Your scheme looks pretty I guess for anti-government types on paper, but you obviously do not know what you are talking about with respect to the allied health professions. No really, I’m not trying to insult, I’m observing that you have no knowledge or understand about what the various roles and layers of health care delivery are, or the skills needed to practice. Your scheme may work for, say, the accounting profession, where malpractice and incompetence might cost you a lot of money, but won’t end in your serious bodily injury or your death. I’d just make the observation that sometimes, under some conditions, the state is the most logical entity to perform the function of licensing and certification.

With that, I’ll withdraw from this futile exercise.

Regarding what salary is efficient, it’s the salary that markets set absent any externalities. You can make an efficiency based arguments for occupational restrictions: the restrictions have value because there is some optimal amount of restriction, and so the costs are offset by the benefits. But if restrictions are too high, then the costs to the customer are not fully offset by the benefits the restrictions provide. Even if you agree with licensing overall, you can agree that in general licensing sets barriers too high or restricts competition too much, in which case wages are inefficiently high. A prime example is the restrictions on foreign dentists. If a dentist is legally allowed to practice in France, Germany, the U.K, Japan, Sweden, Finland…. or any developed country, then US citizens should be allowed to purchase their services full stop. You can make the case that it must be mandated that they reveal where their license is from. This is an inefficient restriction, and so are many others employed in many states, especially overly restrictive limits on hygienists. Thus as long as restrictions like this exist that are more stringent then they should be, competition is more restricted than it should be. OR if there is an equal or lower cost way to get the same level of quality increase then wages are also inefficiently high.

On your other points, obviously the AMA will and has tried to set up barriers to entry, and a primary tool they used was the legal system. My view on occupational licensing overall is that the legal system will be manipulated by these vested interests and so the government should limit it’s functioning as much as possible to ensuring that nobody lies, that good information is readily made available, and that there is competition among credentialing systems. Given that a state is going to license, and I have laid out cases elsewhere where this may make the most sense, they should be very minimal. States should look to other states that have less licensing then them and question whether their more restrictive regimes do actually provide more quality. Their should be cost-benefit applied and the onus should be on those calling for more strict licensing that other states use to prove that it increases quality, and not vice-versa. Anti-trust authorities with a history of cost-benefit should perhaps be given scope to strike these laws down.

With respect to nurse practitioners, physicians assistants, and dental hygienists, there is a wide variation state-by-state in how independent they are allowed to practice and yet I haven’t seen any studies demonstrating that these restrictions increase quality and that any potential increases in quality outweigh the costs. You can tell a story about why hygienist licensing came to the fore due to safety concerns, but the more restricted hygienists are the better it is for dentists economically, and so while your reasoning may have provided justification for proponents to legislators, there was a lot of economic incentive for dentists to push for this as well. Given this we should demand good cost-benefit analysis.

You can be very concerned about quality and health and having well trained professional without supporting occupational licensing. And even if you do support it in general, there needs to be large reforms that prevent entrenched interests from using it as a tool to restrict competition.

In the early years, the AMA, which views the provision of medical care as a “scarce resource,” took the responsibility for “credentialing” physicians. In doing that they undertook to limit the number of available slots in medical schools and to make it prohibitively expensive to earn a medical degree. They were also, as you noted, responsible for dictating what kinds of tests and procedures could be delegated to the allied health professions.

Well, those barriers that they constructed began to fall, especially in the 1970′s, as you noted with respect to D.O.s a little earlier than that, and in the 1990′s with respect to physician assistants and nurse practitioners. But they still exist in some form. There are still limitations to available slots in American medical schools and we know that attending medical school is prohibitively expensive. The AMA is involved in retaining these barriers, but how they do that is rather opaque — whether it is conspiratorial dealing in a smoke-filled room, or based on data-driven models, very few people know. That’s about as anti-competitive as you can get.

But motivated students can overcome these barriers by attending offshore med school, becoming D.O.s, etc. And if they pass the state licensing exam, they can practice medicine, without the sanction of the AMA. That, in fact, makes the state licensing boards pro-competitive, not anti-competitive. In fact, it is in the state’s interest to have a large pool of qualified health practitioners available to their citizens.

All this to say that your scheme to do away with state licensing and leave credentialing to the professional societies will almost certainly make the problem worse, not better. It is the professional societies whose interests are served by limiting slots, constructing barriers to entry, limiting the ability to delegate routine procedures and so on. It is not in the state’s interest to do that. Do I think that state licensing boards are perfect? No, I don’t. I just think they are better able to assure the citizens of their state that a prospective health provider is able to competently do the job than a self-interested professional society.

As for dental hygienists. Historically, office physicians and dentists have not been required to employ licensed and credentialed staff *in their office practice*, because the staff works under the auspices of the professional’s license. Thus you can have unlicensed medical assistants performing procedures in doctors’ offices that in a hospital setting requires a registered nurse to perform, with just a few exceptions. Same with staff in dentist offices. They don’t *have* to be credentialed. The credentialing of dental hygienists, and nurse practitioners, came to the fore when the issue of direct compensation was raised — early 1990′s there was a big push to delegate routine procedures to allied staff to reduce the cost of providing health care. When direct compensation became a reality, the necessity for credentialing and licensing became more urgent. There has been somewhat of an inflationary effect there: a dentist may only want to hire a licensed dental hygienist, because 1) the compensation is there; 2) he won’t have to do the training; 3) he can protect himself and his patients from egregious lapses. Back in the fee-for-service days, staff were trained for this kind of stuff in house. That very rarely is the case any more.

I’d like to know why you believe that a dentist’s earnings — these are small businesses — is “inefficient.” Fair compensation is compensation that will pay one’s expenses, including education expenses, one’s overhead including staff, and provide a satisfactory salary or profit to the practitioner. If you want that compensation reduced, the first place you want to work on is the prohibitively expensive education. Actually getting your state license is the absolute least expensive part of the entire process.

Look, it’s a problem that is far more complex than you make it out to be. I was put off by your assertions of deep dark conspiracies and simplistic “state bad! ADA good!” solutions, instead of actually looking at the realities and complexity of health care delivery and proposing rational solutions. I’m not aware of any rigorous studies on the efficacy of licensed vs. unlicensed dental hygienists, but I’ll certainly take a look and send them your way if they exist. I’d be extremely surprised if any such research exists. One can, of course, find anecdotal news articles about horror stories related to transmitting HIV via unsterile invasive procedures and the like.

In fact, the rarity of such events speaks volumes about the effectiveness of state licensing procedures with respect to determining competency to practice, no?

I think angie’s list is a good model for non-government certification. As far as whether competing models can make a difference I have to disagree. The example that Teach For America in contrast to standard government mandated certification procedures has provided is really important in the education reform debate.

To your last question first: I don’t know what “just compensation” is, do you? How do you know this? I do know that for unlicensed occupations wages are determined in a competitive market, unlike wages for dentists. So I don’t know what “just” is (and neither do you), but I do know what inefficient is, and this is it.

You point to the AMA as an example of why credentialing by private organizations would be counterproductive, but do you think that the emergence of Osteopaths as a competitor to the AMA was a good thing or a bad thing? And the fact of the matter is that the AMA was so successful in it’s preventing competition from arising was by utilizing state licensing and other legal barriers as a tool to prevent competition. To take one example, in the 1950s in Kansas Osteopaths were by law not allowed to prescribe medicine or perform surgery.

Your characterization of licensing boards as simply setting minimum standards in an objective fashion only to ensure safety is quite contrary to the evidence. The fact of the matter is that 20 states already allow hygienists direct access to patients. Where are the studies showing that this has lead to the deaths and diseases your predicting? The lack of evidence of negative effect clearly suggests there is a non-quality, anti-competitive motivation for these regulations.

As far as foreign dentists go, I don’t think the reality as sanguine as you make it seem. For starters, dentists practicing in the US must have graduated from an education program accredited by the ADA Commission on Dental Accreditation. Some states are more strict then others, but if you were allowed to practice dentistry in France, Germany, Japan or some other developed country why should you require any additional tests to practice here?

Unlike blogging, where someone is free to make as much money as they please pulling wacky, irrational opinions out of their ear, based on no knowledge whatever, to advance their personal ideology (and more power to you), and there is no actual harm done except to subtract from the sum total of human knowledge and make bloggers over at the Dish even dumber than they already are, poking around people’s bacteria- and blood-rich orifices with drills and probes and the like requires actual knowledge and care of established professional standards: dentists (and dental hygienists) have to know what they are doing. Bloggers, on the other hand, need have no qualifications or knowledge whatsoever to post any kind of theory or argument. Thus, there is no licensing requirement there.

And the ADA, in their own interest as a professional organization, plays a strong advisory role in setting those minimum standards, as well as an advisory role in setting standards for graduation from professional dental schools. No, the state isn’t obligated to adhere to ADA standards. Nor are professional schools. There are a number of foreign schools that graduate professional dentists (and medical doctors) that aren’t “approved” by the ADA (or AMA). They are free to practice if they pass the state licensing exam.

Other organizations are free to issue their own criteria for determining competency. In fact, there are a number of professional organizations that credential dentists in a particular specialty — oral cosmetic surgery, for example. Other professions, like medicine and nursing, do the same thing. That doesn’t absolve the practitioner from complying with the minimum standards of the various states in order to do business in that state.

In fact, experience has shown that leaving professional credentialing to professional organizations rather than a government entity results in *more* exclusivity and *higher* professional costs for service. You can look at the early experience with the AMA to realize that it would be counterproductive to your purported aims — lower barriers to entering the profession and lower cost for the service. (Which, by the way, I share.)

Evidently you are arguing for cheaper dentistry (and other professional services) and believe that jettisoning minimum standards of practice should do the trick. But I contend that the state has a legitimate interest in protecting citizens by insuring that people who do invasive procedures on human beings should be able to demonstrate a minimum level of competency and accountability in order to do that kind of business in the state, under the force of law. I also contend that the licensed practitioner has every right to be compensated for his services such that the years he spent acquiring the knowledge, skills, and abilities to perform those services provide him some benefit.

I presume you aren’t against just compensation for one’s work.

Alternative credentialing regimes and opposition to licensing are not an ideologically motivated position as you assert, but are in fact just the application of labor economics. There are many liberals who are critical of licensing.

Regarding the ADA, you’re clearly very familiar with the details of the regulation here -although who does the licensing body is not really pertinent, the issue is that some organization is granted a monopoly on licensing- but is there a state whose dental board will grant you a license if you haven’t attended an ADA accredited program? And does the ADA not set the minimum accreditation standards for the required degree programs? My point is that the existing institutions who determine what is required to be licensed may continue to set there own standards, and they may issue and take away credentials in the same way the currently issue licenses, and governments can endorse these standards. That’s fine. But other credentialing organizations should be allowed to offer competing standards.

You are right, though, that it is a big problem for people who are uninsured or otherwise lack access to needed treatment. But I hardly think that allowing unlicensed goofballs without the knowledge, skills, and abilities to provide safe and effective treatment is a good answer to the problem. Perhaps better and more affordable access to qualified practitioners is a better answer.

People are free to go to their mother-in-law’s cousin Jimmy-boy to get a tooth pulled, and if he uses an unsterile pipe wrench to do the job, well that’s their problem. Who pays the hospital bill resulting from hemorrhage or systemic staph infection, then?

But a person who proposes to *go into business* performing semi-invasive procedures in the bacteria-rich orifices of 20 or 30 or 50 people per day, and charge money for it, should be able to demonstrate the knowledge, skills, and abilities to do that in a safe and acceptable manner. Thus, the state requires the requisite education and knowledge, and the demonstration of skills and abilities to do that, and requires that the facilities that perform the procedures have minimal standards of equipment and sanitation, and that the practitioner demonstrate the wherewithal to be accountable for egregious lapses in standards of practice.

You are probably an advocate of “malpractice reform” too, aren’t you? Your personal ideology trumps all common sense.

As to the unlicensed clinics you mention, that’s exactly the problem I’m talking about: the higher the legal barriers, the more people will be pushed into this market. And no, contrary to your claim it’s not just fools, but also the uninsured and people who can’t afford treatment.

On the other hand, people of normal intelligence have an interest in knowing that a dentist and staff that they might patronize have a basic competence, and they also have an interest in having recourse against an incompetent practitioner. And the state has an interest in holding practitioners of professions such as dentistry responsible for basic knowledge and competence in their profession before they do business with the public, and for doing business according to professional standards of conduct. Licensing is meant to do that, with the loss of the license, and concomitant inability to do business in the profession, as the means to protect the public. Beyond that, the average dentist-goer doesn’t have the tools or the background knowledge to be able to judge medical competence.

I’d venture to opine that the average client of the local dentist isn’t interested in your attempt to shoehorn your ideology into the quality of their medical care. Your comparison of dentists with lawnmower mechanics is just silly.

And you would hold the median dentist and dental hygienist doing business in your state accountable for competence, and ensure recourse for harm done, exactly how?

Your second claim is that the dentist puts his license on the line and vouches for the hygienist, and that this is the best or only way to ensure high quality. Again, in many careers where lives are at stake other institutions exist that can ensure quality. You and many other commentators seem to be suffering from status quo bias.

You must also keep in mind that the higher the regulatory barrier to entry, the higher the cost impact will be, which is more likely to push people into black markets. We’ve certainly seen this before with dentistry.

First of all, your teeth have a relatively thin layer of enamel protecting the inner structure of the tooth, including the nerve root. Enamel doesn’t grow by itself. Therefore, if an incompetent person damages your enamel, it doesn’t come back and must be replaced by expensive oral surgery. If you choose not to get the damage repaired, the bacteria in your teeth will soon rot the inner structures of the tooth down to the nerve root. Think about that for a moment.

Secondly, the tissue in your mouth, the gums, cheek, lips and so on, are highly sensitive, quite delicate, and quite rich in blood vessels. The gums can be easily damaged to the extent that transplanting tissue from the upper mouth cavity is necessary to save the tooth. Fum transplants are also very expensive. Add to that the fact of the bacteria — streptococcus, staphylococcus, mainly — reside in substantial quantities in the mouth. Injuring the delicate tissue of the mouth can result in bad infections, even catastrophic infections if the bacteria is pushed into the blood vessels, traveling to the heart valves, or worse, the brain. There are cases of incompetently done teeth cleaning resulting in multi-organ failure and death. Rare, but not unknown. Lack of good sterile practices can result transmission of other infections, including HIV.

It’s not like writing up some theoretical musing on a blog post, no harm done if one gets it wrong. One wants one’s dental hygienist to know what s/he is doing. The dentist hires or contracts with the hygienist and implicitly guarantees that s/he is qualified. So that’s why the dentist’s license is on the line. Because you go to your dentist, you assume that s/he’s qualified by virtue of his license, and that the staff is qualified, and so you allow the hygienist to get in your mouth and poke around with the hope and the confidence that the person isn’t going to destroy your gums and your teeth or cause you to contract a fatal staph infection.

So no, it isn’t some devious conspiracy to pump up wages and subjugate women in female dominated professions to male-dominated professions. The licensing of both the dentist and the hygienist, and the supervision of the hygienist by the contracting doctor is a way to protect the public from random doofuses with drills and sharp objects from poking around your mouth without accountability.

Much the same argument can be made with respect to nurse practitioners working under the supervision of a physician. I can go into detail, if you wish.