The decentralization of the federal government continues; the real fight for professional parity and progress will be in the state house, not Washington, D.C. Membership and participation in your state association, in the coming several years, will be more important than any other type of professional activity.
Health Care Issues Vs. Other Issues
As always, we can expect 1992 state legislators to funnel their energies toward several special "trendy" areas of health care (more on this in a bit). However, health care issues may not be the prime focus of our state-elected officials. Our declining transportation network and unstable economic conditions may monopolize their time. Issues of improving education and the needs for housing are certainly timely topics guaranteed to take much of the time of our legislators. There may even be a preoccupation with the emotionally charged issues of abortion, "death with dignity," and reducing the size of state government. Legislators can hardly be expected to nurture chiropractic concerns when faced with the emotive and media-generated confrontations of hot topics. However, the health care industry is the single largest service sector of our national economy and certainly ranks in at least the top five in every state. Over 1.5 billion dollars a day are spent on health care. This is about 15 percent of our total gross national product (GNP). Therefore, expect a number of key health care priority areas to develop in our states.
Where Will the Action Be in 1992
State legislatures will be dealing with areas of priority in health care that chiropractic state associations may seek to influence. For the chiropractic profession, the new proposals concerning "minimum benefits" or "bare bones" insurance are the most frightening. Essentially, these types of legislation create a new insurance package directed toward small employers. This new package offers only basic coverage and need not conform to current state insurance equality laws which require the offering of a number of mandated benefits (such as chiropractic, podiatry, etc.). Quite simply, minimum benefits laws would circumvent insurance equality laws for which the chiropractic profession worked so hard.
Although bare bones laws are limited in their direction (small employers and those currently uninsured), there is little doubt they are capable of having a major impact on chiropractic utilization. Some fear a total dismantling of insurance equality and a case of "the camel's nose in the tent." Currently eight states have already passed bare bones laws, and at least another 12-15 are expected to have proposals introduced in 1992. Part of the Congress of Chiropractic State Associations annual conference in Orlando, Florida, November 8-10, 1991, is expected to focus on the impact of minimum benefits laws, and what state associations can do. This is an issue that will require chiropractic state associations to demonstrate great resourcefulness, tenacity, creativity, and fund raising capabilities.
Associated with the above topic is the overall issue of uncompensated care. Securing access to health care services for poor and uninsured citizens will be a major health focus for state legislatures. How indigent care will be financed is the key question. Also, legislatures must grapple with the concept of what level of care should be provided, and by whom. Can the chiropractic profession, through its state associations, demonstrate its necessary role as a direct provider of services to the poor? Have we "written off" treating the uninsured and indigent? Does your state association have data or information on DCs who provide gratis care or work in the ghetto or rural poverty regions of your state? Does the legislature perceive chiropractic as a "middle-class only" health care service?
The health care needs of the aged, especially adequate nursing home and long term care is another priority. In some states, especially with large populations of retirees, major health care legislation can be expected to relate to their needs and desires. The chiropractic profession has done very little in implementing a policy on the concerns of the aged. Are we doing research that demonstrates that chiropractic treatment alleviates the discomfort and health problems of an aging population?
Most importantly for chiropractic are bills which limit, add, qualify, or eliminate mandated health care benefits; such bills are sure to appear in most state houses. HMOs, businesses, insurance companies, and the overall established health care industry can be expected to strongly resist any new mandated benefits to their coverage. This should encourage coalitions of podiatrists, vision care specialists, chiropractors, social workers, dentists, physician assistants, psychologists, and others to join forces.
Cost containment and "freedom of choice" debates will be heard in the legislative chambers. Labor unions may become one of the major players as they attempt to resist any coverage reductions to their members. A dozen states have already created powerful and highly visible "expert panels" and blue ribbon groups to study and even recommend elimination of current mandates. Did you know that doctors of chiropractic are number one on the list of provider mandates? As of 1990, 39 states mandated chiropractic providers, while only 26 did the same for podiatrists and only 6 for physical therapists. Although mandated benefits account for eight to ten percent of the total medical benefits paid, those providers who are not diligent may find their coverage removed.
Legislative proposals will scrutinize equality laws and recommend which mandated "benefits" are too costly, duplicative, and unnecessary. Furthermore, they may even recommend that specific benefits (like chiropractic or vision care) be offered, but only as an option to insurers, not as a requirement. One can only imagine the social and financial disaster this type of recommendation would have on a minority provider profession (such as chiropractic). It is legally possible to dismantle current insurance equality legislation, especially under the guise of cost-containment. State associations must prepare for this likely possibility.
State legislators will not escape sensitive and technical discussions on the AIDS crisis. Although the AIDS issue often gets caught up in civil rights and employee rights arguments, most AIDS (and drug/alcohol abuse) legislation is usually heard in health care related committees. AIDS legislation, especially in those states where the AIDS epidemic is most noticeable (such as New York and California), it may, in fact, become the number one health care item dealt with by legislatures. The epidemic shows no signs of abating. Does the chiropractic profession have a role to play on issues such as AIDS? Moreover, "death with dignity" and "right to die" legislative reforms are expected to create enormous emotional hearings and consume our elected official's energies. As a concerned health care profession, should state chiropractic associations have a formal position on sensitive topics such as these?
Finally, the 1980s were the "good times" for health care. The National Governors' Association recently released a study which revealed that 34 out of 50 states will have a budget deficit by 1992, which means that budget shortfalls will create new directions in financing health care. These budget pressures are further exasperated by new Medicaid coverage required by the federal government. Since most state governments are required by their own constitutions to balance their budgets, and state governments are frequently rejecting the option of raising taxes, only one thing can happen -- the programs and services of the "good times" (the 1980s) must be reduced.
Along with this eventual reduction is the growing state-level interest in massive health system reform of the entire delivery system. Legislators in Washington state, California, and Florida have already received serious proposals that would "nationalize" the health delivery system within their states. The general exclusion of chiropractic care within HMOs indicates that state and/or federal efforts to "nationalize" care may very well exclude or make "optional" chiropractic care as well. Each state association has the challenge to rapidly prepare for this potential upheaval in the health care delivery system.
Although national research efforts are already financed and under way, we need many more state specific studies as to chiropractic's overall efficiency, patient demography, geographic distribution, and most importantly, cost effectiveness. All legislators will become "cost-conscious," and those delivery systems which provide effective treatment outcomes and are cost efficient, will thrive. We cannot rely on previous workers' compensation studies; we need new studies and tactics. Lobbyist for state associations know that many individual state legislators and their staff usually dismiss "out-of-state" research and materials as "not pertinent to our state."
What Does It Take to Win?
Well-run and well-financed state chiropractic associations, administered by well-paid and experienced professional staff, are the ones who will survive and prosper in 1992. New emphasis on state government and its further encroachment in health care reimbursement issues require astute associations. State association leaders can and should expect more of their dues monies sent to national associations to be directly "returned." It is fully predictable that national associations will actually become more involved in direct lobbying at the state level as they are pressured to "serve" their local constituencies. Associations must share information with brother associations in other states.
Individual doctors need to be dues paying members in their state association, at the very least. Staff salaries and benefits should reflect the difficult responsibilities and stress in association work. Chiropractic associations with the most stable paid management are the ones to gain success. All state associations should join and support the Congress of Chiropractic State Associations.
Applied, area-specific, economic research needs to be enjoined in every state. The future is now, 1992 is at hand -- business as usual will equal "out of business."
Robert H. Davis
Congress of Chiropractic State Associations