U.S. lawmakers propose sweeping dental reforms

The lack of oral health services for poor, elderly, and rural Americans has been haunting U.S. Sen. Bernard Sanders (I-VT) for years.

On June 7, in hopes of addressing the issue once and for all, he introduced what he called "the most comprehensive dental care legislation in American history."

"Tens of millions of Americans are unable to access affordable dental care, and they suffer as a result of that," said Sanders, announcing the introduction of the Comprehensive Dental Reform Act of 2012 during a press conference at the U.S. Capitol.

U.S. Sen. Bernard Sanders (I-VT)

U.S. Sen. Bernard Sanders (I-VT)

"Simply put, the groups that need care the most are the least likely to get it," he added, citing grim findings from a report prepared for him as chairman of the Senate Subcommittee on Primary Health and Aging. As many as 130 million Americans have no dental insurance, one-quarter of U.S. adults age 65 and older have lost all of their teeth, and about 17 million low-income children do not see a dentist each year, according to the report.

Joining Sanders in his announcement was Rep. Elijah Cummings (D-MD), who introduced identical legislation in the House.

"This bill recognizes the important role of dental care in overall health and expands coverage to those who have so often been left behind," said Cummings, harking back to the 2007 death of Deamonte Driver, a 12-year-old Maryland Medicaid child who suffered from complications of an untreated dental abscess.

"Disparities are systemic in our nation's healthcare system and have resulted in unacceptable differences in access and healthcare outcomes," Cummings said.

Covering all the bases

Their sweeping legislation would extend comprehensive dental coverage to millions of Medicare, Medicaid, and U.S. Department of Veterans Affairs beneficiaries who lack it; increase spending to expand oral health services in communities that currently go without them; and boost oral health literacy and research programs.

The twin bills would also increase funding for safety net clinics serving the poor, such as federally qualified health centers, school-based clinics, and mobile and portable programs devoted to providing care in isolated and rural places. In addition, the measures would create an emergency care coordination grants program aimed at guiding patients with urgent dental needs to clinics rather than emergency rooms.

In addition, the legislation would create an incentive to states to make Medicaid participation more attractive to oral health providers by boosting the federal government's contribution by 10% to help pay for the delivery and administration of dental services in states where providers are paid not less than 70% of usual and customary fees, and where measures are put in place to make provider participation simpler.

"Only 20% of the nation's practicing dentists provide care to people with Medicaid, and only an extremely small percentage devote a substantial part of their practice to caring for those who are underserved," Sanders said. "This bill addresses this by creating an incentive to increase Medicaid reimbursement rates for dentists by assisting the states in covering those costs."

The legislation would employ a variety of strategies to address the shortage of oral health professionals serving in areas now lacking care, Sanders said. According to the U.S. Health Resources and Services Administration, nearly 10,000 additional dental providers are needed to address the current lack of care.

"This bill would begin to address this gap and would also expand the dental workforce to include alternative providers in order to increase access," Sanders said.

The legislation would create an oral health professional student loan program and would authorize new demonstration programs for the training and employment of alternative dental healthcare providers through the federal departments of Veterans Affairs and Defense, the Bureau of Prisons, and the Indian Health Service.

In addition, National Health Service Corps scholarships would be targeted at recruiting and supporting dentists and dental hygienists, as well as dental therapists, midlevel providers who receive technical training to provide care, including simple extractions and restorative procedures.

ADA opposition

While the broad outlines of the bills won praise, those sections dealing with workforce issues received mixed reviews from dental groups, which have been deeply divided over this issue for years.

Among the more than three dozen organizations listed as supporting the legislation was the American Dental Hygienists' Association, whose president offered a statement commending the bills, particularly their attention to workforce expansion through the support of midlevel dental providers.

"Midlevel dental providers currently exist in more than 50 countries and have demonstrated their ability to deliver safe and high-quality level of oral healthcare to patients," said ADHA President Pam Quinones, RDH.

But those same workforce provisions drew criticism from the 156,000-member ADA. In a prepared statement, ADA President William Calnon, DDS, spoke supportively of the broad goals of the legislation, but not of the promotion of workforce expansion through midlevel providers.

"The ADA has written to Senator Sanders to express support for much of the bill and to offer suggestions intended to strengthen some provisions, but also to express the Association's continued opposition to expending precious federal dollars on unproven and, we believe, unnecessary programs to expand the use of so-called midlevel dental providers," Calnon stated. "We hope that our few areas of disagreement do not obscure our welcoming Sen. Sanders to this fight. His bill aims high, and that has long been needed."

The ADA's seven-page letter to Sanders praised sections of the bill, such as the inclusion of adult Medicaid dental coverage and the support of mobile and portable oral health facilities "that meet state standards and certification requirements."

The analysis concluded such steps would offer "long overdue parity of dental services."

But the letter criticized the effort to include Medicare coverage for routine dental care.

"The ADA is very aware that many of our country's vulnerable elderly do not have comprehensive dental coverage. However, Congress should target whatever limited federal resources are available toward robust and adequately funded Medicaid coverage for poor adults which would include many seniors," the letter stated. "A new dental program in Medicare would provide coverage to all beneficiaries, including wealthy recipients who have the ability to pay, thereby misdirecting scarce resources."

The provisions of the legislation would be funded through a 2.5¢ tax on security transactions, said Sanders, adding that he hopes to work with the ADA to win passage.