The Department is a key agency in the effort toward swifter and more genuine progress in dental health. It has the fiscal resources and the dedicated personnel sufficient to play a far more positive role than it has ever done heretofore. The Nation will be well served if the Department will now harness its energy and money to a well-considered, long-term plan of action on dental disease. Full implementation of all the recommendations that appear in this report would be a notably important first step for the Department to take.

CURRENT DENTAL ACTIVITIES OF THE DEPARTMENT

Programs within the Federal Government that bear directly on dental health research, education and service were found by the Committee to be vast in number and complex in substance. Because of the administrative disarray, it was a formidable challenge to achieve a thorough understanding of them together with their interrelationships, strengths, weaknesses, voids or overlaps.

During the course of the Committee's deliberations, a number of presentations were made by program officials of the Department. Materials were provided describing dental health related programs in the Federal Government and, for some programs, their legal bases and their budgets. Though subsequent changes in legislation, organization or appropriations have invalidated some specífics of the presentations and materials, the situation they describe basically still obtains: complexity, diffusion, and proportionately small budgets.

The number of programs of the Federal Government having dental-related components can best be seen in the document entitled "Dental Health Related Programs in Federal Agencies."l In FY 1970, the base year of the report, five Federal departments and two independent agencies were engaged in dental activities. (See Appendix III for main legislative authorizations under which the programs operate).

Within HEW alone, all of the agencies were engaged in dental activities, though only the National Institutes of Health had programs which were exclusively dental.

In FY 1971, Departmental expenditures for dental programs approximated $235 million or 1.6 percent of the Department's $15 billion health budget. This is a steep and unacceptable decline in the percentage of health funds allocated to dental activities, which were 3 percent of the total in 1960.

These dental funds were distributed as shown in Figure I: Service, 56 percent, Manpower and Education, 29 percent, and Research, 15 percent. Descriptions of the major programs in each of these categories follow.

SERVICE

More than twenty programs in the Department are involved in dental service activities. Altogether, it is estimated, based on information obtained in July, 1971, that they spent $130 million in both FY 1971 and 1972, roughly nine times the amount spent in FY 1960. However, this dental total represents less than 1 percent of the total health services budget for FY 1972. By contrast, some 9 percent of all private health service expenditures are devoted to the purchase of dental services.

HEALTH AGENCY PROGRAMS

Dental care programs: The direct care responsibilities of the Department are lodged in the Indian Health Service and the Federal Health Programs Service of HSMHA. Both provide

dental care to eligible beneficiaries.

One of the most significant accomplishments of the direct care programs has been achieved by the Indian Health Service in its program for children. As of 1970, in many schools, children in every grade above the first were on a maintenance basis. About 70 percent of all school children were actually receiving dental care--a much higher rate than that found in the general school population today. This is accomplished, however, by placing a high priority on children and a consequent, relative down-grading of services for the adult members of this beneficiary group.

In terms of dollars spent, the Indian Health Service dental program has grown from about $1.9 million in 1960 to approximately $6.8 million in 1972. The dental portion represents 4.8 percent of the total Indian Health budget, an increase of 0.6 percent since 1960.

The dental program of the Federal Health Programs Service-which includes such categories of beneficiaries as the Merchant Marine, the Coast Guard, the PHS Commissioned Corps and the Federal Prison system--has not fared so well. Its budget has increased by 50 percent over the last decade to stand at $6.1 million; however, this represents a smaller share of the total budget than in earlier years.

Support for direct care projects: Six programs within HSMHA finance the provision of dental services through project grants. Three are administered by the Community Health Service and three by the Maternal and Child Health Service. All of these programs were initiated within the last ten years. Altogether, it is estimated that they spent more than $15 million on dental services in FY 1972, about 6.2 percent of their total budget.

The Health Services Development Grants Program of the Community Health Service is the largest of these programs. It was expected to spend at least $6.3 million in FY 1972, principally on the dental components of comprehensive health centers. Of 34 such comprehensive health centers, 21 provide no dental services whatever. Of the 13 that do provide such services, the program is often minimal in range. Dental services costs account for 4.8 percent of the total budgets for projects funded under this program.

The Health Services Development Grants Program also supports ll service projects that are wholly dental. One is an incremental program for children in a large metropolitan area. Several others are developing community services for the chronically ill and aged and for other homebound people.

The Community Health Service also administers the Migrant Health Program. About three-fourths of the projects supported by this program included some dental care among the range of health services provided for migrant and seasonal farmworkers and their families. For the most part, the dental services have been limited to emergency procedures necessary for the elimination of pain or infection. The Community Health Service is making a major effort to upgrade these programs. Recent regulations declare that a full range of services are essential to health and establish a system of priorities which gives precedence to the treatment of children. However, this change will have its greatest influence on newly developing programs. Less than 6 percent of the total Migrant Health Program budget for FY 1972 was used to support dental services.

The Appalachian Program, administered by the Community Health Service upon delegation by the Appalachian Regional Commission, includes several large multi-county dental programs among the health activities it supports. An estimated 11.7 percent of its total health services budget for FY 1972 was earmarked for support of these dental projects.

Of the three project grants programs administered by the Maternal and Child Health Service, the oldest is the Maternity and Infant Care Program. About half of the Maternity and Infant Care projects provide dental services, although only a fraction of all expectant mothers receive any dental care. Only about 32,000 women received services in FY 1971, with $1.1 million used for this purpose. This sum represented 2.6 percent of the total budget.

The Children and Youth Program supports dental services in 58 of 60 comprehensive care projects, and, in the remaining two, the project has made arrangements for care to be provided by others. It is the largest of the activities of the Maternal and Child Health Service Program, serving principally the children who reside in the ghettos and inr.or city areas of metropolitan areas. In FY 1972, an estimated $4.5 million was used for dental services, approximately 9.5 percent of the total program budget. In this program, too, there are wide differences from project to project in both the range of dental services available and the proportion of eligible children actually receiving care.

From a dental standpoint, the potentially most significant Maternal and Child Health Service grants program supports projects specifically aimed at improving the dental health of children. Because of Departmental neglect, however, that potential is largely unrealized. For example, more than two years ago, the House Subcommittee on HEW Appropriations, in its report on fiscal 1970 appropriations for the Department, said it was "concerned about the lack of a coordinated program for the dental health of children while so many federal dollars are being spent under Medicaid and similar programs to treat dental conditions in adults that could have been prevented "

That concern was valid and remains so today Perhaps the best example of the way in which the Department has failed in this regard is the five-year-old law that led to establishment of pilot dental care programs for needy children under Section 510, Title V of the Social Security Act.

This law, passed in December, 1967, possesses features admirably suited to implementation of what we know today about the optimum treatment of dental disease. If the Department had given it even moderate support and funding during its life, it would have yielded by now a number of invaluable results.

By now, many hundreds of thousands of children who do not have ready access to preventive care would have been the beneficiaries of the law. By now, a number of model experiments would be well underway, in both rural and urban settings, to discover the best ways of organizing and delivering dental care to groups of children. By now, hard data would be available in large measure to help intelligent planning of national programs of dental care.

Instead, because of the Department's refusal to fund the program adequately, almost nothing has been done for a five-year period Less than $3 million has been allocated in total, relatively few children have benefitted, and no information on methods of delivery and organization has been elicited..