Background: Dentistry Practice in Washington. Dentists practicing in Washington State must be licensed by the Dental Quality Assurance Commission (Commission). The state also requires a license or certification for a variety of providers who assist licensed dentists, including dental hygienists, dental assistants, expanded function dental auxiliaries, and dental anesthesia assistants. Each practice has specific education and competency requirements, and is regulated by a professional commission or the Department of Health.

Community Health Aide Program. The Indian Health Service (IHS) is a federal agency responsible for providing federal health services to American Indians and Alaska Natives. IHS is authorized under the Indian Health Care Improvement Act (IHCIA) to develop and operate a Community Health Aide Program (CHAP) in Alaska that serves rural native communities. CHAP establishes a certification process for community health aides who provide health care, health promotion, and disease prevention in rural Alaska Native communities.

Dental Health Aide Program. In 2001, IHS established the Dental Health Aide Program (DHAP) as part of CHAP. DHAP involves training and certification for Dental Health Aides (DHA) in four categories: primary DHA; expanded function DHA; DHA hygienists; and DHA therapists (DHATs). DHATs are certified through DHAP to practice without the direct supervision of a licensed dentist for procedures such as oral exams, preventative dental services, simple restorations, stainless steel crowns, and x-rays. DHAT certification requires a high school diploma, graduation from a two-year educational program, and a 400-hour clinical preceptorship under the supervision of a dentist.

DHAT and State Licensing. DHAP is a federal certification program, which authorizes DHATs to practice only within rural Native Alaska communities served through CHAP. IHS is authorized to establish a national CHAP. Such an expansion expressly excludes DHATs from undertaking services covered under a program unless DHAT services are authorized under state law to provide such services in accordance with state law. Washington does not have a DHAT license and has not authorized the practice of DHATs.

Indian Health Program. Indian health programs are any health program administered directly by the federal IHS, any tribal health program, and any Indian tribe or tribal organization to which the Secretary of the Department of Health and Human Services provides funding.

Urban Indian Organization. Urban Indian organizations are nonprofit corporate bodies situated in an urban center, governed by an urban Indian-controlled board of directors, and provide for the maximum participation of all interested Indian groups and individuals.

Summary of Bill: DHAT services are authorized under the following conditions:

the person providing services is a DHAT certified by a CHAP or a federally recognized Indian tribe that has adopted certification standards that meet or exceed those of a CHAP;
services are rendered within the boundaries of a tribal reservation;
services are operated by an Indian health program or urban Indian organization;
services are provided within the scope of practice set by the CHAP or tribe and pursuant to any written orders from a supervising dentist; and
when a person is working within the scope and direction of a certified DHAT training program.

DHAT services are exempted from licensing requirements for other dental professions.

The Health Care Authority is directed to coordinate with the centers for Medicare and Medicaid services to provide that DHAT services are eligible for federal funding of up to 100 percent.

Staff Summary of Public Testimony: PRO: This legislation has been around for 12 years. This is about access to dental services and being able to afford children in remote areas of Washington state dental care. This program has been working in Alaska for over 10 years. DHATs work under the supervision of a dentist, and that will continue. Current federal law allows for tribes to employ DHATs on the reservation to serve members of their tribes. However, federal law also requires state authorization for a tribe in that state to receive IHS and Medicaid funding. This funding would cost the state nothing and could actually save the state money since a tribal member who sees a dentist at a dental clinic off reservation would have their services partially covered by the state. Doctor Hogan was originally skeptical of the DHAT model, but after researching evidence and reviewing DHAT services in operation in Alaska is very comfortable with the program. The Swinomish DHAT went through a 4-month preceptorship process. Following the process, a scope of practice was developed. Patients can now get appointments for treatment much faster and the dentist on staff can work at the top her scope. DHATs are able to provide additional community outreach to make patients more comfortable in the dental setting. Eighty percent of children on the Colville reservation have issues with decay of their teeth. It is difficult to hire dentists, dental hygienists and other doctors in rural communities like Omak. It is also difficult to find dentists who will see IHS or Medicaid patients. Tribal clinics in rural areas don't just serve tribal members, and sometimes these tribal dental clinics are not located on reservations. There are 27,000 natives in Pierce County, and there is an unmet service need for 12,000 of them.