practices or otherwise to expand clinical services can still provoke resistance by area practitioners.

More generally, the financing of dental services has incited bitter debate since at least the 1920s. One starting point was the work of the private Committee on the Costs of Medical Care. With funding from several foundations, the committee set out to collect data on the cost and availability of health services. Its five-year investigation generated 27 field studies and a controversial final report (Anderson, 1968; Starr, 1982; IOM, 1993b). One part of this investigation was a survey of the incidence of dental disease and of the cost and availability of dental services (McCluggage, 1959). These studies found that 12 percent of health care spending went to dental services versus 30 percent to physician services and 24 percent to hospitals. The proportion of dentists to population varied from 1:500 to 1:4,000 for the population generally, but it was 1:8,500 among the segregated black population. The committee's proposals for change, which included group practice and voluntary private insurance, were strongly opposed by both the medical and the dental professions. The controversy discouraged the Roosevelt administration from including health coverage as part of its social security proposals.

In the 1940s, a series of government actions almost inadvertently encouraged employers to expand nonwage compensation to their employees (Somers and Somers, 1963; Starr, 1982). Substantial growth in private, employment-based health insurance was one major consequence, although dental insurance specifically did not really begin to grow until the 1970s. Less than 2 percent of the population was covered by private dental insurance in 1965 compared to over 25 percent in 1978 (IOM, 1980). When the Medicare program was established in 1965, it excluded dental services—and that exclusion remains in place. Although required to cover some services for children, most state Medicaid programs pay relatively little for dental care, especially for adults IOTA, 1990). Today, not quite half the U.S. population has some form of public or private coverage for dental services (Keefe, 1994).

Controversy has also surrounded other steps to extend access to dental services. In 1970, Congress established the National Health Service Corps (NHSC; P.L. 91-623) to improve health services in underserved areas. Although the focus was on areas with shortages of health personnel, the legislation also included provisions for partly or fully subsidized care to those who could not afford to pay. In most cases, local medical or dental societies as well as local governments had to agree to designations of shortage areas. Opposition by dental groups was apparently more frequent



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