More than three years after the US Congress passed the Patient Protection and Affordable Care Act (ACA), popularly known as “Obamacare,” the controversial law maintains an undeniable presence in the lives of most Americans. Some Republican members of Congress and non-governmental groups are continuing their efforts to orchestrate the ACA’s demise, while Democrats and other organizations are still defending the law and promoting its potential benefits.^1,2

While ACA-related discussions often divide politicians and citizens along party lines, one aspect of the Act that blurs these boundaries is its potential impact on natural and integrative healthcare. Some in the complementary and alternative medicine (CAM) community claim that the ACA removes freedom of choice in healthcare. Other organizations celebrate the inclusion of CAM and integrative health in various parts of the ACA and particularly embrace a provision that calls for non-discrimination against licensed healthcare providers. Most of this discussion centers on two aspects of the ACA: the individual mandate and Section 2706, both of which take effect in January 2014.

Individual Mandate

Although the US House of Representatives voted in July 2013 to delay the individual mandate portion of the ACA,³ the Senate has held no vote on the matter. As of press time, all Americans must have health insurance at the start of 2014.^4,5 The mandate means that individuals without employer-based insurance who choose not to purchase a plan on their own are required to pay a penalty fee when filing their annual income taxes.

The individual penalty fee for 2014 is 1% of a person’s yearly income or $95, whichever amount is higher.⁴ So if a person made $40,000 per year and was without health insurance, he or she would pay a fee of $400. An uninsured person who made just $5,000 in one year would pay the $95 minimum fee. The fee increases each year; in 2016, for example, it will be the higher of 2.5% of a person’s yearly income or $695.⁴ Some persons are exempted from this requirement, including very low-income individuals and those whose religious beliefs are contradictory to purchasing healthcare insurance plans (e.g., Christian Scientists, the Amish, etc.).

The ACA legislation explains that the requirement is expected to increase the demand for healthcare services and thus will increase supply and encourage competitive prices; to reduce the $207 billion cost that the national economy sustains from the “poorer health and shorter lifespan of the uninsured”; and to lower health insurance premiums for all customers by reducing the “cost of providing uncompensated care to the uninsured,” which was calculated at $43 billion in 2008.⁵

Various conservative and libertarian-leaning commentators and groups have criticized the individual mandate for infringing on “basic” notions of freedom and liberty. Some CAM customers and organizations, including Citizens for Health (CFH) and the policy-focused nonprofit Alliance for Natural Health-USA (ANH), also disagree with this tenet of the ACA.^6,7

In 2010, CFH Chairman Jim Turner and Curt Levey, the executive director of the nonprofit Committee for Justice that promotes constitutionalism, published a joint editorial against the ACA before its passage. “Consumers of alternative medicine are used to health insurance plans that offer little or no coverage for holistic treatments and thus don’t meet their needs,” wrote Turner and Levey. “That’s why many of them choose not to purchase health insurance. What they’re not used to — but will have to get used to if the proposed ‘reforms’ become law — is being forced to purchase the very insurance plans that fail to meet their needs. And therein lie the dire consequences of the impending legislation.”⁷

But, to some, Turner and Levey’s preferred option of purchasing no health insurance whatsoever ignores the benefits that CAM supporters can experience from purchasing even a low level of coverage.

“Talking about CAM without talking about catastrophic coverage is to make the same error that medicine makes when it deals with one organ system without thinking of the whole,” said John Weeks, publisher and editor of the popular Integrator Blog who has been writing about and consulting on CAM issues for more than two decades (email, September 13, 2013). “I speak as a person who is an avid user of non-covered [CAM] services who would have been in a disastrous position had the $200,000-plus for my cancer treatment not been covered.”

Similar to CFH, ANH purports that many Americans’ lifestyles and values disagree with typical insurance plans that generally cover only conventional healthcare services and prescription drugs; the organization instead favors enabling health consumers to spend their money on CAM products and services, such as buying dietary supplements and herbs, having acupuncture or massage, being treated by naturopathic physicians, and more.6 According to Darrell Rogers, ANH’s campaigns and communications director, these people often forgo the purchase of health insurance or choose a catastrophic health plan, which has a lower premium (the amount of money one must pay each month for the insurance) but a very high deductible (the amount of money a customer must spend out of their own pocket before the health insurance begins its coverage of services and medicines).⁶ The individual mandate, however, will require both groups to purchase non-catastrophic, more standard health insurance, theoretically leaving them with less money in their monthly budget for their preferred CAM options. (Consumers can retain existing “grandfathered” health plans if they were enrolled in the plan before the date of ACA’s enactment on March 23, 2010.) For how the ACA might increase coverage for these services, read on to section titled “2706: A Provision for Non-Discrimination?”

“While catastrophic plans are permitted under ACA, they are restricted to certain populations,” explained healthcare law attorneys Ryan Abbott, MD, a professor at Southwestern Law School in Los Angeles, and Michael Cohen of the Michael H. Cohen Law Group in Beverly Hills (email, December 3, 2012). “They are available only to individuals who are under 30 years of age or who are exempt from the individual responsibility requirement due to the affordability exemption or the hardship exemption.”⁸

ANH noted that losing the catastrophic plan option will affect millions of consumers. It bases this on the number of people who are enrolled in Health Savings Accounts (HSAs), which are accounts for putting aside money tax-free that can be used on certain medical expenses, similar to flexible spending accounts (FSAs). HSAs are available only to individuals who have catastrophic or other high-deductible plans. As of January 2013, 15.5 million Americans were enrolled in HSA plans.⁹ This is up from 13.5 million in 2012 and 11.4 million in 2011. It is unclear, however, if these people purchase high-deductible plans because it is their preferred option, because it is the only option they can afford, or because it is the only plan offered by their employer.

Although most Americans will not be able to purchase catastrophic insurance, they do have the option to purchase a high-deductible health plan (HDHP) that meets specific requirements, such as a minimum deductible of $1,250 a year for an individual and $2,500 for a family (as of 2013).¹⁰ Unlike catastrophic coverage, however, these plans typically have premiums similar to standard plans.

Customers who purchase HDHPs can take part in HSAs, which are attractive for CAM consumers because (1) funds roll over at the end of each year, (2) some insurance plans allow portions of the premium payment to go into the HSA, and (3) certain CAM therapies are approved, such as acupuncture, chiropractic care, and osteopathy. HSA funds also can be used to purchase herbal dietary supplements and conventional nutritional dietary supplements (vitamins, minerals, etc.), although these must “be recommended by a medical practitioner as treatment for a specific medical condition diagnosed by a physician.”¹¹

“An HDHP with HSA is CAM consumers’ next best option,” said attorney Dr. Abbott, “but they still have premiums which, yes, should be higher than catastrophic plans. So, for someone really not wanting conventional coverage, they’re stuck with a premium based on coverage they don’t want. Their premium is based on the cost of treating other policyholders with conventional care.”

ANH says that HDHPs still are not a great option for CAM-focused individuals. “What will be the cost to the consumer?” asked Rogers. “The monthly premiums for allowed high-deductible/HSA qualified plans are still unknown. If users of natural health have to spend significantly more for insurance plans, they have less to spend on natural health practitioners and products.”

Dr. Abbott and attorney Cohen noted that those who wish to rely only on CAM have two additional, yet limited, options: simply forgo insurance and pay the annual penalty fee or purchase an unapproved plan (such as a catastrophic plan for non-exempt individuals) and likewise pay the annual fee.

2706: A Provision for Non-Discrimination?

One of the facets of Obamacare most celebrated by natural medicine consumers is Section 2706, known as the non-discrimination provision, due to its potential impact on insurance coverage of CAM services and conventional services provided by CAM practitioners. This legislation states that “a group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law.”⁵

Leonard Wisneski, MD, chair for the Integrative Healthcare Policy Consortium (IHPC), noted that patients are shifting from a focus on reactive medicine involving drugs and surgery to more natural approaches with a greater focus on adopting healthier lifestyles and preventive care.

“The inclusion of provisions in the ACA that are supportive of integrative healthcare, such as Sec. 2706, is an important step toward patient-centered care,” he said (email, September 16, 2013).

Weeks of the Integrator Blog — who served as a paid consultant on 2706 matters for several CAM-centered organizations, healthcare companies and clinics, and state agencies — told HerbalGram that 2706 is the “potentially most far-reaching” provision for the CAM community (email, November 19, 2012). As Weeks wrote in a recent Huffington Post column, this section was authored by Senator Tom Harkin (D-Iowa), a longtime champion of natural health causes in the US Congress, with input from various natural health organizations, such as IHPC and the American Chiropractic Association.¹²

Weeks explained that the provision language seems to entail that if a certain service is covered by an insurance plan, this plan cannot limit coverage to the service performed by just MDs, and thus also must cover the service when performed by other licensed practitioners. So if acupuncture is covered by a person’s insurance plan, that person’s acupuncture treatment should be paid for whether carried out by a physician or a licensed acupuncturist. Likewise, if massage is covered, it must be covered when performed by a licensed massage therapist. According to a broader interpretation of 2706, if “care of back pain” is covered, it must be covered by any practitioner licensed to provide such care. Former Washington State Insurance Commissioner Deborah Senn, a consultant to IHPC, successfully had this perspective implemented in Washington State and, when challenged, upheld in federal court.¹²

Depending on how the provision is interpreted, licensed CAM practitioners — such as naturopathic doctors in the 18 states that have provided a path to licensure — could possibly have their services covered by insurance. Jud Richland, chief executive officer of the American Association of Naturopathic Physicians (AANP), has said that if 2706 is “implemented in the way its drafters intended, it will be really significant.”¹³

“My position has always been that 2706 and the other points of inclusion in the research, delivery, health promotion, and workforce provisions of the law are historic in that they give integrative health and licensed so-called ‘CAM’ disciplines many points of legal standing inside the law,” said Weeks. “This is historic. What is not historic is that with all legislation, this is just a beginning.”

Weeks’s optimistic-yet-cautionary attitude is warranted. The remainder of 2706 includes wording that makes the provision potentially less significant; it states, “This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer.”⁵ This is, however, typical insurance lingo and not just when there is a discussion about CAM practitioners.

“While we were pleased to see the non-discrimination provision in ACA,” said Rogers of ANH, “we also recognize that the provision has very limited ability to fold natural health practitioners into the standard of healthcare. Insurance companies are not required to contract with specific healthcare providers — even those willing to agree to an insurance company’s more limited set of covered medical services.”

Weeks retorted, “Listen, we have what we believe is similar language in Washington State and it has enhanced access for the entire, covered population.”

In April of 2013, the US Department of Health and Human Services (HHS) confirmed that 2706 “does not require [insurance] plans or issuers to accept all types of providers into a network,” and “does not govern provider reimbursement rates, which may be subject to quality, performance, or market standards and considerations.”¹⁴ But some parties remained unclear about the legislation’s slightly ambiguous language or were in disagreement (2706 is said to have been created specifically so that CAM practitioners would not be excluded from coverage¹²).

In response, Senator Harkin voiced concern in a report from the Senate Health Education Labor and Pensions Committee that the HHS document apparently “advises insurers that this non-discrimination provision allows them to exclude from participation whole categories of providers operating under a State license or certification…. The Committee directs HHS to work with [the Department of Labor] and the Department of Treasury to correct the FAQ to reflect the law and congressional intent within 30 days of enactment of this act.”¹⁵

Dr. Abbott and Weeks noted that 2706 likely would not see clarification unless it is challenged in court. “Insurers are just supposed to make a good faith, reasonable interpretation of the law,” said Dr. Abbott. “Litigation over this provision is very likely.”

Until then, the individual states hold the most power when it comes to deciding if and which CAM services and/or providers are covered. The ACA requires individual and small group market health plants to offer essential health benefits (EHBs), which each state is in charge of selecting.

“This will vary from state to state,” said Rogers of ANH, “and whether or not CAM therapies will be covered depends entirely on the ‘typical plan’ selected by the state. While some states like California and Washington have decided to include acupuncture as one of services covered under the EHBs, most others have not.”

Meanwhile, various CAM and integrative health organizations have been lobbying lawmakers in Washington, DC, in an attempt to ensure that the states implement 2706 with the level of nondiscrimination they hope for. IHPC, for example, has been leading a 2706 implementation campaign throughout 2013 led by Senn. IHPC’s movement is supported by 14 healthcare organizations including the American Medical Student Association, the American Academy of Pain Management, the American Association for Acupuncture and Oriental Medicine, AANP, Bastyr University, and more.¹⁶ Although the American Medical Association has called for 2706 to be repealed, a bill proposing such legislation — US House Bill 2817, introduced in July 2013 — was not enacted.¹⁷

Conclusion

Other ACA provisions are expected to have small yet positive effects on natural healthcare. Joe V. Selby, MD, director of the new Patient-Centered Outcomes Research Institute (PCORI) — the creation of which was called for in the ACA — has said that CAM is a research area of interest.¹⁸ As of press time, PCORI had funded two CAM-related studies: one led by Dan Cherkin, PhD, director of the Bastyr University Research Institute, to identify the types of treatments that are most likely to help patients with different pain experiences; and another led by chiropractic researcher Michael J. Schneider, DC, PhD, to compare non-surgical treatments (including physical therapy and chiropractic care) for lumbar spinal stenosis. Additionally, PCORI has appointed several integrative medicine practitioners to lead some of its workshops and panels.¹⁸

Dr. Abbott has proposed a reform to ACA called the Evidence-Based Complementary and Alternative Medicine Act, which he said would incentivize CAM private research and development through market exclusivity for CAM products approved by the Food and Drug Administration.₁₉

ACA additionally requires all plans in the Marketplace — the “exchange” gathering all participating health insurance plans from which consumers can shop and apply for coverage — to cover a number of preventive services at no cost to the consumer, including blood pressure and cholesterol screening, diet counseling for adults with a high risk of chronic disease, obesity screening and counseling, folic acid supplements for women who may become pregnant, iron supplements for infants ages 6-to-12 months at risk for anemia, etc.²⁰ It also encourages employer-based wellness programs and mandates insurance coverage for certified midwives.

Unless Congress or the Obama Administration issue further delays or clarifications in the remaining weeks of 2013, the ACA’s impact on natural healthcare in the United States will begin to take shape after implementation of the individual mandate and Section 2706 on January 1, 2014.

—Lindsay Stafford Mader

References

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