By Rick Valachovic, DMD, MPH, Clinical Professor and Director of the NYU Dentistry Center for Oral Health Policy and Management

“Having a healthy mouth means everything.”

Those are Leonard’s words, not mine. He’s a patient at NYU Dentistry and one of the millions of U.S. military veterans who are not eligible to receive dental care through the U.S. Department of Veterans Affairs (VA).

Leonard says he looked everywhere for help with his teeth but couldn’t find it until the VA referred him to VOCARE (Veterans Oral Care Access Resource) at NYU Dentistry.  The program serves veterans who are not eligible to receive oral health care through the VA. In its first year alone, VOCARE provided more than 10,000 dental procedures — free of charge — to 1,022 veterans.

That pent-up demand stems from the nature of VA health coverage. Nine million veterans get their health care through the VA, but only 1.4 million of them are eligible to receive dental care at the VA’s expense. To qualify, veterans’ oral health needs must be connected to their military service or be medically necessary to prepare the veteran for a covered hospital admission. Just as in traditional Medicare and many private plans, routine dental care is not a covered benefit.

Michael O’Connor, co-director with me at the Center for Oral Health Policy and Management and executive vice dean of NYU Dentistry, also co-directs VOCARE, and he’s passionate about serving this population. He vividly recalls a decades-old encounter with his father, a veteran of World War II. He didn’t look well, and knowing of his struggles with alcoholism, Michael feared his father had scurvy.

Michael took him to the VA, where the reception they got was far from welcoming. When the staff tried to release his father without providing care, Michael took down names and made it clear he would hold the staff responsible if his father’s condition worsened. They agreed to keep him overnight and soon learned he did have scurvy, one of many debilitating conditions (including cancer, heart disease, vision problems, diabetes, and a stroke), which Michael would help him manage over the next two decades.

At every VA facility where his father sought care, Michael fought the system and was able to secure great health care for his father. “I kept him alive for 20 years,” but Michael was unable to get his father treatment for one critical concern: his broken and missing teeth.

“I wonder what would have happened to my father if I was able to get him teeth. Would that have changed his life? Would he have no longer been a recluse, ashamed to go out? Would he have gone back to work? Would he have tried to turn himself around? Those questions will never be answered,” Michael says.

VOCARE is part of a VA pilot program, VETSmile, which aims to fill the gap in veterans’ access to dental care by connecting them with dentists in their communities. In July 2021, the VA selected NYU Dentistry to pilot the program in an urban setting. I sit on a technical expert panel advising VETSmile, and in my role at NYU Dentistry, I’m delighted that VOCARE resides within the Center for Oral Health Policy and Management. That connection forces us to also think about policies that can further extend veterans’ access to oral health care.

Although VETSmile is a VA initiative, pilot sites such as NYU Dentistry are responsible for funding the care. To date, the College has raised $900,000 from a mix of public and private sources. The New York State Assembly and New York City Council have allocated funds, and charitable donations have come in from the United Concordia Dental Charitable Fund and the Leukemia & Lymphoma Society, which provides funding specifically for dental care for veterans with blood cancer. Faculty and students at NYU Dentistry have also been moved to contribute.

VOCARE co-director Gabriela Gonzalez, MPA, shares their passion for providing care to former members of the nation’s military services. As the younger sister of a veteran who served in Iraq and Afghanistan, her compassion for this population is rooted in her personal experience as well as her patriotism. She’s been attending national meetings on veterans’ oral health, including the American Dental Association’s Give Veterans A Smile Summit in May. She told me the willingness to treat veterans at no cost is growing, but no one is committing resources on the scale of VOCARE.

According to Gabriela, “Some dental practices set aside part of a day each week to provide pro bono care to veterans, but more often, including at dental schools, it’s one day a year, usually Veterans Day. After a recent presentation at which I spoke about VOCARE, everybody thanked us for providing free dental care to veterans year-round.”

The veterans we’ve treated have also shown their gratitude. “I am so grateful that Brooklyn VA Hospital [connected me to] NYU Dentistry,” Leonard told us. “Coming here, just meeting the staff, was breathtaking, and they guarantee me that they can help me, and they are helping me.” He’s confident many others in his community will benefit as well.

Michael shares his conviction that VOCARE will improve the oral health — and the lives — of today’s veterans. Thinking back on his father’s situation, Michael observes, “One thing I know is, no one feels good about themselves if they can’t smile. No one gets a job if they don’t have teeth. There is a stigma associated with people missing or having no teeth. VOCARE will help in this regard.”

NYU has a five-year partnership with the VA to continue VOCARE, and Michael and Gabriela are now looking at ways to help other dental schools and federally qualified health centers adopt the model. Making more charitable care available is a step in the right direction, but with his background in public health policy, Michael won’t be satisfied until he sees government action to address the root of the problem: the lack of a universal dental benefit for veterans. He is looking forward to a day when he and VA representatives testify before Congress, explaining the importance of dental treatment and preventive care to veterans’ oral, mental, and overall health.

“This care shouldn’t be at the largesse of private institutions like the NYU College of Dentistry. It should be a taxpayer-funded benefit appropriated by Congress,” Michael insists. “Our goal is for Congress to fund dental care at all the VAs across the country, so that these veterans get the care that they deserve — simple as that.”

I couldn’t agree more.

By Rick Valachovic, DMD, MPH, Clinical Professor and Director of the NYU Dentistry Center for Oral Health Policy and Management

Barbie Vartanian, NYU Dentistry’s director of advocacy and policy initiatives, remembers the day she first answered the question posed above. She was in a dental clinic helping answer the phones when a woman on the line requested an appointment. “I have twins and they’re autistic. Will you treat them?” she asked. “Well, sure. Why wouldn’t we?” Barbie replied. Then the caller told her numerous other dental practices had refused to book the appointment. “I hadn’t had Sam yet, but I just thought, ‘Of course! We’re health care providers. That’s our job.’”

Barbie’s teenage son, Sam, is profoundly autistic, so in the years since that call, she’s had her own share of challenges obtaining care for him, and she is not alone. According to the Centers for Disease Control and Prevention (CDC), one in six U.S. children has an intellectual or developmental disability (IDD), and one in four U.S. adults lives with a disability of some sort. According to one study, dental care topped the list of unmet care needs among children with special health care needs, “affecting substantially more children than any other health care need category.”

The Oral Health Center for People with Disabilities

NYU Dentistry is helping to fill this gap. In 2019, the College opened the Oral Health Center for People with Disabilities within our current clinical facilities. The Center’s staff is trained to ensure quality treatment and holistic care for people with disabilities and complex medical conditions, and the environment is designed to put them at ease. The dental operatories are larger than usual, providing 360-degree access to patients and space for their caregivers. There’s a bariatric bench to accommodate heavier individuals, and a reclining platform that allows patients in wheelchairs to receive care without leaving their familiar seating. A multisensory room with weighted blankets, special lighting, and videos on the wall provides a space where patients can become acclimated to the clinic environment.

“From there, we transition them into the dental care setting,” explains Robert Glickman, DMD, associate dean for clinical affairs and hospital relations at NYU Dentistry. “We are able to tailor the appropriate therapy, and the appropriate management of therapy, to the individual’s needs; we’re not limited by the facility’s structural configuration.”

In just three years of often pandemic-constrained operation, the Center has given almost 2,000 underserved patients a much-needed dental home, while also serving another critical function. “We want to ignite in our students a sense of wanting to help, and more importantly, to show them that this should be the routine approach to patient care, not something out of the ordinary,” asserts Robert, who is responsible for overseeing the Disability Center’s academic and clinical missions.

Barbie agrees. She has made it her mission to ensure that individuals with disabilities have access to oral health care. “What is needed to treat our population is a shift in mindset,” she told me.

Changing Attitudes Through Advocacy and Education

Last year, Barbie joined our team in the Center for Oral Health Policy and Management. In her current role, she works with Project Accessible Oral Health, an advocacy group she previously led, and other partners in the effort to improve oral health care for people with disabilities. “We’re seeing momentum like we’ve never had before,” she says.

NYU Dentistry is a leader in serving the IDD population, but we are not alone. Our dental school colleagues at the University of Pennsylvania, Touro University, the University of Michigan, and UTHealth in Houston are also committed to serving this community. The University of the Pacific Arthur A. Dugoni School of Dentistry is another pioneer in this area. Early in September, the school cohosted a two-day event with the Santa Fe Group on achieving oral health equity for people with IDD. My partner at the Center for Oral Health Policy and Management, Dr. Michael O’Connor, was among the presenters.

There’s also an effort being spearheaded by the American Academy of Developmental Medicine and Dentistry to draft a national curriculum on treating the oral health needs of people with disabilities. The idea is that any dental school will be able to take it off the shelf and implement it, providing consistency in what’s being taught across the country.

A 2018 change to the Commission on Dental Accreditation (CODA) standards for dental education programs, which asserts, “Graduates must be competent in assessing and managing the treatment of patients with special needs,” should incentivize programs to make use of the curriculum if they aren’t already addressing this topic. Dental educators in New York State can also take part in Unit Zero, a free, eight-credit, NYU Dentistry continuing education program on caring for people with disabilities. We’re offering the two-day program twice this fall, with support from the Mother Cabrini Health Foundation.

Persistent Barriers

Despite these advances, barriers persist. Sadly, one of these is the stigma and bias associated with treating people with IDD. Steve Perlman, DDS, a clinical professor of pediatric dentistry at the Boston University Goldman School of Dental Medicine and a pioneer in this field, once told Barbie people would say to him, “You must not be a great dentist if you’re treating these people.” As Barbie and others can testify, the people who have dedicated their careers to treating populations with special needs are not only great dentists; they’re also great human beings.

One I’ve come to know and admire is Rita Bilello, DDS, an NYU Dentistry alum and chief executive officer of Metro Community Health Centers, Inc. (MCHC), which runs a federally qualified health center here at NYU Dentistry. Rita and MCHC specialize in serving people with IDD. Rita gained exposure to the medical complexities faced by this population during her general practice residency. When she entered private practice, she became the go-to dentist whenever a person with IDD walked through the door.

“I used to get really, really annoyed at my fellow dentists because they would come to me and ask me for the number at the hospital so the patient could be put to sleep prior to the dental procedure,” she told me. “I’m like, ‘There’s no reason why you need to send this person to a hospital. Just do it.’”

In addition to some dentists’ reluctance to provide care, there’s also the issue of payment. Many people with disabilities are insured through Medicaid. Too few providers accept this insurance (see my last post), and those who do are not compensated for the extra time it takes to provide respectful and compassionate care to these patients.

A Better Model of Care

Thanks to MCHC’s presence on the NYU Dentistry campus, the Center is preparing the next generation of dentists and dental hygienists to treat people with IDD in an integrated care environment. Rita views this delivery model as especially beneficial to the patients she treats. “You can’t separate out one component of a human being and think that you’re going to have overall success in taking care of them,” she says. “By the time a patient gets to me for a dental issue, they’ve usually been to the ENT and the psychiatrist because they’re hitting their head and they’re refusing to eat, and you know what? Sometimes the problem is something as simple as a toothache.”

Having the Center and MCHC in the same building makes it easy for students to collaborate with medical staff on behalf of the Center’s patients. In the process, we hope they will come to share Rita’s enthusiasm (and mine) for integrated care delivery.

 The practice of providing integrated, compassionate care in facilities that can accommodate a wide range of patient needs is still in its infancy, but I’m confident others will adopt this approach. As Robert said to me, “If we were the only institution in the country providing this care, it would be a pretty good thing for people who live in our region, but our effort would be a failure. Our goal in establishing the Center is that other dental schools will try to replicate it.”

An oral and maxillofacial surgeon, Robert remembers vividly the times he was asked to perform extractions on people with IDD who arrived at the hospital in pain in the middle of the night. “To take somebody who doesn’t understand what’s going on, put them to sleep, and then wake them up with less teeth — and everybody’s saying, ‘Well, at least we got the infection out,’ — that’s a failure of the system,” he told me. “When we do a root canal at the Center on a patient who previously would have had that tooth extracted, that’s rather amazing to me.” With on-going advocacy efforts and the commitment of more dental schools to preparing their students to treat people with IDD, we may soon see the shift in mindset that could make it a matter of course.

By Rick Valachovic, DMD, MPH, Clinical Professor and Director of the NYU Dentistry Center for Oral Health Policy and Management

The 2022 legislative sessions in most states have come to a close, and the results are worth celebrating. Five states adopted positive changes to their dental Medicaid laws, and several other states have related legislation pending. Last year, 12 states passed similar bills, and Louisiana broke new ground, approving a comprehensive dental benefit for adults with intellectual and developmental disabilities in its various Medicaid waiver programs. 

While most state Medicaid programs have historically covered emergency dental care for adults, few states offered extensive dental benefits to this population. Recent progress builds on a history of benefit expansion, beginning with the inclusion of dental benefits in the Children’s Health Insurance Program in 2009 and the expansion of Medicaid as part of the Affordable Care Act, signed into law in 2010. As of May, this year, only three state Medicaid programs provided no adult dental benefits and another eight restricted such benefits to emergency care, but most states offered more. Fifteen states provided at least some non-emergency benefits, and 24 states and the District of Columbia provided extensive benefits to adults. Additionally, every state except Alabama provided dental benefits to pregnant women.

These changes represent a major shift in the Medicaid dental benefit landscape. To keep track of these developments, CareQuest Institute for Oral Health, working with the American Dental Association Health Policy Institute (ADA HPI) and other partners, developed a tool for tracking Medicaid adult dental benefits across states. To learn more about it, take a look at CareQuest’s recent webinar on the topic.

At the federal level, there are also glimmers of progress.  In 2021, the Centers for Medicare and Medicaid Services (CMS) appointed Dr. Natalia Chalmers as its first chief dental officer. Last month, the agency’s draft physician fee schedule for FY 2023 proposed paying for a dental exam and treatment preceding an organ transplant as well as several other services. CMS is also seeking comment on what additional dental services Medicare should reimburse.

The cumulative efforts of oral health advocates deserve most of the credit for these gains, but they were facilitated by state budget surpluses in 2021 and 2022, resulting from generous federal COVID-19 relief funding. “This environment has enabled many state legislatures to focus on improving their dental Medicaid programs for dentists and patients,” an update from ADA HPI observed. 

It’s heartening to see the pendulum swinging toward providing greater dental coverage, but even though more Medicaid beneficiaries are now eligible for a wider array of oral health benefits, that doesn’t mean people in need are receiving more care. According to a 2021 research brief from  ADA HPI, fewer than half of dentists in many states are enrolled as Medicaid providers, and even in states with relatively high Medicaid enrollment among dentists, a significant percentage of enrolled providers are not seeing any Medicaid patients. The availability of dentists to see children in the Medicaid and CHIP programs is also far from adequate, according to a recent study in JAMA Open Network.

At other times, practices that want to see Medicaid patients lack sufficient capacity to do so. When Virginia began covering dental procedures for Medicaid beneficiaries in July of last year, one clinic found itself fielding calls from patients up to 60 miles away. In February, the clinic started a waiting list, and by May more than 200 people were still awaiting care.

The expansion of benefits also triggered a 67% rise in the number of adult Medicaid beneficiaries seeking care at Virginia Commonwealth University (VCU) School of Dentistry. The influx of patients allowed students to train in more specialty areas and appreciate the extent of community needs, but these opportunities also came at a cost. “Current reimbursement rates that have not increased in approximately 15 years sometimes fail to meet the actual cost of delivering care,” Lyndon Cooper, DDS, PhD, dean of the dental school, told The Virginian-Pilot. “This challenges us and all other oral health care providers to operate in a fiscally responsible manner.”

What can be done to make Medicaid more attractive to providers and care more accessible to its beneficiaries? Mary Foley, RDH, MPH, who leads the Medicaid/Medicare/CHIP Services Dental Association (MSDA), has ideas. “States have to balance their budgets each year. Most people don’t realize the implications of that,” she points out. “When a crisis emerges — like a pandemic — all of a sudden, everything that isn’t mandated under some law goes by the wayside. The most powerful way to ensure that oral health care services are available to adults and to seniors would be through federal legislation,” she argues.

Mary would like to see passage of the Medicaid Dental Benefits Act of 2021, which would make comprehensive dental care a mandatory component of Medicaid coverage for adults. She’d also like to see federal legislation create oral health benefits in Medicare and in a Medicaid program designed especially for people with intellectual and developmental disabilities. That said, Mary is sympathetic to lawmakers, who have a host of competing priorities. “Advocates who want to mandate every single benefit possible are unrealistic,” in her view.

Unlike commercial dental plans, which typically cap dental benefits at around $1,500 a year, Medicaid plans pay for all “medically necessary” treatment, leaving states open to hefty bills. States also bear costs related to fraud, waste, and abuse, estimated at slightly more than 10% of Medicaid billings in 2017. The good news, Mary says, “Artificial intelligence (AI) is coming fast and furiously to Medicaid.” Her organization has just launched an 18-state learning collaborative to help state Medicaid programs use AI to address utilization review for fraud, waste, and abuse in their dental programs.

A lot has changed since my days as a pediatric dentist in Boston, when economically disadvantaged children lacked access to fluoridation as well as to dental insurance. While pockets of severe dental need remain, most children have better oral health today thanks to policy changes on both these fronts. The progress that’s occurred since I wrote about this topic in Academic Medicine in 2018 in the last two years is also impressive.

I’m hopeful the pendulum will continue to swing in a positive direction, but economic uncertainty makes me wary. Budget surpluses opened the door to this year’s state policy victories. In leaner times, Medicaid reimbursements, and dental benefits specifically, often find themselves on the chopping block. As we celebrate recent victories, we can’t let up the pressure on policymakers. Concerted advocacy was essential to gaining this ground. We’ll need to fight just as hard to hold it and achieve gains at the federal level.

By Rick Valachovic, DMD, MPH, Clinical Professor and Director of the NYU Dentistry Center for Oral Health Policy and Management

Last month I traveled to Washington, DC for the celebration of a colleague and a dear friend. No, she’s not a dentist. She’s a pharmacist. And our dinner companions were physicians, social workers, public health professionals, nurses, and clinicians of other stripes. Many of us had known each other for many years, and in 2007, a core group of us banded together around a common purpose: educating our health professions students for interprofessional practice.

“We had this vision that people should collaborate in practice,” Polly Bednash, PhD, RN, FAAN, recalled when we recently spoke. “The Joint Commission was very clear in its work on patient safety. Almost uniformly, communication problems were what caused errors, and we agreed that we have to figure out how people can talk to each other and trust each other and respect each other’s work and see their work as having value to the whole enterprise.”

At the time, Polly, who currently serves on the Board of Trustees of Dartmouth Health and several other health entities, was leading the American Association of Colleges of Nursing. She, Carol Aschenbrenner, MD (then chief medical education officer at the Association of American Medical Colleges), our counterparts at the American Association of Colleges of Osteopathic Medicine, the American Association of Colleges of Pharmacy, and the Association of Schools and Programs of Public Health, and I (then President and CEO of the American Dental Education Association) would meet every few weeks to wrestle with what it would take to bring our learners together. Along the way, we started to share stories about our professional challenges and personal lives. These comfortable exchanges created an environment for engaging in substantive, frank discussion around interprofessional education (IPE) as well.

By 2009, we had formed the Interprofessional Education Collaborative (IPEC), the group that hosted the celebration dinner I mentioned. The guest of honor was its immediate past chair, Lucinda Maine, PhD, RPh. Having worked closely with Lucinda and the other IPEC founders, this was an event I was not about to miss, and they felt the same about the special bond we had formed, one that transcended other professional relationships.

As Polly put it, “I don’t think this could ever have happened if we hadn’t started to develop personal relationships. We began to actually trust that we were not looking to stake out territory for each profession. Instead, we were driving toward a common goal—the greater good of the people we were supposed to serve as health professionals.”

Today, IPEC is alive and well, and it currently boasts 21 national associations representing various health professions as members. The Core Competencies for Interprofessional Collaborative Practice, which IPEC developed in 2011, have been widely embraced, and in recent years, more universities have established offices and created administrative roles to facilitate IPE on their campuses, thanks in part to IPEC’s influence.

Last month, the organization hosted its fifth annual IPEC Interprofessional Leadership Development Program, a three-day professional development experience facilitated by the Academy for Advancing Leadership (AAL). The theme of this year’s IPEC gathering was bridging the gaps between education and practice.

Unfortunately, those gaps still persist, and can be especially challenging at health professions institutions housed outside of academic health centers. As Karl Haden, PhD, who leads AAL, put it, “Much of education is isolated from practice, and health professions are still largely siloed. The physical and geographic distance between the institutions and their partners is another fundamental challenge.”

Karl acknowledged that some institutions are working hard to create more authentic interprofessional clinical experiences for their students. Making these universally available is going to involve more conversations with the practice community, health systems, and possibly the organized professions, in his view. “That means building bridges to the practice community that haven’t been there before,” he told me.

The NYU College of Dentistry is fortunate to be part of an academic health center and to have had leadership supporting IPE since the days when Michael Alfano, DMD, PhD, was dean. Under Mike’s leadership, NYU’s nursing programs, which were housed at the time in the NYU School of Education, found a new home in a college of nursing housed within the College of Dentistry. The novel arrangement made NYU a pioneer in interprofessional collaboration and fostered the development of many nurse leaders with strong commitments to integrating oral health into overall health care.

The best known of these is Judith Haber, APRN-BC, PhD, FAAN, Ursula Springer Leadership Professor in Nursing at NYU Rory Meyers College of Nursing. Judi took the lead in forming the Oral Health Nursing Education and Practice program, a national initiative aimed at integrating oral health into nursing care and education. She was also the lead author on an influential paper, Putting the Mouth Back in the Head: HEENT to HEENOT, which advocated that all health professionals routinely look inside the mouth when assessing a patient’s eyes, ears, nose, and throat. While not universally employed, the HEENOT exam has been widely disseminated.

When I last spoke with Judi about the early days of IPE, she described oral health as “the key that turned the lock” when NYU faculty were thinking about innovative strategies for meeting accreditation standards related to IPE. “Oral health was a perfect clinical education focus for operationalizing the IPEC competencies in nursing curricula,” she said.

I agree, and patients will benefit. That said, IPE is a two-way street, and even here at NYU, dental students remain relatively separate from their clinical peers in other health professions, just as dentists often do in practice. One positive development is the recent addition of a federally qualified health center (FQHC), Metro Community Health Centers, to the NYU Dentistry clinics. The common location gives dental and dental hygiene students opportunities to collaborate with medical professionals in primary care and behavioral health and to learn how to advocate for patients’ overall health.

Is that enough? Absolutely not. “In our IPEC panel discussions, the disconnect between the education and the practice communities was clear,” Karl told me. “Many practitioners (and health systems) are unaware of IPE efforts. In addition, many educators do not appreciate the challenges graduates face when they enter the practice setting. I think of IPE as a strategy with a vision for how practice should be; in the practice setting, this strategy is often derailed by organizational culture and the imperative for fiscal responsibility and generation of revenue.”

The good news is that students who do take part in authentic interprofessional experiences love them. “It makes them feel like they’re part of something larger than themselves and who they are as a particular discipline,” Polly told me, “and if you can get students exposed to these kinds of collaborative experiences, they will demand more of them.”

That’s what I’ve seen as well. When NYU Dentistry Dean Charles Bertolami, DDS, DMedSc, and I gave a detailed presentation on interprofessional education and clinical practice to NYU’s third year dental students in April, they were excited by the potential of collaborative care to transform dental practice and patients’ lives.

I hope that enthusiasm carries over into classrooms and clinics. IPEC laid a solid foundation for IPE, but over the years, the work of constructing education and practice environments that foster collaboration has become sporadic. In my view, it’s past time to renew our focus on IPE. Dental educators can start by acquainting themselves with a paper I wrote for the Journal of Dental Education on integrating oral and overall health care in this 2021 paper in Frontiers in Oral Health. The authors mine the wisdom contained in three leading integrated practices to propose recommendations for reshaping dental education. I’m also looking forward to reading the results of IPEC’s recently completed scoping review, which provides strong evidence that IPE impacts patient outcomes. The evidence is on our side. Now we need to recommit to doing the hard work of preparing our students for interprofessional collaborative practice.

By Rick Valachovic, DMD, MPH, Clinical Professor and Director of the NYU Dentistry Center for Oral Health Policy and Management

Let’s be honest — none of us were prepared for the COVID-19 pandemic. Still, it’s undeniable that the Centers for Disease Control and Prevention (CDC) was caught flat-footed. The agency’s decision to stick with testing protocols that were no match for the fast-moving coronavirus was the first of several missteps, and they undermined the public’s trust in the once vaunted institution. The erosion has been profound. At the start of this year, 43% of poll respondents — up from 13% in April 2020 — told NBC News that they did not trust the CDC’s coronavirus information.

In the face of this reality, the agency announced this spring it would conduct a one-month review of its structure, systems, and processes. “Never in its 75-year history has CDC had to make decisions so quickly, based on often limited, real-time, and evolving science,” CDC Director Rochelle Walensky, MD, MPH, said in the April announcement. The agency also had to contend with political pressures and years of disinvestment in the nation’s public health infrastructure. Regardless, Walensky acknowledged the CDC must do better the next time a public health emergency occurs and integrate the lessons learned during the current pandemic into “a strategy for the future.”

So, what have we learned from recent events? The CDC has yet to issue its report, but some lessons are all too clear. First and foremost, we can no longer take the CDC — and the rest of our public health system — for granted. In a fascinating online discussion, hosted by the Harvard T.H. Chan School of Public Health, five former CDC directors talked about what went wrong at the agency during the pandemic and what can be done “to rebuild the CDC’s capacity and restore its credibility.” Here are the lessons I took away and other food for thought.

Lesson 1:
Radically increase our investment in public health.

“We have to approach our nation’s health defense with the same urgency we approach our military defense in peacetime,” said Tom Frieden, MD, MPH, CDC director from 2009 to 2017. “We don’t cut military and intelligence-gathering capabilities so that we’re at risk. Why, then, are we starving our health defenses?”

Walensky’s predecessor at the CDC, Robert Redfield, MD, who retired from the U.S. Army as a Colonel, echoed those remarks. “I personally believe that our national security is much more impacted by the capacity of our public health system in this nation than it is by North Korea, Iran, China, or Russia, and yet we don’t invest proportionately to that,” he said.

“We’re basically operating a CDC and a public health system right now that’s funded, on a per-capita basis, less than it was in the 1950s in real dollars,” said Julie Gerberding, who served as CDC Director from 2002 to 2009. Making matters worse, many of those dollars are earmarked in response to specific needs, leaving the agency without “any capacity to continually improve both our bio-preparedness” and to make sustained investments in health equity and chronic disease prevention. “That just doesn’t make any sense in this day and age,” Gerberding observed.

The Biden administration has requested almost $10.7 billion in discretionary budget authority for the CDC in fiscal year 2023, an increase of $2.3 billion over this year’s budget, but as we all know, Congress will ultimately decide whether the CDC receives that funding and how much of it comes “with strings attached.”

Lesson 2:
Modernize how we collect and share data.

It’s hard to believe, but the CDC is highly dependent on other entities for its access to data. Fifty states and more than 3,000 local jurisdictions submit data to the CDC, but they decide what to submit, what format to use, and how their data may be shared. According to Bill Roper, CDC director from 1990 to 1993, we need to create a standardized, nationwide, public health data system the CDC can rely on, and until we do, “Every governor can basically say, ‘No, I don’t think we’re gonna do that,’ and that just blows the whole thing apart.”

The agency only began receiving COVID-19 hospitalization and laboratory data when the Trump administration declared a public health emergency at the start of the pandemic. When that declaration lapses, the agency could lose its access to key metrics needed to track the spread of the virus.

Fortunately, Congress has allocated more than $1 billion since 2020 to support the CDC’s data modernization initiative. In the last year, the agency also created a national Center for Forecasting and Outbreak Analytics to “enable timely, effective decision-making to improve outbreak response using data, modeling, and analytics.” Congressional support for both these initiatives is a great start, but lawmakers will need to sustain that support over many years to create the reliable data and forecasting systems the agency envisions.

Lesson 3:
Take the long view—in time and space.

This lesson is essential to improving public health, and there’s good evidence to back it up. Bill Foege, MD, MPH, who directed the CDC under Presidents Carter and Reagan, reflected on the work done during his tenure to eradicate smallpox. “Our investment … has been recouped every three months, which means that, since smallpox disappeared, our investment has come back 160 times,” he said. “It’s the same with immunization. For every dollar we put into immunization, we get at least 10 dollars back.” He also stressed the importance of looking beyond our borders. “We are involved in global health, and we can’t walk away from that. This is part of protecting us,” he asserted, noting how coronavirus variants developed in less vaccinated parts of the world.

If enough policymakers adopted Foege’s longer view, they might also support expanding CDC investment — a mere $19.5 million in 2021 — in the nation’s oral health. Historically, the agency’s oral health initiatives have been part of an orphan program, disconnected from most other agency initiatives. At present, the CDC funds health departments in 20 states and Puerto Rico to implement school-based sealant programs, community water fluoridation, and/or chronic-disease surveillance programs that encourage the integration of medical and dental care. That’s commendable, but I’d love to see this happening in all U.S. states and territories.

Lesson 4:
Restoring trust will be a heavy lift.

“Worldwide, people have lost faith in institutions,” and the CDC is no exception, observed William Roper, MD, MPH, CDC director from 1990 to 1993. “People are so anxious for a pronouncement from on high that is permanent and forevermore, and that’s just not the scientific process,” he said.

Redfield laid part of the blame on the complex structure of federal public health, noting the CDC director reports to the Secretary of Health and Human Services who reports to the President, and there may be a special White House advisor on health who must also be consulted. “It’s the lack of perception of independence that has undercut trust,” he believes.

How can the CDC restore trust in its authority? Roper thinks it will require speaking with humility and contextualizing pronouncements with, “This is our best advice given what we know today. We may know [something different] tomorrow, and if it is different from what we know today, we will change our advice tomorrow…. People should value that humility.”

Lesson 5:
Nothing will happen without the workforce to do it.

Whatever does or doesn’t change at the CDC in the months and years ahead, we’ll need to build back our public health workforce if we’re to withstand the next public health emergency. As Walensky pointed out during a White House briefing in April, “During the decade prior to COVID-19, the public health workforce lost an estimated 60,000 jobs nationwide.” That was before the pandemic drove still more people to leave the field, including dentists and dental hygienists.

One ray of light: The American Rescue Plan sets aside federal dollars to recruit, train, and develop the next generation of public health leaders. So far, 80 grants have been awarded to 32 states through Public Health AmeriCorps, a partnership between AmeriCorps and the CDC. Once again, it’s a good start, but the initial investment will fund fewer than 3,000 positions — a tiny fraction of workforce we need. With now more than one million U.S. COVID-19 deaths officially counted — more than on battlefields in all the country’s wars combined — it is essential that we take these lessons to heart and act on them at scale before the next public health crisis occurs.

By Rick Valachovic, DMD, MPH, Clinical Professor and Director of the NYU Dentistry Center for Oral Health Policy and Management

Summer is nearly here, and while the pandemic is far from over, people have resumed many of the activities they put on hold when COVID-19 arrived. For me, that has meant traveling to conferences, including the American Dental Education Association (ADEA) Annual Session held in Philadelphia in March. I was impressed that almost 2,000 other ADEA members joined me. The pleasure of reconnecting with old friends was comforting and familiar, but the meeting felt and looked different as well. Women and people of color dominated the stage, and the election of Puerto Rico’s Ana López-Fuentes to succeed ADEA Board Chairs Nader Nadershahi, Keith Mays, and Ryan Quok made one thing abundantly clear:

1.
Diversity in leadership will be the expectation, not the exception, as we enter the next normal.

The following week, I logged on to the annual gathering of the American Association for Dental Research, which held a hybrid meeting in Atlanta. From my perspective, hybrid is the way to go. The technology is there and it’s not expensive to do, and it answers a question we often posed when I was at ADEA: How do we get this great content to more people? The take-away?

2.
Organizations will take advantage of virtual meeting technologies, even if COVID-19 case numbers continue to remain low.

As I write, omicron and its subvariants continue to sicken Americans, including those who have been vaccinated and boosted, and while no one is panicking, many in our community continue to mask and take other precautions even without mandates. Much of the public seems to associate the word “endemic” with “benign.” Health professionals know better. Endemic means we’ll be living with the risks of this disease for some time to come, probably decades. Some regions may eradicate it through vaccination and natural immunity (think measles or polio), but in other regions it will continue to make people sick and die, and more potent variants may well emerge and drive new surges. As a result,

3.
Navigating different perceptions of public health risk will continue to challenge us for the foreseeable future.

In the meantime, the current pandemic continues to pose economic challenges and to have especially negative effects on the health care delivery system and its workforce. Dental practices were not immune. According to research by the American Dental Association Health Policy Institute (ADA HPI), patient volume remained 10% lower than pre-pandemic levels in October 2021, and at the start of this year, shortages of dental assistants and hygienists continued to stymie efforts to return practices to full productivity. What does this mean for the next normal? Writing in Dental Economics, ADA HPI staff observed…

4.
“Practices need to think creatively not only about recruitment, but also staff retention.” Cross-training, professional development opportunities, and technological solutions, in addition to pay increases, were among the strategies they proposed.

As we picture the future, we should also remember that many people will continue to live with the long-term health consequences of COVID-19, and their long-lasting symptoms will have downstream effects — disrupting housing, employment, and family life. I can’t help thinking about all the members of the armed forces who escape the battlefield but spend years rebuilding their bodies and minds. From our work with veterans here at NYU Dental, we know,

5.
Recovery is possible, but it takes substantial will, support, and resources.

For people who were healthy and economically secure, the pandemic spurred several positive developments that will almost certainly be part of the next normal. Many white-collar workers will continue to work from home, sparing them stressful commutes and reducing vehicle pollution. Organizations will take advantage of the reduced costs and increased productivity this arrangement creates. Educators who previously taught exclusively face-to-face have grown comfortable with engaging adult learners online. And perhaps most consequentially,

6.
Telehealth is here to stay.

In the early days of the pandemic, when people were advised to shelter in their homes, patients’ willingness to communicate with their health care providers via telehealth was unknown. No longer. The technology was widely embraced by patients and providers alike. In dentistry, telehealth allowed practices to triage patients during dental emergencies. Dentists also met with patients remotely to review their medical histories. And the experience encouraged dental providers to think about how the technology might become part of their next normal.

Not everyone in our community is ready to incorporate teledentistry into their practices, and an ADEA report makes clear most schools need to do more to prepare students for this type of practice. Luckily, dentistry has pioneers who can guide our path forward. In the past two decades, colleagues at the University of the Pacific Arthur A. Dugoni School of Dentistry used teledentistry to create their Virtual Dental Home; the University of Minnesota School of Dentistry established a teledentistry network linking university specialists to dentists and patients in remote rural areas; and the University of North Carolina Adams School of Dentistry launched a teledentistry service that is increasing access to care in that state.

We can also look to the experience of the Alaska Native Tribal Health Consortium (ANTHC), which has improved oral health outcomes for residents of the Yukon Kuskokwim Delta by using remote technologies to facilitate the work of dental therapists since 2006. Delivering dental care remotely is not as easy as providing mental health counseling from afar, but these efforts show that with the right training, certification, and team structures, technology can help us improve how we care for underserved populations as we enter the next normal.

One more thought about where we’re headed. The pandemic accelerated the proliferation of misinformation and disinformation, forcing members of the academic, practice, and public health communities to contend with heightened levels of hostility from ill-informed members of the public. In such an environment, it’s essential that students learn how to communicate effectively with patients and analyze the research literature – an area where NYU Dentistry excels.  Since 2000, literature appraisal has been a cornerstone of our effort to prepare students for evidence-based practice. As a result, our students don’t simply conform when faculty say, “Do it this way.” They ask us, “Why?”

WARNING:
With the COVID-19 pandemic accelerating the erosion of trust in government and public institutions, the public will continue to ask for compelling reasons to take our advice regarding their oral health. Preparing ourselves and the rising generation of oral health providers to provide persuasive answers must also be part of our next normal.