Is Government Intervention a Negative or Positive Social Determinant of Oral Health

Commentary by Director Paul S. Casamassimo, DDS, MS

PolicyLogo_copyDecember, 2016

Do we develop a Zika vaccine or continue to increase cancer risk with large scale applications of pesticides into the environment? This quandary is still fresh in our minds after constant media coverage ofsteps taken in south Florida to control the infestation of mosquitos potentially carrying the feared virus. The decision to spray with its potential health consequences – and the delay in Congress to move forward with broader controls – illustrate the Reaganism, "We’re the government and we’re here to help."

The Health Policy Institute (HPI) of the American Dental Association recently proposed a new perspective on oral health and disease. 1 The new index places oral health and disease on the persons and lives affected, moving away from traditional metrics that may have hampered efforts to put a face on the diseases our patients experience and how these diseases, their treatment, and their outcomes truly affect lives. The report, Oral Health and Well Being in the United States, is a major step toward in realizing the oft-heard but still unrealized comment from former Surgeon General C. Everett Koop, "One can’t have health without oral health." The HPI adds policy power to this sea change in viewpoint of the effects of oral diseases on lives by calling on the government to look hard at Medicaid dental benefits for adults in the context of a worsening disease picture for the poor in this country.

This step forward comes none too soon as oral health coverage for poor adults remains an easy target. Recently, the State of Wyoming cut adult Medicaid dental benefits dramatically to partially address a significant state budgetary shortfall.2,3 As has been the case historically in many cash-strapped states, oral health is one of the first benefits to go for the publically insured, as well-insured decision-makers invoke the "Headless Horseman" rule to decide what must go. The rule often translates into "no mental, no dental and no vision" to reduce budget shortfalls. Loss of these basic services not only places the poor several steps back in the daily challenges of life, but condemns them to the back of the line in emerging from poverty with a job. It makes catching up, when fiscal times improve, more dream than reality.

Does the government contribute to systemic and individual patient ills in its attempt to improve health for the poor? This is not the only question requiring an answer. Here’s more.

  • Do chronically low Medicaid fees keep patients in a state of poor health because of low participation by dentists? Some evidence suggests yes, as competitive fees in some states have made access for Medicaid patients comparable to the general public.4 Medicaid expansion gave health coverage to many more Americans, but in states without a commensurate fee increase, the coverage may prove less a benefit to oral health.

  • Has the absence of adult dental care and the hollow mandate of pediatric dental care in the Affordable Care Act (ACA) resulted in the unintended consequences of worsening oral health? The ACA threw adult oral health under the bus and all but severed the connection between oral and systemic health in the minds of decision-makers and payers. Further, it has contributed to the growing visibility of the chasm between medicine and dentistry5. It will be interesting to see how this legislatively induced disjunction affects attempts to add oral health to Medicare.

  • How does governmental largesse and dependence on entitlements affect health behaviors, especially when, as in Wyoming, they abruptly stop? The insured, including those covered by Medicaid, tend to have care consistent with a patient-centered medical home.6 Can this positive behavior be switched on and off, as go state revenues?
  • Will dentists drop Medicaid participation due to the federal government’s reluctance to delay implementation of the ACA’s Section 1557 final rule 7 that mandates language and translation capabilities for dentists accepting patients from federal programs? It is too soon to tell. Ditto for the long-term effect of RAC audits on dentists’ participation in Medicaid.

  • Has the government failed to engage a meaningful mechanism to judge accurately the adequacy of dental workforce? A lingering reliance on an antiquated measure of health professions shortage areas (HPSA) will likely result in an overproduction of dental professionals. Further, most will sadly remain far away from economically depressed HPSAs, but will compete with others in overserved areas and cause a likely rise in fees.

Another question prompted by the recent HPI report on indicators of oral health is whether traditional governmental indices and subsequent reporting of dental disease across income, race, and age actually delay meaningful solutions to oral health disparities. Do coarse systems measures of utilization such as "any visit to a dentist in a given year" mean much? Can this type of measure introduce false comfort and prevent decision makers from seeing the faces of the people the HPI report has made visible? At a population level, decisions about beneficial approaches often target the middle of the bell curve. While this approach certainly helps some, it inadequately addresses the needs of those most severely affected, ignores individuals motivated to health, and ultimately complicates appropriate treatment.

There can be no denying that governmental influence in some aspects of oral health has had a major beneficial effect. The government’s steadfast support of water fluoridation has had human and financial benefits the extent of which will probably never be known. More recently, the doubling in numbers of pediatric dentists trained annually under Title VII federal funding has had a similar but perhaps never-to-be-truly-known effect on early childhood caries. Because pediatric dentists on average have Medicaid children as a fifth of their practice – and because they see very young children while most dentists don’t – their impact has been sizable on the amount of treatment provided to patients early in life.

Former president Bill Clinton’s admonition, after lightning passage of the ACA, was, "Now its unintended consequences can be addressed." His statement sums up how we probably should look at government intervention in oral health care across the board, preferably in a pre-emptive fashion. Often the intention of government intervention is good, but the implementation and unseen consequences are not.

References

  1. American Dental Association. ADA Health Policy Institute. Oral Health and Well-Being in the United States. Chicago, IL, 2016.
  2. Letter. Wyoming Department of Health, Ref: F-2016-359, June 21, 2016
  3. Wyoming Department of Health. Biennium 2017-18 Budget Reduction Proposal, June, 2016.
  4. Nasseh K, Vujicic M. The impact of Medicaid reform on children’s dental care utilization in Connecticut, Maryland, and Texas. Health Services Research 2015;50(4):1236-49.
  5. Mertz EA. Dental-medical divide. Health Affairs 2016:35(12):2168-75.