As the dental profession debates its own issues regarding costs and access to care, the dental workforce and dental education, so too are the other health professions. We would suggest that most of our dental workforce is, at best, only casually familiar with how our sister professions examine their own educational requirements, workforce demands and scope-of-practice issues. We argue that dental patients and dentistry will benefit by being fully engaged in a process to remake the U.S. health care system.

A perfect storm is brewing in the U.S. health care system, resulting from an aging population, increases in the frequency of chronic diseases, increases in the percentage of underinsured or uninsured people, and workforce shortages. The net result: more people with more complicated health problems seeking help from a system of treatment-delivery silos.

In addition, health care spending continues to increase at the fastest rate in our history. In 2007, total national health expenditures were expected to rise 6.9 percent—two times the rate of inflation.¹ Total spending was $2.3 trillion in 2007, or $7,600 per person. Total health care spending represented 16 percent of the gross domestic product (GDP). U.S. health care spending is expected to increase at similar levels in the next decade, reaching $4.2 trillion in 2016, or 20 percent of the GDP.¹

Yet, medical errors remain a leading cause of death and injury at hospitals nationwide, resulting in nearly 240,000 potentially preventable deaths per year.² The three main national health care issues are controlling costs, providing care to the uninsured and improving quality of care. According to Federal Reserve Chairman Ben Bernanke, the combination of millions of aging baby boomers and rapidly rising health care costs is accounting for a burgeoning share of both individual and government budgets—a burden that will only increase unless changes are made.³

Dentistry has enjoyed being, on one hand, part of the health care system (we treat patients and interact with other providers as needed) and then, on the other hand, not part of the health care system (our business and reimbursement systems, for good reasons, are totally separate from those of most other medical care providers). This has been a good place to be for the profession and likely will remain so for the time being.

However, the continued application of biomedical science to dentistry, the increased understanding that good oral health is important to overall health and the rising costs of all health care will continue to bring the practice of dentistry closer to the other health care professions. This should not be viewed negatively. On the contrary, it should be viewed as an opportunity to share what dentistry does best and to learn from the emerging issues in the other health fields. If the dental profession chooses to withdraw from the national debate, it stands to lose millions of dollars in reimbursements, and public health—particularly for the poor and underserved—will suffer. The recent announcement by California Gov. Arnold Schwarzenegger about the elimination of adult dental benefits for Medi-Cal recipients due to state budget shortfalls⁴ demonstrates that oral health care funding can be an easy target for funding cuts.

The Kaiser Family Foundation has reported that 46 million Americans lack health insurance coverage⁵ and that for every 1 percent increase in unemployment, the number of uninsured increases by 1.1 million.⁶ A recent study indicates that people without health insurance receive less care and experience less complete recovery from accidents and early onset of chronic illness than do people who have health insurance.⁷ These same medically uninsured people also have poorer oral health and decreased access to dental care.

Elderly people in long-term care facilities are among those at greatest risk of experiencing severe oral disease. The U.S. Census Bureau projects that the number of Americans aged 65 years and older will increase to more than 71 million by 2030—an increase of 30 to 35 million.⁸ Heart disease, cancer, pulmonary conditions, hypertension and diabetes are among the conditions that account for the greatest spending on health care.⁹ These all are conditions that are likely to increase in prevalence as the population ages.

What will this mean for dentistry? We suggest that we will see increased numbers of people with greater levels of oral disease and poorer general health who are left untreated. The health care system as it is currently operated and paid for, including dentistry, cannot serve this increasing segment of our population.

Shortages in the health care workforce will affect the access to and the quality of care. Using data from the U.S. Department of Labor Bureau of Labor Statistics, Collier¹⁰ estimated that the percentage change in the number of job openings in health care fields between 2004 and 2014 will range from 56 percent for home health aides to 13.5 percent for dentists. Positions for registered nurses will increase 29.4 percent, for physicians and surgeons 24.0 percent, for pharmacists 24.6 percent, for dental hygienists 43.3 percent and for physician’s assistants 49.6 percent. In nursing alone, it is estimated that to meet the increased demand for services and to replace an aging workforce, 1.2 million additional nursing graduates will be needed by 2014.¹⁰

The Association of American Medical Colleges¹¹ (AAMC) issued its Statement on the Physician Workforce in June 2006, calling for a 30 percent increase in the number of medical school graduates by 2015. This would increase the annual matriculation in medical schools by nearly 5,000. The association also called for increases in the number of residency positions to provide slots for the additional graduates. According to AAMC,¹² physician shortages as high as 200,000 could be seen by 2020 unless medical school enrollments are increased.

The quality and cost of care is further complicated by the declining interest among medical students in entering primary care specialties such as family medicine, pediatrics and internal medicine.¹³ This is explained mainly as a flight to the higher-paid specialties because of the rising debt incurred to complete a medical education and residency training. With declining interest in primary care and the overall shortage of physicians, the cost will increase and access to treatment will decrease, particularly for the management of chronic disease. One solution is to direct more primary care to nurse practitioners, physician assistants, pharmacists and other providers.

There are emerging changes in the required and recommended training time and earned degree levels for some health workforce areas that will affect quality and cost of health care. The entry-level degree for pharmacists is a doctoral-level degree, requiring four years of education beyond the prepharmacy undergraduate preparation. Physical therapy programs also are moving from a master’s-degree program to a doctoral degree program for entry to practice. The American Association of Colleges of Nursing supports specialization in nursing practice at the doctoral level and lists on its Web site more than 70 nursing schools accepting students into Doctor of Nursing Practice programs.¹⁴

This trend toward professional doctoral degrees in fields that historically have required a bachelor’s or master’s degree as the entry-to-practice degree is causing concern that we are seeing "degree creep" rather than increased skills and knowledge.¹⁵ There is concern that increases in degree levels will exacerbate the workforce shortages, increase the cost of education, increase labor costs and create confusion about the title of "doctor."¹⁰

The proponents of professional doctoral degrees argue that this trend leads to increased knowledge and skills and better patient care. The detractors say it is driven by the desire for the professions to increase their stature within the health care system and perhaps to increase salaries. Concerns already exist about shortages of faculty to teach the future health work-force.¹⁶ Collier,¹⁷ using Bureau of Labor Statistics projections, found schools lacking in capacity to graduate sufficient numbers of students to meet the projected employee demand. Elevated degree levels to qualify for entry to practice will reduce the pool of faculty members qualified to instruct at the higher level, thus further reducing the training capacity of our health sciences schools.

How can the dental profession engage in and contribute to the national discussion? First, encourage a shift from a treatment to a prevention framework. If everyone in the country had basic health insurance coverage and sought the care they needed, who would provide the care and how long would it take to be treated? Uninsured people are a major problem, but perhaps even larger are the problems of our health care delivery system and the lack of emphasis on disease prevention. We have a "sick care" system rather than a "health care" system. To its credit, dental education and practice have emphasized oral disease prevention, while medical education has lagged in teaching prevention as a first step in treatment.

Second, call for greater integration of health care delivery and public health practice. The most costly health problems all have some origins in unhealthy behaviors. Dentists, dental hygienists and dental assistants are among the few practitioners who are experts in trying to change patient behavior to improve health, and organized dentistry has experience in working collaboratively to infuse preventive dental care into the school system, public health clinics and private business.

Third, push for improved coordination and quality of care through workforce reform. We should begin to discuss and debate the very nature of our health care system, which has developed out of historical silos of education and training, each with its own standards of accreditation. This is further complicated by state-by-state variations in scope of practice.

It appears to be time for educators, providers and the government to look at a more comprehensive and coordinated continuum of providers. Rahn and Wartman¹⁶ called for a national commission on the health care workforce to serve as an advising body. A common-sense approach to matching patients’ needs to appropriate levels of training and practice authority are needed now more than ever. Dentistry should set an example by examining its own work-force issues with the goals of controlling costs, improving access to care and improving quality of care.

In summary, as a profession, dentistry has much to offer in redesigning the health care system to control costs and to increase access to and quality of care. Dentists should not stand on the sidelines. We should encourage a national emphasis on disease prevention beyond oral disease and actively join discussions on the form and function of the entire health care system. We should increase our linkages with other professional associations and educational groups for the purpose of improving the coordination among health care providers to improve health outcomes and lower costs.

Most importantly, we need to pay attention to the entire scope of health care delivery and education of the health care work-force for what we can learn and apply to dentistry. Our patients and our profession will benefit. If we remain on the fringes of the debate—rather than being fully engaged—policy decisions will cause the services we offer to slip among health care priorities.