Insurance exchange may solve Minnesota’s pediatric dental woes

Zachary Feinberg went to a mobile dental clinic in Roseville last week for his first checkup in six years. So the 14-year-old wasn’t surprised when the dentist he dubbed “Captain Hindsight” told him he’d need two fillings and a root canal.

“ ‘You should have brushed more,’ ” he said, imitating the dentist. “I was expecting it.”

Like the Stillwater teen, the state received a troubling checkup last week in a report that found that more than a third of Minnesota’s poor children receive no annual dental checkups.

Help could be on the way in the form of MNsure, the state online insurance exchange that launches next month. Because federal policy requires the exchange to include pediatric dental benefits, state officials expect that thousands more Minnesotans will buy coverage and seek long overdue care for their children’s teeth. But they also caution that this expansion of benefits won’t solve all of the state’s dental woes: Many of the neediest children already qualify for state-subsidized dental benefits and don’t use them.

“We need to do more to provide dental care to low-income children. There’s no question about it,” said Merry Jo Thoele, who coordinates oral health planning for the Minnesota Department of Health.

A reminder of that need came from the Commonwealth Fund last week, which ranked Minnesota last in the nation for the rate of low-income children receiving annual dental and medical care. The ranking was based on the 2011-2012 National Survey of Children’s Health, which showed that one in three children living at or below 200 percent of the federal poverty level in Minnesota didn’t receive annual dental checkups, even though they were already eligible for coverage from state-subsidized health care programs.

In its first oral health plan, released this January, the state Health Department issued a goal of increasing the number of children receiving preventive dental care by 10 percent. The agency also listed strategies that could help low-income families, including making greater use of midlevel dental providers and dental hygienists — who under collaborative practice rules can perform basic cleanings and treatments in schools and satellite clinics without dentists looking over their shoulders.

The state also wants to continue to increase the number of school-based dental programs through such organizations as Children’s Dental Services of Minneapolis, which currently works with more than 100 school districts.

“When you think about the barriers low-income people have, one of them is missing work to get to an appointment,” said Sarah Wovcha, the nonprofit’s executive director. “We eliminate that barrier by getting the care directly to the school where the kids are.”

But state leaders and dentists agreed that the biggest dilemma right now is the low reimbursement rate from the state’s Medical Assistance and MinnesotaCare programs to dentists for treating low-income children. The state programs pay about 40 percent of what dentists typically charge.

Many dentists either refuse to treat low-income children covered by the state or take but a handful of them, leaving low-income parents frustrated as they try to schedule checkups for their kids.

Feinberg ended up at the Ucare mobile dental lab in Roseville only because he is covered by Medical Assistance and his grandmother, Judy Johnson, couldn’t find a dentist at home in Stillwater who would accept him.

“It just seems to me that dental care is for the privileged,” she said.

The Minnesota Department of Human Services is reviewing how much it pays dentists after a legislative audit cited the high number of dentists refusing to treat children covered by state health plans. A 5 percent rate increase is already scheduled for 2014, but that likely won’t be enough to lure more dentists back to treating these children, said Scott Leitz, an assistant commissioner for the department.

The MNsure exchange will include medical assistance plans but also new private plans that could be attractive to working families who don’t qualify for state assistance and couldn’t afford dental coverage for their kids before.

“The research is clear that you go twice as often to the dentist if you have some form of insurance,” said Sheila Riggs, who directs the primary care program at the University of Minnesota School of Dentistry. “So more kids having coverage is going to be good.”

A question for dentists is whether the new private plans will pay them at commercial rates or public-program rates. If the plans have low reimbursements, dentists might not take their patients, either.

“We don’t know what we’re getting,” said Dr. Mike Perpich, president of the Minnesota Dental Association.

Commonwealth’s last-in-the-nation ranking of Minnesota surprised dental profession leaders because another health policy organization, the Pew Charitable Trusts, recently gave the state an “A” grade for pediatric dental care, also noting however that the state has a “problem” in the high number of low-income children who don’t receive regular checkups.

Improved payment rates will help, but state leaders said they also need to make dental care more convenient for low-income families. Organizations such as UCare and the Ronald McDonald House Charities are helping by operating mobile clinics that visit areas of the state where dentists are in short supply.

“For the people we are trying to target, you have to bring the clinic to them,” said Dr. Michael Sudit, a Wayzata dentist who is trying to create a similar mobile clinic through the Molar Express organization he founded.

Outreach helped Feinberg, the 14-year-old who received a checkup last Monday and two fillings when he returned Friday.

His last previous dental visit had been so long ago that he remembered extorting a “Star Wars” toy out of his mother if he agreed to go. Since then, he has ignored dental problems and had even stopped chewing on one side of his mouth.

The pain of Friday’s fillings was offset by the joy of missing geometry class. But next up is the root canal. While his grandmother is relieved he is receiving overdue care, Feinberg is nervous about the procedure. Maybe this time he’ll hold out for a better toy.

 

Source: Star Tribune / http://www.startribune.com/lifestyle/kids-health/225128332.html?page=all&prepage=1&c=y#continue

10 tips for a beautiful, healthy smile

These days, everyone wants a shiny, white smile. There are more teeth whitening products on the market today than ever before, from teeth whitening toothpaste, strips, kits and even entire systems. But we all forget there is more to a healthy smile than just white teeth. A healthy smile means so much more. Dr. Shishir Shah of Sun Smile Dental offers some crucial tips on how to get a pearly white and healthy smile.

There is more to it than meets the eye. As with most things in life, knowing is the first step. While it may seem that having white teeth means you have a healthy smile, this is not always the case.
Make dentist visits part of your 3-month ritual. Dr. Shah explains, “The standard twice-a-year dentist visit is just not enough. You should be seeing your dentist every three months (quarterly). Even a thorough cleaning does not last longer than that.” While dentist visits may seem expensive and time consuming, that really is not the case, especially when you consider the cost of other routine expenses (haircuts, hair color, oil changes, etc.)
Day & Night: Brush at the right time. While we all know that brushing first thing in the morning and right before sleeping is recommended by dentists, we may not know the scientific reasoning behind it. Brushing first thing in the morning helps to brush off the plaque and bacteria that builds up throughout the night, according to Dr. Shah, while brushing at night cleans plaque before buildup while sleeping — noting that saliva, which naturally protects teeth from plaque buildup, dries up at night.
Toss that old toothbrush. We have all likely been guilty of overusing a toothbrush beyond the three to four months recommended by dentists. Dr. Shah strongly advises against doing so, stating, “a brush is not meant to be used for more than three months; the brush’s bristles wear down at that point and then fail to serve its purpose.”
Electric is the way to go. While it requires a higher upfront cost, research has shown that electric toothbrushes improved oral hygiene in more than 80 percent of patients, with a significant reduction in plaque and gingivitis. Dr. Shah recommends the use of an electric toothbrush, which helps prevent gum disease. Of course, don’t forget to throw out the old head of the electric brush. A good way to remember this is to change toothbrushes right after your professional cleaning.
A bite guard won’t bite back. Nighttime teeth grinding (nocturnal bruxism) afflicts about 15 percent of the American population, which over time could age a person’s teeth by up to 10 years. The most common cause of nocturnal bruxism is stress, and most people afflicted with it are unaware until it is pointed out by their partner or dentist. While wearing a bite guard may seem uncomfortable at first, experts believe that it can significantly reduce damage from nighttime grinding.

Enjoy sugarless gum. While not a replacement for brushing and flossing, chewing sugarless gum for 20 minutes following meals could help prevent tooth decay. Sugar-containing gum, on the other hand, could lead to further plaque buildup (a precursor for tooth decay).
Say no to soda. With up to 10 teaspoons of sugar in every can of soda and various types of harmful acids (phosphoric, organic, and citric), which can cause the loss of tooth calcium over time, Dr. Shah suggests minimizing soda intake. When thirsty, healthier beverage alternatives include fruit juices; low-calorie, non-carbonated flavored drinks; or a tall glass of water.
Floss regularly. Flossing is something we are most likely to forget or skip, but flossing regularly can help protect gums, keep teeth healthy and prevent expensive oral care treatments over time.
Update your dentist about medical conditions. In order to receive the right treatment by your dentist, always make sure you provide your current medical history. Medications may have an effect on your oral health, and therefore it is important that your dentist knows about which treatments or medications you may be using.

 

Source: UT San Diego

Parental neglect of kids’ teeth at rotting point

Children are turning up for their first day of school with alarming levels of tooth decay, as too many parents neglect to take them to a dentist before they turn 5, oral health experts say.

Whanganui and Hawke’s Bay DHBs are two in the lower North Island which are concerned at high numbers of “no-shows” at their dental clinics, with up to half of preschool appointments not kept by parents.

Whanganui has one of the most worrying rates for children, with about 50 per cent of 5-year-olds of all ethnicities trotting off to their first day of school with teeth already starting to decay.

Whanganui District Health Board clinical manager of oral health services Barbara Dawson said parents were regularly failing to bring their toddlers in for scheduled appointments, with dental hygienists often waiting in vain.

While plenty of preschoolers were enrolled with the service, this was no good if half did not get checked, she said.

“We’ve got a lot enrolled now, we’ve made a real push, and we’re seeing them and their mums here as young as five months. It’s really demoralising when people don’t come, and we do try to reach them again in another six months, then again . . . we’ll try up to three times.”

It was imperative that parents took responsibility, she said. “The children don’t give themselves a lolly, they don’t give themselves the food that causes decay.”

Robin Whyman, principal dental officer for Whanganui, and Hawke’s Bay clinical director for oral health, said research showed that the earlier decay set in, the more problems people would have with it later in life.

More incidences of childhood decay in both Whanganui and Hawke’s Bay were partly due to the lack of fluoride in the water, as well as parents not attending appointments and missing out on preventative dental action, he said.

“It is something to be concerned about. We have to talk to them about diet, about toothbrushing, and give out that advice.”

Otago University head of dental public health Murray Thomson said early childhood dental care was a nationwide problem.

Changes to school dental programmes – where many smaller clinics were closed and services centralised – had not improved access for those who needed it most.

“We need to look at the role of big sugar and big food . . . we live in a country where milk is more expensive than Coke now. Where’s the sense in that?”

Dental Association senior oral health adviser Deepa Krishnan said many parents did not realise they needed to start brushing their children’s teeth twice a day with a fluoride toothpaste as soon as the first baby tooth came through.

Juice or sweet drinks should never be given to children under 2, and sugary foods should be limited.

The highest levels of dental decay are in Northland, where 65 per cent of 5-year-olds are affected, according to the the Public Health Association. At the association’s conference in New Plymouth yesterday, Northland District Health Board oral health adviser Shareen Ali said short-term oral health strategies had worked well, but widespread implementation was desperately needed.

SUGAR NOT SO SWEET FOR HEALTH

Rock band Def Leppard would have a hard time pouring sugar on anyone if a strategy to ban all fizzy drinks from vending machines and make New Zealand “sugar free” catches on.

Sugary drinks would be banned and a tax slapped on all sugar-sweetened drinks under a proposal by Auckland University researcher Gerhard Sundborn, to be presented at the Public Health Association conference today.

In a first step to combat the obesity epidemic, Dr Sundborn said the prolific consumption of sugar-sweetened drinks should be tackled by the Government in a sugar-free strategy, with drinks regulated in the same way tobacco had been.

“These beverages are harmful and very addictive, and these companies look at getting our children hooked. They don’t have any nutritional value in them at all, and a huge amount of sugar, caffeine and flavourings.”

An end-game strategy could see the advertising and sale of sugar-free drinks regulated and replaced by healthier artificially sweetened drinks, or water and milk.

Drinks were the biggest contributor of sugar to children’s diets, and the second-biggest for adults. Currently, 26 per cent of sugar in the average child’s diet is from fizzy drinks, juice, energy drinks and flavoured milk. For adults, sugary drinks were right behind fruit, making up 17 and 18 per cent of sugar content respectively.

Research showed that, when calories were drunk, food intake was not adjusted accordingly, Dr Sundborn said.

Regulating their consumption would be a “significant step” in combating problems such as obesity, diabetes and rotten teeth, he said.

It had already happened at Waitemata and Auckland district health boards, where a policy had been put in place so the hospitals’ vending machines sold only sugar-free drinks. Some schools had maintained the healthy eating regulations scrapped by the Government in 2009, which had banned the drinks. “If that was picked up again, it would make a huge difference.”

 

Source: : Stuff.co.nz

 

In Nursing Homes, an Epidemic of Poor Dental Hygiene

Katherine Ford visited her father, Dean Piercy, a World War II veteran with dementia, at a nursing home in Roanoke, Va., for months before she noticed the dust on his electric toothbrush. His teeth, she found, had not been brushed recently, so she began doing it herself after their lunches together.

But after he complained of a severe, unrelenting headache, she said, she badgered the staff to make an appointment for him with his dentist. The dentist found that a tooth had broken in two, and he showed Ms. Ford the part that had lodged in the roof of her father’s mouth.

“I was livid,” said Ms. Ford, 57, a court reporter. “I’m there every day, pointing out he’s in pain — and he had dental insurance. So there’s no reason this wasn’t addressed.”

In nursing homes across the country, residents like Mr. Piercy are plagued by cavities, gum disease and cracked teeth, in part because their mouths are not kept clean. While residents now require more dental care than in the past, nursing home employees are rarely prepared to provide it. Aides are swamped with other tasks, and when older charges must be helped to the toilet, fed or repositioned in bed, brushing their teeth often falls to the bottom of the to-do list.

Even when care is available, few staff members are trained to cope with the rising numbers of residents with dementia who resist routine dental hygiene.

 

“I always say you can measure quality in a nursing home by looking in people’s mouths, because it’s one of the last things to be taken care of,” said Dr. Judith A. Jones, chairwoman of the department of general dentistry at Boston University. “Aides change someone’s Depends, change a catheter or turn somebody every few hours, but teeth often don’t get brushed twice a day.”

The neglect can lead to terrible pain for the residents. Worse, new studies suggest that this problem may be contributing to another: pneumonia, a leading killer of institutionalized older people.

The lack of daily oral care in nursing facilities is “an epidemic that’s almost universally overlooked,” said Dr. Sarah J. Dirks, a dentist who treats nursing home residents in San Antonio.

There are no current national assessments of oral health in nursing homes, but since 2011, at least seven states have evaluated residents using a survey developed by the Association of State and Territorial Dental Directors. One was Kansas, where dental hygienists examined 540 older residents in 20 long-term-care facilities. Nearly 30 percent of the residents had “substantial oral debris on at least two-thirds of their teeth,” according to a report issued by the Kansas Bureau of Oral Health. More than one-third had untreated decay.

The screeners saw plenty of fillings and crowns but concluded that “regular dental care has become a thing of the past” for many of the residents.

In Wisconsin, nearly 1,100 residents from 24 homes were examined. About 31 percent had teeth broken to the gums, with visible roots; 35 percent had substantial oral debris.

The problem has been graphically documented in state and federal inspections of nursing homes. In Texas, inspectors noted one resident with memory problems in too much pain to eat, her lower gums red, swollen and packed with food debris.

A 2006 study of five facilities in upstate New York found only 16 percent of residents received any oral care at all. Among those who did, average tooth brushing time was 16 seconds. Supplies like toothbrushes were scarce, the report said.

At the Raleigh Court Health and Rehabilitation Center in Roanoke, where Mr. Piercy was a resident, the administrator, Mark Tubbs, said in a statement that he could not discuss Mr. Piercy’s case because of federal privacy laws, and he could not corroborate Ms. Ford’s account. “All patients receive medically necessary, high-quality care, including oral care and hygiene,” Mr. Tubbs said.

Just as nursing home workers are expected to help residents bathe or reposition them to avoid bed sores, they are supposed to brush the teeth of residents who cannot do it themselves. So important is this task that it was federally mandated in the Omnibus Budget Reconciliation Act of 1987, which set new standards for nursing homes.

“They should be getting their care, but a lot of people don’t,” acknowledged Dr. David Gifford, the senior vice president of quality at the American Health Care Association, a trade group representing two-thirds of nursing homes nationwide.

Some residents decline help, he noted, and nursing home employees can do little about it. “It’s a very personal thing to have someone else brush your teeth,” Dr. Gifford said. “A lot of residents don’t want it, don’t like it and will ask not to have it.”

Many arrive at nursing homes with poor teeth, he added, after long periods without seeing a dentist.

Certainly, oral care can be a vexing challenge for nursing homes. Older Americans are more likely than ever to retain their natural teeth. Edentulism, total tooth loss, in older people declined from 1988 to 2004, according to data from the National Health and Nutrition Examination Surveys.

“Before, they came in with dentures,” said Barbara J. Smith, the manager of geriatric and special-needs populations at the American Dental Association. “Now it’s a whole different ballgame.” Dentures are easier for nursing home staff to clean.

Nearly two-thirds of those who stay in a nursing home long term have dementia, and many resist oral care, clenching their mouth shut or even trying to hit aides. The National Institutes of Health is financing research to address such resistance among nursing home residents with dementia.

Many prescription drugs — including some antidepressants, medications for high blood pressure and anti-seizure medications — can reduce saliva and dry out the mouth. Without daily oral care, older people taking such drugs are especially prone to “a relatively rapid deterioration,” said Dr. Ira Lamster, a dentist and a professor of health policy at the Mailman School of Public Health at Columbia.

The consequences are not limited to cavities and gum disease. Since 2004, when researchers first linked oral bacteria to the occurrence of hospital-acquired pneumonia in older people, a series of studies has shown that oral care — from regular brushing to professional dental care — might reduce the risk. Roughly one in 10 cases of deaths from pneumonia in nursing homes could be prevented by improving oral hygiene, according to a 2008 systematic review published in The Journal of the American Geriatrics Society.

But even when residents and their families know that better oral care is needed, paying for it can be a challenge. Medicare does not cover routine dental care like cleanings and fillings. Most states provide at least some dental services to adults on Medicaid, but coverage varies widely, and finding a local dentist who accepts Medicaid payments can be difficult.

More than 30 states allow dental hygienists to provide some treatment without specific authorization from a dentist, according to the American Dental Hygienists Association. But medical directors at nursing facilities do not necessarily see the value of having a dental hygienist on contract or on staff, said Shirley Gutkowski, a dental hygienist of 27 years who educates nursing-home workers in Wisconsin.

Dr. Dirks, the Texas dentist, said she would be “surprised if oral care was even on the radar of the medical directors” at nursing homes. Indeed, her group practice used to contract with 62 nursing homes, but now works only with 24 that make oral health a priority. For change to occur, she said, “every nursing home needs an oral care champion.”

 

Source: NY Times

Five Tips That Can Improve Your Oral Health

Adults have been brushing their teeth for so many years that it is just another routine chore that they do. However, the very nature of a routine such as this means that proper technique is not always adhered to. If your Drake dentist in Charlotte has told you that you have cavities or that your gums are not very healthy, it is time to reevaluate your brushing routine. Following are five tips that can help you take care of your teeth and gums better:

  • Brush for two minutes morning and night.
  • Make sure the gums are brushed, too.
  • Use toothpaste that contains baking soda.
  • Use an electric toothbrush.
  • Floss at least once a day.

Brush for Two Minutes

It is important to spend at least two minutes brushing your teeth. If you can’t spend this much time in the morning due to a hectic schedule, at least spend that amount of time before you go to bed. The amount of time you spend brushing will allow you to adequately brush all areas in your mouth, the back teeth as well as the front, the inside teeth as well as the outside teeth.
Brush the Gums

Brushing your gums keeps them healthy. As you brush your teeth, position the toothbrush so that it massages the gums at the same time. This stimulates blood flow that will help the gums be healthier. In addition, it disturbs colonizing bacteria.
Use Baking Soda Toothpaste

Studies have shown that baking soda neutralizes the acid in your mouth. Bacteria grow in a more acidic environment. Therefore, baking soda can help prevent bacteria growth. If you prefer the strong mint of a different brand of toothpaste, use that one in the morning and baking soda before bed.
Use an Electric Toothbrush

The electric toothbrush has improved over the years. It cleans the teeth better than regular brushing. It also massages the gums better and promotes healthy gums.
Floss Daily

It will come as no surprise that your Drake dentist in Charlotte will attest to the fact that flossing is critical. Flossing removes extra food stuck in your teeth, true, but it also does more than that. It disturbs bacteria and prevents them from colonizing in your gums and around your teeth.

 

Source: Health Avenue

Modern Aging: Oral health is important for older adults

 

A healthy mouth is an important part of overall physical wellness, but oral health is often forgotten when evaluating an older adult’s overall wellness. It is important for older adults to have good oral hygiene practices that include daily brushing and flossing, regular dental office visits and some basic knowledge of what oral health looks like as they age because it will help:

• avoid, reduce or eliminate pain;

• promote and facilitate eating a well-balanced diet; and

• avoid chronic disease and severe health conditions, such as heart disease, stroke, diabetes and respiratory disease.

As your loved one ages, watch for signs that he is having trouble maintaining good oral health. Look for the following:

• Reduced sense of taste: Decay, medication, disease and denture problems can reduce the sense of taste.

• Dry mouth: A reduced saliva flow can leave teeth at risk for decay. Saliva helps protect the teeth.

• Gum disease: Ill-fitting dentures, use of tobacco, poor nutrition, such diseases as diabetes, and a buildup of plaque caused by a lack of daily brushing and flossing can cause gum disease.

• Inflammation from dentures: Ill-fitting dentures can cause inflammation and pain.

• Darkened teeth: Darkening teeth can be a sign that the dentin is changing or deteriorating.

• Thrush: Look for a white film on the tongue, which is caused by an overgrowth of fungus in the mouth.

• Medication side effects: Talk to your pharmacist about medication side effects and interactions.

Resources are available to help you get access to dental care for your loved one. You can start by contacting your Area Agency on Aging, which will have an up-to-date list of dental services and programs available for older adults in your area.

 

Source: Times Dispatch

State certifies health, dental plans for sale next year

The board that oversees the state’s new online health-insurance marketplace has finally certified health and dental plans that can be sold through the exchange in 2014.

At a special meeting Wednesday in Seattle, the Washington Health Benefit Exchange Board voted for certification, an action it had been expected to take in August but twice postponed.

In the end, the board unanimously approved 35 health plans for the individual insurance market, one health plan for the small-business market and four pediatric dental plans.

Certification was a key step leading up to the state’s implementation of the Affordable Care Act, also known as Obamacare.

The certified plans now can be sold through the health-benefits exchange, called Washington Healthplanfinder, which opens for enrollment Oct. 1 and is a core component of Obamacare.

The federal Office of Personnel Management (OPM) is expected to certify eight additional health plans for the individual market in Washington. Altogether, there will be at least 43 individual health plans sold through the state exchange.

Wednesday’s vote restarted a process that had temporarily stalled. The board had been expected to certify plans for the exchange Aug. 21, but panel members at the time said they did not want to certify plans state Insurance Commissioner Mike Kreidler approved Aug. 1 until more insurers had an opportunity to get their plans reviewed again.

Kreidler had approved plans offered by four insurance carriers but rejected plans from five other carriers.

Four of the rejected carriers appealed Kreidler’s decision to an administrative-law judge.

In the past week, Kreidler reached settlement agreements with three of the carriers: Kaiser Foundation Health Plan of the Northwest, Community Health Plan of Washington, and Molina Healthcare of Washington.

The board Wednesday certified the plans offered by all three, as well as those from the four Kreidler had approved earlier: Premera Blue Cross; LifeWise Health Plan of Washington (a subsidiary of Premera); Group Health Cooperative; and BridgeSpan, a subsidiary of Cambia Health Solutions, which is the parent company of Regence Blue Shield.

In general, premiums for the plans from the three additional insurers came in somewhat higher than plans from the four companies previously approved by the state’s Office of the Insurance Commissioner.

Meanwhile, a fourth rejected carrier, Coordinated Care, is in talks with the commissioner’s staff.

During the public-comment period of Wednesday’s board meeting, Coordinated Care President and CEO Jay Fathi said the administrative-law judge ruled Tuesday night that the Office of the Insurance Commissioner should give “prompt, reasonable guidance” to the company to assist its staff in getting its health plans through the approval process.

The exchange board has scheduled a special meeting Friday, when it may vote on certifying Coordinated Care’s health plans.

In the small-business market, the board certified one insurer — Kaiser Foundation Health Plan of the Northwest — to offer health plans in Clark and Cowlitz counties, where the insurer will also offer plans for the individual market.

Kaiser was the only insurer that submitted plans to be sold for the small-business market through the exchange.

Four insurers have been certified to offer pediatric dental plans through the exchange: Delta Dental of Washington, Kaiser, LifeWise and Premera.

After the vote, board member Teresa Mosqueda said the panel’s decision to certify the plans should reassure the public that “we are moving forward.”

“We are going to be ready for open enrollment come Oct. 1, and we are going to have robust plan choices in every corner of this state for all of the population at all incomes,” said Mosqueda, who is legislative and policy director for the Washington State Labor Council and chairwoman of the Healthy Washington Coalition.

 

 

Source: Seattle Times