. SCHEPPACH. Thank you, Mr. Chairman. I appreciate the opportunity to appear before you on behalf of the Nation’s Governors.

I would essentially like to focus on three major issues. First,

what States are currently doing to extend dental health benefits to

children; second, how any particular benefit in SCHIP or Medicaid

relate to new State reform initiatives; and three, I think it is important to be aware of State Medicaid spending and how it is related to other priorities like education.

Since the enactment of the State Children’s Health Care Program in 1997, there has been a substantial expansion of dental

services. While this is an optional benefit, all States have provided

some dental benefits. Currently the enhanced match and increased

flexibility to tailor benefits has contributed to the overall success

of this program.

SCHIP and Medicaid dental benefits are important, but having

benefits does not necessarily mean that individuals receive services. This is particularly true, given the shortage of dentists in

many areas, and more importantly, the more acute shortage of pediatric dentists, especially those trained to provide services to children with special health care needs. Therefore, States have taken

a more holistic approach to this problem. First, they have been

doing a fair amount in terms of promoting education and prevention, in terms of PSAs, public awareness, working with communities on fluoridation. They have also tended to increase coverage

and access at times working with States like Michigan and with

network providers. They have also focused to some extent on enhancing the dental workforce, trying to provide special incentives

for underserved areas, also providing tax credits, loan forgiveness

for the education of dentists and improving finance through increasing reimbursements. Investments in children’s health are extremely important but Governors are also well aware of the need

to look holistically at making investments in children’s futures.

This is especially true in the area of early childhood development.

I would like to turn now and summarize very quickly, Mr. Chairman, some of the things that are happening at the State level in

terms of health care reform. In 2003, the State of Maine enacted

a comprehensive proposal with the goal of universal coverage by

2009. This was quickly followed by Vermont and Massachusetts,

who enacted plans in 2006 with the ambitious goals to cover all of

the insured. There are now about four States who have committed

to universal coverage while another 10 are developing proposals for

universal access. Several others are focused on universal care for

children and many others are pursuing more incremental reforms.

There is a number of common elements in all of these reforms.

They obviously include coverage expansions. They include connectors, essentially trying to bring together providers with low-income

individuals to provide the best appropriate benefits and allowing

choice and portability. They have worked on the so-called tax incentives, making sure everybody is aware of section 125. States are
41

experimenting with both employer mandates in terms of where is

the cutoff in terms of small business. They are experimenting with

individual mandates also with quality improvements and measurements. They are also negotiating with providers to increase a number of affordable benefit packages.

Mr. Chairman, I think we are at the point now where it is very

possible over the next 2 to 3 years that we may witness as many

as eight or ten States who have actually enacted and begun to implement universal care or universal access, and I think as you

move forward on the reauthorization of SCHIP and other programs, you have got to question how that fits in with essentially

what is happening at the State level.

I would just a raise a couple of potential cautions as you move

forward with respect to any mandates on SCHIP or Medicaid.

First, it would require States to spend more money per person on

these programs which redirects funds from eligible expansions. I

think if we continue to have 47 million uninsured, it is a real public policy question of whether we create a more robust benefit package for some or whether we try to get a basic benefit package for

a wider population.

Second of all, it could limit State efforts to create affordable consolidated insurance markets. Most States’ coverage efforts include

negotiations with providers to develop basic benefit packages that

would be subsidized for States and offered through a connector. Essentially what the connector does is, it consolidates the individual

and the small group markets into a pool. It then matches providers

by offering benefits with the demand for health care for State employees, SCHIP, Medicaid as well as small business. This approach

reduces risk, lowers costs, stabilizes the small market, essentially

mandates that changes to benefits packages could become an obstacle to the efficiencies of these pools. Rather than allow Federal programs to be integrated into the overall health care system, SCHIP

and Medicaid may well continue to be separate, more expensive

programs.

I would just like to end with a few comments on Medicaid and

State budgets. Unfortunately, Medicaid has grown about 11 percent per year over the last 25 years. It is now almost 23 percent

of State budgets. It is more than all elementary and secondary education. In some States, it is 34, 35 percent. With State revenues

growing only 5 to 6 percent, Medicaid has been funded by cutting

virtually all other components of State spending.

Mr. PALLONE. I know you said you are wrapping up but you have

already gone over a minute, so——

Mr. SCHEPPACH. Let me just say that we have two challenges, it

seems, universal health care and overall competitiveness. States

are trying to make the balance between education commitments

and health care.

Thank you, Mr. Chairman.

[The prepared statement of Mr. Scheppach follows:]

STATEMENT OF RAYMOND C. SCHEPPACH

Mr. Chairman: I appreciate the opportunity to appear before you today to discuss

the issue of dental health as it relates to Medicaid and S-CHIP. It is important to
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continue to evaluate the structure of benefits for both of these programs and how

they relate to health care reform in general.

This morning I would like to focus on three major issues as follows.

First, what States are currently doing to extend dental health benefits to children

and how this benefit relates to other early childhood services. Second, since there

is essentially an explosion of health care reform activity in the States, is important

to evaluate how any particular benefit mandate relates to these new reform initiatives. Third, it is important to be aware of State Medicaid spending and how it is

related to other State priorities such as education.

DENTAL HEALTH AND EARLY CHILDHOOD

Since the enactment of the State Children’s Health Insurance Program (S-CHIP)

in 1997, there has been a substantial expansion of dental services. While this was

an optional benefit, all States have provided some dental benefits. Clearly, the enhanced Federal match and increased flexibility to tailor benefits have contributed

to the success of S-CHIP benefit program. Without both of these incentives the

strength of the program would be jeopardized.

Access to dental services and outcomes are better in S-CHIP than in Medicaid.

Any further improvements in children’s dental health must come from building on

the strengths and successes of S-CHIP, and that includes both funding and flexibility. Benefit mandates, or any other attempt to make S-CHIP more like Medicaid

will only serve to thwart this progress and could ultimately erode the improvements

made so far. NGA will continue to oppose Federal mandates.

States are using S-CHIP to meet children’s primary health care needs, including

dental health services. Research has shown the S-CHIP enrollees are more likely

to have a medical home and more likely to receive preventive dental care. More

than half of S-CHIP children have had a dental check-up in the past 6 months and

over 80 percent have a usual source of dental care.

States have been working over a number of years to try to improve access to dental care for children. There are a variety of approaches that States have been using,

including those that you have heard about today from Michigan. The good news is

that dental access is improving for children. Beyond dental, States are also working

to meet children’s primary health care needs as well as expand affordable health

coverage. S-CHIP has seen a success in this area too with over 90 percent of children in the program reporting that they have a usual source of medical care. The

overwhelming success of S-CHIP in improving health care coverage and outcomes

is why there is unanimous support among governors for a timely reauthorization of

the program.

While S-CHIP and Medicaid dental benefits are important, simply having a benefit does not necessarily mean that children receive services. This is particularly true

given the shortage of dentists in many areas and more importantly the more acute

shortage of pediatric dentists, especially those trained to provide services to children

with special health care needs. Therefore, States have taken a more holistic approach to dental care by:

• Promoting Education and Prevention. Much of the disease experienced by children could be prevented with better personal care and water fluoridation. Several

States have launched public awareness campaigns to educate parents and children

about proper dental care and to build public support for children’s oral health policy

initiatives.

• Increasing Coverage and Access. Though many low- income children have dental

coverage through Medicaid, most receive no preventive dentist visits. Many States

are trying to strengthen the safety net by encouraging providers to participate in

Medicaid and by including dental benefits in S-CHIP.

• Enhancing the Dental Workforce. Many States are trying to attract dentists to

chronically underserved areas, yet the number of dentists graduating from dental

school is decreasing nationally. To succeed, States are using loan forgiveness, tax

credits, and other incentives and are trying to enhance dentist training to adequately address pediatric needs.

• Improving Financing and Reimbursement. Many providers refuse to participate

in Medicaid because of the low rate at which they are reimbursed. Some States have

increased provider reimbursements in Medicaid to attract new dentists as well as

to bring back dentists who have stopped participating.

Investments in children’s health are extremely important, but Governors are also

well aware of the need to look more holistically at making investments in children’s

futures. This is especially true in the area of early childhood development.
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Motivated by compelling child development research, impressive cost-benefit evidence, and the persistent achievement gap plaguing our Nation’s education system,

governors are pursuing pre-kindergarten expansion, full-day kindergarten, child

care quality improvement and expansion, infant-toddler initiatives, and other strategies to invest in children’s learning and development from birth into the early elementary years. For example:

• New York Governor Elliot Spitzer is calling for full funding of the State’s $645

million Universal Pre-K program and for full-day kindergarten planning grants for

high-need districts.

• Nevada Governor Jim Gibbons has committed $50 million to support full day

kindergarten pilot programs in at-risk schools

• Arizona’s recent ballot initiative will direct $188 million in new funds for early

childhood development and health programs, in addition to a $200 million increase

for voluntary full-day kindergarten programs championed by Governor Janet

Napolitano

• Minnesota Governor Tim Pawlenty has proposed $4000 per child for high quality early learning programs for at-risk 4 year olds.

STATE HEALTH CARE REFORM

The State of Hawaii enacted universal health care access in 1974. From that point

until 2003, neither the Federal Government nor States made very much process in

covering the uninsured. In 2003, the State of Maine enacted a comprehensive proposal with the goal of universal coverage by 2009. This was quickly followed by Vermont and Massachusetts, who enacted plans in 2006 with ambitious goals to cover

all of the uninsured. What is of particular note of all three of these plans is that

they were bipartisan and subsidized coverage for families up to 300 percent of the

Federal poverty level. It is also true that these States had relatively low rates of

uninsured prior to enacting reforms. While the three States face significant challenges to implement their plans, the early success in developing a State consensus

for reforms has stimulated major reforms in another 20–25 States.

There are about four States that have committed to universal coverage while another ten are developing proposals for universal access to coverage. Several others

are focused on universal care for all children and many others are pursing more incremental reforms. There are a number of common elements in these reforms as follows:

State Coverage Extensions. To address the problem of the uninsured, States have

enacted plans or are considering proposals to increase coverage and access for many

Americans. These initiatives include reforming the individual insurance market, requiring individual or employer participation in health insurance, ensuring that all

individual who are eligible for S-CHIP or Medicaid are enrolled and direct subsidies

to low-income individuals.

Connectors. A ‘‘connector’’ or ‘‘exchange’’ model offers health coverage through a

quasi-governmental authority that negotiates with health insurers to offer a minimum standard of benefits within a certain premium range. The connector pools individuals together to offer affordable, private insurance options. Most ‘‘connectors’’

consolidate the small group and individual markets into the pool. Many States are

offering subsidies for low-income individuals to purchase health insurance through

the ‘‘connector.’’ A choice of plans is provided and portability is a major benefit.

Tax Incentives. Section 125 of the IRS tax code permits tax-free deductions of

health insurance premiums from workers’ paychecks, saving money for both the employer and employee. Many health reform plans are requiring employers to set up

the option for their workers to deduct health insurance premiums tax-free. This option is generally paired with a connector model to ensure minimal administrative

burdens for employers.

Employer Mandates. Some States have required employers to either offer insurance to all of their uninsured workers or pay a fee for each uninsured employee.

The employer mandate is seen as encouraging employers to continue to offer coverage and helping to fund the coverage expansion in the State. Generally, those

States requiring employer contributions are those aimed at achieving universal coverage.

Individual Mandates. Some States are moving toward a requirement on individuals to have health insurance coverage. Through State income tax filings, individuals who can afford coverage and are found not to have insurance will be fined. An

individual mandate is being paired with mechanisms to make coverage more affordable for all residents, so individuals have the opportunity to meet the mandate without facing a financial hardship.
44

Quality Improvements and Measurements. Using coverage expansions and Medicaid redesigns as vehicles, many States have incorporated quality improvement and

measurement into their health reform plans to improve efficiency and patient care.

Many States are using disease management programs, applying quality measures

for doctors and hospitals, and taking steps toward interoperability with electronic

data systems.

Benefit Packages. Here, States are negotiating with providers to make a basic

benefit package available to current low-income individuals and small businesses.

Some of these may be paired with health savings accounts. The benefit package is

then offered through the connector.

The question now is how does a mandate for dental health or any other mandate

on the Medicaid of S-CHIP benefit package relate to these reform efforts. I would

argue that it could well be an obstacle in the following two ways.

• Requires States to spend more money per person in these programs, which redirects funds from eligibility expansions; and • Limits State efforts to create affordable consolidated insurance markets.

The goal of State actions is universal coverage or universal access. To attain this

goal, States use a combination of existing programs, including Medicaid and SCHIP, and new mechanisms to expand affordable health insurance. If States are required to meet new Federal benefit mandates in either Medicaid or S-CHIP, they

will have to spend more money per individual currently covered in these programs.

Efforts to enroll eligible uninsured individuals and many planned expansions of

these programs will be more expensive for sates. These increased costs will force

States to redirect funds that could have been used to fund other affordable health

insurance initiatives. Reducing flexibility in these programs is a real obstacle both

to maintaining existing coverage as well as coverage expansion.

New mandates on Medicaid and S-CHIP is also a potential obstacle to State efforts to create affordable consolidated insurance markets. Most State coverage efforts include negotiation, with providers to develop basic benefit packages that

would be subsidized by States and offered through the connector. Often this would

be the same benefit package that is offer by the managed care or other major providers, which is often the same as that provided to State employees. Essentially, the

connector consolidates the small group and individual markets into a pool. It then

matches providers who are offering benefits with the demand for health care by

States via State employees, S-CHIP and Medicaid, as well as small business, State

subsidized previously uninsured and other individuals with COBRA or similar

needs.

This approach spreads risk, lowers cost, and stabilizes this market. Essentially,

mandates that change this benefit package will become an obstacle to the efficiency

of these pools. Rather than allow Federal programs to be integrated into the health

care system, S-CHIP and Medicaid will continue as separate more expensive programs.

Mr. Chairman, we urge you not to impose any additional mandates on States. Instead Congress should work with States to support current health reform efforts.

MEDICAID VS. OTHER DOMESTIC PRIORITIES

Governors prefer maximum flexibility in administering almost all Federal programs. This allows States not only to tailor their programs to the specific needs of

their citizens, but increases the efficiency of programs.

Governors and States now have about 40 years experience with Medicaid. It is

the Nation’s critical safety net health coverage program for low-income individuals

and families. It covers 40 percent of non-elderly Americans living in poverty. It also

covers more than 7 million in Medicare of the almost 44 million enrollees, as well

as 28 million children or 1 in every 4. Finally, it covers long-term care coverage for

8 million low-income Americans with disabilities and chronic illness. In total, the

program now covers 53 million Americans and costs about $317 billion in 2005.

Unfortunately, Medicaid has grown almost 11 percent per year over that last 25

years. It now totals 23 percent of the average State budget, more than States spend

on all elementary and secondary education. In States like Tennessee and Missouri

it constitutes about 35 percent of their State budgets.

With State revenues growing only about 5–6 percent per year, Medicaid has been

funded by cutting virtually all other components of State spending. The stark reality

of this in terms of total State spending is as follows:

• Between 1988 and 2005, a 17-year period, Medicaid has grown from 11.5 to 22.9

percent of State budgets. All components of State budgets have been cut to accommodate this increase.
45

• Elementary and secondary education went from 23.9 percent to 21.8 percent,

while higher education went from 12.8 percent to 10.8 percent over the same period.

The rest of the cuts came from welfare, economic development, environmental, and

infrastructure programs.

Providing health care benefits to all Americans—while critical—is not the only

challenge facing State governments. The new world marketplace will challenge our

standard of living. The United States used to compete with high wage, high technology countries in the developed world or low wage, low technology countries in underdeveloped countries. Now the United States competes with high technology, low

wage emerging nations. Some of these emerging nations are rapidly growing large

countries—such as India and China—while others are the smaller Pacific Rim countries, like Taiwan, Korea, and Singapore. But this list also includes many of the nations of Eastern Europe and emerging regions in South America as they join the

world marketplace.

Some of these countries compete with the United States in the production of manufacturing goods, from textiles to electronics to automobiles, while others are challenging the United States in Web construction, call centers, software development,

and electronic products. Essentially, the changing world market has eliminated

most safe havens where a nation’s output and jobs are not threatened by increased

competition.

The United States’ ability to compete in this new knowledge-based highly competitive world economy will depend on its ability to innovate, which in turn depends

upon the education and training of our workforce. The economic cost of not being

able to innovate will be reflected in the reduction of real wages and real incomes

of United States citizens. This may not lead to any crisis in the short term, but reductions in real wages of 1–2 percent a year over the next decade can have a dramatic impact, particularly on low and middle income Americans. Further, reductions

in this standard will create tensions among the various groups and societal institutions.

While the United States has witnessed cyclical downturns when real wages have

fallen, the trend over the last 200 years has generally been upward. The choice

going forward, however, is between reductions in real wages or accelerating the rate

of innovation. It is not possible to reestablish trade barriers to protect our current

standard of living.

In order to compete in the new emerging global marketplace, we have to dramatically upgrade the education and training of our labor force. To date, our education

performance has been less than stellar.

• U.S. 15 year-olds ranked 24 out of 39 countries on the Program for International

Student Assessment (PISA) of students’ ability to apply mathematical concepts to

real world problems.

• In 2004, the U.S. produced 137,000 new engineers while India provided 112,000

and China produced $352,000 adjusted for quality.

Mr. Chairman, at this time States spend about one-third of their revenues on

health care and about one-third on education. However, the double digit growth in

State health care spending may not be sustained in the future. If the past is a good

indication of the future, it would be financed by cuts in education. Future cuts in

education, however, will lead to declines in our standard of living.

Health care and education are our two major domestic challenges as we go forward as a nation. It is important to have universal health care or universal access.

But it is also important to increase our standard of living, which requires additional

spending on education. Governors are attempting to find the appropriate balance between these two challenges.

Mr. PALLONE. Thank you very much.

Ms. Farrell.

STATEMENT OF CHRISTINE FARRELL, R.D.H., M.P.A., MEDICAID POLICY SPECIALIST, MICHIGAN DEPARTMENT OF COMMUNITY HEALTH, MEDICAL SERVICES ADMINISTRATION

Ms. FARRELL. Good morning, Chairman Dingell, Chairman

Pallone and Ranking Member Deal and the members of the Subcommittee on Health. My name is Christine Farrell and I am employed with the Michigan Department of Community Health, Medi-
46

cal Services Administration, the agency that administers the Michigan Medicaid program. For the past 15 years, I have been the dental policy specialist with the responsibility of managing the Medicaid dental benefit. Since 2000 I have served as the contract manager for the Healthy Kids Dental program and this is our partnership with the Delta Dental Plan in Michigan. In addition, I am also

a part of the dental team. I am a registered dental hygienist.

Apart from my State role, I also have a national role. I am the

national chairperson of the Medicaid/SCHIP Dental Association.

We are an association of dental program managers. As an association, we hope to have a more effective voice for the delivery of oral

health care to the Medicaid and SCHIP populations since we all

share the goal of trying to provide access to oral health services for

our beneficiaries. Medicaid/SCHIP Dental Association has worked

to promote oral health awareness within our respective programs

and we are also working with other oral health advocacy groups,

with the Centers for Medicare and Medicaid Services, the National

Association of State Medicaid Directors and the National Academy

for State Health Policy.

My primary purpose today is to highlight the Michigan Medicaid

program and how we are addressing the issue of access to oral

health care for Medicaid beneficiaries under the age of 21 through

our Healthy Kids Dental program. This is our partnership with

Delta Dental Plan of Michigan and it began on May 1, 2000, and

continues today. In 1999, the Michigan Legislature appropriated an

additional $10.9 million to address the issue of access to oral health

services for Medicaid beneficiaries, especially those in rural areas.

As a result of dental taskforce recommendations, Michigan chose to

use half of these monies to provide infrastructure grants to safetynet providers such as community health centers, local health departments, hospitals and universities. The additional monies went

to develop a demonstration project similar to our MIChild dental

program, which is our SCHIP program which provides a dental insurance product to enrollees. We set out to contract with a dental

insurance carrier to administer the Medicaid dental benefit

through a statewide network of dental providers, and Delta Dental

Plan answered that call.

The Healthy Kids Dental program was implemented on May 1,

2000, in 22 counties providing access to oral health care services

for 50,000 Medicaid beneficiaries. The program was expanded to 37

counties in October 2006 and increased the total beneficiaries to

over 100,000. On May 1, 2000, the program expanded to an additional 22 counties, providing access again to another 50,000 beneficiaries. Today it is in 59 of our 83 counties. The majority of these

counties are rural. They have dental care health professional shortage areas and have little or no dentist participation in the traditional Medicaid program. Some of these counties have no dentists

or one or two.

The Healthy Kids Dental program is designed to mirror an employer-sponsored plan. By partnering with Delta Dental Plan of

Michigan, we gained access to their statewide network because approximately 95 percent of the dentists in Michigan participate with

Delta Dental whereas less than 20 percent of the practicing dentists are Medicaid providers. By using this network, we provide an
47

immediate benefit to our Medicaid beneficiaries. We offer them

greater access to dentists and the ability to develop a dental home.

Another advantage is that they are mainstreamed into the entire

population of Delta subscribers and they do not have the stigma of

public assistance, and as long as a dentist participates with Delta

Dental, they can’t refuse to treat Medicaid beneficiaries.

While Delta administers the Medicaid dental benefit, the advantage to their network dental providers is that Delta administers

the benefit according to their policies and procedures. Providers

submit claims directly to Delta and receive reimbursement from

Delta. Initially they were reimbursed at the Delta premier rate,

which may be commonly referred to as their usual customary

charge. In January 2006, due to budget considerations, Delta Dental and the Medicaid program initiated a reimbursement change to

a fixed fee schedule. While this fixed fee schedule is less than their

premier rate, it is still higher than our standard Medicaid rate. We

were initially concerned that this decrease in reimbursement would

impact the network of participating providers and decrease access.

This fear was unfounded. We have monitored the provider network

and we have retained over 86 percent of the participating dental

providers. We attribute this success to the fact that Delta Dental

has a strong relationship with their dental network and is a highly

respected company by the Michigan Dental Association and its

members.

We have contracted with a University of Michigan researcher,

Dr. Stephen Eklund, to assess the results of the Healthy Kids Dental program and we have just released a study showing that 5

years of operation where it shows that dental visits are 50 percent

higher for children enrolled in the Healthy Kids Dental program

compared to our traditional Medicaid dental program. Additional

results show that travel distance has also been cut in half from the

traditional Medicaid beneficiary experience. In addition, many

Healthy Kids dental beneficiaries have established a dental home

and are developing routine dental recall patterns. The results are

impressive and we are very excited about them.

In addition, Delta Dental Plan recently conducted a survey of

Healthy Kids Dental participants and the majority of them are also

satisfied.

The goal of the Healthy Kids Dental program is to increase access to oral——

Mr. PALLONE. Ms. Farrell, I am going to have to ask you to summarize too.

Ms. FARRELL. Oh, I am sorry.

We think we have demonstrated success and Michigan would

welcome additional Federal assistance to assist us in further expanding the Healthy Kids Dental program and we are in challenging economic times and we continue to look at innovative ways to

increase our oral health care access.

[The prepared statement of Ms. Farrell follows:]

TESTIMONY OF CHRISTINE FARRELL

Good morning Chairman Dingell, Chairman Pallone, Ranking Member Deal and

the members of the Subcommittee on Health.
48

My name is Christine Farrell and for the past 19 years I have been employed by

the Michigan Department of Community Health, Medical Services Administration

(the agency that administers the Michigan Medicaid Program). For the past 15

years, I have been the dental policy specialist with the responsibility of managing

the Medicaid dental benefit. Since 2000, I have served as the contract manager for

the Healthy Kids Dental program; this is our partnership with the Delta Dental

Plan of Michigan.

Apart from my State role, for the past 3 years, I have been the national chairperson of the Medicaid/SCHIP Dental Association (MSDA). This association was

formed 3 years ago at the National Oral Health Conference by Medicaid and SCHIP

dental program managers. As an association, we hope to have a more effective voice

for the delivery of oral health care to the Medicaid and SCHIP populations. Our

mission is to provide a support system and promote collegiality among State Medicaid and SCHIP programs since we all share the goal of trying to provide access to

oral health services for our beneficiaries. Since forming this association, the MSDA

has worked to promote oral health awareness and to increase access to oral health

services for Medicaid and SCHIP beneficiaries within our respective State programs,

with the Centers for Medicare and Medicaid Services (CMS) Chief Dental Officer,

with national policy groups such as the National Association of State Medicaid Directors (NASMD), the National Academy for State Health Policy (NASHP), and

other oral health advocacy groups. Our Association seeks the opportunity to provide

State and national leadership in the development of Medicaid/SCHIP oral health

policy, encourage innovation and collaboration among State Medicaid programs, and

to promote the integration of oral health and primary care in Medicaid/SCHIP programs.

My primary purpose today is to highlight the Michigan Medicaid Program and

how we are addressing the issue of access to oral health care for Medicaid beneficiaries under the age of 21 through our Healthy Kids Dental program. The

Healthy Kids Dental program is our partnership with the Delta Dental Plan of

Michigan. This partnership began on May 1, 2000 and continues today. In 1999, the Michigan legislature appropriated an additional $10.9 million dollars

to address the issue of access to oral health services for Medicaid beneficiaries, especially those in rural areas. As the result of Dental Task Force recommendations,

Michigan chose to use half of the monies to provide infrastructure grants to safetynet providers, such as community health centers, local health departments, hospitals and universities. The additional monies went to develop a demonstration

project similar to the MIChild dental program (Michigan’s SCHIP program) which

provides a dental insurance product to enrollees. We (Medicaid) sent out a proposed

bulletin announcing the intent to contract with a dental insurance carrier to administer the Medicaid dental benefit through a statewide network of dental providers.

The Healthy Kids Dental program was implemented on May 1, 2000, in 22 counties providing access to oral health care services for 50,000 Medicaid beneficiaries

under the age of 21. The program was expanded to 37 counties in October, 2006,

and increased the total beneficiaries enrolled to over 100,000 enrollees. On May 1,

2006, the program expanded to an additional 22 counties providing access to another 50,000 beneficiaries. Today, it is in 59 of the 83 Michigan counties providing

access to oral health care services for over 200,000 beneficiaries. The majority of

these counties are rural, are Dental Care Health Professional Shortage Areas, and

have little or no dentist participation in the traditional Medicaid Program.

The Healthy Kids Dental program is designed to mirror an employer-sponsored

plan. By partnering with Delta Dental Plan of Michigan, we have gained access to

their statewide network. Approximately 95% of the practicing dentists in Michigan

participate with Delta Dental whereas, less than 20% percent of the practicing dentists are Medicaid providers. By using this network, we provide an immediate benefit to our Medicaid beneficiaries by offering them greater access to dentists and the

ability to develop a dental home. Another advantage for the beneficiaries is that

they are mainstreamed into the entire population of Delta subscribers by receiving

a Delta Dental card; they do not have the stigma of public assistance. As long as

the dentist participates with Delta Dental, they cannot refuse to treat Medicaid

beneficiaries unless the office is closed to all new patients.

While Delta administers the Medicaid dental benefit, the advantage to their network dental providers is that Delta administers the benefit according to their policies and procedures, providers submit claims directly to Delta and receive reimbursement from Delta. Initially, the dentists were reimbursed at the Delta Premier

rate (may be commonly referred to as their Usual & Customary Charge). In January

2006, due to budget considerations, Delta Dental and the Medicaid Program, initiated a reimbursement change from the Premier rate to a fixed fee schedule. While

this fee schedule is less than the Premier rate, the rate is still higher than the
49

standard Medicaid fee schedule. We (both Medicaid and Delta Dental) were initially

concerned that this decrease in reimbursement would impact the network of participating providers and decrease access. This fear was unfounded. We have monitored

the provider network and have retained over 86% of the participating dental providers. We attribute this success to the fact that Delta Dental has a strong relationship

with their dental network and is a highly-respected company by the Michigan Dental Association and its members.

A University of Michigan researcher, Dr. Stephen A. Eklund, was contracted to

assess the results of the Healthy Kids Dental program. A study using data from the

first 5 years of operation has just been completed and the results are impressive.

Results show that dental visits are 50 percent higher for children enrolled in the

Healthy Kids Dental program compared to children enrolled in the traditional Medicaid dental program. Additional results show that the travel distance for beneficiaries has been cut in half from traditional Medicaid experience. The median distance traveled is 7.6 miles for Healthy Kids Dental beneficiaries, whereas beneficiaries in the traditional Medicaid Program normally travel twice that distance. In

addition, many Healthy Kids Dental beneficiaries have established a dental home

and are developing routine dental recall patterns. The results of the study are impressive and we (both Medicaid and Delta Dental) are excited about them. It demonstrates that the partnership with Delta Dental is working.

In addition, Delta Dental Plan recently conducted a survey of Healthy Kids Dental participants. Of the respondents, nearly 99 percent are satisfied with the program and 92 percent indicated that their child’s health has improved due to the

Healthy Kids Dental program.

In 2004, the American Dental Association designated the Healthy Kids Dental

program as one of five national models for improving access to oral health services

for Medicaid beneficiaries.

The goal of the Healthy Kids Dental program is to increase access to oral health

services for Medicaid beneficiaries and to eliminate barriers. We believe that the

program has accomplished this goal through our partnership with Delta Dental Plan

of Michigan. We have addressed the three most common complaints typically reported about the Medicaid Program: low reimbursement rates, administrative burden and beneficiary no-show rates. We have also improved the health of the beneficiaries by crafting a new model that is working in Michigan.

While this program has demonstrated success, Michigan would welcome additional Federal assistance to assist us in further expanding the Healthy Kids Dental

program statewide. We are in challenging economic times in Michigan and we continue to look at innovative ways to improve access to oral health care. Additional

Federal support would assist Michigan, and other States, in crafting solutions to improve and expand access to this critical benefit for children.

Mr. PALLONE. Thank you. I would also say you can submit your

full statement for the record too. We are just trying to get you to

summarize your comments within the minutes or so.

Next is Dr. Mosca.

STATEMENT OF NICHOLAS G. MOSCA, D.D.S., CLINICAL PROFESSOR OF PEDIATRIC AND PUBLIC HEALTH DENTISTRY,

UNIVERSITY OF MISSISSIPPI SCHOOL OF DENTISTRY

Dr. MOSCA. Good morning, Mr. Chairman and members of the

committee. My name is Dr. Nicholas Mosca. I am clinical professor

of pediatric and public health dentistry at the University of Mississippi School of Dentistry and also serve as State dental director

for Mississippi. It is an honor to testify on behalf of two organizations, the American Dental Education Association, which represents over 21,000 members at more than 120 academic dental institutions including 56 schools of dentistry in 34 States, the District of Columbia and Puerto Rico, and the American Association

for Dental Research, which represents 5,000 individual and 100 institution members.

Each year about 4,500 pre-doctoral dental students graduate

from dental school. Fourteen thousand dental hygienist students
50

graduate. Eight thousand dental assistants and 800 dental laboratory technologists graduate. Many of these students are trained in

clinical environments where dental care is provided to underserved

low-income populations including individuals covered by Medicaid

and the State Children’s Health Insurance Program.

Let me share with you, as did New Mexico, Utah and California,

a snapshot of Mississippi. During the 2004–05 school year, 7 in 10

third-grade children experienced tooth decay. Two in five had untreated dental disease, and 1 in 10 had urgent need for dental care,

which means that over 3,800 children had urgent need for care. Almost twice as many African-American children were in need of urgent care because of pain or infection.

On March 23, at a Head Start program in Clarksdale, Mississippi, the birthplace of the blues, I saw a 4-year-old child with

an acute dental abscess. We have all been talking about the untimely death of Diamonte Driver but let me also share another example of an access issue. A week ago in USA Today, it was reported that a routine dental visit revealed a cancerous tumor in the

mouth of North Carolina football coach Butch Davis. Coach Davis

is now undergoing chemotherapy for non-Hodgkin’s lymphoma. His

access to oral health care in combination with dental insurance

played a critical role in saving his life. These two examples reveal

opposing sites of access to dental care in America. One individual

lacked consistent care while the other was well insured and had

timely care.

Once upon a time, access to dental care meant the removal of

bad teeth and the fabrication of dentures. Dental care is no longer

akin to making hearing aids or eyeglasses. In other words, we must

work to prevent most infection and pain from occurring in the first

place. Healthy adult mouths have 32 teeth which are supplied by

blood vessels, just like our fingers. How can we afford to allow our

children’s fingers to become infected? How many fingers could you

afford to lose? The real tragedy is that we know how to prevent

most tooth decay in most populations. We only need to act on our

knowledge.

Prevention of disease such as by public water fluoridation or

school-based dental sealant programs is essential to contain the

higher costs associated with care. Children who receive early preventive care are more likely to continue using prevention services

and those who wait to visit a dentist are more likely to have a costly health problem or require an emergency room visit.

Our U.S. academic dental institutions act to mitigate these emergency room visits by serving as safety-net providers to provide comprehensive care at reduced costs and we serve racially and ethnically diverse populations including low-income, elderly, migrant

individuals, home-bound individual, mentally, medically and physical disabled individuals. As providers of services to underserved

populations, academic dental institutions may also enhance Government initiatives to expand access to prevention and dental care.

Schools can work with State oral health programs to support

school-based dental programs, sealant programs, and schools can

conduct research to evaluate the dental workforce capacity needed

to adequately serve those in Medicaid, Ryan White HIV dental clinics and other public assistance programs.
51

Here are some fairly straightforward ways in which Congress can

immediately act to enhance access to vital preventive and restorative services. We urge Congress to adopt the following recommendations for the reauthorization of the SCHIP program, establish a Federal guarantee for dental coverage in SCHIP, develop

a dental wraparound benefit in SCHIP, facilitate ongoing outreach

efforts to enroll all eligible children in SCHIP and Medicaid, and

ensure reliable data reporting on dental care in SCHIP in Medicaid. We further urge Congress to ensure that there is adequate

funding of the Federal programs that increase access to oral health

care and improve oral health infrastructure and dental research

and bolster the oral health care workforce for the Nation. You already had many of these programs named and so I just want to reiterate that we know how to prevent most disease in most populations. We only have to act on this knowledge.

Thank you, and I am happy to field any questions that you may

have.

[The prepared statement of Dr. Mosca follows:]

STATEMENT OF NICHOLAS G. MOSCA, D.D.S.

Mr. Chairman and members of the committee, I am Dr. Nick Mosca, Clinical Professor of Pediatric and Public Health Dentistry at the University of Mississippi

School of Dentistry and Dental Director for the State of Mississippi. I am a member

of the American Dental Education Association (ADEA) and the American Association for Dental Research (AADR). This morning I am testifying on behalf of both

organizations.

The ADEA represents over 120 academic dental institutions as well as all of the

educators, researchers, residents and students training at these institutions and

AADR represents over 5,000 individual members and 100 institutional members.

The joint mission of ADEA and AADR is to enhance the quality and scope of oral

health, advance research and increase knowledge for the improvement of oral

health, and increase opportunities for scientific innovation. Academic dental institutions play an essential role in conducting research and educating and training the

future oral health workforce. These institutions provide dental care to underserved

low-income populations, including individuals covered by Medicaid and the State

Children’s Health Insurance Program.

I thank the committee for this opportunity to testify about access to oral health

care, the role academic dentistry plays in providing care for underserved populations and the role we play in educating a competent and diverse oral health care

workforce for the Nation.

Preventive Care is Essential to Eradicate Oral Health Disparities and Contain

Costs

Americans spend millions of dollars annually in treatment of dental caries (cavities) and tooth restoration. Despite tremendous improvements in the Nation’s oral

health over the past decades, the benefits have not been equally shared by millions

of low-income and underserved Americans.

As the Surgeon General’s report on oral health in America told us 7 years ago,

there are ′′profound and consequential oral health disparities within the population,′′ particularly among racial and ethnic minorities, rural populations, individuals with disabilities, the homeless, immigrants, migrant workers, the very young,

and the frail elderly.′′ At the time of publication of the Surgeon General’s Report

there were 108 million Americans lacking dental insurance, of which 23 million

were children.

Children in households below 200 percent of poverty have three times the tooth

decay of children from affluent homes. Their disease is more advanced and is less

likely to be treated. Eighty percent of untreated dental caries (tooth decay) is isolated in roughly 25 percent of children. The majority of these children are from lowincome and other vulnerable groups—the same groups that rely upon public health

programs for their care. Most adults, particularly as they age show signs of periodontal or gingival disease. Fourteen percent of people age 45 to 54 have severe periodontal disease and that number grows to almost a quarter (23 percent) for people
52

1 ‘‘Early Preventive Dental Visits: Effects on Subsequent Utilization and Costs,’’ Matthew F.

Savage, DDS, MS, Jessica Y. Lee, DDS, MPH, PhD, Jonathan B. Kotch, MD, MPH, and William

F. Vann, Jr., DMD, PhD, Pediatrics Vol. 114, No. 4, October 2004.

2 Ibid

age 65 to 74. Tragically one-third of adults (30 percent) are completely toothless

(edentulous).

Access to oral health care can be a matter of life and death. Those of us who read

the Washington Post were reminded of that recently with the untimely death of

Deamonte Driver, a 12-year-old boy with an abscessed tooth, part of an uninsured

and sometimes homeless family whose Medicaid coverage had lapsed. Deamonte’s

tooth infection spread to his brain. After two brain surgeries and six weeks in the

hospital (and tens of thousands of dollars in medical expenses), he died. A week ago

USA Today reported that a routine dental visit revealed a cancerous tumor in the

mouth of North Carolina football coach Butch Davis. Coach Davis is now undergoing

chemotherapy for non-Hodgkin’s lymphoma. His access to oral health care, in combination with dental insurance played a critical role in saving his life.

America’s most prevalent infectious disease is dental decay (caries) for all ages.

It is five times more common than asthma and seven times more common than hay

fever in children. Early childhood caries is dental decay found in children less than

5 years of age. It is estimated that 2 percent of infants 12–23 months of age have

at least 1 tooth with questionable decay whereas 19 percent of children 24–60

months of age have early childhood caries in the United States. 1

Preventative care is essential to contain costs associated with oral health care

treatment and delivery. Children who have early preventive dental care are more

likely to continue using preventive services. Those who wait to visit a dentist are

more likely to visit for a costly oral health problem or emergency. The average cost

for a dental visit before age one was $262. This doubled to $546 when a child’s first

visit wasn’t until ages 4 to 5 2

Dental caries is a chronic, infectious disease process that occurs when a relatively

high proportion of bacteria within dental plaque begin to damage tooth structure.

If caries can be diagnosed before irreversible loss of tooth structure occurs, it can

be reversed using a variety of approaches that ‘‘remineralize’’ the tooth. In addition

to improved diagnostics, researchers are working to develop a vaccine to prevent

tooth decay while others use new methods to specifically target and kill the decaycausing bacteria.

ACADEMIC DENTAL INSTITUTIONS AND ACCESS TO CARE

U.S. academic dental institutions (dental schools, allied dental programs and

postdoctoral/advanced dental education programs) are safety net providers increasing access to care. These institutions are dental homes for a broad array of racially

and ethnically diverse patients including low-income non-elderly and elderly individuals; migrant individuals; homebound individuals; mentally, medically or physically

disabled individuals; institutionalized individuals; HIV/AIDS patients; Medicaid and

SCHIP children and uninsured individuals.

All U.S. dental schools operate dental clinics and most have affiliated satellite

clinics where preventative and comprehensive oral health care is provided as part

of the educational mission. All dental residency training programs provide care to

patients through dental school clinics or hospital-based clinics. Additionally, all dental hygiene programs operate on-campus dental clinics where classic preventive oral

health care (cleaning, radiographs, fluoride, sealants, nutritional and oral health instruction) can be provided 4–5 days per week under the supervision of a dentist.

All care provided is supervised by licensed dentists as is required by State practice

acts. All dental hygiene programs have established relationships with practicing

dentists in the community for referral of patients. Millions of dollars of uncompensated care are provided by academic dental institutions each year.

As major providers of services to underserved populations, academic dental institutions also play a major role in enhancing private sector initiatives that support

expanded access to dental care. They support school-based sealant programs that reduce the incidence of tooth decay in children; and they evaluate the dental workforce capacity needed to adequately serve those in Medicaid, Ryan White HIV/AID

clinics and other public assistance programs.

EDUCATING THE NATION’S ORAL HEALTH CARE WORKFORCE

Oral health care is important for all Americans including those living in inner cities and in rural underserved areas. There are presently more than 3,400 designated

dental health profession shortage areas, in which 45.3 million people live. It is
53

doubtful that many of these areas can financially support a dentist or attract a dentist by virtue of their infrastructure or location. But the issue remains. There are

unserved and underserved communities and populations, as well as a growing desire

in society to have equitable access to health care and dental care for all. The challenge to dentistry is not only to expand the capacity of the dental workforce; it must

also improve its distribution and access to oral health care. In order to achieve these

objectives it is the mission of academic dental institutions to educate and train the

U.S. dental health care workforce.

Predoctoral Dental Education. Upon successfully completing dental school and

passing a State licensure exam graduates may enter private practice as general dentists. Graduate also have the option to pursue advanced and specialty training.

At the present time about 4,500 predoctoral dental students graduate annually

after 4 years of dental school. The high water mark for dental student enrollment

occurred in the late 1970’s with 6,300 students. Enrollment increased during the

1960’s and 1970’s due to surges in both the baby boomers coming of college age and

the percent of college age adults enrolling in college. Also, there was broad support

for expanding the number of health care providers during that time which led to

Federal student loan and scholarship programs, as well as Federal construction and

capitation grants to schools to support enrollment increases. Then during the late

1970’s and through the 1980’s there were declines in enrollment which can be attributed to a strongly voiced perception of an oversupply of dentists, periods of economic inflation and stagnation, and termination of Federal support for further expansion in the numbers of health care providers. During the mid–1990’s, applicants

to dental school increased as dentistry was once again perceived to be a challenging

and financially rewarding profession. However, enrollment increased only slightly.

It should be noted that there is limited capacity within the current dental education

infrastructure to accommodate much of an enrollment increase. And until recently,

there was not support or need to do so nationally.

At the present time there are 56 U.S. dental schools in 34 States, the District of

Columbia and Puerto Rico. Growing demand for dental care in certain areas of the

country has precipitated the opening of six new dental schools. In 2003 the Arizona

School of Health Sciences, the University of Nevada Las Vegas in 2002, and the

Nova Southeastern University in Florida in 1997. In near future East Carolina University in Greenville, North Carolina plans to open a dental school with a focus on

rural dentistry. The school plans to operate 10 student dental clinics in underserved communities throughout the State enrolling 50 students per class. Midwestern University in Glendale, Arizona will open a dental school in August 2008

with an enrollment of 100 students per class. The dental school is part of

Midwestern’s expansion plan to address the State of Arizona’s health care workforce

shortages. Western University of Health Sciences in Pomona, California plans to

open a dental school in the next few years. The University is in the preliminary

phase of the accreditation process.

Prior to these openings, significant growth took place from 1960–1978 with the

number of dental schools increasing from 47 to 60. This increase of 13 was during

a time of Federal construction grants and a widely perceived need to expand the

number of all health care professionals, including dentists. Between 1986–2001,

seven dental schools closed, all private or private/State-related dental schools.

Dental Residency Training. Approximately 2,800 new graduates and other dentists who have been in practice choose to specialize or advance their training in general dentistry by enrolling in dental residency training programs. There are nine

recognized dental specialties: oral surgery, oral radiology, oral pathology,

orthodontics, endodontics, periodontics, pediatric dentistry, dental public health as

well as two programs in general dentistry, general practice residency and advanced

education in general dentistry. Dental residency training programs last from a minimum of 14 months for Dental Public Health up to maximum of 54 months for oral

surgery. Dental residency programs increase access to oral health care for a broad

array of patients. Dentists may not practice a dental specialty without having successfully completed the required training.

In 1995, the Institute of Medicine called for the creation of a number of graduate

dental education residency positions sufficient to accommodate all graduates by

2005. In 1999, the Journal of Dental Education published a series of articles in a

special issue that set forth a focused and compelling rationale for a mandatory, postgraduate year of dental residency education (PGY–1). The most recent call for a

PGY–1 was in December 2006 at the ADEA Summit on Advanced Dental Education.

Delaware has long required a residency before dentist could begin practice in the

State. Beginning this year the State of New York requires a PGY–1 for initial licensure.
54

Allied Dental Education There are about 300 dental hygiene programs in all 50

States and the District of Columbia. Most dental hygiene programs grant an associate degree, others offer a certificate, a bachelor’s degree, or a master’s degree. Dental hygienists rank among the fastest growing occupations. Each State has its own

specific regulations regarding dental hygiene responsibilities thus services provided

varies from State to State. Nearly 13,900 dental hygienists graduate annually.

There are 272 dental assisting programs located in 47 States and Puerto Rico.

Dental assistants enhance the capacity of a dental office to treat patients by assisting dentists with a variety of treatment procedures. About 8,000 dental assistants

graduate each year.

Eight hundred students graduate annually from the 20 dental laboratory technology programs located in 16 States. These individuals create replacements for natural teeth and corrective devices; fabricate dentures, bridges, crowns and orthodontic appliances and work with a variety of materials such as waxes, plastics, precious and non-precious alloys, porcelains and others to fabricate dental restorations

and tooth replacements.

MEDICAID AND SCHIP

More than 9 million children lack medical insurance and 23 million children lack

dental insurance. Medicaid plays a critical role in children’s access to dental services. In fact, Medicaid pays for 25 percent of all dental expenses for children under

6 years of age. Also, Medicaid covered 66 percent of the dental expenses incurred

for all people with public insurance.

All 25 million children in Medicaid under age 21 are eligible for needed dental

care through the Early Periodic Screening, Diagnosis and Treatment program

(EPSDT). Dental services were among the first three preventive health care services

included in EPSDT. Although all children enrolled in Medicaid qualify for EPSDT

services, less than one in four children on Medicaid receive them.

State Medicaid programs are required to ensure that dental services are available

and accessible and to provide services if a problem is identified that requires treatment. States must also inform Medicaid-eligible persons about the availability of

EPSDT services and assist them in accessing and utilizing these services. Services

include regular screenings and dental referrals for every child at regular intervals

meeting reasonable standards of dental practice established by States in consultation with the dental profession. States must provide, at a minimum, services that

relieve pain and infection, restore teeth, and maintain dental health.

The State Children’s Health Insurance Program (SCHIP) plays a critical role in

providing access to dental care for covered children. Although States have the option

to include dental coverage (presently all States have some level of dental benefits)

the fact that they do so is a significant factor in a parent’s decision to enroll their

children in SCHIP.

As Congress deliberates the reauthorization of the SCHIP, ADEA/AADR urges

Congress to immediately enact legislation that would enhance SCHIP insurance coverage and enhance access to dental care. We recommend that Congress enact following recommendations to improve the system of care: (1) Establish a Federal guarantee for dental coverage in SCHIP; (2) Develop a dental wrap-around benefit in

SCHIP; (3) Facilitate ongoing outreach efforts to enroll all eligible children in

SCHIP and Medicaid; and (4) Ensure reliable data reporting on dental care in

SCHIP and Medicaid.

Dental care for adults under Medicaid is optional. As a result, many States often

reduce or eliminate funding for adult dental programs during difficult economic

times

Today, most States have caps or limits on spending for adult oral health and dental services. Forty-one States offer only emergency care. As States begin to recover

from the recent economic recession, some are reinstating limited oral health and

dental services for adults; however, only a relatively few States provide comprehensive adult services. For many Medicaid-eligible adults this is the only insurance coverage they have for oral health and dental care.

FEDERAL PROGRAMS THAT HELP TO ADDRESS ORAL HEALTH WORKFORCE ISSUES

The Dental Health Improvement Act, a Federal grant program for States, awarded the first 18 grants to States last October to help develop innovative dental workforce programs. The first grants are being used for a variety of initiatives including:

increasing hours of operation at clinics caring for underserved populations, recruiting and retaining dentists to work in these clinics, prevention programs including

water fluoridation, dental sealants, nutritional counseling, and augmenting the

State dental offices to coordinate oral health and access issues.
55

The Title VII General and Pediatric Dentistry Programs are essential to building

the primary care dental workforce are effective in increasing access to care for vulnerable populations including patients with developmental disabilities, children and

geriatric patients. These primary care dental residency programs generally include

outpatient and inpatient care and afford residents with an excellent opportunity to

learn and practice all phases of dentistry including trauma and emergency care,

comprehensive ambulatory dental care for adults and children under the direction

of experienced and accomplished practitioners.

The Centers for Disease Control and Prevention Oral Health Program expands

the coverage of effective prevention programs by building basic capacity of State oral

health programs to accurately assess the needs in their State, organize and evaluate

prevention programs, develop coalitions, address oral health in State health plans,

and effect allocation of resources to the programs. CDC provides technical assistance

to States that is essential to help oral health programs build capacity.

Congress designated dental care as a ‘‘core medical service’’ when it reauthorized

the Ryan White Modernization and Treatment Act in 2006. Seventy-five percent of

the funding for titles I and II must be devoted to core medical services. This should

result in many more afflicted patients receiving the dental care they need. The Dental Reimbursement Program provides access to quality dental care to people living

with HIV/AIDS while simultaneously providing educational and training opportunities to dental residents, dental students, and dental hygiene students who deliver

the care. The Dental Reimbursement Program is a cost-effective Federal/institutional partnership that provides partial reimbursement to academic dental institutions for costs incurred in providing dental care to people living with HIV/AIDS. The

Community-Based Dental Partnership Program fosters partnerships between dental

schools and communities lacking academic dental institutions to ensure access to

dental care for HIV/AIDS patients living in those areas.

The under representation of minorities poses a challenge to the U.S. health care

workforce, including dentistry, especially as immigration trends contribute to increased numbers of minorities in the population. Title VII Diversity and Student

Aid programs play a critical role in helping to diversify the health professions student body and thereby the health care workforce. Of paramount importance are the

Health Careers Opportunity Program, the Centers of Excellence and the Scholarships for Disadvantaged Students. These programs are key drivers in recruiting and

retaining students in the health professions. For the last few years these grant programs have not enjoyed an adequate level of support to sustain the progress that

is necessary to meet the challenges of an increasingly diverse U.S. population.

ACADEMIC DENTAL INSTITUTIONS RECOMMENDATIONS

Oral disease affects individuals, families, the community and society. Poor oral

health can lead to pain and infection, missed work or school and disruptions of vital

functions such as speech and eating, and other productive activities. Oral disease

not only poses a risk to general health it can complicate other existing medical conditions.

While dental care demands are higher than many other health care demands,

many people in the U.S. do not receive basic preventive dental services and treatment. Most oral diseases are preventable if detected and treated promptly. Yet millions of Americans face unacceptable conditions in oral health living daily with pain

and disability without treatment. The major reason for not obtaining dental services

is financial. Since few oral health problems in their early stages are life-threatening,

people often delay treatment for long periods of time. Often, it is hospital emergency

rooms to which they turn once they can no longer stand the pain or their condition

has worsened to the point where they can no longer postpone treatment.

ADEA/AADR urges Congress to adopt our SCHIP recommendations as set forth

in this testimony that will greatly enhance access to vital preventive and restorative

oral health care services: (1) Establish a Federal guarantee for dental coverage in

SCHIP; (2) Develop a dental wrap-around benefit in SCHIP; (3) Facilitate ongoing

outreach efforts to enroll all eligible children in SCHIP and Medicaid; and (4) Ensure reliable data reporting on dental care in SCHIP and Medicaid.

Furthermore, we urge Congress to ensure adequate funding of the Federal programs outlined above, namely Medicaid and SCHIP, the Dental Health Improvement Act, Title VII General and Pediatric Dentistry Programs, the Centers for Disease Control and Prevention Oral Health Program, the Ryan White Modernization

and Treatment Act and the title VII diversity and student aid programs which include the Health Careers Opportunity Program, the Centers of Excellence and the

Scholarships for Disadvantaged Students.
56

Mr. PALLONE. Thank you, Dr. Mosca.

Dr. Corbin.

STATEMENT OF STEPHEN B. CORBIN, D.D.S., M.P.H., SENIOR

VICE PRESIDENT OF CONSTITUENT SERVICES AND SUPPORT, SPECIAL OLYMPICS INTERNATIONAL

Dr. CORBIN. Good morning, and thank you again for having us

here to share information on a very important topic, and a lot of

verbal and written information will come across these tables and

it will go into the record, but I think it is important that we get

back to what this is all about. If you look to your left or your right

and you see on your screen, you will see examples of very serious

early dental infections in young children, as young as 3 or 4 all the

way up to 6 or 7. So at the end of the day Diamonte Driver is a

statistic, a dead child who should still be alive, and again, he is not

the exception. There are many children out there that have these

problems.

There is one barrier we need to get over right in the beginning

and it is not micromanaging the reimbursement levels or anything

like that. It is a conceptual barrier. A decade ago, C. Everett Koop

said if you don’t have oral health, you are not healthy. Medical and

dental science over the past decade has advanced and shown that

Dr. Koop was indeed right and we know that to be the case today.

At the same time, 15 years ago, I heard for the first time in a State

legislature this quote, or this is a paraphrase that is close to a

quote: sure, it would be nice to save the dental program but let us

face it, no one really dies from a toothache. This was not a single

legislature. This is going on over and over, over the past 15 years,

and it really strikes the contrast, the balance about is dentistry

about filling holes in teeth that happen and can happen now or a

year from now or is it about ongoing health care and well-being for

children, adolescents and adults, and I think you will agree with

me, it is the latter. There are many points along the way where

we could have intervened in the death march that took Diamonte

Driver to a way-too-premature end to his life.

I am a board-certified public health dentist. It is a rare breed.

You won’t find another one probably within—oh, other than Burt.

Are you certified? I don’t know. I work with Special Olympics International. We have a global health program now. We have a global

health program because the people who work in health and not

sports were not getting the job done for our population. We do

130,000 free health screenings a year. We have a program called

Special Olympics Special Smiles and based on 5,500 screenings of

our athletes, half of whom are under the age of 21, consider these

statistics. Twelve percent report pain in their mouths at the time

we are doing the screening. More than a third have obvious signs

of gingival infection. That means when you look at it, you can see

it. You don’t need a microscope. A fourth have obvious dental

decay. No X-rays, no taking a sharp pick and sticking it into the

tooth. You look and you see it. A quarter are missing teeth. Missing teeth, that is a reflection of a lack of continuous comprehensive

and early preventive and treatment care. Most of them, at least

half, have dental plaque that leads to oral infections of the soft and

hard tissues. Too many families say that they just don’t have ac-
57

cess to regular dental care for their children. One of ten of their

children is in need of urgent care.

We have also done some research into the issue of training

health professionals, physicians and dentists. We did a national

survey of dental and medical schools and post-graduate programs.

The vast majority of dental and medical students say they don’t

feel prepared to deal with the population of intellectual disabilities

when they graduate, and half or more of the deans tell us their students are not prepared to treat this population when they graduate, so that obviously begs the question of what needs to be done

in terms of professional education.

One of my most recent disappointments, a year and a half ago,

we started a Web-based provider directory where providers could

self-identify as willing to speak to people with intellectual disabilities or their parents about care, not a guarantee of treatment, not

a guarantee of price, just the willingness to speak about care.

There are well over a million health professionals in the United

States and over 150,000 dentists in the United States. We contacted the organizations in writing. We followed up by telephone

calls. We got a few articles in some magazines and journals but I

got to say, a year and a half later it is one of my greatest disappointments. Less than 1,000 people have signed up for this multidisciplinary provider Web site out of well over a million providers,

and I think at last count there was about 258 dentists that had

registered for this. This is certainly very, very disappointing for a

family who has a child with an intellectual disability.

Now, if I could show you one more picture here.

[Slide]

This is Mr. James Pearce. He is from Kentucky. He showed up

at a clinic in Lexington, Kentucky, looking like what he looks like

on the left. That reflects obvious dental disease, and even up on the

screen you don’t have to be a specialist to see that there are some

serious problems there, infected teeth, missing teeth, grossly infected soft tissues. James is ill. He has swelling around the eye

there. James in that picture is barely alive to a lot of people, and

James in that picture on the left is somebody who is not going to

be out in the front working in a business serving customers but

thanks to Dr. Henry Hood, a developmental medicine dentist who

took James on, they were able to do a very good job of dealing with

James’ dental needs. As I said, he has a moderate intellectual disability. James is doing very well now. James can stand out in front.

James is somebody who you could say, I could be a friend to James.

So I think you can see that what happened on the left didn’t happen overnight. That started clearly in his youth, went through his

adolescence, young adulthood and that is what we get. And this is

one of the problems with this population.

Mr. PALLONE. I am going to have to ask you to wrap up again

because you are over a minute too.

Dr. CORBIN. Then I will wrap up and say I endorse many of the

recommendations that I have heard here about how we can maintain an enhanced coverage for this population.

One thing I would really like you to look into is tell me why people with ID are not considered by the Federal Government to be

a medically underserved population and tell me why when a person
58

with intellectual disability in the fifth-grade intellectual level gets

kicked out of the EPSDT program when that person turns 21. It

makes absolutely no sense.

[The prepared statement of Dr. Corbin follows:]

TESTIMONY OF STEPHEN CORBIN

‘‘Sure, it would be nice to save the dental program, but, let’s face it: No one really

dies from a toothache.’’ I start out my testimony today paraphrasing a common

misperception that State legislatures have debated over the past three decades

about Medicaid dental programs. As you will see, this statement is both prescient

and false and underlies much of what is wrong with public dental programs in the

country today.

Good morning. I am Dr. Stephen Corbin, senior vice president for Constituent

Services and Support at Special Olympics International. I am honored to be invited

to participate in this important hearing on access to dental care. This is a matter

to which I have dedicated years of study and service and, I am loathe to admit, have

not seen the breakthrough progress that is so badly needed.

I understand that the recent tragic death of 12-year-old Deamonte Driver from

the complications of untreated dental decay has heightened awareness all the way

up to the halls of Congress that action is essential so that such a tragedy never happens again. As with so many things in society that are unjust and preventable, it

often takes a sudden tragedy to garner attention on long-standing tragedies. It appears that this may be such a case. If we can use the moment constructively, we

can honor the memory of a young child who became the victim of a failed system.

He and his family were ill-served. They did not have any control over the office policies of any healthcare providers or payment policies of a public financing system.

What we all need to realize is that Deamonte Driver not only died as a result

of the passive complicity of a failed system, but he suffered for months, possibly unaccounted years, from the chronic pain of infections that invaded his teeth and eventually spread to supporting structures, his blood stream and his brain. Was this

some exotic new infectious invader unknown to medical science? Was this a unique

case, such as had never been seen before? Was this a clinical condition for which

there is no known treatment? Sad to say, the answers to these questions are ‘‘no,

no and no!’’

If you were to track back to the cause of death in this instance, one could say

that the immediate cause of death was heart failure, precipitated after an infection

of the brain, arising out of a blood-borne infection, that moved from an infected pulp

of a tooth, that had been preceded by a deep carious lesion of the dentin of the

tooth, that was preceded by an extensive carious lesion of the enamel, that was preceded by a minimally invasive carious lesion of the enamel, that was preceded by

a barely detectable lesion of the enamel, that was preceded by an insensitive, incomplete and under funded medical system that never gave Deamonte Driver the

chance he needed. The chance that he needed to recover and survive.

The bottom line is there were numerous points along the way where this death

march could have been halted; where the infection could have been prevented or

intercepted early, or if late, still could have been tackled. And, a young life could

have been saved. Why did Deamonte Driver have to die from probably the most

common childhood affliction, from a disease that we have known how to prevent and

treat for more than 100 years? The answer to this question is complex, and I hope

that, by the end of this hearing, we will know enough to be able to move forward

with specific actions to change this situation permanently.

While I am a dentist and a Board Certified Public Health Dentist (a rare breed

indeed), I currently lead a global multi-disciplinary health program for persons with

intellectual disabilities, some 2.25 million Special Olympics athletes worldwide,

more than half under the age of 21. Special Olympics has stepped forward as a global leader to address the burden of unmet health needs for the more than 170 million

persons around the world, including 6 million in the United States, with intellectual

disabilities. Not because we were inclined to, as a sports organization, but because

we really had no choice. Where those who should have taken care of this have failed

to do so, Special Olympics stepped up. If you are not healthy, how can you successfully compete as an athlete at any level?

Our athletes have this in common wherever they live around the world: they all

have a permanent intellectual disability; they all demonstrate courage on the athletic field and acceptance of others; they all get sick on occasion and have health

challenges like everyone else; they care whether they are well or sick; when they

get sick, they need care; when they have tooth infections they hurt, even if they
59

don’t complain; when they get sick and can’t get the care they need, they suffer and

get sicker; when they finally do get care, too often it is as a last resort when their

options aren’t particularly good.

The way they differ from other people is that they tend to have few available resources for assistance; be underemployed or unemployed—thus, they tend not to

have private medical care, including dental insurance; no one expects them to be

pretty or handsome; no one expects that they need to have a bright white smile;

no one really worries if they are missing some of their front teeth; no one knows

if they have dental infections; no one knows if they are in pain from dental disease;

no one, or hardly anyone, feels responsible for helping them to achieve oral health.

Allow me to lay out some hard facts for you. Special Olympics, through its

Healthy Athletes’ Program, provides free health assessments and some care to more

than 130,000 Special Olympics athletes each year. We conduct more than 600 health

screening events in some 70 countries through the volunteer efforts of 13,000

healthcare professionals and students, supported through the generosity of the U.S.

Centers for Disease Control and Prevention, Lions Clubs International and several

corporate and academic partners. And let me thank the U.S. Congress for appropriations directed to our Healthy Athletes Program over the past 5 years that makes

this broader largesse possible.

We have accumulated across our seven Healthy Athletes screening disciplines,

without a doubt, the largest database of health status and health needs of persons

with intellectual disabilities that has ever existed. Our Special Smiles’ screening

protocol, one of the first disciplines implemented by Special Olympics, was established and validated by the U.S. Centers for Disease Prevention and Control nearly

a decade ago. Over the past 5 years alone, Special Olympics has conducted 530 Special Smiles screening events around the world. More than half of them have taken

place in the United States. We have provided about 12,500 dental screenings at

those events to athletes age 8 years and older.

In this day and age, where dental art and science can produce almost any smile

one could wish, consider the following. Of Special Olympics athletes (n=5447; average age 24 years) volunteering to participate in the Special Smiles Program in the

United States:

• Some 12 percent report pain in their mouths at the time of the screening;

• More than a third have obvious signs of gingival (gum) infection;

• Nearly a fourth have obvious dental decay (without probing or x-rays);

• One quarter are missing teeth, reflecting end-stage treatment of common dental

diseases (like Deamonte Driver);

• Too many have extensive dental plaque that leads to infection of oral tissues,

hard and soft, and ultimately, loss of teeth;

• And, too many athletes and families report that they have never been able to

secure a regular source of dental care for their child, even as nearly one in ten are

in need of ‘‘urgent’’ dental care.

Further, Special Olympics, the sports organization, has done research into the

preparation of dental and medical students in the United States to understand the

scope and quality of their professional education in dealing with the health needs

of people with intellectual disabilities. What did we find? The vast majority of dental and medical students do not feel adequately prepared to work with this population when they graduate from school. They say they want to be prepared, they

just are not. Further, the deans of dental and medical schools and graduate medical

and dental programs acknowledge that their graduates are unprepared to deal with

the needs of this population. If you survey a listing of continuing professional education courses that address the needs of the intellectual disabilities population, you

would be hard pressed to find any.

So, if healthcare professionals aren’t trained during their basic professional preparation, and there is no marketplace for continuing professional education in this

area, should we be surprised that people with intellectual disabilities and their families have difficulty in securing reliable, receptive, qualified sources of dental and

other healthcare for their children?

Here is one of my most recent disappointments. In September 2005, Special Olympics created a Web-based directory of healthcare providers nationwide. That is, we

created a user-friendly way for clinical providers in virtually all health disciplines

to identify themselves to persons with intellectual disabilities and their families as

willing to speak with them about the opportunity to receive health care. Not a guarantee to health care! Not a guaranteed price for health care! Just the opportunity

to discuss the opportunity for healthcare.

After a year and a half of proactive outreach to professional organizations, we

have fewer than 1,000 of the more than 1 million U.S. health professionals reg-
60

istered. Regarding dentistry, we have only 248 names listed (as of February 20,

2007) out of more than 150,000 dentists in America. If you were a person with intellectual disabilities seeking a chance to be healthy or a family with a child with intellectual disabilities, whom you worried about in terms of their health care, how

would all of this look?

I can tell you that Special Olympics Healthy Athletes is special its own right. It

is a place that athletes know is their place. And it is a place for volunteer

healthcare professionals where, for example, a 40-year veteran of clinical healthcare

delivery can say tearfully and happily, ‘‘Now I know why I invested 10 years in my

professional education and all of that money learning how to care for people.’’ In

the end, one can say that it ‘‘ain’t’’ brain surgery. But, for Deamonte Driver, it was

brain surgery when it didn’t have to be. When we do our Special Smiles dental

screenings, in addition to examining the teeth and oral cavity, providing dietary and

oral hygiene education, constructing mouth guards where appropriate and providing

preventive supplies, we also provide our athletes with a report card on their health,

as well as referral information for follow up where needed. Additionally, we provide

lists of community dental providers—lists that are always too short or where the

providers are not conveniently located. We do our best to get athletes connected

with locally-based providers for follow-up care but, sadly, our lists fall short of provider information despite all our efforts.

Now, I need to share a compelling image with you. This is Mr. James Pierce.

James is a person with a moderate intellectual disability. I can show you this picture because James gave us permission. James went to the dentist, Dr. Henry Hood

of the Underwood and Lee Clinic in Lexington, Kentucky, a special dentist and

friend of mine, with what you see. One does not have to be a dental professional

to look at the picture of James and see that he is sick. There is obvious extensive

dental disease, swelling around the eye, a contorted barely alive look. James did not

get this way overnight. This is the accumulated neglect of years of lack of proper

dental care combined with a lack of proper self care. Likely these problems started

in childhood or adolescence and just perpetuated. The bottom line is that James was

generally sick from dental infections. Is this a person who an employer would let

interact with customers, or is this a person that ‘‘belongs in the back,’’ if anywhere

at all.

Look at James today and tell me what you see. Is this someone who can be confident in meeting people; someone who could work out in front? Is this someone who

could succeed at some level? Is this someone you might be interested in knowing?

Dr. Hood, a knowledgeable and caring dental professional, took the time to do an

overall assessment of James and his oral health prognosis and provided the appropriate care. James is doing well and is employed. If James were your son, brother,

friend, which treatment and care would you have preferred? I don’t think we need

to count the votes.

Can we muster the backbone to do what is right; to match our scientific knowledge with our social responsibility? Would we allow or condone those of minimal

means to drive cars without seat belts because we might have to pay for them? Of

course not.

Why would we sacrifice childhoods and even lives for failure to implement the

most obvious of solutions?

Here are some suggestions that could help prevent future dental tragedies:

1. Change the culture around dental care for children. It should be as important

as getting kids immunized or making sure they wear seat belts in cars. Dental care

for children is universally needed.

2. The marketplace is not sensitive to many underserved populations as desirable

business targets. That is, reimbursement levels in public programs have not been

adequate to attract a significant increase in willing providers. In general, enhancements in public dental program reimbursement rates have been inadequate to

achieve the behavior change in providers that is necessary. Reimbursement levels

need to be enhanced to where they are market rational. Thus, we need to work to

build opportunities that work toward full access to dental care for children. Strategies could include incentive payments for individual providers or community-based

programs such as health centers when they reach target goals for providing care to

high-risk populations.

3. Public oral health programs that are operated by government entities need to

be designed to be proactive, not residual or reactive. It is not enough that a child

is eligible to have dental care paid for. There must be a premium on children getting

in for early and regular oral health care. Thus, public programs need additional resources, not just to pay dentists for care, but to provide a solid underpinning for

a program that can produce real results in increasing access and reducing the prevalence of dental need.
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4. Expand eligibility for children needing oral health care. Dental services should

not be elective for States under SCHIP. And, programs should be designed with

enough flexibility so that children are not constantly bounced off eligibility roles because of ‘‘hair trigger’’ provisions.

5. For special high risk populations, such as people with developmental disabilities, extra efforts are needed, including training of clinical providers and enhanced

reimbursement provisions that reflect the additional time that is sometimes required in patient management and treatment. And, while we are at it, why is it that

the population with developmental disabilities is not considered a ‘‘medically underserved’’ group by the Federal Government. That warrants some close follow up and

future discussions by this committee. How is it that when a child with an intellectual disability hits a certain age, even though their disability condition is permanent, they ‘‘age out’’ of their Medicaid (EPSDT) dental benefits in most States to

dramatically reduced ‘‘adult’’ service levels, if they are even available. Children with

intellectual disabilities who are fortunate to receive care under Medicaid or SCHIP,

all of a sudden get pushed out of the system—after years worth of investment of

public resources in their care. This makes no sense at any level.

6. Provide needed quality oversight, research and evaluation of policies concerning

dental care for children and vulnerable groups. This should be an ongoing responsibility of government. It is not enough to be responsive when a highly publicized

tragedy takes place.

These suggestions are not complete, but, hopefully, can help point our collaborative efforts in the right direction.

‘‘Deamonte Driver Saved’’—‘‘DDS.’’ It is possible if we commit ourselves to the

right actions. Thank you.

Mr. PALLONE. Thank you. Thanks a lot really for your testimony

and for your insight.

That concludes our statements by the witnesses, so we are now

going to now go to questions of the panel, and I will recognize myself to begin with that for 5 minutes.

We know that this hearing was brought about because of the

story of Diamonte Driver in the Washington Post recently a few

weeks ago and I think we all noted that this was a young boy who

died from an infection that spread to his brain after his infected

tooth went untreated. We also heard about another 6-year-old boy

in Mississippi who recently died as well due to an infection that

spread from an untreated infected tooth. Now, the pain that these

families have to feel from losing a child is obviously enormous but

our job is to make sure other families don’t have to experience this

tragic loss, and many of you have commented on that. I don’t know

all the details of Diamonte Driver but I know that his Medicaid

coverage had lapsed and so certainly one of the issues would be

about gaps in coverage. Some of you have talked about gaps in coverage and the need to shore up existing public programs. Others

have talked about the lack of reimbursement rate. There are many

factors that go into the problems that we are dealing with here.

I was going to ask Dr. Edelstein, I know you are a little bit familiar with Diamonte, if you could give us your assessment of how

systems broke down to serve him and what could have been done

to prevent this from happening by reference to him.

Dr. EDELSTEIN. Thank you for your question. The obvious and

first-line systems failures are the ones that you have noted. Continuous eligibility would have made it possible for him to retain his

Medicaid benefit even while in a homeless shelter. Care assurance

systems that make sure that dental care is actually available and

not just covered would have made sure there were places he could

have gone, and all the various people who came in contact with

him, the lawyers, social workers, people at the homeless shelter as
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well as school nurses, teachers and others who have come in contact with him could have made referral, if there were a coordinated

system of care in place that is already required by EPSDT legislation.

But then there is a secondary level of systems failures that are

not as obvious, educational systems failures. So few parents yet

know what NIH discovered 40 years ago, that tooth decay is an infectious and transmissible disease acquired by age 1 or 2 and that

real prevention needs to start very early. Public information systems, work force systems many of you have mentioned that there

is need for additional training. HRSA for example in its title VII

program that Ms. DeGette mentioned does train pediatric dentists

but it does not, as it does for physicians, allow curriculum development and faculty support, so those are systems that would address

the problem Dr. Corbin mentioned about preparedness of our future dentists.

Early intervention systems—HRSA supports an early child comprehensive system that Mr. Scheppach mentioned relates to early

childhood development. There is a place for early childhood oral

health care there. And lastly, safety-net systems of care. The rural

health centers, the community health centers, the school-based

health clinics, they are all very, very small and the local community emergency room does not provide definitive care. So all of

these systems had to come together for this monumental failure for

these children.

Mr. PALLONE. Now, he was in a homeless shelter and their Medicaid coverage had lapsed from what I understand. I know they

were covered by Medicaid. So this whole idea of continuous health

coverage under Medicaid or SCHIP, breaks in coverage due to

changes in income or whatever, I think that would come into play.

I was just going to ask Dr. Roth because I know my time is running out, do you have any recommendations about maintaining coverage? We talk about continuous eligibility, a guarantee of coverage

for a full year or presumptive eligibility, allowing a predetermination of eligibility. Did you want to comment on those gaps in coverage or ways to prevent that?

Dr. ROTH. There certainly are ways. It doesn’t take anyone to figure out that you need to be continuously in a dental home to have

good oral health and maintain your oral health. We strongly believe that a family has to become part of a dental system and you

need to train the parents as well as get the children in for ongoing

dental care. So it is simple. It needs the dollars to support the system and patients need access to get into that dental system.

Mr. PALLONE. You mentioned the reimbursement rate under

Medicaid. Did you just want to comment briefly on that, I mean,

because in his case, Diamonte’s, it seems like there was a dentist

that was able to take him but there was no coverage, but you seem

to feel that there are other cases where the reimbursement rate becomes a block.

Dr. ROTH. Well, you do have many dentists around the country

that are not Medicaid providers and the biggest reason for that is

the reimbursement level is so low, it doesn’t even cover the cost of

overhead to provide the dental care. So I would encourage Congress

to provide adequate funding of dental programs. And we are look-
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ing to expand the system to provide another person on the dental

team, the community health coordinator, which is simply a social

worker, if you want to think of it that way, a person to go into the

community that can do the social skills needed to educate the public as well as some clinical skills to their skill sets, if you will. So

I would encourage you to look at our community dental health coordinator as another mid-level provider that can really answer the

access issue from the community level as well as from providing

care and clinical skills.

Mr. PALLONE. Thank you.

Mr. Deal.

Mr. DEAL. Thank you, Mr. Chairman.

I am going to move quickly and I would ask my witnesses to do

the same, so if they could. First of all, Mr. Scheppach, the Governors I know supported the provision that was in the DRA allowing them the flexibility to provide benchmark plans for their Medicaid population. Recently the members of this committee received a

letter from Governor Ernie Fletcher of Kentucky concerned about

a provision that was originally in the Iraq supplemental and I

think it was taken out in the final version that he felt would jeopardize that ability and that flexibility for Governors. Is that still an

important issue, and if so, why?

Mr. SCHEPPACH. Well, yes, it is. I think we had a number of

States, West Virginia, Idaho as well as Kentucky who have actually

taken that provision and really tried to do some preventive care so

that they can better manage long-term chronic illnesses, so that

flexibility is still an important issue to Governors.

Mr. DEAL. Thank you.

Mr. Chairman, I would unanimous consent that the letter from

Governor Fletcher be made a part of the record. I think we have

all received copies of it.

Let me quickly move to highlight what I consider to be important

here. Diamonte Driver is the case that we all cite as the reason we

are here and I have heard a variety of things. I have read your testimony as I have heard your testimony. It all generally starts out

with the system failed him, the systems failed him. I believe Dr.

Edelstein just enumerated who failed him, the lawyers, the teachers, the social workers, the homeless shelter workers and everyone.

I never heard the mother or the parents mentioned as the ones

who failed him. In most of our households, we assume that responsibility as parents. If it lapsed, then whose fault was it? It wasn’t

the child’s fault. It was the parents’ fault for not signing up an eligible child. I wonder if we had had Diamonte dying from an internal bleeding that had occurred because he fell while he was in the

mother’s presence and he had died from that, we would have probably had a child abuse case brought against the mother but here

we blame the systems. We never put personal responsibility in the

equation, and I think it is an important ingredient that has been

overlooked.

But let me hit some of the things I thought you ought to maybe

elaborate on if we have time to do it. First of all is, we have heard

reimbursement rates under Medicaid, under SCHIP, et cetera. One

question I would have, are the reimbursement rates for dentists

disproportionately less than for doctors treating in the medical en-
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vironment, and is the ratio of dentists who are signed up in the

Medicaid programs disproportionately low as a percentage of the

dental population versus the medical enrollment there? Who would

care to comment on that? Dr. Edelstein.

Dr. EDELSTEIN. I would be happy to. The answer to both of your

questions is yes. The rates are lower relative to other providers but

there are problems with Medicaid payments across the board. If

you compare Federal Government rates for physicians in Medicare

with the same services in Medicaid, you can see that differential.

But I want to take a moment to agree with you wholeheartedly

about parental responsibility. There is no question. The question

becomes when parents then do seek care, which is perhaps not the

case we were addressing today but when parents then do seek care,

are they able to obtain it. Too often the answer is no.

Mr. DEAL. Let me go to that because I think that is the next

thing. The number of available dentists, I think Dr. Mosca’s testimony is very informative as to dental schools, the number that are

there, the number that are producing. I used the statistic in my

State, we have 240 retiring every year, only producing 60 in my

State dental schools, as I understand it. That is a huge problem,

the number of available dentists. What do we do about that? Dr.

Mosca, you are probably an expert on that.

Dr. MOSCA. Well, let me just make an additional comment. The

child that I mentioned in Clarksdale who had the dental abscesses

this past Friday actually had access to the care system but did not

receive the treatment that the child needed, and so I would have

to agree with Dr. Edelstein that——

Mr. DEAL. In fact, you point out that EPSDT mandates dental

coverage for children and that only one out of every four children

under Medicaid actually receives those services. Is that right?

Dr. MOSCA. Correct.

Mr. DEAL. OK.

Dr. MOSCA. But I think that in terms of the numbers, I think

that the other layer that we add on to this is the knowledge and

skills. For example, when managing the youngest and the oldest

populations, we rely on the title VII residency training programs

to impart that type of educational experience. It is important to understand how to treat young, young kids and elders because there

are some issues that interface with the level of skills.

Mr. DEAL. My time is running out. Let me just enumerate some

other things I think are important. The geographic distribution of

dentists, many of you have alluded to that. The number of dentists

who are available in community health settings or other clinic settings, I think all of those at distribution of services is a key ingredient and unfortunately, my time is up.

Mr. PALLONE. Mr. Green.

Mr. GREEN. Thank you, Mr. Chairman, and following up our

ranking member, I think the actual case we are talking about, I

think the mother did apply for the Medicaid extension. She lost it

because she was in a homeless shelter and I think the paperwork

may have gone back to a homeless shelter instead of her new residence. Again, my concern is that I have seen what happens. They

are trying to expand Medicaid programs and SCHIP in a lot of our
65

States and they cut that expansion because they really don’t want

to sign up in the name of flexibility a lot more children.

Let me talk about, I am a longtime supporter of health centers

programs and we have introduced legislation to reauthorize it until

2012. One of the key Federal requirements of health centers is they

provide a full range of primary and preventive care including dental care. In fact, in 2005, health centers encountered 1.7 million

visits for preventive dental exams. While the requirement to provide access to dental care can be met through referral arrangements, 73 percent of the health centers provide preventive dental

care either onsite or through contracting arrangements.

Ms. Farrell, you mentioned health centers as recipients of infrastructure grants resulting from Michigan’s dental taskforce recommendations. Can you or the other witnesses speak to the role

health centers play in a safety-net dental provider?

Additionally, Dr. Edelstein, can you speak to the effectiveness of

contracting arrangements between dentists and health centers and

any recommendations you would have.

And lastly, Dr. Roth, when you talk about the community health

coordinator in your testimony, that is not just a social worker, that

is actually a provider that is licensed by the State to be able to do

exams and things like that but also go out and do preventive

health care. So it is a long question about how we can we better

relate to health FQHCs with the dental requirement because my

FQHCs, the few we have, it is typically pediatrics, a lot of children,

and the children are the ones who need the dental care. You will

have 3 minutes to answer that long question.

Ms. FARRELL. Yes. Along with my dental responsibilities, one of

my responsibilities is also our community health centers, all our

cost-based reimbursement policies, our safety-net providers, so I

am very aware of the community health centers in the State of

Michigan. I believe we have 27 federally qualified health centers

with 155 sites throughout the State. Some of them are rural, some

of them are urban, but the majority of them do offer dental care.

When we offer these infrastructure grants, we did 32 sites. Out of

those 32 sites, 15 of them went to, the grants went to community

health centers so they expanded their dental operatories and we

have our Medicaid population and the uninsured in our SCHIP,

they treat all three of those. In addition, we have also partnered

with University of Michigan and the dental students and we rotate

students through community health centers to make them aware

of what is available so we can try to get them to treat and come

back and be providers into that community, which has developed

into a win-win situation where we have had at least five or six dental students from the University of Michigan become providers at

community health centers.

Mr. GREEN. Dr. Edelstein?

Dr. EDELSTEIN. Mr. Green, you mentioned that 73 percent of

community health center grantees have dental programs but in fact

it is far fewer sites that actually have programs and many of the

sites——

Mr. GREEN. Mostly contracting, in all honesty.

Dr. EDELSTEIN. Right, and so what we end up with is a fair number of community health center sites that don’t actually have the
66

capacity to deliver care, and you mentioned contracting as a solution for that. CMS, then HCVA, HRSA, the American Dental Association and the National Association of Community Health Centers

worked on developing a contracting manual that would allow private dentists to provide services to community health center patients. What Congress needs to do is to clarify with the agencies

that that in fact is legal to do because there has been controversy

amongst the primary care associations. So with that clarification,

that approach that you have recommended could expand dramatically.

Mr. GREEN. Dr. Roth, on the community health coordinator, and

I know in your answer to another question you talked about a social worker, which is great, but also it is a provider. This person

would be a provider?

Dr. ROTH. That person would provide clinical skills so they will

do some—very many preventive services. They are not going to be

a licensed provider so it is not another level of a dental hygienist

or a dentist. It is not a licensed person. It is a person that will

work under the scope and under the auspices of a dentist. In a

community health center, they can work offsite so they don’t need

to have a dentist onsite necessarily to work. But they are not licensed, and I want to make that clear right from the start.

Mr. GREEN. OK.

Dr. ROTH. They will have an educational program that takes

about 2 years and we have that ready to start this fall. So we are

looking to pilot those community health coordinators and get them

into community health centers and into schools beginning this fall

in their educational programs. I would encourage Congress to look

at possibly funding some of those pilot sites that we are looking to

do. It is not a lot of money but it certainly will make an enormous

impact in expanding the efficiencies of dental care that has reached

into the communities as well as expanding the dental network of

people that can provide care.

If I can just answer the community health center issue, less than

1 percent of all the practicing dentists, which is 162,000 practicing

dentists in the country, are employed in a community health center. If we can expand that network by providing the dentistry that

needs to be done by going into the communities and partnering and

contracting out, as Dr. Edelstein promoted, that really is an answer

to using a dental workforce that is out there available. They need

to be compensated and need to be able to work, the work is the

problem.

Mr. PALLONE. Next is Dr. Burgess.

Mr. BURGESS. Thank you.

Just to follow up on that, Dr. Roth, Mr. Deal referenced the large

number of dentists that are retiring in Georgia every year. If we

modify the Federal Tort Claims Act somewhat to allow those retired dentists to come into the community health centers and practice, would that not be a beneficial thing? Yes or no will suffice.

Dr. ROTH. Absolutely.

Mr. BURGESS. Thank you.

Let me ask Dr. Mosca a couple of questions because I really appreciate your testimony. I thought it was so critical and of course,

Baylor College of Dentistry is down near my—not in my district
67

but near my area. They, as I understand, provide a significant

amount of low-cost or free care, not just to children but to all patients, to all comers. Other schools provide the same service, I

would assume? Dr. Mosca?

Dr. MOSCA. I am sorry. I thought you were talking to Dr. Roth.

Mr. BURGESS. The care provided by the colleges of dentistry, they

play a big role I know in the Dallas area, Baylor College of Dentistry does and I have even heard from members of your profession

coming to talk to me about nursing home patients who also pose

some of these same problems and are typically underserved but a

lot of this falls to the dental school. Is that not correct?

Dr. MOSCA. That is correct.

Mr. BURGESS. Well, do we have enough?

Dr. MOSCA. Do we have enough dental schools?

Mr. BURGESS. Correct.

Dr. MOSCA. Well, we actually have——

Mr. BURGESS. I asked you first.

Dr. MOSCA. We actually have a number of schools. There have

actually been six new dental schools that are in the process of

opening. The Arizona School of Health Services, the University of

Nevada-Las Vegas opened in 2002, Nova Southeastern University

in 1997, and actually there is a predicted decrease in services up

until I think 2020 and then at that point there will actually be an

increase in providers, and that is because of closing of schools that

occurred a while back, so we are kind of trying to catch up with

the closure of the previous school but these new schools should add

to the workforce.

Mr. BURGESS. We have reached the nadir, but of those people

that are going to be entering the workforce, do we have a concept

of how many will be entering pediadontics and general dentistry as

opposed to the higher reimbursement subspecialties of dentistry?

Dr. MOSCA. About half of the graduates, I mentioned that 4,500

graduates are released each year, and about half, or 2,800, go into

either general dentistry or some specialty training.

Mr. BURGESS. Tell me this——

Dr. MOSCA. The title VII funding actually does allow the dental

schools to increase and support that type of training.

Mr. BURGESS. My observation has been that most people go into

the practice of medicine close to where they trained because they

know the community and they know the other providers in the

area. Is the same true of where dentists choose to practice?

Dr. MOSCA. In Mississippi, about 70 percent of our schools’ graduates have stayed in the State.

Mr. BURGESS. So they do tend to stay close to home. What type

of location decisions are made based on the prospects of perhaps

low reimbursement or a population of low health literacy where the

outcomes may not be as good?

Dr. MOSCA. That is actually an issue that we are trying to solve

within the State of Mississippi. By working with community partners, we are trying to incentivize providers to locate in various

areas. I was just at a meeting 2 weeks ago——

Mr. BURGESS. If I can interrupt you, how do you do that? How

do you provide that incentive?
68

Dr. MOSCA. At the meeting I was at 2 weeks ago, we had the

mayor, we had the county supervisor. We convened the local civic

leadership to actually——

Mr. BURGESS. So the community provides some of that incentive?

Dr. MOSCA. To try to, right, for——

Mr. BURGESS. Pardon me for interrupting, but the chairman has

an iron fist with that gavel and I have to ask some other questions.

You were starting to reference data reporting in your testimony.

What type of data do you want to see and what will you do with

the data as you collect it?

Dr. MOSCA. Well, the data that we have collected has been very

helpful in promoting discussions around policy and I would have to

concur with Dr. Edelstein that we need to look at the outcomes of

the SCHIP programs and capture that data.

Mr. BURGESS. And when will that type of data be available to us

here on this side of the dais?

Dr. MOSCA. I can’t answer that question but I could certainly

provide that answer for you.

Mr. BURGESS. And I think the committee would genuinely appreciate that.

Let me go with what little time I have left to Dr. Scheppach.

Governor Warner sat at that very table about a year and a half ago

and said that Medicaid was on the road to a meltdown because of

the costs and the expansion of costs of the Medicaid program. Do

you think that statement is still valid today or have we fixed it?

Mr. SCHEPPACH. Yes, I do. Even though the growth in Medicaid——

Mr. BURGESS. We fixed it?

Mr. SCHEPPACH. No, we did not fix it.

Mr. BURGESS. And you talked about some of the coverage initiatives that are going on in States to affordable health insurance and

you kind of ran out of time there and you are going to run out of

time again, but can you kind of explain how Medicaid and SCHIP

fit into these State initiatives?

Mr. SCHEPPACH. Well, I think it is important to maintain the

flexibility that we currently have because I think the key component of this is that the States are creating connectors for the small

market.

Mr. BURGESS. And do you think that the flexibility that we provided has allowed those States, Massachusetts, California, to some

degree even Texas to begin to tinker with those and provide those

types of benefits?

Mr. SCHEPPACH. That is right, and that is a benefit that you can

also provide to small business and so on. You can stabilize that

small market. If you start doing independent additional benefits, it

is going to create an obstacle.

Mr. BURGESS. Thank you.

Mr. PALLONE. Thank you, Dr. Burgess.

Ms. DeGette.

Ms. DEGETTE. Thank you very much, Mr. Chairman.

I was sitting here thinking about how important pediatric dental

care is and how it can really prevent so many bigger problems, not

just in the long run but immediately, so I had my staff pull the

SCHIP statute. It is always dangerous when the members of Con-
69

gress start actually reading the statutes, and one of the required

coverages right now under SCHIP is well-baby and well-child care

including age-appropriate immunizations. That is required in all 50

States right now. And so when I look at that, it seems to me that

dental care should be included in that, and so then I was reading

Mr. Scheppach’s testimony about how you think that flexibility

should be maintained with the States in pediatric dental care

under SCHIP. I wanted to ask you a couple of questions about that,

because in reading your testimony, it seems that the main flexibility you are talking about, Mr. Scheppach, is flexibility in how that

dental care is offered. Would that be accurate? I mean, you are not

really saying on behalf of the Governors that we should allow

States flexibility in whether to offer pediatric dental care, just in

how they deliver that?

Mr. SCHEPPACH. Well, I think right now it is an optional benefit,

and I think what we are saying, it should probably continue as an

optional benefit.

Ms. DEGETTE. Well, it is an optional benefit right now but all of

the States up until now have offered dental care, correct?

Mr. SCHEPPACH. That is right, but they have different restrictions essentially on how much they are willing to do, the number

of treatments and that type of thing.

Ms. DEGETTE. Right, but Mr. Green and I are both concerned

about this because his State of Texas is now talking about dropping

dental care for cost concerns and other States like Colorado and

others have talked about it too. So I think we can all agree, all the

whole panel agrees that pediatric dental care can be very cost-effective as well as humane for the kids, right?

Well, I will ask you, Dr. Edelstein. Pediatric dental care can be

very cost-effective and also humane for the kids?

Dr. EDELSTEIN. Cost-effective, humane and essential. I cannot

understand how the mouth can be carved out of the rest of the

body and put restrictions on how much care. It is like saying that

we can diagnose a problem but not treat it. We can do $175 worth

of your appendicitis but we are going to stop there and just close

you up because we have hit the benefit. It is the only service that

is treated as though it weren’t part of the child’s body.

Ms. DEGETTE. Well, and actually that is the other thing. Just

getting back to Mr. Scheppach though, I understand your point

about flexibility and how you offer it but if all the States are doing

it now, I don’t suppose there would be a big objection by the Governors if we just said you have to offer dental care under SCHIP

but still allowed from flexibility.

Mr. SCHEPPACH. Well, I think what would happen essentially is

that wouldn’t allow flexibility, you would set certain standards

around that benefit package and that would be relatively costly

and it would be hard to package it in managed care and combine

it with health care benefits so it is not—I don’t think the legislation would ever say provide health care benefits. You would put

certain standards around it in terms of the numbers of visits and

what is applicable.

Ms. DEGETTE. Well, all the States offer dental so there is going

to be conditions around that. Now, I would really hope the Governors association would work with us as we reauthorize SCHIP
70

because if everybody is offering dental and if what Dr. Edelstein

says is true, and we all believe it, which is dental care is essential

to this and it is also cost effective, I think it would be my inclination and I bet you I can speak for a lot of my fellow panel to include it but we do want to allow the States flexibility to make it

work.

Dr. Edelstein, I wanted to ask you another question, which is related to what you just said about the idea of dentistry being related

to the whole body. I think maybe based on my experiences, the

mother of two—I was watching Mr. Pallone’s kids. We have had

many investments not only into pediatric dentistry but also orthodontia, which are ongoing to this date, but I think a lot of parents

even in my socioeconomic bracket don’t realize the importance of

pediatric dentistry and of taking their kids to the dentist on a regular basis. Would you agree with that?

Dr. EDELSTEIN. It does vary significantly across populations by

education and by opportunity and by their own experience but certainly the value of pediatric dental care is something that has only

grown in awareness in recent years.

Ms. DEGETTE. So for someone to blame the mother of this young

boy who died from an abscessed tooth who was living in a homeless

shelter, I think that is kind of an unfair placement of the blame.

I don’t know if you have a comment on that.

Dr. EDELSTEIN. The only comment I have is specific to this particular child and that is that his presentation was one that did not

scream out initially dental abscess. It took the skills of diagnosticians of dentists and physicians together to identify the original

cause of this problem and that is an indication of how complex it

can be and how the teeth are indeed part of the body. Symptoms

can show up differently than expected.

Ms. DEGETTE. And I would also say I think we need to have a

global—this is a topic for maybe later today or another day. We

need to have much more public awareness of the importance of pediatric dentistry across all socioeconomic groups.

Dr. EDELSTEIN. Particularly starting at age 1 as recommended by

the pediatricians and by the pediatric dentists because that is

when the disease begins.

Ms. DEGETTE. Right. Thank you very much.

Mr. PALLONE. Thank you.

Mr. Murphy of Pennsylvania.

Mr. MURPHY. Thank you, Mr. Chairman.

A couple quick questions. I know in my role as a psychologist for

many years I would sometimes be contacted by dentists who felt

that a child because of their substantial learning problems or behavior problems might require some extra care in preparation for

a dental visit, but I must admit I am not clear on whether or not

these things are handled appropriately by any payments in the

SCHIP program or Medicaid or anything else. Can someone comment on these sorts of needs and is that something that the reimbursement rates are also not adequate to handle?

Dr. ROTH. I can comment on that. You are right, there are some

children that do have special needs whether it is hospitalization for

extensive dental care or simply a mild sedative to make the procedures easier, and there is not coverage for that in most States.
71

Mr. MURPHY. So that is an expense the dentists themselves have

to take care of out of their own pocket in order to do that?

Dr. ROTH. Yes, or the parents choose not to use comfortable

means to deliver the dental care.

Mr. MURPHY. Which of course can mean child’s dental care is

even more aversive.

Second, there have been some things written in the paper about

the amount of paperwork and bureaucracy that is necessary for a

dentist to fill out if they want to participate in these programs. Are

these really mountains of paper? Can someone comment on that?

What do we have and is there a way of making it more effective?

I see Ms. Farrell reaching for her button. Yes?

Ms. FARRELL. We have heard those complaints for a number of

years in Michigan. We have tried to address that administrative

burden. We have streamlined our provider enrollment form. Of

course, with HIPAA and the administrative simplifications, we

have had to go to national code sets. We are going to national claim

forms, which is the ADA claim form, the paper claim form or electronic version. So there are lots of steps that we have tried to, and

I would say the majority of States speaking also in my Medicaid/

SCHIP dental association role. We have all looked at trying to decrease that administrative burden on the dentists to try to get

them to become participants.

Mr. MURPHY. I would hope that could all be simplified.

Dr. Roth?

Dr. ROTH. Well, if I can just add to that quickly. It is not simply

signing up to be a Medicaid provider but it is the claim forms that

you have to fill out when you try to provide the services. They are

not using the standard ADA claim form, which I use for all my

other insurance company forms, so they make the system much

more difficult than it needs to be.

Mr. MURPHY. Do they allow for any electronic forms on this——

Dr. ROTH. They do, but it is also very difficult to get into that

entire system from the Medicaid system itself.

Mr. MURPHY. I know whenever I would fill out forms too, I would

always ask myself how much of this information is really necessary

to make a decision on whether or not to cover this child, and outside of the name, I am not sure how much anybody really reviewed.

Let me ask another question here. A comment was made earlier

about 73 percent of community health centers offer dentistry in

them. How much of this is really—I mean, just to have someone

there doesn’t necessarily mean they can take care of all the demands and needs.

Dr. Edelstein, can you perhaps comment on, I had seen previous

studies that talked about a shortage of psychiatrists, internists,

family physicians and OB/GYNs at community health centers.

What is the shortage of the demands versus what we have needs

for there with dentists at community health centers?

Dr. EDELSTEIN. Yes, let me please clarify that 73 percent. That

is 73 percent of health center grantees but many grantees have

multiple sites so if one site has a dental program and five or six

additional sites do not——

Mr. MURPHY. So that could actually be a skewed upward number?
72

Dr. EDELSTEIN. Very much so.

Mr. MURPHY. OK.

Dr. EDELSTEIN. And it is really estimated that it is closer to half

of community health centers have a dental program——

Mr. MURPHY. So they may have a dentist there but can they fill

the needs of the patients who need them?

Dr. EDELSTEIN. Absolutely not. The community health centers

have prioritized relative to children. The community health centers

in many States have chosen to prioritize uninsured adults who

have no other recourse whereas children do have Medicaid coverage. Medicaid coverage for adults does not include dental services

in the majority of States so the community health centers become

the site of service of last resort for adults. That has crowded out

the kids.

Mr. MURPHY. One of the things that I love about community

health centers is unlike I think any other thing we have in pediatrics, it is in one building where everybody knows each other, where

at the moment a pediatrician, for example, can be meeting with the

family, he can say let me introduce you to the dentist who we are

going to make another appointment for or the psychologist or social

worker or someone else to do that, which is a huge asset. I had

mentioned my bill before, H.R. 1626. I doubt if you have had a

chance to read it, but I hope you would take a look at that in that

it really does allow physicians and dentists and others to volunteer.

Have you ever taken a poll of how many dentists semi-retired or

active would be willing to give some of their time? Does anyone

know that?

Dr. EDELSTEIN. I don’t think that figure is known but it is part

of the volunteer solution, but as we recognize, charitable care and

volunteer care is not a system of care but it can be part of a gateway into contract care in private offices that would work very well

for the majority of FQHC patients.

Mr. MURPHY. Thank you very much.

Mr. Chairman, thank you so much.

Mr. PALLONE. Thank you.

Mrs. Capps.

Mrs. CAPPS. Thank you again. This has been a very fruitful

panel. I just hope we can pick up on a lot of these things. Our

ranking member asked some very pointed questions about parental

responsibility, which I appreciate, and that is one of the topics, the

areas that I think we should go into. I just recall from my days as

a school nurse with parents so concerned about what to do about

this child in pain crying out in the night. That certainly was a high

priority for them. In many parts of my district, most of my district

at that time, it was over 100 miles to go to a dentist who would

take Medicaid. A pediatric dentist was even further and the waiting lists were months and months long. I know some steps have

been taken to remediate that but I also know parents would be so

motivated, they would take whatever cash they had and go to the

dentist in the Yellow Pages and wouldn’t have enough and then it

is rent or food. I mean, these are really tough choices for many of

our families.

Dr. Edelstein, I wanted to give you a chance to expand on your

points about prevention, overall well-being and the cost-effective-
73

ness of early dental care for children. It always pained me as a

school nurse to see kids losing so much valuable class time and not

able to concentrate on their studies. Can you share any information

about how often oral disease accounts for absenteeism, and the reverse, what are the ways that you can document that it is important to a child’s participation in education?

Dr. EDELSTEIN. I think your point earlier that many children are

in the classroom but distracted, they are in the classroom but unable to focus, they are in the classroom but feeling dental pain

intermittently that really does cause them to act out and not perform well as students, and that dental pain doesn’t go home when

they go home from school. It only becomes a problem throughout

the day, and that kind of chronic distraction long before we get to

the kind of infection that we have been talking about earlier.

But you did mention cost-effectiveness of prevention and I wanted to cite a couple of statistics about the tremendous cost-effectiveness so that the Governors and others will consider how much benefit can be gained and cost savings can be made rather than new

expenditures in the Medicaid and SCHIP program. One recent

study from the University of North Carolina pointed out that children who start care at age 1 as currently recommended by pediatricians and pediatric dentists, over the next 5 years consume 40 percent less cost for care than had they not started at age 1 and they

utilize the emergency room less. That is dramatic. Children with

coverage are 30 percent more likely to get preventive care, and routine care instead of emergency care. That Texas study that was illustrated in my slide shows that the average cost for an admission

over a period of multiple years in Texas at discounted rates paid

to the hospital by Medicaid was $6,500. The emergency room visits

were $230 for the same kind of presentation but resulted in no definitive care, and the same kind of care could have been provided

in a dental office for somewhere between $50 and $80. So the opportunity to utilize the lowest cost, most effective, most preventive

site is often overlooked.

Mrs. CAPPS. Just to wrap this up, we have this opportunity, a

unique one as we reauthorize SCHIP, I don’t want us to lose that

change. This is the kind of data then that we can have to help us

understand that access to dental care is really cost-effective. Do

you want to just expand further and then I will open it up if there

is——

Dr. EDELSTEIN. Well, it is our pleasure at the Children’s Dental

Health Project to provide these kinds of data. Almost all of them

are derived from Federal studies. Those that are not are derived

from State studies and some from university studies. We have wellreliable information that can help make sound policy.

Mrs. CAPPS. Anyone else want to pick up on that for the last 45

seconds? Thank you.

Dr. ROTH. I would just like to encourage you to have States look

at those models of care that are successful. You have got the Michigan model and you have got Smile Alabama and TennCare. You

have got some great programs out there that are working and

working very well for the children and the providers in the States.

It doesn’t take that much more money but it is money that is used

wisely in combination with government and the dental community
74

all coming together. So I would encourage you to make that part

of your mission, adequate funding, and then look at the models

that work.

Mrs. CAPPS. Thank you very much. I will yield back.

Mr. PALLONE. Thank you.

The gentlewoman from Tennessee.

Mrs. BLACKBURN. Thank you, Mr. Chairman, and thank you to

each of you for your time today.

Dr. Scheppach, I would like to come to you, if I may, because I

appreciated your testimony, and even though your testimony ran

long, I love the fact that you have a great enthusiasm for what you

do and that you seem to have such a heart for being certain that

the programs work well for our State. I think that that is the area

where the rubber meets the road and our States and our health

care agencies within our States are the ones that are working with

those local communities and keeping the focus on how we preserve

access to health care and how we preserve access to those components of a healthy lifestyle that our constituents all want, and I

noted in your testimony, you had made a statement, if the States

are required to meet new Federal benefit mandates in either Medicaid or SCHIP, they will have to spend more money per individual

currently covered in these programs. Increased costs will force the

States to redirect funds that could have been used to fund other

affordable health insurance initiatives, and many times I think

those of us at the Federal level who look at how we structure a program forget that any time there is a mandate that goes out, that

is paperwork for the provider, it is paperwork for the insurance

company, it is paperwork for the State that is the conduit to those

funds, and when you put that money into paperwork, it is not

going into health care, and what I want to do is have you speak

a little bit to flexibility and your concerns about reducing flexibility

in these programs and the impact you see that a reduction in flexibility and increases in mandates, what that would do to our States

and some of the innovative programs.

Mr. SCHEPPACH. Well, as I indicated before, I think we are at a

basic tipping point with respect to States moving forward and actually doing comprehensive health care reform. I think that within

the next 2 to 3 years, we have already had four who have enacted

it, I think we will have 6, 8, 10 more that will enact it. Some of

those will be big States. We will begin to find out whether personal

mandates work. We will begin to find out whether employer mandates work, whether connectors work and so on. I think that the

root to national reform is through the 50 State houses and we are

only going to be able to get Federal reform after we prove what

works at the State level.

With respect to the mandates, again, you would like to make a

basic public policy decision, are we going to try to have a basic benefit package for the entire population, get everybody in with some

level of coverage or are we going to make a decision to leave a

whole bunch of people out and create a more robust benefit package for certain populations. We talk a lot about quality in these

particular programs. I think we need quality standards across the

board in health care and dental, not necessarily for the SCHIP program but for the entire thing. What we are doing is setting stand-
75

ards around individual programs, which means we keep selective

programs operating rather than trying to get at an efficient market. What we need to do is let the States move forward, help them

to get everybody in the system, work out the bugs, because I think

they will give a direction for national health care reform. When you

put on specific benefit mandates, States aren’t going to be able to

get universal care. So I think you have to make a policy choice: are

we going to get to universal more quickly and allow the States to

provide the leadership or are we going to provide more robust benefits for certain populations.

Mrs. BLACKBURN. So what you are saying is, we have got the

four States that have programs out there that are exercising some

innovation and you have got six to eight States that you feel like

are going to be ready to move forward and implement programs

but if we come in with the mandates and change the structure,

then all of that work just goes out the window?

Mr. SCHEPPACH. I would say it makes it more difficult. I think

there are other places that the Congress can help. I think we need

help on sort of setting up alliances or connectors. I think we need

help on sort of quality measures, price transparency, health IT. We

need to set up an infrastructure so that consumers can make decisions around this rather than concentrating on expanding an individual program.

Mrs. BLACKBURN. Those initiatives that you just mentioned,

those items that you just listed where you need help, are any of

the States leading on innovation in those specific areas?

Mr. SCHEPPACH. A lot of States are. Yes. I mean, the health IT,

we have been working with HHS. We have made contracts to 35

States to work with their stakeholders in those particular States so

that they can deal with the security issues, the confidentiality

issues and so on. So all of these areas we have got States moving:

quality, price transparency, health IT.

Mrs. BLACKBURN. Anybody else want to add something to that

before we leave that? My time is about up.

Dr. Edelstein, go ahead.

Dr. EDELSTEIN. Yes, I appreciate the opportunity. Thank you. I

completely agree with Mr. Scheppach and with the Governors that

basic health care should be the goal, basic health care and not

extra benefits. I am simply saying as we discussed yesterday that

dental care is a component of basic health care and agreeing with

Ms. DeGette that well-child, well-baby care inherently must include oral health care.

Mrs. BLACKBURN. I yield back.

Mr. PALLONE. Thank you. And that concludes all questions for

the first panel. I want to thank you all. I thought it was very insightful and thank you for your participation. We appreciate it.

I would ask the next panel to come forward. I am going to ask

our second panel to be seated so we can continue. And again, I am

going to introduce you all. Welcome. From left to right, we will get

all our signs in place. First on my left is Dr. David Krol, who is

the associate professor of pediatrics and chair of the Department

of Pediatrics at the University of Toledo College of Medicine in

Ohio, and second is Dr. Jack Chapman, who is president of Health

Access Initiative from Gainesville, Georgia, and then last but not
76

least is Ms. Chris Koyanagi, who is policy director for the Bazelon

Center for Mental Health Law here in Washington, DC.

I think you heard before that we are going to ask each of you

to speak for 5 minutes. You can include your written statement for

the record and we of course may ask for additional written questions to follow up afterwards as well. So I will start with Dr. Krol,

if you would, for 5 minutes. Thank you.

STATEMENT OF DAVID M. KROL, M.D., M.P.H., F.A.A.P, ASSOCIATE PROFESSOR OF PEDIATRICS, CHAIR, DEPARTMENT OF

PEDIATRICS, UNIVERSITY OF TOLEDO COLLEGE OF MEDICINE

Dr. KROL. Thanks very much.

As a pediatrician, a general pediatrician who has worked very

closely with dentists and mental health professionals, as the chair

of the department of pediatrics and as a member of the American

Academy of Pediatrics, I and we consider children’s dental and

mental health an integral part of well-child care and ensuring the

bright futures process. We applaud the committee for holding this

hearing.

The prevailing adult acute care model of coverage inappropriately limits preventive and other types of services that are of critical importance for children and adolescents because of their unique

characteristics and environments. If we as a society can commit

more than $2 trillion of our 2007 GDP to health care, there is no

excuse or plausible explanation why our youngest citizens cannot

have the best we have to offer that utilizes the clinical values of

pediatric health care, training and research in its ultimate development. Because many adult diseases appear in childhood, investing

in preventive benefits for children is also cost-effective. However,

this return on investment can take many years to become apparent.

Through regular contact with parents or guardians, pediatricians

and other child health care providers can assess and monitor a

child’s development and screen for developmental problems and

risk behaviors. Although each child develops at his or her own

pace, all children progress through an identifiable sequence of

physical and emotional growth and change. Age-appropriate health

care visits foster positive parenting behaviors, help promote optimal development and initiate early intervention when problems appear imminent.

The major risks to children’s health and development, particularly after infancy, are largely preventable. Well-child care or

health supervision provides a vehicle for health professionals to

promote healthy lifestyle choices, monitor physical and behavioral

pathology and provide age-appropriate counseling or anticipatory

guidance.

Because of the prevalence of obesity, dental caries, attention deficit disorder/hyperactivity, depression and the stresses faced by parents, experts have noted that the term ‘‘well-child care’’ is applicable to fewer and fewer children. Pediatricians reported in a national survey that they face an array of obstacles to providing quality well-child care: time constraints, low levels of payment for pre-
77

ventive pediatric care and lack of payment for specific developmental services.

Optimal relationships between pediatrician, their patients and

the patient’s family occur in a medical home. A medical home is not

a building, house or hospital but rather an approach to providing

comprehensive primary care. A medical home is primary care that

is accessible, continuous, comprehensive, family-centered, coordinated, compassionate and culturally effective. The physician should

be known to the child and family and should be able to develop a

partnership of mutual responsibility and trust with them.

In contrast to care provided in a medical home, care provided

through emergency departments, walk-in clinics and other urgent

care facilities, though sometimes necessary is more costly and often

less effective. Children from low-income families are more likely

than other children to have serious health problems. There is also

an inverse correlation between poverty and education needed to

manage these problems. While most pediatricians provide care for

such families in their practices, financially they are being forced to

limit the number that they can continue to see. One such practice

in my home State of Ohio also takes care of 500 Medicaid children

from Indiana. They have just notified Indiana that they are dropping their patient caseload to 90. While they are retaining the patients that have the most complex problems, the others will need

to be reassigned. The reality is that having a Medicaid/SCHIP card

does not guarantee access to quality pediatric care in a timely fashion. Needed modifications in payment could quickly rectify this situation.

The knowledge and science of healthy child development is a rapidly evolving field and the practice of pediatrics changes accordingly. Launched by the Health Resources and Services Administration’s Maternal and Child Health Bureau in 1990, Bright Futures

is a national child health promotion and disease prevention initiative that provides principles, strategies and tools that can be used

to improve the health and well-being of all children. A comprehensive revision of Bright Futures is near completion by the American

Academy of Pediatrics. The experts drafting the recommendations

have established priorities for each well-child care visit to use as

a guide in discussing health promotion and disease prevention with

families. The first priority for every visit is addressing the concerns

of the family around the health and development of their child.

Dollar for dollar, providing better health care for children represents one of the best returns on investment available. This wise

investment means ensuring that health care systems including

safety-net providers and health insurers are responsible to the

unique health needs of children. As a Nation, we must invest in

improving children’s access to quality care. Just as coming events

cast their shadows before them, so does the health of a nation’s

children foreshadow the health of its future.

Thank you for the opportunity.

[The prepared statement of Dr. Krol follows:]
78
79
80
81

Mr. PALLONE. Thank you, Dr. Krol.

Dr. Chapman, I know it says Mr. Chapman but it also says you

are a doctor so I am going to use that. You are a medical doctor,

correct?

Dr. CHAPMAN. Yes, sir. That is correct.

Mr. PALLONE. Thank you.

STATEMENT OF JACK CHAPMAN, M.D., PRESIDENT, HEALTH

ACCESS INITIATIVE

Dr. CHAPMAN. Mr. Chairman, honorable members of the committee, thank you for allowing me the opportunity to address you

today. My name is Dr. Jack Chapman. I am president of the

Health Access Initiative in Gainesville, Georgia. I am also in the

private practice of ophthalmology and I currently serve as president-elect of the Medical Association of Georgia.

I come before you today to share the story of how we are providing for the health of the low-income uninsured in Hall County,

Georgia, especially children. We have a collaborative effort between

private physicians, the Good News Clinic, the Hall County Health

Department, the Health Access Initiative and the Northeast Georgia Medical Center.

What I would like to convey to you is how the old model worked

and explain the new model now operating in our community.

Good News Clinics was founded in the early 1990’s. It is the largest free clinic in the Southeast and one of the top 10 free clinics

in the Nation. Largely with volunteer physicians, they provide free

medical and dental care including medications to low-income uninsured patients. This is accomplished through a freestanding pharmacy staffed by a full-time pharmacist. In 2006, there were 8,843

medical clinic patient visits, 7,440 dental clinic visits and 66,451

pharmacy visits. The medications they provided to the patient at

no charge had a retail value of $3.8 million. Hall County has a population of over 170,000.

The Hall County Health Department provides a prenatal program in conjunction with the Longstreet Clinic, a private multispecialty group. Prenatal care helps decrease infant mortality and infants’ risk of health problems that would cost far more without prenatal intervention. In 2004, Hall County’s infant mortality rate

was 5.5 percent compared to 8.5 percent for the State of Georgia.

The Hall County Health Department also provides clinical services with 29,737 clients served in 2006.

In collaboration with community partners, Health Access Initiative provides access to health care for uninsured patients. Health

Access is a consortium of partners including over 150 physicians,

the local hospital, health department, free clinic, federally qualified

clinic, United Way 2–1–1, chamber of commerce and other partners. This group came together to primarily fill the need for the

specialty surgical care for the uninsured indigent.

Health Access adds value to the existing resources in the community by providing specialty and surgical needs in a seamless manner. Under the old model, when someone needed surgery, the physician seeing the patient at the Good News Clinic or the health department would be in a predicament. The physician would have to

stop what he or she was doing and take the time to make a num-
82

ber of phone calls in order to find a specialist surgeon that would

do a favor for the clinic. If surgery was indicated, the physician

who was doing the clinic a favor would have to call an anesthesia

friend and ask that physician to do a favor for him. If radiology

was needed, then the same would take place. Of course, the hospital operating room would need to be contacted as well, and this

does not include the challenge if more than one specialty surgeon

is needed as well. Under the old model, it was a cumbersome, timeintensive process without structure, organization or measurement.

Health Access arose out of the Hall County Medical Society.

What it accomplished under the new model is to bring all the participants together in a more coordinated fashion. We have the physicians, hospital, X-ray and labs all agree to provide the care for

qualified patients on the front end. This way when a patient is

seen in the Good News Clinic that requires specialty care surgery,

the physician there makes the determination and writes the order.

In the new model, Health Access is notified and contacts the patient to make all the arrangements. A photo ID is issued to the patient to identify them as the Health Access patient using a customized software tracking program. If anesthesia is required for

surgery, they are already committed to provide the care. The hospital is already on board to provide labs and OR. Also, the radiologist is on board. The new model is seamless and user-friendly. It

is also less of a burden for the volunteer physician and allows the

physician to see more patients.

To track this, the physician’s office providing the care sends a

health claim form over to Health Access with the CPT code, the

ICD9CM code, and the amount of services or care provided. We

then enter this into our client tracking program so that we can

track the care provided as well as how much was provided. We

make sure that the patients keep all appointments and follow-up

visits. Last year we documented a 90 percent compliance rate with

patients keeping their appointments in the physicians’ offices. According to the code, we track the value of services provided. In

2006, Health Access Initiative physicians in Hall County provided

over $815,000 in donated care.

The emergency room is another entry point into our system. Our

ER in Hall County is the third busiest in the State of Georgia with

over 95,000 visits last year. When you think of an ER, you think

of trauma, motor vehicle accident, heart attack. However, the No.

1 diagnosis in our ER is earache. The ER is used as a clinic. The

cost of taking care of a patient in the ER as opposed to the office/

clinic setting is three times. The Good News Clinic has data that

shows their cost of care for a patient is $34 as compared to $221

for the same patient in the ER. The Andrew Young Health Policy

Center at Georgia State University——

Mr. PALLONE. Dr. Chapman, you are about a minute over, so if

you could summarize.

Dr. CHAPMAN. In closing, as you can see, it takes a lot of collaboration to make this work. The new model accomplishes this task.

In fact, the Health Access Initiative was honored for this.

I hope that you will recognize that individual communities can

step up to the plate to provide their citizens in need. I hope you

will continue to encourage and assist as possible. The donated care
83

model is not the answer to the problem of providing health care but

is part of the answer.

I thank you again for allowing me to be here today and I thank

you for your time, service and attention you are giving to this very

important issue.

[The prepared statement of Dr. Chapman follows:]

TESTIMONY OF JACK M. CHAPMAN JR., M.D.

Mr. Chairman, honorable members of the committee, thank you for allowing me

the opportunity to address you today. My name is Dr Jack Chapman. I am President of the Health Access Initiative in Gainesville, GA. I am also in the private

practice of Ophthalmology and I currently serve as President-elect of the Medical

Association of Georgia.

I come before you today to share the story of how we are providing for the health

of the low income uninsured in Hall County Georgia, especially children. We have

a collaborative effort between private physicians, the Good News Clinic, the Hall

County Health Department, the Health Access Initiative, and the Northeast Georgia

Medical Center.

What I would like to convey to you is how the old model worked and explain the

new model now operating in our community.

Good News Clinics (GNC) was founded in the early 1990’s. It is the largest free

clinic in the Southeast and one of the top 10 free clinics in the nation. Largely with

volunteer physicians, they provide free medical and dental care including medications to low income, uninsured patients. This is accomplished through a free standing pharmacy staffed by a full-time pharmacist. In 2006 there were 8843 medical

clinic patient visits, 7440 Dental Clinic visits and 66,451 pharmacy visits. The medications they provided for - all at no charge to the patient - had a retail value of

$3.8 million. Hall County Georgia is located in Northeast Georgia and has a population of over 170,000.

The Hall County Health Department (HCHD) provides a prenatal program in conjunction with The Longstreet Clinic, a private multispecialty group. Prenatal care

helps decrease infant mortality and infants’ risk of health problems that would cost

far more without prenatal intervention. In 2004, Hall County’s infant mortality rate

was 5.5 percent, compared to 8.5 percent for Georgia.

The Hall County Health Department also provides clinical services with 29,737

clients served in 2006.

In collaboration with community partners, Health Access Initiative (HAI) provides

access to healthcare for uninsured patients. HAI is a consortium of partners including over 150 physicians, the local hospital, health department, free clinic, federally

qualified clinic, United Way 2–1–1, Chamber of Commerce, and other partners. This

group came together to primarily fill the need for specialty/surgical care for the uninsured/indigent.

HAI adds value to the existing resources in the community by providing specialty

and surgical needs in a seamless manner. Under the old model, when someone needed surgery, the physician seeing the patient at the GNC or the HCHD would be in

a predicament. The physician would have to stop what he or she was doing and take

the time to make a number of phone calls in order to find a specialist/surgeon that

would do a favor for the clinic. If surgery was indicated, the physician who was

doing the clinic a favor would have to call an anesthesia friend and ask that physician to do a favor for him. If radiology was needed then the same would take place.

Of course, the hospital/operating room would need to be contacted as well and this

does not

Include the challenge if more than one specialty surgeon is needed. Under the old

model it was a cumbersome time intensive process without structure, organization,

or measurement.

HAI arose out the Hall County Medical Society. What is done under the new

model is to bring all of the participants together in a more coordinated fashion. We

have the physicians, hospital, x-ray, and labs all agree to provide the care for qualified patients on the front end. This way, when a patient is seen at the GNC that

requires specialty care/surgery, the physician there makes the determination and

writes the order. In this new model, HAI is notified and contacts the patient to

make all the arrangements. A photo ID card is issued to the patient to identify them

as an HAI patient using a customized software tracking program. If anesthesia is

required for surgery, they are already committed to provide the care for HAI. The

hospital is already on board to provide labs and OR as needed. Also, the Radiologist
84

is on board as well. The new model is seamless and user friendly. This also lifts

the burden from the volunteer physician and allows the physician to see more patients.

To track this, the physician’s office providing the care sends a health claim form

over to HAI with the CPT code, the ICD9CM code, and the amount of services or

care provided. We then enter this into our client tracking program so that we can

track that the care was provided (i.e. the patient kept the appointment), as well as

how much was provided. We make sure that the patient keeps all appointments and

follow-up visits. Last year we documented a 90 percent compliance rate with patients keeping their appointments in the physician’s offices. According to the code,

we track the value of services provided. In 2006, HAI physicians provided over

$815,000 in donated care.

The emergency room (ER) is another entry point into our system. Our ER in Hall

County Ga is the third busiest in the State of Georgia with over 95,000 visits last

year. When you think of an n ER, you think of trauma, MVA, or heart attack. However, the number one diagnosis in our ER is earache. The ER is used as a clinic.

The cost of taking care of a patient in the ER as opposed to the office/clinic setting

is three times. The GNC has data that shows their cost of care for a patient is $34

as compared to $221 for the same patient in the ER. The Andrew Young Health

Policy Center at Georgia State University has similar data.

We have been too successful in getting people to go to the hospital/ER for care.

The ERs have become clinics. At HAI, we work to keep the patient out of the ER.

We want the patient to have a medical home that they use for their care. In fact,

as part of our partnership, we are sent a daily report from the hospital notifying

us if a patient in the HAI program was seen in the ER the day before. We then

contact the patient to find out if the visit to the ER was the appropriate place to

access the care that they needed. If not, then the patient is counseled on the appropriate or better way to obtain the care they need and we make sure they have a

follow up appointment with their primary care provider if needed. We are trying to

change the habits as well as the behavior as it relates to going to the ER.

Another important aspect to providing care and keeping healthcare resource utilization and cost down is to keep the patient from bouncing back and forth into the

hospital. This requires the patient to have the medications needed available. If a

patient does not obtain the medication required then they will have a difficult time

improving and most likely will become worse with a more complicated illness that

will be much more expensive and require much more in resources to treat. Through

our partnership with GNC, HAI staffs a pharmacy tech to help provide free medications to meet acute needs. The medication assistance programs are used to meet

chronic needs.

As you can see, it takes a lot of collaboration to make this work. The new model

accomplishes this task. In fact, the HAI was honored by the Healthcare GA Foundation with the Community Service Collaborative of the Year Award for 2006.

In closing, I hope that you will recognize that individual communities can step

up to the plate to provide for their citizens in need. I hope that you will continue

to encourage and assist as possible, communities to start collaboratives like HAI

and GNC. It really takes all parties coming together and working in a coordinated

manner to provide for this problem.

This donated care model I have described is not THE answer to the problem of

providing healthcare for those who are low income and uninsured, but it can be a

PART of the answer and can go a long way in helping many people who could not

otherwise obtain the healthcare they need.

Thank you again for allowing me to be here today. Thank you for the time, service

and attention you are giving to this very important issue.

Mr. PALLONE. Thank you.

Ms. Koyanagi.

STATEMENT OF CHRIS KOYANAGI, POLICY DIRECTOR,

BAZELON CENTER FOR MENTAL HEALTH LAW

Ms. KOYANAGI. Thank you, Mr. Chairman. I appreciate the opportunity to testify today on children’s mental health.

I think for policy purposes, it is really helpful to think of children

who need mental health services in some different groupings. First

of all, one in five children in this country have a diagnosable men-
85

tal disorder that requires treatment. Eleven percent of children

have a mental disorder that also is accompanied by a significant

functional impairment. Obviously those children need more-intensive services. And 5 percent of children have a mental disorder

which causes extreme functional impairment and those children

need a wider array of services as well as more-intensive services.

And unfortunately for most children, access to mental health

care is pretty abysmal. First of all, obviously children who are uninsured have little recourse, and what that is not the topic today,

I do hope the committee will focus on the issue of uninsured children. But our public mental health systems are now so overburdened that they really cannot accept people who don’t have either

public insurance or private coverage.

But children who have private coverage through employer-based

plans also have limits on their mental health services. Typically

these plans only cover basic mental health, outpatient therapy,

medications and hospitalization, and also there are limits on the

array of those services, typically 30 inpatient days or 20 outpatient

sessions is what you will find in most policies. Legislation introduced by Representatives Kennedy and Ramstad, the Mental

Health Parity Act, would address this problem. We certainly urge

the Congress to enact that bill.

But unfortunately, these limits in private plans have also been

imported into SCHIP and Medicaid. SCHIP permits States to use

benchmark plans, private plans as their models for SCHIP and

many States do, and also now through the Deficit Reduction Act,

Medicaid populations can also be placed into these kinds of benchmark plans which brings all these limits on mental health services

into these public programs so many low-income children also cannot receive the course of mental health treatment that they need.

We would urge Congress to address this in SCHIP by requiring

equity in the mental health benefits and also perhaps to either repeal the benchmark provision in Medicaid or at least require those

benchmark plans include a reasonable mental health package.

In addition, SCHIP has a further problem for us in terms of mental health coverage because States may choose to cover only 75 percent of the actuarial value of the mental health benefit in the

benchmark. So first your benchmark has limits and then under

SCHIP, States can reduce even further and have even tighter limits. Chairman Dingell has introduced a bill, the Children’s Health

First Act, which would rectify that problem and we would urge the

committee to take a look at that.

For children who have more severe mental health disorders, not

only are the limits in the private plans and SCHIP inadequate but

so is the range of services. These children require intensive community-based services such as in-home services, services in school.

Their parents need help in understanding the disorder and how to

respond when crises are emerging. These children need case management to meld these services together and various comprehensive programs, and a point of fact, we generally see that those services are only available under Medicaid.

The gaps in coverage can be disastrous for families. There are

many families who are advised by public officials to give up custody

of their child to a public agency in order to ensure that the child
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has access to these kinds of comprehensive services. The GAO

found almost 13,000 such children in just 19 State child welfare

agencies and 30 county juvenile justice systems but GAO pointed

out that these data grossly understate the problem because so few

States keep the data.

So the bottom line is that Medicaid is the critical safety net for

children with the most serious mental disorders and the only program that covers all the array of services that they need.

I would like to alert the committee that we are extremely concerned that the Medicaid community mental health services package is being amended by CMS, which is both having some audits

conducted of these programs including I think an audit that is

going on now in Georgia and also considering amending its regulations to reduce coverage of the community services. This is ironic

because these community-based services are the least costly and

because they enable children to stay with their own families or in

alternative family-like settings, they are the most effective and the

most likely to have long-lasting effects rather than placing children

in institutions far away from their home.

The Surgeon General in 1999 and the President’s Commission on

Mental Health in 2003 have both made clear that we have now extremely effective treatments for mental health disorders but that

these are far too frequently unavailable. America’s children deserve

a healthy start in life and that would include having early and effective access to treatment for their mental disorders.

Thank you, Mr. Chairman.

[The prepared statement of Ms. Koyanagi follows:]

TESTIMONY OF CHRIS KOYANAGI

Good morning Chairman Pallone, Representative Deal and members of the Subcommittee. My name is Chris Koyanagi. I am the policy director for the Judge David

L. Bazelon Center for Mental Health Law. The Bazelon Center is the leading national nonprofit, legal-advocacy organization representing people with mental disabilities. The Center works to define and uphold the rights of adults and children

with mental disabilities who primarily rely on public services to ensure that they

have equal access to health and mental health care, education, housing and employment.

Thank you for the opportunity to share our insights regarding mental health care

for children in the public and private sector, including barriers to care, the consequences of inadequate access to care, and opportunities for Congress to improve

access and provide a healthy start for children with mental health needs. It is our

hope that this hearing will result in increased support for specific legislative proposals that will provide appropriate and timely access to mental health services and

supports in both the public and private sectors.

During my testimony, I will describe opportunities within the committee’s jurisdiction to address shortcomings in health care coverage for children with mental

health needs such as approving the bipartisan Paul Wellstone Mental Health and

Addiction Equity Act, enacting the bipartisan Keeping Families Together Act, eliminating the discriminatory limits on mental health care in State Children’s Health

Insurance Program (SCHIP), and preserving and strengthening the public sector

Medicaid program.

OVERVIEW OF CHILDREN’S MENTAL HEALTH

Mental disorders affect about one in five American children and five to nine percent experience serious emotional disturbances that severely impair their functioning. Children from low-income households are at increased risk of mental health

problems and research has indicated that children in Medicaid and SCHIP have a

much higher prevalence of mental health problems than other insured children or

even uninsured children. Tragically, a large majority of children struggling with
87

these mental disorders (79 percent by some estimates) do not receive the mental

health services they need. Not surprisingly, uninsured children have a higher rate

of unmet need than children with public or private insurance.

More than just a problem for the uninsured, children covered by private or public

health plans have serious coverage gaps that prevent them from obtaining needed

mental health services. For instance, private health plans set arbitrary limits on

mental health coverage, such as caps on the number of times a child may be seen

by a therapist over the course of a year. Approximately 68 percent of Americans

under the age of 18 are covered by private insurance, while public programs (such

as Medicaid and SCHIP) cover about 19 percent.

Within the public sector, discriminatory limits on mental health services in

SCHIP that would not be permissible in Medicaid have restricted access to care for

children and adolescents. Additionally, current Administrative activities that restrict reimbursement under the Medicaid rehabilitative services option limit access

to a range of critical community-based services for children and adults that help

them remain in the community—a goal supported by the President’s Commission on

Mental Health.

Without early and effective identification and intervention, childhood mental disorders can lead to a downward spiral of school failure, poor employment outcomes,

and, later poverty in adulthood. Untreated mental illness may also increase a child’s

risk of coming into contact with the juvenile justice system, and children with mental disorders are a much higher risk of suicide. According to the Surgeon General,

an estimated 90 percent of children who commit suicide have a mental disorder.

Fortunately, poor outcomes for children with mental health needs can be prevented with access to appropriate services.

INSURANCE REFORM NEEDED TO IMPROVE ACCESS AND AVOID TRAGIC OUTCOMES

Mental health treatment can be very expensive and most families rely upon insurance to help cover the cost of these services. For example, one outpatient therapy

session can cost more than $100. Residential treatment facilities, which provide 24

hours of care, seven days a week, can cost $250,000 a year or more. However, employer based coverage often restricts access to mental health services for children

and adults by placing limits on mental health coverage that they do not place on

medical/surgical care. Limits on mental health coverage includes lower outpatient

office visit limits, lower hospital stay limits, higher outpatient office visit co-payments, and higher outpatient office visit co-insurance. Data show that 94 percent

of health maintenance plans and 96 percent of other plans have these restrictions.

Families that face health insurance restrictions or exhaust their health insurance

benefits are left without options.

Enacting mental health parity legislation (sponsored by Representatives Patrick

Kennedy and Jim Ramstad) would be an essential first step to improving access in

the private sector. Comprehensive parity legislation would help by prohibiting private insurers from denying access to needed services because of stigma and discrimination through current limitations and restrictions on mental health care that

are not placed on general health care. Additionally, this Federal legislation would

extend parity protections to the many self-funded employer-sponsored plans, that

are currently exempt from any State mental health parity laws.

Gaps in services and limits in coverage can be disastrous and could lead to custody relinquishment whereby parents of children with mental disorders forgo custody of their children so they can become wards of the State and eligible for medical

assistance. It is clear that across the country, children needing intensive mental

health treatment are not receiving the care they need early on to prevent a host

of adverse outcomes, including custody relinquishment. According to a General Accounting Office (GAO) report of April 2003, at least 12,700 children were placed in

child welfare or juvenile justice system in 2001, solely to access State-funded mental

health services. But this finding grossly understates the extent of the problem. GAO

also found that most States and counties do not track how often custody relinquishment occurs and the 12,700 figure only reflects data from 19 child welfare departments and 30 county-level juvenile justice systems.

Legislation entitled the Keeping Families Together Act (H.R. 687–S. 382) has

been introduced to help prevent parents from having to choose between custody and

care by funding State-level interagency systems of care to improve mental health

sources for children with mental disorders at risk of or already subjected to custody

relinquishment. This legislation is sponsored by Representatives Patrick Kennedy,

Jim Ramstad, and Pete Stark and Senators Susan Collins and Tom Harkin. It has

been referred to the Energy and Commerce Committee and we urge the committee

to approve this crucial piece of legislation as soon as possible.
88

Many families cite gaps in private insurance coverage as a major factor in their

decisions to relinquish custody of their children. Private insurance plans do not

cover the full array of intensive, community-based rehabilitative services that children with the most severe mental or emotional disorders need’services that would

be covered under Medicaid.

MEDICAID PROVIDES VITAL ACCESS TO MENTAL HEALTH SERVICES

Medicaid is a critical source of support for mental health care, accounting for 20

percent of all mental health spending. Thanks in large part to the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit. Medicaid covers a comprehensive array of mental health services for children, including intensive services

in the community that offer the greatest potential for avoiding costly institutional

care. Medicaid is the only source of coverage that finances a full range of the rehabilitative services needed by children with mental disorders.

Last Congress, the bipartisan Family Opportunity Act was enacted as part of the

Deficit Reduction Act to give States the option of allowing families with children

with disabilities to buy Medicaid coverage for their children. This new law also created a demonstration program to provide home and community- based services to

children with serious emotional and behavioral disorders as alternatives to psychiatric residential treatment. Enactment of these important provisions were a significant step in strengthening the Medicaid program by enabling families to meet

their children’s serious health and mental health needs while still keeping their

families intact.

Further steps that must be taken include strengthening the Medicaid EPSDT benefit so that all children served by Medicaid, including those with mental health disorders, receive comprehensive screening. Non-compliance with EPSDT leads to reduced access to services and puts children in need of treatment at great risk of experiencing a host of other adverse consequences.

Medicaid coverage of community-based services through the rehabilitative services

option is also critically important for children with mental health needs, especially

children with serious disorders. These intensive rehabilitative community-based

services for kids include multisystemic therapy, intensive home-based services for

children and adolescents, therapeutic foster care, and behavioral aide services.

These services are effective alternatives to institutional care for children and adults

with severe mental disorders and are critical to promoting resiliency and recovery

from mental illness. Medicaid is generally, the only source of coverage for them, specifically through the rehabilitative services option.

Unfortunately, the administration has indicated it will narrow coverage under the

rehabilitative services option through regulatory changes. During the Deficit Reduction Act deliberations last Congress, Members deliberately rejected the administration’s proposed changes to Medicaid coverage of rehabilitative services. Nonetheless,

the administration is currently going forward with narrowing the scope of the rehabilitation option through the regulatory process as well as changes in coverage policy implemented through audits by the Health and Human Services Office of the

Inspector General. The integrity of the Medicaid program and the standards set by

Congress regarding the scope of optional service programs must be maintained. The

back door approach being used by the administration, and shunned by Congress in

the recent past, would drastically affect specific interventions that enable children

and adults with serious mental disorders to function independently, learn in school,

socialize age appropriately and experience symptom reduction.

SCHIP CHANGES REQUIRED TO ELIMINATE DISPARITIES AND IMPROVE ACCESS

SCHIP has generally been very successful in expanding health care coverage to

millions of previously uninsured children, and States that simply expanded their

Medicaid programs to cover these additional children offer comprehensive mental

health services. However, States have the option to establish stand-alone SCHIP

plans that are separate from their Medicaid programs and modeled after private insurance benchmark plans. Unfortunately, many States have adopted into these separate SCHIP plans private-insurance style limits on mental health services that

would not be permissible in Medicaid, including caps on inpatient and outpatient

care. A study of SCHIP managed care plans found wide variations in the scope and limits of mental health treatment, with many States limiting outpatient services to 20

visits and inpatient days to 30 or less. These limits are not based on the medical

needs of beneficiaries or best practice guidelines and result in coverage that is wholly inadequate for children with mental disorders. Another study found that children

with complex mental health needs would have access to full coverage of needed serv-
89

ices in only approximately 40 percent of States due to limited benefits in SCHIP

plans.

Mental health services are key components of the range of services children need

for healthy development, and children enrolled in separate SCHIP plans deserve

comprehensive coverage for their mental health needs For these children to have access to appropriate range of services, the law must be amended to ensure that all

SCHIP plans provide mental health coverage that is equivalent to the coverage provided for general health care.

On February 28, 2007, over 40 national organizations representing children in the

child welfare and mental health system sent a letter urging you to use this critical

opportunity afforded by the SCHIP reauthorization process to prohibit disparate

limits on mental health care for children in separate SCHIP plans.

Furthermore, language in the SCHIP statute even allows States to provide significantly less mental health coverage in their separate SCHIP plans than is covered

in the benchmark plan they select. The law allows States that opt to create a separate plan to reduce the actuarial value of the mental health benefit by 25 percent—

that is, the mental health benefit in SCHIP need only be actuarially equivalent to

75 percent of the benefit in the benchmark plan itself. This statutory provision authorizes States to establish SCHIP benefit packages that are totally inadequate for

treating the great majority of childhood mental disorders.

This provision allowing the reduction of mental health benefits to 75 percent of

the mental health benefits in the benchmark plans must be eliminated, and we commend Chairman Dingell for including a provision to do just that in his bill entitled

the Children’s Health First Act.

In conclusion, it is clear that many parents face tremendous barriers to accessing

adequate mental health services for their children. Both the President’s Commission

on Mental Health and the Surgeon General have declared children’s mental health

coverage to be in crisis. It is unthinkable that a child with asthma would enter the

child welfare system solely to access treatment. But, for children with mental health

needs, this is precisely what does happen across the country.

I urge you to take advantage of all legislative opportunities to improve access to

mental health services and supports for children. Proposals before the committee to

remedy the failings of the private and public sector serving children with mental

health needs must be seized to offer these children a fair chance at overcoming the

extra challenges they face.

I thank you for holding this vital hearing and would be happy to answer any

questions you might have.

Mr. PALLONE. Thank you very much, and I want to thank all the

panelists and we will now have some questions. I recognize myself

for 5 minutes for questions.

I am going to start with Dr. Krol. On the first panel, our ranking

member, Congressman Deal, mentioned some technical changes to

the Deficit Reduction Act which are needed to protect the children’s

benefit in Medicaid EPSDT, or Early Periodic Screening, Detection

and Treatment, and then Mr. Scheppach described these changes

as limiting flexibility, but my understanding is the technical

change doesn’t affect flexibility, it merely clarifies that this important children’s benefit is unaffected. In fact, Senators Grassley and

Baucus and Congressman Barton have acknowledged that the Deficit Reduction Act was not intended to affect the EPSDT benefit for

children and I believe the American Academy of Pediatrics supports this technical change.

So I just wanted to ask you, Dr. Krol, why is EPSDT so important for children and why is this technical change needed to protect

children’s coverage, if you will?

Dr. KROL. Thank you for that question. First of all, the American

Academy of Pediatrics does support that technical change wholeheartedly. I can speak as a pediatrician that takes care of kids and

tell you a little bit of why EPSDT is so important to me and the

children that I take care of, and I sometimes cringe when I hear
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the acronym rather than saying it all out because we lose what it

actually means when we just say EPSDT. It makes it a little easier

on us. But the first part is early. What it allows me to do is, I can

assess children as early as possible. When they walk into my

door—well, they are not walking in the door at a week of age but

they are brought into my door and I see these parents and I can

assess risk in this child for a variety of different things and it gives

me the opportunity to connect with my colleagues or my mental

health colleagues if I need a referral. That is the first part. The periodicity is very important. Over time kids change, their circumstances change and the science changes over time, and I need

that ability to over time assess a child. That relationship between

me and that family is extremely important and EPSDT allows me

to do that. But what it really allows me to do is to screen. It allows

me to provide age-appropriate screening, trying to prevent disease

before it happens rather than waiting until the disease comes and

treating the disease. My goal is to have a child go 18 years through

my office, 21 years through my office, sometimes 24 years through

my office, and all I am doing is telling parents what is coming up,

here is what is going to happen with your child, here is what is

going to be going on rather than a child coming in and having some

sort of issue that I am going to have to deal with as far as an illness. What EPSDT allows me to do is to prevent disease, ameliorate needs, address concerns of families and children, especially

when they are adolescents, and it allows me to collaborate to address the disease if they do have that. I think that technical change

is needed to maintain that.

Mr. PALLONE. Do you want to explain that a little more though,

the technical change? What is it going to do?

Dr. KROL. Well, what I think it will do is, it will allow me to do

these, all of these things that I think are required to help me take

care of kids in a better way, to help them live healthy and happy

lives. By taking away these benefits, by removing these benefits,

we just can’t do the job that we are doing right now.

Mr. PALLONE. OK. Let me also ask you, you mentioned obesity

in your statement and I mentioned it in my opening statement and

most people are aware the rates of childhood obesity are rapidly increasing. Can you comment on the impact that that trend is having

on children and maybe on steps that pediatricians could take to

combat the epidemic and also what types of things you think Congress could do to address the childhood obesity problem?

Dr. KROL. It is a significant epidemic and a difficult question to

answer for a variety of reasons, not the least of which is so many

things impact obesity. The simplest way to look at it is calories in

versus calories out, and if you want to affect obesity, you affect one

or the other and ideally both. So on the front end, working with

families and children on what they are taking in as far as what

kind of foods are healthy, amounts, portion size, not sucking down

a two-liter bottle of your favorite soft drink or sugared substance,

and just to bring up the sugared substances, they are common risk

factors to obesity and oral health issues, so there is an opportunity

there to make a difference, not only in obesity but also in oral

health. On the other side of the equation, affecting the calories that

are expended, getting children more active, helping families work
91

with kids because the reality is, if I am going to make a change

in a child, it has to happen within the family. If I tell a family or

if I tell a child you got to eat better, you got to exercise more, but

the environment they live in, they have food instability where they

are not quite sure where their next meal is going to be coming from

and they are buying from their favorite fast-food restaurant because of 99-cent meals or they live in a neighborhood where they

can’t access physical activity or they go to a school that has removed physical activity, physical education from the program or

they have a school lunch which they may qualify for a free school

lunch but junk-food machines are open at the same time and they

take their money and they spend in a junk-food machine rather

than in the healthier lunches. I think there are a lot of barriers

that we have to address. Some of these I can do in my office but

some of these have to happen on a community level that I can help

impact but it really takes a team to address those issues.

Mr. PALLONE. Thank you. Since my children left, I can say that

they are still even today trying to go to McDonald’s whenever possible and I have to constantly tell them that there are alternatives

to McDonald’s when we go out to eat.

Dr. KROL. There are.

Mr. PALLONE. Thank you.

Mr. Deal.

Mr. DEAL. Thank you, Mr. Chairman. With regard to clarifying

the question that came up in the earlier panel and your question

now with regard to the language that was in the Deficit Reduction

Act about the flexibility and the benchmark plans of the States we

have heard from the representative of the Governors’ office, I would

like to ask permission to insert in the record letters from Dr.

McClellan and Secretary Leavitt indicating that they would never

approve a State plan that did not include the EPSDT provision,

and if that needs further clarification to satisfy provider groups or

the Governors, maybe you and I should have a meeting with Secretary Leavitt or perhaps even a hearing in the subcommittee. So

I think that is a clarification.

With regard to that issue of State benchmarks though, I know

that one of our witnesses said they don’t like those but the reality

is that a State benchmark says that your plan has to include, first

of all, the EPSDT screening provisions but it also has to be modeled by what you provide to your State employees and the most

prominent private health insurance plan in your State. Now, what

taxpayers are objecting to is that in almost every instance we find

that the Government programs, whether it be Medicaid or whether

it be SCHIP, provide better benefits than the average taxpayer who

is paying for those are able to buy in their own plans. Now, that

is the consideration, and if you are not aware of that consideration,

then you are not hearing what the public is saying on these issues.

Let me address my remarks to Dr. Chapman, and Mr. Chairman,

he is not only a doctor, he is a doctor two times over. He came to

our community as an optometrist, practiced as an optometrist for

a number of years, decided he wanted to take the next step up,

went back to medical school and now came back and he is an ophthalmologist, a medical doctor and the president-elect of our State
92

medical association, so he is indeed a fine member of our community.

Let me draw some contrast though as to what we have heard in

this hearing today. First of all, we heard in the first panel about

the limitations on dental care, limitations that dealt with the available number of dentists out there, the reimbursement rates that

are perhaps not what they should be, the number of dentists available in community health centers, et cetera. We have heard from

Dr. Krol, who is saying that pediatricians need more money, that

the plans don’t pay enough. Children of course are perhaps the

most mandated covered population group that we have in our country by virtue of all the Government programs that are out there.

But let me contrast that with what Dr. Chapman is talking about.

He is talking about in my community, which I am very proud and

I appreciate him coming here to talk about it. My community, what

happened to Diamonte Driver would never have happened in my

community because it wasn’t a question of whether or not he was

Medicaid-eligible. It wasn’t a question of whether he was SCHIPeligible. He is talking about providing health care, dental and

health care, without cost, without Government programs, without

anything other than a medical and dental community and a community as a whole that is interested in providing these kinds of

services. Now, there are impediments, first of all, with regard to

the Hall County Health Access.

Now, Dr. Chapman, if I am correct, this is what, in collaboration

with the medical community and the hospital, you are attempting

to provide people who come in and don’t have a medical home,

don’t know where to go other than the emergency room, a way of

getting them appointments with doctors, including specialists. Is

that correct?

Dr. CHAPMAN. That is correct. The problem that a lot of the clinics have when they come, they get a few doctors that are really interested in going and providing the care, then they get in there

with a patient and then the patient needs a gallbladder surgery or

needs some kind of other extra care. They look around, there is nobody there. Now when they turn around, we have somebody there.

Mr. DEAL. Of those 150 physicians, I believe you have every specialty covered except maybe one. Is that right?

Dr. CHAPMAN. Yes, sir, we have them all covered.

Mr. DEAL. All right. You have them all covered. And then you

mentioned the component of Good News Clinics. Now this once

again is a totally free clinic. Is that correct?

Dr. CHAPMAN. It is totally free. That is correct.

Mr. DEAL. And it is staffed by both active physicians and active

dentists as well as retired physicians and retired dentists make up

their service providers. Is that correct?

Dr. CHAPMAN. That is correct.

Mr. DEAL. They don’t receive any Federal money?

Dr. CHAPMAN. No Federal money.

Mr. DEAL. No State money?

Dr. CHAPMAN. No State money.

Mr. DEAL. They have community chest and local voluntary charities that provide support, churches, et cetera.
93

Now, with regard to the first one, the Health Access where you

have doctors who are willing to give their time free of charge, if you

wanted to make a $10,000 contribution to that Health Access, you

could write that off as a deduction, couldn’t you?

Dr. CHAPMAN. That is correct.

Mr. DEAL. Can you write off your services that you provide free

of charge in any form or fashion?

Dr. CHAPMAN. No, I cannot.

Mr. DEAL. Do you still have to provide malpractice insurance if

you want to be covered?

Dr. CHAPMAN. I do.

Mr. DEAL. And the retired doctors and dentists in the Good News

Clinic, they can’t write off anything for their services, can they?

Dr. CHAPMAN. No, they cannot.

Mr. DEAL. And if they want liability protection, they have to pay

for it out of their pocket. Is that right?

Dr. CHAPMAN. That is correct.

Mr. DEAL. Thank you, Mr. Chairman.

Mr. PALLONE. Mrs. Capps.

Mrs. CAPPS. Thank you, Mr. Chairman.

Dr. Krol, I want to make sure I have time to ask you a question

further to explain about well-child visits and the importance of a

medical home or primary provider. I am very interested in that.

But I want to start, Ms. Koyanagi, with you to speak about community-based services which is also dear to my heart. I want to

clarify something for the record. On the values of mental health

coverage and private plans as compared to SCHIP, it is my understanding that Congress required when SCHIP was passed in 1997

to provide coverage equaling 75 percent of the value of mental

health coverage offered in private plans that were used as the,

quote, benchmark. Is that correct?

Ms. KOYANAGI. That is correct.

Mrs. CAPPS. I want to make sure that is on the record. You

talked about home- and community-based service for children with

emotional and behavioral disorders. As one who spent a career in

a school setting where a lot of this first comes to light and families

are identified through the IEP process or screening process, the

role of the endangered professional that I represent, which is a

school nurse, that there are roles that are played there at that kind

of place where all children come that then can be seen as part of

the early diagnosis or assessment or picking up these kind of

things to refer and also then some about the wraparound services

that could be available to support a family with a mental health

issue in a child.

Ms. KOYANAGI. That is correct. Schools in fact provide a significant amount of the mental health services that children receive

and many children only receive mental health services through

schools. So they are a very integral part of a community mental

health network.

Mrs. CAPPS. And are there ways that we can in Congress ensure

that this continues or that we build the strength of one communitybased and include the school base include the community base?

Ms. KOYANAGI. Well, there are many ways, yes. The integration

of mental health services with school-based services is one way
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that the Substance Abuse and Mental Health Services Administration promotes. Medicaid could pay more effectively for school-based

health services and mental health services. There are barriers

there that could be eliminated that would make it easier for these

services to be paid for within the schools.

Mrs. CAPPS. And we could provide some incentives for that happening here in Congress because some of those barriers are Federal. Am I right?

Ms. KOYANAGI. Absolutely.

Mrs. CAPPS. I know firsthand that when we can see the school

and the community together as part of a referral and also a treatment facility, that I think it is a win-win. Am I correct?

Ms. KOYANAGI. Yes, that is correct.

Mrs. CAPPS. Thank you.

Dr. Krol, I also agree very much with your emphasis on the importance of regular well-child visits and the importance of a medical home or a health provider where multidisciplinary services

could be centered. Can you explain about that? Should we have, for

example, mental health services as a part of early periodic screening service and should mental health professionals be part of the

medical home?

Dr. KROL. There is no question that mental health should be a

part of that. Just as we mentioned the mouth is part of the body,

the brain is a part of the body as well. There is no way around

that. And in fact, development and mental health issues in younger

children is extremely important. I can tell you in my own community in Toledo, Ohio, we have been talking considerably about the

issue of autism and about trying to find ways to get to kids earlier

in life to help families deal with this, which for many families is

an overwhelming diagnosis anywhere on that spectrum and trying

to find ways to include that within our medical home, within the

services that we provide as a pediatrician but also making the connection out into the community because we cannot do it all in our

office. We have to depend on our colleagues in the community as

well as in the school, and I think what you pointed out is a significant barrier sometimes to many communities is the connection to

mental health services. So you are exactly right. Mental health

should be a significant part of the medical home.

Mrs. CAPPS. Some of the symptoms, speaking of autism, come

about with the early toddler care programs, Head Start programs.

It is when parents become aware that there is something that

needs to be looked into further.

Dr. KROL. You are exactly right, and in my office I depend a lot

on what parents tell me. When a parent tells me that something

is wrong with their child, I take that very seriously and I pursue

that to the point where I feel comfortable and the family feels comfortable that there either is or isn’t something wrong with their

child and so making that a significant and important part of the

services that EPSDT provides and the services that I provide as a

pediatrician in a medical home are very important.

Mrs. CAPPS. Thank you both very much. I yield back.

Mr. PALLONE. Thank you.

Dr. Burgess.

Mr. BURGESS. Thank you again, Mr. Chairman.
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Dr. Krol, let me ask you, if I could, about the issue of medical

devices in regard to children. Of course, adult populations’ medical

devices have achieved a good deal of success but as the late Dr.

Benji Brooks down in Houston where I trained in medical school,

the patron saint of pediatric surgery, used to drill on us in medical

school that kids are different. They are not just little people. So as

far as medical devices are concerned, we talk about things like

shunts, stents and pacemakers and that sort of thing. They have

to be designed specifically for children. Is that correct?

Dr. KROL. That is entirely correct, and while I am a general pediatrician, I depend significantly upon my surgical colleagues and

they bring that to me all the time, the issues that they face regarding trying to adapt adult devices to kids if they can possibly do

that, and the fact is that you can’t. They aren’t little adults.

Mr. BURGESS. Well, has the American Academy of Pediatrics conducted a study to determine if there is an unmet need for pediatric

devices and what that unmet need might be?

Dr. KROL. I have to admit that I don’t know for sure but I can

definitely provide you with that information for your office. My

thought is that we were looking into that considerably. We have

surgical members of our academy that address these issues and

face these issues all the time so I would not be surprised if our

academy has addressed that but I don’t know the specific policy

that we have on it.

Mr. BURGESS. If you find it and you can make it available to the

committee, that would be super.

We of course hear a lot on this committee about things like

health literacy, low health literacy, health disparities. So what

steps can be taken to coordinate care and ensure that children or

in this case the children’s parents actually follow up and take the

physician’s advice and follow up on the care recommended by the

physician and do their appropriate follow-up visits?

Dr. KROL. Well, you pointed out one of the many significant barriers to quality health care for children is the communication that

we have with the parents specifically and a lot of that has to do

with the literacy level, not just health literacy but literacy in general. So trying to find ways to make information and some of this

very technological information that is easy for me to talk with you

about as physicians but to bring that to a level where a family can

understand that and a family that may have a fifth-grade, sixthgrade, eighth-grade reading level is sometimes very difficult. So

trying to find ways to make information available to these families

in a way that they can digest it, understand it, feel informed about

it, able to make competent decisions for their kids is extremely important. So finding any way where we can do that, we work very

hard on trying to do that, not only on a health literacy level but

also on a language level with families that speak different languages that come into our communities. It is a significant barrier

to health care and also a significant barrier to quality. Making sure

that what I am saying is what the family is hearing is very important.

Mr. BURGESS. And along the same lines of the medical devices,

if you have information that any study that the American Academy

of Pediatrics has done regarding levels of health literacy and levels
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of compliance, again I think the committee would be interested in

that.

In your testimony, you say that dollar for dollar, providing better

health care for children represents one of the best returns on investment available and obviously we do have to be concerned about

return on investment when we are talking about the taxpayer’s dollar. So in a program like SCHIP, for example, that was specifically

designed for children, has children as one of the capital letters in

the acronym, would it not make sense to focus on providing care

to children rather than providing care to adults in the SCHIP program?

Dr. KROL. I can say this: As a pediatrician, taking care of a child

is not just about taking care of the child. It is about taking care

of the family that is taking care of that child. It is about an interaction and a relationship with the family. We can’t pull the child

away from that family and take care of them individually. When

they leave my office, they go back to a home environment and go

back to family members, siblings, aunts and uncles, grandmas and

grandpas. We have to approach child health in some ways as family health, and as far as a specific benefit for parents, I will say

that we can’t ignore the fact that children live in families and they

can’t survive on their own without families, and the care that I provide includes care for families and not just children.

Mr. BURGESS. But again, as a dollar for dollar return on investment, a dollar invested in a child’s health is going to go farther

than a dollar invested in an adult’s health. Is that a fair statement?

Dr. KROL. I would say that yes, the money that is spent on children is definitely a great investment. I can’t say that it is necessarily better or worse.

Mr. BURGESS. Well, if we need to develop other programs to take

care of family members who are not children, I mean, it seems to

go beyond the scope of the SCHIP program.

Mr. Chairman, I am going to yield back but I do want to make

one general commercial announcement. We are going to have our

trauma bill up on the floor later today, and of course, as a shameless tie-in to the issue that is before us today, the leading cause

of death for children over the age of 1-year is injury, specifically

motor vehicle crashes, firearms and drownings, so our trauma bill

that we are going to have on the floor today is extremely important

and germane to this discussion.

I will yield back.

Mr. PALLONE. Thank you. It is not a commercial announcement

though, but thank you.

That concludes our questions. I want to thank all of you for being

here today and for bearing with us as we ask questions.

I would just remind Members that you may submit additional

questions for the record to be answered by the relevant witnesses

and the questions should be submitted to the committee clerk within the next 10 days. The clerk will notify your offices of the procedure so obviously we may give you additional written questions and

I hope you bear with us.

Thank you very much, and without objection, this meeting of the

subcommittee is adjourned.
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[Whereupon, at 1:10 p.m., the subcommittee was adjourned.]

[Material submitted for inclusion in the record follows:]
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STATEMENT BY MARK B. MCCLELLAN, M.D., PH.D, ADMINISTRATOR, CENTERS FOR

MEDICARE & MEDICAID SERVICES

Questions have been raised about the new section 1937 of the Social Security Act

(SSA) (as added by the Deficit Reduction Act of 2005) that permits states to provide

Medicaid benefits to children through benchmark coverage or benchmark equivalent

coverage. If a State chooses to exercise this option, the specific issue has been raised

as to whether children under 19 will still be entitled to receive EPSDT benefits in

addition to the benefits provided by the benchmark coverage or benchmark equivalent coverage. The short answer is: children under 19 will receive EPSDT benefits.

After a careful review, including consultation with the Office of General Counsel,

CMS has determined that children under 19 will still be entitled to receive EPSDT

benefits if enrolled in benchmark coverage or benchmark equivalent coverage under

the new section 1937. CMS will review each State plan amendment (SPA) submitted

under the new section 1937 and will not approve any SPA that does not include the

provision of EPSDT services for children under 19 as defined in section 1905(r) of

the SSA.

In the case of children under the age of 19, new section 1937 (a) (1) is clear that

a state may exercise the option to provide Medicaid benefits through enrollment in

coverage that at a minimum has two parts. The first part of the coverage will be

benchmark coverage or benchmark equivalent coverage, as required by subsection

(a) (1) (A) (i), and the second part of the coverage will be wrap-around coverage of

EPDST services as defined in section 1905(r) of the SSA, as required by subsection

(a) (1) (A) (ii). A State cannot exercise the option under section 1937 with respect

to children under 19 if EPSDT services are not included in the total coverage provided to such children.

Subparagraph (C) of section 1937 (a) (1) permits states to also add wrap-around

or additional benefits. In the case of children under 19, wrap-around or additional

benefits that a state could choose to provide under subparagraph (C) must be a benefit in addition to the benchmark coverage or benchmark equivalent coverage and

the EPSDT services that the state is already required to provide under subparagraph (A) of that section. Subparagraph (C) does not in any way give a state the

flexibility to fail to provide the EPSDT services required by subparagraph (A) (ii)

of section 1937 (a) (1).

THE SECRETARY OF HEALTH AND HUMAN SERVICES

August 25, 2006

The Honorable Joseph Barton

Chairman

Committee on Energy and Commerce

House of Representatives

Washington, DC 20515

Dear Mr. Chairman:

Thank you for your letter regarding the Deficit Reduction Act of 2005 (DRA) and

congressional intent with regard to sections 6041 and 6044 of the DRA.

Section 6041 of the DRA created a new section 1916A of the Social Security Act

(the Act) in which States can choose alternative premiums and cost sharing for certain Medicaid beneficiaries. On June 16, 2006, we issued guidance to the States on

cost sharing. As stated in that guidance, for persons with family income at or below

100 percent of the Federal poverty level, we plan to apply the limitations of section

1916 of the ACT so that States may not impose alternative premiums and cost sharing under section 1916A for this group.

Section 6044 of the DRA provides that States can choose to implement benefit

flexibilities authorized by a newly created section 1937 of the Act. However, the

statute prohibits States from requiring enrollment in an alternative benefit package

for our most vulnerable populations; i.e., pregnant woman; certain low-income parents, adults, and children with disabilities; dual eligibles; certain other aged and

disabled individuals in need of long-term care; and adults and children with special

needs.

Regarding Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)

services, our guidance to States issued on March 31, 2006, makes it clear that

States that choose to offer benchmark plans must provide EPSDT to all eligible children.

I look forward to working with you to improve health care for our most vulnerable

populations and to implement these critical DRA provisions. Please call me if you
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have further concerns or questions. I will also provide this response to the cosigner

of your letter.

Sincerely,

Michael O. Leavitt

Secretary

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