A disappointing defeat for dental therapy in Arizona in 2016 has only strengthened the resolve of advocates looking ahead to the next legislative session.
Among them is Kristen Mizzi Angelone, a dental policy expert with the Pew Charitable Trusts, which backs dental therapy efforts across the country.
“Arizona is big state,” she told Watchdog.org. “There are huge sections of the state that don’t have dentists. There are people who have to travel hours and hours and hours just to see a dentist.”
Mizzi Angelone joined legislators and other public health advocates Tuesday to hear about a new report from the free-market Goldwater Institute on Arizona’s dental health crisis. The report says 69 percent of the state has fewer than one dental provider for every 5,000 residents. And an estimated 2.4 million of Arizona’s seven million residents live in federal Dental Professional Shortage Areas.
Pew, Goldwater and the the Inter-Tribal Council of Arizona are part of a broad coalition called Dental Care for Arizona that argues dental therapy is a viable solution to the state’s dental health shortage.
Like nurse practitioners and physician assistants, dental therapists are trained and licensed to perform a limited number of the same procedures as dentists, such as filling cavities and pulling teeth. They also work under dentists’ supervision.
Practiced in 50 countries since 1920, dental therapy made its way to tribal lands in Alaska in 2004. Since then, regular dental care has reached an estimated 40,000 children and adults in 80 previously unserved areas. Before that, the best a village could hope for was once-per-year visit by a dentist who would perform triage on the worst dental problems.
Minnesota was the first of the lower 48 states to adopt licensing, education and testing in 2009. Vermont and Maine also have laws allowing dental therapy. In February, Washington Indian tribes prevailed in getting the state to approve federal funding for dental therapists on tribal lands. Oregon has a pilot program for tribal communities and several states are considering dental therapy licensing including Massachusetts, Michigan, Kansas and North Dakota.
The effort gained attention in 2015 when the Commission for Dental Accreditation (CODA) developed dental therapy standards for states and schools to use when creating their own programs. CODA is an independent arm that operates under the purview of the American Dental Association (ADA).
It’s not as if Arizonans are averse to innovative disruptions in health care. Dental tourism is thriving just across the U.S.-Mexico border in Nogales and Los Algodones, which markets itself as “Molar City.” Los Algodones has around 5,500 people, and according to its website, more than 300 dental clinics that perform quality, high-tech dental work for 70 to 75 percent less than in the U.S.
“Dental therapy will not only help more people get the care they need,” Mizzi Angelone explained. “But this is really a free market, business opportunity to expand and really innovate the dental delivery system in this state.”
This new profession, however, has been a tough sell for some Arizona lawmakers..
The legislature’s “Committee of Reference,” a review panel for occupational licensing proposals, voted 8-1 in December to reject the coalition’s application. Passage would have allowed the full legislature to consider details of the new profession.
The Arizona Dental Association celebrated the committee’s vote, telling members telling members, “We live to fight another day!”
The committee’s lead opponent was state Rep. Regina Cobb, a dentist, former state Dental Association president and member of the ADA’s lobbying council.
At the hearing, Cobb harped on the quality and safety of care, and argued to coalition leader Kristin Boiline that CODA standards aren’t sufficient because they lack a national test such as that taken by dentists.
Cobb: “Is there a test that [dental therapy candidates] can take right now to prove their competency?”
Boilini: “There is in Minnesota, yes.”
Cobb: “But not a national test. And CODA is a national organization.”
Boilini told Watchdog.org that national standards don’t mean a national test, but rather a baseline for each state to tailor its own testing, licensing and education. She said state tests would use questions straight from the National Board Dental Examinations, but only questions related to the narrow scope of dental therapy.
In Arizona, that would be around 80 procedures, compared with dentists who can perform 434.
The lone yes vote was from committee chair Nancy Barto, a state senator from Phoenix. In a phone interview with Watchdog, she called Cobb’s national test discussion a red herring.
“We were not deciding in that hearing what the CODA standard would be for Arizona. That is up to us as a legislature to decide,” she said. “All of that really was unfortunate that it gathered so much attention.”
Boilini agrees the hearing, held before Christmas, made it tough to clarify the finer points about dental therapy, but is confident it served a good purpose.
“This was the first opportunity for legislators to hear about dental therapy, to really talk about dental therapy and what it is. It is a complex issue and is politically polarizing,” said Boililni.
The ADA and its state chapters continue to insist the problem isn’t a shortage of dentists, just uneven distribution Their solution? Professional community outreach to help connect dentists and patients — and more Medicaid money.
Prepared to fight
Armed with more time, information and a growing need, the Dental Care for Arizona coalition is moving forward with a year-long strategy to educate all stakeholders, including the ones who are elected.
“The entire state is a shortage area,” said Barto. “When you have this information that’s starting to coalesce around that fact, it’s going to be hard to deny the need. And if [my colleagues] are aware that this could be part of a comprehensive solution to satisfying a need for low-cost dental services, they’re going to be pushing for it themselves and they’re going to be under pressure to support something like that at the legislature.”
“There is a very pro-business governor in place and a legislature that is looking for ways to innovate the current health care system,” Mizzi Angelone added. “They know that we need to do something different, that the way things have been done over the last 12 years aren’t working.”
Barto says a bill in the works would revamp the review process by broadening the committee itself and moving the hearing from December to the beginning of the legislative session in January.
“It would be quite different and there would be more participation by legislators.” said Barto, adding that she doesn’t want a repeat of last year.
“If Arizona’s legislature is seen as a stopper, that is really a negative.”