We’re just beginning to see the effects of the loss of adult dental Medicaid funding — WSDA News talked with dentists and administrators across the state to get their take on the situation and see how they’re pitching in.
The reverberation from the cuts to adult dental Medicaid is just beginning to hit us, scant three months after its loss. With just emergent care for adults intact (other than the developmentally disabled, who retained their benefit), many believe the state will begin to see a crushing wave of need across the state — and what then?
Even when adult dental Medicaid was in effect, it was a terribly flawed system with abysmal payment rates hovering between 20-40 cents on the dollar, a labyrinth of bureaucracy to wade through just to get paid, and a set of regulations that made taking Medicaid patients a losing proposition for all but Community Health Centers and pediatric practices. Still, for CHCs across the state, Medicaid patients made up the lion’s share of both their practice and their revenue, in part because they had streamlined their billing procedures to the state and often received enhanced Medicaid rates as a Federally Qualified Health Center (FQHC).
Rationing of care?
Mark Secord, CEO of Neighborcare Health, a CHC operating five dental clinics in Seattle, had this to say, “Financially, the cut of adult dental Medicaid services was a $1.2 million hit for our organization. On top of that, the state also eliminated grant money for uninsured dental and medical patients, and overall, that number was about $900,000 for us — with close to $600,000 going to to dental. So this is forcing a huge readjustment in our program, and it’s not stretching at all to say that we are struggling to keep our head above water.”
Neighborcare Health clinics took an even bigger hit when you consider that three of their five clinics are made up of nearly 90 percent adults. For them, the paradigm shift is coming at warp speed. They need to either adapt or die... quickly. Secord continues, saying “I think the decision to cut off adults was a penny-wise, pound foolish solution, rationing of the worst, nonsensical type. It denied 105,000 people access to a service that is proven and efficacious and a heck of a lot better than allowing someone’s teeth to rot before they can ask for help. If we’re going to ration, perhaps we should ration things like cancer treatments where the chance of survival is a very long shot, or care for the highest risk categories for organ transplant patients, because those are procedures that can cost many hundreds of thousands of dollars, so we’re using a tremendous number of resources per person. And so you wonder how many of those patients you would have to deny in order to fun a dental program for 105,000 people. If you look at the greatest good for the greatest number, then what we’ve just done is a foolish rationing decision.”
The reality is that the state was forced to make cuts because of voter mandates prohibiting any new taxes, leaving the legislature no choice but to cut billions of dollars to make up for a deficit that seemed as though it would swallow the state whole.
Gail Kreiger, Chief of Medical Benefits and Clinical Review for DSHS, still agonizes over the decision, but says it simply made the most sense, “The decision to cut adult dental Medicaid was made because it is an optional benefit and it was a sufficient chunk of change to go towards helping them reduce the deficit. There aren’t a lot of programs here in Medicaid when you look at what our options are in terms of helping us participate in a big dollar way towards the deficit — there’s not a lot of extra here to skim off the top. So adult dental Medicaid was a $30 million chunk that we could cut.” Krieger continues, “There’s not a lot we can do —we’re not allowed to change our eligibility because of health care reform, so the only way we can really manage our budget in health care arena is to reduce services, eligibility, or the payment. Eligibility is off the table, which really puts you in a bind. Then, the only things you have to look at are services and the rate. Well, there may be some room in our rates to wiggle, but that’s not my call. To be perfectly honest, we don’t pay a lot, only around 27 cents on the dollar. If you continue to cut the rate, you’ll continue to lose access, and you can’t buy enough space for those folks to be able to get into a dentist’s profile, so where do you make cuts? How do you walk that line? That’s what we’re trying to do now - we’re trying to be responsible and accountable for the whole issue behind the budget deficit and how we can contribute, but it’s really hard. We’ve been doing some other analysis for the next biennium on other opportunities to make cuts, and to be honest the cuts are in single millions of dollars. One program we’re going to change is regarding prior authorizations, but it’s only going to save about $500,000. The number we’re supposed to reach in cuts is so big, and so if you look at it without prejudice, adult dental Medicaid is the cut that makes the most sense. Clearly, we knew we would have problems with it, but somebody has to weigh in and make those decisions.”
Make no mistake about it, even with meager payout rates, everyone in organized dentistry wants the Medicaid benefit back, but state budget woes will likely put that on hold for the near future — especially with the recent additional state shortfall of 700 million, in addition to the five billion or so the state had to cut.
Only three months out, what have the immediate effects been? From practitioners to volunteers and ERs, the effect has been profound.
For Dorothy Smith, a retired banker who volunteers with former WSDA President Dr. Mark Walker at the dental van serving Grace Lutheran Church in Kent, the effect was instantaneous. “Are you kidding?” Smith asks, “The phone rings off the hook. We’re getting applications so fast — it is definitely growing. The van’s mission is to do emergencies first, but we do try and fit in people who might need further work like extractions and fillings. Since we seldom have hygienists volunteering for us any longer, we really can’t do routine cleanings. We send them off to HealthPoint or recommend that they call around to find reduced-fee care elsewhere.”
Nancy Utt, Mobile Dental Program Manager for Medical Teams International (MTI) says, “We have 12 sites that are open to the public with an information line that people can call to get information about those clinics — typically churches and food banks will see members of the public, and one by one, all of our sites have asked us not to have their name listed on our recording anymore. So if you call now, the recording says that all of our public sites are full. That’s been a big change that happened about a month ago. Their waiting lists are now pushing a year out.”
In Seattle, Drs. Amy Winston and Bart Johnson have a collaborative agreement with Swedish Hospital (to read more about their innovative programs, see page 18) to cover that hospital’s emergency room dental needs, and they’re already seeing effects from the lack of funding. “We’ve seen a lot of changes, says Winston, “When a patient presents at the ER with an oral issue, they’re first seen to determine if there is a dental issue that needs to be addressed and if so, we’re brought in. The interesting thing is that shortly after Medicaid was cut we had two patients come in with life-threatening infections in the space of a week — with faces and eyes swollen shut, and one who had a hard time breathing. And this was due, in part, to the Medicaid cuts. They had seen a dentist previously, but because they had no longer had coverage, they were not treated. By the time they presented to a community clinic, their condition was so severe, they were sent to the ER. And, since a lot of people have stopped taking new Medicaid patients, we’ve seen a rise in folks being sent directly to the ER.”
What about at the CHCs? When might they begin to see the effects? Secord says, “Sadly we already have. We have basically shut off almost all new dental adult uninsured dental patients into our system, other than emergent care. The state will pay one way or another, and it doesn’t take many complications to land someone in the hospital — for the patient who becomes septic as a result of an infection in the mouth, the resulting hospital bill can be enormous.”
Secord has been studying ER increases, too, and he quotes a recent study developed by the Washington State Hospital Association, “Dental related ER visits, while a small percentage of the total number of visits, are the number one reason that the uninsured visit the ER. What will happen with everyone who used adult dental Medicaid services last year? Those people are now cut out from using preventative and restorative treatments, and they’re now converted into an acute/emergent system. We already believe that we’re starting to see this because the number of emergency cases is going up rather sharply. It’s not going to take very long for those patients to move from a chronic care model to an acute and emergent care model.”
Dr. Mark Koday, Dental Director at the Yakima Valley Farm Workers Clinic agrees, “We’ve seen big changes. There’s purposeful dropoff because patients are not coming in since we’re billing them now. Not only did we lose adult Medicaid, but we lost state funding to help support the sliding fee scale. We still get some federal funding, but most of the health centers built their adult patient pool close to what they were getting to support the sliding fee scale. When we offer 75 percent off our regular fees and we don’t have funding to support that sliding fee scale, we’re like anybody else, we’re losing money every time we see that patient.”
What about workforce?
But the access problem in the state isn’t just about money. Funding is a huge part of it, but it’s also a workforce issue. While the state’s population has increased by some 14 percent in the last decade, the number of dentists has increased by 19 percent, though placement doesn’t always meet actual need, there are typically only small pockets in the state where that occurs.
In an effort to attack the access issue by expanding workforce capabilities, WSDA launched the EFDA debate in 2007 — the main goal being the increased capacity and efficiency of dental practices. Subsequently, an EFDA bill sponsored by Rep. Eileen Cody was enacted and went into effect in 2008, and the WSDA pressed on, sponsoring workshops for dental assisting educators to develop curriculum in concert with DQAC.
We’re still waiting to see just how effective the state’s EFDA program will be. Some, like pediatric dentist John Gibbons, say that using EFDAs has already increased efficiency — in his practice by 20 percent. Gibbons says, “I think the EFDA model really serves the pediatric practice well. We do a lot of short procedures and we try to be as efficient as we can because the children have a shorter attention span.”
At SeaMar, Dr. Alex Narvaez’ initial projections showed substantial savings — $40,000 a year — by utilizing EFDAs instead of hygienists, but certification on two of the three EFDAs has been slow. They remain enthusiastically optimistic about the benefit of their use, noting that from the salary difference alone, there should be a considerable savings.
Former WSDA President Dr. Mark Walker utilizes two EFDAs in his practice and says, “You definitely get more bang for your buck. It saves me $17 an hour, plus my assistants have been with me for 10 and 15 years respectively, so they really understand the restorative aspect of dentistry, and the quality of their work has been excellent. The patients have really embraced their expanded role and even have asked the other assistants if they are going back to school.”
The state’s first report on EFDAs isn’t due out till 2012, but the three certification programs across the state have grown to five, and the number of assistants enrolling in encouraging. Koday says “We don’t have EFDAs right now in my program, but I’m working up a plan for my executive director and I’m trying to introduce the idea right now. I fully support the idea of EFDAs, but adding new staff at this time is not really possible. We have two issues that we have to deal with: the immediate retrenching to make sure we match our budgets, and then the long-term strategy is going to be things like EFDAs, and how we can lower our costs to treat adults.”
For Dr. Greg Kozlowski of the Quinault Indian Nation, access is largely about finding a practitioner willing to come to the tribe to work. A retired Navy dentist who then took a second career with the Quinault Nation, Kozlowski was one of the people asked to speak at the Senate committee hearings on the dental therapist bill. Kozlowski is planning on retiring from the tribe in 10 months, and worries that the Nation will not be able to find a dentist to take his place. With a patient base that is largely poor and medically compromised, there aren’t a lot of dentists willing to take the post. In fact, they tried to fill a hygienist post for six years without luck. “For us,” he says, “adding a new provider won’t help at all. We just need someone willing to come here and practice.”
Susan Bogni, Oral Health Coordinator for the Washington Association of Community and Migrant Health Centers says, “Our association is putting forth an effort to identify if EFDAs are going to be an effective model for care. Some of our clinics have EFDAs and we will survey them and their doctors so that they can assess from the position. So far, we’ve created a pilot project to assess the baseline infrastructure need to determine whether or not the EFDAs are working at their highest and best capacity, and to determine if access increases once they’re in place. There’s not really a formula for inserting an EFDA into the workplace — hygienists weren’t here years ago and now they’re a part of the dental team, we know what their function is, and everybody works together.”
Getting help to those who need it
Throughout the state, efforts are being made by dentists and organizations to continue providing free or low-cost care to those who need it most. This past year alone saw efforts by at least three dentists to bring access to uninsured veterans in the state — Drs. Theresa Chang, Mike Huey and Ardi Pribadi all held clinics aimed at serving the needs of veterans in their area.
In Walla Walla, Dr. Pat Sharkey continues to donate his time and expertise to the Medical Teams International dental van in his community, just as he’s done since 1999. There, with 17 site visitations a month, volunteers felt they were getting a handle on the needs of the adult uninsured population, but that may well change soon, as patients are no longer seen at community health clinics and dental needs turn from simple to chronic to acute.
In King County, Drs. Amy Winston and Bart Johnson joined forces with Jennifer Freimund and the Access Committee of the Seattle King County Dental Society and Swedish Hospital in a bold partnering to create a new free clinic. The project involved a lot of coordination and forward thinking: Swedish had already partnered with King County Project Access to create a sound model for those without medical insurance. They built a clinic which initially had earmarked an area to be an orthopedic space, but decided to add dental operatories when Winston, Johnson, representatives from Neighborcare and SKCDS determined that the greatest unmet need in the area was extractions for the uninsured. With that in mind, they set out to put together a clinic intended for doing extractions for the working poor. Johnson says, “Not that many resources exist in King County for non-emergent extractions, particularly difficult extractions. We hope the new clinic at Swedish will provide a resource for proactive rather than reactive dental Intervention.”
Swedish and SKCDS got behind the project fully — the hospital dug deep in their pockets to fund the program, and the Society raised money to fund a paid dental assistant (the only paid position at the dental clinic), and set about getting dentists to staff the clinic once it opens. Their first order of business was finding oral surgeons, and to date, they’ve recruited 11 to participate. They’re just about to wrap up the final grant for the equipment, and once that’s done, they put the word out to any dentist in the area who wants to take out teeth. Says Winston, “There is a wide spectrum of dentists who enjoy taking out teeth — so we’re offering it to those people, and then also to dentists who want more extraction experience.” But, since the general practice residency residents will participate at the clinic, the program becomes a teaching experience as well, “The oral surgery component is amazing — to have the expertise of an oral surgeon available for these patients and to teach our residents, I could not ask for a better setup.”
A great “IDEA”
In Spokane, members of the Spokane District Dental Society Foundation have teamed up with the Yakima Valley Farmworker’s Clinic (YVFWC) to create the Inland Dental Expanded Access (IDEA) Clinic. There, volunteer dentists will see qualified patients, including the uninsured, the working poor, and students working to better their lives. The clinic got its start in conversations with YVFWC’s Koday, where Foundation staffers revealed a common need: space. Yakima Valley’s existing space was too small, and SDDSF desperately needed a facility to house their project. The YVFWC will provide clinical space, staff management and operational systems. Advanced Education in General Dentistry residents and students will work beside the dentists and their staff in a private office-like setting. The students and residents will also receive training from the dentists and specialists. SDDSF has commitments from more than 80 dentists, once the program is up and running, and will provide a total of 32 hours a week of complete dental care to adult patients, including dental specialty services. The responsibility for parameters and procedures for care will be maintained by eight professional Dental Advisory Boards of SDDS members.
Of the IDEA Clinic, Mark Koday says, “Once we work out the bugs of getting the new clinic opened, the IDEA clinic should open its doors. We want to make sure everything is running smoothly in the main clinic before we start bringing patients in — the last thing we want is for things to be disorganized in the beginning. There will be three operatories, and their hope is to have at least one dentist working per day, including specialists. There will be an oral surgery suite. We sponsored a residency program there, as well, so we think with the combination of residents working with the volunteers, the expertise will be excellent, plus we’ll be able to serve more patients that way.” Koday continues, “Although we don’t know exactly how the system is going to work, we do know that all of the people who will be seen there, whether a YVFWC patient or an IDEA clinic patient, are part of the underserved population of the area.”
Mount Baker pitches in
In Mount Baker, another collaborative effort was launched between the Mount Baker District Dental Society and the Whatcom Alliance for Healthcare Access (WAHA). The new partnership will link adults needing dental care with dentists who volunteer to treat uninsured, low-income patients in their practices. Participating dentists will be in complete control of patient flow, seeing as many as they like, or as few as they like, per day, per month or per year. The program is modeled after WAHA’s Project Access for specialty medical care and their Donated Adult Dental (DAD) Program. WAHA will administer the program, provide financial screening, and work with dentists to schedule and coordinate care.
Medical Teams International has long been a force for access in the state. Nancy Utt explains, “We have 11 dental vans altogether, four in the Puget Sound area and a fifth in Walla Walla. Each of our vans go to a different site partner, and each partner has a certain population of people whom they serve. We see all kinds of populations from around the state — we travel to schools, senior centers, churches, jails and rehab centers. The way that we access those diverse populations is through our site partners. We’re not seeing an increase in the schools, and the reason that we even go to schools is because some parents are either unable or unwilling to get their kids into the dentist, so while there may be programs serving the population, children don’t actually have access to care. We see those kids through the schools. But all of the adult populations we’re seeing are increasing, with the exception of the jails, which are about the same.”
But these are by no means all of the programs in the state; the list is vast and includes everything from rural programs, to faith-based initiatives, to homeless advocacy programs like Dr. Jeffrey Zent’s and Dr. Ellen Reh’s work with Issaquah’s Tent City, eliminating dental pain and treating disease for 40 homeless residents.
Other notable programs include Dr. Aaron Kelley’s Wenatchee Pain Free for Christmas program that brought several hundred uninsured patients much needed relief from pain over the holidays; Dr. Curt Smith’s work with the Bellingham Donated Adult Dental (DAD) program, bringing low-cost dental care to nearly 250 patients a year using a pool of volunteer dentists and hygienists.
In Spokane, an initiative called Project Dental Access is a dentist-led community effort to provide limited dental care for low-income and uninsured Spokane County residents in pain. It is managed by the Spokane District Dental Society Foundation, a non-profit organization that coordinates volunteer dentist services. Eligibility is based upon financial criteria and need. For a more complete listing, please see page 22.
The role of prevention and education
At the Quinault Indian Nation, Dr. Kozlowski has seen the results in the lack of dental education first-hand, saying “As much as I try and emphasize prevention, it’s often too late here — the kids are coming in too late and require hospitalization. It would be nice if the schools were able to concentrate on educating them well about all issues, include the connection between teeth and the body. When I have a teenager or middle school student in the chair talking about dental issues, I get the sense that they don’t cover these issues in their curriculum. I recall being in school being taught about the anatomy of teeth, but these kids today do not seem to be getting that information.”
Kreiger from DSHS concurs, “I think education is a part of the problem. I’m a nurse, and if people don’t take responsibility for any component of their health status you will see deterioration. In some of the cases I see, there clearly is not an understanding of what it takes to maintain good oral hygiene — they lack discipline and an appreciation for their own health. I wish I understood what causes the disparity — it isn’t like it isn’t being taught at school. I believe that the schools are making a great effort, as are outreach programs going into schools to try and help children. It’s interesting to me, the lack of appreciation for what most of us would consider basic hygiene.
Secord takes that premise one step further, introducing the need for a more holistic approach to education that includes dental education. It’s blue-sky stuff, but he says it’s the way we have to begin to approach the problem. “The educational piece is a tough nut to crack. If you have grown up poor and in a house where you didn’t get dental care as a child, your parents didn’t have it and now you don’t have the money, it may be a real stretch to try and get you or your children excited about flossing and brushing. Nearly 6,000 of the patients we took care of last year at Neighborcare were homeless, if someone is homeless, brushing and flossing are probably pretty low on their priority list. We need to put more resources in education to change societal behavior. Part of this has to do with changing our food supply, looking at fats and sugars in the diet, but of course the poor can’t afford fresh fruits and vegetables — and as a country we subsidize the fast- and processed-food industries. Buying local, organic and good fruits and vegetables are a luxury for anyone, and low-income people have to focus on calories per dollar. So we’re talking about massive social changes to our food supply and incentives to make those available to the masses.”
For its part, the Washington Oral Health Foundation provides vital educational programming to schools all across the state — WOHF President Dr. Michael Aslin says “The Washington Oral Health Foundation is approaching the access issue from a long term point of view, and going about it by working through organizations that can make it part of their culture and increase the chances of actually being able to change the way the next generation understands and values good oral health and preventing dental disease”
WOHF’s mandate includes oral health education and prevention, and its cadre of volunteers work closely with educators, school nurses, and organizations like the Boys and Girls Clubs. WOHF’s innovative collaboration includes an on-site operatory staffed by volunteer dentists and dental students from the University of Washington. With a broad range of opportunities at the Boys and Girls Clubs, all students can be involved — first and second year students provide educational programming, and third and fourth year students can work in the operatory under direct supervision of a UW faculty member.
The Foundation’s Adopt-A-School program includes more than 195 dentists and 490 “adopted” schools from every corner of the state. By working closely with school nurses and administrators, participating dentists are able to identify and treat children who might otherwise live in pain. And each year, nearly 20,000 students a year benefit from presentations offered by WOHF staff, volunteers, and those done by educators from materials mined from the WOHF site. Presentations cover all aspects of preventive care and include diet, tobacco and drug education.
Coping with the loss of funding
With funding slashed, volunteers and program administrators have had to get creative. Medical Team International’s Utt describes one such effort there, “Last year we tried van sharing and it worked out well. Up until then, each van had a clinic manager who moved the van to the site and performed many administrative tasks. Each van could be on the road four days a week so that each clinic manager could have one down day. With the van share program, three clinic managers share two vans, which increases the amount of clinics we can hold. In addition, our clinics are typically six hours, running from 8:00 a.m. - 2:00 p.m., and we started running afternoon clinics from 3:30 - 7:30 p.m., so we’ve not only increased capacity by sharing vans but doubling the number of clinics held per day. However, that means we need more volunteers to staff the vans, so we’re recruiting heavily, and we’re also looking for more staff people. Last year we held about 520 clinics, and we’re anticipating a greater need this year. ”
At Community Health Clinics across the state, the scramble is on to keep their doors open by shifting their client base. Susan Bogni relates, “That’s the question that we’re grappling with right now - how do we manage these new challenges? Do we cut back staff, expand hours? Do we refocus on the patient populations who still have Medicaid coverage? There’s a wide gap between the number of children who come in for medical coverage through Medicaid and those who come in for dental coverage, we’d like to narrow that gap — so maybe when the kids are in clinic for their medical, we can try to get them into dental. Some of the clinics are going into the schools and doing regular checkups, passing out toothbrushes, and occasionally doing varnishes and other outreach efforts to get kids in the clinics.”
Secord concurs with her assessment, “At our Rainier Beach clinic, in particular, where we’re now for the first time co-located with medical, we’re going to be really emphasizing increasing the number of children we’re seeing in the medical practice, but what that entails is shutting off adults. We’re displacing adults with children, hopefully recruited from within the practice. Our ability to keep our system surviving and clinics open is going to depend on things like that.” he continues, “Far and away the biggest thing is trying to change our mix of kids and adults, and the heartbreak of that is that I have sat at the front desk of our clinic in Georgetown and have listened to our staff turning away patient after patient. And the only thing we can tell them is that if they are in pain, they’re welcome to come in on a walk-in basis.”
Other programs in the state
Although this piece has focused primarily on what’s happening with the loss of adult dental Medicaid funding statewide, children and the disabled still need our help. For now, their funding has gone largely untouched, but there are no guarantees. Still, even with funding intact, there are thousands in the state who don’t qualify for care. In Spokane, a coalition of pediatric dentists in the region came together as a unit and decided that all children would receive dental care regardless of their ability to pay. Dr. Chris Herzog of Spokane explains, “It really started back in the 80s when Dr. Bruce Toillion, one of my partners, made a commitment to see Medicaid kids. Then, in 1995, the WSDA, the Spokane District Dental Society and the University of Washington created the ABCD program, which allows for dentist and patient caregiver incentives that have expanded dental access to low-income children under the age of six. The program has been successfully copied in numerous states and is credited with heading off early childhood decay at a very young age, rather than waiting until kids get into grade school.” Herzog continues, “There are still kids who have dental disease, but we’re getting a handle on the problem. We see 200-220 kids a day in our practice, and a lot of those kids are Medicaid, but we have an open door policy and don’t refuse anybody. Because of our program, Spokane Public Health no longer gets call asking where kids can be seen. Connie Robohn, our Executive Director, no longer gets calls; and last year we even cancelled our Give Kids a Smile event because we didn’t have anyone show up.”
Initiatives at the UW
The UW has two clinics doing outstanding work — The Center for Pediatric Dentistry, a joint venture in pediatric oral health care by the University of Washington and Seattle Children’s Hospital, opened on September 1, and the DECOD program, which operates both at the University and in remote locations, providing dental care to those with acquired and developmental disabilities.
The Center for Pediatric Dentistry is addressing childhood dental disease with new approaches, including early intervention with dental visits by age 1. It is a center for clinical care, research, education and public policy. The new facility is the first of its kind in the United States. “We are seeing an alarming increase in early childhood caries,” said Dr. Joel Berg, chair of the Department of Pediatric Dentistry at the UW and director of the new program. “It is truly a national health crisis. This trend, coupled with a shortage of pediatric dentists, educational facilities, and integrated policy approach, was the primary reason and driving force behind the formation of The Center for Pediatric Dentistry.”
Staff includes 10 pediatric dentists, two pediatric oral surgeons, three craniofacial orthodontists and a social worker. The program also provides expanded training to medical school and residency site faculty.Research is another important component of the program, covering risk assessment technology, genetic factors, salivary composition and other areas.
DECOD operates its clinic at UWSoD five days a week, and travels to remote locations like Centralia, Bremerton, Snohomish, Mount Vernon, Yakima, Walla Walla and Clarkston two to twelve times a year. In addition, they also operate at two nursing homes in the Seattle area, Mount St. Vincent’s, in West Seattle and Keiro in the central district. Faculty members work with third- and fourth-year students to provide emergent and preventive care to the state’s most underserved population. Even though the program includes care for people with acquired disabilities, it was singled out by the legislature to continue being fully funded.
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