A battle inside Congress and the Executive branch over the right of patients to choose care from the types of practitioners they prefer is erupting inside the Beltway.
At stake is the meaning and potential revocation of "non-discrimination in health care," Section 2706 of the Affordable Care Act. The requirement is due to become law in January 2014.
Congress and the Executive, in the form of the US Health and Human Services, are sparring over congressional intent. Now seven medical specialties have backed H.R. 2817 to entirely gut the non-discrimination section.
A key dimension to Section 2706 is patient access to covered services from licensed doctors of chiropractic, practitioners of acupuncture and Oriental medicine, naturopathic physicians, massage therapists, and to home births via non-nurse, certified professional midwives.
The potential for medical doctors to offer integrative medicine and health strategies in which a patient has access to covered services of licensed integrative health practitioners is also on the line.
U.S. Senator Tom Harkin (D-Iowa), the key sponsor of the non-discrimination section, was urged to include this language by the Integrative Healthcare Policy Consortium (IHPC) and the American Chiropractic Association. Each represents integrative health professions typically red-lined out of appropriate insurance coverage.
Another profession to whose lobbying Harkin and his colleagues were responsive was the optometrists. These eye-care specialists were concerned with the exclusionary practices of their competitors, the M.D. ophthalmologists.
The "non-discrimination" section would help level the playing field in the Affordable Care Act era.
The first touch came as integrative health and medicine activists, such as IHPC, began witnessing the general disregard of the non-discrimination clause in much state action to meet the Affordable Care Act's requirements. (Some of this wariness was captured in this blog on The Huffington Post: "Non-Discrimination: A 'Big Honking Lawsuit' to Advance Integrative Medicine and Health?")
The Advisory Group on Prevention, Health Promotion, Integrative and Public Health pushed back in their April 5, 2013 annual report to U.S. Surgeon General and USHHS. They urged the agency to "issue guidance to states regarding compliance with Section 2706 ... and its relationship to all plans offered through the states' health insurance exchanges." They also urged "appropriate use of the health care workforce as defined in Section 5101 of the ACA."
Notably, Section 5101-National Healthcare Workforce Commission, specifically includes "licensed complementary and alternative medicine providers [and] integrative health practitioners" in the U.S. health care workforce. The inclusion was historic.
On April 29, 2013, USHHS responded. The agency published Affordable Care Act Implementation FAQs -- Set 15.
It doesn't take a legal expert to read this document as a declaration that the plans and states can use "reasonable medical management techniques" to essentially blow off the section.
U.S. Senator Harkin and his fellow members of the U.S. Senate Appropriations Committee, which sets funding levels for HHS, are among those who found the language disingenuous. They challenged USHHS in a July 11, 2013 committee report. In it, the committee expressed "concern that the FAQ document issued by HHS, DOL, and the Department of Treasury on April 29, 2013, advises insurers that this nondiscrimination provision allows them to exclude from participation whole categories of providers operating under a state license or certification."
The report also took USHHS to task for allowing discrimination in payment rates. They directed the agency to "correct the FAQ to reflect the law and congressional intent."
The call to re-align action on non-discrimination with congressional intent stimulated those who favor of continuing discriminatory practices against all non-M.D. practitioners to go on the offensive. Within weeks, the seven medical specialties sent their July 23, 2013 letter letter to Congressman Andy Harris (R-Maryland).
They wrote to Harris in support of a bill called the Protect Patient Access to Quality Health Professionals Act of 2013 (H.R. 2817). The bill's simple purpose is "to remove the non-discrimination requirements relating to health care providers." The one page missive from the medical groups hangs their hats on everything from comparative educational qualifications to states rights.
The cell of pro-discrimination activists includes professional organizations representing family doctors, ophthalmologists, dermatologists, anesthesiologist, plastic surgeons, obstetricians and otolaryngologists.
These organizations' stab to the heart of Section 2706's revolutionary, inclusive shift in U.S. health policy came as no surprise to close watchers of the non-discrimination effort. The action, and Harris' responsiveness, followed a commitment from the American Medical Association House of Delegates just three months after of the March 2010 passage of the Affordable Care Act. The resolution urged the AMA to "immediately condemn and work to repeal" non-discrimination.
The chiropractic doctors were quick to respond. "The alarm bills ought to be going on here," states Richard Miller, lobbyist for the American Chiropractic Association, in this video regarding the bill and the backers. Their arguments of the medical specialty associations are "outrageous and disingenuous." He continues: "It's really a sickening exercise, a knee jerk attack against the freedom of the people."
Miller continued: "It's hugely significant. I am not sure our members fully know the value of Section 2706 but I'll tell you who does -- the AMA and organized medicine." The introduction of 2817, said Miller, "tells me that they'll fight back in the regulatory arena, in the legislative arena," everywhere.
One would assume, with a title led by "Protect Patient Access," that Harris was responsive to pressure from major national patient groups. Now, picture if you will increasingly informed and Web-empowered modern patients, who are known to have led, for instance, the movement for integrative health options, begging to be hand-cuffed and put back into chains.
I don't think so. The bigger issue is that each of the members who promote this medical organization reaction are threatened economically. Despite the title of this blog, the challenge is not mainly about inclusion of the distinctly licensed so-called "complementary and alternative medicine" or integrative health practitioners.
The more significant concern to the financial status and cultural authority of medical doctors is from advanced practice nurse midwives, nurse anesthetists, primary care nurses, optometrists, and others.
The leaders of these M.D. organizations know that the safety and effectiveness of the care by independently practicing nurses was profoundly endorsed by the powerful 2010 study from the Institute of Medicine of the National Academy of Sciences and the Robert Wood Johnson Foundation. The title speaks volumes: "The Future of Nursing: Leading Change, Advancing Health."
That 2010 report, published the year in which the Affordable Care Act was passed, officially ended the era of medical doctor hegemony. The reaction is against sea-change toward the horizontal, shared authority represented by the present, federal government-backed movement toward interprofessional education and team care. Many of their colleagues are affirmatively engaged in such new-era actions. Notably the medical doctors plus five other professions in the Interprofessional Education Collaborative posts the logo of the Academic Consortium for Complementary and Alternative Health Care as a supporting organization.
All medical doctors are not aligned with this repressive activity. This is rear-guard activity from a set of leaders from a set of specialty organizations engaged in the lowest form of guild behavior.
Miller, the lobbyist for the chiropractic doctors, urges renewed vigilance against efforts to maintain the status quo: "We've gotta bottle it up. If we don't, this will, for all practical purpose, legalize discrimination."
The issue is bigger than discrimination. What is at stake is more significant than patient choice. To follow congressional intent with a broad, progressive implementation of Section 2706, "Non-Discrimination in Health Care," will free up the best minds of our time, from whatever disciplines, to apply the optimal solutions to the horribly costly and wasteful medical outcomes that are the residue of the past century of empowering medical doctors with sole authority of over our health.
It's long past time to give collaboration, inclusion and shared leadership a chance.
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