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November 19, 2012 8:54 AM Yup-Romney Was Right

By Harold Pollack

…when he said: “What I would do if I were a Democrat running four years from now, I’d say, you know what, dental care will be included in Obamcare.

Oral health continues to pose significant access and public health concerns. I’ve worked with various disadvantaged and low-income populations. So many people have obvious dental problems that create broader health problems, are quite painful, and are often stigmatizing in people’s everyday lives.

Aside from basic access issues, oral health care is a huge missed opportunity for broader public health. To take one example, most adults who report that they face individual HIV risks and yet have not been tested have recently visited a dentist. Many of these at-risk young adults have seen no other health care provider. The dental setting is a largely untapped context to diagnose hypertension and other conditions. Particularly with the emergence of improved oral diagnostics for HIV, diabetes, and various other conditions, we can do better.

A 2011 Institute of Medicine report outlines useful responses to these policy failures. Improved training would improve the capacity of dentists and other oral health professionals to serve vulnerable populations. Federally Qualified Health Centers provide particularly important services. Their capacity to provide dental services could be expanded.

We might also reconsider the multidisciplinary character of the oral health care workforce. Licensure requirements and reimbursement practices should be revisited to see which services could be economically and effectively provided by non-dentists in dentists’ offices or in other settings.

One basic problem is dental care’s segregated financing through plans that demarcate specific boundaries from medical care. The Affordable Care Act is embarrassingly silent about oral health. (Just do a word search on the word “dentist.”) Some help was provided to children. ACA included some provisions for the dental work force. Most importantly, FQHCs received significant support. There’s virtually nothing to improve adult access, to improve dental delivery systems, to improve reimbursement for evidence-based clinical dental services. Little public attention has been paid to whether and how dental plans should participate in health insurance exchanges.

We also ask too little of the dental profession itself, which remains ambivalent about its own involvement in public insurance programs. At times, the profession also adopts a guild-like protectionist stance against involvement of others in providing oral health. Even in basic matters such as smoking cessation, many dentists report that they are poorly-equipped to deliver basic preventive services. Dental insurers could provide better coverage for these services, which some plans are now exploring.

This issue hits home for me, particularly as I see state Medicaid programs retrench to limit access to adult dental services.

When my intellectually disabled brother-in-law Vincent moved into our house eight years ago, he hadn’t had a teeth cleaning in years. So we scheduled an appointment with our family dentist. We knew we needed to prepare him for it. So my two daughters, then ages 8 and 10, read him a picture book about going to the dentist.

When the dentist donned her mask, he smiled and said: “Like Hannah said,” The dentist scraped off layers of plaque. He was a fantastic patient; this couldn’t have been a lot of fun. Fortunately, his underlying oral health was good. That’s a sweet memory, for many reasons.

We’ve had various challenges finding a good dentist through the Medicaid program. One day recently, Vincent announced that he and his housemates had all been to the dentist. My wife looked quizzical and asked Vincent to open his mouth. The dentist had barely cleaned Vinnie’s teeth. The guy had made a cursory effort and then just prescribed a prophylactic antibiotic for gum disease.

Since then, Illinois became one of the many states—including many traditionally liberal ones–that have retrenched coverage or consigned adult dental coverage to an emergency-only program.

Romney is right. I only hope that Democrats take his advice.

Postscript: For more, see Sarah Kliff here.

[Cross-posted at The Incidental Economist]

Harold Pollack is the Helen Ross Professor at the School of Social Service Administration at the University of Chicago.
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