With a degree from the University of Southern California and 40 years’ experience practicing dentistry in California and Arizona, Dr. Carlos Ruiz is qualified to practice in the vast majority of U.S. states without taking the current version of a national exam for dentists.

But Hawaii is a different story. Unlike 46 other states, the District of Columbia and Puerto Rico, which allow licensed dentists from other states to practice if they meet certain criteria based on experience and credentials, Hawaii requires dentists moving here from other states to pass a test known as the American Board of Dental Examiners, or ADEX, test. Ruiz’s experience and qualifications aren’t enough – even if they’re equivalent to peers licensed in Hawaii.

Ruiz acknowledges he could simply take the test and move on. But, he says, he first wants to try to change the system, which he asserts is designed to protect not the public, but an insular group of local dentists who don’t want competition.

“Hawaii, even when I started practicing 40 years ago, was notorious about trying to keep people out,” says Ruiz.

Now, a Hawaii lawmaker wants to change that. Rep. Sean Quinlan, who chairs the House Committee on Economic Development, plans to introduce a measure meant to put Hawaii on the same footing as all but a handful of other states when it comes to license requirements for dentists who move to the islands.

The issue, as Quinlan describes it, is stark. He agrees professional licensing laws are necessary to protect public health and safety. But he said Hawaii’s law for dentists is an outlier that is hindering well-qualified professionals from moving here at a time when Hawaii needs them.

“We have a shortage of these knowledge and skill workers,” Quinlan said in an interview. “And these shortages are exacerbated by economic factors like the housing market and the high cost of living. So we’re already at a disadvantage when it comes to other states.”

Among other things, Quinlan’s bill would change the law so Hawaii’s Board of Dentistry could grant a license to an applicant who is a practicing dentist, licensed in another state and meets other qualifications. According to the bill, a prospective licensee also cannot have been disciplined by another licensing board and subjected to court judgments or settlements that show a pattern of negligence or incompetence.

Quinlan’s bill comes at a time when state and federal policymakers in Hawaii and across the nation are taking a hard look at reforming licensing laws. Nearly half a century ago, Hawaii passed the Hawaii Regulatory Licensing Reform Act of 1977 to make sure its occupational licensing laws were protecting the public and not the industries they were set up to regulate.

Since then, more than a dozen states have gone a step further, passing comprehensive reciprocity laws that make it easier for skilled professionals to move freely between states.

Hawaii is inching in that direction. Last month, Rep. Aaron Ling Johanson, who chairs the House Consumer Protection and Commerce Committee, said it might be time for Hawaii to assess the state’s licensure laws and consider reciprocity.

Meanwhile, on the federal level, President Joe Biden in July issued a comprehensive “Executive Order on Promoting Competition in the American Economy.” The order specifically calls out restrictive state licensing requirements, saying they can harm people hoping to move between states.

“While many occupational licenses are critical to increasing wages for workers and especially workers of color,” the order says, “some overly restrictive occupational licensing requirements can impede workers’ ability to find jobs and to move between States.”

Still, licensing laws are mostly a state issue. Although Congress generally can regulate interstate commerce, the states retain the power to pass laws to protect health, safety, welfare and morals, including vocational licensing laws. The result is a patchwork of regulations governing a variety of occupations that can vary widely.

In the case of dentists, according to the American Dental Association, almost all of the states have adopted some sort of “licensure by credential” system. In California, for instance, a dentist moving from another state can be licensed if the dentist has been in active clinical practice for a total of at least 5,000 hours in five of the seven consecutive years prior to applying. In Washington, a dentist can be licensed if the dentist is licensed in another state and has practiced dentistry for at least 20 hours a week for the four consecutive years preceding the application.

Erika Hoeft, a spokeswoman for the American Dental Association, wouldn’t say whether the organization believes states that allow licensure by credentials provide adequate protection to public health and safety. But the Hawaii Dental Association believes laws like the ones in California, Washington aren’t right for Hawaii.

“HDA’s position is that vetting someone based on credentials or past training alone does not assure the people in Hawaii that the applicant is fully qualified,” the association’s executive director, Kim Nguyen, said in a statement. Nguyen declined interview requests, and the association’s lobbyist, Melissa Pavlicek, would not comment on the record.

Unlicensed Dentists Can Treat Hawaii’s Indigent

For its part, the Hawaii Board of Dentistry, which implements the licensure law, appears generally willing to defer to lawmakers. Responding to questions from Ruiz during a Sept. 20 board meeting, for example, the board’s vice chair, Dr. Paul Guevara, noted that the board merely implements the law established by the Legislature, meeting minutes show. He commended Ruiz for working with Quinlan.

But, Dr. Earl Hasegawa, the board chair, cautioned there could be an unintended consequence if Hawaii grants licenses without a test to dentists who are qualified to practice in other states but not licensed in the island state.

Unlicensed dentists can now perform dentistry on low-income people in special clinics under supervision of a dentist licensed in Hawaii. If the dentists qualified to practice in other states were given licenses in Hawaii, Hasegawa said, that would “likely leave the state with a significant manpower shortage to this vulnerable population,” minutes show.

Based on his personal involvement with a number of these clinics, Hasegawa insisted that Hawaii does not have a two-tier system: a higher one for those who can pay and a lower one for indigent patients being treated by dentists not licensed to practice solo under Hawaii law. The Hawaii-licensed dentists supervise the dentists from other states to make sure the malihini tooth doctors do a good job, Hasegawa explained.

Ruiz finds this explanation unconvincing. If all licensed dentists from other states really must pass a test to protect the public from quacks, he said, the rule should apply equally to all dentists, including ones treating low-income people.

“If you’re protecting people, you’ve got to protect everybody — not just ones who have money,” he said.