When I graduated from dental hygiene school in 2007, the job market in my area (Massachusetts and Rhode Island) was pretty favorable for us hygienists. If you had a license (and a pulse) finding a job was relatively easy. But then the 2008 recession hit and the strong demand for hygienists suddenly dropped. And the weak demand that followed remained for many years.
But throughout that same time, according to the Bureau of Labor Statistics, the positive, long-term (10+ years) job outlook for hygienists was never affected. And in those same years we also saw the number of accredited dental hygiene programs increase, which in turn, pumped out more and more graduates.
Many hygienists saw what was happening and wanted something done. They had questions for those in charge. What is the American Dental Hygienists’ Association (ADHA) doing to help us here? Why is the Commission on Dental Accreditation (CODA) approving new schools when so many hygienists can’t find jobs? In this blog post, I will explain what the AHDA and CODA did in response and then I will lay out why I believe their actions were wrong.
What did they do?
The following three questions were taken from a 2016 ADHA FAQ page that lays out what they did. (1)
Question 1
“Does CODA take into account the number of existing dental hygiene programs in a specific area when a new program is seeking accreditation?”
Question 2
“Does CODA take into account the saturation level of dental hygienists in a specific area when a new program is seeking accreditation?”
The ADHA essentially provides the same answer for both questions.
“When a new program applies for initial accreditation through CODA, the following is now included as part of the Initial Application.
1. Describe the results of the institutional needs assessment that provided the basis for initiating a new program.
2. Provide evidence based documentation of current and local/regional data which verifies an adequate patient population, qualified faculty and administration, and present employment opportunities for graduates.”
Question 3
“What is the ADHA doing to advocate on behalf of dental hygienists in regard to the proliferation of schools?”
Part of the answer includes the following:
“In 2010-2011, ADHA coordinated a letter writing campaign that resulted in CODA receiving nearly 700 letters from ADHA members expressing concern about the proliferation of programs and urging CODA to REQUIRE that new dental hygiene programs conduct a comprehensive needs assessment prior to applying for accreditation. CODA adopted this change February 3, 2012, with an implementation date of January 1, 2013.”
I’m sure most hygienists are applauding at this point, so let me now get into why I think you shouldn’t be.
Let’s first start with the big picture. Why does CODA accreditation (and other requirements) for dental hygiene licensure exist in the first place? Let’s look at some statements made by the actual entities that are involved in the process for the answer.
According to the 2019 National Board Dental Hygiene Examination (NBDHE) Candidate Guide. (2)
“The purpose of the NBDHE is to assist state boards in determining qualifications of dental hygienists who seek licensure to practice dental hygiene…State boards use the information provided by the NBDHE to help protect the public health.”
According to the ADHA (3),
“Licensure is a means of protecting the public from unqualified individuals and unsafe practice.”
According to the Central Regional Dental Testing Services, Inc. (CRDTS) (4),
“These examinations will demonstrate integrity and fairness in order to assist State Boards with their mission to protect the health, safety and welfare of the public by assuring that only competent and qualified individuals are allowed to practice dentistry and dental hygiene.”
According to the Commission on Dental Competency Assessments (CDCA) (5),
“…Committed to a national uniform examination process dedicated to the protection of the public through cooperation with state dental boards, testing agencies, organized dental and dental hygiene, and educational institutions.”
According to the New Hampshire Board of Dental Examiners (6),
“The Board of Dental Examiners is responsible for the protection of the public by governing and regulating the practice of dentistry and dental hygiene in New Hampshire.”
I could go on and on here, but I think you get the picture. The primary reason why the licensing of dental hygienists exists is clear. It is to protect the public. So how does restricting the number of dental hygiene schools relate to the mission of protecting the public? Well, it doesn’t and that’s the problem.
Unfortunately, the ADHA and CODA have fallen into a very predictable, historical pattern of behavior—abusing their monopoly power to artificially restrict the number of licensees in an occupation.
For those outside the dental profession, it is important to note here that all licensed dental hygienists in the United States (with very few exceptions) MUST graduate from a CODA accredited program to qualify for a license. So any change to the CODA accreditation process will in turn have a significant national effect. If that isn’t a monopoly then I don’t what is.
In his book, Stages of Occupational Regulation, economist Morris M. Kleiner lays out the goals occupations actually have, in the real world, when seeking government licensing. (7)
“Occupations evolve, organize, and often select licensing as a method to obtain professionalism, quality, and status, as well as to limit the supply of practitioners.”
The American Medical Association (AMA) may be the best example of this kind of behavior. In the book, Guild-Ridden Labor Markets, economist Morris M. Kleiner puts it in no uncertain terms. (8)
“In the United States the American Medical Association has for decades been one of the strongest labor unions in the country, keeping down the number of physicians, keeping up the costs of medical care, preventing competition by people from outside the profession with those in it; all, of course, in the name of helping the patient.”
Kleiner goes on to say,
“The publication of the Flexner Report in 1910, sponsored by the American Medical Association (AMA)…recommended that the number of openings in medical school be limited.”
Milton Friedman, another economist who has studied this issue in depth, comes to the same conclusion. The following excerpts from his book Capitalism and Freedom, highlight the importance of controlling the schools. (9)
“The essential control is at the stage of admission to medical school.”
“The efficient way to get control over the number in a profession is therefore to get control of entry into professional schools.”
…it is the provision about graduation from approved schools that is the most important source of professional control over entry. The profession has used this control to limit numbers.”
Like the ADHA and CODA, the AMA has had the audacity to impose, or tried to impose, requirements that have nothing to do with protecting the public and everything to do with limiting numbers so as to benefit the economic self interests of current practitioners. Milton Friedman gives a few examples. (9)
“The power of the Council on Medical Education and Hospitals of the American Medical Association has been used to limit numbers in ways that cannot possibly have any connection whatsoever with quality. The simplest example is their recommendation to various states that citizenship be made a requirement for the practice of medicine. I find it inconceivable to see how this is relevant to medical performance. A similar requirement that they have tried to impose on occasion is that examination for licensure must be taken in English.
A dramatic piece of evidence on the power and potency of the Association as well as on the lack of relation to quality is proved by one figure that I have always found striking. After 1933, when Hitler came to power in Germany, there was a tremendous outflow of professional people from Germany, Austria and so on, including of course, physicians who wanted to practice in the United States. The number of physicians trained abroad who were admitted to practice in the United States in the five years after 1933 was the same as in the five years before. This was clearly not the result of the natural course of events. The threat of these additional physicians led to a stringent tightening of requirements for foreign physicians that imposed extreme costs upon them.”
The Institute of Justice’s national study, License to Work, sums up this historical, and current, behavior of licensed occupations quite well. (10)
“More than 200 years ago, Adam Smith observed that trades conspire to reduce the availability of skilled craftsmen in order to raise wages, and modern public choice theory and social science research demonstrate little has changed since that time.
Occupational practitioners, often through professional associations, use the power of concentrated interests to lobby state legislators for protection from competition though licensing laws. Such anti-competitive motives are typically masked by appeals to protecting public health and safety, no matter how facially absurd.”
Again, I could go on and on, but you get the point. Clearly, one of the primary reasons why occupations seek and maintain licensure is to artificially restrict entrants into that occupation and unfortunately, dental hygienists are no exception.
But there are some hopeful signs that this kind of behavior may receive the legal scrutiny it deserves. Following the Supreme Court case North Carolina State Board of Dental Examiners v. FTC (2015), dental boards now seem more open to antitrust violations.
In a legal journal article titled, Foxes at the Henhouse: Occupational Licensing Boards Up Close, the author describes what the response has been to this Supreme Court case. (11)
“North Carolina Dental prompted two responses: (1) a barrage of antitrust lawsuits against licensing boards, and (2) a panic among state officials seeking ways to immunize their boards from further suit.”
In another legal journal article titled, Cartels by Another Name: Should Licensed Occupations Face Antitrust scrutiny? The authors lay out what may be coming. (12)
“Licensed occupations have been free to act like cartels for too long without Sherman Act scrutiny. With nearly a third of workers subject to licensing and a continuing upward trend, it is time for a remedy.
Immunity from the Sherman Act on state action grounds is not justified under antitrust federalism when those doing the regulation are the competitors themselves, where they are not accountable to the body politic, where they have too often abused the privilege, and where the anticompetitive dangers are so clear. The threat of Sherman Act liability can provide the necessary incentives…Without it, self-dealing occupational boards will continue to be cartels by another name.”
The facts here seem painfully clear. Reducing the number of dental hygiene schools has nothing to do with protecting the public and has everything to do with protecting the economic self interests of current dental hygienists. As a hygienist myself and as a person who strongly believes in economic liberty, these actions taken by the ADHA and CODA are, to say the least, very disappointing.
Links
(2) https://www.ada.org/~/media/JCNDE/pdfs/2019_NBDHE_Guide.pdf?la=en
(3) https://www.adha.org/licensure
(4) https://www.crdts.org/Default.aspx?PageID=25
(5) https://www.cdcaexams.org/about-the-cdca/
(6) https://www.oplc.nh.gov/dental/
(7) https://research.upjohn.org/up_press/222/
(8) https://research.upjohn.org/up_press/236/
(9) https://www.press.uchicago.edu/ucp/books/book/chicago/C/bo18146821.html
(10) https://www.ij.org/report/license-to-work
(11) https://scholarship.law.berkeley.edu/cgi/viewcontent.cgi?article=4380&context=californialawreview
(12) https://scholarship.law.upenn.edu/cgi/viewcontent.cgi?article=9440&context=penn_law_review
Thanks for shedding needed light on this very important issue. Another issue that I would like a flood light to hit is CODA – controlled by the ADA and not a hygiene association. Totally unacceptable!
Trisha, who or what part of the ADA has control over CODA?
It is my understanding that CODA functions independently and is autonomous in matters of developing and approving accreditation standards, making accreditation decisions on educational programs and developing and approving procedures that are used in the accreditation process.
Like Dental Boards, they are “independent” on paper, but in reality they are significantly moved by self interest.
What the economists and ivy-tower thinkers do when they expound on “the evils” of professional licensure is that they fail to describe what ought to take its place…leaving the public with the idea that they ought to petition the legislature to do away with professional licenses. What then?
I would encourage you to read what the economists actually say. They have plenty to say about what you believe that haven’t said. In the case of Milton Friedman he supported certification over licensure. Go on YouTube and watch his talk to the AMA.
Can you briefly describe the support for certification over licensure? What are the major differences? Do others that speak on this subject agree with Milton Friedman or are there different proposals?
I have a future blog post planned to address this very point. Stay tuned : ).
I mistakenly believe they don’t say more because they speak about it just like you did. You spoke about the “evils” of licensure. You didn’t speak to a preferred alternative if professional licensure were to be abolished.
And, BTW, CODA is not involved in licensure…just school accreditation. I don’t understand the self-interest accusation there.
I prefer private certification. Every state dental board requires graduation from a CODA approved program to qualify for a license (with VERY few exceptions). The ADHA petitions CODA to use its monopoly power to, in effect, limit the number of schools which will in turn limit the number of entrants into the profession. This change will economically benefit ADHA’s current members. You don’t see self interest there?
I mistakenly believe they don’t say more because they speak about it just like you did. You didn’t speak to a preferred alternative if professional licensure were to be abolished.
And, BTW, CODA is not involved in licensure…just school accreditation. I don’t understand the self-interest accusation there.
Can you briefly describe the support for certification over licensure? What are the major differences? Do others that speak on this subject agree with Milton Friedman or are there different proposals?