The Challenge
Thousands of children and adults in the Commonwealth lacked access to dental care because of the shortage of dentists living in parts of Massachusetts and the even greater scarcity of dentists who accept MassHealth (Medicaid in Massachusetts). Dental hygienists, who are highly qualified experts in dental treatment and prevention, had the potential to fill a substantive portion of this need by providing preventive dental care without the supervision of a dentist.

In 2007, Charles Group Consulting was asked by the Massachusetts Dental Hygienists Association (MDHA) to spearhead their effort to pass legislation allowing dental hygienists to practice in public health settings, such as schools and nursing homes, without the direct supervision of a dentist. At the time, Massachusetts law stipulated that a dental hygienist could not tend to patients without the supervision of a dentist.

In response to MDHA’s proposal, the Massachusetts Dental Society stated that they would never allow dental hygienists to work without the supervision of a dentist, or to allow them to bill MassHealth for such services. Charles Group Consulting and MDHA faced a powerful opponent in the dentists who had at their disposal two political action committees with $500,000 to spend, as well as experienced in-house and hired lobbyists.

The Data
According to research compiled by CGC, of the 351 cities and towns in Massachusetts, 69 did not have a resident practicing dentist in 2007, and of the remaining 282 cities and towns, 30% did not have enough practicing dentists to meet community needs.

More remarkably, of those 282 cities and towns which did have a resident dentist, more than 50% were unwilling to accept MassHealth (Medicaid). In FY 2006, only 823 (9.5%) of the approximately 8,620 active licensed dentists in Massachusetts filed even one MassHealth dental claim. The resulting lack of access to oral healthcare was further compounded for residents of rural parts of Massachusetts. As such, it was common in many parts of the Commonwealth for an individual to be forced to wait a duration of six months to one year before being seen by a MassHealth dentist.

The resulting dental crisis in Massachusetts left the most vulnerable populations - minorities, low-income families and individuals, the uninsured, the elderly, and persons in relatively poor health - facing the greatest barrier to oral healthcare. Of Massachusetts’ 351,887 households making under $15,000 per year, less than 50% saw a dentist in 2006, versus the 88% of individuals who received dental care in households that made over $50,000 per year.

Not only morally unacceptable, the situation was also fiscally unwise. Each year, millions of productive hours were being lost due to dental diseases. A survey conducted in 1989 reported that children missed nearly 52 million hours of school, or an average of 1.17 hours per child, due to dental treatment problems. Dental “caries” (decay) was also documented as the most common chronic disease nationwide, affecting 53% of 6-8 year olds and 84% of 17 year olds. These figures became all the more alarming with the recognition that the cost of providing restorative treatment was far more expensive than providing preventive services. In 1993, the Coalition for Oral Health, reported that for every $1.00 spent on prevention the Commonwealth saves between $8.00-$50.00 in restorative care.

Massachusetts laws concerning oral healthcare practice were also contributing to a worker exodus. Dental hygienists living in proximity to neighboring states such as Rhode Island, New Hampshire, Connecticut and Maine, which had already passed legislation allowing registered dental hygienists to practice in public health settings, were beginning to seek work outside Massachusetts’ borders. At the time, 28 other states allowed direct access to a dental hygienist. Massachusetts simply could not afford to lose this valuable workforce.

The Proposed Legislation
In consultation with Charles Group Consulting, MDHA drafted H2221 “An Act to Increase Access to Oral Health.” It set to remedy this social malady by permitting dental hygienists to provide “direct access” care to patients in public schools, Head Start programs, nursing homes, public and private clinics, mobile dental health units, community health centers and other sites deemed appropriate by the Department of Public Health. In addition to providing “direct access” to preventive oral health care services, MDHA’s legislation stipulated that registered dental hygienists operating under public health supervision could be directly reimbursed by Medicaid for services given to eligible patients. In order to recognize the important role that dentists play and so as to not impact on the business of dentists, the bill explicitly prescribed that in the course of an examination by a registered dental hygienist, all abnormalities would be referred to a practicing dentist for treatment.

In addition, because so few dentists at the time were accepting MassHealth, leaving thousands without access to a dentist or a dental hygienist, a separate bill was filed that required all dentists in Massachusetts to accept MassHealth.

The Negotiation
Charles Group Consulting began by arguing that while it is the prerogative of dentists to refuse to treat poor patients, it was unconscionable to, at the same time, deny other professionals the opportunity to provide preventative care to that same population. Since the dentists had previously stated that they would never allow dental hygienists to work unsupervised, CGC knew that a compromise was the only way to gain passage of MDHA’s bill. CGC rewrote MDHA’s bill to include a new clause, one that prevented dentists from turning away patients on public assistance. We knew that the Mass. Dental Society was opposed to our bill allowing hygienists to see patients in public health settings, but we suspected that this new requirement might be even less appealing (but still worthy) and as such, a means to secure a future compromise.

The Compromise
CGC also knew that the Mass Dental Society had their own set of bills they were seeking to pass during the legislative session. Charles Group Consulting had an excellent relationship with the state senator who was the champion of legislation pushed by the dentist. We knew her to be someone deeply committed to oral health. Therefore, it was not surprising that when we met with her, she found our bill reasonable and something she wanted to support. At the time, some in the hygienist community were skeptical of her motives, and could not conceive of a scenario where this same Senator, who was the champion of the dentist, could end up spearheading compromise legislation that would include nearly every key provision sought by the hygienists. But that is exactly what occurred.

Because of our long experience and presence in the State House, and a deep-seated mutual trust, we knew that the Senator’s support for the dentists and their agenda was rooted in her deep concern for the oral health needs of all the residents of the Commonwealth. We also knew that she wanted to achieve a notable success in the area of oral health. After only a few formal and informal meetings, the Senator agreed to the merits of our proposal and brokered a compromise that appealed to both the dentists and the hygienists, leading to passage of some of the most far reaching changes in oral health care in the last decade. It is hard to imagine the bill passing without the Senator’s leadership, but it is equally hard to imagine that she would have been in any position to play that role without those of us in the field of lobbying being able to understand, appreciate and explain her motivations.

The Outcome
CGC successfully passed MDHA’s oral health bill permitting dental hygienists to practice in public health settings, thereby providing Massachusetts residents dental care they would have otherwise been denied. Governor Patrick signed the bill into law in January of 2009. Typically it takes an average of seven years to pass legislation, yet in the face of opposition and powerful lobbying forces, Charles Group Consulting was able to pass MDHA’s oral health bill within two years. As a result, children in schools, elderly in nursing homes, and those who attend community health centers can now receive the oral health care they need and deserve.