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Presidential Library Staff.
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Series/Staff Member:
Subseries:
OA/ID Number:
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FolderlD:
Folder Title:
Appendix: Briefing Book on the Children's Benefit Package, the Prevention Benefit Package, and the
Dental Benefit Package [5]
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C
�APPENDIX
DENTAL BENEFIT PACKAGE
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�For Official Use Only
An Essential Oral Health Benefits Package
for Children, Adolescents, and Adults (under 65 years of age)
BACKGROUND
Although gains in oral heaJth status have been publicized widely for the "average" American,
improvement in oral health has not been experienced uniformly. The common oral diseases: dental
caries (decay or cavities) and periodontal (gum or gingival) diseases, still constitute a significant
disease burden for many Americans. The consequences of not treating these conditions result in
considerable pain, dysfunction, and disability among individuals who lack financial means or have
other barriers to receipt of oral health care. The poor, the elderly, the institutionalized, the
geographically isolated, and the medically, physically, or mentally compromised have not benefitted
proportionately in the reduction of oral diseases or access to the advances of dental science and
practice. In 1989 over 164 million hours ftom work were missed and over 51 million hours of school
were lost because of dental problems. Prevention of oral diseases would substantially reduce losses in
worker productivity and ultimately contribute to improvement in the general well-being of the U.S.
work force.
In addition, oropharyngeal cancer is the sixth most common cancer found among U.S. men and the
twelfth most common among U.S. women. Each year more than 30,000 new cases of oropharyngeal
cancer are diagnosed and more than 8,000 deaths result. Survival from oral and pharyngeal cancer is
particularly poor among poor and African-American populations. Routine periodic dental exams will
lead to earlier detection of oropharyngeal, better treatment options with lower morbidity, fewer
deaths, and lower costs.
Most Americans have some form of medical health insurance; however, only about 40 percent of
Americans (approximately 100 million people) are covered by private dental insurance. The majority
of dental care is paid for "out-of-pocket". Coverage provided through private dental insurance is least
likely for those Americans who are:
•
Unemployed — since dental insurance is employment-based;
•
Elderly adults or seniors — less than 15 percent have dental insurance; and
•
Poor or low income individuals/families — only 10 percent have dental insurance.
Higher levels of income, education, and occupational status are associated with increased use of dental
services. The poor, the elderly, the medically compromised, and the handicapped have not
proportionately shared in or benefitted from the advances of dental science and practice over the past
two decades. These groups endure pain, discomfort, dysfunction, and disfigurement that those who
have access andfinancialmeans to oral health care would find unbaearable and intolerable. Currendy
only 60 percent of the U.S. population receives any oral health care in a given year. Even for those
with dental insurance, copayments and deductibles may be as high as 50 percent for many dental
procedures.
Only a small percentage of dental expenditures (3 percent) comes from public sources: federal, state,
or local. In 1991, Medicaid expenditures for dental services represented less than one percent of the
$77 billion spent on Medicaid. Since 1975, unlike any other health service covered under Medicaid,
Preliminary Staff Working Paper - For Illustrative Purposes Only
�For Official Use Only
Page 2.
constant dollar expenditures for dental services have decreased by nearly one-third (29.7 percent).
Essentially, no oral health care coverage is available under Medicare. In addition, relatively small
segments of the population receive varying degrees of dental coverage through federally operated or
supported programs.
DESCRIPTION OF BENEFITS
The proposed oral health benefits package includes primary services to preserve and protect the teeth
and supporting structures of the oral cavity. These measures include primary prevention services,
acute emergency services, and early intervention measures that are safe, effective, and available
readily in our current health care system. These services are similar to those covered by State Early
and Periodic Screening, Diagnostic and Treatment (EPSDT) programs and are listed in a general
priority sequence as follows:
•
Professional Oral Health Assessment: Thorough examination of the hard and soft tissues of
the oral cavity and related structures provided on an annual basis, for individuals one year of
age and above.
Dental Sealants: For permanent molar teeth in children and adolescents.
Professionally-Applied Topical Fluoride: May be provided up to twice per year for
children, adolescents, and adults who are assessed to be at risk for dental caries.
Oral Prophylaxis (Dental Cleaning): Removal of hard and soft deposits (calculus) and
extrinsic stain provided on an annual basis.
Fluoride Supplements: Available to children aged 13 years and younger whose water supply
contains sub-optimal levels of fluoride.
Acute Emergency Dental Services: Treatment of acute infection, the control of bleeding,
and relief of pain within the oral cavity.
x
Dental Restorative Services: Basic dental restorative services to prevent tooth loss in
children, adolescents, and adults.
Periodontal Maintenance Services: Removal of subgingival calculus through routine scaling
and root planing for those aged 15 years and over.
Endodontic Services: Root canal therapy to retain grossly carious permanent teeth in
children up to the age of 18.
Orthodontic Services: Space maintenance (3 to 10 years of age) to prevent malocclusion and
interceptive orthodontic therapy for children (6 to 11 years of age) with severe malocclusion.
Medically Necessary Dental Care: Catastrophic coverage for dental services, including
prosthetic devices to restore dental function as a medically necessary procedure, for
individuals with birth defects {e.g., cleft lip and cleft palate) and for genetic disorders {e.g.,
ectodermal dysplasias and dystrophic epidermolysis bullosa).
Preliminary Staff Working Paper - For Illustrative Purposes Only
�For Official Use Only
Types of Oral Health Services not included in the package:
Cast restorations (crowns and bridges);
Root canal or pulpal therapy for adults over 18 years of age;
Full and partial dentures for individuals who have lost all their teeth, except for those
individuals with medical conditions requiring these rehabilitative serivces;
Surgical periodontal therapy;
Oral and maxillofacial surgical procedures except extractions; and
Dental implants.
Preliminary Staff Working Paper - For Illustrative Purposes Only
Page 3.
�Page 4.
For Official Use Only
Summary of Proposed Oral Health Benefits
for Children, Adolescents, and Adults (under 65 years of age)
': for Children Adolescents and Adults ;:
Children and Adolescents
(under age 19)
Adults
(under age 65)
X
X
Oral Health Assessment
(oral cxaminazions
Dental
and denial
Sealants
radiographs)
X
(permanent molar teeth)
Professionally-Applied Topical Fluorides
X
X
Oral
X
X
Prophylaxis
(routine denial
cleaning)
Fluoride Supplements
(children rending
in non-Jluoridaied
X
communities)
Acute Emergency Dental Services
(control and relief qf infection, bleeding, and pain)
X
X
Dental Restorative Services (basic dental fillings)
X
X
X
X
Periodontal Maintenance Services
(routine dental scaling <t root planing)
mm-mmm
Endodontic Services
(pulpal and root canal
X
therapy)
Interceptive Orthodontics
(interceptive space maintenance
for severe malocclusion)
and orthodontic
therapy
^mmmmBmmm
wmm m mm:
X
mmmmmm
X
X
Dental Prosthetics
(prosthetic procedures deemed medically necessary for
indivudals suffering from specified birth defects and
genetic disorders)
mm
Preliminary Staff Working Paper -For lUustrative Purposes Only
�For Official Use Only
Page 5.
Estimated Cost of Oral Health Benefits Package
Children, Adolescents, and Adults (under the age of 65)
Target Population (under age 65)
(U.S. Population estimates based upon 1995 projections)
Oral Health Benefits Package
Estimated annual per capita cost for Target Populations ranges from $122 to S128
Estimated annual per capita cost for U.S. Population (appears below)
Estimuled Cost
for
Target Populutiou
(Uninsured & Insured)
Total U.S. (Cbild/Adult) Population - 226.4 million
(139.2 million uninsured and 87 million insured)
Estimated Cost
for
Target Population
(Dentally Uninsured)
Estimated Cost
for
Target Population
(Dentally Insured)
$ 27.5 billion
J/05 annual per capita for U.S.
($i> monihly)
$16.9 billion
$65 annual per capita for U.S.
($5 monihly)
$10.6 billion
($41 annual per capita for U.S.
($3 monthly)
immmmmmmmmmmmtkm iiiiim^^i^^iia^i^
:
mmmmmmmm.
mmMmm:mmmBmum i mmtmmmmmmmmm ^rmmzmm mm ^mmmm&m
U.S. Population in Poverty at 200 % of Fed. Pov. Levd - 70.5 million
$34 annual per capita for U.S.
($3 monihly)
U.S. Population in Poyerty at 150 % of Fed. Pov. I.evd - 48.7 million
$ 6.1 billion
$23 annual per capita for U.S.
($2 monthly)
U.S. Population in Poverty at 100 % of Fed. Pov. Level - 28.7 million
$3.7 billion
, $14 annual per capita for U.S.
($> 1.00 monihly)
�For Official Use Only
Page 6.
SUMMARY
This proposal supports the long-term national goals of Healthy People 2000 National Health
Promotion and Disease Prevention Objectives relating to prevention of dental caries, preventing tooth
loss, reducing levels of untreated disease, and increasing the proportion of the U.S. population
receiving dental sealants and appropriate fluoride protection. The proposed benefits package is both
reasonable and may be targeted, depending on resources available, to various populations. The
suggested services are relatively inexpensive and cost-effective, and are aimed at eliminating the
future need for more extensive and costly restorative and rehabilitative care. By including adults as
well as children in the comprehensive benefit package it is more likely that the goals of Healthy
People 2000 will be achieved. This comprehensive benefit package will not only improve access to
oral health care to many adults currently locked outside the system, but research has shown that
children of parents who themselves receive oral health care are 13 times more likely to receive dental
care than children of parent(s) who do not receive oral health care.
Recently Oregon's Medicaid Plan evaluated 688 services for for possible coverage in their medicaid
plan. The cut-off for covered services was set at 568. In Oregon's landmark plan, all of the services
contained in the present comprehensive benefit plan ranked very high because prevention was a major
thrust of the Oregon plan and savings due to prevention in dentistry is very great. Importantly, the
proposed package places more rigorous, but scientifically-based, limits on the provision of certain
preventive services than have existed in most dental insurance packages in the past.
Preliminary Staff Working Paper - For Illustrative Purposes Only
�For Official Use Only
Estimated Cost of Oral Health Benefits Package -- Total U.S Population
Description of Proposed Oral Health Benefits for Children, Adolescents, & Acijlts (Under the age of 65)
ESTIMATED
TARGET
POPULATION
(1995)
SERVICE
O A HEALTH ASSESSMENT
RL
O A EXAMINATION (INI./PER.)
RL
DENTAL RADIOGRAPHS (2 BU)
DENTAL SEALANTS
DENTAL SEALANTS (6-17 Y/0)
PROFESSIONAL APPLIED TOPICAL FLUORIDE
CHILD TF/HIGH RISK (2-18 Y/O)
CHILD TF/NON-FL C H (2-18 Y O
OM
/
ADULT TF/HIGH RISK (19-64 Y/O)
O A PROPHYLAXIS
RL
O A P O H (CHILD 2-H Y/O)
RL RPY
O A P O H (ADULT 15-64 Y/O)
RL RPY
FLUORIDE SUPPLEMENTS
PROJECTED
UTILIZATION
RATE
COST/UNIT
TOTAL
ANNUAL C S
OT
P R CAPITA
E
COST($)/YR
100X
100X
70X
70X
S18 $2,841,789,939
$16 $2,399,908,338
$12.87
$11.20
8
SOX
$19
$490,368,264
$12.92
2
2
2
45X
55X
102
85X
25X
70X
$16
$16
$16
$785,121,916
$282,233,368
$336,299,225
$12.24
$4.40
$2.24
47,678,263
164,765,583
1
1
60X
45X
70X
70X
$29
$580,721,245
$40 $2,076,046,343
$12.18
$12.60
226,374,000
220,875,947
226,374,000
220,875,947
219,043,263
226,374,000
DENTAL E E G N Y
MREC
EEGNY EA
MREC
XM
SEDATIVE FILLING
E E G N Y TX OF PAIN
MREC
EXTRACTION (SINGLE)
EXTRACTION (SURGICAL)
TRAUMATIC W U D TX
ON
1
1
1
1
1
1
15X
2X
1.5X
10X
IX
0.5X
100X
100X
100X
100X
100X
100X
$24
$814,946,400
$141,360,606
$32
$35
$118,846,350
$47 $1,038,116,953
$S6
$188,377,206
. $55
$62,252,850
$3.60
$0.64
$0.53
$4.70
$0.86
$0.28
1
1
1
1
1.1
0.4
1.3
0.4
70X
70X
70X
70X
$45 $1,020,303,900
$46
$625,188,032
$46 $6,339,240,400
$46 $1,950,535,508
$34.65
$12.99
$42.22
$12.99
1
• . 1
-
10.OX
54. OX
70X
70X
$61
$61
$62,478,640
$3,461,780,152
$4.27
$23.06
0.125
0.17
39. OX
14.2X
70X
70X
$166,804,229
$166
$3,130 $1,180,838,661
$5.66
$52.89
220,875,947
214,277,530
1
1
37,954,200
0.17
64,143,947
64,143,947
150,133,583
ROUTINE RESTORATIVE SERVICES
PRIMARY REST. (CHILD 3-10 Y/O)
29,446,000
48,121,000
P R . REST. (CHILD 6-18 Y/O)
EM
150,133,583
C R N L REST.(ADULT 19-64 Y/O)
OOA
150,133,583
R O REST. (ADULT 19-64 Y/O)
OT
PERIODIC MAINTENANCE C R (SSRP)
AE
CHILD (15-18 Y/O)
14,632,000
ADULT (19-64 Y/O)
150,133,583
INTERCEPTIVE ORTHODONTICS (6-11 Y/O)
29,446,000
S A E MAINTENANCE (3-10 Y/O)
PC
CHILD (6-11 Y/O)
22,326,000
ENDODONTIC SERVICES
CHILD/ADOLESCENT (6-18 Y/O)
48,121,000
MEDICALLY N C S A Y C R (Specific Conditions)
EESR AE
DENTAL PROSTHETIC SERVICES
1,250,000
D0C:0HBP1A.UK1
SERVICE
F E / R MODIFIER
RQY
LJF
1
0.2
0.0256
70X
$400
$344,931,328
$7.17
...
70X
$1,252
$219,100,000
$175.28
(15APR93)
Estimated Total Cost
$27,527,589,854
Annual per capita cost/Targ. Pop
$121.60
Monthly per capita cost/Targ. Po
$10.13
Annual per capita cost/U.S. Pop.
$105.82
Monthly per capita cost/U.S. Pop
$8.82
Preliminary Staff Working Paper - For Illustrative Purposes Only
�For Official Use Only
Estimated Cost of Oral Health Berefits Package -- Dentally Uninsured U.S Population
Description of Proposed Oral Health Benefits for Children, Adolescents, & Adults (Under the age of 65)
ESTIMATED
TARGET
POPULATION
(1995)
SERVICE
O A HEALTH ASSESSMENT
RL
ORAL EXAMINATION (INI./PER.)
DENTAL RADIOGRAPHS (2 BU)
DENTAL SEALANTS
DENTAL SEALANTS (6-17 170)
PROFESSIONAL APPLIED TOPICAL FLUORIDE
CHILD TF/HIGH RISK (2-18 Y/O)
CHILD TF/NON-FL C M (2-18 Y O
OM
/
ADULT TF/HIGH RISK (19-64 Y/O)
O A PROPHYLAXIS
RL
O A P O H (CHILD 2-U Y/O)
RL RPY
O A P O H (ADULT 15-64 Y/O)
RL RPY
FLUORIDE SUPPLEMENTS
SERVICE
F E / R MODIFIER
RQY
PROJECTED
UTILIZATION
RATE
COST/UNIT
TOTAL
ANNUAL C S
OT
PER CAPITA
COST($)/YR
ROUTINE RESTORATIVE SERVICES
PRIMARY REST. (CHILD 3-10 Y/O)
P R . REST. (CHILD 6-18 Y/O)
EM
C R N L REST.(ADULT 19-64 Y/O)
OOA
R O REST. (ADULT 19-64 Y/O)
OT
PERIODIC MAINTENANCE C R (S&RP)
AE
CHILD (15-18 Y/O)
ADULT (19-64 Y/O)
INTERCEPTIVE ORTHODONTICS (6-11 Y/O)
SPACE MAINTENANCE (3-10 Y/O)
CHILD (6-11 Y/O)
ENDODONTIC SERVICES
CHILD/ADOLESCENT (6-18 Y/O)
702
702
$18 $1,747,866,095
$16 $1,476,083,210
$12.87
$11.20
8
502
$19
$301,605,003
$12.92
2
2
452
552
102
852
252
702
$16
$16
$16
$482,895,642
$173,589,937
$206,843,583
$12.24
$4.40
$2.24
29,324,905
101,340,416
1
1
602
452
702
702
$357,177,341
$29
$40 $1,276,889,247
$12.18
$12.60
139,233,176
135,851,554
139,233,176
135,851,554
134,724,347
139,233,176
DENTAL E E G N Y
MREC
EEGNY EA
MREC
XM
SEDATIVE FILLING
E E G N Y TX OF PAIN
MREC
EXTRACTION (SINGLE)
EXTRACTION (SURGICAL)
TRAUMATIC W X N TX
CJD
1002
1002
1
1
1
1
1
1
152
22
1.52
102
12
0.52
1002
1002
1002
1002
1002
1002
$501,239,434
$86,944,995
$73,097,418
$638,502,304
$115,862,938
$38,289,123
$3.60
$0.64
$0.53
$4.70
$0.86
$0.28
13,111,003
29,597,214
92,340,885
92.340.885
1
1
1
1
1.1
0.4
1.3
0.4
702
702
702
702
$627,546,241
$45
$384,527,002
$46
$46 $3,899,001,545
$46 $1,199,692,783
$34.65
$12.99
$42.22
$12.99
135,851,554
131,793,144
1
1
23,344,040
0.17
39,452,258
39,452,258
92,340,885
$24
$32
$35
$47
$fi6
$55
8,999,531
92,340,885
1
... 1
10.02
54.02
702
. 702
$61
$61
$38,427,997
$2,129,196,136
$4.27
$23.06
18,111,003
13,731,789
0.125
0.17
39.02
14.22
702
702
$166
$3,130
$102,594,302
$726,284,456
$5.66
$52.89
29,597.214
\
0.0256
702
$400
$212,152,828
$7.17
MEDICALLY N C S A Y C R (Specific Conditions)
EESR AE
DENTAL PROSTHETIC SERVICES
750,000
0.2
...
702
$1,252
$131,460,000
$175.28
DOC:OHBP1ADU.UK1
LJF
(15APR93)
Estimated Total Cost
$16,927,769,561
Annual per capita cost/Targ Pop
$121.58
Monthly per capita cost/Targ Pop
$10.13
Annual per capita cost/U.S. Pop
$65.07
Monthly per capita cost/U.S. Pop
$5.42
Preliminary Staff Working Paper - For Illustrative Purposes Only
�For Official Use Only
timated Cost of Oral Health Benefits Package -- Dentally Insured U S Population
.
Description of Proposed Oral Health Benefits for Children, Adolescents, I Adults (Under the age of 65)
ESTIMATED
TARGET
POPULATION
(1995)
SERVICE
O A HEALTH ASSESSMENT
RL
84,907,221
O A EXAMINATION (INI./PER.)
RL
82,370,715
DENTAL RADIOGRAPHS (2 BU)
DENTAL SEALANTS
14,590,025
DENTAL SEALANTS (6-17 Y/O)
PROFESSIONAL APPLIED TOPICAL FLUORIDE
24,657,661
CHILD TF/HIGH RISK (2-18 Y/O)
24,657,661
CHILD TF/NON-FL C H (2-18 Y O
OM
/
57,713,053
ADULT TF/HIGH RISK (19-64 Y/O)
O A PROPHYLAXIS
RL
18,328,066
O A P O H (CHILD 2-14 Y/O)
RL RPY
63,337,760
O A P O H (ADULT 15-64 Y/O)
RL RPY
FLUORIDE SUPPLEMENTS
SERVICE
F E / R MODIFIER
RQY
PROJECTED
UTILIZATION
RATE
COST/UNIT
TOTAL
ANNUAL C S
OT
PER CAPITA
COST($)/YR
100X
100X
70X
70X
S18 $1,092,416,309
$922,552,006
$16
$12.87
$11.20
8
SOX
$19
$188,503,127
$12.92
2
2
2
45X
55X
10X
85X
25X
70X
$16
$16
$16
$301,809,776
$108,493,710
$129,277,240
$12.24
$4.40
S2.24
1
1
60X
45X
70X
70X
$29
$40
$223,235,838
$798,055,779
$12.18
$12.60
87,020,735
84,907,221
87,020,735
84,907,221
84,202,717
87,020,735
1
1
1
1
1
1
15X
2X
1.5X
10X
IX
0.5X
100X
100X
100X
100X
100X
100X
$24
$32
$35
$47
$86
$55
$313,274,647
$54,340,622
$45,685,886
$399,063,940
$72,414,336
$23,930,702
$3.60
$0.64
$0.53
$4.70
$0.86
$0.28
11,319,377
16,498,259
57,713,053
57,713,053
1
1
1
1
1.1
0.4
1.3
0.4
70X
70X
70X
70X
$392,216,401
$45
$240,329,376
$46
$46 $2,436,875,966
$749,807,990
$46
$34.65
$12.99
$42.22
$12.99
5,624,707
57,713.053
1
1
10.OX
54. O
X
70X
70X
$61
$61
$24,017,498
$1,330,747,585
$4.27
$23.06
11,319,377
8,582,368
0.125
0.17
39. O
X
14.2X
70X
70X
$166
$3,130
SM, 121,439
$453,927,785
$5.66
$52.89
18,498,259
1
0.0256
70X
$400
$132,595,518
$7.17
MEDICALLY N C S A Y C R (Specific Conditions)
EESR AE
DENTAL PROSTHETIC SERVICES
500,000
0.2
...
70X
$1,252
$87,640,000
$175.28
DENTAL E E G N Y
MREC
EEGNY EA
MREC
XM
SEDATIVE FILLING
E E G N Y TX OF PAIN
MREC
EXTRACTION (SINGLE)
EXTRACTION (SURGICAL)
TRAUMATIC W U D TX
ON
OUTINE RESTORATIVE SERVICES
PRIMARY REST. (CHILD 3-10 Y/O)
P R . REST. (CHILD 6-18 Y/O)
EM
C R N L REST.(ADULT 19-64 Y/O)
OOA
R O REST. (ADULT 19-64 Y/O)
OT
PERIODIC MAINTENANCE C R (S&RP)
AE
CHILD (15-18 Y/O)
ADULT (19-64 Y/O)
INTERCEPTIVE ORTHODONTICS (6-11 Y/O)
S A E MAINTENANCE (3-10 Y/O)
PC
CHILD (6-11 Y/O)
ENDODONTIC SERVICES
CHILD/ADOLESCENT (6-18 Y/O)
DOC:0HBP1ADI.UK1
LJF
1
1
0.17
"
(15APR93)
$10,585,333,476
Estimated Total Cost
$121.64
Annual per capita cost/Targ Pop
$10.14
Monthly per capita cost/Targ Pop
$40.69
Annual per capita cost/U.S. Pop
$3.39
Monthly per capita cost/U.S. Pop
Preliminary Staff Woridng Paper — For Illustrative Purposes Only
�For Official Use Only
Estimated Cost of Oral Health Benefits Package -- U.S Population in Poverty (200Z of Fed. Poverty Level)
Description of Proposed Oral Health Benefits for Children, Adolescents, & Adults (Under the age of 65)
ESTIMATED
TARGET
POPULATION
(1995)
SERVICE
SERVICE
F E / R MODIFIER
RQY
O A HEALTH ASSESSMENT
RL
68,774,849
O A EXAMINATION (INI./PER.)
RL
66,720,279
DENTAL RADIOGRAPHS (2 BW)
DENTAL SEALANTS
11,817,920
DENTAL SEALANTS (6-17 T/0)
PROFESSIONAL APPLIED TOPICAL FLUORIDE
19,972,706
CHILD TF/HIGH RISK (2-18 Y/O)
19,972,706
CHILD TF/NON-FL C H (2-18 Y O
OM
/
46,747,573
ADULT TF/HIGH RISK (19-64 Y/O)
O A PROPHYLAXIS
RL
14,845.733
O A P O H (CHILD 2-K Y/O)
RL RPY
51,303,586
O A P O H (ADULT 15-64 Y/O)
RL RPY
FLUORIDE SUPPLEMENTS
PROJECTED
UTILIZATION
RATE
COST/UNIT
TOTAL
ANNUAL C S
OT
PER CAPITA
COST($)/YR
100X
100X
70X
70X
$18
$16
$884,857,211
$747,267,125
$12.87
$11.20
8
SOX
$19
$152,687,533
$12.92
2
2
45X
55X
10X
85X
25X
70X
$16
$16
$16
$244,465,919
$87,879,905
$104,714,564
$12.24
$4.40
$2.24
1
1
60X
45X
70X
70X
$29
$40
$180,821,029
$646,425,181
$12.18
$12.60
70,486,795
68,774,849
70,486,795
68,774,849
68,204,201
70,486,795
1
1
1
1
1
100X
100X
100X
100X
100X
100X
$24
$32
$35
$47
1
15X
2X
1.5X
10X
IX
0.5X
$253,752,464
$44,015,904
$37,005,568
$323,241,792
$53,655,612
$19,383,869
$3.60
$0.64
$0.52
$4.70
$0.86
$0.28
9,168,695
14,983,589
46,747,573
46,747,573
1
1
1
1
1.1
0.4
1.3
0.4
70X
70X
70X
70X
$45
$317,695,284
$46
$194,666,795
$46 $1,973,869,532
$607,344,471
$46
$34.65
$12.99
$42.22
$12.99
4.556,013
46,747,573
1
1
10.OX
54. OX
70X
70X
$61
$61
$19,454,174
$1,077,905,544
$4.27
$23.06
9,168,695
6,951,718
0.125
0.17
39. OX
14.2X
70X
70X
$166
$3,130
$51,938,365
$367,681,506
$5.66
$52.89
14,983,589
1
0.0256
70X
$400
$107,402,369
$7.17
MEDICALLY N C S A Y C R (Specific Conditions)
EESR AE
1,250,000
DENTAL PROSTHETIC SERVICES
0.2
...
70X
$1,252
$219,100,000
$175.28
DENTAL E E G N Y
MREC
EEGNY EA
MREC
XM
SEDATIVE FILLING
E E G N Y TX OF PAIN
MREC
EXTRACTION (SINGLE)
EXTRACTION (SURGICAL)
TRAUMATIC W U D TX
ON
ROUTINE RESTORATIVE SERVICES
PRIMARY REST. (CHILD 3-10 Y/O)
P R . REST. (CHILD 6-18 Y/O)
EM
C R N L REST.(ADULT 19-64 Y/O)
OOA
R O REST. (ADULT 19-64 Y/O)
OT
PERIODIC MAINTENANCE C R (S&RP)
AE
CHILD (15-18 Y/O)
ADULT (19-64 Y/O)
INTERCEPTIVE ORTHODONTICS (6-11 Y/O)
S A E MAINTENANCE (3-10 Y/O)
PC
CHILD (6-11 Y/O)
ENDODONTIC SERVICES
CHILD/ADOLESCENT (6-18 Y/O)
DCOB1.K
O:HPCW1
0.17
iM
$55
(15APR93)
LJF
Estimated Total Cost
Annual per capita cost/Targ Pop
Monthly per capita cost/Targ Pop
Annual per capita cost/U.S. Pop
Monthly per capita cost/U.S. Pop
1
1
$8,722,231,715
$123.74
$10.31
$33.53
$2.79
Preliminary Staff Working Paper -
For Illustrative Purposes Only
�For Official Use Only
Estimated Cost of Oral Health Benefits Package -- U S Population in Poverty (1501 of Fed. Poverty Level)
.
Description of Proposed Oral Health Benefits for Children, Adolescents, & Adults (Under the age of 65)
ESTIMATED
TARGET
POPULATION
(1995)
SERVICE
O A HEALTH ASSESSMENT
RL
O A EXAMINATION (INI./PER.)
RL
DENTAL RADIOGRAPHS (2 BW)
DENTAL SEALANTS
DENTAL SEALANTS (6-17 Y/O)
PROFESSIONAL APPLIED TOPICAL FLUORIDE
CHILD TF/HIGH RISK (2-18 Y/O)
CHILD TF/NON-FL C M (2-18 Y O
OM
/
ADULT TF/HIGH RISK (19-64 Y/O)
O A PROPHYLAXIS
RL
O A P O H (CHILD 2-U Y/O)
RL RPY
O A P O H (ADULT 15-64 Y/O)
RL RPY
FLUORIDE SUPPLEMENTS
SERVICE
F E / R MODIFIER
RQY
PROJECTED
UTILIZATION
RATE
COST/UNIT
TOTAL
ANNUAL C S
OT
PER CAPITA
COST($)/YR
100X
100X
70X
70X
$18
$16
$611,753,133
$516,629,123
$12.87
$11.20
8
SOX
$19
$105,561,751
$12.92
2
2
45X
55X
10X
85 X
25X
70X
$16
$16
$16
$169,013,475
$60,756,478
$72,395,254
$12.24
$4.40
$2.24
10,263,717
35,469,146
1
1
60X
45X
70X
70X
$29
$40
$125,012,069
$446,911,236
$12.18
$12.60
48,731,612
47,548,044
48,731,612
47,548,044
47,153,521
48,731,612
1
1
1
1
1
1
15X
2X
1.5X
10X
IX
0.5X
100X
100X
100X
100X
100X
100X
$24
$32
$35
$47
$86
$55
$175,433,802
$30,430,748
$25,584,096
$223,475,806
$40,552,028
$13,401,193
$3.60
$0.64
$0.52
$4.70
$0.86
$0.28
6,338,851
10,359,025
32,319,310
32,319,310
1
1
1
1
1.1
0.4
1.3
0.4
70X
70X
70X
70X
$219,641,134
$45
$46
$134,584,451
$46 $1,364,650,541
$419,892,474
$46
$34.65
$12.99
$42.22
$12.99
3,149,836
32,319.310
1
1
10.OX
54. O
X
70X
70X
$61
$61
$13,449,799
$745,218,647
$4.27
$23.06
6,338,851
4,806,126
0.125
0.17
39. OX
14.2X
70X
70X
$166
$3,130
$35,908,006
$254,199,560
$5.66
$52.89
10,359,025
1
0.0256
70X
$400
$74,253,490
$7.17
MEDICALLY N C S A Y C R (Specific Conditions)
EESR AE
1,250,000
DENTAL PROSTHETIC SERVICES
0.2
...
70X
$1,252
$219,100,000
$175.28
DENTAL E E G N Y
MREC
EEGNY EA
MREC
XM
SEDATIVE FILLING
E E G N Y TX OF PAIN
MREC
EXTRACTION (SINGLE)
EXTRACTION (SURGICAL)
TRAUMATIC W U D T
ON
X
ROUTINE RESTORATIVE SERVICES
PRIMARY REST. (CHILD 3-10 Y/O)
PERM. REST. (CHILD 6-18 Y/O)
C R N L REST.(ADULT 19-64 Y/O)
OOA
R O REST. (ADULT 19-64 Y/O)
OT
PERIODIC MAINTENANCE C R (S&RP)
AE
CHILD (15-18 Y/O)
ADULT (19-64 Y/O)
INTERCEPTIVE ORTHODONTICS (6-11 Y/O)
S A E MAINTENANCE (3-10 Y/O)
PC
CHILD (6-11 Y/O)
ENDODONTIC SERVICES
CHILD/ADOLESCENT (6-18 Y/O)
DCOB1.K
O:HPDW1
47,548,044
46,127,600
1
1
8,170,414
0.17
13,808,290
13,808,290
32,319,310
(15APR93)
LJF
Estimated Total Cost
Annual per capita cost/Targ Pop
Monthly per capita cost/Targ Pop
Annual per capita cost/U.S. Pop
Monthly per capita cost/U.S. Pop
$6,097,808,346
$125.13
$10.43
$23.44
$1.95
Preliminary Staff Working Paper — For lUustrative Purposes Only
�For Official Use Only
.stfmated Cost of Oral Health Benefits Package -- U S Population in Poverty (100X of Fed. Poverty Level)
.
Description of Proposed Oral Health Benefits for Children, Adolescents, I Adults (Under the age of 65)
ESTIMATED
TARGET
POPULATION
(1995)
SERVICE
O A HEALTH ASSESSMENT
RL
28,019,383
O A EXAMINATION (INI./PER.)
RL
27,182,336
DENTAL RADIOGRAPHS (2 BW)
DENTAL SEALANTS
4,814,708
DENTAL SEALANTS (6-17 Y/O)
PROFESSIONAL APPLIED TOPICAL FLUORIDE
8,137.028
CHILD TF/HIGH RISK (2-18 Y/O)
8,137,028
CHILD TF/NON-FL C M (2-18 Y O
OM
/
19,045,308
ADULT TF/HIGH RISK (19-64 Y/O)
O A PROPHYLAXIS
RL
O A P O H (CHILD 2-K Y/O)
RL RPY
6,048,262
20,901,461
O A P O H (ADULT 15-64 Y/O)
RL RPY
FLUORIDE SUPPLEMENTS
DENTAL E E G N Y
MREC
EEGNY EA
MREC
XM
SEDATIVE FILLING
E E G N Y T O PAIN
MREC X F
EXTRACTION (SINGLE)
EXTRACTION (SURGICAL)
TRAUMATIC W U D T
ON
X
SERVICE
F E / R MODIFIER
ROY
PROJECTED
UTILIZATION
RATE
COST/UNIT
TOTAL
ANNUAL C S
OT
P R CAPITA
E
COST($)/YR
1002
1002
702
7DX
S18
S16
$360,497,382
$304,442,162
$12.87
$11.20
8
502
$19
$62,206,032
$12.92
2
2
2
452
552
102
852
252
702
$16
$16
$16
$99,597,226
$35,802,924
$42,661,489
$12.24
$4.40
$2.24
1
1
602
452
702
702
$29
$40
$73,667,827
$263,358,407
$12.18
$12.60
1
1
0.17
-
28,716,843
28,019,383
28,716,843
28,019,383
27,786,897
28,716,843
1
1
1
1
1
1
152
22
1.52
102
12
0.52
1002
1002
1002
1002
1002
1002
$24
$32
$35
$47
$86
$55
$103,380,633
$17,932,405
$15,076,342
$131,691,100
$23,896,731
$7,897,132
$3.60
$0.64
$0.52
$4.70
$0.86
$0.28
3,735,394
6,104,425
19,045,308
19,045,308
1
1
1
1
1.1
0.4
1.3
0.4
702
702
702
702
$45
$46
$46
$46
$129,431,412
$79,308,694
$804,169,069
$247,436,637
$34.65
$12.99
$42.22
$12.99
1,856,153
19,045,308
1
1
10.02
54.02
702
702
$61
$61
$7,925,774
$439,146,703
$4.27
$23.06
3,735,394
2,832,181
0.125
0.17
39.02
14.22
702
702
$166
$3,130
$21,160,075
$149,796,169
$5.66
$52.89
6,104,425
1
0.0256
702
$400
$43,756,521
$7.17
MEDICALLY N C S A Y C R (Specific Conditions)
EESR AE
DENTAL PROSTHETIC SERVICES
1,250,000
0.2
...
702
$1,252
$219,100,000
$175.28
ROUTINE RESTORATIVE SERVICES
PRIMARY REST. (CHILD 3-10 Y/O)
P R . REST. (CHILD 6-18 Y/O)
EM
C R N L REST.(ADULT 19-64 Y/O)
OOA
R O REST. (ADULT 19-64 Y/O)
OT
PERIODIC MAINTENANCE C R (SiRP)
AE
CHILD (15-18 Y/O)
ADULT (19-64 Y/O)
INTERCEPTIVE ORTHODONTICS (6-11 Y/O)
SPACE MAINTENANCE (3-10 Y/O)
CHILD (6-11 Y/O)
ENDODONTIC SERVICES
CHILD/ADOLESCENT (6-18 Y/O)
D0C:0HBP1E.WK1
(15APR93)
LJF
Estimated Total Cost
Annual per capita cost/Targ Pop
Monthly per capita cost/Targ Pop
Annual per capita cost/U.S. Pop
Monthly per capita cost/U.S. Pop
$3,683,338,847
$128.26
$10.69
$14.16
$1.18
Preliminary Staff Working Paper - For Illustrative Purposes Only
Estimated Cost of Oral Health Benefits Package -- U S Population in Poverty (1002 of Fed. Poverty Level)
.
Description of Proposed Oral Health Benefits for Children, Adolescents, & Adults (Under the age of 65)
�Clinton Presidential Records
Digital Records Marker
This is not a presidential record. This is used as an administrative
marker by the William J. Clinton Presidential Library Staff.
This marker identifies the place of a tabbed divider. Given our
digitization capabilities, we are sometimes unable to adequately
scan such dividers. The title from the original document is
indicated below.
Divider Title:
3-
�Toward Improving the Oral Health of Americans:
An Overview of Oral Health Status,
Resources, and Care Delivery
Oral Health Coordinating Committee
U.S. Public Health Service
March 1993
�Executive Summary
Dental and oral diseases may well be the most prevalent and preventable disease
affecting Americans. Over 84 percent of U.S. children, 96 percent of U.S. adults, and
99.5 percent of Americans 65 years of age and older have experienced dental caries (also
called "cavities"). Millions of Americans suffer from periodontal diseases and other oral
conditions, and over 17 million Americans (10 million Americans 65 years old or older) have
lost all of their teeth. These oral diseases and conditions negatively impact productivity,
increase heaith care costs, decrease overall health, diminish quality of life, and canresultin
pain, loss of self-esteem, and even death. In 1989, for example, over 164,175,000 hours
were missed from work and 51,679,000 hours were missed from school by school-age
children in the United States because of dental conditions. Yet, highly effective and
inexpensive interventions are available.
Preventive dental services, such as sealants (plastic coatings placed on the biting
surfaces of teeth), are known to be effective in preventing dental caries and are appropriate
particularly for children. Children, adults, and elderiy at high risk for dental disease benefit
from professionally-applied fluoride and other preventive services. Prevention of dental
disease and early intervention when dental disease does occur both improve the oral health of
Americans and save limited heaith careresources.Unfortunately, groups at highest risk for
disease — the poor and minorities — have lower utiliiation rates than the U.S. average,
because of numerous barriers to dental care, principally financial.
Access to appropriate, primary dental care is difficult for those who cannot afford it.
Of the S38.7 billion spent for dental services in 1992, over 90 percent was paid for either
out-of-pocket by dental consumers or through private dental insurance. However, only
95 million Americans (40 percent) have any form of private dental insurance. Public
programs, including Medicaid, pay for only three percent of dental services. Per capita
payments for dental services under Medicaid decreased by almost 30 percent between 1975
and 1990. Access to dental care for the elderly can be difficult as well. After age 65, only
15 percent of Americans have dental insurance, and because Medicare does not pay for
routine dental care, elderly Americans who are unable to pay for oral health care out-ofpocket risk losing a lifetime's worth of investment in oral health.
�Oropharyngeal cancer — more common than leukemia, melanoma of the skin,
Hodgkin's disease, and cancers of the brain, liver, bone, thyroid gland, stomachy ovary, or
cervix - affects primarily older Americans andresultsin an estimated 8,000 deaths annually.
Therelativefive-year survival rate for oral cancer for all Americans is 51 percent, but
among African Americans, therelativefive-year survivalrateis only 31 percent, 23 percent
less than that for white Americans. Regular examinations by a dental professional and early
intervention offer the best hope for improved survival for oral cancer patients. However,
African-American adults have less than half of the average number of dental visits for all
adults.
Millions of Americans are at high risk for oral health problems because of underlying
medical or handicapping conditions,rangingfrom veryraregenetic diseases to more
common chronic diseases like arthritis and diabetes. These conditions not only impact on the
individual's quality of life (i.e., their ability to eat, speak, taste, and swallow), but also can
be a significant source of pain and discomfort. Diabetics often experience more severe
periodontal disease and delayed wound healing, which can impact significantly on oral and
overall health. Congenital anomalies, like cleft lip and palate, usually require extensive
surgical repair. A number of genetic diseases affect oral heaith, including ectodermal
dysplasias, scleroderma, osteogenesis and dentinogenesis imperfecta, and epidermolysis
bullosa.
Among individuais with compromised immune systems, oral diseases and conditions
can have a significant impact on health. Individuals who are HTV-seropositive or with AIDS
are likely to demonstrate a variety of oral complications associated with their disease.
Identification through an oral examination may be the first indication of infectivity that can
be important to initiating treatment. Individuals undergoing organ transplantation or
prosthetic joint replacement are atriskfor complications secondary to untreated oral disease.
In each case, oral health services can significantly reduce the risk of complications and
improve the quality of life of the individual.
Oral diseases and conditions, though nearly universal, can be easily prevented and
controlled at reasonable cost. Prevention and early andregularprimary dental care are the
best strategies to improve the oral heaith and quality of life of all Americans. Unfortunately,
barriers to care, like cost, prevent many poor Americans, minorities, the elderly, and those
without dental insurancefromseeking care. Oniy byremovingthese barriers and ensuring
access to preventive and primary dental services for ail Americans can continued
improvement in oral health and overall health be assured.
ii
�Table of Contents
Forward
vii
Introduction
1
Epidemiology of Oral Diseases
2
Oral Disease Among Children
Oiai Disease Among Adults
Oral Disease and the Hderly
Oral Cancer
2
6
9
10
Oral Health's Impact on Overall Heaith, Quality of Life, and Economic Productivity . .
12
Dental Services: Expenditures, Costs, and Sources of Payment
Out-of-Pocket Payments
Dental Insurance
Medicaid
Medicare
Comparison of Source of Payment for Dental Services and Ambulatory Physician
Services
14
17
19
20
22
Utilization of Dental Services
23
Summary of Oral Health Status and Dental Service Utilization
28
Conclusion
31
References
34
ui
22
�List of Figures
Figure 1: Percent of U.S. Children 5-17 Years of Age Who Have Experienced
Dental Caries, 1986-1987
2
Figure 2: Distribution of Dental Caries Among U.S. Children, 1986-1987
3
Figure 3: Percent of Teeth with Dental Caries That Are Untreated Among
U.S. Children by Race, 1986-1987
3
Figure 4: Percent of Teeth with Dental Caries That Have Been Extracted Among
U.S. Children by Race, 1986-1987
4
Figure 5: Percent of Dental Caries Among U.S. Children That Potentially
Could Be Prevented by Dental Sealants, 1986-1987
5
Figure 6: Dental Sealant Utilization Among U.S. Children 5-17 Years of Age
by Family Income, 1989
5
Figure 7: Percent of Diseased Teeth with Untreated Decay Among Employed
U.S. Adults by Race, 1985-1986
Figure 8: Root Caries Among Employed U.S. Adults, 1985-1986
7
7
Figure 9: Percent of Root Caries Untreated Among Employed U.S. Adults
by Race, 1985-1986
Figure 10: Tooth Loss Among U.S. Adults and Seniors by Race, 1989
8
8
Figure 11: Projected Increase in Number of Teeth at Risk for Dental Disease
Among U.S. Adults
9
Figure 12: Tooth Loss Among the Elderiy by Income, 1989
10
Figure 13: Estimated Number of New Cancer Cases and Number of
Cancer Deaths by Type of Cancer, 1992
iv
11
�Figure 14: Relative Five-Year Survival Rate for Selected Cancers by Race
11
Figure 15: Difference in Relative Five-Year Survival for Selected Cancers by Race . . . 12
Figure 16: Expenditures for Personal Health Care Services by
Service Category, 1992
Figure 17: National Expenditures for Dental Services, 1960-2000
15
15
Figure 18: Percent of Personal Health Care Expenditures for Hospitals, Physician, and
Dental Services, 1960-2000
Figure 19: Source of Payment for Dental Services, 1987
16
16
Figure 20: Percent Change in Consumer Price Index-(Urban) for All Services
and for Dental Services, 1975-1992
17
Figure 21: Percent of Bad Debt/Free Care by Service Category, 1987
18
Figure 22: Percent of Americans with Dental Insurance by Age, 1989
19
Figure 23: Dental Insurance Coverage by Income Level, 1989
20
Figure 24: Percent Change in Medicaid Payments by Service Category, 1975-1990 . .
20
Figure 25: Per Capita Medicaid Payments for Dental Services by State, 1991
21
Figure 26: Percent of Persons with Dental Visit in Past Year by Race, 1983-1989 . . .
24
Figure 27: Percent of Persons with Dental Visit in Previous Year
by Income Level, 1983-1989
Figure 28: Annual Number of Dental Visits for U.S. Children 5-17 Years of Age
24
by Race and Dental Insurance Status, 1989
26
Figure 29: Reason for Last Dental Visit Among U.S. Employed Adults, 1985-1986 . .
27
Figure 30: Reason for Not Seeking Dental Care in Previous Year, 1989
v
27
�List of Tables
Table 1: Sources of Payment for Dental and Ambulatory Physician Services for the Poor
and U.S. Average, 1987
23
Table 2: Interval Since Last Dental Visit by Selected Characteristics, 1989
25
Table 3: Dental Visits Per Person Per Year and Percent with Dental Visit in Previous
Year Among Individuals with Dental Insurance by Selected Characteristics,
1989
26
Table 4: Oral Health Status and Utilization of Dental Services Among U.S. Children. .
28
Table 5: Oral Health Status and Utilization of Dental Services Among U.S. Adults. . .
29
Table 6: Oral Health Status and Utilization of Dental Services Among U.S. Elderly.
30
vi
.
�Forward
The promodon and protection of the heaith of Americans has been the responsibility
of the United States Public Health Service (PHS) since its inception in 1798. Its various
roles indude health surveillance, biomedical and health services research, health promotion,
technical andfinancialassistance to states, support for health professions education, and the
delivery of health services to special populations.
The PHS Oral Health Coordinating Committee (OHCC) is responsible for monitoring
oral health activities within the PHS and for promoting cooperation with other government
agencies and organizations to facilitate achievement of the oral health objectives of Healthy
People 2000: The National Health Promotion and Disease Prevention Objectives. Ongoing
monitoring and analysis of health status and services delivery data, including that for oral
health, is a critical component in ensuring continued progress in health and the extension of
care services to the underserved.
Produced under the auspices of the OHCC, Toward Improving the Oral Health of
Americans is a synthesis of information collected by various agencies of the PHS that
describes the oral health status of various population groups, the impact of oral health on
overall heaith, the economic consequences of its absence, and the availability and financing
of dental care. Taken together, these data support the premise that oral health is an integral
part of total heaith. The OHCC is committed to ensuring the availability of these data on a
regular basis as well as other special analyses as needed.
Although this document would not have been possible without the cooperation of all
OHCC members and their agencies, a special thanks is extended to Dr. Alex White who was
primarily responsible for collecting the data and weaving them into a cohesive unit.
RobertJ. Collins, D.M.D., M.P.H.
Assistant Surgeon General &
Chief Dental Officer, USPHS
vu
�Introduction
Although dental problems don't command the instant fears associated with low
birth weight, fetal death or cholera, they do have the consequences of wearing
down the stamina of children and defeating their ambidons. Bleeding gums,
impacted teeth and rotting teeth are routine matters for the children I have
interviewed in the South Bronx. Children get used to feeling constant pain.
They go to sleep with it. They go to school with it Sometimes their teachers
are alarmed and try to get them to a clinic. But it's all so slow and heavily
encumbered with red tape and waiting lists and missing, lost or canceled
welfare cards, that dental care is often long delayed. Children live for months
with pain that grown-ups would find unendurable. The gradual attrition of
accepted pain erodes their energy and aspirations. I have seen children in
New York with teeth that look like brownish, broken sticks. I have also seen
teenagers who were missing half their teeth. But, to me, most shocking is to
see a child with an abscess that has been inflamed for weeks and that he has
simply lived with and accepts as pan of the routine of life.
1
Jonathan Kozol, in his 1991 book Savage Inequalines: Children in America's
Schools, describes a picture unseen by most policy makers, but all too common for those
who have worked in public programs serving poor, minority, and underserved populations.
Millions of Americans suffer from diseases and conditions of the oral cavity that result in
decreased economic productivity through lost work and school days, needless pain, increased
cost, loss of self-esteem, and death. Oral diseases and conditions, including dental caries
(also known as "cavities"), periodontal diseases, oral cancer, and tooth loss, afflict more
individuals than any other single disease in the U.S. Americans cannot be truly healthy
unless they arefreefromthe burden of untreated oral diseases.
The purpose of this paper is to review the epidemiology of dental and oral diseases,
including dental caries, periodontal diseases, tooth loss, and oral cancer, and the impact that
these diseases and conditions have on Americans. It will describe the need for, and
utilization of, dental services and current expenditures for those services. Finally, it will
identify the current gaps in services that are needed to improve oral heaith.
�Epidemiology of Oral Diseases
Oral Disease Among Children
Dental caries may well be the most common disease found among U.S. children,
affecting over 40 million (84 percent) U.S. children by the age of 17 (Figure I). Dental
caries is a progressive disease process. Unless restorative treatment is provided, the carious
lesion will continue to destroy the tooth, eventually resulting in pain, acute infection, and
costly treatment to restore the
tooth or have it removed.
Fortunately, with early
professional intervention, caries
can either be prevented or treated
easily at minimal cost.
2
During the past 20 years,
on average, there has been a
dramatic decline in the level of
dental caries among school-age
children. Many have suggested
possiblereasonsfor the decline
in dental caries, including: 1)
Figure 1: Percent of U.S. Children 5-17 Years of Age
community water fluoridationr
Who Have Experienced Dental Caries, 1986-1987.
2) increased use of toothpastes
containingfluorides; 3) use offluoridesupplements and mouthrinses; 4) increased
availability offluoridein foods and bottled liquids processed withfluoridatedwater; and 5)
changes in diet (e.g., decreased sugar consumption).
2
3
2
4
5
4
7
While many herald this improvement, millions of children still have significant levels
of dental caries. Seventy-five percent of dental caries in children is concentrated in
25 percent of the population (Figure 2). Higher disease levels generally are found among
minorities, children from poor and low-income families, and children whose parents have
less than a high school education. Among American Indian and Alaska Native children aged
six to eight years, 88 percent have experienced dental caries.* By age 15, the disease rate
increases to 91 percent in this group.
2
�25 Parconf of US. CMMran Suffmr
1mm 75 Percent of D«ntat C*ria3
25%
76%
75%
Percent of U.S. ChUdren
P r a n t of D«TtaJ Caries
Figure 2: Distribution of Dental Caries Among U.S.
Children, 1986-1987.
2
When dental caries in permanent teeth does occur among children, minority children
are less likely to have their disease treated than white children and have more permanent
teeth extracted as a consequence (Figures 3 and 4). The level of untreated dental disease
among American Indian and
Alaska Native children is much
higher than for other minority
children.
2
1
Figure 3: Percent of Permanent Teeth with Dental Caries
That Are Untreated Among U.S. Children by Race, 19861987.
2
�AO
s%
Alrtean
*%
Al Othan
3%
SM
«—\MMIM
^%
i
tO
It
12
13
14
IS
ia
ir
Figure 4: Percent of Permanent Teeth with Dental Caries
That Have Been Extracted Among U.S. Children by Race,
1986-1987.
2
Fluoridation and the use of other fluorides have been successful in decreasing the
prevalence of dental caries on the smooth surfaces of teeth. Unfortunately, these efforts have
much less effea on dental caries that occur in the pits and fissures of teeth (pardculaiiy on
the biting surfaces of teeth) where over 85 percent of dental caries now occur (Figure 5).
Dental sealants (a plastic coating placed on the biting surfaces) applied by a dental
professional are a cost-effective, proven preventive intervention for this type of decay. To
be effective, however, dental sealants must be applied early, periodically assessed, and
reapplied as necessary. Unfortunately, the utilizationrateof dental sealants among all
children,regardlessof ethnic orracialbackground or income level, is significandy less than
the national health promotion and disease prevention target levd of 50 percent. As of 1989,
only 10.9 percent of American children had sealants applied. Many poor Americans are
unable to afford thisrelativelyinexpensive preventive dental care. Less thanfivepercent of
children from families whose income is under 510,000 have dental sealants, compared to
over 17 percent of children in families with incomes in excess of $35,000 (Figure 6). For
children ages 9-11, only six percent of African American children and 10.3 percent of
Hispanic and other minority children had dental sealants, compared to 21 percent of white
children.
2
9
10
�CariM t t * oould
b* priwntad by
87.8%
12.1%
Smootti
•urfac* caii««
Figure 5: Percent of Dental Caries Among U.S. Children
That Potentially Could Pe Prevented by Dental Sealants,
1986-1987.
2
Figure 6: Dental Sealant Utilization Among U.S. Children
5-17 Years of Age by Family Income, 1989.
10
�Children whose parents and caregivers have less than a high school education or
whose parents and caregivers are American Indian and Alaska Nadve are at increased risk
for developing baby bottle tooth decay (also called nursing caries), a severe form of caries
that can destroy primary teeth. This type of dental caries is caused by frequent or prolonged
use of baby bottles that contain milk, sugared water,fruitjuice, or other sugary beverages
during the day or night. The prevalence of baby bottle tooth decay has been estimated at
53 percent among rural American Indian and Alaska Native Health Start Children and as
high as 11 percent in some urban areas. - Children who experience baby bottle tooth decay
are at increased risk for dental disease for life. The psychological trauma and cost associated
with restoration of these grossly carious teeth for these children can be substantial, often
requiring general anesthesia. Nutritional counseling and intervention by dental and other
professionals provide the best means of preventing this serious oral disease.'
11 12
QnH Di§e3S? Amgng Adufo
While the overall oral health of adults is improving, dental caries, gingivitis, and
periodontal diseases continue to affect most adult Americans. A recent national survey found
that 96 percent of employed adults in the U.S. - nearly 100 million individuals — had
experienced dental caries. The number of decayed orfilledteeth is greater for white
Americans than for African Americans and other minorities (10.3 decayed orfilledteeth for
whites versus 6.8 decayed orfilledteeth for African Americans). However, the percent of
diseased teeth with untreated decay is greater among African Americans than whites at all
ages (Figure 7).
13
Gingivitis and adult-onset periodontitis, two diseases that involve the supporting tissue
of teeth, affect nearly half of all Americans between 18 and 64 years of age. Untreated
periodontal disease can lead to tooth mobility, poor esthetics, decreased ability to eat, chew,
or speak, and tooth loss. One measure of periodontal disease is loss of attachment of the
supporting periodontaltissuefromthe teeth, known as recession. Over 45 percent of
employed adults 55-64 years of age had moderate recession. Another measure of active
periodontal disease is the depth of pockets between the teeth and supporting tissue. Over 18
percent of adults 55-64 years of age have pockets 4 millimeters or greater, indicating a
moderately compromised status of the supporting periodontal tissue.
13
�Figure 7: Percent of Diseased Teeth with Untreated Decay
Among Employed U.S. Adults by Race, 1985-1986.
i:l
Untreated periodontal disease can lead to recession (loss) of the supporting tissue
from the tooth, exposing the roots of the teeth. Deprived of their protective tissue, root
surfaces are more susceptible to dental caries than the crowns of teeth. Because the degree
of recession generally increases with age, the rate of decay on the roots of teeth is greater
among older Americans. As Figure 8 illustrates, by 64 years of age, 59 percent of ail
employed Americans (over 60
Poroont vrttti Root Cflitai
ao%
million people) have experienced
dental caries on at least one root
50%
surface. The mean number of
40%
root surfaces affected by decay
among white and African
30%
Americans is approximately the
20%
same; however, African
Americans have a larger
10%
percentage of root surfaces with
0%
1S-1S 20-34 2S-2S K - M I M S 4<M4 46-18 SO-64 56-60 M - M *
untreated disease (Figure 9).
12
Ag* 3roup
Figure 8: Root Caries Among Employed U.S. Adults,
1985-1986.
13
�Figure 9: Percent of Root Caries Untreated Among
Employed U.S. Adults by Race, 1985-1986.
1
3
The end result of untreated dental caries and periodontal disease is tooth loss.
Figure 10 shows that the percent of Americans who have lost all of their teeth increases
dramatically after 45 years of age. In 1989, over 7.2 million Americans (4.8 percent)
between the ages of 18 and 64
were edentulous. The poor
suffer disproportionately from
aw
Attcan
tooth loss. Among both
'Afnahcvu
50%
employed and unemployed adults
WhttM
40%
55-64 years of age whose annual
income was below the Federal
30%
poverty threshold, 35.5 percent
20%
were edentulous.
10
10%
UMV 46
75+
Figure 10: Tooth Loss Among U.S. Adults and Seniors by
Race, 1989.
10
�Fortunately, the rate of tooth loss among Americans is declining, resulting in
increased ability to eat and speak and improved esthetics. This increase in the number of
retained teeth has significant implications for preventive and primary oral health service
needs. As Figure 11 shows,
almost twice as many teeth are
Nmftar ot TMOI M M M tor
projected to be at risk nationally
for dental disease in 2030 as in
1972. This shift is due to both
a decrease in the number of teeth
lost to disease, as well as an
— 1872
-"1980
increase in the population. The
•2030
largest increase inretainedteeth
is among individuals over the age
of 45.
14
18-24
86+
Figure 11: Projected Increase in Number of Teeth at Risk
for Dental Disease Among U.S. Adults. *
1
Oral Disease and the Elderlv
Dental caries, gingivitis, and periodontal disease affect almost all Americans over the
age of 65. Over 99.5 percent of the elderly had evidence of dental decay, missing teeth, or
filled teeth in 1985. More than 63 percent of Americans over 65 years of age had at least
one decayed or filled root surface.
13
Tooth loss among the elderiy is significant. A national survey conducted in 1989
found that five million Americans (28 percent) 65-74 years of age and 4.8 million Americans
(43 percent) 75 years old and over were edentulous (Figure 10). Individuals with incomes
over $35,000 were more likely to have kept their teeth (Figure 12). African Americans had,
on average, fewer teeth than whites. Between 1986 and 1989, the percent of Americans
between the ages of 55 and 64 years who were edentulous decreased by almost three percent,
a significant decrease in such a short time period. This positive trend means that future
cohorts of individuals over 65 years of age should have more teeth and, given adequate
access to care, better oral health.
10
12
�90%
FMntty Inoofiw
MS3S.00C or mon
atiojoo-CAjae
• LMBttanSIOOOO
Figure 12: Tooth Loss Among the Elderly by Income,
1989.
10
Gingivitis and periodontitis affect a majority of Americans over the age of 65 who
have teeth. Over 86 percent of this age group had at least one tooth with moderate or
severe recession, increasing the likelihood of root caries. Over 22 percent of the elderly
had periodontal pockets 4 millimeters deep or greater.
13
Oral Canrer
In 1992, an estimated 30,000 new cases of oropharyngeal cancer were diagnosed and
over 8,000 deaths occurred as a result of this disease. Oropharyngeal cancer is more
common than leukemia, Hodgkin's disease, melanoma of the skin, and cancers of the brain,
cervix, ovary, liver, pancreas, bone, thyroid gland, testis, or stomach. It is the sixth most
common cancer found among U.S. men and the twelfth most common among U.S. women.
Figure 13 shows the estimated number of new cases of cancer and number of cancer deaths
by type of cancer in 1992. Use of tobacco products, induding smokeless tobacco, and
alcohol are associared with over 70 percent of all oral cancer lesions. Oropharyngeal cancer
is most frequent in men over age 40, but can be found in teenagers with a history of
smokeless tobacco use.
1
6
17
10
�Inddance
TrowafCennr
Mortality
Lung
Colon/tUcttl
DMwwnw at Stdn
OROPHARYNOEAL
Thousands
Thousands
Figure 13: Estimated Number of New Cancer Cases and
Number of Cancer Deaths by Type of Cancer, 1992.
14
Figure 14 illustrates the differences in the relative percent of individuals surviving
five years between whites and African Americans for selected types of cancer. For African
Americans, the relativefive-yearsurvival rate for oropharyngeal cancer is only 31 percent,
compared with 53 percent for whites. The 23 percent difference in relativefive-yearsurvival
for oropharyngeal cancer
Psremt al Mridusta SurvMng 5 X M M
Typm of C*ncmr
between African Americans and
Lung
whites is the largest difference
for all types of cancers (Figure
15). A significant portion of this
difference in survival can be
attributed to delayed detection
and treatment of the cancer.
Those who are treated for oral
cancerfrequendyface significant
functional problems,
Utfanoma of sUn
disfigurement that decreases
irouso* am 40% am <» m.*o%ta% so* 100%
quality of life, and an increased
Figure 14: Relative Five-Year Survival Rate for Selected
Cancers by Race (Based on cancer mortality data from
risk of developing new oral
1982-1988).
cancers, as well as other types of
16
14
11
�cancer. Annual visits to an oral health professional greatly increase the probability of eariy
detection and successful treatment outcomes.
fry*
AU
OROPHARYNOEAL
0*
9
%
1%
0
15%
20% 25%
OKImmtum In Ratatfv* Rvw-Ytar awfcai
Figure 15: Difference in Relative Five-Year Survival for
Selected Cancers by Race (Based on cancer mortality data
from 1982-1988).
16
Oral Health's Impact on Overall Health, Quality of Life, and Economic Productivity
Millions of Americans are at high risk for oral health problems because of underlying
medical or handicapping conditions, rangingfromvery rare genetic diseases to more
common chronic diseases like arthritis and diabetes. ' These conditions not only impact on
the individual's quality of life (i.e., their ability to eat, speak, taste, and swallow), but also
can be a significant source of pain and discomfort. For example, diabetics often experience
more severe periodontal disease and delayed wound healing, which can impact significandy
on both oral health and overall health. Congenital anomalies, like cleft lip and palate, often
require extensive surgical repair. A number of genetic diseases affect oral health, such as
the ectodermal dysplasias, in which essential components of skin and teeth fail to develop
properly; scleroderma, a genetic and autoimmune condition affecting the skin, which leads to
limited mouth opening; osteogenesis and dentinogenesis imperfecta, in which bones and teeth
are poorly developed and subject tofracture;and epidermolysis bullosa, which is
1
12
�characterized by severe blistering of skin and mucous membranes leading to loss of essential
body fluids and sometimes fatal secondary infections.
Among individuals with compromised immune systems, the presence of oral disease
has been linked to opportunistic infections. People who are HTV-seropositive or with AIDS
are likely to demonstrate a variety of oral complications associated with their disease due to
suppression of their immune system. These complications primarily affect the soft tissues of
the mouth and include painful oral candidiasis and potential life-threatening fungal infections
("thrush") of the esophagus, hairy leukoplakia (white,raisedlesions on the lateral borders of
the tongue), herpes (multiple, severe cold sores), and Kaposi's sarcoma, a type of cancer
affecting blood vessels.
Many HTV-seropositive individuals experience very aggressive
forms of destructive periodontal diseases, which can significandy compromise their
nutritional status and mayrequirehospitalization. Dental care plays an important role in the
initial diagnosis of HTV infection and in the management of AIDS. Oral manifestations
associated with HTV infection may be an initial presentation of the disease. Because effective
drugregimensare now available that can delay the onset of AIDS after the initial HTV
infection has occurred, early diagnosis and treatment are imperative. Dental professionals
can and do make such diagnoses andreferindividuals for appropriate medical evaluations.
19,20
21
Untreated oral disease and dental treatment without adequate antibiotic prophylaxis are
associated with infective endocarditis, an infection of the valves of the heart that can occur in
individuals with defective heart valves. * Infective endocarditis has a 50 percent mortality
rate, is increasing in prevalence, and the elderly are at high risk. Morbidity and cost
associated with heart valvereplacementafter infective endocarditis are substantial.
Similarly, elderiy with prosthetic joints {e.g., hip, knee, and shoulder joints) are atriskfor
costly infections of those joints due to oral bacteria from untreated oral disease that can
require replacement of the infected joint. " The etiologic bacteria enter the bloodstream
from the oral cavity and initiate an infection around the artificial joint. As the U.S.
population ages, more and more hip, knee, and shoulder replacements will be required,
potentially increasing the number of complications secondary to untreated oral diseases.
Untreated dental disease also complicates the treatment of patients undergoing organ and
bone marrow transplants, sometimes resulting in death. Dental disease also has been
associated with severe complications including pneumonia, urinary tract infections, fever, and
septicemia.
22
34
23
27
21,29
13
�Poor oral health and untreated oral diseases and conditions can have a signiiicant
impact on quality of life. Oral and facial pain affects a substantial proportion of the general
population. Studies to determine the number of individuals experiencing oral pain have
found that, at any given time, between 29 percent and 50 percent of those surveyed reported
some dental and oral pain. *" In these same surveys, the percentage of people who reported
moderate to severe dental painrangedfrom9 percent to 26 percent. " The type of pain
experienced by individuals varied by population groups. Among the elderiy, dry mouth pain
(xerostomia) and denture pain were common. Temporomandibular joint pain was common
among young women. Patients seeking emergency dental care were often in painfromacute
dental and oral infections.
3
6
WJ3
J4
34J7-u
Dental disease also has an impact on the economic productivity and on the ability of
American children to learn. In 1989, over 164,175,000 hours were missedfromwork (an
average of 1.48 hours per employed U.S. adult) and over 51,679,000 hours of school were
lost (117,000 hours missed per 100,000 school-age children) because of dental problems.
Many of those who missed work or school hours could least afford it, including younger
workers, minorities, low-wage earners, and those with severe dental disease. Dental
treatment may be delayed, ultimately requiring more extensive and costly treatment and
resulting in restricted-activity days and bed days. In 1991, for example, U.S. school-age
children experienced over 4,794,000 restricted-activity days (7.3 days per 100 school-age
children) and 2,200,000 bed days (3.36 days per 100 school-age children) as aresultof
dental conditions. Americans 18-64 years of age reported over 8 million restricted-activity
days (5.2 days per 100 adults) in 1991 and 3.9 million bed days (2.56 days per 100 adults).
42
43
Dental Services: Expenditures, Costs, and Sources of Payment
In 1992, an estimated $38.7 billion was spent on dental services,representingabout
5.3 percent of all expenditures for personal health care in the U.S. (Figure 16), upfromoniy
S2.0 billion in I960. By the year 2000, an estimated $62.3 billion will be spent for dental
services (Figure 17).
44
14
�MJtt
prulml
figure 16: Expenditures for Personal Health Care
Services by Service Category, 1992.**
Amount (hi
no
1M0
1M6
1«TO
107S
IOW
I W
1000
1006
2000
Figure 17: Nadonal Expenditures for Dental Services,
1960-2000"
15
�While total expenditures for dental services continue to increase, the levd of spending
for dental services as a percent of personal health care continues to decline. As Figure 18
shows, since 1960, this percent
has fallen from over dght
percent to 5.3 percent in 1992.**
R%
This trend is projected to
continue, so that by the year
2000, dental expenditures will
represent about four percent of
n
personal health expenditures.
Phymicten
**
Growth in the price of
10*
dental services has outpaced the
I « — OmtM MTftoM
consumer price index for urban
It•
iw tm im IMO iHS I M im a00
areas (CPI-U) for all goods and
services since the early 1980s,
Figure 18: Percent of Personal Heaith Care Expenditures
but continues to be lower than
for Hospital, Physician, and Dental Services, 1960-2000.
the CPI for physidan and
hospital services. In part, this
trend has resulted in the decrease
in relative spending for dental
u%
services. Figure 19 illustrates the
/ >
growth in the CPI for dental
12%
services since 1975. It is
10%'
\
1 \
\
1 \
estimated that the cost of dental
8% i A * /
— CPMJrQan
'V / \
.
services will continue to outpace
•*• Oantal Smr*cm
a%
the cost of ail goods and services
>
»\
4%
for the next 10 to 15 years.
'...^
r v . . ..A.J
M
j
i
/ v
/
y
1
1
45
/
, /
i
2%
^
r
.i. '
j
f
0%
YMT
Figure 19: Percent Change in Consumer Price IndexUrban for All Services and for Dental Services, 1975-1992.
16
�In 1987, an average of S295 was spent for dental services for those Americans with a
dental expense.* Over 90 percent of these expenditures for dental services were paid by
private sources, either out-of-pocket by dental consumers or through private health insurance
(Figure 20). Only three percent of dental expenditures come from public sources, prindpally
from Medicaid.
4
Out-oHmckst
56%
Bad
Pi I vals dantsi 34%
Irauranoa
Figure 20: Source of Payment for Dental Services, 1987/
Out-of-Pocket Pavments
The primary source of payment for dental services is out-of-pocket. In 1987, the
mean annual out-of-pocket expense for dental services was $165.20.' On average,
Americans paid almost S50 more out-of-pocket annually for dental services than for
ambulatory physician services.
i4
The out-of-pocket cost of dental services can have a significant impact on the poor
(i.e., those Americans below the Federal poverty level). The poor who sought dental care in
1987 paid an average of S113 per year out-of-pocket, while middle income individuals paid
an average of $164.60 per year out-of-pocket. It is important to note that for a poor family
17
�of three, the $113 paid out-of-pocketrepresented1.2 percent of total annual income. The
$164.60 paid by a middle income family of three represented less than one-half of one
percent of its annual income. For the poor, 1.2 percent of total annual income is not only a
significant ponion of availableresources,but this amount does not purchase the same level
of dental care as that of the middle class. Basic needs, like housing, food, clothing, and
transportation, consume most of the income of a poor family, so that little is left for needed
oral health services.
Out-of-pocket paymentsrepresenta significant source of payment for dental services
for tworeasons.First, there is limited payment for dental services under public programs
(discussed below), and approximately 150 million Americans have no private third-party
dental insurance coverage. Second, even for those with dental insurance, the number of
covered services may be limited, depending on the plan. Furthermore, copayments and
deductibles may be as high as 50 percent for many dental procedures.
10
The large proportion of out-of-pocket payments for dental services results in
significant amounts of bad debt and free care. In 1987, for example, over $2 billion of
dental services were provided as
either bad debt or free care,
representing approximately seven Srricm Catmgory
percent' of the costs associated
with providing dental services.
This compares to five percent for
inpatient hospital services and
ambulatory physician services
and one percent for outpatient
prescribed medicines (Figure
21).
44
PmrotrH Bad IMsUFrm Can
Figure 21: Percent of Bad Debt/Free Care by Service
Category, 1987.
44
18
�Dental Insurance
10
Approximately 95 million Americans have some form of dental insurance. Most
individuais who have dental insurance are between 25 and 54 years of age or are the
dependents of employed adults with dental insurance. The distribudon of dental insurance by
age group is shown in Figure 22. Since dental insurance coverage is usually employmentbased, individuals who do not
work or who work part-dme are
less likely to be insured. The
Pwcant by Omtrml Inaurano* Stmw
100%
proportion of dentally insured
individuals decreases in two age
ao%
groups. Nearly 12 million
previously insured young adults
tnaunnoa Statin
00%
H N O OanM I
lose their dental insurance
40%between the ages of 18 and 24.
The percent of individuals with
20%insurance increases until age 54,
when workers begin to retire.
By the age of 65, only
AO* Group
15 percent have dental
Figure 22: Percent of Americans with Dental Insurance by
insurance - a decrease of over
Age, 1989.
33 percentfromthe 45-54 age
group.
,0
Whether an individual has dental insurance is associated with the annual income level.
Approximately 10 percent of individuals with annual incomes of less than $10,000 have
private dental insurance (Figure 23). However, almost 60 percent of individuals with
annual incomes of $35,000 or more have private dental insurance. For those below the
poverty threshold, only 10.6 percent have dental insurance, while 47.7 percent of those
above the poverty level are insured.
10
19
�Pwcant by Dantai Inauranoa Stama
100%
78%
mom
50%
2S%
Inooma Lmai (In tftousanda)
Figure 23: Dental Insurance Coverage by Income Level,
1989.
10
Medicaid
In fiscal year 1991, over $709 million was spent to provide dental services to
approximately 5.2 million Medicaid recipients. Medicaid recipients receiving dental
services represented less than 17 percent of all Medicaid-eligible individuals. Expenditures
for dental services represented less than one percent of the $77 billion spent on Medicaid in
1991. Unlike any other service
covered under Medicaid,
expenditures for dental services
Oantai
have decreased by 29.1 percent
since 1975 (Figure 24).
Medicaid payments for dental
SMtad ranlng
services were principally for
children receiving benefits
through the Aid to Families with
Praacrtpflon dniQi
Dependent Children (AFDC)
IntHmadfatfa cara
program (48.6 percent). Yet
-too % -w ii o% ao % ioo % i w %3aa%3Bo%
only about 20 percent of
t Chang* (1878.1900)
Medicaid eligible children
Figure 24: Percent Change in Medicaid Payments by
receive any dental services.
Service Category, 1975-1990.
47
44
44
20
�In 1991, nationwide an average of $136 was spent per recipient for dental services
under Medicaid. However, because benefit levels for dental services are determined by each
state, there is significant variability in the per capita spending among states (Figure 25). For
example, in 1991, the per capita
expenditure for dental services
ranged from $73 in
Humbmat
Pennsylvania, $124 in Georgia,
$169 in New York, $223 in
California, to $328 in Alaska.
This considerable variability is
due, in part, to differences in
covered services, eligibility
criteria, and reimbursement
levels. In most states, for
example, dental services for
die m
twa tra tito
na
adults are extremely limited or
Par C*0/ta Mftdicatd Paymant
are not covered.
Figure 25: Per Capita Medicaid Payments for Dental
Services Among Dental Medicaid Recipients by State,
1991.
47
47
In 1990, the Office of Technology Assessment (OTA), United States Congress, issued
a report entitled "Children's Dental Services Under the Medicaid Program." This report,
prepared in response to a request from the U.S. House of Representatives' Committee on
Energy and Commerce, sought to determine whether the dental care programs for Medicaid
beneficiaries, particularly children eligible for the Early and Periodic Screening, Diagnosis,
and Treatment Program, conform to a minimum level of dental care. The OTA found that:
49
•
there are significant differences among those stales surveyed in the dental services
offered through their Medicaid programs;
•
each of the states surveyed failed to adequately cover "basic" dental services in its
Medicaid program;
21
�there were some services that some dentists feci they do not provide equally to their
Medicaid patients under 18 compared to their other young patients; and
a variety of barriers restrict the low-income child's access to dental services under
state Medicaid programs (including administrative hassles and paperwork associated
with claims submission and prior approval and low reimbursement rates for dental
services).
Medicare
Payment for routine dental services is prohibited under statute except in very limited
circumstances, (e.g., medically necessary dental care and surgery on the jaw not involving
the teeth). As a result, essentially no Federal dollars are expended for dental services under
Medicare.
Comparison of Source of Pavment for Dental Services and Ambulatory Phvsician Services
As Table 1 illustrates, the distribution of sources of payment for dental services is
different from that of ambulatory physician services. A much larger percentage of dental
services than physician services are paid for out-of-pocket. For example, the poor paid
56 percent of the cost of dental care out-of-pocket, compared to only 19 percent out-ofpocket for ambulatory physician services. Medicaid paid for only 15 percent of the
expenditures for dental services among the poor in 1987, compared to 31 percent for
ambulatory physician services in the same group. Medicare paid 22 percent of the expenses
for ambulatory physician services for the poor in 1987, but zero percent for dental services.
The level of bad debt and free care for dental services among the poor and near poor was
higher than the national average, and, as a percentage, was higher for dental services than
for physician services (seven percent versus five percent).
46
22
�Table 1: Sources of Payment for Dental and Ambulatory Physician Services for the
Poor" and U.S. Average, 19S7.*
6
Source of Payment
Dental
Physician
Poor U.S.
Average
Poor U.S.
Average
Percent
Out-of-pocket
56
56
19
26
Private insurance
16
34
10
38
Medicare
0
0
22
14
Medicaid
15
2
31
8
Other public programs
3
1
12
10
Workers' compensation, private charity, and
freefromprovider including bad debt
10
7
5
5
Poor are those individuals earning less than 100 percent of the Federal poverty level.
Utilization of Dental Services
Since 1983, the percent of Americans with at least one dental visit per year has
increased modestlyfrom55 percent to 57.3 percent,representingabout 135 million persons
in 1989. As Figures 26 and 27 illustrate,from1983 to 1989, African Americans and poor
and low income individuals were less likely to have had a dental visit in the past year when
compared to whites or to higher income groups.
10
23
�dace
am
50%
AMean
40%
OOMT
30%
V%
10%
0%
taa
IOM
IHB
Figure 26: Percent of Persons with Dental Visit in Past
Year by Race, 1983-1989.
10
Figure 27: Percent of Persons with Dental Visit in
Previous Year by Income Level, 1983-1989.
10
10
Utilization of dental services remains quite variable throughout the population. Race
and ethnicity, age, and income were significant factors in dental utilization. Those with a
dental visit in the past two years were more likely to be white, non-Hispanic, have a higher
income, have at least a high school education, and have dental insurance (Table 2).
Unfortunately, poor and low-income groups - the same groups that have the highest levels of
dental disease — have the lowest utilization rates. Among edentulous Americans over the
age of 35, less than 13 percent had a dental visit during the year preceding the interview, and
over 60 percent had not been to a dentist in over five years.
24
�10
Tabic 2: Intervti Since Last Dental Visit by Sdocfad CharacTitisdcs, 1989.*
Quuactenstic
Less than two years
Two years or more
Never
Percent
Race
White
68.6
22.1
4.4
African American
55.5
32.0
5.8
Other
61.3
24.8
6.7
Non-Hispanic
67.9
22.8
4.1
Hispanic
56.5
27.6
9.7
Mexican-Amencan
49.4
31.1
13.1
Other Hispanic
65.5
23.6
5.1
Less than 9 years
39.6
49.0
5.9
9-11 years
49.7
43.8
1.3
12 years
65.2
29.4
0.5
13 years or more
78.7
17.2
0.2
Less than $30,000
53.1
36.4
7.0
$10,000-$19,999
55.7
33.5
6.6
$20,000-534,999
68.7
23.6
4.6
$35,000 or more
80.3
14.0
2.9
Having private dental
79.1
15.8
3.3
Without private dental insurance
61.5
29.6
6.0
Hispanic on gin
Education level
Family income
Dental insurance coverage
' Sow* do a« aim to 100 perceza becaiua 'UnJaxrwu' not iaciudod ia labis.
While dental insurance increased the utilizationratefor all groups, differences in
utilization among insured individuals were also found. African Americans and individuals
with lower incomes with dental insurance had less utilization and fewer visits than similarly
covered white Americans (Table 3).
10
25
�Table 3: Dental Visits Per Person Per Year and Percent with Dental Visit in Previous Year
Among Individuals with Dental Insurance by Selected Charaaeristics, 1989.
1
0
Dental visits per person with
dental insurance per year
Characteristic
Race
Percent with 1 or more dental
visits in previous year
Percent
White
2.8
72.6
African American
1.7
61.0
Less than S 10,000
2.1
65.2
JIO.OOO-SIP^
2.1
55.0
S20,000-$34,999
2.3
66.3
$35,000 and over
3.1
77.9
Family income
Indeed, African American children with dental insurance had fewer visits than white
children without dental insurance (Figure 28).
10
A m u * Numfear <* OanM V M ^ CMUran (-17
Ran
BwhrtM
• AMCMI Anwriem
Figure 28: Annual Number of Dental Visits for U.S.
Children 5-17 Years of Age by Race and Dental Insurance
Status, 1989.
10
26
�Reasons for seeking dental care vary by individual. In 1985-1986, a national survey
found that neariy three million African Americans (29.7 percent) last sought dental care for
either a toothache or to have a tooth extracted. Less than 13 percent of whites sought care
for these reasons (Figure 29).
14
There are many
explanations for differences in
the lack of utilization of dental
services. About one-half of
those surveyed who had not seen
a dentist in the previous year
reported that they did not
perceive they had a dental
problem (Figure 30), although
epidemiological data would
suggest that this perception is
incorrect. Cost was the second
most common reason offered for
not visiting the dentist for
individuals up to the age of
35 years. Fear of the dentist did
not appear to be a significant
factor in failure to seek care.
RMSOHtarList DwnaJ Vtert
Denture
BtMding Gums |
10
50%
Race
Bwhitss
(African Airmicans
Figure 29: Reason for Last Dental Visit Among U.S.
Employed Adults, 1985-1986.
14
Figure 30: Reason for Not Seeking Dental Care in
Previous Year, 1989.
27
�Summary of Oral Health Status and Dental Service Utilization
Tables 4-6 provide summary informadon on the oral health of children, adults, and
the elderly, and the utilizarion of dental services among these groups. Table 4 summarizes
informadon for U.S. children. The majorfindingsfor children include:
•
African Americans and other minoriries have a higher percentage of untreated disease
than the U.S. average;
•
Poor children and minorities have less private dental insurance than the average for
all children;
•
Fewer minority and poor children have dental sealants;
•
Ten percent fewer minority and poor children had a dental visit in the preceding year
when compared to the U.S. average, even though these groups have a higher percent
of untreated disease; and
•
The average number of dental visits per year for poor and minority children is less
than the U.S. average.
Table 4: Oral Health Stams and Utilization of Dental Services Among U.S. Children.
Condition
Percent of dental caries untreated
(5-17 years old)
Poor*
African
American
Hispanic
U.S. Average
—
27.2%"
—
15.3%
Percent with any private dental insurance
7.8%
31.9%
28.7%
44.3%
Percent with dental sealants
4.3%
4.2%
5.1%
10.9%
48.8%
49.9%
47.9%
61.7%
1.1
1.0
1.6
2.1
Percent with at least one dental visit in
the preceding year
Average number of dental visits per year
Under S 10.000
Include! African Americana and all minontiea
28
�Table 5 shows the major findings for dental disease among U.S. adults and their
utilization of dental services. The findings include:
•
The level of coronal and root caries among minorities is greater than the national
average.
•
Fewer minorities and poor adults have dental insurance than the national average;
•
Fewer minorities and poor adults have had a dental visit in the preceding year,
•
The average number of dental visits for poor and minority adults is less than the
average for all U.S. adults; and
•
Poor adults have lost more teeth than the average U.S. adult.
Table 5: Oral Health Status and Utilization of Dental Services Among U.S. Adults.
Poor'
African
American
Hispanic
U.S.
Average
— Coronal
-
22.1%
23.0%
8.1%
- Root
—
70.3%
—
53.5%
Percent with any private dental insurance
13.3%
35.6%
31.2%
43.9%
Percent with at least one dental visit in the
preceding year
42.7%
43.9%
45.2%
57.7%
Percent edentulous
8J%
4.2%
2.3%
4.8%
Average number of dental visits per year
1.4
1.3
1.5
2.1
Condition
Percent of dental caries untreated
Undo- $10,000
29
�Finally, Table 6 provides a summary of the majorfindingsamong U.S. elderly.
These include:
•
Only 15 percent of the elderly have any private dental insurance, and Medicare does
not reimburse for routine dental services;
•
Twenty-two percent of elderiy African Americans and 25 percent of poor elderiy had
at least one dental visit in the preceding year, about one-half of the nanonal average
for all elderly;
•
Minority and poor elderly have fewer visits than the U.S. average — elderiy African
Americans have less than one-half the average number of visits among the elderly;
and
•
Over one-half of the poor elderiy had lost all their teeth.
Table 6: Oral Health Status and Utilizarion of Dental Services Among U.S. Elderiy.
Condition
Poor'
Percent with any private dental
insurance
5.7%
11.1%
15.6%
15.0%
Percent with at least one dental
visit in the preceding year
25.0%
22.1%
39.7%
42.7%
Percent edentulous
51.1%
37.9%
28.6%
34.1%
1.3
0.6
1.2
2.0
Average number of dental visits
per year
Uader S 10,000
30
African
American
Hispanic
U.S. Average
�Conclusion
While significant improvements have been made in preventing and controlling dental
caries and periodontal diseases during the past two decades, millions of Americans have been
left behind, resulting in needless pain, increased cost, decreased health, and loss of selfesteem. Almost all Americans have been affected by oral diseases. Poor and low-income
individuals, minorides, and individuals with litde educanon are particularly at risk. Oral
diseases remain an unnecessary obstacle to better health.
Access to primary and preventive dental care can be difficult, especially for those that
cannot afford dental care. Regrettably, Americans for whom the burden of oral disease is
greatest often have the most difficulty gaining access to the dental care system. Access to
needed services is critical to narrow the disparity in disease between the poor and the middle
class and between whites, African Americans, and other minorities. Access to dental care
for elderly Americans is particularly difficult, since they often lose their dental benefits at
retirement and Medicare does not pay for dental services. The elderly are atriskof losing a
lifetime's worth of investment in oral health.
Regular dental care is important for a number of other oral diseases besides dental
caries and periodontal diseases. Oral cancer, which affects primarily adults over 55 yean
old, results in significant morbidity and disfigurement associated with treatment, substantial
cost, and over 8,000 deaths annually. The percent of individuais with oral cancer that
survive five years is 22 percent lower among African Americans than whites. Routine dental
examinations are the best strategy to narrow the gap in survival between African Americans
and whites, since early detection and treatment are imperative. Yet, African Americans are
less likely to have a dental visit than whites.
Dental and oral diseases have a significant impact on general health. For example,
dental and oral diseases and treatment associated with these diseases canresultin infective
endocarditis (which has a 50 percent mortality rate), infections of artificial knee, hip, or
shoulder joints, and in complications associated with organ and bone marrow
transplantations. Oral complications associated with HTV infection also can have a
significant impact on overall health, resulting in loss of appetite, painful mouth sores,
hospitalization, and potentially life-threatening fungal infections. Most of these complications
among people with HTV/AIDS can be managed by a dentist in an outpatient setting.
However, because many people with AIDS cannot afford dental care, access is often
31
�compromised. As the number of AIDS cases continues to rise, barriers to obtaining oral
health care can only exacerbate the problem.
One of the principal barriers to dental care is cost. Over 150 million Americans have
no dental insurance coverage. Public programs pay for less than three percent of all dental
services, and eligibility for these programs is highly variable. Most states provide only
limited dental services for adults, or none at all. In many states, dental benefits available to
children under the Medicaid program do not even include basic dental services. The
30 percent decrease in per capita payments for dental services under Medicaid between 1975
and 1990 stands in stark contrast to all other medicai expenditure categories under Medicaid,
none of which declined during this period.
For individuals who do not have access to physician or other primary health care
services, hospital emergency rooms provide a safety net to ensure at least some level of care,
albeit expensive. For oral health problems, however, no such mechanism exists. Very few
hospitals provide dental services, and those that do offer only emergency services to relieve
pain and provide palliative treatment for injuries and infections. Dental schools and
hospital-based postdoctoral dental education programs are a source of care for some of those
who cannot afford to pay, but not all people, especially poor people, have the time,
resources, or transportation necessary to seek care at dental education institutions. The
additionalfinancialburden "free care" places on these schools can be significant.
Community and migrant health centers (CMHCs) may be a source of dental care but are not
found in every community. Further, only about one-half of CMHCs provide basic dental
care services. More importandy, community and migrant health centers do not have the
resources to meet this need alone. The unfortunate reality is that individuals who cannot
afford routine dental care and who are not covered by either public programs or private
dental insurance do not receive care.
50
Fiscal crises in many of the states place ever-increasing burdens on the poor. The
Center for Budget and Policy Prioritiesrecendyfound that during each of the last two years,
state programs assisting the poor were cut more deeply than at any time since the early
1980s. The Centerreportedthat over the last two years, reductions in general assistance
benefits, a program of lastresortfor the non-elderly poor who do not quality for AFDC,
affected more than half a millionrecipients.In addition, seven states made cuts in their
general medical assistance programs for low-income people who do not qualify for Medicaid.
Given that Medicaid beneficiaries eligible for dental services are not accessing dental care
currendy and that such a substantial proportion of dental services are paid for out-of-pocket,
31
32
�these reductions made by the states can only mean less access to dental care for those most at
risk for disease.
As currendy structured, the dental care delivery system will not adequately meet the
needs of all Americans, especially those who are unable to afford dental care, who have no
dental insurance, and who are at high risk of dental and oral diseases. Only by ensuring
access to primary and preventive oral health services for all Americans byremovingbarriers
to care can continued improvement of the oral health and general health in the United States
be assured.
33
�References
1.
Kozoi, Jonathan Savage Inequalities: Children in America's Schools (New York:
Crown Publishers, Inc.) 1991, pp. 20-21.
2.
Oral Health of United States Children: The National Survey of Dental Caries in U.S.
School Children: 1986-1987. Epidemiology and Oral Disease Prevention Program,
National Institute of Dental Research. Bethesda, Maryland. NIH Publication No. 89-.
2247, September 1989.
3.
Newbrun, E. "Effectiveness of waterfluoridation"f Public Health Dentistry
1989;49(5):279-289.
4.
Glass, R.L. "Fluoride dentifrices: the basis for the decline in caries prevalence"
Journal Royal Society of Medicine 1986;79(Supplement 14): 15-17.
5.
Ismail, A.I., Burt, B.A., Hemdershot G.E., Jack, S., and Corbin, S.B. "Findings
from the dental care supplement of the National Health Interview Survey, 1983"
Journal American Dental Association 1987; 114:617-621.
6.
Clovis, J. and Hargreaves, J.A. "Fluoride intake from beverage consumption"
Community Dentistry Oral Epidemiology 1988;16(1):11-15.
7.
Naylor, M.N. "Possible factors underlying the decline in caries prevalence" Journal
Royal Society Medicine 1985;78(Supplement 7):23-25.
8.
Personal Communication. Dental Branch, Indian Health Service, U.S. Public Health
Service, Rockville, Maryland. February 1993.
9.
Healthy People 2000: National Health Promotion and Disease Prevention Objectives
U.S. Public Health Service, Washington, D.C. DHHS Publication No. (PHS) 9150212, 1990.
10.
Bloom, B., Gift, H . C , and Jack, S.S. Dental Services and Oral Health; United
States, 1989. National Center for Health Statistics. Vital Health Stat 10(183). 1992.
11.
Broderick, E., Mabry, J., Robertson, D., and Thompson, J. "Baby bottle tooth
decay in Native American children" Public Health Reports 1989;104:50-4.
12.
Kelly, M. and Bruerd, B. "The prevalence of nursing bottie decay among two Native
American populations" / Public Health Dentistry 1987;47:94-7.
34
�13.
Oral Health of United States Adults: The National Survey of Oral Health in U.S.
Employed Adults and Seniors: 1985-1986. Epidemiology and Oral Disease
Prevention Program, National Institute of Dental Research. Bethesda, Maryland.
NTH PubUcation No. 87-2868. August 1987.
14.
Reinhardt, J.W. and Douglass, CW. "The need for operative dentistry services:
projecting the effects of changing disease patterns" Operative Dentistry 1989; 14:11420.
15.
Jack, S.S., and Bloom, B. Use of dental services and dental health' United States,
1986. National Center for Health Statistics. Vital Health Stat 10(165). 1988.
16.
Cancer Facts and Figures - 1992. American Cancer Society, Atlanta, Georgia, 1992.
17.
Cancers ofthe Oral Cavity and Pharynx: A Statistics Review Monograph, 1973-1987.
U.S. Department of Health and Human Services, Centers for Disease Control,
Atlanta, Georgia and the National Institutes of Health, Bethesda, Maryland. 1991.
18.
Broadening the Scope: Long-Range Research Plan for the Nineties National Institute
of Dental Research, National Institutes of Health. NIH Publication No. 90-1188,
September 1990.
19.
Barone, R., Ficarra, G., Gaglioti, D., Orsi, A., and Mazzotta, F. "Prevalence of
oral lesions among HTV-infected intravenous drug abusers and otherriskgroups"
Oral Surg Oral Med Oral Pathol 1990;69:169-73.
20.
Feigal, D.W., Katz, M.H., Greenspan, D. et.al. "The prevalence of oral lesions in
HTV-infected homosexual and bisexual men: three San Francisco epidemiological
cohorts" AIDS 1991;5:519-25.
21.
Barr, C E . and Marder, M.Z. AIDS: A Guide for Dental Practice (Chicago:
Quintessence Publishing) 1987, pg. 49.
22.
Cananza, J.R., and Fermin, A. Glickman's Clinical Periodontology 7th Edition,
(Philadelphia: W. B. Saunden Co., Harcourt Brace, Jarovich, Inc.), 1990, pp. 567586.
23.
Sande, MA., Kaye, D., and Root, R.K. Endocarditis (New York: Churchill
Livingston), 1984, pp. 7-8.
24.
Durack, D.T. Peterson, R.G. "Changes in the epidemiology of endocarditis"
American Heart Association Monograph Series 52, 1977, pp. 3-8.
35
�25.
Jacobson, J.J., Schweitzer, S., DePorter, D.J., and Lee, JJ. "Chemoprophylaxis of
dental patients with prosthetic joints: a simulation model" J Dental Educ
1988;52(ll):599-604.
26.
Tsevat, J., Durand-Zaleski, I., and Pauker, S.G. "Cost-effectiveness of antibiotic
prophylaxis for dental procedures in patients with artificial joints" Amer J Pub Heaith
1989;79(6):739-43.
27.
Shuman, S.K. "A physician's guide to coordinating oral health and primary care"
Geriatrics 1990;45(8): 47-51,54,57.
28.
Wilson, R.L., Martinez-Tirado, J., Whelchel, J., and Lordon, R.E. "Occult dental
infection causing fever in renai transplant patients" American Journal Kidney Disease
1982;2(3):354-56.
29.
Harms, K.A. and Branny, A.T. "Cardiac transplantation: dental considerations"
Journal American Dental Association 1986; 112(5):677-81.
30.
Locker, D. "The burden of oral disorden in a population of older adults" Comm
Dent Health 1992;9:109-24.
31.
Gushing, A.M., Sheiham, A., and Maizels, J. "Developing socio-dental indicators the social impact of dental disease" Comm Dent Health 1986;3:3-17.
32.
Rdsine S. "Dental health and public policy: the social impact of dental disease"
American J Public Health 1985;75(l):27-30.
33.
Bailit, H.L. "The prevalence of dental pain and anxiety: their relationship to quality
of life" New York State Dent J 1987;27-30.
34.
Locker, D. and Grushka, M. "The impact of dental and faciai pain" J Dental
Research 1987;66(9): 1414-1417.
35.
Reisine, S.T. "The impact of dental conditions on social functioning and the quality
of life" Ann Rev Pub Health 1988;9:1-19.
36.
Stembach, R.A. "Survey of pain in the United States: the Nuprin pain report" Gin J
Pain 1986;2(l):49-53.
37.
Kiyak, H.A. and Mulligan, K. "Studies of therelationshipbetween oral health and
psychological well-being" Gerodontics 1987;3:109-112.
36
�38.
Marbach, J.J., Lennon, M.C., Link, B.G., and Dohrenwend, B.P. "Losing face:
sources of sugma as perceived by chronic facial pain patients" J Behav Medicine
1990;13(6):583-604.
39.
Erlandsson, S.I., Rubinstein, B., Axelsson A., and Carlsson, S.G. "Psychological
dimensions in patients with disabling tinnitus and craniomandibular disorders" British
DemalJ 1991;25:15-24.
40.
Schnurr, R.F., Brooke, R.I., and Rollman, G.B. "Psychological correlates of
temporomandibular joint pain and dysfunction" Pcun 1990;42:153-165.
41.
Keller, D.L. "Reduction of dental emergencies through dental readiness" Mil Med
1988;153(10):498-501.
42.
Gift, H.C., Reisine, S.T., and Larach, D.C. "The social impact of dental problems
and visits" American J Public Healih 1992;82(12): 1663-1668.
43.
Adams, P.F. and Benson, V. Currem Estimates Jrom the National Health Interview
Survey. 1991. National Center for Health Statistics. Vital Health Statistics 10(184).
44.
Office of National Cost Estimates, Office of the Actuary, Health Care Financing
Administration, U.S. Department of Health and Human Services, Washington, D.C.
45.
Health Personnel in the United States. Eighth Repon to Congress, 1991. Health
Resources and Services Administration, U.S. Public Health Service.
46.
National Medical Expenditure Survey: Annual Expenses and Sources of Payment for
Health Care Services Research Findings 14. Center for General Health Services
Intramural Research, Agency for Health Care Policy and Research. Rockville,
Maryland. 1992.
47.
"A Statistical Report on Medicaid" Health Care Financing Administration, December
1992.
48.
Division of Medicaid Statistics, Office of Statistics and Data Management, Bureau of
Data Management and Strategy, Health Care Financing Administration.
49.
U.S. Congress, Office of Technology Assessment, Children's Dental Services Under
the Medicaid Program - Background Paper, OTA-BP-H-78 (Washington, D . C :
U.S. Government Printing Office, October 1990).
50.
Personal Communication. Bureau of Primary Health Care, Health Resources and
Services Administration, U.S. Public Health Service, Rockville, Maryland. February
1993.
37
�51.
"States' Fiscal Crises Force Cuts in Programs for Poor" The Washington Post,
February 10, 1993.
38
�
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Health Care Reform
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2006-0810-F
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<p>This collection consists of records related to Hillary Rodham Clinton's Health Care Reform Files, 1993-1996. First Lady Hillary Rodham Clinton served as the Chair of the President's Task Force on National Health Care Reform. The files contain reports, memoranda, correspondence, schedules, and news clippings. These materials discuss topics such as the proposed health care plan, the need for health care reform, benefits packages, Medicare, Medicaid, events in support of the Administration's plan, and other health care reform proposals. Furthermore, this material includes draft reports from the White House Health Care Interdepartmental Working Group, formed to advise the Health Care Task Force on the reform plan.</p>
<p>This collection is divided into two seperate segments. Click here for records from:<br /><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0810-F+Segment+1"><strong>Segment One</strong></a> <br /><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0810-F+Segment+2"><strong>Segment Two</strong></a></p>
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Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Appendix: Briefing Book on the Children's Benefit Package, the Prevention Benefit Package, and the Dental Benefit Package [5]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
General Files
Identifier
An unambiguous reference to the resource within a given context
2006-0810-F Segment 1
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 46
<a href="http://clinton.presidentiallibraries.us/items/show/36144" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12090749" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
5/5/2015
Source
A related resource from which the described resource is derived
42-t-2194630-20060810F-Seg1-046-010-2015
12090749