• Mission & Governance
• Member Services
• How to Get Involved
• Standing Committees
• NCSL Foundation

• Issue Areas: A-Z
• State-Federal Relations
• NCSL Standing Committees
• News from D.C. and the States

• About State Legislatures
• Elections, Campaigns & Redistricting
• NCSL's StateConnect Directory
• Web Sites

• Online Guide to NCSL Services
• Staff Sections and Networks
• Meetings & Professional Development
• Staff Directories

• Meetings Calendar
• Online Registration
• Meetings Home Page
• Legislative Summit

• Bookstore
• State Legislatures Magazine
• NCSL's StateConnect Directory

Rural Health Brief

IMPROVING ORAL HEALTH SERVICES IN RURAL AREAS:
THE ROLE FOR STATES

July 2003

For More Information:
Tim Henderson, NCSL @ 202/624-3573
Marcia Brand, Office of Rural Health Policy @ 301/443-0835

On July 21, 2003, NCSL convened a one-day national meeting in San Francisco, California of state lawmakers and rural health and oral health care officials representing 20 states to debate and discuss obstacles, opportunities and workable solutions for states to effectively improve access to oral health services in rural communities (see attached agenda).

Access to oral health care is becoming a significant policy concern for most states. The meeting convened with a series of NCSL-facilitated panel and small group discussions among participants structured to maximize audience participation and allow ample time for general discussion. Lawmakers in attendance learned about and debated the relevance of the above issues to their states and reached the following conclusions:

1. The changing supply, productivity and age of dental health professionals are cause for concern. There has been an overall decline in the number of dentists per capita since the 1980s, along with an increase in the proportion of dentists who are female who often work less than full time. Enrollment in dental schools has also lessened. Despite an increase in the supply of dental hygienists in recent years, most hygienists work only on a part time basis. In Washington state, about 25 percent of all hygienist positions are vacant. Moreover, while more dentists are working fewer hours, about 35 percent of dentists nationwide are older than age 55, amounting to as many as half of all dentists reaching retirement within the next 10 years. A larger proportion of specialty dentists than general dentists are nearing retirement.
2. State fiscal problems are threatening to increase difficulties in accessing dental services for low-income populations. To lower costs, at least 25 states have reduced or eliminated dental benefits or restricted program eligibility, particularly for adults, under their Medicaid programs. About 37 states have frozen or reduced Medicaid payments to dental providers, causing greater concern over rates of provider participation.
3. Rural areas face some of the biggest challenges with accessing dental care. Typically, dentists practicing in rural communities are older than their urban counterparts, and the average age rises as the population becomes increasingly sparse. In Washington state, 57 percent of all dentists in rural areas, compared to about half in the state's urban areas, are expected to retire in the next 10 years. Vacancy rates for hygienists also are higher in the state's rural dental practices (47 per 100 dentists) than urban practices (33 to 43 per 100 dentists), despite the fact that rural hygienist salaries are high. Rural communities typically have a larger proportion of adults than do urban areas.
4. Workable opportunities and solutions exist for states to improve access to oral health care in rural communities and elsewhere. These include:

1. Improving Provider Participation in Medicaid and Other State Plans. Aside from raising payment rates, states can simplify the provider enrollment and billing/reimbursement process and provide outreach and support services.
2. Training More Dental Professionals Interested in Rural Practice. States can provide incentives or other forms of support to establish scholarships and rural clinical training sites or preceptorships for dental and hygiene students from in-state and rural communities.
3. Increase attention to prevention in rural areas with lower fluoridation rates by investigating school water fluoridation and reimbursing for dental sealants under Medicaid.
4. Increasing the Supply of Providers in Rural Practice. Several such opportunities exist for states, including:

• Create or enhance loan repayment programs for dentists and hygienists;
• Consider supporting or operating mobile dental vans in certain situations;
• Encourage state-designated critical access hospitals (CAHs) and community health centers (CHCs) to open and operate a dental unit;
• Exempt retired volunteer dentists from liability for work in mobile vans, CAHs, CHCs or other settings;
• Start a revolving loan fund for establishing rural practices and enhance sales of rural practices with grants for equipment upgrades;
• Consider other financial incentives through reimbursement to reward rural providers and those who see high numbers of low-income patients.
• Loosen supervision requirements for hygienists, particularly in public health and low-income settings.

1. Several states have enacted effective strategies to improve access to oral health care in rural areas:

1. In recent years, mobile dental units and services operated in rural Colorado, Washington and other states have generated large numbers of patient care visits.
2. Utah initiated differentiated Medicaid rates to dental providers in 1998 whereby rural dentists received a 20 percent increase in reimbursement for all Medicaid patient treated, resulting in some increase in provider participation. The legislature is considering making additional increases in Medicaid reimbursement and implementing a case management system to encourage more appropriate and timely access of dental benefits by Medicaid patients.
3. The Wisconsin legislature agreed to subsidize the building of a new dental clinic in rural Marshfield to improve provider supply.
4. The Alabama Medicaid agency formed a dental task force to address provider billing and reimbursement concerns, resulting in increases in payment rates, several concentrated outreach initiatives to sustain and improve provider participation (focus initially on rural counties) in the program, and significant increases in dental utilization by Medicaid patients.
5. Minnesota's legislature created a program to reimburse retired dentists for the cost of license renewal and malpractice insurance if they perform 100 hours of volunteer dentistry in a year. Similar initiatives have been enacted in Georgia, Oregon, Maine and South Carolina.
6. Nebraska established a consortium to fund education of dental students for rural practice in Nebraska, Kansas, South Dakota and Wyoming. The state also now requires mandatory water fluoridation in communities with 1,000 or more residents.
7. California recently passed a law allowing licensed dentists (and physicians) from Mexico to participate in a pilot program for practice in the state's underserved communities.

There was a consensus among workshop attendees for NCSL to convene additional forums for state officials that discuss challenges and opportunities for improving state rural health care programs and policy.

San Francisco Marriott HoteL, 55 Fourth Street, Club Room

Convened by NCSL with Support from:
The U.S. Health Resources and Services Administration's Office of Rural Health Policy

7:30 - 8:30am Continental Breakfast and Registration

8:45 - 9:00am Welcome: Tim Henderson, NCSL

9:00 - 10:30am Challenges in Improving Oral Health Services in Rural Areas

10:30 - 10:45am BREAK

11:00 - 12:00pm Overview of State Strategies to Address Rural Oral Health

12:15 - 1:15pm LUNCH

1:30 - 2:15pm Mobile Dental Services

2:15 - 3:00pm Effective Clinic Start-Up Grants

3:00 - 3:15pm BREAK

3:15 - 4:00pm Differential Medicaid Rates

4:00 - 5:00pm Provider Recruitment and Retention Programs

5:00pm WrapUp and Adjournment