of Compact Privilege, but they do not surrender final authority over who may work in the state. Why Licensure Portability? One commonly cited policy idea for addressing dental workforce challenges is licensure portability. Proponents of licensure portability argue that by smoothing the process of transferring licensure, labor markets can be strengthened, and workforce challenges can be alleviated.2 The argument goes that compacts facilitate mobility, ease administrative burden, and expand employment opportunities into new markets: In turn, this mobility benefits everyone by freeing the market to do what functioning markets do. Opponents cite concerns about patient safety and quality of care, and for dental boards, there is a particular concern about variation between states in the examination of prospective licensees, especially related to hand skills.6 Arguments in favor of interstate licensure for dentists and hygienists typically track with broader ones about interstate licensing in general, but like other healthcare professions, legitimate reasons for licensure demand careful assessment of any proposals that would lower necessary standards. Some professions lend themselves to easy reciprocity between states’ licensing boards. It is unlikely that a bad haircut or a poor flower arrangement will lead to a lifethreatening or life-altering event.8 In these kinds of scenarios, differences in state law do not matter all that much, but reducing the number of practicing surgeons with suboptimal skills matters quite a bit to the people being operated on. The Current and Future State of Georgia’s Dental Workforce Georgia’s current status shows some workforce shortfall and significant distributional challenges. Georgia currently has 5,211 dentists, all specialties, in its workforce, and it has 6,193 hygienists. The math works out to 49 dentists and 58 hygienists per 100,000 people.9 Density varies by rurality, with as many as 100 dentists per 100,000 people in Fayette County, and 0 per 100,000 people in more than 20 other counties. Over 40 Georgia counties have one dentist or less. Dentist Subset All Dentists <10 Years 10+ Years 2019 Count 4,572 1,093 3,479 Remained in State 4,399 980 3,419 Left State 173 113 60 Entered State 290 207 83 2022 Count 4,689 1,187 3,502 Net Migration 117 94 23 Net Migration Percent 2.6% 8.6% 0.7% SOURCE: ADA Health Policy Institute11 Absolute numbers only provide part of the picture. The Health Resources and Services Administration (HRSA) uses economic models to estimate supply and demand for the healthcare workforce. HRSA estimates that the 2024 supply of general dentists in the United States can adequately meet 98% of demand, and they project that in 2036 supply will meet 95% of demand.10 Georgia’s supply is estimated to be 86% of demand, trending positive to 93% by 2036.10 Georgia’s hygienist supply is 73%, moving to 76%. In both cases, HRSA predicts Georgia’s workforce will better match local demand even as national supply and demand diverge.10 The supplementation of Georgia’s dental workforce is, in part, the result of positive net migration. Dentists with under 10 years of experience, those most likely to move, are moving to Georgia more frequently than dentists leave (Table 1).11 Georgia’s net migration of new dentists is 7th in the nation. Table 1. Migration Flow of Georgia Dentists by Experience 2019-2022 How Could Expanded Licensure Portability Impact Georgia Dentistry? To assess DDH’s potential impact on Georgia dentistry, one must first clarify exactly what compacts, and other interstate licensing laws, actually do. Existing studies provide a poor comparison for dentists. They either look at universal licensing recognition (ULR) for a variety of professions, or they examine health compacts designed for people, such as nurses and physicians, whose practice, clinical and business, differs from the dental profession.12–15 Dental practice, particularly for owners, is distinctly local and hands on. Several findings are still worth consideration. Universal licensing measures broadly do not appear to incentivize movement, but compacts may help determine the destination of those inclined to move.12,13,15 One study did find a slight uptick in nurse outflows between compact states.16 Border counties are of particular interest since they are places where interstate practice is enabled by proximity.12,14,15 ULR/compacts for some professions, specifically nurses, may promote cross-border work. Physicians appear to expand their interstate practice, likely in partnership with large multistate hospital systems, with a compact in place, but physicians in border counties were likely already invested in local cross-border practice before compact formation.15 Add to this one final open, and difficult to answer, question: At what point does quality start to slip as licensing standards are eased? The argument between some and no licensing is easy to settle, but parsing out the influence of individual licensing requirements can be methodologically difficult.17 Several of the studies focused on dentistry have produced mixed or null results when asking what quality enhancement variation in standards brings to patients.17 Given the limited evidence, DDH may present an opportunity to better study this question as states opt in to membership at different times. In sum, predicting the impact of Georgia’s membership in DDH is difficult. Without being able to observe DDH in action, conjecture is all that remains. Compact membership is unlikely to have a large impact on Georgia’s most pressing workforce challenges, particularly as relates to the distribution of providers or the supply of hygienists. DDH may open new business opportunities for dentists involved with larger health care entities. It may also allow dentists to practice in Georgia without the same clinical testing that is currently required. The unknowns currently outweigh the knowns, but Georgia, thanks to its current circumstances, need not rush to seek compact membership. | 13 Jan 2025
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