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Chiropractic in the United States:
Training, Practice, and Research

Chapter IV: Supply, Distribution, and Utilization
of Chiropractors in the United States
Ian D. Coulter, PhD; Paul G. Shekelle, MD, PhD

**Comments in red by Stephen Barrett, M.D.

A. Current and Projected Supply of Chiropractors

In 1970, there were an estimated 13,000 chiropractors licensed in the United States (Cooper, 1996). This number had increased to 40,000 in 1990 and to approximately 50,000 in 1994. Thus, there is roughly one chiropractor for every 5,000 U.S. residents. Estimates of the proportion of chiropractors who are in full-time practice range from 82 percent in a large national survey conducted in 1993 (Christensen) to 96 percent in a 1995 survey of members of the American Chiropractic Association (Goertz, 1996). Almost 90 percent of chiropractors report working at least 30 hours per week (Christensen, 1993), and the average chiropractor claims to work about 42 hours per week (Goertz, 1996). Estimates of the percentage of chiropractors in solo private practice range from 67 percent (Christensen, 1993) to 76 percent (Goertz, 1996), indicating that most chiropractors have remained in solo practice.

In 1995, there were 14,040 students enrolled in the 16 accredited chiropractic colleges, 2,864 of whom graduated in that year (Center for Health Policy Studies). The enrollment patterns in chiropractic colleges have been stable for the last several years with no new colleges being established since 1994. It appears that enrollments in chiropractic colleges are beginning to stabilize after a period of growth. However, with about 2,900 graduates per year, an increasing proportion of chiropractors is recent graduates.

A recent study estimated that the number of chiropractors will double by the year 2010 (to over 100,000), far exceeding the 16 percent increase projected for medical doctors (Cooper, 1996).

**At 16%, the projected increase in medical doctors would be about 100,000, which is much greater numerical growth than is projected for chiropractors.

This projection is based on two assumptions: (1) the number of chiropractor students will increase by 25 percent over the next 5 years and then stabilize and (2) 27 percent of currently active chiropractors will die or retire by 2010. Thus, it appears that chiropractors will represent a substantially larger proportion of health care professionals in the coming years.

**This assumes that the nearly all new graduates will succeed in practice, which may not be true. At current levels of demand, the chiropractic marketplace appears overcrowded. If the percentage of Americans using chiropractors does not increase considerably, many new graduates will fail.

B. Geographic Distribution

Colleges of chiropractic are not evenly distributed throughout the United States. Of the 16 accredited schools, 4 are in California, 2 in Texas, 2 in Missouri. The other eight are distributed in Oregon, Minnesota, Illinois, New York State, Georgia, Iowa, Connecticut, and South Carolina. Partly as a result of the distribution of the colleges, the practitioners are not evenly distributed throughout the states. Data from the Federation of Chiropractic Licensing Boards (FCLB) on the number of chiropractors licensed in each of the States in 1993 and 1995 (FCLB, 1996) are presented in Table IV-1. States with more than 3,000 chiropractors in 1995 were: California, New York, Florida, Pennsylvania, and Texas. Twenty-two States had more than 1,000 chiropractors. California, with 9,879 licensed chiropractors, had twice the number of the next largest state (New York).

The FCLB information, in conjunction with data on the estimated population in each state during these years, permitted estimation of the number of licensed chiropractors in each state per 100,000 population (Table 11). Because some chiropractors are licensed in more than one state and a substantial fraction is not practicing full-time (or at all), these numbers undoubtedly overestimate the supply of chiropractors. In addition, the dramatic differences in the reported number of chiropractors between 1993 and 1995 in some States (e.g., Hawaii, Illinois, New York, and Pennsylvania) casts further doubt on the accuracy of these data. Alternatively, changes in examination requirements, maintenance of inactive vs. active licenses and examination and license fees may account for year to year differences.

Nevertheless, the data are probably adequate for identifying States or at least regions that have particularly high or low population-to-chiropractor ratios. Specifically, States with the fewest chiropractors per 100,000 population in 1995 were: District of Columbia, Louisiana, Maryland, Mississippi, and West Virginia. The States with the most chiropractors per capita were: Arizona, Colorado, and Hawaii. It appears that States in the West have been generally more hospitable to chiropractors than those in the South and East. About 60 percent of chiropractors worked in urban or suburban communities, 35 percent in small towns, and 5 percent in rural areas (Goertz, 1996).

C. Utilization of Chiropractic Services

The proportion of the United States population that uses chiropractors and the number of chiropractic visits per capita have about doubled in the past 15-20 years. A 1980 national survey commissioned by the United States Department of Health, Education, and Welfare reported that 3.6 percent of the population used chiropractors that year and that there were 62 visits per 100 person-years (Von Kuster, 1980). The 1980 National Medical Care Utilization and Expenditure Survey found that 4 percent of the population saw a chiropractor (Mugge, 1984; Mugge, 1986). A community-based study of claims data collected between 1974 and 1982 reported that there were 41 chiropractic visits per 100 person-years (Shekelle, 1991). Each of the above studies also reported both large-area and small-area geographic variations in chiropractic use. More recently, a national telephone survey of the United States adult population reported that 7 percent of persons had used a chiropractor in the prior year (Eisenberg, 1993), and the chiropractic visit rate, as calculated from a recent cluster sample in 5 communities in the U.S., was 100 visits per 100 person-years (Hurwitz, in press). In this study, there were only small (less than 10 percent) differences in the estimated use rates among sites (San Diego, California; Portland, Oregon; Vancouver, Washington; Minneapolis-St. Paul, Minnesota; Miami, Florida).

Table 11. Number of Licensed Chiropractors
per 100,000 Population, by State: 1993 and 1995

STATE

1993

1995
 

Licensed Chiros.

Number per 100,000

Licensed Chiros.

Number per 100,000
Alabama

661

16.4

671

16.6
Alaska

162

29.4

186

33.8
Arizona

2,167

59.1

2,384

65.1
Arkansas

493

21.0

508

21.6
California

10,692

35.9

9,879

33.2
Colorado

1,566

47.6

1,696

51.5
Connecticut

893

27.2

858

26.1
Delaware

200

30.0

209

31.4
District of Columbia

93

15.3

39

6.4
Florida

3,896

30.1

4,355

23.0
Georgia

2,026

31.3

2,237

44.7
Hawaii

486

43.8

712

64.3
Idaho

301

29.9

338

33.6
Illinois

2,399

21.0

2,912

25.5
Indiana

919

16.6

900

16.2
Iowa

1,270

45.7

1,231

39.1
Kansas

614

24.8

637

25.7
Kentucky

1,162

31.5

1,055

28.6
Louisiana

566

13.2

592

14.0
Maine

358

29.2

375

30.5
Maryland

489

10.2

488

10.2
Massachusetts

1,422

23.6

1,220

20.3
Michigan

2,390

25.7

2,440

26.2
Minnesota

1,582

36.2

1,613

36.9
Mississippi

335

13.0

330

12.5
Missouri

1,864

36.4

1,856

36.3
Montana

364

45.6

228

28.5
Nebraska

263

16.7

281

17.8
Nevada

308

25.6

326

27.1
New Hampshire

401

36.2

435

39.2
New Jersey

2,850

36.9

2,701

34.9
New Mexico

558

36.8

577

38.1
New York

7,558

42.0

4,926

27.4
North Carolina

1,101

16.6

1,292

19.5
North Dakota

205

32.1

224

35.1
Ohio

1,563

14.4

1680

15.5
Oklahoma

960

30.5

980

31.1
Oregon

785

27.6

877

30.9
Pennsylvania

5,127

43.1

3,190

26.8
Rhode Island

161

16.0

158

15.8
South Carolina

1,015

29.1

1,097

31.4
South Dakota

188

27.0

201

28.9
Tennessee

600

12.3

780

16.0
Texas

3,347

19.7

3,682

21.7
Utah

425

24.7

580

33.6
Vermont

330

58.6

261

46.4
Virginia

950

15.4

1,090

17.6
Washington

1,593

32.7

1,625

33.4
West Virginia

280

15.6

255

14.2
Wisconsin

1,661

34.0

1,764

36.1
Wyoming

198

43.6

183

40.3

Source: Federation of Chiropractic Licensing Boards. Official Directory:
Chiropractic Licensure and Practice Statistics: 1996-97 Edition.

References

Center for Studies in Health Policy, Inc. Washington, DC. Personal communication of unpublished 1995 data from Meredith Gonyea, PhD.

Christensen M, Morgan D (eds). Job Analysis of Chiropractic: A Project Report of the Practice of Chiropractic Within the United States. Greeley, CO: National Board of Chiropractic Examiners, 1993.

Cooper RA, Stoflet SJ. Trends in the education and practice of alternative medicine clinicians. Health Affairs 1996;15:226-38.

Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States. N Engl J Med 1993;328(4):246-52.

Federation of Chiropractic Licensing Boards. Official Directory: Chiropractic Licensure and Practice Statistics: 1996-97 Edition. Federation of Licensing Boards, 1996.

Goertz C. Summary of the 1995 ACA annual statistical survey on chiropractic practice. J Amer Chiropr Assoc 1996;33(6):35-41.

Hurwitz EL, Coulter ID, Adams AH, Genovese BJ, Shekelle PG. Utilization of chiropractic services in the United States and Canada: 1985-1991. Am J Publ Hlth 1998;88:771-776.

Mugge RH. Persons Receiving Care from Selected Health Care Practitioners, United States, 1980. National Medical Care Utilization and Expenditure Survey. Series B, Descriptive Report No. 6. DHHS Pub. No. 84-20206. National Center for Health Statistics, Public Health Service. Washington, DC: US Government Printing Office, Sept. 1984.

Mugge RH. Utilization of Chiropractic Services in the United States. National Center for Health Statistics. Paper prepared for presentation at the Meetings of the American Public Health Association in Las Vegas, NV, Oct. 1, 1986.

Shekelle PG, Brook RH. A community-based study of the use of chiropractic services. Am J Publ Hlth 1991;81:439-42.

Von Kuster T, Jr. Chiropractic Health Care: A National Study of Cost of Education, Service, Utilization, Number of Practicing Doctors of Chiropractic and Other Key Policy Issues. Washington, DC: The Foundation for the Advancement of Chiropractic Tenets and Science, 1980.

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