Issues in Chiropractic Care: The Legislative Fight for Medicare Coverage

A bipartisan bill sponsored by Representative Brian Higgins (D-NY) and Tom Reed (R-NY), the Chiropractic Medicare Coverage Modernization Act of 2019 (HR 3654) would provide Medicare coverage for all services provided by a chiropractor as allowed by their state license.

“Since the profession was first included in the federal Medicare program almost 50 years ago, an antiquated statute—with no valid scientific or policy basis—has limited coverage of chiropractic to one service, manual manipulation of the spine,” said John Falaradeau, Senior Vice President of Public Policy and Advocacy for the American Chiropractic Association (ACA).

According to the ACA, the existing statute has no valid scientific or policy basis, and chiropractors are the only physician-level providers under Medicare restricted in this matter. Chiropractors are already defined as physicians by the Medicare program as it extends to this individual service. The ACA emphasizes that the bill does not create new benefits or services; rather, it provides patients the opportunity to receive Medicare coverage for services that chiropractors are already able to practice under their state license.

“H.R. 3654 would give America’s seniors more choice regarding who they receive their Medicare-covered services from as well as reduce their out-of-pocket costs and logistical hassles.”

One-fifth of the United States population will turn 65 by 2030. For the first time in U.S. history, older adults will outnumber children under the age of 18. With 10,000 Baby Boomers celebrating reaching retirement age every day, the impact it will have on Medicare is unparalleled.

Many things have changed in the intervening years since the Medicare program was proposed by President Dwight Eisenhower at the first ever White House Conference on Aging in 1961.

The country has almost doubled in population. The Baby Boomer cohort has navigated a corporate environment that shifted from workplace-backed pension plans to placing the responsibility on employees to save for their retirement. Furthermore, older Americans have had to manage their personal savings to survive two devastating recessions.

Social Security benefits have also lost a third of their purchasing power in the last 20 years—an alarming reality when almost half of unmarried elderly recipients rely on it as their main source of income. These benefits do not go far in today’s world; the average monthly income from Social Security is $1,461. Many of those reliant on Social Security are equally reliant on Medicare, and the oldest and poorest spent the most on healthcare. In fact, those receiving Medicare benefits who are 85 and older spent almost 30 percent of the income on health benefits. This leaves little funds leftover for out-of-pocket healthcare expenses, particularly preventive care and holistic treatment options.

Dr. Vern Saboe continued the chiropractic clinic that his father began in 1956 in the city of Albany, Oregon, just 30 minutes south of the state capital of Salem. Despite being in his 38^th year of practice, Dr. Saboe has no plans to “completely retire.” He sees this bill as an opportunity for more elderly Medicare patients to access his care.

“The elderly tend to live on a fixed budget with little discretionary income,” said Dr. Saboe. “As a result, many Medicare patients simply cannot afford to see a chiropractor, so they go to their medical doctor because those services are covered and more times than not, they leave with another prescription.” With such limited coverage, he often donates many of the things he provides to his Medicare patients.

He referred to chiropractic as a “one-stop shop” where chiropractors can provide “a consultation and history taking, back and neck examination, X-rays when appropriate and all of the typical physiotherapy treatments such as therapeutic exercise, neuromuscular re-education, fall prevention, [and et cetera].”

He continued, “chiropractors is most states provide physiotherapy modalities such as high intensity cold laser therapy, ultrasound, electrical stimulation, diathermy, traction, heat and cold therapy.” These services are not currently reimbursable under Medicare and the proposed bill “remedies this oversight.”

In addition to expanding patients’ ability to choose medical care that meets their needs, there are potential cost savings of millions of dollars.

Social Security benefits and Medicare account for 45 percent of federal program expenditures. Medicare is funded through two separate trust funds: the Hospital Insurance (HI) Trust Fund and the Supplementary Medical Insurance (SMI) Trust Fund. The trust funds are financed through sources that include general tax revenue, premiums paid by those enrolled, and payroll taxes. The HI trust fund covers Medicare Part A, which pays for inpatient hospital services, skilled nursing facility and home health services following hospital stays, and hospice care. This fund is expected to be depleted by 2026.

The SMI fund supports Medicare Part B, which pays for physician, outpatient, home health, and other services, as well as Part D, which provides subsidized access to drug insurance coverage for all voluntary enrollees and subsidies for low-income enrollees. While the SMI fund is anticipated to remain funded through the future, costs are expected to increase from 2.1 percent of the country’s gross domestic product (GDP) to almost 4 percent in 2038. This increase represents billions of dollars.

“The elderly have a high incidence of chronic back and neck pain,” said Dr. Saboe. He cited a study published in the Journal of the American Board of Family Medicine that found that greater availability of chiropractic care may offset primary care physician visits for issues related to back and neck pain among older adults enrolled in the Medicare system. These savings were estimated to total $83.5 million.

Further research recently published in The American Journal of Managed Care found “small, consistent differences” that provided initial evidence of a relationship between access to chiropractic care and spending on imaging and testing for spinal conditions. While further research remains, this evidence indicates that access to chiropractic care could lead to a modest annual reduction in per-patient spending.

With Medicare annually spending $400 to $500 million on chiropractic care, these findings could demonstrate that chiropractic services are not merely additive and instead assist the program in recapturing portions of payments for chiropractic care.

Almost 10 percent of older adults suffer from chronic back pain that impacts their everyday lives.

ACA President Robert C. Jones, DC stated,“According to the  Agency for Healthcare Research and Quality, between 1993 and 2012, hospitalizations for opioid overuse increased fivefold among Americans age 45 to 85 and older.”

Many older adults rely on opioids to manage pain, particularly those who are low-income. Almost 19 percent of elderly adults covered only by Medicare filled at least one outpatient opioid prescription and 7.6 percent filled at least four or more. The average annual rate of frequent opioid use is higher among those who are poor; 9.5 percent of elderly adults below the poverty line obtained four or more opioid prescription fills throughout the year.

Dr. Jones continued, remarking that these increased hospitalizations ”underscores the importance for Medicare beneficiaries to have better access to safer pain management options such as the non-drug services provided by chiropractors.”

Dr. Steven Becker with West LA Chiropractic specializes in treating patients with acute low back and neck pain. Elderly patients typically need “more chronic or long term treatment.” He offered an example: “I [see] you for back pain, treat[ed] you two to three times and then you went back to work. Someone who is elderly would need longer care.” While they may have acute episodes, a “higher percentage [of elderly] are susceptible.”

He believes the proposed bill would enable elderly patients to “receive access to care they otherwise need or deserve.” By allowing those covered through Medicare to choose chiropractic care for treatment, this may “save [them] from opioids, and prescription medicine that have their own effects.”

Recent research shows that greater access to chiropractic services for back pain is associated with a lower likelihood of opioid use.

“As policymakers seek to prevent the use of unnecessary drugs and surgery, chiropractors are poised to assist in the opioid effort by lowering the reliance on those drugs, especially in cases related to spinal pain,” said Falaradeau. “To the extent that it arbitrarily restricts access to chiropractic services, the current Medicare policy exacerbates these problems.”

Surveys of patients who received chiropractic care for back pain underscore these remarks. The Center on an Aging Society at the Georgetown University Health Policy Institute found that patients who received chiropractic treatment for their back pain were more satisfied with their care than those who saw medical doctors. In particular, they are more likely to report that their doctor explained their treatment and recommended self-care techniques that could be performed at home.

Many chiropractors have waited a long time for this kind of parity. “I think that it would go a long way toward leveling the playing field across all providers,” Dr. Becker stated.

“There’s no kind of provider type [through Medicare] that hasn’t had an increase in 40 years. If you did this to a cardiologist, there wouldn’t be any cardiologists,” said Dr. Becker. He emphasized that limited coverage under Medicare demonstrates a “certain kind of bias.” While bringing coverage up-to-date with state licensure requirements is an improvement, there’s “still an elephant in the room.”

The playing field among chiropractors and other medical providers in the United States has long been uneven. While now relatively established, chiropractic was viewed poorly by mainstream medicine, even deemed by the American Medical Association (AMA) as an “unscientific cult” until the early 1980s.

Tactics such as overly restrictive and burdensome state licensing requirements were employed by the AMA, as well as recommending that its members not associate with “unscientific practitioners”—specifically chiropractors. For example, Nebraska did not issue any chiropractic licenses between 1929 and 1950. The state’s newly created Basic Science Board had developed an exam biased against those with chiropractic training. Questions were designed for those with standard medical training, including portions on surgical procedures and child birthing techniques.

The AMA even formed a Committee on Quackery in 1963, which adopted a document known as the “Iowa Plan”. This plan sought to restrict the ability of chiropractors into hospitals and medical insurance, as well as continue the practice of making ethical complaints against chiropractors.

However, these efforts were uncovered in the landmark trial Wilk v. American Medical Association. Brought forward by Dr. Chester Wilk in 1976, the case took place a mere four years after Medicare included limited chiropractic coverage. The Committee on Quackery had only been dissolved a year prior. It would take another 11 years for the case to be resolved.

In the legal proceedings that followed, the AMA turned over hundreds of pages of documents that showed the scope of their efforts to restrict chiropractic. A permanent injunction was awarded in 1990 against the American Medical Association (AMA) for violating antitrust laws by conducting a de facto boycott to suppress chiropractic as a profession.

Dr. Becker emphasizes that the profession’s gains despite these efforts are the result of chiropractic’s successes over the years, particularly with the military. Considering Medicare coverage hasn’t changed since the 1970s, the proposed bill is “not just a legislative move, but based on prior success.”

Back pain is one of the most common causes of disability among U.S. military personnel. Congress passed a bill in 2000 that required the Defense Department to offer chiropractic care for active-duty personnel, as well as active Reserve and National Guard members. Chiropractic care was expanded to 65 military clinics and hospitals and a series of clinical trials were conducted to test the effectiveness of treatment. This year, the Defense Department submitted a report to Congress that found evidence that chiropractic care improved key fitness characteristics and improved readiness in active-duty service members.

Those no longer on active duty benefit as well. The Department of Veterans Affairs (VA) began providing chiropractic care throughout their health system in 1999, responding to demand from veterans. Between 2005 and 2015, the number of veterans receiving chiropractic increased from 4,000 to 37,000. The partnership between chiropractic providers and the VA has grown from 27 on-station clinics to over 65, in addition to chiropractic residency programs offered at five VA clinics.

The VA considers chiropractic treatment as a first-line treatment to reduce pain intensity and manage chronic pain. Veterans develop chronic pain and report more severe pain at higher rates than the general population. A study published in the Association of Pain Intensity found that veterans with moderate and severe pain were more likely to attempt suicide, even after adjusting for attempt history. Accordingly, reducing physical and perceptive pain, especially through non-invasive and low-risk, non-addictive methods, could prevent Veteran suicide.

The Chiropractic Medicare Coverage Modernization Act of 2019 is early on in the process. The bill is only at the first stage of the legislative process, still in the committee phase where legislative staff are preparing a summary. The ACA has heard “little to no resistance” from other healthcare professions and plan to “aggressively” push the legislation with patient advocacy groups in 2020.

While the outcome of this legislation remains to be seen, the ramifications of this legislation on Medicare patients and the chiropractic profession writ large may be enormous. There’s much at stake: the legitimacy and parity of the chiropractic profession among other physician-level providers, the ability of elderly patients under Medicare to choose their treatment, and the potential to provide non-addictive chronic treatment options for high-risk populations.

The ability to receive quality healthcare at affordable prices is a top concern for America’s elderly, according to the Pew Research Center. Over 10 percent of adults over the age of 65 had trouble paying their medical bills and one in five reported skipping a doctor visit, not taking a test, or avoid filling a prescription because of costs. The part of this legislation that matters most to chiropractors such as Dr. Saboe is the Medicare patients that it will impact. For him, it is “patients who will benefit the most from this legislation.”

Bree Nicolello

Writer

Bree is an urban planner and freelance writer based in Seattle, WA. She has worked on land use and housing policy issues throughout the Pacific Northwest. She previously led Run Oregon Run, a nonprofit dedicated to helping Oregonians run for office and apply to boards and commissions. When not writing, she is lovingly tending to her cast iron pans.