Understanding the Challenges of U.S. Acupuncture Practice (Pt. 4)

Editor’s Note: Part 1 of this eight-part series appeared in the June issue. Pt. 3 (August issue) ran as a web exclusive due to space restrictions in the print issue.

---

The exosystem comprises the linkage and processes taking place in two or more settings.¹ The exosystem in this section represents state health policy and varied acupuncture regulations.

1. Federal Health Policy

Health policies can influence the acupuncture profession. The policies in this section that serve as examples include the Affordable Care Act (ACA), Caregivers and Veterans Omnibus Health Services Act of 2010, and Medicare.

The Affordable Care Act is the health reform law passed in March 2010. This law aims to expand health insurance to cover more populations, reduce the expense for low-income families, increase the coverage of Medicaid, and help lower the expense of health care.²

The ACA requires that insurance companies cover essential health benefits (EHB) and other medical services.³ Through the statistical data of the ACA, five states and four territories in the United States covered acupuncture as an EHB starting January 2014.⁴

More beneficiaries and acupuncturists should benefit from the ACA. Fan inferred that about 75 million Americans could receive acupuncture coverage due to the implementation of the ACA.⁴ Furthermore, Bushak pointed out that insurance companies should treat all practitioners equally under the umbrella of the ACA.⁵

However, the ACA does not clearly define how to bring acupuncturists to the same level as medical doctors. Instead, interpretation of the ACA was passed on to individual states. In addition, the ACA emphasizes nondiscrimination for health care providers, but does not enforce that insurance companies treat licensed acupuncturists the same as mainstream medical professionals.

In reality, there is much confusion and controversy in implementing the ACA, and most insurance companies still refuse to cover acupuncture therapy. However, despite the non-coverage of acupuncture, the ACA at least provides the legal ground for acupuncture professionals to enjoy equal rights as mainstream medical professionals. Therefore, such health policies as the ACA might be beneficial in helping integrate the acupuncture profession into mainstream medicine.

The Caregivers and Veterans Omnibus Health Services Act of 2010 is omnibus health legislation for caregivers and veterans passed by the 111^th Congress.⁶ Directed by this health care policy, the Secretary of Veterans Affairs (VA) established a program of comprehensive support for family caregivers of any veteran, and assigned primary providers to offer VA medical care.

Psychological distress and long-term chronic pain of veterans may lead to inappropriate use of opioid medications, which has gradually fed into the opioid crisis nationwide. Veterans are a high proportion of the victims of the opioid epidemic, and acupuncture can relieve the pain they are trying to address, which could be a potential solution.⁷

According to the VA Handbook, acupuncturists’ occupation and employment positions were included in the VA’s system, which was influenced by the policy of the Caregivers and Veterans Omnibus Health Services Act of 2010.⁷ Therefore, the act may help expand acupuncture services to all veterans and further promote acupuncture.

Medicare is the federal health insurance program for seniors or specific populations with disabilities.⁸ Although Medicare provides specific services, it does not cover acupuncture treatment for conditions except chronic low back pain.⁹

As a national-level health policy, if Medicare were to cover acupuncture, it could establish an example for other insurance companies, which would benefit the acupuncture profession and the general public. However, without the Medicare coverage as referenced, there are fewer opportunities for other insurance companies to consider coverage of acupuncture.

As a result, non-coverage of acupuncture by Medicare currently brings even greater inequality to two professions – the acupuncture profession without insurance coverage vs. the mainstream medical practice with insurance coverage.

2. Varied Regulations

There is little research about how varied regulation of acupuncture may influence acupuncture practice. However, there is a study in the medical field that discusses how varied medical laws affect the use of medicine.

This study, conducted by Pacula, et al., examined the impact of medical marijuana laws (MMLs) on marijuana use and found that the variation in MMLs in different states could influence recreational marijuana use and dependence.¹⁰ For example, states under the protection of MMLs might increase the use of recreational marijuana compared to other states without the umbrella of MMLs. However, increased use of recreational marijuana in MML states may result in more negative consequences, such as driving accidents, increased crime and a negative impact on health.

Similarly, the acupuncture profession has varied regulations across different states, which might influence acupuncture professionals’ interstate practice. According to the Council of Colleges of Acupuncture and Oriental Medicine, acupuncturists in most states practice as independent providers of health care because the right to practice acupuncture by statute exists in all states except Alabama, South Dakota and Oklahoma.¹¹

In a few states, practitioners of acupuncture must have supervision, prior referral or initial diagnosis by a Western medical doctor, which may limit the acupuncturists’ purview.

The acupuncture profession does not have legislative consistency. Currently, there exist variations among acupuncture practice acts, definition and scope of practice.¹² CCAOM points out that acupuncturists will lose the benefit to practice universally across states due to these inconsistent statutes regulating the scope of acupuncture practice.¹¹

For example, acupuncture point injection therapy is currently part of the scope of practice for licensed acupuncturists in Arkansas, Colorado, Florida, New Mexico, South Carolina, Washington, and West Virginia.¹² Acupuncturists cannot perform point injection in any other state.

Dworkin argued that this interstate reciprocity is a nonissue for medical physicians, who are licensed in every state.¹³ It is unknown whether the variations in regulation within acupuncture training will lead to inconsistencies in the quality of medical care and health outcomes.¹⁴

However, the training that acupuncture professionals have received in school will affect their practice type after their graduation. For example, a study by Kalauokalani, et al., demonstrated that there exists a difference in acupuncture styles between physicians who perform acupuncture vs. licensed acupuncturists in treating low back pain.¹⁵ This study found that 70 out of 137 physician acupuncturists performed acupuncture based on their knowledge of neurology and anatomy. In contrast, 89% of nonphysician acupuncturists (n=50) practice acupuncture based on traditional Chinese medicine (TCM) theory.¹⁵ The difference in practice style is associated with their prior professional training.

Additionally, the definitions of statutes and regulations, as well as scope of practice, vary among different states. These inconsistencies reflect not only in state statutes, but also in the administrative structure.¹⁶ As McKenzie, et al., pointed out, some states have detailed statutes, regulations and an independent acupuncture board to administer local acupuncture practice.¹⁶

Some states do not have detailed and precise regulations, and are dependent on other health care boards. According to the state licensure requirements interactive map by the NCCAOM, 47 states have passed acupuncture laws, 12 states’ medical boards administer acupuncture practice with the help of an acupuncture committee, and 35 states have independent acupuncture boards.¹⁷

Varied regulations impact the profession, the health care system and patients. For instance, in a study of 10 non-physician clinicians, Cooper, et al., argued that these clinicians should integrate their regulatory legislation to avoid the potential of pluralism practice fragmenting the U.S. health care system.¹⁸

Offit argued that alternative medicine that remains an unregulated industry should admit its risks and that it can be harmful to patients’ health.¹⁹ On the other hand, Cohen stated that uniformed legislation could improve a profession’s image, standardize treatment protocols, accelerate the process of credentialing, and increase insurance payment.²⁰

Without consistent regulation, the acupuncture profession will have less opportunity to integrate into mainstream medicine. State- or federal-level health policy may play a role; however, there is little research to demonstrate how health policy at the state or federal level influences these regulations.

References

1. Bronfenbrenner U. Ecology Models of Human Development. In: Postlewaite TN, Husen T. (Eds.): International Encyclopedia of Education, 2^nd Edition, Volume 3. Oxford, England: Elsevier: pp. 1643-47.
2. The Affordable Care Act (ACA). HealthCare.gov. Read Here
3. Essential Health Benefits. HealthCare.gov, Jan. 26, 2014. Read Here
4. Fan AY. “Obamacare” covers fifty-four million Americans for acupuncture as Essential Healthcare Benefit. J Integr Med, 2014;12:390-393.
5. Bushak L. “Affordable Care Act Raises Status of Alternative Medicine; Insurance Companies ‘Shall Not Discriminate’ Against Practitioners.” Sept. 28, 2013 Retrieved from [url=https://www.medicaldaily.com/affordable-care-act-raises-status-alternative-medicine-insurance-companies-shall-not-discriminate]https://www.medicaldaily.com/affordable-care-act-raises-status-alternative-medicine-insurance-companies-shall-not-discriminate[/url]
6. Caregivers and Veterans Omnibus Health Services Act of 2010. Congress.gov.
7. “Acupuncturists Now Included in the Veterans Health Administration.” National Certification Commission for Acupuncture and Oriental Medicine, Dec. 12, 2018. Read Here
8. What’s Medicare? Medicare.gov. Read Here
9. “CMS Finalizes Decision to Cover Acupuncture for Chronic Low Back Pain for Medicare beneficiaries.” Centers for Medicare and Medicaid Services, Jan. 21, 2020.
10. Pacula RL, Powell D, Heaton P, Sevigny EL. Assessing the effects of medical marijuana laws on marijuana use: the devil is in the details. J Policy Analysis Manage, 2015;34:7-31.
11. Acupuncture and Oriental Medicine in the United States. Council of Colleges of Acupuncture and Oriental Medicine, September 2015. Read Here
12. “Point Injection Legalities.” PointInjection.com, April 12, 2012. 
13. Dworkin RW. Science, faith, and alternative medicine. Policy Rev, 2001;108:3.
14. Lin K, Tung C. The regulation of the practice of acupuncture by physicians in the United States. Med Acu, 2017;29:121-127.
15. Kalauokalani D, Cherkin DC, Sherman KJ. A comparison of physician and nonphysician acupuncture treatment for chronic low back pain. Clin J Pain, 2005;21:406-411.
16. McKenzie M, Sale D, Ward-Cook K, et al. Acupuncture and Oriental Medicine. In: Clinicians’ and Educators’ Desk Reference on the Integrative Health and Medicine Professions, 3^rd Edition. Academic Collaborative for Integrative Health, 2017.
17. State Licensure Requirements Interactive Map. National Certification Commission for Acupuncture and Oriental Medicine, 2018). Read Here
18. Cooper RA, Henderson T, Dietrich CL. Roles of nonphysician clinicians as autonomous providers of patient care. JAMA, 1998;280(9):795-802.
19. Offit P. Killing Us Softly: The Sense and Nonsense of Alternative Medicine. HarperCollins UK, 2013.
20. Cohen MH. Complementary medicine: Legal status of the non-licensed provider in the USA. Compl Ther Nurs Midwif, 1997;3(4):100-102.