When California Governor Gray Davis signed the state's $99 billion dollar budget on Aug. 2, doctors of chiropractic across the state breathed a collective sigh of relief. Thanks to the efforts of several legislators who saw its value, chiropractic was retained as part of the state's Medi-Cal program, allowing more than 600,000 Californians to continue receiving much-needed care.
"Retaining Medi-Cal in the state budget in the face of a daunting and unprecedented $38 billion deficit serves as precedent for other state health programs and many third-party payors," observed Dr. Douglas Wilson, president of the California Chiropractic Association. "The state of California recognized chiropractic care is more cost-effective than other forms of treatment and should not be considered an 'extra' that the system can do without."1
Considering the myriad rumors surrounding what health care programs would (or would not) be included in the budget in the months leading up to its passage, the chiropractic profession escaped the crisis relatively unscathed. All "optional" Medi-Cal benefits currently provided by state, including chiropractic, were retained. Gov. Davis originally sought to eliminate 18 optional Medi-Cal benefits, including coverage for chiropractic; adult dental care; medical supplies; hospice care; and prosthetic devices.
Additionally, reimbursement rates to health care practitioners who treat Medi-Cal patients were reduced by 5 percent - a financial blow to some providers, but far less than the 10 percent to 15 percent reductions proposed in January by Davis, who has taken a decidedly negative stance toward chiropractic since he became governor. In addition to the proposed cuts in this year's budget, he has been notoriously slow in appointing members to the state's board of chiropractic examiners.
Although chiropractic dodged a legislative bullet in California, 2003 has been a rough year for the profession. According to a report issued by the National Conference of State Legislatures (NCSL) in July, seven states - Nebraska, New Jersey, North Dakota, Ohio, Texas, Utah and Vermont - have reduced chiropractic services to some extent.2 Barring an unexpected financial turnaround, these reductions will likely carry into 2004 and beyond.
Changes to Medicaid Services
Nebraska - Changes to existing law limited adult visits to a doctor of chiropractic from 25 to 20 per year. However, in one of the few bright spots related to Medicaid and chiropractic, reimbursement rates for all practitioners were increased by 2 percent.
New Jersey - While chiropractic services weren't eliminated entirely (as per Gov. James McGreevey's original budget plan), they were reduced, and the eligibility guidelines for health insurance were tightened.
North Dakota - In one of the states hit hardest by the budget crisis, legislators restricted chiropractic visits to 12 per year, limited X-rays to two per year, and lowered reimbursement rates to providers. The state also was forced to impose restrictions or limitations on adult dental services, adult vision services, and visits to occupational therapists, physical therapists, speech therapists and psychologists.
Ohio - As in New Jersey, Ohio Gov. Bob Taft's original budget plan called for the removal of chiropractic services from Medicaid. Legislators managed to save chiropractic from the chopping block completely, but services will be reduced beginning next January. Additionally, a reimbursement rate freeze was imposed on "non-institutional providers."
Texas - Coverage of chiropractic services for adult recipients enrolled in Medicaid was eliminated, along with coverage of eyeglasses, podiatry, hearing ads and psychological services. Texas also eliminated in-home and family-support mental health services; reduced the number of personal attendant service hours for community care clients by 15 percent; discontinued reimbursement of graduate medical education; and reduced reimbursement rates for hospitals, physicians, dentists, nursing facilities, community care programs, home- and community-based services, mental health and mental retardation rehabilitation services, and managed care organizations.
Utah - Chiropractic service levels were reduced. However, the state also allocated $1.9 million from its supplemental general fund to restore Medicaid eligibility to those who were aged, blind, and/or disabled with income at or below 100 percent of the poverty level, and increased eligibility limits for the working disabled.
Vermont - As previously reported,8 in November 2002, the state invoked an emergency rule (which became effective in the 2003 fiscal year) that eliminated chiropractic services to Medicaid beneficiaries over the age of 21.
In addition to the states that actually dropped or reduced chiropractic services, several others - including Indiana, Michigan, Minnesota and New Hampshire - considered imposing limits on chiropractic or restricting access to care. Some of these states were able to avoid this by cutting funding to other programs and utilizing a $10 billion federal aid package Congress earmarked for Medicaid earlier this year.
A Downward Trend?
Medicaid was established in 1965 as a means of providing medical assistance for certain individuals and families with low incomes and resources. Although the federal government establishes general guidelines for the program, the program's requirements for eligibility are established by each state. Federal and state governments share in the cost of the program. In addition to basic services that each state is required to provide, states have the choice of offering up to 34 additional Medicaid services, one of which is chiropractic.
In the early and mid-1990s, chiropractic appeared to experience significant growth under state Medicaid programs. A report published by the Department of Health and Human Services (DHHS) in 1998 found that 30 states offered some form of coverage for chiropractic care under Medicaid, and while most states made changes to the level of chiropractic services between Jan. 1990 and Dec. 1997, only four states adopted changes that only limited their programs.3 By May 1999, the number of states with Medicaid programs that reimbursed for chiropractic services had risen to 33.4
Similarly, as the number of states including chiropractic under Medicaid increased, so did the number of DCs participating in the program. For example, a report published by the DHHS in 2002 found that the number of chiropractors submitting claims containing outpatient therapy services codes grew by more than 3,700 percent in a two-year span - from 624 in 1998 to 24,007 in 2000.5 But as the economy slowed down in the early part of this decade and available funds dried up, state legislators began tightening their belts and looking for ways to trim their budgets. One of the innocent victims of the economic downturn has been chiropractic. In the past two years, nine states have either reduced or eliminated coverage for chiropractic services under Medicaid, and at least 17 states have considered dropping chiropractic from their Medicaid programs.2,6
References
- Quote from Douglas Wilson, DC. Sent via e-mail to Dynamic Chiropractic, Aug. 8, 2003.
- FY 2003-2004 NCSL Medicaid Budget Survey. Sixth draft. The National Conference of State Legislatures, Washington, D.C., July 18, 2003.
- Chiropractic Care: Medicaid Coverage. The Department of Health and Human Services, Office of Inspector General, September 1998.
- Steyer TE, Freed GL, Lantz PM. Medicaid reimbursement for alternative therapies. Alternative Therapies in Health and Medicine Nov./Dec. 2002;8(6);84-88.
- AdvanceMed PSC CERT Therapy Services Error Rate Study. Final Report on Utilization. Appendix B: Unique provider tables. The Centers for Medicare & Medicaid Services, Washington, D.C., Sept. 16, 2002.
- Fiscal problems cause states to reconsider Medicaid services. NCSL News, July 24, 2003.
- More Medicaid cuts loom for chiropractic. Dynamic Chiropractic May 19, 2003. www.chiroweb.com/archives/21/11/15.html
- Vermont cuts chiropractic from Medicaid. Dynamic Chiropractic, Dec. 16, 2002. www.chiroweb.com/archives/20/26/09.html.
