By Joel Teitelbaum

Background

Strengthening and modernizing the health care workforce was a major goal of the Affordable Care Act. The health reform law contains dozens of provisions related to health care workforce issues, including national workforce policy development (what the law refers to as workforce “innovations”), increasing the supply of health care workers, education and training of the workforce, strengthening primary care, and other supports and improvements to the existing workforce. This Implementation Brief focuses on the provisions of the ACA aiming to strengthen the dental health workforce.

Providing access to high quality oral health care is an important component to improving the health of people in the United States. A person’s oral health is connected to that person’s overall well-being, and can be an indicator of serious health problems.^[1] Often, symptoms of disease first show up in the mouth, and certain infections in the mouth, if untreated, can spread to other parts of the body.^[2] However, the current supply of dentists, particularly in medically underserved areas, is inadequate. As of September 2009, there were 4,230 dental health professions shortage areas, within which more than 42 million people live. The U.S. Health Resources and Services Administration (HRSA) estimates that it would take an increase of more than 9,500 dental professionals in order to reduce the ratio in shortage areas to 1 dental professional for every 3,000 individuals.^[3]

Changes Made by the Health Reform Law (P.L. 111- 148, §§ 5303-5304)

The ACA made a number of changes aimed both at making education in dental care fields more accessible and desirable, and supporting the existing dental care workforce. Of primary importance was expanding dental training programs and improving the quality of education, incentivizing individuals to choose dental-related careers in high demand, and incentivizing dental professionals to practice in underserved areas. To achieve these goals, the ACA authorizes the Secretary of Health and Human Services (HHS) to make contracts and/or grant awards under a number of different programs:

1)   Support and Development of Dental Training Programs: The Secretary is authorized to make grants/contracts to entities that have approved training programs in general dentistry, pediatric dentistry, or public health dentistry programs.^[4] The entities may use the funds for:

• planning, developing, and operating, or participating in “an approved professional training program in the field of general dentistry, pediatric dentistry, or public health dentistry for dental students, residents, practicing dentists, dental hygienists, or other approved primary care dental trainees, that emphasizes training for general, pediatric, or public health dentistry”;
• providing financial assistance to oral health professional students who plan to practice general pediatric dentistry, public health dentistry, or dental hygiene;
• planning, developing, and operating programs for the training of oral health care providers who plan to teach;
• providing financial assistance in the form of traineeships and fellowships to dentists who plan to teach;
• meeting the costs associated with dental faculty development programs in primary care;
• providing financial assistance to dental schools for geriatric workforce development and geriatric career incentive awards;
• meeting the costs associated with pre- and post-doctoral training in primary care programs; and
• providing technical assistance to pediatric training programs.

2)   Faculty Loan Repayment: The Secretary is authorized to make grants/contracts to educational programs in general, pediatric, or public health dentistry for the purposes of establishing a loan repayment program for faculty of dental programs.^[5] Oral health specialists eligible for the program are individuals who agree to serve full-time as faculty members.^[6] Upon completion of each year of service, the program will pay an amount equal to 10, 15, 20, 25, and 30 percent, respectively per year for 5 years, of the individual’s student loan balance.

3)   Alternative Dental Health Care Training: The Secretary is directed to establish a demonstration program for entities to train or employ alternative dental health care providers.^[7] The purpose of the demonstration is to increase access to dental health care services in rural and other underserved communities.

Implementation

Agency

HRSA is the fiscal and administrative agent for the loan and grant programs.

Key Dates

None.

Process

The health reform law does not provide specific direction to HHS regarding the administrative process used to implement the law. The agency therefore has the discretion to use a range of tools to implement the statute, such as publishing regulations in the Federal Register with a public notice and comment period, or using other types of approaches such as posted policy instructions, funding availability announcements (where applicable), official letters to affected entities (such as letters to state Medicaid agencies), and posted rulings and notices. Agency websites can be checked regularly for updates.

Key Issues

Grant & Demonstration Program Funding: Prior to the ACA, training grants for primary care medicine and for dentistry were consolidated, meaning that several different primary health care professions were left to battle over a single appropriation amount. However, the ACA separated dental training grants from other primary care training grants, and thus HRSA is able to submit a separate budget request specific to dental health training grants. According to HRSA’s FY 2012 budget request, oral health training is increasing from 32.9 million to 35.4 million. That said, funding for the ACA oral health grant and demonstration programs has been authorized but not appropriated. Given the current budgetary and political climate, will they be funded and, if so, can funding be sustained long enough to increase participation in dental care fields (including in particularly underserved areas)?

Supply: Generally, will the new ACA provisions reduce barriers and disincentives that currently discourage individuals from pursuing dental care careers? For example, will the loan repayment program drive dentists into faculty positions, as required under the program?

Alternative Dental Health Care Training Demonstration Program: What standards will the Secretary attach to this demonstration program? How will it be evaluated? How much of an increase in dental care penetration in rural and other underserved communities is required?

Agency Action

On September 17, 2010 the Secretary of HHS announced that $23.9 million is available for workforce grants for the training of oral health specialists.

Authorized Funding Levels

Thirty million dollars is authorized to be appropriated for the Dentistry Training Grants and the Faculty Loan Repayment Grants for fiscal years 2010, and such sums as necessary for the years 2011 through 2015. Congress authorized to be appropriated such sums as necessary for the Alternative Dental Healthcare Demonstration Project.