Improving Access to Oral Health Care for Vulnerable and Underserved Population




Committee on Oral Health Access to Services

Board on Children, Youth, and Families

Board on Health Care Services

INSTITUTE OG MEDICINE AND
NATIONAL RESEARCH COUNCIL
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
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Committee on Oral Health Access to Services Board on Children, Youth, and Families Board on Health Care Services

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Govern- ing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineer- ing, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropri- ate balance. This study was supported by Contract No. HHSH25034002T between the National Academy of Sciences and the U.S. Department of Health and Human Services and Contract No. 15328 between the National Academy of Sciences and the California HealthCare Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-20946-5 International Standard Book Number-10: 0-309-20946-3 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap. edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2011 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent ad- opted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine) and NRC (National Research Council). 2011. Improving access to oral health care for vulnerable and underserved populations. Washington, DC: The National Academies Press.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Coun- cil is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON ORAL HEALTH ACCESS TO SERVICES FREDERICK P. RIVARA (Chair), Seattle Children’s Guild Endowed Chair in Pediatrics; Professor of Pediatrics, School of Medicine, University of Washington PAUL C. ERWIN, Professor and Chair, Department of Public Health, University of Tennessee, Knoxville CASWELL A. EVANS, JR., Associate Dean for Prevention and Public Health Sciences, College of Dentistry, University of Illinois, Chicago THEODORE G. GANIATS, Professor, Department of Family and Preventive Medicine, School of Medicine, University of California, San Diego SHELLY GEHSHAN, Director, Pew Children’s Dental Campaign, Pew Center on the States KATHY VOIGT GEURINK, Clinical Associate Professor, Department of Dental Hygiene, School of Health Professions, University of Texas Health Science Center PAUL GLASSMAN, Professor of Dental Practice, Director of Community Oral Health, Arthur A. Dugoni School of Dentistry, University of the Pacific DAVID M. KROL, Team Director, Senior Program Officer, Human Capital, Robert Wood Johnson Foundation JANE PERKINS, Legal Director, National Health Law Program MARGARET A. POTTER, Associate Dean; Director, Center for Public Health Practice; Associate Professor of Health Policy & Management, Graduate School of Public Health, University of Pittsburgh RENEE SAMELSON, Associate Professor of Obstetrics and Gynecology, Albany Medical College PHYLLIS W. SHARPS, Professor and Associate Dean, Community and Global Programs, School of Nursing, Johns Hopkins University LINDA H. SOUTHWARD, Research Fellow & Research Professor, Social Science Research Center, Mississippi State University MARIA ROSA WATSON, Research Director, Primary Care Coalition of Montgomery County BARBARA WOLFE, Professor of Economics and Population Health Sciences; Public Affairs and Faculty Affiliate, Institute for Research on Poverty, University of Wisconsin-Madison v

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Study Staff TRACY A. HARRIS, Study Director PATTI SIMON, Senior Program Officer MEG BARRY, Associate Program Officer ROSEMARY CHALK, Director, Board on Children, Youth, and Families WENDY E. KEENAN, Program Associate AMY ASHEROFF, Senior Program Assistant vi

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Reviewers T his report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confiden- tial to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: BRUCE J. BAUM, National Institute of Dental and Craniofacial Research PAUL CASAMASSIMO, Nationwide Children’s Hospital DANIEL G. DAVIDSON, private practice A. CONAN DAVIS, University of Alabama R. BRUCE DONOFF, Harvard School of Dental Medicine CHRISTINE M. FARRELL, Michigan Department of Community Health JANE GILLETTE, Mint Dental Studio JOHN S. GREENSPAN, University of California, San Francisco MICHAEL J. HELGESON, Apple Tree Dental CATHERINE HESS, National Academy for State Health Policy CYNTHIA E. HODGE, National Dental Association Foundation GENEVIEVE KENNEY, The Urban Institute vii

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viii REVIEWERS JULIA LEAR, The George Washington University HUGH SILK, University of Massachusetts Medical School and Hahnemann Family Health Center GEORGE W. TAYLOR, University of Michigan Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclu- sions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by DONALD M. STEINWACHS, Johns Hopkins University, and GEORGES C. BENJAMIN, American Public Health Association. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Foreword O ral health care is not uniformly attainable across the nation. Un- fortunately, individuals who face the greatest barriers to care are often among the most vulnerable members of our society. The impact of unmet oral health care needs is magnified by the well-established connection between oral health and overall health. These problems led the Health Resources and Services Administration and the California Health- Care Foundation to ask the Institute of Medicine (IOM) to advise them on how to improve access to oral health care. The IOM committee, led by Frederick Rivara, was charged with assessing the current oral health care delivery system; exploring its strengths, limitations, and future challenges; and describing a vision for the delivery of oral health care to vulnerable and underserved populations. The committee worked in parallel with a second IOM committee that focused on the role of the U.S. Department of Health and Human Services in improving oral health. Together, they comprise an extensive examination of the status of oral health and oral health care in America. In its examination of the evidence, the committee uncovered decades of efforts that have been insufficient in eliminating significant disparities in access to oral health care. However, this examination also revealed an array of groups committed to improving access and highlighted common goals and opportunities for collaboration and innovation. Examples appear throughout the report and inform the committee’s recommendations. The committee calls for a renewed commitment and a confluence of energies directed at tackling these familiar and persistent challenges. This report presents a vision for oral health care in the United States ix

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x FOREWORD where everyone has access to quality oral health care throughout the life cycle. The committee acknowledges that realizing this vision will require numerous coordinated and sustained actions, with special attention to the distinct and varied needs of the nation’s vulnerable and underserved popu- lations. Achieving this goal will require flexibility and ingenuity among leaders at the federal, state, local, and community levels acting in concert with oral health and other health care professionals. We hope this report will encourage these groups to act on behalf of the nation’s vulnerable and underserved populations and to take the important and necessary next steps to improve access to oral health care, reduce oral health disparities, and improve oral health. Harvey V. Fineberg, M.D., Ph.D. President, Institute of Medicine July 2011

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Preface A s Americans, we have become increasingly cognizant and, it is hoped, intolerant of the disparities in access to health care in this country. While our health care system has the capabilities for amazing treat- ment of a wide array of maladies, this care is not uniformly available to all. Disparities exist, however, not only in access to the latest in life-saving technology but also in access to the most basic of routine health care. The Patient Protection and Affordable Care Act of 2010 is intended to improve access to care for all and reduce these disparities in health care and health. Oral health care is one of those dimensions of our health care delivery system in which striking disparities exist. More than half of the population does not visit a dentist each year. Poor and minority children are substan- tially less likely to have access to oral health care than are their nonpoor and nonminority peers. Americans living in rural areas have poorer oral health status and more unmet dental needs than their urban counterparts. Older adults, especially those living in long-term care facilities, have a high prevalence of oral health problems and difficulty accessing care by individu- als trained in their special needs. Disabled individuals uniformly confront access barriers, regardless of their financial resources. The consequences of these disparities in access to oral health care have a strong influence not only on oral health but on overall health as well. Poor oral health can lead to malnutrition, childhood speech problems, and serious, and sometimes fatal, infections. Poor oral health is associated with diabetes, heart disease, and premature births. Oral disease in pregnant women and young moth- ers can be transmitted vertically to their offspring, perpetuating a cycle of disease. xi

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xii PREFACE In 2000, the surgeon general issued a report on oral health in this country calling for action to improve the oral health of the nation. The many efforts in both the public and private delivery systems to address these disparities have been important, but they have not been successful in eliminating them. Therefore, with support from the Health Resources and Services Administration and the California HealthCare Foundation, the National Research Council and the Institute of Medicine, through col- laborative efforts between the Board on Children, Youth, and Families and the Board on Health Care Services, formed the Committee on Oral Health Access to Services. The charge was to assess current access to oral health care especially for vulnerable and underserved populations and to provide a vision of how oral health care should be addressed by public and private providers across the nation. The committee held five meetings and one public workshop. We en- gaged in vigorous, thoughtful discussions regarding the causes of the cur- rent disparities in access to oral health care and the best approaches to addressing the problem both in the short and long term. We did so cog- nizant of the economic challenges facing the nation and individual states today, and with the awareness that oral health care is a part of our overall health care delivery system. It is our hope that the findings and recommen- dations of this report will help policy makers, service providers and their professional organizations, and funders and government agencies to address these access problems in new, meaningful, and innovative ways that will result in oral health for all. The committee could not have done its work without the outstand- ing guidance and support provided by the NRC-IOM staff: Tracy Harris, study director; Patti Simon, senior program officer; and Meg Barry, as- sociate program officer. Amy Asheroff provided skilled logistic support to the committee. Rosemary Chalk’s guidance and counsel were invaluable throughout our deliberations. The health professionals who participated in our workshop and provided information to the committee deserve special thanks for their time and effort. All Americans deserve to enjoy good oral health. We hope this report will help the nation achieve that vision. Frederick P. Rivara, Chair Committee on Oral Health Access to Services July 2011

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Acknowledgments T he Committee on Oral Health Access to Services benefited from the contributions of many individuals. The committee takes this op- portunity to recognize those who so generously gave their time and expertise to inform its deliberations. The committee benefited from presentations made by a number of ex- perts outside the committee. The following individuals shared their experi- ences and perspectives during public meetings of the committee: Ann Battrell, American Dental Hygienists’ Association Marcia K. Brand, Health Resources and Services Administration Gina Capra, Health Resources and Services Administration James Crall, American Academy of Pediatric Dentistry Terry Dickinson, Virginia Dental Association Bruce Dye, Centers for Disease Control and Prevention Greg Folse Steven Geiermann, American Dental Association Michael Griffiths, Institutional Dental Care David Grossman, GroupHealth Cooperative David Halpern, Academy of General Dentistry Lawrence Hill, CincySmiles Foundation John McFarland, National Network for Oral Health Access Peter Milgrom, University of Washington Laurie Norris, Pew Children’s Dental Campaign Greg Nycz, Family Health Center of Marshfield, Inc. Edward O’Neil, University of California, San Francisco xiii

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xiv ACKNOWLEDGMENTS Jesley Ruff, American Dental Partners Bob Russell, Iowa Department of Public Health Mary Kate Scott, Scott & Company, Inc. Robert Shesser, George Washington University Mark Siegal, Ohio State Department of Health Kristen Simmons, Willamette Dental Woosung Sohn, University of Michigan Ron Tankersley, American Dental Association Jessica Van Arsdale, Humboldt State University Louise Veselicky, West Virginia University The committee commissioned papers to provide background informa- tion for its deliberations and to synthesize the evidence on particular issues. We thank the following individuals for their contributions to these papers: David Armstrong, Center for Health Workforce Studies, University at Albany Howard Bailit, University of Connecticut John D’Adamo, University of Connecticut Burton Edelstein, Columbia University Margaret Langelier, Center for Health Workforce Studies, University at Albany Jean Moore, Center for Health Workforce Studies, University at Albany We extend special thanks to the following individuals who were essen- tial sources of information, generously giving their time and knowledge to further the committee’s efforts: Kay Johnson, Johnson Group Consulting Lew Lampiris, American Dental Association Richard W. Valachovic, American Dental Education Association Many within the Institute of Medicine were helpful to the study staff. The staff would like to thank Patrick Burke, Greta Gorman, Roger Herdman, William McLeod, Janice Mehler, Abbey Meltzer, Lauren Tobias, and Ben Wheatley for their time and support to further the committee’s efforts. We also thank Mark Goodin, copyeditor. Finally, the committee gratefully acknowledges the assistance and sup- port of individuals instrumental in developing this project: Marcia Brand, Health Resources and Services Administration; Len Finocchio, California HealthCare Foundation; and Mark Nehring, Health Resources and Services Administration.

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Contents SUMMARY 1 1 INTRODUCTION 17 Barriers to Oral Health Care Access, 18 The Consequences of Poor Oral Health, 19 Efforts to Improve Access to Oral Health Care, 19 Study Charge, Scope, and Approach, 21 Guiding Principles, 24 Definitions of Key Terms, 25 Notable Past Work, 27 Organization of the Report, 34 References, 35 2 ORAL HEALTH STATUS AND UTILIZATION 41 The Connection Between Oral Health and Overall Health, 41 Overview of Oral Health Status and Access to Oral Health Care in the United States, 43 Oral Health Status and Access to Oral Health Care for Vulnerable and Underserved Populations, 47 Factors That Contribute to Poor Oral Health and Lack of Access to Oral Health Care, 60 Findings and Conclusions, 67 References, 67 xv

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xvi CONTENTS 3 THE ORAL HEALTH CARE WORKFORCE 83 The Dental Workforce, 83 Education and Training of the Dental Workforce, 94 The Nondental Workforce, 105 Public Health Workers, 112 Interprofessional Education, Training, and Care, 113 Regulating the Dental Workforce, 115 Innovations in the Oral Health Care Workforce, 121 Findings and Conclusions, 134 References, 137 4 SETTINGS OF ORAL HEALTH CARE 157 Private Delivery Systems, 158 The Oral Health Safety Net, 162 Capacity and Efficiency of the Current System, 173 Innovations in Settings of Care, 178 Findings and Conclusions, 185 References, 186 5 EXPENDITURES AND FINANCING FOR ORAL HEALTH CARE 193 Overview of Expenditures, 194 Overview of Coverage, 197 Private Sources of Financing, 200 Publicly Subsidized Coverage, 202 Additional Sources of Federal and State Funding for Oral Health Services, Infrastructure, and Research, 211 The Patient Protection and Affordable Care Act, 215 Innovations in Financing and Coverage, 216 Limitations, 221 Findings and Conclusions, 221 References, 222 6 A VISION FOR THE DELIVERY OF ORAL HEALTH CARE TO VULNERABLE AND UNDERSERVED POPULATIONS 229 Overall Conclusions, 230 A Vision for Improving Access to Oral Health Care, 230 Recommendations, 231 Closing Thoughts, 252 References, 253

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xvii CONTENTS APPENDIXES A Acronyms 255 B Commissioned Papers 259 C Workshop Agendas 261 D Summary of Advancing Oral Health in America: A Report of the IOM Committee on an Oral Health Initiative 265 E Committee and Staff Biographies 271