The dental safety net system is made up of

Are Dental Schools Part of the Safety Net? Howard L. Bailit, DMD, PhD Abstract: This article examines the current safety net activities of dental schools and reviews strategies by which schools could care for more poor and low-income patients. The primary data come from the annual Survey of Dental Education, a joint American Dental Education Association (ADEA) and American Dental Association (ADA) activity. The analyses use descriptive statistics and are intended to give ballpark estimates of patients treated under varying clinical scenarios. Some 107.4 million people are underserved in comparison to utilization rates for middle-income Americans. In 2013-14, pre- and postdoctoral students treated about 1,176,000 disadvantaged patients. This is an estimate; the actual value may be 25% above or below this number. The impact of potential strategies for schools to provide more care to poor and low-income patients are discussed; these are larger class size, more community-based education, a required one-year residency program, and schools becoming part of publicly funded safety net clinics. While dental schools cannot solve the access problem, they could have a major impact if the payment and delivery strategies discussed were implemented. This article was written as part of the project Advancing Dental Education in the 21 st Century. Dr. Bailit is Professor Emeritus, Department of Community Medicine, School of Medicine, University of Connecticut. Direct correspondence to Dr. Howard Bailit, Department of Community Medicine, School of Medicine, University of Connecticut, 263 Farmington Ave., Farmington, CT 06030-6325; 860-679-5487; bailit@uchc.edu. Keywords: dental education, dental schools, health care disparities, access to health care, underserved patients, dental health services, dental care delivery, community-based dental education, GME, FQHCs Submitted for publication 1/11/17; accepted 2/21/17 doi: 10.21815/JDE.017.012 The dental safety net system is made up of public and voluntary sector dental clinics that provide care to poor and low-income patients at reduced or no cost. Poor refers to those with family incomes below the Federal Poverty Level (FPL), and low-income refers to those with family incomes 100-199% of FPL. It was estimated in 2006 that the dental safety net system has the capacity to care for 10 to 12 million patients annually. 1 Federally Qualified Health Centers (FQHCs) are the largest component of this safety net system, reported in 2005 to provide care to about five million disadvantaged patients annually. 2 Are dental schools part of the dental safety net system? On the one hand, the answer is, clearly, yes. The reduced fee care provided by junior and senior students mainly goes to poor and low-income patients. But, from another perspective, the answer is no. With a few notable exceptions, most states do not formally recognize the safety net role of private or public dental school patient care clinics and provide them additional subsidies to cover the cost of treating poor and low-income patients. These subsidies are necessary for two reasons. First, in most states, Medicaid fees are so low that both public and private sector dentists (and dental schools) lose money caring for Medicaid patients. 2,3 Second, only 28% of the poor and low-income population mainly children are enrolled in the Medicaid program. 4 For these two reasons, FQHCs receive special public subsidies for treating these patients. 3 FQHCs are reimbursed per visit at a higher than fee-for-service rate for treating Medicaid patients, and they receive a special federal subsidy (330 grants) for treating poor and low-income patients who are not Medicaideligible. While public dental schools receive some state educational subsidies, most public and private schools do not receive direct patient care subsidies for treating disadvantaged patients. The obvious question is: why not? The goals of this article are to examine the current safety net activities of dental schools and to examine strategies for increasing the capacity of dental schools to care for poor and low-income patients. Because the primary mission of dental schools is education and research, any changes to patient care systems to promote access to care must consider the impact on educational programs and finances. The specific objectives of this article are to 1) estimate the magnitude of the current access disparity problem; 2) determine the numbers of poor and low-income patients that now receive care in dental school clinics; and 3) discuss the feasibility and relative effectiveness of strategies for increasing the impact of dental schools on reducing access disparities. This article was written as part of the project Advancing Dental Education in the 21 st Century. es88

Methods Advanced or postgraduate education programs in dentistry are divided into two main types. First are general dentistry residency programs (Advanced Education in General Dentistry, AEGD, and General Practice Residency, GPR, programs). Second are graduate programs in the recognized dental specialties. A subset of the second type consists of specialty programs that have a large hospital component: pediatric dentistry and oral and maxillofacial surgery (OMFS). In this article, the term resident refers to postgraduates in general and pediatric dentistry and OMFS. With the exception of OMFS and pediatric dentistry, trainees in the recognized dental specialties are called postgraduate specialty students. In dental school-based postgraduate programs, students pay tuition. In contrast, in hospital-based programs, federal funds (through Graduate Medical Education, GME) are used to pay dental residents a stipend and reimburse hospitals for the cost of the training programs. This is discussed in more detail below. A primary source of the data used in this study is the annual Survey of Dental Education, a joint American Dental Education Association (ADEA) and American Dental Association (ADA) activity. 5 All dental schools are required to complete these surveys annually. The survey collects data in the areas of Academic Programs, Enrollment, and Graduates (Volume 1); Tuition, Admission, and Attrition (Volume 2); Faculty and Support Staff (Volume 3); Curriculum (Volume 4); and Finances (Volume 5). In addition, special surveys periodically address advanced dental education, clinic fees and revenues, allied dental education, and related topics. The Survey of Dental Education provides the only comprehensive data set for dental education available, but it has limitations. At the time of writing this article, all five surveys were not available for the latest years (2014-15 or 2015-16), so the data used come from surveys for 2011-12 to 2013-14. In addition, the quality of the data is variable; and, most importantly for this study, the surveys do not include the number of patients treated or services provided in dental school clinics. For predoctoral dental students, information is available on the number of patient visits provided in dental school and community clinics. With estimates of the average number of visits per patient per year, the number of patients treated annually was determined. For residents and postgraduate specialty students, no information is available on visits or patients. ADEA periodically reports on postgraduate program fees and revenues, and the range is very large, indicating substantial differences among schools in the design and operation of these programs. 6 Therefore, the estimates of postgraduate program productivity are speculative: since they are based on the most productive programs, they are upper boundary estimates. All the other data used in this article come from published reports from the federal government, the ADA, and ADEA and research studies by individual investigators. The analyses use simple descriptive statistics and are based on the best information available. They are intended to give ballpark estimates of patients treated under various clinical scenarios. The assumptions used in these estimates can and should be questioned because of the paucity of information collected in the Survey of Dental Education on patient visits, patients, and services. Results Based on data from the Medical Expenditure Panel Survey, Table 1 shows the percentage of the Table 1. Percentage of U.S. population with dentist visit by family income group and source of payment, 2012 Number % with Total Expenses % Private Family Income Group (000) Visit (000,000) Health Insurance % Medicaid Poor (<100% of FPL) 46,993 24.1% $4,403 17.3% 40.3% Low (100% to 199% of FPL) 60,455 25.6% $4,255 24.9% 18.3% Middle (200% to 399% of FPL) 94,168 36.2% $18,307 46.3% 3.1% High (400% or more of FPL) 111,875 50.3% $30,487 51.6% 0.6% FPL=Federal Poverty Level Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey. Table 3.1.a. Dental services: median and mean expenses per person with expense and distribution of expenses by source of payment, United States, 2012. Rockville, MD: Agency for Healthcare Research and Quality, 2012. August 2017 Supplement Journal of Dental Education es89

2012 non-institutionalized U.S. population with one or more dental visits, expenditures, and sources of payment by family income. 4 Utilization differences among the 107.4 million poor and low-income populations were modest. In aggregate, only about one-fourth of them saw a dentist annually. In contrast, middle- and high-income populations had average utilization rates of 36.2% and 50.3%, respectively. In addition, there were large disparities in annual expenditures per person with a visit by income group. Indeed, 85% of dental expenditures were from middle- (31.8%) and high- (52.3%) income groups. Not surprisingly, these two groups also had the highest percentages of people covered by private dental insurance (46.3% and 51.6%, respectively). Only 28% of the combined poor and low-income groups were covered by the Medicaid program, and these were mainly children. Other relevant demographic variables associated with lower utilization rates and poor or low family incomes were Black or Hispanic race and less education (data not shown). In terms of estimating the number of people with income-related inadequate access to care, it depends on the reference population. One view is that the two lower income groups (poor and lowincome) with the lowest utilization rates (107.4 million people) are underserved. Another approach is to have the two lower income groups achieve the utilization rate (at least one visit/year) of middleincome families; then, about 12 million would be defined as underserved. A third perspective is that all Americans should have the same utilization rates as the upper-income population. There is no consensus on this issue. This article considers the two lower income groups (107.4 million people) underserved. The most recent Survey of Dental Education data are for the year 2013-14, when there were 65 dental schools. 5 These schools enrolled 5,810 juniors and 5,386 seniors that year: a total of 11,196 students, spending most of their time in patient care. In 2012-13, schools also educated some 487 AEGD and GPR residents and 3,244 postgraduate specialty students, a total of 3,731. Schools also employed 3,196 fulltime clinical dental faculty members (2010-11 year). Thus, the total school workforce providing care to patients for those years was around 18,000. Another 2,936 residents were in advanced clinical education programs, located in non-dental school organizations (e.g., hospitals). Those residents are not counted in this analysis since they operate independently of dental schools. Current Impact on Oral Health Disparities Students. To attract patients, dental student clinic fees are usually set 40% to 60% below market fees. 6 As a result, students mainly treat patients from poor and low-income (not necessarily Medicaidenrolled) families. 7 In 2013-14, students provided 2,590,603 patient visits in dental school clinics and 420,556 in extramural clinics for a total of 3,011,159 visits. 5 Based on discussions with dental school clinic directors and a survey of several dental schools, 8 the estimated average number of visits per patient per year in dental school clinics is five. In contrast, extramural clinic patients average 2.5 visits per year. Thus, dental students treated about 518,120 patients annually in dental schools and 168,222 patients in extramural clinics for a total of 686,342 patients. Residents and postgraduate specialty students. The number of patients treated by residents and postgraduate specialty students is not known. Postgraduate specialty student fees are 70% to 80% of market fees and are probably beyond the financial capacity of most poor and low-income patients. In contrast, AEGD/GPR and pediatric dentistry residents often treat poor and low-income patients. In 2012-13, there were 487 AEGD/GPR and 492 pediatric dentistry residents in U.S. dental schools. 5 As an upper boundary estimate, the average resident treated eight patients per day for 250 days per year, and each patient averaged four visits. This comes to 489,500 patients treated annually. Combining student and resident data, dental schools treated about 1,176,000 disadvantaged patients that year. This is a ballpark estimate, and the actual value may be 25% above or below this number of patients (881,882 to 1,469,802). Although dental schools make a significant contribution to the access problem, it is also clear that relative to the over 100 million people who have inadequate access to dental care, the impact is limited. Faculty members. Patients treated in dental school faculty practices are usually charged market level fees and, as such, mainly come from middleand high-income families. For this reason, faculty patients are not counted in the number of poor and low-income patients treated by dental schools. Strategies to Increase Schools Impact on Disparities This section examines the feasibility of several options for strategies to increase the impact of es90

dental schools on access disparities. It also considers the potential impact of these strategies on schools educational programs and finances. Dental students and residents. One option is to increase predoctoral dental student enrollment, so that more poor and low-income patients could be treated in dental school clinics. Assuming the same level of production, a 25% enrollment increase from 11,196 to 13,995 juniors and seniors would raise the number of poor and low-income patients receiving care to 857,927, an increase of about 171,585 patients. The financial feasibility of increasing the capacity of existing schools to accept more students while at the same time maintaining or improving the quality of educational programs is a complex issue. At face value, established schools would have difficulty obtaining the resources needed to expand physical facilities (e.g., number of chairs), faculty, and staff to accommodate more students in school clinics. 8 However, many are rotating senior students to community facilities and expanding hours of operation in order to increase enrollment with existing resources. Much of this expansion is associated with international student programs. 9 Hence, a 25% increase in enrollment is feasible, but the overall increase in the number of underserved patients would be quite modest. In theory, schools could also increase the number of postgraduate specialty students and AEGD/ GPR and pediatric dentistry residents. However, since most postgraduate specialty students do not treat poor or low-income patients, expanding those programs would have little impact on disparities. General and pediatric dentistry residents do care for substantial numbers of poor and low-income patients, but schools would likely find it difficult to expand these programs for several of reasons. First, dental schools are not eligible to apply for federal government-sponsored GME grants from the Center for Medicare and Medicaid Services. Without GME resident stipends, schools would not be able to recruit residents. Schools could partner with hospitals or FQHCs that are eligible for GME funds, but most hospitals, in my experience, have little interest in supporting dental school-run general dentistry residency programs. The fact is that AEGD/ GPR residents do not generate significant patient care revenues for hospitals. In contrast, hospitals are interested in supporting pediatric dentistry and OMFS residents because these residents do generate hospital revenues, providing care to patients in hospital operating rooms. A second reason is that, even if dental schools were eligible to apply for GME funds, the total number of AEGD/GPR and pediatric dentistry residents in schools, hospitals, and other locations may not change much. Currently, some AEGD/GPR GME-supported residency positions are not filled each year. 5 That is, there are more positions than applicants. Therefore, expanding these programs in dental schools makes little sense, unless there is a significant increase in dental graduates interested in general dentistry residency programs. In fact, this is likely to happen as more graduates look for positions with large group practice companies, which give preference to applicants who have had a residency. 10 It is reasonable to expect that, in the future, most general dentistry residency positions will be filled. The problem is that there may not be adequate numbers of these programs with GME support to meet the demand of new graduates. Also, it is unclear if the American Academy of Pediatric Dentistry and the American Association of Oral and Maxillofacial Surgery would support a major expansion of residency programs and residents. For these reasons, expanding residency programs is unlikely to be a promising option for most schools. Community-based dental education. The amount of time seniors spend in community dental clinics providing care to lower income patients has been increasing. 11 In the graduating class of 2015, 41% of seniors reported they spent at least a month in extramural rotations in their fourth year, and another 46% reported having spent one to four weeks. 12 This trend has been aided by the fact that the Commission on Dental Accreditation (CODA) now requires all dental schools to make available opportunities for students to have learning experiences in community settings and to encourage students to take advantage of them. 13 Those settings could include FQHCs, hospitals, prisons, and Indian Health Service and other community clinics. This trend has important implications for access disparities, school finances, and the quality of dental education. Senior students and general and pediatric dentistry residents working in community facilities can have a major impact on disparities. When students have access to a clinical and administrative support system, including full-time dental assistants, one study found that, instead of treating two patients a day, they treated six to ten patients. 14 That study compared the number of services provided per fulltime equivalent (FTE) student in an FQHC dental clinic in California and a Midwest dental school August 2017 Supplement Journal of Dental Education es91

Table 2. Per FTE senior student ten-month average productivity in a Federally Qualified Health Center (FQHC) and a dental school FQHC Dental School Category Mean Mean Range Diagnostic 1,212 97 69-133 Preventive 728 84 55-117 Restorative 380 70 51-109 Crowns 10 Removable prosthodontics 19 3 0-7 Fixed prosthodontics 5 0-15 Endodontics 16 2 0-7 Periodontics 185 4 0-12 Surgery 251 33 8-75 Other 516 Source: Le H, McGowan T, Bailit H. Community-based dental education and community clinic finances. J Dent Educ 2011;75(10 Suppl):S48-53. (over ten months), finding that senior students in the FQHC were much more productive (Table 2). Based on 2012-13 numbers, 5 if all schools had their seniors spend 70 days in community rotations, this would come to 377,000 days in community sites (70 days X 5,386 students). Assuming students averaged eight visits per day, it would come to 3 million visits or 1.2 million patients (2.5 visits/patient). Community-based dental education can also have a positive impact on school finances. When seniors are assigned to community clinics, schools can use the freed-up operatories to increase class size, which would generate additional tuition and fees without more facilities, faculty, and staff. Also, Mashabi and Mascarenhas reported that student productivity at their school increased following community rotations, so there was no decline in clinic revenues even with fewer students in the clinic. 15 For a more detailed description of the financial benefits of community-based dental education, see Table 3. Another source of new revenues could be payments to schools from FQHCs and other delivery settings. Because FQHCs are reimbursed per visit (e.g., $150) rather than per service for treating Medicaid patients, students seeing eight patients per day would generate $1,200 in gross revenues. In their study of one FQHC, Le et al. found that the marginal cost of having a student was about $200 per day mainly the cost of a full-time dental assistant. 14 Students in that study had minimal impact on community faculty patient revenues, since community faculty members continued to treat patients as they supervised one or two students. At the University of Michigan, the dental school requires most community clinics to contribute $200 per day for senior students and $300 per day for general dentistry residents. 16 These payments generate over a million dollars in income for the school each year. With respect to the quality of education, Knight and Bean reported that most senior students at their schools preferred to provide care in community ver- Table 3. Senior student clinic revenues and expenses in schools with community-based education experiences Small Pilot Study Results The results of a small pilot study of a convenience sample of eight schools suggested that senior clinics in these schools had higher expenses than collected revenues and, as such, sustained significant average losses per senior student ($28,750) and per chair ($37,961). Senior student-collected revenues only covered 35.4% of per chair operating expenses. Thus, student revenues were unlikely to ever cover clinic expenses. The bottom line is that, for a class of 100 seniors using 100 chairs, the average school would lose $3.7 million. This study also indicated that schools with extensive and limited community-based dental education programs ran about the same losses per chair. This suggested that senior clinic operating expenses and aggregate clinic losses were basically a function of the number of chairs. Simply stated, schools with more chairs per student ran higher losses. The difference between schools with limited and extensive days in community rotations was the number of enrolled students relative to the number of chairs. Schools with extensive community programs averaged many more students (114 versus 73) but far fewer chairs per student (0.57 versus 0.93). Their net loss per student was much lower than for schools with the fewest days in community rotations. Thus, while it is true that schools with 50 or more days in the community generated less clinic revenue per student than schools with minimal community days, clinic losses were substantially lower in the schools with the most days in the community because they had fewer chairs per student. This is the primary reason that community education programs actually reduce rather than increase per student clinic losses. There is another dimension to this issue that goes beyond senior clinic revenues and expenses: larger class size was also associated with more revenues from tuition. Source: Bailit H, McGowan T. Senior dental students impact on dental school clinic revenues: the effect of community-based dental education. J Dent Educ 2011;75(10 Suppl):S8-13. es92

sus dental school clinics. 17,18 Those students valued learning to work with a trained clinical and administrative support staff, treating more patients, and, most importantly, gaining more skills, knowledge, and self-confidence. The major limitation of most community rotations is that students do not provide expensive, elective services such as bridges and implants. Of course, this is also a problem in dental school clinics, since few poor and low-income patients can afford these expensive services. Required dental residency programs. About 34% of students in the graduating class of 2016 said they intended to enroll in advanced education programs in the dental specialties and general dentistry. 19 The remaining graduates planned to enter private practice in some capacity, join the armed services, work in safety net clinics, etc. If all states required a one-year residency to be eligible for licensure, another 3,960 graduates of the 2016 class would participate. Almost all of these additional graduates would have to take training in general dentistry since specialty programs are already oversubscribed. Of course, in the short term, it would be very difficult to establish enough AEGD/GPR programs to accommodate another 3,960 graduates, especially since hospitals have little financial incentive to accept more general dentistry residents. Some dental schools may have the physical capacity to accept more AEGD/GPR residents, but cannot provide them with GME stipends. Another problem is patient revenues versus expenses. Most schools do not run delivery systems with the same efficiency as FQHCs or private practices, and they do not receive public subsidies for treating Medicaid or poor and low-income uninsured patients. Thus, these residency programs would be likely to result in a net financial loss for schools that are already hard pressed financially. However, if these structural problems could be overcome, the additional AEGD/GPR residents could substantially expand the safety net capacity of dental schools. For example, if residents averaged eight patients a day for 250 days per year, about 2 million more patients would receive dental treatment (3,960 residents X 8 patients/day X 250 days/year divided by 4 visits/person). This is in addition to the approximately 500,000 patients now receiving care in dental school AEGD/GPR and pediatric dentistry residency programs. Realistically, however, it would be many years before schools could overcome the barriers preventing them from expanding general dentistry residency programs. Dental Schools as Safety Net Clinics While dental students mainly treat poor and low-income patients, a study of six dental school clinics published in 1995 reported that, on average, 13% of their patients were covered by Medicaid. 7 Many states do not cover adult dental care, and Medicaid fees are often lower than student fees. In two states (North Carolina and New York), dental schools have negotiated an enhanced reimbursement rate for treating Medicaid patients. 20 These states recognized that dental school clinics are an important part of the dental safety net and that schools required additional financial support to provide care to Medicaid patients. A strong case can be made for a national effort to change federal Medicaid laws, so that all dental schools, public and private, would receive greater public subsidies for treating Medicaid patients. With adequate Medicaid fees and with a federal FQHC type 330 grant to cover the costs of providing care to poor and low-income patients who are not Medicaideligible, dental students, residents, postgraduate specialty students, and faculty would have a strong financial incentive to care for Medicaid patients. Assuming that third-year students continued to train in traditional dental school clinics because of their limited clinical skills and knowledge and that faculty members spent 50% of their time in clinical teaching/ practice, there would be approximately 11,000 seniors, residents, and faculty members providing care in U.S. dental schools. If they practiced in reasonably efficient dental delivery systems, using the medical model of clinical teaching (instructors continue to practice as they supervise one or two students), they could provide care to close to 3.8 million patients annually (assumptions: 11,000 dental providers X 7 patients per day X 200 days per year/4 visits per patient). This would be a large increase over the estimated 1,176,000 poor and low-income patients now treated in dental schools. Realistically, it would take many years before schools could reorganize their current clinical operations into the proposed system. The obvious barrier is finding the resources (e.g., financial, management, faculty) needed to turn traditional dental school clinics into efficient delivery systems, following the medical model of clinical education. The current model of clinical dental education is about 200 years old, and the culture associated with this system is firmly entrenched and will be very difficult to change. 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However, if the system could be changed, there are other advantages besides reducing access disparities. First, from the public perspective, it would greatly expand the safety net system without requiring a massive investment in new FQHC facilities and personnel. Second, it would reduce competition between dental schools and private practitioners for a limited number of full-pay and privately insured patients. Third, with a stable and adequate source of revenue, schools could reduce the rate of tuition increases and raise faculty salaries to more competitive levels. Fourth, it would reduce the need for some states to use general tax funds to subsidize public dental school clinical operations. This is because Medicaid is jointly financed by the federal and state governments. Depending on the state s per capita income, the federal contribution runs from 50% to 80% of Medicaid expenses. In states with low per capita incomes such as New Mexico, Mississippi, Louisiana, and West Virginia, state general fund subsidies to dental schools could possibly be reduced, as more clinical expenses would be covered by the federally subsidized Medicaid program. Even wealthier states would benefit financially from dental schools generating more net revenues from patient care programs. While there are many advantages, the political reality of obtaining federal or state support for this approach is not promising. Nevertheless, it has occurred in two states, and with a concerted political effort by organized dentistry and other interested stakeholders, more states could follow. Discussion Currently, dental schools have a limited impact on access disparities. At best, students and general dentistry residents provide care to about 850,000 disadvantaged patients annually. The primary barrier to caring for more patients is the dominant clinical education model: dental school clinics operate as teaching laboratories rather than as efficiently run delivery systems. As a result, fewer patients receive care, and clinics require larger subsidies. However, dental schools have several options for decreasing disparities by the direct delivery of care. These options are organized in Table 4 in ascending order of potential effectiveness. One promising educational trend that is reducing access disparities is community-based dental education. Most fourth-year students now spend a significant number of days in community rotations (at least three weeks for 63% of them in 2015), and almost half of third-year students spent at least one week there as well, 12 and seniors have been found to be more productive in well-run FQHCs and other safety net clinics as well as more productive after returning to the dental school clinic. 14,15 Unlike dental schools, community delivery sites use the medical model of clinical teaching, so faculty members continue to treat patients as they supervise one or two students or residents. These community rotations provide students more clinical experience working in a real delivery system, they reduce access disparities, and they can increase dental schools net operating revenues. 14-16 As the number and size of FQHC dental clinics continue to expand and as schools look for new revenue sources, eventually community-based dental education could become the dominant educational model for senior students. Another promising strategy for reducing access disparities is to require all dental graduates to have at least one year of residency training to be eligible for state licensure. This would result in about 3,960 more Table 4. Dental school options to reduce access disparities Option Estimated National Impact Increase number of dental students by 25% or more. Have senior students and general and pediatric dentistry residents spend from 70 to 100 days providing care in dental safety net clinics. Require all dental graduates to spend at least one year in an accredited clinical program for general dentistry or the dental specialties to be eligible for state licensure. Have federal and state governments make dental schools part of the dental safety net and provide them with supplemental payments to care for Medicaid-eligible and other poor and low-income patients. If schools operated efficient dental clinics where senior students, residents, and faculty members practiced together, schools could treat millions of additional disadvantaged patients. The East Carolina University rural dental group practices are an example of this type of system. Low Medium Medium plus High es94

graduates enrolling in AEGD or GPR programs. These additional residents would care for another 2 million mainly poor and low-income patients. To implement this strategy, dental schools need to be eligible to apply for GME grants that provide resident stipends and cover program costs. Schools also need to operate their general and pediatric dentistry clinics as professional delivery systems, using the medical clinical education model. They can also continue to partner with the growing numbers of FQHCs and private group practices to provide sites for resident rotations. To fully engage dental schools in addressing the access problem, federal and state governments need to consider them as part of the safety net system and make them eligible for enhanced Medicaid payments. In this way, all students, residents, and faculty could focus on providing care to Medicaid patients. Two state Medicaid programs (in North Carolina and New York) now recognize this special role of dental schools and provide them with additional payments for treating Medicaid patients. 20 This strategy also requires dental schools to operate senior, resident, and faculty clinics as efficiently run delivery systems rather than as teaching laboratories. If all dental schools focused on Medicaid patients under this new payment system, another 3.8 million patients could potentially receive care. The political and economic reality of this new system would face serious challenges, and it would take a major effort by key stakeholders to get federal and state governments to recognize the special role of dental schools in reducing access disparities. Conclusion While dental schools cannot solve the access problem, they can have a major impact if the payment and delivery strategies discussed in this article were implemented. Importantly, these strategies would also improve the quality of dental education and provide schools with additional revenues that they can invest in slowing the growth of tuition and improving academic and research programs. The bottom line is that the major dental organizations need to band together in an all-out effort to convince the federal government to allow dental schools to directly apply for GME grants to support dental residents, including both general and specialty residents. This lobbying effort also needs to make dental schools part of the dental safety net, so that schools would receive federal and state subsidies to care for poor and low-income patients. Editor s Disclosure This article is published in an online-only supplement to the Journal of Dental Education as part of a special project that was conducted independently of the American Dental Education Association (ADEA). Manuscripts for this supplement were reviewed by the project s directors and the coordinators of the project s sections and were assessed for general content and formatting by the editorial staff. Any opinions expressed are those of the authors and do not necessarily represent the Journal of Dental Education or ADEA. REFERENCES 1. Bailit H, Beazoglou T, Demby N, et al. Dental safety net: current capacity and potential for expansion. J Am Dent Assoc 2006;137(6):807-16. 2. Beazoglou T, Heffley D, Lepowsky S, et al. Dental safety net in Connecticut. J Am Dent Assoc 2005;136:1457-62. 3. Beazoglou T, Bailit H, Drozdowski MM. Federally qualified health center dental program finances: a case study. Public Health Rpts 2010;125:888-95. 4. Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey. Table 3.1.a. Dental services: median and mean expenses per person with expense and distribution of expenses by source of payment, United States, 2012. 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