Addressing Florida’s Access to Dental Care with Street-Level Bureaucrats

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Michael Turtz
April 15, 2024

More than five million citizens in Florida live in areas that have either limited or no access to dental care. In 2021, oral health issues led to more than $620 million in preventable emergency room visits and hospital stays. In addition, 54 of the 67 counties in Florida have less than average access to dental care. All of this data was assembled from Wellbeing Florida. In 2023, the U.S. Government Accountability Office stated that patients around the United States had to travel on average 23.9 miles to get healthcare services after rural hospitals closed in their areas. In the United States, over 100 rural hospitals closed from January 2013 through February 2020. The American Dental Association also found that in 2001, 27 percent of dentists practicing were 55 years and older. By 2021, the percentage of dentists practicing over 55 years old had risen to 36.1 percent. There is a greater need for dentists to practice immediately after dentistry school due to the aging dentist population.

The State of Florida currently has one publicly funded dental school (University of Florida) which serves a population of 22.2 million residents. The State of Florida approved a second dental school (Florida Atlantic University). That school is intended to recruit and train its students to serve in rural and underserved areas across the state.

On an operational level, once the new dental school has third- and fourth-year students, there will be a need to create rural training rotations for dental students and residents to be exposed to underserved areas. Universities cannot guarantee that their graduates will want to work in these communities after they graduate, however, if they create rural training rotations there are clinical opportunities for dental students and dental residents to be exposed to underserved areas. These opportunities, along with recruitment focused on students from rural and underserved areas have led to increases in the number of oral health professionals in other states.

Healthcare professionals and Public Administration professionals should collaborate in order to communicate with one another, specifically with Street-Level Bureaucrats. Michael Lipsky introduced Street-Level Bureaucrats in his 1980 book titled Street-Level Bureaucracy: The Dilemmas of the Individual in Public Service. Street-Level Bureaucrats (SLBs) are commonly public service workers, such as police officers, teachers and social workers. Average citizens encounter SLBs on a daily basis or on the front line because SLBs act as an instrument of the government. SLB actions are a direct representation of government, and it is not unusual for SLBs to impact socioeconomically disadvantaged groups. Lipsky found that SLBs have large caseloads, ambiguous agency goals and inadequate resources.

Steven Maynard-Moody and Michael Musheno expanded on Lipsky’s work in their 2003 book titled Cops, Teachers, Counselors: Stories from the Front Lines of Public Service. They offered an approach in the form of a narrative to confront inherent problems in street-level bureaucrats’ discretion and judgment. This was the first major SLB study to rely on storytelling. Their methodology was through storytelling which allowed for more of a two-way interaction between storyteller and audience. It is less obtrusive and can reveal the storyteller’s judgments.

Based on Maynard-Moody and Musheno’s earlier findings in a 2000 Journal of Public Administration Research and Theory article titled “State Agent or Citizen Agent: Two Narratives of Discretion”, SLBs describe themselves as citizen-agents rather than state-agents. Rather than focusing on norms, rules and laws, SLBs focus on specific individuals and circumstances. They also don’t view themselves as policymakers or even policy implementers. They view themselves as empowered, citizen agent decision makers to ration resources and provide access to certain programs. Essentially, Maynard-Moody and Musheno believed these citizen agents maintain the normative order of society.

SLBs interact the most with their citizens, especially in rural and underserved areas. SLBs understand individuals’ needs and circumstances in their towns and cities better than any other profession. For example, teachers interact the most with children. According to Wellbeing Florida, a quarter of Florida’s third-grade children suffer from untreated tooth decay. Florida is ranked sixth in the nation for the highest percentage of third-grade children with unfilled cavities. Also, geriatric social workers interact with our elderly communities. Among those over 65 years of age, one in three people have significant dental issues as a result of tooth decay or gum disease, and 14 percent of seniors ultimately have all their teeth extracted.

Bringing in dental students and residents to help citizens who do not have access to care in rural and underserved areas is only half of the equation. Understanding who the patients and citizens are, their stories and their backgrounds is just as important. Qualitative research with SLBs will be beneficial for healthcare professionals who want to solve the access to care issue in underserved and rural areas. SLBs such as teachers and geriatric social workers interact the most with patients and citizens who need for dental care. The College of Dentistry at Florida Atlantic University has an opportunity to be a catalyst for collaboration and change with individuals, communities and government entities when it comes to solving the rural and underserved access to care in the State of Florida.

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Author: Michael Turtz, MPA, is currently the Director of Administration at the Charles E. Schmidt College of Medicine at Florida Atlantic University. Michael is also currently a Ph.D. Candidate in FAU’s School of Public Administration. Email: [email protected]

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