Pew: Many U.S. states still fall short in kids' oral care

Healthcare reform will provide dental coverage for an additional 5.3 million children by 2014, but most states don't have basic policies and programs in place to translate the expanded coverage into more dental care, according to a report released today by the Pew Center on the States.

Most of the new coverage will come through public insurance programs such as Medicaid and CHIP, but federal and state governments need to adopt policies that support prevention and expand the types of providers available to treat kids, according to the report, "The State of Children's Dental Health: Making Coverage Matter."

The 2011 Pew report card was produced with support from the W.K. Kellogg Foundation and the DentaQuest Foundation. The 50-state report card, which is updated annually, found that 22 states had raised their 2010 grades. Only seven states earned an A grade: Alaska, Connecticut, Maine, Maryland, Massachusetts, Minnesota, and South Carolina. Five states -- Florida, Hawaii, Indiana, Montana, and New Jersey -- received F grades.

The grades were based on how well a state met the following eight criteria:

1. Having sealant programs in at least 25% of high-risk schools
2. Allowing a hygienist to place sealants in a school-based program without requiring a dentist's exam
3. Providing optimally fluoridated water to at least 75% of residents who are served by public systems
4. Meeting or exceeding the 2007 national average (38.1%) of Medicaid-enrolled children ages 1 to 18 receiving dental services
5. Paying dentists who serve Medicaid-enrolled children at the 2008 national average (60.5%) of median retail fees
6. Reimbursing medical care providers through state Medicaid program for preventive dental health services
7. Authorizing a new type of primary care dental provider
8. Submitting basic screening data to the national database that tracks oral health conditions

"Many states earn high marks for effort, but results have fallen short of what they need to be," said Sterling Speirn, president and CEO of the W.K. Kellogg Foundation. "We need to support more innovative approaches to addressing the gap that leaves too many children and families without dental care."

Impact of healthcare reform act

The Affordable Care Act authorized grants for all 50 states for fluoridation and sealant efforts, but the U.S. Congress has not appropriated funds to fund the programs, the report pointed out. Studies have shown that sealants reduce caries by 60% to 70%, Gehshan noted.

"The states aren't ready to serve the children who will be covered the new law, and they need to get moving," said Shelly Gehshan, director of the Pew Children's Dental Campaign.

The law also authorized pilot programs for new types of dental providers, but funding has not yet been secured. In fact, when Congress passed a funding bill in April for the remainder of the current budget year, the measure specifically prohibited funding for alternative dental healthcare provider demonstration projects.

The ADA "has consistently opposed funding these demonstration projects, which could support programs allowing midlevel providers to perform surgical/irreversible procedures," the organization stated in an alert to members.

"It's helpful to have examples like the dental therapists working in native tribes in Alaska, and all evidence has shown that they are providing high-quality work," said Speirn, who noted that the Kellogg Foundation is funding a $16 million program to develop midlevel provider programs in five U.S. states. "They're also using dental therapists in 50 other countries, which is quite a track record."

Despite the ADA's opposition, many private practitioners support the concept, Speirn noted.

"A lot of local dentists have been in touch with us saying they're very interested in the idea, which can provide long-term gains," he said.

Looking ahead

Key findings from the Pew report Since 2010, 22 states have improved their grades. The gains were achieved primarily by reimbursing physicians for preventive dental services, expanding water fluoridation, and increasing the number of Medicaid-enrolled children who receive care. Grades dropped in six states, mostly due to Medicaid reimbursement rates that have not kept pace with the growth in dentists' fees. Only seven states merited A grades: Alaska, Connecticut, Maine, Maryland, Massachusetts, Minnesota, and South Carolina. Maryland was the only one that met seven policy goals; no state met all eight benchmarks. Twenty states received a B grade by meeting five benchmarks. Eighteen states and the District of Columbia received a grade of C or D, meeting just three or four of Pew's policy goals. Five states -- Florida, Hawaii, Indiana, Montana, and New Jersey -- received an F, meeting two or fewer benchmarks.

The first graduates of Minnesota's groundbreaking dental therapist program will start providing treatment in June, and the dental community will soon be able to assess their impact on underserved communities, Speirn pointed out.

Legislation in five states to develop midlevel provider programs died this year in the face of staunch opposition from dental associations. "Change takes a long time," Gehshan acknowledged.

"We've taken practicing dentists to Alaska where they see the quality of work, and they can't see any differences," Speirn said. "I respect that dental associations don't want a second-class system, but the track record has been good."

These new types of providers are definitely worth trying, Gehshan added. "The evidence on their quality of care is established and incontrovertible," she said.

More than 16 million low-income children go each year without seeing a dentist. Gehshan pointed to the statistic as the most disturbing finding in the report, calling it "very risky."

Ralph Fuccillo, president of the DentaQuest Foundation, noted that the disparity of caries rates among minority children. African-American kids have 10% more caries than whites, and the rates are even higher among Hispanics, he said.

"It affects their school work, even their sleeping and eating," Fuccillo said.

Maryland, one of the states which earned an A grade, has made significant progress since the death of 12-year-old Diamonte Driver, who died because of an abscessed tooth, Gehshan noted.

"It was a wake-up call for the nation as a whole," she said, "and Maryland took it to heart and made great progress."

Grades dropped in six states primarily because Medicaid reimbursement rates have not kept up with the growth in dentists' fees, the report noted.

"We have money left on the table now," Gehshan said. "We have payment sources but can't find dentists to treat many of these children."

States must ensure their Medicaid reimbursement rates are high enough to cover dentists' costs, which will encourage more dentists to accept these patients.

"This is a fixable problem," Gehshan concluded. "It won't break the bank to improve the dental health of our children."