Vol. 36, No. 1-Winter
Issue
19
Dentistry in HEW’s Forward Plan for Health John C. Greene, DMD, MPH” Today the health industry is one of the largest in this country. More than eight percent of our Gross National Product is spent for health-and there are more and more people questioning whether the nation is healthier as a result. Questions are being asked too about what is the Federal role and the state role and the private sector role in the scheme of things. Certainly, the huge Federal monetary investment in health presupposes a strong Federal role in coordinating and integrating the activities of the several sectors to assure coherence and prudence-in health planning and programming. There is a Federal responsibility, in short, to see to it that the public’s tax dollar is well spent. That’s no small job. The Federal Government is already footing the bill for just over 25 percent of the nation’s expenditures for personal health care, which last year totaled approximately $100 billion. The Government is meeting 65 percent of the total bill for health research, and that bill currently totals something like $4 billion. HEW alone spends roughly a quarter of its better than $100 billion budget on health, with about 1.2 percent or $330 million of the health budget going to dental activities, by the way. HEW’s National Institutes of Health is the largest single source of health research support. It administers 65 percent of the total Federal health research expenditure. About 2# percent of the NIH budget-some $44 million-is allocated to the National Institute of Dental Research. Not only is the Federal health budget already big but it continues to grow-and grow more rapidly than private expenditures. Much of the rise has been due to Medicare and Medicaid costs. They are rising at an annual rate of $5.0 billion. By contrast, the total state share of health expenditures has remained reasonably level over the years, even though state Medicaid payments have also risen rapidly. So, at the state level, increases pace but do not surpass the rate of increase in health care expenditures from all sources combined. That sort of trending may suggest-to those who haven’t thought of it before-the wisdom of enlarging the financial role of state and local governments as a means not only of strengthening health programs but also of easing somewhat the heavy Federal burden. Certainly Federal strategy calls for increasing state and local participation. But of course there’s a problem with that, and the problem is that state indebtedness is increasing twoand-one-half times faster than Federal indebtedness. Net state fiscal capacity fell from a surplus of $0.7 billion in 1973 to a deficit of $7.7 billion in 1974. And the problems are not all fiscal. Consider the implications of the new planning legislation. It establishes a whole system of state and local planning agencies and invests them with some rather extensive responsibilities. This means that states will have to develop staffs and methodologies and planning tools of their own, and it will take time, maybe years, before state and local planning agencies can begin to function at full effectiveness. All of which is by way of saying that we are all in “this” together, with the “this”-the solution of the nation’s health problems-being a matter so critically important that it deserves and gets one of the nation’s highest priorities, so costly that perhaps the one thing more expensive than finding the necessary answers would be the failure to do so, and so complex in organization and administrative requirements that only if all of us work together in the most ordered, practical and integrated way, can we hope to map the way toward the solutions that must be found.
‘Chief Dental Officer, PHS, Special Assistant for Dental Affairs, Office of the Assistant Secretary for Health, Rockville, Maryland 20852.
20
Journal of Public Health Dentistry
The Forward Plan for Health is the Public Health Service’s statement on where we should go from here and how we should get there. It offers a remarkably candid appraisal of the “the health world and its environment.” And it indicates where, over the next five years, the Federal Government should direct its health resources. Since the Forward Plan serves as the framework for the formulation of the PHS budget, it obviously has a good deal of clout. Overall, though, the Plan tends to be general rather than specific in its “perception and proposals,” and health matters are organized along functional or thematic-rather than categorical-lines. There are seven major themes: One-Management-has to do with the internal workings of PHS and needn’t concern us here. The others are called Knowledge Deuelopment; Prevention; Improving the Health Care System; Assuring the Quality of Care; National Health Insurance; and Tracking and Eualuation. Each of them discusses a specific set of problems, the respective roles and responsibilities of Federal, state, local government and the private sector, PHS’s own objectives and strategies, and proposed plans and initiatives. The fact that the Plan is organizationally thematic and stylistically generalized presents dentistry with some peculiar problems-or perhaps I should say challenges. On the one hand there is the very real possibility that functionalism, which is designed to eliminate both overlaps and oversights while serving the cause of total health, may eventually accomplish all those things. On the other hand, though, we have to work hard to make the dental case. However, non-categorical the premise of health agencies and their programs and planning, the staff orientation is almost always predominantly medical. When that is the case, the dental connotations may be ignored because they are not really understood nor appreciated. It is interesting in that connection to note that the dental activities given the most emphasis in this Forward Plan are the children’s program which the Administration included in last year’s Comprehensive Health Insurance Plan, and a proposal for a fluoridation/prevention dentistry program at the National Center for Disease Control. In both instances, these are programs which the dental profession has pushed hard for, both in private councils and public forums. It is pertinent, too, that my appointment as special assistant for dental affairs was made at just about the time the first draft of the present Forward Plan was completed. My staff and I were asked to criticize the draft, which we did. Our suggestion that we call in representatives of the major dental organizations to get their viewpoints was accepted. The meeting was held and the Assistant Secretary for Health-Dr. Cooper-took part in it. Public health dentistry was represented. A substantial portion of the dental material now contained in the Plan is there because of these efforts. I have already voiced my concern that there is still far too little emphasis given dentistry. It remains a distinctly minor theme, but the point has at least been made that dental health is an integral part of the propositions considered. I wish now to consider some of the themes in terms of the general directions they set and particular questions they raise for those of us in dental health. The first of the themes is Knowledge Development. The title is a good one, since it permits the linking of research and development as a topic for discussion without inciting riot over the definition of terms. The underlying argument is that “there is almost no area of health where the available knowledge is adequate to the challenge faced.” The magnitude of the Federal role in research is so great, the theme points out, that any change in Federal policy or levels and consistency of funding has tremendous impact on the national health effort. In recent years there has been a downtrend in the dollar level of Federal support as well as in the proportion of total health costs which research represents. The theme also notes what it calls “an erratic funding pattern for health services research in regard to knowl-
Vol. 36, No. 1-Winter
Issue
21
edge development as essential to effecting improvements in the delivery and financing of health services and also to improving the quality of care. Other concerns are the question of research priorities-the allocation of resources to knowledge development in health, as well as the place of biomedical research in the continuum of health activities. Apart from the statement that research is needed to determine the relation of nutrition to dental caries, there is almost no dental inclusion in this theme of knowledge development. Nonetheless, we in dentistry can see the need for a strong dental emphasis in some of the specific issues raised here-research in health education, for example, or in the social and economic costs of dental illness or aging and long term care and in dental health services research. The fact that they are not included is a major deficiency in the Plan. Once we were on the verge of learning quite a lot about the dental problems of the aged and the costs and complications of their care. That opportunity rather slipped away from us. Now more than ever we need to know about service needs and the methods of service delivery. What is the impact, if any, of dental health on the total mental and physical well being of the aged or institutionalized or chronically ill? What are the costs’? Indeed what are the costs-the social no less than the economic costs-of dental illness to anyone? We’ve talked a lot about this sort of thing over the years. But how much do we really know about such ordinary-sounding matters as reduced efficiency or man hours lost because of dental problems? Or the cost to families of long term dental carehow they meet them, how they bear up? And what about personalities stunted and talents wasted and families destroyed because of deformers and cripplers like gross malocclusions and oral clefts? As for health education-well, who has a greater need to get a handle on it than dentistry? The Forward Plan states that “the critical knowledge deficit indulging our health education is in communicating to professionals or to the public new knowledge that requires a change in behavior.” The Plan lists dramatic examples like alcohol abuse, smoking and highway safety. We could list some less colorful but just as puzzling questions-how to establish good oral health habits in children, how to persuade everyone to brush and floss, how to win the day for fluoridation? Health education also receives strong emphasis in the second theme-Preuention. This theme, in many ways the most specific of the seven, addresses the three stages of prevention: primary, secondary, and tertiary. But it is stated emphatically that the basic assumption of the theme is “that despite major gaps in our knowledge, enough is known about the links between major diseases and their causes to justify a special emphasis on primary preventive action now.” The theme on Prevention is noteworthy for its activism. It is also the theme in which the dental component gets its greatest emphasis. In a special appendix it recommends special strategies in prevention. One of these is Child Health, which lists dental health as one of the essentials of a preventive health care strategy for children and recommends, in that connection, the fluoridation of school water supplies, the sponsoring of a National Conference on Dental Health Education and Prevention, and the encouragement of the expansion of the dental component of the EPSDT program through workshops for dental people and EPSDT coordinators. The big item, though, is the third strategy proposed: the “Nationwide Fluoridation of Drinking Water,” which gives support to a Center for Disease Control (CDC) proposal for a program of developmental assistance to support the acquisition, installation, and start up costs of fluoridation for community and school water supplies. The proposal also covers technical assistance, fluoridation monitoring programs, consumer health education, and consultation on promoting consumer acceptance. In all these things, CDC will work closely with the dental profession, both its public
22
Journal of Public Health Dentistry
and private sectors. In turn, it will need the profession’s vigorous support. But even more, perhaps, it will need yours at the state and local level. Given our full backing, CDC, with all its experience and know-how, should be able to supply the fluoridation program with just the impetus it needs. And let me add a note here. I know some of you have had some misgivings about the relocation of fluoridation and the other preventive programs from the old Division of Dental Health-now the Division of Dentistry-to CDC. I believe that in the long run, you’ll decide it was a good move. For one thing, the Division’s responsibilities are now more sharply focused on manpower and the manpower problems continue to b e worthy of such focalized attention. Later today, Dr. Cox will be talking to his Division’s current programs and plans. As for fluoridation, CDC now has staff positions and funds to begin its new campaign. The new program has Dr. David Sencer’s support, and Dr. Sencer, the Director of CDC, has mine and-I am sure-yours-if you know him. The third theme is devoted to lmproving the Health Care System-that is to say, improving the delivery of health care services. I would like to quote the basic premise of this theme, which is that “ . . . there are enormous strengths in the American health care system. Improvements in the system should be brought about by building on these firm foundations, not by sweeping away the present system to make way for a new structure.” Not only is this the philosophy of Assistant Secretary Cooper, but it’also seems to me to reflect the thinking of our new Secretary, Dr. Mathews. The achievements of the present system are seen in this theme to be rooted in two strong characteristics of American society-first, a commitment to individual and local initiative and diversity; and, second, the ability of science and technology to help solve social problems. Interestingly enough, these strengths are also given most of the credit for some of the care system’s biggest problems: the maldistribution of personnel and facilities, spiralling health costs, and uneven quality of care. There are, of course, some contemporary complications of note,-the economic crisis, which puts a damper on all of us at every level of action; the new National Health Planning and Resources Act, and the trend toward having state and local governments bear a greater share of the financial burden, both of which I mentioned earlier; and national health insurance and all it implies. One of the proposals for dealing with the economic problems of care calls for the expansion of “cost containing activities such as Health Maintenance Organizations.” As you know, the HMO amendments currently before the House eliminate preventive dental care for children as a required service and make supplemental health benefits, including dental care, optional services. The ADA has submitted a statement to the subcommittee opposing the new bill, citing what it considers to be the additional and unwarranted advantages given HMO’s. That points up the need to make our voices heard when new programs are being developed. That brings us to the Health Resources Planning and Development Act, which calls for joint Federal, state, and local action. I regret to report that there has, however, been little or no dental involvement in its implementation to date. HEW is currently developing health planning guidelines and standards which are to be published early next year for comment. Since these will obviously affect dentistry, it is essential that dentists let their views be known. You should review the guidelines and standards with the utmost care and I should think this organization may want to take a formal position on them. Among the numerous other strategies which the Forward Plan puts forth for improving the health care system are many which focus on manpower. They include the evaluation of new kinds of manpower; developing common criteria for identification of health scarcity areas; augmenting the National Health Service Corps; influencing the ultimate geographic location of health manpower now in training; continuing the emphasis on primary care providers; special project programs of Federal support to profes-
Vol. 36, No. 1-Winter Issue
23
sional schools tied to new responsibilities that the schools must undertake; development of a mechanism outside of government to provide advice on what clinical specialties are needed; continued examination of the physician extender concept, and so on. All of these must have a familiar ring to any dentist. In many of the areas touched upon, dentistry has been the pioneer. That is true in auxiliary utilization, but we have yet to answer some basic questions on ultimate role content and role relationships within dentistry. And we have only( just begun to consider the place of dentistry in primary health care. Dentistry is also just beginning to be concerned with specialization and its impact on maldistribution. Specialization is not yet a problem in dentistry. The point is, though, that we still have time to take steps to avoid the kinds of oversupply and imbalances that have so aggravated maldistribution in medicine that Congress is proposing legislative remedies. Surely, since we in dentistry still have some lead time, we should begin seriously to weigh alternative courses of action and not wait for solutions to be legislated for us in a crisis atmosphere. I don’t want to trespass too far on Dr. Cox’s territory, but I hope he won’t mind if I speak briefly to another PHS strategy for dealing with maldistribution. That is the National Health Service Corps. It seems to me to provide such a practical answer to the nialdistribution problem for so many localities that we should make it better known and more fully utilized. Right now the NHSC is supplying dentists to 75 of 736 designated critical shortage areas. In view of its potential, that’s not nearly enough. But it is a beginning, and, for the first time, dental students this year will be eligible for NHSC scholarships. Fifty will be awarded. A token, perhaps, but still an important beginning. The fourth theme, Assuring the Quality of Health Care, seeks to provide a framework for integrating diverse Federal health responsibilities into a coherent program to improve the quality of health services in the United States. It sees a critical need for national health policy to focus the health care system on producing high quality results. The theme proposes several courses of action, including the instruction of health professionals in quality assurance methodologies. Another is that HEW “fully implement the quality assurance program sponsored by the Department; in particular, establish PSRO as an operational quality assurance system throughout the nation as rapidly as possible.’’ Since there is very little dental emphasis in the PSRO program at the moment, the big question is, or should be, how dentists can make their presence felt. And we should ponder that especially, now that there is likelihood that ambulatory care will be included under PSRO’s. The bright side here is the ADA’s interest in the development of review criteria, something also called for in the Forward Plan. With all the future seems to hold for us-NHI in special-it would be disastrous, in my view, for the profession to turn away from peer review and PSRO’s. The fifth theme is National Health Insurance. It is an interesting one which assumes for the purposes of discussion that the Administration’s Comprehensive Health Insurance Plan (CHIP), the dental care plan for children included, will prevail in the end. But CHIP you know, and I would like to leave that and look instead at a couple of other statements in the Plan. The first is that: we must guard against the temptation to exaggerate the payoff of national health insurance . . . health services constitute only one of the many factors determining health status. . . . Therefore, to assume that the adoption of a national health insurance system will, by itself, make for a healthier society is to attach to it a purpose for which it is not intended, and a goal that it cannot achieve.
I do not argue with that statement. I would like to add something to it-and that is that we should not underestimate NHI’s potential impact, either, especially not with respect to dental health, which is as yet so dependent upon treatment. One of the big challenges for all of us in dentistry is that of activating latent demand-of seeing to it
24
Journal of Public Health Dentistry
that those who need care get it-that they use the services available to them. Public health dentists have long talked of health education and behavioral research in this regard, but relatively little has been accomplished. Now, surely, is the time to get on with it. If we move into NHI without having thoroughly explored the question of how to motivate people to take constructive action on behalf of their own health, we may never realize the full potential national health insurance may hold for dental health. Two other statements worth noting in the NHI theme are these: “the growth of demand for dental services under CHIP is expected to be relatively small, due primarily to the limitation of CHIP benefits to children under 13 years of age.” This is indeed the best served group, but its inclusion will release family funds-for the purchase of dental care for others, perhaps? In any event, a program other than CHIP might have a different impact. The second statement is that there is not likely to be a shortage of dental services by the time NHI is implemented. The reason? Because the total dental manpower pool will be increased by 25 percent during the ’ ~ O S ,the growing supply and use of auxiliary personnel will expand dentist productivity, and because “dentists might also be willing to work more hours a week.” As an overall evaluation, I suspect this is right. But whether we will be able to meet dental care demands in particular areas is at best a moot question. We can’t take it for granted that dentists will be where they are needed. We can’t take it for granted that other converging influences will not intensify demands at much higher levels than anticipated here. Far fewer people are covered b y dental insurance than by medical. The growth in dental coverages is great but it is also recent, and we have yet to take a true measure of its impact. The uncertain nature of our response to such a fundamental issue underscores the iniportance of the final theme, Tracking and Evaluation. Its basic tenet is one most of us here have learned the hard way: that in order for government to make informed decisions, assess those decisions and operate its program effectively, we must have an adequate information base. That is true in regard to all the previously discussed themes. It is something that is brought home to me on my job almost every day. Yet, despite the large numbers of separate statistical activities, critical gaps in usable information still exist in various health areas, particularly in relation to manpower resources, the utilization of services, and the costs and quality of care. The most significant challenge in health statistics is the development of a data system capable of satisfying the multiple needs for data at the state and substate levels, and of providing the data needed for evaluation of the impact of major Federal programs. Nationally, the strategy is to accelerate the implementation of the Cooperative Health Statistics System to provide comparable data on vital events, health manpower, health facilities, and the utilization of health care at the national, state, and local levels. This is especially important to the new health systems agencies, PSRO’s, and NHI, as well as to researchers and health system managers in the private sector. As you know, the Cooperative Health Statistics System will provide and process data through a coalition of various national, state and local agencies. This is an important advance toward a national system and one that gives due recognition to the responsibility of state and local government. The major initiative next year will be the acceleration of the development and implementation of the components of the Cooperative Health Statistics System for which there is greatest need for resource planning purposes. Though plans call for the completion of most of the major data systems-manpower, facilities, and hospital care-over the next five years, the data system for dental manpower will, I am sure, take less than that because of the considerable work already done in this connection by the dental division.
Vol. 36, No. 1-Winter Issue
25
Henceforth, we are also going to have better utilization data from the Health Interview Survey because it has redesigned its sample and quadrupled its size. The enlargement of the sample means that, for the first time, we will be provided with state and smaller area data. ‘That is the Forward Plan for Health. It is an essay in good stewardship-an effort to make public health activity a part of the real world. As dentists, I think we have some reason to be dissatisfied that the explicit dental emphasis is so slight. But remember that this plan, like its predecessors, will be updated annually. We will have our chance, therefore, to make our interests clear and our voices heard. And so, at this time in spite of the criticisms that can be made of the current version, I choose to be optimistic about the direction it sets for public health and about dentistry’s place in the ultimate scheme of things. And the role of my office is primarily to assure appropriate dental involvement in the planning and implementation of HEW’S programs and to provide an avenue for the major non-Federal dental voices to be heard in the process. This organization can be of great assistance in this effort.
Ancient, Medieval, Modem Confusion certainly exists about the use of ancient to describe an era of human development. The confusion seems to have been cleared substantially b y the investigation of a Professor of Anthropology at the University of California. His study of the dated skeletal remains of two-footed hominids-their hip-joints, thigh bones, legs, feet, vertebrae, teeth, facial contours, skulls, and foramina makes the pyramid-building Egyptians merely recent youngsters on Planet Earth. Early paleontological findings, combined with recent discoveries and statistically tested, show that two-footed locomotion must have occurred three million years ago. An increase in size of human brains, accompanied by group-activity, had developed by two million years ago. The next time you are tempted to use “ancient” to describe an era, observe the stop-sign! -Henry M . McHenry in Science for October 31, 1975 (KAE)
Helping Children Overcome Fear The National Institute of Dental Research has funded a three-year study at Case Western Reserve University to be supervised by psychologist Barbara Melamed, Ph.D. ($36,200 for the first year). With three dentists, Roland Howes, Stephen Hutherson, and Richard Hirschman, the group plans to determine the benefit to a group of children from a combination of an exploratory film and specific behavioral approaches by the dentist. -Research News from NIDR for August, 1975 (KAE)
Issue
19
Dentistry in HEW’s Forward Plan for Health John C. Greene, DMD, MPH” Today the health industry is one of the largest in this country. More than eight percent of our Gross National Product is spent for health-and there are more and more people questioning whether the nation is healthier as a result. Questions are being asked too about what is the Federal role and the state role and the private sector role in the scheme of things. Certainly, the huge Federal monetary investment in health presupposes a strong Federal role in coordinating and integrating the activities of the several sectors to assure coherence and prudence-in health planning and programming. There is a Federal responsibility, in short, to see to it that the public’s tax dollar is well spent. That’s no small job. The Federal Government is already footing the bill for just over 25 percent of the nation’s expenditures for personal health care, which last year totaled approximately $100 billion. The Government is meeting 65 percent of the total bill for health research, and that bill currently totals something like $4 billion. HEW alone spends roughly a quarter of its better than $100 billion budget on health, with about 1.2 percent or $330 million of the health budget going to dental activities, by the way. HEW’s National Institutes of Health is the largest single source of health research support. It administers 65 percent of the total Federal health research expenditure. About 2# percent of the NIH budget-some $44 million-is allocated to the National Institute of Dental Research. Not only is the Federal health budget already big but it continues to grow-and grow more rapidly than private expenditures. Much of the rise has been due to Medicare and Medicaid costs. They are rising at an annual rate of $5.0 billion. By contrast, the total state share of health expenditures has remained reasonably level over the years, even though state Medicaid payments have also risen rapidly. So, at the state level, increases pace but do not surpass the rate of increase in health care expenditures from all sources combined. That sort of trending may suggest-to those who haven’t thought of it before-the wisdom of enlarging the financial role of state and local governments as a means not only of strengthening health programs but also of easing somewhat the heavy Federal burden. Certainly Federal strategy calls for increasing state and local participation. But of course there’s a problem with that, and the problem is that state indebtedness is increasing twoand-one-half times faster than Federal indebtedness. Net state fiscal capacity fell from a surplus of $0.7 billion in 1973 to a deficit of $7.7 billion in 1974. And the problems are not all fiscal. Consider the implications of the new planning legislation. It establishes a whole system of state and local planning agencies and invests them with some rather extensive responsibilities. This means that states will have to develop staffs and methodologies and planning tools of their own, and it will take time, maybe years, before state and local planning agencies can begin to function at full effectiveness. All of which is by way of saying that we are all in “this” together, with the “this”-the solution of the nation’s health problems-being a matter so critically important that it deserves and gets one of the nation’s highest priorities, so costly that perhaps the one thing more expensive than finding the necessary answers would be the failure to do so, and so complex in organization and administrative requirements that only if all of us work together in the most ordered, practical and integrated way, can we hope to map the way toward the solutions that must be found.
‘Chief Dental Officer, PHS, Special Assistant for Dental Affairs, Office of the Assistant Secretary for Health, Rockville, Maryland 20852.
20
Journal of Public Health Dentistry
The Forward Plan for Health is the Public Health Service’s statement on where we should go from here and how we should get there. It offers a remarkably candid appraisal of the “the health world and its environment.” And it indicates where, over the next five years, the Federal Government should direct its health resources. Since the Forward Plan serves as the framework for the formulation of the PHS budget, it obviously has a good deal of clout. Overall, though, the Plan tends to be general rather than specific in its “perception and proposals,” and health matters are organized along functional or thematic-rather than categorical-lines. There are seven major themes: One-Management-has to do with the internal workings of PHS and needn’t concern us here. The others are called Knowledge Deuelopment; Prevention; Improving the Health Care System; Assuring the Quality of Care; National Health Insurance; and Tracking and Eualuation. Each of them discusses a specific set of problems, the respective roles and responsibilities of Federal, state, local government and the private sector, PHS’s own objectives and strategies, and proposed plans and initiatives. The fact that the Plan is organizationally thematic and stylistically generalized presents dentistry with some peculiar problems-or perhaps I should say challenges. On the one hand there is the very real possibility that functionalism, which is designed to eliminate both overlaps and oversights while serving the cause of total health, may eventually accomplish all those things. On the other hand, though, we have to work hard to make the dental case. However, non-categorical the premise of health agencies and their programs and planning, the staff orientation is almost always predominantly medical. When that is the case, the dental connotations may be ignored because they are not really understood nor appreciated. It is interesting in that connection to note that the dental activities given the most emphasis in this Forward Plan are the children’s program which the Administration included in last year’s Comprehensive Health Insurance Plan, and a proposal for a fluoridation/prevention dentistry program at the National Center for Disease Control. In both instances, these are programs which the dental profession has pushed hard for, both in private councils and public forums. It is pertinent, too, that my appointment as special assistant for dental affairs was made at just about the time the first draft of the present Forward Plan was completed. My staff and I were asked to criticize the draft, which we did. Our suggestion that we call in representatives of the major dental organizations to get their viewpoints was accepted. The meeting was held and the Assistant Secretary for Health-Dr. Cooper-took part in it. Public health dentistry was represented. A substantial portion of the dental material now contained in the Plan is there because of these efforts. I have already voiced my concern that there is still far too little emphasis given dentistry. It remains a distinctly minor theme, but the point has at least been made that dental health is an integral part of the propositions considered. I wish now to consider some of the themes in terms of the general directions they set and particular questions they raise for those of us in dental health. The first of the themes is Knowledge Development. The title is a good one, since it permits the linking of research and development as a topic for discussion without inciting riot over the definition of terms. The underlying argument is that “there is almost no area of health where the available knowledge is adequate to the challenge faced.” The magnitude of the Federal role in research is so great, the theme points out, that any change in Federal policy or levels and consistency of funding has tremendous impact on the national health effort. In recent years there has been a downtrend in the dollar level of Federal support as well as in the proportion of total health costs which research represents. The theme also notes what it calls “an erratic funding pattern for health services research in regard to knowl-
Vol. 36, No. 1-Winter
Issue
21
edge development as essential to effecting improvements in the delivery and financing of health services and also to improving the quality of care. Other concerns are the question of research priorities-the allocation of resources to knowledge development in health, as well as the place of biomedical research in the continuum of health activities. Apart from the statement that research is needed to determine the relation of nutrition to dental caries, there is almost no dental inclusion in this theme of knowledge development. Nonetheless, we in dentistry can see the need for a strong dental emphasis in some of the specific issues raised here-research in health education, for example, or in the social and economic costs of dental illness or aging and long term care and in dental health services research. The fact that they are not included is a major deficiency in the Plan. Once we were on the verge of learning quite a lot about the dental problems of the aged and the costs and complications of their care. That opportunity rather slipped away from us. Now more than ever we need to know about service needs and the methods of service delivery. What is the impact, if any, of dental health on the total mental and physical well being of the aged or institutionalized or chronically ill? What are the costs’? Indeed what are the costs-the social no less than the economic costs-of dental illness to anyone? We’ve talked a lot about this sort of thing over the years. But how much do we really know about such ordinary-sounding matters as reduced efficiency or man hours lost because of dental problems? Or the cost to families of long term dental carehow they meet them, how they bear up? And what about personalities stunted and talents wasted and families destroyed because of deformers and cripplers like gross malocclusions and oral clefts? As for health education-well, who has a greater need to get a handle on it than dentistry? The Forward Plan states that “the critical knowledge deficit indulging our health education is in communicating to professionals or to the public new knowledge that requires a change in behavior.” The Plan lists dramatic examples like alcohol abuse, smoking and highway safety. We could list some less colorful but just as puzzling questions-how to establish good oral health habits in children, how to persuade everyone to brush and floss, how to win the day for fluoridation? Health education also receives strong emphasis in the second theme-Preuention. This theme, in many ways the most specific of the seven, addresses the three stages of prevention: primary, secondary, and tertiary. But it is stated emphatically that the basic assumption of the theme is “that despite major gaps in our knowledge, enough is known about the links between major diseases and their causes to justify a special emphasis on primary preventive action now.” The theme on Prevention is noteworthy for its activism. It is also the theme in which the dental component gets its greatest emphasis. In a special appendix it recommends special strategies in prevention. One of these is Child Health, which lists dental health as one of the essentials of a preventive health care strategy for children and recommends, in that connection, the fluoridation of school water supplies, the sponsoring of a National Conference on Dental Health Education and Prevention, and the encouragement of the expansion of the dental component of the EPSDT program through workshops for dental people and EPSDT coordinators. The big item, though, is the third strategy proposed: the “Nationwide Fluoridation of Drinking Water,” which gives support to a Center for Disease Control (CDC) proposal for a program of developmental assistance to support the acquisition, installation, and start up costs of fluoridation for community and school water supplies. The proposal also covers technical assistance, fluoridation monitoring programs, consumer health education, and consultation on promoting consumer acceptance. In all these things, CDC will work closely with the dental profession, both its public
22
Journal of Public Health Dentistry
and private sectors. In turn, it will need the profession’s vigorous support. But even more, perhaps, it will need yours at the state and local level. Given our full backing, CDC, with all its experience and know-how, should be able to supply the fluoridation program with just the impetus it needs. And let me add a note here. I know some of you have had some misgivings about the relocation of fluoridation and the other preventive programs from the old Division of Dental Health-now the Division of Dentistry-to CDC. I believe that in the long run, you’ll decide it was a good move. For one thing, the Division’s responsibilities are now more sharply focused on manpower and the manpower problems continue to b e worthy of such focalized attention. Later today, Dr. Cox will be talking to his Division’s current programs and plans. As for fluoridation, CDC now has staff positions and funds to begin its new campaign. The new program has Dr. David Sencer’s support, and Dr. Sencer, the Director of CDC, has mine and-I am sure-yours-if you know him. The third theme is devoted to lmproving the Health Care System-that is to say, improving the delivery of health care services. I would like to quote the basic premise of this theme, which is that “ . . . there are enormous strengths in the American health care system. Improvements in the system should be brought about by building on these firm foundations, not by sweeping away the present system to make way for a new structure.” Not only is this the philosophy of Assistant Secretary Cooper, but it’also seems to me to reflect the thinking of our new Secretary, Dr. Mathews. The achievements of the present system are seen in this theme to be rooted in two strong characteristics of American society-first, a commitment to individual and local initiative and diversity; and, second, the ability of science and technology to help solve social problems. Interestingly enough, these strengths are also given most of the credit for some of the care system’s biggest problems: the maldistribution of personnel and facilities, spiralling health costs, and uneven quality of care. There are, of course, some contemporary complications of note,-the economic crisis, which puts a damper on all of us at every level of action; the new National Health Planning and Resources Act, and the trend toward having state and local governments bear a greater share of the financial burden, both of which I mentioned earlier; and national health insurance and all it implies. One of the proposals for dealing with the economic problems of care calls for the expansion of “cost containing activities such as Health Maintenance Organizations.” As you know, the HMO amendments currently before the House eliminate preventive dental care for children as a required service and make supplemental health benefits, including dental care, optional services. The ADA has submitted a statement to the subcommittee opposing the new bill, citing what it considers to be the additional and unwarranted advantages given HMO’s. That points up the need to make our voices heard when new programs are being developed. That brings us to the Health Resources Planning and Development Act, which calls for joint Federal, state, and local action. I regret to report that there has, however, been little or no dental involvement in its implementation to date. HEW is currently developing health planning guidelines and standards which are to be published early next year for comment. Since these will obviously affect dentistry, it is essential that dentists let their views be known. You should review the guidelines and standards with the utmost care and I should think this organization may want to take a formal position on them. Among the numerous other strategies which the Forward Plan puts forth for improving the health care system are many which focus on manpower. They include the evaluation of new kinds of manpower; developing common criteria for identification of health scarcity areas; augmenting the National Health Service Corps; influencing the ultimate geographic location of health manpower now in training; continuing the emphasis on primary care providers; special project programs of Federal support to profes-
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sional schools tied to new responsibilities that the schools must undertake; development of a mechanism outside of government to provide advice on what clinical specialties are needed; continued examination of the physician extender concept, and so on. All of these must have a familiar ring to any dentist. In many of the areas touched upon, dentistry has been the pioneer. That is true in auxiliary utilization, but we have yet to answer some basic questions on ultimate role content and role relationships within dentistry. And we have only( just begun to consider the place of dentistry in primary health care. Dentistry is also just beginning to be concerned with specialization and its impact on maldistribution. Specialization is not yet a problem in dentistry. The point is, though, that we still have time to take steps to avoid the kinds of oversupply and imbalances that have so aggravated maldistribution in medicine that Congress is proposing legislative remedies. Surely, since we in dentistry still have some lead time, we should begin seriously to weigh alternative courses of action and not wait for solutions to be legislated for us in a crisis atmosphere. I don’t want to trespass too far on Dr. Cox’s territory, but I hope he won’t mind if I speak briefly to another PHS strategy for dealing with maldistribution. That is the National Health Service Corps. It seems to me to provide such a practical answer to the nialdistribution problem for so many localities that we should make it better known and more fully utilized. Right now the NHSC is supplying dentists to 75 of 736 designated critical shortage areas. In view of its potential, that’s not nearly enough. But it is a beginning, and, for the first time, dental students this year will be eligible for NHSC scholarships. Fifty will be awarded. A token, perhaps, but still an important beginning. The fourth theme, Assuring the Quality of Health Care, seeks to provide a framework for integrating diverse Federal health responsibilities into a coherent program to improve the quality of health services in the United States. It sees a critical need for national health policy to focus the health care system on producing high quality results. The theme proposes several courses of action, including the instruction of health professionals in quality assurance methodologies. Another is that HEW “fully implement the quality assurance program sponsored by the Department; in particular, establish PSRO as an operational quality assurance system throughout the nation as rapidly as possible.’’ Since there is very little dental emphasis in the PSRO program at the moment, the big question is, or should be, how dentists can make their presence felt. And we should ponder that especially, now that there is likelihood that ambulatory care will be included under PSRO’s. The bright side here is the ADA’s interest in the development of review criteria, something also called for in the Forward Plan. With all the future seems to hold for us-NHI in special-it would be disastrous, in my view, for the profession to turn away from peer review and PSRO’s. The fifth theme is National Health Insurance. It is an interesting one which assumes for the purposes of discussion that the Administration’s Comprehensive Health Insurance Plan (CHIP), the dental care plan for children included, will prevail in the end. But CHIP you know, and I would like to leave that and look instead at a couple of other statements in the Plan. The first is that: we must guard against the temptation to exaggerate the payoff of national health insurance . . . health services constitute only one of the many factors determining health status. . . . Therefore, to assume that the adoption of a national health insurance system will, by itself, make for a healthier society is to attach to it a purpose for which it is not intended, and a goal that it cannot achieve.
I do not argue with that statement. I would like to add something to it-and that is that we should not underestimate NHI’s potential impact, either, especially not with respect to dental health, which is as yet so dependent upon treatment. One of the big challenges for all of us in dentistry is that of activating latent demand-of seeing to it
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Journal of Public Health Dentistry
that those who need care get it-that they use the services available to them. Public health dentists have long talked of health education and behavioral research in this regard, but relatively little has been accomplished. Now, surely, is the time to get on with it. If we move into NHI without having thoroughly explored the question of how to motivate people to take constructive action on behalf of their own health, we may never realize the full potential national health insurance may hold for dental health. Two other statements worth noting in the NHI theme are these: “the growth of demand for dental services under CHIP is expected to be relatively small, due primarily to the limitation of CHIP benefits to children under 13 years of age.” This is indeed the best served group, but its inclusion will release family funds-for the purchase of dental care for others, perhaps? In any event, a program other than CHIP might have a different impact. The second statement is that there is not likely to be a shortage of dental services by the time NHI is implemented. The reason? Because the total dental manpower pool will be increased by 25 percent during the ’ ~ O S ,the growing supply and use of auxiliary personnel will expand dentist productivity, and because “dentists might also be willing to work more hours a week.” As an overall evaluation, I suspect this is right. But whether we will be able to meet dental care demands in particular areas is at best a moot question. We can’t take it for granted that dentists will be where they are needed. We can’t take it for granted that other converging influences will not intensify demands at much higher levels than anticipated here. Far fewer people are covered b y dental insurance than by medical. The growth in dental coverages is great but it is also recent, and we have yet to take a true measure of its impact. The uncertain nature of our response to such a fundamental issue underscores the iniportance of the final theme, Tracking and Evaluation. Its basic tenet is one most of us here have learned the hard way: that in order for government to make informed decisions, assess those decisions and operate its program effectively, we must have an adequate information base. That is true in regard to all the previously discussed themes. It is something that is brought home to me on my job almost every day. Yet, despite the large numbers of separate statistical activities, critical gaps in usable information still exist in various health areas, particularly in relation to manpower resources, the utilization of services, and the costs and quality of care. The most significant challenge in health statistics is the development of a data system capable of satisfying the multiple needs for data at the state and substate levels, and of providing the data needed for evaluation of the impact of major Federal programs. Nationally, the strategy is to accelerate the implementation of the Cooperative Health Statistics System to provide comparable data on vital events, health manpower, health facilities, and the utilization of health care at the national, state, and local levels. This is especially important to the new health systems agencies, PSRO’s, and NHI, as well as to researchers and health system managers in the private sector. As you know, the Cooperative Health Statistics System will provide and process data through a coalition of various national, state and local agencies. This is an important advance toward a national system and one that gives due recognition to the responsibility of state and local government. The major initiative next year will be the acceleration of the development and implementation of the components of the Cooperative Health Statistics System for which there is greatest need for resource planning purposes. Though plans call for the completion of most of the major data systems-manpower, facilities, and hospital care-over the next five years, the data system for dental manpower will, I am sure, take less than that because of the considerable work already done in this connection by the dental division.
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Henceforth, we are also going to have better utilization data from the Health Interview Survey because it has redesigned its sample and quadrupled its size. The enlargement of the sample means that, for the first time, we will be provided with state and smaller area data. ‘That is the Forward Plan for Health. It is an essay in good stewardship-an effort to make public health activity a part of the real world. As dentists, I think we have some reason to be dissatisfied that the explicit dental emphasis is so slight. But remember that this plan, like its predecessors, will be updated annually. We will have our chance, therefore, to make our interests clear and our voices heard. And so, at this time in spite of the criticisms that can be made of the current version, I choose to be optimistic about the direction it sets for public health and about dentistry’s place in the ultimate scheme of things. And the role of my office is primarily to assure appropriate dental involvement in the planning and implementation of HEW’S programs and to provide an avenue for the major non-Federal dental voices to be heard in the process. This organization can be of great assistance in this effort.
Ancient, Medieval, Modem Confusion certainly exists about the use of ancient to describe an era of human development. The confusion seems to have been cleared substantially b y the investigation of a Professor of Anthropology at the University of California. His study of the dated skeletal remains of two-footed hominids-their hip-joints, thigh bones, legs, feet, vertebrae, teeth, facial contours, skulls, and foramina makes the pyramid-building Egyptians merely recent youngsters on Planet Earth. Early paleontological findings, combined with recent discoveries and statistically tested, show that two-footed locomotion must have occurred three million years ago. An increase in size of human brains, accompanied by group-activity, had developed by two million years ago. The next time you are tempted to use “ancient” to describe an era, observe the stop-sign! -Henry M . McHenry in Science for October 31, 1975 (KAE)
Helping Children Overcome Fear The National Institute of Dental Research has funded a three-year study at Case Western Reserve University to be supervised by psychologist Barbara Melamed, Ph.D. ($36,200 for the first year). With three dentists, Roland Howes, Stephen Hutherson, and Richard Hirschman, the group plans to determine the benefit to a group of children from a combination of an exploratory film and specific behavioral approaches by the dentist. -Research News from NIDR for August, 1975 (KAE)
