Dentist workforce size is not a major factor in access for the underserved

Robert A. Faiella, DMD, MMSc, President, American Dental Association
July 26, 2013

The good news is that DentistryiQ, along with countless other media outlets, state and federal lawmakers, and other health care providers are calling for solutions to the multiple barriers to achieving good oral health faced by tens of millions of Americans – barriers that collectively amount to a dangerous dental divide. Additional good news is that the dental profession is expanding its efforts to break down those barriers at the national, state, local and even individual levels. The new ADA campaign, Action for Dental Health: Dentists Making a Difference, embodies dentistry’s commitment to leading change, by delivering care now to those with the most immediate needs, strengthening and expanding the public/private safety net, and realigning the public health system away from surgical intervention and toward dramatically increasing oral health education and prevention at the community level.

Dentists have the best job in 2013

The not-so-good news is that the ongoing debates over scope of practice are drowning out more productive discussions of how to reach that goal. DentistryiQ’s coverage of a recent report from the Pew Children’s Dental Projectis a case in point.

Based in its analysis of projected dentist retirements, government–designated dental Health Professional Shortage Areas (HPSAs) and Children’s Medicaid utilization rates, Pew argues that there aren’t enough dentists to provide care to all those who need it; the impending retirement of a sizeable cadre of Baby Boomer dentists will only make the situation worse. This leads Pew to advocate for midlevel dental providers as the best solution to access disparities.

But as DIQ associate editor Lauren Burns’s article, "The Two Types of Dentist Shortages that Limit Children’s Access to Care"illustrates, the share of a state’s children receiving care under Medicaid, and the percentage of a state’s population living in dental HPSAs are only distantly related, if at all. Look at the two tables in Ms. Burns’s article. On the left we have the 10 states with the greatest percentages of their populations living in dental HPSAs. On the right, the 10 states with the worst children’s Medicaid utilization. Only one state, Florida, appears on both lists! And Florida’s Medicaid program is notorious as one of the worst in the country.

In fact, HRSA’s system of identifying and recording shortage areas is a poor indicator of Medicaid-covered children’s access to care. In the period from 2000 to 2011:

• Mississippi ranked 17th in improving access to dental care for Medicaid children. The portion of Medicaid kids with a dental visit went from 22% in 2000 to 43% in 2011, despite the fact that Mississippi has the biggest dentist shortage, in terms of the percent of the population un-served, according to the government’s HPSA methodology.
• States that had increases in the percent of the population living in HPSAs actually did better in terms of access for children covered by Medicaid over the same period than those that had decreases in dental HPSAs populations.
• Access to dental care among Medicaid children actually increased in 47 out of 50 states.

Ms. Burns implies that the ADA “argues against” misdistribution of the dentist workforce as a cause of access problems. This is incorrect. The ADA has for decades stated that while the overall number of dentists is adequate to meet the population’s needs, there are indeed areas where there simply aren’t enough of them, generally because those areas are too remote or impoverished to sustain a dental practice. And we have advocated, with some success, for proven solutions, like loan repayment programs, whether publically or privately funded, that make it possible for dentists to provide care where they are most needed.

Reports of a “trend” in state legislatures to authorize midlevel providers can be misleading. Ms. Burns writes, “More states are considering legislation that would expand access to care for its citizens. Two states – Alaska and Minnesota – have signed into law legislation that allows dental therapists to provide care that a dentist would typically provide.” (A minor correction – Minnesota is the only state to legalize midlevels. Alaska’s Dental Health Aide Therapists practice under the authority of the Alaska Native public health system – the state has no jurisdiction over them.) If this is this a trend, it is trending in the opposite direction. Fourteen states entertained legislative proposals to authorize some type of midlevel provider this year. None of them did so. At the federal level, Congress has declined for three straight years to appropriate money for midlevel programs.

Pew concludes, “Though some states have bolstered Medicaid reimbursement rates and streamlined paperwork requirements, neither of these strategies is likely to significantly improve low-income children’s access to care,” and that only adding midlevel providers to the workforce will “ensure that more children and families get the care they urgently need.” But there are numerous, well-documented examples that oppose this perspective. States like Connecticut, Alabama, Maryland, Michigan, Georgia, Tennessee and others have dramatically increased children’s Medicaid utilization through various combinations of red tape reduction and improved funding of Medicaid programs. State governments can easily take away what they have given, but the fact remains – Medicaid reforms work.

We can only hope that a loud and fruitless debate over scope of practice will give way to more reasoned and productive dialogue. The ADA is determined to make that happen. Through Action for Dental Health, we are targeting specific, proven solutions toward specific problems. We’re helping states replicate programs that move patients out of hospital ERs and into the dental chair. We’re helping dentists provide care to the 1.3 million nursing home residents who cannot travel to a dental office. We’re pushing for increased water fluoridation, getting more private practice dentists to contract with safety net clinics, training community dental health coordinators, and enlisting other health professionals to make oral health a greater priority. And yes, we will continue to advocate at the state and national levels for Medicaid programs that work, not only for children, but also for the almost entirely ignored population of low-income adults.

Dentistry doesn’t have all the answers, and we know we can’t do this alone. But we also know that only a multi-faceted, targeted approach to the numerous barriers that impede oral health will work, and we are committed to leading the way, with proven, actionable solutions.

THERE'S MORE TO THIS CONVERSATION:
Read a Florida dentist's response to this article: "I'm confused" – A Florida dentist tackles recent statements made by ADA in regards to access to dental care