This year, the Illinois legislature was considering measures to expand oral health treatment in a state where millions of people live in dental care deserts.
But when the Illinois State Dental Society met with key lawmakers virtually for its annual lobbying day in the spring, the proposals to allow dental hygienists to clean the teeth of certain underprivileged patients without a dentist seemed doomed.
State Sen. Dave Syverson, a Republican legislative leader, warned against the bills even if they sounded minor. “It’s just getting the camel’s nose under the tent,” he said in an audio recording of the meeting obtained by KHN. “We’ll have, before long, hygienists doing the work that, if they wanted to do, they should have gone to dental school for.”
The senator added that he missed “the reception and the dinners that you guys host” and the “nice softball questions that I usually get” from the dental society’s past president, who happens to be his first cousin.
The bills never made it out of committee.
The situation in Illinois is indicative of the types of legislative dynamics that play out when lower-level health care providers such as dental hygienists, nurse practitioners and optometrists try to gain greater autonomy and access to patients. And the fate of those Illinois bills illustrates the power that lobbying groups such as the Illinois dental society have in shaping policies on where health professionals can practice and who keeps the profits.
“There’s always a struggle,” said Margaret Langelier, a researcher for the Center for Health Workforce Studies at the University of Albany in New York. “We have orthopedists fighting podiatrists over who can take care of the ankle. We have psychiatrists fighting with clinical psychologists about who can prescribe and what they can prescribe. We have nurses fighting pharmacists over injections and vaccinations. It’s the turf battles.”
In 2015, the Illinois Dental Practice Act was revised to let hygienists treat low-income patients on Medicaid or without insurance in “public health settings” — such as schools, safety-net clinics and programs for mothers and children — without a dentist examining them or being on-site. Besides doing cleanings, the hygienists can take X-rays, place sealants and apply fluoride.
The state dental society, in a memo to members, wrote that the fact it took years for hygienists to develop their public health training program shows “they have no real interest in providing access to care to needy patients.”
As it is, Illinois trails many other states in allowing dental hygienists unsupervised contact with patients. In Colorado, on the extreme end, hygienists can own practices.
“It’s just the nature of the beast politically in Illinois. The dental lobby isn’t as strong in those other states,” noted Margaret Vaughn, executive director of the Illinois Rural Health Association. “The Illinois State Dental Society is much more powerful, and they’re much more organized than the hygienists are politically.”
From 2015 to 2019, the dental society spent more than $55,000 on lobbying, for its annual gathering and meals for lawmakers, typically hosted at a swanky Italian spot near the state Capitol in Springfield, according to public disclosures. In the same period, the Illinois Dental Hygienists Association reported spending nothing in its lobbying reports. (Neither group has listed any expenditures since the beginning of 2020.)
The dental society has two exclusive lobbyists and four lobbying firms on contract, state records show. The hygienist group, meanwhile, employs no lobbyists and contracts with just one firm.
The dental society donates generously to both Republicans and Democrats. Its political action committee had nearly $742,000 in cash on hand as of June 30, according to Reform for Illinois’ Sunshine Database. While the PAC has given $4,050 since 2014 to support the campaigns of state Sen. Melinda Bush, a Democrat who sponsored the nursing home bill, the database shows it has contributed far more to help elect Syverson, the senator who spoke at the conference. It has given more than $123,000 to his campaigns since 1999, with bigger annual gifts than to Bush.
“I receive contributions from many groups on both sides of issues,” Syverson emailed KHN. “They are not contributing to influence my vote on a particular bill. In fact, if a PAC sent a check while we were negotiating or voting on an issue they are involved with, I would not accept it.”
The hygienists’ PAC gave $1,100 to the campaign committee of Bush, according to the database, but nothing to Syverson. Bush did not respond to requests for comment.
“The bottom line is, if you don’t have a healthy mouth, you don’t have a healthy body,” said Ann Lynch, director of advocacy and education for the American Dental Hygienists Association. “It only makes sense that we would remove any barriers that do not allow a licensed health care provider to practice at the top of their scope.”
But Dave Marsh, a lobbyist for the Illinois dental society, said it would be dangerous for hygienists to treat nursing home residents, who are often elderly and sick.
“I just don’t feel anybody with a two-year associate’s degree is medically qualified to correct your health,” Marsh added. “They’re trained to clean teeth. They take a sharp little instrument and scrape your teeth. That’s what they do. That’s all they do.”
He said the problem is not a shortage of dental professionals but, rather, a lack of dentists who can afford to accept Medicaid patients — and “nobody wants to raise taxes to actually be able to reimburse” dentists at higher rates.
He also pointed to the scarcity of research on the benefits of dental hygienists having more professional freedom.
Langelier acknowledged that little academic literature exists on this topic, in part because of inadequate data collection on oral health. But in 2016, a study she co-authored in Health Affairs found that, as dental hygienists gained more autonomy, fewer people had teeth removed because of decay or disease. And she said Medicaid data shows more children had dental visits as hygienists expanded their practice.
“I don’t want this to be acrimonious,” said Laura Scully, chair of the access-to-care committee of the state hygienists association. “I would like it to be more of a collaboration, because truly that’s what this is about: getting together so we can help more people.”
Karen Webster works as a dental hygienist for the Tri City Health Partnership, a free clinic in St. Charles, Illinois, about 40 miles west of Chicago. In the past, she could only briefly screen patients before scheduling them with one of the center’s volunteer dentists, often months out.
“Imagine if you had a toothache and the doctor couldn’t see you that day,” she said, noting that her patients have low incomes. “They can’t afford the services. They wait till something hurts.”
But since becoming a public health dental hygienist, Webster now does immediate cleanings, takes X-rays she sends to teledentists for exams, and applies a solution called silver diamine fluoride that can halt tooth decay.
“The whole thing, start to finish, it’s just a lot more efficient,” she said.
Shawn Hayes was thankful to be holed up at a city-run hotel for people with COVID-19.
The 20-year-old wasn’t in jail. He wasn’t on the streets chasing drugs. Methadone to treat his opioid addiction was delivered to his door.
Hayes was staying at the hotel because of a coronavirus outbreak at the 270-bed Kirkbride Center addiction treatment center in Philadelphia, where he had been seeking help.
From early April to early May, 46 patients at Kirkbride tested positive for the virus and were isolated. The facility is now operating at about half-capacity because of the pandemic.
Drug rehabs around the country — including in Pennsylvania, Illinois, Indiana, Minnesota and Florida — have experienced flare-ups of the coronavirus or COVID-related financial difficulties that have forced them to close or limit operations. Centers that serve the poor have been hit particularly hard.
And that has left people who have another potentially deadly disease — addiction — with fewer opportunities for treatment, while threatening to reverse their recovery gains.
“It’s hard to underestimate the effects of the pandemic on the community with opioid use disorder,” said Dr. Caleb Alexander, a professor of epidemiology and medicine at the Johns Hopkins Bloomberg School of Public Health. “The pandemic has profoundly disrupted the drug markets. Normally that would drive more people to treatment. Yet treatment is harder to come by.”
Keeping Clients Safe
Drug rehabs aren’t as much of a COVID “tinderbox” as nursing homes, Alexander said, but both are communal settings where social distancing can be difficult.
Shared spaces, double-occupancy bedrooms and group therapy are common in rehabs. People struggling with addiction are generally younger than nursing home residents, but both populations are vulnerable because they’re more likely to suffer from other health conditions, such as diabetes or cardiovascular disease, that leave them at risk of succumbing to COVID-19.
To keep clients safe, some addiction treatment centers employ safety precautions similar to hospitals, like testing all incoming patients for COVID-19, noted Dr. Amesh Adalja, a senior scholar at the Johns Hopkins University Center for Health Security. But drug rehabs must avoid some strategies, such as keeping potentially intoxicating hand sanitizer on the premises.
Adalja said he hopes safety measures make people feel more comfortable about seeking addiction help.
“There’s not going to be anything that’s zero risk, in the absence of a vaccine,” he said. “But this is in a different category than going to a birthday party. You don’t want to postpone needed medical care.”
Still, some people requiring drug or alcohol rehab have stayed away for fear of contracting COVID-19. Marvin Ventrell, CEO of the National Association of Addiction Treatment Providers, said many of its roughly 1,000 members saw their patient numbers down by much as 40% to 50% in March and April before bouncing back to 80%.
Unlike many other centers, Recovery Works, a 42-bed treatment center in Merrillville, Indiana, has seen more clients than normal during the pandemic. The facility had to close for a few days early on after a suspected COVID-19 case, but reopened after the person tested negative. It has since split its therapy sessions into three groups, staggered mealtimes and banned visitors, CEO Thomas Delegatto said. It then had an influx of patients.
“I think there are a variety of reasons why,” Delegatto said. “A person who was struggling with a substance use disorder, and who was laid off and a nonessential worker, might have seen this as an opportunity to go to treatment without having to explain to their employer why they’re taking two, three, four weeks off.”
He also noted that alcohol sales went up at the beginning of the pandemic as anxiety and isolation rose, and sheltering in place may have made some families realize that a loved one needed help for an addiction.
Centers Serving The Poor Hit Hard
Homeless and poor Americans, because they often live in close quarters, have been particularly prone to catching COVID-19 — leaving drug rehabs dedicated to this population especially vulnerable.
Haymarket Center, a 380-bed treatment and sober living facility in Chicago’s West Loop that serves many people who are homeless, recently had an outbreak of 55 coronavirus cases among clients and staff members.
Two employees there tested positive for COVID-19 in late February, but testing was available then only for people showing symptoms, said Haymarket president and CEO Dan Lustig.
Haymarket worked with nearby Rush University Medical Center to test its clients. Twenty-six men, though asymptomatic, were found to be positive for COVID-19.
The center isolated those patients and eventually went from double- to single-occupancy rooms, improved its air filtration system and changed the way it served food. It now tests all new admissions.
“What we found was by doing serial testing we could tamp down the epidemic, not just at Haymarket but the whole city,” said Dr. David Ansell, senior vice president for community health equity at Rush, which partnered with the city and other health systems on a COVID-19 response for Chicago’s homeless population.
The pandemic’s economic fallout has also forced some facilities to scale back. The Salvation Army is shuttering a handful of its roughly 100 adult rehabilitation centers nationwide due to COVID-related revenue losses. Those rehabs were funded by the organization’s resale shops, which were forced to close during stay-at-home orders.
“A lot of what we do relies on donations or items that were donated and then sold in our stores,” said Alberto Rapley, who oversees business development for the Salvation Army’s rehab facilities in the Midwest. “When financially we struggle, that is then felt on the other side.”
For instance, the Salvation Army drug rehab in Gary, Indiana, which is set to close in September, treated as many as 80 men at a time in its free, abstinence-based program. The next closest facility will be in Chicago, more than 30 miles away.
Outbreak Contained, But Beds Still Limited
Philadelphia’s Kirkbride Center also serves a mostly homeless and low-income population. Dr. Fred Baurer, the facility’s medical director, said Kirkbride was “flying blind” early in the pandemic, with little testing capacity and personal protective equipment.
On April 8, the first COVID-19 case appeared on Kirkbride’s long-term men’s wing. Over the next week, six more men on the unit showed symptoms and tested positive, as did 12 of the remaining 22. All quarantined at a local Holiday Inn Express.
Kirkbride started requiring face masks, testing all new clients for COVID-19 and prohibiting people in its various units from mingling.
The rehab has been about half-full lately — it’s usually closer to 90% occupied — partly because it stopped taking walk-in clients and confined new admissions to single rooms.
“I’m starting to feel more confident we’re past the worst of this, at least for now,” Baurer said.
Hayes, who has recovered from COVID-19 without experiencing any symptoms, was discharged from the facility June 15 to a sober living house. He plans to attend 12-step meetings regularly. He hopes to get his GED and eventually enter the mental health field.
He recognizes the need to stay vigilant about his recovery now, at a time of increased anxiety and despair.
“Regardless of the coronavirus or not, the addiction crisis is still there,” Hayes said. “It’s bad. It’s really bad.”
Published courtesy of KHN (Kaiser Health News), a nonprofit news service covering health issues. KHN is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.
