The budding 2020 presidential primary season for Democrats is already focusing on health care. Some advocate for single payer. Others don’t. The prospective force of the issue was underscored on February 27, 2019 when Congresswoman Pramila Jayapal (D-WA) and 106 Democratic co-sponsors introduced Medicare for All legislation. For those involved in the movement to shift US health and medicine toward an integrative model, a question arises: What might be expected, given existing US experience, for coverage and inclusion of integrative health and medicine services if single payer legislation becomes the law of the land?
My interest is not with what is in Jayapal’s legislation. In fact, details are not yet available. Rather, it is with what the national experience to date has been relative to integrative health and single payer systems. We have national experience to explore.
The military has spawned two large single payer systems: the Veterans Administration (VA) and the Department of Defense (DoD). The former has put its VA Office of Patient Centered Medicine and Cultural Transformation under the direction of a professional who spent 15 years running integrative medical initiatives in large health systems, Tracy Gaudet, MD. The VA’s Integrative Health Coordinating Center, led by a former integrative medicine Consortium chair, Ben Kligler, MD, MPH, is driving integration of chiropractic, acupuncture, mindfulness, Tai chi and other integrative practices and practitioners into systems throughout the 18 VA regions.
No private not-for-profit system has ever empowered integrative direction nor embraced an integrative model so thoroughly as the single payer Veterans Administration.
The context of this integration – which distinguishes it from private insurance and private hospitals – helps explain the motivation for integrative inclusion. Gaudet and Kligler are leading a VA “whole health for life” initiative. The integrative practices and practitioners are but one part of an broad effort to engage the veteran’s whole heath. As described in this article, the VA “whole health” model begins with engaging the self-care of the individual veteran. It extends to families, employment, and multiple social determinants of health. The VA is connected for life to its veterans and their families. The guiding philosophy is of integrative health rather than a reductive focus on disease, drugs and procedures. Integrative practices and practitioners are embedded in the clinical and community service portions of the paradigm shift toward health related. They are not an add-on to appeal to consumers. They are core to the strategy that this single payer system incentivizes.
While a minor portion of some progressive private not for profit hospital revenues may embrace a health orientation and be directed toward addressing determinants of health, insurance-based payment and delivery remain specialty medicine led, production focused, and largely inhospitable toward integrative practices.
The single payer Department of Defense (DoD) offers a pattern of uptake of complementary and integrative medicine (CIM) practices and practitioners not unlike that at the VA. A 2017 report on CIM in the DoD found that each month, such services were included in roughly 76,000 patient visits at military treatment facilities. These were provided by 1,750 practitioners. The programs reflected a government investment of $112.7 million per year in labor to provide the services. This commitment also far overshadows any complementary and integrative medicine initiative in the private sector.
Functionality concerns stimulated early DoD interest. Controlling pain without drugs that make a soldier or pilot drowsy through non-pharma approaches such as battlefield acupuncture were potentially life-saving advances. Like performers and athletes who were early adopters of many health-optimizing integrative strategies, the DoD – like the VA – cares about outcomes.
Notably, the integrative inclusion in the DoD’s single payer environment also rested on inputs from integrative medicine pioneers. Working with and through such professionals as former Samueli Institute CEO Wayne Jonas, MD and medical acupuncturist Richard Neimtzow, MD, the DoD developed the breakthrough 2010 Total Force Fitness for the 21st Century. A 2017 report led by RAND researcher and naturopathic doctor Patricia Herman, ND, PhD shows, shows continuing expansion in use of complementary and integrative services in the DoD.
An important, common characteristic that the VA and DoD share with Medicare that supports thinking differently about priorities is that they don’t need to deal with the insurer’s perverse incentives to do more under the 80/20 rule. It’s simple math. The more people are treated – or over-treated – and the more unhealthy they are, the more money flows through the private insurer’s hands. See chart. The commitment to shareholders to be profitable requires them to come down on the side of an increase of disease.
A second characteristic of the VA and and DoD single payer models separates their financial incentive context (and incentive structure) from that of Medicare for All. In both the VA and the DoD, physicians and other practitioners – including chiropractors, and acupuncturists and other integrative health providers – are employed. As such, practitioners’ payment is not production focused. The VA and DoD practitioners are not typically individually incentivized to do more. Nor is the VA owned hospital system as a whole incentivized, to continuously do more angioplasties and hip replacements and you name it that are in the private hospital’s revenue projections.
Thus, Medicare’s ability to align all resources of payment and delivery around a VA-like goal such as “whole health” – with its integrative practitioner contributions – faces delivery barriers that are more challenging than in the VA and DoD. Medical direction in private hospitals tends to rest with chief medical officers tightly linked to high-paid and high-production specialists. This distinction between the VA/DoD and Medicare may explain why the latter, as a third USA single-payer system, has been less interested in integrating complementary and integrative practices than the other two.
As of this writing, details of the Medicare for All legislation, H.R. 1384, were not yet posted on Congress’ website. Jayapal’s public pronouncements have not directly mentioned any key words that indicate explicit inclusion of integrative practices in the way, for instance, dental care and mental health have each been named. (An email to lobbyists associated with the chiropractic, acupuncture and naturopathic medicine fields provided no answers at this time.)
What then are we likely to we see if Medicare for All comes to be? Multiple signs suggest that Medicare may be becoming more permeable to integrative practices and practitioners. A thrust of the Affordable Care Act shifts Medicare payment to private hospitals and clinics toward accountable payment models to reverse the perverse incentives. A survey found that integrative health leaders in large academic medical organizations find the context is creating greater alignment and uptake. Another trend pushing Medicare toward more openness is the nation’s chronic pain crisis due to over-reliance on opioids. A series of National Academy of Medicine reports and actions are promoting non-pharmacologic approaches as are guidance documents from the CDC and FDA. Finally, one might reasonably assume that the move to single payer would provide its own boost toward Medicare adopting a broader, whole health perspective like the VA.
Integrative action in the VA and DoD single payer contexts is robust, relative to the private insurance system. Whether Medicare will strengthen its engagement with complementary and integrative approaches is speculative. One thing is certain. The private medical industry’s antagonism toward the Democrats’ Medicare for All has been swift, organized and powerful. In Health Care and Insurance Industries Mobilize to Kill ‘Medicare for All’, The Washington Post reported that:
Doctors, hospitals, drug companies and insurers are intent on strangling ‘Medicare for All’ before it advances from an aspirational slogan to a legislative agenda item.
These stakeholders defending their lion’s share of the $3.3-trillion industry created the Partnership for America’s Healthcare Future. Their worry: Democratic control of the presidency and both chambers in 2020 could create a change moment that could upend their worlds.
These powerful stakeholders don’t have integrative medicine in their sights. Their last consideration is killing or stemming the advance of the movement toward integrative health and medicine. This movement is a fly on that elephants back.
Yet at the same time, the present experience in the USA with single payer suggests that single payer will be good for complementary and integrative practices and practitioners. Under single payer, relatively low cost, high-touch, human-centered, health-focused approaches will be better welcomed as potential parts of the solution to advancing health through better care at lower costs than they are in the present system.
Note: The subject of single payer is a flashpoint for many in the broad integrative community. Please consider sending comments to firstname.lastname@example.org. If I receive many, I will use them as a basis to return to the subject.