In 1787, a decade before he became the second president of the United States, John Adams wrote to members of the Constitutional Convention that the country he and others had helped to create should be "a nation of laws, not of men." Nearly 220 years later, the United States is indeed a nation of laws - many of which relate to the chiropractic profession.Between 1913, when the first chiropractic licensing act was passed in Kansas, and 1974, when the last licensing act was passed in Louisiana, thousands of bills concerning chiropractic were introduced, amended, tabled, vetoed, or signed into law; hundreds of similar pieces of legislation have gone through the same process between 1974 and the present day.
Each state's legislative session carries with it alternating emotions of hope and fear for doctors of chiropractic and the patients they treat. There is hope that a law will be passed that improves the profession's scope of practice or increases reimbursement rates for certain services; alongside that hope is the fear that a bill could be introduced to restrict chiropractic practice rights, or to allow another health care profession to perform many of the same procedures that once belonged solely to chiropractors.
As we go to press, more than 40 bills that could affect the practice of chiropractic have been introduced by various state legislatures. While space and time restrict Dynamic Chiropractic from providing an analysis of every bill that has been introduced, this article reviews nine of the more important pieces of legislation being considered. Future issues of DC will provide an update on the status of these bills as needed, and examine chiropractic laws being proposed in other states.
In Connecticut, legislators have introduced a handful of bills aimed at restoring a variety of optional services (including chiropractic), enhancing the state's Medicaid program, and ensuring that chiropractors receive equal compensation for their services. Among the bills currently being deliberated:
- Senate Bill 509 and House Bill 6126 would individually amend sections of the state's general statutes to require health insurance companies to reimburse doctors of chiropractic at the same rate as allopathic physicians, osteopaths, and other health care providers. SB 509 would also prohibit insurers and health care centers from imposing disparate deductibles based solely on a health care provider's license. HB 6126 would also mandate that health insurance policies may not limit or place conditions on the services rendered by a chiropractor (or on the reimbursement of those services) unless those limitations apply to all classes of physicians.
- Two other bills with apparently similar purposes (HB 6110 and SB 606) would amend existing law and restore coverage of several optional health care services available under Medicaid and state-administered general assistance programs. Chiropractic, along with podiatry, naturopathy and other forms of care, would be reinstated as "covered medical services" under those programs.
- HB 6943 would require the Commissioner of Social Services to amend the state's Medicaid plan. The bill would require that "Not later than October 1, 2005, the Commissioner of Social Services shall amend the Medicaid state plan to provide coverage under Medicaid for services provided by chiropractors, naturopaths, psychologists, podiatrists, physical therapists, occupational therapists, speech therapists and interpreter services for deaf and hearing impaired individuals while such persons receive medical treatment from a Medicaid provider."
In Georgia, companies that offer health benefits to their employees currently are required to include chiropractic services as a "mandated health benefit." Approximately one dozen such mandated health benefits exist in Georgia law, and cover a wide range of services for workers (and, in some instances, their children). A new bill making its way through the legislature would allow some employers to offer an alternative plan containing fewer benefits.
Senate Bill 174, introduced by Sen. Cecil Staton (R-Macon), would allow small businesses (those with 50 employees or fewer) the option of offering a "group alternative health benefit plan" that would contain a limited selection of state-mandated health benefits. Chiropractic care would not be included in the alternative health benefit plan.
The idea behind the bill, according to Sen. Staton, is to make it easier for employers to offer some form of health insurance to more employees, while reducing overall health insurance costs. "Many [businesses] are being forced to drop coverage because of mandates," he told the Atlanta Journal-Constitution. "This will provide coverage for those who can't afford Cadillac coverage."
Not all of Georgia's legislators share the same feelings for SB 174, however; in the same article, Sen. Seth Harp (R-Columbus) called the bill a "stinking dead horse."
House Bill 1001 is the state's two-year budget proposal, designed to appropriate money to carry on state government functions and make various distributions to schools and other political subdivisions. Included in the bill is language that would increase overall funding for Medicaid by 5 percent - but would also eliminate most chiropractic services for children under the age of 12.
Section 210, subsection (b)(2) of HB 1001 states: "A Medicaid recipient who is less than twelve (12) years of age is not eligible for chiropractic services under the Medicaid program unless a physician licensed under IC 25-22.5 determines that the service is medically necessary." In Indiana, only medical doctors and doctors of osteopathy are classified as "physicians." No definition of "medically necessary" is included in the text of the bill.
Another piece of legislation, Senate Bill 430, would allow physical therapists to perform "manual therapy" on patients, but would prohibit them from performing a "manual adjustment." Currently, only chiropractors, medical doctors and osteopathic physicians may "manually manipulate, manually adjust, or manually mobilize the spinal column or the vertebral column of an individual."
New language in SB 430 defines a manual adjustment as a manual or mechanical intervention that may have velocity, lever, amplitude, or recoil, and that: may carry a joint complex beyond normal range of motion; is applied without exceeding the boundaries of the joint complex's anatomical integrity; and is intended to result in the cavitation of a joint or "a reduction of a subluxation."
Senate Bill 5 would apply a series of sweeping changes to the state's workers' compensation system. Under the current system, workers injured in the course of their job are allowed to select any medical doctor or chiropractor on the state's approved doctor list who is willing to treat them. Provisions in SB 5 would change existing regulations by allowing for the formation of workers' compensation health care networks, while still giving workers the choice of seeing a chiropractor or medical doctor for treatment.
To participate in a network, a health care provider would need to apply to the Department of Workers' Compensation for certification. Existing health maintenance organizations and physician provider organizations could also apply for certification.
Injured employees would be allowed to choose a "treating doctor" for their injury from a list of all treating doctors contracted with the network in that worker's service area. Each network would be responsible for determining the specialty or specialties of doctors who could serve as treating doctors. In other words, in some networks, chiropractors would be considered treating doctors; in other networks, they would only be considered "specialists." Injured patients could see a specialist for care, but would be required to be referred to the specialist by the treating doctor.
Workers dissatisfied with their initial choice of doctor could select an alternate treating doctor, but would need to obtain authorization from the network to select any subsequent treating doctor. In addition, employees with a chronic, life-threatening injury or chronic pain could select a non-primary care physician specialist in the network to serve as the employee's treating doctor. However, the employee would have to apply to the network's medical director for such a change to take place.
Michael Devitt is the senior associate editor at MPA Media.