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Dynamic Chiropractic – January 29, 1996, Vol. 14, Issue 03

ACA Response to Cianciulli Article

By Garrett Cuneo, HCD(hc),FICC(hc)
I read with great disappointment Dr. Arnold Cianciulli's article in the December 18 issue of Dynamic Chiropractic where, among other things, he criticized ACA's recent efforts to win expanded access to chiropractic services under Medicare.

My connection with Dr. Cianciulli goes back at least 12 years, during seven of which he served as a member of ACA's Board of Governors. He is sometimes controversial, but is a fighter committed to this profession. And while he is someone I respect, in this instance, Dr. Cianciulli is dead wrong.

Let me deal with one issue right from the very beginning. The ACA worked very hard to introduce the Crane amendment, which passed the House Ways & Means Committee. For those that have developed an understanding of politics on a state level, just getting an amendment introduced into the US Congress is a major accomplishment. The Crane amendment would have expanded our physician status under Medicare.

The Crane amendment, while not achieving the parity on reimbursement that we were striving for, would have represented significant progress toward our goal of "leveling the Medicare playing field" for DCs and their patients. Among other things, the amendment would have:


  • granted DCs the same status as "physicians," in terms of professional recognition, as MDs and DOs. Under existing Medicare law, DCs are "physicians" for purposes of "manual manipulation of the spine."


  • allowed DCs to order diagnostic tests, including x-rays, and permitted diagnostic facilities to be reimbursed on the order of a DC. This would have increased patient access to chiropractic care by eliminating current ordering prohibitions.


  • allowed DCs to be reimbursed for the "technical component" of x-rays that were ordered and taken in their offices;


  • erased a major obstacle to DCs' participation in Medicare HMOs by granting them full physician recognition to "read" and "interpret" x-rays, a problem that currently obstructs participation in Medicare HMOs;


  • required DCs to be recognized as full-fledged physicians for providing "opinion evidence" about patients' conditions. This was expected to have similar spin-off effects in federal workers' compensation and student loan programs.


  • struck down current limitations that pose barriers to DCs gaining privileges at Medicare accredited hospitals. Some hospitals say they'll lose accreditation if they allow DCs to do more than Medicare allows.


  • omitted offensive language on Medicare claims forms that belittles DCs by telling patients that they are not "physicians" for any service other than spinal manipulation;


  • improved the profession's standing in many private pay systems by broadening the definition of recognized chiropractic services. Since Medicare's fee schedule, along with its standards and definitions, are being adopted by the private sector at a rapid pace, this could have had long-term implications.

Now it's no secret that the battle over Medicare reform and our attempts for broad inclusion in it have been long and difficult. So, let me present you with the key facts concerning our efforts: what we successfully accomplished, what we failed to do, and how others involved in the process, including the AMA, fared in the same instances. Then you can decide about the quality of our efforts and whether we have been prudent in using our resources. You be the judge.

December of 1994 saw the collapse of the Clinton national health reform initiative and the election of a new GOP-controlled Congress. That's when representatives of ACA's Legislative Commission, ACA-PAC and the Board of Governors gathered in Washington to develop strategy and to map our a legislative and regulatory game plan for 1995 and the new 104th Congress.

At that strategy session, a number of key issues were discussed, including a detailed review of historic and current concerns regarding the profession's inclusion in the federal Medicare program. ACA's government relations staff and political consultants predicted that Medicare and Medicaid reform, under the new Republican-controlled Congress, would emerge as a major issue in 1995.

That prediction, which proved accurate, was based on the key assumption that the GOP would advance a dual agenda of trying to balance the federal budget, while at the same time trying to enact a major tax cut. An economic analysis, prepared by our consultants, provided an inescapable conclusion: Left untouched, current Medicare and Medicaid expenditures would grow to 42 percent of the federal budget by the year 2002. This would make it impossible for them to achieve their goals without instituting a massive reduction (on the order of $200+ billion dollars) in the anticipated growth in spending for Medicare and Medicaid. Accordingly, a political climate would develop which would be dominated by the issue of program reductions, making the likelihood of any expansion, for chiropractic or any other service, extremely unlikely.

There are those who would suggest that faced with this sobering assessment the ACA should have simply up and walked away from the Medicare issue a year ago. After all, we had the perfect excuse to do so, and evidently in the eyes of some of our critics that would have been the easy and expedient thing for us to have done. But to have done so would have been nothing less than an abandonment of our duties and responsibilities to our membership, not to mention the profession itself.

Since when is it O.K. for us to give up fighting for what we know is just and right, simply because the odds of winning are against us? We not only took on the Medicare issue, we did so seeking that chiropractic be brought into parity on a full scope of practice level.

Despite the uphill nature of the fight the ACA made considerable progress with the "full scope" approach. The first action on Medicare reform took place in the U.S. Senate where we recruited Senator Orrin Hatch (R-Utah) to offer a "full scope" amendment in the Senate Finance Committee. Sensitive to the "budget cutting" atmosphere prevailing in Congress, we attached a "budget neutrality" provision, developed by private actuaries to the original Hatch proposal. When the Hatch amendment was considered in committee the Congressional Budget Office (CBO) refused to recognize the budget neutrality provision as workable, and indicated to the committee that the Hatch amendment would have significant budgetary costs.

Few are aware that under the terms of a "unanimous consent" agreement, the Senate Finance Committee agreed to accept the "full scope" Hatch amendment, provided the CBO could be persuaded to reexamine their position and "score" (calculate) the amendment as having a favorable budget impact. Senator Hatch and the ACA were unable to accomplish this in the 72 hours specified by the committee.

The next action took place in the U.S. House of Representatives. There, earlier in the year, the ACA recruited Congressman Phil Crane (R-Ill.), senior member of the House Ways & Means Committee, to support ACA's "full scope" proposal. For the record, Crane was also sponsor of H.R. 997, a more limited free standing bill which would have provided reimbursement for x-rays and physical exams, sponsored by the International Chiropractors Association (ICA), but also supported by the ACA as an alternative option.

Prior to consideration of Medicare reform by the House Ways & Means Committee, Congressman Crane submitted ACA's proposal and various iterations of it to the CBO for analysis. As late as the final day of consideration of Medicare reform legislation by the committee, Congressman Crane was unable to procure a timely or favorable response from CBO on any of the proposals put forth for CBO scoring, including ACA's "full scope" proposal and H.R. 997.

Despite the fact that it did not have an official CBO score, the Crane amendment passed the committee overwhelmingly on a voice vote. This was no small task, as the Republican leadership had issued strict marching-orders that no amendment was to be offered or passed which had not been scored favorably. (Immediately following passage of the Crane amendment, Congressman Bill Thomas (R-California), chairman of the Health Subcommittee of Ways and Means was overheard commenting that the vote was "unbelievable...!")

Passage of the Crane amendment was significant, not only because of its content, but inclusion of the amendment in the final House-passed legislation. Theoretically, this would have provided our congressional supporters, including Crane, with an opportunity to negotiate an expansion of the provision during the House-Senate conference on the final bill, a consideration perhaps overlooked by uninformed critics of the Crane effort.

Subsequent to its passage, the CBO scored the Crane amendment as costing the federal treasury $l.7 billion over a seven-year period. (ACA's private actuaries estimated the cost at no more than $15-31 million per year.) It was on this basis that the Crane amendment was deleted from the final bill that went to the House of Representatives for a vote.

About the time the Crane provision was dropped, several national media outlets reported that a "deal" had been struck between the AMA and House republican leaders. As a result, there has been considerable discussion within the profession, and Dr. Cianciulli alludes to it, that AMA won a considerable victory in the Medicare bill. Let's take a closer look.

The seven-year Medicare plan sent to the President contains $21.8 billion in reductions in the growth of payments for all Medicare Part B providers, including medical physicians. And what of the AMA's great deal? It amounted to little more than a slight adjustment to the "conversion factor" for calculating Medicare payments. (A reduction in the level of planned cuts of less than l.5 percent -- big whopping deal!)

And on top of that, if the legislation doesn't save the money the GOP says it will, it contains a mechanism that would require almost $37 billion in additional reductions from medical physicians and other providers! The Congressional Budget Office (CBO) report, specifically shows these reductions.

And that's not all of the cuts. Hospitals, clinical labs, almost every industry in health care is experiencing severe cuts.

But let me turn back to our efforts in the House of Representatives to win a specific chiropractic expansion in Medicare. Few realize that the Crane amendment wasn't the only pre-chiropractic provision the ACA had in the works. The ACA worked closely with a group of moderate-conservative Democrats, known as the "blue dog" coalition, which produced the only alternative bill to the GOP-back plan.

The ACA won their agreement to include our original "full scope" provision in their bill! The night before the scheduled introduction of their bill, the CBO completed a last-minute "score" of their overall proposal and as part of that exercise calculated the ACA amendment as costing $8-9 billion over a seven-year period. The new CBO score erased much of the anticipated savings in the bill, and the blue dogs were forced to drop our provision. The blue dog bill was later defeated on the floor of the House.

As anyone can see from the verifiable facts outlined above, the ACA achieved in a terribly difficult environment considerable tactical success in its efforts, only to be stymied in every instance by the budget calculations of the CBO.

Now there are those who may wish to somehow blame the ACA for the actions of the CBO. This is plainly absurd and reflects a lack of knowledge regarding the national legislative process. It also ignores the fact that a variety of amendments have been prepared by ACA and proposed by CBO in an effort to devise a proposal that would not have a significant, negative budgetary impact. And what the critics don't tell you (or don't know) is the fact that the chiropractic profession is far from alone in having problems with the CBO. You should know that while CBO scoring has merely thwarted our efforts to expand chiropractic services, for other industries CBO actions have been devastating and will result in budget hits of billions of dollars!

I could go on, but that's the basic story. It is not a lie or a hoax, but the reality of the political system. Frankly, if we were as significant a political force 10 years ago as we are today, we would be in the same position as the American Medical Association: trying to explain to their members why their benefits are going to be cut again, instead of trying to explain why our efforts to increase our benefits weren't successful. But it's not 10 years ago, and today is a different political environment.

Garrett F. Cuneo
Executive Vice President
American Chiropractic Association

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