By now every chiropractor in the nation realizes that they will be affected by national health care. Some have become aggressive, lobbying Congress and encouraging their patients to send letters to their representatives and the president. Others have buried their head in the sand and have taken a wait-and-see attitude. Regardless of the position they have taken, all of them must face four basic concerns regarding their future with national health care.
Management Style
National health care will be mandated by the federal government through the National Health Board. Their responsibility is to set a national health care budget, set prices, and determine what health care services will be included in the least expensive health insurance an American will be offered -- the core benefit package.
After these decisions have been made, the national health board will delegate the implementation of national health care to large groups called provider groups or area health plans (AHP). These provider groups will most likely be composed of large hospital groups, large HMOs, and insurance companies. The responsibilities of provider groups are twofold: First, to enroll people in their plan, and secondly, to contract with doctors and other medical entities to provide health care. As a result, DCs in the United States who wish their services covered by national health insurance will need to be providers in at least one AHP; every potential chiropractic patient in the United States will be enrolled as a member in an AHP. These AHPs then control the distribution of all patients to all chiropractors.
AHPs may adopt a Medicare-style management where every doctor who is licensed in a jurisdiction would be permitted to join any and all AHPs. This is similar to your ability to join Medicare. AHPs however may use an HMO-style management where they select only a certain number of chiropractors from an area. In this case some doctors practicing in a given area would be included as health care providers; others would be excluded.
While this selective inclusion/exclusion is one of chiropractic's major concerns, recent unofficial indicators suggest that all licensed providers in an area will have an opportunity to be a provider of national health care.
Core Benefit Plan
The second concern of chiropractors is that they will not be included in the core benefit package. As it stands now, every citizen of the United States will be covered with at least the most basic of health care services. This basic coverage is referred to as the core benefit package, or bare bones package. Initially, it was thought that this coverage would be free to every person in the United States. Recently, however, there are thoughts of having each employed person in the United States pay 20 percent of the cost of this coverage. More complete coverage will also be available at extra cost to those people who desire extra coverage. This will come in the form of intermediate and deluxe insurance packages, and the cost to the patient will be greater.
Chiropractic's major concern: Will chiropractic be included in the core benefit package? Analysts have estimated that as high as 80 percent of the people in the United States will be covered by the core benefit package only. If chiropractic is not included in the core benefit package, 80 percent of the people in the United States could be without chiropractic coverage when the national health care plan is fully implemented. This is a very real possibility. With the huge cost involved in national health care, the core benefit package will have to omit some services. By omitting chiropractic from the core benefit package and placing it in an intermediate or deluxe coverage, the national health care policymakers could give the public the impression that chiropractic is covered in national health care when in essence it is excluded from a vast majority of people in the United States. This is why it is imperative that patients write their representatives urging them to include chiropractic in the core benefit package immediately.
Rates and Caps
If chiropractic is included in a Medicare-style program where every doctor of chiropractic is covered under national health, and if chiropractic is included in the core benefit package, then where will national health care insurance have saved money in the field of chiropractic. Ontario Health Insurance Plan (OHIP) is a good example of a governmental health care plan that in the past has placed rates and caps on chiropractic services. A chiropractor practicing in Ontario is paid approximately $10 for an adjustment with an annual cap of $220 per patient for all services rendered during the year. In the United States, Medicare has a price cap and fixes the rates that can be charged. What we see as Medicare coverage today could be very similar to the coverage we see for chiropractic care at large in the future.
Service-Specific Plans
It appears that the National Health Board will provide only a general plan for national health care and that the National Advisory Board will be responsible for specific interpretation of the plan. In addition, with the mounting pressure that the National Health Board is receiving and with the mounting costs that are now apparent with national health care, it is very possible that many of the policies involved with national health care will be "thrown back" to the states and the states will have a certain amount of latitude in providing the national health care. Florida's new Health Care Reform Act is a good example. If the National Health Board's basic plan is general, it may call for coverage of certain conditions rather than inclusion of certain professions. In other words, the National Health Board may say, "Low back pain is to be a covered service in the core benefit package," but they will not necessarily name chiropractors in the coverage plan.
If the National Health Board is not specific and if the states are given a greater role in deciding the care of their citizens, then chiropractic care runs the risk of being fragmented and varied from state to state, just as our scope of practices varies from state to state at this time. In that event, chiropractors will need to be aggressive on both the national and state levels to receive the coverage that the American people need.
Therefore, the concerns are:
> Will all chiropractors be in the national health plan?
> Will chiropractic be included in the core benefit package?
> Will the amount chiropractors can charge, the services they can charge for, and the number of visits be adequate under national health insurance?
> Will chiropractic have to fight on both the national and regional level for inclusion?
The results of these concerns will only be answered through time and with diligent effort from the chiropractic profession. Many chiropractors have been extremely active both directly and through their patients in contacting their legislators, and the results appear to be making a difference. Though there has been nothing official, each day chiropractors seem to get more good news and assurance on an individual basis and through the media, but the fight has only begun. Each chiropractor in the United States, whether they have been politically active in the past or not, should take this opportunity to support their national organizations, state organizations, and most of all rally their patients around the cause of inclusion of chiropractic in national health care.
David J. Kats, DC
Lincoln, Nebraska
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