After years of wrangling, dozens of lawsuits and a Supreme Court decision, the re-election of President Obama sealed the fate of the Patient Protection and Affordable Care Act: the law would stand.
When the bulk of the law takes effect in 2014, some 30 million uninsured Americans will receive health coverage; insurers will no longer be able to deny coverage to those already sick; and new measures will try to stop the skyrocketing cost of health care.Supporters hail the law as the greatest expansion of the social compact since the Medicare/Medicaid expansion of the 1960s.
But for naturopathic doctors (NDs) seeking to expand access to their medicine, the survival of health care reform marks not the completion of their work, but the beginning.
The law contains provisions that could help put naturopathy and other forms of complementary, alternative and integrative medicine (CAM) on more equal footing with conventional medicine, but much depends on how state and federal regulators interpret the intentions of Congress. That makes the next 12 months a crucial time for natural health providers to ensure their voice is heard.
"If the law is implemented as intended, NDs in 16 states will immediately be covered by insurance," says Lorilee Schoenbeck, ND, a Vermont practitioner and board member of the American Association of Naturopathic Physicians (AANP). "That will be the largest single event to impact our profession in years. And it's a change our nation needs. Our health care system needs prevention-oriented, low-cost primary care that's effective for chronic illness. There's no profession that does that better than us."
The greatest potential change lies in a nondiscrimination clause that could help provide insurance coverage for naturopathic visits in licensed states. Many other parts of the law create opportunities for CAM providers to show their care brings about healthier patients.
Here is an overview of what the Affordable Care Act means for naturopathic medicine and what's at stake in how the law is implemented. (See also our story on what the law means for acupuncture, nutrition, midwifery and other CAM fields.)
Naturopathic policy-watchers rejoiced when Sen. Tom Harkin, D-Iowa, inserted into the law a section stating that insurers "shall not discriminate" against care providers acting "within the scope of that provider's license." (See the full text of section 2706.)
Sixteen states and the District of Columbia offer licensure to naturopathic doctors. Harkin's clause appears to suggest that if insurers cover a health condition, they must pay any providers who are licensed to treat that condition. If the insurer covers a service provided by medical doctors (MDs) or osteopaths, for example, it must also cover that service when provided by another legal provider, such as NDs, acupuncturists or chiropractors.
"In the short run, this is the single most important part of the law for NDs," says Jud Richland, chief executive officer of AANP. "If it's implemented in the way its drafters intended, it will be really significant."
The clause still allows insurers to pay providers at different rates and does not apply to Medicare and Medicaid. But it could help make naturopathic care affordable for millions of new patients.
There's no guarantee, however, that state and federal regulators will interpret the clause that way as they implement the complex law. Some state agencies have indicated they are not aware of the nondiscrimination language or do not believe it mandates equal coverage. The federal government directed states to spell out exactly what health services insurers should cover under 10 broad "essential health benefits" categories. It's not clear whether naturopathic care must be mentioned in benefits packages to be covered.
"In my opinion, they don't need to mention us specifically," says Dr. Schoenbeck. "Naturopaths are not a service — we are a provider type that provides the same services already covered."
She points out that NDs use many of the same billing codes as MDs for routine visits. "As a profession, we have to explain this to regulators or they're not going to know it," she says. "We at AANP are educating our state directors in the field to take action."
One promising sign: The nondiscrimination language resembles Washington state's 1995 "every category of provider" law, which requires private commercial insurers to cover licensed CAM providers. Sorting out the state law took several years and legal victories over insurers seeking to block it, but Washington is now a leader in access to natural health care, says Deborah Senn, the state's insurance commissioner from 1993 through 2001.
AANP has hired Senn to help make its case to federal regulators. "The change has been very popular in Washington because it's about consumer choice," says Senn. "Implementation was very successful here, and we expect it will be successful nationwide."
Another opportunity for NDs lies in the law's focus on "patient-centered medical homes," a team-care approach to coordinating doctors and specialists around a patient's needs. The law specifically states (in section 3502) that care teams may include licensed CAM practitioners.
Medical homes are a method for helping patients make decisions, find enough time to speak with doctors, avoid unnecessary tests and keep up with preventive care (see an explanatory video). Seattle's Group Health Cooperative already uses medical homes to provide preventive screenings and same-day visits with multiple doctors.
The goals of medical homes are well-aligned with naturopathic care, says Dr. Schoenbeck.
"The medical home model is very naturopathic in its concept," she says. "It puts the patient at the center of care. It allows patients to identify their own health goals. It helps them identify barriers to health, it's prevention-oriented, and it deals with chronic illness.
"They can be a great opportunity for naturopathic doctors."
Wellness and Prevention
Some of the law's most important provisions for natural health practitioners don't mention their professions by name. Instead, they focus on shifting the focus of U.S. health care from treating disease to promoting wellness through healthierlifestyles.
This goal surfaces in dozens of parts of the law, such as free screenings and vaccinations; expanded maternity and newborn care; and incentives for workplace weight-loss and smoking-cessation programs. Large health care facilities may take interest in hiring practitioners who can help patients eat better, exercise and reduce stress, says Alan Weil, executive director of the National Academy for State Health Policy.
"There's an emphasis not just on prevention but on improving population health and holding provider groups accountable for improving health," says Weil. "Those are certainly opportunities for CAM providers."
New "accountable care organizations," which pay care providers based on outcomes rather than the amount of service provided, could reward practitioners who use cost-effective natural approaches to avoid surgery and hospitalization. That could lead large health care companies to hire more wellness practitioners or make more referrals to them, according to Weil.
"As large health providers get organized, they could be looking for more and more of these professionals," says Weil. "There's a push in that direction, and it's quite a push."
The law also creates a new Patient-Centered Outcomes Research Institute (PCORI) to fund research that examines how treatments affect real patients (as opposed to lab subjects). The institute, which has already awarded $40 million, wants to compare different treatments, study outcomes over time and support innovative research models. Those goals align closely with whole-practice studies conducted by naturopathic researchers, says Michael Cronin, ND, president of AANP's board of directors and past president of Southwest College of Naturopathic Medicine.
"It's a new research model that is very complementary to the way naturopaths practice," says Dr. Cronin. "It measures not just one variable, but asks the question 'Is the whole patient interaction effective?' 'Did they get better?'”
PCORI has not yet awarded grants to naturopathic research, but it may become a source of funding, says Erica Oberg, ND (’03), MPH, a clinical researcher and clinic director at Bastyr University California. Through innovations such as involving patients in awarding funds and designing studies, PCORI could support research questions overlooked by pharmaceutical companies.
"Involving patients is significant," says Dr. Oberg. "A patient may not care about a minor difference in blood pressure, for example, but may care about side effects, how they feel when taking medication, or what it costs."
A New Game
With the main thrust of the law taking effect in less than a year, states are scrambling to define essential benefits, create online insurance marketplaces (or "exchanges"), and sort through everything else in the far-reaching law. That means natural medicine must act quickly to help regulators interpret key elements, says Dr. Oberg, who also directs Bastyr's Center for Health Policy and Leadership.
"It's an amazing opportunity for CAM providers, but a lot depends on the next 12 months," she says. "If we're not involved, we'll be ignored as a small discipline."
A petition on Whitehouse.gov calling on the Obama administration to include naturopathic doctors as primary care providers received 28,000 signatures, clearing the threshold for an official response from the administration.
Of course, other professions are active too. The American Medical Association last year signaled its opposition to the nondiscrimination clause in section 2706. Dr. Cronin of the AANP called for practicing NDs, students and naturopathic schools to work together in advocating for their profession.
"It's going to be a fight, and the more energy we bring to it with aligned strategy, the better," he says. "If we team up now, we've got a really good chance of achieving significant results."
He says successes now will lead to more openings as the law is updated.
"There will be refinements to the law along the way," says Dr. Cronin. "If NDs get involved and continue to prove effective, more opportunities will open up. If we can get a hit in the first inning, when we go into the second, third and fourth innings we'll be given more at bats. It's a new game."
Learn more about studying natural medicine at Bastyr University.