Fight looms as dental therapy bill introduced in New York

“There’s a decided lack of dentists whose practice will include Medicaid patients,” Woerner said. “For example, in my district, it is only the Saratoga Community Health Center, which is run by the hospital. They have one dentist and two hygienists and that’s it for the entire population.”

Across the state, soaring Medicaid rates are bringing into sharp focus the scarcity of dental care options for low- and middle-income people on public health insurance.

About 9 million New Yorkers — or half the state’s population — are on a public health plan. Another 1 million state residents are uninsured. But just one in three dentists in the state participates in Medicaid, and of those who do, most are located in New York City, according to a 2022 study.

The result is an unsustainable patient backlog not only at the handful of upstate clinics that serve Medicaid patients, but in hospital emergency rooms that are clogged with adults and children who have preventable dental problems.

On a local level, the issue was recently exacerbated by the closures of two hospital-run dental centers in Albany and Lake Placid that cut off access for thousands of patients. 

Meanwhile, more than 81,000 Capital Region residents were added to state-funded insurance plans in the three years of the pandemic when Medicaid eligibility checks were paused, according to figures from the state Department of Health.

To meet this need, some states have been experimenting with the creation of a new category of dental care, called dental therapy, which builds on capabilities of dental hygienists and seeks to bolster the dental workforce in underserved communities.

Woerner, a Democrat, has drafted a bill for the upcoming legislative session that would create a pathway for dental hygienists to become “dental therapists” or “advanced dental therapists.”

Much like nurse practitioners or physician assistants, these mid-level clinicians would be authorized to provide pain relief, fill cavities, replace crowns and perform simple extractions under the supervision of a dentist. 

This bill is the first of several that will seek to address the shortage of dentists who practice in a public health setting, according to Woerner.

A dental therapist would need a bachelor’s degree to practice, and an advanced dental therapist would require a master’s degree from an accredited program, according to the legislation. Though some states have found ways to utilize dental therapists, others have struggled to get training programs off the ground.

New York’s dental therapy bill is a long way from becoming law; there is no matching state Senate version and it provokes a battle with dentist associations, which have long opposed the model.

Why dentists don’t take Medicaid

For a small dental practice, the idea of working with Medicaid patients can be overwhelming, oral health advocates say. With so much pent-up demand, participating with Medicaid usually prompts a deluge of phone calls. 

Many providers also start out with an enormous amount of debt and the Medicaid reimbursement rates for dental procedures is a fraction of what commercial health plans pay. 

The average dental student in the U.S. graduates with about $300,000 in debt, while medical students come out of school with just over $200,000 in student loans, according to the most recent figures from the American Dental Education Association and the Association of American Medical Colleges. 

Low-income patients are also seen as less reliable; they may have trouble getting to their appointments due to transportation or child care issues.

Finding a specialist — say, a periodontist (who works with the gums and bone that supports the teeth) or an oral surgeon — is virtually impossible for Medicaid subscribers, patient advocates say. This scarcity of high-level care means extraction is often the only option.

Dr. Lawrence Kotlow, a pediatric dentist in Albany who specializes in infants and toddlers, said he accepts Medicaid for surgery because “otherwise no one would get care.”

He also empathizes with dentists who turn these patients away. Since COVID, the cost of providing masks and protective equipment has exceeded Medicaid’s reimbursement for a consultation, Kotlow said.

“With Medicaid, you’ve got three things: One is low fees, you’ve got too many patients that have failed to show for their appointments and third, because of COVID, our costs have dramatically increased and they’re going to stay that way, because nothing goes down,” Kotlow said. “If we can’t raise our fees somewhat to compensate, we’re going to take patients who are going help pay our bills and cover our overhead.”

Greg Hill, executive director of the New York State Dental Association, said hesitation among dentists largely comes down to stagnant Medicaid reimbursement rates — a problem that won’t be solved by creating a new profession. 

“The cost is the cost. The cost of the supplies for a dental therapist is the same as the cost of the supplies for a dentist. We have not seen any evidence that the cost is any less,” Hill said. “Increasing the reimbursement rates has to be one of our key priorities for the state and it’s something we continue to work on.”

A fight looms

Dental therapists have worked in the U.S. since 2005, when Alaska, after overcoming a legal challenge from the American Dental Association, used the new care model to treat native populations. Tribes in Washington, Oregon and Idaho have since embraced the model and a dozen other states have introduced dental therapy bills. 

Minnesota, which became the first state to certify dental therapists statewide in 2009, has successfully integrated the clinicians into the dental workforce. Other states, like Vermont and Maine, have encountered logistical and financial setbacks.

But state and national dentist groups have vehemently opposed allowing non-dentists to drill into teeth. The ADA initially warned that dental therapy education and training was inadequate and the mid-level clinicians would put patients at risk. But more than 1,000 studies and surveys from around the globe have since shown the dental therapy model to be safe and effective.

At one safety-net provider in Minnesota, clinicians, administrators and patients overwhelmingly reported positive experiences with the dental therapy workforce, according to a study by Oral Health Workforce Research Center at the University at Albany’s School of Public Health.  

A review of dental claims data revealed that by leaning on dental therapists, dentists were freed up to provide a higher level of service, wait times for care decreased and patients had more of their dental needs met per visit.