LOS ANGELES -- After providing dental care for more than 7,000 low-income children under age six, the Center for Oral Health's WIC Dental Collaborative Project is coming to a close. Advocates who underscore the importance of oral health to overall health lament the June 30 end of the successful initiative when funding expires.
"I could cry," said Harold Slavkin, dean emeritus of the University of Southern California's Ostrow School of Dentistry. "This kind of program isn't a big-ticket item, yet doing away with it is bad investing for little people born in poverty."
Tooth decay is the most common chronic childhood disease -- five times more common than asthma -- according to the American Academy of Pediatric Dentistry. The Center for Oral Health's 2006 California Smile Survey shows 71% of California children have tooth decay by the third grade.
The Center for Oral Health project provides free and low-cost dental care for kids ages five and younger at community-based WIC centers. WIC is USDA's Special Supplemental Nutrition Program for Women, Infants and Children. The groundbreaking dental program originally was intended to operate for only two years, ending Dec. 31, 2011, but it recently received a six-month extension.
Dentists participating in the Center for Oral Health program come from public health departments and organizations, safety-net clinics or private practices. Participating children receive a dental risk assessment, fluoride varnish application, teeth cleaning and a referral to a dental clinic. The latter is critical because low-income and minority populations have trouble gaining access to dental services and instead often incur expensive emergency department visits.
The program, initially funded by Kaiser Permanente and the U.S. Health Resources and Services Administration, is currently funded by First 5 Commission of Los Angeles. Supporters say it has achieved its goals, which are:
- Providing better care by transforming the traditional dental service delivery model, in which families often bring their children to a clinic when dental decay may already be present;
- Creating a community-based early intervention model that helps establish a dental home for children, maximizing the use of the most cost-effective dental care providers while ensuring comprehensive and coordinated care;
- Improving patients' oral health as measured by reduced invasive restorative and surgical procedures; and
- Reducing the cost of dental services through early preventive dental care.
Center for Oral Health administrators said "results from the project suggest it could become a valuable model for policymakers seeking effective ways to provide much needed and affordable dental care to underserved communities."
An Unwelcome End
"We're quite devastated that the program is ending," Arlene Glube, director for Southern California operations at the Center for Oral Health, said. "Overall, we have a huge dental problem in California."
"Nothing will replace it," said John Kehoe, senior manager with the WIC program in Los Angeles. "We have minimal space and staffing, it's a pretty basic and simple process, yet it's gotten plenty of bang for the buck. This program put dental preventive care on families' radar for the rest of their lives and they know how to utilize these kinds of services."
"We hoped the stars would line up properly ... and that this program was sustainable," said Francisco Ramos-Gomez, pediatric dentistry professor at UCLA's School of Dentistry and a Center for Oral Health board member. "Children with dental problems can't be school-ready, and can't speak or nourish themselves properly."
He added, "We need to convince the 'powers that be' of quality improvements we've made with the WIC program and to raise public awareness so providers, administrators, insurers and fundraisers continue investing in a program like this."
Reducing Costs, Expanding Access
A February report from the Pew Center on the States concludes that states can reduce hospital visits, strengthen oral health and reduce costs by making modest investments to improve access to preventive care. It cited 2007 California data of more than 83,000 emergency visits for preventable dental problems.
"The fact that so many Americans go to hospitals for dental care shows the delivery system is failing," Shelly Gehshan, director of the Pew Children's Dental Campaign, said in a press release.
Further, a preliminary analysis conducted by UC-Berkeley as part of a federal grant application to expand the Center for Oral Health program to other sites reveal that dental care spending for children enrolled in Medi-Cal and the WIC program are 40% to 50% less than for children not enrolled in the program. Medi-Cal is California's Medicaid program.
"Plus between 70% and 80% of children on WIC are on Medi-Cal," said attorney Joel Diringer, a health policy expert and Center for Oral Health board member. Grant results are expected in May.
Beyond reducing costs, the program has also helped expand access to dental care. "Coverage alone doesn't reduce access barriers," said Diringer. "There aren't enough pediatric-oriented dentists or general dentists willing to service children -- they're just not comfortable."
Additionally, he said, children are approximately two to three times less likely to have dental insurance than medical insurance. Many employer plans offer medical insurance, but not dental, to families. "Programs like WIC can fill those gaps and save money," he said.
Microcosm of Health Care Reform
A viable dental services community portal like the WIC program has wider implications for health care reform, Glube said.
"We're finally recognizing that the mouth is part of the rest of the body," said Eileen Espejo, associate director at the advocacy organization Children Now. "WIC sites are great sources of access behind the intention of the Affordable Care Act -- to provide access to the most vulnerable populations that need this coverage and care. Right now, I'm not aware of anything that could fill this 'cavity.'"
The Center for Oral Health's measurable success sends important messages about early engagement and prevention, Diringer noted. "Health reform is a very prevention-oriented approach to primary care," he said.
He noted that the Affordable Care Act includes oral health care as an essential benefit for children under 21. It also awards grants to support the operation of school-based health clinics, including those that provide oral health services.
Sustainability of the WIC program means getting dental providers reimbursed for services provided at the WIC sites, Diringer said, but two obstacles remain.
"First, despite a federal mandate to pay for care outside of the 'four walls' of a community clinic, the state has made reimbursement for those services by Medi-Cal very difficult."
Second, in recent years, Los Angeles County has sustained significant managed care penetration in Medi-Cal's Denti-Cal program, he said. "Community providers at WIC sites have difficulties filing reimbursement claims to Denti-Cal since often they're not part of all managed care plans or aren't the child's assigned dentist."
Meanwhile, the state has shifted more Medi-Cal beneficiaries into managed care in an effort to saves money; however, that system ultimately provides less care, Diringer argued. He said, "We should convince the state it should be paying for case management that would get the kids linked up with a dental home at an early age."
He worries that children whose dental insurance is through a managed care plan don't receive necessary services in a timely manner. "Dentists are paid per capita regardless of the amount of services provided," he said. "Service utilization and reporting of services are much lower for managed care plans compared to fee-for-service plans."
Ramos-Gomez said under L.A. dental managed care programs, a child may wait from 18 to 24 months for a dental check-up. Invasive dental care also pays dentists better -- more root canals and crowns, for example. "We should pay providers for keeping children's mouths healthier," he said.