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4 HHS and Oral Health: Past and Present Poor oral health remains a serious national health problem. —Garth Graham, Deputy Assistant Secretary for Minority Health, Office of Minority Health Launch of the 2010 HHS Oral Health Initiative, April 26, 2010 (HHS, 2010f) This chapter describes previous and current oral health reform efforts and oral health activities initiated at the federal level, focusing in particu- lar on cross-agency initiatives within the U.S. Department of Health and Human Services (HHS). It also describes the current HHS Oral Health Initiative and provides recommendations for the future focus of this effort. Appendix B includes organizational charts of the key HHS agencies and divisions involved in oral health. THE HISTORY OF HHS AND ORAL HEALTH The earliest recognition of the impact of poor oral health in America dates back to concerns for the oral health of the nation’s military, but the government’s involvement in oral health care was limited. In the 18th and 19th centuries, the military considered oral health care to be the responsi- bility of the individual soldier, and this care was primarily provided by civil- ian dentists, or, on an emergency basis, by ill-trained army physicians (King and Hynson, 2007). By the mid-1800s, predecessors of the American Den- tal Association (ADA) began to press government leaders about the lack of access to oral health care for the nations’ soldiers and sailors. Finally, in 1911, after numerous hearings and many failed bills, President Taft signed legislation creating the U.S. Army Dental Corps (King and Hynson, 2007). Perhaps the U.S. government’s first notable role in establishing the importance of oral health within federal-level health agencies was in 1931 when the U.S. Public Health Service (USPHS) created a Dental Hygiene Unit at the National Institutes of Health (NIH) and designated Dr. H. 141
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142 ADVANCING ORAL HEALTH IN AMERICA Trendley Dean as the first dental research scientist (NIH, 2010). Dr. Dean examined the epidemiology of communities that presented with “mottled enamel” (i.e., fluorosis), but further research also suggested a benefit from fluoride in community drinking water on the prevalence of tooth decay. In 1944, a Dental Health Section was established for the first time within the Department of Health, Education, and Welfare (DHEW), predecessor to the modern-day HHS, under the Bureau of State Services, predecessor to the today’s Health Resources and Services Administration (HRSA) (National Archives, 2010). In 1945, Grand Rapids, Michigan, with the support of Dr. Dean and the NIH, became the first city in the world to add a controlled level of fluoride to its community water supply (NIDCR, 2010f). On June 24, 1948, President Harry Truman signed Public Law 80-755, the National Dental Research Act, and thereby created the National Institute for Den- tal Research, predecessor to the current National Institute for Dental and Craniofacial Research (NIDCR), as well as the National Advisory Dental Research Council (NIH, 2010). By 1950, the results of the first 5 years of the Grand Rapids study confirmed that optimal water fluoridation was a safe, effective, and economical method for helping to prevent dental caries, and the Public Health Service adopted a policy of encouraging community water fluoridation (Lennon, 2006). The 1960s Strengthened by the success of the water fluoridation studies, by the mid-1960s, oral health care’s position in the federal bureaucracy expanded when a Division of Dental Health (later called Division of Dentistry) was established within DHEW. Its director served as dental advisor to President Johnson’s Office of Economic Opportunity, the agency responsible for ad- ministering programs such as Head Start (Diefenbach, 1969). The division administered a variety of programs centered on dental education, the dental workforce, dental caries prevention, and the use of fluorides. The work of the Division of Dental Health might be considered the first major oral health “initiative” conducted by the federal government. At this time, programs such as Head Start discovered that oral health care was one of the services most requested by impoverished families (Diefenbach, 1969). Social Security Amendments of 1965 and 1967 re- quired the inclusion of dental care in its program and also allowed for the development of special projects aimed at the oral health of children (Coker, 1969). At the same time, the advancing scientific understanding that tooth decay and periodontal disease are bacterial infections that can be controlled through preventive measures brought a growing sense of optimism that the prevalence of these conditions could be radically reduced over time. Through funding incentives, the Division of Dental Health sought to en-
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143 HHS AND ORAL HEALTH: PAST AND PRESENT courage dental schools to teach prevention and to establish departments of preventive dentistry. However, when the division’s funding was later eliminated, virtually all of the participating dental schools either eliminated these departments or collapsed them into others.1 In the 1960s, the federal government also sought to improve access to oral health care through expansions and innovations in the oral health workforce. For example, the Health Professions Educational Assistance Act of 1963 provided the first federal support for dental education (Diefenbach, 1969).2 The act (and later amendments) improved the financial base of existing dental schools, initiated new school construction, and sought to produce nearly 1,000 additional dental graduates within only a few years. In addition, the Health Manpower Act of 1968 provided even more fund- ing to improve and expand training programs under Title VII of the Public Health Service Act.3 At this time, DHEW began to estimate the status of the dental work- force as part of its estimation of the health workforce (NCHS, 1968). DHEW was also actively involved in promoting workforce innovations (e.g., the use of nondentist personnel) such as dental auxiliary utilization, otherwise known as four-handed dentistry, and dental school-based train- ing in expanded auxiliary management (TEAM) programs (Gladstone and Garcia, 2007; Johnson, 1969). These educational initiatives were designed to spur the adoption of team care in dentistry, with each member of the dental team working up to the capacity of his or her training, in order to provide more care at less cost. The Indian Health Service embraced the team care concept and demonstrated the effectiveness and efficiency of dental assistants in expanded functions in several sites, then expanded their utilization wherever it was practical (Abramowitz and Berg, 1973). In addition, an early innovation to integrate dental and nondental health care professionals is noted in the creation of craniofacial teams—in 1962, the National Institute for Dental Research funded the first multidisciplinary study of cleft palate at the University of Pittsburgh Health Center (NIH, 2010). In an article appearing in the June 1969 issue of the American Journal of Public Health and the Nation’s Health, Dr. Viron Diefenbach, then direc- tor of the Division of Dental Health of the Public Health Service, asserted that the 1960s would be remembered as a time of astounding scientific advances, and also one in which public policy began to address the strik- ing inequalities in access to health care (Diefenbach, 1969). Specifically, he 1 Personal Communication, A. Horowitz, University of Maryland, September 14, 2010. 2 Health Professions Educational Assistance Act of 1963, Public Law 129, 88th Cong., 1st sess. (September 24, 1963). 3 Health Manpower Act of 1968, Public Law 490, 90th Cong., 2d sess. (August 16, 1968).
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144 ADVANCING ORAL HEALTH IN AMERICA expressed optimism for “revers[ing] the spiral of dental illness in the United States” (Diefenbach, 1969). The 1970s In the early 1970s, the federal government made substantial investments in the entire health care workforce. By the early 1970s, rural states had ap- proached Congress about the worsening crisis due to the lack of health care professionals available to care for rural communities. In response, in 1970, the Emergency Health Personnel Act4 created the National Health Service Corps (NHSC). Since 1972, the NHSC has assigned USPHS Commissioned Corps officers or civil servants to provide care in underserved areas (HRSA, 2010d). Amendments to this law in the 1970s and 1980s allowed for both scholarships and loan repayment in order to attract more health care pro- fessionals to serve in the NHSC (HRSA, 2010d). In addition, President Nixon signed the Comprehensive Health Manpower Training Act of 1971, which continued the federal government’s involvement in the financing of health professions education, including dental education.5 This law strove not just to increase numbers but also “to improve the distribution of such personnel—both geographically and by medical specialty—and to promote the more effective use of health manpower” (Woolley and Peters, 2011b). Later, President Ford signed the Health Professions Educational Assistance Act of 1976.6 This law did not focus on increasing numbers, but rather on better distribution, both by specialty area as well as geographic location. The law included special provisions for education and training of general dentists and expanded function dental auxiliaries and revised and expanded the NHSC (Woolley and Peters, 2011a). In addition to workforce investments, one major activity that did launch in the early 1970s was the National Caries Program (NCP). The program was housed within the NIH, and its goal was to substantially reduce the prevalence of dental caries in the United States (Harris, 1992). The NCP expenditures for the first year of operation exceeded $6 million, with $2 million in grants, $3 million in contracts, and $900,000 in labora- tory and clinical research (Harris, 1992). The NCP continued until 1984. While investments in the workforce overall were substantial and DHEW oral health activities had been successful, attention to oral health in par- ticular was waning. A later review of HHS oral health programs found that 4 Emergency Health Personnel Act of 1970, Public Law 623, 91st Cong., 2d sess. (December 31, 1970). 5 Comprehensive Health Manpower Training Act of 1971, Public Law 157, 92d Cong., 1st sess. (November 18, 1971). 6 Health Professions Educational Assistance Act of 1976, Public Law 484, 94th Cong., 2d sess. (October 12, 1976).
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145 HHS AND ORAL HEALTH: PAST AND PRESENT “the oral health activities of the department, and the resources devoted to those activities, have been disaggregated, dispersed, reduced drastically, or altogether eliminated since 1972” (Interim Study Group on Dental Activi- ties, 1989). Since then, multiple agencies within HHS have been responsible for various programs related to oral health, and the need for integration of these activities across the department has become a recurring theme. Healthy People (1979–Present) In 1979, Surgeon General Julius B. Richmond issued Healthy People: The Surgeon General’s Report on Health Promotion and Disease Preven- tion, which highlighted the dramatic impact of public health efforts in fighting communicable diseases and laid out a national agenda for the fu- ture role of public health efforts in noninfectious diseases—that is, health promotion and disease prevention (DHEW, 1979). This report highlighted dental health as a “prominent threat to the good health of children” and identified “fluoridation and oral heath” as one of 15 priority areas. It also illustrated goals along the age continuum, namely, to reduce deaths among infants, children, young adults and adults, and to reduce the number of sick days among older adults. That same year, the Office of Disease Prevention and Health Promotion was established under the purview of Assistant Surgeon General Michael McGinnis, who also had borne responsibility for the development of the surgeon general’s report.7 In 1980, this office, working closely with the Centers for Disease Control and Prevention (CDC) and the other agencies of the USPHS, oversaw the production of Promoting Health/Preventing Disease: Objectives for the Nation (known as Healthy People 1990), which outlined 226 objectives to achieve significant improvements in the health of the nation by 1990 (USPHS, 1980). Objectives tended to be chosen, in part, based on whether they were measurable, whether improvement was consid- ered possible or likely, whether there were science-based interventions, and whether they were easily understood both by health care professionals and the general public (Andersen and Mullner, 1990; McGinnis, 2010). While important, the presence of ongoing data sources was not a precondition for these objectives, with the expectation being that the objective would drive data collection8 (McGinnis, 2010). While Healthy People 1990 had a mortality-based framework, Healthy People 2000 focused on the broader goals of increasing the span of healthy life, reducing disparities, increasing access to preventive services, and age- 7 Personal Communication, M. McGinnis, Institute of Medicine, July 30, 2011. 8 As this did not fully come to fruition, Healthy People 2020 required the existence of or the commitment to develop a tracking source.
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146 ADVANCING ORAL HEALTH IN AMERICA specific targets (McGinnis, 2010). As the number of individual objectives was growing, Healthy People 2000 identified about 20 priority areas, one of which was oral health (HHS, 1991). Healthy People 2010 changed its fo- cus yet again, to concentrate on increasing the quality and years of healthy life and eliminating health disparities. Oral health was identified as one of 28 “focus areas” (HHS, 2005). Overall, the Healthy People goals are intended to be used as a guide for the nation, not just for the use of the federal government. Partners in the development of Healthy People goals and objectives include federal agencies, the Healthy People Consortium (an alliance of non-federal stake- holders committed to supporting Healthy People goals), and public-private partnerships developed through memorandums of understanding (MOUs). For Healthy People 2010, HHS had MOUs with the American Association for Dental Research and the Academy of General Dentistry (HHS, 2003b). (Healthy People 2010 and 2020 are also discussed in general in Chapter 2 as well as later in this chapter.) The 1980s In 1980, the Division of Dentistry consolidated with Division of As- sociated Health Professions to form the Division of Associated and Den- tal Health Professions under the Bureau of Health Professions (National Archives, 2010). During the 1980s, federal activity was proceeding along many different tracks, largely in an uncoordinated manner. Preparations for the second national health objectives report (Healthy People 2000) were under way, which engaged the participation of agencies across the department. Also, in 1987, Congress directed the National Institute for Dental Research to develop a multiagency national plan for improving the oral health of adults (especially older adults) that would engage both the public and private sectors to address education, research, and delivery of oral health services (Gershen, 1991; Interim Study Group on Dental Activi- ties, 1989; NIH, 2010). The Maternal and Child Health Bureau (MCHB) took the lead in conducting a workshop examining children’s access to oral health care (HRSA, 1990). Through the Omnibus Budget Reconciliation Act of 1989 (OBRA 1989),9 Congress initiated significant changes in the MCHB block grant program. In addition, Congress codified previous regulatory requirements applicable to the Medicaid Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefits for individuals under age 21. Prior to 1989, dental coverage had been a regulatory requirement; the 1989 amendments 9 Omnibus Budget Reconciliation Act of 1989, Public Law 239, 101st Cong., 1st sess. (December 19, 1989).
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147 HHS AND ORAL HEALTH: PAST AND PRESENT mandated dental services provided at intervals meeting reasonable stan- dards of dental practice as well as at medically necessary intervals, and con- sisting of relief of pain and infections, restoration of teeth, and maintenance of dental health10 (OIG, 1996). Finally OBRA 1989 also mandated that all state Medicaid programs increase their eligibility levels to 133 percent of the federal poverty level (FPL) and give states the option to increase it to 185 percent of the FPL. The Meskin Report (1989) As part of the appropriations process for fiscal year 1988, the congres- sional appropriations committees in both the House and the Senate man- dated a study of the oral health activities of HHS (Interim Study Group on Dental Activities, 1989; USPHS, 1989). The objectives of that study, now known as the Meskin report (after chairman Lawrence H. Meskin), resemble the charge that has been put forward to this Institute of Medicine (IOM) committee—namely, “to address the identification of appropriate goals and priorities in oral health” and “to consider appropriate organiza- tional and administrative arrangements for achieving maximum coordina- tion” (Interim Study Group on Dental Activities, 1989). As a result of this mandate, HHS formed the Interim Study Group on Dental Activities to identify goals and priorities in the areas of oral health research, education, prevention, and service provision. The appointed study group consisted of 12 members representing both the public and private sectors, along with four HHS agency representatives who served as consultants. All 12 of the study group members were dentists, with the exception of then executive director of the ADA. To inform this study, an inventory of oral health activities within HHS was conducted by a contractor and presented to HHS in January 1989 (USPHS, 1989). The group also solicited input from 30 individuals and or- ganizations including the ADA, the American Association of Public Health Dentistry (AAPHD), the American Association of Dental Schools, state departments of health, and the World Health Organization. This process identified a number of needs within HHS, including: • A strengthened central focus; • An increased federal government leadership role; • Better coordination among agencies; • Identification of agencies’ oral health goals; • Dental presence in all agencies; • Strengthened regional offices; 10 42 U.S.C. §1396d(r)(3).
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148 ADVANCING ORAL HEALTH IN AMERICA • Greater input from states; • Greater interaction with national dental organizations; • More input from private dentistry; • Increased access for underserved and special populations; and • Greater prevention orientation (USPHS, 1989). The Interim Study Group on Dental Activities submitted its report, Im- proving the Oral Health of the American People: Opportunity for Action, to the USPHS in March 1989, and this was subsequently submitted to the House of Representatives Appropriations Committee in May 1989 (Interim Study Group on Dental Activities, 1989; USPHS, 1989). The report began by noting the dramatic improvements in the scientific understanding of oral disease in the post–World War II era. It said that these developments had “caused a fundamental shift in the focus of dentistry from the repair and replacement of teeth to the prevention of disease and the preservation of the natural dentition for a lifetime” (USPHS, 1989). “Indeed,” the report continued, “leaders in the dental community now talk of the prospect of essentially eliminating caries and periodontal disease in the early decades of the 21st century” (USPHS, 1989). The question was how to realize this potential—specifically, how HHS could be structured to promote this objective. The study group found that decentralization in recent years has resulted in severe fragmentation of the remaining oral health programs, decreased interagency communication, and limited opportunities for collaboration among the various [d]epart- mental programs, despite the fact that they share the goal of improving the oral health of the [n]ation. Decreased collaboration leads to duplication of efforts in some areas and absence of efforts in other areas, and results in uncoordinated oral health programs which lack direction or purpose. The attainment of a unified program is hindered primarily by the lack of a clear focus for the [d]epartment’s oral health activities. No single entity has been empowered and enabled to coordinate oral health activities. . . . The [s]tudy [g]roup was unable to identify within the [d]epartment . . . a discernible oral health policy. (USPHS, 1989) The study group’s recommendations (see Box 4-1) included that HHS name an individual to serve as the focal point of oral health activities throughout the department. This would be a full-time position within the USPHS at the level of the Office of the Assistant Secretary for Health. They stated that the individual needed to have clearly visible administrative and policy responsibility, serving as the principal oral health advisor to the secretary of HHS. The group recommended that the individual should be advised by a formally chartered committee with representatives primarily from the private sector, along with ex officio representatives from the U.S.
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149 HHS AND ORAL HEALTH: PAST AND PRESENT B OX 4-1 Meskin Report Recommendations • E stablish a focus for oral health activities in the Department of Health and Human Services with clearly visible administrative and policy responsibility. • T he individual serving as the focus for oral health activities in the DHHS should be advised by a formally chartered committee. • E stablish a strong, clearly identified, oral health presence in any DHHS agency that regularly conducts oral health activities. SOURCE: USPHS, 1989. Departments of Defense (DOD) and Veterans Affairs (VA). The group also emphasized that all HHS agencies with oral health activities should have a strong, clearly identified oral health presence. The Oral Health Coordinating Committee (1990) Due, in part, to the findings of the Meskin Report, on February 26, 1990, then Assistant Secretary for Health James Mason established the Oral Health Coordinating Committee (OHCC) to help coordinate federal activi- ties in improving oral health (USPHS, 2002). The chief dental officer of the USPHS was delegated the leadership of the OHCC on behalf of the assistant secretary of health; however, this person had (and still has) full-time respon- sibilities elsewhere within HHS. The Meskin committee’s recommendation that one person serve in a dedicated full-time role as a focal point for oral health policy within HHS was not adopted. The OHCC continues to draw its leadership and its staffing from the operating divisions within HHS, but it has neither line authority nor its own budget (Bailey, 2010). The Meskin committee had also recommended that the advisory committee have signifi- cant private-sector representation; however, the OHCC was not structured to include this point of view. In 1996, the Office of the Inspector General (OIG) released a report indicating many children were not receiving EPSDT services that were sup- posed to be available through Medicaid (OIG, 1996). Approximately 80 percent of the states attributed the problem to a shortage of dentists willing to accept Medicaid patients. The OIG offered a single recommendation on how this should be addressed at the federal level: “The department should convene a work group that, at a minimum, would include the HCFA
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150 ADVANCING ORAL HEALTH IN AMERICA [Health Care Financing Administration], HRSA, [the Administration for Children and Families], [the Office of Public Health and Science], and [the HHS Assistant Secretary for Planning and Evaluation] to develop an integrated approach to improve dental access and utilization for EPSDT eli- gible children (OIG, 1996).” The assistant secretary of health and the NIH responded that the existing OHCC could adequately serve this purpose without creating a new workgroup. The OIG agreed, and revised its recom- mendation to state that “with expanded membership, the existing PHS Oral Health Coordinating Committee Working Group could fulfill this need” (OIG, 1996). The recommendation indicated that the workgroup should consider ways to encourage professional volunteerism, support demonstra- tions aimed at increasing provider participation in Medicaid, and improve outreach to eligible families. Over the course of the remainder of the 1990s and then through most of the 2000s, however, the members of the OHCC served more as senior advisors rather than having a role in developing a plan as suggested by the OIG. The HRSA-HCFA Initiative (1998–2001) The HRSA-HCFA Oral Health Initiative aimed to improve collabora- tion at the national level in order to improve access to oral health care at the local level. Goals of the initiative were to • Eliminate disparities and barriers to care, • Respond to unmet needs for clinical services, • Increase the number of dental professionals, • Expand the dental public health infrastructure, • Restructure and increase coordination among federal oral health programs, and • Coordinate federal initiatives with key partners in the dental com- munity (HHS, 2000c). The initiative included three main types of activities: integrating ac- tivities within and between federal agencies, partnering with stakeholders, and sharing scientific data (HHS, 2000c). For example, HRSA and HCFA sought interagency collaborations to provide information to communities based on information gathered from efforts such as the National Health and Nutrition Examination Survey (NHANES) and Healthy People (HHS, 2000c). Other state and regional activities included oral health summits and workshops, regular conference calls with state dental directors, on-site reviews of state programs, recruitment of dental consultants, and solicita- tion of federal funds for dental programs (HHS, 2000c). The HRSA-HCFA initiative continued for 3 years and was arguably
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151 HHS AND ORAL HEALTH: PAST AND PRESENT one of the HHS’s most successful and far-reaching oral health initia- tives. In testimony to this IOM committee, the incoming president of the ADA, Raymond Gist, praised the HRSA-HCFA effort, saying that it was a “sweeping oral health initiative” (Gist, 2010). He said that the effort not only highlighted and boosted HRSA’s oral health programs, it also recog- nized that HRSA needed to forge a closer relationship with (what is now) the Centers for Medicare and Medicaid Services (CMS) and programs such as Head Start. Longer-term objectives for the HRSA-HCFA initiative had been to “expand funding for dental programs in community health centers, increase the number of grants for sealant programs, expand the number of loans and scholarships for dental students willing to practice in underserved areas, support development of state infrastructures, provide GIS mapping for all states” to enable them to assess oral health care infrastructure at county and subcounty levels, “simplify the designations for Health Profes- sional Shortage Areas, and change federal policies that restrict provider enrollment and access to care” (HHS, 2000c). However, the HRSA-HCFA initiative ended after the transition in administrations following the 2000 presidential election. The Surgeon General’s Report (2000) On May 25, 2000, the USPHS issued its landmark report Oral Health in America: A Report of the Surgeon General (HHS, 2000b). The report alerted the nation of a “silent epidemic” of oral disease in America and brought attention to the deep disparities in oral health status as well as who receives adequate oral health care services nationwide. The report also helped to reframe the term oral health, so that it not only includes dental care and teeth but also overall oral health, including periodontal disease, oral cancer, and craniofacial issues such as cleft palate. In reviewing the existing body of knowledge on oral health issues at that time, the surgeon general noted that safe and effective measures existed to prevent the most common oral diseases—dental caries and periodontal disease. For example, the report noted that good oral hygiene practices such as simple brushing and flossing can prevent gingivitis and that the effectiveness of water fluori- dation for the prevention of dental caries had been proven for decades. But the report also found that lifestyle choices such as tobacco use, excessive alcohol use, and poor dietary choices can be detrimental to oral health. Overall, the report’s major message was that oral health is essential to gen- eral health and well-being and can be achieved by all Americans. However, not everyone is achieving the same degree of oral health (HHS, 2000b). In conjunction with the release of this report, the surgeon general held two meetings focusing on children’s oral health. The “Surgeon General’s Work- shop,” held March 19–21, 2000, involved 80 invited experts who were
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196 ADVANCING ORAL HEALTH IN AMERICA KEY FINDINGS AND CONCLUSIONS The committee noted the following key findings and conclusions: • Oral diseases can affect all Americans, and vulnerable and under- served populations are especially at risk. Therefore, the prioritiza- tion of oral health as a key issue for HHS falls in line with its basic mission. • HHS has had some notable successes in improving oral health in the past, yet that prior work has not had the necessary transforma- tive impact on oral health. • HHS needs to capitalize on its prior efforts and then build on that work to elevate the priority and visibility of oral health in all rel- evant divisions of HHS. • The oral health activities of HHS are spread throughout the agency with little communication and coordination between divisions. • The failure of previous HHS initiatives to produce significant re- sults resulted from a lack of coordination, a lack of clear goals, a lack of resources, and a lack of high-level accountability. • HHS has many unique opportunities to influence the oral health system, particularly through education grants, fostering payment innovation, promoting research, coordinating with other agencies that collect oral health data, and developing quality measures. • The ACA has many authorized provisions related to oral health, but most remain unfunded. • HHS has many opportunities to partner with the private sector (e.g., professional societies) as well as other parts of the public sector (e.g., states, other federal agencies). REFERENCES AAPD (American Academy of Pediatric Dentistry). 2010. Head start dental home initiative. http://www.aapd.org/headstart/ (accessed June 15, 2010). Abramowitz, J., and L. E. Berg. 1973. A four-year study of the utilization of dental assistants with expanded functions. Journal of the American Dental Association 87(3):623-635. ADA (American Dental Association). 2007. American Indian and Alaska Native oral health access summit: Summary report. Santa Ana Pueblo, NM: American Dental Association. ADA. 2009. Proceedings of the March 23-25, 2009, access to dental care summit. Chicago, IL: American Dental Association. ADA. 2010. Dr. Bailey named PHS dental chief. http://www.ada.org/news/4309.aspx (accessed February 25, 2011). AHRQ (Agency for Healthcare Research and Quality). 2010. Medical expenditure panel sur- vey: Survey background. http://www.meps.ahrq.gov/mepsweb/about_meps/survey_back. jsp (accessed November 24, 2010). Andersen, R., and R. Mullner. 1990. Assessing the health objectives of the nation. Health Affairs 9(2):152-162.
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