Chiropractors Seek Alignment in Health Plan

Dr. Monique Maniet, a Takoma Park, Md., veterinarian, periodically suffers spasms in her neck and shoulders so severe that she can’t turn her head. But after a visit to her chiropractor, “I have mobility back. I feel liberated.”

The treatment, which takes about 20 minutes and costs $39, is covered by her health insurance. But she worries that once the Clinton Administration finishes reforming America’s health care system, it won’t be covered anymore.

The 45,000 chiropractors in the United States are nervous too.

Once dismissed as quackery by the medical Establishment, chiropractic has achieved growing acceptance. Treatments are now covered by most insurance plans, several dozen hospitals around the country have chiropractors on staff and the field enjoys fierce loyalty among millions of Americans who see chiropractors each year.

Much of that progress for those in the field could be lost if the Administration’s reform initiative excludes chiropractic from the basic package of medical benefits to be offered to all Americans. And the nation’s chiropractors are not waiting for the White House to make its decisions before speaking out. They have launched a massive lobbying effort to make their case known in Congress, where the ultimate decisions will fall.

Petitions are being circulated in chiropractic offices, and full-page ads are appearing in major newspapers.

Even if they find themselves shut out by the White House, chiropractors are confident they won’t be ignored on Capitol Hill.

“We can’t compete with the American Medical Assn. dollar for dollar, but what we have on our side is positive patient constituents,” said Dr. Louis Sportelli, a Pennsylvania chiropractor and past chairman of the American Chiropractic Assn.

In case loyal patients aren’t enough, chiropractors also maintain one of the nation’s largest medical political action committees to funnel financial support to sympathetic members of Congress and state elected officials.

Chiropractors are not the only health care professionals who feel threatened by the Administration’s reform effort. Podiatrists, optometrists and psychologists, for example, also fear that the standard benefit package will not adequately cover the services they provide. Several of these non-physician groups have aligned themselves with the chiropractors in a newly formed coalition to present a coordinated message to the White House and Congress.

But the chiropractors appear likely to wage one of the most aggressive, and visible, battles for inclusion in the reform program. The intensity of their campaign reflects not only the large number of practitioners and their patients, but also the profession’s continuing struggle for respectability.

Chiropractic (Greek for “done by hand”) is based on the theory that diseases may be caused by disturbances of the nervous system, and that manipulation, or “adjustment,” of the spinal column can promote healing.

Chiropractors define what they do as correcting misalignments of vertebrae that result in harmful pressures on nerves in the spinal cord. Because these nerves connect to every organ and body part, such misalignments can cause harmful conditions all over the body, they say.

The increasing credibility achieved by chiropractic reflects its success in relieving certain muscular and skeletal problems, especially lower back pain, an affliction that plagues millions of Americans. But there is still widespread skepticism about its effectiveness for other kinds of ailments, particularly those not muscular or skeletal in origin.

Some anecdotal evidence suggests that chiropractic has more widespread applications, but it has not been corroborated by scientific studies.

Chiropractors are worried that the Administration’s health reformers will regard their services as marginal and exclude them from the basic coverage package. In addition, they are concerned that primary care physicians, operating under the new “managed care” concept of health care delivery, will be reluctant to refer patients to them.

“We feel like we are right on the borderline, especially because of questions and animosity against the profession by traditional medicine,” said Paul T. Kelly, a lobbyist for the American Chiropractic Assn. “We fear that gatekeepers will prevent patients from getting to chiropractors.”

Chiropractors argue that their emphasis on prevention, and their avoidance of high-cost drugs and surgery, is consistent with the Administration’s health care philosophy.

“I think chiropractic will be included because when they start looking at it, they will be asking the following questions: Is it effective clinically? Is it cost-effective? And the answer to both is yes,” Sportelli said.

While no final decisions have been made by the health care reform task force headed by First Lady Hillary Rodham Clinton, chiropractors, like other groups, have been given an opportunity to present their case, according to Michael Lux, special assistant to the President for public liaison.

“What we are trying to do in our package is be scientific about what kind of preventive measures and treatments will cost less money in the long run and have a pay-back over time,” Lux said. “Can we document their claims in any kind of scientific way? If we can, there’s a very good chance it will be in the package.”

Moreover, services currently covered in many plans stand a good chance of being covered in the reform package, he said.

“That’s something we will take a serious look at,” Lux said. “We want to have a benefits package that is fairly similar to most peoples’ experience. We don’t want to radically veer away from that.”

Until the final decisions are made, chiropractors are taking no chances. They are lobbying Capitol Hill well in advance of the announcement of the reform package. They are forwarding reams of petitions to the White House, generated by individual practitioners and state chiropractic associations and signed by consumers, urging that the reform proposals preserve their right to choose chiropractic care as a covered service.

In addition, they are running full-page newspaper ads and airing 30-second spots on both cable and network television.

“Over 31 million Americans suffer from back-related problems,” reads one ad placed by the chiropractic association in Roll Call, the newspaper that serves Capitol Hill. “The cost to society is a staggering $18 billion in direct cost annually--and another $50 billion in related expenses and lost income due to absenteeism and reduced productivity.

“Doctors of chiropractic play a vital role in the treatment of back pain and other spinal related disorders,” says the ad, which is slated to run again in the newspaper several times during the coming months. “They are portal-of-entry, primary care providers--helping to meet the health care needs of over 19 million patients each year. . . . Chiropractic’s non-surgical and non-pharmaceutical approach is in demand. It’s safe. It’s effective. And it’s a vital way of saving our health-delivery system vast amounts of money.

Chiropractic has a vital role in health care reform!”

And the chances are good that members of Congress will listen. Far more than their counterparts in other non-medical health fields, chiropractors exercise significant political power.

In part, their clout reflects widespread consumer support: Nearly 19 million people visited chiropractors in 1990, according to the American Chiropractic Assn., making the field among the most popular non-medical specialties in the country.

The profession backs up its grass-roots popularity with political action committee funds. Its 1991-92 spending on PAC donations totaled $641,746, a 270% increase over the previous year, making chiropractors the fourth-largest medical PAC in the nation after the American Medical Assn., the American Dental Assn. and the American Academy of Ophthalmology.

Not surprisingly, the money tends to go to lawmakers with jurisdiction over health legislation. Key recipients include Rep. Henry A. Waxman (D-Los Angeles), chairman of the House Energy and Commerce health subcommittee; Rep. Pete Stark (D-Oakland), chairman of the House Ways and Means health subcommittee, and Rep. Thomas J. Bliley Jr. (R-Va.), ranking Republican on Waxman’s subcommittee.

In the Senate, the beneficiaries include Majority Leader George J. Mitchell (D-Me.) and Sen. John D. (Jay) Rockefeller IV (Va.), chairman of the Medicare and long-term care subcommittee of the Finance Committee; Sen. Tom Harkin (D-Iowa), chairman of the Senate appropriations subcommittee of the Labor and Human Resources panel, and Sen. Bob Packwood (R-Ore.), second-ranking Republican on the Medicare subcommittee.

“By no means are they (the chiropractors) a force to be taken lightly in the political arena,” said Arthur Caplan, director of the University of Minnesota Medical School’s Center for Biomedical Ethics. “If you respect consumer choice, then they are doing something right--because there are lots of them, doing very well, and they have lots of loyal clients.”

Chiropractors’ training includes at least two years of college with a curriculum concentrated in the basic and biological sciences, followed by four years of resident instruction at a chiropractic college, where they obtain degrees as doctors of chiropractic. They must then pass a licensing examination.

But in the eyes of many physicians and other practitioners of conventional medicine, chiropractic is still somewhat suspect.

“The medical Establishment views them as kooks,” Caplan said. “Many doctors believe that chiropractic techniques can give pain relief for joint or muscle problems, but they think the underlying philosophy is total nonsense. The problem chiropractic faces in getting included (in the Administration’s benefit package) is that people are concerned about the slippery slope. If chiropractic gets in, can Rolfing and aroma therapy be far behind?”

Beginning in the 1960s, the AMA labeled chiropractic an “unscientific cult,” and attempted to have the field outlawed. In 1980, four chiropractors sued the AMA and ultimately won.

“We called it quackery and we called it a cult, but we don’t dare use those terms now, by order of the court,” said Dr. James Todd, executive vice president of the AMA. “We saw them as a danger to the public because they had no scientific foundation to any of their theories or treatments at that particular time.”

The AMA is still concerned that chiropractors will attempt to exceed their limited licenses by operating as primary-care physicians.

“The issue at the moment is their ability to make an appropriate diagnosis,” Todd said. “That is fundamental to any medical management. Once a diagnosis is made, there probably are many limited-license practitioners who can participate in care, but we want to make sure that the diagnosis is made by people adequately educated to do it.”

Sportelli counters that chiropractors “are almost a natural to be primary-care providers” because of their whole-body approach, which includes evaluation of diet and other lifestyle behaviors. He insists that their diagnostic ability “may well exceed” their therapeutic ability.

“Chiropractors are eminently qualified to make a diagnosis and determine one of three ways patients can be handled,” Sportelli said. “Either they belong in the chiropractor’s office, or they are outside the realm of the chiropractor and need a specific referral, or we co-manage, either with a specialist or a family physician. Patients may need the best of both. If the whole trend today is toward prevention, no professional emphasizes that more than doctors of chiropractic.”