Governing therapeutic pluralism: An environmental scan of the statutory regulation and government reimbursement of traditional and complementary medicine practitioners in the United States

Abstract

The World Health Organization has called on nation-states to statutorily govern, and integrate into state-funded healthcare systems, practitioners of traditional and complementary medicine (T&CM) (whose therapeutic approaches that fall outside the boundaries of conventional biomedicine). To date, however, there exist few rigorous reports of the degree to which individual nations have responded to this call. This study, an environmental scan, comprehensively documents the statutory governance and government reimbursement of T&CM practitioners in the United States (US). Across the US, where health practitioner governance falls within state and territorial (rather than federal) jurisdiction, over 300 laws have been enacted to statutorily regulate a wide range of T&CM practitioners. Nurse-midwives and chiropractors are universally licensed across all 56 US regulatory jurisdictions (50 states, 5 territories and the District of Columbia); other major T&CM practitioner groups are regulated in fewer jurisdictions (acupuncturists, n = 52; massage therapists, n = 50; direct-entry [non-nurse] midwives, n = 36; naturopaths, n = 24). Additional statutory stipulations exist to govern chiropractic assistants (n = 30), auricular (ear) acupuncture practitioners (n = 24), homeopathic practitioners (n = 3), and psychedelic facilitators (n = 1), as well as biomedical professionals who practice acupuncture and related techniques, e.g., ‘dry needling’ (n = 44). While professional entry requirements for licensed T&CM practitioners are substantially harmonized across jurisdictions, restricted titles and statutory scopes of practice vary. Ten states have furthermore implemented ‘safe harbor’ (‘negative licensing’) exemption laws enabling otherwise-unregulated T&CM practitioners to legally practice. Limited government reimbursement for T&CM care is available across several federal and state programs, including Medicare, Tricare, Veterans Health Authority, and Medicaid. Nurse-midwifery and chiropractic care is most frequently reimbursed; acupuncturists, naturopaths and massage therapists are eligible for much more limited coverage. Medicaid programs for low-income people in ten states furthermore cover the services of (unlicensed but statutorily-recognized) birth doulas. Additional research is needed to assess the impact of these regulations on US health care.