October 15, 2003
Washington, D.C.

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I’m delighted to be with all of you today, and I’m especially happy to be discussing the importance of oral health with this esteemed group of health care professionals.
 
We are moving oral health to the front burner at HRSA. There are many excellent reasons for doing so, of course, but one stems from a trip I took last summer.
 
I’ve done a lot of traveling since becoming HRSA administrator in March 2001.  In Hawaii, I saw a health center dentist doing tremendous work out of a mobile dental van that she takes to schools to treat children.  And in a trip to some of the remotest parts of Alaska, I visited health centers that make terrific use out of what they call a “cart,” which is a machine that uses telehealth technology to improve care in those frontier communities. At a modest investment, the cart provides telehealth links to specialists as far away as Washington state and even Ohio who weigh in on patients’ symptoms on the full range of cases --dermatology; ob/gyn; eye, ear, nose and throat; psychology; and radiology.  It’s really quite impressive.
 
But a trip I made in the summer of 2002 really left me with an indelible memory and a determination to improve the way HRSA’s grantees deliver oral health care.  I was visiting some community health centers in rural Michigan, and the folks at the health center in Alpena, far up on Lake Huron, told me the tragic story of a young man—just 20 years old—who had an abscessed tooth.  Because no dental care was easily available to him, his condition worsened and he ended up having all of his teeth removed.  He spent some days in intensive care, and needed quite a bit of specialized care later—all because he couldn’t get an abscessed tooth treated.  That story made quite an impact on me.
 
We know we can do better.   The easiest way to see the difference between the rich and poor in America is to look in people’s mouths.   Marcia Brand, a former dental hygienist who now heads up HRSA’s Office of Rural Health Policy, tells me that many welfare clients who have failed in their attempts to enter the work force cited “bad teeth” as the reason they thought they were unsuccessful.  For many Americans, an oral health problem doesn’t just mean they don’t have Hollywood smiles, it means untreated pain, disfigurement and hours lost to school and work.  After all, a lot of entry-level jobs these days are service jobs that require face-to-face interaction.
 
Our belief at HRSA is that oral health – along with mental health – is an integral part of comprehensive primary and preventive care.  We need to see patients in their entirety, because that is how they come to us.  The brain and the mouth are inseparable from the body.  They are component parts of a single entity, and we must treat them that way.  We must treat the whole person.
 
So at HRSA we have decided to increase the focus on access to oral health care.  We have already taken steps to make access to dental care a core part of President Bush’s initiative to expand the health center network.  I’ll tell you more about our strategy to do that in a few minutes.
 
But before I do that, I’d like to share with you a new, updated draft statement of HRSA’s missions and goals in the field of oral health.  The language in it shouldn’t surprise you, because it is consistent with the agency’s longstanding interest in improving oral health.
 
And of course it supports the oral health goals of Healthy People 2010 and the Surgeon General’s call to action at state, local and national levels.  But it is something we felt we needed to put down on paper to re-emphasize our determination and clarify our intention to improve oral health outcomes for the nation.
 
We haven’t set it in stone yet.  In fact, we welcome your ideas, so we’re distributing the draft for your comments.  You can simply email any additions or revisions you feel would be useful to my senior advisor, Steve Smith.  His email address is shown on the handout.
 
Here’s HRSA’s mission:

• To improve the nation’s health by expanding access to comprehensive, culturally competent, quality oral health care as an integral component of comprehensive health care.

And these are our goals:

• First, to improve the health infrastructure and systems of care -- especially for underserved, vulnerable and special needs populations – so that access to comprehensive, quality oral health services is expanded.
• Second, to improve oral health status and outcomes so that they reduce health disparities among Americans.
• Third, to improve the quality of oral health services -- preventive and curative -- especially for underserved, vulnerable and special needs populations.
• And fourth, to promote oral health by building public-private partnerships, including strengthening dental public health infrastructure.

Now, I realize there are many ways to go to reach these four goals.  And I offer all of the following ideas only as representative of the many options we are considering.  You may have your own notions and, if you do, I urge you to send them to Steve.
 
Take goal number one, to improve the health care infrastructure to expand access to oral health care.  We could decide, for example, to increase access to oral health services by 100% or more for the population served by our maternal and child health programs by 2010.
 
Or we could decide to increase the number of people who receive oral health care from NHSC personnel by “x” percent in some future year.
 
As I mentioned a minute ago, we’ve already taken steps to improve oral health services at health centers, and I’ll tell you about that soon.
 
On goal number two, to improve oral health outcomes to reduce health disparities, we could decide to increase the number of minority and disadvantaged dental and dental hygiene students trained with funds provided under Title VII of the Public Health Service Act.  That would help because we know that minority practitioners are more likely to work with a minority patient base.
 
Or we could opt to increase services at health centers that would promote expanded access to oral health care -- services such as case management, outreach, community education, and translation.  Since almost two-thirds of health center patients are members of minority groups, any impact on oral health outcomes there will certainly reduce existing disparities in oral health care.
 
To reach our third goal -- to improve the quality of oral health services -- we might decide we need to make better use of existing telehealth technology.  By offering regular distance-learning opportunities to oral health professionals across the country, we’ll keep them abreast of the latest developments in their field and the procedures they should adopt to improve the care they provide.
 
To meet the fourth goal -- to promote oral health by building public-private partnerships – we could expand partnership activities with private dental organizations to identify and support oral health clinicians who choose to practice in underserved areas.
 
We also could enlist the expertise of former NHSC dentists in building these partnerships.  These dentists may be in private practice now, but they – far better than most – understand the challenges of treating underserved populations. We know that the NHSC service makes lasting impacts on clinicians and their knowledge would, I’m sure, be useful to us.  Steve tells me that Forrest Peebles, now in HRSA’s Office of Performance Review in our Seattle regional office, credits his NHSC service as a dentist in South Dakota for his career focus in public health.
 
The point I want to make is that all these options to meet our goals are, for now, just that – options.  With your help, and with the advice of other expert partners in the oral health field, we feel confident that HRSA will develop sound objectives that are fully capable of meeting our goals and fulfilling our mission in oral health.
 
Now let me tell you briefly about our progress we’ve made in meeting the goals President Bush set for us in expanding the HRSA-supported consolidated health center system – and on the importance we have placed on expanding oral health care as part of the overall expansion.
 
I’m sure most of you know that in 2001, shortly after taking office, the President announced a five-year plan to increase the number of patients treated annually in health centers from about 10 million in 2001 to more than 16 million by 2006.  That would involve expanding the health center network from about 3,200 sites across the country in 2001 to about 4,400 by 2006.
 
So far we’re ahead of schedule.  In 2002 HRSA exceeded our targets by funding 171 new health center access sites and by expanding capacity at 131 centers – 42 sites beyond our goal.  We also surpassed our goals for fiscal year 2003, which ended at the end of September.  Our goal for the year was 90 new access points; we surpassed that by 10.  We wanted to expand medical capacity at 80 centers, and we exceed that goal by eight.
 
Health centers registered impressive gains in service delivery during 2002, the first full year of the expansion:

• In 2002, health centers served more than 11.3 million patients.  That’s an increase of more than a million patients over the 2001 figures.  So that you have a measure of comparison, that’s close to double the annual average increase during the years 1998-2001.  Total patient encounters grew from 40.3 million in 2001 to just under 44.8 million in 2002 – that’s more than 4.4 million additional encounters over the year.
• Health centers managed this phenomenal increase while maintaining the focus on their traditional patient base – those who need us the most.  In 2002, 39 percent of our patients had no health insurance; 88 percent earned 200 percent or less of the poverty line; and 64 percent were members of a minority group.
• In 2002, health centers treated 373,000 more uninsured patients than in the previous year; during the 1998-2001 period, the annual average growth was 150,000 uninsured patients.
• And health centers continued in 2002 the trend of expanding the services they offer: 68 percent of grantees now offer mental health treatment and counseling; 69 percent have pharmacy services; and 72 percent of grantees offer preventive dental care.

That last statistic is pretty good, but we want to do better.  I remember that young man in Michigan and his abscessed tooth.
 
We have adopted three strategies to improve access to oral health services as part of the President’s expansion initiative:

• One -- All new health center access points must provide patients ready access to primary, preventive and supplemental health services, and that includes primary oral health care.  When we talk about primary oral health care, the range of services should include preventive care and education, emergency services, basic restorative services and periodontal services – all but the most specialized oral health care.
• The second strategy is this: existing health centers that currently offer some form of dental care must make plans to expand it.
• And three – we intend to improve the quality of oral health care programs in the health center system.

Here’s the result at the end of the first full year of implementing the President’s initiative: health centers treated an additional 232,000 dental patients in 2002, bringing the total to more than 1.6 million patients.  We increased patient dental encounters over the year by 557,000, bringing the number of dental visits to almost 3.8 million.
 
Since the president’s expansion initiative began two years ago, HRSA has invested almost $19 million to establish oral health programs at new health center sites and about $20 million to expand and improve quality in oral health care at existing centers.
 
Another thing HRSA is doing to upgrade oral health care at health centers involves the creation of a "Best Practices Compendium,” which will contain strategies and techniques that can serve as a guide for health centers looking to expand access to oral health care and improve the quality of oral health services.  We hope to be able to post the compendium on the Internet next month (now available at http://www.mchoralhealth.org/materials/multiples/BPHC.html).  Some of the abstracts that will be featured in the compendium were discussed in August at the National Primary Oral Health Care Conference in Arizona.  About 300 oral health care professionals, representing virtually every state, attended the conference, which HRSA was proud to sponsor.
 
That’s a summary of what we doing to promote better oral health care for children and adults at our health centers.
 
We are also working hard to improve oral health care through programs in other parts of HRSA.  In HRSA’s Maternal and Child Health Bureau, our efforts in the Community Integrated Services Systems program promote the goals of the Children’s Health Insurance Program: that is, to support states in developing community health programs that provide comprehensive systems of care for children.
 
We funded the CHIP/CISS program because we realize the importance of comprehensive primary health care, especially for children under 5.  I’ll say it again: comprehensive care must include oral health and mental health services.  The health care we provide through federal dollars should reflect that unity and that essential “connectedness.”
 
HRSA also improves oral health services for children through our State Oral Health Collaborative Systems Grant Program.  Just a couple of weeks ago, we announced nearly $3 million in new funding to 45 states, Micronesia and the Marshall Islands to strengthen state oral health programs whose patients are women and children eligible for Medicaid and S-CHIP.  Those funds support broad-based efforts to improve overall dental coverage by stimulating planning and public/private partnerships and by encouraging community support systems.  Funds also will be used to treat and prevent early childhood decay through dental sealant and other prevention programs.
 
Through our HIV/AIDS Bureau, HRSA recently awarded $9.8 million to 64 dental schools and dental education programs to help them cover the rising costs of providing oral health services for underserved and uninsured Americans living with HIV/AIDS.
 
Treatment supported by those grants, awarded under the Ryan White CARE Act’s Dental Reimbursement Program, includes the full range of oral health services: diagnostic and preventive care, oral health education, oral medicine and oral surgery.  And by funding access to these services at dental schools and teaching hospitals, the grants also train new generations of dentists and dental hygienists to provide oral health care for people with HIV.
 
Impaired oral health is often the earliest clinical sign of HIV infection and may indicate the disease’s progression.  As a result, dentists are often the first health care providers to identify patients who are HIV-positive.  So that’s another benefit of these grants: they help public health professionals track the spread of HIV in a community.
 
Another HRSA program, launched a little over a year ago, awarded 12 grants worth almost $3 million to support partnerships between dental education programs and community-based dental providers.  Funds from the program (called the Ryan White CARE Act Community Based Dental Partnership Program) are used to extend oral health service delivery and provider training into community settings, especially in underserved areas. 
 
We feel confident that this new program will expand even further the benefits of the Dental Reimbursement Program by nurturing successful public-private partnerships and by stimulating innovative community-based service-learning opportunities.  And it could well serve as a model to reach the fourth goal I mentioned earlier – promoting oral health by building public-private partnerships.
 
We also have oral health components in our rural health grants.  In FY 2003, our Office of Rural Health Policy awarded 14 grants worth $2 million to coalitions of rural health care organizations to improve access to oral health services.  Residents of many rural communities find it difficult to access oral health care because local dentists are few and even those who are available are often far away.  Many folks end up in rural emergency rooms seeking dental care, where doctors treat them for pain and infection but can’t provide restorative care.  These grants create innovative partnerships among rural institutions to try and resolve those problems.
 
And, of course, HRSA’s Bureau of Health Professions supports several programs that promote better oral health care, especially among the nation’s underserved populations.  Kerry Nesseler, whom you’ll hear from next, will tell you about those.
 
I hope she won’t mind me mentioning that eight of the current roster of 48 Ready Responders are dentists.  For those of you who may not know, the Ready Responders are a team of health care professionals HRSA created after 9-11 that we will rush to all types of regional or national disasters.
 
Normally, Ready Responders are assigned to provide health care in underserved areas like any other NHSC clinician. But they also agree to complete disaster readiness training courses each year and to respond to our nation’s call in times of emergency.
 
Let me wrap up by saying that we at HRSA greatly value your expertise and solid record in expanding oral health services to those who need it most.  From you, we hope to gather ideas to improve access to these services in a way that moves us closer to the day when health disparities among the American people are eliminated, and that stain on our nation is only an unfortunate memory.
 
We hope you will use this extraordinary assembly as a working meeting to identify strategies and plans that HRSA can realistically adopt to reach our goals and complete our mission in oral health care:
 
to improve the nation’s health by expanding access to comprehensive, culturally competent, quality oral health care as an integral component of comprehensive health care.
 
Thank you for listening and good luck.