Legal and policy approaches can be important tools for achieving healthier communities. A new report—The Role of Law and Policy in Increasing the Use of the Oral Health Care System and Services—provides evidence-based information and identifies priority areas that can help communities achieve Healthy People objectives.
This Bright Spot describes a series of reforms to the oral health care system in Maryland following the death of 12-year-old Deamonte Driver from an untreated tooth abscess in 2007.
Challenge: Lack of access to oral health services leading to poor health outcomes
In the late 1990s, fewer than 1 in 5 dentists in Maryland participated in the state’s Medicaid program because of low reimbursement rates.1 Maryland’s Medicaid program had one of the lowest average fees per dental claim and the average cost per recipient was one of the lowest in the country. In addition, only half of Maryland jurisdictions had public health (safety‐net) dental services.2
As a result, Maryland residents with Medicaid had poor access to dental care. In 1997, about 19 percent of Maryland children enrolled in Medicaid received an oral health service compared with the national average of 27 percent.3
The Maryland Office of Oral Health (OOH) was established in 1996 to help address these issues—but the defining event that changed the oral health environment statewide was the death of 12-year-old Deamonte Driver, who died from an untreated tooth abscess in 2007.
Deamonte’s family was enrolled in Maryland’s Medicaid plan, but it had been almost impossible for his mother to find a dentist who would treat them—and then they lost their coverage without warning. By the time Deamonte got care for his tooth, the infection had spread to his brain. After 2 brain surgeries and 6 weeks in the hospital, Deamonte died.
Deamonte’s death catalyzed a series of reforms to the oral health care system in Maryland in the years that followed, particularly for Maryland residents enrolled in Medicaid.
Strategy: Collaborate at all levels to create impactful policies
After Deamonte’s death, many oral health champions emerged at the local, state, and federal levels who were committed to developing new legislation and programs, including U.S. Representative Elijah Cummings, U.S. Representative John Sarbanes, and Maryland Governor Martin O’Malley.
This wasn’t the first time that policymakers in Maryland had attempted to make oral health reforms. In the 1990s, Dr. Harry Goodman—the director of the Maryland OOH at the time—had developed a plan focused on oral health screenings in schools. This plan received widespread support but didn’t ultimately receive enough funding for implementation.
Then, in 1998, the Maryland legislature passed Senate Bill 590. This legislation included a 5-year plan that placed the OOH in statute, called for a state Oral Health Advisory Committee, mandated a plan to increase the number of dentists participating in the state Medicaid program, and required an oral health needs assessment for Maryland school children.4
This legislation laid the groundwork for the reforms that took place after Deamonte’s death—including establishing the foundation for the Dental Action Committee (DAC). O’Malley and Maryland Secretary of Health and Mental Hygiene John Colmers convened the DAC in 2007 to make recommendations for improving oral health access for all children in Maryland.
Dr. Debony Hughes, the current director of the OOH, says the DAC was formed to make these recommendations so that no other child would die from an oral health care problem. “We were so shocked by Deamonte’s death that we vowed this was something that we couldn’t let happen again,” she says.
The DAC made 7 recommendations to improve access to oral health care services in Maryland, including creating a single vendor insurance administrator for Medicaid, increasing dental reimbursement rates, ensuring all counties have a local dental clinic, establishing public health dental hygienists who could provide care in nursing homes, schools, and other settings without a dentist present, incorporating dental screenings in public schools, and training dental and medical professionals on oral health risk assessments.5
All of these recommendations have been implemented, with the exception of incorporating dental screenings for public school children.The reforms that resulted from the DAC’s recommendations included efforts to strengthen the oral health workforce (especially in underserved areas), more public oral health education, cavities management grants, and improvements to oral health surveillance and infrastructure statewide.
The Oral Health Safety Net legislation also passed in 2007, which supported collaborative and innovative ways to expand oral health capacity for vulnerable populations in Maryland by funding health departments and federally qualified health centers. It also funded 2 new programs—an oral disease and injury prevention program, and a program that provides sealants in schools.
In 2010, the DAC was converted into a nonprofit organization called the Maryland Dental Action Coalition (MDAC). MDAC includes physicians, pediatricians, researchers, public health professionals, and many other stakeholders. These advocates and others have built strong relationships with legislators, which allows them to continue educating lawmakers about policies that improve oral health care access.
These relationships highlight the importance of people from different sectors working together to improve access. “We don't work in silos,” Hughes says. “If we’re telling our population that good oral health is related to overall health, then we can't separate them.”
Impact: More children receive oral health care services
Because of Maryland’s numerous oral health policy reforms and initiatives, there’s been an increase in oral health care utilization rates and an increase in dentists participating in the state Medicaid program:
In 2009, 649 dentists participated in the state Medicaid program—as of 2018, this increased to approximately 1,600 participating dentists.
In 2009, there were 286,000 children and adults that received dental care through Maryland’s Medicaid program—as of 2018, this increased to approximately 316,000 children and adults.
In 2011, the Pew Charitable Trusts recognized Maryland as a national leader in children’s oral health. Maryland was the only state to meet 7 of 8 policy benchmarks for addressing children’s oral health needs.6
Hughes has seen how these improvements have improved patient care first hand. She remembers a 7-year-old patient whose 2 front teeth were completely black from tooth decay, so she never smiled. After she was treated, her personality completely transformed—and Hughes says that “she had the biggest smile that you could imagine.” For Hughes, it’s experiences like this that make all the work and the push for policy change worthwhile.
Looking Ahead: 100% of children accessing and using oral health care services
In the future,Hughes would like to see a continuous climb in utilization of oral health care services, especially among pregnant women—and 100% utilization for children.
She also hopes future laws and policies will support oral health screenings for all public school children. Dental caries is the number one preventable chronic disease in children.Finding tooth decay early will help more children access oral health care services—and prevent future problems.
Additionally, Hughes would like to see more policies and programs that support collaboration between medical and dental providers—like the current Maryland OOH program focused on identifying childhood obesity in the dental office, which is funded by the Health Resources and Services Administration (HRSA).7
About the Law and Health Policy Project
The goal of the Healthy People Law and Health Policy project was to highlight how evidence-based legal and policy interventions and strategies can facilitate progress toward Healthy People 2020 targets by improving community health and well-being. In addition to reports and webinars, the project included "Bright Spots," or success stories, that highlighted successful policy interventions that led to improved health outcomes. The project was a collaboration between the HHS Office of Disease Prevention and Health Promotion (ODPHP), the Centers for Disease Control and Prevention (CDC), the CDC Foundation, and the Robert Wood Johnson Foundation.
Related Healthy People 2030 objectives:
- Reduce the proportion of children and adolescents with lifetime tooth decay — OH‑01
- Reduce the proportion of children and adolescents with active and untreated tooth decay — OH‑02
- Reduce the proportion of adults with active or untreated tooth decay — OH‑03
- Reduce the proportion of older adults with untreated root surface decay — OH‑04
- Increase the proportion of oral and pharyngeal cancers detected at the earliest stage — OH‑07
- Increase use of the oral health care system — OH‑08
- Increase the proportion of low-income youth who have a preventive dental visit — OH‑09
- Reduce the proportion of people who can't get the dental care they need when they need it — AHS‑05