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There’s a crisis facing American dentistry, impacting millions of American children and families who lack access to affordable care. And marginalized communities of color are disproportionately impacted, with Black, Hispanic and Native Americans, all groups with an above-average risk of contracting and dying from COVID-19, more likely to suffer from oral health issues.
The American Dental Association reports a 69% drop in children’s visits to the dentist in 2020. This means that up to 7.6 million kids went without basic preventative health services like teeth cleanings and checkups that avert more serious problems down the track. Not only will that mean more kids suffer from poor oral health, it will also likely impact their education, as students with dental problems are more likely to skip or face problems at school.
Disruptions brought on by COVID-19 certainly contributed to this crisis. But the truth is, things weren’t so great even before the pandemic. In 2019, the CDC found that 23% of children from low-income families had untreated cavities in their permanent teeth, twice that of children from higher-income households. This paradigm also connotes racial inequities and divides that are likely to have been exacerbated by the pandemic. Americans of color are more likely to be from low-income households, and pre-pandemic rates of untreated tooth decay among Black and Hispanic Americans were nearly twice the rates for White Americans.
There’s no doubt that temporary reforms could help, like indemnifying dentists who reopen and provide services whilst taking reasonable precautions from Covid-related lawsuits, as the American Dental Association recommends. However, given the long-term issues raised by an estimated 54 million Americans living in regions of the country with inadequate access to professional dental care, and given that six out of 10 Americans who haven’t seen the dentist in a year identify high costs as the reason, it’s time for policymakers to consider a longer-term solution: occupational licensing reform.
In theory, requiring professionals to earn a license is a way to ensure the public can trust their doctors, lawyers and dentists to know what they’re doing. In practice, though, state, federal and local licensing regimes don’t always improve professional integrity. And often, they merely prevent competent care providers who are licensed in other parts of the country (or in developed nations with equally high standards) from servicing new areas. This barrier to prospective professionals looking to enter new markets insulates those who already hold the required licenses from competition. This is true in any industry, including dentistry.
This paradigm doesn’t just hurt dentists’ bottom lines. All that time spent passing additional exams and all that money spent paying additional fees gets passed on to the patient. It forces Americans in dire need of affordable services to pay a premium, thereby undermining their living standards.
Data shows we need about 10,000 dental care practitioners to address community shortages across America. Besides recognizing licenses acquired in other states and liberalizing licensing requirements for foreign professionals who’ve been certified by accredited institutions in comparable countries, states should foster access to care by liberalizing "scope of practice" laws.
Dental hygienists and therapists are mid-level professionals who require less training and so cost less than dentists. They’re qualified to provide low-risk preventative services, like teeth cleanings and sealing, which can protect consumers from needing more expensive procedures like extractions and root canals down the track. Yet, scope of practice laws limit the procedures that these hygienists and therapists can perform and set required hours of dentist supervision. That means patients can’t employ them without going through a licensed dentist. Various states have liberalized scope of practice laws, allowing patients to employ these mid-level professionals directly. However, many limits remain. As of 2018, 42 states allowed patients direct access to dental hygienists in some form, but states like Alabama and Mississippi, both home to large, underserved communities, maintain restrictive scope of practice laws that require direct supervision for preventive services.
Liberalizing access to dental hygienists improves affordability, access to care and oral health outcomes. And liberalizing access to dental therapists reduces wait times for services, improves affordability and encourages more Americans to seek preventative care that could make a major difference in their lives. Reducing or repealing these restrictions should be a no-brainer.
It might mean a loss in clientele for fully-licensed dentists in specific states. But that’s a small trade-off for expanded employment opportunities for thousands of mid-level professionals, as well as significantly improved health and living standards for ordinary Americans.
A first-world country ought to be able to provide first-world health and dental care to all, including its most disadvantaged. And not just for those with the means to pay a premium. The pandemic may be a temporary disruption, but licensing reform will address long-term inequities, including those between Americans of different incomes and racial demographics. It’s a bold, proven policy that has teeth.
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Satya Marar is a Washington DC-based policy professional and Senior Contributor with Young Voices. His writings on licensing and economic reform have appeared in RealClearPolicy, The Hill, Australian Financial Review and other leading publications.
