Report

The Cost of Delay

State Dental Policies Fail One in Five Children


Executive Summary

The Cost of Delay: State Dental Policies Fail One in Five Children finds that two-thirds of states are doing a poor job. The report was produced by the Pew Center on the States with support from the W.K. Kellogg Foundation and the DentaQuest Foundation.

Pew assessed and graded states and the District of Columbia on eight proven policy solutions that ensure dental health and access to care. A 50-state report card  shows that just six states earned an “A” and that 36 states received a “C” or lower.

Report Contents A

Cost of Delay: Policy Benchmarks

Pew assessed and graded states and the District of Columbia on whether and how well they are employing eight proven and promising policy approaches at their disposal to ensure dental health and access to care for disadvantaged children.

 

Policy benchmark #1: State has sealant programs in place in at least 25 percent of high-risk schools.
Dental sealants are recognized as one of the best preventive strategies for children at high risk for cavities. Sealants—clear plastic coatings applied by a hygienist or dentist—cost one third as much as filling a cavity. Studies have shown that sealant programs targeted to schools with many high-risk children are a cost-effective strategy—but this strategy is vastly underutilized.
 
Percentage of high-risk schools with sealant programs, 2009 Number of States
75-100% 3
50-74% 7
25-49% 7
1-24% 23
None 11
 
Policy benchmark #2: State does not require a dentist's exam before a hygienist sees a child in a school sealant program. 
How many kids are served by a dental sealant program and how cost effective it is depends in part on whether the program must locate and pay dentists to examine children before sealants can be placed. Dental hygienists are the primary providers in school-based dental sealant programs, but states vary greatly in their laws governing hygienists' work in these programs.
 
State allows hygienists to provide sealants without a prior dentist's exam, 2009 Number of States
Yes 30
No 21
 
Policy benchmark #3: State provides optimally fluoridated water to at least 75 percent of citizens on community systems.
A 2001 Centers for Disease Control (CDC) study estimated that for every $1 invested in water fluoridation, communities save $38 in dental treatment costs. The CDC also identified community water fluoridation as one of the 10 great public health achievements of the 20th century and a major contributor to the dramatic decline in tooth decay over the last five decades. Yet more than one quarter of Americans do not have access to optimally fluoridated water.
 
Percentage of Medicaid children receiving any dental service, 2007 Number of States
75-100% 26
50-74% 16
25-49% 7
Less than 25% 2
 
Policy benchmark #4: State meets or exceeds the national average (38.1 percent) of children ages one to 18 on Medicaid receiving dental services.
States are required by federal law to provide medically necessary dental services to Medicaid-enrolled children, but nationwide in 2007, only 38.1 percent of such children ages 1 to 18 received any dental care.
 
Percentage of Medicaid children receiving any dental service, 2007 Number of States
59% or greater 0
50-58% 3
38.1-49.9% 26
30-38.0% 13
Under 30% 9
 
Policy benchmark #5: State pays dentists who serve Medicaid-enrolled children at least the national average (60.5 percent) of Medicaid rates as a percentage of dentists' median retail fees.
Dentists point to low reimbursement rates, administrative hassles and frequent no-shows by Medicaid-enrolled patients as deterrents to serving them. In 26 states, Medicaid programs reimburse less than 60.5 cents of every $1 billed by a dentist. Even in the three states with the highest scores, children on Medicaid still lagged behind the estimated 58 percent of privately insured children who use services each year.But states are taking steps to address these issues, and as a result are seeing significant improvements in dentists' willingness to treat children on Medicaid and in children's ability to access the care they need.
 
Medicaid reimbursement rates as a percentage of dentists' median retail fees, 2008 Number of States
100% or greater 1
90-99% 2
80-89% 3
70-79% 10
60.5-69% 9
50-60.4% 10
40-49% 12
Less than 40% 4
 
Policy benchmark #6: State Medicaid program reimburses medical care providers for preventive dental health services.
Doctors, nurses, nurse practitioners and physician assistants are increasingly being recognized for their ability to provide children in high need with preventive dental care. Currently, 35 states take advantage of this opportunity by making Medicaid payments available to medical providers for preventive dental health services.
 

Medicaid pays medical staff for early preventive dental health care, 2009

Number of States
Yes 35
No 16
 
 
Policy benchmark #7: State has authorized a new primary care dental provider, 2009
Some communities with a dearth of dentists, such as rural and low-income urban locales, have little chance of attracting enough new dentists to meet their needs. An increasing number of states are exploring new types of dental professionals to expand access and fill specific gaps. In a model proposed by the American Dental Association (ADA), these professionals would play a supportive role similar to a social worker or community health worker. In remote locations, the most highly trained professionals could provide basic preventive and restorative care as part of a dental team with supervision by an offsite dentist.In 2009, Minnesota became the first state in the country to authorize a new primary care dental provider.
 
State has authorized a new primary care dental provider, 2009 Number of States
Yes 1
No 50
 
 
Policy benchmark #8: State submits basic screening data to the national database, 2009
Expertise and the ability to collect data and plan programs are critical elements of an effective state dental health program. They also are necessary for states to appropriately allocate resources and compete for grant and foundation funding—all the more important at a time when state budgets are increasingly strained.
 
State submits basic screening data to the national database, 2009 Number of States
Yes 37
No 14
   

 

Report Contents B

Cost of Delay: Four Effective State Strategies

Sealants

Studies have shown that sealant programs targeted to schools with many high-risk children are a highly recommended cost-effective strategy for providing sealants to children who need them. Sealants are one-third of the cost of fillings, and they can be applied by a less expensive workforce. But not all states have kept pace with current clinical and scientific recommendations. While dental hygienists in all states can apply sealants, some states require an examination by a dentist, or the physical presence of a dentist.

Most sealant programs identify target schools by the percentage of students who are eligible for free or reduced-cost lunch; other programs rely on parent surveys. Both approaches recognize that children living in poverty suffer two times more untreated tooth decay than their peers

State examples:

  • In Ohio—a state whose school-based sealant programs have been lauded by the Centers for Disease Control for eliminating income disparity in sealants—the strategy is to reach out to all children in second and sixth grades in schools where at least 40 percent of the student body is enrolled in the free and reduced-cost lunch program.

  • New Mexico's Office of Oral Health has been sending dentists, hygienists and dental assistants to schools with high proportions of at-risk children to provide oral hygiene education, screening and sealants since 1979. For areas beyond its reach the office contracts with other providers. 

Fluoridation

Water fluoridation policy is set at both state and local levels. While fluoridation decisions are frequently made by a health board or water utility, state legislatures and agencies can provide leadership and assistance. Currently, 12 states and the District of Columbia have mandatory fluoridation laws. On average, residents in states with fluoridation laws have more access to fluoridated water than residents in states with no such laws.

State example:

As of 2006, 78 percent of Texans had access to publicly fluoridated water, surpassing the national goal of 75 percent. The Texas Fluoridation Program awards start-up grants to local communities, provides engineering services and maintains data records to support their water fluoridation efforts. In communities with fluoridated water, tooth decay has decreased, while rates of decay have risen among children in communities without fluoridation. But the state's success in fluoridating its communities' water did not come without difficulty. Faced with vocal opposition from a few local groups, the Texas legislature commissioned a report from the state's oral health program to investigate the safety and economic viability of water fluoridation. The report confirmed the proven health benefits gained from drinking water with optimal levels of fluoridation. Experts also determined a savings of $24 per child in Medicaid expenditures for children because of the cavities that were averted by drinking fluoridated water.

Medicaid

Federal law requires all states to provide medically necessary dental services for Medicaid-enrolled children. But nationwide, only 38.1 percent of such children ages one to 18 received any dental care in 2007. In part, this is because not enough dentists are willing to treat Medicaid-enrolled patients. Dentists point to low reimbursement rates, administrative hassles and frequent no-shows by patients as deterrents to serving them. Because of high overhead costs, dentists need to be compensated through Medicaid at a rate of at least 60 percent of their usual fees to break even.

Pew's analysis found that Medicaid reimburses dentists at a national average of 60.5 percent of their usual fees, with 26 states falling below this level. But raising rates alone often is not enough—streamlining the administrative burdens for participating dentists and working collaboratively with providers are also important.

State examples:

Tennessee and Alabama both streamlined the administrative processes for their Medicaid dental programs. Tennessee bid out a contract to a specialized vendor and Alabama obtained a grant to revamp its own internal processes—and raised rates to levels close to dentists' retail fees. In both states, the number of children receiving dental services more than doubled over just four years.

In Virginia, prior to reforms implemented in 2005, dentists were paid less than half of what it cost them to provide care. Consequently, only about 620 dentists statewide had been seeking reimbursement for treating Medicaid patients.Some dentists were seeing Medicaid patients for free so that they could sidestep the onerous paperwork involved. The state overhauled its Medicaid system—scrapping eight individual managed care organizations in favor of one private operator—and raised reimbursement rates by 30 percent. The number of participating dentists has more than doubled to 1,264 as of September 2009, and 94 percent of providers indicated in a recent survey that they are satisfied with the program.

Workforce Models

Communities that have a dearth of dentists available—such as rural and low-income urban communities—have little chance of attracting enough new dentists to meet the need. A growing number of states are exploring ways to expand the types of skilled professionals who can provide high-quality dental health care to disadvantaged children and their communitis. The types fall into three main baskets: medical providers; dental hygienists, and new types of dental professionals. These providers could expand access to basic care and refer more complex cases to dentists who may provide supervision on- or offsite.

State examples:

  • A pioneering project in North Carolina enlists pediatricians and other medical providers to offer dental care to infants and toddlers. Preliminary results from a forthcoming evaluation show that children who participated in the program had a 40 percent reduction in cavities compared to those who did not.

  • A Dental Health Aide Therapist program was launched in Alaska in 2003 under the authority of the Alaska Native Tribal Health Consortium to serve residents of remote Native Alaskan villages that typically rely on outside dentists to serve their communities once or twice a year. Today, there are dental therapists practicing in 11 villages. The therapists provide basic restorative and preventive services in satellite clinics in far-flung communities under the supervision of dentists at a hub clinic.

  • In 2009, Minnesota became the first state in the country to authorize a new primary care dental provider.

Learn more about expanding the dental workforce

Cost of Delay: State Fact Sheets

Below are the individual fact sheets that quantify and describe each state's investments in children's dental health. States are measured against national benchmarks for eight proven policy approaches. 

 

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