Author: NC Oral Health Collaborative

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.

Teeth aren’t the only things in your mouth that need to be cared for. From your gums to your tongue, molars to canines, everything in your mouth needs proper care to stay healthy. In this blog post, we’ll take a look at what you can do to care for your gums — and why it’s so important.

How to Care for Your Gums

When it comes to gum health, you fortunately don’t have to learn a bunch of new rules. The basics are pretty much the same:

1. Brush twice per day with fluoride toothpaste
2. Floss consistently
3. Visit the dentist regularly for a routine checkup

While the routines are the same, there are a few tips and tricks you can learn to take better care of your gums.

But First, Why Does Gum Health Matter?

Your gums and underlying bone play an important role in your mouth: they keep your teeth in place. If they aren’t healthy, that job can be a harder one to do. Poor gum health can lead to disease that can affect other parts of your body. In fact, gum disease has been linked to heart disease, diabetes, and even dementia, among other conditions.

The bottom line: healthy gums reduce risk of oral infections, tooth loss, and cavities along with heart disease, diabetes, and other negative health impacts associated with the oral-systemic connection.

There are two main types of gum disease:

• Gingivitis — Gingivitis is a rather mild gum infection with symptoms like swelling and bleeding. It can typically be treated easily, just by following the three steps above (brush, floss, visit the dentist).
• Periodontitis — Periodontitis, on the other hand, is the more serious gum disease that comes about when gingivitis is left untreated. Its symptoms include the same swelling and bleeding caused by gingivitis, along with tooth sensitivity, pain while chewing, receding gums, and bone loss that can lead to loose teeth or tooth loss.

Treatment for Gingivitis and Periodontitis

With periodontitis, the infection impacts your gum tissue as well as the bones that hold your teeth in place. These cases can sometimes be treated non-surgically if they aren’t too far advanced.

Gingivitis or periodontitis can usually be treated without surgery. Advanced cases of periodontitis may require more invasive care, however, potentially including surgery. Depending on the severity, the disease may require a variety of different surgeries, bone grafts, and other methods of regenerating lost tissue.

Habits for Good Gum Health

• Brushing — To avoid gum disease, make sure to brush all sides of your teeth in a circular motion. Be gentle along your gumline, but make sure that you brush where your gums meet your teeth. Bacteria can easily build up along the gum line, which is a recipe for gum disease and tooth decay if left unattended.
• Flossing — When you floss between your teeth, don’t just go straight in and out. Move the floss back and forth as you ease in. This helps make sure you are dislodging any food residue or bacteria that has built up between your teeth, and it will help clean and strengthen your gums.
• Fluoride — Finally, consider adding a fluoride mouthwash to your oral health care routine. Mouthwash isn’t a replacement for brushing and flossing, but it can help add an extra layer of cleaning and protection.

Other Factors Impacting Gum Health: Food & Drink

A well-balanced diet can help strengthen your gums. Nutrients like vitamin C, vitamin D, omega-3 fatty acids, various B vitamins, and zinc have all been linked to gum health. Vitamin C, for example, plays a major role in collagen production, an important component of gum tissue. Vitamin C deficiency can result in bleeding or inflamed gums.

Smoking and drinking are also important considerations when it comes to gum health. The best recommendation is always to quit smoking altogether — both for cancer prevention and overall oral health management — and limit alcohol consumption. If you do smoke and/or drink, however, staying hydrated is a good way to mitigate some of the negative effects.

Drinking water won’t prevent the oral and pharyngeal cancers that smoking causes, but it will help with dry mouth that can result from tobacco or alcohol consumption. Click here for more about the ways that dry mouth can lead to tooth decay and gum disease.

All in all, gum disease and the habits that help prevent it follow the same narrative of most oral disease. While it is entirely preventable, if left unattended, gum disease can get seriously out of hand, leading to poorer overall health and more invasive, expensive treatments. Good personal habits go a long way, but they must be paired with affordable, accessible, preventive care.

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.

It’s no secret that there is an oral health care access gap for North Carolinians with Medicaid insurance. It’s practically a rule of thumb that if you are born poor, you will have less access to health care services (medical and dental), and in turn will likely end up with greater incidence of dental disease.

There are many reasons why this is true. From the food on your table (click here to learn more about how where you live can impact access to healthy food) to the transportation you can access, the distance between your home and the nearest oral health care facility, and more, social determinants of health can significantly impact access to care.

In fact, an estimated 80 percent of a person’s health is the result of factors outside of a medical office.

That isn’t to say that the oral health care system itself is an insignificant factor. For a variety of reasons, there simply are not enough providers who accept Medicaid insurance, which creates large areas where adults and children alike cannot access the care they need and deserve.

North Carolina Medicaid Oral Health “Secret Shopper” Survey

The NCOHC team recently conducted an internal secret shopper survey in Western North Carolina, a region with significant oral health care access issues for Medicaid-insured individuals. Over the course of several weeks, NCOHC staff contacted oral health care providers listed on the website Insure Kids Now to inquire about an appointment for a seven-year-old child with Medicaid insurance.

Of 119 WNC locations, 50 were listed as accepting children with Medicaid insurance. Fifty-seven were listed as not accepting Medicaid, and 12 did not indicate whether or not they accept Medicaid. Upon calling each location, NCOHC found that only 35 locations were currently accepting Medicaid-insured children. A total of 70 did not accept Medicaid, and NCOHC staff were unable to reach the remaining 14 locations. Three counties were found to not have a single Medicaid-accepting oral health care provider.

Note: The NCOHC survey was conducted to serve as a preliminary look at the oral health care landscape in Western North Carolina, an area with significant access concerns. And while it was not conducted as a comprehensive research project, NCOHC’s findings do reflect some of the access gaps identified in the recent American Dental Association Health Policy Institute’s report on Medicaid access in North Carolina. Particularly, maps in the report of meaningful pediatric Medicaid dental office locations starkly visualize the relative scarcity of providers in the western part of the state compared to North Carolina’s urban centers.

Increasing Medicaid Acceptance by Oral Health Providers in North Carolina: What Can We Do?

It’s important to ask why these access gaps occur. Even when there are dental providers in an area, why do so many not accept Medicaid insurance?

Addressing Payment Disparities

Medicaid reimbursement rates for oral health care tend to be lower than the rates private insurers pay, often falling below the actual cost of performing some procedures. For many private practices, this can pose a significant financial issue.

Possible paths forward include increasing reimbursement rates to a level where Medicaid is on par with private insurers and simplifying the filing and appeals processes.

Strengthening the Oral Health Care Safety-Net

Another option is to patch up the holes in our “safety-net” facilities. Across North Carolina, Federally Qualified Health Centers (FQHCs), local health departments, and other safety-net facilities care for large numbers of our state’s residents who have Medicaid insurance or are uninsured or underinsured.

FQHCs, for example, receive federal funding that helps reduce the financial gap between Medicaid reimbursement rates and private insurance rates (as well as the gap between patients with insurance and those who can’t pay at all). Despite this support, many FQHCs still struggle to cover their costs. Additional funding will be needed to ensure the sustainability of these organizations’ efforts.

Similarly, local health departments and other safety-net facilities often receive funding from the government, charitable organizations, and private donors that help them see any patient, regardless of their ability to pay.

Systems-Level Reform to Address Medicaid Oral Health Care Access in North Carolina

To solve the Medicaid access gap issue, we must ask the right questions — and address the systemic challenges driving these disparities. For example:

• What policies or other initiatives could strengthen the safety-net environment, allowing facilities like FQHCs to expand into regions that are underserved?
• Can we achieve policy reform to increase reimbursement rates?
• If so, how long will that take, and what can we do to help those in need in the meantime?

The solution to North Carolina’s Medicaid oral health care access issues will likely require organizing to build support for changes to the Medicaid system while also driving policy change to better support the safety net. No less important, however, and as NCOHC always emphasizes, we are far more likely to solve the problem through collaboration.

Doing nothing simply isn’t an option.

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.

This year’s Oral Health Day was a tremendous success!

Oral Health Day 2022 centered the work necessary to create a truly equitable oral health system. Following the theme “Equity in Action,” speakers discussed disparities and the actionable steps we can all take to improve oral health for everyone, from pursuing racial equity to increasing access for individuals with disabilities, and more.

If you missed the event and want to enjoy the full experience, you can find the event recording here.

Dr. Eleanor Fleming’s Keynote Address

Dr. Eleanor Fleming kicked off the first day with rousing remarks on race and racism in oral health, highlighting systemic factors that impact our teeth and the need for antiracist collaboration to overcome barriers to care. Dr. Fleming currently serves as assistant dean of equity, diversity, and inclusion at the University of Maryland School of Dentistry and is a nationwide leader in this work.

 

Fleming discussed the social determinants of health and the many ways that the world around us can impact our health. Most of her remarks, however, centered around antiracism, tying the need for antiracist effort to the ultimate goal of equity in oral health care.

Fleming identified ways that racism goes beyond hurting individual people or groups to “actually sap the strength of the whole society.” She said that we all have skin in the game when it comes to actively challenging racism at the personal, structural, and systemic levels.

 

Panel Discussion

After Fleming’s keynote address, Dr. Lewis Lampiris, associate adjunct professor at the University of North Carolina Adams School of Dentistry, moderated a lively panel discussion that included representatives from community, insurance, philanthropy, academia, and more.

Marie Helms, a mother of two, kicked off the panel talking about her experience finding oral health care for her daughter, who was diagnosed with spastic quadriplegic cerebral palsy at 6 months old.

 

Panelist Rachel Radford followed with examples of hardships her family has experienced finding oral health care for her two children, both of whom have autism.

 

Radford also talked about her own experience with oral health care. She didn’t see a dentist until she was 22 years old and was made fun of by her first provider for being nervous. She talked about the way this made her feel and how dental anxiety stemming from that incident made it difficult to continue seeking oral health care.

Continuing the conversation, Dr. Amadeo Valdez gave perspectives on equity issues from his roles as an oral health care provider and dental residency program director. Valdez works for the Mountain Area Health Education Center, the AHEC program serving Western North Carolina.

 

Lampiris asked Curt Ladig, president and CEO of Delta Dental of North Carolina, how private insurers can contribute to equity in oral health care. Ladig explained that his core beliefs center around access for everyone, something he brings to his work as he guides the direction of the insurance company.

 

Yazmin García Rico, director of Hispanic/Latinx policy and strategy at the North Carolina Department of Health and Human Services, joined the panel discussion to speak from her perspective within government. She talked about the need for a more robust workforce spanning the entire state.

 

García Rico also talked about diversity among providers as an important priority and mentioned language access as a major need in oral health spaces.

Finally, Dr. Susan Mims spoke from her perspective both as a pediatrician and as the current president and CEO of the Dogwood Health Trust. Dogwood Health Trust funds programs to improve the health and wellbeing of Western North Carolinians, including the Patient Advocate Pilot, an NCOHC-led initiative advancing care coordination and case management for vulnerable populations.

Mims spoke about the opportunities that philanthropic organizations have to advance equity in oral health, especially when it comes to pushing boundaries and trying new things. She also told personal stories from her time as a health care provider, witnessing the toll that poverty takes on people’s health.

 

Many panelists examined a specific and pressing policy need in North Carolina: Medicaid Expansion.

Radford’s final remarks during the discussion took a personal note. She enrolled in Medicaid coverage during the COVID-19 pandemic, but she and many others stand to lose that coverage unless Medicaid Expansion is passed.

 

Day Two: Equity in Action

This year’s Oral Health Day was the first to span two days. On the second day, participants from across the United States reconvened to participate in a collaborative workshop, identifying policy solutions to the inequities discussed the day before.

Prior to the workshop portion, NCOHC Director Dr. Zachary Brian kicked off the day with a data-based overview of disparities faced in North Carolina. With that background in mind, attendees split into four groups to discuss current realities and actionable solutions.

The NCOHC team was blown away by the level of engagement during the solutions workshop, and we are hard at work developing a comprehensive “Equity Action Framework” to share publicly. The framework will outline achievable, collaborative solutions to the problems facing communities across North Carolina, and will guide NCOHC’s work heading into 2023.

If you would like a copy of the report, make sure to sign up to receive NCOHC emails here.

You can find the full event recording below:

 

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.

On March 28, 2022, the Poor People’s Campaign held its first Moral Monday march in Raleigh since the COVID-19 pandemic began. The rallies, which began in North Carolina in 2012 and have radiated across the United States since, have long covered a wide range of issues that disproportionately impact those living in poverty.

Covering issues ranging from fair housing to union-friendly labor policy, prison reform, and more, the Poor People’s Campaign describes itself as a “national call for moral revival,” building on the movement of the same name launched by Rev. Dr. Martin Luther King Jr. in 1967.

The March 28th rally in Raleigh came in preparation for a Poor People’s March on Washington, again echoing Dr. King’s movement, expected to take place on June 18, 2022.

As he did for many Moral Mondays prior to the COVID-19 pandemic, Dr. Howard Eisenson attended the March 28th rally in Raleigh. He plans to attend the March on Washington on June 18th as well.

Before heading over to Raleigh, Eisenson sat down with NCOHC to talk about his career as a physician, his advocacy work, and a health care policy proposal that an increasing share of Americans support: single-payer health insurance.

While NCOHC has no position on national health care reform policies like single-payer or a public option, our work centers around structural reforms that promise to increase access and equity in oral health care. This blog post is not an endorsement of any national policy reform initiative. Rather, it is meant to explore what single-payer insurance is and why many Americans are working to change the way health care is administered in the United States.

“What many of us feel it’s time for in the wealthiest country on earth is a health care system that serves everybody, that provides for the common good,” said Eisenson.

Eisenson was the Chief Medical Officer for the Lincoln Community Health Center (CHC) from 2012 to 2021. Today, in semi-retirement, he still works for a program called “Just for Us,” a collaboration between the Lincoln CHC and the Duke Division of Community Health.

Working in home health care has been an eye-opening experience for Eisenson. Insurance plans often have very narrow networks, high co-pays, and other barriers that prevent homebound patients from accessing the services they need.

“I’ll give you a quick example from last week,” he said. “I went out to see a patient one morning. ‘How are you doing?’ ‘Terrible,’ she said. I asked her, ‘well, what’s the matter? What’s going on?’ She said, ‘I heard that my insurance won’t pay for my insulin anymore. Pharmacy tells me that.’”

Another call to the pharmacy revealed that her insurance no longer covered her Lantus insulin.

“No doubt what happened is the pharmaceutical manufacturer raised the price,” said Eisenson. “So, we had to find a substitute insulin product. We did, but it took much worry on the part of the patient, phone calls to the pharmacy, a fair amount of my time, re-writing the prescription, a lot of downstream administrative work that would have been avoided had there been one insurance plan that served everybody.”

The Poor People’s Campaign’s list of demands includes the expansion of Medicaid in every state and adoption of a single-payer health insurance system. Eisenson believes that this step is vital if the United States is to achieve equitable access to health care services.

“When you have a publicly funded plan, their main mission at the end of the day is to provide value to the public. That’s what we need. Health care is not your typical consumer product. It’s not like buying a refrigerator where you can shop around for as long as you want,” said Eisenson. “A market-driven approach to health care is inadequate – it leaves too many people out.”

“And we need to cover things like dental care. Who wants to have a mouth full of rotting teeth, or no teeth? And yet dental care is accessible to so few people,” he said. “Dental emergencies occasion so many emergency room visits. Untreated dental problems make so many chronic health problems worse. Not to mention what they do to quality of life. Dental care, vision care, hearing aids, all of these things ought to be included in a comprehensive health package and made available to everyone.”

What Is a Single-Payer Health Care System?

In single-payer health care systems, one entity — usually a government — is charged with administering health insurance for an entire population. Basically, a national insurance system would take the place of our current network of private insurance companies. The actual delivery of health care would remain private, but the financing mechanisms would be controlled by the federal government.

Essentially, a single-payer system would operate like the current Medicare system, only everyone would have access to it.

Supporters argue that a single-payer health care system provides many benefits, including:

• Savings created by increased efficiencies
• Access for everyone, regardless of employment status or financial situation
• Reduced health care spending per capita

However, a transition to a single-payer system wouldn’t be easy or without downsides. For instance, more than 600,000 people in the U.S. currently work in the health and medical insurance industry. Many jobs would be lost in a transition to a single-payer system.

“You can’t just push people out of their jobs without making provisions for them to land on their feet,” said Eisenson.

Lateral transitions and re-training programs are a tall order for those who have made careers in the insurance industry. Yet, creating these opportunities is a need that many prominent advocates for single-payer health care do recognize.

Agreement on Principle: A First Step Toward Single-Payer Health Care

“There are so many details to work out, but the first step is to agree on the common principal,” said Eisenson. “I think most Americans would agree that access to quality health care should be a human right. If someone has a fire in their house, the fire department doesn’t check to see first whether they have paid their fire insurance. If someone is having an emergency and needs the police or an ambulance, nobody is checking to see if they deserve to have help. Everyone gets to send their children to school. These are common goods. Those of us working toward single-payer think that health care should also be a common good.”

The Bottom Line

At the end of the day, change must happen to achieve equitable access to health care. At NCOHC, we believe that diverse coalitions of advocates passionate about improving our health care systems are the key to discovering and implementing the best solutions. That means diversity in cultures, backgrounds, experiences, and viewpoints, and we welcome all to take a seat at the table in this conversation.

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.

At NCOHC, we see integrated care structures at the center of a more equitable, accessible health care system. Oral health is an important part of a person’s overall health, and our bodies benefit most when our medical and dental needs are met in a “whole-body” approach.

The same goes for mental health, another often siloed health care practice. Not only do our medical, dental, and mental health needs overlap, but deficiencies in any of the three can have serious impacts on the rest of our bodies.

Oral Health and Mental Health: A Two-Way Street

Many social determinants of health have significant impacts on both oral and mental health. For example, while food access has well-documented impacts on oral health, it also affects mental health. One study conducted during the COVID-19 pandemic found a 257 percent higher risk of anxiety and a 253 percent higher risk of depression among food-insecure individuals.

The same goes for economic stability. Societal forces like income, housing, and transportation that can prevent someone from accessing oral health services often carry negative mental health consequences as well.

The comedian Moses Storm discussed his own poverty in his recent HBO Max special, saying that “poverty is a disease, and its most sinister symptom is fear. It’s something that I carry with me to this day… It’s no revelation that poverty is a major stressor, and we know that chronic stress causes damage to the cerebral cortex, the part of your brain that’s in charge of risk/reward, long-term planning.”

Can Oral Health Affect Mental Health?

Oral health itself can impact mental health, too. Poor oral health is strongly associated with fear, anxiety, and shame. Among children, untreated tooth decay can lead to school absenteeism, learning deficiencies, and difficulty socializing and making friends. Among adults, similar impacts can be seen maintaining employment, relationships, and more.

Similarly, people living with mental illnesses like anxiety and depression can face difficulty maintaining daily routines. This and other effects of mental illnesses, such as excessive smoking or drinking as coping mechanisms, impact oral health.

A 2016 article in the Canadian Journal of Psychiatry discussed the fact that “many psychiatric disorders, such as severe mental illness, affective disorders, and eating disorders, are associated with dental disease.”

The bottom line is that poor oral health and mental illnesses are often, in a way, symptoms of each other, results of a network of stressors, barriers to care, and societal factors that many people face. As such, they are intertwined, both impacting each other in many ways.

According to Storm, “Basically all the tools that get you out of poverty get damaged by being poor.”

That sentiment is reflected by the compounding effects of poor health, and poor health and poverty are also intertwined in this kind of feedback loop.

The Need for Systems-Level Change

Whether brushing teeth and visiting the dentist to improve oral health or adopting mindfulness routines and seeking behavioral health care to improve mental health, self-care routines are vital. But, the burden of improvement can’t always be placed on the individual.

Many of the societal factors that impact mental health are structural in nature. While they are important, meditation sessions, mindfulness routines, and daily walks must be accompanied by structural improvements to health care access, income, affordable housing, transportation, and so much more.

The same goes for oral health, and health care in general. Too many people simply cannot access the care they deserve. Solving this problem is one of the most important things health care professionals can do to improve and ultimately save lives.

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.

Dentists may be one step closer to administering HPV vaccines in pursuit of whole-person health. Earlier this year, the American Dental Association (ADA) Code Maintenance Committee approved new CDT codes for oral health care provider-administered HPV vaccinations. This is a crucial step in addressing HPV, the most common sexually transmitted infection and a leading cause of oropharyngeal cancer.

The human papillomavirus (HPV) is the most common sexually transmitted infection in the U.S. At first glance, it may seem harmless compared to other sexually transmitted infections and diseases. In many cases, people don’t even know when they have contracted HPV.

But HPV is responsible for 12 percent of cancers worldwide, including cervical cancer, penile cancer, and many oral cancers. In fact, according to the CDC, HPV is thought to be responsible for 70% of all oropharyngeal cancers. 70%!

The vaccine has been proven to prevent both HPV and associated cancers. Specifically, of the 36,500 annual cancer cases caused by HPV, it has been found that 33,700 could have been prevented through vaccination.

Why Oral Health Care Provider-Administered HPV Vaccines?

“HPV is the leading cause of oropharyngeal cancers (cancers in the throat, back of the mouth, base of the tongue, and tonsils) in the United States,” said NCOHC Director Dr. Zachary Brian, who serves on the Code Maintenance Committee as a representative for the American Association of Public Health Dentistry (AAPHD) . “It’s more than appropriate that oral health care providers not only educate about HPV-associated risks but also serve on the frontlines to administer this life-saving vaccine.”

Brian, along with Dr. Sharon Perlman, a dental provider and CCARE Lynch Syndrome co-founder, drafted the new HPV vaccine code. Perlman also served on the Code Maintenance Committee as an AAPHD representative.

“We are lucky to have a strong advocate in Dr. Perlman,” said Brian. “She was a critical component in the drafting and passage of this new code.”

With oropharyngeal cancers claiming one life every hour in the U.S., and just over 50 percent of adolescents not completing the HPV vaccine series, there is clear room for improved prevention through increased access and education.

In 2021, NCOHC spoke with Dr. Jennifer S. Smith, a vaccine epidemiologist who has worked to improve HPV vaccine acceptance to prevent cervical cancer. She said that while the HPV vaccine has proven to be a valuable preventive tool for many forms of cancer, acceptance continues to be an issue.

One of Smith’s colleagues, Dr. Noel Brewer, found that informed providers who understand potential outcomes need to be part of the vaccination process. For example, the pediatricians who often administer HPV vaccines may not be as familiar with the realities of cervical cancer compared to oncologists who take care of cervical cancer patients. The perspective of a health care professional familiar with the disease endpoint – in this example cervical cancer – is vital in answering questions and encouraging vaccine acceptance.

Similarly, dental professionals can play a valuable role in educating people about oropharyngeal cancers and the benefits of HPV vaccination.

The best time to vaccinate against HPV is between 11 and 14 years old. Parents will understandably have questions, not just about the vaccine itself but about the health outcomes it can help prevent.

“Dental professionals already play a vital role in early detection and oral cancer literacy,” said Brian. “This uniquely positions us to engage in direct prevention as well.”

What is the Code Maintenance Committee, and Why is an HPV Code Important?

The ADA’s Code Maintenance Committee evaluates and votes on changes to the CDT Code, or the Code on Dental Procedures and Nomenclature. The procedural codes are meant to ensure a level of consistency in dental treatment, and they are used to file insurance claims for oral health care services.

“The adoption of the code marks the first of many steps, and it opens several doors,” said Brian. “It signals broad agreement on oral health care provider-administered HPV vaccines to payers and policymakers, and it provides a framework to integrate HPV vaccination into the practice of dentistry.”

At NCOHC, we’re pleased to see the dental profession moving in this direction, and we believe these changes can make a profound difference in preventing HPV and, ultimately, oropharyngeal cancers.

What’s Next?

The adoption of the new CDT codes alone won’t allow oral health care providers in most states to begin HPV vaccination.

In some states such as Illinois and Oregon, where dentists are already authorized to administer various vaccines, there likely won’t be much delay in adjusting their regulatory frameworks to allow for HPV vaccination. However, in most states, including North Carolina, state law will need to change for oral health care providers to be authorized to administer the vaccine. \

“We will need to modify state law to incorporate HPV vaccination into the scope of practice for oral health care providers,” said Brian. “For that to happen, it will be critical that we work closely with our partners across the state, including our medical counterparts and other advocacy groups.”

Insurers will also be important partners in this effort. While the necessary legal changes are being made, payers will also need to engage to encourage and support oral health care providers’ administration of the HPV vaccine.

“Once the policy has been updated and the reimbursement framework is in place, the dental profession will have a significant opportunity to improve population health,” said Brian. “The dental community could rapidly increase the availability of the HPV vaccine and add a much-needed perspective to cancer prevention efforts.”

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.