CS FOR HOUSE BILL NO. 105(FIN) "An Act relating to coverage for adult dental services under Medicaid; and providing for an effective date." 9:46:25 AM This was the first hearing for this bill in the Senate Finance Committee. BILL HOGAN, Deputy Commissioner, Department of Health and Social Services, informed the Committee this legislation would change Medicaid coverage to allow adult recipients to receive up to $1,150 annually in preventive and restorative dental care services such as cleaning, exams, tooth restoration and both upper and lower dentures. Adult dental care is currently limited to emergency care for the immediate relief of pain or acute infection. The most common outcome of the current care is the extraction of teeth. This Medicaid expansion would benefit "the most needy Alaskans: those with disabilities and seniors". Approximately 16,000 of the adults currently enrolled in the State's Medicaid program could benefit from this proposal. Mr. Hogan noted this was one of the first Medicaid programs to specify a maximum limit. In addition, the bill would include a three-year termination date. "This will allow the Department and the Legislature to evaluate the effectiveness of the program," to include participation levels "and the true cost and value of the program". The Department is actively working with stakeholders, particularly the Alaska Mental Health Trust Authority (AMHTA), "who consider this a significant issue within communities throughout Alaska". AMHTA would provide the State match required by Medicaid for this program. Mr. Hogan stated that between $700,000 and $800,000 of AMHTA mini-grant program funds are spent annually on providing dental care to AMHTA beneficiaries, particularly those with behavioral health issues and developmental disabilities. Those funds could be better utilized for other beneficiary needs were this program implemented. Mr. Hogan shared that the Division of Vocational Rehabilitation in the Department of Labor and Workforce Development annually expends $100,000 to help individuals in their program "obtain dental care to increase the likelihood that they could be employed". 9:49:53 AM JANET CLARK, Assistant Commissioner, Finance and Management Services, Department of Health and Social Services stated that the Department's assumptions in the original fiscal note were extensively reviewed during the bill's hearing before the House Finance Committee. As a result, the fiscal note that reported from House Finance was considerably less than the initial fiscal note. Many of the assumptions were changed, including the decision to reduce the number of recipients served by the program in its initial two years due to access and start-up issues. The original assumption that the program would serve 35 percent of eligible adults is reflected in the program's third year of operation. Ms. Clarke continued that, in addition, the Department's emergency dental care expenses were reduced for year two and three of the program, based on the assumption that the Medicaid preventive care service would reduce the demand on emergency dental care service. Ms. Clarke stated that the Department's original fiscal note was developed with the understanding that Federal Medical Assistance Percentage (FMAP) funding would be reduced from 57 to 50 percent; however that reduction had not transpired. Therefore, the fiscal note was revised to reflect the current 57.58 percent FMAP level. Another "key" fiscal element was AMHTA's commitment to provide their FY 07, FY 08 and FY 09 dental services budget to the program. Thus, as reflected in Fiscal Note #2, dated May 4, 2006, AMHTA would contribute $425,000 in FY07, and $1,425,000 each for FY 08 and FY 09. The FY 07 fiscal note was also reduced, as the program would not be anticipated to begin until late in the fiscal year. Ms. Clarke noted that the State's FY 08 general fund match obligation would be $1,300,000. This, with the assistance of the AMHTA funding, would leverage approximately $10.3 million in services. The fiscal note also reflected the termination of the program in FY 09. Efforts to refine the fiscal note assisted in reducing the program's impact on the State's general fund. Senator Dyson inquired to the income and asset levels a non- AMHTA recipient, "non-disabled, non-elderly adult" must have to qualify for the program. Ms. Clark responded that a 21 through 64-year-old person, who was not in one the aforementioned categories and who did not have children, would not typically qualify for Medicaid. Senator Dyson acknowledged. 9:54:04 AM Co-Chair Wilken asked regarding the Department's efforts "to work with the Alaska Dental Association to get them to allow temporary dental licenses for those dentists from outside Alaska" who wish to provide basic dental services in rural areas of the State during the summer. Mr. Hogan deferred to the Department's Dentist, Dr. Brad Whistler. 9:54:46 AM DR. BRAD WHISTLER, Dentist, Department of Health and Social Services, testified via teleconference from an offnet site. Community health centers and tribal dental programs have discussed this issue with the Alaska Dental Board. The Board is considering issuing courtesy licenses, which are different than temporary licenses. The Department deferred to the community and tribal dental programs to further this issue with the Alaska Dental Board. Co-Chair Wilken identified his interest to be with the issuance of temporary licenses rather than courtesy licenses. Continuing, he asked the status of Board action regarding the issuance of temporary licenses "to people that want to come and help Alaskans". Mr. Whistler had not been personally involved in the actions of the Dental Board. However, he understood that "the only issue that is being addressed by the Dental Board at this time is the courtesy license issue". Co-Chair Wilken asked whether Dr. Whistler planned on asking the Dental Board to consider "granting temporary licenses that could take care of some of our more indigent people by what amounts to volunteers". Mr. Whistler, speaking on behalf of the Department, stated he would "be happy to" advance that subject. He explained that a temporary license could be issued to a dentist desiring to practice in Alaska, provided they held a license in another state. This license would suffice until the time the Dental Board could meet and "do licensure by credentials". A courtesy license could be issued to a dentist who planned on providing volunteer services, as a person holding a courtesy license could not charge a fee for their service. A courtesy license would not be appropriate for the needs of a community health center or tribal program, as their desire is to employ dentists. 9:56:34 AM Co-Chair Wilken asked Dr. Whistler to provide his office a letter detailing the efforts being taken by the Department "to enable temporary licenses" in the State. The letter should include such things as the feasibility of the licensure, the steps that would be required to further the effort, and the benefits that would be anticipated. He also requested a copy of any correspondence between the Department and the Dental Board relating to this issue. Co-Chair Green supported Co-Chair Wilken's request. Co-Chair Wilken shared his concern about the proposed dental program by repeating the "old saying that those that forget history are doomed to repeat it. And here we go again." He recalled discussions that occurred when the Denali Kid Care program was proposed. While that program "was presented with a firm number of expenditure", the cost associated with that program "has far exceeded" what had been anticipated for a variety of reasons. The Power Cost Equalization program is another program whose expenses dramatically increased. Its expenses increased from eight million dollars a year to $80 million dollars in six years. Co-Chair Wilken questioned the true fiscal impact of the bill, as, while he appreciated the inclusion of the $1,150 per person annual dental service limit, the number of program recipients is unknown. Therefore, to gain his support, he suggested an annual maximum expenditure level be specified for the program. The intent would be to terminate the program once the limit was reached. This would provide the Legislature with "a hard indication of just the demand" on the program. Co-Chair Wilken asked that the bill be held in Committee to further discuss how to incorporate such language. Co-Chair Green acknowledged. 9:58:31 AM Senator Olson asked the Department's and the Alaska Dental Board's "views" on licensing dental hygienists who received training in countries other than the United States. Mr. Hogan deferred to Dr. Whistler. 9:58:46 AM Dr. Whistler clarified that the Department is not involved with the Alaska Dental Board and the issuance of licenses. The Department, in this process, has focused on "Medicaid financing and reimbursement for those providers that are practicing under general supervision of dental staff". The Department has participated in "expanding private capacity" and has been supportive of the program encouraging "tribal expansion and provision of care to Indian Health Service (IHS) beneficiaries in the State". Senator Olson asked whether he would be correct in communicating to his constituents in the IHS program that Dr. Whistler and the Department were supportive of the program. Dr. Whistler stated that the Department has been and would continue to support IHS activities. As a dental officer of the State, he is aware that this model has been successful in New Zealand, Australia, Great Britain and other countries. The dental access issue is widespread in the United States, and this concept and others have been discussed. The American Dental Hygiene Association has proposed "an expanded dental hygiene model to address some of these same issues." Numerous discussions between private dentistry and public health dentists have occurred on the issue of how to meet the needs of "the underserved". Personally, he believed this program was worthy of consideration and could work. It has been successfully implemented in other areas of the world. He agreed that the program should be evaluated to ensure that it would be "an appropriate model for the State". 10:01:49 AM ANDY POPE, a senior citizen, testified in Juneau in support of the bill. Senior citizens, particularly low-income seniors, "are probably the only class [of citizens] in this State excluded from the dental health care". Native health corporations provide dental care to Natives and employed people have access to employer insurance plans. Seniors cannot purchase private insurance, and if it were available, the cost would exceed senior's financial capacity. "There are programs for alcoholics and narcotics, but not low-income seniors." This is "an overdue benefit" for seniors. The bill is "well constructed" and the $1,150 per person annual limit would provide "a safety cap", which, by requiring people to participate for expenses above the limit, would curtail excessive expenses. However, people might have a problem finding a dentist "that would let you get something done for a down payment". He doubted the program would escalate out of control. "All individuals would be treated the same". The $1,150 per person limit "is reasonable", and the termination date would control the parameters of the program. He urged the Committee to adopt this "long overdue" legislation. 10:04:25 AM DR. KATHINKA WHITE, Representative, Alaska Primary Care Association, Inc., spoke in support of the bill. The Association "represents 24 health care organizations operating 115 non- profit community health centers and other safety net providers" that offer health and dental care to "the uninsured, underinsured, underserved populations in the State". Her testimony was as follows. I am speaking to you on behalf of Alaskans that remain untreated victims of our nation's silent epidemic, oral disease. Dental carries and periodontal disease are infectious diseases caused by the transmission of bacteria from the parent to child or from partner to partner. In the year 2000, in the publication "Oral Health in America" the Surgeon General released a milestone report that provided overwhelming evidence of this epidemic. It emphasized that the mouth is a point of entry for infection, which can spread to other parts of the body and pointed to emerging associations between oral diseases and other physical ailments such as diabetes, heart disease, strokes, adverse pregnancy outcomes including low birth weight babies. The report makes it clear that oral health is integral to overall health. Oral health care represents the most frequently reported unmet health need among low-income persons. The inability to access proper dental health resources has had devastating personal consequences for many Alaskans, including severe oral facial pain, infection, impaired ability to eat, poor diet, nutritional status, speech difficulties, lost work days, and unnecessary tooth loss. Currently dental services for adults are limited to the relief of pain and infection only. These services do not include root canals resulting in the extraction of most teeth. Many individuals would rather live in continuous pain than have their teeth extracted because the social consequences of oral disfigurement diminishes their self- image and sense of self worth. Adults without adequate dental care resources express a feeling that their lack of dental coverage and resulting inability to get appropriate dental care reflects society's lack of recognition of them as people with intrinsic value. The Surgeon General's report also noted this relationship between oral facial disfigurement due to oral disease and the associated social stigma, low esteem, and anxiety experienced which in turn limits their educational, career, and marriage opportunities. Among adults seeking jobs those with visual carries and missing teeth were less employable than those with healthy smiles, resulting in increased numbers of adults on state funding ATAP [Alaska Temporary Assistance Program], unemployment, and food stamp programs. In closing, oral health means much more than healthy teeth. Oral health is integral to the general health and well being of all Alaskans. Not allowing dental care benefits that include prevention and routine dental care knowingly puts our most vulnerable citizens at a greater health risk. Alaska cannot afford these long-term financial and human welfare costs. Alaska Primary Care Association and the Municipality of Anchorage support HB 105 and believe its time for the dental Medicaid program to be restructured to include preventative and restorative services. Thank you. 10:08:14 AM Co-Chair Wilken asked whether the Primary Care Association (PCA) had contacted the Alaska Dental Board in support of issuing temporary dental licenses. The issuing of these licenses would assist in serving some of the people she had spoken of. Dr. White was unsure. She was aware, however, that the Alaska Dental Board had not taken any action in that regard. PCA has taken a position in support of the dental health aide program. She also supported that program as she had personally worked in many remote Bush villages and could attest to the skills, knowledge, and empathy of the people involved in the program. Co-Chair Wilken thought that the PCA's "voice would be very powerful" in bringing the temporary license issue to the attention of the Alaska Dental Board. Their participation could advance the efforts included in this legislation. Therefore, he urged her organization to investigate how other states' experiences with temporary dental licenses could assist in allowing "dentists to come and serve some of the less abled of our society". Dr. White responded positively to Co-Chair Wilken's suggestion. The Association would support this endeavor, as many of its member "community health centers are under-served. That's a big problem for us." She was currently involved in an effort to create an Alaska oral health care partnership to provide "more dental care and better retention in the State". Co-Chair Wilken appreciated Dr. White's comments. Senator Olson asked the number of dentists employed by PCA. Dr. White stated she was the sole PCA dentist. PCA is advancing the aforementioned oral health network to improve access to dental care "by establishing a more cohesive structure with the community health center dental clinics", furthering a shared provider program to improve dental care access, and advancing other aspects to improve dental care opportunities through the organization. 10:11:24 AM JEFF JESSEE, Chief Executive Officer, Alaska Mental Health Trust Authority, thanked the Committee for considering this bill. AMHTA is interested "in this bill and dental services in general because" many of AMHTA's "beneficiaries have tremendous dental needs". AMHTA annually funds a mini-grant program that "provides grants of up to $3,000 directly to individual beneficiaries for a wide range of things" such as laptop computers, a car to transport them to work, or other expenses that would improve their quality of life. AMHTA "was stunned" to find that approximately 70 to 80 percent of the mini-grant funding was used for dental services. Spending one's mini-grant funds on dental care would not be expected to be "way up on people's list of things they want to do in their spare time or with any additional dollars they might have". Mr. Jessee noted AMHTA worked closely with the Department to construct a bill with cost containment provisions such as the individual dental service limit and the termination date. In addition to working on this "very important bill", AMHTA is working on a program through which dentists could donate dental service and be compensated for their out of pocket expenses. Another effort being advanced by AMHTA is the development of partnerships with community health centers "to get them up and running on providing more comprehensive dental care". Nonetheless, the funding mechanism proposed in this bill "is critical" to these endeavors and to meeting the dental needs of AMHTA beneficiaries. 10:13:54 AM There being no further testimony, Co-Chair Green ordered the bill HELD in Committee in order to develop language addressing Co-Chair Wilken's concern. 10:14:22 AM