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Strengthening Oral Health in the U.S. through Integration and Workforce Development: Lessons from State and Federal Health Officials

Coverage and service delivery of dental services remains separate from medical coverage. As states are not required to include dental services for adults in their Medicaid programs, the ability for low-income individuals to access dental care is often a factor of where they live. Additionally, 69 million Americans live in health professional shortage areas, without access to a dental provider. Given gaps in access to dental insurance and providers, state health policy is an important area for achieving oral health equity.

Recent State Action on Oral Health

In the past year, Kansas, Louisiana, Maine, Maryland, New Hampshire, and Tennessee increased coverage of dental services for adults in their Medicaid programs, and ten states increased Medicaid reimbursement rates for certain dental services.

Over the past year NASHP has convened state health officials monthly to discuss policy topics at the intersection of oral health, social determinants of health, health equity, and overall health. In June 2022, federal health officials joined the group to discuss critical issues related to promoting oral health care access as part of overall health. The discussion aligned with the recently released National Institutes of Health (NIH) report, Oral Health in America. Topics included integrating oral health across physical and behavioral health sectors, workforce innovations, and opportunities for federal-state collaboration.

Primary, Oral Health, and Behavioral Health Care Integration

Participants discussed how basic dental care contributes to whole person health and can greatly impact an individual’s quality of life, including factors such as self-esteem, employability, and social connections in addition to overall health. Tobacco cessation counseling was noted as a key example of a cross-cutting service since it intersects with oral, overall, and behavioral health. Despite the importance of oral health, state officials cited challenges with persistent silos between primary and oral health care, often exacerbated by the inoperability of medical and dental electronic health records. Participants noted that agency definitions of primary care do not consistently include oral health, which likely contributes to disconnects between care settings and providers.

Pediatric primary care provider education and training with an emphasis on oral health care is one strategy that can foster integration between these sectors.  Well-known initiatives such as Iowa’s I-Smile and Washington State’s Access to Baby and Child Dentistry include training for medical providers on preventive oral health services. Other state Medicaid programs are adding requirements for primary care medical providers to offer similar services. Beginning in April 2023, Medicaid primary care medical providers in Massachusetts must apply fluoride varnish and connect pediatric patients to a dental home to ensure more children receive preventive services and are connected to dental resources.

The relationship between oral and mental health is noteworthy. Mental health can affect or be affected by an individual’s oral health. The impact of substance use disorder (SUD) is also important to consider in the context of oral health and behavioral health. Participants discussed several considerations for better integration between these sectors. For example, states remain interested in exploring providing Medicaid dental benefits for adults with SUD or other behavioral health needs who otherwise would not receive dental coverage. Utah received approval for an 1115 Waiver to cover dental services for certain Medicaid expansion adults with a SUD through Project FLOSS, which has found that SUD patients who received oral health care were more likely to remain in and complete SUD treatment.  Another strategy for consideration is developing recovery-friendly dental practices, which Rhode Island is undertaking with a focus on elements such as using non-stigmatizing language at dental offices. The state’s oral health coalition held a training for dental providers including a SBIRT (Screening, Brief Intervention, and Referral to Treatment) coach and will focus on this topic in future trainings.

Oral Health Workforce

A major challenge to achieving oral health equity remains that more than 69 million individuals live in health professional shortage areas with an insufficient capacity of dental providers. Several workforce strategies have emerged to address a shortage of dentists including dental therapy, community health workers (CHWs), public health dental hygienists, and community dental health coordinators. Recently, the COVID-19 pandemic highlighted how CHWs can connect community members with vital resources. As the community-based workforce continues to expand, the challenge will be working across different provider groups to best meet the oral health needs of populations.

Illinois has grown its CHW workforce to connect individuals with dental care. The Illinois Department of Health received a grant from the Health Resources and Services Administration (HRSA)’s Bureau of Health Workforce to train CHWs in oral health. The grant aligns with the Illinois Oral Health Plan goal to align infrastructure and workforce to promote timely and equitable access to oral health care. To date, over 300 CHWs have been trained on the basics of oral health and health promotion in collaboration with local community colleges and universities. The state is working with CHWs to integrate and expand oral health promotion outside of the healthcare setting. Additionally, to measure the impact of CHWs on oral health, the Department of Health proposed a surveillance plan to analyze the potential impact of a community-based workforce on reductions in emergency room use for dental problems. As Illinois incorporates CHWs into their oral health workforce, the Medicaid program is working with the Illinois Community Health Worker Association to implement a CHW service benefit in the state.

State-Federal Collaboration on Oral Health

As in states, federal involvement in oral health does not sit within one agency. Centers for Disease Control and Prevention, Centers for Medicare & Medicaid Services (CMS), HRSA, Indian Health Services, Substance Abuse and Mental Health Services Administration (SAMHSA) and Veterans Administration all touch oral health care policies, programs, and workforce.

Federal funding opportunities can support states in piloting and building out new care delivery and workforce models. For example, with an increased focus on behavioral health and oral health integration, states can seek SAMHSA grants to support oral health care access and care coordination. These include grants for Certified Community Behavioral Health Clinics and Promoting Integration of Primary and Behavioral Health Care grants. HRSA and CDC also have funding for CHWs that could be leveraged to train additional staff in oral health promotion.

State and federal officials noted recommendations by national experts can impact oral health care delivery. One avenue includes the United States Preventative Services Task Force (USPSTF). In late 2021, the USPSTF recommended primary care clinicians apply fluoride varnish in children younger than five to prevent cavities and prescribe oral fluoride supplementation for children six months and older whose water supply does not contain enough fluoride. This decision drives states like Massachusetts to allow medical assistants to apply fluoride varnish as well as the coverage requirements for Affordable Care Act compliant health plans.

CMS quality measures also drive oral health care improvement efforts at the state level. The CMS 2022 Child Core Set (the set of children’s health care quality measures for Medicaid and the Children’s Health Insurance Program) includes three dental and oral health measures; oral evaluation, topical fluoride for children, and sealant receipt on permanent first molars. States use these measures to design oral health quality improvement initiatives including incentive payments and performance improvement projects in managed care programs. In August 2022, CMS released a notice of proposed rulemaking mandating states report the Child Core Set annually. The goal of this proposed rule is to promote consistent use of quality measures and identify gaps and disparities among Medicaid members.

Conclusion

State and federal health policy are important levers in increasing dental care access for low-income individuals and improving overall health. Policymakers remain committed to integrating oral health care with primary care and behavioral health care services through workforce, coverage, and other innovations. Federal funding allows states to test innovative models, however state officials cite a need for support in determining long-term sustainability of models absent of one-time funding.  NASHP will continue to work with state officials to lift up promising practices to improve oral health care and track emerging innovations.

Acknowledgements

This work was supported by the CareQuest Institute for Oral Health. The authors are appreciative of state officials, Carrie Hanlon, and Hemi Tewarson for their review and feedback.

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