CAM in the Health Care Reform Bill

March 27, 2010

This week President Obama will sign the final piece of health reform legislation, concluding an epic battle that ultimately lead to the passage of the Patient Protection and Affordable Care Act (PPACA). The bill enforces the largest change to US healthcare for decades and has provided an opportunity for Complementary and Alternative Medicine (CAM) advocates to be federally endorsed in our future healthcare system.

CAM proponents tout a few sections in the PPACA as a victory for their cause. One of these sections is 3502, entitled Establishing Community Health Teams To Support The Patient-Centered Medical Home, which endorses government grantsto establish community health teams,” which are defined as “community-based interdisciplinary, interprofessional teams.” It goes on to say that such a ‘team’ may include, “doctors of chiropractic, [and] licensed complementary and alternative medicine practitioners[1].

The requirements of such a health team are listed and one of them ultimately reads, “to provide support necessary for local primary care providers… to provide coordination of the appropriate use of complementary and alternative (CAM) services to those who request such services.” What this entails, is that there will be an influx of federal spending into CAM services with the enactment of the new bill.

Fortunately, the section provides other requirements for ‘health teams’ such as,

to support patient-centered medical homes, defined as a mode of care that includes… safe and high-quality care through evidence-informed medicine, appropriate use of health information technology, and continuous quality improvements.

Health teams will also be required to (bare with me here),

“provide support necessary for local primary care providers to… provide quality-driven, cost-effective, culturally appropriate and patient- and family-oriented healthcare… [and]collect and report data that permits evaluation of the success of the collaborative effort on patient outcomes, including collection of data of patient experience of care and identification of areas for improvement.”

This could mean that even though CAM will be supported by our government plan there will be some restrictions in place requiring CAM therapy to adhere more to an ‘evidence-informed’, ‘quality-driven’ and ‘cost-effective’ form of medicine. Guidelines may be implemented to track the progress and efficacy of health teams using CAM therapies. If this was true, I would suspect an initial rise in CAM from the increase in government funding but an ultimate demise in the long-term as an enormous surge of government-sponsored data separates cost-effective treatments from sham.

Unfortunately, this hasn’t been shown to be true in relation to The National Center for Complementary and Alternative Medicine (NCCAM), which has been criticized for spending hundreds of millions of tax dollars on studies of CAM and never confirming the efficacy of a single therapy nor declaring any as ineffective. This shows that data gathered from CAM due to the healthcare reform bill might never actually lead to any meaningful conclusions or changes in healthcare.

Another section of the PPACA, supported by herbalists, is number 4206: Demonstration Project Concerning Individualized Wellness Plan[2]. The section describes the establishment of “a pilot program to test the impact of providing at risk populations… an individualized wellness plan that is designed to reduce risk factors for preventable conditions.” The program will include nutritional counseling and will provide dietary supplements that have health claims approved by the FDA. Examples include calcium supplementation for those at risk of osteoporosis and prenatal folic acid to decrease the incidence of neural tube defects. Seeing as this is guided by the FDA’s recommendations I can only join in the approval of such a “wellness plan”, and expect it to be a big hit in the new healthcare system.

Chiropractic has found a niche in the soon-to-be National Healthcare Workforce Commission as described in section 5101[3] of the PPACA. “The Commission,” as it is referred to, will be responsible for analyzing and disseminating information to the government, state and local agencies, Congress, healthcare organizations, and professional societies about the US healthcare workforce. It will be responsible for developing and commissioning “evaluations of education and training activities to determine whether the demand for healthcare workers is being met.”

In so doing, it will recommend to the government which institutions deserve grants for the government in order to “develop a fiscally sustainable integrative workforce that supports a high-quality, readily accessible healthcare delivery system that meets the needs of patients and populations.” It will also “study effective mechanisms for financing education and training for careers in healthcare.” Basically, the Commission will be channeling tax dollars to different healthcare institutions based on their analysis of demand in our healthcare system.

The Comptroller General, Gene L. Dodaro, will appoint the members of the Commission no later than September 30th of this year. It will consist of 15 members representative of the healthcare workforce, employers, third-party payers, representatives of consumers, State or local workforce investment boards, and educational institutions. It seems like there will be a host of different viewpoints and interests influencing the recommendations that this commission will be making.

Therein lies the problem. The section about the Commission specifically defines the ‘healthcare workforce’ as, “all healthcare providers with direct patient and support responsibilities,” and specifically includes licensed CAM practitioners and chiropractors in the definition. If proponents of such CAM therapies infiltrate the Commission, taxpayers could end up funding disproportionate amounts of money to medical therapies unsupported by science.

Another section of the PPACA that has been hailed as a victory by CAM proponents, especially chiropractors, is section 2706 in the Senate-approved H.R. 3590 bill, which prohibits “discrimination” against any health care provider. Chiropractors who feel they are being ‘discriminated’ against in the medical community see this as an end to their problems. Interestingly, this section is colloquially dubbed the “Harkin amendment”, after the Iowa Senator’s introduction of the section into the new healthcare reform bill. David Gorski has written about him on a number of occasions. Tom Harkin is the man most responsible for the creation of the aforementioned NCCAM and also the Dietary Supplement Health and Education Act (DSHEA) of 1994, which allows “herbal supplement” manufacturers to make dubious health claims with little or no regulation.

Fortunately, I couldn’t find any sign of section 2706 in my ‘quick’ look-through of the 2,407 page PPACA (my web browser crashed every time I tried searching the document) but it may crop up somewhere in the overwhelmingly lengthy and technical health reform bills so let’s keep a look out for it. The American Chiropractic Association (ACA) is saying, however, that the amendment did pass and will become law once Obama signs the bill this week.

On a positive note, the PPACA bill has in it a section on immunization[4] and describes a new program that will come into effect to maximize vaccinations throughout the country. This is a huge blow to the anti-vaccine movement, which has been surprisingly quiet about this.

In summary, we should be prepared for an infiltration of CAM therapies into the new healthcare system that will come into effect starting this year. The PPACA healthcare bill is not a disaster for science-based medicine by any means, but it is not bullet proof. The bill specifically mentions it’s endorsement of CAM and the more it acts on this, the more difficult it will be to eradicate passionately advocated therapies with no evidence supporting them in the years to come. Now is the time, more than ever, to ensure that the US health care system does not begin to excessively promote sham therapies. Otherwise, we will risk developing a foundation to the new healthcare system that incorporates scientifically unsound medicine.

[1] Page 1049 of the PPACA

[2] p1215 of the PPACA

[3] p1255 of the PPACA

[4] p1199 of the PPACA