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N at i o n a l C o n f e r e n c e o f S tat e L e g i s l at u r e sImproving LifetimeOral Health:Policy Optionsand InnovationsBY TAHRA JOHNSON AND KRISTINE GOODWINMany Americans lack access to basic, affordable oral healthspeaking. Dental expenses for U.S. children ages 5 to 17 werecare. Tooth decay is the most preventable unmet health needabout 20 billion in 2009—almost 18 percent of all health carein the United States, yet one-quarter of children have toothcosts for this group.2decay before they enter kindergarten and one-third of adultsreport having it.1 Growing evidence links oral disease to chronicIn sum, tooth decay and unaddressed oral health problemshealth conditions such as diabetes, heart and lung diseaseadd up to poor health outcomes and rising health care costs.and potential pregnancy complications. Costly for families,Emergency room (ER) visits for preventable dental conditionscommunities and states, untreated tooth decay can lead to paincost 1.6 billion in 2012,3 and the cost of a procedure, such as aand infection, missed school days, and problems with eating andtooth extraction, can increase nearly 10 times when performed in
POLICYMAKERS CONVENE TO SHARE CHALLENGESAND POLICY OPTIONSMore than 50 legislators, legislative staff, providers and others convened at NCSL’s Legislative Summit in August 2015to discuss state options for improving oral health care and reducing costs for all populations. The session, “Smart Investments in Oral Health: State Policy Options for Improving Care and Reducing Costs,” featured national expert Andrew Snyder from the National Academy for State Health Policy. Snyder highlighted initiatives that address oral health coverage,integration of oral health with primary care, innovations in oral health care delivery and public health strategies. Accordingto Snyder, oral health is an important issue for state policymakers for the following reasons: Oral disease is preventable, but is highly prevalent and chronic. Significant disparities exist among groups in the U.S., and there are long-standing, persistent barriers to low-incomepeople accessing care. 108 million Americans lack dental coverage. Poor oral health has potential negative effects on development, nutrition, education, employability and quality of life. Oral disease has been linked to avoidable emergency room visits and has connections to systemic conditions like cardiovascular disease, stroke, and diabetes.IMPROVING ACCESS RESULTSIN BETTER, LESS COSTLY CAREExpandaccessHealthierpatients andless-costly careIncreasepreventive careFewer ED vistsSource: Representative Susan Allen, “Missouri Oral Health Initiatives,”NCSL Legislative Summit, August 2015.Missouri Representative Susan Allen and Kentucky Representative Thomas Burch shared challenges and oral healthinitiatives in their states. In Missouri, for example, Representative Allen pointed to provider shortages, especially in certaingeographic areas, and costly visits to the hospital emergency room for unaddressed oral health needs. In 2013, nearly60,000 emergency department visits were due to tooth and jaw disorders and other dental problems. There, patients receive treatment that addresses the symptoms of pain, not the underlying causes, which could be better addressed in thedentist’s office, Allen said. The trend is costly to the state: Dental emergency department (ED) visits cost about 300 pervisit and totaled 17.5 million in 2013. Expanding access to preventive services results in a positive return on investment,she concluded. Other speakers and attendees shared policy options that address unmet needs and improve oral healthoutcomes. Many of these examples are featured throughout this brief.NATIONAL CONFERENCE OF STATE LEGISLATURES2
an emergency room instead of a dental office.4These factors are costly for states and affect thequality of life for individuals and families.Concerned about these cost and health status trends, policymakers have adopted myriadstrategies to improve oral health for children andadults. This report highlights targeted state policyoptions for improving oral health for children andadults, as well as system-level reforms to improve care and reduce costs for all populations.STATE OPTIONS FOR IMPROVINGCHILDREN’S ORAL HEALTHTooth decay is more prevalent among childrenfrom lower-income families and children of certainracial and ethnic groups, according to the Centers for Disease Control and Prevention (CDC).Total U.S. dental expenditures for children up to21 years old exceeded 25 billion5 in 2012, placing a significant financial burden on state budgets. According to a 2013 report from The PewCharitable Trusts, annual Medicaid spending fordental services is expected to increase by 170percent—from 8 billion in 2010 to 21 billion in2020. State legislators have adopted numerousstrategies to improve oral health practices andcare for children.Bright Futures offers pediatric care providersAssess and Screen inPrimary Care Settingsand families tools for evidence-based care forchildren from birth to age 21. For example, oralhealth risk assessments are recommended at thePediatricians are often the first medical providersto examine a baby or toddler’s mouth. By the age6- and 9-month well-child visits with primary careof 6 months, oral health screenings should be-providers. A pediatrician can identify conditionsgin and continue as a routine part of every doc-like plaque, cavities or inflammation of the gums,tor’s visit, according to the American Academy ofand also refer a patient to a dental provider. OralPediatrics. The American Academy of Pediatrichealth risk assessments provide early trackingDentistry (AAPD) recommends that a child gofor a child’s oral health history that can be laterto the dentist by age 1. The federal Health Re-referenced by his or her future dental provider.sources and Services Administration (HRSA) es-Early evaluation can help maintain good oraltablished the Bright Futures Guidelines in 1990health and prevent or treat disease.to improve the standard of care for children andadolescents. Since 2002, the American AcademyApplying fluoride varnish is another way pediatri-of Pediatrics (AAP) has overseen developmentcians and primary care providers can help withand dissemination of these guidelines. Thepreventive oral health procedures. States havemajority of states use the recommendations innow begun reimbursing doctors through Med-Bright Futures to guide which services the stateicaid. According to The Pew Charitable Trusts,Medicaid program covers.most Medicaid programs pay between 15 and63NATIONAL CONFERENCE OF STATE LEGISLATURES
30 for the procedure. Fluoride varnish can re-money by preventing the need for dental-relatedduce the rate of tooth decay by one-third, lead-emergency room visits and other costly den-ing to significant cost savings, such as avoidingtal care. Not all policymakers embrace sealantrestorative dental care or hospital visits.7programs, and some concern exists about thesafety of sealants; however, one-time applica-School-based Prevention and Caretion of sealants has not been found to providechronic exposure, and applying them properly re-Most dental disease can be prevented by earlyidentification and intervention with care suchduces exposure. Based on a review of evidenceas dental sealants and fluoride treatments.about sealant safety and risks, the AssociationSealants—plastic coatings applied to vulner-of State and Territorial Dental Directors recom-able molars—help prevent decay and may savemends sealants for all children. Dental sealantsNATIONAL CONFERENCE OF STATE LEGISLATURES4
ness about healthy oral hygiene for children whodo not regularly visit a dentist.9School sealant programs exist in most statesand vary in scope, complexity, funding methodsand other factors. According to a 2013 report byThe Pew Charitable Trusts, successful sealantprograms target high-need children, use a costefficient workforce, and eliminate reimbursementand regulatory barriers for providers. Some programs arrange to apply sealants at school-basedclinics or in mobile vans, while others link schoolsto private dental practices where children canreceive the services. Policymakers have takensteps to expand access to and reimburse forsealant services and providers. Laws in severalstates allow dental hygienists and assistants toapply sealants in schools or other public healthsettings. These policies expand access to preventive services, especially for underserved children and adolescents. Arkansas lawmakers created a collaborative care program in 2011 that allows qualified dental hygienists—who collaborate withconsulting dentists—to provide sealants andother procedures in public health settings. Colorado lawmakers established a grant program in 2013 to support school-based dentalsealant programs, community water fluoridation and other strategies. A 2009 Massachusetts law authorized publichealth dental hygienists to provide sealantsand certain other preventive services without a dentist’s prior examination. The lawalso allows reimbursement under Medicaidand the Children’s Health Insurance Program (CHIP).applied in school-based programs reduce toothRaise Awareness AboutHealthy Behaviorsdecay by as much as 60 percent.8 They also canreduce dental health disparities and lead to follow-up care and enrollment in health insurance.Around 80 million Americans have limited healthThe U.S. Preventive Services Task Force ratesliteracy—the ability to understand and interpretschool-based sealant programs as an evidence-health information—which puts them at greaterbased approach for reducing tooth decay. Therisk for lacking access to care and having poortask force evaluated four sealant delivery pro-health.10 People with poor health literacy aregrams in 2013 and found that sealants reducedmore likely to have fewer preventive procedures,tooth decay up to 48 months after application. In-potentially leading to costly ER visits or chronicschool sealant programs also help raise aware-health conditions. This group can include older5NATIONAL CONFERENCE OF STATE LEGISLATURES
STATE MEDICAID COVERAGE OF ADULT DENTAL DCGAALLATXMDSCARMSNo dental Emergency onlyLimitedExtensiveSource: Center for Health Care Strategies, Inc., “Medicaid Adult Dental Benefits: An Overview,” February 2016No dental benefitsadults, people with limited education and thoseEmergency onlywith limited English proficiency. Some statesple and employers. Employed adults lose morehave launched oral health campaigns to spreadLimitedawareness like Delaware’s “Healthy Smile.oral health problems or dental visits, accordingHealthy You.”than 164 million work hours annually because ofto the CDC.13ExtensiveExpand Coverage for Low-Income AdultsASGUMPVIPRSTATE OPTIONS FOR IMPROVINGADULT ORAL HEALTHThe vast majority of adults who gained or willPoor access to dental services has economicdo so through state Medicaid programs.14 Anconsequences for states. Visits to the emergen-estimated 800,000 will gain coverage throughcy room for dental reasons cost 1.6 billion inthe state or federal health insurance exchanges.2012 and rarely addressed the underlying con-According to a February 2016 report from thedition. Estimates show that 79 percent of theseCenter for Health Care Strategies, 46 statespatients could have been treated in a commu-and the District of Columbia currently cover atnity setting.least emergency dental services (e.g., relief forgain some dental coverage through the Affordable Care Act (ACA)—about 17.7 million—will11uncontrolled bleeding or trauma) for adults withMedicaid is a major payer of these costs. CaseMedicaid; of those, 13 states cover emergencyin point: A study of Maryland’s Medicaid costscare only, 18 states and the District of Columbiashowed a potential savings of 4 million if dentalcover certain limited services (such as preventivevisits to the emergency room were diverted toand restorative procedures), and 15 states offera more appropriate setting.extensive coverage to their base Medicaid adult12In addition, pooradult oral health is costly to both working peoNATIONAL CONFERENCE OF STATE LEGISLATURESpopulation.6
Expand Oral Health WorkforceSeveral states have restored adult dentalcoverage in recent years, after eliminat-States struggle to find an adequate numbering them during the economic recession.of oral health providers who accept Medicaid.A 2014 California law covers certain den-Dentists often decline to participate in Medic-tal benefits for all adults on Medi-Cal (theaid because of lower reimbursement rates thanstate’s Medicaid program). In 2014, Idahoin the commercial market. According to thelawmakers reinstated dental benefits forAmerican Dental Association (ADA), 35 percentadults enrolled in Medicaid, including cover-of dentists accept Medicaid patients. For adultage for routine exams and preventive andservices in states with at least limited benefits,other dental services. Washington restoredthe reimbursement rates averaged 40.7 percentdental coverage in 2013 for Medicaid-en-of commercial reimbursement in 2014. Alaska,rolled adults to include restorative and pre-Arkansas and North Dakota had the highest re-ventive services, emergency services, rootimbursement rates, at around 60 percent of thecanals, cavity care, and routine checkups and cleanings.commercial rate.15Some states are providing preventive den-Some states have adopted financial and other in-tal benefits to adults for the first time. Incentives—including enhanced reimbursement or2013, Colorado lawmakers passed Sen-reduced administrative burden (less time fillingate Bill 242, which provided dental benefitsout forms)—to increase the number and avail-to all adult Medicaid enrollees, with up toability of oral health providers who are willing to 1,000 in dental benefits each year. Southprovide care to Medicaid patients. States alsoCarolina will cover cleaning, fillings and ex-have taken steps to increase the capacity of thetractions for adults with very low incomesexisting oral health workforce to meet demandor disabilities.by, for example, using telehealth (providing ser7NATIONAL CONFERENCE OF STATE LEGISLATURES
vices remotely) or changing provider roles andconcerns about liability may cause dental profes-practice settings. California lawmakers passedsionals to delay treatment for pregnant women.legislation in 2014 to reimburse hygienists andIn addition to the consequences of dental healthdentists for telehealth dental services.problems during pregnancy, a woman’s oralhealth also can affect her children.Improve Oral Health Accessfor Pregnant WomenPregnant women and young children often aremore likely to see a primary care provider thanDental disease in pregnant women is associateda dental professional, so other providers suchwith pre-term birth, low birthweight and gesta-as obstetricians, gynecologists and pediatricianstional diabetes, all of which can harm the babymay be engaged in their patients’ oral healthand may result in a more costly pregnancy. Den-care. The New York State Department of Healthtal care is safe throughout pregnancy, althoughcreated “Oral Healthcare During Pregnancy andmisapprehension about treatment safety andEarly Childhood: Practice Guidelines,” which pro-NATIONAL CONFERENCE OF STATE LEGISLATURES8
vide screening and treatment recommendationsWisconsin19—are piloting another new type offor prenatal care providers, oral health profes-provider, Community Dental Health Coordinatorssionals and child health professionals.16(CDHC), who are trained by the American DentalAssociation. CDHCs are usually recruited fromthe same communities they serve and in additionSTATE OPTIONS FORIMPROVING ORAL HEALTHFOR ALL POPULATIONSto some basic, preventive services, may providehealth education, connect patients with dentaltreatment, and arrange additional services suchas transportation and child care.Although some state policies are focused onspecific populations, many states are tak-Coordinate Primary Care and Oral Healthing steps to improve oral health for everyonethrough improved access to providers, im-The connection between oral health and physi-proved systems of care and other overarchingcal health is well documented; for example, stud-strategies described here.ies show significant annual cost-savings for themedical treatment of diabetic patients when theyEnsure an AdequateOral Health Workforcereceive regular periodontal care.20 And on themedical side, almost all state Medicaid programsEven with new professionals entering the field—reimburse primary care doctors and nurses forthe number of dentists has slightly increasedproviding oral exams, screenings and preventiveeach year since 2001—some 49 million Ameri-services, such as fluoride treatments and parentcans live in a designated dentist shortage area.education.17The Health Resources and Services Administra-Several states have taken steps to integratetion estimates that the country needs 7,300 neworal health into broader health system deliverydentists to fill the gaps. State legislatures havereforms and to coordinate physical, mental, be-explored creative ways to ensure access to oralhavioral and oral health for individuals enrolledhealth care by addressing the workforce.in Medicaid. For example, Oregon lawmakersFor example, many states expanded dental hy-passed House Bill 3650 in 2011 to create a newgienists’ licenses to allow greater scope of prac-payment and delivery system known as Coordi-tice or practice in community-based settings.nated Care Organizations (CCOs). The state’sIn 2014, 37 states allowed dental hygienists to16 CCOs deliver physical, behavioral and oralprovide certain preventive services to patients,health services to Medicaid enrollees.often without direct supervision by a dentist, andExpand Access to Providersthrough Teledentistry16 states allowed direct Medicaid reimbursementto hygienists, according to the American DentalHygienists’ Association.Telehealth can help achieve the goals of thetriple aim—improving care and health whileStates such as Alaska, Maine and Minnesotalowering costs—by improving access to ap-have created new provider types, such as dentalpropriate, lower-cost services, such as timelytherapists and community dental providers. Den-primary or specialty care, or through lower-costtal therapists typically are trained to perform ba-settings, including clinics, homes or workplaces.sic restorative services, such as fillings and rootTelehealth adoption and expansion across thecanals on baby teeth, and non-surgical extrac-nation bring various challenges, some of whichtions. Data show the addition of a mid-level pro-present policy questions for state leaders. Forvider allows participating clinics to see more pa-example, lack of broadband and cellular con-tients and adds revenue, in part by allowing thedentist to work at the top of his or her license.18nectivity, and availability and affordability ofEight states—Arizona, California, Montana, Min-der telehealth. The telehealth field is changingnesota, Oklahoma, Pennsylvania, Texas andrapidly, and in some cases, technology may bedevices for consumers and providers can hin-9NATIONAL CONFERENCE OF STATE LEGISLATURES
getting ahead of policy. Policymakers are work-The decision to fluoridate the water supply ising to craft frameworks that capitalize on the ad-typically made at the local level and has metvancements and potential for telehealth, whilewith resistance in some communities. A fewmaintaining an appropriate level of oversight tostates mandate fluoridation or regulate how thesafeguard state investments and ensure effec-system functions. Twenty-six states and Wash-tive health care delivery.ington, D.C., meet or exceed the average national percentage (74.6 percent) of citizens whoTeledentistry can leverage and expand the reachget their drinking water from a fluoridated sys-of the existing workforce. For example, a 2010tem.23 These rates vary and in 13 states at leastCalifornia demonstration project called Virtual60 percent of the adult population does not haveDental Home showed that telehealth-enabledaccess to fluoridated water systems.24dental teams could provide comprehensive carefor people who were inadequately served in a tra-Maximize Current Dataditional dental setting.21 The project’s success ledto a 2014 law including teledentistry as a specialtyPolicymakers have enacted data and surveil-for Medicaid reimbursement. Arizona, California,lance strategies that help them understand oralFlorida and New York all have some form of cov-health challenges and unmet needs and developerage of teledentistry in Medicaid.targeted responses. For example, Colorado andWisconsin use data to evaluate the effectivenessUnderstand the State Rolewith Community Water Fluoridationand efficiency of their school sealant programsas well as to allocate funding.Community water fluoridation has proven to beCONCLUSIONa cost-effective public health measure to prevent tooth decay. For 70 years, adjusting theAs the examples provided in this report suggest,level of this naturally occurring mineral in publicwater supplies has helped prevent tooth decaythere is not one singular strategy for improvingfor residents of all ages, but especially for chil-oral health for children and adults. Instead, leg-dren whose adult teeth are still forming. Theislators are adopting a wide range of strategiesCDC estimates that every 1 invested in wateraimed at addressing specific problems and re-fluoridation saves 38 in dental treatment.moving barriers to good oral health care.NATIONAL CONFERENCE OF STATE LEGISLATURES2210
13. Centers for Disease Control and Prevention, Division of OralHealth, “Adult Oral Health” (Atlanta, Ga.: CDC, 2013), http://www.cdc.gov/oralhealth/children adults/adults.htm.NOTES1. Centers for Disease Control and Prevention, Division ofOral Health, “Adult Oral Health” (Atlanta, Ga.: CDC, 2013), http://www.cdc.gov/oralhealth/children adults/adults.htm.14. M. Vujicic and K. Nasseh, “Reconnecting Mouth and Body:ACA Fails to Meet Dental Care Needs but States Can Pick upSlack,” Health Affairs Blog (Aug. 26, 2013), eds-but-states-can-pick-up-slack/.2. Susan O. Griffin, et al., “Use of Dental Care and EffectivePreventive Services in Preventing Tooth Decay Among U.S.Children and Adolescents — Medical Expenditure Panel Survey,United States, 2003–2009 and National Health and NutritionExamination Survey, United States, 2005–2010,” Morbidity andMortality Weekly Report 63, no. 2 (Sept. 12, 2014): 54-60, htm.15. K. Nassah, M. Vujicic, and C. Yarbrough, A Ten-Year, Stateby-State Analysis of Medicaid Fee-For-Service ReimbursementRates for Dental Care Services (Health Policy Institute ResearchBrief) (Chicago III.: American Dental Association, October2014),http://www.ada.org/ rief 1014 3.ashx.3. T. Wall and M. Vujicic, Emergency Department Use forDental Conditions Continues to Increase (Health Policy InstituteResearch Brief) (Chicago, Ill.: American Dental Association, April2015).http://www.ada.org/ rief 0415 2.ashx.16. “Oral Health Care during Pregnancy and Early ChildhoodPractice Guidelines” (Albany, NY: New York State Department ofHealth, 2006), https://www.health.ny.gov/publications/0824.pdf.4. Dianne Sefo, “Seeking Treatment for Oral Care Problemsin Emergency Rooms” (New York, N.Y.: Colgate PalmoliveCompany, Colgate Oral Care Center, 2016). w-281474979192045.17. Health Policy Institute, “Supply of Dentists” (Chicago, Ill.:American Dental Association, February 2016), cy-institute/data-center/supply-of-dentists.18. The Pew Charitable Trusts, Expanding the Dental Team:Increasing Access to Care in Public Settings (Washington, D.C.:The Pew Charitable Trusts, June 2014), http://www.pewtrusts.org/ /media/Assets/2014/06/27/Expanding Dental CaseStudies Report.pdf.5. Centers for Disease Control and Prevention, Division of OralHealth, “Preventing Tooth Decay,” (Atlanta, Ga.: CDC, s/oralhealth/.6. National Conference of State Legislatures, The BrightFutures Guidelines: Improving Children’s Health (Denver: lth.aspx.19. Stacie Crozier, “CDHC program is nearly complete,” ADANews, (Oct. 21, 2013), chive/october/cdhc-program-is-nearly-complete.7. Pew Centers on the States, “Reimbursing Physicians forFluoride Varnish” (Washington, D.C.: The Pew Charitable cians-for-fluoride-varnish.20. A. Snyder, Oral Health and the Triple Aim: Evidence andStrategies to Improve Care and Reduce Costs (Washington,D.C.: National Academy for State Health Policy, April /04/Oral-TripleAim.pdf.8. The Guide to Community Preventive Services, “PreventingDental Caries: School-Based Dental Sealant DeliveryPrograms,” (Atlanta, Ga.: The Community Guide, tingmaterials/RRschoolsealant.html.21. Paul Glassman, Maureen Harrington, Elizabeth Mertz, andMaysa Namakian “The Virtual Dental Home: Implications forPolicy and Strategy” (Bethesda, Md.: HHS Public Access, July2012), 9/.9. Ibid.22. Centers for Disease Control and Prevention, “Cost Savingsof Community Water Fluoridation” (Atlanta, Ga.: CDC, updatedJuly 10, 2013), m.10. Nancy D. Berkman, et al., “Low Health Literacy and HealthOutcomes: An Updated Systematic Review,” Annals of InternalMedicine 155, no. 2 (July 19, 2011): 97, http://citeseerx.ist.psu.edu/viewdoc/download?doi 10.1.1.673.4819&rep rep1&type pdf.23. Centers for Disease Control and Prevention,. “2012 WaterFluoridation Statistics” (Atlanta, Ga.: CDC, updated Nov. 22,2013), ts.htm.11. T. Wall and M. Vujicic, Emergency Department Use forDental Conditions Continues to Increase (Health Policy InstituteResearch Brief) (Chicago, Ill.: American Dental Association, April24. Oral Health America, “Are Older Americans Coming of AgeWithout Oral Healthcare?” (Chicago, Ill.: OHA, 2014), http://b.3cdn.net/teeth/1a112ba122b6192a9d 1dm6bks67.pdf.2015).12 Ibid.11NATIONAL CONFERENCE OF STATE LEGISLATURES
AcknowledgmentsSupport for publication was provided by a grant from the DentaQuest Foundation.See more at: http://dentaquestfoundation.org.NCSL ContactTahra Johnson, MPHPolicy m T. Pound, Executive Director7700 East First Place, Denver, Colorado 80230, 303-364-7700 444 North Capitol Street, N.W., Suite 515, Washington, D.C. 20001, 202-624-5400www.ncsl.org 2016 by the National Conference of State Legislatures. All rights reserved. ISBN 978-1-58024-852-5
der from the National Academy for State Health Policy. Snyder highlighted initiatives that address oral health coverage, integration of oral health with primary care, innovations in oral health care delivery and public health strategies. According to Snyder, oral health is an important issue for state policymakers for the following reasons:
