Anyone who’s been to the dentist recently knows that sometimes the biggest dread isn’t the drill, but the bill. One reason dental work is so expensive is that dentists lobby against competition. A recent investigation by the Washington Post found that the American Dental Association (ADA) and state dental boards lobby to keep out competition that could improve access to—and lower the cost of—dental care.

In 2014, a fight erupted in Maine between dentists and state legislators over a bill to establish dental therapists to provide additional services to Maine’ underserved communities. A dental therapist works in concert with a licensed dentist to provide preventative and restorative care that does not require cutting into teeth, such as applying local anesthetic or placing temporary crowns. A dental therapist is also a cheaper option to a dentist because their training is less expensive. State senator David Burns said that although the bill ultimately passed, “it was brutal, very brutal.” According to the Post, during “the Maine debate, so many dentists flooded the statehouse in Augusta that besieged lawmakers taped up signs declaring their offices a “Dental Free Zone.”

This behavior is typical of so-called bottleneckers. The term, which was the title of a new book by the Institute for Justice (IJ), is defined as “a person who advocates for the creation or perpetuation of government regulation” in order to restrict competition and accrue “an economic advantage without providing a benefit to consumers.”

Since merely protecting their bottom line was a hard position to defend, dentists and the ADA argued that dental therapists are “lesser trained” and “provide second-class care.” However, Pew Charitable Trusts and other foundations argue that therapists could improve access and affordability for dental care. John Grant, director of the Pew Charitable Trusts’ dental campaign said, “Therapists are not a silver bullet but a significant way to begin addressing the problem.”

Not only have Dental boards fought to prevent dental therapy, they have also come under increased scrutiny by federal government for other anti-competitive behavior. According to the Washington Post:

The Federal Trade Commission has battled dentists in state after state over anti-competitive conduct. In 2007, the FTC successfully settled a complaint over a South Carolina dental board requirement that dentists examine children in school clinics before hygienists can clean their teeth, adding greatly to the cost. In 2015, the FTC won a Supreme Court ruling against the North Carolina dental board, which tried to block teeth-whitening businesses from operating in malls.

Under the North Carolina dental board decision, state licensing boards are required to have significant oversight from their respective state governments. Otherwise, they are not immune from liability under federal antitrust law. This provides an excellent opportunity for states to reexamine the necessity of their existing occupational licenses and implement much needed reforms. Those reforms can include eliminating unnecessary licenses, or for occupations in which some type of government regulation can be empirically proven as necessary, the regulation and its requirements can be tailored to the demonstrable need—presumably something less restrictive than an occupational license. The IJ report Boards Behaving Badly introduces an inverted pyramid of occupational regulatory options for just such a purpose, particularly identifying less restrictive forms of regulation other than an occupational license.

While the Maine fight highlighted the kind of uphill battle that licensing reform entails, it also showed that reform can pass. There is also hope that these reforms will improve dental care. As Louis Sullivan, former secretary of health and human services under President George H.W. Bush, told the Post, “doctors strongly opposed the creation of nurse practitioners in the 1970s. Now doctors — and the health-care system — can’t live without them.”