BACKGROUND: THE FUTURE OF DENTAL EDUCATION IN ARKANSAS: A View From the Profession Arkansas State Dental Association December 12, 2012 For more than six decades, the state of Arkansas has participated in an arrangement with other Southern states through the Southern Regional Educational Board (SREB) and the Arkansas Health Education Grant Program (ARHEG). The relationship between the state, SREB, and ARHEG has allowed Arkansas s college graduates pursuing a career in dentistry to receive doctoral training at institutions in other states in exchange for a negotiated fee that pays a portion of out-of-state tuition. Under the administration of the Arkansas Department of Higher Education (ADHE), the ARHEG program has effectively utilized funds allocated by the General Assembly to alleviate the price of out-of-state tuition for students who seek training in dentistry, optometry, podiatry, chiropractic, osteopathic, and veterinary medicine. Dentistry in our state has benefitted from this arrangement as well, having secured training for Arkansas s students at out-of-state dental schools, notably the University of Tennessee (Memphis), Louisiana State University, Baylor University, University of Louisville, University of Missouri at Kansas City, University of Oklahoma, and Meharry University. In fiscal year 2011-12, our state provided $1.96 million of ARHEG/SREB grants for one year s worth of dental training for 120 of its students. With the publication of Interim Study Proposal 2007-173 (http://bit.ly/rpkhqx) in 2008, serious dialogue began as to whether the time had come for Arkansas to build its own dental school. Since that time, several reports have echoed that of ISP 2007-173, indicating that Arkansas is dentally underserved and that many of its citizens would benefit from the charitable care a dental school would provide. Furthermore, reports have shown, on average, dental students graduate with considerably higher debt than that of their peers graduating from medical school. This figure is exacerbated even further by the fact that Arkansas s dental students have no choice but to pay out-of-state tuition. The purpose of this paper is to offer comments from the Arkansas State Dental Association as to the current SREB/ARHEG arrangement, costs and availability of dental education for Arkansans and the potential of constructing a dental school in our state.
Would the cost of a dental school be prohibitive? Let s answer that question based on funding considerations. The cost to the state to pay a portion of the out-of-state tuition for the current positions in the six SREB dental schools mentioned above is considerably less than the cost to operate a dental school. The present agreement with SREB is generally acceptable, although the program needs to be monitored to ensure that funds are available to pay a portion of the out-of-state tuition for all Arkansas students who intend to return to Arkansas to practice. Even with state funds alleviating a portion of the out-of-state tuition, Arkansas s dental students will still pay considerably more than their in-state counterparts at every dental school with the exception of Baylor and Meharry (a private school). For example, as you will see in Table 2 of this document, the University of Tennessee, which accepts the highest number of Arkansas students and thus is the biggest recipient of Arkansas state dollars, received $33,408 more per year for each Arkansas student than they receive from a Tennessee student. In fact, SREB/ARHEG grant money barely covers the mandatory fees and costs (not including tuition) for D-1 students. With 87 allocated slots for Arkansas students at UT, the school received $1.4 million dollars in SREB/ARHEG funding from Arkansas for the 2011-12 school year. Since 2008, UT alone has received $4.89 million through the state s SREB/ARHEG program. Table 1 of this document provides an overview of the number of dental students in each class at the various dental schools in our region. A notable aspect of the report indicates that SREB/ARHEG contributions have increased 18.5 per cent in a four-year period, indicating the state will continue to pay out more than $2.3 million annually to other states for dental education. While this amount pales in comparison to the cost of establishing and operating a dental school, the money that is paid for tuition, fees, and other related items is exported to other states rather than remaining in Arkansas as part of our state s economy. The disparity reflected in this current model is growing at a continual rate. One of the more notable outcomes of this white paper was the realization that the tuition and fees paid by Arkansas students in 2011 plus the state s SREB/ARHEG funds totaled $8,037,595. These are public and private funds for dental education that leave Arkansas in a single year, and that number will continue to increase. Bear in mind that this figure does not include living expenses. It is for this purpose that we believe that if/when the Governor and General 2
Assembly decide that a dental school is necessary; it should be a public program, affiliated with and administered by the University of Arkansas for Medical Sciences. UAMS and ASDA are engaged in ongoing discussions for the development of a contingency plan in the event that the decision is made to build a dental school. Does Arkansas offer an adequate supply of dentists? Arkansas has increased its future supply of dentists by 23.7 per cent in the past four years. However, virtually all of Arkansas s recent graduates will leave with a debt load far surpassing their counterparts in other states with dental schools. The ISP study from 2007 predicted that Arkansas would lose half of its supply of dentists within a ten-year period, but the study was conducted prior to the economic downturn of 2008-9. However, a 2011 survey commissioned by ASDA and conducted by the University of Arkansas at Little Rock Institute of Government indicated that the economic downturn had affected the retirement plans of 46 percent of dentists, which obviously affects the workforce. The ISP also assumed that all dentists would retire at age 62. However, roughly 41 percent of dentists surveyed in 2011 indicated that they intend to work beyond the age of 67. The ISP (as well as other dental workforce studies) made a common but statistically acceptable assumption that dentists only practice in one location. However, the UALR survey indicated that about 15 percent of Arkansas dentists practice in more than one location, many of which may be in communities or areas that otherwise are indicated as being underserved. What about Arkansas s supply of dentists in underserved areas? As with other health care professionals, dentists tend to practice in communities where they have a vested interest. These communities are most often areas with an adequate population to support a dental practice. Obviously, not every community has a dentist, and the distribution of dentists within certain regions of Arkansas tends to be problematic. Many states have experienced success in attracting dentists to underserved areas by offering loan repayment programs that guarantee a set dollar amount towards student debt in exchange for the doctor s services. Whether or not Arkansas ever builds a dental school, a similar loan repayment program could be a successful tool in providing care in rural areas. Our state would be well served by a comprehensive program to increase oral 3
health literacy for Arkansans in rural areas, thereby reducing the incidence of dental caries and helping patients establish a dental home. What dental services for the public could be provided through a dental school? Presently, ASDA enjoys an excellent working relationship with Dr. Daniel Rahn, Chancellor of UAMS and the Center for Dental Education. The Center plays an important role in representing dentistry within the UAMS system, and ASDA encourages full funding for the Center in the legislative budgeting process. ASDA is in full agreement with the current plans to provide residency programs in advanced general dentistry, oral surgery, and pediatric dentistry at UAMS. Not only will the residencies at UAMS offer additional post-graduate training, they will also provide an optional care facility for patients who require oral surgery under general anesthesia. Likewise, the program will provide the surgery team at UAMS with dentists who will administer critical oral surgery for patients who are awaiting organ transplants or surgery for other serious health conditions. What is the cost of dental education for Arkansans? The cost for dental education for Arkansans is very high compared to costs of other medical programs. The American Dental Education Association (Survey of Dental School Seniors, 2011 Graduating Class) reports that the average debt for private and private state-related dental schools was $245,497 compared to $116,407 just 15 years earlier. The average debt for all dental schools, both public and private was $203,374 in 2011 compared to $84,247, again more than doubling figures from 15 years earlier. By comparison, the average debt for medical school graduates in 2011 was $161,290, according to the American Medical Association website (Background: Student Debt Statistics) The attached Table 2 reflects the costs for tuition and fees that Arkansas students pay in the seven dental schools that participate in the SREB program or have a direct contract with ADHE. Unlike other reports that include projected costs for room, board, and other subjective data, the attached report provides an apples to apples comparison of the mandatory costs (tuition, fees, and other required costs) of attaining a dental degree without regard to costs that could be attributed to standard of living choices. It should be noted, however, that in addition to education costs dental students also pay their own living expenses for the four years of dental school, not including their residency or additional years of specialty training. It is also notable that all participating dental schools (again, 4
with the exception of Baylor and Meharry) bill the students for the non-resident fee over and above the amount covered by the SREB/ARHEG allocation. What are the real and potential effects of rising indebtedness for Arkansas s dental graduates? No doubt out-of-state tuition and fees for Arkansas s dental students will continue to increase as other states legislatures see no downside to raising out-of-state tuition as a means of supporting their in-state dental schools with Arkansas dollars. As stated earlier in this paper, dental schools can potentially profit from exorbitant out-of-state tuitions, realizing more and more that Arkansas s students provide a financial windfall which the schools otherwise would not have. Arkansas s future dentists have no choice but to pay out-of-state rates, the price of which is already high and rising, with or without SREB/ARHEG assistance. These out-of-state charges leave all new graduates with an inevitable financial disadvantage upon graduating. Without a targeted program to help repay student debt, will new dentists be able to practice in underserved areas of Arkansas? Doubtful, as an increasing number of these communities simply do not have an adequate support system to provide a sufficient income for the young dentist burdened with student debt. Basic infrastructure challenges in many rural areas create obstacles to the development of a viable dental practice (e.g. lack of local employers who offer dental insurance, inadequate supply of trained dental staff, lack of significant medical providers, reduction in the number of emergency responders, consolidation of school systems, etc.) There is little doubt that the level of indebtedness is much greater than ever before and will continue to increase. New graduates must go to areas that offer them the most potential for income to pay back an excess of student debt accrued through out-of-state rates. Summary: ASDA and the dental profession are dedicated to the oral health of the public to ensure an adequate supply of dentists for our state. In the event that the Governor and General Assembly decide to create a dental school in Arkansas, ASDA will gladly offer its services to work closely with UAMS and the Center for Dental Education to create a quality program for our state. Likewise, ASDA offers its full support to Arkansas students studying at the regional dental schools mentioned earlier and will continue to work closely with the ADHE with regard to the ARHEG program. 5
In that regard, ASDA recommends the following: 1. Full SREB funding for all Arkansas dental students enrolled at SREB and ADHE contracted schools 2. Full funding for the Center for Dental Education at UAMS 3. Creation of a loan repayment program to attract young dentists to underserved areas of our state. The future of dental education in Arkansas clearly rests in the hands of the Governor, the General Assembly, the dental profession, and, ultimately, the citizens of Arkansas. Again, if that future is to include the establishment of a dental school, it should be a public program affiliated with and administered by UAMS with emphasis on a curriculum to include outreach programs to address oral health issues in Arkansas s rural communities. 6
Table 1 - ARHEG Dental Summary: Actual Students per Institution per Class Year, and Allocations Compiled September 10, 2012 YEAR INST DI D2 D3 D4 TOTAL ANNUAL ACTUAL ALLOCATION SREB FEE TOTAL PAID 2008-09 UT 18 18 17 15 68 72 $ 15,000.00 $ 1,020,000.00 2009-10 UT 23 18 18 16 75 77 $ 15,900.00 $ 1,192,500.00 2010-11 UT 23 22 17 18 80 82 $ 15,900.00 $ 1,272,000.00 2011-12 UT 26 22 21 17 86 87 $ 16,400.00 $ 1,410,400.00 2008-09 LSU 4 2 0 4 10 16 $ 15,000.00 $ 150,000.00 2009-10 LSU 4 4 0 2 10 16 $ 15,900.00 $ 159,000.00 2010-11 LSU 2 3 4 0 9 16 $ 15,900.00 $ 143,100.00 2011-12 LSU 3 2 3 4 12 16 $ 16,400.00 $ 196,800.00 2008-09 UMKC 2 1 2 1 6 8 $ 15,000.00 $ 90,000.00 2009-10 UMKC 1 2 1 2 6 8 $ 15,900.00 $ 95,400.00 2010-11 UMKC 1 1 2 1 5 8 $ 15,900.00 $ 79,500.00 2011-12 UMKC 2 1 1 2 6 8 $ 16,400.00 $ 98,400.00 2008-09 Baylor 1 2 0 1 4 12 $ 15,000.00 $ 60,000.00 2009-10 Baylor 1 1 2 0 4 12 $ 15,900.00 $ 63,600.00 2010-11 Baylor 1 1 2 1 5 12 $ 15,900.00 $ 79,500.00 2011-12 Baylor 1 1 1 1 4 12 $ 16,400.00 $ 65,600.00 2008-09 Meharry 0 2 0 0 2 4 $ 15,000.00 $ 30,000.00 2009-10 Meharry 1 0 0 1 2 4 $ 15,900.00 $ 31,800.00 2010-11 Meharry 1 2 0 2 5 4 $ 15,900.00 $ 79,500.00 2011-12 Meharry 0 1 0 2 3 4 $ 16,400.00 $ 49,200.00 2008-09 Louisville 1 1 2 1 5 4 $ 15,000.00 $ 75,000.00 2009-10 Louisville 1 2 1 2 6 4 $ 15,900.00 $ 95,400.00 2010-11 Louisville 0 2 1 1 4 4 $ 15,900.00 $ 63,600.00 2011-12 Louisville 1 0 2 0 3 4 $ 16,400.00 $ 49,200.00 2008-09 Oklahoma 0 0 1 0 1 4 $ 15,000.00 $ 15,000.00 2009-10 Oklahoma 2 0 0 0 2 4 $ 15,900.00 $ 31,800.00 2010-11 Oklahoma 0 2 0 0 2 4 $ 15,900.00 $ 31,800.00 2011-12 Oklahoma 2 1 1 2 6 4 $ 16,400.00 $ 98,400.00 2008-09 UAlab-Birm 0 0 0 1 1 0 $ 15,000.00 $ 15,000.00 2009-10 UAlab-Birm 0 0 0 0 0 0 $ 15,900.00 $ - 2010-11 UAlab-Birm 0 0 0 0 0 0 $ 15,900.00 $ - 2011-12 UAlab-Birm 0 0 0 0 0 0 $ 16,400.00 $ - $ 6,841,500.00 TOTAL ENROLLED SREB STUDENTS PER YEAR vs. TOTAL SREB ALLOCATIONS Note: All contracts are SREB except for UMKC (ADHE contract) Year Actual Allocation Differ Total Grant $/year 2008-09 97 120-23 $1,455,000.00 Note: UT increased enrollment from 18 to 23 in 2009-10 DI class. 2009-10 105 125-20 $1,669,500.00 As of 2012-13 DI class, enrollment was increased to 33, ten of which 2010-11 110 130-20 $1,749,000.00 are not funded by SREB (23). 2011-12 120 135-15 $1,968,000.00 TOTAL: $6,841,500.00 Note: The chart at left indicates that the total number of dental students in SREB program has increased 24% in the past four years. However, Arkansas has not utlized its total number of allocations in the same time period. Note: SREB contributions have increased 35.3% over the past four years. Yearly breakdown of D4s with SREB, Licenses given to SREB recipients, and Number of Licenses Issued Year SREB D4 Grad SREB lic All Licenses Difference 2008-09 23 16 29 13 2009-10 23 21 39 18 2010-11 23 14 30 16 2011-12 23 19 38 19 White Sheet Table 1 12-11-12, 4:49 PM
Table 2 Annual Dental School Costs for D1 Students - Tuition/Maintenance Plus Mandatory Fees/Costs (Living Expenses Not Included) September 10, 2012 Baylor LSU UMKC Meharry Louisville Oklahoma UT Resident Tuition $13,315.00 $16,768.00 $26,262.00 $42,235.00 $26,430.00 $19,147.00 $24,442.00 Non Resident Tuition $24,115.00 $36,405.00 $52,340.00 $42,235.00 $55,606.00 $45,448.00 $57,850.00 Mandatory Fees & Costs $13,600.00 $5,782.00 $1,358.00 $12,077.00 $8,745.00 $20,510.00 $16,161.00 Tuition+Fees (Resident) $26,915.00 $22,550.00 $27,620.00 $54,312.00 $35,175.00 $39,657.00 $40,603.00 Tuition+Fees (Non-Resident) $37,715.00 $42,187.00 $53,968.00 $54,312.00 $64,351.00 $65,958.00 $74,011.00 difference $10,800.00 $19,637.00 $26,348.00 $0.00 $29,176.00 $26,301.00 $33,408.00 ARHEG grant (2012-13) -$16,900.00 -$16,900.00 -$16,900.00 -$16,900.00 -$16,900.00 -$16,900.00 -$16,900.00 NRT+Fees-ARHEG grant $20,815.00 $25,287.00 $37,068.00 $37,412.00 $47,451.00 $49,058.00 $57,111.00 Arkansas students receiving grant money will still pay this much more per year than an in-state student -$6,100.00 $2,737.00 $9,448.00 -$16,900.00 $12,276.00 $9,401.00 $16,508.00 $80,000.00 $70,000.00 $60,000.00 $50,000.00 $40,000.00 $30,000.00 $20,000.00 $10,000.00 $0.00 Baylor LSU UMKC Meharry Louisville Oklahoma UT Tuition+Fees (Non-Resident) Tuition+Fees (Resident) difference NRT+Fees-ARHEG grant FINAL Dental School Costs D-1s-1, 12/11/2012, 4:51 PM