Author: NC Oral Health Collaborative

As we step into 2024, we’re taking a moment to reflect on 2023 as we begin building on what we accomplished last year.

What a year 2023 was… Among many other headlines, one of the biggest for North Carolina was the passage of Medicaid Expansion, which finally went into effect statewide on December 1st. After more than a decade of advocacy from across our state, approximately 600,000 people who were living in the health care coverage gap are newly eligible for no- or low-cost health care.

Read what our Vice President of Oral Health, Dr. Steve Cline, had to say about Medicaid Expansion and the dental safety net.

2023 was also a big year for the North Carolina Oral Health Collaborative (NCOHC) and our incredible coalition of oral health advocates. NCOHC transitioned to new leadership as Dr. Steve Cline took over as the Vice President for Oral Health at the Foundation for Health Leadership and Innovation (FHLI) and Crystal Adams was promoted to the Director of NCOHC.

As we look back at what we achieved together, we are also thinking about how we will continue to advance oral health equity in 2024 and beyond.

We are thrilled to announce that we received our largest ever grant–$1.8 million over two years—from the Blue Cross and Blue Shield of North Carolina Foundation. This will support our work influencing policy, developing and promoting workforce strategies, elevating partnerships, and engaging with communities across North Carolina.

Moreover, it will enable us and our partners to advance the recommendations from the North Carolina Institute of Medicine (NCIOM) Oral Health Transformation Task Force Report.

We are also delighted to announce that The Duke Endowment—a longtime partner and supporter of our collaborative work—has continued to invest in oral health equity by awarding NCOHC a $1.2 million grant over the next three years. We are also grateful for the ongoing support of the Dogwood Health Trust and the CareQuest Institute.

With this funding secured, we will expand our programs and support a more accessible, equitable oral health ecosystem, especially for rural and other underserved communities across our state.

Read about our collective successes with our statewide partners and get a sneak peek of what’s to come in 2024.

2023 Legislative Breakfast

Additionally, NCOHC announced its legislative priorities for the 2023-2024 legislative session, which include:

1. Enacting a state budget to allow House Bill 76 (Medicaid Expansion) to take effect — we did it!
2. Creating a Rural Areas Forgivable Loan Pilot Program to encourage dentists, hygienists, and assistants trained in North Carolina to stay and bring more providers to rural communities by adding funding for dental staff loan forgiveness.
3. Promoting legislation to allow all dental staff to practice at the full scope of their training and licensure (e.g., removing regulatory burdens for hygienists and assistants).

Along with that, the North Carolina Rural Health Association, another FHLI program, announced its 2023 legislative priorities, which included 1) Medicaid Expansion and access to care, 2) health workforce pipeline, 3) maternal and child health, and 4) broadband for all.

Oral Health Day 2023: Challenges and Opportunities for the Dental Team

On June 21, 2023, we hosted Oral Health Day 2023. The theme for this year’s event was, “Challenges and Opportunities for the Dental Team.” Kathy Colville provided a keynote speech and panelists brought expertise and ideas for how North Carolina can become a healthier, more equitable state.

“We have truly amazing and exceptional people holding up an inadequate system,” said Colville, President and CEO of the North Carolina Institute of Medicine (NCIOM). She also spoke about the necessity of a systems-level approach to improving oral health and how integral oral health is to many meaningful aspects of our lives:

“The mouth communicates, eats, smiles, frowns, and makes silly faces. Our mouth and teeth allow us to show emotion, communicate our thoughts, and be human. With proper oral health, our mouth can do all of these things better.”

Other key topics discussed throughout the day included 1) Medicaid Expansion and dental reimbursement rates, 2) building community trust, and 3) advocating for and investing in an adequate, accessible, and equitable oral health care delivery model throughout North Carolina.

We hope you will join us for Oral Health Day 2024, which will be announced soon!

Community Oral Health Transformation (COrHT) Wrap-Up Convening

In October we joined forces with the Blue Cross and Blue Shield of North Carolina Foundation and the CareQuest Institute for Oral Health to host a final COrHT Initiative convening. The two-year initiative launched in 2022 to help safety-net practices pilot a value-based care payment model, following CareQuest’s “three-domain framework” that includes:

1. Tele-prevention (teledentistry)
2. Minimally invasive care (non-surgical treatment of disease)
3. Integration of oral health with overall health care

The initiative was so successful that we are excited to announce it will continue to live on! 2023 was originally intended to be the final year of the initiative, but at the 2023 convening every participating site agreed to stay involved and keep the initiative going.

We look forward to continuing to collect data, coach providers, and help explore avenues to transition to a value-based oral health system.

Western North Carolina (WNC) Oral Health Convening

We facilitated a WNC Oral Health Convening at the Lake Junaluska Conference Center in Waynesville this year with support from the Dogwood Health Trust. Dedicated oral health leaders working directly in small towns and rural communities throughout the Appalachian region came together for an engaging discussion about access to care, the current dental workforce, and policy priorities.

Following the sale of Mission Hospital to HCA Healthcare, NCOHC stepped in to help continue the convening of a WNC Steering Committee that formerly worked through the Mission Hospital Children’s Dental Clinic.

The goals of the committee and ongoing convenings are to 1) increase health care integration by facilitating collaboration among dental, medical, and public health providers, 2) expand access to oral health care for rural and other underserved communities, and 3) enhance oral health literacy for families, policymakers, and providers, and more.

Oral Surgery Mini-Residency in WNC

NCOHC partnered with the Mountain Area Health Education Center (MAHEC) to launch a mini-residency program at their WNC facilities. The goal was to better equip oral health safety-net providers in the region with the skills to meet people’s comprehensive oral health care needs, rather than referring them to an outside specialist.

The first cohort of four safety-net dentists received hands-on complex surgeries training. There is a severe shortage of specialty and surgical oral health care available to uninsured North Carolinians or those with Medicaid insurance. By “training up” already qualified providers in safety-net settings, people who would otherwise be left without options will be able to access the care they need and deserve.

Patient Advocate Pilot Program

This year marked year two of the Patient Advocate Pilot Program. Four dental practices in the WNC region hired patient advocates, employees who help people navigate the system and access the entire spectrum of health services, including oral health care.

NCOHC provided training and ongoing support, and we are continuing to collect data from the patient advocate pilot. Ultimately, we will use this information to analyze the effectiveness of the program, which will wrap up in 2024.

Participating sites include Mountain Community Health Partnership, Blue Ridge Health, MAHEC Dental Health Center and Center for Advanced Training, and the ECU Community Service Learning Center in Sylva, North Carolina.

2024 Preview: What to Expect

NCIOM Oral Health Transformation Task Force Recommendations

In January 2022, NCIOM and NCOHC launched the Oral Health Transformation Initiative, a multi-sector task force to evaluate, assess, and make oral health system transformation recommendations. More than 70 key oral and health care stakeholders, policymakers, academics, and other influencers have contributed through collaborative design to identify critical oral health opportunities in North Carolina.

The task force will release an Oral Health Transformation Task Force Recommendations Report by February 2024. The report will cover issues ranging from payment and benefit design to care integration, pathway development, and consumer experience. It will also lay out a path forward to implement key policy priorities to improve access and equity in oral health care across North Carolina.

Portrait of Oral Health Report

As we have done in the past, NCOHC engaged with UNC-Chapel Hill MPH capstone students throughout the year, enabling them to gain hands-on experience synthesizing data and interviewing key stakeholders to develop an informative report about the status of oral health in North Carolina.

This year, a group of four students are still dedicating their time, energy, and talent to put together the Portrait of Oral Health 2024. This report will be an updated version of the original Portrait of Oral Health [PDF] published in 2017 by a group of oral health professionals, government officials, and community-based organizations.

Join Us on the Road to More Equitable Oral Health Across NC

With 2023 swiftly falling into our rearview mirrors, we feel deeply grateful for the dedicated partnerships and collaborative efforts we have had the privilege to be part of. As we enter a new year, we feel excited about embarking on the open road ahead together.

Our team will continue to advocate for and advance policies and initiatives that create a healthier, more equitable oral health landscape for every North Carolinian. Stay tuned for details about events like this year’s Legislative Breakfast and Oral Health Day.

NCOHC, a Foundation for Health Leadership & Innovation program, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. Sign up for our monthly newsletter to join the network and get involved!

Medicaid Expansion finally took effect statewide on December 1st, 2023, thanks to over a decade of advocacy by countless organizations and individuals. All of us here at NCOHC and the Foundation for Health Leadership & Innovation (FHLI) are thrilled to see this important step forward for North Carolina take effect, but we will also continue working hard to improve health access and equity for all North Carolinians.

Medicaid Expansion is expected to provide over 600,000 people in the health care coverage gap, including veterans, frontline workers, small business owners, parents, and many more, with access to health insurance. This includes residents with incomes too high to qualify for Medicaid but too low to receive health care subsidies through the Affordable Care Act marketplace.

This insurance will include comprehensive health coverage, including dental, behavioral health, and vision care.

Find out whether you may be eligible for benefits and what Medicaid Expansion means for rural and other underserved communities across our state.

FAQs About Medicaid Expansion in North Carolina

Here are answers to some frequently asked questions about Medicaid Expansion in North Carolina effective December 1st, 2023:

Who is eligible for Medicaid Expansion in NC?

Most adults ages 19-64 who earn up to 138% of the federal poverty line (e.g., singles earning about $20,000/year or families of three earning about $34,000/year) may be eligible. Read more about eligibility requirements.

How can I apply for Medicaid in North Carolina?

Applying online through ePASS is the quickest option. For a step-by-step tutorial, watch this how-to YouTube video from the NC Department of Health and Human Services (NCDHHS). You can also apply in person, by phone, or by mail.

How long will it take for my Medicaid application to be processed?

It may take up to 45 days (about 1 and a half months) for your application to be processed. Apply today to access your benefits as soon as possible.

What does Medicaid health coverage include?

Medicaid includes primary care, hospital stays, maternity care, vision and hearing, dental/oral health care, and more.

What does Medicaid pay for?

Full Medicaid health care coverage pays for your doctor visits, yearly check-ups, emergency care, mental health, and more. There are no monthly fees and copays are never more than $4.

What Medicaid Expansion Means for Rural & Underserved Communities in NC

The 2023 North Carolina Rural Health Snapshot [PDF] report compiled by the North Carolina Rural Health Association (NCRHA), an FHLI program, shows that rural residents are 40% more likely to be uninsured and eligible for Medicaid Expansion.

It is expected to create an estimated 37,200 jobs, generate thousands in savings for small businesses, and bring billions of dollars in federal funding back to North Carolina annually. In addition to strengthening our economy, it will help our communities become more resilient and increase access to timely, affordable health care.

According to the NCRHA’s sweeping analysis, previous studies also show that Medicaid Expansion is associated with improved hospital financial performance and fewer hospital closures. Since 2010, when Medicaid Expansion first became an option for every state, seven rural hospitals have closed in North Carolina. We need to rebuild and expand the rural health infrastructure to effectively serve our rural and other historically underserved communities.

As hundreds of thousands of people gain access to coverage through Medicaid Expansion, we must continue to work at every level to create a more accessible and equitable health care system. This means expanding the number of culturally competent providers who accept Medicaid insurance for all types of care, including oral health and specialty services.

Stay Tuned for More on Medicaid Expansion in North Carolina

FHLI and all our programs will continue to advocate for all North Carolinians and leverage policies that increase health care access and equity across our state. While Medicaid Expansion is an important win expanding access to care across our state, much work will still need to be done to ensure those who gain coverage have access points to receive quality care.

Follow us on social media and sign up for our newsletter to stay up to date about Medicaid Expansion.

 

At the 2023 NC Dental Hygienists’ Association Annual Session, Christina Bridges, QOM, LMBT, owner of Myofunctional Matters Therapy Partners, presented about myofunctional therapy. NCOHC sponsored the event, which provided hygineists from across the state with opportunities to gather, share ideas, and learn about new and interesting advancements in oral health.

Although highly relevant to oral health, you may be wondering, what is myofunctional therapy?

In Christina’s words, “myofunctional therapy is physical therapy for the muscles of the tongue, face, lips, throat, and soft palate to treat dysfunction.” It retrains muscle function in these body parts, which make up the orofacial complex.

Integrating Oral & Whole-Body Health

Christina noted that medical and dental professionals tend to treat the body and mouth separately. Yet, integrating and coordinating services is crucial to increasing access and equity in our health care systems.

She said, “As dental professionals, we can get so accustomed to seeing things through our own lenses that we forget to look at the person as a whole. We are intricately made beings and no system in the body works in isolation. Myofunctional therapy is a magical place where medical and dental professionals come together in true preventive care. Patients win when we collaborate!”

Benefits of Myofunctional Therapy for Patients

In her practice, Christina uses myofunctional therapeutic techniques as well as massage and bodywork to help patients with orofacial myofunctional disorders (OMDs). A few examples of OMDs include tongue ties, functional airway obstruction, mouth breathing, temporomandibular joints (TMJ) pain and discomfort, and many more.

Christina said the benefits of myofunctional therapy vary depending on the patient’s age and OMD. It can help children address issues early and prevent them from escalating into more serious problems. It can also help teenagers and adults find relief from pain and discomfort:

Benefits for Children	Benefits for Teenagers & Adults
Correct craniofacial growth/airway development Improve sleep quality (can also improve behavior and school performance) Stop bedwetting, snoring, sleeping walking, and night terrors Reduce dental decay and improve diet due to increased willingness to try new foods Prevent orthodontic relapse/eliminate need for orthodontics	Improve nasal breathing and sleep quality (can also increase energy) Improve or eliminate TMJ pain or discomfort Reduce sleep apnea/hypopnea events Reduce/stop bruxism (teeth grinding) Improve periodontal stability of teeth Prevent orthodontic relapse Improve ease of swallowing Reduce gag reflex sensitivity Reduce muscle tension in the head/neck

Life-Changing Outcomes: Myofunctional Therapy Success Story

Screening for myofunctional disorders can help connect patients with life-changing care. The right treatment can enable patients to speak, smile, and feel more confident, reduce pain, and improve quality of sleep, breathing, eating, and overall health.

One of Christina’s patients, a male teenager named Joseph, was originally referred to an orthodontist due to an undiagnosed and untreated tongue tie. He felt tired all the time and had difficulty waking in the morning. When Joseph came to Christina and her team, they quickly diagnosed the issue and performed myofunctional therapy as well as a tongue tie release.

Afterward, Joseph’s mother reported that he sleeps better now, has more energy, and is alert, calmer, and more productive. His posture has also improved; he stands up straight, whereas before he hunched over and had to push his chin out to breathe. For Joseph, and many patients like him, myofunctional therapy has improved his quality of life in meaningful ways.

Telehealth Myofunctional Therapy

Myofunctional therapy can also be done via telehealth. This can help reduce certain barriers like long journeys and wait times. However, many patients still face challenges related to internet access and reliability due to limited broadband infrastructure in rural and other areas.

According to Christina, telehealth works well for older children and adults. She says the same process can be performed as in an office setting. Telehealth is difficult for young children, though, who see better results with in-person sessions. Currently there are only a few myofunctional therapists in NC, making telehealth a vital option for age-appropriate patients.

Barriers to Accessing Myofunctional Therapy

Christina says, myofunctional therapy is rarely covered by insurance, especially when performed by those with a dental background. Unfortunately, prohibitively high costs leave many patients without a way forward. Her hope is that one day these services will be covered by dental or medical insurance. However, she sees great value in dental professionals providing these services because of how it builds on oral health care expertise.

Screening Patients for Myofunctional Disorders

NCOHC’s Program Manager, Heather Edly, JM, RDH, BSPH, CHES, said there has been a spike in myofunctional disorders like TMJ pain due to stressors exacerbated by COVID-19. Often, the only option for dental hygienists is to recommend a mouth guard, which may fail to address the root cause.

Learning to screen for myofunctional disorders can help hygienists connect patients to other types of care and improve oral health outcomes.

Christina said, “Every hygienist should know the signs and symptoms of myofunctional disorders and how to screen for them. As the primary preventive oral healthcare professional, the dental hygienist is the perfect professional to do this. Addressing these myofunctional issues is often the most preventive service we can offer. This is because myofunctional therapy addresses the root cause of so many dental and health issues experienced by our patients.”

If interested, you can learn about key clinical markers for myofunctional disorders here. To stay current with oral health news in North Carolina, sign up for the NCOHC monthly digest newsletter today.

For years, Medicaid Expansion in North Carolina has been health advocates’ proverbial white whale. When it comes to policy changes that could dramatically improve access and equity in health care across the board, Medicaid Expansion would be a huge step in a positive direction.

North Carolina has unfortunately remained among the 11 states across the country that haven’t expanded Medicaid since its enabling federal legislation, the Affordable Care Act (ACA), was signed into law in 2010.

A Fresh Opportunity for Medicaid Expansion

As the 2023-2024 legislative session kicks off, members of the state House of Representatives are striking a new tune. On Feb. 8, 2023, Three Republican representatives and one Democrat filed House Bill 76, which will expand Medicaid in the state if passed into law.

A bipartisan group of 49 legislators had signed onto the bill as co-sponsors. On Feb 15, the bill passed its first two votes in the North Carolina House before passing its third and final vote on Feb 16. Now, the legislation is in the North Carolina Senate’s hands. If it passes through the upper chamber, it will head to Governor Roy Cooper’s desk to be signed into law.

North Carolina is one of 26 states (including Washington, D.C.) to offer extensive oral health benefits to both children and adults with Medicaid insurance. Because of this, anyone who gains coverage under Medicaid Expansion would gain oral health benefits.

What is the Coverage Gap?

The ACA enabled Americans to purchase health insurance through a government-managed marketplace, known as the “exchange.” To qualify for health insurance and tax credits through the exchange, individuals or families must earn enough income to be at or above the federal poverty level (FPL).

In North Carolina, Medicaid insurance only kicks in at or under 42 percent of the FPL, meaning anyone between 43 and 100 percent of the FPL have no options for health insurance. This is the coverage gap.

For example, a single parent with one child would need to earn $18,310 per year to qualify for tax credits and health insurance through the exchange. If they earn less than $18,310 but more than $7,240, however, no insurance options would be available.

Source: Care4Carolina

Medicaid Expansion was a provision of the ACA. Unlike the exchange, expansion was made voluntary on a state-by-state basis. States that choose to expand Medicaid fill in that gap, offering Medicaid services to anyone up to 100 percent of the FPL.

By The Numbers: Expansion’s Potential for North Carolina Health

More than 500,000 North Carolinians stand to gain health coverage if Medicaid Expansion is passed. Of those who would gain coverage, more than three quarters are employed and one in three are parents.

Financially, North Carolina stands to gain significantly if it closes the health care coverage gap. By expanding Medicaid, North Carolina could:

Create 37,200 jobs

Bring $4 billion in federal funding into the state every year

Save businesses $1,685 in lost productivity per employee per year

A Long Road Ahead for 2023 Medicaid Expansion

Senate Majority Leader Phil Berger has signaled that his chamber may not be as eager to take up the House’s version of Medicaid Expansion. There are several provisions that appeared alongside expansion in a Senate proposal during the 2021-2022 session that are not part of this year’s bill.

As House Bill 76 moves through the chambers, elected officials will have several chances to add or amend the legislation’s text. The NCOHC team is tracking this legislation and will post updates as it moves forward, so be sure to stay tuned for updates.

NCOHC, a program of the Foundation for Health Leadership & Innovation, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. To stay up-to-date and get involved, join us today as a North Carolinian for Change.

Goodbye 2022, hello 2023! What a year…

From a loooooong midterm election season to the World Cup, inflation, the war in Ukraine, the continuation of the COVID-19 pandemic, and so much more, there has been a lot on our minds. So much so that it is difficult at times to remember the accomplishments we all certainly made throughout the year.

Here’s a snapshot of NCOHC’s 2022. Our coalition of oral health advocates accomplished a lot, but there is always more to do as we usher in 2023.

Oral Health Day 2022

We decided to go big for Oral Health Day 2022, tackling the topic, “Equity in Action,” to try and define how we can all work toward a more accessible oral health system.

Dr. Eleanor Fleming gave the keynote address, highlighting systemic factors that impact our teeth and the need for antiracist collaboration to overcome barriers to care.

Oral Health Day attendees heard from a lively panel featuring providers, payers, government, and community members discussing their personal experiences and paths forward toward an improved oral health system.

Oral Health Day 2022 was the first to span two days. On the second day, NCOHC invited all participants to a collaborative workshop where we worked together to identify actionable policy solutions to oral health inequities.

Altogether, we were beyond impressed with the engagement and collaboration we witnessed over the course of Oral Health Day 2022, and we are excited to see that groundwork come to fruition in the coming years!

Student Partnerships Galore

NCOHC was fortunate to work with so many incredible student interns this year. You’ve probably already seen some of their work, and you will continue to see their content published in 2023.

Amber Moholehski – Amber returned to NCOHC after a prior internship through Campbell University. This past spring and summer, she worked on analyzing the existing landscape for dental assisting education in North Carolina, identifying key needs and options for future policy advocacy.

Sydney Patterson – Sydney is a public health student at East Carolina University. She joined NCOHC this past summer to write blog posts about various oral public health topics.

Parth Patel and Nidhi Oruganti – Parth and Nidhi worked together this past summer to explore North Carolina’s Medicaid system and innovative ways to incentivize more private practice providers to participate. Both Parth and Nidhi are undergraduate students at UNC-Chapel Hill.

Bryan Francis – Bryan worked with us during her fall semester to expand upon Parth and Nidhi’s summer work. She focused on policy pathways to expand and enhance the existing dental safety net. Expect to see more from Bryan, Parth, and Nidhi’s work in 2023!

Campbell University 2022 Cohort – Every year NCOHC has the pleasure of working with a cohort of Campbell University public health students. This year, Austin Blake, Juniki Langle, Jordan Moseley, and Matthew Pacofsky worked with us to explore dentist-administered HPV vaccines.

COrHT Initiative

In 2022, NCOHC and the CareQuest Institute for Oral Health fully launched the Community Oral Health Transformation (COrHT) Initiative in North Carolina. With 14 clinics onboarded into the program, we are putting resources into communities across our state to explore a value-based model of care. We hope this initiative sets the stage for evidence-based policy reform to structurally improve access and equity in oral health care for everyone in North Carolina.

Oral Health Transformation Initiative

Beginning in January 2022, NCOHC launched another initiative in partnership with the North Carolina Institute of Medicine (NCIOM). The Oral Health Transformation Initiative is currently in its second phase, where a task force is engaging in a 12-month evaluation of oral health transformation models from across the United States.

You can expect this task force to wrap up its work in 2023, with a full report on its findings to follow.

Oral Surgery Mini-Residency

In a continued effort to better equip our existing oral health safety net providers to meet the comprehensive needs of the people they serve, NCOHC partnered with the Mountain Area Health Education Center (MAHEC) to launch a mini-residency program.

This program will “train up” existing safety net dental teams, equipping providers with the confidence to offer more complex surgeries themselves rather than referring patients to specialists. For uninsured people and those with Medicaid insurance, accessible specialist care can be incredibly difficult to find.

In 2023, the first mini-residency cohort will begin their studies at MAHEC’s western North Carolina (WNC) facilities.

Patient Advocate Pilot

NCOHC solidified the framework for its Patient Advocate Pilot Program, which will fully launch in 2023. Across WNC, four practices have worked with NCOHC to prepare contracts and set the groundwork to hire “patient advocates,” employees who will help people navigate the system and access the care they need.

Brush Book Bed

Wrapping up nearly two years of planning, NCOHC was able to launch a pilot Brush, Book, Bed program with five pediatric primary care practices in WNC. NCOHC and its partner organization, Reach out and Read, were able to provide thousands of books and oral health kits to these practices, which were trained to provide basic oral health education and fluoride varnishes to their early childhood patients.

The End of a Productive Legislative Biennium

2023 marks the beginning of a newly elected legislature in North Carolina. NCOHC is excited to build upon many legislative wins from the past two years, from Executive Order 193 authorizing dentists to join the COVID-19 vaccination effort to Session Law 2021-95 and the state budget’s extension of the North Carolina Medicaid for Pregnant Women (MPW) program.

In 2023, we look forward to working with legislative and advocacy partners to continue improving the oral health status of all in our state.

Looking Forward to 2023

As we reflect on 2022, we are humbled by the incredible partnerships and coalitions we have the opportunity to be a part of. Our goal is to create a North Carolina where everyone can access the care they deserve, and 2022 represented many steps in that direction.

There is still so much work to be done, but we are entering 2023 confident and energized for what is to come!

NCOHC, a program of the Foundation for Health Leadership & Innovation, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. To stay up-to-date and get involved, join us today as a North Carolinian for Change.

After four years as the director of NCOHC, Dr. Zachary Brian has taken the next step in his career.

Dr. Brian will join UNC-Chapel Hill with a dual appointment with the Adams School of Dentistry and the Gillings School of Global Public Health. While his time with NCOHC has come to an end, it is clear that his impact on oral health in North Carolina is far from over!

Since he joined FHLI in 2018, Dr. Brian has led the NCOHC team along with countless partners and advocates to policy victories that are actively transforming access to care in North Carolina. His leadership was fundamental in achieving regulatory rule changes allowing more children to receive preventive oral health care and passing landmark oral health legislation, making North Carolina’s dental landscape more equitable and accessible.

From key pandemic provisions allowing dentists to administer COVID-19 vaccines to recent expansion of North Carolina’s Medicaid for Pregnant Women program, the entire NCOHC team is incredibly proud of what our broad coalition has been able to accomplish during Dr. Brian’s tenure.

Dr. Brian’s impact certainly won’t end with his departure. This past year, NCOHC was able to launch several programs and initiatives that also promise to positively transform oral health access and equity. The COrHT Initiative, the Oral Health Transformation Initiative, Brush Book Bed, and the Patient Advocate Pilot Program are all ongoing projects exploring new and innovative ways to get care to those who need it most.

The NCOHC team is certainly sad to see Dr. Brian go, but we are also well-equipped to continue our important work as we head into the new year. Dr. Steve Cline, who has served on NCOHC’s advisory team and FHLI’s board, has stepped in as interim vice president of oral health. Crystal Adams, formerly our associate director, has received a well-deserved promotion to director of NCOHC.

We are incredibly proud of Dr. Brian. From the entire NCOHC team, thank you for your tireless work to improve oral health access and equity in North Carolina!

NCOHC, a program of the Foundation for Health Leadership & Innovation, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. To stay up-to-date and get involved, join us today as a North Carolinian for Change.

Daniel E. Dawes began his 2020 book, “The Political Determinants of Health,” with a story about a farmer looking for land to plant an orchard. He finds a plot of land split into three sections: one with rocky soil, one with poor soil, and one with rich soil.

In the story, the farmer planted fruit trees in all three sections of his newly acquired land. As you can probably guess, the trees in the rich soil grew fast and strong, producing abundant fruit while the trees in the other two sections struggled, withered, and died off.

While the trees’ outcomes could be attributed to their respective soil conditions, location wasn’t the only factor at play. The farmer paid extra attention to the best-performing trees; the ones planted in the fertile soil. Because the trees in the other sections didn’t grow as fast or as strong, he paid less attention to them and provided them with less care.

Dawes’ lesson from this story is that people’s health outcomes are often based on limited choices and opportunities. Each tree planted had the same innate function: to grow and bear fruit. The trees that died didn’t decide they wanted to be unhealthy. Rather, they succumbed to a lack of resources in their immediate surroundings.

In this story, the farmer is a stand-in for the role of a government. From there, Dawes expands into a new framework for understanding health outcomes, equity, and the inequities that plague health care in America.

What are the “Political Determinants of Health”?

The political determinants of health are an attempt to explain the various ways that politics – voting, government, and policy – create the social drivers of health and impact actual health outcomes, access to care, and more.

Dawes is a public health policy expert, educator, researcher, and executive director of the Satcher Health Leadership Institute at the Morehouse School of Medicine. His “Allegory of the Orchard” is the foundation for his political determinants of health model.

The political determinants of health can be broken into three categories: voting, government, and policy. According to the Satcher Institute, “The political determinants of health create the social drivers — including poor environmental conditions, inadequate transportation, unsafe neighborhoods, and lack of healthy food options — that affect all other dynamics of health.”

Image source: Daniel E. Dawes (2020), The Political Determinants of Health, John Hopkins University Press

An Argument for Multiple Approaches

Advocacy groups and health care organizations that seek to resolve existing inequities often fall into one of two buckets: those that seek to impact policy and other structural forces; and those that seek to directly allocate resources to those in need.

The political determinants of health illustrate the important fact that little can be done to permanently resolve inequities if overarching structures are not changed. However, that doesn’t mean organizations seeking structural policy change have the only “right” answers. Systems change takes a long time, and people experiencing health inequities need help now.

Resource Allocation

That’s where resource allocation comes in. Providing low-cost health care, transportation services, free equipment, and other means of direct aid are equally necessary, even if they don’t address the root causes of inequity.

As health advocates work to create more equitable systems, organizations can work together to find a balance, meeting immediate needs on one hand while influencing policy and creating structural change on the other.

Addressing the Political Determinants of Oral Health

As NCOHC and our partners work to build a more equitable oral health system, policy will continue to play a leading role. Understanding the interaction between the political determinants of health and the social drivers of health also underscores the need for a diverse coalition of advocates working toward these structural changes.

Policy changes that range from specific, targeted reforms allowing hygienists to fill all the roles they are trained for to broader updates to the Medicaid structure are necessary to increase access to care across the state. However, reforming the Dental Practice Act isn’t the only thing that can be done to impact oral health. Affordable housing, fair wages, and healthy food advocacy will also impact oral health, and vice versa.

The bottom line is that everyone, everywhere has a role to play in creating better systems, and all those roles, no matter how niche, fit into a network of advocacy that must work together if we are to succeed in creating a better future for all North Carolinians.

NCOHC, a program of the Foundation for Health Leadership & Innovation, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. To stay up-to-date and get involved, join us today as a North Carolinian for Change.

A recent announcement from the Centers for Medicare and Medicaid Services (CMS) signals a possible expansion of dental services available for Medicare beneficiaries.

Proposed changes to the procedures covered under Medicare would be a significant step in the right direction. NCOHC commends CMS for this historic move toward a more equitable oral health care system for older adults, and look forward to further expansion of services to ensure comprehensive oral health care for a population that is sadly often left out of the conversation

Specific details are still somewhat uncertain, but any changes to Medicare’s dental coverage would be limited to its current framework in which dental services are tied to other medical procedures.

Background: Medicare and Dental Coverage — Reinforcing a Historic Divide in Care

Medicare is currently only allowed to reimburse for limited dental procedures deemed necessary to treat a covered medical condition. For example, an infected tooth removal may be covered if the patient is about to begin radiation treatment for certain cancers.

The structure as it currently exists ignores several factors, including the fact that oral disease can significantly impact a person’s quality of life, regardless of other medical conditions. It also ignores the oral-systemic connection and the many diseases and health conditions that can result from poor oral health.

Nearly a year ago, NCOHC Director Dr. Zachary Brian published his thoughts on the need for a Medicare Dental Benefit.

In Brian’s words, “Dental coverage under Medicare is sorely needed, but to make Medicare dental benefits anything but universal diminishes the message that public health-minded dentists have fought so hard to advance: that oral health is overall health.”

Any changes to Medicare’s dental coverage outside of the current framework tying oral health care to other medical procedures would need to happen through legislation. Earlier in 2022, Congress appeared on the brink of passing a Medicare dental benefit. The change, championed by Senator Bernie Sanders (I-VT), nearly made it into the Inflation Reduction Act. The provision didn’t make it into the bill, but momentum appears to be building behind a more comprehensive dental benefit.

What Could Change with Dental Benefits Under Medicare, and When?

The proposed changes to Medicare coverage put forward by CMS could take effect as early as January 2023. The changes would include an expansion of covered dental services associated with the success of other covered medical procedures – they wouldn’t include any standalone dental services.

While this expansion is necessary, NCOHC also looks forward to more movement in support of adding a full dental benefit for Medicare participants. The timeline of this type of action is much more uncertain and will depend in no small part on the outcome of the 2022 midterm elections.

A Call to Action

Older adults are too often left out of the conversation when it comes to oral health care, especially preventive oral health care. Our current structures reinforce a mindset that certain oral health outcomes are inevitable.

The reality, however, is that most oral disease is entirely preventable, even for older adults. That means that tooth loss and the need for dentures, for example, are not simply foregone conclusions associated with age. With proper care, anyone can live a full life with their natural teeth.

An expansion of Medicare services to include a dental benefit is a necessary step as we work toward a more equitable future. This change requires legislation at the national level, and it is on all of us to help advocate for this change.

NCOHC, a program of the Foundation for Health Leadership & Innovation, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. To stay up-to-date and get involved, join us today as a North Carolinian for Change.

There are stories about “midnight raids” in the 1960s depicting disability rights advocates in Berkeley, CA, smashing and re-paving curbs so they would slope down to meet the street at intersections, allowing people in wheelchairs to cross.

These stories aren’t entirely accurate — although some “midnight raids” certainly did happen. What is true is that activism in the 1960s did result in a revolution in accessible infrastructure design, beginning with “curb cuts.”

In 2018, the podcast 99% Invisible covered the history of curb cuts, outlining the story of disability rights activist Ed Roberts, who contracted polio at 14 years old and ended up paralyzed below the neck.

Roberts joined a group of student activists at UC Berkeley called the “Rolling Quads,” who led the charge to get curb cuts installed across the city. While those curb cuts weren’t all installed during so-called midnight raids, they did result from grassroots advocacy targeting the Berkeley City Council.

Fast forward to today and curb cuts are nearly ubiquitous across the US, in part thanks to the Americans with Disabilities Act, another outstanding demonstration of the power of policy advocacy.

“The Curb-Cut Effect”

The “curb-cut effect” is now a term used to refer to the many ways addressing one group’s unique needs can benefit everyone. Research has shown that curb cuts positively impact nearly everyone, from mothers with strollers to elderly pedestrians, travelers with suitcases in tow, and more.

There are many examples of curb-cut effects in everyday life. Outlined by the 99% Invisible podcast, captions meant for the hard of hearing help everyone trying to watch a ball game in a noisy bar. Entering a building with your hands full is much easier with automatic door buttons installed for wheelchair users.

The hosts even noted that the football huddle was actually invented when Gallaudet University, a school for the deaf and hard of hearing, played other deaf football teams and wanted to hide their signs from being seen.

The Curb-Cut Effect in Oral Health Policy

In oral health, NCOHC believes the curb-cut effect is present across policy proposals to increase access and equity in care. As the saying goes, “A rising tide lifts all boats.”

Example: Emergency Department Diversion

North Carolinians visit emergency departments (EDs) for dental-related needs at twice the national rate, a trend that accounts for an annual $2 billion in health care bills across the United States.

The cost of care at an emergency department is very high. On top of that, most EDs are not equipped to resolve oral disease — they can only mitigate it. This means that if you visit an ED with a toothache, you are likely to receive an opioid and an antibiotic, resolving pain and swelling temporarily. Until you receive a root canal or other surgical treatment, however, that pain and swelling will return, landing you right back in an ED.

So, for the population making ED visits, the benefits of diversion to an oral health provider are clear: the cost would be lower, and oral disease could actually be resolved, removing the need for repeat visits (and bills).

What about the curb-cut effect in this situation? For one, diversion programs could reduce the demand for ED services, reducing wait times for everyone else who needs emergency care.

Additionally, a large portion of the population visiting EDs for oral health care do not have insurance or the income to pay expensive out-of-pocket bills. Because of this, there is significant opportunity to reduce uncompensated care costs through policies and programs that would divert care to oral health providers.

There are a variety of ways that uncompensated care costs are covered, including billions in public funds. For example, the federal government paid around $21.7 billion to cover uncompensated care costs in 2017. Reducing uncompensated ED oral health care costs could certainly impact the amount of tax dollars doled out each year for these services.

The Need for Equity

As policies are enacted to address specific population needs, equity must always be considered. Looking back at historic policies, even when curb-cut effects happen, inequities persist.

Take the GI Bill as an example. The legislation that provides a range of benefits for those who served in the U.S. military has positive impacts reaching far beyond its target population. In the years after World War II, the GI Bill was partially responsible for an economic boom for contractors as the demand for housing increased alongside a rise in homeownership.

Unfortunately, red lining policies prevented Black veterans and their families from benefitting from the bill, cutting an entire population out of the positive impacts in a way that persists today.

For oral health providers and advocates, two things are important to remember: 1) specific, targeted legislation can have far-reaching benefits, and 2) steps must be taken to ensure that inequities are addressed whenever policy is enacted.

NCOHC, a program of the Foundation for Health Leadership & Innovation, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. To stay up-to-date and get involved, join us today as a North Carolinian for Change.

As the monkeypox outbreak continues to spread, we sat down to explore what oral health connections exist, what is currently being researched, and what you should know about monkeypox with relation to oral health

What is Monkeypox?

Monkeypox is a viral disease with symptoms similar to, but much milder than, smallpox. It is rarely fatal, and is primarily spread by close personal contact, often skin-to-skin.

Monkeypox was first discovered in 1958 in monkeys being kept for research. The first human case was recorded in 1970.

Common symptoms of monkeypox include fever, fatigue, and flu-like symptoms. The disease also presents with a rash on the skin reminiscent of smallpox. While it should be taken seriously, it is much less deadly. In fact, of the 14,000 cases worldwide as of July 20, 2022, only five deaths had been reported.

Oral Symptoms of Monkeypox

Overall, oral manifestations of monkeypox appear to be relatively rare. A recent report in the Journal of Oral and Maxillofacial Surgery did outline two cases of oral lesions associated with monkeypox.

In both cases, the oral lesions appeared before the skin rash. In the first case, oral lesions were the first symptom.

The Centers for Disease Control and Prevention (CDC) is urging providers to be on the lookout for symptoms that could be associated with monkeypox, including oral manifestations. Although oral symptoms seem to be relatively uncommon as of August 2022, providers with patients presenting oral lesions might consider monkeypox among potential causes.

What Else Should Oral Health Providers Know?

The CDC has published guidance for providers treating patients with monkeypox. The organization outlines considerations for infection control and provider safety, including PPE, waste management, and other precautions to prevent transmission.

Learning from the Past

Many are discussing the similarities between the current monkeypox outbreak and HIV. For many providers, it is easy to look back on the early 1980s with regret for how the community responded to the emerging HIV epidemic. Too many patients with HIV were met with fear and shame, unable to receive the care they needed, including oral health care.

We recently sat down with Dr. Lewis Lampiris, who was a practicing dentist in the 1980s as the HIV epidemic emerged. His story offers insight into the important role oral health providers need to play when a new disease emerges, and we believe it can offer guidance as we navigate the monkeypox outbreak.

“As a dentist I feel responsible for taking care of everybody who walks through that door, regardless of who they are, what they look like, what kind of condition they are in,” said Lampiris. “It’s an obligation to take care of people. That comes part and parcel with your degree as a dentist, as a physician.”

NCOHC, a program of the Foundation for Health Leadership & Innovation, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. To stay up-to-date and get involved, join us today as a North Carolinian for Change.