Executive Session

Floor Speech

By:  Ben Cardin
Date: March 7, 2013
Location: Washington, DC

BREAK IN TRANSCRIPT

Mr. CARDIN. Mr. President, I come to the floor to note a sad anniversary. Friday, March 1, marked 6 years since the tragic death of a 12-year-old Maryland child named Deamonte Driver. I have spoken about him many times since his passing, which happened just weeks after I came to the Senate.

The death of any child is tragic; Deamonte's was even more so because it was entirely preventable. He died from untreated tooth decay. It started with an infected tooth. Deamonte began to complain about headaches in early January 2007. By the time he was evaluated at Children's Hospital's emergency room, the infection had spread to his brain, and after multiple surgeries and a lengthy hospital stay, he passed away.

The principal at Deamonte's school, Gina James, remarked, ``Everyone here was shocked. They couldn't understand how he could have a toothache and then die. We sometimes give the little kids candy as a reward; well, for a while they stopped taking it because they would say, `if I get a cavity, will I die?' ''

Because Deamonte did not get a tooth extraction that would have cost about $80, he was subjected to extensive brain surgery that eventually cost more than $250,000. That is more than 3,000 times the cost of an extraction.

After Deamonte's death, more Americans began to recognize the link between dental care and overall health that medical researchers have known for years.

Former Surgeon General C. Everett Koop once said that ``there is no health without oral health.'' The story of the Driver family has brought Dr. Koop's lesson home in a painful way.

Children living in poverty have twice as much tooth decay as middle- and upper-income children, and nearly 40 percent of black children have untreated tooth decay in their permanent teeth.

This has serious implications for their overall health. Untreated oral health problems in children can result in attention deficits, poor school performance, and problems sleeping and eating. And these problems carry over to adulthood. Improper oral hygiene can increase an adult's risk of having low birth-weight babies, developing heart disease, or suffering a stroke.

Employed adults lose more than 164 million hours of work each year due to dental disease and dental visits, and in 2009 over 830,000 emergency room visits were the result of preventable dental conditions. Poor oral health is also associated with a number of other diseases, including diabetes, stroke and respiratory disease. In older adults, poor oral health is significantly associated with disability and reduction in mobility.

Medical researchers have discovered the important linkage between plaque and heart disease, that chewing stimulates brain cell growth, and that gum disease can signal diabetes, liver ailments and hormone imbalances. Further, oral research has led to advanced treatments like gene therapy, which can help patients who have chronic renal failure.

They have also discovered that oral disease is far more prevalent than you might imagine. In fact, dental decay is the most common chronic childhood disease in the United States. Dental disease affects 1 in 5 children aged 2 to 4, and more than half of all children have dental disease by the time they reach second grade. By the age of 17, approximately 80 percent of young people have had a dental cavity.

The average 50-year-old in the United States has lost 12 teeth, and by age 65 over one-quarter of Americans have lost all their teeth. More than 10 percent of the nation's rural population have never visited a dentist.

These are sobering statistics. But here is the good news: Dental decay is a dynamic disease process, and not a static problem. Before a cavity is formed in the tooth, the caries infection can actually be reversed. That means that we can prevent tooth decay, as long as dental care is made available and good oral hygiene practices are used.

Deamonte's story was told around the world. But nowhere did it hit harder than in his home State of Maryland. I am proud of how the Maryland Congressional Delegation, Governor Martin O'Malley, and the Maryland General Assembly have responded to the need for better access to oral health care.

In 2010 and 2011, the Pew Center on the States named Maryland a national leader in improving dental access for low-income Marylanders. We were the only State to meet seven of Pew's eight dental policy benchmarks, and we ranked first in the nation for oral health. CMS also invited our State officials to share their story at its national quality conference in August 2011 and placed Maryland's achievements in its Best Practices Guide.

I will mention just some of what Maryland has accomplished: In 2010, our State secured $1.2 million in Federal funding to develop a statewide Oral Health Literacy Campaign, called ``Healthy Teeth, Healthy Kids.'' More than 368,000 children and adults in Medicaid received dental care in 2011; 82,000 more than in 2010. The percentage of pregnant women receiving dental care in 2011 was 28.4 percent, compared to 26.6 percent in 2010.

Created by the Robert T. Freeman Dental Society and funded in part by the State, the Deamonte Driver Mobile Dental Van Project provided diagnostic and preventive services for over 1,000 Prince George's County children who live in neighborhoods where otherwise care would be unavailable to them.

The Kaiser Family Foundation awarded a $200,000 grant to the Maryland Dental Action Coalition that funded a pilot dental screening program at a school-based health center in Prince George's County.

The Dental Action Coalition also began granting and reimbursing primary care providers to apply fluoride varnish for children up to 3 years of age. By June 2012, 385 primary care providers had administered over 58,000 treatments.

The Maryland Community Health Resources Commission continues to expand oral health capacity for underserved communities. Since 2008, the Commission has awarded 20 dental grants totaling $4.6 million. These grants have funded services to more than 35,000 low-income children and adults in our State.

I am also very proud of what Congress has done. In the CHIP Reauthorization Act passed a few months after Deamonte died, we established a guaranteed oral health benefit for children. With the leadership of Senators BAUCUS, GRASSLEY, ROCKEFELLER, COLLINS, and former Senator Bingaman, we created grants to the States to improve oral health education and treatment programs. We also addressed one of the problems that Deamonte's mother faced in trying to get care for him--a lack of readily available information about accessible providers.

For a variety of reasons, it is difficult for Medicaid and CHIP enrollees to find dental care, and working parents whose children qualify for those programs are likely to be employed at jobs where they can't spend 2 hours a day on the phone to find a provider. So HHS must include on its Insure Kids Now Web site a list of participating dentists and benefit information for all 50 States and the District of Columbia.

Also, in 2009, Congress passed the Edward M. Kennedy Serve America Act. That law created the Healthy Futures Corps, which provides grants to the States and nonprofit organizations so they can fund national service in low-income communities. It will allow us to put into action tools that can help us close the gap in health status--prevention and health promotion. For too long we have acknowledged health disparities, studied them, and written reports about them. With the help of the senior Senator from Maryland, my colleague, Senator Barbara Mikulski, we added language to that law specifying oral health as an area of focus.

Now the Healthy Futures Corps can help recruit young people to work in the dental profession, where they can serve in areas that we have shortages of providers in urban and rural areas. It will fund the work of individuals who can help parents find available oral health services for themselves and their children. It will make a difference in the lives of the Healthy Futures Corps members who will work in underserved communities and in the lives and health of those who get improved access to care. Then in the 2010 Affordable Care Act, we enacted several landmark provisions designed to improve oral health.

The ACA funds and encourages a number of oral health prevention activities. First, it directs the CDC to establish a 5-year national oral health education campaign. This campaign is required to use science-based strategies and to target children, pregnant women, parents, the elderly, individuals with disabilities and ethnic and racial minority populations, including Native Americans.

The ACA also created demonstration grants to study the effectiveness of research-based oral health programs, which will be used to inform the public education campaign.

The health care law expands an existing school-based dental sealant program to each of the 50 States and territories and to Indians, Indian tribes, tribal organizations and urban Indian organizations. It directs the CDC to enter into cooperative agreements with State, territorial and Indian organizations to establish guidance, conduct data collection and implement science-based programs to improve oral health.

ACA also authorizes HHS to make grants to dental schools, hospitals, and nonprofits to participate in dental training programs. This funding can be used to provide financial assistance to program participants, including dental and dental hygiene students as well as practicing dentists, and for loan repayment for faculty in dental programs. The ACA also provides grants for up to 15 demonstration programs to train alternative dental health providers in underserved communities.

The law authorizes and requires a number of public health initiatives that should improve access to oral health care, including an $11 billion, 5-year initiative that funds construction, capital improvements and service expansions at community health centers, where so many oral health services are provided.

It also establishes a National Health Care Workforce Commission to serve as a resource to evaluate education and training to determine whether demand for health care workers is being met, and identify barriers to improvement. We need that information. That was Senator Bingaman's provision and it should be funded as soon as possible.

But perhaps the most important provision is a requirement that health plans cover a set of essential health benefits, EHBs, that includes pediatric dental care. Beginning January 1, 2014, the law says that oral health care for children must be part of the essential health benefits package that must be offered in the new health insurance exchanges and in the small group and individual insurance markets that exist outside the exchanges.

When the ACA was passed nearly 3 years ago, I had great hopes that in a few years, I could stand here on the Senate floor and celebrate all the progress we had made in bringing affordable dental care to every child in this nation. I had hoped this would be a day to talk about what a difference Congress has made in the oral health of America's children. We celebrated that section of the law, because it meant that once and for all, oral health would be available to America's children. It gave many of us hope that we would be able to get every child basic dental care and begin to erase the epidemic of dental disease that still affects millions of American children. Now, however, the affordability of that benefit is at risk.

The ACA includes a Finance Committee provision that allows stand-alone dental plans to exist in the market. In a colloquy on September 26, 2011, Senators BAUCUS, STABENOW, and Bingaman engaged in a colloquy.

They clarified that the intent of the law in allowing stand-alone dental plans was not to create separate standards but to ensure competition in the insurance exchanges and allow choice in the marketplace.

Later, I joined 10 of my colleagues in writing to HHS Secretary Sebelius, urging her to ensure that all children who receive their dental coverage through a stand-alone dental plan should have the same level of consumer protections and cost-sharing as those who get coverage through a plan that offers integrated benefits.

Last week, HHS published a final rule on the benefits that creates a separate out-of-pocket limit for stand-alone dental plans, but only specifies that the limit be ``reasonable.'' There are two huge problems with this approach. First, an additional out-of-pocket limit will make the benefit far less affordable for many families. It was not what Congress intended. The whole point of adding pediatric dental benefits to the essential health benefits package was to make certain that oral health not be considered separate from overall health.

We have been here before. This approach is similar to policies that were set decades ago for mental health services--separate policies to cover mental health treatment, separate limits on coverage, and separate copays. Mental health was treated as second-class health care. We know now that this was an injustice. It was wrong to treat those services, and the patients who used them, as second-class. Many of my colleagues were here in Congress when we fought the battles for mental health parity. It was a difficult battle, but we won. It seems to me that this is what we are doing now with dental care, rather than treating it as part of the Essential Benefits Package, which was our intent in the Affordable Care Act.

Section 1402(b) of the law also establishes an out-of-pocket limit for all families and lowers that limit for families with incomes under 400% of the Federal poverty level. By creating a separate limit, HHS is reducing the number of families who will be able to afford dental coverage for their children.

Second, the rule has left the determination of what is a ``reasonable'' out-of-pocket limit to each State. With pressure from insurance companies, a State could decide to provide an out-of-pocket limit of $1,000 or more per child, which could more than double out-of-pocket costs for a family with five children.

In the Federally run exchanges, HHS has the authority to set a ``reasonable'' out-of-pocket limit. Last Thursday, in a Finance Committee hearing, I asked Jon Blum, the CMS Deputy Administrator, about the idea of segregating dental benefits from health benefits and increasing cost-sharing. This is what he said: ``Well I think one of the lessons that we learned within the Medicare program is that when the care is siloed, our benefits aren't fully integrated. That can often lead to worse total health care consequences. I can pledge to get back to you with direct answers to your questions. But I do agree with your general principle that when benefit design is broken up and care is not coordinated, that it can often lead to bad quality of care. ``

Later that day, I spoke with CMS acting administrator Marilyn Tavenner. I asked her to take into account the affordability of a plan that had separate, high cost-sharing, and she agreed to consider my views. Less than 24 hours later, CMS released a proposed ``guidance'' to insurers, setting a maximum out-of-pocket limit of $1,000. When I contacted HHS to ask whether this was a per-family or per-child limit, the expert in charge of the rule was unable to tell me. They did not know whether this meant extra costs per year of $1,000 or $5,000 for a family with five children. This tells me that the affordability of care was a secondary consideration when this final rule was written.

There are still millions of American children without coverage for dental care. If we are to make real progress in improving the health of Americans, we cannot afford to continue giving oral health care second-class treatment.

The question now is whether the guidance to plans will go forward. It is contrary to Congressional intent and contrary to the best interests of American families to allow it to stand.

On this sixth anniversary of the death of Deamonte Driver, let's pledge to do better for our children.

Madam President, I call to the attention of my colleagues a colloquy between Senators Bingaman, STABENOW, and BAUCUS in the Record of September 26, 2011, at page S5973.

With that, I yield the floor.