Access to Care

Identifying Need, Mobilizing Resources, and Finding Solutions

Debra Belt

Copyright 2002 Journal of the California Dental Association.

Perhaps the reports from dentists working in grassroots community and mobile dental clinics paint the most immediate picture of the dental care crisis in California. These clinics, scattered throughout the state, provide what is referred to as a "safety net" of care for the 7.3 million California residents without health care insurance. The number of state residents lacking dental coverage is estimated to be three times that number.

"I’m almost afraid to admit how great the need is for dental services," said Richard K. Chang, DDS, one of the founders of Tzu Chi Free Clinic in Alhambra, which provides free dental care to underserved members of the community. Through its mobile service, Tzu Chi is able to provide extended care to schoolchildren in four Southern California counties. "In the clinic, it’s a common occurrence to see children with rampant decay. We can’t do enough to help meet the need for not only dental treatment, but basic dental education."

Guillermo C. Vicuña, DDS, co-founder and clinical director of dental services at Su Salud Community Disease Prevention & Education Center in Stockton, has worked for more than 20 years to combat one of the worst dental care situations in the nation. "When you look at the numbers -- approximately 700,000 medically uninsured in the San Joaquin Valley -- the statistics are staggering," Vicuña said. "This is in our own backyard, and it’s not very different than a third-world country. You don’t have to go far -- minutes from South Stockton are labor camps, churches, and barrios where access to medical and dental care is a fundamental problem. In many cases, we see children with significant decay in every tooth."

Articles from daily newspapers all over California file similar reports from community clinics -- La Puente: "Mura, 10, is in pain and has trouble chewing. One baby tooth has a hole as big as a pencil." Whittier: Priscilla, 6, has teeth so decayed the gums collapse into the decay. The stories are similar in San Jose, Inglewood, Compton, Oroville, and many areas throughout the state.

These chronicles from the front line of the battle with what the U.S. surgeon general calls a "silent epidemic" of dental and oral disease are just pieces of the vast issue known as access to care.

Definitions

The definition of access to care varies slightly from professional to professional, but dentists, public health officials, government, clinic directors, dental school faculty, and organized dentistry all bring up common themes relating to the issue. These various aspects reach into virtually every issue in dentistry and, indeed, society at large. Finances, bureaucracy, fragmentation, social status, education costs, work force, aging population, and rapidly changing national demographics all come into play. More-specific influences such as cultural beliefs, linguistic differences, regional limitations, and transportation are subtle currents in the mainstream issue.

"There are a lot of definitions of access to care," said Elizabeth Mertz, MPA, project director for the Center for the Health Professions at the University of California, San Francisco. "Basically, it means the ability of anyone who needs dental care to get it regardless of his or her ability to pay for it. People should be able to receive care in a reasonable amount of time and within a reasonable distance of where they live."

David M Perry, DDS, a leader on CDA’s access to care task force, emphasizes that preventive care and education about oral health are also essential to access to care.

"Access to care is the ability of a person to easily receive good dental care without having barriers to care because of socioeconomic or geographical reasons," Perry said. "Access to care also means preventive dental care and access to knowledge about oral hygiene and disease prevention."

Arlene Glube, BS, RDH, chair of the Dental Health Foundation and a member of CDA’s task force on access to care, points out the importance of locating services and resources for people who are in need of care.

"To me, access to care means identifying all the possible resources in a community to ensure that the public receives the care it needs," Glube said.

Depending upon whom you ask, a different aspect of the access picture will come into focus. Some bring up problems with government programs and provider availability, others mention the lack of a cohesive "big picture" strategy to address access, others concentrate on helping dental students with burdensome debts so they are able to practice in underserved areas upon graduation.

The clear picture that emerges from these snapshots is that access to care means many things, and that there is no one solution. These complex factors contribute to the immensity of the issue, but have also helped focus attention and accelerate action on access concerns.

The Priority of Access

On a national level, the Surgeon General’s Report on Oral Health, Healthy People 2010 recommendations, and summits conducted by the American Dental Association, Health Care Financing Administration, and Health Resources Service Administration have heightened the priority of access to care in the 21st century.

In May 2000, David Satcher, MD, PhD, released the first Surgeon General’s Report on Oral Health, which advocated the often-quoted "total health" approach to well-being. The report focuses on the correlation between oral health and overall good health throughout life and furthered the idea of the mouth as the "mirror for general health."

"The report elaborates on the meaning of oral health and explains why oral health is essential to general health and well-being," Satcher wrote in the report’s executive summary.

The surgeon general’s report was also considered a notable call to action on access-to-care issues. Satcher pointed out that not all Americans are achieving the same degree of oral health. "Many among us still experience needless pain and suffering, complications that devastate overall health and well-being, and financial and social costs that diminish the quality of life."

Scope of the Issue

Statistics in the Surgeon General’s report reflect care inequities in all age groups on a national level: Approximately 44 million Americans are without medical insurance, and 108 million are without dental coverage.

In December 2000, the Center for the Health Professions at UCSF issued a report on "Improving Oral Health Care Systems in California" that stated that "over 10 million American children lack health insurance while over 23 million children lack dental insurance." Insured children are 2.5 times more likely to receive dental care than are uninsured children, and children from families without dental insurance are three times as likely to have dental needs as compared with their insured peers.

California, with its dramatically diverse population of 33.8 million, reports higher than average numbers of uninsured residents. A March 2001 briefing from the California Senate Committee on Health and Human Services specifies that "California lags behind the national average on most dental health indicators." In a May 2000 report on California’s uninsured population, the Center for Health Policy Research at the University of California, Los Angeles, states that in 1999, 7.3 million adults and 2 million children in California were without health insurance. The state’s uninsured rate is 30 percent higher than the rest of the United States (24 percent compared with 17 percent nationally). Reflecting the same trend noted nationally, it is believed that nearly three times these numbers of people do not have dental insurance.

"In plain language, it is our understanding that one-third of the population, approximately 11 million, in California do not have access to oral health care by a dental professional," said Steven D. Chan, DDS, CDA president.

The UCSF Center for the Health Professions points out that while health insurance coverage is not the only factor in determining oral health, health and dental insurance coverage are an important indicator of access to care.

It is well-documented that many families without health and dental insurance will wait until a problem becomes a crisis before seeking help. Something that could be taken care of early becomes a critical situation demanding urgent care and increased cost.

Who Needs Access?

"California’s underserved community consists of significant numbers of children, the working poor, immigrants, migrant farm workers, rural residents, the elderly, the developmentally disabled, and minority populations," Mertz said. "Many community health centers servicing these populations are overburdened and struggling, and when the poor and uninsured are just lucky to get service, comprehensive care is not very likely."

Children

The number of children in California without medical insurance is well-documented. As mentioned earlier, the number of children without dental care is expected to be three times greater than the 2 million without medical insurance. Mertz estimates that 28 percent of elementary schoolchildren in California have no dental insurance. Figures for high school age students are significantly higher with 44 percent lacking dental coverage.

Community clinics cite specific regional figures relating to uninsured children: Vicuña at Su Salud said approximately 150,000 of the uninsured in the San Joaquin Valley are children. The Health Trust in Santa Clara County reports estimated 70,000 at-risk children.

Mertz at the UCSF Center for the Health Professions points out that good oral health care is essential for children in particular, as it lays the foundation for a lifetime of oral health and prevention of oral disease.

Working Poor

Current research has shed considerable light on the numbers of working adults in California who are without health insurance. Figures from the UCLA Center for Health Policy Research specify that 82 percent of the uninsured are in working families and that 47 percent are in families headed by at least one full-time, full-year employee. Large numbers of uninsured Californians have low or moderate incomes; 69 percent have family incomes below the 200 percent federal poverty guidelines level. This level is $22,500 for a family of two, $28,300 for a family of three, and $34,100 for a family of four.

An October 2000 report on the uninsured in California published by The Sacramento Bee brought to light the fact that many young adults between the ages of 19 and 34 are without health insurance. This group makes up as much as 40 percent of the state’s uninsured, according to the report. Uninsured people in this age group often work in lower-paying and entry-level jobs as well as jobs outside of the corporate realm. This includes waiters, waitresses, cooks, service workers, artists, musicians, dancers, actors, retail clerks, agricultural employees, part-time college-level teachers, and many other essential and vital sectors of the work force.

The UCLA Center for Health Policy Research reports that one in five California employees works for employers that do not offer health benefits. The Center also states that 2.3 million employers do not offer health benefits.

Racial and Ethnic Minorities

The UCLA Center for Health Policy Research reports that uninsured rates are highest for Latinos at 40 percent, an estimated 3 million of California’s uninsured. Asian American and Pacific Islanders account of 22 percent of the state’s uninsured and African Americans 23 percent.

Vicuña of Su Salud said that 65 percent of the children born at San Joaquin General Hospital are Hispanic, and that schools in the area report a 60 percent to 70 percent uninsured rate. Vicuña’s region is especially affected due to the migrant farm workers toiling in the fertile fields of the region to produce a significant portion of the state’s agriculture.

"Access is a real fundamental problem for the migrant population," Vicuña said. "Children have no social security number and don’t qualify for Medi-Cal or Healthy Families. Their parents are earning minimum wage and would have to spend three or four days’ wages just to pay for a visit to a dental office."

The Dental Health Foundation states that in California, a higher prevalence of dental caries is generally found among minority children, including African-American, Hispanics, and Native Americans from poor and low-income families. The rate of permanent tooth extraction from untreated disease in these same groups is also higher.

Senior Citizens

In its "Oral Health Report Card," Oral Health America reported in 2000 that 85 percent of people 65 and older are without dental insurance. Medicare provides only limited dental benefits for diagnosis of specific conditions.

Additional factors such as such as finances, transportation, and overall health status can create additional barriers to receiving dental care. There is also increasing focus on improving dental care standards for residents in nursing homes.

Developmentally Disabled

There are several studies documenting access problems for people with developmental disabilities. UCSF Center for the Health Professions notes that these problems are related to inadequate training in treating disabled people, lack of general dentists and dental specialists who accept Medicaid reimbursement, and behavioral problems.

Availability and Accessibility of Dentists

As mentioned earlier, medical and dental insurance is not the only factor in access to care. Access to care does not simply mean providing dental care to the poor and uninsured. It also means ensuring that there are enough dentists in areas where they are needed and that there are enough dentists coming out of dental schools to meet future demands.

The Health Resources and Services Administration reports a 12 percent per capita decline nationwide in the availability of dentists from 1991 to 1998. In its "State Health Workforce Profiles," the administration noted that the shortage poses a threat to the availability and quality of dental care. Meanwhile, the demand for dental services is expected to increase over the next 10 to 12 years as baby boomers approach retirement age.

A study on the health care workforce in 10 states found that in 1998, California had 55 practicing dentists per 100,000 population. The same study reported that in 1999-2000 there were 6.11 dental students per 100,000 population in California. In 2000, the number of dental graduates per 100,000 population was 1.49.

The Health Resources and Services Administration also noted that the percentage of minorities being trained in every segment of health care is not increasing at the same rate as the growth of minorities in the overall population. The U.S. Census Bureau reports that 52.1 percent of California’s population is minority/ethnic.

Charles N. Bertolami, DDS, DMS, dean of the UCSF School of Dentistry points out that dental schools are committed to training diverse groups of students in order to increase access to dental care to all members of society.

"The problem is that the applicant pool for certain groups is unbelievably small," Bertolami said. "If someone is from an economically disadvantaged group, the notion of aspiring to be a dentist is not conceivable. This is why UCSF has established mentorship, summer enrichment, and post-baccalaureate reapplication programs aimed at enlarging applicant pools."

He points out that these programs are founded on the belief that students from underserved groups will have a greater tendency to return to their communities and provide care after graduation.

In addition to the waning number of dentists and a shortage of ethnic dentists, the access problem in California is also defined as a maldistribution of dentists. In a study on the geographic distribution of dentists, the UCSF Center for the Health Professions found that many of California’s rural and urban communities may not have enough dentists, which could limit access to dental care. The study found that out of 487 Medical Service Study Areas -- geographic regions defined by state agencies for the administration of various programs -- 97 areas, or 20 percent, are currently at or below the federal standard of one primary care dentist for every 5,000 people. Of the 97 areas that have dentist shortages, 66 are rural and 31 are urban. Thirty-two study areas, mostly rural, do not have any dentists at all.

The shortage areas identified span the state from Shasta County to San Bernardino, Alpine to Imperial County. The study also highlighted that regions with a shortage of dentists tend to have a higher percentage of minorities, lower-median incomes, and a higher percentage of children. "Communities that have the highest need for services are the communities least likely to have them," Mertz said.

Bertolami said the maldistribution of dentists is explained by the simple fact that dentists tend to work in areas where the per capita income can support their practices. "In some areas, like downtown San Francisco, there are lots of dentists," Bertolami said. "The suburbs are pretty well covered. That leaves rural and low-income central urban areas."

The study also found that minority dentists are more likely to practice in minority communities, but they are a small portion of the dental workforce. "Although this pattern has been documented for doctors and nurses, this new information demonstrates this is also true for the dental profession," Mertz added.

In further defining barriers to access to care, experts note that access to care is a two-way street, and patient utilization needs to be addressed. Glube of the Dental Health Foundation said that there is the expectation that people are clamoring to see a dentist.

"I run the treatment program for San Bernardino County and in tracking referrals, out of 100 people referred for care, 33 are actually billed back," Glube said. "This is due to many reasons such as lack of trust, language barriers, and cultural beliefs. Access to care means addressing these issues and educating a large and diverse population to the importance of seeing a dentist."

Perry, of CDA’s access task force, points out that limited financial resources affect access to care in ways beyond lack of insurance. "Often the level of daily problem-solving -- maintaining reliable transportation, child care, and basic needs on a minimal budget -- makes dental care a low priority until there is an emergency."

Grassroots Efforts

In working to alleviate the major access problems -- treating the poor and uninsured, reaching underserved areas, and providing education on the importance of oral health -- a patchwork of community clinics around the state help fill gaps in dental care at the grassroots level. Some local clinics have to scramble to manage dental emergencies with the volunteer staff they can piece together. Others have been highly successful at securing local funding, grant money, and volunteer help. These successful local clinics have been able to stem the tide of dental emergencies and have even been able to shift their focus to a maintenance mode.

Here’s a look at how some local clinics have made access to care a reality in their area.

Sister Ann Community Dental Clinic

Sister Ann Community Dental Clinic in Napa has been in operation since 1991. When the clinic first opened, it was the first in Napa County to accept large numbers of Denti-Cal patients; and dental emergencies were the norm. Eleven years later, the clinic sees more than 8,000 patients a year and has a large population on maintenance.

"We’re more like a private clinic now," said Edward Bartlett, DDS, director of Clinical Services, who has worked full-time at the clinic since it opened. "Were able to focus more on education, caries control, and prevention."

Bartlett works with four other dentists at Sister Ann and takes pride in being part of the only community-based clinic in Napa.

"This program takes very good care of folks and ensures that their health is not compromised," Bartlett said. "Our sliding fee schedule allows us to see people who may have no other resources. There is great satisfaction in being able to give people the care they need."

Dale Berry, executive director of Sister Ann, said the clinic’s success is based on a skilled, dedicated staff and a minimalist approach with staffing and finances. He credits Bartlett as central to running a high-quality, efficient, and productive operation that keeps expenses in check. The clinic uses donated equipment and purchases new equipment as necessary and when grant funding becomes available. Berry said he is currently working to expand grant funding to meet increasing community needs and is looking to local charities, federal funds, and community foundations. Sister Ann Clinic continues to receive generous support from the Napa Valley Wine Auction and receives 75 percent of its funding from Healthy Families, Denti-Cal, and Children’s Treatment Program reimbursements.

The clinic’s success is also attributed to the initial efforts of Sister Ann McGuinn, former administrator of Queen of the Valley Hospital in Napa, and members of the Napa-Solano Dental Society.

Sister Ann is anticipating another move next year into a nine-operatory clinic in the Napa Valley Vintners Community Health Center that is currently being built. This will allow the clinic to keep pace with the increasing number of patients seeking care. Berry estimates that the clinic will need to serve twice as many people in the next five years.

"I’m truly amazed at what has been accomplished here," Berry said. "A lot of credit goes to the local dental society members, who have been supportive for many years. They continue to coordinate a sealant clinic once a year, serve on the clinic’s board, and provide material and moral support. Funding from the Napa Valley Wine Auction and others has also been critical to our ability to provide dental care to the most vulnerable people in our community.

"Sister Ann Clinic is proof of what a few people committed to a cause can accomplish."

Franklin-McKinley School Clinic

In 1992, William Comport, DDS, wanted to do something about the lack of dental care for the estimated 70,000 at-risk children in Santa Clara County. He began by treating young patients in his office free of charge through the Save Our Kids’ Smiles program.

In 1996, he set up a dental clinic in the Franklin-McKinley School District office in East San Jose. The clinic was an effort to help solve some of the transportation problems Comport encountered with the SOKS program.

"Patients enrolled in the program would often have a difficult time getting to my office," said Comport, whose practice is in South San Jose. "The issue was that my office was not near SOKS patients. The good thing about the Franklin-McKinley clinic is that the site is right where the kids are."

In setting up the clinic, Comport solicited used equipment and secured donations from local dental society members, the CDA Alliance, and a local study club, and a grant from Healthy Start. Then he and Diane Cardoway, RDA, became the sole providers, working two Fridays a month to offer full-service dental care to children in the district. The number of students qualifying for the federal school lunch program identified the Franklin McKinley District as a high-need area.

In addition to providing screenings, cleanings, fillings, and sealants to kindergarten through eighth-grade students visiting the clinic, Comport also offers friendly words, encouragement, and a sympathetic ear.

"Part of the philosophy at the clinic is to get to know the kids and encourage them to stay in school and see the potential for what they can do with their lives," he said. "The idea is to enhance their self-esteem and well-being as well as provide dental care."

As Comport continued to work in the clinic, the Health Trust and the California Endowment provided a significant boost to offering dental care to underserved children in the area.

"There is no way we would be where we are today without the commitment and hard work that Bill Comport has put into helping children in Santa Clara County find a dental home," said David H. Lees, DDS, JD, MBA, director of the Children’s Dental Health Initiative, which is administered through the Health Trust.

The Health Trust is a public charity funded by proceeds from the sale of the Good Samaritan Health System. In 1997 the Health Trust began providing financial support for the Franklin-McKinley clinic that Comport began with the help of his colleagues at the Santa Clara County Dental Society.

After the Health Trust entered the ring with Comport, the program began to grow. Comport said there are about 12 to 15 volunteers working at the two-chair clinic in addition to a full-time staff consisting of Andre Metcalf, DDS, and Soka Mok, RDA. The focal point of the expansion this year is a three-operatory, state-of-the-art mobile clinic.

"The mobile clinic will travel to other schools where a need has been identified," Lees explained. "This provides a base for us to expand upon. There is no way one clinic can address the needs of all children who are without dental insurance. We are working to bring other local organizations together in a collaborative effort in the hope of expanding care to all at-risk children in Santa Clara County."

The Health Trust President Gary B. Allen said that a strategic plan is needed to coordinate existing providers and create a new service delivery model.

"Even with our new mobile dental clinic up and running, existing dental services for the at-risk children’s population may see 7,000 children annually. A plan is needed to serve the other 63,000 children who are in need of dental care," Allen said.

In helping the Health Trust meet its goals, the California Endowment has agreed to provide additional support by backing a dental health needs assessment.

As the allied forces grow, Comport continues to volunteer at the Franklin McKinley clinic and still sees SOKS patients in his own office. He structures his time to set aside an hour for each young patient so there is time to talk and work through fears and still get dental work done.

"I’m hooked on this kind of work, and I have a good time doing it," Comport said. "When I come home from the clinic, my wife often notes that I’m energized from the experience."

Comport added that he is looking to the new mobile clinic to help expand the volunteer dental force in Santa Clara county.

"As dentists, we have skills that offer so much to children. If we can fill a cavity in a permanent molar and prevent decay from spreading, we have had an impact on a child’s entire life."

Su Salud Community Disease Prevention & Education Center

Heralding the motto "to prevent is to cure," Su Salud Community Disease Prevention & Education Center is receiving national attention for its progressive, preventive, and humanistic approach to health care, which naturally includes dental health.

Vicuña is co-founder of Su Salud and has worked for decades visiting labor camps and barrios and conducting health fairs at churches and fairgrounds to provide care for the poor. The persistent efforts of Vicuña, staff, and volunteers led to a partnership with San Joaquin General Hospital and the creation of cohesive screening and referral resources, a full-time dental clinic, and the Disease Prevention and Education center.

Since the full-time dental clinic at San Joaquin General Hospital opened in September of 2000, the number of patients has increased to 400 per month. The clinic works on a sliding scale, charging 10 percent of patients’ net income per month. It also helps enroll the eligible in Healthy Families or Medicaid. In addition to the partnership with San Joaquin General Hospital, Su Salud received a grant from San Joaquin County Health Care Services and has also garnered support from Colgate-Palmolive.

Beyond the clinic’s full-service dental care, Su Salud focuses on the highly important aspect of health and dental education. "The No. 1 health problem for the uninsured is lack of knowledge," Vicuña said. "We are most proud of this program that offers primary care, sealants, fluoride, information on dental disease, dietary information, and live demonstrations on oral care."

Buddhist Tzu Chi Clinic

The Buddhist Tzu Chi Free Clinic in Alhambra has been providing medical and dental care since 1992 to underserved members of the local community.

In addition to the clinic, which has four dental operatories, Tzu Chi recently expanded its dental services by purchasing a fully equipped mobile dental van that travels to schools in low-income areas in Los Angeles, San Fernando, San Bernardino, and San Diego counties. The mobile clinic provides all levels of dental care -- from screenings to extractions -- on a weekly basis to elementary through high school students.

While being triumphant in its mission, the clinic operates with the ongoing challenge of meeting overwhelming health care needs with a limited volunteer corps.

Richard K. Chang, DDS, one of the founders of the clinic, pointed out that the mobile dental clinic could service more areas with an increased volunteer force. "Our biggest problem is manning the mobile clinic. Any amount of volunteer time is acceptable -- even twice a year."

Tzu Chi currently works with 35 volunteer dentists.

"Our idea is to have as many people involved as possible," said Chang, who works at the clinic every Wednesday. "The reason for our clinic is to offer the opportunity to do something for others."

Chang notes that several volunteer dentists have mentioned a surprising side effect of their charitable work.

"Volunteering relieves the stress of working in a dental office," he said. "In volunteer work, there is no monetary return, but the emotional gain is liberating. You feel like a better person."

The clinic receives its funding through an organization based in Taiwan. Chang said the organization is similar to the United Way. Other resources come from private funding.

Resources

There are many more community clinics and mobile services throughout the state -- Dientes! Community Dental Clinic in Santa Cruz and its Watsonville school-based clinic, St. Raphael’s and St. Mary’s in Stockton, La Clinica De La Raza in Oakland, San Gabriel Valley Foundation in La Puente, and CHAP Dental Clinic in Pasadena, to name only a few. Each clinic operates in its own way and to the best of its ability based on the resources of the community. There is no one formula that clinics use to fund their services and increase access to dental care.

"The biggest challenge is that every county has hidden resources, and there may be resources we don’t even know about," said Glube of the Dental Health Foundation. "In San Bernardino County, where I work, there are very few resources. Luckily, we have the Loma Linda University School of Dentistry that provides a wonderful resource for low-income patients. San Bernardino County also has over 1,000 dentists with provider numbers to treat Medi-Cal patients."

As with Glube, those working to increase access to care throughout the state piece together a sometimes-fragile network of sources. The examples above illustrate the different approaches. Some such as Comport in San Jose and Chang in Alhambra collaborate with schools in low-income areas. Others, such as Vicuña in Stockton, are able to utilize county funds and make connections with private business. Sister Ann Clinic found its initial connection though Queen of the Valley Hospital and seed money through Proposition 10 tobacco funds. With the help of private business and a highly efficient clinic with low overhead, the clinic has thrived. Other areas find funding through religious organizations, public charities, city development funds, and community foundations.

In discussing access resources, many say the state’s Denti-Cal and Healthy Families programs are underfunded and inefficient. As with the larger access picture, the issues surrounding government programs are complex and extend beyond a single aspect such as reimbursement rates. For a closer look at the state’s government funded programs, see "State Programs Face Challenges in Widening Access," by David Pisani, CDA’s manager of policy development and analysis.

In looking at resources, local dental societies play a pivotal role in providing a volunteer work force and raising funds.

"The delivery of services is still on a one-to-one basis -- dentist to patient -- and CDA membership has done an incredible job of this through day-to-day donation of services," said Perry, of CDA’s access task force. "Member dentists have organized to provide dental services to a spectrum of communities including disabled, elderly, and indigent populations."

California’s five dental schools also provide a sizeable resource for increasing access as faculty and students volunteer in force. University of Southern California students spend Saturdays working with the volunteer Ayuda organization, which sets up clinic in several Southern California counties, and USC faculty give time to the Union Rescue Mission Clinic. Loma Linda students provide the much-needed service of screening children younger than 5, as well as other services, such as operating the clinic in Mecca. UCLA operates community outreach programs at the Venice Dental Center, Roybal Clinic, and L.A. Free Clinic. The University of the Pacific is working to increase care to the large underserved population in the San Joaquin Valley, and UCSF is the fourth-largest Denti-Cal provider in the state and runs a no-cost clinic for the homeless.

"The commitment dental schools are trying to engender among students is that part of the ethical requirement of being a professional entails caring for those in need, regardless of financial circumstances," said UCSF’s Bertolami. "The idea is that if you’re going to be part of a profession, you must profess something."

Organized Dentistry’s Role

As dental schools, community clinics, mobile services, and individuals throughout California continue to work to increase access to dental care, organized dentistry is focusing on cohesive solutions through strategic planning, legislative activity, and the recently established CDA Foundation.

"Clearly, there is no magic bullet that will singularly solve the access problem," said CDA President Chan. "Realistic solutions will require that all stakeholders collaborate to make a difference."

Chan noted that recent CDA action geared toward access solutions include the 2001 House of Delegates adoption of policy recommendations by the CDA task force on access to care. The five point policy recommendations are:

* To assert that oral health is integral to general health;

* To promote an increase in the availability of providers to the underserved and special-needs population;

* To reduce financial barriers to oral health care;

* To support effective and efficient dental delivery systems; and

* To seek cooperative alliances with other stakeholders.

The fundamental policy recommendations are the work of CDA’s access to care task force, which is working on the clearly defined public policy goal of establishing CDA as a leader in improving access to oral health service, thereby increasing member ability to provide innovative quality dental care to all Californians, and heightening the respect of the public and Legislature.

CDA also supported significant legislation in 2001 relating to access to care. The most prominent, licensure by credential, was introduced by Assemblyman Sam Aanestad, DDS, and signed by Gov. Gray Davis. The legislation will establish a process for licensure by credential under which certain out-of-state licensed dentists could qualify to practice in California without having to take the California licensure exam. Many believe this could help address the shortage of health care providers in rural areas.

CDA was also successful in supporting Assemblywoman Wilma Chan’s dental student debt relief legislation. The legislation sought to create a program providing student loan debt relief for newly licensed dentists who are willing to commit to practicing for a certain period in an underserved area. However, according to CDA’s Public Policy Division, budget deficits and limits on new program funding resulted in the Assembly Appropriation Committee amendment of the bill to instead require the Office of Statewide Planning and Development to study the feasibility of establishing a California dental loan forgiveness program.

In working to address similar access needs, the CDA Foundation developed the Dental Graduate Loan Reduction Program to provide recent dental graduates an opportunity to reduce or eliminate student loan in exchange for practicing in an underserved area.

However, CDA Foundation Executive Director Jon Roth, CAE, said the Foundation’s essential role is to begin acting as the facilitator to address the access issue from a macroperspective.

"The major barrier to access to care is the absence of a globally agreed upon strategy and unified application of resources," Roth said. "The major issue is that there is no centralized organization addressing the problem from a broad-scale approach. There are many, many local grassroots programs providing an important safety net for people who do not receive care. However, organizations with similar goals are duplicating efforts statewide and the main issue of access is eluded."

Roth emphasizes that the Foundation will support important local efforts by providing financial and material grants to nonprofit organizations and clinics.

"We cannot lose the momentum of the local programs while we address the larger scale issue, but we have to move beyond only addressing the issue on a local scale and start collaborating and dedicating efforts toward serious statewide and regional efforts," Roth added. "We have the network, we have the skills and the time is now."