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Dental licensure reform: The case for expanding interstate portability

August 24, 2021

By Jonathan Nash

The history of dental licensure reform over the past 50 years can be reduced to two main fundamental issues, both of which remain substantially unresolved:
• The outdated use of the clinical exam as a basis for initial licensure.
• The restrictions on license holders to freely relocate and practice in other states without facing the burden of having to take another clinical exam.

Photo of Dr. Nash
Dr. Nash

My arguments for the elimination of the clinical exam were presented in Part One. Part Two of this series is devoted to the second fundamental issue, known as “reciprocity,” “portability,” and “licensure by credentials.”

History and general considerations

The barriers for licensed dentists to easily move across state lines has been a sore issue for the dental profession for many years, especially when compared to the relative ease of licensure portability enjoyed by many other health professions.

In 1971, we were strongly advocating for some form of nationwide reciprocity. From an historical perspective, it is notable that the status quo remained mostly unchanged for 40 more years. However, in the past decade we have seen some significant movement in a positive direction.

In 2012 the ADA adopted a formal policy on this matter entitled “Licensure by Credentials,” which encouraged state boards of dentistry to accept pathways for licensed dentists that would allow for licensure without completing an additional clinical examination.

That policy stated, in part, that “requiring a candidate who is seeking licensure in several jurisdictions to demonstrate his or her theoretical knowledge and clinical skill on separate examinations for each jurisdiction seems unnecessary duplication. Further, the ADA believes that an evaluation of a practicing dentist’s theoretical knowledge and clinical skill based on his or her performance record can provide as much protection to the public as would an evaluation based on examination. Issuing a license using a performance record in place of examinations is termed licensure by credentials." Six years later, the ADA formed a licensure reform coalition with the ADEA and ASDA which resulted in the formation of the Coalition for Modernizing Dental Licensure and the promulgation of a landmark position paper in September 2018 entitled “Report of the Task Force on Assessment for Readiness to Practice” (TARP). With regard to the issue of portability, this report emphasized the need for a system of compacts between states in order to facilitate the licensing of dentists from other states. Currently, the ADA is partnering with the Council of State Governments, the Department of Defense, and the American Dental Hygienists’ Association to develop model legislation for interstate licensure compacts (see editor’s note below).

The current ADA policy on initial licensure and portability (which updated and replaced the 2012 policy statement referenced above) can be found here: Comprehensive Policy on Dental Licensure (Trans.2018:341).

Recommendations for breaking the status quo and making tangible progress: a challenge to the leadership of our profession

It has been difficult for me to realize that we are still discussing and complaining about these same fundamental issues that we were confronting 50 years ago when I served as ASDA’s first chair of dental licensure reform. As I lamented in the previous article, “friendly” debate and deliberation solely within the dental profession is obviously not an effective formula for success if we are to make tangible progress going forward.

Modifying state laws to provide for licensure by credentials (or other means for recognizing the license from other states without requiring applicants to take another exam) can be tackled on a state-to-state basis. As mentioned above, the ADA’s current initiative to develop model legislation for interstate licensure compacts is a good example of this strategy. However, once completed, these good ideas will need to be implemented using effective grass roots strategies such as the “Ohio Model” described in part one: https://www.dentallicensure.org/en/news-and-resources/dental-licensure-webinars.  Realistically, this is a long and arduous process.

Another potential avenue of pursuit that might be worthy of consideration deals with the anti-competitive implications of existing state barriers. The aforementioned TARP Report catalogued various antitrust concerns and initiatives since 2015. It highlighted the case of "The North Carolina State Board of Dental Examiners v. Federal Trade Commission," in which the Supreme Court held that state licensing boards are not automatically exempted from antitrust scrutiny, “although the extent to which the Court’s decision will in practice increase State licensing boards’ exposure to antitrust actions and constrain occupational regulation is unclear.” TARP also pointed out that the adverse effects of restricted portability have captured the attention of the FTC’s Economic Liberty Task Force, a Special White House Task Force, the National Bureau of Economic Research, and the U.S. Department of Labor.

As of today, a serious, well-funded challenge to the current status quo, from either a local or national antitrust/anti-competitive angle, has yet to be pursued by stake holders. There have been no legal challenges in state or federal courts, or via formal complaint to the appropriate agencies. However, I think that this approach warrants serious consideration, including strategic analysis based on consultation with legal scholars and lobbyists who have expertise in this area of the law. Even if it is deemed most appropriate to challenge individual State laws one at a time, several positive court decisions could have a domino effect on other States.

If our profession can summon the will to earnestly champion this cause, strong advocacy measures are required. Writing letters to Congress, appealing to individual state boards, signing petitions, visiting with politicians once a year on National Lobby Day, or promulgating strong-sounding resolutions has not worked and will not get the job done.

Inquiries and comments can be directed to: jnashdds@gmail.com. Dr. Nash was ASDA chair of dental licensure reform in 1971, and founder and chairman of the National Council for Improvement of Dental Licensure 1969-73.

Editor’s note: The ADA is partnering with the Council of State Governments, the Department of Defense and the American Dental Hygienists’ Association to develop model legislation for interstate licensure compacts that will offer an opportunity to create reciprocity among participant states to reduce the barriers to license portability and employment. The Council of State Governments will host a kickoff meeting to launch the initiative on Aug. 24 at 2 p.m. EST via Zoom. Leaders, subject matter experts and members of the dentistry and dental hygiene professions will discuss the future of dental profession licensure and mobility.