The New York State Department of Health is proposing to use Medicaid to fund community water fluoridation in an effort “to promote dental health for children on Medicaid”¹. The target population is poor children.

The NYSDOH says that the Medicaid funds will be used for community water fluoridation equipment, chemical additives, supplies, and staff time in population centers (cities of over 50,000) where the majority of Medicaid eligible children reside.²

There will be two public comment days to oppose this change.  FAN urges all New Yorkers interested in this issue to make the effort to attend and comment:

• May 4 in New York City: at the NYU Kimmel Center (60 Washington Square Park South), from 9:30am – 2:30pm.

• July 12 in Albany: at the Empire State Plaza, Meeting Room #6. That meeting will go from 10:30am – 3:30pm. More details and logistical information will be sent out closer to the event.

These meetings will be webcast live and will be open to the public. No pre-registration is required. Individuals who wish to provide comment will be asked to register on site.  Public comments are limited to 5 minutes per presenter.  If you have any questions regarding either hearing, please email DSRIP@healthy.ny.gov .

The Medicaid Redesign Team is also accepting comments via email: dsrip@health.ny.gov – deadline May 13th.

While committee members need to hear from all New York residents, we especially need the support of local medical, scientific, legal, and engineering professionals.  Your opposition, expert advice, and testimony could easily mean the difference between success and failure.

This is an Environmental Justice issue as poor children are the target of this proposal and they may be disproportionately impacted because of the following:

• African-American and Mexican-American children have significantly higher rates of the more severe form of dental fluorosis.
• Fluoride is Neurotoxic.
• Fluoride is an Endocrine Disruptor.
• Fluoride is a Developmental Toxicant.
• Fluoride is defined as an “unapproved drug” by the Food and Drug Administration.
• Bottle-fed infants in fluoridated areas receive 100 times EPA’s “safe level” of fluoride.
• Bottle-fed infants in fluoridated areas receive up to 175 times more fluoride than human-fed infants.
• Recent studies have shown that fluoridation is likely linked to higher rates of ADHD and hypothyroidism

FAN will be making a submission to the state which we will share with you. We will be citing FAN’s report, Water Fluoridation and Environmental Justice, submitted to the Environmental Justice Interagency Group in September 2015.  In the interim, please submit your own comments and if at all possible, attend one of the public meetings.

If you or your family have felt the impact of over-exposure to fluoride, then it’s crucial that officials hear your story since the dental-lobby claims that there are no victims of fluoride.

Ellen Connett
Managing Director
Fluoride Action Network

References:

1. New York State Medicaid Redesign. 2012. New York State Department of Health.
2. Medicaid Redesign Team. Waiver Webinar. July 3, 2012. New York State Department of Health.
3. A Plan to Transform the Empire State’s Medicaid Program – Multi Year Action Plan, by the NY Department of Health, Better Care, Better Health, Lower Costs. Companion Document: Final Reports of the MRT Work Groups.

Additional Information on NY Medicaid Redesign Proposal

• The 1115 waiver is designed to permit New York to use a managed care delivery system to deliver benefits to Medicaid recipients, create efficiencies in the Medicaid program, and enable the extension of coverage to certain individuals who would otherwise be without health insurance. In addition, New York´s goals in implementing its 1115 waiver include improving access to health services and better health outcomes for New Yorkers through multiple programs. (see website)

• The New York State Department of Health stated in a July 3, 2012, webinair:

–Water fluoridation is the most cost- effective approach to reducing tooth decay

–A $1 million investment is estimated to increase the number
of children on fluoridated drinking water by 200,000 to 1.7
million children resulting in enhanced dental health and
reduced Medicaid expenditures.

The New York State Department of Health’s Rationale for using Medicaid

Annual Cost: $ 1.0 million 

Annual Net Savings: $14.28 million

Health Disparities Impact:   Significant benefits would accrue to all children covered by Medicaid.

Benefits of Recommendation:  Even though the Department of Health and Human Services and New York State Department of Health fully support drinking water fluoridation, approximately 30% of all children in New York receive community drinking water that is not fluoridated.  Community water fluoridation at current levels results in a 20 to 40 percent reduction in tooth decay  nationwide.   Assuring fluoride in community drinking water is especially important today because many people cannot afford dental care. Fluoridation of community drinking water helps people of all ages and income groups. Systematic reviews of the scientific evidence have concluded that community water fluoridation is effective in decreasing dental caries prevalence and severity (McDonagh MS, et al, 2000³⁰, Truman BI, et al, 2002³¹, Griffin SO, et al, 2007³² ). Effects included significant increases in the proportion of children who were caries-free and significant reductions in the number of teeth or tooth surfaces with caries in both children and adults (McDonagh MS, et al, 2000b, Griffin SO, et al, 2007).   When analyses were limited to studies conducted after the introduction of other sources of fluoride, especially fluoride toothpaste, beneficial effects across the lifespan from community water fluoridation were still apparent (McDonagh MS, et al, 2000b; Griffin SO, et al, 2007). Tooth decay is the most common chronic disease in children accounting for about 30% of all health care expenditures in children. Although dental caries is preventable, many children unnecessarily suffer the consequences because of poor dental care and the inability to access preventive and treatment services in a timely manner. Untreated dental disease in children can lead to chronic pain, medical complications, early tooth loss, impaired speech development, poor nutrition and resultant failure to thrive or impaired growth, inability to concentrate in school and missed school days, and reduced self- esteem. The burden of oral disease is far worse for those who have restricted access to prevention and treatment services. Limited financial resources, lack of dental insurance coverage, and a limited availability of dental care providers all impact access to care and lead to widespread disparities in health.

Concerns with Recommendation:   Some members of the public are opposed to fluoridation, in part due to concerns about excessive exposure to fluoride. Excessive intake of fluoride during the first 8 years of life leads to changes in the tooth enamel called dental fluorosis. It is a disturbance in the mineralization of enamel. Its manifestation ranges from barely noticeable fine lacy white markings to pitting of surface.  A report released late last year by the Centers for Disease Control and Prevention linked fluoride to an increase among children in dental fluorosis. About 40 percent of children ages 12 to 15 had dental fluorosis, mostly very mild or mild cases, from 1999 to 2004³³. That percentage was 22.6 in a 1986-87 study.  In fluoridated areas, dental fluorosis is seen mostly in milder forms and therefore, considered as a cosmetic effect and not an adverse functional effect. In fact, studies show that teeth with enamel fluorosis are more resistant to tooth decay.

Impacted Stakeholders:  All New Yorkers, most notably children will be affected by the lack of access to fluoride. Critical inadequacies in access to oral health care in the U.S., particularly in the low-income population, have been a focus of increasing concern in the health policy community in recent years.  Poor children suffer the most dental disease and are less likely to receive dental care.  The burden of dental disease and conditions is not distributed evenly in children. The Surgeon General’s report documented that poor children suffer far more, and more extensive and severe, dental disease than other children; indeed, they are about twice as likely to have untreated caries³⁴. Another federal report, by the U.S. General Accountability Office, indicates that 80% of untreated caries in permanent teeth are found in roughly 25% of children who are 5 to 17 years old – mostly from low-income and other vulnerable groups³⁵. That report also estimates that poor children suffer nearly 12 times more restricted-activity days, such as missing school, as a result of dental problems, than higher-income children. Because poverty is more prevalent among minority children than among whites, income- related disparities in oral health status can translate also into racial/ethnic disparities. At the same time that poor children have more dental disease than other children, they are less likely to receive dental care.910 In 2006, nearly a quarter of all children age 2-17 had not had a dental visit in the past year, but poor and low-income children were more likely to lack a recent visit than higher-income children (31% and 33% versus 18%).³⁶

Financial Impact:  Studies comparing the cost-effectiveness of water fluoridation compared with other strategies for reducing tooth decay always conclude that water fluoridation is the most cost-effective approach.  Analysis of dental procedures in predominantly fluoridated community water versus non- fluoridated drinking water communities in New York State suggests savings of $24 per child²⁹.  Out of the approximately 2 million children on Medicaid in New York State, about 500,000 live in less fluoridated counties and another 1.5 million live in mostly fluoridated counties. With $1 million investment, we estimate that the number of children on fluoridated drinking water will increase by 200,000 to 1.7 million children. At a savings of $24 per child, and a utilization of 35%, we estimate the annual savings to be $14million.Thus an investment of $10 million is likely to yield savings of $140 million to the Medicaid program. This is a conservative estimate, as claims for adjunctive services such as examinations; radiographs and complex treatments; and costs related to transportation, emergency room visits, and lost productivity are not included. Such annual decreases in claims per recipient when applied to lifetime exposure of the whole population have large societal benefits.  Barriers to fluoridation of public drinking water include lack of resources for community water systems to purchase equipment and chemical additives to institute fluoridation or to upgrade old equipment.

References:

29. Kumar JV, Adekugbe O, Melnik T. Geographic Variation in Medicaid Claims for Dental Procedures in New York State: Role of Fluoridation under Contemporary Conditions. Public Health Reports 2010;125 (Sept-Oct):647-654
30. McDonagh MS, Whiting PF, Wilson PM, et al. Systematic review of water fluoridation. BMJ 2000;321(7265):855–9.
31. Truman BI, Gooch BF, Evans CA Jr, editors. The guide to community preventive services: interventions to prevent dental caries, oral andpharyngeal cancers, and sports-related craniofacial injuries. Am J Prev Med 2002;23(Suppl 1).
32. Griffin SO, Regnier E, Griffin PM, Huntley V. Effectiveness of Fluoride in Preventing Cavities in Adults. J Dent Res 2007:86(5):410-415.
33. Beltrán-Aguilar ED, Barker L, Dye BA. Prevalence and Severity of Dental Fluorosis in the United States, 1999 – 2004. NCHS Data Brief No. 53.  November 2010.
34. US Department of Health and Human Services. Oral health in America: A Report of the Surgeon General. Rockville (MD): National Institute of Health; 2000.
35. GAO, MEDICAID: Extent of Dental Disease in Children Has Not Decreased, and Millions Are Estimated to Have Untreated Tooth Decay, GAO- 08-1121 (Washington, D.C.: Sept. 23, 2008).
36. Bloom B and Cohen RA. Summary Health Statistics for U.S. Children: National Health Interview Survey, 2006. National Center for Health Statistics. Vital Health Stat 10(234). 2007.