Mandating the DVA to incorporate chiropractic care for veterans is a great victory for the profession

In early December 2001, the US Senate passed legislation mandating the establishment of a permanent chiropractic benefit within the Department of Veterans Affairs (DVA) health care system. which is the DVA Health Care Enhancement Act of 2001 (HR 3447). On January 23, 2001, President Bush signed the bill into law (PL 107-135).

Fighting the Good Fight

For many years, the chiropractic profession has worked to ensure that our nation’s veterans have access to chiropractic care. Despite its proven efficacy, public acceptance, and widespread inclusion in insurance plans of all types—including Medicare and the Department of Defense—the DVA has failed to integrate chiropractic into the VA health care system. Accordingly, veterans are denied access to the preferred treatment for a variety of neuromusculoskeletal-related maladies.

Because of the DVA’s failure to provide this care to veterans, Congress is now poised to pass historic legislation that would mandate a permanent benefit, authorize the hiring of doctors of chiropractic, set a broad scope for treatment conditions, and allow the profession to oversee program development and implementation.

A milestone occurred in 1999, when the American Chiropractic Association (ACA) and the Association of Chiropractic Colleges (ACC) worked to achieve the inclusion of a chiropractic provision in the Veterans Millennium Health Care Act (HR 2116). This law (PL 106-117) required the DVA to develop a new policy on chiropractic care by consulting with the chiropractic profession.

The ACA and ACC developed a set of policy recommendations, which included: a broad scope of practice for chiropractors; hospital privileges; direct access to chiropractic care; availability of chiropractic at all DVA treatment facilities, including DVA hospitals and clinics; availability of care in rural and other areas not close to a DVA treatment facility; and other recommendations that would lead to the full integration of chiropractic care into the DVA health care system.

The Run-Around

On February 24, 2000, representatives from the ACA, ACC, and other chiropractic organizations met with officials of the Veterans Health Administration (VHA) to discuss implementation of the new legislative mandate. The main objectives were to seek direct patient access to chiropractors and a broad scope of practice for DCs participating in the VHA. It became clear that the DVA was not sincere about providing a comprehensive chiropractic benefit to veterans.

The DVA’s policy stated, "It is VHA policy that VHA medical centers and clinics may offer chiropractic spinal manipulative therapy for musculoskeletal problems of the spine." The use of the word "may" meant that the DVA would not be mandating individual medical facilities to provide chiropractic care and that each individual VA medical facility could choose whether or not chiropractic would be made available. Accordingly, chiropractors would not be hired as employees, but as contractors. An additional concern was that patients seeking chiropractic care would need a referral from a medical gatekeeper, which basically meant that the chiropractic benefit was nearly eliminated.

Fortunately, Congress shared our concerns, and we were contacted by the House VA committee to testify at a hearing specifically on chiropractic care. Rick McMichael, DC; and George Goodman, DC, and Reed Phillips, DC, testified on behalf of the ACA and ACC, respectively. During the hearing, many members of the committee sharply criticized the DVA’s failure to take aggressive action to ensure veterans are provided with chiropractic care.

Congressman Cliff Stearns (R-Fla) stated, "Congress, as early as 1978, authorized the VA to provide chiropractic services to eligible veterans. But over its existence, VA has never employed its first chiropractor as a VA staff practitioner in this professional field; has never developed, without prodding from Congress, any meaningful policy on chiropractic care; and until this hearing has never had to defend its decisions to severely restrict or deny chiropractic care to veterans." Representative Bob Filner (D-Calif) went as far as suggesting that the VA be held in contempt of Congress.

Big Bad Bullies

Prominent medical organizations, including the American Medical Association (AMA) and American Osteopathic Association (AOA), used the opportunity to attack our profession. In a written statement, the AMA testified that "expanding current statutory authority regarding the role of chiropractic services could lead to a substantial decline in the quality of health care provided to VA patients."

The AOA stated that it "believes that doctors of chiropractic do not have the necessary medical knowledge or clinical training to be given a ‘full scope of practice’ in the care of musculoskeletal and neurological conditions. Although many conditions are treatable via osteopathic manipulation and chiropractic treatment, this course of treatment should be prescribed by an osteopathic or allopathic physician after the patient has been thoroughly examined and evaluated."

After the negative testimony by the AMA and AOA, how could anyone still believe that MDs or DOs would properly refer patients to chiropractic care? The hearing exposed the VA bureaucracy’s resistance to implement a strong chiropractic benefit.

The committee responded to the DVA’s inaction: "Chiropractic services are licensed in 50 states and abroad and are routinely covered by health insurers, Medicare, and many state Medicaid programs. Even though chiropractic services have been in existence for over 100 years, the VA has yet to employ on staff its first chiropractic practitioner, and the VA openly admits to authorizing only a scant amount of reimbursement for contracted services. Chiropractic is a legitimate form of therapy that thousands of veterans have been paying out of their pocket to obtain. For veterans who choose VA as their caregiver—and based on what we learned at our hearing about current VA policy—we cannot defend VA’s continued restrictive use of this professional service. "

After this, the VA developed a published policy on chiropractic care, but its purpose seems aimed at restricting veterans’ access to these services. As a result, we worked with key members of Congress on a statutory change that would mandate the DVA to offer chiropractic care on a direct-access, full-scope basis. The House VA Committee voted to approve legislation (HR 2792) mandating the inclusion of a permanent chiropractic benefit, which was substantially based on the Department of Defense language that the ACA and ACC worked to pass last year (PL 106-398).

House Rules

On October 23, 2001, the House of Representatives unanimously passed this legislation. During Senate deliberations, where significant resistance to the inclusion of a chiropractic provision existed, the medical establishment fought to limit the scope of practice for doctors of chiropractic or kill the chiropractic legislation outright. These groups have not made secret their opposition to ACA’s legislation. The American Physical Therapy Association (APTA) stated to Congress: "APTA fears these programs and other services will be compromised unless all provisions relating to chiropractic services are stricken from HR 2792."

The final VA legislative language agreed upon by the House and Senate in December represents a significant victory for the chiropractic profession and patients. This new benefit will be effective immediately, unlike the Department of Defense benefit that will be phased-in over 5 years. CP

Jay Witter IV, is the ACA vice president of government relations. He can be reached at: 800-986-4636, ext 214.