If you think Democrats and Republicans can’t agree on anything related to health care, you’d be wrong. A remarkable bipartisan effort is taking shape at the state level that could result in millions of Americans having better access to care in a way barely addressed by federal lawmakers.
I’m talking about better access to dental care. Recent poll results and comments by policy advisors on both sides of the political divide show that there is growing bipartisan agreement on ways to improve the oral health of Americans.
While the Affordable Care Act helped increase access to dental care for low-income children enrolled in the Medicaid program, it did very little otherwise to address what continues to be a “silent epidemic” in this country.
“Silent epidemic” is the term former U.S. Surgeon General David Satcher used in a seminal report in 2000 to describe a growing but, until then, little understood crisis.
“It (is) abundantly clear,” Satcher wrote, “that there are profound and consequential disparities in the oral health of our citizens. Indeed, what amounts to a “silent epidemic” of dental and oral diseases is affecting some population groups.”
This burden of disease restricts activities in school, work, and home, and often significantly diminishes the quality of life. Those who suffer the worst oral health are found among the poor of all ages, with poor children and poor older Americans particularly vulnerable. Members of racial and ethnic minority groups also experience a disproportionate level of oral health problems. Individuals who are medically compromised or who have disabilities are at greater risk for oral diseases, and, in turn, oral diseases further jeopardize their health.
More than a decade and a half after Satcher’s report, tooth decay is still the number one chronic disease affecting children. More than a third of elementary school children have untreated tooth decay. One reason is that only about one-third of U.S. dentists accept Medicaid. Another big reason is that a growing number of Americans live in communities were dentists are few and far between. In fact, since 2000, the number of people living in dental shortage areas, often called dental deserts, has nearly doubled, from 25 million to 49 million.
To reverse these trends, Republicans and Democrats in many states are supporting efforts to expand the dental workforce to include midlevel providers, often called dental therapists. Several conservative groups and politicians like that idea because, as they note, no new government programs or taxes are needed. It’s a free-market remedy that creates jobs and reduces costs. They and community and patient advocacy groups and more liberal politicians also like it because the use of dental therapists has been shown to decrease disparities in dental care in both rural and urban areas.
As the PBS show Frontline reported a few years ago, people who live in dental deserts—there were 4,438 of them at last count—are at greater risk of tooth decay and severe health problems. They also spend more money on care, in large part because they often go to a hospital emergency room when pain becomes unbearable. Not only is care provided in the ER expensive, often only the symptoms are treated. The underlying problems are seldom addressed. ER doctors typically write a prescription for pain pills and suggest the patient see a dentist. The problem with that, of course, is that patients who go to the ER when a toothache becomes unbearable would have gone to a dentist in the first place if they could have afforded it or if they could have found a dentist who accepted Medicaid.
Of particular concern to Republican lawmakers is the fact six out of ten dental deserts are in rural communities, and a majority are in states with Republican governors and state legislatures.
The biggest reason people in rural areas find it especially difficult to get the dental care they need is because most dentists set up their practices miles away in prosperous urban and suburban areas. That’s understandable when you consider that the average newly minted dentist with student debt leaves school owing between $237,000 and $291,000, according the American Dental Education Association. More than 30 percent of dental school graduates in the class of 2016 reported debt of more than $300,000.
To help ensure their constituents’ oral health needs are being met, lawmakers of both parties in several states are considering doing what at least 50 other countries around the world have done: authorize the licensure of dental therapists—similar to nurse practitioners and physician assistants—to practice in dentistry.
A November poll found that 81 percent of Americans favor allowing dental therapists to practice. That support cuts across party lines and regional boundaries. That’s not surprising when you consider that 45 percent of those surveyed said cost and access issues kept them from getting needed dental care.
Dental therapists are now practicing in Minnesota and in Native American communities in Alaska and Washington, and they’ll soon be able to practice in Maine and Vermont and on tribal communities in Oregon. Several other states, including Kansas, Massachusetts, Michigan, New Mexico, North Dakota and Ohio, could follow suit this year.
Dental therapists, whose scope of practice ranges from education and prevention to fillings and uncomplicated extractions, work as part of a dentist-led team, not as solo practitioners. When they encounter patients with problems beyond what they’re licensed to do, they refer them to their supervising dentists. Although they can’t set up their own independent practices, they can help reduce the number of dental deserts in the United States, so long as they’re able to work remotely under the general supervision of a dentist, as they do in Alaska and most other places. Dental therapists began treating patients in Native Alaskan communities twelve years ago and now serve more than 45,000 patients, many of whom live in some of the most remote places on earth.
Among the champions of dental therapists is Grover Norquist, founder of Americans for Tax Reform (AFTR), the conservative organization that advocates for lower taxes and more limited government. A recent AFTR poll showed overwhelming bipartisan support for dental therapists, as did the November poll mentioned above. State chapters of Americans for Prosperity, another conservative organization, are also on board.
Other conservative organizations could soon join them. Among those who went on a recent site visit to the University of Minnesota School of Dentistry, one of the schools that trains dental therapists, were representatives of the Goldwater Institute, The Charles Koch Institute and the Heartland Institute.
The bipartisan support for dental therapists is real. When bills to allow the licensure of dental therapists are introduced in state legislatures, they typically have support of both Democrats and Republicans.
So why aren’t dental therapists practicing in every state? I’ll explain why in a future post.