Burton L. Edelstein DDS MPH Board Chair, Children’s Dental Health Project

1. Medicaid, CHIP, & Healthcare Reform:Options and Opportunities for Florida Children’s Oral Health Burton L. Edelstein DDS MPH Board Chair, Children’s Dental Health Project Professor of Dentistry and Health Policy Columbia University Florida Public Health institute Webcast 11-5-09

2. Acknowledgement The Florida Public Health Institute & The Children’s Dental Health Project have partnered to advance policies that improve children’s oral health and use of dental services

3. Premise Insurance coverage for children’s dental services has been an integral part of public insurance since 1965. Even now, it is part of Congress’ effort to reform health insurance. Yet despite these longstanding programs, only 1-in-5 Medicaid insured children in Florida make it to a dentist in a year. Florida’s performance serving the dental needs of low income children is one of the lowest in the country and its program for adults is limited and threatened. It matters It is fixable People on this webcast can fix it!

4. Webcast Plan • The Mouth • The Issue: Oral health &dental care of FL’s children (all children!) • The Opportunities: Congressional options for states from 1965 to 2009 and what FL does with them. • Access versus Utilization • Fixes • Going forward: FPHI, CDHP, and you

5. The Mouth

6. An organ of Digestion Respiration Communication Protection Sex Home to unique structures Teeth and pulp Occlusion Periodontium Tongue Salivary glands TMJ The Mouth: So what anyway? Why all the fuss?

7. The Issue: Oral Health & Dental Care of FL Children

8. The Problem The World of Children’s Oral Health in FL is Upside Down Kids with most needs get least care Kids with least needs get most care

9. FL Children’s Oral Health Status Child and Adolescent Health Measurement Initiative. 2007 National Survey of Children's Health, Data Resource Center for Child and Adolescent Health website. Retrieved [10/31/09] from www.nschdata.org

10. FL Children’s Oral Health Status: Parent Assessment by Age But how well does parent assessment fit with clinical examination?

11. FL Parents Do Very Well Assessing Their Children’s Oral Status

12. Yet Problems Remain (Regardless of who you ask)

13. And they matter

14. They matter at many levels • Tooth-level impact: ECC is best predictor of future cavities. Because dental repair does not reduce disease activity, caries progression – even after repair – is common. • Mouth-level impact: ECC is a disease of the mouth that is expressed on the teeth. Unless the mouth is treated, caries progression will continue • Child-level impact: Decreased quality of life, function, mood, growth, social comfort and occasional local and distant significant infections • Family-level impact: Financial, work, and interpersonal stress • Societal-level impact: Avoidable cost demands on Medicaid, facility demands on ORs, and aggregate missed work by parents

15. Dental disturbances are common & permanent Developmental, carious, traumatic Periodontal disease begins gingivitis/periodontitis/ANUG hormonal correlates Occlusion develops esthetics & function determined TMJ disturbances occur pain/dysfunction stress, trauma, excessive use Oral cancer risk factors are established Tobacco as primary risk factor Esthetic issues arise Attractiveness employability piercing Eating Disorders dental erosion, soft tissue injury Especially for adolescents

16. So Who Has Poor Oral Health in FL?Oral Health by Income 1-in-6 Poor children; 5 x more than Affluent children

17. So Who Has Poor Oral Health in FL?Oral Health by Race/Ethnicity 1-in-8 Hispanic children 4x greater; than white children

18. So Who Has Poor Oral Health in FL?Oral Health by Insurance 1-in-10 Medicaid children; 2x Privately Insured Children

19. So Who Has Poor Oral Health in FL?Oral Health by Consistency of Insurance 1-in-8 “gap” children; 2x children with Consistent Coverage

20. So Who Has Poor Oral Health in FL?Oral Health by Family Structure 1-in-6 Mom-only children; 4x Two Parent children

21. So Who Has Poor Oral Health in FL?Oral Health by Medical Home 1-in-10 children without a Medical home; 2x children with Medical Home

22. So Who Has Poor Oral Health in FL?Oral Health by Severity of Special Needs 1-in-4 CSHCN; 4x Children without special needs

23. Summary of FL Children’s Oral Health • Much like the nation’s • Tooth decay remains most prevalent childhood disease • Profound disparities by • Income • Race/ethnicity • Insurance status • Family Structure • Special needs • (Also by parent education, rurality, migrancy, homelessness, immigrant and native status)

24. Sources of Health & Health Disparities Psycho-Social Biological Beha- vioral Environ-mental Genetic

25. Sources of Health and Disparities Newacheck 2006 Fisher Owens 2007

26. Rethinking the Players: Roles for All!

27. Potential Interventions

28. Dental Care of Florida Children

29. Dental Care: US Picture Most underserved are young children of low income minority families whose parents have little education

30. Children’s Use of Dental Services:FL v. US Children NO YES NO YES j 1.5x more Florida parents report no dental visit in a year than do parents across the US. Which children are they?

31. Children’s Use of Dental Services:FL Young children YES VISIT NO VISIT More than half of young children have no dental visit

32. Children’s Use of Dental Services:FL Multiracial children YES VISIT NO VISIT Racial-ethnic minority children have fewer visits

33. Children’s Use of Dental Services:FL Spanish language children YES VISIT NO VISIT Spanish speaking children have fewer visits

34. Children’s Use of Dental Services:FL Poor children YES NO Half of poor children have no visits

35. Children’s Use of Dental Services:FL Children in Medicaid

36. Children’s Use of Dental Services:Parent v. Medicaid reporting 64% of Medicaid & CHIP (Healthy Kids) Parents report that their child had a dental visit in a year But the State of Florida reports that only 21% of Medicaid children had a dental visit in a year Likely both over-reporting by parents and under-reporting by state and influence of Healthy Kids group Either way far too few children are obtaining needed care Parents YES NO State YES NO

37. FL Medicaid performance compared to other states FY 2008 Update (CMS): 21% had a visit; 14% had a preventive visit; 8% had a reparative visit

38. Does lack of access explain poorer health status for vulnerable children? Determinants of health status

39. What can we conclude so far? • Too many of FL’s children suffer too much, too early in life, from a preventable disease. • Disease is prevalent & inequitably distributed and we know where it is. • Primary disease determinants are not access to reparative care. Therefore interventions are needed at two levels: • repair for extant disease • risk mitigation/disease management for new disease.

40. The Opportunities: Options Provided by Congress

41. US Healthcare Insurance “System”

42. US Healthcare Insurance “System”:Dental Coverage

43. Medicaid for Children: EPSDT Early & Periodic Screening Diagnostic and Treatment Services • Covers children birth through18 years • Must cover children to at least 100% of poverty (higher for under 5) • Individual entitlement • Mandatory on states • Paid by states and federal government • No copayments or cost sharing allowed • States can go higher • Includes comprehensive dental

44. CHIP for Children:1997 Provisions “Medicaid Light” States were given the options of: • Expanding Medicaid • Mimicking Medicaid • Creating a novel new program • Covers children birth through18 years • Targets children from 100-200% poverty, States can go higher • State entitlement • Paid by states and federal government (larger federal share than Medicaid EPSDT) • Income-related copayments or cost sharing allowed • Dental was optional and varied widely (unless Medicaid was expanded or mimicked)

45. FL EPSDT and CHIP Programs Modified from Jill Boylston Herndon 2009

46. CHIP for Children:New in 2009 for Medicaid and CHIP Migrating to Prevention 1. At birth ECC counseling for all 2. Mandatory reporting on numbers of children with new sealants Parental Assistance 3. Mandatory beneficiary information 4. InsureKidsNow help finding a participating dentist Program Improvements 5. Mandatory performance reporting 6. MACPAC: Medicaid and CHIP Payment and Access Commission 7. Quality Assurance reporting requirement 8. Congressional study of • Dentists “willingness” to care for the underserved • New midlevels • Medicaid network adequacy • Providers for CSHCN • Geographic availability of dentists

47. Healthcare Reform(Health Insurance Reform)

48. FL Coverage Conclusions The good news: • FL’s socially vulnerable children have excellent insurance coverage. • FL’s coverage includes comprehensive dental services. The bad news: • FL’s coverage does not translate into care except for 1-in-5 covered children. • FL’s system is complex with different components having different networks and administrators.

49. Why Coverage Doesn’t Translate Into Care: Inadequate Funding of Care “ While several factors contribute to the low use of dental services among low-income persons who have coverage, the major factor is difficulty finding dentists to treat them.” (GAO)

50. Access or Utilization?