John Falardeau is the senior vice president for government relations for the American Chiropractic Association (ACA) and is responsible for monitoring legislation, formulating policy and carrying out the overall political strategy for the organization.
From your perspective as a non-chiropractor who works tirelessly to help chiropractors and their patients to advance their cause in Washington, D.C., what would you say have been the major positive achievements in recent years? I can tell you this: Even in my relatively short time with this group, eight years, without question what I've seen is a more universal acceptance on Capitol Hill of the services provided by doctors of chiropractic. Especially during health care reform, in 2009 and 2010, we visited probably over 200 offices [of senators and members of Congress], and in not one of those offices was there any pushback or any indication that what we did was not important. Many of them, in fact, if they weren't chiropractic patients themselves, they had a family member or a friend who was. And they had nothing but glowing things to say about what you folks do. That, to me, is what I have seen. I have seen the acceptance grow and it is continuing to grow.
What are the largest immediate and long-term challenges the profession faces in the political and policy realms? One of the challenges that we're going to be facing in a couple of years is the loss of one of our biggest advocates on Capitol Hill, Senator Tom Harkin of Iowa. He is not going to run for re-election in 2014. That challenge of political turnover is always on our minds. Last year at this time, it was uncertain if Senator Orrin Hatch from Utah, another of our biggest advocates, was going to win re-election. He was in a very tough primary fight, which he ultimately won. But that type of turnover is something we're always concerned with.
It takes time for a congressional ally of chiropractors to rise through the ranks to achieve the positions of power, which in Senator Harkin's case is the chairmanship of the Senate Health, Education, Labor and Pensions Committee. When someone like that retires, it's a major loss. I'm also aware that when you mention Senators Hatch and Harkin, one is a Republican and the other a Democrat. So chiropractors have, over time, cultivated support on both sides of the aisle. It's not a partisan issue. You're right, it's not partisan by any means. When health reform was being legislated, both houses were controlled by Democrats, so we had to work a little more closely with Democrats than Republicans, just based on the numbers. It's also very important to remember that our biggest advocates are patients, who understand first-hand what chiropractors have to offer and can convey this to their representatives.
The Importance of Participation
Would you say it's important for chiropractors and their patients to send letters and e-mails to Washington; that this really matters? Oh, yes. It really matters, especially when bills are before the Congress, because dealing with issues there is in many ways a numbers game. The number of calls, letters and e-mail messages are counted by congressional offices. When one of our bills is being considered, we need to build up the numbers. Because when a legislative assistant goes in to the member of Congress and says, "Congressman, I received 75 e-mails on this chiropractic bill yesterday," that really makes a difference. Numbers make a difference, because all of those people are voters.
Let's use health care reform as an example. At this point, it's in the implementation stage, where the executive branch is developing rules and regulations which will be used in implementing the law. When proposed rules are put out, we generally don't call the rank and file to comment on them. In this case, at this stage with the Administration, our input needs to reflect quality rather than quantity. The people in administrative roles are not up for re-election, so it's not so much a numbers game as it is when we're trying to get a law passed.
So, what we have been doing with the proposed rules is that we've sent templates to state associations, through the Chiropractic Summit, so that they can weigh in. That's more of the "grass tops" lobbying rather than grassroots lobbying. You just have to find that balance.
The Critical Role of Research
When you're talking to federal regulators, what tools are most helpful to you? For example, how important is it for you to have strong research supporting the effectiveness or cost-effectiveness of chiropractic care? That's huge, very huge. The holy trinity, if you will, of health care reform is cost, access and quality. These days, cost is a big segment of that. When I can exhibit cost-effectiveness through research, that resonates. Eyebrows rise for that more than for the other two. It's very important. The research that's being done is tremendous and it helps us. We have good patient satisfaction, which is part of quality, and we have good access with most insurance plans, including direct access through Medicare. But cost-effectiveness is a key driver in policy here in Washington.
There are articles every day about health care costs, and you very rarely see the cost of anything go down. So it's very important that we be able to talk cost-effectiveness.
There was a cost-effectiveness research review performed by a non-chiropractor that was published in the European Spine Journal in 2011. [Lin CW, Haas M, Maher CG, Machado LA, van Tulder MW. Cost-effectiveness of guideline-endorsed treatments for low back pain: a systematic review. Eur Spine J. Jul 2011;20(7):1024-1038.] Among their conclusions was that for subacute and chronic low back pain (which is tremendously costly to society), spinal manipulation has been shown to be cost-effective. On the other hand, for medications, the researchers said they could not find any evidence of cost-effectiveness. The studies have apparently never been done. Which means that for chronic low back pain, there is stronger evidence of cost-effectiveness for the main method used by chiropractors than for the main method used by MDs. And yet insurance companies will often just wave claims through the gate if they involve prescriptions for painkillers. Do you feel that the bias behind that approach is gradually being worn away by evidence of chiropractic cost-effectiveness? It's like trying to turn an aircraft carrier on a dime. I spent four years on an aircraft carrier and I know it's hard to do. You're absolutely right and it's essential that we get this message out there more and more. F4CP [the Foundation for Chiropractic Progress] does a wonderful job at that. During the week of this year's National Chiropractic Legislative Conference, they ran ads in major Hill publications and in The Wall Street Journal. That helps tremendously.
But I wish they could have done it, I wish we could have done it, for weeks afterwards. This is a campaign to change minds. It needs to be sustained, so that people hear the message over and over again. Think of the "Just Say No" campaign about drugs, which some of us older guys can remember, or Michelle Obama's "Get Up and Move" campaign. It's not a one-week campaign; she's been doing it since the Obama Administration came into office. I wish we had the resources within this profession to mount a campaign that would last for a long time.
Back in the Clinton health care reform effort of 1993-1994, I've seen some of what the ACA office did, and it was really good. They were able to run commercials on "The Larry King Show" on CNN. At that time, cable advertising was relatively cheap. But now it's gotten to the point where it's almost as much, or even more, than network advertising. I wish the profession could fund that kind of sustained campaign, but those kinds of resources are just not in our coffers right now. I would like someday to see the research talked about repeatedly, because that's what it's going to take.
Another key challenge we face is that virtually anything that's done legislatively on Capitol Hill has to go through the Congressional Budget Office (CBO), which has many flaws. They're not set up to investigate or determine savings. For example, in the VA [Veterans Administration], for the past several Congresses we've had a bill to further integrate chiropractors in the VA system. And there have been Congressional Budget Office estimates of what it would take to do that.
Congressional Budget Office Considers Only Costs, Not Savings
CBO is looking at what would be paid for those services, rather than including in their calculations the services that would be displaced, such as medication costs and MD visits? Exactly. So, if the bill calls for having doctors of chiropractic in 120 more facilities in the VA, the only thing they do is take what the average doctor of chiropractic makes in the VA, and multiply it by 120. That's all they do. So when Congress asks CBO, "What is this going to cost?" that's the only thing they have to go on.
During health care reform, there were several instances not related to chiropractic, where Speaker Nancy Pelosi came down hard on CBO, saying how can you claim it's going to cost this amount, this is awful, your numbers are wrong. But then there were other points where she was praising CBO.
We've seen the same thing under Speaker John Boehner, just on different issues. CBO is non-partisan, not the servant of the party in the majority. Yes. The current cost-estimation arm of the U.S. Congress is flawed. The back surgeries that are saved if more veterans go to doctors of chiropractic are not considered in CBO computations.
Dr. Daniel Redwood, the interviewer, is a professor at Cleveland Chiropractic College – Kansas City. He is the editor-in-chief of Health Insights Today, associate editor of Topics in Integrative Healthcare, and serves on the editorial board of the Journal of the American Chiropractic Association. Visit Dr. Redwood's website and health-policy blog at www.redwoodhealthspeak.com.
Part 2 of this interview with John Falardeau is scheduled to run in the Aug. 1, 2013 issue of DC. The entire interview appeared originally in the June 2013 issue of Health Insights Today, a newsletter published by Cleveland Chiropractic College – Kansas City. It is reprinted with permission from the college.