PHE 610 Module 10 Final Project Example

Closing the Gap at the Edge of the Mouth: A Policy Analysis of Dental Therapist Licensure in a Northern Plains State

[Student Name]

Southern New Hampshire University

PHE 610: Health Policy and Management

Final Project: Policy Analysis

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Closing the Gap at the Edge of the Mouth: A Policy Analysis of Dental Therapist Licensure in a Northern Plains State

Summary

Too few people are licensed and paid to treat teeth where the poorest residents of this Plains state live. Of its 61 counties, 49 carry a federal dental shortage designation and four have no dentist at all, while reservation clinics book routine fillings four to six months out. This analysis compares four responses and recommends a phased policy. The state should let tribal clinics hire federally certified dental therapists at once and, in the same bill, open a state license for therapists in shortage and safety net settings that takes effect automatically after three years unless the legislature acts to stop it. Medicaid should pay for therapist services from the start. This approach scores highest when effectiveness and equity are weighted most, and remains close to the top when feasibility is weighted heavily.

The Problem

Untreated tooth decay is the most prevalent condition in the world, and oral diseases affect billions of people while receiving little attention from health systems (Peres et al., 2019). In the United States, the burden follows income, race and geography. Northridge et al. (2020) document lower dental use among low-income, rural, Black, Hispanic and American Indian residents and among people with disabilities.

In this state, the gap is visible in three numbers. Fewer than a third of dentists accept new Medicaid patients. Adult Medicaid covers only emergency extractions. And Medicaid claims show about 6,000 emergency department visits a year for nontraumatic dental conditions, most ending with a prescription rather than treatment. One of those patients, a young father in the far west of the state, died of a spreading tooth infection last winter after three offices would not book him. The problem is not a lack of dental science but a lack of anyone authorized and paid to provide basic restorative care where these residents live.

Why the System Produces the Gap

Three features of the American health system explain the gap. First, dental care is delivered almost entirely by private practices that locate where paying patients are, and a new dentist carrying heavy educational debt has little reason to open a practice in a shrinking farm county. Second, dental care is financed apart from medical care. Patients pay a larger share of dental costs than of any other service, and cost blocks dental care more than any other type of care, across income and insurance groups (Vujicic et al., 2016). Third, the licensing statute reserves the drill for dentists alone, while more than fifty countries rely on dental therapists, often in school programs (Mathu-Muju et al., 2013).

The Affordable Care Act eased the second problem for children but not adults. Medicaid expansion added tens of thousands of adults in the state, yet their dental benefit stops at extraction. Nationally, expansion raised dental visits mainly where adult benefits were generous and dentists were plentiful (Wehby et al., 2019), neither of which describes this state.

The Policy and Its History

The bill under analysis would license dental therapists to provide preventive care, fillings and simple extractions under a collaborative agreement with a dentist, limited to shortage areas and settings serving mostly public or uninsured patients, with direct Medicaid billing. It died in the House health committee in two sessions, each time after dental association witnesses argued that irreversible work belongs to dentists. Read through the streams model of Kingdon (2011), the policy stream was ready and the problem stream had data, but the politics stream, a committee chair allied with the association, was closed. A new chair, a governor who has named rural health a priority and a widely reported death have since shifted the streams.

Stakeholders

Nine stakeholders were analyzed using the position, interest and influence method of Varvasovszky and Brugha (2000). The decisive features are an imbalance of power and a contest of frames. The dental association has money, members in every district and credibility on clinical matters, and it presents the bill as a threat to patient safety. Tribal governments, community health centers, rural legislators and the governor's office support the bill and frame it as access, with tribes adding sovereignty over their own clinics. Patients, who stand to gain the most, have no organization speaking for them. The Medicaid agency is neutral but controls the billing rules any option depends on.

Options and Comparison

Four options were defined: the status quo; higher Medicaid fees with expanded loan repayment; authorization limited to tribal clinics; and statewide licensure as drafted. Following the advice of Bardach and Patashnik (2020) to make trade-offs explicit, the criteria were weighted before any scoring: 30 percent each for effectiveness and equity, 15 for safety, 15 for the odds of passage and implementation, and 10 for cost.

Table 1. Weighted Comparison of Options

Statewide licensure leads, but a sensitivity check that raises feasibility to 35 percent reverses the order of the top two options. The choice therefore turns on how much weight to give the chance of passage, which suggests a design that starts with the feasible option and builds toward the effective one.

Recommendation

The state should enact a phased dental therapy law. The first phase opens tribal clinics to therapists with federal tribal certification and obliges Medicaid to reimburse them. The second phase, written into the same bill, extends licensure statewide to shortage counties and safety net clinics three years later unless the legislature votes to stop it. The safety objection is answered with evidence and safeguards. In Alaska, communities with more dental therapist treatment days had fewer extractions and more preventive care (Chi et al., 2018), and the bill would limit scope, require referral rules in every collaborative agreement and report chart reviews to the dental board each year of phase one.

Implementation

The Medicaid agency would publish billing codes and a fee within six months; the health department would sign agreements with the three tribal health programs within nine; and the oral health program would build a reporting system and chart review protocol within a year, adding one data analyst. The main risks are a shortage of supervising dentists and slow Medicaid rules, both addressed by starting in tribal clinics, where supervising dentists are already employed, and by a joint work plan with dates. Progress would be reviewed every quarter against the five CFIR domains described by Damschroder et al. (2009), from the program's own design to the wider professional climate.

Evaluation

Outcomes in tribal clinics that add therapists will be compared with outcomes in matched clinics that do not, over a window running from two years before the start of phase one to three years into it, using Medicaid claims and clinic records. It tracks dental visits per 1,000 enrollees, the ratio of restorations to extractions, emergency department visits for dental conditions, routine appointment wait times and adverse events, with every figure split by rural, tribal and urban residence. The phase-one report in month 30 gives the legislature in-state evidence before phase two takes effect.

Communication

The committee will receive a one-page brief that pairs the story of the father who died with a single figure on shortage counties, states the recommendation in three sentences and answers the safety objection on its own line. State legislators favor short, local briefs that combine data with a story (Brownson et al., 2011) and rely on trusted sources from their own districts (Dodson et al., 2015), so the messengers will be a tribal health director and a rural legislator rather than agency staff.

Limitations

The strongest outcome evidence comes from Alaska's tribal system, which differs from this state in geography and payment. The weights and scores reflect judgment, which is why a sensitivity test was included. Cost estimates depend on a fiscal note not yet updated. And because the policy has not been tried here, projected effects remain projections until phase one reports.

Conclusion

The state's dental gap is a product of design: where private practices locate, how dental care is financed and who the law allows to provide it. A phased dental therapy law changes the third of these at modest cost, begins where it is most feasible and builds in the in-state evidence its opponents have asked for. It will not solve the financing problem alone, and the state should revisit adult dental benefits once therapists are in place. But it offers the clearest path to care for the residents who now wait months or drive hours for a filling.

References

Bardach, E., & Patashnik, E. M. (2020). A practical guide for policy analysis: The eightfold path to more effective problem solving (6th ed.). CQ Press.

Brownson, R. C., Dodson, E. A., Stamatakis, K. A., Casey, C. M., Elliott, M. B., Luke, D. A., Wintrode, C. G., & Kreuter, M. W. (2011). Communicating evidence-based information on cancer prevention to state-level policy makers. Journal of the National Cancer Institute, 103(4), 306-316. https://doi.org/10.1093/jnci/djq529

Chi, D. L., Lenaker, D., Mancl, L., Dunbar, M., & Babb, M. (2018). Dental therapists linked to improved dental outcomes for Alaska Native communities in the Yukon-Kuskokwim Delta. Journal of Public Health Dentistry, 78(2), 175-182. https://doi.org/10.1111/jphd.12263

Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4, Article 50. https://doi.org/10.1186/1748-5908-4-50

Dodson, E. A., Geary, N. A., & Brownson, R. C. (2015). State legislators' sources and use of information: Bridging the gap between research and policy. Health Education Research, 30(6), 840-848. https://doi.org/10.1093/her/cyv044

Kingdon, J. W. (2011). Agendas, alternatives, and public policies (Updated 2nd ed.). Longman.

Mathu-Muju, K. R., Friedman, J. W., & Nash, D. A. (2013). Oral health care for children in countries using dental therapists in public, school-based programs, contrasted with that of the United States, using dentists in a private practice model. American Journal of Public Health, 103(9), e7-e13. https://doi.org/10.2105/AJPH.2013.301251

Northridge, M. E., Kumar, A., & Kaur, R. (2020). Disparities in access to oral health care. Annual Review of Public Health, 41, 513-535. https://doi.org/10.1146/annurev-publhealth-040119-094318

Peres, M. A., Macpherson, L. M. D., Weyant, R. J., Daly, B., Venturelli, R., Mathur, M. R., Listl, S., Celeste, R. K., Guarnizo-Herreño, C. C., Kearns, C., Benzian, H., Allison, P., & Watt, R. G. (2019). Oral diseases: A global public health challenge. The Lancet, 394(10194), 249-260. https://doi.org/10.1016/S0140-6736(19)31146-8

Varvasovszky, Z., & Brugha, R. (2000). How to do (or not to do) . . . A stakeholder analysis. Health Policy and Planning, 15(3), 338-345. https://doi.org/10.1093/heapol/15.3.338

Vujicic, M., Buchmueller, T., & Klein, R. (2016). Dental care presents the highest level of financial barriers, compared to other types of health care services. Health Affairs, 35(12), 2176-2182. https://doi.org/10.1377/hlthaff.2016.0800

Wehby, G. L., Lyu, W., & Shane, D. M. (2019). The impact of the ACA Medicaid expansions on dental visits by dental coverage generosity and dentist supply. Medical Care, 57(10), 781-787. https://doi.org/10.1097/MLR.0000000000001181