Legislative Alchemy is the process by which credulous state legislators turn practitioners of pseudoscience into state-licensed health care professionals. In addition to unleashing quackery such as homeopathy, colonic irrigation, moxibustion, reiki, cranial sacral therapy and the detection and correction of subluxations on the public, these practice acts typically give chiropractors, naturopaths and acupuncturists the freedom of being governed by their own regulatory boards, to which the practitioners themselves are appointed. The boards, in turn, write the administrative rules governing practitioners and handle public complaints about their services. In the worst cases, legislatures simply hand out the privilege of practicing medicine to pretty much anyone.
State practice acts also establish the education and training standards for practitioners by requiring graduation from their accredited schools. Here the federal government lends a hand, by turning accreditation over to private agencies run by the practitioners themselves. The federal government also supports the schools by giving them taxpayer-funded student loans and research money.
If the legislature doesn’t give CAM practitioners everything they want the first time around, they return year after year until fully satisfied. The brass ring is full primary care practitioner status with full health care insurance coverage.
Over half of the state legislatures have either shut down for the year or didn’t have a session in the first place. CAM practitioners haven’t been particularly successful in 2014 but there is still plenty of mischief to be done in the statehouses. Let’s look at how they’ve fared so far.
Chiropractors are licensed in all 50 states and all of their practice acts include the detection and correction of subluxations. What more could they want? Well, prescription privileges, for one thing, and turf protection for another.
It would be nice if those chiropractors who want to see their profession move toward evidence-based practice would begin with reform of the chiropractic practice acts, but there is no evidence they are taking this route. Perhaps they can get their act together and begin with next year’s legislative sessions.
For now, in what I see as a glimmer of hope that legislators are beginning to “get it,” chiropractors are seeing some pushback. For years, chiropractors have, via protective legislation, successfully blocked physical therapists from performing spinal manipulation, making the argument that PTs aren’t sufficiently educated and trained, which compromised safety. There is no credible evidence to support this position. There is yet another these attempt at turf protection pending in California right now.
But Washington State’s governor just signed a bill into law permitting PTs to perform spinal manipulation, although the requirements for getting the necessary “spinal manipulation endorsement” from the state are somewhat onerous. PTs still can’t legally advertise that they perform chiropractic “adjustment, spinal adjustment, maintenance or wellness manipulation, or chiropractic care of any kind.” Of course, why would they want to?
Chiropractors suffered another defeat in Washington as well. A bill allowing them to perform physicals for school sports and commercial driver’s licenses failed to pass.
Two attempts to expand chiropractic practice, one obvious and one a bit sneakier, also didn’t make it. In Hawaii, chiropractors are limited to the diagnosis and treatment of neuromusculoskeletal conditions related to the spine. A bill would have permitted chiropractors to call themselves “physicians” and to diagnose and treat any patient with any disease or condition by any physical, chemical, electrical or thermal method (including dietary supplements), using diagnostic imaging, ordering lab tests, or using any other method of diagnosis or treatment taught by chiropractic schools and approved by the state chiropractic board. In other words, as long as a chiropractic school taught it and the chiropractic board approved it, you can do it, no matter how ludicrous or dangerous.
In New Mexico, the festively-named Sen. Cisco McSorley once again went to bat for chiropractors and once again struck out. New Mexico is the closest chiropractors have gotten to being full-fledged PCPs, and even at that they have a ways to go. (Despite continued efforts, as Harriet Hall and I have discussed.) As of now, with a little additional training, “advanced practice” chiropractors have limited prescription privileges. Sen. McSorley’s bill would have substantially expanded their ability to prescribe and administer drugs.
In response to SBM posts on chiropractic’s dedication to the subluxation, DCs post comments that we are out of date, that chiropractic schools don’t teach the subluxation any more except as a historical concept, and that only the old-timers still believe in it. Tell that to the Minnesota legislature, where Senate Bill 1665 and House Bill 1850 are pending, redefining chiropractic as:
The health care discipline that recognizes the innate recuperative power of the body to heal itself without the use of drugs or surgery by identifying and caring for vertebral subluxations and other abnormal articulations by emphasizing the relationship between structure and function as coordinated by the nervous system and how that relationship affects the preservation and restoration of health.
Sure sounds like the old subluxation to me. The bills would also allow detection of these non-existent subluxations by CAT and PET scans and MRI.
Chiropractors have long denied the risk of stroke from chiropractic neck manipulation. In Wisconsin, Senate Bill 518 is now before the House Public Health Committee. It would create a Task Force on Neck Manipulation to:
examine risks, benefits, and alternatives to procedures associated with manual and manipulative treatment of the cervical spine. The task force shall also determine the necessity of informing patients of possible side effects resulting from treatments of the cervical spine.
The Task Force would consist of three chiropractic representatives, plus on MD, one DO and one PT, as well as legislative members, giving science a fighting chance.
In the last two years, naturopaths added Colorado and Maryland to the list of states where they can legally diagnose and treat patients, for a total of 18. In those states where they aren’t licensed or registered they can still offer advice as long as they don’t claim the ability to actually diagnose and treat patients, a limitation that appears to be honored mainly in the breach. The goal of the American Association of Naturopathic Physicians is full primary care physician status in all 50 states. Naturopaths fell short of that goal in their latest efforts, with both Colorado and Maryland putting substantial limitations on their scope of practice.
As the AANP promised, the naturopaths will come back year after year and try for more until they get what they want. True to their word, they were back before the Colorado legislature this year in an attempt to expand their scope of practice. Currently, NDs cannot see patients who are under two years of age at all. If the patient is between two and eight, they must give the parents a list of CDC-recommended vaccinations and urge that the child have a relationship with a licensed pediatric health care provider. (A fortunate provision, considering yet another survey demonstrates that ND students are anti-vaccination.) They must also disclose to patients that they are not physicians. Fortunately, a bill to do away with these limitations was defeated. The bill would also have lifted similar restrictions on practitioners of “complementary and alternative medicine,” which, in Colorado, means pretty much anyone who wants to set up shop as a CAM provider. A bill to expand the ND scope of practice also failed in Alaska.
In Hawaii, naturopaths have limited prescription privileges. A Hawaiian physician-legislator introduced a great bill that would have made it a requirement that naturopaths have the same education and training and MDs and DOs to obtain these privileges. Unfortunately, what actually passed, and is now on the Governor’s desk, simply requires beefed up continuing education in pharmacology and prescribing.
A bill to license naturopaths (Iowa) and a bill to implement a 2005 licensing law (Idaho) did not pass. ND licensing bills are still pending in Illinois, Michigan, New Jersey, Rhode Island, New York (passed in Senate, Assembly bill still under consideration), and Pennsylvania (Passed in House, now before Senate). While they vary in specifics, all of these bills would allow NDs to see any patient with any disease or condition, use pseudoscientific treatments like colonic irrigation and functional medicine, prescribe and sell homeopathic remedies and dietary supplements, diagnose and treat nonexistent diseases like chronic yeast overgrowth and adrenal fatigue, and order lab and other diagnostic tests, such as “live blood analysis.” Some would permit limited prescription privileges, like IV administration of “natural” substances. All would allow self-regulation and default to naturopathic organizations to determine who could practice.
Bills favorable to acupuncturists aren’t doing so well in the Deep South. Acupuncture is not licensed in Alabama, and things don’t look too promising. A bill to license and regulate practitioners of acupuncture and Oriental Medicine is stuck in the Senate Committee on Health with the legislature scheduled to adjourn on May 19th. Next door, in Mississippi, a bill to get acupuncturists out from under the requirement that the patient obtain a physician’s referral failed again this year. And next door to them, in Louisiana, another state that doesn’t license acupuncturists, a bill to create a commission to study whether the state should license them is still pending.
A bill pending in Arizona expands the scope of practice of auricular acupuncture to include treatment for post-traumatic stress disorder, although it limits treatments to five needles per ear, as if that matters. In California, a bill to certify Traditional Chinese Medicine Traumatologists passed in the Senate and is now before the Assembly. TCM traumatology is defined as a system of treatment of musculoskeletal conditions by stimulation of “acupressure points” to “open the body’s defensive chi and stimulate energy movement in the meridians.”
Other CAM-friendly legislation
I’ve saved one of the worst for last. A “chronic Lyme disease” bill passed in the Vermont legislature and is now on the governor’s desk. In an indication of just how strong the Chronic Lyme lobby is, the bill had 31 co-sponsors in the Vermont House.
Not only does it buy into the fictitious disease itself, it includes diagnosis and treatment of multiple systemic infectious disease syndrome. Although the bill doesn’t call it by that name, the syndrome (discussed by Harriet Hall here) is described in its provisions.
The bill notes “a range of opinions in the medical community regarding proper treatment of Lyme disease.” Actually, the “medical community” is confident that CLD is an inappropriate diagnosis and that long-term antibiotic therapy is unwarranted and potentially dangerous. Only outliers, who have created an equally fictitious specialty, Lyme-Literate Medical Doctors (LLMDs), believe CLD is a reality. Naturopaths, on the other hand, don’t seem to have a problem with the widespread condemnation of health care professionals who exploit patients by telling them they have CLD, and why would they? Fortunately for them, NDs, who have a broad scope of practice in Vermont, including prescribing privileges, are included among those who can diagnose and treat CLD.
Apparently because CLD is more of a collection of symptoms looking for a label, diagnosis need not include an actual lab test showing an infection. It can include:
a clinical diagnosis . . . that does not meet the [CDC’s] surveillance criteria but presents other acute and chronic signs or symptoms of Lyme disease as determined by a physician [including NDs]. The clinical diagnosis shall be based on knowledge obtained through medical history and physical examination alone or in conjunction with testing that provides supportive data for the clinical diagnosis.
Naturally, physicians who diagnose and treat CLD do so under the threat of being disciplined for substandard practice. The bill eliminates that possibility. Long-term antibiotic therapy “for the purpose of eliminating or controlling a patient’s infection or symptoms” is permitted and physicians cannot be subject to discipline for prescribing long-term antibiotics as long as the patient is monitored and certain medical record requirements are met. Health insurance will have to cover long-term antibiotic treatment, eliminating cost to the patient as a factor in treatment decisions.
And now, a pitch
The Society for Science-Based Medicine keeps a running tab of CAM-friendly (and the occasional not-so-friendly) bills in the state legislatures. We can’t track all of them, nor can we track every move every bill makes as it wends its way through various legislative committees and onto the floor of legislative chambers and then to the governors’ desks for signing or veto. However, you can keep up with bills in your state and, by going to your state’s legislative website, track them yourself. If you don’t like what you see, contact your legislators and let them know. If you do, let them know that too. There are plenty of posts on SBM with plenty of reasons to support or oppose (depending on what the legislation is trying to do) legislation. Over on the Oppose Naturopathic Licensing! website, I also keep up with naturopathic licensing bills, as well as other bills affecting naturopaths. Plus, you’ll find lots of information on why naturopaths should not become licensed health care practitioners. Even if all you can do is send a link, please do it.
You can bet the chiropractors, naturopaths and acupuncturists, and their lobbyists, are wandering the statehouse halls, even as you read this. Unfortunately, science-based medicine doesn’t have a lobbyist.