HEW Response to Chiropractic's "White Paper" on
Health, Education and Welfare Secretary's Report
Independent Practitioners under Medicare
In December 1968, the Department of Health, Education and Welfare submitted to Congress its recommendation that "chiropractic service not be covered in the Medicare program." The recommendation was a part of HEW's report to Congress on a study of chiropractic made by HEW, as directed by Congress. The report was entitled "Independent Practitioners Under Medicare" Thereafter, chiropractic distributed its so-called "White Paper" criticizing the HEW study to members of the Congress and to State Legislators.
The Department of Health, Education and Welfare subsequently submitted this analysis of the "White Paper." to Congress. This page provides the full text of the HEW response in ordinary type interspersed with chiropractic's criticisms in yellow boxes.
This is an analysis of chiropractic's "White Paper" concerning the recommendation on chiropractic in the report, "Independent Practitioners Under Medicare," which was submitted to Congress by the Department of Health, Education, and Welfare in December 1968. The White Paper, prepared jointly by the American Chiropractic Association, the Council of State Chiropractic Examining Boards, and the International Chiropractors Association (although later orally disavowed by ICA), was released at a news conference on May 16, 1939, with a news release which stated that chiropractic spokesmen ". . . accused the U.S. Department of Health, Education, and Welfare of submitting a 'fixed' report to Congress, with false and unreliable information, and charged that it 'exceeded its authority' in a recommendation to exclude chiropractic from Medicare coverage."
The Department's report was prepared at the request of Congress, which directed the Secretary of HEW in Section 141 of Public Law 90-248 as follows:
The Secretary shall make a study relating to the inclusion under the supplementary medical insurance program (part B of title XVIII of the Social Security Act) of services of additional types of licensed practitioners performing health services in independent practice. The Secretary shall make a report to the Congress prior to January 1, 1939, of his finding with respect to the need for covering, under the supplementary medical insurance program, any of the various types of services such practitioners perform and the costs to such program of covering such additional services, and shall make recommendations as to the priority and method for covering these services and the measures that should be adopted to protect the health and safety of the individuals to whom such services would be furnished.
Although the report included recommendation on nine other practitioner groups, the White Paper and this analysis concern only the section on chiropractic.
After evaluation of extensive materials (submitted to the Department by the two national chiropractic associations) on the historical development of chiropractic, the definition and the clinical and scientific basis of practice, education and training, relationships with other health care professionals and with health care institutions, and costs—all in relation to the health care needs of the elderly and Federal responsibility for beneficiaries under the program—the Department recommended that chiropractic services not be included in the Medicare program:
Chiropractic theory and practice are not based upon the body of basic knowledge related to health, disease, and health care that has been widely accepted by the scientific community. Moreover, irrespective of its theory, the scope and quality of chiropractic education do not prepare the practitioner to make an adequate diagnosis and provide appropriate treatment. Therefore, it is recommended that chiropractic service not be covered in the Medicare program.
Chiropractic Charge: The Report Failed to Advise Congress
Chiropractic Charge: The Report Failed to Advise Congress
Claim: Insofar as chiropractic is concerned, the Health, Education and Welfare Report completely fails to advise the congress as to "needs" and "costs." . . . Instead, the report devotes its principal attention to a philosophic discussion of the theories of various recognized schools of the health arts in the form of a debate between medicine vs. chiropractic health care.
HEW's Response to the Charge that the Scope of Its Report was Improper
The White Paper charges that the Department failed to comply with the Congressional request for the study: (1) by having the Public Health Service conduct the study, contrary to Congressional intent; (2) by exceeding its authority in ignoring the specific limitations placed upon the study; and (3) by ignoring " . . . the Medicare beneficiary's need for chiropractic, and the cost of chiropractic services to the government and to the individual receiving service."
The Public Health Service prepared the report for the Secretary because it has primary responsibility for the professional and medical aspects of the Medicare program. In neither Section 141 of Public Law 90-248 nor the pertinent sections of the reports of the House Ways and Means and the Senate Finance Committees is any mention made of excluding the Public Health Service from participation in the study, The Congress has not expressed disapproval of assignment of the study to the Public Health Service, either while it was in progress or since the report was submitted to Congress.
The White Paper states ". . . a conference committee rejected a proposal that [the study] be made by the medically-oriented United States Public Health Service." The House and Senate bills for the 1967 social security amendments contained identical provisions for the study; therefore the study provision was not subject to consideration by the conference committee. The conference committee did, however, eliminate the provisions in the 1965 and 1967 Senate bills which provided for the inclusion of chiropractic services.
Broad interpretation was given to the phrase "licensed practitioners" in the Congressional directive. In view of the intent of Congress in asking for the study, the erratic nature of licensure justifies this interpretation. Theoretically, licensure is to protect the public. In practice it is sometimes sought by a profession as a means of establishing the parameters of its discipline and protecting its title, or it is a method of control through registration, with little effort to set or enforce standards. It was not logical, therefore, to use licensure as the criterion for selecting professions for study; i.e., why study physical therapy, which is licensed, but exclude occupational and speech therapy merely because they are not licensed? Selected for the study, therefore, were those disciplines that provide services used by a substantial number of elderly persons and that had expressed wishes for independent practice coverage in Medicare, or changes in methods of reimbursement.
The White Paper states that the report ignored the need and cost items of the Congressional directive. The directive of the study included four items: (1) the need of covering such additional services, (2) the cost of covering them, (3) the priority and methods of covering these services, and (4) the measures that should be adopted to protect the health and safety of the individuals to whom such services would be furnished.
Although the report concluded that, in order to protect the health and safety of Medicare beneficiaries, chiropractic services should not be included in the program, the report, nonetheless, included discussion and statistical data on the extent to which older people use chiropractic services. The findings of the USPHS study of utilization of chiropractic services cited in the White Paper were reported in detail in the HEW report. Demand as expressed in utilization, however, is not synonymous with need. In order to determine if the elderly need chiropractic services, the services a chiropractor provides were considered first. It was then necessary to evaluate the value and appropriateness of these services as established in scientific research, and the qualifications of chiropractors to provide the services in terms of their educational preparation.
Since cost estimates depend on specific services to be covered and on the method of coverage, cost estimates in the several areas of study could be obtained only after the recommendations regarding changes in Medicare coverage were made. As was true for several other services for which no change in coverage was recommended, the cost of coverage of chiropractic services was not estimated since the scope and kind of coverage would have to be known to determine potential costs.
Chiropractic Charge: The Report was "Fixed"
Claim: Directly contrary to Congressional intent, the Health Education and Welfare Report was prepared within the United States Public health Service, with the result that the Congress had specifically intended to circumvent: A biased report which is wholly unreliable.
Fact: The principal device for the preparation of the . . . report was the appointment of two committees on nongovernmental persons. Both such groups had an overwhelming built-in professional and institutional bias against chiropractic which made it impossible for them to provide objective and unbiased advice.
HEW Response to the Charge that Its Report was"Fixed"
The White Paper charges that the report was "fixed" (1) because at least six of the eight members of the expert review panel on chiropractic and ". . . at least twelve [of the twenty-two members of the Ad Hoc Consultant Group] were professionally or institutionally prejudiced against chiropractic—in view of the position of their professions or organizations, (2) because chiropractic observers were not permitted at meetings of the Ad Hoe Consultant Group and representatives of the chiropractic profession were not included on the expert review panel, and (3) because Do. John Cashman, Director of Community Health Service and responsible for the staff and consultants preparing the report, was alleged to have ". . . admitted privately to a representative of the chiropractic profession that he was opposed to chiropractic before the study began."
Review of the composition of the consultant groups and of their procedures during the study substantiates the fact that the study was carried out with as much impartiality and objectivity as possible.
To attempt a study such as this without the chief reservoir of technical and scientific knowledge—the health and scientific professions—would have been impossible. Fortunately, these professions are sufficiently large and diverse to contain within their ranks, particularly in education and research institutions, many persons of independent mind whose dedication to their science and to the public interest comes before their membership in a professional organization. Such persons were chosen as consultants; none was a spokesman for his profession's position on Medicare; four of the physician consultants were not even members of the American Medical Association; and a number of the consultants, both medical and nonmedical, have been "pioneers" in the health field, espousing innovative ideas and policy before they were acceptable generally.
The objectivity of the study would have been greatly compromised if representatives of the ten professions being studied, or of any other organizations with a vested interest in the conclusions to come from the study, had been included in the advisory groups or had been present during decision-making discussions. On the other hand, input from the professional groups being studied was necessary. This was achieved, without jeopardizing objectivity, through two mechanisms: (1) the professional associations were asked to submit detailed reports on their professions, including their views on Medicare coverage and on any other matter they wanted considered; and (2) spokesmen for the associations met with the over-all consultant group to present and discuss their views and to clarify aspects of their theory and practice. .
The Ad Hoc Consultant Group advised on the total study, including all ten practitioner groups studied. Hence, in addition to the members of scientific professions previously mentioned, it included other persons with special knowledge of the health and other needs of Medicare beneficiaries.
The Ad Hoc Group itself recognized and discussed two possible sources of bias. The first was from attempts by organized groups or individuals with special interests to influence the study. The Group decided that it would not hear or consider material from any group other than those being studied, and that no outside observers would be allowed lest they influence or inhibit the discussions. Thus, when the American Medical Association contacted the former Secretary of HEW and asked to meet with the Ad Hoc Consultant Group, the Group unanimously agreed that such a meeting would be inappropriate.
The second potential source of bias discussed by the Group was that resulting from the fact that its members were sophisticated, professional persons, well-informed about health matters, and inevitably had opinions on all the practitioner groups being studied, including chiropractic. This was coped with in two ways. First, the Group recognized the potential hazard and expressed determination to put aside preconceived ideas and give each profession a thorough, fair, and impartial study. Second, procedures were planned, as described above, to ensure that each profession's view got a fair hearing and that views of competing groups were excluded.
The Expert Review Panel on Chiropractic served as technical and scientific advisors to the Ad Hoc Consultant Group. These Panel consultants met the same criteria as the Ad Hoc Consultant Group regarding professional standing and capacity for impartiality and objectivity. In addition, they had to have special expertise in sciences related to chiropractic, and several of them, through their personal professional interests, had acquired considerable knowledge of chiropractic.
The crux of the charge of bias and prejudice in the White Paper is simply: Is "informed" opinion, such as that represented by the study's advisory groups, inevitably "prejudiced" opinion? Can a group of prominent scientists and other persons, assigned a task such as this study, give fair and impartial consideration to the needs and welfare of Medicare beneficiaries?
The White Paper also suggests that the report was fixed because representatives of the chiropractic profession were not permitted to observe at the meetings of the Ad Hoc Consultant Group. These meetings were not public hearings; they were study sessions at which the consultants, and the representatives of the professional organizations at some sessions, could explore the study issues, ask questions, and express opinions without the inhibition of being continually on public display. Hence, only staff were admitted as observers.
The White Paper alleges that Dr. John W. Cashman (an Assistant Surgeon General of the USPHS and Director of the Community Health Service), who was responsible for the staff and consultants preparing the report, ". . . admitted privately to a representative of the chiropractic profession that he was opposed to chiropractic before the study began." Dr. Cashman states this is not correct. It is obvious that if, in fact, this were his position, he would not have so stated to someone representing the chiropractic profession. It appears that this is an effort to embarrass Dr. Cashman and question his integrity.
False Issue No. 1—Chiropractic Education
Claim: Chiropractic education is not acceptable.
Fact: Chiropractic education is a highly sophisticated, scientific and professional course of instruction requiring four academic years of resident instruction in colleges of chiropractic.
HEW Response to "False Issue No. 1"
The White Paper objects to the report's findings on chiropractic education, claiming that "chiropractic education is a highly sophisticated scientific and professional course of instruction requiring four academic years of resident instruction in colleges of chiropractic." Tables comparing chiropractic and medical school curricula and educational entrance requirements are cited as support of this claim.
The report noted that chiropractic schools offer a wide range of courses similar to schools of medicine and osteopathy. But neither range of courses, nor number of hours in them assures a meaningful educational experience. The significant shortcomings in chiropractic education that are relevant to quality remain as cited in the report:
- the admission requirements for students are notably low;
- the educational system does not provide for inpatient clinical. training, which exposes the student to the breadth and depth of experience necessary to develop the requisite diagnostic and treatment skills;
- the faculty teaching required scientific and technical courses generally lack the necessary academic qualifications;
- the number of faculty, in relation to the number of students, is very low;
- the profession has failed to establish a nationally recognized accreditation program;
- there is a major schism within the chiropractic field on theory and practice.
The "White Paper" further states: "The validity of a Doctor of Chiropractic degree is attested to by the United States Office of Education in its most recent edition of the publication Academic Degrees, p. 169." The following information was provided by the Office of Education:
The purpose of the monograph [Academic Degrees] was to provide a "Dictionary of Degrees" for use by professional educators and the general public. It was not intended to be a guide to personnel in the Office of Education for eligibility determination or any other statutory function; rather, as the introduction states, it was designed to "afford information which will facilitate reduction in the number of such degrees currently offered and in greater uniformity in the use of standard abbreviations to represent them."
Two different methods were used for compiling the lists of academic degrees contained in the monograph, one for those represented as in current use, the other for those reported as not in current use. In addition, a distinction was made between degrees conferred by "recognized" colleges and universities and degrees given by spurious institutions.
Chapter 8, Subsection 18, of the monograph lists the Doctor of Chiropractic as degree conferred by four recognized colleges and universities; nine other chiropractic degrees are also listed, of which seven are cited as spurious and two as infrequently used.
Since Dr. Eells is deceased, we have no way of accounting for the listing of Doctor of Chiropractic as a "recognized" degree. He indicates that information "on current practices with reference to academic degrees," was obtained from registrars of institutions of higher education listed in Education Directory, 1939-1960—Part 3 - Higher Education. On the basis the institutions listed in this Directory, however, we are of the opinion that it was very unlikely that any of them conferred the Doctor of Chiropractic Degree and, therefore, Dr. Ellis must have obtained his information from another source. Again, there is a discrepancy in the publication Academic Degrees which suggest that perhaps a typographical error was committed. Chapter IX lists in alphabetical order all of the academic degrees "currently or formerly conferred or offered by American institutions of higher education." On page 236 "Doctor of Chiropractic" is listed as spurious.
We have no way of determining the current usage of Academic Degrees. Within the Office of Education it has no bearing at all in determining institutional eligibility for funding. Moreover, the Office does not "recognize" academic institutions or degrees. For purposes of determining eligibility for Federal assistance, the Commissioner of Education is required to publish a list of nationally recognized accrediting agencies and associations which he determines to be reliable authorities as to quality of training offered. This is the extent of USOE's function to recognize.
False Issue No. 2—Chiropractic Philosophy
Claim: That certain quotations from early writings of the chiropractic profession represent modern day chiropractic.
Fact: The Health, Education and Welfare report cites quotations out of context and confuses hypotheses for chiropractic clinical findings, thus deceiving the Congress and the American people.
HEW Response to "False Issue No. 2"
Chiropractors entered three objections to the report's discussion of chiropractic philosophy: (1) that the quotations regarding philosophy are from early writings that do not represent modern-day chiropractic; (2) that quotations are cited out of context; and (3) that the report confuses "hypotheses" for "chiropractic clinical findings." In other sections the White Paper objects to all discussion of chiropractic philosophy as inappropriate.
The HEW report quoted only from currently used chiropractic textbooks written by the leaders of the chiropractic profession. Appendix C of the report lists the schools at which these books are used. The staff who performed the search of chiropractic literature were aware of the hazards of distorting authors' meanings when quoting. Hence, quotations were as inclusive as possible. When this was not adequate to avoid distortion, paraphrasing was employed, and this was not objected to by the White Paper. No specific examples of quotations distorted by use our of context were cited.
Staff found no evidence that the philosophy as described in the report is obsolete or inconsistent with present-day chiropractic principles, theory, and practice. A. E. Homewood, D.C., in a book published in 1962 and currently used in seven chiropractic schools (in six as the principal textbook of a course), agrees with this view, as shown in the following quotation:
Unfortunately, the principles and theory propounded by D.D. Palmer did not meet the needs of the educators in the early days of chiropractic history and much of his teaching was either lost or distorted by the peculiar interpretations which better suited the circumstances. Therefore it is necessary to constantly quote from the works of D.D. Palmer to establish the exact principles and separate them from the peculiar ideas and theories from the fertile brains of others. Many of these latter theories do not stand with the light of present day knowledge, yet the teachings of D.D. Palmer will be found consistent with the 'facts of our present stage of intellectual insight and are likely to be found capable of withstanding investigation in the light of new knowledge yet to be discovered—for these are basic truths and principles. [A. E. Homewood, The Neurodynamics of the Vertebral Subluxation (n.p.: By the Author, 1962, p. 7. (Submitted to the Public Health Service by the International Chiropractors Association]
As to the confusion in terminology, there is a considerable semantic difficulty between chiropractic and other health professions in the use and interpretation of a number of terms. This difficulty is nowhere more evident than in this section of the White Paper, which is exceedingly difficult to comprehend outside the context of chiropractic philosophy. Hence, it is appropriate that the White Paper raise the problem in this section on philosophy.
In differential diagnosis, doctors of medicine and osteopathy use clinical observation and findings (or facts) to formulate and test a number of hypotheses until they arrive at the diagnosis or diagnoses that account for their observations and findings. For example, if a patient presented symptoms of a lung condition, the doctor of medicine or osteopathy might test hypothetical diagnoses of emphysema, lung cancer, and tuberculosis against clinical observations and findings.
From the presence of the tubercle bacillus and other corroborative clinical findings, together with negative findings for emphysema and cancer, he would conclude that his hypothesis of tuberculosis was correct and would initiate appropriate treatment. Chiropractors say this is treatment "by hypothesis." A chiropractor would also make clinical observations, and might also conclude that the patient had tuberculosis. However, he would treat him for the "chiropractic clinical fact" of a subluxation, for: "The probability or non-probability of the hypothesis does not alter the chiropractic clinical facts," which is the cause of the "physiology gone wrong" as described in the quotation on page 11 of this paper.
Thus, the White Paper says that "Chiropractic treats the ailment disclosed by the clinical facts, not by hypothesis." (Meaning of "ailment" here unknown.) It is the "chiropractic clinical fact" (i.e., a subluxation) in this sense that the White Paper does not want confused with a "hypothesis," by which is meant a diagnosis of a specific disease. But to other health profession, the relationship of this "chiropractic clinical fact" to the disease process is a completely unproven hypothesis. The theory is acceptable only to those who accept the "basic truths and principles" of chiropractic philosophy, mentioned in the quotation from Dr. Homewood above.
The Department's report recommends that chiropractic subject these "basic truths and principles" to examination through scientific research. Since they are amenable to such testing of validity, and since they are contrary to theories that have been so demonstrated, they are not acceptable as assumptions underlying either a philosophy or a science. Until they are scientifically validated, the scientific community must continue to consider them hypotheses.
False Issue No. 3—Diagnosis
Claim: Doctors of chiropractic are unable to diagnose patients and therefore are not able to know when to refer patients for treatment by other health practitioners.
Fact: Every chiropractic college teaches physical examination and diagnostic procedures and examines (or tests) in physical, clinical, laboratory, and differential diagnosis, in addition to chiropractic analysis. Before receiving a license to practice chiropractic, candidates are examined in diagnosis either by official State Boards or by the National Board of Chiropractic Examiners or both.
HEW Response to "False Issue No. 3"
The White Paper disputes the study conclusion that chiropractors' education and experience do not prepare them to make an adequate diagnosis and therefore to know when to refer patients to another source of treatment, citing as evidence: (1) classwork in diagnosis, textbooks used, and clerkships and externships; and (2) the fact that chiropractors make referrals. The inadequacies of chiropractic education, despite the textbooks used and the attempt to include broad content, are discussed in a preceding section (page 6).
Regarding referrals, the White Paper cites a survey showing that 90.3 percent of chiropractors make referrals. However, the basis for these referrals is unknown. The following quotation is as close as chiropractic literature comes to setting guidelines for referrals:
Nevertheless, there are, indeed, limitations, chiropractic is not a panacea. Some pathologic changes are irreversible. Large-scale tissue destruction may make replacement with normal tissue impossible. Again, while chiropractic has much to contribute to the improvement of vision, it cannot, under the conditions of modern life, completely obviate the need for glasses as one grows older, nor can it substitute for the services of a dentist. And while many common infections present no special problems for the doctors of chiropractic, there are circumstances involving infectious agents of unusual virulence and a patient of unusually low resistance in which medical attention becomes advisable. [American Chiropractic Association and International Chiropractors Association, Opportunities in a Chiropractic Career (New York: Vocational Guidance Universal Publishing and Distributing Corporation, 1967) p. 17. (Submitted to the Public Health, Service by the International Chiropractors Association)]
Therefore, it appears as if the basis of chiropractic referrals is the severity of the patient's condition rather than the diagnosis. The crux of the relationship of diagnosis to chiropractic is the fact that chiropractic philosophy deemphasizes diagnosis. This was shown in the preceding discussion of chiropractic philosophy (the White Paper's "False Issue No. 2" above), and is stated succinctly and directly by chiropractors in materials submitted to the Public Health Service as follows:
Because of the emphasis constantly being placed upon diagnosis by the medical profession, it is difficult for the average lay person to realize that the chiropractor need not diagnose and therefore diagnosis is unimportant to him. [B.J. Palmer Chiropractic Clinic, Neurocalometer, Neurocalograph. Neurotempometer - Research (Davenport, Iowa: By the Author, n.d.), p. 3. Quotation from Preface by L.W. Sherman, D.C., Ph.C., then Assistant Director, B.J. Palmer Chiropractic Clinic. (Submitted to the Public Health Service by the International Chiropractors Association)]
For the chiropractor, diagnosis does not constitute, as it does for the medical doctor, a specific guide to treatment. It is not a major goal of the doctor of chiropractic to specifically name a disease. He does not look upon diseases as an entity to be combated. For him disease is a process; it is physiology gone wrong. The problem is to ascertain why it has gone wrong, and what needs to be done to right the wrong. This is a goal not attainable by routing [sic] conventional, diagnostic methods. [American Chiropractic Association and International Chiropractors Association, Opportunities in a Chiropractic Career (New York: Vocational Guidance Manuals, Education Book Division, Universal Publishing and Distributing Corporation, 1967), p. 17.]
The [HEW] report concluded that the inadequacies of chiropractic education, coupled with a theory that deemphasizes proven causative factors in disease processes, proven methods of treatment, and differential diagnosis, results in the following hazards to patients: (1) appropriate treatment could be delayed or prevented entirely, (2) appropriate treatment might be interrupted or stopped completely, (3) the treatment offered could be contraindicated, (4) all treatments have some risk involved with their administration, and inappropriate treatment exposes the patient to this risk unnecessarily.
False Issue No. 4—Cause of Disease
Claim: Chiropractic regards subluxations as the sole cause of disease.
Fact: This is incorrect. Chiropractic care is primarily concerned with the well being and recovery of the patient and with the restoration and maintenance of good health. Present day chiropractic does not hold that the subluxation is the only cause of disease. Whatever may have been said in chiropractic literature years ago, today's chiropractic education and practice recognizes multiple causes of, and multiple methods of treatment for, disease.
HEW Response to "False Issue No. 4"
The White Paper incorrectly cites the report's statements on subluxation as a cause of disease and on the scope of chiropractic practice. Nowhere does the report state that chiropractors regard subluxations as the sole cause of disease. The report, documented with extensive quotations from chiropractic literature, refers to subluxations as considered by chiropractic to be " the most significant causal factor" in disease and, in relation to chiropractic philosophy, as the "ultimate causal factor," and it specifically warns about problems of definition "since the nonchiropractor may not understand the chiropractor's interpretation of this causal relationship." The report specifically states (page 165): "It should be pointed out here that many chiropractors do not believe that a subluxation is the only cause of disease, that spinal analysis is the only diagnostic tool, or that the chiropractic adjustment is the only valid treatment." This is followed by quotations from four chiropractors to this effect.
The White Paper also states that the report "fails to indicate that the majority of patients treated under chiropractic are suffering from neuro-musculo-skeletal problems." The Department's report, on page 163, states (emphasis added): "Thus, although chiropractors see more patients with musculoskeletal problems than any other kind, it is apparent that they consider themselves competent to treat a wide variety of illnesses. This belief stems largely from their philosophy or approach to health and disease. As a result of this belief, chiropractors do not limit their practice to the care of patients with musculoskeletal problems." Further, the report cites statistics provided by a chiropractic association (page 158): "In a survey made in 1963 for the American Chiropractic Association, 85 percent of the chiropractors reporting said that they treat musculoskeletal problems most frequently. Approximately 81 percent indicated that conditions other than musculoskeletal ranked first, second, or third among conditions most frequently treated."
True Issue No. 1—Need for Chiropractic
Issue: Is there a need?
Fact: Yes. The need for chiropractic services is best ascertained by the American people's demand for such services. The following clearly proves the need for chiropractic services as recognized both in law and in practice.
HEW Response to "True Issue No. 1"
The White Paper asks whether there is a need for chiropractic, and answers: "Yes. . ..The need for chiropractic services is best ascertained by the American people's demand for such services."
Neither demand nor utilization is evidence of need. Nor is recognition by any agencies or organizations, whether governmental or non-governmental, as cited extensively in the White Paper, evidence of need. The determination of need is a clinical matter which must consider (a) the diseases and conditions for which services are required; and (b) the demonstrated efficacy of specific services as therapy for the diseases and conditions.
The White Paper cites the shortage of doctors in rural areas as evidence of need for chiropractors. There is a shortage of practically all types of health manpower in rural areas, as stated by the White Paper, but here as well as in the cities specific services are "needed" only if they are efficacious as therapy.
True Issue No. 2—Cost of Chiropractic in Medicare
Issue: Will chiropractic benefits add costs to the Medicare program?
Fact: No. . . . Inclusion of chiropractic will save the Medicare costs for part A for patients treated by doctors of chiropractic and will not add to costs in Part B in any significant way, if at all.
HEW Response to "True Issue No. 2"
The White Paper claims that the inclusion of chiropractic services in Medicare will add no costs to the program. However, the Office of the Actuary, Social Security Administration, has recently estimated for a member of Congress that the probable additional cost in 1969, to include chiropractic services under Medicare on the same basis as doctors of medicine and doctors of osteopathy, would be $60 million or 26¢ per month per enrollee.
True Issue No. 3—Effectiveness of Chiropractic Services
Issue: Are chiropractic services effective in helping sick people?
Fact: Yes. The efficacy of chiropractic is a factual and empiric determination, not a theoretical consideration. Chiropractic must be measured by the result obtained in various types of clinical situations.
HEW Response to "True Issue No. 3"
The White Paper asks whether chiropractic services are effective in helping sick people, and answers: "Yes. The efficacy of chiropractic is a factual and empiric determination, not a theoretical consideration. Chiropractic must be measured by the result obtained in various types of clinical situation." The research cited in the White Paper as evidence of effectiveness of chiropractic services, however, falls considerably short of the task. One study uses costs as a measure of effectiveness; the other is a tabulation of patients seen in a clinic. Neither study, however, utilized meaningful criteria as a determination of effectiveness. As noted in the report, no valid clinical study, using appropriate scientific controls, has ever been done concerning chiropractic. There have not been valid studies of : (1) the role of subluxation in disease causation, particularly related to diseases other than musculoskeletal; (2) the validity of the chiropractic "spinal analysis" as a diagnostic technique; and (3) the efficacy of the chiropractic "spinal adjustment" as a therapeutic measure for the wide range of diseases for which it is used.
True Issue No. 4—States Rights and Freedom of Choice
Issue: Will the Federal Medicare program run roughshod over States' Rights? and over the patients' freedom of choice of health services?
Fact: This is for Congress to determine. The very first two sections of the Medicare law are captioned as follows: (1) "Prohibition against Any Federal Interference . . . " and (2) Free Choice by Patient Guaranteed."
HEW Response to "True Issue No. 4"
The White Paper cites Sections 1801 and 1802 of the Medicare law as relating respectively to States' rights and to freedom of choice of patients, and claims that failure of Medicare to cover chiropractic services violates these two sections.
Section 1801 forbids the Federal Government from exercising any control or supervision over the practice of medicine or the manner in which medical services are provided, or over organized settings in which services are provided. Relations with State and local government are not involved Medicare is a Federal program; it is not a Federally-aided State program, although certain Federal Medicare functions are administered through State Agencies. Hence, the Federal Government is responsible—- and must remain responsible—for the safety and welfare of beneficiaries, for the line of responsibility is directly from the Federal Government to the citizen-beneficiary.
Section 1802 guarantees beneficiaries freedom of choice among the services offered, specifying "any institution, or person qualified to participate (emphasis added). Medicare is not a comprehensive program; selection of services to be included is based upon the necessity for or the contribution of the service in maintaining or improving the health status of beneficiaries.
This article was revised on August 5, 2018.