|Implemented in this survey?|
At the end of the 2008 legislative session, Kentucky swiftly passed a state law requiring children to have their oral health examined by a dentist or other healthcare provider before starting school. The mandatory dental exam has recently become an increasingly popular approach among state lawmakers; Kentucky is now the 10th state to pass such a law in recent years in order to address disparities in dental health among its population.
Kentucky's House Bill 186, which was passed by an overwhelming majority during the 2008 legislative session and signed into law by Kentucky governor Steve Beshear a year ago, requires that any five or six year old child enrolling in public school for the first time show proof of a dental examination prior to enrollment.
Kentucky's law is one of several that have been adopted by states in recent years in order to address what analysts describe as an overlooked epidemic of poor oral health among the nation's children. Kentucky in particular has one of the worst oral health profiles of any U.S. state; it has the greatest number of adults under 65 without teeth, and just half of its residents have dental insurance. At the same time, the state lacks dental providers in poor and rural areas, and only a quarter of its total providers accept Medicaid. Until recently, the state had one of the lowest Medicaid reimbursement rates nationwide.
Kentucky's dental exam law adds a dental screening or examination to the list of immunizations, eye test and physical examination that are already required prior to school enrollment. The law is one step toward improving the oral health of the states' children. A 2005 report produced by the nonprofit group Kentucky Youth Advocates revealed that half of the state's children between ages two and four had cavities, and that only a third of those children covered by Medicaid had used dental services in the past year. In 2006, Kentucky's Cabinet for Health and Family Services adopted changes, including a US$2 dental visit co-pay for adults, to expand the number of children's dental services covered by Medicaid. The changes also increased by 30% the reimbursement fee for children's Medicaid dental services. The current law, supporters say, will help ensure that children are seen by providers and get the services they need to protect their oral health from a young age.
House Bill 186 is designed to address poor oral health in Kentucky by implementing an enforced, one-time visit to a dental health provider for young children. Similar laws have been adopted in other states in order to establish a dental home for children from early in life, so that more children receive routine dental care and become less reliant on costly and sometimes invasive emergency care in childhood and later in life; the same objective has been cited for Kentucky's law. It is also hoped that Kentucky's law will address the number of school days that children miss due to pain associated with dental problems.
The law incentivizes parents to have their children's oral health examined by making such examinations a condition of enrollment in the public school system. However, in most states, this aspect of the law has not been enforced. The same may turn out to be true in Kentucky, and there is no other penalty for parents who do not comply in the event that a school does not enforce the enrollment clause.
Parents, Children in public schools, State Board of Education and public schools
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
According to the 2008 report by the Association of State and Territorial Dental Directors and the Children's Dental Health Project, the most robust evidence on the effectiveness of school dental screening programs comes from Britain, where such programs have been in place for nearly a century. According to researchers who evaluated the British program, there is no evidence that enforced screening results in measurable improvements in children's oral health. The ASTDD report concludes that while dental screening laws have become politically popular, there is little statistical or clinical basis to support them.
House Bill 186 was introduced by Democratic representative Thomas Burch at the beginning of the 2008 legislative session; the bill was lobbied for by state children's advocates, described below. The original text of the bill would have implemented the requirement beginning with the 2011-2012 school year; this was moved up a year before the bill was nearly unanimously approved by the House. A month later, following few and minor amendments, it was unanimously approved by Senate lawmakers and subsequently signed into law by Governor Steve Beshear. The law follows on recent state changes in Medicaid designed to improve children's access to dental health care, described above. It required no specific funding; the major change it requires is administrative in nature and tasked to the Kentucky Board of Education.
|Implemented in this survey?|
Two states, Kansas and Pennsylvania, have dental screening laws dating to the first half of the twentieth century--but these two states form an exception. For the most part, dental screening laws are a recent phenomenon; Illinois adopted one in 2004, California in 2006, and Iowa and New York in 2007. More and more states are considering such laws in response to evidence of an epidemic of tooth decay among the nation's children. According to a 2008 report by the Association of State and Territorial Dental Directors and the Children's Dental Health Project, states considered nearly 70 laws to improve oral health in the 2007 legislative session.
While some of the recently passed laws require dental exams, others require screenings; most states will accept both. An exam is generally performed by a dentist; screenings may be conducted by hygienists, sometimes school nurses, and sometimes (as in the case of Kentucky's law) other healthcare providers. New York, for example, requires that students be examined by a licensed dentist; in Georgia, students may be screened by a dentist, hygienist, or school nurse.
The dental screening programs in Pennsylvania and Kansas are also unique in that they provide for school-based dental care, which almost none of the more recently adopted programs do. The primary aim of the more recent programs is instead to encourage widespread dental screening of all students in the public school system. Some states require a one-time exam upon entry into the system; others require proof of examination at periodic intervals. New York, for example, requires proof of examination prior to kindergarten, second, fourth, seventh and tenth grades. Some programs are supported by state funding; others are not. Many apply only to children in public schools, though some apply to children in private schools as well. Nearly all of the laws allow parents to obtain waivers to the requirement. With the exception of Illinois's law, most programs do not penalize parents or students who do not comply. (Illinois's law has a provision that permits schools to withhold report cards from students who don't show proof of required periodic dental screenings. )
Mandatory screening and examination laws have received some criticism for failing to address the high cost of medical care for the uninsured and the dearth of providers who accept Medicaid. Kentucky's law follows on changes to the state's Medicaid reimbursement fees and covered dental services for children. Other state bills currently under consideration are also attempting to address such hurdles. South Carolina, for example, is currently considering a bill to establish a program that would begin to offer free in-school dental check-ups to students in public schools in the state's poorest counties. This approach is also expected to partly address another critique of mandatory screening and exam laws, which is that most of the current laws in general don't collect data on follow-up, treatment and referral following mandatory exams.
The approach of the idea is described as:
renewed: The approach revisits that taken by two states in the first half of the twentieth century.
Democratic and republic lawmakers widely supported the bill, which was lobbied for by youth and poverty advocates in the state. Blueprint for Kentucky's Children, a coalition of youth and poverty groups, which formed in 2007 to advocate for legislation to improve health and wellbeing of children in Kentucky, strongly advocated for the passage of House Bill 186. One member of the coalition, Kentucky Youth Advocates, had issued a report on access to dental care in Kentucky, in 2003, and another report on parents' concerns about the state of Kentucky children's oral health, in 2005.
In addition to working to pass HB 186, the coalition also lobbied in support of bills to facilitate children's enrollment in the state children's health insurance plan (KCHIP) and forgive school loans to dental graduates who commit to working in underserved areas; the latter bill, HB 416, did not pass because of concerns about funding. House Bill 186 also had the support of the Kentucky Dental Association and the state's governor. As cited above, lawmakers from both parties supported the bill's passage; HB 186 passed with a vote of 93 to 0 in the House, and 36 to 0 in the Senate.
|Rep. Thomas Burch||very supportive||strongly opposed|
|Gov. Steve Beshear||very supportive||strongly opposed|
|Democratic lawmakers||very supportive||strongly opposed|
|Republican Lawmakers||very supportive||strongly opposed|
|Parents||very supportive||strongly opposed|
|Educators||very supportive||strongly opposed|
|Kentucky Dental Association||very supportive||strongly opposed|
|Blueprint for Kentucky's Children||very supportive||strongly opposed|
|Rep. Thomas Burch||very strong||none|
|Gov. Steve Beshear||very strong||none|
|Democratic lawmakers||very strong||none|
|Republican Lawmakers||very strong||none|
|Kentucky Dental Association||very strong||none|
|Blueprint for Kentucky's Children||very strong||none|
The dental screening law has yet to be adopted, as it is not slated to go into effect until the 2010-2011 school year.
The Kentucky law did not specify a mechanism for monitoring or evaluation of the dental screening program. In fact, many states that have adopted similar laws have limited to no mechanisms for monitoring and evaluation. Some critics have argued that without a provision for follow-up care, mandatory dental examination laws will do little to improve children's oral health. Criticism has also focused on the general lack of funding support for such laws and the general absence of provisions for data collection.
Some data have nonetheless been generated by existing programs. Illinois requires dental screenings for kindergarteners, fifth graders and ninth graders, and enforces the requirement by witholding report cards from students who aren't screened; in this state, 80% of students have now been screened. Among the remaining 20%, 10% obtained exemptions from screening. Evidence from both Illinois's and Georgia's required dental screening programs indicates that school nurses are key to ensuring compliance in the schools. In Pennsylvania, which has one of the two oldest screening programs in the U.S., 70% of students have their exams performed by a private dentist, despite the option of school-based screenings. Data show that of the students who received in-school exams, 55.4% were referred for further treatment, and 21.4% of those who replied to survey questions said they had followed up on those referrals. A mandatory dental screening program that went into effect in California in 2007 is supported by public funding and is being evaluated by that state's Department of Public Health; data on the program's efficacy is scheduled to be presented to the state's legislature in early 2010.
Because most similar programs in other states are new, it is difficult to predict from experience what may result from the passage of Kentucky's law. If Illinois's experience is any indication, the law may be effective in encouraging the majority of students to visit a dentist or oral healthcare provider at least once; but so far, this does not appear to be a guarantee that follow-up care will be obtained or that improved oral health will result.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
It will not be possible to judge the impact of this law until its implementation.
Association of State and Territorial Dental Directors and the Children's Dental Health Project. "Emerging Issues in Oral Health." October 2008. www.astdd.org/docs/FinalSchoolScreeningpaper10-14-08.pdf.
Kentucky Youth Advocates. "Kentucky's Cavity." 2005. www.kyyouth.org/Publications/05_pub_DentalCareReport.pdf
Urbina, Ian. "In Kentucky's Teeth, Toll of Poverty and Neglect." New York Times, December 24, 2007, National Desk, p.1.
Elena Conis, Emory University