House Joint Resolution (HJR) 198 of the 2000 Session of the General Assembly, as introduced, directed the Joint Commission on Health Care to continue its study of ways to increase access to dental care throughout the Commonwealth. In addition, House Joint Resolution 296, as introduced, requested the Department of Medical Assistance Services (DMAS) to study the feasibility of expanding coverage for dental care, including dentures, to Medicaid recipients.

Neither HJR 198 nor HJR 296 were adopted by the General Assembly. However, both resolutions were communicated to the Joint Commission via letter from the Speaker of the House of Delegates. The Speaker's letter states that:

"The House Rules Committee believes that the issues addressed by the resolutions merit review. Therefore, the Commission is directed to undertake the study and to submit a written report of its findings and any recommendations to the Governor and the 2001 Session of the General Assembly."

Specifically, the HJR 198 study is to include, but not but limited to, an analysis of:

(i) various ways to increase the number of persons with dental insurance;
(ii) the number of dentists participating in the Medicaid program, the results of recent actions taken to increase the number of participating dentists, and other actions that could be taken to increase further the number of participating dentists;
(iii) potential safety concerns regarding the use of dental amalgam; and
(iv) barriers to access to care and other appropriate issues identified by the Joint Commission on Health Care.

The specific provisions of HJR 296 call for a study of the feasibility of expanding coverage for dental care, including dentures, to Medicaid recipients. The study is to examine eligibility, coverage, and reimbursement policies, and determine appropriate guidelines for providing such services. A copy of the Speaker's letter, HJR 198 and HJR 296 is attached at Appendix A.

Based on our research and analysis during this review, we concluded the following:

• The U.S. Surgeon General released a report on oral health in America and found racial and ethnic minorities experience a disproportionately high level of oral health problems. Oral health problems also are more prevalent in underserved areas. The report also identified clear associations between chronic oral infections and other health problems.

• While the overall ratio of dentists to population in Virginia is adequate, there are 43 underserved areas in the Commonwealth. Approximately 145 dentists are needed to eliminate these underserved areas. Significant progress has been made by the Virginia Department of Health in designating these localities as dental health professional shortage areas (HPSAs). Dental HPSA designations are important because dentists who work in these areas qualify for federal loan repayment assistance which is a significant financial incentive.

• Very few dentists participate in Virginia's scholarship and loan repayment program due to the very limited amount of funding ($25,000) available through the program.

• While the number of dentists participating in Medicaid has increased in recent years (808 in 1997 - 949 in 2000), there still are too few dentists to serve children eligible for services. Reimbursement has been identified as a key reason for limited participation. The 1998 Appropriations Act directed DMAS to increase reimbursement to 85% of UCR; however, current reimbursement is about 65% of UCR.

• There are far more Virginians without dental insurance (41%) than medical insurance (13%). The most recent data on Virginians is 4 years old; more current data on the insurance status of Virginians are needed.

• The number of persons with dental coverage is increasing as more employers offer dental benefits to attract workers. Several alternative dental benefit plans are emerging that are increasing the number of persons with at least some level of dental benefits.

• Currently, 27 states offer dental benefits to Medicaid adults. Virginia does not provide dental benefits to Medicaid adults. The cost to do so would be approximately $8.2 million GF (includes coverage for general dental benefits and dentures).

• Dental amalgam is the most frequently used material to restore decayed teeth. Amalgam contains a small amount of elemental mercury which is a toxic substance. There has been a continuing controversy over whether the level of mercury in amalgam causes health problems. While some research has concluded that persons with amalgam were less healthy than those with no amalgam, several U.S. government studies have concluded it is inappropriate to restrict the use of amalgam. Several anti-amalgam groups continue to argue for restricting or prohibiting the use of dental amalgam. The American Dental Association (ADA) and the Virginia Dental Association (VDA) believe amalgam is safe.

A number of policy options were offered for consideration by the Joint Commission on Health Care regarding the issues discussed in this report. These policy options are listed on page 49. Public comments were requested on a draft of this report. A summary of the public comments is attached at Appendix B.