A proposal to ensure that natural, complementary, alternative and integrative health and wellness services are included as viable healthcare options in the implementation of the Affordable Care Act, rather than being systematically excluded as they have been from many private health insurance plans.
Even without insurance coverage, well over half of all Americans are optimizing their wellness by using natural, alternative, complementary, and/or integrative medical approaches. By resourcing the over 70 separate non-traditional healthcare modalities, the public is expanding the definition of healthcare to include vastly more than pharmaceuticals, surgery & radiation. There is evidence that the use of these modalities in conjunction with promoting awareness of the innate healing intelligence of the body can significantly improve outcomes while reducing the overall cost of healthcare, opening up the possibility of transitioning from a “disease care” to a “health care” model.
This proposal is supportive of and complementary to the President’s discussion of healthcare in his 2012 victory speech. And there is notable bi-partisan support for making natural health care options a part of national healthcare, which speaks to the President’s call for trans-partisanship.
Additionally, what we propose will forward the work started by the White House Commission on Complementary and Alternative Medicine Policy (WHCCAMP) established by Bill Clinton in March 2000 with its final report delivered to President George W. Bush on April 1, 2001.
The inefficiencies of our country’s healthcare system are often insightfully ascribed to it being based on a “disease care” rather than true “health care” model, in which perverse incentives exaggerate inefficiencies. The Affordable Care Act is a monumental achievement worth not only celebrating but strengthening, so it’s worth working actively to make sure that one of its unintended consequences is not a further entrenchment and calcification of these fundamental problematic dynamics. This is what our proposal seeks to address.
The utilization of natural, alternative, complementary, and/or integrative medical approaches in the U.S. has been growing for decades and has tremendous momentum. Even without insurance coverage, well over half of all Americans are optimizing their wellness by resourcing these healing modalities. By using various forms of bodywork and massage, chiropractic and osteopathic manipulation, acupuncture, mind-body medicine, vitamins and other supplements, chelation and any of another 70 separate modalities, the public is redefining healthcare to include much more than pharmaceuticals, surgery & radiation. And since the U.S. public has overwhelming demonstrated its intention to rely upon natural healing and health alternatives, we think it would be egregious to systematically exclude natural health care options from national healthcare policies and consideration as has happened in the past.
There are four primary points regarding natural, complementary, alternative, and integrative healthcare modalities that we’d like the administration to consider:
1. Some modalities are now ready for inclusion. Current CAM modalities such as acupuncture, naturopathy, chiropractic, massage therapy, and licensed midwives have the kind of validation systems that meet standard certification and licensing requirements for individual practitioners common in the health care system.
Section 2706 of the Affordable Care Act (“Non-Discrimination in Health Care” which will apply to all insurance programs) is its most significant inclusiveness measure for these providers, potentially opening consumer choice to millions of Americans. Fundamentally, Section 2706 prevents plans from arbitrarily excluding the participation and coverage of categories of non-MD providers in their health plans when this participation is within their scope of practice and licensure.
Other modalities have taken beginning steps in that directing such as having their substantive content included in Continuing Education programs of widely recognized established health care groups.
2. Research and clinical practices in CAM modalities are advancing rapidly. ACA implementation rules should encourage the evolution of standards for their inclusion. There are already enough research results on additional CAM modalities that suggest potential improvements in outcomes and cost of health care approaches to support a policy of further research on CAM as part of a national health care program.
Section 2706 will have to be fleshed out by exchanges across the country. The Administration can write standards for federal exchanges that are as broad as possible with the express purpose of encouraging choice. This would be a model for states. As the market develops, further data can be collected to substantiate or disprove the effectiveness of these additional CAM modalities.
As we move in the direction of standard recognition set out above we also need to expand the opportunities for consumers to engage their own wisdom and choice. CAM modalities are already being utilized at least occasionally by about 100 million Americans, and paid for primarily out-of-pocket.
This suggests that one of the major efforts to be undertaken as we move toward a stronger—more productive, less expensive—health and wellness system is to expand the health savings account option (HSAs) that are already part of the Affordable Care Act. Most innovation takes hold as early adopters engage with emerging opportunities. Their use of new information and choices helps to identify emerging approaches with value and to eliminate unproductive ones. Health Savings Accounts (HSAs) are a tool that can be expanded to aid this part of the innovation process. There are currently active lobbying efforts to expand HSA coverage. (It is worth noting that these efforts originate mostly from the other side of the aisle, so this approach may also have value in the context of partisan negotiations).
The administration can encourage states to include these modalities in the emerging health insurance exchanges prior to the January 1, 2014 deadline. The experience with health savings accounts shows that if given the opportunity, people choose alternative health options. It is important to stretch beyond party lines and embrace the opportunity for choice that is embodied in expanding the use of health savings accounts.
Also, data is continually emerging that points to weaknesses of the traditional medical system such as iatrogenic diseases, deleterious drug interactions, and standard practices like mammography and back surgery that are proving not to improve outcomes. (eg., 40% of all back surgery turns out not to be non-effective.) At the same time, a large volume of additional data is emerging suggesting that emerging CAM alternatives deserve further study.
3. ACA rules can allow for research and for provisional and experimental treatments, creating a path for the evolution of approved treatments based on a “probable cause” standard for evaluating CAM modalities.
Insurance buyers (including insurance plan underwriters, federal program administrators and large self insured businesses) currently tend to evaluate and approve reimbursement for treatment approaches based on a “preponderance of the evidence” standard. This has led to many widely-discussed problems (eg., the delays and expenses associated with the trials required for FDA approval of new pharmaceutical products.)
In the case of safe, non-invasive CAM modalities, a different approach is warranted. Patient outcomes can be improved and system costs reduced by shifting to a “probable cause” standard in evaluating them, allowing the integration of emerging CAM treatment modalities—first for more research, then for earlier (compensated provisional or experimental) use.
4. Research on cost effectiveness is useful in assessing the value of various CAM modalities.
A 2005 National Institute of Health review of studies entitled “Is complementary and alternative medicine (CAM) cost-effective? A systematic review” surveyed a number of studies, and included suggestions of how to evaluate studies, concluded:
“Regarding study quality, 14 (36%) studies were found to meet all four criteria. These exemplary studies indicate CAM therapies that may be considered cost-effective compared to usual care for various conditions: acupuncture for migraine, manual therapy for neck pain, spa therapy for Parkinson’s, self-administered stress management for cancer patients undergoing chemotherapy, pre- and post-operative oral nutritional supplementation for lower gastrointestinal tract surgery, biofeedback for patients with “functional” disorders (eg, irritable bowel syndrome), and guided imagery, relaxation therapy, and potassium-rich diet for cardiac patients…. Whereas the number and quality of economic evaluations of CAM have increased in recent years and more CAM therapies have been shown to be of good value, the majority of CAM therapies still remain to be evaluated.” 
Also important to the discussion of cost, according to Fareed Zakaria, “Just 5% of Americans accounted for half of our nation’s health care costs in 2009. This is perhaps the crucial statistic to understand about America’s health care problem”.  5% of the US population uses 50% of our healthcare resources! This statistic could be dramatically impacted if alternative and natural options were promoted along side traditional medical treatments. For example, advocates of chelation assert that it can reduce amputations and open heart surgery by 2/3. (Chelation is a form of complementary therapy involving the intravenous infusion of substances intended to remove calcium from hardened arteries.) This assertion, and other credible claims for significant benefits from natural approaches, should be the subject of adequately-funded unbiased investigation.
BUILDING ON THE WORK OF THE ADMINISTRATION:
This proposal furthers the innovative measures that have already been taken by this and prior administrations toward including natural and alternative medicines in our national healthcare models. The ten principles established by President Clinton’s WHCCAMP for making its recommendations are an excellent source of guidance even today, 10 years later:
- A wholeness orientation in health care delivery.
- Evidence of safety and efficacy.
- The healing capacity of the person.
- Respect for individuality.
- The right to choose treatment.
- An emphasis on health promotion and self-care.
- Partnerships as essential to integrated health care.
- Education as a fundamental health care service.
- Dissemination of comprehensive and timely information.
- Integral public involvement.
The recommendations of this commission were largely ignored by President Bush. It is crucial to continue the work of the WHCCAMP if this administration is to implement the Affordable Care Act in a way that sustainably optimizes the health and wellbeing of the nation. Establishing the National Prevention Council as part of ACA with a mandate of preventing disease in a public health context is an important step in this direction.
Natural health approaches are a low-cost high-yield component of any serious attempt to fulfill this responsibility to public health. We applaud the efforts of the National Prevention Council and its action plan which collaborates with “state, tribal, local, territorial, public, and private partners—to begin to move our health system from one based on sickness and disease to one based on wellness and prevention.” We suggest standardizing this approach by examining all health policies at all levels through the lens of natural healing.
END OF LIFE
Also, crucial to the discussion of complementary, alternative and integrative health and wellness is end of life care. Rather than a balanced integration of body, mind and spirit there is currently a nearly exclusive overemphasis on the physical body and a de-emphasis or total neglect of mind and spirit in approach to end of life care. The current medical practice has too often been to keep the physical body alive at the expense of the mind and spirit. We urge the administration to learn from and be guided by the lessons learned by the hospice movement in our national policies regarding end of life care.
Well over half of all Americans are already optimizing our wellness by using natural, alternative, complementary, and/or integrative medical approaches. Evidence supports the conclusion that using these modalities while promoting awareness of the innate healing intelligence of the body can significantly improve outcomes while reducing overall cost. It is time to build a true health care model to support the optimal health and well-being of all U.S. citizens.
It is important to note that this proposal is supportive and complementary to the President’s discussion of healthcare in his victory speech. And also to note that it provides a way to reach across the aisle. There is significant bi-partisan support for making natural health care options a part of our national healthcare policy, so this proposal also expresses the President’s call for trans-partisanship. It efficiently and wisely embodies “conservative” principles of personal responsibility and cost effectiveness while protecting the rights of every citizen to a vital, healthy life.
 The Additional information in the commission can be found here: http://www.whccamp.hhs.gov The Executive Summary can be found here: http://www.whccamp.hhs.gov/es.html The Recommendations & Actions can be found here: http://www.whccamp.hhs.gov/pdfs/fr2002_chapter_10.pdf