Dr. Olson asked if this ordinance would allow an employee to smoke outside.  Mr. Grosklags reported that most ordinances specify a certain distance that the smoker must be from the building.  Mr. Kuhn asked if this applied to city parks.  Mr. Grosklags responded that this does not apply to outdoor areas.  He added that the Winter 2003-2004 edition of Respect, a publication by the Illinois Licensed Beverage Association (ILBA), had a clip that said the ILBA anticipates smoking ban proposals to be introduced in the near future, and DeKalb was listed in there.  Mr. Grosklags encouraged participation to defeat the smoking ban proposals. 

Mr. Heinisch stated that he has a lot of respect for Mr. Grosklags and does not have a problem with the statement that smoking causes cancer.  He is also in favor of volunteer efforts that encourage nonsmoking leadership within our community and in the Health Department, but he does have a problem with trying to legislate, not for smoking, but for government legislating common sense in communities.  He feels this can be done with the right kind of leadership in the community. 

Dr. Lane stated that the problem is not in interfering with a person’s right to smoke, but in protecting those who have to work in an environment where smoking is permitted and suffering as a result of that.  While smoking can harm pregnant women and their unborn children, many places will not institute a no smoking policy unless legislated because of the possible loss of customers.  She feels this is as close to a public health issue as any.  Mr. Grosklags pointed out that there are all kinds of OSHA regulations to protect the workplace so this is not unique, and could be just another of those regulations.  He added that this is strictly a health issue of protecting people that have to work in an environment where smoking is allowed, as well as people in that environment who are non-smokers. 

Mrs. Gastiger agreed with the issue of government intrusion, and cited the example of wearing a seat belt, which is common good versus an individual rights issue.  She agreed this does generate controversy, but she would have to support it from a public health standpoint.  Mr. Wolf agreed, adding that as a public health entity, it is our responsibility to promote the common good.  He stated that Mr. Heinisch’s point is valid in that the legislature can go overboard, but in this situation, he compares it to noise ordinances and repressing individual behavior for the common good.

Mrs. Fullerton stated that she understands the public health aspect is a function of this body.  She wondered if there was some way to reduce smoking on the individual’s own volition rather than through an ordinance.  Dr. Shear compared this to the seat belt law and pointed out that if one doesn’t want to wear their seat belt, they could kill themselves but not hurt anyone else.  This is not the case with smoking, as smoking is the number one killer associated with cancer and heart disease.  In her role with public health, she would support such an ordinance. 

Dr. Olson questioned how feasible it would be to have DeKalb be smoke-free and not Sycamore.  He feels this would cause problems as they are essentially one community.  He dislikes having the government be intrusive.  Mr. Kuhn stated that, from a public health viewpoint, he would support the issue.  Being a medical practitioner, he knows how harmful second-hand smoke is, however he is also concerned about the government being intrusive.  He is hesitant to support it at this time if it only covers public areas and not all of the City of DeKalb. 

Mr. Grosklags stated that he was asking the Board of Health to endorse the resolution to eliminate smoking in public places in the City of DeKalb, and the agency could be listed on education materials or advertising as a supporter.  Dr. Bishop stated that he would be supportive of the development of a resolution, but it would be helpful to clarify some issues to offer a clear endorsement.  He pointed out that the proposal is more of a blanket statement that this resolution is a good thing, but the coalition needs to continue with a clearer definition in order for the Board to support it now.  Mr. Grosklags asked for specific concerns, and Dr. Bishop responded that a definition of “public place” is needed as it is too vague at this point.  Mr. Grosklags stated that no ordinances thus far have included public parks.  Dr. Bishop stated that endorsement of this resolution would have the Board of Health’s name and reputation attached to it, and he is unsure what is being endorsed and would like to see it clarified.  Mrs. Gastiger pointed out that the resolution must be manageable and reasonable, and she would want to guarantee the right of non-smokers to be smoke-free. 

Mr. Kuhn asked if the Board of Health had a representative on the coalition at this time.  Mr. Grosklags stated that it is Mrs. Grush or her designee.  Mr. Wolf feels that the Board or agency should have a continuing presence on the coalition.  He stated that while he is hearing support of the concept, there remain details that need to be worked out. 

Mr. Wolf moved that the agenda item be tabled pending further clarification of public places and brought back to the November 2004 Board of Health meeting.  Dr. Bishop seconded.  Motion carried.

The next Board of Health meeting will be held on the 30^th of November.  It was decided that Mr. Grosklags would provide a revised resolution at that time.  Mrs. Grush stated that her understanding of the resolution is that there is support from the Board, but not if it applies to public parks, public places, outside one’s home or walking down the street.  She believes the coalition is in the beginning stages of going throughout the county to gain support.

Mary Uscian, Former Director of TriCounty Community Health Center, Malta

Mrs. Grush reported that the Governor signed into law HB 752 that requires children in grades Kindergarten, second and sixth, to have dental exams.  This was presented at the last Board of Health meeting before being signed into law, and Mrs. Grush suggested, at that time, that Mrs. Uscian, a co-founder of TriCounty Community Health Center, be invited to speak to the Board of Health because of her experience in conducting of a feasibility study and attempting to establish a dental clinic.  The Bill was signed into law, and Mrs. Grush has agreed to serve on the advisory panel as the State requested that a representative from a health department that did not have a dental clinic participate.  The first teleconference was this week.  Mrs. Grush pointed that while the mission of the Health Department is to promote health, this new law is going to be extremely difficult for school districts to comply with. 

Mrs. Uscian stated that her report was a comprehensive analysis that was done a couple years ago when she was the Director of TriCounty Community Health Center.  A dentist from Brazil who was getting her masters in Public Health conducted a comprehensive feasibility study of the indigent population in need of dental services.  This was not a needs assessment, but rather offered alternatives, resources, how would the service be provided, etc.  She was also asked to explore all models from self-sufficient to a referral system. 

First, it was necessary to examine if there were enough residents in need of services.  Data was collected from September 2001 to April 2002 on the target population not receiving dental care, those without health insurance or on Public Aid.  The raw numbers were studied to determine what a clinic would need to operate full-time.  At that time, there were 4,000 Medicaid recipients in DeKalb County and 9,900 (11%) uninsured.  Patients at TriCounty and the Health Department were surveyed, with almost 100 surveys collected.  The target population was asked if they had ongoing dental health care, with 30% of IPA patients and 54% of uninsured responding they did not.  The survey identified that there were at least 6,000 individuals, and possibly 11,000, that would utilize services but had no place to go. 

The concept of a self-sufficient for-profit dental clinic was studied, as well as what people could pay and were able to pay for care.  A flat fee for dental care was developed as it was easier to work with that system no matter what service was provided.  A flat fee approach for the billing of services was used.  The survey respondents were asked what the most was that they would be willing to pay for dental care, with the result being from $10 to $70.  The average amount was $47, and 77% of clients identified $50 or less as the maximum they were willing or able to pay. 

With clients willing to pay $47, revenue and expenses of such a program were studied.  A budget was developed with minimal staffing and paying fair market prices and the revenue mix of Medicaid and clients that were willing to pay around $50.  Other resources were also examined that TriCounty could tap into to offset costs with a handful of resources identified that would provide start-up funding.  The Illinois Department of Public Health (IDPH) had a grant that would provide $35,000 for start-up, but no operating funds.  There were also a couple of federal grants and some from the community, all for start-up funds with not one for ongoing salaries.   Mrs. Uscian spoke with other clinics and identified that supplies could potentially be donated.  With 70% of the budget being personnel and no resources for day-to-day operations, clients would need to pay the bulk of the charges.  With 60% of clients on Medicaid and 40% uninsured, the lowest cost she could charge for supplies was $32.77.  She stated this was not realistic based on the expenses at TriCounty.  The majority of clients needing dental care would actually be 25% on Medicaid and 75 % uninsured, which brought the cost up to $52 to support a “bare bones” not-for-profit type of clinic. 

Another scenario that was studied was the referral system whereby community dentists would be asked to accept a set number of patients per month at a low cost or no charge.  With 5,000 individuals needing dental care and 44 dentists practicing in the area, this averaged out to 125 dental visits per dentist per year or 10 per month.  These figures were assuming that all 44 dentists would participate. 

Another scenario was to use a mobile van rather than a fixed clinic.  It was found that this did not reduce costs, as 70% of costs are personnel and there would also be the expense of maintaining the van.  While it would appear that this option could potentially improve access to a certain degree and could serve more people because of traveling to communities, it has been determined in other areas that a fixed location improves access. 

Another model that was studied was the volunteer basis.  The largest volume clinic in northern Illinois is in DuPage County, with 32 dentists volunteering four hours per month in the part-time clinic.  There is one paid staff member that is a volunteer coordinator.  Everything else for the clinic is donated.  These 32 dentists are 4% of the 809 practicing dentists in the community.  With DeKalb County’s 44 dentists, 4% would be less than two dentists. 

The conclusions were that the most likely successful scenario was to operate the clinic with paid staff to assure continuity and having the service available.  Based on the reality of the mix of patients (25% Medicaid and 75% self-pay uninsured) and charging $50 for the service, it was the conclusion that TriCounty could not take the chance of operating another program that would lose money.  Even though respondents indicated in the survey that they would be willing to pay around $50, the reality of them being able to come up with the money was questionable. 

Dr. Shear asked if the issue was supplies and how much that would cost.  Mrs. Uscian responded that she was making the assumption that supplies would be donated.  It was assumed that TriCounty would only be doing cleanings, fillings and extractions.  Mrs. Uscian added that Crusader Clinic is a federally funded health center, with the government providing one-third of anticipated costs and charging patient fees.  Dr. Olson pointed out that IPA does not pay anything for individuals over 18 years of age.

Mrs. Grush agreed that the reality of clients being able to pay $50 for dental care was not realistic.  Mrs. Uscian pointed out that the fee for service at TriCounty is $20 and many people cannot pay that.  Mrs. Gastiger asked if NIU students were considered in this population.  Mrs. Uscian responded that it was the uninsured, some of which may be NIU students. 

Dr. Lane asked if dentists in the area were asked for recommendations on solving this problem.  Mrs. Uscian responded that a dental services feasibility study committee was formed, and eight dentists that had expressed interest were invited.  Two attended the first meeting and none attended subsequent meetings.  Two dentists expressed their sentiment that the need was already being met and that estimates of the need were exaggerated.  Based on need, dentists do take some uninsured clients so are seeing some of this population.  Mrs. Lux stated that sometimes a school nurse will call a dentist and explain a situation, and the dentist will end up seeing them.  Dr. Olson pointed out that DeKalb Community Child Care (4-C) has a small program.  He added that 2 of the 44 dentists are specialists. 

Dr. Shear indicated that she had called Dr. Todd Curtis, President of the local dental society, and he indicated that this is something he has been considering.  They are having a meeting on the 6^th of October, and Dr. Shear suggested that Mrs. Uscian talk to him.  Mrs. Uscian responded that it would clearly be best if the local dental society was willing to develop a referral system, which would serve 6,000 to 8,000 individuals.  She pointed out that their needs are much more extensive than the rest of the population because they will typically need more work.  While she is sympathetic to the situation, she does not think DeKalb County would offer such a program at this time.  Mrs. Uscian indicated that she had talked to the Community Foundation, and while they are a wonderful resource, they do not fund ongoing operations.  Dr. Olson stated that some dental supply houses would donate goods.  Mr. Heinisch stated that there used to be three dental schools, but the problem is the distance from DeKalb County that they are located.  Mrs. Uscian added that they are already being asked to take care of the Chicago population. 

Mrs. Grush reported that she called the DeKalb School District and asked how many children were on the free or reduced lunch program.  While there were 4,755 children on this program last year, there are    5,319 this year, an increase of almost 600 students.  28% of students are on the free lunch program and 5% are on the reduced.  One-third of students are poverty low-income, with another level of students whose families are struggling.  These statistics show that 40% of the students in DeKalb would have extreme difficult paying for a dental exam or dental work.  She stated that she does not believe dentists are going to see all students on Medicaid.  Dr. Olson stated he had talked to Springfield and asked about the manpower issues and was told there were plenty of waivers built into the Law.  Mr. Kuhn stated that he had talked with Dr. Hammond, Superintendent of Sycamore School District, and he indicated there was no way a report card would be held for lack of a dental exam.  Mrs. Grush stated that, while the intentions are laudable, this will be a bureaucratic nightmare for school districts. Schools will have to get waivers in with dental exams or show proof that a child has an appointment within 60 days by May 15. 

Mrs. Uscian sympathizes with the school districts and thinks this is an extremely poor piece of legislation.  She added that they should also fund the law if they are going to keep it.  Mrs. Uscian pointed out that children need dental care, not only for oral care, but for systemic diseases.  There is no way for the local community to absorb this cost as the resources are just not available. 

Dr. Shear stated that some dental care does not require a dentist.  Mrs. Grush pointed out that the Law requires that the dental exam be done by a dentist.  Mrs. Uscian added that the state does have a sealant program, but it does not come with adequate funding to support it.  Dr. Shear suggested just looking at hardship cases and utilizing a referral system for specific children.  Mrs. Uscian responded that there would need to be a triage of some type in place.  Dr. Olson pointed out that one-half of the dentists do not see children, so that limits the number of children seen even more.  Mr. Kuhn feels it would be worth it to have a dialogue with the Dental Society.  Mrs. Grush stated that Dr. Olson could be a liaison and representative of the Board of Health.  Dr. Olson stated that the local society is more of a study club, and he belongs to the Fox Valley chapter that is an “official” one.  He added that one-half of patients do not have dental insurance, so the idea that only insured are receiving dental care is not the case.  Dr. Olson indicated he would talk to the Dental Society and report at the next Board meeting.  Mrs. Grush will keep the Board informed through her activities on the State committee.