An alert went out two weeks ago to a set of policy-oriented integrative health and medicine types. The Trump administration had published a report – “Reforming America’s Healthcare System Through Choice and Competition.” The email suggested that there was support here for the non-discrimination in healthcare provision of the Affordable Healthcare Act (a.k.a. “Obamacare”). Was this actually a dovetailing support of the Trump administration with the healthcare policy of his predecessor? I took a look and then connected a lobbyist who was on the ground when the Obama administration’s Section 2706: Non-Discrimination in Health Care was being drafted. The findings on the Trump study were mixed.

The report was developed following a White House directive, Executive Order 13813, issued October 12, 2017, that “directed the Administration, to the extent consistent with the law, to facilitate the development and operation of a health care system that provides high-quality care at affordable prices for the American people by promoting choice and competition.”  A trio of agencies shared the lead: Health and Human Services, Treasury and Labor.

The emailed missive to the group of us policy actors directed us to page 36 of the 114 page report. The section focused on activities of government at all levels that influence competition. A key priority was the sensitive battleground where professions typically battle to pass laws that cut in two directions: expand their own scope of practice, and limit the scopes of others that they believe infringe on theirs. The recommendations in this section were unidirectional and headlined “Broaden Scope of Practice”:

• States should consider changes to their scope-of-practice statutes to allow all healthcare providers to practice to the top of their license, utilizing their full skill set.
• The federal government and states should consider accompanying legislative and administrative proposals to allow non-physician and non-dentist providers to be paid directly for their services where evidence supports that the provider can safely and effectively provide that care.
• States should consider eliminating requirements for rigid collaborative practice and supervision agreements between physicians and dentists and their care extenders (e.g., physician assistants, hygienists) that are not justified by legitimate health and safety concerns.
• States should evaluate emerging healthcare occupations, such as dental therapy, and consider ways in which their licensure and scope of practice can increase access and drive down consumer costs while still ensuring safe, effective care.

These recommendations are door openers. And yet one cannot miss that chiropractors, acupuncturists, naturopathic doctors , massage therapists or licensed, direct-entry, Certified Professional Midwives are not mentioned here. In an interview for this article, John Falardeau, the long-time lobbyist and senor vice president for public policy and advocacy for the American Chiropractic Association spoke to the oversight that was most evident to him: “Despite omitting Doctors of Chiropractic, it is pretty positive stuff.”

The opportunities were not lost on certain professions, The American Academy of Nurse Practitioners’ immediately sent a media release commending the scope of practice recommendations. The association’s president Joyce M. Knestrick, PhD, APRN, C-FNP, FAANP, spoke to their alignment:

We commend the Administration’s efforts to ensure access to high-quality care is not harmed by needless barriers to practice. We wholeheartedly agree that outdated scope of practice laws need to be removed and all healthcare providers should practice to the top of their license, utilizing their full skill set. We share the aim of the Administration that we all should be working together striving to create a health care system that works for patients and providers alike. We are encouraged and agree with the Administration’s recommendation that patients suffer when faced with barriers to access resulting from outdated scope of practice laws.

(Notably, the American Society of Anesthesiologists sent a release citing another part of the document that they believe supports their campaign to limit the scope of the advance practice nurse anesthetists.)

While I haven’t gone line-by-line through the entire document the absence of mention of chiropractors and other integrative health professions from the scope of practice section appears to be the pattern with the entire document. While the leverage may be there, these integrative professions don’t explicitly exist.

The historic problem of invisibility and non-inclusion has been addressed by chiropractors, naturopaths, acupuncturists and other integrative fields, at the state level, by pushing for state laws that require that they be included. A key area is in insurance coverage. The chief version of such a law  is the “Any Willing Provider” stature. Similar laws that may fall under this umbrella are the “Every Category of Provider” statute in Washington state that has created the most significant inclusion of licensed “CAM” practitioners insurance schemes in the United States. Notably, it was viewed by some as the model for non-discrimination in the Affordable Care Act. On these, the report stops short of calling for removal but tilts that way:

Federal and state policymakers should carefully scrutinize the impact on competition and consumers of [Any Willing Provider] laws, rules, and proposals, along with other restraints on network formation and selective contracting.

Where states nominally include licensed integrative practice professions under insurance, these professional organization frequently utilize “network adequacy” provisions in state law to force insurers to actually contract with sufficient members of their fields in order to make sure the benefit is accessible. The Trump document urges that both Medicare Advantage programs and state lawmakers “consider loosening network adequacy standards and avoid stringent requirements.” Falardeau, who prefers to speak of requirements like AWP as “patient protection requirements” rather than mandates, sees these recommendations as harmful toward such protection.

Overall, Falardeau views these twin lenses as the “traditional mantra from Republicans.” Whether the document deserves even as much attention as I have given it here is questionable, in his view. “There is nothing actionable here,” he said. The proof of the pudding will be in “which of the recommendations have legs – which show up in legislative or regulatory language.” He paused: “With the Democrats in control of the House I don’t expect the reports and its recommendations will go far.” I reminded him of 2001, when the publication of the Clinton-era White House Commission on CAM Policy died a quick death after its release in the Bush administration. “Good example,” said Falardeau.

Note: Special thanks to integrative policy wonks Heather Carrie, MAS and Pamela Snider, ND for alerting me to the study.