The Tank Force hearing, moderated by Vice President Al Gore, included 12 separate panels, and a total of 66 panelists. Reve Askew, DC, a member of the board of governors of the American Chiropractic Association (ACA), was selected to be a member of the General Health Care Providers panel. Dr. Askew was the only panelists to represent the chiropractic profession. He was asked to make a three minute opening statement, and join in his panel's responses to approximately 45 minutes of questions from Task Force officials, including Secretary of Health and Human Services Donna Shalala.
As Dr. Askew's presentation represented (ex officio) every chiropractor in the country, we're presenting his statement in full. A list of panels and panel members is also included at the end of Dr. Askew's statement (see page 5).
A segment of Dr. Askew's statement was presented in an article on the Task Force hearing in the March 30, 1993 New York Times. In a related article in the same issue, Vice President Gore was also quoted: "The days of business as usual are over. We are determined to bring this country sweeping and comprehensive health care reform." Moreover, he asserted, "... everyone who has been making lots of money off health care in the last 10 years will need to sacrifice in order to make the system work."
Mr. Gore stressed the administration was "... determined to help doctors by reducing paperwork and administrative costs and by doing something to curb malpractice suits."
Statement by Reve Askew, DC, before the Task Force on National Health Care Reform Panel, Monday, March 29, 1993:
Good morning. I am Dr. Reeve Askew, a member of the American Chiropractic Association's Board of Governors, and a practicing doctor of chiropractic in Easton, Maryland. On behalf of the ACA's 22,000 members, I would like to thank you for this opportunity to address the Task Force. The ACA welcomes the opportunity to work with you toward systemic reforms that will guarantee access to affordable health care for all Americans. For years the ACA has supported universal health care for all Americans regardless of their income, controls on overall health care spending and guarantees of consumer freedom of choice in the selection of licensed health care providers. America's 45,000 doctors of chiropractic (DCs) are anxious to help tackle the problems that have left far too many Americans exposed to the great physical and economic risks associated with their inability to obtain appropriate health care services.
You have asked me to address the issue of how I, as a "front-line" provider of care, would suggest controlling health care costs. Several methods of controlling costs have been mentioned. Unfortunately, many of these can be accomplished only at the expense of some degree of health care access or quality. For instance, some view limits on the scope of a standard benefits package as one way to reduce costs. However, such a proposal may put at risk individuals with special health care needs such as the disabled. In addition, a strictly limited benefits package might erect barriers to the millions of Americans who choose to receive their care from licensed alternative providers such as chiropractors. Clearly, this would reduce access to health care services at a time when we can least afford it.
Unfortunately, this is often the case with health care policies -- they can "cause as much as they cure." I certainly don't claim to have answers that will avoid unintended consequences. But, I do feel that my suggestions can help hold down costs without unacceptable compromises in health care access or quality.
Expand Access to Non-MD Health Care Providers
Everyone agrees that expanded access to primary care is essential. However, the failure of medicine to provide an adequate supply of primary providers is well documented. In order to fill this gap, policies must focus on expanding access to non-MD providers such as chiropractors, nurse practitioners and others. Today, these providers are meeting the primary care needs of millions of Americans and have done so for years. Nearly 19 million Americans received health services from a DC in 1990 and, according to one survey, 85% of employers provide coverage for chiropractic are.
Unfortunately, non-MD providers are often overlooked by policymakers simply as "specialists." While it is certainly true that these providers specialize in the treatment of specific conditions, they also perform a range of high quality primary care services. For example, DCs specialize in treating neuromusculoskeletal conditions especially those related to the back and neck. However, DCs are also trained, licensed and obligated under state law to diagnose any and all health conditions. In satisfying this task, they use the standard procedures common to all providers, such as physical examination, laboratory tests and x-rays. The federal government takes advantage of these services by authorizing DCs to perform them under the federal Workers' Compensation Act and under the federal highway administration's commercial truck driver certification program.
Non-MD health professionals also reduce health spending by providing care at significantly lower costs. Over the years, many studies have proven the cost effectiveness of chiropractic care for treatment of back and neck ailments. This fact was best summarized in a study recently published in the Journal of American Health Policy which stated that for similar conditions, "chiropractic users tend to have substanially lower total health care cost" than do users of other modes of care.
If we are to control costs, we must channel more Americans to primary care providers. Primary care identifies health problems early, before they become complicated and expensive to treat. It is preventative, emphasizing healthy life-style and nutritional habits. And it keeps people out of the expensive institutional settings. These are all attributes of the practice of chiropractic and other non-MD health professions. I think the Task Force would be remiss if it did not take aggressive measures to ensure that Americans enjoyed expanded access to all primary care providers especially non-MD providers.
Freedom of Choice
Of course, suggestions to increase access to alternative providers begs the questions, "How?" First and foremost, government policies should provide an iron-clad guarantee that patients will have the freedom to choose their health care provider. Freedom of choice is fundamental to this country's traditions and should not be undermined in our health care system. In fact, a majority of the states have enacted health provider freedom-of-choice laws in recognition of the need to provide this guarantee. Forty-one states have freedom-of-choice laws guaranteeing access to doctors of chiropractic and many others ensure access to podiatrists, optometrists, psychologists and other licensed providers.
It is important to stress that freedom-of-choice laws do not "mandate" coverage of new services. Quite to the contrary, they merely expand the pool of providers eligible to render care which is already covered under a health benefits plan. Such laws simply give patients the opportunity to choose any licensed provider to treat conditions or provide services authorized under the plan. In so doing, these laws expand the pool of providers without adding new services or costs. The ACA would strongly recommend that any national health reform proposal include a guarantee of provider freedom-of-choice.
Other ways to control costs include:
Integrated Health Systems
Alone, non-MD providers may not be qualified to treat all conditions presented to them. But this is no reason to dismiss the idea of utilizing them to a greater degree. In instances when a condition is beyond the scope of a provider's expertise, it is the professional and moral obligation of the provider to refer the patient. This is certainly how DCs practice. According to ACA's annual survey, DCs refer nearly 20% of their patients to MDs and other health providers.
To help provide a single point of access to a full range of primary care, federal policies should encourage the establishment of integrated health systems staffed by providers of all disciplines. This would provide consumers with access to the full range of necessary primary and preventative health care services at one location.
Federal Health Manpower Programs
Existing programs like the National Health Service Corps (NHSC) should be fully funded and expanded to include all licensed health providers as eligible participants. These program encourage the practice of primary health care by offering scholarships and student loan repayment in return for commitments to practice in medically underserved areas. Chiropractic and other non-MD professions need to be made fully eligible for these programs.
In addition, non-MD professional teaching institutions should be assisted in obtaining federal grants for primary care research and students attending these institutions should be made eligible for the full range of federal educational loans. It is unfortunate that this is not now the case, but we remain hopeful that these policies will change under this administration.
Outcomes Assessment Research
The government should continue its work through the Agency for Health Care Policy & Research (AHCPR) to determine the best treatments for common illnesses. With two DCs serving as advisors, the chiropractic profession is currently participating in an AHCPR study to determine the most appropriate treatment for low back pain. ACA encourages the administration to continue seeking broad input from all health care disciplines as outcomes research continues. With so many millions of American consumers utilizing these services, it is obvious that these professions have much to offer in the area of outcomes research.
Malpractice Reform
We are all familiar with the costs associated with the practice of "defensive medicine." In an attempt to avoid liability, too many health providers feel compelled to order extra tests and services -- practices which drive costs higher. The chiropractic profession is justifiably proud of its record of quality and safety -- a mere 1.8% of a DCs practice cost goes towards malpractice insure coverage. Still, in order to promote the highest quality chiropractic care, the chiropractic profession has developed a set standards of care known as the Mercy Center Guidelines. The document has been endorsed by the ACA and the Federation of State Chiropractic Licensing Boards and distributed to the entire profession.
Despite the profession's admirable record of quality, ACA realizes the current medical liability system needs substantial reform and is working toward this goal as a member of the National Medical Liability Reform Coalition. We would encourage the task force to take a close look at the coalition's proposals.
Conclusion
If we are to expand access to health care coverage to everyone in this country, health costs must be controlled. The ACA believes that this can be achieved in part by expanding access to alternative providers, guaranteeing patients the freedom to choose them, and expanding federal health manpower and research programs so that all licensed health care disciplines have access to them.
I thank you for the opportunity to share my views.
Reeve Askew, D.C.
Easton, Maryland
Health Care Task Force
Public Hearing
March 29, 1993
8:00 - 8:05 Opening Proceeding
Panel 1: 8:05 - 9:05 Consumers
Daniel Schulder, Director of Legislation, National Council of Senior Citizens
Phyllis Torda, Director of Health and Social Policy, Families USA
Max L. Richtman, Executive Vice President, National Committee to Preserve Social Security/Medicare
Peter Thomas, Attorney, Representing Members of CCD, Consortium for Citizens with Disabilities
Lavola Burgess, President, American Association of Retired Persons
Bill Keane, Board Member of Coalition Member Organization on behalf of Long-Term Care Campaign
Panel 2: 9:10 - 10:10 Business
Gary Frank Petty, Treasurer and Member of the Board of Directors, Small Business Legislative Council
Margaret Smith, Chair, Legislation, National Small Business United
Samuel Carradine, Executive Director, Minority Contractors Association
Stephen Elmont, Vice President, National Restaurant Association
Andra Bennett, Executive Director, National Association of Private Enterprise
Panel 3: 10:15 - 11:15 Underserved
Larry Naake, Executive Director, National Association of Counties
Anne Hill, Director of Program Development, National Urban League
Nancy Danielson, Legislative Representative, National Farmers Union
Raul Yzaguirre, Present, National Council of La Raza
Michael Anderson, Executive Director, National Congress of American Indians
Panel 4: 11:20 - 12:20 General Health Care Providers
Virginia Trotter Betts, President, American Nurses Association
Dr. Jack Harris, President, American Dental Association
Ann Elderkin, President Elect, American Academy of Physician Assistants
Reeve Askew, Member, Board of Governors, American Chiropractic Association
Sheldon Goldstein, Executive Director, National Association of Social Workers
Bryant Welch, Executive Director for Professional Practice, American Psychological Association
Panel 5: 12:35 - 1:35 Physicians
Dr. Raymond Scaletter, Chairman of the Board of Trustees, AMA
Dr. Jane Orient, Executive Director, American Association of Physicians and Surgeons
Dr. Richard Butcher, President, National Medical Association
John M. Tudor, President, American Academy of Family Physicians
Howard Pearson, President, American Academy of Pediatrics
Melvin Sabshin, Medical Director, American Psychiatric Association
Panel 6: 1:40 - 2:40 Insurance
Bill Gradison, President, Health Insurance Association of America
Eric Gustafson, President, Independent Insurance Agents of America
Mary Nell Lehnhard, Senior Vice-President, Blue Cross Blue Shield Association
Jack Moynihan, Executive Vice President, Group Insurance, Metropolitan Life Corporation (on behalf of) Alliance for Managed Competition
James Doherty, President, Group Health Association of America
Panel 7: 2:45 - 3:35 Pharmaceuticals
Robert F. Allnutt, Executive Vice President, Pharmaceutical Manufacturers Association
Dee Fensterer, President, Generic Pharmaceutical Industry Association
Dr. Charles West, Executive Vice President, National Association of Retail Druggists
G. Kirk Raab, Board of Directors, Chair on Health Care Reform, Industrial Biotechnology Association
Dr. John Gans, Executive Vice President, American Pharmaceutical Association
Panel 8: 3:40 - 4:40 Hospitals
Dick Davidson, President, American Hospital Association
Michael Bromberg, Executive Director, Federation of American Health Systems
Jerry Dykman, Executive Vice President, American Protestant Health Association
Sister Bernice Coreil, Senior Vice President, Catholic Health Association
Lawrence A. McAndrews, President, National Association of Children's Hospitals
Panel 9: 4:55 - 5:45 General Health Care Providers
Val Halamandaris, President, National Association for Home Care
Dr. Paul Willging, Executive Vice President, American Health Care Association
John Mahoney, President, National Hospice Organization
Stuart Eizenstat, Consultant, Health Industry Manufacturers Association
Panel 10: 5:50 - 6:50 Labor
Karen Ignani, Director of Employee Benefits, AFL-CIO
John J. Sweeney, International President, Service Employees International Union
Gerald McEntee, International President, American Federation of State, County, and Municipal Employees
Cindy Zehnder, International Representative, International Brotherhood of Teamsters
Robert Georgine, President, Building Trades Council
Alan Reuther, Legislative Director, UAW
Panel 11: 6:55 - 7:55 Consumer
Cathy Hurwitt, Legislative Director, Citizen Action
Carol Reagan, Director of Health, Children's Defense Fund
Mary Cooper, Associate Director, National Council of the Churches of Christ in the USA
Leslie Scallett, Chair, Mental Health Liaison Group
Joan Kuriansky, Executive Director, Campaign for Women's Health
William Shaker, Executive Director, American Council for Health Care Reform
Panel 12: 8:00 - 9:00 Business
Jerry Jasinowski, resident, National Association of Manufacturers
Robert C. Winters, Chairman, Health, Welfare, and Retirement Income Taskforce, The Business Roundtable
Robert Patricelli, Chairman, Health and Employee Benefits Committee, Chamber of Commerce
Tracy Mullin, President, Government and Public Affairs Division, National Retail Federation
Patricia Nazemetz, Director of Benefits, Xerox Corporation on behalf of Washington Business Group of Health
Ellen Goldstein, Director of Health Policy and Communications, Association of Private Pension and Welfare Plans
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