Health Care Reform
Oral Health Care for African Americans
Oral health is an important but often forgotten component of overall health that is linked to diabetes, stroke, and heart disease complications. According to the Surgeon General’s report, the first report on oral health in the U.S. focused on the needs of oral health exclusively and pointed out that it is a silent epidemic of dental and oral diseases, a burden of diseases that restricts activities (DHHS, 2017). The report served as a catalyst for numerous policy changes related to oral health care. However, while advances have been made in oral health for vulnerable and underserved populations, it is still a major source of suffering. This can be attributed to the disproportionate rates of poor oral health. Hence, oral health continues to be a priority area of focus in Healthy People 2020, aiming to improve oral health through increasing access to dental care and reducing craniofacial injuries, conditions, and disease, as well as oral health through treatment and prevention (DHHS, 2017). Other than being an indicator of well-being, the main value of good oral health can be found in its ability to improve the ability of a person to engage with others, allow for the functions that are more fundamental, such as swallowing, chewing, touching, tasting, and smelling (DHHS, 2017).
Conversely, poor oral health has been shown to contribute to lost productivity for adults as well as children. Children with untreated dental pain or infections have a higher likelihood of poor performance in school or missing them altogether. Hence, due to oral health problems, children will miss approximately 50 million hours of school, translating to 10 million school days (Como et al., 2019). Increased rates of absenteeism from school often are linked to missed working days for their caregivers (Como et al., 2019).
Conflicts Between State and Federal Policies
Medicare exempts coverage of most dental services, including services that are connected with the teeth replacement, removal, filling, treatment or care of teeth or structures that directly support teeth except for payment made under the Hospital Insurance part A in the case of in patient services at the hospital because of the clinical status and underlying medical condition or because of the dental procedure severity, that calls for hospitalization related to the provision of the said services. Under this provision, the C.M.S. currently allows for dental exams to be covered by Medicare in specific circumstances such as, prior to having a heart valve replacement or kidney transplant. Medicare also covers treatment services that are necessary for the covered procedure, such as jaw reconstruction after an injury or for extractions that are done in preparation for jaw neoplastic diseases radiation treatment (DHHS, 2015).
The federal government pays between 50% and 83% of each Medicaid expenditure of a state on services rendered to the covered populations; the federal government’s funding is inversely related to the state’s per capita income (DHHS, 2015). In addition to this financial support, states that offer Medicaid cover enjoy a wide flexibility in the administration of their programs; however, states have minimum requirements to meet to benefit from the federal funding. Thirty-seven states, including the District of Columbia, had, as of March, 2019, expanded programs to cover vulnerable groups (K.F.F., 2019). Specifically, the coverage attracts 100% federal funding of the costs adults incur (between the years 2014 and 2016) and was projected to reach 90% by 2020 (A.C.A., 2010). Estimates as of December of 2017 was 9.8 million adults who had received dental care benefits following Medicaid expansion (American Dental Association, Health Policy Institute, 2019; Vujicic, 2015).
Standards of Care Approach Versus Current Approach Used
African Americans have certain beliefs and attitudes regarding oral health. For example, a pregnant woman’s diet is believed to be an important factor in the later growth of ‘soft teeth’ or a child’s dental caries (da Fonseca & Avenetti, 2017). Some African Americans also believe that when left untreated, caries can result in serious problems. Lewis et al. (2015) point out that among the African-American elderly, oral pain is linked oftentimes to needing dental care. Additionally, there are parents who have fatalistic mindsets, such as most children will at one point develop cavities, and thus, these parents have less knowledge of the oral health needs of their children. Such parents also tend to fail to brush their children’s teeth or seek dental care. Also, they are likely to give children sweetened drinks, soda, or juice (Naidu & Nunn, 2020). There are contrasting beliefs between parents who regularly visit dentists and those who do not do so, with the former having stronger beliefs in preventive care and being more knowledgeable on tooth and gum infant care and the long-term effects of oral diseases. Assari and Hanni (2018) point out that some of the parents who do not utilize dental services express dissatisfaction with the care they had received previously, an attitude that informed their present practices.
The commonly reported home remedies used by African Americans comprise of methods for relieving swelling and pain, such as using cotton balls soaked in aspirin solution, saltwater, or alcohol, or for relief of toothache pain by using cotton wool soaked in oil of cloves or sugar and turpentine solutions; and self-medicating using O.T.C. medications (Dujister et al., 2019). Practices vary by geography and among middle-class younger African Americans due to their higher levels of income and education, increasing their propensity to access professional dental care (Satcher & Nottingham, 2017). Traditional practices could continue and more so among African American low-income families and those who do not have health or dental insurance.
Currently, children and adults of African-American descent have lesser outcomes compared to their white counterparts regarding dental health. According to P.E.W. Research (2016), lower rates of preventive care and dental visits may contribute to the higher incidences of tooth decay that go untreated. Insufficient preventive care and untreated tooth decay have numerous consequences; with time, the gums and teeth may become seriously diseased and require costly extraction and treatment. In line with the high rates of untreated decay, African American adults have a higher likelihood of losing teeth because of dental disease.
The Proposed Approach
The proposed approach is to have all children have mandatory sealants on permanent teeth. Every state has laws that require children to get certain vaccines before they can go to school or daycare. In the same breath, schools and daycares will be expected to admit back to school only children with sealants for their permanent teeth. When oral care is started at an early age, the consequent negative statistics among Black adults will be minimized if not totally eliminated. Tooth sealants cover the surface of molars in children to prevent the collection of plaque and food particles. Sealants help reduce the risk of tooth decay in the long term by providing an additional layer of protection on the child’s teeth from everything that can cause tooth decay. Dental sealants are ideal for patients whose back teeth have deep divots and pits (Dye et al., 2015).
To ensure that the dental sealant program is successful, dentists must be incentivized to offer dental care for children with Medicaid coverage and from vulnerable populations. The Medicaid child health benefits program, referred to as the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT), offers a legally required, comprehensive pathway to the treatment of oral health for low-income youth and children. The EPSDT benefits provided by states are for children eligible for Medicaid who are enrolled in the oral health periodic assessment program on a state-set schedule and in consultation with dental care experts such as the American Academy of Paediatric Dentistry (AAPD). However, the screening schedule fails to establish screening services hard limit; if a child requires more frequent visits for preventive care because, for example, the child is prone to developing cavities, a process needs to be put in place to ensure that the said visits are paid for as an inclusion of the EPSDT benefits (DHHS, 2013).
In 2014, the C.M.S. made clarifications on Medicaid policies on coverage to make it easier for the programs to bill oral health services to Medicaid provided to children who are Medicaid enrolled (DHHS, 2014). By placing emphasis on children’s dental sealants’ importance as part of preventive care, C.M.S., as of 2015, included dental sealants for children with a high risk of caries and aged 6-9 years in the core set of quality measures which states are encouraged to use for fee-for-service and managed providers in both CHIP and Medicaid (DHHS, 2019).
Percentage of G.D.P. for Proposed Approach
States should encourage approval for the implementation of D.T.I. offering a financial incentive to dentists and oral health providers so as to encourage children under 21 years to utilize the services under the following: continuity of care, early childhood preventive dental screenings, evaluations investigations of non-surgical management of caries, and caries risk assessments and treatment. The D.T.I., with combined state and federal match, is worth a total of $750 million. The current-dollar G.D.P. is $20.93 trillion; hence, the percentage of G.D.P. that needs to be allocated for D.T.I., which will enable preventive dental care for children while competitively reimbursing dentists via Medicaid will be approximately 0.4%.
References
American Dental Association, Health Policy Institute (2019). Medicaid expansion and dental benefits coverage. Chicago: American Dental Association. cited 2019 Oct 16. Available from: https://www.ada.org/~/media/ADA/Science%20 and%20Research/HPI/Files/HPIgraphic_1218_3.pdf?la=en. 60
Assari, S., & Hani, N. (2018). Household income and children’s unmet dental care need; blacks’ diminished return. Dentistry journal, 6(2), 17.
Como, D. H., Stein Duker, L. I., Polido, J. C., & Cermak, S. A. (2019). The Persistence of Oral Health Disparities for African American Children: A Scoping Review. International journal of environmental research and public health, 16(5), 710. https://doi.org/10.3390/ijerph16050710
da Fonseca, M. A., & Avenetti, D. (2017). Social determinants of pediatric oral health. Dental Clinics, 61(3), 519-532.
Duijster, D., de Jong-Lenters, M., Verrips, E., & van Loveren, C. (2015). Establishing oral health promoting behaviours in children–parents’ views on barriers, facilitators and professional support: a qualitative study. B.M.C. oral health, 15(1), 1-13.
Dye, B. A., Thornton-Evans, G., Li, X., & Iafolla, T. J. (2015). Dental caries and sealant prevalence in children and adolescents in the United States, 2011-2012.
Kaiser Family Foundation (2019). Status of state Medicaid expansion decisions: interactive map [Internet]. New York (N.Y.): 2019 May 12, Retrieved on 2021 3rd June. Available from: https://www.kff.org/health-reform/slide/current-status-of-the-medicaidexpansion-decision
Lewis, A., Wallace, J., Deutsch, A., & King, P. (2015). Improving the oral health of frail and functionally dependent elderly. Australian dental journal, 60, 95-105.
Naidu, R. S., & Nunn, J. H. (2020). Oral Health Knowledge, Attitudes and Behaviour of Parents and Caregivers of Preschool Children: Implications for Oral Health Promotion. Oral Health Prev Dent, 18, 245-252.
P.E.W. Research (2016, May 12th). Dental Health Is Worse in Communities of Color https://www.pewtrusts.org/en/research-and-analysis/articles/2016/05/12/dental-health-is-worse-in-communities-of-color
Satcher, D., & Nottingham, J. H. (2017). Revisiting oral health in America: A report of the surgeon general.
The Patient Protection and Affordable Care Act of 2010, 42 U.S.C. § 1396a(a)(10)(A)(VIII).
U.S. Department of Health and Human Services (2015). Federal financial participation in state assistance expenditures; federal matching shares for Medicaid, the Children’s Health Insurance Program, and Aid to Needy Aged, Blind, or Disabled Persons for October 1, 2016 through September 30, 2017. Fed Regist. 2015 Nov 25;80(227):73779
U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services (2019). 2019 core set of children’s health care quality measures for Medicaid and CHIP (Child Core Set) [Internet]. Baltimore (M.D.): Retrieved on 2021, 3rd June. Available from: https://www.medicaid.gov/medicaid/quality-of-care/downloads/performancemeasurement/2019-child-core-set.pdf.
U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services (2014). Letter from Cindy Mann, Director, to state Medicaid directors and state health officials, Re: Medicaid payment for services provided without charge (free care) [Internet]. Baltimore (M.D.): 2014 Dec 15, Retrieved on 2021 June 3rd from: https://www. medicaid.gov/fed
U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services (2013). Keep kids smiling: promoting oral health through the Medicaid benefit for children and adolescents [Internet]. Washington, DC: Retrieved on 2021 3rd June from: https://www.medicaid.gov/medicaid/benefits/downloads/keep-kids-smiling.pdf.
Vujicic M (2015). The booming Medicaid market, JADA.146(2):136-8.
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