On March 30th, President Obama signed the final piece of healthcare 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. This entry is an attempt to present excerpts from the PPACA itself that could lay the groundwork for incorporating CAM into the 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 grants “to 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 reads, “to provide support necessary for local primary care providers… [and] 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 (bear 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, although CAM will be supported by our federal plan, there will be some restrictions in place requiring it to adhere 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 were true, I would suspect an initial rise in government-funded CAM but a downfall in the long run. A new surge of government-sponsored data should separate cost-effective treatments from sham if CAM therapists are held to such standards.

Unfortunately, the government has a poor track record of declaring therapies ineffective. Nowhere has this been more obvious than in 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 federally funded data gathered about CAM might similarly never actually lead to meaningful conclusions or changes in our healthcare. If this were true, CAM incorporated into the healthcare system would stay for the ride regardless of its efficacy and cost-effectiveness.

Another section of the PPACA, supported by herbalists, is number 4206: Demonstration Project Concerning Individualized Wellness Plan[2]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 with the approval of such a “wellness plan”, and expect it to be a big hit in the new healthcare system. Since herbalists see this as an opportunity for the government to incorporate their therapies into these wellness plans, I hope that the program will continue to adhere to FDA recommendations, especially if it is approved for wide-scale use.

On other fronts, chiropractors have found a niche in the soon-to-be National Healthcare Workforce Commission as described in section 5101 of the PPACA. “The Commission,” as it is referred to, will be responsible for analyzing and disseminating information to the federal government, state and local agencies, Congress, healthcare organizations, and professional societies about the US healthcare workforce. It will develop “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 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.” Put more simply: 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 30^th 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 within the definition. If proponents of such CAM therapies infiltrate the Commission, taxpayers could end up funding disproportionate amounts of money to medical institutions unsupported by science.

Another section of the PPACA that has been hailed as a victory by CAM proponents, especially chiropractors, is section 2706³, which prohibits health insurance discrimination against any “health care provider who is acting within the scope of that provider’s license or certification under applicable state law.” Chiropractors, who feel that they are being ‘discriminated’ against within the medical community, see this as an end to their problems. Interestingly, section 2706 is colloquially dubbed the “Harkin amendment”, after it was introduced by the Iowa Senator himself. 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.

The section itself is simply entitled Non-Discrimination in Health Care and prevents insurance companies from discriminating against particular medical modalities. At first glance this seems like a free pass for CAM, especially with the American Chiropractic Association s (ACA) claims that the inclusion of this provision has “potential for positive, long-range impact on [their] profession and the patients [they] serve.”  But the provision itself makes a point to address that, “nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary [of Health & Human Services] from establishing varying reimbursement rates based on quality or performance measures.”

If this provision is calling for an end to discrimination of health modalities that is not based on quality or performance, than I don’t understand why CAM proponents are so happy about this. Don’t they understand that it’s their quality and performance that is under scrutiny and that these characteristics are determined by science? It’s as if the ACA believes the main reasons they are ‘discriminated against’ are not based on evidence at all. I actually agree with the proposition that heath care modalities shouldn’t be discriminated against for unscientific reasons.

On a more positive note, the PPACA bill has in it a section on immunization ⁴and 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. Hopefully, it will help more patients to be vaccinated, especially those without the resources to do so.

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 bulletproof either. The bill specifically mentions its 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 to ensure that the US healthcare system does not begin to excessively promote sham therapies. Otherwise, we will risk developing a new foundation to our healthcare system that incorporates scientifically unsound medicine.

References

1. Page 395 of the PPACA (http://democrats.senate.gov/reform/patient-protection-affordable-care-act-as-passed.pdf )
2. p458 of the PPACA
3. p42 of the PPACA
4. p453 of the PPACA

ABOUT THE GUEST BLOGGER: Matt Roman is a Polish-American, who immigrated to the Unites States in 1985 and studied neuroscience and chemistry at Franklin and Marshall College. He is currently enrolled as a medical student at Jagiellonian University in Cracow, Poland. His interest in complementary and alternative medicine began with his involvement in courses and research at The Institutes for the Achievement of Human Potential in Philadelphia before he became immersed in the skeptical movement and a science-based approach to medicine. He hopes to specialize in internal medicine in the United States and enjoys blogging about a diverse range of general science topics. A different version of this post first appeared on the blog Science-ology in March 2010.