Fighting a War for Our Veterans
[originally published in KCN, March 2002]
Dear Valued Veterans,
Just wanted to let you know that in addition to the standard medical services that we have offered you in the past, you now have direct access to chiropractic care — no referral needed. Our medical facilities will soon be staffed by doctors of chiropractic standing ready to serve your health care needs. We sincerely hope you will take advantage of this exciting new benefit. You deserve it.
Your friends at the VA.
Probably not a letter you veterans out there will receive from the Department of Veteran Affairs (VA), so I thought I’d better write it. It is absolutely true though, thanks to the Department of Veterans’ Affairs Health Care Programs Enhancement Act of 2001 that President Bush signed into law in January of this year. A definite cause for celebration for the chiropractic and veteran community alike, for we chiropractors had to fight a “war of our own” to finally see this victory. With the failure of our initial effort dating back to 1936, when Dr. B.J. Palmer, the founder of chiropractic, introduced a bill to provide chiropractic services to veterans through the VA, chiropractors have been fighting hard ever since to bring chiropractic care to our nation’s deserving men and women that have fought for our country.
I feel sorry for the chiropractors that will have to “break this one in” though, because the medical prejudices that we had to wade through to get to this point, were, well let’s just say, pretty thick. Just before the bill was to be sent off to the President’s desk to be signed, I was delighted to read an article in the Chiropractic Journal that reported the kind sentiments posted on the Internet of Ludmil Chotkowski, M.D. who stated, “This is a great victory for quackery and will be hailed by the chiro community to the hilt. I have just phoned the White House requesting the President veto this to spare veterans from chiropractic quackery and to save the government from wasting money on a hoax.” I guess George didn’t get his message.
In my attempt to hail this one “to the hilt,” I’d like to lead you through some of the history that brought us to where we are today. I mentioned that our first unsuccessful attempt to bring chiropractic care to our veterans occurred back in 1936. It would take 42 years before Congress quieted our persistent attempts by authorizing the VA to offer chiropractic in 1978. And while the VA complied with Congress, the way they implemented chiropractic into their program made it real clear where they stood with the whole idea. To date, chiropractic “technically” has been available to veterans since this time. The problem: (1) hardly anyone knows about it, and (2) the VA is not too eager to utilize it and has indicated such by their own admission. Those veterans that do happen to get the golden referral from their “licensed medical officer” can expect a lot of hoops and an embarrassingly low number of visits to be authorized. And, oh, did I mention that you’d better have low back pain? — because they won’t pay for anything else.
Time marched on, and it looked like we were actually getting somewhere in 1986 when the VA kicked off a “Chiropractic Services Pilot Program Evaluation Study.” The study evaluated the therapeutic benefits and cost-effectiveness of, as it was reported, “providing certain chiropractic services to a group of veterans who were experiencing a very select subset of low back pain.” [That sounds very encompassing]. The study concluded in 1988, and their report became available two years later. Naively we were expecting great things. Their conclusion was that while the benefits from the chiropractic care were as good as those obtained from their traditional medical care, the costs associated with the chiropractic care were significantly higher. Remember, it took them two years to crunch these numbers. Funny how their conclusions sharply contrasted those of a similar study published around the same time by the British Medical Research Council. This multi-year chiropractic care-effectiveness study conducted by Britain concluded that “the potential economic, resource, and policy implications of [their] results were enormous,” and that “introducing chiropractic into the National Health Service (NHS) should be considered.” Meanwhile in the United States, the VA concluded, based on their study, that they did not anticipate making chiropractic care more widely available to veterans. No surprise. Our efforts continued nonetheless.
Nearly a decade later, a concerted effort to bring the VA issue back to the table was spear-headed by the International Chiropractic Association (ICA) with the introduction of the Veterans’ Chiropractic Act of 1998. While these efforts were shot down, they did get the ball rolling and by 1999 we saw language added to the the Veterans’ Millennium Health Care Act , thanks to the American Chiropractic Association (ACA) and the Association of Chiropractic Colleges (ACC), that would establish chiropractic’s role in the VA. The law was signed by President Clinton and took effect in January of 2000. The law specifically stated that the VA had 120 days to consult with the chiropractic profession in order to establish a policy for the VA regarding the chiropractic treatment of veterans. Apparently the VA didn’t need much input from the chiropractic profession, aside from their one day contact in February — because by May, in compliance with the law, they produced their “new and improved” chiropractic policy — which, to put it lightly, was a “slap in the face.” The policy indicated that the VA medical centers and clinics “may” offer chiropractic spinal manipulative therapy. It utilized none of the recommendations proposed by the chiropractic profession and, as the ACC stated, “merely dusted off it’s existing ‘referral only’ approach.” In September of that year, the House’s Veterans’ Affairs Committee met to make amendments to the Veterans’ Millennium Health Care Act. No mention was made of chiropractic and the issue was “put on hold” until the next year.
The next month, however, (October 2000) the ACA, ICA, and the ACC took the Department of Veterans’ Affairs to task by testifying before the House Committee on Veterans’ Affairs Subcommittee on Health. Dr. Rick McMichael, on behalf of the ACA, testified, “It is clear that the current VA bureaucracy is quite satisfied with merely having issued a so-called chiropractic ‘policy’— and now that the policy has been issued, they could care little whether the policy is appropriate or ensures adequate access to chiropractic care. Certainly, no substantive activity is currently taking place within the VA to encourage the use of chiropractic care. The bureaucracy’s contentment with their chiropractic policy most likely stems from the fact that they know, or suspect, that their policy will probably prove both inconsequential and ineffective — and as such, will have no significant impact in the way they conduct business today.”
The VA had a chance to speak as well. Their testimony dwelled a lot on what they considered to be a lack of conclusive research to back up chiropractic — which certainly makes my mouth drop. There has been nothing but research to back up what we do. The ACC reminded the Committee that even they [the Committee] have gone on record citing the 1997 Agency for Health Care Policy Research study which stated: “There is as much or more evidence for the effectiveness of spinal manipulation as for other non-surgical treatments for back pain”, and a New England Journal of Medicine report that said that the effectiveness of spinal manipulation for certain types of acute pain maladies is no longer in dispute. The ACA and ACC also pointed out in their written report to the VA that “since only 15% of all medical procedures have been documented by research, and only 1% have been shown to have any scientific value, the research that has led to the high ranking of chiropractic intervention takes on even greater significance.” Incidentally, I wonder if the medical doctor that was representing the VA that day, was a reader of VA’s own quarterly Journal of Rehabilitation Research and Development. Three years previous it published its first ever article on chiropractic entitled the “Use of Chiropractic Manipulation in Lumbar Rehabilitation.” The paper was a thorough review, including not only the scientific literature supporting chiropractic care, but solidly presenting the rationales for using chiropractic for low back pain rehabilitation in the VA population. Somehow, I doubt this one made it to his desk.
The doctor representing the VA also indicated that the VA would not be hiring chiropractors any time soon because their databases up to that point had not tracked any of the chiropractic services, albeit limited, that they had provided to date. [Must have been a Y2K thing]. Given more time, he testified, “they would be able to implement the policy and to gain experience in the provision of chiropractic care before making assessments about our policy or the level of chiropractic services that veterans need.”
The political goo thickened with not-so friendly written testimonies from chiropractic’s historical archenemies. The American Medical Association stated that “expanding current statutory authority regarding the role of chiropractic services could lead to a substantial decline in the quality of health care provided to VA patients.” The American Physical Therapy Association (APTA) added their two cents by commenting that VA beneficiaries “may not be appropriate candidates for spinal manipulation given that they are largely a geriatric population.” And finally, the American Osteopathic Association stated in a press release, that expanding chiropractor’s scope of practice within the VA [which would allow patients to see chiropractors without a referral] would “prevent patients from receiving the quality of care that they expect and deserve.”
Boy, we sure do have a lot of friends! Good thing our patients like us.
Well, suffice it to say, the chiropractors countered with some pretty compelling testimony, laying out a strong case for full inclusion of chiropractic in the VA health care system. I’d encourage you to view the testimony yourself at http://www.veterans.house.gov/hearings/schedule106/oct00/10-3-00/witness.htm.
But perhaps the most critical words of the day were directed at the Department of Veteran Affairs (VA) from the subcommittee chairman himself, Rep. Cliff Stearns (R-FL). “Congress, as early as 1978, authorized VA to provide chiropractic services to eligible veterans. But over the period of its existence, VA has never employed its first chiropractor as a VA staff practitioner in this professional field; has never developed, without prodding from Congress, any meaningful policy on chiropractic care; and until this hearing, has never had to defend its decisions to severely restrict or deny chiropractic care to veterans. In this member’s opinion,” Stearns continued, “if a health care service is licensed and fully legitimate in all 50 states and abroad, if millions of Americans are willingly paying for this service every day, if health insurers – and even the federal Medicare program – approve reimbursements for the service as a routine activity of doing business. . . then VA needs to better articulate why VA seems to deny these services to eligible veterans.” He later followed up with a letter to the VA’s Health Department Under Secretary. In the last paragraph of his letter he commented, “Chiropractic is a legitimate form of therapy that many thousands of veterans have been paying out of their own pockets to obtain. For veterans who choose VA as their caregiver – and based on what we learned at our hearing about current VA policy – we cannot defend VA’s continued restrictive use of this professional service.”
One year later, Representative Christopher Smith (R-NJ), the now acting subcommittee chairman, proved the hearing wasn’t a fleeting memory when he “walked the walk” that Stearns had talked and proposed legislation that mandated the inclusion of chiropractic benefits into the Department of Veterans’ Affairs. The subcommittee passed the legislation with an overwhelming 30 to 1 vote. Shortly thereafter, the legislation became a bill and was added as Title II of the “Disabled Veterans Service Dog and Health Care Improvement Act of 2001.” To our complete surprise, the House of Representatives passed the bill — by a voice vote nonetheless!
Not giving up, the American Physical Therapy Association quipped up again and told Congress “APTA fears these programs [for veterans], and other services, will be compromised unless all provisions relating to chiropractic services are stricken from [the House Bill].” I don’t think the Leaders of the House and Senate Veterans’ Affairs committees were listening anymore as they later met and reached an agreement on the details of the proposed chiropractic benefit they intended to incorporate into the Department of Veterans’ Affairs health care system. After the final agreement was reached, the U.S. House of Representatives quickly moved to incorporate the agreed-to legislative provisions into a new bill that was voted on and approved by the full House of Representatives the next evening. Unfortunately, I think the service dogs lost out.
On to the Senate it went, where it was unanimously passed without amendment.
The final step was the President’s desk, where on January 23, 2002, George W. Bush put pen to paper and signed the Department of Veterans’ Affairs Health Care Programs Enhancement Act of 2001 into law. [Release the fireworks!]
So what can veterans (who are enrolled in the system of patient enrollment under section 1705 of title 38, United States Code) expect with this new law? (1) An immediate phase-in of the program. (2) Designation of at least one VA medical center in each geographic service area of the Veterans’ Health Administration to provide chiropractic services. The designated sites will be medical centers and clinics located in urban and rural areas. (3) Scope of chiropractic services that “shall include a variety of chiropractic care and services for neuromusculoskeletal conditions, including subluxation complex.” (4) Dissemination of educational materials on chiropractic to primary care teams “for the purpose of familiarizing such providers with the benefits of chiropractic care and services.” And (5) establishment of a chiropractic advisory committee that will advise the Secretary on protocols governing referral to doctors of chiropractic, direct access to chiropractic care, scope of chiropractic, and other issues.
Well, there you have it. Our well deserving veterans now finally have the option of seeing a chiropractor, and they don’t need to ask permission — something that many of us non-veterans are starting to take for granted. You would think that those who have fought to maintain the freedoms we enjoy in this country could have been granted some of their own a little earlier on. I’m just glad the chiropractic profession didn’t back down. Our task now is to ensure that the VA moves forward to implement the new law. Maybe we can find a use for those service dogs after all.