ALEC's Dental Therapy Model Legislation and Georgia's Dental Landscape
Recent efforts by the American Legislative Exchange Council (ALEC) have placed dental therapy back in the spotlight. On July 26th, 2024, their Health and Human Services Task Force narrowly approved model legislation for a Dental Therapists Act which state legislatures could use to enable the licensing of dental therapists. The American Dental Association (ADA) continues to emphasize that, “any proposed new member of the dental team should be based on determination of need, sufficient education and training, and a scope of practice that ensures the protection of the public’s oral health.” With this policy in mind, the ADA opposes the adoption of ALEC’s proposed model. For Georgia in particular, ALEC’s model looks like a red herring that distracts from more beneficial investment opportunities.
Who is ALEC and What Are They Proposing
ALEC identifies itself as, “America’s largest nonpartisan, voluntary membership organization of state legislators dedicated to the principles of limited government, free markets, and federalism.” They maintain a model policy library of legislative ideas workshopped by their members. This policy library includes proposed, but not necessarily fully adopted, model legislation such as the Dental Therapists Act put forward by their Health and Human Services Task Force.
If enacted, the proposed model legislation would govern the licensing and practice of dental therapists in the state that passes it. Much like other licensing laws, the legislation requires graduation from an accredited program, passing a national board dental therapy examination, and completing training in CPR and infection control. Notably, the law does not specify an accrediting body in its model form, raising a question about whether the Commission on Dental Accreditation would have oversight of newly formed dental therapy programs.
The model legislation goes on to define dental therapy by limiting the practice of dental therapists to procedures defined in the law as well as subject to the terms of a collaborative management agreement maintained with a licensed dentist. Authorized procedures range from oral evaluation to tooth reimplantation and stabilization. It also requires that dental therapists limit their practice to federally defined shortage areas or practice settings in which at least 50 percent of the population consists of specified populations: veterans, long-term care patients, tribal lands, uninsured patients, and others. Absent from the legislation is a requirement that patients see a licensed dentist for evaluation prior to receiving regular treatment from a dental therapist.
Projecting Georgia’s Dental Workforce and Opportunities for Investment
The rationale for legislating dental therapy into existence largely stems from a desire to bolster the dental workforce, particularly for underserved populations. However, creating a mid-level provider risks investing limited resources into an area with weak returns, neglecting more pressing opportunities and needs. Uptake of the dental therapy model in parts of the country experimenting with it have been limited, and other segments of the dental workforce would benefit from increased investment.
In Georgia, one pressing need is the rural health care workforce. The American Dental Association points to a 2019 report from Minnesota that indicated that 73% of dental therapists practiced in metropolitan areas. Georgia has 22 counties without a dentist and 44 counties with only 1 dentist, but dental supply is trending positive, with Health Resources and Services Administration projections indicating that Georgia is closing the gap when it comes to the supply of general dentists, moving from 86% capacity to 92% in the next 10 years. Georgia policy makers are already taking steps to align incentives to reduce distribution challenges as new providers enter the workforce, without burdensome mandates dictating where and with whom those providers must practice.
When it comes to workforce capacity, Georgia’s major need is dental hygienists. HRSA projections suggest that by 2034, Georgia will need an additional 1,420 full-time dental hygienists to meet demand, with new hygienists entering the workforce at best preventing the gap from growing worse over time rather than closing it. These predictions suggest that investments in building the capacity of Georgia’s workforce should be aimed at drastically increasing the number of hygienists. An increase in the number of dental assistants may also be required as well.
Georgia and Dental Therapy
Like the American Dental Association, Georgia Dental Association has consistently questioned the value and cost effectiveness of establishing a mid-level provider. In the past, justification of this critique has included international examples. Looking to Canada’s more than 40-year experiment with dental therapy, it is hard to ignore the ultimate result. Canada’s last dental therapy school closed in 2011, and during the 2013-2014 registration year, only 238 dental therapists held a license in the clinical restorative practice category. More than half were in private practice, rather than in the federal jobs the program was designed to supply. While dental therapy in the United States would not necessarily follow the trajectory of Canada’s, their example does suggest an important consideration.
Workforce shortages and distribution challenges are typically the result of market forces that affect the entire dental team, and places where dental therapy has had more success, like New Zealand, have historically employed dental therapists in the public sector. This in turn suggests a broader strategic approach to managing dental workforce shortages. Policy must be designed so as to shift market incentives appropriately, or it must be designed to fill gaps left by market failures. ALEC’s policy model neither provides for public health investment in dentistry nor shifts the incentives of private practitioners to encourage provision of necessary services in places with limited supply.
Prior to considering dental therapy, Georgia has other, likely more cost effective, options to consider. Investment in expanding the dental hygiene workforce is a must. Medicaid reform, particularly enhancing reimbursement and lowering administrative burden, could enable dentists to treat more low-income patients. Further investment in the public health sector and expanding opportunities for teledentistry, which may particularly help rural patients, would be helpful as well.
What’s Next
ALEC will vote on whether to adopt the model legislation at its upcoming December meeting. If ALEC accepts the model legislation, it will become part of its policy library, and it will remain available to state policy makers. To become law, the model legislation would need to be taken up and passed by state legislatures, and it would be fully subject to the normal legislative processes that all bills go through. The American Dental Association will continue to encourage ALEC not to adopt the model legislation.
Georgia Dental Association will continue to advocate for policy that makes sense for Georgia. To get involved, consider attending a legislative reception (worth 1 CE credit), giving to GDAPAC, joining our contact dentist program, and participating in LAW Day 2025 (recently move to January 30th). There are many opportunities to help advocate for policy that ensures Georgians have the quality dental care they need for decades to come.
