This article was published by the National Health Federation
on October 30, 2012.
Dr. Smith is a lifetime member of the NHF since the early 1980s.

Obamacare & Chiropractic

“If we do not fix our health care system,

America may go the way of General Motors;

paying more, getting less, and going broke.” ^[1]

President Barack Obama

Arguably, the medical armamentarium of wonder drugs and heroic surgery has led to limited success with crisis care in America’s emergency room. Although this apparent success sensationalized by dramatic television programs embellished the positive aspects of medical care, it also has it downside.

The out-of-control nature of medical profiteering has also led to massive prescription drug usage, abuse, and addiction; the overuse of antibiotics has led to super germ infections; and the high percentage of unnecessary, ineffective, and costly surgeries that makes one question the overall value of this so-called modern era of medicine that has taken America to the brink of bankruptcy.

The foremost problem is that Obamacare did not break up the medical cartel—the AMA, Big Pharma, Big Hospitalists, and Big HMOs. As such, waste, abuse, fraud, and high costs illustrate the lack of a free market in the healthcare industry—the hallmark of the medical monopoly’s war against chiropractors and all other CAM providers.

Another factor that drives medical costs is that Health Maintenance Organizations have an oxymoronic policy that refuse to pay for maintenance care! This irony is also prevalent in Medicare’s policy despite the call for preventative measures by the Obama administration.

Section 2251.3 of the (Medicare Carriers) Manual states:

 “. . . [a] treatment plan that seeks to prevent disease, promote health and prolong and enhance the quality of life, or therapy that is performed to maintain or prevent deterioration of a chronic condition is not a Medicare benefit. Once the maximum therapeutic benefit has been achieved for a given condition, ongoing maintenance therapy is not considered to be medically necessary under the Medicare program.”^[2]

This Medicare policy speaks volumes about the nature of the American “sick-care” policy as Senator Tom Harkin [D-Iowa] described.

“For many years I’ve been saying that we don’t so much have a health care system in America as a sick-care system.  If you’re sick, you get care.  Up to the point of sickness or disease — you’re pretty much on your own. To date, wellness and prevention have been the missing pieces in the national conversation about health care reform.  It’s time to make them the centerpiece of that conversation.”^[3]

Obviously Medicare like the HMOs has no interest in disease prevention and shuns the ounces of prevention or even the ounces of cure, such as chiropractic care for low back pain. Indeed, few people realize the number of back pain patients and the staggering costs. Musculoskeletal disorders (MSDs) alone currently affect 44.6 million Americans and cost our society an estimated $267.2 billion every year[4], and when combined with all persons with MSDs in addition to other medical conditions, the cost of treatment in the 2002-2004 time period was estimated to be $849 billion per year.[5]

 To put this into perspective, the U.S. spent twice as much on health as it did on food in 2006—and more than China’s citizens consumed altogether. In addition, the increase in U.S. health care spending in the three-year period is more than the amount U.S. consumers spent on oil and gasoline during all of 2006 when energy prices began to reach new heights.^[6]

Until America emphasizes and incentivizes preventative care, this nation will continue to see no light at the end of the healthcare tunnel no matter how many people are covered by Obamacare insurance. This is most evident in the monies spent on sickness vs. wellness care. Last year, $2.4 trillion dollars were spent in this country on medical care and 95 cents of every dollar were spent to treat disease after it had already occurred.

A recent report from the Institute of Medicine admitted, “Health care in America presents a fundamental paradox.”[7]  Not only paradoxical, it is obviously costly and wasteful. According to the study, the American healthcare (medical) system wastes $750 billion annually, which equates to 30% of every medical dollar spent.^[8]

This annual (one-year) cost of medical waste/fraud equates to 164% of the entire (ten-year) cost of the Afghan war (2001-2011) at $455.4 billion according to the Center for Defense Information.[9]

As well as fraud and waste in medical care, the healthcare system was also wrought with abuse from HMOs, some of which were skimming millions off the top for executive salaries and overhead.  The Medical Loss Ratio provision of the Affordable Care Act, also known as the “80/20 rule”, requires insurers to spend at least 80% of each premium dollar on medical care and quality improvement, rather than on administrative costs. In some extreme cases, insurance plans spent more than 50 percent of every premium dollar on administrative costs. [10]

During this call for reform and despite the numerous cost-effectiveness studies that confirm chiropractic care is faster, safer, cheaper, and more effective for the majority of back pain cases, medical and political opponents still resist chiropractic’s inclusion.

For example, Obamacare coverage in California is  questioning whether chiropractic care will be added. “The situation,” according to Tom Daly, ACA legal counsel, “is that California selected the Kaiser HMO as the benchmark for the Exchange. However, it has a specific exclusion for ‘chiropractic services and services provided by chiropractors.’ The California Chiropractic Association is pursuing legislation which would keep the benefits section for the Exchange but eliminate the plan’s exclusion section as it pertains to DC’s.”[11]

 This confounding exclusionary Kaiser policy seems analogous to the AMA’s illegal boycott of the 1960s than reflecting the evidence-based research of the last few decades that shows chiropractic’s superiority.[12]

However, this impediment may prove to be short-lived and inconsequential considering Section 2706, so-called provider “Non-Discrimination in Health Care” law won by the American Chiropractic Association, will apply to all insurance entities, including insurance entities in the Exchanges, even Kaiser. While this provision does not require a health plan to contract with every available health care provider, it does prevent health plans from excluding an entire type of provider from its network.

Section 2706 is healthcare reform’s most significant inclusiveness measure for DCs, NDs, LAcs, massage therapists, and licensed midwives, potentially opening consumer choice to over 50-million more Americans.

While most people enjoy the idea of freedom of choice in the selection of their doctors, including licensed alternative doctors, the AMA has steadfastly opposed this non-discrimination section.

 “Much of the information currently known about these [CAM] therapies makes it clear that many have not been shown to be efficacious,’’ the AMA said in a July, 2009 policy statement.^[13] Again, the AMA has developed “professional amnesia” to the evidence-based research and public popularity of CAM.[14]

The AMA shamelessly denied trying to stifle competition and said it was only trying to ensure that medicine was based on science, according to an article in the Boston Globe, “Senators Seek Coverage for Alternative Therapies.”^[15] This alibi was similar to the red herring of “public safety” used by the AMA in the Wilk trial that proved to be false considering the AMA attorneys failed to produce one witness who had been hurt by chiropractors.

Undeterred, Sen. Tom Harkin (D-IA) came to the defense of CAM when he said at a congressional hearing that “It’s time to end the discrimination against alternative healthcare practices.”^[16]

Of course, this met with strong criticism from medical chauvinists like Dr. Harriet Hall, a retired Air Force flight surgeon, who said she worried that “ill-informed members of Congress will elevate practitioners of alternative medicine to the same level as medical doctors.”^[17] 

As chairman of the Office of Alternative Medicine for the past 17 years, undoubtedly Sen. Harkin must have been rather offended at her remark that he is “ill-informed.” Dr. Hall continued to show her bias when she said, “If it were shown to be truly effective, it would be part of regular medicine.’’

The suggestion that medicine is scientific is ironic considering a revealing article in Business Week, “Medical Guesswork” where Dr. David Eddy, the guru of evidence-based healthcare, confesses that only 15% of what doctors do is backed by hard evidence. While there has been progress in recent years, most physicians say the portion of medicine that has been proven effective is still outrageously low in the range of 20% to 25%.^[18]

Actually, this is not new criticism. On June 9, 2006, the CBS Evening News aired a segment, “Attacking Rising Health Costs,” stating 30-40% of spinal fusions, heart bypasses, knee and hip replacement surgeries were unnecessary according to Dr. Elliott Fisher of The Dartmouth Institute of Health Policy, who later said that 30 percent of hospital stays in the United States are probably unnecessary.[19] He noted the problems included patients who were not given good information to make an “informed consent” decision as to alternatives like chiropractic care or the inherent risks of medical procedures.

The strategies used by many insurance companies to rein in costs have had a significant impact on spine practices and patient care. Surgeons have been seeing sudden and unannounced coverage changes for common spinal procedures over the past year, leading to denied claims and a loss of revenue and resources.

“The industry has realized that the cost of spine surgery is too high to continue down the old path,” says Barbara Cataletto, MBA, CPC, CEO of Business Dynamics.^[20]

Another recent positive policy change concerning chiropractic care for chronic low back pain occurred when the University of Pittsburgh Medical Center Health Plan announced as of January 1, 2012 candidates for spine surgery must include verification that the patient has “tried and failed a 3-month course of conservative management that included physical therapy, chiropractic therapy, and medication.”^[21] This certainly is a step in the right direction, but one that will be resisted by the mainstream spine surgery community.

For example, in 2011 Blue Cross/Blue Shield of North Carolina announced a policy change to exclude spine fusion surgery if the only criteria were abnormal discs. In response, a letter to BC/BS of NC from nine medical spine associations protested vehemently again in complete denial of the newfound evidence.^[22]

Surgeons and spine practices have begun to receive coverage denials for procedures and practices that were previously covered by insurance companies. This has become especially prominent in spinal fusion cases, where surgeons must have all the documentation of failed non-operative treatment on file. “If your documentation from the hospital does not include the physician notes of conservative care through surgery, you will not be paid for the hospital stay or physician work,” says Ms. Cataletto

So, what can we conclude now about the role of chiropractic in Obamacare? Certainly the evidence-based cost-effectiveness trend will continue to support the inclusion of chiropractic care and Section 2706 will protect chiropractors and their patients from unwieldy restrictions as we’ve seen in the past. 

It’s past time American patients were allowed freedom of choice in healthcare and it’s past time chiropractors were allowed to compete on a level playing field in order to help millions of patients and save billions of dollars in our cash-strapped healthcare industry.