The Health Care Workforce in Eight States: Education, Practice & Policy > Michigan

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On this page: Project Description | Study Methodology | State Summary | Workforce Supply and Demand | Health Professions Education | Physician Practice Location | Licensure and Regulation of Practice | Improving the Practice Environment | Exemplary Workforce Legislation, Programs and Studies | Policy Analysis | Data Sources

PROJECT DESCRIPTION

Historically, both federal and state governments have had a role in developing policy to shape the health care workforce.  The need for government involvement in this area persists as the private market typically fails to distribute the health workforce to medically underserved and uninsured areas, provide adequate information and analysis on the nature of the workforce, improve the racial and ethnic cultural diversity and cultural competence of the workforce, promote adequate dental health of children, and assess the quality of education and practice. 

It is widely agreed that the greatest opportunities for influencing the various environments affecting the health workforce lie within state governments. States are the key actors in shaping these environments, as they are responsible for:

• financing and governing health professions education;
• licensing and regulating health professions practice and private health insurance;
• purchasing services and paying providers under the Medicaid program; and
• designing a variety of subsidy and regulatory programs providing incentives for health professionals to choose certain specialties and practice locations.

Key decision-makers in workforce policy within states and the federal government are eager to learn from each other.  This initiative to compile in-depth assessments of the health workforce in 8 states is an important means of insuring that states and the federal government are able to effectively share information on various state workforce data, issues, influences and policies. 

Products of this study include individual health workforce assessments for each of the eight states and a single assessment that compares various data and influences across the eight states.  In general, each state assessment provides the following:

1. A summary of health workforce data, available resources and a description of the extent the state invests in collecting workforce data.  [Part of this information has been provided by the Bureau of Health Professions];
2. A description of various issues and influences affecting the health workforce, including the state’s legislative and regulatory history and its current programs, financing and policies affecting health professions education, service placement and reimbursement, planning and monitoring, and licensure/regulation;
3. An assessment of the state’s internal capacity and existing strategies for addressing the above workforce issues and influences; and
4. An analysis of the policy implications of the state’s current workforce data, issues, capacity and strategies.

The development of the project’s data assimilation strategy, content and structure was guided by an expert advisory panel.  Members of the advisory panel included both experts in state workforce policy (i.e., workforce planners, researchers and educators) and, more broadly, influential state health policymakers (i.e., state legislative staff, health department officials).  The advisory panel has helped to ensure the workforce assessments have an appropriate content and effective format for dissemination and use by both state policymakers and workforce experts/officials.

STUDY METHODOLOGY

Study Purpose and Audience

Key decision-makers in workforce policy within states and the federal government are eager to learn from each other.  Because states increasingly are being looked to by the federal government and others as proving grounds for successful health care reform initiatives, new and dynamic mechanisms for sharing innovative and effective state workforce strategies between states and with the federal government must be implemented in a more frequent and far reaching manner.  This initiative to compile comprehensive capacity assessments of the health workforce in 8 states is an important means of insuring that states and the federal government are able to effectively share information on various state workforce data, issues and influences.

Each state workforce assessment report is not intended to be voluminous; rather, information is presented in a concise, easy-to-read format that is clearly applicable and easily digestible by busy state policymakers as well as by workforce planners, researchers, educators and regulators.

Selection of States

NCSL, with input from HRSA staff, developed a methodology for identifying and selecting 8 states to assess their health workforce capacity.  The methodology included, but was not limited to, using the following criteria:

1. States with limited as well as substantial involvement in one or more of the following areas: statewide health workforce planning, monitoring, policymaking and research;
2. States with presence of unique or especially challenging health workforce concerns or issues requiring policy attention;
3. States with little involvement in assessing health workforce capacity despite the presence of unique or especially challenging health workforce concerns or issues requiring policy attention;
4. Distribution of states across Department of Health and Human Services regions;
5. States with Bureau of Health Professions (BHPr) - supported centers for health workforce research and distribution studies;
6. States with primarily urban and primarily rural health workforce requirements; and
7. States in attendance at BHPr workforce planning workshops or states that generally have interest in workforce modeling.

Collection of Data

NCSL used various means of collecting information for this study.  Methods exercised included:

1. Phone and mail interviews with state higher education, professions regulation, and recruitment/retention program officials;
2. Custom data tabulations by national professional trade associations and others (i.e., Quality Resource Systems, Inc.; Johns Hopkins University School of Public Health) with access to national data bases;
3. Tabulations of data from the most recent edition of federal and state government databases (e.g., National Health Service Corps field strength);
4. Site visit interviews with various officials in the eight profile states;
5. Personal phone conversations with other various state and federal government officials;
6. Most recently available secondary data sources from printed and online reports, journal articles, etc.; and
7. Comments and guidance from members of the study’s expert advisory panel.

STATE SUMMARY

Michigan is a large, industrial, heavily unionized state that has historically provided a generous array of health care services.  Its population is much less minority/ethnic in nature than the nation as a whole.  Employers participate in a large way to covering health insurance costs, contributing to low insurance rates.  The proportion of children and adults who are uninsured is well below the national average. 

Moreover, Michigan enjoys having fewer proportions of its population lacking geographical access to health care professionals.  The percent of the population living in primary care and dental health professional shortage areas (HPSAs) is below the national average.  In relation, the ratio of National Health Service Corps providers per 10,000 population in the state is nearly twice the national average.  Moreover, a recent evaluation of Michigan's state loan repayment program, intended to attract health professionals into underserved areas of the state, found that nearly 60 percent of primary care providers completing their service obligation during the 1990s were still practicing in an underserved area.  There is increasing interest in finding new sources of funds to expand the program.

Statewide, Michigan's per capita health workforce counts exceed nationwide ratios.  The number of registered nurses, dentists, dental hygienists, physician assistants and pharmacists per 100,000 population all are above national averages.  Physician supply per capita generally mirrors the national average.

However, new and growing problems with health workforce supply have surfaced.  Medicaid provider reimbursement rates for most health professionals have been frozen or reduced in recent years due to the state's budget problems.  Budget and economic difficulties have also increased the number of uninsured, particularly in the Detroit area where large numbers of residents without health insurance coverage have no access to primary care physicians. 

As is occurring in most states, there is increased evidence of an overall shortage of nurses and at least a geographic maldistribution (particularly in the state's rural, upper peninsula region as well as the inner city of Detroit) of physicians, dentists and pharmacists in Michigan.  Growing concerns about a pharmacist shortage, particularly in the state's rural areas, are occurring at the same time that applications to Michigan's pharmacy schools have risen sharply.  Although there is growing concern that Michigan will be facing an overall shortage of dentists in the near future, oral health experts generally agree that the state’s dental workforce shortage now is largely a maldistribution problem.  The dentist shortage is seen becoming acute in rural areas and also in impoverished areas of larger cities.  

Sources:  U.S. Census Bureau, AARP.

Only one-fifth of Michigan residents are minorities.

Table I-b.

Sources: CDC, AARP, GAO.

Less than half of Michigan adults with incomes less than $15,000 made a dental visit in the preceding year.

Table I-c.

HPSA = Health Professional Shortage Area

Sources: KFF, AARP, BPHC-DSD.

Michigan has a greater proportion of non-elderly and children without health insurance than the U.S. as a whole.

Table I-d.

RN= Registered Nurse, LPN= Licensed Practical Nurse, CNM= Certified Nurse Midwife, NP= Nurse Practitioner CRNA= Certified Registered Nurse Anesthetist

Source: HRSA-BHPr.

One-third of physicians in Michigan are international medical graduates.

Table I-e.

HPSA= Health Professional Shortage Area

Source: BPHC-NHSC.

Michigan has nearly twice as many National Health Service Corp professionals per 10,000 population as the U.S. as a whole.

Table I-f.

MCOs = Managed Care Organizations    HMOs = Health Maintenance Organizations    OB/GYN = Obstetrician/Gynecologist

* This requirement does not preclude MCOs from including additional professions on their provider panels.

Sources: HPTS, AARP.

Twenty-seven percent  of Michigan residents receive health care form an HMO.

Table I-g.

¹ Generally seen as an indicator of significant participation in the Medicaid program.
² Denominator number from HRSA State Health Workforce Profile, December 2000.

¹ Denominator number is state population from 2000 U.S. Census.

Sources: AAMC, AAMC Institutional Goals Ranking Report, AACOM, Barzansky et al. “Educational Programs”, State higher education coordinating boards.

Three-quarters of newly entering medical students in Michigan are state residents. Table II-b.

¹ Includes estimated number of osteopathic residencies/residents not accredited by the Accreditation Council for Graduate Medical Education.
² Does not include residents from Canada.
³ Explicit payments for both direct and indirect GME cost.

Sources: AMA, AMA State-level Data, AACOM, State higher education coordinating boards, Henderson “Funding”, Oliver et al. “State Variations.”

One-quarter of allopathic residents in Michigan are from in-state medical schools.  Nearly one-third of residents are international medical graduates.

Table II-c.

¹ Denominator number is state population from 2000 U.S. Census.

Sources: AAFP, AAFP State Legislation, Kahn et al., Pugno et al. and Schmittling et al. “Entry of U.S. Medical School Graduates”.

Only fifteen percent of Michigan medical school graduates were first year residents in family medicine. Table II-d.

¹ Annual figure for Associate, Baccalaureate, Masters and Doctoral students/graduates for most recent years available.
² Denominator number is the state population from the 2000 U.S. Census.

Sources: NLN, AACN, State higher education coordinating boards.

The number of baccalaureate degree nursing students in Michigan rose slightly from 2001 to 2002. The number of baccalaureate degree nursing graduates and master’s students and graduates declined in the same period.

Table II-e.

* Denominator number is state population from 2000 U.S. Census.

Source: AACP.

Table II-f.

¹ Denominator number is state population from 2000 U.S. Census.
²  Data was only available from four of the programs in Michigan.

Sources: APAP, APAP Annual Report.

Table II-g.

* Denominator number is state population from 2000 U.S. Census.

Source: ADA.

Table II-h.

* Denominator number is state population from 2000 U.S. Census.

Sources: ADHA, AMA Health Professions.

III.   PHYSICIAN PRACTICE LOCATION

The following tables examine in-state physician practice location from two different vantage points: (1) of all physicians who were trained (went to medical school or received their most recent GME training) in the state between 1975 and 1995, and (2) of all physicians who are now practicing in the state, regardless of where they were trained.  Complied from the American Medical Association’s 1999 Physician Masterfile by Quality Resource Systems, Inc., the data importantly illustrates to what extent physician graduates practice in many of the state’s small towns, using the rural-urban continuum developed by the U.S. Department of Agriculture.

Practice location (URBAN/ RURAL) of physicians who received their medical school training in Michigan between 1975 and 1995.

Table III-a.

¹ 1995 Rural/Urban Continuum Codes for Metro and Nonmetro Counties.  Margaret A. Butler and Calvin L. Beale. Agriculture and Rural Economy Division, Economic Research Service, U.S. Department of Agriculture.

Codes # 00-03 indicate metropolitan counties:

00: Central counties of metro areas of 1 million or more

01: Fringe counties of metro areas of 1 million or more

02: Counties with metro areas of 250,000 - 1 million

03: Counties in metro areas of less than 250,000

Codes # 04-09 indicate non-metropolitan counties:

04: Urban population of 20,000 or more, adjacent to metro area

05: Urban population of 20,000 or more, not adjacent to metro area

06: Urban population of 2,500-19,999, adjacent to metro area

07: Urban population of 2,500-19,999, not adjacent to metro area

08: Completely rural (no place w population > 2,500), adjacent to metro area

09: Completely rural (no place w population > 2,500), not adjacent to metro area

NA: Not Applicable; no counties in the state are in the R/U Continuum Code.

Practice location (URBAN/ RURAL) of physicians who received their most recent GME training in Michigan between 1978 and 1998.

Table III-b.

¹  1995 Rural/Urban Continuum Codes for Metro and Nonmetro Counties.  Margaret A. Butler and Calvin L. Beale.  Agriculture and Rural Economy Division, Economic Research Service, U.S. Department of Agriculture.

Codes # 00-03 indicate metropolitan counties:

00: Central counties of metro areas of 1 million or more

01: Fringe counties of metro areas of 1 million or more

02: Counties with metro areas of 250,000 - 1 million

03: Counties in metro areas of less than 250,000

Codes # 04-09 indicate non-metropolitan counties:

04: Urban population of 20,000 or more, adjacent to metro area

05: Urban population of 20,000 or more, not adjacent to metro area

06: Urban population of 2,500-19,999, adjacent to metro area

07: Urban population of 2,500-19,999, not adjacent to metro area

08: Completely rural (no place w population > 2,500), adjacent to metro area

09: Completely rural (no place w population > 2,500), not adjacent to metro area

NA: Not Applicable; no counties in the state are in the R/U Continuum Code.

IV.  LICENSURE AND REGULATION OF PRACTICE

States are responsible for regulating the practice of health professions by licensing each provider, determining the scope of practice of each provider type and developing practice guidelines for each profession.  The tables below illustrate the licensure requirements for each of the health professions covered in this study as well as additional information on recent expansions in scope of practice or other novel regulatory measures taken by the state.

Table IV-a.

Sources: State licensing board, HPTS.

Table IV-b.

Source: State licensing board.

Table IV-c.

Sources: State licensing board, AANA, ACNM, Pearson “Annual Legislative Update”, HPTS.

Table IV-d.

Source: State licensing board.

Table IV-e.

Source: State licensing board.

Table IV-f.

Source: State licensing board, ADHA.

Glossary of Acronyms

CNM: Certified nurse midwife.

CRNA: Certified registered nurse anesthetist.

DEA:  Drug Enforcement Agency.

HPSA: Health Professional Shortage Area

NCLEX: National Council Licensure Examination, administered by the National Council of State Boards of Nursing.

NP: Nurse practitioner.

RDHAP: Registered dental hygienist in alternative practice.

Source: State health officials.

Michigan uses recruitment and placement programs for all the major health professions. State health officials rated the impact of such programs high.

LOAN REPAYMENT/ SCHOLARSHIP PROGRAMS *

Table V-b.

* Includes only state-funded programs which require a service obligation in an underserved area.  (NHSC state loan repayment programs are included since the state provides funding.)

N/A* = Data was not applicable.

Source: State health officials.

WORKFORCE PLANNING ACTIVITIES*

Table V-c.

* One state health official supplied these responses. Therefore, data may be limited and may not accurately reflect all current workforce-planning activities in the state.

Michigan frequently collects and analyzes physician supply data from both primary and secondary sources, and produces workforce reports for nurses.

VI. EXEMPLARY WORKFORCE LEGISLATION, PROGRAMS AND STUDIES

The following abstracts describe several of Michigan’s recent endeavors to understand and describe the status of the state’s current health care workforce.

Legislation and Programs

S-1000 (2002)

This law allows a dental hygienist to administer intraoral block and infiltration anesthesia to patients 18 years of age or older. The hygienist must be certified and under the direct supervision of a dentist.

Michigan Center for Nursing

The Michigan Center for Nursing was developed from recommendations in a 2001 report from the Michigan Department of Consumer and Industry services.  The purpose of the Center is to make recommendations for cultivating and maintaining a high-quality nursing workforce in Michigan; to foster strategic alliances among nurses, educational institutions, employers and other stakeholders for improvement in the recruitment, education, retention of nurses, and the delivery of health care; and to establish a central resource for nursing workforce data collection and analysis. 

Oral Access Grants

Michigan Department of Community Health (DCH), April 2000

The DCH began awarding grants to agencies in 2000 to improve access to oral health for Medicaid beneficiaries and to increase competency of dental students as providers for underserved populations. Agencies receiving grants in the program work with the University of Michigan Dental School to rotate dental students into community health centers.

Studies

Informing the Debate: Nursing Workforce Requirement for the Needs of Michigan Citizens

Institute for Public Policy and Social Research and Institute for Health Care Studies, 2002

This paper discusses the nursing workforce shortage and expected shortages in the state. The paper cites a 24 percent decline in the number of newly licensed nurses in the state since 1997 and the aging workforce as signs of a shortage in the state. According to the report, the nurses must deal with lack of control of their practice, cuts in support staff and resources, mandatory overtime, and staffing shortages resulting in compromised quality of care. The report recommends developing structures within state government for gathering and maintaining information on the profession, developing public and private partnerships to recruit and educate new nurses, and developing incentives for health care delivery systems and educational institutions to partner for change.

Michigan State Loan Repayment Program Evaluation Report 1991-1999

Michigan Center for Rural Health, 2001

This report is an evaluation of the state’s loan repayment program for health professionals. The report looks at the distribution for providers participating in the program and the retention rates of the providers by location, specialty, and gender. According to the report around 58 percent of primary care providers completed their service obligation and were still practicing in the area.

Study of the Current and Future Needs of the Professional Nursing Workforce in Michigan

Michigan Department of Consumer and Industry Services, 2001

This study looked at data from licensure surveys of Michigan nurses, focus groups of nurses, and a survey of hospitals on the use of nursing personnel for the purpose of developing a profile of the current supply of nurses in the state; identifying factors affecting the quantity and quality of the nursing workforce; reviewing trends in health care delivery; and developing recommendations for further study and policy discussion.

VII. POLICY ANALYSIS

Statewide Organizations with Significant Involvement in Health Workforce Development/Analysis

• Michigan Department of Community Health
• Michigan Center for Nursing
• Michigan Nurses Association
• Michigan Health and Hospital Association

Evidence of Collaboration:  Minimal (largely associated with workforce data collection and profession recruitment and retention)

Michigan is a large, industrial, heavily unionized state that has historically provided a generous array of health care services.  Its population is much less minority/ethnic in nature than the nation as a whole.  Employers participate in a large way to covering health insurance costs, contributing to low insurance rates.  The proportion of children and adults who are uninsured is well below the national average. 

Moreover, Michigan enjoys having fewer proportions of its population lacking geographical access to health care professionals.  The percent of the population living in primary care and dental health professional shortage areas (HPSAs) is below the national average.  In relation, the ratio of National Health Service Corps providers per 10,000 population in the state is nearly twice the national average.  Moreover, a recent evaluation of Michigan's state loan repayment program, intended to attract health professionals into underserved areas of the state, found that nearly 60 percent of primary care providers completing their service obligation during the 1990s were still practicing in an underserved area.  There is increasing interest in finding new sources of funds to expand the program.

Statewide, Michigan's per capita health workforce counts exceed nationwide ratios.  The number of registered nurses, dentists, dental hygienists, physician assistants and pharmacists per 100,000 population all are above national averages.  Physician supply per capita generally mirrors the national average.

However, new and growing problems with health workforce supply have surfaced:

• Medicaid provider reimbursement rates for most health professionals have been frozen or reduced in recent years due to the state's budget problems.  Just a quarter of all dentists are enrolled to serve Medicaid patients; but of those, about 30 percent receive annual payments greater than $10,000 -- twice the proportion of physicians participating in Medicaid.
• Budget and economic difficulties have also increased the number of uninsured, particularly in the Detroit area where large numbers of residents without health insurance coverage have no access to primary care physicians and are seeking basic and costly health care in emergency rooms of the city's public hospitals which already are suffering financial distress.  The city's network of free clinics, increasingly having difficulty attracting primary care physicians and nurses due to poor Medicaid payment rates and other factors, has been unable to handle the increased demand.
• As in other states faced with addressing budget shortfalls, Michigan's legislature has been forced in the past few years to make significant cuts to state-funded colleges and universities.  All four medical schools, 41 of 48 nursing schools, all three schools of pharmacy, and one of the state's two dental schools are publicly funded.  Although the state tends to export many of the physicians it trains, about two-thirds of the physicians educated at Michigan's one osteopathic medical school ultimately in the state to practice.  
• As is occurring in most states, there is increased evidence of an overall shortage of nurses and at least a geographic maldistribution (particularly in the state's rural, upper peninsula region as well as the inner city of Detroit) of physicians, dentists and pharmacists in Michigan.  Growing concerns about a pharmacist shortage, particularly in the state's rural areas, are occurring at the same time that applications to Michigan's pharmacy schools have risen sharply.

Physicians and Medicaid Support

In recognition that a small proportion of physicians in Michigan see Medicaid patients, the state Medicaid agency with the Department of Community Health undertook an initiative in 1997 as part of its policy to support graduate medical education to encourage the training of more physicians exposed to the importance of providing basic primary care services to Medicaid patients.  The state sought to structure payments to bring physician education more in line with its specific public policy goals to train appropriate numbers of primary care providers, enhance training in rural areas, and support education in ways of particular importance in the treatment of the Medicaid eligible population. 

For the first three years of the new policy, a historic cost pool reimbursed each hospital the same amount in payments that it received in 1995 based on their 1995 costs for medical education.  A second pool, the primary care pool, seeks to encourage the education of young physicians in the primary care fields of general practice, family practice, preventive medicine, obstetrics and geriatrics.  Payments from the primary care pool to hospitals are based on the institution’s number of residents in primary care and its share of Medicaid patients.  To qualify for reimbursement from either pool, a hospital must submit a report to the state detailing resident profiles and how it is using the funds to support specific public policy goals and priorities.  A third pool, the Innovations in Health Professions Education Grant Fund, was established with GME funds formerly included in capitation payments to managed care organizations (MCOs) to foster innovations in health profession education and accelerate the pace of change currently sweeping the state’s health care delivery system.  Grants are awarded on a competitive basis to programs that support the goals of the new GME initiative, with emphasis on innovative training in managed care arrangements. 

The initiative’s overall impact on addressing state workforce goals is not yet known.  The state does believe that such programs would be more effective if a more coherent policy approach could be developed between Medicaid and Medicare and other payers.  State efforts such as Michigan may need to exercise caution on how specifically they direct their initiatives regarding state workforce needs.  Physicians have typically responded to other market changes more quickly than to state financing changes. In Michigan, there appears to be no shortage of primary care physicians, but there is evidence of a shortage of some specialists willing to be part of managed care networks. 

In 2001, a new formula was established which takes into consideration utilization by and service to the state’s Medicaid population.  Furthermore, Medicaid agreed to provide funding to educate third and fourth year students at the state’s one public dental school that is developing specialized curricula and programs intended to increase further the participation of dentists in Medicaid.  Funding covers teaching and other administrative costs that are matchable under Medicaid’s intergovernmental transfer mechanism to draw additional federal matching funds and provide new revenue for the state’s dental school. 

Nursing

Although data on the state's changing demand for and supply of nurses is lacking, there is a growing consensus that the nursing shortage in Michigan, like elsewhere, is largely associated with an insufficient capacity of nurse training programs associated with shortages of faculty, space and other resources to educate more nurses.  Increasing numbers of qualified applicants are being turned away from nursing schools. 

In recognition of the growing concerns about a nursing shortage in the state, the legislature in 2000 directed the Michigan Department of Consumer and Industry Services, in conjunction with the state board of nursing, state nurses association, state hospital association and others, to commission a study to determine the extent and nature of the problem.  The study, issued in 2001, found that Michigan’s rate of growth in the number of registered nurses is slower than the national growth rate, and similar to findings in other states, reported that Michigan hospitals have serious difficulties filling vacant nursing positions.  The study also concluded that additional information on nursing supply and demand in the state is sorely needed.  The report also recommended that ongoing collaborative partnerships among nurses, nurse educators, nurse employers and others be established to build capacity for state-level workforce development and research.

A follow up 2002 report by a health services research group has provided additional information about Michigan’s nursing workforce shortage and expected shortage and again called for creating structures within state government for collecting nursing supply and demand data and developing public and private partnerships among nursing groups in the state.

The 2001 study, in particular, provided the impetus for the creation of the Michigan Center for Nursing whose purpose is to make recommendations for cultivating and maintaining a high-quality nursing workforce in Michigan through the fostering of strategic alliances among the above-noted entities and other organizations.  The Center also is the state’s central resource for nursing workforce data collection and analysis.

Concurrent with these efforts to better understand and address the state’s nursing shortage are growing concerns about nursing shortages in rural areas of the state.  Moreover, there is evidence of continued tensions between employers and nurses over working conditions and other issues.  A lengthy nurses strike at northern Michigan hospital has been problematic.  Recent information also finds that nursing school enrollment is rising, but shortages of faculty and clinical training opportunities are increasing as well.

Dentistry

Although there is growing concern that Michigan will be facing an overall shortage of dentists in the near future, oral health experts generally agree that the state’s dental workforce shortage now is largely a maldistribution problem.  The dentist shortage is seen becoming acute in rural areas and also in impoverished areas of larger cities.   This is particularly evident is the low number of dentists (less than 25%) statewide and in many rural counties willing to serve a significant volume of Medicaid patients.  Access to oral health care for many Medicaid beneficiaries was further compromised in 2003 when the legislature agreed to eliminate Medicaid dental benefits for adults as part of the state’s continued fiscal crisis.

Following that change, another measure introduced (but not enacted) in the legislature would offer dentists who treat Medicaid beneficiaries a tax credit equal to either their annual student loan payments or $5,000, whichever is less.  To be eligible, dentists must be state residents, have their primary practice in the state, and provide at least 12 hours of dental services to Medicaid beneficiaries each month.

Initiatives in Michigan to address this problem do remain.  In 2000, the Department of Community Health awarded 22 agencies oral health access grants.  In one example, five of these agencies subcontracted with the University of Michigan Dental School to rotate dental students into five community health centers in diverse geographic and population areas to treat Medicaid beneficiaries.  The two main goals of this pilot program was to increase access to oral health services for Medicaid beneficiaries, and increase students’ competency as providers in caring for underserved populations.  As a result of the rotation activities, all five community health centers have hired dentists who were former students of the program to join their dental staff.  In addition, the University of Michigan uses this partnership as a recruitment tool to attract students to dental school.

The overall supply of dental hygienists in Michigan appears to be adequate.  Over 9,000 hygienists are in practice in a state with 12 hygiene training programs.  The demand for hygienists in rural areas of the state, however, looks to be exceeding their supply.  As elsewhere, hygienists have few opportunities to practice with limited dentist supervision.  A recent change does allow hygienists to practice with less supervision in certain public health settings. 

Data Sources

Workforce Supply and Demand

American Association of Retired Persons, Public Policy Institute (AARP). Reforming the Health Care System: State Profiles 2000.  (Washington, DC: 2001).

American Association of Retired Persons, Public Policy Institute (AARP). Reforming the Health Care System: State Profiles 2003.  (Washington, DC: 2003).

Bureau of Primary Health Care, Division of Shortage Designation (BPHC-DSD). Selected Statistics on Health Professional Shortage Areas (Bethesda, MD: December 2003).

Bureau of Primary Health Care, National Health Service Corps (BPHC-NHSC). National Health Service Corps Field Strength: Fiscal Year 2003 (Bethesda, MD: January 2004).

Centers for Disease Control,  National Center for Chronic Disease Prevention and Health Promotion.  National Oral Health Surveillance System,  Oral Health Profiles.  (Atlanta, GA: 2003)

Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Information and Analysis (HRSA-BHPr). State Health Workforce Profiles (Bethesda, MD: December 2000).

Kaiser Family Foundation, Kaiser Commission on Medicaid and the Uninsured (KFF). Health Insurance Coverage in America: 2002 Data Update (Palo Alto, CA: January 2002).

National Conference of State Legislatures, Health Policy Tracking Service (HPTS).

National Conference of State Legislatures, Health Policy Tracking Service. Primary Health Care and Vulnerable Populations  (Washington, DC: January 2000).

Personal conversations with CMS regional office officials.

S. Norton and S. Zuckerman. “Trends in Medicaid Physician Fees” Health Affairs. 19(4), July/August 2000.

State Medicaid programs (data from NCSL survey).

United States General Accounting Office (GAO). Oral Health: Dental Disease is a Chronic Problem Among Low-Income Populations.  (Washington, DC: April 2000) GAO/HEHS-00-72.

Health Professions Education

American Academy of Family Physicians (AAFP)

American Academy of Family Physicians. State Legislation and Funding for Family Practice Programs. (Washington, DC).

American Association of Colleges of Nursing (AACN)

American Association of Colleges of Osteopathic Medicine (AACOM). Annual Statistical Report. (Chevy Chase, MD).

American Association of Colleges of Pharmacy (AACP). Profile of Pharmacy Students. (Alexandria, VA).

American Dental Association (ADA)

American Dental Association. 1997-1998 Survey of Predoctoral Dental Educational Institutions. (Washington, DC).

American Dental Hygienist Association (ADHA)

American Medical Association (AMA). Health Professions Career and Education Directory.

American Medical Association. State-level Data for Accredited Graduate Medical Education Programs in the U.S.: 2002-2003. (Washington, DC: 2001)

Association of American Medical Colleges (AAMC)

Association of American Medical Colleges.  Institutional Goals Ranking Report. (AAMC website).

Association of Physician Assistant Programs (APAP).

Association of Physician Assistant Programs. Sixteenth Annual Report on Physician Assistant Educational Programs in the United States, 2002-2003. (Loretto, PA: 2001).

Barzansky B. et al., “Educational Programs in U.S. Medical Schools, 2002-2003” JAMA. 290(9), September 3, 2003.

Henderson, T., Funding of Graduate Medical Education by State Medicaid Programs, prepared for the Association of American Medical Colleges, April 1999.

Kahn N. et al., “Entry of U.S. Medical School Graduates into Family Practice Residencies: 1997-1998 and 3-year Summary” Family Medicine. 30(8), September 1998.

Kahn N. et al., “Entry of U.S. Medical School Graduates into Family Practice Residencies: 1996-1997 and 3-year Summary” Family Medicine. 29(8), September 1997.

Kahn N. et al., “Entry of U.S. Medical School Graduates into Family Practice Residencies: 1995-1996 and 3-year Summary” Family Medicine. 28(8), September 1996.

National League for Nursing (NLN)

Oliver T. et al., State Variations in Medicare Payments for Graduate Medical Education in California and Other States, prepared for the California HealthCare Foundation. (Data from the Health Care Financing

Administration, compiled by the Congressional Research Service.)

Pugno P. et al.. “Entry of U.S. Medical School Graduates into Family Practice Residencies: 1999-2000 and 3-year Summary” Family Medicine. 32(8), September 2000.

Schmittling G. et al. “Entry of U.S. Medical School Graduates into Family Practice Residencies: 1998-1999 and 3-year Summary” Family Medicine. 31(8), September 1999.

State higher education coordinating board/university board of trustees (data from NCSL survey).

Physician Practice Location

1999 American Medical Association Physician Masterfile. Computations were performed by Quality Resource Systems, Inc. of Fairfax, Virginia.

Licensure and Regulation of Practice

American Association of Nurse Anesthetists (AANA)

American College of Nurse Midwives (ACNM). Direct Entry Midwifery: A Summary of State Laws and Regulations. (Washington, DC: 1999).

American College of Nurse Midwives. Nurse-Midwifery Today: A Handbook of State Laws and Regulations. (Washington, DC: 1999).

American Dental Hygienist Association

National Conference of State Legislatures, Health Policy Tracking Service.

Pearson L., editor.  “Annual Legislative Update: How Each State Stands on Legislative Issues Affecting

Advanced Nursing Practice” The Nurse Practitioner. 25(1), January 2000.

State licensing boards (NCSL survey).

Improving the Practice Environment

State health officials (NCSL survey).