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NCBI Bookshelf. Alex White, D. Patton, D. Kohn, D. Lipton, D. Congress directed that the report include specific findings with respect to coverage of a number of services, including medically necessary dental services.
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General Dentistry Services in Wilmington, North Carolina
As of , the Bureau of Health Workforce had identified nearly 6, areas in the US with inadequate professional dental care. Around 54 million people live in those shortage areas, and it is estimated that nearly 10, additional practitioners are necessary to meet their needs.
This paper explores the academic literature on occupational licensing to understand whether licensing laws are contributing to this shortage and if reforming those laws could increase access to dental care. Licensing laws are intended to safeguard consumers from being harmed by ill-qualified or undertrained practitioners. In the field of dentistry, this means that in addition to requiring dentists to have a license, states also place a number of restrictions on mid-level practitioners like dental hygienists.
Mid-level practitioners are qualified to perform preventative dental procedures like cleanings and sealants, but licensing laws limit their ability to perform these services. As a result, the number of services that can be provided outside of dental offices shrinks, raising the price of dental care. Of US adults who did not visit the dentist in the past year, over half pointed to high fees as their reason for not seeking care.
Licensing also reduces the number of dental service providers available to consumers because it acts as a barrier to employment. Further, state-specific licensing makes it harder for dentists to relocate to states with higher demand for dental services, as different states have different requirements for licensure.
Occupational licensing reforms in other industries have lowered costs, improved opportunities for workers, and increased consumer access to services. Changes in the dental field could have similar results. In light of this, policymakers should focus on pursuing reforms to current occupational licensing laws, such as expanding autonomy for mid-level providers.
Occupational licensing laws—entry regulations placed on professions by state and local government agencies—affect broad swaths of the American economy. These regulations require practitioners to obtain state-certified licenses before they can practice their professions legally. Licensing requirements affect all kinds of professional work, from hairdressers and plumbers to doctors and lawyers.
Although the occupations licensed and the stringency of licensing rules vary by location, every state requires that dentists be licensed.
Dental licensing is meant to protect consumers and ensure that only qualified practitioners perform technical procedures, but licensing may actually restrict the availability of dental-care services to consumers.
Smith, Vidalia Freeman, and Jacob M. Consumers and Workers? There is a need in the United States for greater access to dental and oral health services. As of , over five thousand three hundred dental Health Professional Shortage Areas had been identified nationwide. Nearly fifty-four million people live in those shortage areas, and the Bureau of Health Workforce estimates that almost ten thousand additional practitioners are needed to meet their needs.
Occupational licensing rules likely are contributing to this shortage as they often prevent mid-level dental-care providers, such as dental therapists and dental hygienists, from performing low-risk, non-invasive procedures without supervision by a licensed dentist. According to occupational licensing research, such restrictions may shrink the available pool of dental-care providers and increase the cost of receiving those procedures.
Kleiner and Robert T. For example, teeth cleaning sometimes is restricted to the practice of dentistry despite its low risk. Freed, Dorothy A. Perry, and John E. This research-in-focus piece examines existing research on occupational licensing with specific emphasis on aspects that relate to dental care. We first highlight the need for accessible dental care.
We then examine the effect of occupational licensing on access to dental care, specifically focusing on how it impacts quality, cost, and availability. We explore how mid-level providers may expand access to care, and we end with a conversation about reforming occupational licensing laws. Our key finding is that reforming laws that limit access to mid-level dental-care providers could reduce dental costs and provide more opportunities for Americans to receive dental care.
The quality of dental care available to Americans has improved dramatically over the past fifty years, yet disparities remain. Evans and Dushanka V. The Centers for Disease Control and Prevention found that Hispanics and African Americans had rates of untreated tooth decay almost twice that of whites—36 and 42 percent, respectively, versus 22 percent.
Minorities also account for a significantly larger fraction of low-income households than whites. Despite that evidence, the report states that 80 percent of low-income adults and 63 percent of all adults had not visited a dentist within the last year. A more recent estimate from the Centers for Disease Control and Prevention shows that 35 percent of adults had not seen a dentist within the previous year.
The primary reason people give for not visiting a dentist is the cost of services. Of adults who had not visited a dentist in the last year, 59 percent pointed to high fees for dental care as the main reason for not seeking oral health services, as shown in Figure 1. Dentists, attorneys, and physicians were some of the earliest occupations to be licensed by states.
As of , 50 percent of states required dentists to be licensed. By , every state required a license to practice dentistry. Licensing rules are meant to protect consumers from predatory or incompetent professionals in service industries. Occupational licensing works by creating a barrier to entry into a field.
Economists in recent decades have invested substantial effort in identifying the effects of occupational licensing regulations. The studies generally examine the costs of licensing—both to consumers and to laborers who must become licensed —their impact on quality, their impact on wages, and their impact on the overall size of the licensed workforce. Dentistry occupies a different space from that of many licensed occupations because of the risk and complexity of dental procedures, but economists have found that licensing in dentistry has produced similar outcomes to other industries.
Stricter licensing tends to reduce the supply of labor to the affected occupations and raises prices without always increasing the quality as intended. At its core, licensing is meant to ensure high quality of service for consumers.
Despite these intentions, it is unclear whether occupational licensing actually leads to better results. The Mercatus Center published a review of the findings of nineteen studies examining occupational licensing and related outcomes. According to the researchers, only three of the studies found that occupational licensing regulations had a positive effect on outcomes for consumers, whereas four of them found negative impacts related to occupational licensing.
Most of the studies—63 percent— found that the results were unclear, mixed, or neutral. One study from that review was a paper by economists Morris Kleiner and Robert Kudrle.
Their findings suggest that stricter licensing requirements for dentists did not improve oral health outcomes but did raise prices of dental services. Another study, focused on the effects of state licenses for child care providers, finds that licensing did improve the quality of care that children received. Likewise, all nineteen papers reviewed in the study by the Mercatus Center find that licensure increases prices.
Removing some of these barriers could help lower prices and thus increase access to dental care. Because licensing rules act as barriers to entry into licensed occupations, the supply of new professionals is reduced and competition between providers is less vigorous.
The main beneficiaries of such barriers to entry are the licensed practitioners already in the market. Using labor-market data from the Census Bureau and data from previous work, economists Peter Blair and Bobby Chung created a model that examined occupations that were licensed in one state but not in a neighboring state. They find that in states with occupational licensing, the number of laborers in that industry was 17—27 percent lower, on average, suggesting that licensing has a negative and significant effect on the supply of labor in licensed occupations.
Blair and Bobby W. A study by economists Janna Johnson and Morris Kleiner finds that individuals in occupations with state-specific licensing requirements have an interstate migration rate 16 percent lower than that of similarly licensed individuals who have the option of passing a national exam recognized by state licensing boards. Johnson and Morris M. Furthermore, they point out, dentists, dental hygienists, and social workers have very low interstate migration rates compared to the other occupations studied.
Although national exams are administered for all three of those occupations, the authors point to state-specific courses for social workers and clinical exams for dental professionals as possible causes of the relatively low rates of interstate migration observed in those occupations.
Mid-level providers are professionals in health care fields that can perform many of the same functions performed by doctors and dentists, but they require less training and therefore offer services at lower costs.
Source: Jay W. Mathu-Muju and Kavita R. Reforms that allowed for mid-level providers in the healthcare industry and subsequent policy changes that have widened their scope of practice—the number of procedures they are licensed to perform—have led to better outcomes for both consumers and service providers.
Research suggests that laws expanding the scope of practice for physician assistants and nurse practitioners have led to higher wages for mid-level practitioners, less expensive procedures for consumers, and an overall increase in access to health care.
Hooker and Christine M. Kleiner, A. Marier, K. Park, and C. Dentistry has seen similar reforms with the incorporation of mid-level providers, but a number of opportunities still remain for lowering occupational licensing barriers and increasing consumer access.
Table 1 provides a breakdown of the average cost and length of schooling for dentists and related mid-level dental care providers. They can, however, provide less complicated procedures at a lower cost. Dental hygienists, whose role typically includes performing routine teeth cleanings and other preventative-care procedures, are the most common mid-level providers of dental care.
They are limited by scope-of-practice laws that dictate the number of hours required to receive and maintain certification, what procedures hygienists are allowed to perform, and the type of supervision required.
Over the past few decades, states have begun to reduce those restrictions to make dental-hygienist care more accessible to consumers by allowing patients to have direct access to dental hygienists.
Those reforms mean that dental hygienists can treat patients without the authorization or supervision of a licensed dentist. As of April , forty-two states allowed patients direct access to dental hygienists in some form. The types of services that dental hygienists can provide vary by state.
Colorado and Maine, for example, impose few limits in their scope-of-practice laws, whereas many southeastern states, such as Alabama and Mississippi, have enacted much more restrictive scope-of-practice laws. Figure 2 illustrates the wide variation in scope-of-practice laws throughout the United States.
Each state is given a score based on the level of autonomy of dental hygienists. Source: M. Langelier, et al. A number of studies suggest that expanding the scope of practice for dental hygienists expands access to primary dental care.
Another report from the National Center for Health Workforce Studies finds similar results, as greater autonomy for dental hygienists is positively correlated with access to oral health services and oral health. Langelier, Tracey A. Much as past reforms led to higher wages for nurse practitioners and lower costs for consumers, reducing licensing restrictions on dental hygienists could result in better outcomes for both hygienists and their patients.
Dental therapists, another type of mid-level dental care provider, recently have begun to practice in the United States. Dental therapists offer preventative care similar to dental hygienists, but they also can offer restorative or permanent procedures, including filling cavities or performing simple extractions.
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Covid-19: Dentist group instructs law firm to investigate claims rejections
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Perhaps it is an old-fashioned word, but this is not how gentlemen carry on. Even allowing for the climate of extreme sensitivity that prevails at present, especially on campus — witness the current furore at the University of Calgary over the naming of flag-football teams — the comments in question are utterly outrageous. People can and do make offensive jokes in private, and considerable space should be allowed for this. But no one who has been properly socialized makes these sorts of jokes, even in private. While it is extremely unlikely any of the participants meant anything by their remarks beyond that, and while it is clear they did not mean anyone else ever to hear of them, now that they have become public knowledge they cannot be made unknowledge. That it would even occur to those studying for a profession that holds the power to put patients under sedation — students who are within a few months of practising — to joke about the criminal potential this presents casts serious doubt on their judgment, on top of everything else: It is just culpably stupid to think that anything posted online is likely to remain private.
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