These letters illustrate the varying opinions elicited when challenging problems are presented. Unfortunately, it is not possible within the scope of a thousand-word editorial, nor in this letter, to give due attention to the complex issues under discussion. Even the detailed list of references cited in the editorial are but a minuscule fraction of the extensive evidence base that exists to support the points raised and the opinions expressed in the editorial.
Dr. Manne brings up some excellent points regarding the need for oral health education and systems changes to improve access to care for the under-served. Without question, dentists who care for Medicaid patients must be compensated adequately for their services. In addition, there is a clear need to improve the "oral health literacy" of the public, of other health care providers and of policy-makers. To do so effectively, broad-based coalitions need to be established that bring the practicing dental community together with other stakeholders.
For example, in Massachusetts we have created the Oral Health Advocacy Taskforce. It is a broad-based statewide coalition of consumers, advocates, health care professionals, academics and insurers. Its goal is to improve the oral health of the Commonwealth by expanding access to oral health care educational, prevention and treatment services for all residents. The Massachusetts Dental Society is an essential component of this initiative.
Currently, our major efforts are directed in two main areas: a public awareness campaign and state-level efforts to reform Medicaid dental. This year, we launched a bold new multistate campaign (Watch Your Mouth, "www.watchyourmouth.org"), in coordination with New Hampshire and Maine, to increase public awareness of children’s oral health and of the importance of oral health to overall health and well-being.
Regarding Medicaid reforms, we have successfully advocated for increasing provider reimbursement rates; for funding and implementation of a third-party administrator for the MassHealth (Medicaid) dental program to get the government bureaucracy out of managing the program, making it easier for dentists to file claims and get paid promptly; and for implementing a "caseload cap," so that dentists can exercise control over the numbers of Medicaid patients they see.
However, perhaps our most important achievement has been winning the federal lawsuit against the state’s Medicaid program. In a decision rendered on July 14, 2005, U.S. District Court Judge Rya Zobel ruled that Massachusetts officials were in violation of federal law in running the MassHealth (Medicaid) dental program for 450,000 low-income children in the Commonwealth.1 One of many practical outcomes of this lawsuit will be mandated increases in reimbursement rates to dentists, to promote their participation as Medicaid providers.
It also is important to note that, at the national level, the American Dental Association is actively engaged in the reform of Medicaid.2 Among its many efforts, the ADA is working to facilitate public-private partnerships that improve access to oral health care; to facilitate the establishment of school-linked programs to better reach under-served children; to encourage programs that value prevention and disease management, that are science- and evidence-based and that invest in strategies with strong potential for long-term savings through preventive care; and to ensure that the financing of the Medicaid program is sound and responds to market demands and state economic needs.3
At the state level, the ADA is providing assistance on Medicaid issues to its constituent societies. For example, the ADA report "State Innovations to Improve Dental Access to Oral Health Care for Low-Income Children: A Compendium Update"4 is a compilation of data drawn from each state’s Medicaid and Children’s Health Insurance Program. It addresses such barriers as poor financing, administrative red tape, lack of patient case management and low oral health literacy.
A guiding principle underlying these many efforts, in Massachusetts and nationally, is a recognition of the essential role of private practice dentists. True success in enhancing access to dental care and eliminating oral health disparities in America will be achieved because of private practitioners, not despite them. It is thus puzzling to read Dr. Curtis’ comments regarding "nationalized health." On the contrary, it is evident that involvement of private practitioners and the ADA will be the foundation of any effective solutions. Thus, for any solution to be effective, it clearly must take into consideration the needs of the profession.
There also is an important and essential role for government to play in seeking solutions. We rely on our democratically elected government to provide us with many basic protections—a military, a justice system, police and firefighters to protect against various threats and hazards. We rely on government to ensure the safety of our food, water and medicines. We rely on government to protect us against epidemic infections. We rely on government to provide us with safe roads, bridges and other infrastructure.
It is, thus, not unreasonable to expect that a basic government function also should be to protect the neediest in our society from illness and from poor oral health. If we claim to truly be a civilized society, then we have to accept that health is a basic human right, and that we, as a society, have a moral obligation to provide the needy with access to health care, including oral health care. We simply cannot accept the persistence of the disparities that now exist and yet still consider ours a civilized society. Of course, there is "no free lunch." As Supreme Court Justice Oliver Wendell Holmes Jr.5 wrote almost 80 years ago, "taxes are what we pay for civilized society."
The problem of health disparities remains a daunting challenge. The most recent national data show that, despite overall improvements in oral health over the past decade, important disparities remain.6 Related to this, it has been well-documented that there is a relative lack of diversity in the health professions, and this fact has been deemed to be an important social and health problem in America.
In 2004, the Institute of Medicine7 reviewed the evidence for the value of diversity in the health care work force and concluded that greater racial and ethnic diversity among health professionals will improve access to, and quality of, health care for all Americans. This report presents extensive evidence and cogently makes the case for this being an issue of national priority. Regarding efforts to promote diversity in dental education and practice, many national, as well as local, initiatives have been entrained to address the problem.
Lastly, it is important to address Dr. Curtis’ comments regarding American values. American society is founded on laudable core values. Ours is, in many ways, a glorious history of which we can all be proud. Unfortunately, our nation’s history is tainted by a great shame, and it would be both unjust and counterproductive for any of us to deny the facts of history and its consequences.
For hundreds of years, our society cruelly enslaved and oppressed people based entirely on their origins. Regrettably, to this day, both overt and covert discrimination remain significant problems in America. While, in an idealized world, it would be nice to wipe the slate clean and start afresh, the negative legacy of our past will not disappear on its own, nor can it be wished away. Were it only true that time heals all wounds. Rather, it will require concerted effort on the part of all of us to achieve the desired outcomes. To successfully address the oral health needs of our nation’s increasingly diverse population will require full and equal participation by all Americans.
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