A bit of integrative medicine history was made in January 2012 when the U.S. Indian Health Service (IHS) quietly announced that licensed naturopathic doctors, acupuncturists and chiropractors would be included in 2012 in the IHS' student loan repayment programs.
The announcement magnetized students and recent graduates. Was this finally an end to what they view as discriminatory exclusion and a long-overdue chance to relieve their debt burden?
The inclusion was immediately celebrated by the American Association of Naturopathic Physicians (AANP). The AANP had targeted such inclusion as its top federal priority for the last decade. The American Chiropractic Association followed suit with a release to their own members.
These practitioners may be an exceptional fit for tribal health. Licensed naturopathic doctors link their primary care scope to expertise in natural healing methods such as herbal medicine and sweats (cleansing), lifestyle change and a belief in the importance of spirit in health. Emerging research on naturopathic diabetes care is also hopeful in a population in which this condition is epidemic. Naturopathic doctors would seem uniquely useful.
While the connections are not as direct, practitioners of acupuncture and Oriental medicine and chiropractors are similarly disposed, philosophically, toward indigenous and natural healing methods.
But a charge running beneath mission for many of those drawn to this opportunity is money. While the general public is likely to associate high student loan debt with medical doctors, the educational mortgage on their futures for these licensed professionals can be even more excruciating. The licensed naturopathic physicians are averaging $150,000. The tab for acupuncture and Oriental medicine professionals is $55,000 -- higher if they go on to become a Doctor of Acupuncture and Oriental Medicine. Chiropractic student loan debt is increasingly problematic and is in the $135,000-$145,000 range.
The quality that can be excruciating is that at this point in history the naturopathic and acupuncture professions have just enough cultural recognition to go into debt but not enough yet to get out of it. Their education is federally recognized so they can take out loans. But the practices of these two provider types are poorly imbedded in public or private payment and delivery, limiting income opportunities. Notably, a Feb. 2 Congressional Briefing focused on federal laws and regulations viewed as discriminating against these disciplines.
The IHS was so deluged by queries that the AANP sent out a note two days later telling their members in all capital letters to "PLEASE DO NOT CONTACT" the Indian Health Service "as they are being inundated with calls from NDs."
I spoke with Jacqueline K. Santiago, Chief, IHS Loan Repayment Program. She clarified that the decisions to include these categories of providers came via a circular sent to the tribes. "It wasn't a very big response," she said, that led to the inclusion. One tribe each had noted interest in including naturopaths and acupuncturists. Two wished chiropractors back on the list. Chiropractors had been on the list before.
In an interview with me for this posting on Jan. 26, 2012, David O'Bryon, JD, executive director of the Association of Chiropractic Colleges shared that chiropractors have been on and off the list a few times over the years. Few chiropractors have actually been hired by tribes. O'Bryon believes it is because "when a spot opens (the tribes) typically want a person with a plenary [general practice] license." He thinks the impact of hiring a chiropractor could be substantial enough for the tribes to think out of their box: "Pain and pharma are huge costs." Hiring chiropractors, he opined, could save big.
The AANP letter suggests hopefully that "this paves the way for inclusion in all federal loan repayment programs and is a significant step towards equity in education for naturopathic students."
The flood of callers makes it clear that demand for participation on the provider side is pent-up. What is also clear in the case of this regulatory change is that participation of these licensed so-called complementary and alternative medicine (CAM) practitioners will only happen if individual tribes invite them in.
IHS leaders and other policymakers may one day view these natural health disciplines as exceptional contributors to tribal health. For now, participation will be determined via personal relationships, one professional to one tribe at a time.
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