Running Head: PUBLIC HEALTH, HEALTHCARE FOR ALL, AND CHINESE MED 1

Public Health, Healthcare for All, and Chinese Medicine

by Snohomish Brown LAc

Pacific College of Oriental Medicine

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Abstract: The role of acupuncture and Chinese medicine in today's health care system

continues to evolve as people discover its effective usefulness in treating a variety of

conditions. Unfortunately current healthcare policies and legislation make it difficult to extend

these benefits to the more vulnerable populations and it still remains out of reach for many

consumers. The advantages and disadvantages presented by current healthcare policy are

relatively dependent upon one's point of view as the various stakeholders experience health

outcomes largely determined by socio-economic status. In the long term however, it remains

in each of our best interests to recognize our collective burden; that the cost of caring for the

uninsured eventually falls upon the rest of us too (Garthwaite, 2015).

In our assessment of the Affordable Care Act (ACA), for example, the advantages of

greater access to care and expansion of services appear to outweigh the disadvantages of

additional government spending. However, it seems as though those advantages may be

short lived with the threat of Republican efforts to repeal and replace the ACA looming.

Notable other advantages that may soon go away as a result of repeal include coverage for

chronic pre-existing conditions, Essential Health Benefits (EHBs), and the expansion of

Medicare and Medicaid for the poor, as well as federal tax credit premium subsidies to assist

those who qualify to pay for health insurance (California Health Benefits Review Program,

2011). For many newly insured, these subsidies in the form of tax credits, are the only way to

make health insurance affordable to them. If these were no longer available and if the federal

government also stopped subsidizing insurance companies to lower their premiums, then

surely many more Americans would not be able to afford insurance either, nor be able to pay

for healthcare when they need it (Dranove, 2017).

“CBO and Joint Committee on Taxation estimate that enacting the Better Care

Reconciliation Act of 2017 would reduce federal deficits by $321 billion over the coming
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decade and increase the number of people who are uninsured by 22 million in 2026 relative to

current law.“ (Congressional Budget Office, 2017). Many states will likely repeal EHB

mandates within their state, although some may choose to keep those provisions in place.

California will probably continue to maintain a strict mandate of coverage for most of its

population as it strives to move toward a single-payer system (California Healthcare

Foundation, 2014). Benefits of the federal budget deficit are short sighted, however, as less

insured vulnerable populations will incur greater costs at the state level in the long term,

costing tax payers as much, if not more, later on (Garthwaite, 2017).

Craig Garthwaite is a researcher with the Commonwealth Fund whose drive to

understand the true cost of public insurance programs led him to question the rationale

behind repeal and replace. “We want a debate about the Affordable Care Act and the

Medicaid expansion and public insurance in general to be based on economic facts,”

Garthwaite says. “There are people who say it costs too much. What do we mean when we

say it costs too much?” (Garthwaite, 2015). If policymakers truly want to balance state

budgets, regardless of whether they want to offer statewide public health insurance plans or

not, they must factor in the costs of uncompensated care. “There will always be a minimum

level of care that people are going to consume,” Garthwaite says. “So we need to have a

conversation about how to most efficiently provide that care—otherwise we’re left with sloppy

arguments. Choosing to ignore this population doesn’t mean the cost of that care is ever

going to go away.” (Garthwaite, 2015). The application of acupuncture and Chinese medicine

to solve some of the health concerns of this growing uninsured population may help, but there

is not enough understanding around the current research to demonstrate acupuncture's

effectiveness definitively and then there is the cost for which these services need to be

adequately compensated.
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Grassroots efforts and alliance coalitions have garnered unprecedented support for

legislation to create a single-payer healthcare policy in California. This would mean that all

healthcare would be paid for by the government and everyone would receive coverage based

upon need, but the plan to pay for it has not been worked out yet (Mason, 2017). Also, no

one really knows what this might mean for reimbursements as there has been a conservative

effort to reduce costs for many Medicaid services despite simultaneous efforts to expand

services for needy populations since the mid 1970s (McGreevy, 2017). Many imagine that

single-payer would look like Medicaid for all, and knowing what reimbursement rates look like

for Medicaid, we can imagine that incomes might be too low for many TCM practitioners to

remain open without making significant changes to their business model. Medi-Cal

(California's Medicaid program) reinstated acupuncture benefits in June of 2016 for its

beneficiaries, but it only pays a little more than five dollars for a fifteen minute unit of face to

face treatment (Department of Health Care Services Medi-Cal, 2016). This does not seem

like a feasible pay rate to put together any kind of business model in the greater Los Angeles

Metropolitan area. Perhaps this is less of a problem in rural areas, or with a community style

clinic with multiple patrons receiving care together in a large open room. But certainly even in

those cases, it would be difficult to run a profitable practice. Thankfully, perhaps for

acupuncturists at least, the Assembly Bill has been shelved until this year in the California

Legislature while these issues get worked out (Dayen, 2017). But the need for action still a

priority in the face of new federal legislation, that seeks to strip health care benefits for many

people.

Not too long ago, the accrediting agency that grants deemed status to hospitals who

receive Medicaid funding issued a stern warning to Physicians urging them to reconsider non-

pharmacological approaches to pain management in light of the current opioid epidemic. “This
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Joint Commission document puts a tremendous tool in the hands of anyone seeking to

promote integrative pain treatment.” (Weeks, 2015). For acupuncturists looking for

recognition of value added services, this may provide a useful avenue to provide care to the

under serviced. The recommendation lacks punitive measures of enforcement however, and

as the general consensus among physicians remains that the Joint Commission acts

somewhat as an impediment to their jobs; it might be an empty gesture nevertheless.

On the other hand, policy changes in the way that disease classifications are handled

are set to include Traditional Chinese Diagnostic terminology as part of the ICD-11 revision.

Currently those who are working on this project are seeking input from those in the field of

Chinese medicine to make comment and evidence based suggestions. "This work is

something, which is relatively unprecedented in the area of traditional medicine, particularly at

this level," said Dr. Molly Meri Robinson Nicol, technical officer at WHO (Rosen, 2016). "The

ICTM, including the selection included in ICD-11, will be the foundation on which future

research will be based. This classification will serve as a tool for the collection of clean, clear

data on who is using traditional medicine, what they are using it for, if it works, if it is safe, how

much it costs, and how it compares to other medicines in similar situations." (Rosen, 2016).

Since 1999, the United States made ICD coding mandatory for mortality data. Over the past

17 years, hospitals have been adopting and maintaining ICD implementation updates. The

most recent update was the ICD-10 in October of 2015, which required its use for all inpatient

hospital procedures (Duran, 2011). Nicol noted that the ICTM also will support clinical

research and documentation, policy development, and healthcare reimbursement, in such a

way that it will be consistent and capable of comparison globally. “Acquiring a set of

diagnostic codes along with the incorporation of a Doctorate degree as a professional entry-

level requirement in the U.S., will pave the ground for TCM practitioners. We are heading
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down the same road that fairly recently, Doctors of Chiropractic traveled” (Rosen, 2016). Let's

hope she is right about that.

The plan to educate other healthcare administrators and legislators could be outlined

briefly as: write letters, make phone calls, and send petitions. It is more effective to sway the

minds of politicians with sufficient numbers however, and so it will be necessary to form

coalitions with others of like mind. The next step or action plan in California would therefore

be to choose a strong Acupuncture lobbying power and become a member. Then it might be

prudent to take on any of their specific recommendations and wait and see. Alliances are

important in spite of the fact that support for the single payer bill in California appears to be

dividing once again into separate factions (Dayen, 2017). By contrast, the success of the

APTA lies in their sheer numbers and the significant lobbying power those individuals are able

to purchase (Haughney, 2017). Let this be a valuable lesson to acupuncturists and perhaps

an urgent call to action as well.

If California legislators seek to remedy the changes which are likely to take place on

the Federal level by passing a single payer for all bill, that will dramatically change things

(Dayen, 2017). The concern is that the result will be a system that looks like Medi-Cal for all,

where the payouts to acupuncturists are less than what one can afford to keep a practice

running. Certainly this factor will cause some practitioners to move out of state or possibly

influence an increase in reimbursement rates if this becomes a problem for too many

providers, but only time will tell. For the consumer, this could be a mixed blessing also. With

the government in charge of managing payment for all healthcare services, there are

concerns of inefficiency, bureaucracy and corruption.

There is a feeling that the private sector is much more capable at managing healthcare

than the public sector (Dayen, 2017). There is ample evidence that the reverse is true
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however, as government programs are subsidiary to private sector aims to make a profit and

the private sector believes it can only lose money by caring for vulnerable populations. On

the contrary, “an analysis of uncompensated care data from Medicare Hospital Cost Reports

from 2011 to 2015 found that uncompensated care burdens fell sharply those states where

Medicare was expanded” (Dranove et al, 2017). Between 2013 and 2015, operating costs for

uncompensated care fell from 3.9 percent to 2.3 percent. This is a big deal when profit

margins for these non-profit hospitals are often around two percent. “Estimated savings

across all hospitals in Medicaid expansion states totaled $6.2 billion.” (Dranove et al, 2017).

The largest reductions in uncompensated care were found in hospitals located in expansion

states that care for the highest proportion of low-income and uninsured patients. Federal or

state legislation that scales back or eliminates Medicaid expansion is likely to expose these

safety-net hospitals to large cost increases. “Conversely, if the nineteen states that chose not

to expand Medicaid were to adopt expansion, their uncompensated care costs also would

decrease by an estimated $6.2 billion.” (Dranove et al, 2017). This is all the evidence we

need to push for a healthcare for all system. It is so clear by now that we will end up paying

for other's healthcare regardless because we all need each other to make the world go round.

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Bio

Snohomish Brown LAc, CMT is a Licensed Acupuncturist and expert in soft tissue massage,
lymphatic drainage, myofascia release and tuina. Other modalities include moxibustion,
cupping, guasha, and electro-stimulation. He offers herbal formula recommendations, as well
as nutrition and lifestyle coaching for reproductive health, pain management, and longevity.
snohomishbrown@gmail.com