Millions of Floridians live in places where it’s hard to find a dentist, and the problem is even worse if you are poor.
Everyone knows there is stigma attached when people have to live with missing teeth because they can’t afford to get the problem fixed. It can affect employment, self-esteem, and cause serious medical issues. Research shows that low-income adults suffer a disproportionate share of dental disease nationally, and are nearly 40 percent less likely to have had a dental visit over the past year compared to those with higher-incomes, according to the Center for Health Care Strategies.
Most health insurance plans don’t cover dental expenses, or they cover only a fraction of what can become very expensive procedures. On top of that, Medicaid – the government health insurance program for the needy – will only cover emergency services for extracting teeth, to relieve pain or infection related to dentures, or “limited” X-rays or exams for those 21 and over, according to the Florida Agency for Health Care Administration.
Now, two major players involved in public policy in Florida – the Florida Dental Association and the conservative James Madison Institute think tank – are backing very different proposals in the state legislature to improve access to dental care.
The Florida Dental Association is pushing a legislative proposal for a student loan repayment program for dentists who agree to work with county health departments in parts of the state where it’s hard for people to get dental care. The grants would go up to $50,000 a year, and during the program’s start up, it would be limited to just 10 applicants. The money would help dentists repay student loans for tuition, books, dental equipment and supplies.
Joe Anne Hart, the Chief Legislative Officer for the Florida Dental Association, says her group would love to have 100 to 300 dentists in the loan program, “but if we can start to get this on the books and show the state this is going to be a great return to get individuals served in an appropriate setting, then our goal is hopefully that will increase as the state sees the benefit.”
It’s worth noting, she says, that just one dentist in a community can treat up to 2,000 patients a year.
The student loan forgiveness program actually began in the 1990’s and also included people studying to be doctors, nurses and chiropractors. The Legislature stopped funding it in 1997. This year’s effort to revive the program for dentists is being sponsored in the House by Port Charlotte Republican Rep. Michael Grant.
For dentist Myron Schrock, the state’s loan program was key to his career. He had nearly $100,000 in student loan debt in the mid-1990s when he took advantage of the program, and ended up working in Gulf County in the far western Panhandle in a position that provided him $25,000 over two years (on top of his salary) to repay student loans.
“There was a lot of poverty in Gulf County at the time especially, and lots of dental needs that weren’t getting met. They needed some help pretty bad,” Schrock recounts.
He ended up working in the tiny Panhandle community of Wewahitchka for two years before moving on to rural Blountstown, where he still sees some of the same patients from Gulf County. “It’s been a good thing for me, and also for the community, and getting some people to these under-served areas as an incentive (for dentists) I think is a good idea.”
State lawmakers passed the legislation in the 2016 session, but then-Gov. Rick Scott vetoed it, saying the bill duplicated existing social-service programs like the statewide Medicaid Care program and KidCare, Florida’s health insurance program that covers children up to 18 years old.
Another piece of Rep. Grant’s student loan bill calls for the Florida Department of Health to set up a “donated dental services program” that would include more than 400 dentists for people who are elderly, disabled, or have medical problems. Patients would be assigned to a dentist after a physician has examined them and determined that they need to get dental work before going further with medical treatment.
Meanwhile, the James Madison Institute, a conservative, libertarian-leaning group based in Tallahassee, has a different idea about what could solve the crisis in dental care access: deregulation. The professional dental associations in Florida and nationally oppose that.
The James Madison Institute is pushing the state to reform its dental licensing regulations to embrace the concept of “dental therapists” – mid-level practitioners who would work alongside dental hygienists under a dentist’s supervision and could perform routine preventative care like fillings and stainless steel crowns. They could do more complex procedures, too, under a dentist’s supervision.
Sal Nuzzo, vice president of policy and director of the James Madison Institute’s Center for Economic Prosperity, says the group’s goal is to find a way to get patients who have dental problems “into a chair with a qualified oral healthcare professional.”
“This challenge is exacerbated by a lack of supply of dentists not just in Florida, but nationwide. Florida is a high-stress state when it comes to this shortage,” Nuzzo said.
The James Madison Institute’s report, Dental Therapists: Sinking Our Teeth into Innovative Workforce Reform, makes the case that Florida should join states like Maine, Alaska, Washington and Vermont, which allow dental therapists.
St. Petersburg state Sen. Jeff Brandes has filed a bill that would allow dental therapists to perform specified services under the general supervision of a dentist. The Florida Dental Association fiercely opposes the idea, saying that dental therapists are not the equivalent of, for example, nurse practitioners who work in doctor’s offices.
The group says that dental therapists don’t have the same level of training as a dentist – that they could be high school graduates with just three years of dental therapy training before they would be allowed to perform extractions, partial root canals and other “irreversible surgical procedures” under the general supervision of a dentist. General supervision means that the dentist does not have to be in the same building, or even the same state, and does not have to check the work.
“So that’s what the ‘supervision’ is?” asks Florida Dental Association lobbyist Hart.
Professional dentists, on the other hand, have to first earn an undergraduate degree, then go to an accredited dental school, and may go on to graduate school for certain specialties like periodontics.
The Florida Dental Association’s parent organization, the American Dental Association, also opposes using dental therapists in place of dentists.
Several national public policy organizations, however, support the idea of using more dental therapists – among the most notable is the Pew Charitable Trusts. The Florida Policy Institute, a nonpartisan research group, also supports the move to allow dental therapists to help people who live in under-served areas get dental care.
“Right now, Florida is experiencing a shortage of dentists, particularly in rural areas,” says Holly Bullard, Florida Policy Institute’s chief strategy and operations officer. “Dental therapy can help fill this oral health gap. The issue has support from groups across the policy spectrum.”
Bullard says the Florida Policy Institute also supports the student loan forgiveness proposal backed by the Florida Dental Association.
“There is no reason why lawmakers can’t pass both of these important bills,” she said.