September 2020 Volume LV Number 5

 
 
 
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AAPD Public Policy Advocacy for Children’s Oral Health

July 2020 Volume LV Number 4

 The AAPD continues to vigorously advocate for critical issues impacting children’s oral health care. The 2020 Legislative and Regulatory Priorities, as developed by the Council on Government Affairs and approved by the board of trustees, are available on the AAPD website.14
 
In additional to our efforts at the federal level in Washington, D.C., our state Public Policy Advocates continue to make impor- tant strides on legislative and regulatory matters at the state level. Our success in D.C., is thanks in no small part to the work of Congressional Liaison Heber Simmons Jr., our lobbying consultants at Hogan Lovells, and of course the AAPD Political Action Committee. Dr. Simmons will retire from his duties at the end of 2020, culminating 23 years of outstanding service and
tremendous achievement as Congressional Liaison. Fortunately, Heber has trained and transitioned our two Co-Congressional Liaisons who follow in his foot steps: former AAPD Presidents Drs. Warren Brill (Baltimore, Md.) and Jade Miller (Reno, Nev.).
 
Pediatric Oral Health Advocacy Conference (POHAC) in Washington, D.C.
 
On March 1-4, 2020, over 350 AAPD members from 39 states plus D.C., advocated for children’s oral health in Washington, D.C., by visiting with their members of Congress. AAPD at- tendees included members of the Council on Government Affairs, PAC Steering Committee, Executive Committee, and Budget and Finance Committee. Thirty-four AAPD state Public Policy Advocates particpated as well. Sixty pediatric dentistry residency programs were represented, with more than 200 residents in attendance. For the fifth year in a row, the AAPD held a special pre-conference advocacy orientation and train- ing session solely for residents.
 
Attendees heard updates on key AAPD public policy issues, fo- cusing on Title VII pediatric dentistry funding and dental faculty loan repayment tax exclusion, the Ensuring Lasting Smiles Act (ELSA), and the REDI Act (see more details below). For the sec- ond straight year the keynote entertainment was the comedy troupe Capitol Steps, who delivered entertaining song, dance, and monologues poking fun at both political parties and all aspects of the 2020 presidential election. HRSA Chief Dental Officer Dr. Renee Joskow provided an update on agency activities plus the pending Surgeon General’s Report on Oral Health, expected to be released later in 2020. AAPD Chief Policy Officer Dr. Paul Casamassimo discussed the AAPD pediatric dentist workforce study and its policy implications. PEDO Talk Podcast moderator Dr. Joel Berg recorded two podcasts on stage: one with Congressional staffers Lauren Jee (Senior Health Policy Counsel for Senator Ben Cardin of Maryland) and Jamie Neill (Legislative Assistant for Congressman Mike Simpson of Idaho), and the other with AAPD Congressional Liaison-designees Drs. Warren Brill and Jade Miller.
 
In addition to briefings from AAPD’s Washington representative Michael Gilliland from Hogan Lovells and COO/General Coun- sel C. Scott Litch, attendees heard a rousing and inspirational closing speech from Congressional Liaison Dr. Heber Simmons Jr. To further prepare for Congressional visits, attendees also witnessed a "mock visit" featuring President-elect Dr. Jessica Lee, Vice President Dr. Jeannie Beauchamp, and Kate McAuliffe of Hogan Lovells.
 
The AAPD PAC hosted a fundraiser for Congressman (and dentist) Jeff Van Drew (R-N.J. 2nd). He was introduced to AAPD attend- ees as follows:
  • Jeff Van Drew was born in New York City. He gradu- ated with a B.S. from Rutgers University and received
  • a D.M.D. degree from Fairleigh Dickinson University. Dr. Van Drew operated a dental practice in South Jersey for 30 years before retiring. He has served as president of the New Jersey Dental Society and a board expert of the New Jersey Board of Dentistry 
  • Van Drew served on the Dennis Township Committee in 1991, and as Mayor from 1994 to 1995 and from 1997 to 2003. He served on the Cape May County Board of Cho- sen Freeholders from 1994 to 1997, and was a Dennis Township Fire Commissioner from 1983 to 1986.
  • In 1994, as a Cape May County Freeholder, Van Drew made support for a local community college a major campaign issue. In 2002, ground was broken on the site of the
  • future Atlantic Cape Community College campus in Cape May County.
  • First elected in 2007, Dr. Van Drew served four terms in the New Jersey State Senate. In 2008, he sponsored the Fair Market Drug Pricing Act to establish the New Jersey Prescription Card Program to reduce drug prices.
  • In 2018 Dr. Van Drew was elected to Congress in New Jersey’s Second Congressional District. The district had been represented by Republican Frank LoBiondo from 1995 until his retirement. The district is the southernmost in New Jersey and the state’s largest, encompassing rural farms from Salem County to the Jersey Shore and Atlantic City. Interestingly, President Barack Obama won the district in 2008 and 2012, while President Donald Trump won in 2016.
  • Congressman Van Drew has demonstrated a willingness to work on a bipartisan basis, addressing issues of vital concern to the residents of his district. He and his wife have two children and one grandchild, and reside in Den- nis Township.
Dr. Van Drew made impassioned remarks about the need for bi-partisan cooperation and compromise in Congress. The event, co-hosted with ADPAC, AAOMS PAC and Hogan Lovells PAC, and augmented by individual contributions from AAPD attendees, raised over $17,000.
 
The AAPD PAC honored Congressman Henry Cuellar (D-Texas 28th) as the Legislator of the Year. Mr. Cuellar serves on the House Appropriations Committee, and supported inclusion of Medicaid dental audit report language in the FY 2020 spend- ing bill. He was not able to attend in person due to the Super Tuesday Texas Primary.15 Therefore Immediate Past President Dr. Joseph Castellano and CEO Dr. John Rutkauskas presented the award in Mr. Cuellar’s Congressional office on Feb. 27, 2020.
 
The specific advocacy requests made by attendees during Capitol Hill visits were:
 
HRSA Title VII Pediatric Dentistry Appropriations and DFLRP Tax Relief
Provide FY 2021 funding of $40.673 million for the HRSA Title VII Primary Care Dental Training Cluster and related oral health programs, with not less than $12 million for Pediatric Den- tistry Training programs including a new dental faculty loan repayment program grant cycle with preference for pediatric dentistry faculty.
 
As part of this effort, attendees urged House Members to sign onto a Dear Colleague letter spearheaded for the 3rd year in a row by Congresswoman Julia Brownley (D-Calif.-26th) that asked Members to support Title VII pediatric dentistry. Ulti- mately 65 House Members signed onto the letter.
 
Pass legislation to make the Dental Faculty Loan Repayment Program (DFLRP) non-taxable to recipients. Co-sponsor S. 359/H.R. 996.
 
Ensuring Lasting Smiles Act
Co-sponsor the Ensuring Lasting Smiles Act (S. 560/H.R. 1379) legislation that would require all private group and individual health plans to cover the full medically necessary treatment of patients with congenital anomalies, including related dental procedures.
 
Thanks to strong bi-partisan support, the Senate bill currently has 40 co-sponsors and the House bill has 300 co-sponsors. This legislation is supported by a coalition of 22 dental and medical provider and patient advocacy organizations.
 
Resident Education Deferred Interest Act
Co-sponsor the Resident Education Deferred Interest Act (H.R 1554), legislation that would halt interest accrual while loans are in deferment during residency training.
The REDI act currently has 85 co-sponsors.
 
Fact sheets used in Congressional visits are available on the AAPD website at https://www.aapd.org/advocacy/legislative- and-regulatory-issues/legislative-and-regulatory-fact-sheets/.
 
AAPD sincerely thanks all those members who took time from their busy schedules to attend this important conference. Many thanks to the state and district chapters which help support residents’ attendance at the conference.
 
62 House Members Sign Congressional Dear Colleague Letter in Support of Title VII Pediatric Dentistry Funding
One of the key advocacy requests made by attendees at the 2020 AAPD POHAC during their visits to Congressional offices was to support FY 2021 funding of $12 million for Title VII Pe- diatric Dentistry. This amount includes funding for the Dental Faculty Loan Repayment Program. During visits, House Mem- bers were asked to sign onto a Dear Colleague letter circulated by Congresswoman Julia Brownley (D-Calif.-26th). A copy of the letter, signed by 62 House members, can be accessed on the AAPD website.16
 
FY 2020 Final Omnibus Appropriations Bill Provides $12 million for Pediatric Dentistry
Congress passed two legislative spending bills on Dec. 19, 2019, totaling $1.4 trillion to keep the government running through the remainder of fiscal year 2020. The bills include funding for the AAPD’s key appropriations issue. H.R. 1865, known as the domestic priorities and international assistance appropriations minibus, totaled $540.4 billion and was made up of eight appropriations bills: Labor-Health and Human Ser- vices-Education, Agriculture, Energy and Water Development, Interior-Environment, Legislative Branch, Military Construction- Veterans Affairs, State-Foreign Operations, and Transportation- Housing and Urban Development. H.R. 1158, the national secu- rity appropriations minibus, totaled $860.3 billion and includes the Defense, Commerce-Justice-Science, Financial Services and General Government, and Homeland Security appropriations bills. President Trump signed both measures into law on Dec. 20, 2019, as P.L. 116-94 and P.L. 116-93.
 
In terms of AAPD’s top funding priority, Title VII pediatric dentistry, the following favorable report language from House Committee Report 116-6217 from May 15, 2019, became official:
 
"Oral Health Training
The Committee recommends $40,673,000 for Oral Health Training programs, the same as the fiscal year 2019 enacted level and $40,673,000 above the fiscal year 2020 budget request. These programs serve to increase the number of medical graduates from minority and disadvantaged backgrounds and to encourage students and residents to choose primary care fields and practice in underserved urban and rural areas.
 
The Committee includes not less than $12,000,000 for General Dentistry Programs and not less than $12,000,000 for Pediatric Dentistry Programs. The Com- mittee directs HRSA to provide continuation funding for predoctoral and postdoctoral training grants initially awarded in fiscal year 2015, and for section 748 Dental Faculty Loan Program (DFLRP) grants initially awarded in fiscal years 2016, 2017, 2018 and 2019. The Committee continues to support DFLRP awards with a preference for pediatric dentistry faculty supervising dental students or residents and providing clinical services in dental clinics located in dental schools, hospitals, and community- based affiliated sites."
 
Report Language Related to Dental Medicaid
Report language from House Committee Report 116-62 related to dental Medicaid became official as well. This urges CMS to appoint a chief dental officer and instructs auditors of dentists to utilize the clinical guidelines, best practices and policies of the AAPD and ADA. This language was strongly supported by the ADA and AAPD.
 
Tax Repeals of Note in Final FY 2020 Omnibus Spending Bill
P.L. 116-94 referenced above also included the repeal of several problematic tax provisions.
  • Permanent repeal of the 2.3 percent medical device tax that was included in the Affordable Care Act. Implemen- tation of this tax had been delayed by Congress several times, but was scheduled to begin in 2020. Many health- care organizations, including the Organized Dentistry Co- alition (coordinated by ADA, of which AAPD is a member) had long advocated for this permanent repeal.
  • Full repeal of the "Cadillac tax" on high-cost employer- provided health plans. Enacted as part of the Affordable Care Act, the Cadillac tax would have imposed a 40 percent excise tax beginning in 2022 on employer-provided health plans that exceed $11,200 for an individual and $30,100 for a family.
  • Repeal of the UBIT tax on employee fringe benefits provided by tax-exempt organizations. Originally enacted under the 2017 tax law, this provision required as- sociations and other tax-exempt organizations to pay a 21 percent unrelated business income tax (UBIT) on employee benefits, such as parking and transportation. Known as the "church parking tax", there was a two-year advocacy and grassroots campaign by the American Society of Associa- tion Executives (ASAE) and the UBIT Coalition, working towards repeal. 
HRSA Title VII FY 2020 Post-Doctoral Training Grant NOFO Released; AAPD Provides Technical Assistance to Encourage Applications
In anticipation of a new HRSA grant cycle and in our effort to promote a robust number of pediatric dentistry applications, AAPD prepared a free webinar pediatric dental program direc- tors on grant writing and planning. This was presented live by Academic Trustee at-large Dr. Homa Amini on Oct. 11, 2019, and is available for online viewing/listening at any time for AAPD members.18
 
When the HRSA Notice of Funding Opportunity (NOFO) for Postdoctoral Training in General, Pediatric, and Public Dentistry was released on Nov. 13, 2019, the AAPD immediately notified pediatric dentistry program directors of the Feb. 12, 2020, ap- plication deadline. According to HRSA:
 
"The program provides funding to improve access and delivery of oral health care services for all individuals, particularly vulnerable populations and individuals located in rural and/or underserved areas. Eligible ap- plicants include entities that have programs in dental schools, or approved residency or advanced education programs in the practice of general, pediatric or public health dentistry, which may include dental schools, public or private not-for-profit hospitals, or other public or private non-profit entities, including faith-based and community based organizations."
 
The AAPD was pleased that the HRSA NOFO adopted many AAPD recommendations that such grants focus on program quality upgrades that improved care for under-served areas and populations, in-stead of merely expansion of positions. AAPD also sent reminders of a HRSA technical assistance webi- nar on Dec. 13, 2019, and subsequent conference call in Janu- ary, along with several additional reminders and guidance prior to the grant deadline. HRSA recently announced 27 Title VII FY 2020 grants to enhance postdoctoral dental residency train- ing programs in rural communities. Six awards were directed solely to pediatric dentistry programs, and another ten include pediatric dentistry in collaboration with general dentistry and dental public health. HRSA awarded a total of $13,004,548, with $8,092,627 supporting pediatric dentistry.
 
HRSA Retains Sealant Measure Based on AAPD-ADA Recommendations
On Dec. 13, 2019, the Health Resources and Services Administration (HRSA) announced in the Federal Register that based upon public feedback, the agency will retain the dental sealant measure for 2020 UDS reporting (Dental Sealants for Children Between 6-9 Years). HRSA also decided to not add the fluoride varnish measure for 2020 UDS.19 As reported in the November 2019 PDT, on Aug. 27, 2019, the AAPD and ADA wrote HRSA urging them not to replace the measure of Dental Sealants for Children Between 6-9 Years. This measure is utilized in HRSA’s oversight of its community health centers program. HRSA had requested public com- ment on a proposal to replace this measure with one titled Primary Caries Prevention Intervention as Offered by Primary Care Providers (CMS74v9). The letter, signed by then-ADA President Jeffrey M. Cole, ADA Executive Director Kathleen T. O’Loughlin, then-AAPD President Kevin J. Donly, and AAPD Chief Executive Officer John S. Rutkauskas stated: "Research has shown that seal- ants are effective in preventing occlusal carious lesions in the molars of children when compared with controls without sealants." The letter referenced the evidence-based clinical practice guideline released in 2016 by the ADA and AAPD that found sealants could minimize the progression of noncavitated occlusal carious lesions and effectively prevent and arrest pit-and-fissure occlu- sal carious lesions of primary and permanent molars in children and adolescents compared with the nonuse of sealants or use of fluoride varnishes. The letter is available on the AAPD website.20

AAPD, ADA, and AGD Oppose CMS Plan to Rescind Access Monitoring Review Plans by State Medicaid Agencies
On Sept. 13, 2019, the AAPD, ADA and AGD (Academy of General Dentistry) wrote the Centers for Medicare and Medic- aid Services (CMS) to comment on their proposed rule CMS- 2406-P2, entitled Medicaid Program; Methods for Assuring Access to Covered Medicaid Services-Rescission.
 
The AAPD-ADA-AGD regulatory comment letter noted that Medicaid plays an essential role in our nation’s oral health safety net, as over 23 million Medicaid enrollees receive dental services via Fee-for-Service (FFS) and an additional 5.3 million Medicaid enrollees receive them via combined FFS/managed care. These include pregnant women, children, the elderly, the disabled, and patients with a chronic and/or complex health condition. It is critical that these beneficiaries have access to quality services received in a timely manner. While acknowl- edging CMS efforts to strike a balance between maintaining access to care and providing states with flexibility, the groups opposed CMS’ proposal to rescind the November 2015 Medic- aid access rule. That rule required states to develop and submit an access monitoring review plan (AMRP). These AMRPs provide a means for CMS to measure access to care and reim- bursement rates. Further, using a checklist developed by the ADA,21 state dental associations review the AMRPs and ensure that the states have plans in place to ensure access to care for FFS beneficiaries. It is important that state dental associa- tions and other stakeholders – such as state pediatric dentistry chapters with our Public Policy Advocates network – undertake this review.
 
Therefore, the comment letter urged CMS to develop a template and standardize AMRPs, and also utilize the ADA’s checklist as a foundational tool for such standardization for the dental benefit within Medicaid FFS programs. Within the rule, CMS notes that it is developing a methodology for reporting Medicaid access data in lieu of AMRPs. The comment letter recommended that CMS should first issue criteria for improv- ing the AMRPs before loosening the monitoring requirements: "Any methodology used in place of an AMRP must be built on sound data and analyses, must be reported by states to CMS on an annual basis, and must be in place before the AMRP require- ment is rescinded." The ADA, AGD, and AAPD also requested the opportunity to participate in the review process. Ultimately, it was recommended that CMS should monitor rate reductions and maintain a process for beneficiaries and providers to pro- vide input on the implications of rate reductions. While there is a lot of variation between states on Medicaid FFS reimburse- ment rates, the comment letter noted that on average in 2016, Medicaid FFS reimbursement was 49.4 percent of fees charged by dentists for children and 37.2 percent for adults.22 This short- fall in reimbursement threatens access to care.
 
Organized Dentistry Coalition Supports Repeal of Section 1557 Language Posting Requirements
On Aug. 13, 2019, the Organized Dentistry Coalition (ODC), which includes the AAPD and ADA, submitted a regulatory comment letter to the U.S. Department of Health and Human Services Office for Civil Rights’ (OCR) supporting a proposal to amend portions of the Section 1557 Final Rule. This is the provision of the Affordable Care Act that prohibits health care entities that receive federal financial assistance from discrimi- nating on the basis of race, color, national origin, age, disability and sex. Implemented in 2016, the final rule applies to health care providers who receive certain funds through HHS, includ- ing Medicaid and the Children’s Health Insurance Program. Among other provisions of the OCR’s proposal, there would be a repeal of the Section 1557 requirements for covered dental practices to post taglines in the top 15 non-English languages spoken in the state and notices of nondiscrimi- nation. The proposal would also expand permissible use of audio-based interpretation services for individuals with limited English proficiency. The ODC letter said each dental coalition member "strongly supports non-discrimination in health care and equal access to care for all patients without regard to race, color, national origin, sex, age, religion or disability,’ but noted dentists have reported ‘great difficulty’ complying with this provision of the rule." Further, coalition members "believe that the repeal of these requirements will lead to cost savings and will allow staff to spend time on appropriate patient care and communication instead of time on interpreting and comply- ing with the regulations." The coalition also expressed support for the proposed rule’s exemption from the auxiliary aids and services requirements for covered entities with fewer than 15 employees.
 
The PPA network has proved tremendously effective in conveying important COVID-19 information to chapter members while sharing state-level decisions with the AAPD. They have been closely involved in advocacy with their governor, state legisla- tors, state and local public health officials, and their state Medicaid agency (SMA).
See the full list of AAPD PPAs on page 32.
 
 
Dental Letter, State Legislative Hearing, Press Coverage, and New Legislative Bill Put Spotlight on Unreasonable Medicaid Dental Audits in Nebraska
The AAPD, American Dental Association, Nebraska Society of Pediatric Dentistry and Nebraska Dental Association (NDA), troubled by the growing number of Medicaid pediatric dental audits in Nebraska that are harming children’s access to oral care, wrote the state’s Medicaid agency on November 6, 2019 stating that the audits have led to "unfortunate outcomes detrimental to the program’s goal of improving oral health access for children of low-income families." The organizations said they believe that dental auditors were not basing their re- views on AAPD’s accepted clinical recommendations and were "second-guessing clinical decision-making by pediatric dentists absent appropriate peer review by a dentist with equivalent educational training." The audits questioned the use of stain- less steel crowns in children at high caries risk, many with signs of severe decay on multiple teeth, and requested significant refund of payments for alleged inappropriate treatment. The letter asked the Nebraska Division of Medicaid and Long-Term Care to halt the audits and require all future Medicaid dental auditors to utilize dental profession clinical guidelines, best practices and policies of the appropriate specialty organiza- tion, and require contracted auditors to utilize licensed dentists of equivalent education and training as the dentists being audited and to have experience in treating Medicaid patients. There was featured story about the letter in ADA News, includ- ing a front page story in the printed version, and AAPD also posted the letter and summary on our website.23
 
On Dec. 13, 2019, the Nebraska Legislature’s Health and Human Services Committee held a hearing that included testimony on the Medicaid UPIC (Uniform Program Integrity Contractor) den- tal audits. The dental audit portion lasted for a little under an hour. The witnesses all did an outstanding job; these included pediatric dentists Drs. Marty Killeen (the first pediatric dentist impacted by these audits), Jill Wallen (head of pediatric den- tistry at the University of Nebraska dental school), and Jessica Meeske (former AAPD NorthCentral Trustee and member of the AAPD’s Committee on Dental Benefit Program and Pediatric Dental Medicaid and CHIP Advisory Committee), along with the mother of a special needs child. In a bit of great timing, coordi- nated between the Nebraska Society of Pediatric Dentistry and AAPD, there was a front page news story Friday morning of the hearing in the Omaha World-Herald and a subsequent editorial supporting the dental community’s position.24
 
A subsequent state legislative hearing was held in February 2020 with many of the same witnesses from the December hearing, along with NDA contact lobbyist Kim Robak. This was followed by the introduction of legislation, LB 1105, that expands the state’s existing RAC audit law to require all Medicaid audits to have peer review by same specialists and follow the best practices and guidelines of national organizations. If approved, LB 1105 may turn out to be a model law for other states to consider, and possibly submitted to NCSL and/or NCOIL25 for their endorsement.
 
Grass Roots Network
The AAPD occasionally issues Action Alerts asking that Members of Congress be contacted on important legislative or regulatory priorities for pediatric dentistry. We use a software program that is very simple and easy to use. If you wish to join over 600 of your colleague on our Grass Roots Network and receive all future alerts, you can sign up on the AAPD website.26
 
State Public Policy Advocates (PPAs)
The AAPD through the Council on Government Affairs (CGA) initiated a state Public Policy Advocate initiative in 2012 to strength- en and coordinate state-level advocacy efforts by our state chapters. A PPA serves as the state pediatric dentistry chapter’s ad- vocate for the oral health issues of infants, children, adolescents and patients with special health care and developmental needs. The PPA represents the chapter in promoting children’s oral health issues with the state legislature and other elected bodies, state regulatory agencies (including Medicaid and health departments), licensing bureaus, professional health and child welfare organi- zations, oral health coalitions, foundations, institutions of dental education, publicly-funded safety net programs, and the private sector benefits industry. The PPA closely coordinates their activities with those of the state dental association. PPAs serve as an advocacy liaison between the state pediatric dentistry chapter and the state dental association.
 
We continue to convene PPA quarterly conference calls to share information and discuss strategy. Annual written reports from PPAs are including the Council on Government Affairs annual report that is available on the AAPD website. There are PPAs in 47 states plus the District of Columbia. Note the following new or replacement PPAs as approved by the CGA over the past year:
 
Kentucky: Kirby Hoetker
North Carolina: Dylan S. Hamilton 
South Dakota: Karli Williams
 
If you want to get more involved with advocacy at the state level and help your state chapter, please contact your PPA. They will be happy for assistance. The current listing can be found in the PDF below.

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