Despite ongoing efforts to increase access to oral healthcare for children in Medicaid programs, a new report issued November 30 by the U.S. Government Accountability Office (GAO) reveals that little has changed in the past decade. Although progress has been made, nearly two-thirds of the Medicaid children in the U.S. failed to get any dental care as recently as 2008, according to a GAO analysis of state reports. There were 30 million poor children enrolled in the program that year.
"Nationwide, reported utilization of any Medicaid dental service increased -- from 27% of children in federal fiscal year 2001 to 36% in federal fiscal year 2008," the GAO found. "But despite this increase, no dental service was reported for nearly two-thirds of Medicaid-enrolled children."
In the decade that has passed since the surgeon general described the silent epidemic of oral disease affecting children in low-income families, dental disease and access to dental services have remained a significant problem for these children, the report authors concluded.
— Katherine Iritani, GAO healthcare
acting director
"Utilization of services is still low," Katherine Iritani, the GAO's healthcare acting director, told DrBicuspid.com. "National surveys suggest the rate of untreated decay is not changing. It isn't a good situation."
And efforts to address barriers to care have so far fallen short. A federal Insure Kids Now website set up to help poor families find dentists participating in Medicaid and the Children's Health Insurance Program (CHIP) was found to be rife with broken and incorrect links, wrong numbers, and outdated information, the GAO noted.
Low participation by dentists in Medicaid and CHIP also continues to be a major problem, according to the GAO's analysis of data collected by the Association of State and Territorial Dental Directors.
"Our analysis shows that 25 of 39 states reported that fewer than half of the dentists in their states treated any Medicaid patients during the previous year," the GAO noted. Locating dentists willing to care for poor special needs children remains particularly challenging, according to the report authors.
The U.S. Department of Health and Human Services' (HHS) Health Center and National Health Service Corps programs have helped increase the number of dentists and hygienists working in some underserved communities, but not enough. Shortages of oral healthcare providers in thousands of areas across the country continue to further complicate access to care, according to the report.
Midlevel providers could work
Efforts to provide more dental services by expanding the roles of dental hygienists, primary care physicians, and new dental care provider models are being explored by some states, the report noted. Others are considering midlevel providers, such as dental therapists now at work in tribal areas of Alaska, to expand care to poor and rural areas that are currently underserved by dentists.
While controversial in the U.S. and strongly opposed by the ADA, the Academy of General Dentistry, and many other dental trade organizations, dental therapists have worked in other countries for years. Health officials interviewed by GAO investigators in New Zealand, the U.K., Australia, and Canada "expressed no reservations about the quality of care provided by the dental therapists," according to the report.
"One academic dental therapy official told us that in 2010 between 40% and 70% of Australian children, depending on the state, obtained dental services through publicly funded school-based dental programs primarily staffed by dental therapists," the authors noted.
Fixing what's broken
The report, prepared in accordance with the CHIP Reauthorization Act of 2009, recommends that federal officials institute procedures to correct problems with the Insure Kids Now website and gather more comprehensive and reliable data on the provision of dental services to children through Medicaid, CHIP, and managed care programs. In a response included in the report, HHS officials concurred with the recommendations and said measures were being taken to address them.
The GAO report casts a strong light on the shortcomings of the nation's oral healthcare system, according to Burton Edelstein, DDS, MPH, a professor of dentistry and health policy and management at Columbia University and president of the Children's Dental Health Project.
"The GAO's new report substantiates and validates what too many mothers, child advocates, pediatricians, and Medicaid-participating dentists have long known: that too many families find the doors of the majority of dental offices closed to their children," Dr. Edelstein told DrBicuspid.com. "These findings provide evidence that dentists, federal agencies, governors, state Medicaid programs, and managed care vendors all need to take collective responsibility for failing two in every five of our nation's children."
Dr. Edelstein also praised the report's exploration of alternative dental providers, including dental therapists, as possible models for expanding the current dental workforce.
"The report answers Congress' question about the potential role for additional kinds of dental personnel working under a dentists' supervision to help meet children's needs," he said. "The health reform law authorizes funding that will (if appropriated) enable dental authorities to try out dental therapists and other types of midlevel providers, and then have these trials evaluated by the Institute of Medicine."
A sobering reminder
The report comes as a validation of concerns about persistent oral health disparities and barriers to care, said Shelly Gehshan, director of the Dental Health Initiative at the Pew Center on the States. The GAO also provided an important look at workforce models that might address the problems, she said.
"The GAO confirms that new providers can provide quality care at lower costs and in places where dentists are not available," Gehshan said. "The dental team needs to be bigger. We need more options. We estimate that 5.3 million new children will have dental coverage by 2014 through the Affordable Care Act. If two-thirds of kids are not getting care now, where will they go?"
But Liz Rogers, director of communications and public affairs for Oral Health America, said that the report's findings simply raise the same questions that have been haunting public health officials for years.
"Each time we hear a story of a child going to bed in pain, or a child unable to concentrate in school or eat because of untreated tooth decay, and every time we read yet another report showing that our healthcare delivery system is not working for our poorest children, we have to ask why, and again why, until we finally get to the heart of the problem," she said. "What kind of country do we want to be, and where do we want to spend our resources? How can we expect our children to get jobs and succeed in life if they are unable to sleep, eat, and concentrate in school? Let's keep this conversation going, and let's continue to ask why."
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