Battle Heats Up Over Your Right to Access Practitioners of Your Choice

By John Weeks

Comedian Tom Lehrer wrote a song called “National Brotherhood Week” during the height of the antidiscrimination efforts in the United States in the mid-1960s. One of the off-color refrains goes: “The black folks hate the white folks/And the white folks hate the black folks/To hate all but the right folks/Is an old established rule.”

The Affordable Care Act—aka Obamacare—has language embedded in it that attempts to remedy another form of discrimination. At issue is whether you will face continued discrimination in your access to licensed practitioners of your choice.

From the battle shaping up, Lehrer’s lyrics are just as applicable to this antidiscrimination effort—if in need of reframing.

Discrimination in healthcare

At stake is Section 2706, “Non-Discrimination in Health Care.” US Senator Tom Harkin (D-IA) placed this language in the law at the urging of the American Chiropractic Association and the Integrative Healthcare Policy Consortium. The optometrists also urged Harkin to insert the language.

The meaning of the law is in dispute. One view holds that if a health plan in the new system covers a service, it must cover it from any licensed practitioner who has this service in his or her scope. Acupuncture treatment can’t be limited to medical doctors, or massage therapy to nurses.

A more expansive interpretation holds that if a plan covers treatment of back pain, for instance, then the plan must cover services of those licensed to care for back pain. The distinction here is that this interpretation is not about the modality (such as acupuncture needles) but the condition (such as back pain). So if you have back pain, you can get it treated by whomever you like, as long as they are licensed. This interpretation is in line with a legal decision in US appeals court in San Francisco related to similar language in a Washington state law. This would have huge implications for access to integrative health practitioners.

The biggest fight over the nondiscrimination clause is not relative to integrative health professions. With an end to discrimination, either anesthesiology or primary care could be performed by an advanced practice nursing specialist rather than an anesthesiologist or family doctor. An optometrist could not be trumped by an ophthalmologist, or a licensed midwife by an obstetrician.

The issue of patient-centered care

Section 2706 places a great deal of healthcare freedom and choice in you the voter, the end-user, the client, the patient. This direction aligns nicely with the movement toward “patient-centered care” trumpeted by the medical doctors in the mainstream payment and delivery system.

Or so it would seem. Yet within three months of the passage of the Affordable Care Act in March 2010, the American Medical Association’s House of Delegates passed a resolution to toss out the non-discrimination clause. One wonders if they miss the irony in calling what they promote “patient-centered.”

The present march toward the January 2014 implementation of “nondiscrimination in health care” sees antagonists coming out of the woodwork. Members of Congress, federal agencies, and the competing professions are acting out Lehrer’s lyrics.

In April 2013, members of the US Advisory Group on Prevention, Health Promotion, and Integrative and Public Health (aka, the Prevention Advisory Group), urged the US Department of Health and Human Services (HHS) to “issue guidance to states regarding compliance with Section 2706 ... and its relationship to all plans offered through the states’ health insurance exchanges.” Notably, they also urged “appropriate use of the healthcare workforce” represented by “licensed complementary and alternative medicine providers [and] integrative health practitioners.”

Within weeks, HHS responded— negatively. In something called “Implementation FAQs -- Set 15,” HHS used language that essentially declared that healthcare plans and states can use “reasonable medical management techniques” to essentially blow off the non-discrimination requirement.

Senator Harkin, whose committee position on the US Senate Appropriations Committee gives him budget authority over HHS, told the agency that the FAQ allows insurers to exclude whole categories of providers. He directed the HHS to “correct” its statement “to reflect the law and congressional intent.”

Are we in for more of the same?

Harkin’s move fired up the medical specialists who favor continuation of the present discriminatory, MD-dominant system. Within weeks, seven specialties asked Andy Harris (R-MD) to promote H.R. 2817 “to remove the non-discrimination requirements relating to healthcare providers.” The specialty consortium includes family doctors, ophthalmologists, dermatologists, anesthesiologists, plastic surgeons, obstetricians, and otolaryngologists.

The professions that will benefit through giving patients more access to practitioners of their choice responded quickly. The 13-member Patients’ Access to Responsible Care Alliance sent a letter arguing that H.R. 2817 would “reduce competition and concentrate market share and economic benefit into the hands of select providers—a misguided policy that would increase costs for consumers and the delivery system as a whole.” The Coalition for Patients’ Rights, representing 35 professional organizations, sent a similar letter.

Ironically, the nurses, optometrists, psychologists, speech therapists, physical therapists, and others who are aligned against medical doctors being in charge of all medicine have historically been designated by medical doctors as “allied health providers.” Their present work against the MD specialties to foster a system of health that is no longer defined by discrimination gives a different meaning to “allied health providers.”

In a verse late in his song, Lehrer writes: “Oh, the Protestants hate the Catholics/And the Catholics hate the Protestants/And the Hindus hate the Muslims/And everybody hates the Jews.”

If you like the idea of ending discrimination in healthcare, hum along to Lehrer’s tune: “The optometrists hate the ophthalmologists/And the ophthalmologists hate the optometrists/ And the obstetricians hate the midwives/And everyone hates the AMA.”

When it comes to ending discrimination in healthcare, the false front of “allied health” must drop and this work of these professions in this new alliance must prevail. Your right to choose will march through that downed barrier. In a future era of mutual respect for all practitioners operating within their scope of practice, we can form a system where all professions are horizontally allied in a patient-centered system.

Note: If you are interested in supporting non-discrimination in US health care, contact the Integrative Healthcare Policy Consortium (ihpc.org).

 

John Weeks is the editor of “The Integrator Blog News and Reports” (theintegratorblog.com), a leadership-oriented news, networking, and organizing journal for the integrative medicine community, and a columnist for Integrative Medicine: A Clinician’s Journal.