Blaire Briody, The Fiscal Times, Author at ��ϳԹ�� News

Kids and Dental Health: Rising Costs and Struggling State Programs a Dangerous Mix

Blaire Briody, The Fiscal Times — Tue, 20 Jul 2010 16:38:48 +0000

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Let’s face it: A visit to the dentist doesn’t exactly make kids smile. But avoiding the dentist’s chair is not only costing kids their health, it’s costing their parents and the American taxpayer tons of money.

A study from the July issue of found that one in four children under age 11 in California has never seen a dentist. Nationally, the numbers aren’t much better. A February report from the found that one out of every five children under the age of 18 goes without dental care every year.

In 2009, the total dental expense for children in the U.S. was approximately $30.6 billion, one-third of all spending on dental care. Dental costs are roughly 20 percent of a child’s total health care expenses, and these costs are growing quickly. According to the Pew report, total annual spending for dental care is expected to increase 58 percent – from $101.9 billion to $161.4 billion – between 2009 and 2018.

When parents don’t take their children for routine checkups and diagnostic tests, the risks of tooth decay and hospitalization rise. “The use of ambulatory surgery for dental problems is among the top five reasons for [same-day] surgery in kids under five,” says Dr. James J. Crall, child advocate at the , who recommends that children have their first visit by age one. “The best way is to find the kids early on who are demonstrating signs that they are high risk, and getting ahead of it rather than trying to fix mouths full of cavities in two- or three-year-old kids, which many times requires either the use of sedation or taking the kid to the hospital. So the cost of dental conditions is actually higher than what’s recorded under dental services; there are those other aspects of health care that get rolled into it.”

A 2004 study from the American Academy of Pediatrics looked at Medicaid costs – both dental and medical dental costs-in preschool-age children in North Carolina. “When they incorporated those costs, they found that the younger the child’s age when they first got their checkup and dental visit, the lower the overall cost over the entire preschool year,” says Dr. Crall.

Both costs and tooth decay are rising for children under five. According to a 2007 Centers for Disease Control and Prevention , in the past decade, the number of cavities in children between the ages of two and five has increased 15 percent. For children with families living under the poverty line, it’s even worse: They’re twice as likely to have untreated tooth decay. “It sort of gives us pause to think about what the future might be,” says Dr. Crall. “Tooth decay in primary teeth is one of the better predictors as to whether kids are going to have tooth decay in permanent teeth.”

In This Economy, Fewer Patients
The recession has exacerbated the problem. Dr. Lindsay Robinson, a pediatric dentist in Grass Valley, Calif., says her patient roster has dropped off significantly in the past two years. “Due to the economy, I’ve seen a decrease in demand. That’s not to say that children don’t need the care, but in general, people are being extremely conservative right now as far as any kind of out-of-pocket, or perceived out-of-pocket.” One of her recent patients, a five-year-old boy, was diagnosed with a small cavity but didn’t return to have the problem addressed until a year and a half had passed. He was in so much pain that Dr. Robinson had to extract the tooth. “We had to put in a space maintainer, which is about triple the cost,” she says. “It’s this whole idea of preventing the need for costly care down the road.”

Income is a strong determinant of dental visits. In 2004 (the earliest data available), 62 percent of children from high-income families saw the dentist at least once, compared to 34 percent of children from . Dr. Crall says that about 75 to 80 percent of dental disease in the country is in 20 to 25 percent of the children, and those children tend to be low income and covered by public programs.

In 2004, 26 percent of children had public coverage under Medicaid or the Children’s Health Insurance Program (CHIP), which launched in 1997, and 20 percent had no coverage, whereas 54 percent of children had private coverage. About twice as many children lack dental coverage as those that lack medical insurance.

As the California study found, children with public insurance are much less likely than those with private insurance to see the dentist. The authors suggest the shortage of pediatric dentists who accept Medicaid is a factor. Only 5 percent of California dentists in private practice are pediatric dentists, and only 42 percent of all participate in Medicaid. “These findings raise concerns about Medicaid’s ability to address disparities in dental care access and, more broadly, in health care,” the authors write in the study.

The Medicaid Conundrum
Ironically, dental care is much less expensive under Medicaid, due to below-market prices negotiated by the state. But lower payments mean fewer dentists are willing to treat Medicaid patients. Dr. Robinson says that when she started her practice in 1996, she saw primarily Medicaid patients, but as costs have risen and Medicaid fees remain constant she’s had to adjust. Only 10 percent of her patients are now on Medicaid. “It’s becoming unsustainable for a private practice to have primarily Medicaid patients,” she says. “The payer mix had to adjust with the economy.”

In addition, many states – the most recent being – have dropped their coverage for parents, which is a factor in their child’s dental visits. “Parental use of dental services, and what their experiences have been in the past, could very well be at work here,” says Dr. Crall. “If you have a child on Medicaid, odds are that his or her parents aren’t covered for dental services, because adult dental services are considered optional by the states. And I can tell you, over the past 10 years they’ve been dropping adult dental coverage like a hot potato, given the fiscal situation.”

Under President Obama’s health care reform bill, , allowing more children to be covered for dental services. Starting in 2014, health plans purchased through the state-run must also include pediatric oral care for dependents under 21.

“The cost to the state is going to be enormous,” says Dr. Robinson of California. “Currently, we can barely afford the matching dollars to pull the federal dollars down for the Medicaid program. And when we add more people to the rolls, it’s going to be increasingly difficult for the state to pay their portion.”

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Health and Class: A New Look at Poverty and Illness

Blaire Briody, The Fiscal Times — Tue, 29 Jun 2010 14:48:49 +0000

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What makes someone healthy? Certainly exercise and diet. But what about a college degree? Or say, a higher salary? A new study found that the more income and education people have, the less likely they are to have colds, headaches, flu and chronic physical pain.

The study, published in March by The Archives of Internal Medicine, asked 350,000 participants to remember their symptoms the day before. People who did not finish high school were nearly twice as likely to report having a cold, a headache or pain than those with a college degree. Among those earning less than $12,000 a year, 46 percent report feeling physical pain on any given day, double that of the average American. This was true even when factors such as age, access to health care and medical history were considered.

What researchers are trying to understand is why? Health differences across socioeconomic gradients have been looked at in many studies before, but most have focused on chronic conditions: obesity, heart disease, etc, and others have looked at access to health care and . It’s no secret that poor living conditions can affect health. Buildings without heat or air cooling; rooms with layers of peeling lead paint; rats and roaches and other vermin that carry disease-all conspire to compromise health in impoverished areas. The high incidence of is just one indicator. But the study signifies that education and psychological stress may be just as important markers of disease and pain as poor environment.

“Everyone thought it was going to be access to health care-you know, people with more money or education would have better access to health care, and hence they would do better,” says , who led the study. “But that doesn’t seem to be the case from the research that’s out there. So it really is a puzzle as to why this is. It may be that people with lower levels of resources-educational and financial-are under higher levels of stress, which then has an impact on a variety of things.”

Health Inequality

The authors of the study run though possible explanations: Crowded living conditions and greater use of public transportation could mean increased exposure to infection. Increased headaches and pain could be related to differences in noise exposure, working environments, posture, or increased muscle tone from chronic stress.

One of the first to tackle the subject of health inequality along socioeconomic lines, was a London professor in 1985 with the . He was surprised to find that people in high status jobs-meaning more responsibility and stress-actually had a lower risk of heart disease than lower-tier employees.

“Autonomy, control, empowerment, turn out to be crucial influences on health and disease,” said Sir Marmot in a PBS documentary on his research called He found that not only do the poor live on average six years less than the rich, but those in the middle class will die two years sooner than rich, and this continues all the way down the socioeconomic pyramid.

Only recently have studies begun to address everyday health. Dr. Nancy Adler, a health psychology professor at University of California, San Francisco, collaborated on a study where participants rated themselves on where they stood on the socioeconomic ladder, and were then exposed to a flu virus. Those who rated themselves low on the ladder were more likely to develop a cold. “The best way to think about this is it’s a ripple effect, which is, being of low status, living in poor areas just subjects you to a whole lot more challenges to the body, both psychological and physical,” she says.

Other Findings

In fact, stress, the psychological effects of low income, and poor living conditions have been looked at as a determinant of health in many studies, particularly at the . Researchers there have found that stress from financial insecurity or conflict can take a toll on many systems in the body including cardiovascular, immune, metabolic and nervous systems. This, on top of poor diet and exercise, fewer healthy food options in poor neighborhoods, and increased exposure to infection, one can see how it starts to add up.

Of course, access to health care also plays a part, as many supporters of the health care bill will point out. But according to Dr. Adler, it’s not as much of an issue in this case. “We’ve quite explicitly not looked at the role of health care for three reasons: One is it’s really well studied, it’s the first thing everyone thinks of. The second is access to health care tends not to be as helpful in avoiding the onset of diseases, in part because our health system is not very good in prevention. The other thing is that we find these SES gradients in insured populations, we find it in countries that have universal access to care, so it just doesn’t look like much of the action is in health care.”

As the health care debate continues and the new bill is implemented, the pervading health inequalities in America should not be overlooked. As one congressman, Rep. Pete Stark (D-CA) said when calling for an amendment to the Constitution to guarantee health care for all, “The health of every American is vital to their unalienable rights of ‘life, liberty, and the pursuit of happiness.'”

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Medicaid’s Ticking Bomb – Long Term Care – Could Wipe Out State Budgets

Blaire Briody, The Fiscal Times — Wed, 23 Jun 2010 09:11:00 +0000

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A claims the costs of Medicaid’s long-term care services could cripple states’ already-fragile budgets.

The study, “Medicaid Long-Term Care: The Ticking Time Bomb,” runs through worst and best-case scenarios: the best being that Medicaid costs as a percentage of state budgets will nearly double by 2030, from the current 20 percent to 35 percent in some states. The worst? These costs will nearly triple, rising to 50 percent of the operating budget in one state – with long-term care accounting for 25 percent of that. “Obviously, this is not sustainable,” write the authors.

Long-term care is particularly cost-prohibitive; services include nursing home care, and treatment for chronic diseases like diabetes, arthritis, cancer and hypertension. 60 percent of Americans suffer from at least one chronic disease; for those over 80 years old, 80 percent have two or more chronic diseases. For the nearly 9 million patients that are eligible for both Medicare and Medicaid services, 98 percent of expenditures are for chronic diseases. accounts for 32 percent of total Medicaid spending. “Even with the level of growth in Medicaid, long-term care costs are forecasted to grow even faster,” says Robert Campbell, who serves as the state government leader at Deloitte LLP and who contributed to the study.

With so many states already mired in budget problems, and with unemployment contributing to a 6.5 percent increase in Medicaid enrollment in 2009, it’s no wonder the authors of the study compare the scenario to a ticking time bomb. Their solutions range from making long-term care services more “community focused” to “exploring new public and private financing.” But in the end, solutions remain vague. Separate proposals to curve the state Medicaid conundrum include one that imposes a new tax on hospitals and managed care plans. Some companies, like Walgreens, are simply dropping their Medicaid patients altogether.

New York State has the highest Medicaid spending in the country, with currently 30 percent of the state budget devoted to the program, and the study illustrates the problem all too acutely, predicting a 50 percent increase in the next twenty years. When asked to comment on the report, spokesperson Jeffrey Hammond with the New York State Department of Health said, “The department is reviewing the report. With that said, the department understands that long-term care costs are growing exponentially in Medicaid.”

“States shouldn’t wait for the crisis to hit, given how clear it is what’s coming,” says Campbell. The authors of the study conclude, “[This] is one of the most urgent health care problems for most states. Failure to innovate with medical and administrative management initiatives will likely result in increasing costs, voter discontent, poor quality and fiscal challenges.”

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