New York TimesOctober 11, 2007

Health History and Oral Cancer Screening Caries Check, Clinical and Radiographic Periodontal Assessment

27% of Children have untreated disease

29% of Adults have untreated disease

Data higher than 1980 and significantly higher than 1999

Factors Related to Disparities in Access to

Oral Health Care

Harvey Weingarten DDS

University of Notre Dame

February 2008

Many poor, lower income families don’t have any insurance, cash or governmental entitlement programs

Access to care is an issue even with those who can afford dental treatment

• In 1982 we had 5,750 graduates of dental school

• In the last fifteen years 7 dental schools have closed their doors

• In 2003 we had 4,400 graduates of dental schools

Average age of Dentist is 49 years old

Beginning in 2012 more dentists will be retiring than graduating

States need to liberalize expanded auxiliaries laws

DDS◦3,213 practicing in Indiana◦Statewide Ratio 1:1,952 people

RDH◦3,661 practicing in Indiana◦Statewide Ratio 1:1,713 people

78

32

0

10

20

30

40

50

60

70

80

Percentage

N=451 of 498 (91%) of IUSD grads from 1994 – 1999 (contacted in 2003)

In State Students Out of State Students

Hamilton County 1: 999Marion County 1:1,370Boone County 1:1,407Floyd County 1:1,469Howard County 1:1:1491

Warren County 1: 8,785Switzerland County 1: 9,718Crawford County 1:11,216Starke County 1:11,467Ripley County 1:14,855

Population 266,160

137 Dentists or 1 per 1,943

231 Hygienists or 1 per 1,152

5000000

5200000

5400000

5600000

5800000

6000000

6200000

6400000

'90 '92 '94 '96 '98 '00 '02 '04 '06

0

500

1000

1500

2000

2500

'90 '92 '94 '96 '98 '00 '02 '04 '06

Sources: Indiana Professional Licensing Agency & US Census Bureau

1400

1450

1500

1550

1600

1650

1700

1750

'90 '92 '94 '96 '98 '00 '02 '04 '06

Sources: Indiana Professional Licensing Agency & US Census Bureau

DHPSA designations enable $25K-35K annual tax free loan repayment plus salary – incentive for new graduates to practice in rural and inner city underserved areas

More Counties qualify than are designated

Ratio of 1 dentist per 5,000 or more people

In 32 of 92 counties (35%) >75% of land is farmland

46 of 92 counties (50%) are officially

designated as rural Nearly 2/3 of Indiana’s

23 million acres are farmlands◦ 5/92 counties >90%

farmland◦ 6/92 counties <33%

farmland

11 of 92 counties do not have any Medicaid providers

52 CHCs with 25 Dental Clinics (13 are in Indianapolis)◦ See attached table listing community health centers and dental

clinics)

Distribution◦DDS with smallest patient pool are in affluent areas◦DDS with largest patient pool are in rural and

impoverished inner-city areas

Limitations due to lack of current epidemiological data◦ Last statewide survey 1992-93

No data on the oral health of special population groups; adults; elderly; disabled

Marion County survey of children conducted in 2000 by IUSD for MCHD

Services Provided March 2003 - Dec

2006

10,938 children examined to date

16,928 sealants placed

7,831 Fluoride varnish

1,919 BW x-rays (6-14 yrs)

674 days at 575 sites in Indiana

Children with untreated carious lesions: 52%

35% = non-urgent17% = urgent

All are children from low income families

66

73

62

64

66

68

70

72

74

Urban Rural

30

13

25

18

0

5

10

15

20

25

30

Urban Rural

non-urgent urgent

Economic Issues Number of Dentists / Ratio of Dentists to

Population Geographic distribution

Unfunded Unaccepted Inaccessible Unconvinced Unmotivated Powerless

6.2 million Hoosiers

From 2000 to 2004 Indiana lost 138,800 jobs

Change: manufacturing jobs, service sector and small business (less likely to provide dental insurance to employees)

Food Stamps and Temporary Assistance for Needy Families (TANF) have nearly doubled in 5 years

Highest per capita rate of medically bankrupt families (>77,000 Hoosiers)

>30% of Hoosiers who are uninsured are employed by companies that offer coverage, but it’s not affordable, or they are not eligible (part time/seasonal)

Indiana health insurance rates have increased by double digit rates for the last four years, higher than the national average.

Many Hoosier small businesses have dropped health and dental insurance benefits

Source: Kaiser Family Foundation 2004

$4.5 Billion annual budget Dental expenditures = 2.5%

21-30% of children enrolled received dental care in a given year

Reimbursement rates are higher than the national norm

24% of Indiana children 0-18 are covered by Hoosier Healthwise

24% children 0-18 years (nat’l 26%) 9% women 19-64 (nat’l 9%) 4% men 19-64 (nat’l 6%)

Undocumented Immigrant Children: eligible only for Pkg E Medicaid (E=Emergency only – no dental care unless life threatening)

Indiana Population 6,271,973 Indiana population July 2005 Estimated 4.4% are Hispanic = 275,966 160,000 Hispanic citizens 65,000 Undocumented immigrants* Other estimates 50,000 – 10,000

* Pew Hispanic Center 2004

91% of children <poverty level 39% Hispanic 30% enrolled in Hoosier Healthwise vs

55% in other schools 29% had severe caries vs 17% in other

schools

Framework for Service-Learningat Indiana University School of Dentistry

Source: YoderKM, J Dent Education ,Feb 2006

Use service-learning to reduce two common barriers:

Medicaid acceptance: cause students to see, and reflect on, the extent of the effects of disparities in access to care

Dental services for young children: offer service-learning rotations in the 1st & 2nd years that allow students to work with very young children (ie. Head Start)

2

12

59

17

10

0

10

20

30

40

50

60

Percentage

>5 yrs 4 yrs 3 yrs 2 yrs 1 yr

Accelerate recruitment of candidates from underserved rural counties and minority populations

Attempt to retain a greater number of graduates in Indiana

Integrate community based service-learning throughout the curriculum and structure it to enhance clinical and cultural competency skills development

Create a new option or expand the extramural program to encourage exploration of alternative practice settings, (Community health centers, US Public Health Service, International programs)

Continue Counseling students about potential financial incentives for staying in Indiana and practicing in underserved areas & lobby to develop other options

◦ Health Service Corps – loan repayment for working in community health centers ($25 – 35K year tax free)

◦ Explore possibilities for loan repayment options for private practice models serving underserved areas (Washington State)

◦ Lobby for higher Medicaid reimbursement rates for dentists serving special needs populations and underserved geographic areas (Minnesota model)

Sister Maura Brannick Chapin Street Health Center

IUSB Dental Education Clinic

Indiana Health Centers

Heart City Dental Clinic

Qualify

Working Poor Clinic

$10 Co-pay per appointment

Reduced Lab Fees

Volunteer DDS and Hygienist

Educational Clinic

Reduced Fees

Will file all insurance programs

Open to patients of Heart City Health Center. Medicaid and referral from Elkhart Hospital

Income Based Sliding Fee Schedule- 40% of U and C Grants from local business and Trustee

office