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Healthcare System
Unfortunately current healthcare policies and legislation make it difficult to extend these
benefits to the more vulnerable populations and it still remains out of reach for many
consumers. The advantages and disadvantages presented by current healthcare policy are
relatively dependent upon one's point of view as the various stakeholders experience health
outcomes largely determined by socio-economic status. In the long term however, it remains
in each of our best interests to recognize that we are all in this together as the burden of
caring for the uninsured eventually falls upon the rest of us too (Garthwaite, 2015).
In our assessment of the Affordable Care Act (ACA), for example, the advantages of
greater access to care and expansion of services appear to outweigh the disadvantages of
short lived with the threat of Republican efforts to repeal and replace the ACA looming.
Notable other advantages that may soon go away as a result of repeal include coverage for
chronic pre-existing conditions, Essential Health Benefits (EHBs), and the expansion of
Medicare and Medicaid for the poor, as well as federal tax credit premium subsidies to assist
those who qualify to pay for health insurance (California Health Benefits Review Program,
2011). For many newly insured, these subsidies in the form of tax credits, are the only way to
make health insurance affordable to them. If these were no longer available and if the federal
government also stopped subsidizing insurance companies to lower their premiums, then
surely many more Americans would not be able to afford insurance either, nor be able to pay
“CBO and Joint Committee on Taxation estimate that enacting the Better Care
Reconciliation Act of 2017 would reduce federal deficits by $321 billion over the coming
decade and increase the number of people who are uninsured by 22 million in 2026 relative to
current law.“ (Congressional Budget Office, 2017). Many states will likely repeal EHB
mandates within their state, although some may choose to keep those provisions in place.
California will probably continue to maintain a strict mandate of coverage for most of its
Foundation, 2014). Benefits of the federal budget deficit are short sighted, however, as less
insured vulnerable populations will incur greater costs at the state level in the long term,
understand the true cost of public insurance programs led him to question the rationale
behind repeal and replace. “We want a debate about the Affordable Care Act and the
Garthwaite says. “There are people who say it costs too much. What do we mean when we
say it costs too much?” (Garthwaite, 2015). If policymakers truly want to balance state
budgets, regardless of whether they want to offer statewide public health insurance plans or
not, they must factor in the costs of uncompensated care. “There will always be a minimum
level of care that people are going to consume,” Garthwaite says. “So we need to have a
conversation about how to most efficiently provide that care—otherwise we’re left with sloppy
arguments. Choosing to ignore this population doesn’t mean the cost of that care is ever
going to go away.” (Garthwaite, 2015). The application of acupuncture and Chinese medicine
to solve some of the health concerns of this growing uninsured population may help, but there
effectiveness definitively and then there is the cost for which these services need to be
adequately compensated.
Grassroots efforts and alliance coalitions have garnered unprecedented support for
legislation to create a single-payer healthcare policy in California. This would mean that all
healthcare would be paid for by the government and everyone would receive coverage based
upon need, but the plan to pay for it has not been worked out yet (Mason, 2017). Also, no
one really knows what this might mean for reimbursements as there has been a conservative
effort to reduce costs for many Medicaid services despite simultaneous efforts to expand
services for needy populations since the mid 1970s (McGreevy, 2017). Many imagine that
single-payer would look like Medicaid for all, and knowing what reimbursement rates look like
for Medicaid, we can imagine that incomes might be too low for many TCM practitioners to
remain open without making significant changes to their business model. Medi-Cal
(California's Medicaid program) reinstated acupuncture benefits last year in June for its
beneficiaries, but it only pays a little more than five dollars for a fifteen minute unit of face to
face treatment (Department of Health Care Services Medi-Cal, 2016). This does not seem
like a feasible pay rate to put together any kind of business model in the greater Los Angeles
Metropolitan area. Perhaps this is less of a problem in rural areas, or with a community clinic.
But certainly even in those cases, it would be difficult to run a profitable practice. Thankfully,
perhaps for acupuncturists at least, the Assembly Bill has been shelved until next year in the
California Legislature while these issues get worked out (Dayen, 2017). But the need for
action still a priority in the face of new federal legislation, that seeks to strip health care
The Acupuncture for Heroes and Seniors Act of 2017 is still only a bill on Capital Hill,
introduced for the second time by Judy Chu, Representative from California; but it promises to
provide access to qualified acupuncturist services for military members and their dependents
under the TRICARE program (H.R. 2839, 2017). Veterans enrolled in the Department of
Veterans Affairs (VA) health care system will be able to seek treatment from trained
higher under the General Schedule. It's difficult to say what sort of reimbursement level that
might be, but estimates for Los Angeles annual salary range between $81,000 and $105,000
(Federal Pay, 2017). Other provisions of this bill direct the Secretary of the VA to carry out
such programs in at least one VA facility in each Veterans Integrated Service Network in both
urban and rural areas. Also, the Secretary is directed to establish the Advisory Committee on
Acupuncturist Services. Title XVIII of the Social Security Act is amended to provide Medicare
coverage for acupuncturist services and the Public Health Act is amended to make
acupuncturists eligible for appointment in the commissioned Regular Corps and the Ready
The Judy Chu Bill is a similar bill as last time, presumably with the same strengths and
weaknesses as before. It features again: parity with other physicians, advisory committee
with only four acupuncturists, acupuncturists are defined as having appropriate certification or
licensure in their respective state. This distinction presumably excludes physical therapists
who perform dry needling, and perhaps other physicians who lack appropriate licensure or
certification. Essentially however, they would complete with other providers, but consumers
would not need a referral to access services (H.R. 2839, 2017). Social security budget
constraints as well as veteran's affairs resources are both woefully underfunded as it is. So,
here again the main weakness of this bill is determining how to pay for it.
The policies currently in place to protect the scope of practice of acupuncture from
encroachment by other professions vary state to state. At least six states, including New York
and California, have made dry needling illegal, yet many more states have affirmed its
practice is within the scope of Physical Therapists (PTs), largely due to the political influence
of the American Physical Therapist Association (APTA). Injury lawsuits are on the rise in
some states where dry needling is still allowed, yet only account for 1% of complaints say
malpractice insurers for PTs (Haughney, 2017). The paucity of experience most physical
therapists have after their weekend training compared to the three to four years of
experience most certified acupuncturists enjoy often results in poor outcomes, bruise injuries,
and even in some cases punctured lungs or other organs when consumers go to see a
physical therapist for dry needling (Haughney, 2017). Moreover the evidence does not seem
to support the theory behind trigger point needling as aggressive needling techniques do not
retention time. Therefore “the position statements by the APTA and many State Boards of
Physical Therapy do not seem to be consistent with the existing literature. “ (Dunning et al,
2014). Many of the reasons that this is still an issue in many states relates to the problem our
industry faces in other lobbying efforts as well. We don't have enough numbers nor enough
consensus on the issues facing acupuncturists and lobbying is expensive. Having a stronger
national presence would certainly effect access to acupuncture services however, and
Recently the accrediting agency that grants deemed status to hospitals who receive
Medicaid funding issued a stern warning to Physicians urging them to reconsider non-
pharmacological approaches to pain management in light of the current opioid epidemic. “This
Joint Commission document puts a tremendous tool in the hands of anyone seeking to
promote integrative pain treatment.” (Weeks, 2015). For acupuncturists looking for
recognition of value added services, this may provide a useful avenue to provide care to the
under serviced. The recommendation lacks punitive measures of enforcement however, and
as the general consensus among physicians remains that the Joint Commission acts
On the other hand, policy changes in the way that disease classifications are handled
are set to include Traditional Chinese Diagnostic terminology as part of the ICD-11 revision.
Currently those who are working on this project are seeking input from those in the field of
Chinese medicine to make comment and evidence based suggestions. "This work is
something, which is relatively unprecedented in the area of traditional medicine, particularly at
this level," said Dr. Molly Meri Robinson Nicol, technical officer at WHO (Rosen, 2016). "The
ICTM, including the selection included in ICD-11, will be the foundation on which future
research will be based. This classification will serve as a tool for the collection of clean, clear
data on who is using traditional medicine, what they are using it for, if it works, if it is safe, how
much it costs, and how it compares to other medicines in similar situations." (Rosen, 2016).
Since 1999, the United States made ICD coding mandatory for mortality data. Over the past
17 years, hospitals have been adopting and maintaining ICD implementation updates. The
most recent update was the ICD-10 in October of 2015, which required its use for all inpatient
hospital procedures (Duran, 2011). Nicol noted that the ICTM also will support clinical
way that it will be consistent and capable of comparison globally. “Acquiring a set of
diagnostic codes along with the incorporation of a Doctorate degree as a professional entry-
level requirement in the U.S., will pave the ground for TCM practitioners. We are heading
down the same road that fairly recently, Doctors of Chiropractic traveled” (Rosen, 2016). Let's
The plan to educate other healthcare administrators and legislators could be outlined
briefly as: write letters, make phone calls, and send petitions. It is more effective to sway the
minds of politicians with sufficient numbers however, and so it will be necessary to form
coalitions with others of like mind. The next step or action plan in California would therefore
be to choose a strong Acupuncture lobbying power and become a member. Then it might be
prudent to take on any of their specific recommendations and wait and see. Alliances are
important in spite of the fact that support for the single payer bill in California appears to be
dividing once again into separate factions (Dayen, 2017). By contrast, the success of the
APTA lies in their sheer numbers and the significant lobbying power those individuals are able
to purchase (Haughney, 2017). Let this be a valuable lesson to acupuncturists and perhaps
If California legislators seek to remedy the changes which are likely to take place on
the Federal level by passing a single payer for all bill, that will dramatically change things
(Dayen, 2017). The concern is that the result will be a system that looks like Medi-Cal for all,
where the payouts to acupuncturists are less than what one can afford to keep a practice
running. Certainly this factor will cause some practitioners to move out of state or possibly
influence an increase in reimbursement rates if this becomes a problem for too many
providers, but only time will tell. For the consumer, this could be a mixed blessing also. With
the government in charge of managing payment for all healthcare services, there are
There is a feeling that the private sector is much more capable at managing healthcare
than the public sector (Dayen, 2017). There is ample evidence that the reverse is true
however, as government programs are subsidiary to private sector aims to make a profit and
the private sector believes it can only lose money by caring for vulnerable populations. On
the contrary, “an analysis of uncompensated care data from Medicare Hospital Cost Reports
from 2011 to 2015 found that uncompensated care burdens fell sharply those states where
Medicare was expanded” (Dranove et al, 2017). Between 2013 and 2015, operating costs for
uncompensated care fell from 3.9 percent to 2.3 percent. This is a big deal when profit
margins for these non-profit hospitals are often around two percent. “Estimated savings
across all hospitals in Medicaid expansion states totaled $6.2 billion.” (Dranove et al, 2017).
The largest reductions in uncompensated care were found in hospitals located in expansion
states that care for the highest proportion of low-income and uninsured patients. Federal or
state legislation that scales back or eliminates Medicaid expansion is likely to expose these
safety-net hospitals to large cost increases. “Conversely, if the nineteen states that chose not
to expand Medicaid were to adopt expansion, their uncompensated care costs also would
California currently has a mandate that all plans sold to consumers must at least offer
acupuncture benefits as an additional rider if they are not included as part of coverage
(Goodacre Insurance Services, 2015). This mandate only affects small group plans
(California Health Benefits Review Program, 2011). There are several other plans, most of
them more expensive than the benchmark plan, that offer better acupuncture coverage, but
Consequently, each plan may cover acupuncture differently or have limits or caps on
coverage (Goodacre Insurance Services, 2015). Insurance plans are meant to be competitive
and it stands to reason that if there is enough demand for acupuncture, then subscribers will
pay for it. Kaiser HMO was used as benchmark plan for California's comparison of benefits
among other similarly rated plans (The Henry J. Kaiser Family Foundation, 2017). It listed
acupuncture as a covered benefit, but only to treat nausea related to pain disorders.
Allied Specialty Health (ASH) contracts with many acupuncturists, perhaps more than
most of the other networks (California Health & Wellness, 2017). It is difficult to estimate, but
I am aware of many insurance companies and plans that are contracting with ASH since they
have gathered such a large network of acupuncturists. When I was offered to join, I found the
contract offered low reimbursement rates of roughly $40 per visit in many cases. I turned it
down, feeling that this was not enough to pay for my time or expenses related to running a
business and that this would burden me with too much paperwork and result in burnout.
Plans like Kaiser and ASH that offer acupuncture to their subscribers, intend to keep
subscribers utilizing services within their network of contracted providers, so that they can
keep their reimbursement costs to providers as low as possible. Some more expensive plans
cover the cost of acupuncture services even out of network however, and this is where I am
often approached to work with patients who have insurance benefits they can use. Blue
Cross and Blue Shield offers their subscribers to pay 50% of out of network costs, but I
imagine that with most contracted in-network providers reimbursement rates for this company
may be about roughly equivalent either way. (Blue Shield of California, 2015). The only
difference is that the ACA allows for out of network balancing to shift the responsibility of the
other half of treatment to the patient. Those providers in-network would only be allowed to
charge what they had agreed to in their network agreement. In Los Angeles there are
sufficient consumers with ample income to afford out of pocket fees for services and the
majority of my patients pay in full at the time of service. I have a few patients who will request
a Super-bill to make a claim for reimbursement with their insurance company, but I do not
network with any and do not see any reason to either. Unless we move to a single payer
system, and it is such a big mystery what that will look like if that happens, I guess I should be
References
Acupuncture for Heroes and Seniors Act of 2017, H.R. 2839, 115 th Congress, (2017).
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